Common Stress Reactions Following Exposure To Trauma
Psychological and EmotionalInitial euphoria, relief
Guilt about surviving or not having suffered as much as others
Anxiety, fear, insecurity, worry
Pervasive concern about well-being of loved ones
Feelings of helplessness, inadequacy, being overwhelmed
Vulnerability
Loss of sense of power, control, well-being, self-confidence, trust
Shame, anger over vulnerability
Irritability, restlessness, hyperexcitability, impatience, agitation, anger, blaming (anger at source, anger at those exempted, anger at those trying to help, anger “for no apparent reason”)
Outrage, resentment
Frustration
Cynicism, negativity
Mood swings
Despair, grief, sadness
Periods of crying, emotional “attacks” or “pangs”
Feelings of emptiness, loss, hopelessness, depression
Regression
Reawakening of past trauma, painful experiences
Apathy, diminished interest in usual activities
Feelings of isolation, detachment, estrangement, “no one else can understand”
Denial or constriction of feelings; numbness
“Flashbacks,” intrusive memories of the event, illusions, pseudo-hallucinations
Recurrent dreams of the event or other traumas
Cognitive
Poor concentration
Mental confusion, slowness of thinking
Forgetfulness
Amnesia (complete or partial)
Inability to make judgments and decisions
Inability to appreciate importance or meaning of stimuli
Poor judgment
Loss of appropriate sense of reality (denial of reality, fantasies to counteract reality)
Preoccupation with the event
Repetitive, obsessive thoughts and ruminations
Over-generalization, over-association with the event
Loss of objectivity
Rigidity
Confusion regarding religious beliefs/value systems; breakdown of meaning and faith
Self-criticism over things done/not done during trauma
Awareness of own and loved ones’ mortality
http://www.aspirace.com
April 12, 2010
April 11, 2010
DISASTER COUNSELING SKILLS
For Mental Health and Human Services Workers
in Major Disasters
DISASTER COUNSELING SKILLS
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.
SOME DO'S AND DON'T'S
Do say:
These are normal reactions to a disaster.
It is understandable that you feel this way.
You are not going crazy.
It wasn't your fault, you did the best you could.
Things may never be the same, but they will get better, and you will feel better.
Don't say:
It could have been worse.
You can always get another pet/car/house.
It's best if you just stay busy.
I know just how you feel.
You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
PROBLEM-SOLVING
Disaster stress often causes disorganized thinking and difficulty with planning. Some survivors react by feeling overwhelmed and become either immobilized or unproductively overactive. Workers can guide survivors through the following problem-solving steps to assist with prioritizing and focusing action.
Identify and define the problem
Describe the problems/challenges you are facing right now.
Selecting one problem is helpful, identify it as the most immediate, and focus on it first. The problem should be relatively solvable, as an immediate success is important in bringing back a sense of control and confidence.
Assess the survivor's functioning and coping
How have you coped with stressful life events in the past?
How are you doing now?
Through observation, asking questions, and reviewing the magnitude of the survivor's problems and losses, the worker develops an impression of the survivor's capacity to address current challenges. Based on this assessment-the worker may make referrals, point out coping strengths, and facilitate the survivor's engagement with social supports. The worker may also seek consultation from medical, psychological, psychiatric, or disaster relief resources.
Evaluate available resources
Who might be able to help you with this problem?
What resources/options might help?
Explore existing sources of assistance and support such as immediate and extended family, friends, church community, health care providers, etc. and how the survivor might obtain their help. Refer the survivor to the appropriate relief agencies and assess if the survivor is able to make the calls and complete the required applications. Assist with accessing resources when necessary.
Develop and implement a plan
What steps will you take to address this problem?
Encourage the survivor to say aloud what he or she plans to do and how. Offer to check-in with the survivor in a few days to see how it is going. If the worker has agreed to perform a task for the survivor, it is very important to follow through. Workers should promise only what they can do, not what they would like to do.
A WORD OF CAUTION
When confronted with a disaster survivor's seemingly overwhelming needs, workers can feel the understandable impulse to help in every way possible. Workers may become over involved and do too much for the survivor. This is usually not in the best interest of the survivor. When survivors are empowered to solve their own problems, they feel more capable, competent, and able to tackle the next challenge. Workers should clearly understand the scope of their role in the disaster relief effort and recognize that empowering survivors is different from doing for them.
CONFIDENTIALITY
A helping person is in a privileged position. Helping a survivor in need infers a sharing of problems, concerns, and anxieties-sometimes with intimate details. This special sharing cannot be done without a sense of trust, built upon mutual respect, and the explicit understanding that all discussions are confidential and private. No case should be discussed elsewhere without the consent of the person being helped (except in an extreme emergency when it is judged that the person will harm himself or others). It is only by maintaining the trust and respect of the survivor that the privilege of helping can continue to be exercised.
in Major Disasters
DISASTER COUNSELING SKILLS
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.
SOME DO'S AND DON'T'S
Do say:
These are normal reactions to a disaster.
It is understandable that you feel this way.
You are not going crazy.
It wasn't your fault, you did the best you could.
Things may never be the same, but they will get better, and you will feel better.
Don't say:
It could have been worse.
You can always get another pet/car/house.
It's best if you just stay busy.
I know just how you feel.
You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
PROBLEM-SOLVING
Disaster stress often causes disorganized thinking and difficulty with planning. Some survivors react by feeling overwhelmed and become either immobilized or unproductively overactive. Workers can guide survivors through the following problem-solving steps to assist with prioritizing and focusing action.
Identify and define the problem
Describe the problems/challenges you are facing right now.
Selecting one problem is helpful, identify it as the most immediate, and focus on it first. The problem should be relatively solvable, as an immediate success is important in bringing back a sense of control and confidence.
Assess the survivor's functioning and coping
How have you coped with stressful life events in the past?
How are you doing now?
Through observation, asking questions, and reviewing the magnitude of the survivor's problems and losses, the worker develops an impression of the survivor's capacity to address current challenges. Based on this assessment-the worker may make referrals, point out coping strengths, and facilitate the survivor's engagement with social supports. The worker may also seek consultation from medical, psychological, psychiatric, or disaster relief resources.
Evaluate available resources
Who might be able to help you with this problem?
What resources/options might help?
Explore existing sources of assistance and support such as immediate and extended family, friends, church community, health care providers, etc. and how the survivor might obtain their help. Refer the survivor to the appropriate relief agencies and assess if the survivor is able to make the calls and complete the required applications. Assist with accessing resources when necessary.
Develop and implement a plan
What steps will you take to address this problem?
Encourage the survivor to say aloud what he or she plans to do and how. Offer to check-in with the survivor in a few days to see how it is going. If the worker has agreed to perform a task for the survivor, it is very important to follow through. Workers should promise only what they can do, not what they would like to do.
A WORD OF CAUTION
When confronted with a disaster survivor's seemingly overwhelming needs, workers can feel the understandable impulse to help in every way possible. Workers may become over involved and do too much for the survivor. This is usually not in the best interest of the survivor. When survivors are empowered to solve their own problems, they feel more capable, competent, and able to tackle the next challenge. Workers should clearly understand the scope of their role in the disaster relief effort and recognize that empowering survivors is different from doing for them.
CONFIDENTIALITY
A helping person is in a privileged position. Helping a survivor in need infers a sharing of problems, concerns, and anxieties-sometimes with intimate details. This special sharing cannot be done without a sense of trust, built upon mutual respect, and the explicit understanding that all discussions are confidential and private. No case should be discussed elsewhere without the consent of the person being helped (except in an extreme emergency when it is judged that the person will harm himself or others). It is only by maintaining the trust and respect of the survivor that the privilege of helping can continue to be exercised.
April 10, 2010
Developing A Recovery And Wellness Lifestyle, A Self-Help Guide: Sleep
Developing A Recovery And Wellness Lifestyle
A Self-Help Guide
Sleep
You will feel better if you sleep well. Your body needs time every day to rest and heal. If you often have trouble sleeping–either falling asleep, or waking during the night and being unable to get back to sleep–one or several of the following ideas might be helpful to you —
Go to bed at the same time every night and get up at the same time every morning. Avoid "sleeping in" (sleeping much later than your usual time for getting up). It will make you feel worse.
Establish a bedtime "ritual" by doing the same things every night for an hour or two before bedtime so your body knows when it is time to go to sleep.
Avoid caffeine, nicotine, and alcohol.
Eat on a regular schedule and avoid a heavy meal prior to going to bed. Don't skip any meals.
Eat plenty of dairy foods and dark green leafy vegetables.
Exercise daily, but avoid strenuous or invigorating activity before going to bed.
Play soothing music on a tape or CD that shuts off automatically after you are in bed.
Try a turkey sandwich and a glass of milk before bedtime to make you feel drowsy.
Try having a small snack before you go to bed, something like a piece of fruit and a piece of cheese or some cottage cheese so you don't wake up hungry in the middle of the night. Have a similar small snack if you awaken in the middle of the night.
Take a warm bath or shower before going to bed.
Place a drop of lavender oil on your pillow.
Drink a cup of herbal chamomile tea or take several chamomile capsules before going to bed.
You need to see your doctor if —
you often have difficulty sleeping and the solutions listed above are not working for you.
you awaken during the night gasping for breath
your partner reports that your breathing is interrupted when you are sleeping
you snore loudly
you wake up feeling like you haven't been asleep
you fall asleep often during the day
Do you have a hard time getting to sleep or staying asleep?
If so, what are you going to do to help yourself get a good night's sleep?
A Self-Help Guide
Sleep
You will feel better if you sleep well. Your body needs time every day to rest and heal. If you often have trouble sleeping–either falling asleep, or waking during the night and being unable to get back to sleep–one or several of the following ideas might be helpful to you —
Go to bed at the same time every night and get up at the same time every morning. Avoid "sleeping in" (sleeping much later than your usual time for getting up). It will make you feel worse.
Establish a bedtime "ritual" by doing the same things every night for an hour or two before bedtime so your body knows when it is time to go to sleep.
Avoid caffeine, nicotine, and alcohol.
Eat on a regular schedule and avoid a heavy meal prior to going to bed. Don't skip any meals.
Eat plenty of dairy foods and dark green leafy vegetables.
Exercise daily, but avoid strenuous or invigorating activity before going to bed.
Play soothing music on a tape or CD that shuts off automatically after you are in bed.
Try a turkey sandwich and a glass of milk before bedtime to make you feel drowsy.
Try having a small snack before you go to bed, something like a piece of fruit and a piece of cheese or some cottage cheese so you don't wake up hungry in the middle of the night. Have a similar small snack if you awaken in the middle of the night.
Take a warm bath or shower before going to bed.
Place a drop of lavender oil on your pillow.
Drink a cup of herbal chamomile tea or take several chamomile capsules before going to bed.
You need to see your doctor if —
you often have difficulty sleeping and the solutions listed above are not working for you.
you awaken during the night gasping for breath
your partner reports that your breathing is interrupted when you are sleeping
you snore loudly
you wake up feeling like you haven't been asleep
you fall asleep often during the day
Do you have a hard time getting to sleep or staying asleep?
If so, what are you going to do to help yourself get a good night's sleep?
April 09, 2010
An Overview of the Illness Management and Recovery Program
An Overview of the Illness Management and Recovery Program
for more on this topic,
mft ceus
The Illness Management and Recovery Program consists of a series of weekly sessions where mental health practitioners help people who have experienced psychiatric symptoms to develop personalized strategies for managing their mental illness and moving forward in their lives. The program can be provided in an individual or group format, and generally lasts between three and six months. In the sessions, practitioners work collaboratively with people, offering a variety of information, strategies, and skills that people can use to further their own recovery. There is a strong emphasis on helping people set and pursue personal goals and helping them put strategies into action in their everyday lives.
Materials for Providing the Illness Management and Recovery Program
In the Practitioners’ Workbook (this document) there are two sets of materials for Illness Management and Recovery: the Practitioners’ Guide (Chapters 1-10) and Educational Handouts. The educational handouts contain practical information and strategies that people can use in the recovery process. The handouts are not meant to stand alone. Practitioners are expected to help people select and put into practice the knowledge and strategies that are most helpful to themselves as individuals. The following topics are covered in nine educational handouts:
Recovery Strategies
Practical Facts about Schizophrenia/Bipolar Disorder/ Depression
The Stress-Vulnerability Model and Strategies for Treatment
Building Social Support
Using Medication Effectively
Reducing Relapses
Coping with Stress
Coping with Problems and Symptoms
Getting Your Needs Met in the Mental Health System
Chapter 1 of the Practitioners’ Guide contains overall strategies for conducting the program, and Chapters 2-10 contain practitioner guidelines for using each of the educational handouts to conduct sessions. The guidelines contain specific suggestions for using motivational, educational, and cognitive behavioral techniques to help people use strategies from the handouts in their daily lives. They also provide tips for developing homework assignments and for dealing with problems that might arise during sessions.
Getting started
First, practitioners are advised to familiarize themselves with the format, content and tone of the program. This can be accomplished by first reading the following:
Chapter 1 of the Practitioners’ Guide
Educational Handout #1 (“Recovery Strategies”)
Practitioner Guidelines for Educational Handout #1 (“Recovery Strategies”)
It is optimal for practitioners to read the remaining educational handouts and accompanying practitioners’ guidelines before beginning to work with people. Practitioners are advised to review specific handouts and guidelines prior to addressing these particular topic areas with people.
Preparing For Sessions
The first session is usually spent on orientation, using the “Orientation Sheet” (see Appendix 1) as a guide. The second (and sometimes third) session is spent on getting to know the person better, using the ”Knowledge and Skills Inventory” (see Appendix 2) as a guide. This inventory is focused on the person’s positive attributes rather than their problems or “deficits.” It is important to gather information in a friendly, low- key manner, using a conversational tone. The remaining sessions are focused on helping people to learn and practice the information and strategies in the educational handouts and to set and pursue their personal goals. Each session should be documented, using the “Progress Note for Illness Management and Recovery” (Appendix 3). The format of the progress note helps practitioners to keep track of the person’s personal goals, the kinds of interventions provided (motivational, educational, cognitive-behavioral), the specific evidence-based skill(s) that are taught (coping skills, relapse prevention skills and behavioral tailoring skills) and the homework that is agreed upon.
Before beginning each educational handout, the practitioner is encouraged to review the contents of the handout and the practitioner guidelines of the same title in the Practitioners’ Guide. Most educational handouts will require two to four sessions to put the important principles into practice. Preparation for sessions is most effective when practitioners review the educational handout and the corresponding practitioners’ guidelines side-by-side, noting the goals of the handout, the specific topic headings, the probe questions, the checklists, etc. As noted above, sessions should be recorded on the form “Progress Note for Illness Management and Recovery” (Appendix 3). Although for many people it is most helpful to go through the handouts in the order they are listed, it is important to tailor the program to respond to individual needs. For example, when a person is very distressed by the symptoms he or she is experiencing, it would be preferable to address this problem early in the program using Educational Handout #8, “Coping with Problems and Symptoms. ” Practitioners need to be responsive to people’s concerns and use their clinical judgment regarding the order and pacing of handouts.
Back to top
Importance of Recovery
There is widespread acceptance of the importance of recovery as a guiding vision for helping people who experience psychiatric symptoms to achieve personal success in their lives. The term recovery means different things to different individuals. Each person is free to define it in his or her terms. For some individuals, recovery means no longer having any symptoms or signs of a mental illness. For others, recovery means taking on challenges, enjoying the pleasures life has to offer, pursuing personal dreams and goals, and learning how to cope with or grow past one’s mental illness despite symptoms or setbacks.
Regardless of the personal understanding each individual develops about recovery, the overriding message is one of hope and optimism. The recovery vision is at the heart of the Illness Management and Recovery Toolkit. Through learning information about mental illness and its treatment, developing skills for reducing relapses, dealing with stress, and coping with symptoms, people can become empowered to manage their own illness, to find their own goals for recovery, and to assume responsibility for directing their own treatment. People who experience psychiatric symptoms are not passive recipients of treatment, and the goal is not to make them “comply” with treatment recommendations. Rather, the focus of Illness Management and Recovery is providing people with the information and skills they need in order to make informed decisions about their own treatment.
Broadly speaking, the goals of Illness Management and Recovery are to:
Instill hope that change is possible
Develop a collaborative relationship with a treatment team
Help people establish personally meaningful goals to strive towards
Teach information about mental illness and treatment options
Develop skills for reducing relapses, dealing with stress, and coping with symptoms
Provide information about where to obtain needed resources
Help people develop or enhance their natural supports for managing their illness and pursuing goals
Back to top
Importance of Helping People Set and Pursue Personal Goals
Being able to set and pursue personal goals is an essential part of recovery. At the same time that information and skills are being taught in the Illness Management and Recovery Program, people are also helped to define what recovery means to them and to identify what goals and dreams are important to them. The first educational handout, “Recovery Strategies,” contains specific information about setting goals. However, throughout the entire program, practitioners help people set meaningful personal goals and follow up regularly on those goals. As people gain more mastery over their psychiatric symptoms, they gain more control over their lives and become better able to realize their vision of recovery. In each session of the program, practitioners should follow up on the participants’ progress towards their goals. “Goals Set in the Illness Management and Recovery Program” (Appendix 5) helps practitioners to keep track of a person’s goals. Another form, “Step-By-Step Problem-Solving and Goal Achievement” (Appendix 6) is useful for helping a person plan the steps for achieving a goal (or solving a problem).
Back to top
Logistics
The content and teaching methods used in the Illness Management and Recovery Program are derived from multiple studies of professionally based illness management training programs for people who have experienced psychiatric symptoms. Information is taught using a combination of motivational, educational, and cognitive-behavioral teaching principles. Critical information is summarized in educational handouts that are written for people who experience psychiatric symptoms but are also suitable for distribution to anyone with a professional or caring relationship with a person who experiences psychiatric symptoms (such as a case manager or a family member).
The information and skills taught in Illness management and Recovery are organized into nine topic areas: recovery strategies, practical facts about mental illness, the stress-vulnerability model, building social support, using medication effectively, reducing relapses, coping with stress, coping with problems and symptoms, and getting your needs met in the mental health system. There are educational handouts and practitioners’ guidelines for each topic area.
Each topic is taught using a combination of motivational, educational, and cognitive behavioral methods. Also, in order to help people apply the information and skills that they learn in the sessions to their day-to-day lives, the practitioner and the person collaborate to develop homework assignments at the end of each session. These homework assignments are tailored to the individual, to help him or her practice strategies in “the real world.” Because developing and enhancing natural supports is a goal of Illness Management and Recovery, people are encouraged to identify significant others with whom they can share the handout materials and who may support them in applying newly acquired skills or completing homework.
The amount of time required to teach Illness Management and Recovery depends on a variety of factors, including people’s prior knowledge and level of skills, the problem areas that they would like to work on, and the presence of either cognitive difficulties or severe symptoms that may slow the learning process. In general, between three and six months of weekly sessions of 45 to 60 minutes may be required to teach Illness Management and Recovery. Following the completion of the nine topic areas, people may also benefit from either booster sessions or participation in support groups aimed at using and expanding skills.
for more on this topic,
mft ceus
The Illness Management and Recovery Program consists of a series of weekly sessions where mental health practitioners help people who have experienced psychiatric symptoms to develop personalized strategies for managing their mental illness and moving forward in their lives. The program can be provided in an individual or group format, and generally lasts between three and six months. In the sessions, practitioners work collaboratively with people, offering a variety of information, strategies, and skills that people can use to further their own recovery. There is a strong emphasis on helping people set and pursue personal goals and helping them put strategies into action in their everyday lives.
Materials for Providing the Illness Management and Recovery Program
In the Practitioners’ Workbook (this document) there are two sets of materials for Illness Management and Recovery: the Practitioners’ Guide (Chapters 1-10) and Educational Handouts. The educational handouts contain practical information and strategies that people can use in the recovery process. The handouts are not meant to stand alone. Practitioners are expected to help people select and put into practice the knowledge and strategies that are most helpful to themselves as individuals. The following topics are covered in nine educational handouts:
Recovery Strategies
Practical Facts about Schizophrenia/Bipolar Disorder/ Depression
The Stress-Vulnerability Model and Strategies for Treatment
Building Social Support
Using Medication Effectively
Reducing Relapses
Coping with Stress
Coping with Problems and Symptoms
Getting Your Needs Met in the Mental Health System
Chapter 1 of the Practitioners’ Guide contains overall strategies for conducting the program, and Chapters 2-10 contain practitioner guidelines for using each of the educational handouts to conduct sessions. The guidelines contain specific suggestions for using motivational, educational, and cognitive behavioral techniques to help people use strategies from the handouts in their daily lives. They also provide tips for developing homework assignments and for dealing with problems that might arise during sessions.
Getting started
First, practitioners are advised to familiarize themselves with the format, content and tone of the program. This can be accomplished by first reading the following:
Chapter 1 of the Practitioners’ Guide
Educational Handout #1 (“Recovery Strategies”)
Practitioner Guidelines for Educational Handout #1 (“Recovery Strategies”)
It is optimal for practitioners to read the remaining educational handouts and accompanying practitioners’ guidelines before beginning to work with people. Practitioners are advised to review specific handouts and guidelines prior to addressing these particular topic areas with people.
Preparing For Sessions
The first session is usually spent on orientation, using the “Orientation Sheet” (see Appendix 1) as a guide. The second (and sometimes third) session is spent on getting to know the person better, using the ”Knowledge and Skills Inventory” (see Appendix 2) as a guide. This inventory is focused on the person’s positive attributes rather than their problems or “deficits.” It is important to gather information in a friendly, low- key manner, using a conversational tone. The remaining sessions are focused on helping people to learn and practice the information and strategies in the educational handouts and to set and pursue their personal goals. Each session should be documented, using the “Progress Note for Illness Management and Recovery” (Appendix 3). The format of the progress note helps practitioners to keep track of the person’s personal goals, the kinds of interventions provided (motivational, educational, cognitive-behavioral), the specific evidence-based skill(s) that are taught (coping skills, relapse prevention skills and behavioral tailoring skills) and the homework that is agreed upon.
Before beginning each educational handout, the practitioner is encouraged to review the contents of the handout and the practitioner guidelines of the same title in the Practitioners’ Guide. Most educational handouts will require two to four sessions to put the important principles into practice. Preparation for sessions is most effective when practitioners review the educational handout and the corresponding practitioners’ guidelines side-by-side, noting the goals of the handout, the specific topic headings, the probe questions, the checklists, etc. As noted above, sessions should be recorded on the form “Progress Note for Illness Management and Recovery” (Appendix 3). Although for many people it is most helpful to go through the handouts in the order they are listed, it is important to tailor the program to respond to individual needs. For example, when a person is very distressed by the symptoms he or she is experiencing, it would be preferable to address this problem early in the program using Educational Handout #8, “Coping with Problems and Symptoms. ” Practitioners need to be responsive to people’s concerns and use their clinical judgment regarding the order and pacing of handouts.
Back to top
Importance of Recovery
There is widespread acceptance of the importance of recovery as a guiding vision for helping people who experience psychiatric symptoms to achieve personal success in their lives. The term recovery means different things to different individuals. Each person is free to define it in his or her terms. For some individuals, recovery means no longer having any symptoms or signs of a mental illness. For others, recovery means taking on challenges, enjoying the pleasures life has to offer, pursuing personal dreams and goals, and learning how to cope with or grow past one’s mental illness despite symptoms or setbacks.
Regardless of the personal understanding each individual develops about recovery, the overriding message is one of hope and optimism. The recovery vision is at the heart of the Illness Management and Recovery Toolkit. Through learning information about mental illness and its treatment, developing skills for reducing relapses, dealing with stress, and coping with symptoms, people can become empowered to manage their own illness, to find their own goals for recovery, and to assume responsibility for directing their own treatment. People who experience psychiatric symptoms are not passive recipients of treatment, and the goal is not to make them “comply” with treatment recommendations. Rather, the focus of Illness Management and Recovery is providing people with the information and skills they need in order to make informed decisions about their own treatment.
Broadly speaking, the goals of Illness Management and Recovery are to:
Instill hope that change is possible
Develop a collaborative relationship with a treatment team
Help people establish personally meaningful goals to strive towards
Teach information about mental illness and treatment options
Develop skills for reducing relapses, dealing with stress, and coping with symptoms
Provide information about where to obtain needed resources
Help people develop or enhance their natural supports for managing their illness and pursuing goals
Back to top
Importance of Helping People Set and Pursue Personal Goals
Being able to set and pursue personal goals is an essential part of recovery. At the same time that information and skills are being taught in the Illness Management and Recovery Program, people are also helped to define what recovery means to them and to identify what goals and dreams are important to them. The first educational handout, “Recovery Strategies,” contains specific information about setting goals. However, throughout the entire program, practitioners help people set meaningful personal goals and follow up regularly on those goals. As people gain more mastery over their psychiatric symptoms, they gain more control over their lives and become better able to realize their vision of recovery. In each session of the program, practitioners should follow up on the participants’ progress towards their goals. “Goals Set in the Illness Management and Recovery Program” (Appendix 5) helps practitioners to keep track of a person’s goals. Another form, “Step-By-Step Problem-Solving and Goal Achievement” (Appendix 6) is useful for helping a person plan the steps for achieving a goal (or solving a problem).
Back to top
Logistics
The content and teaching methods used in the Illness Management and Recovery Program are derived from multiple studies of professionally based illness management training programs for people who have experienced psychiatric symptoms. Information is taught using a combination of motivational, educational, and cognitive-behavioral teaching principles. Critical information is summarized in educational handouts that are written for people who experience psychiatric symptoms but are also suitable for distribution to anyone with a professional or caring relationship with a person who experiences psychiatric symptoms (such as a case manager or a family member).
The information and skills taught in Illness management and Recovery are organized into nine topic areas: recovery strategies, practical facts about mental illness, the stress-vulnerability model, building social support, using medication effectively, reducing relapses, coping with stress, coping with problems and symptoms, and getting your needs met in the mental health system. There are educational handouts and practitioners’ guidelines for each topic area.
Each topic is taught using a combination of motivational, educational, and cognitive behavioral methods. Also, in order to help people apply the information and skills that they learn in the sessions to their day-to-day lives, the practitioner and the person collaborate to develop homework assignments at the end of each session. These homework assignments are tailored to the individual, to help him or her practice strategies in “the real world.” Because developing and enhancing natural supports is a goal of Illness Management and Recovery, people are encouraged to identify significant others with whom they can share the handout materials and who may support them in applying newly acquired skills or completing homework.
The amount of time required to teach Illness Management and Recovery depends on a variety of factors, including people’s prior knowledge and level of skills, the problem areas that they would like to work on, and the presence of either cognitive difficulties or severe symptoms that may slow the learning process. In general, between three and six months of weekly sessions of 45 to 60 minutes may be required to teach Illness Management and Recovery. Following the completion of the nine topic areas, people may also benefit from either booster sessions or participation in support groups aimed at using and expanding skills.
April 07, 2010
Anniversary Reactions to a Traumatic Event
Anniversary Reactions to a Traumatic Event:
The Recovery Process Continues
As the anniversary of a disaster or traumatic event approaches, many survivors report a return of restlessness and fear. Psychological literature calls it the anniversary reaction and defines it as an individual's response to unresolved grief resulting from significant losses. The anniversary reaction can involve several days or even weeks of anxiety, anger, nightmares, flashbacks, depression, or fear.
On a more positive note, the anniversary of a disaster or traumatic event also can provide an opportunity for emotional healing. Individuals can make significant progress in working through the natural grieving process by recognizing, acknowledging, and paying attention to the feelings and issues that surface during their anniversary reaction. These feelings and issues can help individuals develop perspective on the event and figure out where it fits in their hearts, minds, and lives.
It is important to note that not all survivors of a disaster or traumatic event experience an anniversary reaction. Those who do, however, may be troubled because they did not expect and do not understand their reaction. For these individuals, knowing what to expect in advance may be helpful. Common anniversary reactions among survivors of a disaster or traumatic event include:
Memories, Dreams, Thoughts, and Feelings: Individuals may replay memories, thoughts, and feelings about the event, which they can't turn off. They may see repeated images and scenes associated with the trauma or relive the event over and over. They may have recurring dreams or nightmares. These reactions may be as vivid on the anniversary as they were at the actual time of the disaster or traumatic event.
Grief and Sadness: Individuals may experience grief and sadness related to the loss of income, employment, a home, or a loved one. Even people who have moved to new homes often feel a sense of loss on the anniversary. Those who were forced to relocate to another community may experience intense homesickness for their old neighborhoods.
Fear and Anxiety: Fear and anxiety may resurface around the time of the anniversary, leading to jumpiness, startled responses, and vigilance about safety. These feelings may be particularly strong for individuals who are still working through the grieving process.
Frustration, Anger, and Guilt: The anniversary may reawaken frustration and anger about the disaster or traumatic event. Survivors may be reminded of the possessions, homes, or loved ones they lost; the time taken away from their lives; the frustrations with bureaucratic aspects of the recovery process; and the slow process of rebuilding and healing. Individuals may also experience guilt about survival. These feelings may be particularly strong for individuals who are not fully recovered financially and emotionally.
Avoidance: Some survivors try to protect themselves from experiencing an anniversary reaction by avoiding reminders of the event and attempting to treat the anniversary as just an ordinary day. Even for these people, it can be helpful to learn about common reactions that they or their loved ones may encounter, so they are not surprised if reactions occur.
Remembrance: Many survivors welcome the cleansing tears, commemoration, and fellowship that the anniversary of the event offers. They see it as a time to honor the memory of what they have lost. They might light a candle, share favorite memories and stories, or attend a worship service.
Reflection: The reflection brought about by the anniversary of a disaster or traumatic event is often a turning point in the recovery process. It is an opportunity for people to look back over the past year, recognize how far they have come, and give themselves credit for the challenges they surmounted. It is a time for survivors to look inward and to recognize and appreciate the courage, stamina, endurance, and resourcefulness that they and their loved ones showed during the recovery process. It is a time for people to look around and pause to appreciate the family members, friends, and others who supported them through the healing process. It is also a time when most people can look forward with a renewed sense of hope and purpose.
Although these thoughts, feelings, and reactions can be very upsetting, it helps to understand that it is normal to have strong reactions to a disaster or traumatic event and its devastation many months later. Recovery from a disaster or traumatic event takes time, and it requires rebuilding on many levels - physically, emotionally, and spiritually. However, with patience, understanding, and support from family members and friends, you can emerge from a disaster or traumatic event stronger than before.
The Recovery Process Continues
As the anniversary of a disaster or traumatic event approaches, many survivors report a return of restlessness and fear. Psychological literature calls it the anniversary reaction and defines it as an individual's response to unresolved grief resulting from significant losses. The anniversary reaction can involve several days or even weeks of anxiety, anger, nightmares, flashbacks, depression, or fear.
On a more positive note, the anniversary of a disaster or traumatic event also can provide an opportunity for emotional healing. Individuals can make significant progress in working through the natural grieving process by recognizing, acknowledging, and paying attention to the feelings and issues that surface during their anniversary reaction. These feelings and issues can help individuals develop perspective on the event and figure out where it fits in their hearts, minds, and lives.
It is important to note that not all survivors of a disaster or traumatic event experience an anniversary reaction. Those who do, however, may be troubled because they did not expect and do not understand their reaction. For these individuals, knowing what to expect in advance may be helpful. Common anniversary reactions among survivors of a disaster or traumatic event include:
Memories, Dreams, Thoughts, and Feelings: Individuals may replay memories, thoughts, and feelings about the event, which they can't turn off. They may see repeated images and scenes associated with the trauma or relive the event over and over. They may have recurring dreams or nightmares. These reactions may be as vivid on the anniversary as they were at the actual time of the disaster or traumatic event.
Grief and Sadness: Individuals may experience grief and sadness related to the loss of income, employment, a home, or a loved one. Even people who have moved to new homes often feel a sense of loss on the anniversary. Those who were forced to relocate to another community may experience intense homesickness for their old neighborhoods.
Fear and Anxiety: Fear and anxiety may resurface around the time of the anniversary, leading to jumpiness, startled responses, and vigilance about safety. These feelings may be particularly strong for individuals who are still working through the grieving process.
Frustration, Anger, and Guilt: The anniversary may reawaken frustration and anger about the disaster or traumatic event. Survivors may be reminded of the possessions, homes, or loved ones they lost; the time taken away from their lives; the frustrations with bureaucratic aspects of the recovery process; and the slow process of rebuilding and healing. Individuals may also experience guilt about survival. These feelings may be particularly strong for individuals who are not fully recovered financially and emotionally.
Avoidance: Some survivors try to protect themselves from experiencing an anniversary reaction by avoiding reminders of the event and attempting to treat the anniversary as just an ordinary day. Even for these people, it can be helpful to learn about common reactions that they or their loved ones may encounter, so they are not surprised if reactions occur.
Remembrance: Many survivors welcome the cleansing tears, commemoration, and fellowship that the anniversary of the event offers. They see it as a time to honor the memory of what they have lost. They might light a candle, share favorite memories and stories, or attend a worship service.
Reflection: The reflection brought about by the anniversary of a disaster or traumatic event is often a turning point in the recovery process. It is an opportunity for people to look back over the past year, recognize how far they have come, and give themselves credit for the challenges they surmounted. It is a time for survivors to look inward and to recognize and appreciate the courage, stamina, endurance, and resourcefulness that they and their loved ones showed during the recovery process. It is a time for people to look around and pause to appreciate the family members, friends, and others who supported them through the healing process. It is also a time when most people can look forward with a renewed sense of hope and purpose.
Although these thoughts, feelings, and reactions can be very upsetting, it helps to understand that it is normal to have strong reactions to a disaster or traumatic event and its devastation many months later. Recovery from a disaster or traumatic event takes time, and it requires rebuilding on many levels - physically, emotionally, and spiritually. However, with patience, understanding, and support from family members and friends, you can emerge from a disaster or traumatic event stronger than before.
April 06, 2010
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.
http://www.aspirace.com
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.
http://www.aspirace.com
April 05, 2010
Depression and Mood Disorders
Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
Subscribe to:
Posts (Atom)
