Family Therapy and Mental Health

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Family Therapy and Mental Health

• University of Guelph
• Office of Open Learning

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Course Instructors

• William Corrigan, MTS, RMFT,
• AAMFT Approved Supervisor
• 519-578-7443
• williamcorrigan_at_rogers.com
• Carlton Brown, M.Sc., M.Div., RMFT,
• AAMFT Supervisor Candidate
• 905-388-8728
• carl_at_mftsolutions.ca

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By the End of Today

• Introductions
• Historical overview of family therapy
• Models of illness in a developmental perspective
• Assessing structure and function (the McMaster
  Model)
• Classification of mental illness (ICD-9, DSM-IV)

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Ice Breaker

• Pick a card
• Half the cards depict psychiatric symptoms or
  illnesses
• Half the cards depict psychiatric medications
• Find your mate!

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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?

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Historical Overview of Family Therapy and Mental
Health

• Early psychotherapy dominated by
• Sigmund Freud (1856 1939)
• Carl Rogers (1902 1987)
• Both assumed that psychopathology arose from
  unhealthy interactions with others
• Treated by a private relationship
• (client-therapist)

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Pioneers of Family Therapy

• Murray Bowen (1913 1990)
• Psychiatrist specialized in schizophrenia
• 1951, used a cottage on grounds of Menninger
  Clinic in Topeka, Kansas to study families of
  schizophrenics
• developed ideas about mother-child symbiosis
• 1954, NIMH, hospitalized whole families of
  schizophrenics for observation and research
• Emphasized cost effectiveness of family therapy
  better results sooner

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Pioneers of Family Therapy

• Salvador Minuchin
• Psychiatrist, trained in Argentina
• Developed a family approach to working with
  delinquents and urban slum families
• Became director of the Philadelphia Child
  Guidance Clinic in 1965 and by the 1970s it was
  the worlds leading center for Family Therapy and
  training (Nichols Schwartz, 1995)
• Developed Structural Family Therapy, 1974

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Pioneers of Family Therapy

• Palo Alto Group
• Bateson, Haley, Weakland, Jackson Satir
• 1956, Toward a Theory of Schizophrenia, one of
  the most discussed papers in the history of
  psychiatry
• 1959, Jackson forms MRI, independent of Bateson
  project, Satir joins him from Chicago
• 1967, Watzlawick, Bodin, Weakland Fisch form
  the Brief Therapy Center at MRI

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Pioneers of Family Therapy

• Palo Alto Group
• Benefits
• New language
• Interpersonal instead of intrapsychic
• Creative
• Risks
• Reduces therapy to a game of control
• Simplistically applied, it can do harm
• Implies that interactions cause illness (maybe
  not)

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Family therapy in the 21st Century

• Systems still at the core
• Intelligent systems (beyond inanimate)
• Differential impact
• Causal processes
• Individual symptomatology
• Integration of family systems with early theories
  of psychotherapy
• Increasing influence of biology
• Lebow JL (2005) Handbook of Clinical Family
  Therapy, New York John Wiley Sons

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Break!
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The Family Lifecycleand Mental Illness

• An Overview

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Models of Illness in a Developmental Perspective

• Biology
• Models of Individual Development
• The Family Life Cycle
• Models of illness

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Biology

• (Paul Tillich no psychology, sociology or
  spirituality without biology)
• Genes code the synthesis of all biological
  proteins
• proteins comprise enzymes that help make
  neurotransmitters
• neurotransmitters affect the way we think and feel

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Neurotransmitters

• Acetylcholine memory
• Serotonin mood
• Dopamine thinking and movement

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• All thinking, feeling and behaviour has a
  biological basis

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Individual Life Cycle

• Erikson
• Piaget
• Kohlberg
• Mahler
• Kegan
• Solomon

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Erikson

• Trust vs. mistrust
• Object permanency first task of the ego
• Sense of being all right
• Always a shadow of paradise forfeited
• Applications
• Borderline Personality Disorder (object
  permanency)
• Being all right vs. psychodynamic theory of
  psychosis development
• Communications theory, narrative, and its never
  too late to have a happy childhood

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Erikson

• Autonomy vs. shame and doubt
• Holding on, letting go
• Anal stage
• Doing well enough
• Shame upright and exposed
• Doubt what I have left behind (undone)
• Applications OCD? Depression?

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Erikson

• Initiative vs. guilt
• Industry vs. inferiority
• Identity vs. role confusion
• Intimacy vs. isolation
• Generativity vs. stagnation
• Ego integrity vs. despair

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Piaget

• Sensorimotor intelligence (0 2 years)
• Reflexes
• Coordination of reflexes
• Making interesting events reappear
• Means/ends and search for absent objects
• Experiments (new means)
• Imagery to invent new means and object permanence

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Piaget

• Prelogical thought (2 5 years)
• Inference through images and symbols
• Not logical
• Magical thinking
• Confusion of imagined with real events
• Confusion of perception with actual change (e.g.
  fluid in a tall thin glass looks more than same
  in short fat glass, four pieces of peanut butter
  sandwich is more than the same sandwich cut in
  two)

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Piaget

• Concrete operational thought (6 10 yr)
• Able to reason logically about concrete objects
• Classification, e.g. humans belong to the animal
  kingdom, dinosaur enthusiast
• Ordering, comparison, e.g. if altb and bltc then altc

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Piaget

• Formal operational thought (11 yr to adult)
• Formation of the inverse of the reciprocal
• Capacity to order triads of relations
• True formal thought. Construction of all
  possible combinations of relations, systematic
  isolation of variables, deductive
  hypothesis-testing
• The ability to see the world from perspectives
  other than your own concrete position

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Kohlbergs moral stages

• Preconventional
• Heteronomous morality (avoid punishment)
• Instrumental purpose (serve own needs)
• Conventional
• Mutual (Be a good person)
• Social system (Keep the system going)
• Postconventional
• Social contract (freely entered into)
• Universal ethics (universal moral principles)

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Margaret Mahler

• Normal Developmental Stages of Infants
• Autistic
• Symbiotic
• Separation-individuation
• Differentiation
• Practicing
• Rapprochement
• Consolidation of individuality

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The Family Life Cycle

• 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 system

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The Family Life Cycle

• Symptoms and dysfunction are examined in
• a context and in relation to what the culture
  considers normal over time
• In family therapy, we try to help families cope
  better with their issues so that the family as a
  unit can proceed in its development

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The Family Life Cycle

• Six stages
• Leaving Home Single Young Adults
• The Joining of Families Through Marriage The New
  Couple
• Families with Young Children
• Families with Adolescents
• Launching Children and Moving On
• Families in Later Life

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Six Stages of the Family Life Cycle

• Leaving Home Single Young Adults
• Accepting responsibility for oneself
• Differentiation
• Development of peer relationships
• Establishing oneself in work, financial
  independence

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Six Stages of the Family Life Cycle

• 2) The Joining of Families Through Marriage
• The New Couple
• commitment to a new system
• formation of marital system
• realignment of relationships to include spouse

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Six Stages of 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
• Realignment of relationships to include parenting
  and grandparenting roles

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Six Stages of 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
• Refocus on midlife marital and career issues
• Begin shift toward caretaking of older generation

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Six Stages of 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

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Six Stages of 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 spouse, siblings, and
  others preparing for death

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General Principles

• Development is stressful
• Stress is often the greatest at transition points
  between stages
• Developmental tasks that arent resolved will
  create stress and cause further problems
• Stress on top of a predisposition toward illness
  may cause the illness to precipitate

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Stress and Diathesis

• Diathesis - disposition, the way things are
  arranged, i.e. the way your body is made up
• genetic predisposition
• What happens when you add a stress to a diathesis?

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Family Life Cycle and Mental Illness

• Imagine impact of serious mental illness on any
  individual in a family system
• How does impact vary with stage of family
• life cycle?
• How does impact vary depending on individuals
  role in system?
• How would other parts of system change to
  accommodate (or if they didnt)?

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Flow of Stress Through the Family

• Carter McGoldrick (1999)
• Distinguish between horizontal stressors and
  vertical stressors
• Horizontal stressors include
• Developmental
• Unpredictable
• Historical events

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Flow of Stress Through the Family

• 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

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Flow of Stress Through the Family

• More stress on either 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)
• E.g. the onset of symptoms has been found to
  correlate significantly with the addition or loss
  of a family member (Hadley, 1974)

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Illness

• A defective gene may result in a defect in
  neurotransmission, causing a disorder
• Decreased Acetylcholine memory loss (dementia)
• Decreased Serotonin decreased mood (depression)
• Increased Dopamine delusions and hallucinations
• Decreased Dopamine movement disorders
  (Parkinsons Disease)
• Or a defective gene may not result in a defect,
  not causing a disorder

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Stress - Diathesis

• Diathesis tendency
• Biological predisposition
• A tendency toward
• Decreased Acetylcholine memory loss (dementia)
• Decreased Serotonin decreased mood (depression)
• Increased Dopamine delusions and hallucinations
• Decreased Dopamine movement disorders
  (Parkinsons Disease)
• Add a stressor and a disorder may present
• Tendency overwhelming stress illness

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Stress, Illness and Development

• Stress causes development
• Evolutionary truce -gt conflict -gt growth to
  deal with change
• Stress also may cause illness
• Diathesis stress illness
• What does illness do to development?

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Experiment

• Be the Smith Family
• psychodrama of a normal family life cycle
• Leaving home, young couple, new children,
  adolescents, moving on, etc.
• Psychodrama with an illness
• Mr. Smith carries a gene for voice
• The gene expresses the voice in Michael (son)
• What happens to development?

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Treatment

• Mental disorders have a biological basis and are
  treatable by biological interventions, and
• Psychotherapy is a biological intervention
• Changes in mood, thinking, or behaviour change
  neurotransmitter function
• Psychotherapy affects thinking, feeling and
  behaving
• Psychotherapy is a social activity that affects
  psychological and biological function

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Lunch!
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In a nutshell

• mental health has oscillated between genes and
  environment
• Engel 1977 combined the two
• biopsychosocial
• deinstitutionalization of mentally ill in 1960s
• research on expressed emotion (EE) in 1970s EE
  ?relapse
• help families without blaming them

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Implications

• education reduces anxiety reduces EE
• practical information on how to treat illness and
  manage crises
• research psychoeducation medication is more
  effective than medication alone
• but the trend of late has been a return to the
  medical model (managed care?)

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Biopsychosocial Prayer

• God grant me the serenity to take or change my
  medication as required
• The courage to adopt new coping strategies that
  lessen the effect of my illness on myself and on
  my family
• And the wisdom to know when to do which

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Partnership (Chapter 2)

• Biological vs. Emotional
• there is always an emotional overlay
• adaptation to biological illness - sometimes
  problematic
• Illness Interrupts Development
• educate families to respond to the mentally ill
  person at the development stage at which they
  find them at that moment
• Tailor the Treatment to the Family
• the correct mix of psychoeducation and family
  therapy

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The McMaster Modelof Family Functioning
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The McMaster Model

• Diagnosis of families requires a conceptual model
  of family functioning
• The MMFF is one attempt to provide a schema to
  rate clinical observations and assist with
  diagnosis

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The McMaster Model

• Started in 1962 with the Family Categories Schema
  of Epstein, Sigal Rakoff - study of 110
  non-clinical families
• Revised several times to current presentation and
  tested thoroughly for reliability and validity
• Provides full spectrum of ratings from health to
  pathology

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Assumptions Underlying the MMFF

• The parts of the family are interrelated
• One part of the family cannot be understood in
  isolation from the rest of the system
• Family functioning cannot be fully understood by
  simply understanding
• each of the parts

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Assumptions (contd)

• A familys structure and organization are
• important factors determining the behaviour of
  family members
• 5) Transactional patterns of the family system
  are among the most important variables that shape
  the behaviour of family members

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Six Dimensions of Family Functioning

• Problem Solving
• Communication
• Role Functioning
• Affective Responsiveness
• Affective Involvement
• Behaviour Control

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Problem Solving

• Refers to a familys ability to resolve problems
  to a level that maintains effective family
  functioning
• Problems are divided into instrumental
• (, food, clothing, housing, etc.) and
  affective
• (emotional issues)

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Problem Solving

• Seven steps to problem solving
• Identify the problem
• Communicate it to the right people
• Develop a set of solutions
• Decide on one solution
• Carry out the action required
• Monitor to ensure action is carried out
• Evaluate the effectiveness

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Communication

• Defined as the exchange of information between
  family members
• Also divided into instrumental and affective
  areas
• Assessed on two dimensions
• Clear vs. masked
• Direct vs. indirect
• Focused more on verbal communication than
  non-verbal

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Role Functioning

• Family roles are defined as the repetitive
  patterns of behaviour by which family members
  fulfill family functions
• Five areas of function
• 1) Provision of resources
• 2) Nurturance and support
• 3) Adult sexual gratification
• 4) Personal development
• 5) Maintenance and management of the system

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Role Functioning

• Two other aspects of role functioning
• Role allocation how roles are assigned and
  distributed (e.g. appropriate/inappropriate,
  implicit/explicit, autocratic/democratic, shared
  among all members)
• Role accountability making sure that functions
  are fulfilled reinforces commitment and
  effectiveness

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Affective Responsiveness

• Defined as the ability to respond to a given
  stimulus with the appropriate quality and
  quantity of feelings
• Two aspects to consider
• Responding with a full range of feelings
• Does the response match the stimulus and/or
  context

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Affective Responsiveness

• Distinguish between welfare emotions and
  emergency emotions
• Welfare emotions include
• affection, warmth, tenderness, support, love,
  consolation, happiness, and joy
• Emergency emotions include
• Anger, fear, sadness, disappointment, and
  depression

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Affective Involvement

• Defined as the extent to which the family shows
  interest in and values the particular activities
  and interests of individual family members
• Ranges from a complete lack of involvement to
  extreme involvement

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Affective Involvement

• Six types of involvement
• Lack of involvement
• Involvement devoid of feelings
• Narcissistic involvement
• Empathic involvement
• Over-involvement
• Symbiotic involvement

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Behaviour Control

• Defined as the pattern a family adopts for
  handling behaviour in three areas
• Physically dangerous situations
• Meeting and expressing psychobiological needs
  (e.g. eating, sleeping, toileting, etc.)
• Interpersonal socializing behaviour both between
  people in the family and between family members
  and outsiders

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Behaviour Control

• Four styles of behaviour control
• Rigid little room for negotiation
• Flexible reasonable, with room for negotiation
• Laissez-faire no standards
• Chaotic unpredictable, shifts between other
  styles without predictability

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Case Study

• Watch movie clip
• Assess family using McMaster Rating Scale

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Break
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Classification of Disease

• ICD-9
• ICD-9-CM
• DSM-IV
• DSM-IV-TR

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Classification of Disease

• World Health Organization ICD-9
• International Classification of Diseases, 9th
  revision
• Mortality data only (ICD-9 is for dead people)
• ICD-9-CM
• International Classification of Diseases, 9th
  revision, clinical modification
• Based on ICD-9
• Official coding for illnesses in the United States

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Implications

• Disease Classification is internationally agreed
  upon
• It also forms the basis for billing from
  governments and third parties

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Classification of Mental Disorders

• Based on ICD-9-CM
• Called Diagnostic and Statistical Manual of
  Mental Disorders (DSM)
• Current edition is the Fourth Edition, published
  in 1994 (DSM-IV)
• A text revision was published in 2000 (DSM-IV-TR)

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ICD-9-CM Codes Found in the DSM

• MENTAL DISORDERS (290-319)
• DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS
  (320-389) (sleep disorders, medication-induced
  disorders)
• DISEASES OF THE GENITOURINARY SYSTEM (580-629)
  (sexual dysfunction)
• SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS
  (780-799) (Delirium NOS, breathing-related sleep
  disorder, age-related cognitive decline,
  encopresis with constipation, deferred diagnosis
  GOK)
• INJURY AND POISONING (800-999) (child neglect and
  abuse)

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The V-Codes

• SUPPLEMENTARY CLASSIFICATION OF FACTORS
  INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH
  SERVICES (V01-V85)
• non compliance with treatment spousal abuse
  child abuse and neglect relational problems
  occupational problem academic problem
  acculturational problem bereavement religious
  or spiritual problem malingering antisocial

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Definition of a Mental Disorder

• clinically significant behavioral or
  psychological syndrome or pattern that occurs in
  an individual and that is associated with present
  distress (e.g., a painful symptom) or disability
  (i.e., impairment in one or more important areas
  of functioning) or with a significantly increased
  risk of suffering death, pain, disability, or an
  important loss of freedom.

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Mental Disorder, continued

• Must not be expectable and culturally sanctioned
  response to a particular event (e.g. death of
  loved one)
• Must be a current manifestation of dysfunction
• Deviant behaviour and conflicts with society are
  not included unless the deviance or conflict is a
  symptom of individual dysfunction, as above

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Mental Disorder, continued

• The DSM-IV classifies disorders, not people
• Not a schizophrenic but an individual with
  Schizophrenia (295)
• Not an alcoholic but an individual with
  Alcohol Dependence (303.90)

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How Diagnoses are Arranged

• Five Axes
• Axis I
• Clinical Disorders
• Other Conditions That May Be a Focus of Clinical
  Attention (V-Codes)
• Axis II
• Personality Disorders
• Mental Retardation

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How Diagnoses are Arranged

• Five Axes
• Axis III
• General Medical Conditions
• Axis IV
• Psychosocial and Environmental Problems (V-Codes,
  also coded on Axis I if a primary concern)
• Axis V
• Global Assessment of Functioning (GAF)

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What MFTs need to know

• What you already know or are learning, i.e.
  models of family therapy
• Some familiarization with the DSM-IV in order to
  understand the narrative under the label
• From other sources, learn about etiology and
  treatment
• Then you can provide psychoeducation as well as
  therapy

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Assignments

• In-class presentation (30)
• In-class quiz (10)
• Final paper (60)

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In-Class Presentation

• working in groups
• describe a mental health problem (DSM-IV)
• etiology (what causes it?)
• how does it impact family members?
• what are current, effective, family intervention
  treatment models that help?
• 22 minutes, 2 pages
• class discussion

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In-Class Presentation Topics

• October 2
• schizophrenia and other psychotic disorders
• psychotic couples
• bipolar disorder
• bipolar couples
• October 16
• personality disorders
• antisocial, borderline, narcissistic, dependent,
  histrionic
• couples histrionic-obsessive, narcissistic-border
  line, dependent-narcissitic

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In-Class Presentation Topics

• October 30
• anxiety
• panic, agoraphobia, OCD
• PTSD, social anxiety, GAD
• extramarital affairs, natural disasters
• November 6
• depression (whats the use?)
• suicide, aging, brain injury, substance abuse
• special topics (eating disorders, ADHD)

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Quiz

• Attendance is necessary to pass the quiz
• It will be fun!

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Final Paper

• 60
• 15-20 pages
• grammar and style
• researched and critical
• creative

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Final Paper

• create a case study using a character and family
  from a novel or film of your choice
• provide a genogram and case history (make it up)
• describe the family as a system, identify the
  patient, supply a diagnosis, etiology and
  treatment plan (you are an MFT who is part of a
  treatment team)
• what medications will be used?

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Final Paper

• what is the likely progression of treatment?
• what further research needs to be done in this
  area?

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Questions
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Charades
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Next Class is Next Friday

• In this room
• Schizophrenia and other psychotic disorders
• Bipolar affective disorder
• Student presentations
• Do the readings but dont let the stress make you
  crazy!