Michelle D. Sherman, Ph.D.
Director, OKC VAMC Family Mental Health Program Clinical Professor, University of Oklahoma Health Sciences Center,
Overview
1. Rationale for creation of REACH (Reaching out to Educate and Assist Caring, Healthy Families)
2. Selection of the evidence-based model to tailor
for PTSD and the VA
3. The REACH intervention & guiding principles 4. Participation, outcome, and satisfaction data
75% of married/cohabiting OEF/OIF/OND veterans
referred for mental health evaluation at the VA had “some family problem” in the past week
86% of veterans in a VA PTSD outpatient program
reported that PTSD was a source of family stress
Partners of veterans with PTSD experience:
◦ High levels of caregiver burden
◦ High levels of overall psychiatric stress
Compared to partners of veterans without PTSD,
they report:
◦ Lower relationship satisfaction ◦ Poorer psychological adjustment
Jordan et al., 1992; Calhoun et al., 2002; Beckham et al., 1996; Manguno-Mire et al., 2004
What About Family Involvement?
79% of veterans expressed interest in greater family involvement in an outpatient VA PTSD program
Over ¾ of live-in female partners of veterans with
PTSD rated getting couples/family therapy as very important in coping with PTSD in the family
Conjoint treatment has been found to be effective
with other disorders (depression, substance abuse, schizophrenia)
Sherman et al., 2004; Batten et al, 2009; Beach et al., 1996; Jacobson et al., 1991; O’Farrell et al., 2006; Pfammatter et al., 2006
ISTSS guidelines (Glynn, Drebing & Penk, 2009)
recommend family education/support for PTSD treatment
VHA Handbook 1163.04 (July 1, 2011):
“Opportunities for family consultation and family education (e.g., SAFE Program) or family
psychoeducation (FPE) must be available for all veterans with serious mental illness…”
Recommends: the DOD & VA “should institute
programs of research to evaluate the efficacy,
effectiveness, and implementation of all their PTSD screening, treatment, and rehabilitation services”
Recommends that “couple and family
therapy…need to be rigorously evaluated…for efficacy, effectiveness, and cost” (pages 13-14).
Manualized interventions originally created for
schizophrenia
Goal: To equip families with the skills known to
reduce relapse and improve quality of life
Emphasis on:
◦ Careful assessment
◦ Education about the illness ◦ Problem-solving
Meta analyses have concluded that benefits
of FPE for schizophrenia (when added to
standard pharmacotherapy) include:
◦ Reduced risk of relapse
◦ Remission of residual psychotic symptoms ◦ Enhanced social & family functioning
◦ Financial savings
** Findings are robust across cultures & sustainable across time.
** FPE is increasingly being used with a variety of other mental illnesses
Further, families who get FPE report:
◦ Less burden
◦ Decreased burnout & distress
◦ Fewer psychosomatic difficulties
REACH = Reaching out to Educate and Assist
Caring, Healthy Families
Chose McFarlane’s Multifamily Group Model due to
its strong evidence base & group format
Modified for use in the VA system and for use with
PTSD
Funded in 2005 as part of VACO Mental
2 focus groups (veterans with SMI/PTSD and family
members)
Goal = To better understand the needs and treatment
preferences of local families
Findings:
◦ Veterans want family involvement to help family better understand their illness
◦ Family members want to be involved in veteran’s care
◦ Want evening services
Instillation of hope
Acknowledgment of PTSD as a real
phenomenon, yet empowering to make
positive changes
Focus on making small “1mm” changes
Treat veterans/support persons as “guests in
Emphasis on a “long-haul” mentality
(marathon rather than a sprint”)
Challenge by choice
REACH is not solely about/for the veterans
REACH PTSD Cohort Eligibility Criteria:
1) Primary diagnosis of PTSD
2) Residence within 90 miles of the VAMC
3) Adult family member/friend willing to
participate
Exclusion criteria:
1) Primary substance abuse disorder
2) Imminent danger to self or others
Elicit referrals from staff from numerous
programs:
“On-call” REACH psychologist meets with
interested veteran immediately after his/her
scheduled psychiatric appointment
◦ Motivational interviewing
◦ Emphasis on helping them achieve goals by involvement of family member
Phase One
:
Four weekly 45-minute single familysessions
Goals:
◦ Build rapport
◦ Assess precipitants & prodromal signs ◦ Begin to enhance coping strategies
◦ Define goals for this family
◦ Assess social history, family resources, support network
Goals:
o Psychoeducation about PTSD and its impact on family o Teach communication, problem-solving and coping
skills
o Relationship enhancement
Structure:
◦ Check-in and follow-up on homework
◦ 20 minute didactic (interactive) presentation
◦ Split into break-out groups (veterans and
support persons separately) for 15-20 minute presentation/discussion
◦ Reconvene for entire class demonstration and in-session practice
1.
PTSD diagnosis, treatment, and effects on
relationships
2.
Managing anger/conflict effectively and
promoting wellness
3.
Communication skills
4.
Creating a low stress environment
5.
Depression and its impact on the family
Six monthly 90-minute multi-family groups
Practice with problem-solving process
Review and rehearse skills from Phase II
Entire curriculum and student workbook are
available for free download:
www.ouhsc.edu/REACHProgram
Special thanks to the SCMIRECC for funding
In addition to working with veterans with PTSD
and their families, we provide REACH to two
other diagnostic groups:
1. Affective Disorders (AD) including depressive disorders and bipolar disorder
2. Schizophrenia spectrum disorders (SSD)
Have done “engage interviews” with 3,380
veterans to inform them about REACH
791 Veterans have participated in REACH
40 Nine-month PTSD cohorts
40 Nine-month Mood disorders cohorts
~95% of participants in clinical REACH
Program consent to voluntary REACH
evaluation
Veterans and family members complete a
battery of self-report measures at 4 times
◦ Baseline
◦ End of Phase 1
◦ End of Phase 2
Veterans (n=100) Family (n=96) Age (mean (IQR)) 55.8 (57-62) 52.7 (46-61) % Male 99% 4% % Married 87% 93% Race/ethnicity White 87% 82% Hispanic 4% 1% Black 8% 7% Native American 1% 8% Fischer et al., (2013)
Veterans (n=100) Family (n=96) Education Less than HS 5% 10% HS/GED 33% 38% Some college 35% 36% College graduate+ 18% 15% No information 9% 1% Relationship to veteran Spouse -.- 91% Parent -.- 3% Sibling -.- 4% Child -.- 2%
Veterans (n=100) Family (n=96) Measure Estimate Sign. Estimate Sign. PTSD Facts 6.29 <0.01 8.19 <0.01 PTSD Understanding 1.03 <0.01 1.11 <0.01 PTSD Coping 0.52 <0.01 0.95 <0.01 Empowerment1 1.84 0.01 18.2 <0.01
1 Rogers (veterans)/Koren (family) score sums * Repeated measures analysis (SAS Genmod)
Veterans (n=100) Family (n=96) Measure Estimate Sign. Estimate Sign. Social Support1 0.21 0.02 0.32 <0.01
Problem Solving2 - 0.02 NS 0.22 <0.01
Relationship
Satisfaction3 0.22 <0.01 5.13 <0.01
Symptoms (Brief Symptom Index)
Global Sx Index -0.19 <0.01 -0.20 <0.01 Depression -0.33 <0.01 -0.19 0.03
1 Multidimensional Scale of Perceived Social Support (avg.) 2 McCubbin Family Problem Solving Communication Scale (avg.)
3 Dyadic Adjustment Scale-7; distressed relationships only * Repeated measures analysis (SAS Genmod)
For family, increases in perceived ability to cope
and empowerment mediate
*improvements in
social support and problem solving; increases in
perceived coping are associated with
improvements in BSI global symptom severity
and depression scores
96% of participants said they were either “very satisfied” or
“mostly satisfied” with the REACH Project
98% of participants were “very satisfied” or “mostly satisfied”
with their doctors
96% of participants rated the quality of REACH as “excellent”
or “good”
97% said REACH “helped a great deal” or “helped somewhat” 100% said they would recommend REACH to someone with a
Compared 12 months before starting
REACH to 12 months after finishing REACH
On average, veterans
used fewer VA
outpatient mental health services
in the 12
months AFTER REACH than they had in the
12 months before starting (
1.71
encounters/month versus
2.89
encounters
Durham and the Bronx VA have done MFGs for
PTSD and TBI, incorporating some of REACH
(Perlick et al., 2013; Straits-Troster et al., 2013)
Atlanta VA and Reno Vet Center are providing
REACH for PTSD
Togas, Maine VA is applying for funding to
implement and evaluate REACH
Honolulu VA / National Center for PTSD are using
the REACH curriculum for their research project with OEF/OEF PTSD couples
REACH-PTSD is a feasible, well-received,
effective family intervention for trauma
◦ Additional tool for clinicians (before, after or during EVTs for PTSD)
◦ Introduces norm of family involvement
◦ Assessing need for modifications to tailor REACH to appeal specifically to OEF/OIF-era veterans
Fischer, E.P., Sherman, M.D., Owen, R., & Han, X. (2013). Outcomes of
participation in the REACH multifamily group program for Veterans with PTSD and their families. In press.
Sherman, M.D., Perlick, D., & Straits-Troster, K. (2013). Adapting the multifamily group model for treating Veterans with PTSD. Psychological
Services.
Sherman, M.D., Fischer, E.P., Bowling, U.B., Dixon, L.B., Ridener, L., & Harrison, D. (2009). A new engagement strategy in a VA-based family psychoeducation program. Psychiatric Services, 60, 254-257.
Sherman, M.D., Fischer, E.F. Sorocco, K., & McFarlane, W. (2009).
Adapting the multifamily group model to the Veterans Affairs system: The REACH program. Professional Psychology: Research and Practice, 40(6), 593-600.
Thank you!
Michelle D. Sherman, Ph.D.
405-456-5171
