Youth Homicide

Youth And Firearms
In the United States today, children and young adults are at greater risk of becoming victims of violence than any other age group.1 In 1998, firearm-related injuries were the second leading cause of death for persons aged 15 to 19. They were the leading cause of death for African-American and Hispanic youth.2

Youth Victim Statistics
•Most young homicide victims are killed with guns. In 1998, 82 percent of homicide victims 15 to 19 years old were killed with firearms. The firearm homicide rate for this age group increased 44 percent between 1987 and 1998.3
•In 2000, one in eight people murdered was younger than 18 years old.3
•Homicides of juveniles ages 15 to 17 were more likely to involve a firearm than were homicides of adults.4
•Firearms were involved in 3,761 deaths of children aged 19 and under in 1998. That is 10 children everyday. Of these, 2,184 were murdered, 1,241 committed suicide, and 262 were victims of accidental shootings.5
Youth Perpetrator Statistics
•Between 1980 and 1997, the large majority (93 percent) of known juvenile homicide offenders were male.6
•Males are far more likely than females to kill with a firearm. Between 1980 and 1997, 73 percent of male juvenile homicide offenders used a firearm, while 14 percent used a knife. In contrast, 41 percent of female juvenile offenders used a firearm and 32 percent used a knife.6
•In a study regarding gun acquisition and use by juvenile offenders, 84 percent of the gun carriers reported acquiring their first gun before the age of 15. They also reported feeling safer, more powerful, and excited when carrying a gun.7
•One study of urban juvenile arrestees found that more than two-thirds of the juveniles said their primary reason for owning and carrying a weapon was self-protection. A smaller number also reported using their weapon for drug trafficking or other illegal activity.8
Carrying or Possession of Firearms
•Having a parent who owned a gun for sport increased the odds more than fivefold that a boy owned a gun for sport. However, parental gun ownership had no impact on the likelihood that a boy owned a gun for protection. Conversely, having peers who owned guns for protection increased the odds more than sixfold that a boy owned a gun for protection.8
According to the 1999 Youth Risk Behavior Survey:

•Nearly 20 percent of the students surveyed reported carrying a weapon during the past 30 days.9
•Male students (28.6 percent) were more likely than female students (6 percent) to report carrying a weapon.9
•African-American and Hispanic female students (11.7 percent and 8.4 percent, respectively) were more likely than white female students (3.6 percent) to have carried a weapon.9
Alcohol and Other Drug-Related Firearm Violence
Drugs and firearms are connected in three ways:

1.Drugs can induce criminal or violent activity.
2.Crimes are committed by drug users to support their addictions.
3.Crimes committed by drug users are an integral part of doing business.10
Youth who had ever used marijuana were more likely to have carried a handgun (21 percent vs. 7 percent) at some point than youth who never used marijuana.6 In addition, a longitudinal study of 1,500 young males in Pittsburgh showed a higher frequency of carrying a concealed weapon in the year they started dealing drugs.11

REFERENCES
1.Rennison, C.M. Criminal Victimization 2000: Changes 1999-2000 with Trends 1993-2000. Publication No. NCJ 187007. Washington, DC: Bureau of Justice Statistics, 2001.
2.America's Children: Key National Indicators of Well-Being. Bethesda, MD: National Institute of Child Health and Human Development, 2001.
3.National Center for Injury Prevention and Control. Injury Fact Book 2001-2002. Atlanta: Centers for Disease Control and Prevention, 2001.
4.1999 National Report Series: Kids and Guns. Washington, D.C. Office of Juvenile Justice and Delinquency Prevention, 1999.
5.In America...Facts on Youth, Violence and Crime. Washington, DC: Childrens' Defense Fund, 2001, www.childrensdefense.org.
6.Snyder, H.N., and Sickmund, M. Juvenile Offenders and Victims: 1999 National Report. Washington, D.C. Office of Juvenile Justice and Delinquency Prevention, 1999.
7.Ash, P.; Kellermann, A.L.; Fuqua-Whitley, M.A.; et al. (1996). Gun acquisition and use by juvenile offenders. JAMA 275(2):1754-1758.
8.Lizotte, A., and Sheppard, D. Gun Use by Male Juveniles: Research and Prevention. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, 2001.
9.Kann, L.; Kinchen, S.A.; Williams, B.I.; et al. (2000). Youth Risk Behavior Surveillance United States, 1999. Morbidity and Mortality Report 49(SS05):1-96.
10.Eliot, D.S. Youth Violence: An Overview. Boulder, CO: Center for the Study and Prevention of Violence, 1994.
11.Van Kammen, W., and Loeber. R. Delinquency, Drug Use and the Onset of Adolescent Drug Dealing. Pittsburgh: University of Pittsburgh, 1994.

Mood Disorders

MOOD DISORDERS CEUs
How much of the population is affected by mood disorders?
Each year, almost 44 million Americans experience a mental disorder. In fact, mental illnesses are among the most common conditions affecting health today.
What causes mood disorders / mental illness?
Researchers believe most serious mental illnesses are caused by complex imbalances in the brain's chemical activity. They also believe environmental factors can play a part in triggering, or cushioning against, the onset of mental illness.
Are mood disorders treatable?
Like other diseases, mental illnesses can be treated. The good news is that most people who have mental illnesses, even serious ones, can lead productive lives with proper treatment. Mood disorders are one form of serious mental illness.
What are some common mood disorders?
Two of the most common mood disorders are depression and bipolar disorder, also known as manic-depressive illness.
Bipolar Disorder
Description: Extreme mood swings punctuated by periods of generally even-keeled behavior characterize this disorder. Bipolar disorder tends to run in families. This disorder typically begins in the mid-twenties and continues throughout life. Without treatment, people who have bipolar disorder often go through devastating life events such as marital breakups, job loss, substance abuse, and suicide.
Symptoms: Mania-expansive or irritable mood, inflated self-esteem, decreased need for sleep; increased energy; racing thoughts; feelings of invulnerability; poor judgment; heightened sex drive; and denial that anything is wrong. Depression-feelings of hopelessness, guilt, worthlessness, or melancholy; fatigue; loss of appetite for food or sex; sleep disturbances, thoughts of death or suicide; and suicide attempts. Mania and depression may vary in both duration and degree of intensity.
Formal Diagnosis: Although scientific evidence indicates bipolar disorder is caused by chemical imbalances in the brain, no lab test exists to diagnose the disorder. In fact, this mental illness often goes unrecognized by the person who has it, relatives, friends, or even physicians. The first step of diagnosis is to receive a complete medical evaluation to rule out any other mental or physical disorders. Anyone who has this mental illness should be under the care of a psychiatrist skilled in the diagnosis and treatment of bipolar disorder.
Treatment: Eighty to ninety percent of people who have bipolar disorder can be treated effectively with medication and psychotherapy. Self-help groups can offer emotional support and assistance in recognizing signs of relapse to avert a full-blown episode of bipolar disorder. The most commonly prescribed medications to treat bipolar disorder are three mood stabilizers: lithium carbonate, carbamazepine, and valproate.
Depression
Description: When a person's feelings of sadness persist beyond a few weeks, he or she may have depression. According to the National Institute for Mental Health, three to four million men are affected by depression; it affects twice as many women. Researchers do not know the exact mechanisms that trigger depression. Two neurotransmitters-natural substances that allow brain cells to communicate with one another-are implicated in depression: serotonin and norepinephrine.
Symptoms: Changes in appetite and sleeping patterns; feelings of worthlessness, hopelessness, and inappropriate guilt; loss of interest or pleasure in formerly important activities; fatigue; inability to concentrate; overwhelming sadness; disturbed thinking; physical symptoms such as headaches or stomachaches; and suicidal thoughts or behaviors.
Formal Diagnosis: Four or more of the previous symptoms have been present continually, or most of the time, for more than 2 weeks. The term clinical depression merely means the episode of depression is serious enough to require treatment. Major depression is marked by far more severe symptoms, such as literally being unable to drag oneself out of bed. Another form of depression, known as seasonal affective disorder, is associated with seasonal changes in the amount of available daylight.
Treatment: Some types of cognitive/behavioral therapy and interpersonal therapy may be as effective as medications for some people who have depression. Special bright light helps many people who have seasonal affective disorder.
Three major types of medication are used to treat depression: tricyclics; the newer selective serotonin re-uptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAO inhibitors). Electroconvulsive therapy uses small amounts of electricity applied to the scalp to affect neurotransmitters in the brain. Usually referred to as ECT, this highly controversial and potentially life-saving technique is considered only when other therapies have failed, when a person is seriously medically ill and/or unable to take medication, or when a person is very likely to commit suicide. Substantial improvements in the equipment, dosing guidelines and anesthesia have significantly reduced the possibility of side effects.
For more information and referrals to specialists and self-help groups in your State, contact:
Depression and Bipolar Support Alliance (DBSA) (formerly the National Depressive and Manic-Depressive Association)
730 N. Franklin Street, Suite 501
Chicago, IL 60601-3526
Telephone: 800-826-3632
Fax: 312-642-7243
www.dbsalliance.org

Facts on Mental Health Disorders

Anxiety Disorders
Panic DisorderPanic disorder affects about 2.4 million adult Americans and is twice as common in women as in men. A panic attack is a feeling of sudden terror that often occurs with a pounding heart, sweating, nausea, chest pain or smothering sensations and feelings of faintness or dizziness. Panic disorder frequently occurs in addition to other serious conditions like depression, drug abuse, or alcoholism. If left untreated, it may lead to a pattern of avoidance of places or situations where panic attacks have occurred. In about a third of cases, the threat of a panic attack becomes so overwhelming that a person may become isolated or housebound—a condition known as agoraphobia. Panic disorder is one of the most treatable of the anxiety disorders through medications or psychotherapy. Early treatment of panic disorder can help prevent agoraphobia.

Obsessive-Compulsive Disorder (OCD)

OCD affects about 3.3 million adult Americans, and occurs equally in men and women. It usually appears in childhood. Persons with OCD suffer from persistent and unwelcome anxious thoughts, and the result is the need to perform rituals to maintain control. For instance, a person obsessed with germs or dirt may wash his hands constantly. Feelings of doubt can make another person check on things repeatedly. Others may touch or count things or see repeated images that disturb them. These thoughts are called obsessions, and the rituals that are performed to try to prevent or get rid of them are called compulsions. Severe OCD can consume so much of a person's time and concentration that it interferes with daily life. OCD responds to treatment with medications or psychotherapy.

Post-Traumatic Stress Disorder (PTSD)

PTSD affects about 5.2 million adult Americans, but women are more likely than men to develop it. PTSD occurs after an individual experiences a terrifying event such as an accident, an attack, military combat, or a natural disaster. With PTSD, individuals relive their trauma through nightmares or disturbing thoughts throughout the day that may make them feel detached, numb, irritable, or more aggressive. Ordinary events can begin to cause flashbacks or terrifying thoughts. Some people recover a few months after the event, but other people will suffer lasting or chronic PTSD. People with PTSD can be helped by medications and psychotherapy.

Generalized Anxiety Disorder (GAD)

GAD affects about 4 million adult Americans and twice as many women as men. GAD is more than day-to-day anxiety. It fills an individual with an overwhelming sense of worry and tension. A person with GAD might always expect disaster to occur or worry a lot about health, money, family, or work. These worries may bring physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, trouble swallowing, trembling, twitching, irritability, sweating, and hot flashes. People with GAD may feel lightheaded, out of breath, or nauseous, or might have to go to the bathroom often. When people have mild GAD, they may be able to function normally in social settings or on the job. If GAD is severe, however, it can be very debilitating. GAD is commonly treated with medications.

Social Anxiety Disorder

Social phobia affects about 5.3 million adult Americans. Women and men are equally likely to develop social phobia, which is characterized by an intense feeling of anxiety and dread about social situations. These individuals suffer a persistent fear of being watched and judged by others and being humiliated or embarrassed by their own actions. Social phobia can be limited to only one type of situation—fear of speaking in formal or informal situations, eating, drinking, or writing in front of others—or a person may experience symptoms any time they are around people. It may even keep people from going to work or school on some days, as physical symptoms such as blushing, profuse sweating, trembling, nausea, and difficulty talking often accompany the intense anxiety. Social phobia can be treated successfully with medications or psychotherapy.

Attention-Deficit/Hyperactivity Disorder (ADHD)

ADHD affects as many as 2 million American children and is a diagnosis applied to children and adults who consistently display certain characteristic behaviors over a period of time. The most common behaviors fall into three categories: inattention, hyperactivity, and impulsivity. People who are inattentive have a hard time keeping their mind on any one thing and may get bored with a task after only a few minutes. People who are hyperactive always seem to be in motion. They can't sit still and may dash around or talk incessantly. People who are overly impulsive seem unable to curb their immediate reactions or think before they act. Not everyone who is overly hyperactive, inattentive, or impulsive has an attention disorder. While the cause of ADHD is unknown, in the last decade, scientists have learned much about the course of the disorder and are now able to identify and treat children, adolescents, and adults who have it. A variety of medications, behavior-changing therapies, and educational options are already available to help people with ADHD focus their attention, build self-esteem, and function in new ways.


Depressive Disorders
About 18.8 million American adults experience a depressive illness that involves the body, mood, and thoughts. Depression affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. People with a depressive illness cannot just "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years.



Depression can occur in three forms:
Major Depressive Disorder


Major depressive disorder involves a pervading sense of sadness and/or loss of interest or pleasure in most activities that interferes with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. This is a severe condition that can impact a person's thoughts, sense of self worth, sleep, appetite, energy, and concentration. The condition can occur as a single debilitating episode or as recurring episodes.

Dysthymia
Dysthymia involves a chronic disturbance of mood in which an individual often feels little satisfaction with activities of life most of the time. Many people with dysthymia also experience major depressive episodes in their lives leading to a recurrent depressive disorder. The average length of an episode of dysthymia is about four years.

Bipolar Disorder
Bipolar Disorder, or manic-depressive illness, is a type of mood disorder characterized by recurrent episodes of highs (mania) and lows (depression) in mood. These episodes involve extreme changes in mood, energy, and behavior. Manic symptoms include extreme irritable or elevated mood; a very inflated sense of self-importance, risk behaviors, distractibility, increased energy, and a decreased need for sleep.

The most important thing to do for people with depression is to help them get an appropriate diagnosis and treatment. Treatment, usually in the form of medication or psychotherapy, can help people who suffer from depression.

*Do not ignore remarks about suicide.
If someone tells you they are thinking about suicide, you should take their distress seriously, listen, and help them get to a professional for evaluation and treatment. If someone is in immediate danger of harming himself or herself, do not leave the person alone. Take emergency steps to get help, such as calling 911. You can also call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).




Eating Disorders
Anorexia Nervosa


People with this disorder see themselves as overweight despite their actual body weight. With this disorder, a person works to maintain a weight lower than normal for their age and height. This is accompanied by an intense fear of weight gain or looking fat. At times, a person can even deny the seriousness of their low body weight. Eating becomes an obsession and habits develop, such as avoiding meals, picking out a few foods and eating these in small quantities, or carefully weighing and portioning food. People with anorexia may repeatedly check their body weight, and many engage in other techniques to control their weight, like compulsive exercise or purging by vomiting or using laxatives. Some people fully recover after a single episode; some have a pattern of weight gain and relapse; and others experience a deteriorating course of illness over many years.

Bulimia Nervosa
Bulimia is characterized by episodes of binge eating—eating an excessive amount of food at once with a sense of lack of control over eating during the episode—followed by behavior in order to prevent weight gain, such as self-induced purging by vomiting or misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. Because purging or other compensatory behavior follows the binge-eating episodes, people with bulimia usually weigh within the normal range for their age and height. However, like individuals with anorexia, they may fear gaining weight, desire to lose weight, and feel dissatisfied with their bodies. People with bulimia often perform the behaviors in secrecy, feeling disgusted and ashamed when they binge, yet relieved once they purge.


Schizophrenia
More than 2 million Americans a year experience this disorder. It is equally common in men and women. Schizophrenia tends to appear earlier in men than in women, showing up in their late teens or early 20s as compared to their 20s or early 30s in women. Schizophrenia often begins with an episode of psychotic symptoms like hearing voices or believing that others are trying to control or harm you. The delusions— thoughts that are fragmented, bizarre, and have no basis in reality—may occur along with hallucinations and disorganized speech and behavior, leaving the individual frightened, anxious, and confused. There is no known single cause of schizophrenia. Treatment may include medications and psychosocial support like psychotherapy, self-help groups, and rehabilitation.

Childhood Traumatic Grief

Childhood Traumatic Grief

Childhood traumatic grief is a condition that children may develop after the death of
a significant person under circumstances that have been traumatic for the child.
We are beginning to understand how to identify this condition. In childhood traumatic
grief, a child has reactions and symptoms similar to those found in children
with PTSD. These reactions make it difficult for the child to follow the usual path
of bereavement and reminiscence about the deceased person in a positive and
meaningful way.
There are promising treatments that have been shown to be most helpful for children
with childhood traumatic grief. Treatment can be done with individuals and with groups
of children of different ages, and it should address both trauma and grief symptoms.
Treatment initially involves treating the trauma aspects of the condition and then
moving on to help the child deal with bereavement issues and master specific tasks.
The intervention described in this program draws from a variety of existing approaches.
The treatment includes teaching the child skills for managing stress, helping the child
to create a story about the death, and finally supporting the child while engaging in
specific activities related to bereavement. The goal of the treatment is to enable the
child to remember and cope with previously troubling thoughts and feelings about the
death and go on to have more positive and comforting memories about the person.

OVERVIEW OF CHILDHOOD TRAUMATIC GRIEF
WHAT IS CHILDHOOD TRAUMATIC GRIEF?
After being broadsided, the car was spinning out of control. When it stopped, eightyear-
old Devon, who was buckled up in the back seat and pinned in the car, yelled for
his mother to wake up. He heard the sirens, then watched the paramedics drag his
mother onto the street and saw blood running down her face. Later, whenever he rode
in a car, he refused to put on his seat belt because he wanted to get out as fast as
possible in case of an accident.
Twelve-year-old Anna’s brother drowned in the neighbor’s pool. She had a fight with him
right before he left, teasing the five-year-old about not being able to swim. Later she
frequently had nightmares in which she couldn’t breathe, so she stayed up most of
the night. In school, she was exhausted, sleepy, and couldn’t concentrate. Her grades
plummeted, but she said she didn’t care and deserved whatever punishment she got.

Childhood traumatic grief is a condition in which children who lose
loved ones under very unexpected, frightening, terrifying, traumatic
circumstances develop symptoms of posttraumatic stress and
other trauma symptoms that interfere with their ability to progress
through typical grief tasks, because they are stuck on the traumatic
aspects of the death. —Judith Cohen

Childhood traumatic grief can develop following the death of a significant person
when the death has been perceived by the child as traumatic. The hallmarks of the
condition are reactions related to (1) trauma, a situation that is sudden and terrifying
and that results in death and may have also been life threatening for the child, and
(2) grief, feelings of intense sadness and distress from missing the person who died
and the changes that have resulted. The distinguishing feature of childhood traumatic
grief is that trauma symptoms interfere with the child’s ability to navigate the typical
bereavement process. In other words, a child’s preoccupation and inability to relinquish
a focus on death leaves little or no room for other more helpful thoughts about
the person who died, leaves little emotional energy for adjusting to change, and
compromises the child’s ability to function in school or with friends. According to our
current understanding, childhood traumatic grief is distinct from uncomplicated
bereavement and conditions such as PTSD, yet it shares features of both. The
definition, characteristics, and assessment of childhood traumatic grief are still
evolving and likely vary due to such things as the type of death, age and cognitive
ability of the child, culture and beliefs, and family situation.
The child’s perception, not just the cause of death, plays a key role in determining the
development of symptoms. Not every child develops traumatic grief after a death that
happened in a particularly dramatic or threatening manner, such as death from a homicide,
war, or motor vehicle accident. In some cases, childhood traumatic grief can result
from a death that most would consider expected or normal, such as death from illness
or natural causes. There may be isolated traumatic moments that can be lodged in
the child’s memory, such as seeing a parent in profuse pain, that provoke the child’s
reaction. Childhood traumatic grief can affect children’s development, relationships,
achievement, and later effectiveness in life if not treated or otherwise resolved.

Children loose their developmental momentum that they had been
pursuing. They need support to regain that developmental momentum,
and without the support it often happens that children really stop
gaining these skills that are appropriate for their age, and that has
long-term repercussions. —Alicia Lieberman

The traumatic aspects of the death and the child’s relationship to the person that
died are entwined in such a way that thoughts or reminders of the trauma and
overwhelming painful grief about the person who died are linked together. The child’s
traumatic reaction can stem from the sudden and horrific nature of the death with
or without the child’s life also being in danger. The grief reaction stems from the
sadness of missing the person and all that has changed. The child contends with
the complex mix of trauma and grief. Hence, in providing treatment the clinician must
address both.
A child survivor of a car crash in which her mother was killed may be confronted with
reminders of the smell of rubber and gasoline, the fear of being trapped in the car,
the sight of blood and a mother’s lifeless body, and a caretaker whose absence is felt
every waking moment.
CULTURAL AND INDIVIDUAL VARIATIONS
Communication, expression and behavior following trauma and death can vary according
to one’s race, ethnicity, culture, and religion. It is important to be fully aware of these
variations in order to accurately identify those reactions outside the norm of what is
accepted and that prevent the child from participating fully in productive activities.
For example, intense displays of emotion may be more common in some cultures than
in others, and spiritual beliefs about an afterlife may influence a child’s reactions and
expressions. In some cultures it may be common practice to refrain from using the
name of the deceased for a certain period of time, hence, what may be interpreted
as avoidance in one setting is respectful and necessary in another. Either through
naturally occurring common practices or due to unfortunate war or devastation,
children in different countries may also have more or less exposure to death throughout
their life, which can influence their response. Regarding intervention, you must be
sensitive to instances when certain treatment principles may be contrary to what is
accepted practice in the child’s particular family. For those times when a practitioner is
unfamiliar with a family’s practices and beliefs it is essential to seek consultation or
consider additional referral.

OVERLAP OF CHILDHOOD TRAUMATIC GRIEF,
POSTTRAUMATIC STRESS DISORDER, AND TRAUMA REACTIONS

The typical traumatic stress symptoms that children might experience
with childhood traumatic grief include things like intrusive thoughts
or recurring images associated with the death of their loved one. It
could be the child becoming very constricted emotionally, becoming
numb as a way of not dealing with all the pain associated with the
tragic circumstances of their loved ones death. The child who has
childhood traumatic grief doesn’t have to have all those symptoms,
just some of them. —Anthony Mannarino

There is overlap in the reactions and symptoms of uncomplicated bereavement,
PTSD, and childhood traumatic grief. Children may show different signs of childhood
traumatic grief at different ages. However, difficulties specific to childhood traumatic
grief that can occur across developmental stages include those listed below. Although
the following reactions and symptoms are consistent with characteristics of PTSD,
they are notable as indicators of childhood traumatic grief because of the direct
reference to the traumatic death. A helpful way of understanding the following reactions
is to view them as indicating a child’s distress, communicating to others that the child
is not letting go of thoughts, feelings, and behaviors related to the images, details,
circumstances, and actions surrounding the death.
• Intrusive memories and preoccupations about things that happened before,
during, and after the death: These can appear through nightmares, guilt, or
self-blame about how the person died, or recurrent or intrusive thoughts about
the horrifying manner of death. Thoughts may also focus on wished-for protective
or rescue interventions, such as regret for not doing something that would have
changed the outcome.
A seven-year-old boy keeps thinking he should have done CPR to save the life of
his three-year-old sister who was caught in the crossfire of a drive-by shooting.
• Avoidance and a fear of strong feelings: This can be expressed by withdrawal
or by the child avoiding reminders of the person, the way the person died, or the
event that led to the death. In attempting to keep strong unpleasant feelings
related to the death at bay, the child may also try to dampen all feelings, which
results in what adults would understand as “numbing.”
A 14-year-old girl could not go to any fast-food restaurant after her father was
accidentally shot to death in one while they were getting milkshakes.
• Physical or emotional symptoms of increased arousal: These can include
irritability, anger, trouble sleeping, decreased concentration, a drop in grades,
stomachaches, headaches, increased vigilance, and fears about safety for
oneself or others. The reaction can generalize and occur in a context that
resembles, but is different than, the original situation.
A four-year-old girl started crying and screaming “stop shooting my mommy”
when she heard the fireworks at the park on the Fourth of July.
• Re-enactment: In re-enacting aspects of the events that are perceived to
have led to the death, there is an attempt to intervene, manage feelings of
helplessness, and undo what has been done and identify ways to prevent the
tragedy and death.
A six-year-old bereaved survivor of a motor vehicle crash repeatedly drew and cut
out replicas of the car and steering wheel. He built an oversized speedometer so
the driver of the other car would notice he was driving too fast. The boy went on
to make a car with extra protection that was strong enough to withstand any crash.

HOW IS CHILDHOOD TRAUMATIC GRIEF RELATED TO
OTHER TRAUMA REACTIONS?
Traumatic events can involve an actual death, other loss, serious injury, or threat to
the child’s own life or well-being. These events could include natural or man-made
disasters, violence, war, or accidents. A child may be traumatized by direct exposure,
witnessing the event, or hearing about another person’s experience. For some children,
the response can have a profound effect on how they view themselves and the world.
They may develop changes in their behavior (externalizing problems) or emotional
functioning (internalizing problems). Left untreated, the severe trauma-related reactions
can lead to more serious and chronic difficulties and, in some cases, coalesce into
PTSD. PTSD is diagnosed when the child has specific symptoms that continue for a
month or more following exposure to a traumatic event. The symptoms fall into the
three categories of re-experiencing, hyperarousal, and avoidance.
When children with childhood traumatic grief show reactions and symptoms characteristic of PTSD, the reactions and symptoms are directly related to the death and interfere with the child’s day-to-day functioning and bereavement work. Children may present with other symptoms not necessarily associated with PTSD but related to bereavement and traumatic death. These may include guilt, yearning, anger, and rescue and revenge fantasies.

Eleven-year-old Lisa witnessed her mother’s murder. In an interview with a therapist
five days after her mom was fatally shot and stabbed by her estranged boyfriend, Lisa
revealed her feelings about revenge when describing a dream: “In my dream I had the
same knife he used to stab my mother and the same gun that he shot her with. Then
I went up to him and said ’Do you remember this, now you can feel it’ And I stabbed
him right where he stabbed my mother. Then I said, ’I guess you remember this too,’
and then I shot him.”
It was hard for Lisa to talk about her mother, who she dearly loved, without feeling as
if she was back in that room. In the days and weeks after the murder, when she had
that feeling, she would focus on her mother being killed. But as she stood at the door,
frozen in place, one suspects she worried about herself as well as about her mother
being killed.
In childhood traumatic grief, the interaction of traumatic and grief symptoms is such
that any thoughts or reminders, even happy ones, about the person who died can lead
to frightening thoughts, images, or memories of how the person died.
Kevin, the 17-year-old brother of 15-year-old Briana, was killed in an avalanche. His body
was never found. She was haunted by feelings of guilt for not demanding he stay at the
lodge. She was so distraught that she isolated herself from friends. On further questioning,
it became clear that Briana and Kevin had many of the same friends. So when Briana
was with them, she was reminded of the good times they used to have together. But
this quickly led to her thinking about Kevin suffocating and it being her fault.

Three types of reminders may trigger unpleasant and distressing reactions:
1. Trauma reminders: places, situations, people, sights, smells, or sounds
reminiscent of things associated with the actual death. These may include the
street corner where a fatal accident occurred, the bedroom where a parent died,
or the sound of an airplane reminding a child of a mother who died in a crash.
2. Loss reminders: people, places, objects, situations, thoughts, or memories
that are reminders of particular aspects of the person who died — for example,
photo albums, an empty chair at the dinner table, or a new coach who has
replaced a parent who previously headed a child’s sports team.
3. Change reminders: situations, people, places, or things reminding the child
of changes in his or her life resulting from the death — for example, moving to
a new house or having to walk home with a babysitter rather than an older
sibling who died.
Reminders can certainly provoke sadness or thoughts about the deceased. However,
in childhood traumatic grief, these reminders may lead to the child re-experiencing
the traumatic events that led to the death. The terror associated with these memories
results in increased arousal symptoms. The child then attempts to handle the
distressing re-experiencing and symptoms with avoidance or numbing, often
characterized as a deadening of emotions in older children and a fear of feelings in
younger children. Because traumatic aspects of the death are so upsetting, the child
tries to avoid all reminders of the trauma, loss, or resulting changes so as not to
stir up unpleasant thoughts or feelings.
For example, a younger child may be afraid to sleep alone at night because of
nightmares about a tragic shooting, whereas an older child may avoid flying in a
plane because it brings up painful memories about a father who died in a plane crash.
One of the most common reminders of the trauma, loss, and change is the person’s
own family. Looking across at each other, knowing each has experienced the same
death even if having individual reactions, can be upsetting.

HOW DOES CHILDHOOD TRAUMATIC GRIEF DIFFER
FROM UNCOMPLICATED GRIEF?
Any death can be difficult for a child, and certain reactions are more likely than others.
Uncomplicated bereavement is the intense sadness and longing for the deceased
that children typically feel after the loss of a loved one. Complicated bereavement
has been described in adults as bereavement complicated by separation distress
and traumatic symptoms related to the loss of the security-enhancing relationship
with the deceased. This has not been clearly defined as a condition for children.

Uncomplicated or typical grief reactions in children vary according to age, developmental
level, previous life experiences, culture, beliefs, emotional health prior to the death,
and the family and social environment. Over time, a child is relieved of extreme
sadness and is able to engage in accepted mourning rituals, and, when appropriate,
remember good times and have positive feelings about the person who died. However,
while grieving, a child typically may have:
• Emotional reactions: feeling sad, angry, anxious, numb, lonely, guilty, powerless,
shamed, insecure, and remorseful.
• Changes in behavior: lack of interest and participation in usual activities,
diminished self-care, unpredictable or odd behavior, angry or aggressive
behaviors, increased risk taking, irritability and conflict with others, impulsivity,
regression to earlier behaviors, changes in sleep behaviors (increased or
decreased), difficulty sleeping or sleeping alone, changes in appetite (increase
or decrease in weight), and changes in physical health.
• Difficulty with interpersonal interactions: withdrawal, social isolation, peer
difficulties, clinging, irritability, difficulty sharing memories, difficulty participating
in group or athletic activities, and general lack of interest in others.
• Changes in thinking: constant thoughts and memories about the loved one,
persistent thoughts about the death, disbelief about the death and the finality
of the death, constant or intrusive thoughts about death, preoccupation with
one’s own or a loved one’s physical health and safety, difficulty making decisions,
confusion, impaired memory and concentration, lowered self-esteem and selfconfidence,
disillusionment, thinking that the death was one’s fault, and
survivor guilt.
• Altered perceptions: believing the deceased is still present, feeling the person’s
presence nearby, seeing the person’s face in a crowd, smelling the person’s
perfume, hearing the person’s voice, and experiencing vivid dreams about
the person.
• Physical reactions: susceptibility to illness, loss of energy, fatigue, difficulty or
changes in eating, physical complaints, and changes in physiological arousal
(for example, increased heart rate, respiration, and startle response).
• Changes in academic functioning: poor school performance, difficulty studying
or concentrating, and potential school failure.

In nontraumatic bereavement, kids may be sad, or upset, or feel lonely,
but they are able to continue on with activities and eventually maybe
enjoy life again and be re-engaged with people and situations. The child
with traumatic grief is kind of stuck, so a child may not want to be
around a cousin who is the same age as a sister who died because
it’s too upsetting, or a boy may not want to play baseball anymore
because he can’t bear the thought of looking in the stands and his
father not being there, and he falls apart. So these things segue into
the awful reminders, and the child then avoids every reminder, even a
positive one. —Robin Goodman

Throughout their lives, children continue to adjust to the loss and develop new ways
of coping. Over time, it is helpful for children to relate to their loss by engaging in,
and mastering, certain bereavement tasks. The following chart presents the outcome
of common bereavement tasks and how childhood traumatic grief interferes with
completion of these tasks.

Completion of Bereavement Tasks for Children with Uncomplicated Grief
and Indicators of Difficulty for Children with Childhood Traumatic Grief
In uncomplicated bereavement typically
children will:
Accept the reality and permanence of
death
Experience and cope with difficult
emotional reactions
Adjust to changes in their lives and
changes in their identity that result from
the death
Develop new relationships or deepen
existing ones
Childhood traumatic grief interferes
with bereavement due to:
Difficulty with accepting or unwillingness
to accept that the person has died due
to associations of the death with the
traumatic circumstance
Intense, distressing feelings that are
triggered by reminders leading to
avoidance or lack of feelings
Changes that lead to unpleasant reminders
of the way the person died, possible
overidentification with the person who
died, feeling overly responsible
Feelings such as guilt, anger, and
revenge interfering with the formation
of new relationships

In uncomplicated bereavement, children may feel sad when remembering the
deceased person but are generally able to have positive memories of the person and
continue with necessary life activities. It is important to keep in mind that bereaved
children are at risk for other types of mental health problems such as depression,
anxiety, and substance abuse either alone or in conjunction with childhood traumatic
grief. In childhood traumatic grief specifically, the terrifying and frightening aspects
of the death are so prominent that they get in the way of adjusting to life in ways that
are deemed helpful for the bereaved. Because positive memories of the person
who died lead directly to frightening reminders of the death, without help, the child
never reaches the point of finding comfort in memories, calling up better times, or
participating in what are culturally customary mourning practices. The child may also
have been unable to participate or benefit from various rituals used to ease grief, for
example, avoiding a funeral or being unable to cry for many months. In childhood
traumatic grief, the traumatic reactions make it difficult for the child to
• reminisce or enjoy positive memories of the deceased person when that is
deemed comforting in the child’s culture,
• cope with the many life changes that occur as a result of the death, and
• continue with normal development in ways that are expected and necessary.

In uncomplicated bereavement typically
children will:
Maintain a continuing, healthy
attachment to the deceased person
through remembrance activities
Find some meaning in the death and
learn about life or oneself
Continue through the normal
developmental stages
Childhood traumatic grief interferes
with bereavement due to:
Difficulty or avoidance of positive memories
because they are linked to horrible images
and upsetting thoughts and feelings
Inability or resistance to moving past
the terrifying, unpleasant aspects of
the death, negative feelings about self
related to the death or person
Emotional reactions and resulting
behavior, e.g., withdrawal, anger, and
distrust, interfering with the ability
to engage in positive, age-appropriate
activities and relationships
WHO SUFFERS FROM CHILDHOOD TRAUMATIC GRIEF?
Children can develop childhood traumatic grief when they experience the death of a
significant person, such as a parent, a sibling, or a close friend. Children of all ages,
even a young preschooler, can have a traumatic reaction to a death, especially of a
primary caregiver. It is estimated that five percent of all children in the United States
experience the death of a parent before the age of 15, and children under the age of
three are often present when a sibling or parent dies in a traumatic circumstance,
making young children particularly vulnerable and in need of attention.
However, not all children who have experienced a death develop childhood traumatic
grief. In fact, many recover and do well over time. Although it is true that the majority
of children who experience a death do not develop childhood traumatic grief, the
number of children who do struggle with childhood traumatic grief is quite significant.
For example, up to 70 percent of children in inner city communities have seen
someone shot or stabbed. Even if only five percent of these children develop childhood
traumatic grief, this translates into thousands of children developing this condition
each year. Although all children witnessing a homicide are likely affected in some way,
some are better able to tolerate the experience, whereas others are deeply impacted
and cannot continue on as well as before the death.

Eating Disorders

EATING DISORDERS
What are eating disorders?

Who has eating disorders?

What are the symptoms of eating disorders?

What medical problems can arise as a result of eating disorders?

What is required for a formal diagnosis of an eating disorder?

How are eating disorders treated?

For a referral to the nearest therapist specializing in eating disorders

What are eating disorders?

Eating disorders often are long-term illnesses that may require long-term treatment. In addition, eating disorders frequently occur with other mental disorders such as depression, substance abuse, and anxiety disorders (NIMH, 2002). The earlier these disorders are diagnosed and treated, the better the chances are for full recovery. This fact sheet identifies the common signs, symptoms, and treatment for three of the most common eating disorders: anorexia nervosa, bulimia nervosa, and binge-eating disorder (NIMH, 2002).
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Who has eating disorders?

Research shows that more than 90 percent of those who have eating disorders are women between the ages of 12 and 25 (National Alliance for the Mentally Ill, 2003). However, increasing numbers of older women and men have these disorders. In addition, hundreds of thousands of boys are affected by these disorders (U.S. DHHS Office on Women's Health, 2000).
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What are the symptoms of eating disorders?

Anorexia nervosa - People who have anorexia develop unusual eating habits such as avoiding food and meals, picking out a few foods and eating them in small amounts, weighing their food, and counting the calories of everything they eat. Also, they may exercise excessively.

Bulimia nervosa - People who have bulimia eat an excessive amount of food in a single episode and almost immediately make themselves vomit or use laxatives or diuretics (water pills) to get rid of the food in their bodies. This behavior often is referred to as the "binge/purge" cycle. Like people with anorexia, people with bulimia have an intense fear of gaining weight.

Binge-eating disorder - People with this recently recognized disorder have frequent episodes of compulsive overeating, but unlike those with bulimia, they do not purge their bodies of food (NIMH, 2002). During these food binges, they often eat alone and very quickly, regardless of whether they feel hungry or full. They often feel shame or guilt over their actions. Unlike anorexia and bulimia, binge-eating disorder occurs almost as often in men as in women (National Eating Disorders Association, 2002).
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What medical problems can arise as a result of eating disorders?

Anorexia nervosa - Anorexia can slow the heart rate and lower blood pressure, increasing the chance of heart failure. Those who use drugs to stimulate vomiting, bowel movements, or urination are also at high risk for heart failure. Starvation can also lead to heart failure, as well as damage the brain. Anorexia may also cause hair and nails to grow brittle. Skin may dry out, become yellow, and develop a covering of soft hair called lanugo. Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur as a consequence of this eating disorder. Severe cases of anorexia can lead to brittle bones that break easily as a result of calcium loss.

Bulimia nervosa - The acid in vomit can wear down the outer layer of the teeth, inflame and damage the esophagus (a tube in the throat through which food passes to the stomach), and enlarge the glands near the cheeks (giving the appearance of swollen cheeks). Damage to the stomach can also occur from frequent vomiting. Irregular heartbeats, heart failure, and death can occur from chemical imbalances and the loss of important minerals such as potassium. Peptic ulcers, pancreatitis (inflammation of the pancreas, which is a large gland that aids digestion), and long-term constipation are also consequences of bulimia.

Binge-eating disorder - Binge-eating disorder can cause high blood pressure and high cholesterol levels. Other effects of binge-eating disorder include fatigue, joint pain, Type II diabetes, gallbladder disease, and heart disease.
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What is required for a formal diagnosis of an eating disorder?

Anorexia nervosa - Weighs at least 15 percent below what is considered normal for others of the same height and age; misses at least three consecutive menstrual cycles (if a female of childbearing age); has an intense fear of gaining weight; refuses to maintain the minimal normal body weight; and believes he or she is overweight though in reality is dangerously thin (American Psychiatric Association [APA], 1994; NIMH, 2002).

Bulimia nervosa - At least two binge/purge cycles a week, on average, for at least 3 months; lacks control over his or her eating behavior; and seems obsessed with his or her body shape and weight (APA, 1994; NIMH, 2002).

Binge-eating disorder - At least two binge-eating episodes a week, on average, for 6 months; and lacks control over his or her eating behavior (NIMH, 2002).
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How are eating disorders treated?

Anorexia nervosa - The first goal for the treatment of anorexia is to ensure the person's physical health, which involves restoring a healthy weight (NIMH, 2002). Reaching this goal may require hospitalization. Once a person's physical condition is stable, treatment usually involves individual psychotherapy and family therapy during which parents help their child learn to eat again and maintain healthy eating habits on his or her own. Behavioral therapy also has been effective for helping a person return to healthy eating habits. Supportive group therapy may follow, and self-help groups within communities may provide ongoing support.

Bulimia nervosa - Unless malnutrition is severe, any substance abuse problems that may be present at the time the eating disorder is diagnosed are usually treated first. The next goal of treatment is to reduce or eliminate the person's binge eating and purging behavior (NIMH, 2002). Behavioral therapy has proven effective in achieving this goal. Psychotherapy has proven effective in helping to prevent the eating disorder from recurring and in addressing issues that led to the disorder. Studies have also found that Prozac, an antidepressant, may help people who do not respond to psychotherapy (APA, 2002). As with anorexia, family therapy is also recommended.

Binge-eating disorder - The goals and strategies for treating binge-eating disorder are similar to those for bulimia. Binge-eating disorder was recognized only recently as an eating disorder, and research is under way to study the effectiveness of different interventions (NIMH, 2002).
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For a referral to the nearest therapist specializing in eating disorders, contact:

National Association of Anorexia Nervosa and Associated Disorders
P.O. Box 7
Highland Park, IL 60035
Hotline: 1-847-831-3438
http://www.anad.org/

National Eating Disorders Association
Informational and Referral Program
603 Stewart Street, Suite 803
Seattle, WA 98101
1-800-931-2237
http://www.nationaleatingdisorders.org

Note: The above is a suggested resource. It is not meant to be a complete list.

Disaster Reactions of Potential Risk Groups

Training Manual
for Mental Health and Human Service Workers
in Major Disasters
SECTION 3
Disaster Reactions of Potential Risk Groups

Although there are many feelings and reactions people share in common following a disaster, there are also expressions that are more specifically influenced by the survivor's age, cultural and ethnic background, socioeconomic status, pre-existing physical, and psychosocial vulnerabilities. Disaster mental health workers are better prepared to design effective interventions when they have an understanding of how demographic and health factors interact with disaster stress.

This section describes groups commonly found within communities following a disaster and provides suggestions for disaster mental health interventions. Common issues, concerns, and reactions are also briefly presented in this section.

Common Needs and Reactions

First is a review of some thoughts, feelings, and behaviors common to all who experience a disaster:

Concern for basic survival

Grief over loss of loved ones and loss of valued and meaningful possessions

Fear and anxiety about personal safety and the physical safety of loved ones

Sleep disturbances, often including nightmares and imagery from the disaster

Concerns about relocation and related isolation or crowded living conditions

Need to talk about events and feelings associated with the disaster, often repeatedly

Need to feel one is a part of the community and its disaster recovery efforts
Potential Risk Groups

Each disaster-affected community has its own demographic composition, prior history with disasters or other traumatic events, and cultural representation. When disaster program planners review the groups impacted by a disaster in their community, consideration should be given to the following, as well as additional groups unique to the locale:

Age groups

Cultural and ethnic groups

Socioeconomic groups

People with serious and persistent mental illness

Human service and disaster relief workers
The majority of survivors are resilient and with time can integrate their disaster experiences and losses and move on. However, survivors who have significant concurrent psychosocial, health, or financial problems are at greater risk for depression, anxiety, post-traumatic stress symptoms or an exacerbation of their pre-existing condition. When survivors have personally sustained severe disaster losses (e.g., death of a loved one, devastation of home and community), their reactions are more intensely expressed and over a longer period of time (Solomon & Green, 1992). This section includes a brief overview for each group. The disaster reactions described normally resolve over time with sufficient support and physical recovery. References for more detailed information are provided.

Age Groups

Each stage of life is accompanied by special challenges in coping with the aftermath of a disaster and age-related vulnerabilities to disaster stress. For children, their age and development determine their capacity cognitively to understand what is occurring around them and to regulate their emotional reactions. Children are more vulnerable to difficulty when they have experienced other life stresses in the year preceding the disaster, such as a divorce, a move, or the death of a family member or pet (Vogel & Vernberg, 1993). For adults, stress associated with family and home disruption, financial setbacks, and work overload predominate. For older adults, concerns regarding health, financial stability, and living independently become primary.

The age groups considered in this section are:

Preschool (ages 1-5)

Childhood (ages 6-11)

Pre-adolescence and Adolescence (ages 12-18)

Adults

Older Adults
Reactions and problems vary depending upon the phase of the post-disaster period. Some of the problems discussed appear immediately; many appear months later.

Preschool (ages 1-5)

Small children view their world from the perspectives of predictability, stability, and the availability of dependable caretakers. Disruption in any of these domains causes distress. Preschool age children often feel powerlessness and fear in the face of a disaster, especially if they are separated from parents. Because of their age and small size, they are unable to protect themselves or others. As a result, they may feel considerable anxiety and insecurity.

In the preschool years, children generally lack the verbal and conceptual skills necessary to understand and cope effectively with sudden unexpected stress. They typically look to parents and older siblings as behavior models, as well as for comfort and stability. Research has shown that children's reactions are more related to how their family or caregiver is coping than the actual objective characteristics of the disaster itself (Green et al., 1991).

Children who have lost one or both parents are especially in need. Loss of a relative, a playmate, or a pet is also a disturbing event for children. They will need opportunities to express their grief. One of the major fears of childhood is abandonment, so children need frequent reassurance they will be cared for.

Preschoolers express their upset through regressive behaviors such as thumb sucking, bed-wetting, clinging to their parents, a return of fear of the dark, or not wanting to sleep alone. They often have sleep problems and frightening dreams. These problems are best understood as normal expressions of anxiety about the disruption of their familiar routines and previously secure worlds.

In the natural course of events, small children will try to resolve traumatic experiences by reliving them in their play activities. They may reenact the earthquake, flood, or tornado repeatedly. Children should be encouraged to verbalize their questions, feelings, and misunderstandings about the disaster so that adults can listen and explain. Relief of disaster fears and anxiety is attained through reestablishing the child's sense of security. Frequent verbal reassurance, physical comforting, more frequent attention, comforting bedtime rituals, and mealtime routines are helpful. As much as possible, young children should stay with people with whom they feel most familiar.

Childhood (ages 6 - 11)

School age children are developing the cognitive capacity to understand the dangers to family and environment inherent in disasters. They are more able to understand the disaster event and the mitigating role of disaster preparedness. This awareness can also contribute to preoccupation with weather and disasters, and fears about family members being killed or injured. School age children have a great need to understand what has happened and the concrete steps that they can take for protection and preparedness in the future.

Children often have special bonds with playmates or pets. When the disaster causes loss of significant others due to death or relocation, the child may grieve deeply. They experience the full range of human emotions, but may not have the words or means to express their internal experience. Adults can assist children to express these powerful emotions through talking, play, art, and age-appropriate recovery or preparedness activities.

School age children also manifest their anxiety through regressive behavior. Returning to behavior appropriate for a younger age is trying for parents, but serves an initially functional purpose for the child. These behaviors include: irritability, whining, clinging, fighting with friends and siblings, competing with younger siblings for parents' attention, or refusing to go to school. Bedtime and sleep problems are common due to nightmares and fearfulness about sleeping alone or in the dark.

Sometimes children's behavior can be "super good" at home, because they are afraid of further burdening their parents or causing more family disruption. They may show disaster stress at school through concentration problems, a decline in academic performance, aggression toward classmates, or withdrawal from social interactions. Some children may have somatic reactions and seek attention from the school nurse for stomach aches, headaches, nausea, or other complaints.

Pre-adolescence and Adolescence (ages 12 - 18)

This age group has a great need to appear competent to the world around them, especially to their family and friends. They struggle with the conflicts inherent in moving toward independence from parents on the one hand and the desire to maintain the dependence of childhood on the other. Approval and acceptance from friends are of paramount importance. Adolescents need to feel that their anxieties and fears are both appropriate and shared by their peers.

Disaster stress may be internalized and expressed through psychosomatic symptoms such as, gastrointestinal distress, headaches, skin problems, or vague aches and pains. Sleep problems such as insomnia, night terrors, or sleeping excessively may signal internal upset. Adolescents may turn to alcohol or drugs to cope with their anxiety and loss.

Social or school problems may also occur. Acting out or rebellious behavior may involve fighting with others, stealing, or power struggles with parents. Other adolescents may express their distress through withdrawal from friends and family and avoidance of previously enjoyed activities. School performance may decline. When the disaster causes major destruction of home and community, an older adolescent may postpone the developmental step of moving away from home.

Adults

Adults are focused on family, home, jobs, and financial security. Many are involved with caring for elderly parents as well. Pre-disaster life often involves maintaining a precarious balance between competing demands. Following a disaster, this balance is lost with the introduction of the enormous time, financial, physical, and emotional demands of recovery. Children in the family are in special need of attention and familiar routines, yet parents do not have enough hours in the day to accomplish all that is before them.

Over time, this stress overload can be manifested through physical symptoms of headaches, increased blood pressure, ulcers, gastrointestinal problems, and sleep disorders. Somatic reactions are especially present in those who are less able to experience and express their emotions directly. Cultural, gender-based, or psychological factors may interfere with emotional expression and seeking social support.

Emotional reactions often oscillate between numbness and intense expression. Anxiety and depression are common, as adults grapple with both anxiety about future threats and grief about the loss of home, lifestyle, or community. Anger and frustration about relief efforts abound, sometimes reflecting a displacement of the "less rational" anger that the disaster happened to them and was out of their control.

Older Adults

In the normal course of life, older adults typically have coped with losses prior to the disaster. They may have successfully adjusted to losses of employment, family, home, loved ones, or physical capabilities. For some, coping with these prior losses has strengthened resilience. For others, the prior losses may have worn down the individual's reserves and the disaster is an overwhelming blow (Norris et al., 1994). As a result of the disaster, irreplaceable possessions such as photographs or mementos passed on through generations may be destroyed. Pets or gardens developed over years may be lost. Mental health workers must recognize the special meaning of these losses, if they are to assist with grieving.

Older adults living on limited incomes tend to reside in dwellings that are susceptible to disaster hazards due to the location and age of the buildings. Because of financial limitations and age, they may not be able to afford the repairs to their homes. Leaving familiar surroundings is especially difficult for those who experience deficits in hearing, vision, or memory, because they rely on known environmental cues to continue living independently.

Many older adults fear that if their diminished physical or cognitive abilities are revealed, they risk loss of independence or being institutionalized. As a result, they may under report the full extent of their problems and needs. They may continue living in damaged or unsanitary conditions, because they do not have the physical strength, stamina, or cognitive organizational ability to undertake disaster clean up. Disaster mental health workers must carefully assess the range and full extent of problems in living faced by the older survivor. Often, concrete practical assistance for recovery, stabilization, and engagement with appropriate resources allows the older adult to continue living independently.

A larger proportion of older persons, as compared with younger age groups, have chronic illnesses that may worsen with the stress of a disaster, particularly when recovery extends over months. They are more likely to be taking medications that need to be replaced quickly following a disaster. While older adults may be in more need of multiple services for recovery, they are often especially reluctant to accept help and what they perceive as "handouts." Disaster mental health programs can more quickly gain acceptance when they work closely with known, trusted organizations and employ older adults as outreach workers.

Disaster Reactions and Intervention Suggestions
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options

PRESCHOOL
(1 - 5)

Resumption of bed-wetting, thumb sucking
Clinging to parents
Fears of the dark
Avoidance of sleeping alone
Increased crying


Loss of appetite
Stomach aches
Nausea
Sleep problems, nightmares
Speech difficulties
Tics


Anxiety
Fear
Irritability
Angry outbursts
Sadness
Withdrawal


Give verbal assurance and physical comfort
Provide comforting bedtime routines
Avoid unnecessary separations
Permit child to sleep in parents' room temporarily
Encourage expression regarding losses (i.e., deaths, pets, toys)
Monitor media exposure to disaster trauma
Encourage expression through play activities
CHILDHOOD
(6 - 11)

Decline in school performance
Aggressive behavior at home or school
Hyperactive or silly behavior
Whining, clinging, acting like a younger child
Increased competition with younger siblings for parents' attention


Change in appetite
Headaches
Stomach aches
Sleep disturbances, nightmares


School avoidance
Withdrawal from friends, familiar activities
Angry outbursts
Obsessive preoccupation with disaster, safety


Give additional attention and consideration
Relax expectations of performance at home and at school temporarily
Set gentle but firm limits for acting out behavior
Provide structured but undemanding home chores and rehabilitation activities
Encourage verbal and play expression of thoughts and feelings
Listen to the child's repeated retelling of disaster event
Involve the child in preparation of family emergency kit, home drills
Rehearse safety measures for future disasters
Develop school disaster program for peer support, expressive activities, education on disasters, preparedness planning, identifying at-risk children
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Emotional Symptoms

PRE-ADOLESCENCE AND ADOLESCENCE
(12 - 18)

Decline in academic performance
Rebellion at home or school
Decline in previous responsible behavior
Agitation or decrease in energy level, apathy
Delinquent behavior
Social withdrawal


Appetite changes
Headaches
Gastrointestinal problems
Skin eruptions
Complaints of vague aches and pains
Sleep disorders


Loss of interest in peer social activities, hobbies, recreation
Sadness or depression
Resistance to authority
Feelings of inadequacy and helplessness


Give additional attention and consideration
Relax expectations of performance at home and school temporarily
Encourage discussion of disaster experiences with peers, significant adults
Avoid insistence on discussion of feelings with parents
Encourage physical activities
Rehearse family safety measures for future disasters
Encourage resumption of social activities, athletics, clubs, etc.
Encourage participation in community rehabilitation and reclamation work
Develop school programs for peer support and debriefing, preparedness planning, volunteer community recovery, identifying at-risk teens
ADULTS

Sleep problems
Avoidance of reminders
Excessive activity level
Crying easily
Increased conflicts with family
Hypervigilance
Isolation, withdrawal


Fatigue, exhaustion
Gastrointestinal distress
Appetite change
Somatic complaints
Worsening of chronic conditions


Depression, sadness
Irritability, anger
Anxiety, fear
Despair, hopelessness
Guilt, self doubt
Mood swings


Provide supportive listening and opportunity to talk in detail about disaster experiences
Assist with prioritizing and problem-solving
Offer assistance for family members to facilitate communication and effective functioning
Assess and refer when indicated
Provide information on disaster stress and coping, children's reactions and families
Provide information on referral resources
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options

OLDER ADULTS

Withdrawal and isolation
Reluctance to leave home
Mobility limitations
Relocation adjustment problems


Worsening of chronic illnesses
Sleep disorders
Memory problems
Somatic symptoms
More susceptible to hypo- and hyperthermia
Physical and sensory limitations (sight, hearing) interfere with recovery


Depression
Despair about losses
Apathy
Confusion, disorientation
Suspicion
Agitation, anger
Fears of institutionalization
Anxiety with unfamiliar surroundings
Embarrassment about receiving "hand outs"


Provide strong and persistent verbal reassurance
Provide orienting information
Use multiple assessment methods as problems may be under reported (e.g., repeat observations, geriatric screening questions, discussion with family)
Provide assistance with recovery of possessions
Assist in obtaining medical and financial assistance
Assist in reestablishing familial and social contacts
Give special attention to suitable residential relocation
Encourage discussion of disaster losses and expression of emotions
Provide and facilitate referrals for disaster assistance
Engage providers of transportation, chore services, meals programs, home health, and home visits as needed
Cultural and Ethnic Groups

Disaster mental health programs must respond specifically and sensitively to the various cultural groups affected by a disaster. In many disasters, ethnic and racial minority groups may be especially hard hit because of socioeconomic conditions that force the community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values often contribute to disaster outreach programs' difficulty in establishing access and acceptance. Communities that take pride in their self-reliance are reluctant to seek or accept help, especially from mental health workers.

Cultural sensitivity is conveyed when disaster information and application procedures are translated into primary spoken languages and available in non-written forms. Intense emotions are typically experienced and expressed in a person's language of origin, so outreach teams that include bilingual, bicultural staff, and translators are able to interact more effectively with disaster survivors. Whenever possible, it is preferable to work with trained translators rather than family members, especially children, because of privacy concerns regarding mental health issues and the importance of preserving family roles.

Cultural groups have considerable variation regarding views on loss, death, home, spiritual practices, use of particular words, grieving, celebrating, mental health, and helping. The role of the family, who is included in the family, and who makes decisions also varies. Elders and extended family play a significant role in some cultures, whereas isolated nuclear families are the decision-makers in others.

It is essential that disaster mental health workers learn about the cultural norms, traditions, local history, and community politics from leaders and social service workers indigenous to the groups they are serving. Program outreach workers and mental health staff are most effective when they are bilingual and bicultural. During the program development phase, establishing working relationships with trusted organizations, service providers, and community leaders is helpful. Being respectful, nonjudgmental, well informed, and following through on stated plans dependably are especially important for outreach workers.

Socioeconomic Groups

Many affluent, middle to upper middle class people live with a sense of security and see themselves as invulnerable to the devastation and tragedy associated with disasters. Because of their financial resources and life situations, they may have been protected from crises in the past, and have purchased insurance for "protection" in the future. They are more accustomed to planning and controlling life events, rather than unexpected overwhelming events controlling them. Shock, disbelief, self blame, and anger predominate in the hours and days following a major disaster, as the reality of losses, danger, and the work that lies ahead begins to sink in.

Higher income families may never have received assistance from social service agencies before. Accepting clothing, food, money, or shelter can be difficult and sobering. While they may need emergency assistance initially, they often do have social, financial, family, or other resources that engage quickly and buffer the disaster's impact.

Affluent families typically rely on known professionals for their support-their family physician, minister, or psychotherapist. Disaster mental health programs focus on educating local health care professionals and religious leaders about disaster stress, because these providers are most likely to encounter upper class survivors in need. Psychosocial Issues for Children and Families in Disaster: A Guide for the Primary Care Physician (CMHS, 1995) is an informative resource for training. Recovery programs can also coordinate disaster mental health counseling and support groups through these known and trusted entities.

In contrast, low-income survivors have fewer resources and greater pre-existing vulnerability when disaster strikes. While they may have developed more crisis survival skills than the more protected upper class individuals, they often lack the availability of support and housing from family and friends and do not have insurance coverage or monetary savings. Without these, the recovery process is even more arduous and prolonged, and sometimes impossible. Federal and State disaster assistance programs are designed to meet serious and urgent needs. The intent of these programs is not to replace all losses. Uninsured, poor families may have unmet needs and should be referred to non-profit disaster relief organizations and unmet needs committees. If they are renters, they may be faced with unaffordable increases in rent after landlords have invested money to repair their properties. They may be dislocated to temporary disaster housing that is undesirable and removed from their social supports. Relocation may make transportation and getting to appointments more difficult.

Faced with these multiple challenges and assistance that falls short of solving the problems before them, low-income disaster survivors can feel overwhelmed. For those with limited reading and writing abilities, obtaining accurate information and completing forms is difficult. Disaster mental health workers are most effective when they provide concrete problem-solving assistance that facilitates addressing priority needs. Workers must be knowledgeable about the full range of community resources available to people of limited economic means and actively engage this resource network with those in need.

People With Serious and Persistent Mental Illness

Clinical field experience has shown that disaster survivors with mental illness function fairly well following a disaster, if essential services have not been interrupted. People with mental illness have the same capacity to "rise to the occasion" and perform heroically as the general population during the immediate aftermath of the disaster. Many demonstrate an increased ability to handle this stress without an exacerbation of their mental illness, especially when they are able to maintain their medication regimens.

However, some survivors with mental illness have achieved only a tenuous balance before the disaster. The added stress of the disaster disrupts this balance; for some, additional mental health support services, medications, or hospitalization may be necessary to regain stability. For individuals diagnosed with Post Traumatic Stress Disorder (PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior traumatic events.

Many people with mental illness are vulnerable to sudden changes in their environment and routines. Orienting to new organizations and systems for disaster relief assistance can be difficult. Program planners need to be aware of how disaster services are being perceived and build bridges that facilitate access and referrals where necessary. Disaster mental health services designed for the general population are equally beneficial for those with mental illness; disaster stress affects all groups. In addition, when case managers and community mental health counselors have a solid understanding of disaster mental health issues, they are able to better provide services to this population following a disaster. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster provides a comprehensive discussion of planning, preparedness, and options for service delivery with this population (CMHS, 1996).

Human Service and Disaster Relief Workers

Workers in all phases of disaster relief, whether in law enforcement, local government, emergency response, or victim support, experience considerable demands to meet the needs of the survivors and the community. Typically, disaster workers are altruistic, compassionate, and dedicated people who occasionally have difficulty knowing when it is time to take a break from the operation. For many, the disaster response takes precedence over all other responsibilities and activities. The brochure, Prevention and Control of Stress Among Emergency Workers-A Pamphlet for Workers, is an excellent resource for both disaster relief workers and mental health providers (NIMH, 1987). This brochure highlights the importance of having a personal emergency preparedness plan, so that workers are assured that their families are safe while they devote themselves to disaster relief for the community.

Relief workers may witness human tragedy and serious physical injuries, depending on the nature of the disaster and their role. This contributes to the psychological impact of their work. In disasters in which there is a high level of exposure to human suffering, injuries, and fatalities, providing psychological support and interventions for workers is especially necessary. In addition, relief workers and first responders should be considered a target group for ongoing services during the course of the disaster mental health recovery program.

As some order returns to the community, many workers, particularly volunteers, return to their regular jobs. However, they may attempt to continue with their disaster work. Over time, the result of this overwork can be the "burn-out" syndrome. This state of exhaustion, irritability, and fatigue creeps up unrecognized and can markedly decrease the individual's effectiveness and capability. These workers may be avoiding problems at home by working constantly. Disaster mental health workers should be on the lookout for workers whose coping resources have eroded due to their personal vulnerabilities and seemingly unrelenting workload. The next section in this manual, "Stress Prevention and Management," offers suggestions for identifying, educating, and intervening with those who may be having stress reactions and difficulty coping.

References and Recommended Reading

Bolin, R. & Bolton, P. Race, Religion and Ethnicity in Disaster Recovery. Colorado: University of Colorado Institute of Behavioral Science, 1986.

Center for Mental Health Services. Manual for Child Health Workers in Major Disasters. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 86-1070. (Rev. ed. in press.)

Center for Mental Health Services. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.

Center for Mental Health Services. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Washington, D.C.: US Department of Health and Human Services; Publication No. (SMA) 95-3022, 1995.

Gerrity, E. T. & Steinglass, P. Relocation stress following natural disasters. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.

Gist, R. & Lubin, B. (Eds.). Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.

Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C. & Smitson-Cohen, S. Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 945-951, 1991.

Green, B. L. & Solomon, S. D. The mental health impact of natural and technological disasters. In Freedy, J. R. & Hobfoll (Eds.). Traumatic Stress: From Theory to Practice. New York: Plenum, 1995.

LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L. & Prinstein, M. J. Helping Children Prepare for and Cope with Natural Disasters: A Manual for Professionals Working with Elementary School Children. BellSouth Corporation, 1995. (To obtain copies: Contact Dr. La Greca, Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124.)

Mitchell, J. & Bray, G. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.

National Institute of Mental Health. Prevention and Control of Stress Among Emergency Workers: A Pamphlet for Workers. Washington, D.C.: U. S. Department of Health and Human Services; Publication No. (ADM) 90-1497, 1987.

Norris, F. H., Phifer, J. F. & Kaniasty, K. Individual and community reactions to the Kentucky floods: Findings from a longitudinal study of older adults. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.

Saylor, C. F. (Ed.). Children and Disasters. New York: Plenum Press, 1993.

Solomon, S. D. & Green, B. L. Mental health effects of natural and human-made disasters. PTSD Research Quarterly, 3 (1), 1-8, 1992.

Sue, D. W. & Sue, D. Counseling the Culturally Different: Theory and Practice. New York: Wiley, 1990.

Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.

U. S. Department of Health and Human Services. Action Plan of the Administration on Aging to Strengthen the Disaster Response Capacity to Serve Older People. Rockville, MD, 1994. Vogel, J. M. & Vernberg, E. M. Children's psychological responses to disasters. Journal of Clinical Child Psychology, 22(4), 464-484, 1993.

Bipolar Continuing Education CEU

Family Psychoeducation
Workbook
Chapter 10: Other Clinical Models for Psychoeducational Multifamily Groups
Introduction

As the effectiveness of the Family Psychoeducation approaches to the treatment of schizophrenia has become established, interest has developed in extending these models to other conditions. That has led to the development of several newer approaches designed for consumers with specific diagnoses or for specific situations, such as when a given consumer has no family available or family involvement is complicated by a history of trauma within the family. The design of these newer models has proceeded with the same method as was done in working with people who experience schizophrenia: specific aspects have been designed to ameliorate phenomena that have been shown to influence outcome in previous research. That is, they are rooted in empirical findings, rather than theory, and those findings range over the entire body of psychiatric and psychological research, including both biological and psychosocial studies. Though they do not have the depth of outcome study results that has been shown for the models for people who experience schizophrenia, evidence is accumulating that they are just as effective. The practitioner who sets out to apply these models should review the available literature, since at the time of this writing many of these models were being tested, but results were not yet published.

Included here are brief summaries of descriptions of psychoeducational multifamily group treatment approaches for people with several common diagnoses as well as a model for ameliorating the effects of chronic medical illness on the family. The practitioner interested in applying these newer methods should consult the volumes in which they are described fully and seek training from qualified trainers.

Multifamily Groups for Bipolar Illness

David A. Moltz, M.D.
Margaret Newmark, M.S.W.

The psychoeducational multifamily group model must be significantly modified for people who experience a bipolar disorder. The symptoms, course and family responses have been shown to be different than in schizophrenia, and recent biological research has highlighted major differences in brain function between the disorders. A key finding is that family “expressed emotion” (defined earlier in text as behaviors perceived by the consumer as being critical and/or lacking warmth/support) affects relapse, but there is an even greater biological contribution to relapse than in schizophrenia. For instance, Miklowitz and his colleagues found that family psychoeducation, in the form of single-family behavioral management, reduced relapses markedly, but from nearly 90% to about 50%, as opposed to the 40% to 15% reduction observed for consumers with schizophrenia. Thus, biological and psychosocial factors seem to be more evenly weighted in determining course of illness in bipolar disorder; nevertheless, family psychoeducation remains a powerful treatment in preventing relapse and improving longer-term outcomes.

A Model for Bipolar Disorder

This model, developed by Moltz, Newmark, McFarlane and associates, was first implemented at a public mental health center in the South Bronx of New York City and later at a community mental health center in coastal Maine. It has been effective in both settings. Only one other group has published a report of psychoeducational multifamily group approach. Anderson and associates compared a family process multifamily group to a psychoeducational multifamily group for short-term treatment of hospitalized consumers with affective disorders. One of the few significant differences between the groups was that those attending the psychoeducational group reported greater satisfaction than those attending the process group. Therefore, whether or not the psychoeducational format had measurable clinical advantages, it was more valued by family members. For further information please refer to the references in Chapter 12.

The key elements of this model are the same as in the approach for consumers with schizophrenia. Each is modified in important ways to match the clinical and psychosocial problems encountered in bipolar disorder.

The materials cited in Chapter 12 contain information regarding the use of single family groups for individuals with bipolar disorder.

Joining

Initial joining sessions are held separately for the consumer and the family.
Individual and family sessions have similar structure, since the individual with bipolar illness is usually able to participate fully.
Meetings with the consumer and the other family members are often carried out separately during the acute phase of illness, but usually together if joining occurs after the manic phase is over and family meetings with the consumer are less likely to be emotionally intense.
Content

The content of the joining sessions is modified to reflect the specific impact of bipolar illness on the family. It includes:

Extensive discussion of the history of symptoms and course of illness
Identifying precipitants and prodromal signs
Emphasis on differing attitudes and attributions
Discussion of inter-episode functioning, that is to say, “how is life between episodes?”
Conjoint sessions

After several sessions with the family and the consumer meeting separately, they are seen together for one or more conjoint sessions facilitated by the two practitioners who will be co-facilitating the group. These conjoint sessions allow the family to come together as a unit prior to the multifamily group, while the separate sessions allow each party to express their concerns without constraints and thereby diminishes conflict during the joinings.

Educational workshop

The structure and format of the bipolar workshop are similar to the schizophrenia workshop except that the consumer is included. Content is determined by the specific characteristics of the illness and includes:

Symptoms of manic and depressed episodes, differences from normal highs and lows
The issue of will-power
The question of the “real” personality
The impact of acute episodes on the family
The long term impact of the illness on the family
Theories of etiology of the illness
Short and long-term treatment strategies
Ongoing group meetings

The structure of the multifamily group meetings is essentially the same as the schizophrenia model.

Challenges to group formation and maintenance

Several issues related to specific characteristics of bipolar illness have presented challenges to group formation and process:

Diagnostic ambiguity
Maintaining the group structure
Co-occurring conditions, especially substance abuse in consumer and other family members.
Outcomes

In general, consumers reported that:

they were less angry over time;
they had less debilitating episodes when they did occur;
they were better able to manage symptoms and episodes;
they experienced fewer hospitalizations; and
they were more able to appreciate their family’s experience.
Family members reported:

increased confidence in their ability to cope with the illness;
increased confidence in the consumer’s ability to manage the illness; and
benefits from the program even if the consumer did not attend.
Practitioners reported:

it took about two years to master the techniques;
they learned to see their role more as consultant than therapist;
they better appreciated family’s and consumer’s experience of illness and efforts to cope with it; and
each person’s struggle with illness is different.
Multifamily Group Treatment For Major Depressive Disorder

Gabor Keitner, M.D. Ivan W. Miller, Ph.D.
Laura M. Drury, M.S.W. William H. Norman, Ph.D.
Christine E. Ryan, Ph.D. David A. Solomon, M.D.

To date, the only previous multifamily group treatment for consumers who experience depression has been the model developed by Anderson (1986). This multifamily approach has been used at the University of Pittsburgh for many years, however the only empirical data collected on this model is a comparison of participants’ satisfaction with the group. This study indicated that consumers and families were very satisfied with the treatment and believed that they obtained significant benefits. However, despite the fact that this intervention has been incorporated into several long-term studies of depression, there has been no study of the potential effects of this multifamily treatment on outcome or course of illness in major depression. Such studies are underway now and preliminary results are promising.

Conducting multifamily group treatment for people with depression

Consumers with mood disorders participated in psychoeducational multifamily groups in a 5-year federally-sponsored research study. Consumers with unipolar and bipolar illness were combined in order to ensure a critical mass of consumers and families, and also because we felt that there was a significant overlap in the themes of remission and relapse between unipolar and bipolar forms of mood disorders. In addition, both unipolar and bipolar consumers had a common experience in the depressive phase of the illness and it was assumed that a certain percentage of unipolar consumers may eventually experience an episode of mania.

Much of the following material was drawn from previous descriptions of psychoeducational groups.

Overview of goals and structure

Helping consumers and family members become knowledgeable about the signs and symptoms of depression and mania;
Promoting relationships and increasing understanding of the effects of the illness by sharing information, support and members' perspectives on family interactions;
Consumers and family members gain insights and learn new coping strategies in dealing with different phases of the consumer's illness; and
Consumers and families have a better understanding of how they can work with each other and with mental health professionals to deal with the illness.
Family and group composition

A core feature of this program is that both the consumer and family members attend the sessions. All family members of the household over the age of 12 are expected to attend. A minimum of four families seems to be necessary to insure adequate activity and group discussion. Groups of five to six families, or twelve to fourteen people, are optimal. Groups typically include consumers with both bipolar disorder and others with major depression.

Practitioners

Two co-leaders are needed. The leaders deal with any consumers or family members who become upset during a session. Leaders should be experienced in working with consumers, their families, and also in group process and therapy. They should know about current issues and treatments of major depression and bipolar illness, including the biopsychosocial model of mood disorders.

Clinical procedures

The group leaders (practitioners) should meet before each session to discuss the content of the session and the division of tasks between them. They should also meet immediately after the session to review and assess group members and plan future agendas and strategies. This debriefing is especially important if a crisis occurred during the group session with either a consumer or a family member.

Screening session

This is an individual meeting between the consumer, family member(s) and one of the two co-leaders. It serves to:

Introduce the consumer and family to the therapist;
Provide an opportunity to assess the family's and consumer's knowledge about mood disorders, coping skills and methods of dealing with the illness;
Build an alliance between the therapist consumer, and family; and
Let the therapist assess the appropriateness of the family and the consumer for the psychoeducational group.
Structure of psychoeducation groups

Please refer to the references in Chapter 12 for specific information about the structure of these groups.

Conclusion

The optimal treatment of depression has yet to be defined. Pharmacotherapy, psychotherapy, family therapy, and group therapy all play a role for some consumers at some point in the illness. The multifamily group format is a welcome addition to the currently available treatments for depression. The role of the family is significant in determining the course of the depression and its response to treatments.

Multifamily Psychoeducational Treatment of Borderline Personality Disorder

Cynthia Berkowitz, M.D.
John Gunderson, M.D.

The development of psychoeducational multifamily treatment of borderline personality disorder (BPD) is prompted by four factors:

the need for novel psychosocial interventions in this disorder,
the success of psychoeducational multifamily treatment of schizophrenia,
the need for more effective family interventions in this disorder, and
the emergence of a deficit model of BPD.
Dialectical Behavioral Therapy has been developed by Marsha Linehan and colleagues as a disorder specific treatment of BPD, focusing on the diminution of the self-destructive behavior that is the major cause of morbidity in BPD. It is the only psychosocial treatment of this disorder that has been subjected to a controlled outcome study. Linehan has established the effectiveness of this cognitive-behavioral treatment of BPD.

Practitioners who treat individuals with BPD know that the recurrent crises that mark the course of the illness often occur in response to interactions between the individual with BPD and relatives. This pattern strongly suggests that a treatment targeted at altering the family environment could positively influence the course of the disorder. The findings of Young and Gunderson, (1995) suggest that adolescents with BPD saw themselves as being significantly more alienated than did adolescents with other disorders. Their research found that alienation in the family environment is a useful target for intervention and indicates that psychoeducation may be able to diminish feelings of alienation.

Based on studies of the role of expressed emotion (EE) in BPD by Jill Hooley as well as by John Vuchetich, (the latter study in association with development of the current treatment), we hypothesize that EE in the family may be a risk factor for worsening psychosocial functioning in the individual with BPD.

Rationale for psychoeducational multifamily treatment of BPD

The following principles borrow heavily from the previous work of Anderson, Hogarty, Falloon, Leff and McFarlane in the development of psychoeducational treatment but also incorporate emerging concepts of BPD, particularly the functional deficit model.

BPD is characterized by functional deficits of (i) affect and impulse dyscontrol, (ii) intolerance of aloneness and (iii) dichotomous thinking. If individuals with BPD have functional deficits in their ability to cope, it follows that they would benefit from an environment that could help them cope with those deficits.
The functional deficits above may render individuals with BPD handicapped but not disabled. This means that they can be held accountable for their actions but that change for them occurs very slowly and with great difficulty.
BPD is an enduring disorder characterized by recurrent crises. The specific goal of the treatment is to diminish crises rather than to cure the disorder. We hypothesize that stress in the family environment may significantly influence the course of the disorder.
Families can influence the course of illness in that they can either diminish the stresses that cause relapses or inadvertently create them. Families are asked specifically to make the home environment calmer and to reduce the stress the consumer who experiences BPD is subjected to.
Living with an ill relative has stressful consequences for the family. A major goal of the current treatment is to diminish stress within the family.
Family members will want to use education to change their behavior if they believe they can help an ill family member by doing so.
Stress within the family may have at its root alienation between the individual with BPD and the family. Psychoeducational treatment moves parents away from issues of their possible causal role in the occurrence of the illness and away from blaming and criticizing the individual with BPD.
The role of the multifamily group in treatment of BPD

The mechanisms of the multifamily group directly address the particular problems facing the families of individuals with BPD, including the need for:

improved clarity of communication and directness;
diminished hostility; and
diminished over-involvement.
Structure of psychoeducational multifamily group treatment

The same three-stage structure used in the treatment of people with schizophrenia can be applied to people with borderline personality disorder. In this model, family psycoeducational treatment begins with a joining phase followed by an educational workshop. Families then join a multifamily group for an extended period of biweekly treatment. Again, the details of conducting the joining sessions, educational workshop and multifamily group sessions are described in the references listed in Chapter 12.

Treatment outcome

The psychoeducational multifamily group treatment of BPD is currently under study in a project involving two multifamily groups. Each of the families consisted of a mother or two parents with a daughter having BPD. Data is currently available for only eight of the participating families:

66.7 percent felt that the multifamily group helped them to modulate angry feelings
66.7 percent felt less burdened
All participating families felt that the group improved their communication with their daughters (75 percent felt that the improvement was “very great” )
All participating families felt that the treatment improved their knowledge of the disorder
91.6% of parents felt that the treatment had helped them to set limits
All of the participating families felt supported by the group
Conclusion

While the evidence supporting its effectiveness for people who experience borderline personality disorder is preliminary, the data available suggests that consumers are experiencing improved communication and diminished hostility within their families.

Multifamily Behavioral Treatment of Obsessive Compulsive Disorder

Barbara Van Noppen, M.S.W.
Gail Steketee, Ph.D.

Education about consumers with obsessive compulsive disorder (OCD) and the reduction of critical responses to behavioral symptoms are important family factors in the course of illness and possibly in treatment outcome for OCD. Clinical investigation of family members’ responses to OCD symptoms and of their impact on the symptoms can lead to the development of family behavioral interventions that may help both the consumer and the family. Multifamily behavioral treatment (MFBT) includes consumers and their significant others in a 20-session intervention (12 weekly and 6 monthly sessions) over a period of 9 months. Preliminary findings revealed efficacy of MFBT comparable to standard individual behavioral therapy. Furthermore, reductions in the symptoms experienced by consumers with obsessive compulsive disorder who completed MFBT have been maintained at one-year follow-up.

Multifamily behavioral treatment (MFBT)

MFBT, compared to single-family behavioral therapy, offers the opportunity for reduction in perceived isolation, enriched opportunities for problem solving and emotional distancing, enabling family members to respond in a less personalized way to the symptoms. A sense of community and social support often develops through the course of the MFBT, as families share stories with one another. There is a lessening in feelings of shame and stigma, which encourages family members to take a larger role in treatment and join with the consumer to combat the symptoms of obsessive compulsive disorder. The presence of other families with similar problems provides an opportunity for consumers and families to learn effective negotiation of agreements and to adopt symptom management strategies modeled by other members of the group. Additional potential benefits of multifamily intervention are reduced therapist burnout and greater cost-effectiveness of treatment.

A recent uncontrolled trial by Van Noppen and colleagues examined the effects of MFBT for 19 consumers and family members treated in 4 groups. Consumers experienced significant reductions in obsessive compulsive symptom severity and similar reduction in scores on a measure of family functioning. Among MFBT consumers, 47% made clinically significant improvements (reliably changed and scoring in the non-clinical range on OCD symptoms) at post-test, and 58% achieved this status at 1-year follow-up. Results from MFBT were comparable to those achieved by individual behavior therapy. Overall, the multifamily intervention was quite effective, although some consumers did not show strong gains and there is clearly room for improvement.

Features and procedures of MFBT

MFBT is similar to methods described by McFarlane and Falloon, but uses interventions specifically aimed at reducing obsessive-compulsive symptoms and changing dysfunctional patterns of communication. This family group treatment incorporates psychoeducation, communication and problem-solving skills training, clarifying boundaries, social learning and in vivo rehearsal of new behaviors. There is also in-group observation of exposure and response prevention with therapist and participant modeling.

4-6 families (no more than 16 total participants is recommended), including consumer and others who have daily contact with the consumer. Co-leaders are optimal; at least one leader should have an advanced degree in social work, psychology or certified counseling and experience in clinical work with individuals, families and groups.
Sessions are 2 hours long and typically meet in the late afternoon or early evening.
The key clinical procedures include:

Each consumer and family has a pre-treatment screening by phone with the therapist(s) to determine appropriateness for the group and readiness for treatment; following this, two intake sessions are scheduled;
At the intake sessions, 1 1/2 hours each, pretreatment forms are completed, symptom severity and family response styles determined, goals of the group and behavioral therapy principles are discussed, and pre-treatment concerns and questions are addressed;
Treatment is comprised of 12 weekly sessions and 6 monthly group follow-up sessions, providing:
education about OCD and reading of self-help material;
education about families and OCD;
in vivo exposure and response prevention plus homework and self-monitoring;
homework discussion with family group feedback and problem-solving; and
behavioral contracting among family members and communication skills training.
Conclusion

MFBT appears to be a good alternative to labor-intensive individual behavioral treatment. Recent research findings suggest that MFBT may especially help consumers who experience obsessive compulsive disorder and have not benefited from standard individual treatment and who are living with family members. MFBT incorporates family members into behavioral treatment by teaching family members and consumers to negotiate contracts. The goal of this treatment is to encourage anxiety reduction for the consumer, to educate and model reasonable interactive responses within families, and to remove family members from the consumer’s compulsions in a supportive manner.
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