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Family Therapy and
Mental Health
University of Guelph
Centre for Open Learning and
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Carlton Brown, M.Div., RP, RMFT
AAMFT Approved Supervisor
905-388-8728
[email protected]
William Corrigan, B.A., M.T.S., RMFT
AAMFT Approved Supervisor
519-265-3599
[email protected]
Get the slides: http://www.mftsolutions.ca/Pages/MentalHealthCourse.html
By the End of Today
• Introductions
• Models of illness in a developmental
perspective
• Introduction to the DSM-5
• Assessment and Treatment
• Assignments
• Schizophrenia
Ice Breaker
Pick a card
Half the cards depict psychiatric symptoms or
illnesses
Half the cards depict psychiatric medications
Find your mate!
Introductions
Name
Background/experience in mental health
What fascinates you about the field of
mental health?
What makes you nervous/afraid about the
field of mental health?
The Family Life Cycle and
Coping with Illness
The Family Life Cycle (Carter &
McGoldrick)
Individual life cycle is embedded within the family
life cycle
We are born into and raised in a context – the
family – with a history, rules, roles, etc.
View symptoms and dysfunction within the
context of the family system
Families may become stuck or frozen in one stage
of development
Goal is to help family become unstuck so
development can continue
The Family Life Cycle
Six stages:
1) Leaving Home: Single Young Adults
2) The Joining of Families Through Marriage:
The New Couple
3) Families with Young Children
4) Families with Adolescents
5) Launching Children and Moving On
6) Families in Later Life
The Family Life Cycle
1) Leaving Home: Single Young Adults
Accepting responsibility for oneself financially,
emotionally
Differentiation/individuation
Development of intimate peer relationships
Establishing oneself in work/career
Develop identity separate from family
Staying connected in a meaningful way
Shifting roles
The Family Life Cycle
2) The Joining of Families Through Marriage:
The New Couple
Commitment to a new system
Realignment of relationships to include partner
Forming new rituals and traditions
Creating new rules and roles
Negotiating boundaries
Intimacy ↔ Autonomy
(do they really know what they’re getting into?)
The Family Life Cycle
3) Families with Young Children
Accepting new members into the system
Adjustment of marital system to allow for children
Joining in child rearing, financial and household tasks;
values, traditions, rituals, etc.
Realignment of relationships to include parenting and
grand-parenting roles
Time management and shifting priorities
Balancing obligations between nuclear family,
extended family and outside
Fertility issues
The Family Life Cycle
4) Families with Adolescents
Increasing boundaries to allow independence
Shifting of relationships to allow adolescent to move
in and out of the system
Negotiate roles and responsibilities
Power struggles and managing conflict
Refocus on midlife marital and career issues
Begin shift toward caretaking of older generation
(“sandwich” generation)
The Family Life Cycle
5) Launching Children and Moving On
Accepting a multitude of exits from and entries to
family system
Renegotiation of marital system as a dyad
Development of adult-adult relationships with
children
Realignment of relationships to include in-laws and
grandchildren
Refocusing energy on self, partner, and future
Planning for retirement
Involvement in care for older generation
The Family Life Cycle
6) Families in Later Life
Accepting shifting generational roles
Maintaining functioning in face of decline
Supporting older generation without over-functioning
for them
Dealing with loss of parents and extended family
Dealing with loss of spouse, siblings, and peers
Coping with illness and disability; loss of function
Preparing for death
The Family Life Cycle
“Normal” is defined in many ways, with influence
from culture, ethnicity, religion, and wider
society (e.g. enmeshment)
Stress is often the greatest at transition points
between stages as system adapts to changes
It is assumed that developmental tasks that aren’t
resolved “pile up” and create stress or further
problems in the family system
Can be used to predict challenges for family and
to normalize experience
The Family Lifecycle &
Stressors
Horizontal stressors include:
Developmental
Unpredictable
Historical events
Vertical stressors include the impact of past and
present issues at various levels of each system
at a point in time
System levels include:
Individual, immediate family, extended family,
community and larger society
The Family Life Cycle &
Stressors
Stress on one axis will be greatly compounded by
stress on the other axis
“When a horizontal stress intersects with a
vertical stress, there seems to be a huge leap in
anxiety in the system” (Carter, 1978)
The onset of symptoms has been found to
correlate significantly with the addition or loss
of a family member (Hadley, 1974)
Time Phases of Illness (Rolland, 1994)
Shows the dynamic unfolding of the illness
process over time (vs. static state)
Each phase has its own psychosocial demands
and tasks which require different strengths or
changes from family
Time Phases of Illness: Crisis
Pull together to cope with immediate crisis (↑ cohesion)
Learning to cope with symptoms or disability
Adapting to health care settings and treatments
Establishing and maintaining workable relationships with health
care team
Family must grieve the loss of life they knew before illness
Gradually accept illness as permanent while maintaining a sense of
continuity between past and future
Family needs to create a meaning for the illness that maximizes a
sense of mastery and competency
Develop flexibility toward future goals, reorienting hopes and
dreams
Time Phases of Illness: Chronic
Time span between initial diagnosis/readjustment and
terminal phase
Can be marked by constancy, progression, or episodic
change
Referred to as “the long haul”; day-to-day living with
illness
Maintain semblance of normal life while living with illness
and uncertainty
Family may feel saddled with an exhausting problem
without end
Maintaining maximum autonomy for all family members
helps offset trapped, helpless feelings
Time Phases of Illness: Terminal
Inevitability of death becomes apparent and dominates
family life
Family must cope with issues of separation, death,
mourning, and resumption of family life beyond loss
Families that adapt the best are able to shift their view of
mastery from controlling the illness to a successful
process of letting go
Optimal coping involves emotional openness as well as
dealing with the myriad of practical tasks at hand
Tension between desire for intimacy and push to let go
Time Phases of Illness
Interplay between illness, individual and family life
cycles
Goodness of fit between psychosocial demands of
illness and family style of functioning and
resources distinguish successful vs.
dysfunctional coping and adaptation
Transition periods in illness life cycle are times to
re-evaluate structure
“Unfinished business” from previous phase can
block transition
Time Phases of Illness
Illness and disability tend to push individual and
family developmental processes toward
transition and increased cohesion
What is the fit between the psychosocial demands
of a condition and family and individual life
structures and developmental tasks at a
particular point in the life cycle?
How will this fit change as the course of the illness
unfolds in relation to the family life cycle and
the development of each member?
Time Phases of Illness
When inward pull of illness and phase of the life
cycle coincide, there is a risk that they will
amplify one another e.g. child-rearing
When onset of illness coincides with a transition in
family or individual life cycle, issues related to
previous, current, and anticipated loss will be
magnified
By adopting a longitudinal perspective, we can
stay attuned to future transitions in illness,
individual or family life cycles
Exercise: Family Sculpting
Experiential exercise with families or groups
Create a sculpture (a.k.a. tableau) of family
members
Use physical space to represent issues
Expressed through non-verbals: body posture,
closeness/distance, facial expressions, gestures,
sometimes props
Divide into small groups
Sculpt one family w/illness in one life cycle stage
Try to depict the issues present
Family Life Cycle and Illness
1. Leaving Home: Single Young Adults
• Non-normative or “out of sync” w/life cycle
• Illness or disability in a young adult may require
a heightened dependency and a return to the
family of origin for caretaking
• A serious illness provides a sanctioned reason to
return to the “safety” of the child-rearing period
(secondary gain)
• Risk of over-protection, triangulation
Family Life Cycle and Illness
2. The Joining of Families Through
Marriage: The New Couple
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My problem vs. our problem
Boundaries with in-laws
Gender socialization and rigid roles
Sustaining intimacy depends largely on
establishing viable caregiving boundaries
Long-term viability of relationship may
depend on openly discussing and legitimizing
both partners’ needs
Family Life Cycle and Illness
3. Families with Young Children
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Challenge of what to say, how much, and when
Being realistic vs. maintaining hope/optimism
Financial strain of lost wages, time off, etc.
Impact on child-rearing is twofold: one parent lost to
illness and other’s presence diminished by caregiving
demands – feels like single-parent family
Children can become parentified
Grandparents may be recruited to help, creating
other tensions and developmental “detour”
Family Life Cycle and Illness
4. Families with Adolescents
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Conflict of need for increased cohesion and
increasing need for autonomy
Risk of parentification
Shift in roles and responsibilities can create
resentment/conflict
Challenges of discipline: guilt, acting-out, etc.
Balancing emotional needs and self-care
Fear of abandonment
Family Life Cycle and Illness
5. Launching Children and Moving On
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Illness can be more disruptive in launching
stage because inward pull for cohesion
clashes with need for autonomy
Loyalty conflicts
Demands of present vs. future planning
Allocating resources
Developmental regression in children
Family Life Cycle and Illness
6. Families in Later Life
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Longer life expectancy means ever-growing
numbers of families are coping with chronic
disorders over an increasingly greater part of
life cycle
Concerns for an ill parent can be projected
onto one`s spouse creating conflict or
distance
Attending to unfinished business
Differentiate between each partner’s need for
space vs. distancing from fear
Introducing the DSM-5
“Open it up. It looks scientific.”
- Robert Spitzer, chair of the task force that created DSM-III
“Suicide rates are unchanged over the last
115 years, so we aren’t getting anywhere.”
- David Mays, Psychiatrist
Disease
a condition of a living animal or plant or of
one of its parts that impairs normal
functioning
typically manifested by distinguishing signs
and symptoms
Signs and Symptoms
Signs: something you can see that points
to the underlying disease
Symptom: something the patient
complains about that indicates
something is wrong
Signs and Symptoms
“I have a fever” is a symptom (something
the patient complains about)
An elevated temperature is a sign
(something you can see)
Physical Disease
Significant research into underlying causes
e.g. infection->immune response>pyrogens->hypothalamus->raised body
temperature
Mental Disorder
What are the signs and symptoms of a
mental disorder?
Is a mental disorder a disease?
What do we know about the underlying
mechanisms?
DSM vs. ICD
The World Health Organization created
the International Classification of
Diseases so that health providers around
the world would have a common
language to talk about causes of death
ICD-CM
The Clinical Modification of the ICD so that
health providers could talk a common
language of disease while treating
people who were still alive
DSM
The Diagnostic and Statistical Manual of
Mental Disorders was probably first
created as a way of making sure that
asylum patients were included in the
census
It later became an expansion of the ICDCM around mental illness, so that
psychiatrists and psychologists around
the world could talk the same language
DSM-ICD
ICD-6 1949: first mental disorders
ICD-7 1950ish: DSM I
ICD-8 : DSM II
ICD-9 1977: DSM III
ICD-10 1993: DSM IV and DSM 5
(ICD-11 coming soon?)
Early DSM
DSM I and II were descriptive,
psychodynamically-based books
A prototypical description of a particular
illness was given
Clinicians would decide if their patient fit
the prototype
Diagnosis by prototype is
culturally dependent
London: Manic-Depressive illness
New York: Schizophrenia
Using: same prototype
WHO 1959
We should at least describe well
If two people across the globe could come
up with the same diagnosis, at least we
would be reliable
DSM-III (1980)
Made a fundamental break with ICD-9
Became more observational and
descriptive, less psychodynamic
Effort to increase reliability
DSM-III
Introduced algorithm
Diagnosis is no longer a clinical art
Just follow the steps
DSM-IIIR and IV
Introduced Axes
1.Diagnosis
2.Personality/MR
3.Medical
4.Social
5.GAF
DSM-5 Task Force
Headed by David Kupfer
Seconded by Darrel Regier
Stringent conflict of interest guidelines (no
drug companies)
Etiology is Still Unclear,
but...
decided to make DSM-5 more
developmentally based, and to speak to
etiology
arranged by common genetics
narrative on predisposing factors
Elimination of Axes
Axis I - dystonic (don’t like it, seek
treatment)
Axis II - syntonic (doesn’t seem like a
problem, avoid treatment)
Noble Intention,
Unforeseen Consequence
Personality Disorders and Mental
Retardation were put on Axis II so that
they would receive attention
They received increased stigmatization,
and less funding for treatment
DSM-5
Reintegrates personality disorders and
developmental delays to reduce stigma,
enhance funding for treatment
The Other Axes
Axis III - already on Axis I of ICD
Axis IV - psychosocial, integrated as V
codes in ICD-9 and Z codes in ICD-10
Axis V - nobody misses the GAF (well,
some do…)
In Place of the GAF
The WHODAS
Less Pressure to Find a
Single Diagnosis
You can list as many diagnoses as you like
Not Everyone Hates It
“I love this book...best DSM ever written.”
Jack Klott
Unintended Consequences
In the DSM-5, each diagnosis has a list of
predisposing factors
e.g. socially isolated child, predisposing
factor is severe child abuse
So what might you conclude if you see a
socially isolated child?
plus ca change...
“The history of the DSM is a history of
unintended consequences” - Rich Simon
Specific Changes
Disruptive Mood Dysregulation Disorder
296.99 (F34.8)
Hopefully will reduce the diagnosis of
bipolar disorder in children
Specific Changes
PTSD
Now you not only can get it by being in a
traumatic situation
Now you can also get it by hearing about a
traumatic situation
Specific Changes
What is the only behavioural addiction in
the DSM-5?
Specific Changes
Can you be grieving and depressed at the
same time?
Specific Changes
Does anyone have Asperger’s Disease
anymore?
Porn addiction? Sex addiction? Any
addiction?
Is there such a thing as drug dependence?
Functional Consequences
Change the way we think about people
Realize how this diagnosis helps this
person get along in the world
(Sounding more and more like MFTs)
GAD or PTSD?
A 7-year-old boy who lives in New Orleans
with a pervasive, disabling, disruptive
fear of hurricanes
(hint: Mom and Dad lived through Katrina)
DSM-5 will make
notetaking more difficult
Discourages simple, categorical diagnosis
Requires more complex, narrative
diagnosis
Much like MFT :)
Maybe Too Complex
Less clinical usefulness
Increased concern about third-party
funding
“It could be fun” - Jack Klott
Recommended Reading
Allen Frances, Essentials of Psychiatric
Diagnosis
Allen Frances, Saving Normal
James Morrison, DSM-5 Made Easy
Joel Paris, The Intelligent Clinician’s Guide
to the DSM-5
Joel Paris and James Phillips, eds, Making
the DSM-5
Biopsychosocial
Assessment
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Demographics
• Name
• Contact info
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• Address, phone # (messages?), email
Date of birth
Relationship status
Ethnicity
Preferred language
Referral source
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Family History
• Genogram
• Substance use/abuse
• Mental health issues, hospitalizations,
suicide attempts
• Disability/illness
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Family History
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Life cycle stages/issues
Legal involvement
Medical history
Trauma/abuse (bullying, witnessing)
Significant losses
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Presenting Problem
• Description
• History (start, progression, worst, effects,
coping)
• Attempted solutions
• Stage of change
• Motivation
• internal/external
• responsibility
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Risk assessment
• Suicidality
• Risk factors
• Warning signs
• Protective factors
• Self-harm
• History, severity, frequency
• Homicidal
• History, threats, escalation/pattern
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Social Support
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Ecomap
Friends
Religion/spirituality
Extended family
School
Work
Leisure/hobbies/interests
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Other Considerations
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Medications
Pain management
Nutrition
Sleep
Financial situation/debt
Legal status
Education
Collaterals
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Case Examples
1.
2.
3.
4.
“I’m bouncing off the walls!!!”
“I don’t know, I’m just anxious”
“He’s just lazy!”
“I can’t sleep”
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Treatment
Linda Seligman and Lourie W. Reichenberg
(2014), Selecting Effective Treatments: A
Comprehensive, Systemic Guide to Treating
Mental Disorders, 4th ed. San Francisco:
John Wiley & Sons.
Treatment Irony
Mental Disorders are syndromes, not diseases
(no clear pathways)
Yet frequently are treated pharmaceutically
Treatment Reality
Severe mental illnesses frequently require
medication
MFTs do not prescribe
So what are we doing here?
Role of MFT in Treatment
Despite the tendency to treat mental illness
with drugs, a number of mental illnesses
respond better to therapy
At the very least, therapy should be
considered in addition to medication
Never tell a patient he doesn’t need
medication
Medication
Most important with severe illness:
- Severe depression
- Mania
- Psychosis
What therapists can do
1. Educate: help patients and families
understand the illness
2. Reduce stress: research shows that stress
makes mental illness worse
3. Encourage patients to stay on their
medication
4. Facilitate communication between
patients , families and caregivers
Assignments
Date
Disorder
Presenter
Nov 20
PTSD
Sarah and Geoff
PD
Purple
OCD
Justin and Jenna
ADHD
Stacey and Mark
Narcissistic PD
Grigoriy and
Andrew
Borderline PD
Margarete and Amy
Nov 21
Class Presentation
Core elements (DSM-5)
Family etiology
Impact on the family
Treatment of the individual & family
The Quiz
Is based on what happens in class
Pay attention
The Final Paper
Have fun
Show us you learned something
The Final Paper
Case study of an individual, couple or
family with a mental health disorder
Fictitious (movie, TV, novel, imagination)
The Final Paper
Genogram
Case history
Family system
Presenting problem
The Final Paper
Your treatment of the family as an MFT
Who else is treating the family?
How did you get involved?
The Final Paper
Treatment goals
Likely progression of the family
Medications that might be used
The Final Paper
Contextual considerations
Future directions
I’m Still Here
The Truth About Schizophrenia
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Psychosis
Schizophrenia Spectrum and Other Psychotic
Disorders
psychosis |sīˈkōsəs|
a severe mental disorder in which thought and
emotions are so impaired that contact is lost with
external reality.
ORIGIN mid 19th cent.: from Greek psukhōsis
‘animation,’ from psukhoun ‘give life to,’ from
psukhē ‘soul, mind.’
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Schizophrenia
Two or more
delusions
hallucinations
disorganized speech
disorganized behaviour (catatonia)
negative symptoms (diminished emotional
expression)
1 month severe, 6 months persistent
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Delusions
Erroneous beliefs
Usually involve misinterpretations of
perceptions or experiences
Many possible themes
Delusional themes
Persecutory: someone (maybe you) is out to
get me
Referential: that TV announcer is talking
about me, newspaper article is about me,
biblical prophecy is about me
Somatic: I have cancer, gas poisoning, a
transmitter planted in my brain
Delusional themes
Grandiose: I actually work for the CIA, I’m the
son of God, etc.
(personal experience: two deities can coexist
on the same floor, but not two government
agents)
Religious delusions are common, especially if
the person is having auditory hallucinations
(Who is speaking?), and also because of lot
of our “subclinical” cultural context is
religious
Bizarre Delusions
Sometimes difficult to judge what is bizarre
If clearly impossible or not derivative of
normal life experience, then bizarre
E.g. someone has removed all my internal
organs and left no marks (bizarre) vs. the
police are watching me when in fact not
true (nonbizarre)
Hallucinations
Most common: hearing a voice or voices
Must be fully awake
Must not be culturally condoned
One or more voices carrying out a running
commentary on the person’s behaviour is
considered “particularly characteristic of
Schizophrenia”
Disorganization
Thinking
Evidenced in speech, changes topics, tangential
conversation, loose associations (I saw a duck
which means I’ll lose my job today)
Severely disorganized: word salad,
incomprehensible
Mild disorganization is normal in university
course instructors and other non-schizophrenic
individuals
Disorganization
Behaviour
Avolition, non goal oriented behaviour
Silliness
Unpredictable agitation
Poor attention to ADL’s (activities of daily
living), e.g. disheveled
Inappropriate, e.g. winter coat in summer,
public masturbation, unpredictable shouting,
swearing
Catatonia
Decreased reactivity to environment
Varying degrees
May be unaware of surroundings, may
actively resist movement, assume bizarre
posture, etc.
May be secondary to something else, not
necessarily diagnostic of schizophrenia
Schizophreniform Disorder
Like Schizophrenia, two or more symptoms
Total duration is 1 – 6 months (i.e. less than 6
months)
Schizoaffective Disorder
Like schizophrenia, with a major mood
component
Must also have delusions or hallucinations
without mood for 2 or more weeks at some
point in the illness
Delusional Disorder
One or more delusions for at least 1 month
Minor hallucinations allowed
Functioning is not impaired and behaviour is
not obviously odd (but may be odd with
respect to the delusion)
Delusional Subtypes
Erotomanic – ______ is in love with me
Grandiose – I am burdened with a special
purpose
Jealous – my spouse is unfaithful
Persecutory – I’m being poisoned,
blackballed, talked about
Somatic – I have bad body odor, lice, my
bowel isn’t functioning properly
Brief Psychotic
A. Sudden onset of delusions, hallucinations,
disorganized speech or behaviour
B. Lasts at least a day but less than a month,
and the person returns to full functioning
C. Not better explained by depression,
bipolar disorder or schizophrenia (or
medical)
Impact on Relationships
Video clip - I’m Still Here, part II
Benny and Joon
Role play(s)
What can MFTs do?
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Manage the Psychosis
Medication helps
Dopamine receptor antagonists (standard
antipsychotics or neuroleptics)
Haldol (haloperidol)
Thorazine (chlorpromazine)
Serotonin-dopamine antagonists (atypical
antipsychotics or neuroleptics)
Risperdal (risperidone)
Clozaril (clozapine)
Newer Antipsychotics
Olanzapine
Sertindole
Quetiapine
Treatment Protocols
Choose a medication that has tolerable side
effects, start with a low dose
Standard antipsychotics have extrapyramidal
side effects (movement disorders)
Atypical antipsychotics have a host of other
side effects (leukopenia, weight gain)
Consider ECT as an alternative therapy
What MFT’s can do
Encourage patients to be patient with their
doctors (the right medication at the right
dose takes time)
Encourage patients to tell their doctors what
their side effects are (stiffness, weight gain,
sexual dysfunction)
Encourage patients to stay on their
medications even when they feel well
Family
Psychoeducation:
SCHIZOPHRENIA
Family Psychoeducation
(William McFarlane, 1991)
Between 1-2% of population afflicted
Only 25% of first-episode patients recover
40% chance of relapse in first year after
episode
Family psychoeducation response to:
Disappointing record of meds
Complex burden imposed on families
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Family Psychoeducation
(William McFarlane, 1991)
Def’n:
Training to create an interactional environment
that compensates for functional disability in one
member
Multiple-Family Therapy
1960s – H. P. Laqueur & T. Detre
Reduce blame, emotional support, trade
techniques
Balance needs of patient and family
Showed early promising results
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Family Psychoeducation
(William McFarlane, 1991)
Goals:
Prevention of relapse
Gradual integration of patient into community
Symptomatic stability & “stress resilience”
Structure:
Joining phase
Educational workshop
Community re-entry
Social and vocational rehab
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Family Psychoeducation
(William McFarlane, 1991)
Joining
Supportive and informed alliance w/family
Meetings wo/patient, reduce anxiety
Connect with educational workshop
Elicit responses to illness, listen & validate
Allow expression of loss
Short sessions with patient alone
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Family Psychoeducation
(William McFarlane, 1991)
Educational workshop
For families and friends (not patients)
One day, 4 – 7 families
Lecture & discussion, AV aids
Develop cross-family linkages
Topics include: brain function, medication effects,
symptoms and signs
Discuss family guidelines (see handout)
Q&A
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Family Psychoeducation
(William McFarlane, 1991)
Community re-entry
MFG continues, every 2 weeks, 1 ½ hours, for at
least 12 months
Continues until return of “spontaneous signs of
life”
Themes include: recognizing relapse, boundaries,
setting limits, medication compliance, increasing
responsibility and social activity and dealing with
dangerous behaviour
Validation, guidelines, group problem-solving
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Family Psychoeducation
(William McFarlane, 1991)
Social and vocational rehab
After about one year, wo/relapse
Apply carefully modulated pressure to increase
responsibilities and foster more active social life
Build on small tasks mastered
Patient plays more active role
Family coaches and cheerleads
Monitor for signs of relapse
Slow return to social activities re. stress
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