Family Therapy and Mental Health

Family Therapy and Mental Health
University of Guelph Centre for Open Learning and Educational Support

Your Crazy Hosts Carlton Brown, M.Sc., M.Div., RMFT
AAMFT Approved Supervisor William Corrigan, B.A., M.T.S., RMFT AAMFT Approved Supervisor (Who the hell are these guys?) Get the slides:

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) Introduction to the DSM-5 Assignments

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

Introductions Name Background/experience in mental health
What fascinates you about the field of mental health? What makes you nervous/afraid about the field of mental health?

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)

Influence of Social Work
Late nineteenth century Saw the family as the unit of intervention one goal was what is now known as ‘family preservation’ Family Service Association of America organization of social work agencies created a handbook for social workers on marriage counselling in 1943 Introduced the idea of family casework – workers were assigned to a family and interviewed couples conjointly as part of assessment

Marriage Counselling Pioneers include:
Paul Popenoe, American Inst. of Family Relations, 1930, in L.A. Abraham & Hannah Stone, 1930 in N.Y. Emily Hartshorne Mudel, 1932, Marriage Council of Philadelphia Formed the American Association of Marriage Counsellors, 1945 Produce four publications on marriage counselling between California, 1963, first state to legislate marriage, family and child counsellors as distinct from psychologists, psychiatrists, and social workers AAMC renamed AAMFC in 1970; became AAMFT in 1978

Pioneers of Family Therapy
John Bell The “Accidental Family Therapist” Began treating families in 1951 but didn’t publish his ideas until later, having minimal impact Nathan Ackerman ( ) Psychoanalyst and child psychiatrist Studied mental health problems among the unemployed in a depression-struck mining town in Pennsylvania By the 1940’s he was seeing whole families 1950, paper entitled “Family Diagnosis: An Approach to the Pre- School Child” considered the founding document of family therapy by some (Broderick & Schrader, 1991) 1958, The Psychodynamics of Family Life, first book-length treatise of diagnosis and treatment of family relationships A psychologist at Clark University in Worcester, Mass. John Bell’s “mistake” - met w/John Sutherland from the Tavistock Clinic in London - Sutherland described the work of John Bowlby seeing whole families and Bell took him to mean altogether in one room at the same time, but Sutherland meant individual interviews with each family member - Bell went back to US and began seeing families conjointly - reported his work in 1953 to other psychiatrists but it didn’t have much impact Ackerman: “I went to see first hand, the mental health effects on the families of unemployed miners. The experience was a shocker; I was startlingly awakened to the limitless, unexplored territory in the relations of family life and health. I studied 25 families in which the father, the sole breadwinner in the mining community, had been without work for between two and five years. The miners, long habituated to unemployment, idled their empty hours on the street corner, or in the neighbourhood saloon. They felt defeated and degraded. They clung to one another to give and take comfort and to pass away the endless days of inactivity. Humiliated by their failure as providers, they stayed away from home; they felt ashamed before their wives. The wives and mothers, harassed by insecurity and want from day to day, irritably rejected their husbands; they punished them by refusing sexual relations. The man who could no longer bring home his pay envelope was no longer the head of the family. He lost his position of respect and authority in the family; the woman drove him into the streets. Often, she turned for comfort to her first son. Mother and son then usurped the leadership position within the family. Among these unemployed miners, there were guilty depressions, hypochondriacal fears, psychosomatic crises, sexual disorders, and crippled self-esteem. The configuration for family life was radically altered by the miner’s inability to fulfill his habitual role as provider.”

Theodore Lidz (1911–2001) interest in families of schizophrenics, 1941 developed concepts of ‘marital schism’ (distant and hostile) and ‘marital skew’ (one partner dominating the other) consulting editor of Family Process in 1961 Lyman Wynne ( ) saw families starting in 1947 1952, worked with families of schizophrenics at NIMH took over for Bowen in 1959 as Chief of Family Research in 1956/57, attended APA meetings with Bowen, Jackson, Lidz & Ackerman Developed concepts of pseudomutuality and pseudohostility

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” Bowen Studied mostly mom’s and kids, too complicated to get dads kept them for one to two months at a time Bowen’s project at NIMH was seen as the “Camelot” of research by Jackson & others Observations of symbiosis led him to the idea of differentiation which became a cornerstone of his theory

Bowen (cont’d) 1959, Bowen published “Intensive Family Therapy”, where he introduced the idea of triangulation NIMH project was restricted in budget because it was producing results that were “heretical to prevalent ideologies” (according to Bowen); Bowen decided to leave NIMH for Georgetown University 1966, Bowen produces the first major theoretical paper on family systems, “The Use of Family Theory in Clinical Practice” – described six major concepts of Bowen theory 1967, the “Anonymous Paper” was presented at the Family Research Conference to a shocked audience Anonymous paper was called that because the original editor and publisher were overly concerned about publishing such personal material and anonymous authorship helped to resolve the issue the paper was a personal account of Bowen’s application of his theory of differentiation to his own family Panel discussion included: Watzlawick (chair), Weakland, Whitaker Participants included: Bell, Minuchin, Ackerman

Carl Whitaker 1943, Oakridge TN – w/John Warkentin, brought spouses and children into sessions with patients Pioneered the use of cotherapy in treatment , saw 30 couples in conjoint marital therapy Uses a variety of experiential methods to loosen people up and get them in touch with their immediate experience

Ivan Boszormenyi-Nagy 1957, founded the Eastern Pennsylvania Psychiatric Institute in Philadelphia, a center for research and training in families and schizophrenia 1965, edited Intensive Family Therapy with James Framo, which brought together work being done on schizophrenia and the family from around the country Trained such therapists as James Framo, David Rubenstein, Geraldine Spark, Gerald Zuk Introduced the criterion of morality to therapeutic goals and techniques (e.g. trust, loyalty, ledger of entitlement & indebtedness)

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 1970’s it was the world’s leading center for Family Therapy and training (Nichols & Schwartz, 1995) Developed Structural Family Therapy, 1974

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” (Broderick & Schrader in Gurman & Kniskern, 1991) 1959, Jackson forms MRI, independent of Bateson project, Satir joins him from Chicago 1959, Jackson coins the term ‘conjoint therapy’ 1960, Jackson agrees w/Ackerman to co-sponsor Family Process, first journal devoted to family therapy - Bateson - anthropologist & philosopher, married to Margaret Mead, anthropologist - developed modern systems theory and cybernetics - Haley - communications theorist - sent to study Erikson & hypnotherapy - developed paradoxical approach of MRI - Weakland - chemical engineer & anthropologist - analysed communication in film - Jackson - psychiatrist, worked with schizophrenics - Satir - worked and taught at the Chicago Psychiatric Institute - started seeing families in 1951 - “probably more than any other early founder, she was responsible for popularizing the movement” (Broderick & Schrader, p. 29)

Palo Alto Group 1967, Beavin, Watzlawick & Jackson produce The Pragmatics of Human Communication 1967, Watzlawick, Bodin, Weakland & Fisch form the Brief Therapy Center at MRI January 1968, Don Jackson dies at the age of 48 Jackson was described as one of the top ten psychiatrists of his time and his death was a huge loss to the budding field of Family Therapy

Palo Alto Group Jackson borrowed from biology and systems theory and created a new language of psychotherapy: Family homeostasis Symptoms have function Rules hypothesis Complementary/symmetrical Quid pro quo (couples, not gender, make the rules) Double bind Jackson was described as one of the top ten psychiatrists of his time and his death was a huge loss to the budding field of Family Therapy

Palo Alto Group Jay Haley – control is everything (M. Erickson) Symptoms must be outwitted by smart therapists Symptoms are used by the patient to gain control Therapist prescribes treatment Paradoxical prescriptions to “outwit” the patient’s resistance Jackson was described as one of the top ten psychiatrists of his time and his death was a huge loss to the budding field 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) Jackson was described as one of the top ten psychiatrists of his time and his death was a huge loss to the budding field of Family Therapy

From Streams to a River March 1957, John Spiegel organized a panel on Family Research for the Orthopsychiatry Association this was the first national meeting where ideas on family research on schizophrenia were presented Spiegel, Bowen, Lidz, & David Mendel (who later developed Multiple Impact Therapy) met and shared their work June 1957, APA meeting in Chicago, another panel on family research on schizophrenia Ackerman, Jackson, Bowen, & Lidz presented this conference led to Jackson’s book, The Etiology of Schizophrenia (1959)

From Streams to a River The way ideas evolve (Chapter 2, Nichols and Schwartz) Many competing ideas One dominant idea Supplanted by another dominant idea

From Streams to a River Arising from competing ideas:
The power of the psyche (Freud) Environmental reinforcers (behaviourists) The power of the family (family therapy)

From Streams to a River Family Therapy as the Most Recent Big Idea
Essentialist (zeal) Transitional (okay, maybe it’s not the miracle cure) Ecological (integrative?)

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

Break!

The Family Life Cycle and Coping with Illness
William Corrigan, BA, MTS Couple and Family Therapist AAMFT Approved Supervisor

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 family system Families may become stuck or frozen in one stage of development Goal is to help family become unstuck so development can continue

The Family Life Cycle Six stages: 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

The Family Life Cycle Leaving Home: Single Young Adults
Accepting responsibility for oneself financially, emotionally Differentiation/individuation Development of intimate peer relationships Establishing oneself in work/career Develop identity separate from family Staying connected in a meaningful way Shifting roles

The Family Life Cycle 2) The Joining of Families Through Marriage:
The New Couple Commitment to a new system Realignment of relationships to include partner Forming new rituals and traditions Creating new rules and roles Negotiating boundaries Intimacy ↔ Autonomy (do they really know what they’re getting into?)

The Family Life Cycle 3) Families with Young Children
Accepting new members into the system Adjustment of marital system to allow for children Joining in child rearing, financial and household tasks; values, traditions, rituals, etc. Realignment of relationships to include parenting and grand-parenting roles Time management and shifting priorities Balancing obligations between nuclear family, extended family and outside Fertility issues

The Family Life Cycle 4) Families with Adolescents
Increasing boundaries to allow independence Shifting of relationships to allow adolescent to move in and out of the system Negotiate roles and responsibilities Power struggles and managing conflict Refocus on midlife marital and career issues Begin shift toward caretaking of older generation (“sandwich” generation)

The Family Life Cycle 5) Launching Children and Moving On
Accepting a multitude of exits from and entries to family system Renegotiation of marital system as a dyad Development of adult-adult relationships with children Realignment of relationships to include in-laws and grandchildren Refocusing energy on self, partner, and future Planning for retirement Involvement in care for older generation

The Family Life Cycle 6) Families in Later Life
Accepting shifting generational roles Maintaining functioning in face of decline Supporting older generation without over- functioning for them Dealing with loss of parents and extended family Dealing with loss of spouse, siblings, and peers Coping with illness and disability; loss of function Preparing for death

The Family Life Cycle “Normal” is defined in many ways, with influence from culture, ethnicity, religion, and wider society (e.g. enmeshment) Stress is often the greatest at transition points between stages as system adapts to changes It is assumed that developmental tasks that aren’t resolved “pile up” and create stress or further problems in the family system Can be used to predict challenges for family and to normalize experience

The Family Lifecycle & Stressors
Horizontal stressors include: Developmental Unpredictable Historical events Vertical stressors include the impact of past and present issues at various levels of each system at a point in time System levels include: Individual, immediate family, extended family, community and larger society

The Family Life Cycle & Stressors
Stress on one axis will be greatly compounded by stress on the other axis “When a horizontal stress intersects with a vertical stress, there seems to be a huge leap in anxiety in the system” (Carter, 1978) The onset of symptoms has been found to correlate significantly with the addition or loss of a family member (Hadley, 1974)

Time Phases of Illness (Rolland, 1994)
Shows the dynamic unfolding of the illness process over time (vs. static state) Each phase has its own psychosocial demands and tasks which require different strengths or changes from family

Time Phases of Illness: Crisis
Pull together to cope with immediate crisis (↑ cohesion) Learning to cope with symptoms or disability Adapting to health care settings and treatments Establishing and maintaining workable relationships with health care team Family must grieve the loss of life they knew before illness Gradually accept illness as permanent while maintaining a sense of continuity between past and future Family needs to create a meaning for the illness that maximizes a sense of mastery and competency Develop flexibility toward future goals, reorienting hopes and dreams

Time Phases of Illness: Chronic
Time span between initial diagnosis/readjustment and terminal phase Can be marked by constancy, progression, or episodic change Referred to as “the long haul”; day-to-day living with illness Maintain semblance of normal life while living with illness and uncertainty Family may feel saddled with an exhausting problem without end Maintaining maximum autonomy for all family members helps offset trapped, helpless feelings

Time Phases of Illness: Terminal
Inevitability of death becomes apparent and dominates family life Family must cope with issues of separation, death, mourning, and resumption of family life beyond loss Families that adapt the best are able to shift their view of mastery from controlling the illness to a successful process of letting go Optimal coping involves emotional openness as well as dealing with the myriad of practical tasks at hand Tension between desire for intimacy and push to let go

Time Phases of Illness Interplay between illness, individual and family life cycles Goodness of fit between psychosocial demands of illness and family style of functioning and resources distinguish successful vs. dysfunctional coping and adaptation Transition periods in illness life cycle are times to re-evaluate structure “Unfinished business” from previous phase can block transition

Time Phases of Illness Illness and disability tend to push individual and family developmental processes toward transition and increased cohesion What is the fit between the psychosocial demands of a condition and family and individual life structures and developmental tasks at a particular point in the life cycle? How will this fit change as the course of the illness unfolds in relation to the family life cycle and the development of each member?

Time Phases of Illness When inward pull of illness and phase of the life cycle coincide, there is a risk that they will amplify one another e.g. child-rearing When onset of illness coincides with a transition in family or individual life cycle, issues related to previous, current, and anticipated loss will be magnified By adopting a longitudinal perspective, we can stay attuned to future transitions in illness, individual or family life cycles

Exercise: Family Sculpting
Experiential exercise with families or groups Create a sculpture (a.k.a. tableau) of family members Use physical space to represent issues Expressed through non-verbals: body posture, closeness/distance, facial expressions, gestures, sometimes props Divide into small six small groups Sculpt one family w/illness in one life cycle stage Try to depict the issues present

Family Life Cycle and Illness
Leaving Home: Single Young Adults Non-normative or “out of sync” w/life cycle Illness or disability in a young adult may require a heightened dependency and a return to the family of origin for caretaking A serious illness provides a sanctioned reason to return to the “safety” of the child-rearing period (secondary gain) Risk of over-protection, triangulation

The Joining of Families Through Marriage: The New Couple My problem vs. our problem Boundaries with in-laws Gender socialization and rigid roles Sustaining intimacy depends largely on establishing viable caregiving boundaries Long-term viability of relationship may depend on openly discussing and legitimizing both partners’ needs

Families with Young Children Challenge of what to say, how much, and when Being realistic vs. maintaining hope/optimism Financial strain of lost wages, time off, etc. Impact on child-rearing is twofold: one parent lost to illness and other’s presence diminished by caregiving demands – feels like single-parent family Children can become parentified Grandparents may be recruited to help, creating other tensions and developmental “detour”

Families with Adolescents Conflict of need for increased cohesion and increasing need for autonomy Risk of parentification Shift in roles and responsibilities can create resentment/conflict Challenges of discipline: guilt, acting-out, etc. Balancing emotional needs and self-care Fear of abandonment

Launching Children and Moving On Illness can be more disruptive in launching stage because inward pull for cohesion clashes with need for autonomy Loyalty conflicts Demands of present vs. future planning Allocating resources Developmental regression in children

Families in Later Life Longer life expectancy means ever-growing numbers of families are coping with chronic disorders over an increasingly greater part of life cycle Concerns for an ill parent can be projected onto one`s spouse creating conflict or distance Attending to unfinished business Differentiate between each partner’s need for space vs. distancing from fear

Lunch!

The McMaster Model of Family Functioning
Has anyone hear of the McMaster model? Does anyone have experience using it? If so, where and when… Used in CAS for home studies for foster care placement and adoption Easy to learn, intuitive sense Will review model then look at clinical rating scales which may be useful in assessing families

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

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

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 The development of the MMFF is grounded in some basic assumptions of systems theory

Assumptions (cont’d) A family’s 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 Note the emphasis on transactional patterns – a piece emphasized in family therapy that was downplayed or sometimes ignored in psychotherapy

Six Dimensions of Family Functioning
Problem Solving Communication Role Functioning Affective Responsiveness Affective Involvement Behaviour Control Excellent summary of these in Table 4.1 (pp ) of the chapter from Walsh

Problem Solving Refers to a family’s 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) Families that have difficulty coping with instrumental problems almost always struggle with affective problems while the reverse is not necessarily true – could struggle with affective problems and be fine with instrumental ones

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 It is believed that healthier families: complete most if not all the steps and have fewer unresolved problems It may be hard to tell that healthy families have worked through all seven steps because they may not be able to describe the process they use since it appears second nature It is easier to identify families that have difficulty with the steps The lower the functioning, the less steps completed in the problem solving process A normal family may have some unresolved problems but they do not interfere with effective family functioning (e.g. parents disagree on how to discipline a child but remain a ‘united front’ in front of the children) Only the most effective families evaluate the problem solving process Difficulties with instrumental problems lead to lower rating than difficulty with only affective problems

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 Clear vs. masked = is the message clear or is it camouflaged, muddied or vague Direct vs. indirect = is the message directed to the appropriate person (e.g. triangles, detouring, not speaking to someone, etc.) One criticism of the MMFF could be it’s focus on verbal communication. It does so because it’s attempting to describe objective criteria and there is too much room for subjective interpretation in trying to describe and analyse non- verbal communication. The MMFF is used in a lot of research and they needed it to have specific criteria in order to produce high reliability and validity. Discrepancies between verbal and non-verbal communication can be captured as ‘masked’ or under another area such as roles or affective responsiveness The level of health or pathology in parents’ communication should be weighed more heavily than that of children The lower the level of communication functioning in a single member, dyad, or triad, the lower the overall rating The greater the number of family members at a lower level of health/pathology in the communication area, the lower the overall rating of the family

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 1 includes money, food, clothing and shelter 2 includes comfort, warmth, reassurance and emotional support 3 includes mutual satisfaction with sexual relationship 4 includes developing skills for personal achievement 5 includes a variety of functions: decision making, boundaries, behavioural control, household finance, health-related functions

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 Healthy families assign roles in a reasonable fashion, roles are age appropriate and encourage personal development Necessary functions are fulfilled and there are clear lines of accountability Effective families share roles which allows for flexibility Imagine how this applies to families with a ill member – what might happen?

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 Think of response as being measured on an arc, with too little on one end, just enough in the middle, and too much on the other end

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 Healthy families are able to express a full range of emotions, and experience appropriate emotions in a given context with reasonable intensity and duration Consider cultural variability in expression In healthy families, inappropriate displays of affect are not disruptive to family functioning

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 Keep in mind the individual life cycle and the family life cycle as this area is discussed re. what is normal ie. adolescence

Affective Involvement
Six types of involvement: Lack of involvement Involvement devoid of feelings Narcissistic involvement Empathic involvement Over-involvement Symbiotic involvement 2 some interest, primarily intellectual 3 interest only to the degree that it reflects the self eg. Searching for Bobby Fisher; social psychology concept BIRGing – basking in reflected glory See also Dwight (Robert De Niro) in This Boys Life re. scouting 4 seen as optimal, involved for the sake of others 5 excessive interest in one another 6 an extreme and pathological involvement in others, lack of differentiation 4 is the best; followed by 2, 3 or 5; 1 and 6 are the worst (most disturbed)

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

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 Descending in effectiveness from 2 to 1 to 3 to 4 In effective families, there may be small inconsistencies but they do not affect family functioning Focus on consistency and flexibility

Case Study watch the clip use the rating scale to assess this family
72

Introducing the DSM-5 Carl and William

“Open it up. It looks scientific.”
- Robert Spitzer, chair of the task force that created DSM-III

“Suicide rates are unchanged over the last 115 years, so we aren’t getting anywhere.” - David Mays, Psychiatrist

Disease a condition of a living animal or plant or of one of its parts that impairs normal functioning typically manifested by distinguishing signs and symptoms

Signs and Symptoms Signs: something you can see that points to the underlying disease Symptom: something the patient complains about that indicates something is wrong

Signs and Symptoms “I have a fever” is a symptom (something the patient complains about) An elevated temperature is a sign (something you can see)

Physical Disease Significant research into underlying causes
e.g. infection->immune response- >pyrogens->hypothalamus->raised body temperature

Mental Disorder What are the signs and symptoms of a mental disorder?
Is a mental disorder a disease? What do we know about the underlying mechanisms?

DSM vs. ICD The World Health Organization created the International Classification of Diseases so that health providers around the world would have a common language to talk about causes of death

ICD-CM The Clinical Modification of the ICD so that health providers could talk a common language of disease while treating people who were still alive

DSM The Diagnostic and Statistical Manual of Mental Disorders was probably first created as a way of making sure that asylum patients were included in the census It later became an expansion of the ICD- CM around mental illness, so that psychiatrists and psychologists around the world could talk the same language

DSM-ICD ICD-7 1950ish -> DSM I ICD-8 -> DSM II
ICD > DSM III

Early DSM DSM I and II were descriptive, psychodynamically-based books
A prototypical description of a particular illness was given Clinicians would decide if their patient fit the prototype

Diagnosis by prototype is culturally dependent
London: Manic-Depressive illness New York: Schizophrenia Using: same prototype

WHO 1959 We should at least describe well
If two people across the globe could come up with the same diagnosis, at least we would be reliable

DSM-III (1980) Made a fundamental break with ICD-9
Became more observational and descriptive, less psychodynamic Effort to increase reliability

DSM-III Introduced algorithm Diagnosis is no longer a clinical art
Just follow the steps

DSM-IIIR and IV Introduced Axes Diagnosis Personality/MR Medical
Social GAF

DSM-5 Task Force Headed by David Kupfer Seconded by Darrel Regier
Stringent conflict of interest guidelines (no drug companies)

Etiology is Still Unclear, but...
decided to make DSM-5 more developmentally based, and to speak to etiology arranged by common genetics narrative on predisposing factors

Elimination of Axes Axis I - dystonic (don’t like it, seek treatment)
Axis II - syntonic (doesn’t seem like a problem, avoid treatment)

Noble Intention, Unforeseen Consequence
Personality Disorders and Mental Retardation were put on Axis II so that they would receive attention They received increased stigmatization, and less funding for treatment

DSM-5 Reintegrates personality disorders and developmental delays to reduce stigma, enhance funding for treatment

The Other Axes Axis III - already on Axis I of ICD
Axis IV - psychosocial, integrated as V codes in ICD-9 and Z codes in ICD-10 Axis V - nobody misses the GAF

In Place of the GAF The WHODAS
See the chapter on assessment measures in the DSM-5

DSM-5 Better diagnostic tests quick screening (WHODAS)
in depth (PROMIS)

Less Pressure to Find a Single Diagnosis
You can list as many diagnoses as you like

Change in Epistemology
Recognizes that life is not categorical, but we need categories anyway

More Psychodynamic Reintegrates what was lost from DSM I and II

Not Everyone Hates It “I love this book...best DSM ever written.” Jack Klott

Unintended Consequences
In the DSM-5, each diagnosis has a list of predisposing factors e.g. socially isolated child, predisposing factor is severe child abuse So what might you conclude if you see a socially isolated child?

plus ca change... “The history of the DSM is a history of unintended consequences” - Rich Simon

Specific Changes Disruptive Mood Dysregulation Disorder 296.99 (F34.8)
Hopefully will reduce the diagnosis of bipolar disorder in children

Specific Changes PTSD Now you not only can get it by being in a traumatic situation Now you can also get it by hearing about a traumatic situation

Specific Changes What is the only behavioural addiction in the DSM-5?

Specific Changes Can you be grieving and depressed at the same time?

Specific Changes Does anyone have Asperger’s Disease anymore?
Porn addiction? Sex addiction? Any addiction? Is there such a thing as drug dependence?

Functional Consequences
Change the way we think about people Realize how this diagnosis helps this person get along in the world (Sounding more and more like MFTs)

GAD or PTSD? A 7-year-old boy who lives in New Orleans with a pervasive, disabling, disruptive fear of hurricanes (hint: Mom and Dad lived through Katrina)

DSM-5 will make notetaking more difficult
Discourages simple, categorical diagnosis Requires more complex, narrative diagnosis Much like MFT :)

Maybe Too Complex Less clinical usefulness
Increased concern about third-party funding “It could be fun” - Jack Klott

Recommended Reading Allen Frances, Essentials of Psychiatric Diagnosis
Allen Frances, Saving Normal Joel Paris, The Intelligent Clinician’s Guide to the DSM-5 Joel Paris and James Phillips, eds, Making the DSM-5

Assignments Date Disorder Presenter Nov 15 Patti & Karen Nov 29
Schizophrenia Amy Chris Bipolar Patti & Karen Nov 29 Depression Andrew & Dulcie Anxiety/OCD/Trauma Inge & Heather Dec 6 Sex, Drugs and Food Mimi & Janet Neurodevelopment Mari Dec 13 Personality Nany & Monica Others Nat, Debbie & Keehan

Class Presentation Core elements (DSM-5) Family etiology
Impact on the family Treatment of the individual & family

The Quiz Is based on what happens in class Pay attention

The Final Paper Have fun Show us you learned something

The Final Paper Case study of an individual, couple or family with a mental health disorder Fictitious (movie, TV, novel, imagination)

The Final Paper Genogram Case history Family system Presenting problem

The Final Paper Your treatment of the family as an MFT
Who else is treating the family? How did you get involved?

The Final Paper Treatment goals Likely progression of the family
Medications that might be used

The Final Paper Contextual considerations Future directions

Family Therapy and Mental Health

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