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Family Therapy and Mental Health University of Guelph Centre for Open Learning and Educational Support Your Hosts 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 • • • • • 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 • • • • • • 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 • • • • • • 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 • • • • • 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 • • • • 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 8 2 Demographics • Name • Contact info • • • • • • Address, phone # (messages?), email Date of birth Relationship status Ethnicity Preferred language Referral source 8 3 Family History • Genogram • Substance use/abuse • Mental health issues, hospitalizations, suicide attempts • Disability/illness 8 4 Family History • • • • • Life cycle stages/issues Legal involvement Medical history Trauma/abuse (bullying, witnessing) Significant losses 8 5 Presenting Problem • Description • History (start, progression, worst, effects, coping) • Attempted solutions • Stage of change • Motivation • internal/external • responsibility 8 6 Risk assessment • Suicidality • Risk factors • Warning signs • Protective factors • Self-harm • History, severity, frequency • Homicidal • History, threats, escalation/pattern 8 7 Social Support • • • • • • • Ecomap Friends Religion/spirituality Extended family School Work Leisure/hobbies/interests 8 8 Other Considerations • • • • • • • • Medications Pain management Nutrition Sleep Financial situation/debt Legal status Education Collaterals 8 9 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” 9 0 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 14 1 1 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.’ 11 1 1 Schizophrenia Two or more delusions hallucinations disorganized speech disorganized behaviour (catatonia) negative symptoms (diminished emotional expression) 1 month severe, 6 months persistent 1 1 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? 1 2 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 133 1 3 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 134 1 3 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 135 1 3 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 136 1 3 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 137 1 3 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 138 1 3 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 139 1 3