Family Therapy and Mental Health

1
Family Therapy and Mental Health

• University of Guelph
• Office of Open Learning

2
Today worry
3
(No Transcript)
4
Course Instructor

• Carlton Brown, M.Sc., M.Div., RMFT
• 3-1216 Upper Wentworth Street, Hamilton ON L9A
  4W2
• Tel [phone]
• Email carl_at_mftsolutions.ca
• Slides http//www.mftsolutions.ca/Pages/MentalHea
  lthCourse.html

5
Review

• Comments from last class
• Questions about assignments
• Areas not covered

5
6
Presentation

• Panic and OCD - Roberta

6
7
Presentation

• PTSD - Hong

7
8
Break
9
Presentation

• ADHD - Talaria

9
10
Anxiety Disorders

• Panic Disorder (PD) w/ or wo/Agoraphobia
• Specific Phobia
• Social Phobia (social anxiety disorder)
• Obsessive-Compulsive Disorder (OCD)
• Posttraumatic Stress Disorder (PTSD)
• Acute Stress Disorder (PTSD lite)
• Generalized Anxiety Disorder (GAD)

11
Anxiety Disorders - Prevalence

• From The Anxious Brain, M. Wehrenberg S.
  Prinz, 2007
• Nearly 26 of adult Americans suffer from anxiety
  in a given year
• 6.8 Social Anxiety Disorder
• 3.1 Generalized Anxiety Disorder
• 2.7 Panic Disorder

12
Anxiety Disorders - Comorbidities

• Panic disorder
• 25 also have GAD
• 15-30 also have SAD
• 10-20 also have specific phobia
• 8-10 also have OCD
• 50 with PD and GAD also have depression

13
Phobias DSM-IV-TR Criteria

• Marked and persistent fear that is excessive or
  unreasonable, cued by the presence or
  anticipation of a specific object or situation
  (e.g. flying, heights, animals, receiving an
  injection, seeing blood)
• Exposure to the phobic stimulus almost invariably
  provokes an immediate anxiety response, which may
  take the form of a situationally bound or
  predisposed panic attack

14
Phobias DSM-IV-TR Criteria

• The person recognizes that the fear is excessive
  or unreasonable.
• The phobic situation(s) is avoided or else is
  endured with intense anxiety or distress

15
Phobias DSM-IV-TR Criteria

• The avoidance, anxious anticipation, or distress
  in the feared situation(s) interferes
  significantly with the persons normal routine,
  occupational (or academic) functioning, or social
  activities or relationships, or there is marked
  distress about having the phobia
• In individuals under the age of 18 years, the
  duration is at least 6 months

16
Phobias DSM-IV-TR Criteria

• The anxiety, panic attacks, or phobic avoidance
  associated with the specific object or situation
  are not better accounted for by another mental
  disorder
• Specific type
• Animal type
• Natural environment type
• Blood-injection-injury type
• Situational type
• Other type

17
Developmentally Normal Fears

18
Phobias Prevalence

• Fears are very prevalent
• Phobias occur in about 11 of the population
• More common among women
• Tends to be chronic

19
Phobias Treatment(Bourne, 2005)

• Relaxation training
• Abdominal breathing
• Deep muscle relaxation
• Cognitive therapy
• Cognitive restructuring re. fearful thoughts
• Positive self-talk and coping statements

20
Social Anxiety DisorderDSM IV Criteria

• Intense fear of social (new people) or
  performance situations. Fear of acting in a way
  that will be humiliating or embarrassing.
• Exposure to feared situation provokes anxiety
  e.g. panic attack.
• Recognizes fear is excessive or unreasonable.
• Feared situations are avoided or endured with
  intense anxiety or distress.

21
Social Anxiety DisorderDSM IV Criteria

• Avoidance, anticipation, or distress interferes
  significantly with life.
• In individuals under 18, duration of at least six
  months.
• Not due to substances or other medical or mental
  health condition.
• If another condition exists, fear in 1. is
  unrelated to it.

22
SAD General info.

• Most common anxiety disorder
• Equal prevalence in men and women clinically but
  higher incidence in women
• Affects 3-13 of people in US
• Two peaks 11-15 and 18-25 yrs. old
• Physical, social educational changes may be
  part of etiology
• About 66 are unwed and have lower social and
  education levels than normal

23
SAD Etiology

• Inborn shy temperament
• Slow to warm up
• Resistant to change
• Solemn, dont smile much
• Avoids large groups of people
• Not all shy children develop SAD, but all with
  SAD suffered shyness as a child
• Shame as traumatic stress

24
SAD General Tx Principles

• Avoidance perpetuates disorder
• More likely to need medication to cope
• Exposure to feared situations is necessary
• Social impairment requires skills-training
• Address
• Cognitions, Physiology, Behaviour
• High incidence of comorbidities/dual diagnosis

25
SAD Addressing Cognitions

• Psycho-education
• There is no real risk of danger, fear is
  unnecessary
• Fear of exposure/risk of humiliation vs. danger
• Sensations are reactions to embarrassment
• Learn to tolerate uncomfortable sensations
• Learn to calm the body and challenge false
  beliefs (FEAR False Evidence Appearing Real)
• Use opposite action vs. avoidance
• Use thought logs cognitive distortions list

26
SAD Changing False Beliefs

• Learn and practice alternative beliefs
• Identify and change inner dialogue (self-talk)
• Be realistic
• Search for evidence that disproves false beliefs
  e.g. exceptions
• Emphasize difference between how they feel and
  what actually happened (behavioural)
• Use affirmations

27
SAD Addressing Physiology

• Rule out medical conditions e.g. heart, thyroid,
  hormone, hypoglycemia, adrenal fatigue
• Teach diaphragmatic breathing and progressive
  muscle relaxation
• Teach mindfulness skills
• Three deep breaths and good preparation

28
SAD Medications

• More use of PRNs with SAD than others
• Need for in vivo practice
• Beta blockers Propranolol (Inderal) Atenolol
  (Tenormin)
• Benzopiazepines Clonazepam Alprazolam
• MAOIs Phenelzine
• SSRIs Prozac

29
SAD Addressing Behaviour

• In Vivo exposure
• Assess social skill deficits
• Social skills training for specific fears,
  assertiveness, anger and conflict management
• Systematic desensitization or EMDR
• List every feared situation, rank from 0-100,
  imagery coping skills
• Create hierarchy for in vivo exposure then
  practice

30
SAD Working with Families

• Family members either push too hard or back off
  completely
• Help them to find balance, matched with clients
  skill and developmental level
• Remember that negative experiences reinforce
  fears
• Help client negotiate practice with family
• Help family manage their own anxiety

31
GAD DSM-IV-TR Criteria

• Excessive anxiety and worry (apprehensive
  expectation), occurring more days than not for
• at least 6 months, about a number of events or
  activities (such as work or school performance)
• The person finds it difficult to control the worry

32
GAD DSM-IV-TR Criteria

• The anxiety and worry are associated with three
  or more of the following symptoms
• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance

33
GAD DSM-IV-TR Criteria

• The focus of anxiety and worry is not confined to
  features of another Axis I disorder (PD, OCD,
  etc.) and the anxiety and worry do not occur
  exclusively during PTSD
• The anxiety, worry or physical symptoms cause
  clinically significant distress or impairment in
  social, occupational, or other important areas of
  functioning

34
GAD DSM-IV-TR Criteria

• The disturbance is not due to the direct
  physiological effects of a substance, general
  medical condition, and does not occur exclusively
  during a Mood Disorder, a Psychotic Disorder, or
  a Pervasive Developmental Disorder.

35
GAD Reid Wilson, 2007

• PD is the easiest to treat, with the best
  outcome, whereas GAD is the hardest to treat
• Worry about at least two of the following
• Minor things 91
• Family/home 79
• Financial 50
• Work/school 43
• Illness/health/injury 14

36
GAD Reid Wilson, 2007

• Its not the content of the worry, its the
  process that is problematic
• They worry in order to try and prevent what they
  are worrying about (to stay safe)
• Chronic worry leads to procrastination
• Becomes a self-perpetuating problem
• Nervous system is always on guard to threat and
  they dont know what its like to be relaxed

37
GAD Treatment(R. Wilson, 2007)

• If its worth worrying about, its worth problem
  solving!
• Teach them problem solving skills
• Help them make a decision w/reasonable risk and
  follow through (e.g. cost/benefit analysis)
• Learn how to tolerate consequences/uncertainty
• Distinguish signals from noise
• Catch episodes and intervene early
• Mindfulness (present focused)

38
GAD Treatment(R. Wilson, 2007)

• Train in multiple relaxation techniques
• e.g. biofeedback, breathing, progressive muscle
  relaxation, meditation, yoga, guided imagery
• Help them recognize the absence of relaxation as
  a cue for skills
• Keep a worry log
• Cognitive restructuring
• Designate worry times worry free zones

39
Lunch
40
Assessment

• Beck Anxiety Inventory
• Social Anxiety Scale

40
41
The Litany Against Fear

• I must not fear. Fear is the mind-killer.
• Fear is the little-death that brings total
  obliteration.
• I will face my fear.
• I will permit it to pass over me and through me.
• And when it has gone past I will turn the
• inner eye to see its path.
• Where the fear has gone there will be nothing.
• Only I will remain.
• from Frank Herbert's Dune book series (1965)

42
Anxiety Disorders Medications (J. Preston, 2003)

• Panic Disorder
• SSRIs Paxil Zoloft
• Minor Tranquilizers Xanax, Ativan, Klonopin
• OCD
• Anafranil (a tricyclic antidep) and SSRIs
  (Prozac, Luvox, Paxil, Zoloft)
• PTSD
• SSRIs, esp. Zoloft

43
Anxiety Disorders Medications (J. Preston, 2003)

• Social Anxiety
• Effexor SSRIs esp. Paxil
• GAD
• Effexor, SSRIs, and non-habit forming
  tranquillizer BuSpar

44
Systematic Desensitization

• Create a hierarchy of exposure
• From easiest to hardest
• Usually begins with imagery
• Pair images with relaxation techniques
• Exposure Procedure
• Enter the situation
• Retreat only if anxiety is out of control
• Recover, then continue

45
Exposure Therapy

• What promotes success
• Cooperation of your partner or spouse
• Willingness to tolerate some discomfort
• Ability to handle the initial symptoms of panic
• Ability to handle setbacks
• Willingness to practice regularly

46
Treatment

• Support
• Discuss the event
• Educate regarding coping mechanisms (relaxation,
  diet, exercise, etc) e.g. CISM handout
• Medications
• Therapies

46
47
Medications

• Imipramine - effective treatment of panic
• Amitriptyline - chronic pain, PTSD
• SSRIs, MAOIs, anticonvulsants, propranolol
• Xanax (but may introduce or exacerbate
  substance-abuse disorder)
• in general, the drugs help with depression,
  anxiety and hyperarousal
• but not with avoidance, denial and emotional
  numbing
• Kaplan and Sadock 1998

47
48
Therapies

• Critical Incident Stress Debriefing
• for groups affected by the same event
• note the medical community sometimes has
  difficulty with this intervention although if
  done right it is quite effective (Mitchell)
• EMDR (but why does it work?)
• Supportive, educative, exploratory therapy that
  forms a ritual for moving through the event
  (Gordon, Baucom and Snyder)
• Integrative and Behavioural Family Therapies

48
49
Integrative Family Therapy

• Rowe and Liddle, 2008
• Treatment of children is more effective when the
  parents are treated too
• Comorbid substance abuse with PTSD
• Trauma affects whole systems systemic treatment
  is therefore indicated

49
50
Family-Based Intervention

• Not only debrief the trauma but
• Strengthen interpersonal relations and supports,
  e.g. parents with teens
• Help parents restore/maintain functioning
• Liddles MDFT applied to Hurricane Katrina
• Assess specific needs, e.g. new school, family
  stress, loss of friends, behavioural/drug
  problems, pre-existing issues (coping)
• developmental and systems theories

50
51
High Conflict Divorce

• 10 - 20 of divorces are high conflict
• 70 of these parents have personality disorders
• traumatic PTSD
• Lebow, 2005 Integrative Family Therapy
• reduce trauma solution-focus, disengagement,
  rules for communication, negotiation
• treat trauma reattribution, child treatment,
  parent-child, catharsis, anger, extended family,
  individual

51
52
Behavioural Family Therapy

• Non-blaming stance ideal for these families
• The concept that families develop patterns of
  behaviour that, while appearing counterproductive
  to the observer, nevertheless represent their
  best efforts to respond to their current
  circumstances is the cornerstone of BFT
  (Falloon, p.67)

53
Behavioural Family Therapy

• Most extensively studied model of family
  intervention for severe mental illness
• Combines education and social learning strategies
  designed to equip families with knowledge and
  skills to better manage illness
• Particular focus on communication and
  problem-solving skills

54
Behavioural Family Therapy

• Assessment (Falloon, 1991)
• Conducted on two levels
• Problem analysis
• Functional analysis
• Problem analysis is the process of pinpointing
  the exact behaviours that are causing concern
• Functional analysis attempts to define the
  context in which these behaviours contribute to
  dysfunction

55
Behavioural Family Therapy

• Problem Analysis
• Individual, dyadic and family sessions are used
  to join with the family and to explore each
  family members perception of the problem
• Patience and focus are needed to help family
  describe problem in specific behavioural terms
• Charting may be used to track frequency of
  problem behaviours

56
Behavioural Family Therapy

• Problem Analysis
• At the completion of this phase the therapist
  will
• Have pinpointed one or more family problems
• Have defined the frequency of their occurrence
• Have some preliminary hypotheses about the
  factors contributing to the problem(s)
• A hierarchy of problems to address may need to be
  established

57
Behavioural Family Therapy

• Functional Analysis
• Extends problem analysis to the system level
• Identifies antecedents and consequences of
  problem behaviour
• Antecedents are stimuli that trigger behaviour
  (e.g. loud noise, drug use, lack of sleep)
• Consequences are reinforcing stimuli that either
  increase or decrease probability of behaviour
  reoccurring

58
Behavioural Family Therapy

• Sample questions for functional analysis
• What would the person (or family) gain or lose if
  the problem were resolved?
• Who (or what) reinforces the problem with
  attention, sympathy, and support?
• Under what circumstances is the problem increased
  or decreased in intensity?
• What do family members currently do to cope with
  the problem?

59
Behavioural Family Therapy

• Functional Analysis
• Also includes investigation into strengths and
  weaknesses of family in coping with problem
• Coping methods are evaluated in terms of
  effectiveness
• Shaping the familys existing coping skills is
  much easier than teaching new skills from scratch
• Narrative exceptions
• Solution focused translate old
  skills to new problem

60
Behavioural Family Therapy

• Five Techniques
• Education
• Communication training
• Problem-solving training
• Operant conditioning
• Contingency contracting

61
Behavioural Family Therapy

• Education
• Could include information on illness, individual
  and family development, principles of social
  learning, stress management, etc.
• Goal is to provide family with rationale for
  management of the problem and subsequent
  interventions

62
Behavioural Family Therapy

• Communication training
• Skills include active listening, expressing
  positive feelings, making positive requests,
  expressing negative feelings, compromise and
  negotiation, and requesting time out
• See Mueser p.64-66 in text for summary of skills
  and steps to training
• Note communication skills need to precede
  problem-solving skills

63
Behavioural Family Therapy

• 3. Problem-solving guidelines (Jacobson
  Christensen, 1996)
• In stating a problem, try to begin with something
  positive
• Be specific
• Express your feelings
• Be brief when defining problems
• Both people should acknowledge their role in
  creating and maintaining problem

64
Behavioural Family Therapy

• 3. Problem-solving guidelines
• Discuss only one problem at a time
• Paraphrase
• Dont make inferences - talk only about what you
  can observe
• Be neutral rather than negative
• Focus on solutions

65
Behavioural Family Therapy

• 3. Problem-solving guidelines
• Behaviour change should include mutuality
• and compromise
• Discuss pros and cons of proposed solutions
• Reach agreement

66
Behavioural Family Therapy

• 4. Operant Conditioning Strategies
• Two predominant methods
• Shaping
• Time out procedures
• Taught through instruction, behavioural
  rehearsal, and modeling

67
Behavioural Family Therapy

• 5. Contingency Contracting
• Used to replace hostile, coercive, blaming
  patterns by cooperative, mutually pleasing
  behaviour
• Contract between two or more family members that
  specifies behaviours each desires the other to
  perform
• Rewards are included and specified

68
Break
69
And Now for Something Completely Practical

• Fun with Dick and Jane

69
70
Last Class November 5th

• Here again
• Quiz (Dont worry)
• Life is difficult, and then you die (aging,
  depression, eating disorders)

70