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 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

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Today

• Depression and Suicide
• Lunch
• Eating Disorders
• Exam
• Course Evaluation
• Done like Dinner!

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Review

• Any issues from previous class(es)?
• Okay with the final paper?
• Anything else you want to know about mental
  health?
• Last class was highly rated - feedback?

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Presentation

• Depression - Naz

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Break

• 1030 - 1100

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Major Depressive Episode

• An ordinary patient

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Major Depressive Episode

• Five or more of the following over a two week
  period, at least one of the first two
• Depressed mood (irritable child or adolescent)
• Diminished interest or pleasure in almost all
  activities most of the day, every day
• Significant unintentional weight loss/gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation

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Major Depressive Episode

• Five or more, continued
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Difficulty thinking or concentrating
• Recurrent thoughts of death, SI, with or without
  plan
• Exclude Mixed Episode
• Significant impairment of occupational or social
  functioning

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Major Depressive Episode

• Not due to drugs or a medical disorder
• Not due to bereavement

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Depression mood and thinking

• Depressed mood causes negative thinking,
  cognitive triad
• Bad thoughts about self
• Bad thoughts about world
• Bad thoughts about future
• Negative thinking perpetuates the depressed mood
• Freeman and Reinicke 1995, Segal et al 2002

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Treatment

• Treat the mood directly with antidepressant
  medication (or better music)
• Treat the thinking with therapy

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Medications for Anxiety and Depression

• Improve the function of endogenous
  norepinephrine, serotonin and dopamine
  (neurotransmitters associated with mood)

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Medications

• Serotonin-Specific Reuptake Inhibitors (SSRIs)
• 2-4 weeks response time
• suicide risk in children
• Generally much safer than TCAs or MAOIs (below)

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Medications

• Heterocyclic (Tricyclic) Antidepressants (TCAs)
• Amitriptyline, imipramine are examples
• 3-6 weeks response time
• Overdose very dangerous

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Medications

• Monoamine Oxidase Inhibitors (MAOIs)
• Inhibit monoamine oxidase, so monoamines last
  longer
• High blood pressure side effect ( tyramine)
• Special diet
• 3-8 weeks response (must start at low dose)
• Overdose can be fatal
• E.g. Nardil, ENSAM, Parnate

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Therapy

• Behavioural (do pleasant or rewarding activities)
• Social skills (reduce social isolation)
• Cognitive (change thoughts, images,
  interpretations)
• Interpersonal

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Which works better?

• Treatment of Depression Collaborative Research
  Program (1989)
• Historic multisite coordinated study
• 250 patients
• Randomly assigned
• Interpersonal psychotherapy (IPT)
• Cognitive-Behavioural Therapy (CBT)
• Imipramine (tricyclic antidepressant)
• Placebo

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TDCRP results

• no evidence of greater effectiveness of one of
  the psychotherapies as compared with the other
  and no evidence that either of the
  psychotherapies was significantly less effective
  than the standard reference treatment
• Severely depressed imipraminegtIPTgtCBTgtplacebo
• Elkin et al, 1989, p. 980

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Which therapy works best?

• Why will almost anyone tell you that CBT is the
  best practice for treatment of depression if
  IPTgtCBT?
• See also Duncan and Miller (2000) The Heroic
  Client
• Why is medication the treatment of choice for
  depression?

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Depression

• Segal 2002
• Prevalence worldwide
• 17 -20 meet some criteria
• 10 major depression
• Twice as common in women
• Suicide rate
• In recurrent depression 15

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Recurrence

• Defined as at least two episodes of major
  depression with a non-depressed period in between
• About 20 of first timers will relapse
• Overall average rate of recurrence 50
• Two or more episodes 80 risk
• Each recurrence worsens the disease

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Relapse Prevention

• Treat a major depressive episode with either
  medication or therapy (work equally well)
• Stop treatment when the depressive episode is
  over
• Who relapses?

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Segal 2002, p. 24
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Preventing Relapse

• Therapy or medication appear to treat depression
  equally well (medication slightly better for
  severe depression)
• Risk of relapse is significantly higher without
  therapy
• The studies were done with cognitive behavioural
  therapy

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The Power of Therapy

• After recovery from a depressive episode, all
  subjects had normal thinking
• Introduce any stressful or traumatic event all
  people become sad, with concomitant cognitive
  triad (bad self, bad world, bad future)
• Cognitive therapy seems to help people stay well
  after depression

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Does it make them think better?

• Mood affects thinking
• After depressive episode, thinking returns to
  normal

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Further studies

• Induce a sad mood (country music)
• Thinking becomes distorted
• People who ruminate on their thoughts (whats
  wrong with me that my wife left me, stole my
  truck and ran over my dog?) stay depressed
• People who distract themselves and move on,
  recover

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Decentering of Thoughts from Self

• Segal 2002
• The essential ingredient in Cognitive Therapy is
  not the content of the therapy, but the process
  of decentering
• I have thoughts instead of I am my thoughts
• Objectification of thoughts, or decentering of
  the self from thinking

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CBT vs. other therapies

• Self psychology is a form of decentering
• Interpersonal therapy works better than CBT
• Family therapy, narrative therapy,
  solution-focused therapy almost any form of
  therapy that encourages externalizing of problems
  or objective examination of thinking, ought to
  protect people from depression

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Family Therapy for Depression

• Gupta 2005
• Bidirectional effects
• Marital stress depression
• parenting problems

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Family Therapy and Depression

• Gupta 2005
• Depression -gt marital conflict
• Individual and marital therapy both effective in
  treating depression and improving relationship
• Marital conflict -gt depression
• Marital therapy effectively treats both the
  depression and the relationship
• Individual therapy makes the relationship worse

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Treatment

• Behavioural Marital Therapy BMT or BFT
• Conjoint marital IPT (IPT CM)
• Parenting interventions (Barkley)

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Suicide Stats

• Approximately 4000 Canadians commit suicide each
  year about 11/day
• The World Health Organization estimates as many
  as 20 suicide attempts for every suicide death
• Men are 4x more likely than women to complete
  suicide (lethal means)

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Suicide Stats

• Hospitalization rate for attempted suicide among
  females is highest aged 15 to 19
• Among teens, girls are more likely than boys to
  have suicidal thoughts (8.4 vs. 4.6)
• Almost half of those admitted to hospital for
  attempted suicide have a major mental health issue

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6 Steps to Suicide Intervention

• 1. Engage
• engage the person in conversation, listen,
  empathize with feelings, be understanding,
• be honest and genuine
• 2. Identify
• identify warning signs
• 3. Inquire
• ask the person directly, Are you having thoughts
  of suicide?

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6 Steps to Suicide Intervention

• 4. Estimate
• have they attempted before? do they have a plan?
• (where, when, how) what supports do they have?
  
• 5. Contract
• negotiate a no-suicide contract, be specific
  about
• follow-up and what to do if they feel suicidal
  again,
• identify supports and resources with them
• 6. Follow through
• follow through on plans agreed upon

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Narrative Questions for Depression (Freedman
Combs)

• What made you vulnerable to depression so that it
  became able to dominate your life?
• In what contexts is depression most likely to
  take over?
• What kinds of things happen typically that lead
  to depression taking over?

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Narrative Questions for Depression (Freedman
Combs)

• What has depression gotten you to do that is
  against your better judgement?
• What effect does depression have on your life and
  relationships?
• How has depression led you into the difficulties
  you are now experiencing?
• Does depression blind you from noticing your
  strengths or can you see them through it?

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Narrative Questions for Depression (Freedman
Combs)

• Have there been times when you have been able to
  resist the pull of depression? Times when
  depression could have taken over but you were
  able to keep it at bay?
• From Narrative Therapy The Social Construction
  of Preferred Realities by Jill Freedman and Gene
  Combs (1996)

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Lunch

• 1230 - 115

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Presentation

• Eating Disorders - Kelli

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Stages of Change

• Pre-contemplation Leave me alone!
• Contemplation I know I have an eating disorder,
  but Im not sure Im ready to change.
• Preparation Im getting ready to make small
  changes.
• Action I am working to stop dieting/binging/
  eating/ vomiting/overexercising.
• Maintenance Im trying to keep up the changes I
  have made.
• Active Recovery The eating disorder is no
  longer a major part of my life.

Prochaska, Norcross DiClemente, 1994
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Exam Questions

• Diathesis means _______.
• Axis I is used to code _____ (flowery) illness,
  and Axis II is used to code ____ _____ and ___
  ____.
• This man later became the administrator of the
  hospital at which he had been a patient
  (True/False)
• What is Mr. Joness diagnosis?
• Captain Queeg has a __________ personality
  disorder.

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Exam Questions

• Mr. Gekko is an obviously successful businessman
  and absolutely nothing is wrong with him
  (True/False). If False, he likely has a
  _________ _________ disorder.
• Besides not loving anything, what is Mr. Udalls
  mental health concern?
• Agoraphobia is defined as anxiety about, or
  avoidance of, places from which escape might be
  difficult in case of panic attack (True/False)
• What is Conrad describing?
• Antidepressant medication is more effective than
  interpersonal therapy. True or False?

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Course Evaluations and Final Questions
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Goodbye!

• Final paper due Friday, November 26th
• Email it to carl_at_mftsolutions.ca
• I hope you enjoyed the course

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