FAMILY-ORIENTED CARE IN ADULT PSYCHIATRIC RESIDENCY

FAMILY-ORIENTEDCAREIN ADULTPSYCHIATRICRESIDENCY

UpdatedOctober 2021

GAPCommitteeontheFamily EllenBerman,AlisonHeru,ChayaninFoongsathaporn,SarahNguyen,JohnRolland, NehaSharma,JohnSargent,JodiZik

Originalcurriculumwrittenby EllenBerman,AlisonHeru,HenryGrunebaum,AllanJosephson, GregMiller,JohnRolland,JohnSargent,GwynCattell

Introduction 2

TrainingGoals 3

FamilyOrientedCareinallTreatmentSettings 4

Milestones 7

FamilySkillsforSite-specificSettings 8

Emergencypsychiatry

InpatientPsychiatry

AddictionPsychiatry

Consultation/ LiaisonPsychiatry

GeriatricPsychiatry

Outpatientclinic/CommunityPsychiatry

ChildandAdolescentPsychiatry

ADULTDidacticCurriculum:

BasicConcepts 15

SystemicPractice

References 22

Appendix 24

Introduction

Utilizationoffamilysystems-basedtechniquesinthediagnosisandcareofpatientsisa keyevidence-basedtoolforpsychiatricdisorders.However,asitisnotacurrentACGME trainingrequirement,itispossibletocompletepsychiatryresidencywithoutexposuretothiskey framework.Here,wehighlighttheimportanceofconsideringpatientsthrougha‘familysystems’ lensandtheincorporationofmultipleindividualsfromanindividualpatient’sidentifiedsystem intheircare.Thisisintendedtobeaguideforprogramstoteachbasicattitudes,knowledge,and skillsinfamilysystems-basedcareasafoundationforresidentstobuildupon.

Currentmedicinecurriculaemphasizepatientautonomy,oneofthecorepillarsofethics. Autonomyisthecornerstoneoftheeverydaypracticewithinmedicineofcommunicatingall risks,benefits,andalternativesofaproposedtreatmenttoapatientmakingdecisionsabout desiredpathsforward.Thispreventspaternalisticcareinwhichthedoctor‘knowsbest’and makesdecisionsforthepatient.Unfortunately,theemphasisofthispillarhasmorphedovertime intotheideathattheindividualpatientisthe only personwithwhomthisinformationshouldbe providedorfromwhominformationshouldbeobtained.Thereisextensiveresearch(Heru2006) thatprovesconclusivelythatfamilysupport,education,andpsychoeducationimproveboth patientandfamilyfunctioninginmedicalandpsychiatricillness.Whenaclinicianfocusessolely ontheidentifiedpatient,theymisstheabilitytoobtainkeyinformationthatmayinfluence diagnosisandtreatmentaswellasoverlooktheopportunitytoutilizethestructureandsupport systemaroundapatienttostrengthentheircareandimprovetreatmentoutcomes.

Thenetworkandfamilydynamicsaroundapatientcanbecriticaltoprovidingaccurate informationonmedicationadherenceandsymptoms,supportingrecovery,andhandling emergencies.Markedlyimprovedpatientoutcomesoccurwhenfamilymembersareseenas alliesandofferedsupport,assessment,andpsychoeducation(Dixonetal,2001,Heru2006).In fact,APAPracticeGuidelinesforschizophrenia(2020),majordepressivedisorder(2010),and bipolardisorder(2002)includetheexpectationthatpatients’familymemberswillbeinvolvedin theassessmentandtreatmentofpatients.Yettraininginhowtoincorporatethesepracticesare oftenminimalornonexistentduringresidency

Afamilysystemsorientationisdistinguishedbyitsviewofthefamilyasatransactional system.Stressfuleventsandproblemsofanindividualmemberaffectthewholefamilyasa functionalunit,withrippleeffectsforallmembersandtheirrelationships. Inturn,thefamily response—howthefamilyhandlesproblems—contributessignificantlytopositiveadaptationor toindividualandrelationaldysfunction. Thus,individualproblemsareassessedandaddressed inthecontextofthefamily,withattentiontosocioeconomicandotherenvironmentalstressors (Rolland&Walsh,inpress).

Afamilysystemsapproachisdistinguishedlessbywhoisintheroomandmorebythe clinician’sattentiontorelationshipsystemsinassessmentandtreatmentplanning. Weneedto considerhowfamilymembersmaycontributeto—andbeaffectedby—problemsituations.Most importantly,regardlessofthesourceofdifficulties,weinvolvekeyfamilymemberswhocan contributetoneededchanges. Interventionsareaimedatmodifyingdysfunctionalpatterns, tappingfamilyresources,andstrengtheningbothindividualandfamilyfunctioning.

Afamilysystemiclensisusefulforworkingwithalltypesoffamilies,e.g.refugeefamilies, thinkingthroughchildadoptionprocesses,workingwithfamilieswithspecificsocial disadvantagesetc.Incorporatingissuesofrace,gender,sexualorientation,etcisimportantinthis workasisworkingwithlargersystemssuchasschools,workplaces,andhealthcaresettings.The expertiseineachtrainingprogramwilldeterminethedepthofspecificareasoffamilyteaching e.g.childpsychiatristshaveagoodgraspofassessingthedevelopingadolescentandthetypical familyscenariosthatmightensue.Someusefulreferencesareincludedbelow

Afamily-orientedapproachfacilitatesperiodicconsultationovertime(e.g.withchronic psychiatricandmedicalillness;Rolland,2018),ofteninrelationtotransitionsinindividual, family,andillnessdevelopment. Afamilysystemiclensallowsphysicianstoincorporatethese considerationsthatcanotherwisegounder-recognized,intotheirdiagnosticandtreatment planning.

Asopposedtopreviousviewpointsthatfamilytherapyistheonly‘family’skilltobe taughtduringresidency,theGAPcommitteeproposesthatpsychiatricresidentsshouldbetrained inskillsoffamilyinclusion,support,andpsychoeducation,andthattheseskillsshouldbetaught throughouttheresidency(GAP,2006,GAP,2008).Ourgoalistohaveresidentsbeableto consideranycasethroughafamilysystemslens,tounderstandhowpatients’illnessesandtheir familysystemshavebidirectionaleffectsoneachother,toperformabasicassessmentoffamily systemfunctioning,andtoutilizethisinformationindiagnosticandtreatmentplanning.The followingisaproposalforasetofattitudes,knowledge,andskillstoconstitutebestpracticein understandingpatientsthroughafamilysystemslensaswellasacurriculumwhichdepartments cancrafttotheirownneeds.

TrainingGoals

Systems-basedthinkingwillenabletraineesto

1.Allywithfamilymemberstoworkwiththepatienttocomplywithgoalsofcare(e.g.take medications,complywithlifestylechanges,maintainsobriety). Teachersfocusonengagement,joiningwithfamilies

2.Helppatientsunderstandtheinfluencesoftheirfamiliesintheirownlives,suchas intergenerationaltransmissionoftraumaandresilience.

Teachersfocusonthecreationofagenogram,andthelocationoftheindividualwithintheir familysystem

3.Understandthatmentalhealthincludesthecreationandmaintenanceofhealthyrelationships.

Teachersfocusonassessingawillingnesstolistentoothers’pointsofviewandtheco-creation ofasharedrealityandbeliefsystem:abeliefthatrelationshipscanchangeovertime,andhowto createnewfamilynarratives.

4.Understandtheimpactofillnessonthefamilyunitandtheimpactofthefamilyunitonillness.

Teachersfocusontheconceptofafamilysystem,clarifyingtheroleswithinthefamily, includingcaregivingresponsibilities.

5.Assessthefamilyforstrengthsandweaknesses.

Teachersfocusonhowfamiliesmaintainahealthyemotionalclimate,allocateroles,decideon rules,problemsolvingabilitiesetc

6.Gatherinformationfrommultipleinformantsinthesameroom

Teachersfocusonutilizingcommunicationtechniques toelicit,guide,andredirectinformation frommultipleindividualsofasystemwithvaryingperspectivesinthesameroom.Teachershelp studentsunderstandthattherearemultiplerealitiesinfamiliesandlearnhowtomaintain multidirectionalpartiality.

Knowledge,Skills,andAttitudesAcrossAllTreatmentSettings

Familyorientedcareandsystemsbasedthinkingachievestheabovetraininggoalsby cultivating:

Knowledge BeginningLevel

Healthyfamilyfunctioningatthevariousphasesofthefamilylifecycle.Systemsconceptsare applicabletofamilies,multidisciplinaryteamsinclinicalsettings,andmedical/government organizations. However,familysystemsaredistinguishedbydeepattachmentbonds,specific generationalhierarchy,goalsofemotionalsafetyand,formanyfamilies,childrearing.

Systemicthinking,unlikealinearcauseandeffectmodel,examinesthefeedbackloopsbywhich multiplepersonsorgroupsarriveataspecificwayoffunctioning. Understandingboundaries, subsystems,andfeedbackloopsiscriticaltounderstandinginterpersonalconnections.

Understandhowthefamilyaffectsandisaffectedbypsychiatricandmedicalillnesses.

Impactofinterpersonalstressonbiologicalsystems.

Theroleofexpressedemotion(EE)inpsychiatricillness. EEdescribesthelevelofcriticism, hostilityandemotionalover-involvementinfamilies. Ithasbeen studiedextensivelyacrossthe healthcarespectrumandculturalvarianceissignificant. Thecomponentsoffamilypsychoeducation,anditsassociatedresearchinimprovingpatientand familyoutcomes.

AdvancedLevel

Principlesofadaptiveandmaladaptiverelationalfunctioninginfamilylifeandfamily organization,communication,problemsolving,andemotionalregulation.

Roleoffamilystrengths,resilience,inreducingvulnerability. Coupleandfamilydevelopmentoverthelifecycle.

Understandingmultigenerationalpatterns.

Howage,gender,class,culture,andspiritualityaffectfamilylife. Thevarietyoffamilyforms(e.g.,singleparent,stepfamilies,same-sexparents)

Specialissuesincouplesandfamilies,including loss,divorceandremarriage,immigration, illness,secrets,affairs,violence,alcoholandsubstanceabuse,sexuality,includingLGBTQi Relationshipoffamiliestolargersystemse.g.,schools,work,healthcaresystems,government agencies.

Skills

Familyinterviewingskills,especiallymanaginghighlevelsofemotionandmakingroomfor multiplepointsofview

Promotingresilience,hopeandstrength.

Basicpsychoeducationtechniques,whichincludesprovidingatherapeuticspaceforemotional processing, providinginformationabouttheillness,skillssuchasbettercommunication, problem-solving,andrelapsedrillandsupport.

Collaborativetreatmentplanningwithfamilymembersandotherhelpingprofessionals.

Treatmentplanningshouldincludeallmembersofthesystem:patient,familymembers,and membersofthetreatmentteam.Goodplanningestablishesaroleforfamilymembers,helps definecriteriaformanagingemergencies,looksforareasofstrengthandresilienceandprovides clearandrealisticgoalsfortreatment.

Knowledgeof,andreferralto,localandnationalresources,bothinthecommunityandonline.

Attitudes

Appreciatethemultiplepointsofviewinafamily.

Interestinfamilymembersaspeoplewiththeirownneedsandhistory. Includingfamilymembersasaresourceinrecovery.

Understandcaregiverburdenandrewardsandthatstressextendstoallfamilymembers.

TrainingTechniques

Inordertocultivatetheappropriateknowledge,skills,andattitudesregardingfamilyand systemsbasedcare,teachersmaywanttoconsider:

Mostlearningtakesplaceatthelevelofpatient,supervisorandresident. Itiscriticalthatthe residentseesfacultymembersdealingwithpatientsinobservedorsharedfamilysessions,and /orseesvideosmadebyfacultyorprofessionallymadevideos. Attitudesarebestlearnedby modeling.

Familyinvolvementmustbeseenasroutineinallsettings.Therefore,residentsshouldbepresent whenafamilyisinterviewedintheemergencyroom,theinpatientunitandanyspecialtyclinic, beginninginPGY1. Whilefacultymaybemostconcernedabouttheacquisitionofknowledge, theresidentsreportthattheirprimaryconcernsinlearningtoworkwithfamiliesare:fearofthe meetinggettingoutofcontrol,alackofunderstanding ofsystemdynamics,anduncertainty abouthowtodealwithmultiplepeoplewithconflictingconcerns. Ourfirstgoalistoreducethe residents'anxietyenoughtoincreasetheirwillingnesstospendtimewithfamiliesandlearnfrom thatexperience. Particularlyatthebeginningoftraining,asupervisororexperiencedstaff personshouldbepresentintheroomtomodelhowtomanageafamilythatisdisorganizedand frightened.However,competencyrequireshands-onsupervisedskilldevelopmentinadditionto adidacticcurriculum.

Intheoutpatientclinic,familyinterviewsshouldincludevideooraudiosupervision,orshared workwithafamilytherapist.Residentsareparticularlylikelytolearnhowfamiliescopeand howtheycanlearnnewskills,byattendingfamilypsychoeducationgroups.

Areasoffocuscanincludetimemanagementandaddressingthefearthatfamilysessionsmay getoutofcontrol. Theinfluenceoftheresidents’ownlifeexperiencesandbackground includingpotentialgenerationalorculturaldifferencesontheirassessmentandinteractionswith patientfamilydynamics.Inskilldevelopment,ourgoalisefficientinterviewing,historytaking, andsupportincontrollingsessions.

Itisdifficulttospecifywhichtechniquesaremostusefulindidacticsessionsaseachpresenter willhaveadifferentskillsetforengagingtheclass.Thetechniquesthatworkbestaretheones mostcomfortabletothepresenter.Anytechniquethatgetsemotionsinvolved,suchasroleplay, sculpting,discussingmovieclips,bringinginfamilymemberstodiscusstheirexperiences,or self-exploration,willgeneratethemostpowerfullearning.Iftimepermits,explorationofthe resident'sownfamily,includingagenogram,isanexceptionallyhelpfultechnique,especiallyif accompaniedbyaskingtheresidentstointerviewtheirownfamilies.

Familiesaresubsystemsofculture,communityandorganizations,thereforewerecommendthat familyandculturebetaughtconcurrentlywithcrossoverbetweenclasses. Classesingroupor

organizationalissuescanalsobetaughtincollaborationtoprovideaconsistentsystems approach.

Milestones: Togaugearesident’sperformanceandguideresidentevaluation

Level1.

Arrangestomeetfamiliesandestablishesanalliance. Obtainscollateralinformationaboutthepatient'sillness. Issupportiveandcollaborativeinthefaceofmultiplepointsofviewandhighlevelsofemotion. Includesfamilyintreatment,dischargeandfollow-upplanning. Encouragesfamilymemberstoseekcommunityresourcesandprovidesinformation.

Level2.

Obtainsathreegenerationgenogramandfamilytimeline. Providesfamilywithinformationregardingtheirdevelopmentalstage,andnormativefamily issues.

Inquiresappropriatelyaboutcultural/racial/ethnicissuesimpactingillnessandtreatment. Understandsandsupportsfamiliesofvariedstructureandcomposition. Providesbasicpsychoeducation.

Recognizesandpromotesresilience,hopeandstrength.

Recognizeswhenfamilytherapyisindicatedandrefersappropriately

Level3.

Assessafamilyanddevelopasystemicformulation. Interveneinsimpleproblemssuchascommunicationdifficulties,settinglimitsandproblem solving.

Managesanddiscussesconfidentialityinoutpatientsettingsallowingfamilyinclusionin treatmentplanning.

Workswithothertherapistsandsystemsinvolvingthepatient(school,childwelfare,etc.). Identifieshowsystemicissuesplayoutinsettingssuchashealthcare,schoolandmilitary systems.

Level4.

Recognizesandtreats(orrefersappropriately)issuesthatneedspecializedinterventione.g. chronicmedicalillness,sexuality/genderissues,familyviolence,addictionetc.

Assessesandtreatscouplesandadultfamilieswhopresentwithsystemicissuesratherthan psychiatricillness.

Recognizesandmanageshis/herownfeelingsandattitudesaboutfamiliesandcoupleswhose structureandattitudesarewidelydifferentthantheirown.

Level5.

Describesdifferingschoolsoffamilytherapyandchoosetechniquesappropriatetothefamily's needs.

Identifyandassesstheimpactofstructuralracismanddiscriminationasitimpactsfamily functioning

Obtainsmasteryandcomfortconductingcouplesandfamilytherapyinawidevarietyof situations.

SiteSpecificTraining

Eachtrainingsitelendsitselftoteachingandreinforcinganarrayoffamily-oriented systems-basedskills.

EMERGENCYPSYCHIATRY

KNOWLEDGE:

Understandinghowtoincludefamilyandfriendswhenpatientspresentwithemergencies.

SKILLS:

Patientsmaybetoodistressedtogiveanaccuratehistory.Familymembersmayhavecritical informationtooffer,andareusuallyinvolvedintheemergenceofthecrisis.Residentscan developskillsinhistorytakinganddevelopingafamilyallianceatmomentsofstress.Reachout tofamilymembersandcaregivers,evenbyphoneorvirtually(egZoomorothertele-health platform).

Assessthefamilydevelopmentalstagebecausepatientsoftenpresentwhenthefamilyisina developmentaltransition.

Involvefamilyintreatmentplanning:Canthefamilyensurethesafetyofthepatientandothers athome? Reviewsymptomsthatwouldindicaterenewedemergency.

Includefamilyintreatmentdecision-making.Ifthefamilysupportsthetreatmentplan,the patientismorelikelytofollowthrough. Educatefamilyaboutresourcesoutsidethehospital.

Supervisortasks: Bepresentandmodelinteractionswithdistraughtfamilies.Demonstratehow todevelopboundariesandsetlimitswhentimeisshort.Acknowledgedifficultiesofworkingin acrisismode.

ATTITUDES:

Compassionforthedifficultiesofhavingafamilymemberadmittedtoapsychiatricinpatient facility,oftenagainsttheirwill,andhowthisimpactsfamilyrelationships.

Respectforthestrugglesofafamilylivingwithandsupportingamemberwithchronicmental illness.

Appreciateandvalidatetheemotionalreactionsoffamilymembers,suchasanxiety,angerand withdrawal,tothepatient’sillnessandhospitalization.

Takeintoconsiderationthefamily’sconcernsabouttoo-earlydischargeorinadequatefollow-up plans,caregivingandfurtheremergencycare.

SuggestedReading: NguyenS.A.,HeruA.M.,Combrink-GrahamL.(2019). TheFamilyinPsychiatricEmergencies: AnAcrosstheLifespanApproach.InGlickRL,Berlin.JS,FishkindAB,andZellerSL(Eds.), EmergencyPsychiatry:PrinciplesandPractice,2nd edition. Philadelphia,PA:Lippincott, Williams&Wilkins. https://www.amazon.com/Emergency-Psychiatry-Rachel-Lipson-Glick/dp/1975113683

PSYCHIATRICINPATIENTUNIT

KNOWLEDGE:

Beabletoexplaintofamiliestherelationshipbetweenfamilyfunctioningandillness.

SKILLS:

Conductafamilyinterviewwiththepatientpresent,regardlessoftheirdiagnosis,aswellas meetingwiththefamilyprivately,ifindicated.

Providefamilypsychoeducationduringthehospitalization. Explainhowfamilyinclusioninfollow-uptreatmentstabilizespatients. Answeringtheirquestionsaboutcaregivingandproblem-solvehowtomanageemergency situationswhentheyarise.

Providefamilywithresources:discusssocialsupport,respite,andself-care,andaboutfamily supportorganizationssuchasNationalAssociationfortheMentallyIll(NAMI),Depression BipolarSupportAlliance(DBSA),andotheronlineresources.

SupervisorTasks. Modelhowtomanageafamilymeeting,includingorientationtothepurpose ofthemeeting,managementofaffectduringthemeeting,andendingthemeetingontime.

ATTITUDES:

Compassionforthedifficultiesofhavingafamilymemberadmittedtoapsychiatricinpatient facility,oftenagainsttheirwillandhowthisaffectsfamilyrelationships.

Respectforthestrugglesoffamilieslivingwith&supportingamemberwithchronicmental illness.

Appreciationforandvalidationoftheemotionalreactionsoffamilymemberstothepatient’s illnessandhospitalization.

Listeningtothefamily’sconcernsandtakingthemintoconsideration,particularlyaround concernsofdischargeandtransitionsbackhomeornextlevelofcare.

SuggestedReadings: HeruA,DruryL.(2007)WorkingwithFamiliesofPsychiatricInpatients.J.HopkinsUniv. Press.

Heru,A.M.,Drury,L.OvercomingBarriersinWorkingWithFamilies. Acad Psychiatry 30, 379–384(2006).https://doi.org/10.1176/appi.ap.30.5.379

SUBSTANCEUSEDISORDERS(SUD)

SUDtreatment,especiallymedication-assistedtreatments(MAT),requiresaspecialized treatmentteamandmayrequiremultipletypesoftreatment(individual,group,AlAnon,inpatient detox,etc). Familypsychoeducationandperhapsfamilytherapy,areanimportantpartof treatment.

KNOWLEDGE:

UnderstandingthatSUDsarecommonlyco-occurringconditionswithotherpsychiatricdisorders includingdepression,anxiety,andbipolardisorder

ParentswithSUDsmayneglecttheirchildren,soassessmentofthefamilyiscrucial. UnderstandhowSUDscanaffectfamilyfunctioningandwhattypesoffamilytreatmentaremost effective.

SupervisorTasks: HelptheresidentexaminetheirownfeelingsaboutSUDs. Demonstrate collaborationwithotherteammembers.Supportresidentdecision-makingregardingthechoice ofpsychoeducation,familytherapy,orsupportingfamilymembersintheabsenceoftheperson withSUD.

SKILLS:

Takinga3or4generationgenogramforSUDSandotherpsychiatricdisorders.Attentionto geneticsandvigilanceaboutothertypesofaddictioninfamilymembers. Assessmentoffamilyperspectiveonsubstanceuse. UnderstandingtheroleofSUDSinthefamily. Psychoeducation.FamiliesneedguidelinesabouthowtomanageSUDSinthefamilyandstrong encouragementtoattendAl-Anon,Nar-Anon,etc.

ATTITUDES:

Anopenandnon-blamingapproach

UnderstandingfamilynarrativesofSUDS

Willingnessforcollaborationwithallteammembers

SuggestedReadings: Hudak J,KrestanJA,BepkoC.Alcoholproblemsandthefamilylifecycle,inTheExpandedFamily LifeCycle,3rded.EditedbyCarterB,McGoldrickM.NewYork,Allyn&Bacon,1999.

Almanza-AvendañoAM,RomeroMM,Gomez-SanLAH.IDidn'tSeeItasaProblem,IThought ItWasGoingtoBeTakenAway:NarrativesFromFamilyMembersofUsersinRehab.Frontiers inPsychiatry,2021,12:1404 https://www.frontiersin.org/articles/10.3389/fpsyt.2021.649961/

O’FarrellTJ,Fals-StewartW.Behavioralcouplesandfamilytherapyforsubstanceabusers. Curr Psychiatry Rep,2002;4:371–376 DOI:10.1007/s11920-002-0085-7

CONSULTATION/LIAISONPSYCHIATRY

KNOWLEDGE:

Understandhowacute,chronic,andterminalmedicalillnesscanaffectfamilyfunctioningand viceversa.

Understandhowpatientandfamilydynamicsandneedsmayresultinconflictincareteams,or betweenfamiliesandcareteams.

SKILLS:

Useknowledgeofsystemstomanagestaffandfamilyconflicts. Assessmentoftheimpactofchronicillnessonthefamily,includingrolechange,changeto familyroutines,andemotionalneedssuchasguilt,shame,helplessness,andthereactivationof oldfamilyconflictsaroundillnessdecision-making.

Helpthefamilyunderstandtheillnessinlongitudinalanddevelopmentalterms. Facilitatecommunicationaroundillness,treatment-relatedissues,andmedicaldecision-making. Conflictamongfamilymembers,orbetweencareteamsandfamilymembers,aroundmajor proceduresanddeathanddyingissues,areparticularlystressful.

Understandtheculturalandspiritualbeliefsthatguidethefamily.

Consultwithfamilymembersnearthetimeofinitialdiagnosisandatmajornodalpointsduring thecourseoftheillness(e.g.,re-hospitalization,recurrence,orprogressionoftheillness,transfer torehabilitationorhospice).

Assessforcaregiverburden/depressionandmanageappropriately.Lookforandsupport resilience.

Supervisiontasks: Encouragetheresidenttomeetwithpatientsattimeswhenthefamilymay bepresent.Modelwaystohandleissuesarounddeathanddying,includingfamilyemotionsand potentialconflict.

ATTITUDES:

Respectthedifficultyofafamilybalancingmedicalreasonforadmissionandpsychiatriccause forconsultation

Respectforthestrugglesofafamilynavigatingconsequencesofmedicalcrisisinshortandlong term

Appreciateandvalidateavarietyofemotionalandbehavioralreactionsoffamilymembersto thesecrisesandutilizeskillstocontinuecommunication

Takeintoaccounttheroleoffamilycanplayinresilienceandcaregivingaswellasstress

Utilizefamilymembersasaresourcetobetterunderstandapatient’senvironmentoutsideofthe hospital

SuggestedReadings:RollandJS:Families,IllnessandDisability:AnIntegrativeTreatment Model.NewYork,BasicBooks,2020.

HeruAM,ImprovingMaritalQualityinWomenwithMedicalIllness:Integrationof Evidence-basedProgramsintoClinicalPractice.J.ofPsychiatricPractice,16:297–305,2010. DOI:10.1097/01.pra.0000388625.91039.ea

HeruAM.WorkingwithFamilieswithMedicalIllnesses.Routledge,2013.ISBN 9780415656481Ebook:https://www.routledge.com/cart

GERIATRICPSYCHIATRY(InpatientandOutpatient)

Changesinphysicalandmentalstatusoftennecessitateeventualreorganizationofliving situation,treatmentprocessesandgoals. Workingwithfamiliesorcaregiversisessentialand necessarywhenworkingwitholderadults. Caregiverscanbeotherfamilymembers:partners whoareoftenagingthemselves;childrenwhoareusuallygrownandhaveotherresponsibilities; othercaretakerswhoarehiredforthejob.

KNOWLEDGE:

Understandchangingfamilyrelationships:familylifecyclesandtransitions;relationalethics; familystories,lifereviewandattachment.

Applysystemicideasineverydayworkwithinmultidisciplinaryteamsandsystemicconsultation tocarehomestounderstandthebiomedicalapproachtofamilycaregivingandsystemic perspectivesindementiacare.

Acknowledgedemographictrends;culturalcontext;rolesandrelationshipsinlaterlifeto understandthecontextofcaregivingandserviceprovisionforolderadults

SKILLS:

Identifymulti-generationalandculturaldifferencesthatinfluencethecurrentcircumstancesand presentingproblems.

Identifyrolechangesandshiftsinrelationshipsastheyrelatetoincreasedphysicalneedsand physicalandcognitivedecline.

Providepsychoeducationonlifetransitions,dementiacare,caregiverstress,andendoflifecare thatcanincludesupportfromorganizationssuchasAlzheimer’sAssociationandotherlocal supportgroups.

SupervisorTasks:

Demonstratecollaborationandmulti-disciplinaryapproachtosupportdecision-makingfor medicallyandpsychiatricallycomplexolderadults. Helpresidentsincludefamilymembersand caregiversaspartofroutineassessmentandplanofcare,includingendoflifecareissuesthat mayarise.

ATTITUDES:

Residentsshouldappreciatemulti-generationalandculturaldifferencesthatmayinfluence approachestotreatmentinthecareofolderadultsandtheircaregivers. Residentsshould continuetorespectpatientautonomyanddignitywhilecontinuingtoincludecaregiversandtheir familiesintreatmentplanningandappreciatehowchangesandtransitionsinroleswithinthe familyaffectthecurrentcircumstances.

SuggestedReading: Rolland,J.S.(2018). Helping couples and families navigate illness and disability: An integrated approach.NewYork:GuilfordPress.

HeruAM.ImprovingMaritalQualityinWomenwithMedicalIllness:Integrationof Evidence-basedProgramsintoClinicalPractice.J.ofPsychiatricPractice,16:297–305,2010. DOI:10.1097/01.pra.0000388625.91039.ea

HeruAM. WorkingwithFamilieswithMedicalIllnesses.Routledge,2013.ISBN 9780415656481Ebook:https://www.routledge.com/cart https://www.caregiver.org/resource/caregivers-guide-understanding-dementia-behaviors/

OUTPATIENTANDCOMMUNITYPSYCHIATRY (PGY3and4YEARS)

KNOWLEDGE:

Recognizetheeffectofchronicillnessburdenonthefamilyandthefamilyontheillness. Understandwhatintimacyisandhowtodiscussthevariousaspectswithpatientsandfamilies

Beabletousearelationalapproachevenifonlyonepersonispresent

Understandwhentoconsideranindividualneedstosetboundarieswithfamilymembersversus whenthefamilydynamicsneedtoshifttoallowrelationalchange.

Understandthedifferencebetweenfamilypsychoeducationandfamilytherapyandwheneachis indicated.

Understandingtheeffectsofparentalillnessonthechildren,andidentifyresourcesforthe parentsandchildren.

SKILLS:

Partnerwiththepatienttosupportfamilyinvolvement,anddetermininganagenda Beabletodiscusswiththepatientthebenefitsofeitheranindividualshiftorarelationalshift withfamily

Developatreatmentplanwiththepatientandfamily.Thisincludeseducationaboutthecourseof theillness,theroleandsideeffectsofmedication,anagreementaboutwhatconstitutesarelapse orcrisis,whenthephysicianorhospitalshouldbecontacted,andwhetherornotthefamilyhasa roleinmedicationmonitoring.Withimpairedyoungadultslivingathome,reachagreement aboutfamilyrules(structureofthepatient’sday,alcohol,ordruguse,andfinances).

Supportfamilieswhoseillmembersrefusetreatment.

Understandandnormalizelifetransitions:falloutfromdivorce,death,chronicillness. Assessanddevelopfamilyresilience. Assessneedsoffamilymembersoftheidentifiedpatient,suchaschildrenorspouse. Assessandtreatfamiliesenteringthesystemascouplesorfamilygroups,usingan evidence-basedmodel.

SupervisorTasks: Firstmodel,thensuperviseresidents’inafamilyassessmentandtreatment modelwhichincorporatesafamilylens.

ATTITUDES:

Residentsshouldnotacceptthepatient’sfirst"no"toafamilymeetingasafinaldecision.Inthe samewaythatonewouldnotaccepta"no"tomedicationswithoutcontinueddiscussion,the residentwithapatientinseriousdistressorwitharelationalproblemmustfeelconfidentin workingwiththefamilyconnectionaspartoftreatment.

CHILDANDADOLESCENTPSYCHIATRY(InpatientandOutpatient)

Thechildandadolescentpsychiatryrotationisanexcellentsitewithinwhichtolearnfamily skills. Inthesesettingstheworktendstobechild-centered,andtheresidentmustbeencouraged tothinkoftheparentsasindividualsintheirownrightandwiththeirownhistories,ratherthan seeingthemonlyasparents.Parentingissuesareheavilydeterminedbytheparent’sownrearing.

KNOWLEDGE:

Howchilddevelopmentandpsychopathologyissituatedwithinfamiliesandfamilyriskand resilience,andtheimpactoffamilyinteractionsuponbothdevelopmentandpsychopathology.

SKILLS:

Familyinterviewingiscentraltolearningfromachildandfamilyaboutthepresentingproblems andshouldberefinedinthisrotation.Managingboundariessothattheparentretainsauthority, whiletakingthechild’sconcernsseriously, isamajorissueininterviewingwithminorchildren. Hearingfromallfamilymembers,includingallthechildreninthefamily,andvaluingdiffering perspectives.

Assessingfamilyinteractionsespeciallyinrelationtothechildpatient. Dealingwithfamilyconflict,recognizingandreconcilingdiverginggoalsthataparentandchild mayhave,andcreatingaframeforfamilyengagement.

Assistingfamiliesinnavigatingnormativetransitionsintheirchild’sandfamily’slife.

SupervisorTasks: Modeltheuseofsystems-basedevaluationofstrengthsandchallengesinthe assessmentofchildren.Thisshouldbemodifiedfordevelopmentalstagesofthechildand family.Includeanunderstandingofthelegalrequirementsofcaregiverinvolvement.Discuss howtocreateatreatmentmodelthatincorporatesthseinthechild’secosystemsuchasthe child’sfamily,extendedsupportnetworks,andschool.

ATTITUDES:

Residentsshoulddeveloprespectforandcompassionforbothchildrenwithmentalhealth challengesandalsofortheirparents,andcompassionfortheparentswhoaredealingwitha strugglingandoftendifficultchild.Residentsshouldalsodeveloprespectforthediversityof familiesandnormalchild-rearingpatterns,andtheinfluenceofcultureandethnicityonfamily life.

SuggestedReadings:

Sargent,J.(2009).FamilyTherapy.InKaplan&Sadock’sComprehensiveTextbookof Psychiatry,9thEdition.Philadelphia:LippincottWilliamsandWilkens.

Josephson,A.(2008).Reinventingfamilytherapy:teachingfamilyinterventionasanew treatmentmodality.AcademicPsychiatry32(5):405-13

ADULTDIDACTICCURRICULUM

Thecurriculumisknowledge-basedandrepresentsbasicconcepts.Wehavevignettesbythe authors,ifneeded,butitisbestiftheclass,includingthesupervisor,usesvignettesfromtheir ownexperiences.Materialforuseinclassisinreferences,buttheclassisurgedtodrawontheir ownexperiencesasthissupportsstrength-basedteaching.Thefollowingarekeytopicsand conceptsforeachofthetrainingyears.

BASICCONCEPTSFORPGY1AND2

1. Whereareyouinthefamilyandindividuallifecycles?Whatareyourexperienceswith psychiatricillnessinfamily/friends? Opendiscussionabouthowindividualandfamily lifecyclesinteract.Drawgenogramsofs/ointheclassorthesupervisor.

McGoldricketal.PerspectivesontheEvolvingFamilyLifeCycleinTheExpandedFamily LifeCycle4thed.,AllynBacon,2011

McGoldricketal. GenogramsAssessmentandTreatment.4thed.,Norton,2020

LibbonR,TrianaJ,HeruA,BermanE. FamilySkillsfortheResidentToolbox:the10-min Genogram,Ecomap,andPrescribingHomework.AcadPsychiatry,2019;43(4):435-439.doi: 10.1007/s40596-019-01054-6.Epub2019Mar23.

2. Healthyfamilyfunctioningandfamilyresilience.Recommendaskingresidentstotalkto theirparents/elders,abouttheirlivesandfamilylifecycle,whentheywereyourage. Opendiscussionaboutwhatmakesahealthyresilientfamily

3. HowdoIconnectwiththefamilyratherthanjustoneperson?Howdoyoulearntohold multipleperspectives?HowdoItrynottotakesides/multidirectionalpartiality?Howdo Iseeeachpersoninapositiveway?HowdoIfocusonfamilystrengths, ratherthan focusingonsomeonebehavingbadly(whichisreallyhardbecauseitisoverlearnedin individualtherapy).

4. Whatarethecommonfactorsusedacrossalltherapies,bothindividualandfamily.When touseindividualrelationalapproachversusfamilysystemicapproach.

Laska,KevinM;Gurman,AlanS;Wampold,BruceE(December2014)."Expandingthelensof evidence-basedpracticeinpsychotherapy:acommonfactorsperspective".Psychotherapy: Theory,Research,Practice,Training.51(4):467–481.doi:10.1037/a0034332

Frank,JeromeD;Frank,Julia(1991)[1961].Persuasionandhealing:acomparativestudyof psychotherapy(3rded.).Baltimore:JohnsHopkinsUniversityPress.

WeissmanMM,MarkowitzJC,KlermanGL. The Guide to Interpersonal Psychotherapy. Oxford:OxfordUniversityPress;2018.

5. HowdoIdecideifafamilyneedssupportoreducationorfamilytherapy?

Libbonetal.ColoradoJournalofPsychiatryandPsychology(inpress)

HeruAM. Family-centeredCareintheOutpatientGeneralPsychiatryClinic. JPsychiatrPract.2015Sep;21(5):381-8.doi:10.1097/PRA.0000000000000097.PMID: 26352224

6. Psychoeducation:Research,currentuseandculturaladaptations

McFarlaneWR.FamilyInterventionsforSchizophreniaandthePsychoses:AReview.Fam Process.2016Sep;55(3):460-82.doi:10.1111/famp.12235.

LópezSR,GamezD,MejiaY,CalderonV,LopezD,UllmanJB,KopelowiczA. Psychosis LiteracyAmongLatinosWithFirst-EpisodePsychosisandTheirCaregivers. PsychiatrServ. 2018Nov1;69(11):1153-1159.doi:10.1176/appi.ps.201700400.

SAFEProgramVA: https://www.ouhsc.edu/safeprogram/ NAMI:https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Family-to-Fa mily

7. Attachmentstylesandcouplestherapy:Emotionfocusedtherapy,JohnGottmanandthe evidencebaseforcouplestherapy

WiebeSA,Johnson,SM.AReviewoftheResearchinEmotionallyFocusedTherapyfor Couples,FamilyProcess2016;55,3:390–407.

8. Whatistheevidencebasebehindourwork?

HeruAM. Familypsychiatry:fromresearchtopractice. AmJPsychiatry,2006;163(6):962-8 doi:10.1176/ajp.2006.163.6.962.

SharmaN&SargentJ.OverviewoftheEvidence-BaseforFamilyInterventionsinChild Psychiatry.ChildAdolescPsychiatrClinNAm:FamilyBasedTreatmentinChildand AdolescentPsychiatry.2015;24:3:471-485.https://DOI:10.1016/j.chc.2015.02.011

SYSTEMICPRACTICEFORPGY3AND4

Theseseminarsfollowthebasicseminars.Thefocusisonclarificationofwhatsystemsthinking means.Systemsthinkingorrelationalthinkingistobedifferentiatedfromsystems-based practice. Theselecturesrequireknowledgeofsystemicpractice.Iftherearenolocalexperts, residencyprogramscanreachouttonationalexpertsattheAssociationofFamilyPsychiatrists, anaffiliatedAPAorganization,forhelpwithvirtual/remoteorinpersonteaching.

1. RelationalFormulation,nestedsubsystems,boundaries,historyoftheseconcepts, contributionstothedevelopmentoffamilytherapy(seeTableonVarietiesofFamily Therapies).

2. Howtodefineandidentifycommonsystemsconceptssuchascircularpatterns,feedback loops,triangulation.Teachcircularquestioning.

3. Framing.Thisconceptisthefamilysystemsequivalentofinsight. Howtointerveneto effectcommunicationchangeandbehaviorchange

4. Workingatinterfaces:community,legal,government,agenciesetcothertreaters, consultation.Includesystemicandindividualracism

5. Understandingthecomplexityofintimacy

6. Emergencysituations.Whentoreportregardingabuse.Dealingwithfamilytrauma. Heru,A.(2007).Intimatepartnerviolence:Treatingabuserandabused.Advancesin PsychiatricTreatment,13(5),376-383.doi:10.1192/apt.bp.107.003749

Varietiesoffamilytherapy

Psychodynamic AssumptionsandMajorConcepts

Familyrelationshipsarebasedonpreviousparent–childrelationshipsofeachparent. Difficultiesarisefromdevelopmentalarrest,currentinteractionsandprojections,andcurrent stressors.

Improvementsdevelopthroughtheprocessoffamilymembersgaininginsightinto problematicrelationshipsfromthepast.

Therapyconsistsinsharedexplorationofpastrelationshipsandcurrentdistortionsandrole confusions.

Therapyalsoencouragesthedevelopmentofmutualappreciationoftheneedsandlimitsof familymembers.

MajorTheoreticiansandPractitioners

NathanAckerman

JamesFramo

IvanBoszamenyi-Nagy

Experiential/Existential

AssumptionsandMajorConcepts

Thefamilyisadevelopingorganism,andthegoaloftherapyistoencouragethegrowthof thefamilyanditsmembersthroughtheprocessoftherapy

Thisprocessisbestsupportedbyencouragingexpressiveness,openness,andcommunication withinthefamilythroughoutthetherapeuticencounter

Thefamilyisresponsibleforitssolutions;thetherapistisafacilitatorwhoencourages growthandconfrontsstagnation.

MajorTheoreticiansandPractitioners

CarlWhitaker

VirginiaSatir

Intergenerational/Bowenian

AssumptionsandMajorConcepts

Thefamilyisanemotionalrelationshipsystem,withthegoalofrelationshipstopromote engagement,fosterdifferentiation,andavoidfusion.

Inconflictualsituations,engagingathirdparty(triangulation)stabilizesthefamilysystem.

Individualsmarrypartnersatthesamelevelofdifferentiation,leading,atlowlevelsof differentiationinmarriedcouples,toseverepersonalandrelationshipdifficulties.

Therapyisaimedatclarifyingcurrentrelationships,promotingindividuation,resolving currentconflictualinteractions,andworkingthroughintergenerationalandintrojected difficultiesandpatternsofbehavior.

MajorTheoreticianandPractitioner MurrayBowen

Structural AssumptionsandMajorConcepts

Focusedoncurrentorganizationofthefamilyasdemonstratedthroughrepeatedpatternsof interaction.

Particularlyattentivetohowthefamily'sorganizationpromotesorinhibitstaskperformance, especiallychildrearing.

Analysisofinteractionsallowsthetherapisttodeterminethenature(distancevs.closeness) andtheflexibilityoffamilyrelationshipsinrelationtotaskperformance.

Thetherapistpromotesinteractionsinsessionstodeterminefamilyrelationshipsandthen intervenesinthoseinteractionstointroducegreaterflexibility,alternativepatternsand structures,andmoreeffectivetaskperformance. Enmeshment(ineffectivecloseness)anddisengagement(excessivedistance),aswellas rapidfluctuationsbetweenextremes,aremanifestationsofdysfunctionalfamily relationshipswhenassociatedwithsignificantsymptomsinafamilymember.

Thisformoffamilytherapywasdevelopedtorespondtochildandadolescentemotionaland behavioralproblemsandisparticularlyeffectiveinthosesituations.

Thetherapistisboththedirectoroftherapeuticactionandparticipantintheprocessof therapy

MajorTheoreticianandPractitioner SalvadorMinuchin

Systemic/Strategic AssumptionsandMajorConcepts

Symptomaticbehaviorisembeddedwithinthepatternsofcommunicationandrelationships inafamily

Ineffectiveattemptsatsolutionstoproblematicbehaviorbecomepartofthepatternalsoand thuspartoftheproblem.

Thetherapistisresponsiblefordevelopingandprescribingtasksandbehaviorsthatdisrupt usualpatternsofinteractionwhilestrengtheningother,moreproductivepatterns.

Thetherapistmaintainsastanceofneutralityanddistancewithrespecttothefamilyas wholeandindividualmembers.

Specificmethodsofquestioningdesignedtoelicitinformationaboutfamilyrelationships (circularquestioning)areused;posinghypotheses,reframing,externalizingblame,andthe useofpositiveconnotationarecommontechniques.

MajorTheoreticiansandPractitioners

JayHaley

CloéMadanes

MaraSelvini-Palazzoliandcolleagues(Milangroup)

Cognitive-behavioral

AssumptionsandMajorConcepts

Conceptsoflearningtheory—conditionalcontingency,reinforcement,extinction—explain problematicbehaviorandidentifytherapeuticinterventions.

Sessionsareentirelyproblem-andsolution-focusedinthepresent.

Skillstrainingisemphasizedthroughouttreatment;homework,recordkeeping,and between-sessionstasksareusedregularly

Therapyisaimedatchangingbothcognitionsandbehaviorandusesnewcognitionsamong familymemberstodirectandevaluatebehaviors.

Particularlyusefulformanagingmildtomoderatedisruptivebehaviorsinchildrenand adolescents,focusingtreatmentonparentskillstraining.

MajorTheoreticiansandPractitioners

GeraldPatterson

JamesAlexander

Referenceshavebeencitedthroughoutastheypertaintoeachsection. Thefollowingare additionalgeneralreferences:

TheAmericanPsychiatricAssociationPracticeGuidelinefortheTreatmentofPatients WithSchizophrenia,ThirdEdition:https://doi.org/10.1176/appi.books.9780890424841

APAMajorDepressiveDisorderTreatmentGuidelines: https://psychiatryonline.org/guidelines

APABipolarDisorderTreatmentGuidelines:https://psychiatryonline.org/guidelines

BermanEM,HeruAM,GrunebaumH,RollandJ,WoodB,BrutyH;Groupforthe AdvancementofPsychiatryCommitteeontheFamily.Familyskillsforgeneralpsychiatry

residents:meetingACGMEcorecompetencyrequirements. AcadPsychiatry.2006 Jan-Feb;30(1):69-78.doi:10.1176/appi.ap.30.1.69.PMID:16473998

KeitnerGI,HeruAM&GlickID.ClinicalManualofCouplesandFamilyTherapy,AAPI, Washington,2009 (ebook)$8ISBN-13:9781585622900emailsupport@ebooksgift.com.

HeruAM.WorkingwithFamilieswithMedicalIllnesses.Routledge,2013.ISBN 9780415656481Ebook:https://www.routledge.com/cart

NguyenS.A.,HeruA.M.,Combrink-GrahamL.(2019). TheFamilyinPsychiatricEmergencies: AnAcrosstheLifespanApproach.InGlickRL,Berlin.JS,FishkindAB,andZellerSL(Eds.), EmergencyPsychiatry:PrinciplesandPractice,2nd edition. Philadelphia,PA:Lippincott, Williams&Wilkins. https://www.amazon.com/Emergency-Psychiatry-Rachel-Lipson-Glick/dp/1975113683

NguyenS.A.andHeruA.M. Family-CenteredCareinPublicSectorSettings.InSowersS., McQuistionH.,FeldmanJM,RanzJ,RunnelsP.(Eds.),TextbookofCommunityPsychiatry,2nd edition,inpress,

WalshF ApplyingaFamilyResilienceFrameworkinTraining,Practice,andResearch: MasteringtheArtofthePossible. FamProcess.2016Dec;55(4):616-632.doi: 10.1111/famp.12260.

WalshF.Traumaticlossandmajordisasters:strengthening familyandcommunityresilience. FamProcess.2007Jun;46(2):207-27.doi:10.1111/j.1545-5300.2007.00205.x.PMID:17593886 Review.

APPENDIX

Pleaseuseanyofthesecasesforteaching.Permissionwasgrantedforpublication.

ThecaseexamplesadopttheMcMasterApproachtoFamilyAssessment (Epsteinetal1983). Thismodelusessixdimensionsoffamilyfunctioningtoguideassessmentandtreatmentand has acomprehensive,timeefficientwaytoevaluatestrengthsandweaknessesinfamilyfunctioning.

1. ProblemSolving:abilitytoresolveproblemsatalevelthatmaintainseffective familyfunctioning.

2. Communication:exchangeofinformationamongfamilymembers.

3. Roles:establishedpatternsofbehaviorforhandlingfamilyfunctions,including provisionofresources,support,personaldevelopment.

4. AffectiveResponsiveness:extenttowhichindividualfamilymembersexperience appropriateaffectandemotions.

5. AffectiveInvolvement:extenttowhichfamilymembersareinterestedinand placevalueoneachother’sactivitiesandconcerns. Ahealthyfamilyhasanintermediate levelofinvolvement,neithertoolittleortoomuch.

6. BehavioralControl:howafamilyexpressesandmaintainsstandardsforthe behaviorofitsmembers. Examplesincludepatternsofcontrol(flexible,rigid,chaotic, etc).

CaseExample#1

Ms.Smithisa23yosingle,Caucasianfemalewhopresentstoestablishcareaftermovingtoa newarea.ShehasapastmedicalhistoryofchronicLymedisease,fibromyalgia,irritablebowel disease,chronicpainpreviouslyonhighdoseopioidsandpastpsychiatrichistoryofmany hospitalizationsandsuicideattempts,depressionwithchronicsuicidalideation,anxiety,anorexia nervosa,opioidandbenzodiazepinedependenceinfullsustainedremission. Hermother completedsuicidebyoverdosetwoyearsagoandherfatherhasbeenabsentfromherlifesince hermother’sdeathduetohisextensivedruguseandinabilitytocopewithhisownfeelingsof griefandloss. Ms.Smithisanonlychild. Shehasremainedsoberfromsubstancesfortwo yearsaftercompletingninemonthsofresidentialtreatmentandongoingconnectionwith AlcoholicsAnonymous(AA). Sinceattainingsobriety,herchronicsuicidalideationpersisted butshehashadnosuicideattempts. Hertreatmentteamconsistsofherprimarycaredoctor (eatingdisordersspecialist),psychiatrist,DBTtherapist,eatingdisordersprogramtherapist, dietician,andsupportnetworkincludingAAandherAAsponsor. Eachclinicianwasfocusing onasingleproblem:herPCP,dietician,andeatingdisorderstherapistwerefocusedonhereating disorder;herDBTtherapistandpsychiatristwerefocusedonherchronicsuicidalideationand feelingsofabandonmentaswellasmaintenanceofhersobriety;herAAsponsorwashelpingher maintainhersobriety

Family Assessment with Ms. Smith, her psychiatrist, primary care doctor (PCP), DBT therapist, eating disorders program therapist, dietician, and AA sponsor

HerpsychiatristscheduledaonehourmeetingwithherPCP,therapists,dietician,andsponsorto developatreatmentplanforMs.Smith.Thefirststepistoclarifyeachperson’sunderstandingof herpresentingproblems. Eachclinicianprovidesappropriateandeffectiveinterventionsthatare incorporatedintoaunifiedtreatmentplan,utilizingtheMcMasterModel

Problem Solving

Despitetheinstabilityinherfamilylifeandhousingsituation,ongoingcollaborationwithher treatmentteamandsupportnetworkbecomesher“family”and providesthestabilitysheneeds.

Communication

Afterthemeeting,eachclinicianhasacomprehensiveunderstandingofhoweachofher symptomsisperpetuatedandsometimesworsenedbyherothersymptoms.Thegroupmakes a planforallcommunicationtogothroughherprimarycarephysician.

Roles

ThetreatmentteammeetingallowseachcliniciantounderstandhisorherroleinMs.Smith’s careandagreethathersymptomsneedtobeaddressedasawhole.

Affective Responsiveness

Ms.Smithisangrythathermotherdiedandherfatherlefther. Sheusedtospendtimewithher motherandmissesheragreatdeal. Thistriggersherurgestoactimpulsively. HerAAsponsor isscaredwhenMs.Smithisimpulsive. HerpsychiatristandPCPfeeloverwhelmedbecauseshe isinconstantcrisis.

Affective Involvement

Eachmemberofhertreatmentteamisinvestedinherwell-beingandcareandtheneedfor consistentboundaries.

Behavior Control

AdequatewhenMs.Smithisinbettercontrolofherfeelings.

Case Formulation

Ms.Smith’semotionalbalance(familystability)wasdisruptedbythelossofherparentsand movetoanotherstate(familytransitions). Earlycollaborationofcareprovidedincreased

stabilityandunderstandingofallofMs.Smith’sneedsfrommultipleperspectives. Everyone agreedthatmonthlycheck-incallstogetherasacohesivetreatmentteamallowedfor identificationoftriggersandearlierinterventionstomaintainremissionandfacilitate relapse prevention. Asshecontinuedtoexperienceissuesofabandonmentandloss,thestabilityand consistencyofherfollowupshelpedhertoavoidactingonhersuicidalideationandimpulses. Thecohesivenessofhertreatmentteamformeda“family”systemthatshecouldrelyuponto maintainhersobrietyandrecovery,andnavigatecrises.

Learning Points

Whenpatientsdonothavefamilywhoarepresentorcanparticipateintheirtreatment,treatment teammembersandsocialandcommunitysupportnetworkscanbecomeanextended“family.” However,likeanyfamilysystem,ensuringconsistentboundariesandlimit-settingwithinthe family,andinthiscase,thetreatmentteam,iscrucialtomaintainstabilityandfunction.

CaseExample#2

MrsNguyenisa64-year-old,married,Vietnamese-speakingwomanwithobstructive sleepapnea,bilateralcataracts,recurrenturinarytractinfections,andvaginalprolapse. Shepresentstotheoutpatientpsychiatryclinicwithsevereanxietyanddepression. She waspreviouslyasuccessfulbusinessownerbutinthepasttwoyearsshehas progressivelydeclinedandbecomebed-ridden,isolative,andunabletowork. Shelives withherhusband,andherfamilyconstellationincludesason,andtwoadultdaughters wholivenearbyandareinvolvedinhercare. Shehashadtwopriorextendedinpatient hospitalizationsof2-3monthseach,duetodifficultywithdischargeplanning. When depressed,sheisunabletocareforherselfindependentlyandbecomesextremely aggressive,promptingfamilytobringhertotheemergencyroom(E.R.)foradmission. Thishasbeenarepeatedcycleevery6monthsover thelasttwoyears. Shehashad manymedicationtrialsof antidepressants,benzodiazepines,antipsychoticsandmood stabilizers,andbiologicaltrialsoftranscranialmagneticstimulation(TMS), electroconvulsivetherapy(ECT),andketamineinfusions.

Invitingthefamilyintoconversation. Sincesheisaccompaniedbyoneofherdaughters,the psychiatristinviteshertojointhesecondhalfoftheevaluation.Thedaughterisgratefultobe included.Thepatient’shusbandjoinsbyphoneusingavideoconferenceinterpreterservice. Thefamilyprovidesinformationaboutanextensivetraumahistory:witnessingextensive violenceandthepatientherselfisavictimofsexualabuse. Herdaughternotesherstrengthsof beingagoodmother,raisingthreesuccessfulchildren,andmaintainingabusinessformany years. Inthismeetingitis revealedthatinthelasttwoyears,hertwodaughtersrecentlymoved outofthehome,married,andhadchildren.

Shareddecision-makingbetweenprofessional,patient,andfamily.Followupvisitsfocuson collaboratingwiththefamilyandvalidatingandaddressingthepatient’sextensivetrauma history. Consistentcallstoboththehusbandanddaughter,aswellasconnectingthepatientwith aVietnamese-speakingtherapist,allowthepatienttobecomemoreengaged. Thefamily membersbecomeawareofthepatient’striggersandbegintounderstandhowtomanageher physicaloutbursts.Theylearnhowtode-escalatethepatientathome,ratherthanbringingherto theER. Thepatient’smedicationlistisreduced,withemphasisonissuesofadherence,and trauma-focusedpsychotherapytoaddressyearsofrepressedmemoriesandfeelingsthatwere triggeredbyhertwoadultdaughtersleavingthehome.

Caseformulation.Thepsychiatrist’sdiscussionwithMrsNguyen’sfamilyhelpedplaceher symptomsinalargerrelationalcontext. Thefamily’semotionalbalance(familystability)had beendisruptedbythenumerouschangessuchasherinabilitytowork,herdaughtersleavingthe home(familytransitions)aswellasalongstandingtraumahistorythatwasneverpreviously discussedoraddressed. Thepsychiatristacknowledgedthefamily’sstrengthsandcaringforone anotherandinvitedthefamilyintosessionstoexplorehowthefamily’sfunctioningand involvementmightplayapartinMrsNguyen’ssymptompresentation,herlevelofengagement, andultimatelysymptomalleviation(familyasasystem).

LearningPoints.Includingthefamilyaskeymembersofthetreatmentteamallowedboththe psychiatristandthefamilytoidentifythefamily’sstrengthsaswellasbarrierstotreatment:Mrs Nguyen’sunaddressedtrauma,languageandculturalbarriers. Useoflanguageinterpreters helpedMrsNguyenfeelmorecomfortablecommunicatingwithherentiretreatmentteamand allowedforongoingpsychoeducationandcollaborationthroughoutherhospitalization.

CaseExample#3

Mr.Cadieisasingle,50-year-oldformerlyincarcerated,homeless,Caucasianmanlivingina halfwayhouse. Hehasdiagnosesofbipolardisorderandalcoholdependence.Neighborscalled policebecauseheisoutsideyellingatmidnight.Heisadmittedtoamedicalfloorwith uncontrolleddiabetes,alcoholdependence,andmetabolicsyndrome.Heistransferredtoa psychiatricinpatientunitwherehevoicesangryfeelingstowardshismotherforbetrayingthe memoryofhisfatherwhodied4yearsago.Acasemanagerandhis75-year-oldmother,Mrs. Zabir,arehisonlysocialcontacts.Hismotheriswell,worksparttimeandrecentlyremarried. Sheseeshersonperiodicallybutexpressesfearabouthisimpulsivityandangersincehethrew hisphoneatheramonthago.TheoutpatientpsychiatristarrangestomeetwithMrs.Zabirand thecasemanagertodevelopatreatmentplan.

Family Assessment with Mr. Cadie, his mother and stepfather, case manager, and psychiatrist

Themeeting,whichisscheduledfor1hour,beginswiththestatedgoalofdevelopinga treatmentplanforMr.Cadie.Eachfamilymemberisaskedtoidentifyproblems.Mr.Cadiesays

thathedoesnotwantanycontactwithhismother.Mrs.Zabirsaysthatshewantshersontohave goodmedicalcare.Mr.ZabirsaysthathewantstobeabletohelpMr.Cadieinanywaythathe can.Thecasemanagerasksaboutmedicalproblemsandexpressesconcernabouttreatment complianceespeciallywithhisdiabeticmedication.

Problem Solving

Whensober,Mr.Cadiehasgoodandadequateproblem-solving,takeshismedicationreliably, andstaysinthehalfwayhousewherehefeelscomfortable. Communication

Whensober,allagreethathecommunicatesadequately.

Roles

Hismothermanagesallhisfinancesandallarehappywiththatrole.Intermsofotherrolessuch associalcontact,friendships,andrelationships,allagreethatMr.Cadiehasbecomeisolatedand sociallylesscompetentandnowfrequentlyabusesalcohol.

Affective Responsiveness

Thepatientisangrywithhismotherandsadaboutthelossofhisfather.Mr.Cadieusedtospend timewithhisfatherandmisseshimagreatdeal.Hismotherisafraidofhim;hernewhusbandis unsureofthesituation.

Affective Involvement

Thepatientismoreisolatedsincehisfatherdiedandhismotherismoreinvolvedwithhernew husband.

Behavior Control

AdequatewhenMr.Cadieissober.

Case Formulation

Allagreedwiththeassessmentandthefollowingproblemlistwasgenerated. Mr.Cadiehassignificantchallengesgettinghishealthcareneedsmet.

Alcoholabuseisaresultofhissocialisolation. Mr.Cadieneedsnewsocialcontacts.

Mrs.Zabirhasanewlifeandwantstohavelessinvolvementwithherson.Sheisafraidofhim whenhehasbeendrinking.

Mr.ZabirisunsurehowmuchhewantstobeinvolvedwithMr.Cadie.

Thepsychiatristfacilitatesafamilydiscussionaboutproblemresolutionandpsychoeducation. ThefamilydecidesthatagoodinterventionistohaveMr.ZabirdriveMr.CadietoAAmeetings threetimesaweek.Mrs.Zabirwillwaittohearfromhersonwhenhenextwantstotalkwith her.Shewillnotvisithimathishome.Ifhersonwantstotalktoher,theywillmeetinaneutral placesuchasJoe’sDiner.(ThisplacewaschosenbyMr.Cadieashehadfondmemoriesthereas achildwithhisparents.)ThecasemanagersuggeststhatMr.Cadiecallhisbrotherwhoisoutof statetotalkonthephoneonceaweek.(Thecasemanagerhasinmindapossibletransferof medicalpowerofattorneytoMr.Cadie’sbrother.)Afollowupmeetingisarrangedfor1month.

Learning Points

ThefamilyrelationshipshavetochangeafterMr.Cadiethrewaphoneathismother.Afamily approachallowsthefamilymemberstorenegotiatetheirownrelationshipswiththeguidanceof professionals.Thisfamilyassessmentandinterventionisproactivewiththegoalofpreventing futuredeteriorationofthepatient,encouragingsobriety,andreducingisolationandallowing,if necessary,foratransitionofpowerofattorneytoanotherfamilymember.

CaseExample#4

Ms.Taliaisa37-year-old,Hispanicwomanwithmorbidobesity,obstructivesleepapneaand asthma.Shepresentswithanxietyandpanicattacks.Shehasapasthistoryofsubstanceabuse andhasbeeninprisonfordrug-relatedcrimes.Sheisreceivingdisability.Herfamily constellationconsistsoffourteenagesonsinhermother’scustody.Hersonslivebetweenher houseandhermother’shouse.Ayounggirlbaby,whoisthechildofherniece,islivingwiththe patient.Theniece,whoisactivelyusingsubstances,sometimesstayswiththepatientand sometimesdisappearsforweeks.Aboyfriendalsosometimesstayswithher.Ms.Taliawants custodyofthebabygirlandpresentsintheclinicaskingforhelpwithherpsychiatricsymptoms sothatshecanbewellenoughtogotocourttogetcustody.

Family Assessment with Ms Talia and her mother

Thepsychiatristmetwiththepatientandthemotherandcompletedthefamilyassessmentover severalroutinevisits.Medicationmanagementalsooccurredinthetreatmentsessions.

Problem Solving

Ms.Taliareliesonhermothertohelpwithallproblems.Shestatesthatshewouldliketobe moreindependentbutdoesnotknowhow.Themothersupportshergoal.

Communication

Themotherandthedaughterdoeverythingtogether.Ms.Taliasharesallherthoughtsand feelingswithhermother Themotherdoesnotshareherthoughtswiththepatientandsaysthat she“justwantstohelp.”Themotherisnotcriticalandsays,“Itismydutyasamothertohelp.”

Roles

Themotherandthedaughterspendmostoftheirtimecaringforchildren,theirsandchildrenof theextendedfamily.Themother,althoughonafixedincome,providesasmuchfinancialsupport aspossibleforherdaughter.Herdaughterisalsoonafixedincomebutgivesawayfoodand moneytootherfamilymembersandherboyfriend.

Affective Responsiveness

Thepatientisanxiousmostofthetime.Sheexperiencespleasurewithherbabygirlinthehouse, dressingherandchangingheroutfitsmanytimesaday.Themotherthinkssheisobsessedwith thebabyandshetreatsthebabylikeadoll.Thepatientcriesandfeelsoverwhelmedalotand feelsguiltybecauseshedependsonhermotherformoneyandemotionalsupport.Themother experiencesanormalandfullrangeofemotions.

Affective Involvement

Thereisover-involvementbetweenthepatientandhermother,withguiltonthepartofthe patientfordependingonhermother.Themotheraccompanieshertoallappointments,grocery shopping,etc.Themotheracknowledgesherover-involvementbutsays,“Itismydutytohelp.”

Behavioral Control

Therearenohouserules.ItisunclearfromappointmenttoappointmentwhoislivinginMs. Talia’shouse.Sheisthinkingaboutsettingrulesaboutsubstanceabuseandthrowingherniece outofherhousebutisnotabletobecause“thereisnowhereforhertogo.”

Case Formulation

Ms.Taliahasgeneralizedanxietydisorder,panicdisorder,personalitydisorderwithdependent andhistrionictraitsandasignificantpasthistoryofsubstanceabuse. Herfamilyassessment revealsanover-involvedrelationshipwithhermotherandachaoticlivingsituation.Family strengthsarecaringofothersandtheirself-identificationasstronggoodmothers.Ms.Taliaand hermotheragreewiththeformulation.ThemotherandthepatientagreethatMs.Talianeedsto

setlimitswiththenieceandherboyfriendandtellthemtheycannotstaythereiftheyare“high” or“crashing.”Sheagreestotellfamilymembersandhersons,thatshecannolongergivethem money,whensheherselfdoesnothaveenoughforgroceries.Shesaysthatalthoughsheagrees andknowssheneedstodothis,shecannot,becauseshe“feelsbadforotherpeople.”The mother,supportedbythepsychiatrist,takesthestancethatwhilethisisanadmirableandvalued familytrait,shewillnotgetbetterandthuswillnotbeabletogetcustodyofthebabygirlunless shesetslimitsandcontrolsherhomeenvironment.Ms.Taliaasksformedicationstohelpher. Thepsychiatristagreesthatmedicationsarepartoftheplanbutthatthepatientneedstodoher partandsetuphouserules.Themotherandthepatientagree.

Ateachmeetingtheplanisreviewed.EventuallyMs.Taliaputsoutthefreeloadersandsets familyrulesforthosewhoremaininherhouse.Ms.Taliareportsthatherlevelofanxietyand panichasnotchangedbutsheisfeelingbetternowthatshehassomecontroloverherlife. Monthlyvisitswiththepatientandhermothersetgoalssuchasthepatienttakinghercitalopram 20mg,asprescribedandkeepingallhermedicalappointments.Shealsosetsgeneralhealth goalssuchashealthiereatingandmoreexercisetotrytoavoidfrequenthospitalizationsfor asthmaattacks.

Learning Points

TherearemanypotentialinterventionsforMs.Talia.Thefamilyassessmentapproachpinpointed familystrengthsthatcanbeusedintreatment:herrelationshipwithhermother,strongmothering qualitiesandherdesiretocareforthegirlbaby.Thepatient’srelationshipshaveunsettling elements,e.g.,dressingupthebabygirlandover-involvementwithhermother,butfocusingon thesedeficitsmayresultinalienatingthepatientandhermother.Medicationadministrationis incorporatedintoalargercontractwiththepatientandhermother.Withoutafamilyassessment, thestrengthsandweaknessesofthefamilysystemwouldnothavebeenevident.The recommendationsareframedinafamilycontextwithanemphasisonfamilystrengths.

CaseExample#5

Ms.SharonisaBlackwomanwhopresentswithanxietysymptomsandrequests benzodiazepines.Sheisnewtotheclinicandstatesthatshehasbeentreatedinthepastfor PTSDandhashadseveralhospitalizations.SheliveswithMs.Annawhomshedescribesasher caregiver.YouaskhertobringMs.Annatothenextappointment.Atthenextfewappointments, youfindoutthatMs.AnnahassignificantdepressivesymptomsandisMsSharon’ssignificant otherbutisafraidtoacknowledgethisoutoffearofjudgement,stigma,andrejection. Ms.Anna wasdisownedbyherreligiousandconservativefamily. Bothwomenexpresssuicidalthoughts andwanttofigureouthowtosupporteachotherbetter.

Family Assessment with Ms Sharon, Ms Anna, the psychiatrist, and the social worker

Aonehourfamilyassessmentmeetingisscheduled.

Problem-Solving

Theyeachidentifyproblemsbutdonotcommunicatethemtoeachother,nordotheytrytosolve themtogether Communication

Thereispoorcommunicationforbothduetofearsofjudgementandrejection,andguiltof burdeningeachother.

Roles

Theyeachcontributetothehouseholdincomeforrentandfood.Theyareinanintimateand caringrelationshipthattheybothfindsatisfying. However,botharealienatedfromtheirfamilies andonlyhaveeachothertorelyon.

Affective Responsiveness

Theyhavewarmcaringfeelingsforeachotherbutdonotcommunicatethesefeelings.Theyeach haveintermittentsuicidalideation,butdonotwanttocommunicateandburdenoneanother

Affective Involvement

Theyspendmostoftheirtimetogetherandhavefewfriends.Theybothfeellonelyandisolated.

Behavioral Control

Theyengageinsecretivesuicidalandselfinjuriousbehaviorsfromtimetotime.Theywouldlike tochangethis.

Case Formulation

BothMs.AnnaandMs.Sharonagreetheywanttoworkonimprovingtheirrelationship. The psychiatristismostconcernedabouttheirsuicidalideationandselfinjuriousbehaviorandwork ondevelopingamutualsafetyplan.Infollowingappointments,thetreatmentteamworkson establishingrapportandfosteringasupportive,acceptingenvironmentwheretheybothfeelmore comfortablesharingwiththecliniciansaswellaseachother. Theyworkonspendingquality timetogether,acceptingthattheirrelationshipisstrong,andfeelingmorecomfortablewiththeir sexualidentities.Theyworkonimprovingtheircommunication,problem-solving,andsharing morepositivefeelings.

Learning Point

Althoughthiscouplecannotchangethecircumstancesoftheirlives,theycanreduceactingout behaviorandimprovethequalityoftheirrelationship.

Abovefivecaseexamplesfrom: NguyenS.A.andHeruA.M. Family-CenteredCareinPublicSectorSettings.InSowersS., McQuistionH.,FeldmanJM,RanzJ,RunnelsP.(Eds.),TextbookofCommunityPsychiatry,2nd edition, in press.