Alison M. Heru, MD

Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.

She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.

Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).

Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.

He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.

In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.

Measuring relational functioning briefly

In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.

The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.

The BMAS demonstrated acceptable reliability, especially for such a brief measure. It also demonstrated concurrent and convergent validity with a much longer commonly used clinical outcome scale. The BMAS is a useful assessment tool for patients with any clinical condition for which it is desirable to track how the patient is experiencing his or her life situation at a given point in time and when there is a desire to monitor change over time. Notably, BMAS includes health relationships as a measure of good clinical outcome.

A daughter’s documentary about her father

One media workshop slated for the APA meeting will be offered by three members of the Association of Family Psychiatrists: Dr. Michael S. Ascher, Dr. Ira Glick, and Dr. Igor Galynker. They will present a film, "Unlisted: A Story of Schizophrenia." This is a soul-searching examination of responsibility – of parents and children, physicians and patients, and of society and citizens – toward those afflicted with severe mental illness. The film was made by Dr. Delaney Ruston, a Seattle general physician who documents the rebuilding of her relationship with her father. "Unlisted" examines the challenging family dynamics that are present when schizophrenia occurs. Dr. Ruston works hard to overcome the obstacles in accessing appropriate treatment for her father, and her documentary exposes the many failings of the American mental health system as experienced by the families. Dr. Ruston traces the progression of her father’s illness. She studies his medical files and narrates from his autobiographical surrealist novel. In beautifully portrayed scenes, "Unlisted" enters the inner life of Richard Ruston with a clarity and affection missing from many films about people with mental illness.

In summary, family-oriented patient care can be delivered in many ways, from focusing on relational improvement in individual work, to being aware of how to assess and measure relational functioning briefly at each visit, to being able to listen to the accounts of family members and invite them into the treatment room.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.

She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.

Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).

Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.

He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.

In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.

Measuring relational functioning briefly

In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.

The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.

The BMAS demonstrated acceptable reliability, especially for such a brief measure. It also demonstrated concurrent and convergent validity with a much longer commonly used clinical outcome scale. The BMAS is a useful assessment tool for patients with any clinical condition for which it is desirable to track how the patient is experiencing his or her life situation at a given point in time and when there is a desire to monitor change over time. Notably, BMAS includes health relationships as a measure of good clinical outcome.

A daughter’s documentary about her father

One media workshop slated for the APA meeting will be offered by three members of the Association of Family Psychiatrists: Dr. Michael S. Ascher, Dr. Ira Glick, and Dr. Igor Galynker. They will present a film, "Unlisted: A Story of Schizophrenia." This is a soul-searching examination of responsibility – of parents and children, physicians and patients, and of society and citizens – toward those afflicted with severe mental illness. The film was made by Dr. Delaney Ruston, a Seattle general physician who documents the rebuilding of her relationship with her father. "Unlisted" examines the challenging family dynamics that are present when schizophrenia occurs. Dr. Ruston works hard to overcome the obstacles in accessing appropriate treatment for her father, and her documentary exposes the many failings of the American mental health system as experienced by the families. Dr. Ruston traces the progression of her father’s illness. She studies his medical files and narrates from his autobiographical surrealist novel. In beautifully portrayed scenes, "Unlisted" enters the inner life of Richard Ruston with a clarity and affection missing from many films about people with mental illness.

In summary, family-oriented patient care can be delivered in many ways, from focusing on relational improvement in individual work, to being aware of how to assess and measure relational functioning briefly at each visit, to being able to listen to the accounts of family members and invite them into the treatment room.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.

She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.

Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).

Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.

He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.

In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.

Measuring relational functioning briefly

In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.

The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.

The BMAS demonstrated acceptable reliability, especially for such a brief measure. It also demonstrated concurrent and convergent validity with a much longer commonly used clinical outcome scale. The BMAS is a useful assessment tool for patients with any clinical condition for which it is desirable to track how the patient is experiencing his or her life situation at a given point in time and when there is a desire to monitor change over time. Notably, BMAS includes health relationships as a measure of good clinical outcome.

A daughter’s documentary about her father

One media workshop slated for the APA meeting will be offered by three members of the Association of Family Psychiatrists: Dr. Michael S. Ascher, Dr. Ira Glick, and Dr. Igor Galynker. They will present a film, "Unlisted: A Story of Schizophrenia." This is a soul-searching examination of responsibility – of parents and children, physicians and patients, and of society and citizens – toward those afflicted with severe mental illness. The film was made by Dr. Delaney Ruston, a Seattle general physician who documents the rebuilding of her relationship with her father. "Unlisted" examines the challenging family dynamics that are present when schizophrenia occurs. Dr. Ruston works hard to overcome the obstacles in accessing appropriate treatment for her father, and her documentary exposes the many failings of the American mental health system as experienced by the families. Dr. Ruston traces the progression of her father’s illness. She studies his medical files and narrates from his autobiographical surrealist novel. In beautifully portrayed scenes, "Unlisted" enters the inner life of Richard Ruston with a clarity and affection missing from many films about people with mental illness.

In summary, family-oriented patient care can be delivered in many ways, from focusing on relational improvement in individual work, to being aware of how to assess and measure relational functioning briefly at each visit, to being able to listen to the accounts of family members and invite them into the treatment room.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

While reading a recent article about Richard Fee, a 25-year-old college graduate who committed suicide in 2011, I couldn’t help wondering whether things might have turned out differently had his family – particularly his parents – had more to say about his psychiatric care.

Richard’s parents reportedly had a hard time accessing appropriate care for their son and suggested that his doctors’ adherence to privacy laws might have explained their behavior. Dr. Waldo M. Ellison, the psychiatrist who conducted Richard’s initial evaluation, "explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father," the article said ("Drowned in a Stream of Prescriptions," New York Times, Feb. 2, 2013).

The Times article discussed Richard’s struggles with attention-deficit/hyperactivity diagnoses, his dark mood and growing paranoia, and his agitated, violent behavior.

Richard’s father, Rick Fee, reportedly tried to share details about his son’s behavior with the doctor but was met with resistance. "I can’t talk to you," Mr. Fee recalled Dr. Ellison telling him. "I can’t talk with you unless your son comes with you." Later in the article, however, Mr. Fee noted that Dr. Ellison "had spoken with him about his son for 45 minutes, then they scheduled an appointment for the entire family."

The Health Insurance Portability and Accountability Act (HIPPA) sets rules for the use of health information. The intent of the federal privacy law is to give patients more control over their care, but, unfortunately, the intent is often misunderstood as restricting to whom professionals can talk. What do federal privacy laws actually say about talking with family members?

The HIPAA Privacy Rule at 45 CFR 164.510(b) specifically permits covered entities to share information that is directly relevant to the involvement of a spouse, family members, friends, or other persons identified by a patient, in the patient’s care or payment for health care.

If the patient is present, or is otherwise available prior to the disclosure, and has the capacity to make health care decisions, the covered entity may discuss this information with the family and these other persons if the patient agrees or, when given the opportunity, does not object. The covered entity also may share relevant information with the family and these other persons if it can be reasonably inferred, based on professional judgment, that the patient does not object. Under these circumstances, for example:

• A physician may instruct a patient’s roommate about proper medicine dosage when she comes to pick up her friend from the hospital.

• A physician may discuss a patient’s treatment with the patient in the presence of a friend when the patient brings the friend to a medical appointment and asks if the friend can come into the room. Even when the patient is not present because of emergency circumstances or incapacity, a covered entity may share information with the person when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient. See 45 CFR 164.510(b).

In light of those allowances:

• A surgeon may, if consistent with such professional judgment, inform a patient’s spouse who accompanied her husband to the emergency room that the patient has suffered a heart attack and provide periodic updates on the patients’ progress and prognosis.

• A doctor may, if consistent with such professional judgment, discuss an incapacitated patient’s condition with a family member over the phone. In addition, the privacy rule expressly permits a covered entity to use professional judgment and experience with common practice to make reasonable inferences about the patient’s best interests in allowing another person to act on behalf of the patient to pick up a filled prescription, medical supplies, X-rays, or other similar forms of protected health information.

For example, when a person comes to a pharmacy requesting to pick up a prescription on behalf of an individual, he identifies by name, a pharmacist, based on professional judgment and experience with common practice.

What to do if a patient objects

If a family member is urgently trying to reach you, it is most likely because the person has information she deems pertinent for the safe care of your patient. You can listen to anything they say. The privacy act is about protecting patient information, so that you may not tell them details of what the patient has told you in confidence, unless there are issues of safety or the possibility of harm to self or others.

Nonemergent situations allow time for the psychiatrist to educate the patient on the benefits of family involvement. As I have written previously, the literature is quite clear: Family involvement improves the outcome of many psychiatric illnesses (Am. J. Psychiatry 2006;163:962-8). It should be part of our informed consent process that we let patients know this. For example, we might want to say something like this: "In major depression, the literature shows that patient outcome is much better if family functioning is good. Let’s schedule a family consultation, one session, to assess the family functioning." Or we might say: "With bipolar disorder, when family members are knowledgeable about the signs and symptoms of relapse, the patient has a better outcome."

Patients might fear family involvement because they think the psychiatrist will divulge secrets or because the patient fears being attacked by angry family members. The patient should be reassured that the purpose of the meeting is to promote general treatment goals, such as maintaining optimal functioning with lowest medication doses, and to work on future treatment goals as a team.

When the psychiatrist lays out a clear plan for the meeting, the patient grasps the importance of having everyone on board. This is what we should tell patients: "At the family meeting we will review your family’s concerns and your concerns. Many family members need help understanding your illness, the role of medications, and how best to manage when, for example, you miss a dose of medications or have questions about how closely they need to monitor things.

"If you all agree on what is important and what is less important, things will go more smoothly for you. The main focus is to have a plan going forward of how we should work as a team to get you the best treatment possible, maintain your health, and prevent relapses."

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

While reading a recent article about Richard Fee, a 25-year-old college graduate who committed suicide in 2011, I couldn’t help wondering whether things might have turned out differently had his family – particularly his parents – had more to say about his psychiatric care.

Richard’s parents reportedly had a hard time accessing appropriate care for their son and suggested that his doctors’ adherence to privacy laws might have explained their behavior. Dr. Waldo M. Ellison, the psychiatrist who conducted Richard’s initial evaluation, "explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father," the article said ("Drowned in a Stream of Prescriptions," New York Times, Feb. 2, 2013).

The Times article discussed Richard’s struggles with attention-deficit/hyperactivity diagnoses, his dark mood and growing paranoia, and his agitated, violent behavior.

Richard’s father, Rick Fee, reportedly tried to share details about his son’s behavior with the doctor but was met with resistance. "I can’t talk to you," Mr. Fee recalled Dr. Ellison telling him. "I can’t talk with you unless your son comes with you." Later in the article, however, Mr. Fee noted that Dr. Ellison "had spoken with him about his son for 45 minutes, then they scheduled an appointment for the entire family."

The Health Insurance Portability and Accountability Act (HIPPA) sets rules for the use of health information. The intent of the federal privacy law is to give patients more control over their care, but, unfortunately, the intent is often misunderstood as restricting to whom professionals can talk. What do federal privacy laws actually say about talking with family members?

The HIPAA Privacy Rule at 45 CFR 164.510(b) specifically permits covered entities to share information that is directly relevant to the involvement of a spouse, family members, friends, or other persons identified by a patient, in the patient’s care or payment for health care.

If the patient is present, or is otherwise available prior to the disclosure, and has the capacity to make health care decisions, the covered entity may discuss this information with the family and these other persons if the patient agrees or, when given the opportunity, does not object. The covered entity also may share relevant information with the family and these other persons if it can be reasonably inferred, based on professional judgment, that the patient does not object. Under these circumstances, for example:

• A physician may instruct a patient’s roommate about proper medicine dosage when she comes to pick up her friend from the hospital.

• A physician may discuss a patient’s treatment with the patient in the presence of a friend when the patient brings the friend to a medical appointment and asks if the friend can come into the room. Even when the patient is not present because of emergency circumstances or incapacity, a covered entity may share information with the person when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient. See 45 CFR 164.510(b).

In light of those allowances:

• A surgeon may, if consistent with such professional judgment, inform a patient’s spouse who accompanied her husband to the emergency room that the patient has suffered a heart attack and provide periodic updates on the patients’ progress and prognosis.

• A doctor may, if consistent with such professional judgment, discuss an incapacitated patient’s condition with a family member over the phone. In addition, the privacy rule expressly permits a covered entity to use professional judgment and experience with common practice to make reasonable inferences about the patient’s best interests in allowing another person to act on behalf of the patient to pick up a filled prescription, medical supplies, X-rays, or other similar forms of protected health information.

For example, when a person comes to a pharmacy requesting to pick up a prescription on behalf of an individual, he identifies by name, a pharmacist, based on professional judgment and experience with common practice.

What to do if a patient objects

If a family member is urgently trying to reach you, it is most likely because the person has information she deems pertinent for the safe care of your patient. You can listen to anything they say. The privacy act is about protecting patient information, so that you may not tell them details of what the patient has told you in confidence, unless there are issues of safety or the possibility of harm to self or others.

Nonemergent situations allow time for the psychiatrist to educate the patient on the benefits of family involvement. As I have written previously, the literature is quite clear: Family involvement improves the outcome of many psychiatric illnesses (Am. J. Psychiatry 2006;163:962-8). It should be part of our informed consent process that we let patients know this. For example, we might want to say something like this: "In major depression, the literature shows that patient outcome is much better if family functioning is good. Let’s schedule a family consultation, one session, to assess the family functioning." Or we might say: "With bipolar disorder, when family members are knowledgeable about the signs and symptoms of relapse, the patient has a better outcome."

Patients might fear family involvement because they think the psychiatrist will divulge secrets or because the patient fears being attacked by angry family members. The patient should be reassured that the purpose of the meeting is to promote general treatment goals, such as maintaining optimal functioning with lowest medication doses, and to work on future treatment goals as a team.

When the psychiatrist lays out a clear plan for the meeting, the patient grasps the importance of having everyone on board. This is what we should tell patients: "At the family meeting we will review your family’s concerns and your concerns. Many family members need help understanding your illness, the role of medications, and how best to manage when, for example, you miss a dose of medications or have questions about how closely they need to monitor things.

"If you all agree on what is important and what is less important, things will go more smoothly for you. The main focus is to have a plan going forward of how we should work as a team to get you the best treatment possible, maintain your health, and prevent relapses."

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

While reading a recent article about Richard Fee, a 25-year-old college graduate who committed suicide in 2011, I couldn’t help wondering whether things might have turned out differently had his family – particularly his parents – had more to say about his psychiatric care.

Richard’s parents reportedly had a hard time accessing appropriate care for their son and suggested that his doctors’ adherence to privacy laws might have explained their behavior. Dr. Waldo M. Ellison, the psychiatrist who conducted Richard’s initial evaluation, "explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father," the article said ("Drowned in a Stream of Prescriptions," New York Times, Feb. 2, 2013).

The Times article discussed Richard’s struggles with attention-deficit/hyperactivity diagnoses, his dark mood and growing paranoia, and his agitated, violent behavior.

Richard’s father, Rick Fee, reportedly tried to share details about his son’s behavior with the doctor but was met with resistance. "I can’t talk to you," Mr. Fee recalled Dr. Ellison telling him. "I can’t talk with you unless your son comes with you." Later in the article, however, Mr. Fee noted that Dr. Ellison "had spoken with him about his son for 45 minutes, then they scheduled an appointment for the entire family."

The Health Insurance Portability and Accountability Act (HIPPA) sets rules for the use of health information. The intent of the federal privacy law is to give patients more control over their care, but, unfortunately, the intent is often misunderstood as restricting to whom professionals can talk. What do federal privacy laws actually say about talking with family members?

The HIPAA Privacy Rule at 45 CFR 164.510(b) specifically permits covered entities to share information that is directly relevant to the involvement of a spouse, family members, friends, or other persons identified by a patient, in the patient’s care or payment for health care.

If the patient is present, or is otherwise available prior to the disclosure, and has the capacity to make health care decisions, the covered entity may discuss this information with the family and these other persons if the patient agrees or, when given the opportunity, does not object. The covered entity also may share relevant information with the family and these other persons if it can be reasonably inferred, based on professional judgment, that the patient does not object. Under these circumstances, for example:

• A physician may instruct a patient’s roommate about proper medicine dosage when she comes to pick up her friend from the hospital.

• A physician may discuss a patient’s treatment with the patient in the presence of a friend when the patient brings the friend to a medical appointment and asks if the friend can come into the room. Even when the patient is not present because of emergency circumstances or incapacity, a covered entity may share information with the person when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient. See 45 CFR 164.510(b).

In light of those allowances:

• A surgeon may, if consistent with such professional judgment, inform a patient’s spouse who accompanied her husband to the emergency room that the patient has suffered a heart attack and provide periodic updates on the patients’ progress and prognosis.

• A doctor may, if consistent with such professional judgment, discuss an incapacitated patient’s condition with a family member over the phone. In addition, the privacy rule expressly permits a covered entity to use professional judgment and experience with common practice to make reasonable inferences about the patient’s best interests in allowing another person to act on behalf of the patient to pick up a filled prescription, medical supplies, X-rays, or other similar forms of protected health information.

For example, when a person comes to a pharmacy requesting to pick up a prescription on behalf of an individual, he identifies by name, a pharmacist, based on professional judgment and experience with common practice.

What to do if a patient objects

If a family member is urgently trying to reach you, it is most likely because the person has information she deems pertinent for the safe care of your patient. You can listen to anything they say. The privacy act is about protecting patient information, so that you may not tell them details of what the patient has told you in confidence, unless there are issues of safety or the possibility of harm to self or others.

Nonemergent situations allow time for the psychiatrist to educate the patient on the benefits of family involvement. As I have written previously, the literature is quite clear: Family involvement improves the outcome of many psychiatric illnesses (Am. J. Psychiatry 2006;163:962-8). It should be part of our informed consent process that we let patients know this. For example, we might want to say something like this: "In major depression, the literature shows that patient outcome is much better if family functioning is good. Let’s schedule a family consultation, one session, to assess the family functioning." Or we might say: "With bipolar disorder, when family members are knowledgeable about the signs and symptoms of relapse, the patient has a better outcome."

Patients might fear family involvement because they think the psychiatrist will divulge secrets or because the patient fears being attacked by angry family members. The patient should be reassured that the purpose of the meeting is to promote general treatment goals, such as maintaining optimal functioning with lowest medication doses, and to work on future treatment goals as a team.

When the psychiatrist lays out a clear plan for the meeting, the patient grasps the importance of having everyone on board. This is what we should tell patients: "At the family meeting we will review your family’s concerns and your concerns. Many family members need help understanding your illness, the role of medications, and how best to manage when, for example, you miss a dose of medications or have questions about how closely they need to monitor things.

"If you all agree on what is important and what is less important, things will go more smoothly for you. The main focus is to have a plan going forward of how we should work as a team to get you the best treatment possible, maintain your health, and prevent relapses."

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at [email protected].

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at [email protected].

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at [email protected].

The American Family Therapy Academy recently issued a policy statement protesting the DSM-5, and asks the American Psychiatric Association to consider the importance of relational and family context to psychiatric diagnoses.

AFTA, a multidisciplinary group, does not support the current revision of the DSM, stating that it "continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines." This statement refers to the substantial body of research concerning the role of relational factors in mental health and mental illness, and also refers to the large number of effective family treatments, including, but not limited to, family therapy.

The academy criticizes the DSM’s use of the biomedical model and its omission of the role of family and sociocultural contexts on well-being. AFTA states that the DSM "delegitimizes the focus on relationship, life stage, community, and access to power and resources." AFTA points out that the DSM fails to take into account culture, class and ‘destructive unjust social factors,’ such as poverty, hunger, homelessness, violence, racism, and other forms of oppression. AFTA considers these factors to be important in reaching a diagnosis that accurately describes patients.

Many psychiatrists, especially family, social, and cultural psychiatrists, agree with AFTA’s position. Several family researchers and family psychiatrists have been pushing for many years to get relational diagnoses included in the DSM-IV and the DSM-5 (J. Fam. Psychol. 2006;20:359-68), citing decades of excellent research into relational diagnoses. Their attempts are supported by nonmedical health care professionals who complain that they cannot get paid by insurance companies for treating families. However, putting any diagnosis in the DSM so the insurance companies get paid is a backward way of thinking. Any diagnostic system of American psychiatry should not be framed or influenced by financial organizations that want to ration health care.

Some psychiatrists who contributed to the DSM offer the disclaimer that "they do not mean this to be a bible." However, the DSM is frequently used "as a bible," for example, in the courts. More importantly, reductionist diagnostic descriptions in the DSM narrow the public’s and the professionals’ thinking about psychological difficulties, and, by extrapolation, limit the conceptualization of what types of interventions might be helpful.

For example, describing psychiatric illnesses as biological leads to the assumption that biological interventions are needed. If an illness is defined using a biopsychosocial explanation, however, this broader understanding leads to a wider array of possible treatments. A psychiatric diagnostic system should recognize all the factors that are known to contribute to psychological health and illness to be of most use in patient care.

There is also a strong argument for not including relational diagnoses in the DSM. The argument is this: Relational factors are process factors, rather than static factors. For example, expressed emotion (EE) is not a characteristic of a family but rather a description of family distress that arises as a result of living with a disease. It is a description of a family process. Providing psychoeducation to a distressed family substantially reduces the level of EE and the subsequent risk of patient relapse. EE is a measure of relational process. If EE is entered into the DSM, there is a danger of its being seen as a static entity.

A delicate balance exists between the utilitarian need for a system of diagnoses and the risk of overdefining people and their relationships as "pathological." It was not that long ago that we pathologized homosexuality and described the entity of the "schizophrenogenic mother."

Dr. Larry Freeman, a member of the Association of Family Psychiatrists, adds: "Be wary of a pressure beyond medical circles to utilize psychiatry as a force for social control. I do a great deal of workers’ [compensation], and so-called ‘preexisting conditions’ are commonly framed as the "cause" of a worker’s emotional response to injury, and therefore, [the worker’s] current psychiatric conditions are not accepted as a consequence of the original injury event.

"Be careful that we do not enable this distortion further in our efforts to include context and history."

How should we include patient contexts such as violence, abuse, trauma, poverty, injustice, or relational dysfunction? How do we acknowledge that these factors play a significant role in the lives of our patients? For children, this is especially important as treatment often focuses on changing or stabilizing their environment, and ensuring that there is adequate attachment and nurturance.

How do we ensure that these relationships and contexts are adequately defined so we can monitor the effectiveness (or not) of interventions? AFTA supports the creation of a work group that will focus on developing an alternative to the DSM for the conceptualization of emotional distress. David Elkins, Ph.D., is planning an international summit in 2013 with representatives from all therapist groups to discuss the feasibility of such a system.

Another way forward is to develop a diagnostic system that focuses on health. The Global Assessment of Functioning (GAF), describes with reasonable accuracy a person’s individual level of functioning on a scale of 1 to 100. The Global Assessment of Relational Functioning (GARF) describes the health of a relationship on a scale of 1-100. Using these scales, pathology and health coexist on a continuum, with anchors throughout the scale. These systems are currently crude instruments, but imagine how much better they could become if they were the focus of research, clinical trials, etc.

There will always be the need for individual diagnoses, where the melancholic continues to suffer despite having an excellent social and family context, and there will always be cases where we cannot decide if the patient is ill unto himself or if his illness is informed by the context of his life.

But consider the inverse, the person who is optimistic and functional in spite of the dire context of his life, people who hold beliefs, convictions, and so on that raise them above their life circumstances. (Think of visionaries like Gandhi or Mandela). In the same way, there are relationships that function well, despite the presence of adversity. How do we develop a system that aspires to "health" instead of pathology? The American health care system (or rather its illness care system) needs to morph into true health care with a focus on prevention on both an individual and relational front.

For additional information, see Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment (Washington: American Psychiatric Association Publishing, 2006).

Dr. Alison Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The American Family Therapy Academy recently issued a policy statement protesting the DSM-5, and asks the American Psychiatric Association to consider the importance of relational and family context to psychiatric diagnoses.

AFTA, a multidisciplinary group, does not support the current revision of the DSM, stating that it "continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines." This statement refers to the substantial body of research concerning the role of relational factors in mental health and mental illness, and also refers to the large number of effective family treatments, including, but not limited to, family therapy.

The academy criticizes the DSM’s use of the biomedical model and its omission of the role of family and sociocultural contexts on well-being. AFTA states that the DSM "delegitimizes the focus on relationship, life stage, community, and access to power and resources." AFTA points out that the DSM fails to take into account culture, class and ‘destructive unjust social factors,’ such as poverty, hunger, homelessness, violence, racism, and other forms of oppression. AFTA considers these factors to be important in reaching a diagnosis that accurately describes patients.

Many psychiatrists, especially family, social, and cultural psychiatrists, agree with AFTA’s position. Several family researchers and family psychiatrists have been pushing for many years to get relational diagnoses included in the DSM-IV and the DSM-5 (J. Fam. Psychol. 2006;20:359-68), citing decades of excellent research into relational diagnoses. Their attempts are supported by nonmedical health care professionals who complain that they cannot get paid by insurance companies for treating families. However, putting any diagnosis in the DSM so the insurance companies get paid is a backward way of thinking. Any diagnostic system of American psychiatry should not be framed or influenced by financial organizations that want to ration health care.

Some psychiatrists who contributed to the DSM offer the disclaimer that "they do not mean this to be a bible." However, the DSM is frequently used "as a bible," for example, in the courts. More importantly, reductionist diagnostic descriptions in the DSM narrow the public’s and the professionals’ thinking about psychological difficulties, and, by extrapolation, limit the conceptualization of what types of interventions might be helpful.

For example, describing psychiatric illnesses as biological leads to the assumption that biological interventions are needed. If an illness is defined using a biopsychosocial explanation, however, this broader understanding leads to a wider array of possible treatments. A psychiatric diagnostic system should recognize all the factors that are known to contribute to psychological health and illness to be of most use in patient care.

There is also a strong argument for not including relational diagnoses in the DSM. The argument is this: Relational factors are process factors, rather than static factors. For example, expressed emotion (EE) is not a characteristic of a family but rather a description of family distress that arises as a result of living with a disease. It is a description of a family process. Providing psychoeducation to a distressed family substantially reduces the level of EE and the subsequent risk of patient relapse. EE is a measure of relational process. If EE is entered into the DSM, there is a danger of its being seen as a static entity.

A delicate balance exists between the utilitarian need for a system of diagnoses and the risk of overdefining people and their relationships as "pathological." It was not that long ago that we pathologized homosexuality and described the entity of the "schizophrenogenic mother."

Dr. Larry Freeman, a member of the Association of Family Psychiatrists, adds: "Be wary of a pressure beyond medical circles to utilize psychiatry as a force for social control. I do a great deal of workers’ [compensation], and so-called ‘preexisting conditions’ are commonly framed as the "cause" of a worker’s emotional response to injury, and therefore, [the worker’s] current psychiatric conditions are not accepted as a consequence of the original injury event.

"Be careful that we do not enable this distortion further in our efforts to include context and history."

How should we include patient contexts such as violence, abuse, trauma, poverty, injustice, or relational dysfunction? How do we acknowledge that these factors play a significant role in the lives of our patients? For children, this is especially important as treatment often focuses on changing or stabilizing their environment, and ensuring that there is adequate attachment and nurturance.

How do we ensure that these relationships and contexts are adequately defined so we can monitor the effectiveness (or not) of interventions? AFTA supports the creation of a work group that will focus on developing an alternative to the DSM for the conceptualization of emotional distress. David Elkins, Ph.D., is planning an international summit in 2013 with representatives from all therapist groups to discuss the feasibility of such a system.

Another way forward is to develop a diagnostic system that focuses on health. The Global Assessment of Functioning (GAF), describes with reasonable accuracy a person’s individual level of functioning on a scale of 1 to 100. The Global Assessment of Relational Functioning (GARF) describes the health of a relationship on a scale of 1-100. Using these scales, pathology and health coexist on a continuum, with anchors throughout the scale. These systems are currently crude instruments, but imagine how much better they could become if they were the focus of research, clinical trials, etc.

There will always be the need for individual diagnoses, where the melancholic continues to suffer despite having an excellent social and family context, and there will always be cases where we cannot decide if the patient is ill unto himself or if his illness is informed by the context of his life.

But consider the inverse, the person who is optimistic and functional in spite of the dire context of his life, people who hold beliefs, convictions, and so on that raise them above their life circumstances. (Think of visionaries like Gandhi or Mandela). In the same way, there are relationships that function well, despite the presence of adversity. How do we develop a system that aspires to "health" instead of pathology? The American health care system (or rather its illness care system) needs to morph into true health care with a focus on prevention on both an individual and relational front.

For additional information, see Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment (Washington: American Psychiatric Association Publishing, 2006).

Dr. Alison Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The American Family Therapy Academy recently issued a policy statement protesting the DSM-5, and asks the American Psychiatric Association to consider the importance of relational and family context to psychiatric diagnoses.

AFTA, a multidisciplinary group, does not support the current revision of the DSM, stating that it "continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines." This statement refers to the substantial body of research concerning the role of relational factors in mental health and mental illness, and also refers to the large number of effective family treatments, including, but not limited to, family therapy.

The academy criticizes the DSM’s use of the biomedical model and its omission of the role of family and sociocultural contexts on well-being. AFTA states that the DSM "delegitimizes the focus on relationship, life stage, community, and access to power and resources." AFTA points out that the DSM fails to take into account culture, class and ‘destructive unjust social factors,’ such as poverty, hunger, homelessness, violence, racism, and other forms of oppression. AFTA considers these factors to be important in reaching a diagnosis that accurately describes patients.

Many psychiatrists, especially family, social, and cultural psychiatrists, agree with AFTA’s position. Several family researchers and family psychiatrists have been pushing for many years to get relational diagnoses included in the DSM-IV and the DSM-5 (J. Fam. Psychol. 2006;20:359-68), citing decades of excellent research into relational diagnoses. Their attempts are supported by nonmedical health care professionals who complain that they cannot get paid by insurance companies for treating families. However, putting any diagnosis in the DSM so the insurance companies get paid is a backward way of thinking. Any diagnostic system of American psychiatry should not be framed or influenced by financial organizations that want to ration health care.

Some psychiatrists who contributed to the DSM offer the disclaimer that "they do not mean this to be a bible." However, the DSM is frequently used "as a bible," for example, in the courts. More importantly, reductionist diagnostic descriptions in the DSM narrow the public’s and the professionals’ thinking about psychological difficulties, and, by extrapolation, limit the conceptualization of what types of interventions might be helpful.

For example, describing psychiatric illnesses as biological leads to the assumption that biological interventions are needed. If an illness is defined using a biopsychosocial explanation, however, this broader understanding leads to a wider array of possible treatments. A psychiatric diagnostic system should recognize all the factors that are known to contribute to psychological health and illness to be of most use in patient care.

There is also a strong argument for not including relational diagnoses in the DSM. The argument is this: Relational factors are process factors, rather than static factors. For example, expressed emotion (EE) is not a characteristic of a family but rather a description of family distress that arises as a result of living with a disease. It is a description of a family process. Providing psychoeducation to a distressed family substantially reduces the level of EE and the subsequent risk of patient relapse. EE is a measure of relational process. If EE is entered into the DSM, there is a danger of its being seen as a static entity.

A delicate balance exists between the utilitarian need for a system of diagnoses and the risk of overdefining people and their relationships as "pathological." It was not that long ago that we pathologized homosexuality and described the entity of the "schizophrenogenic mother."

Dr. Larry Freeman, a member of the Association of Family Psychiatrists, adds: "Be wary of a pressure beyond medical circles to utilize psychiatry as a force for social control. I do a great deal of workers’ [compensation], and so-called ‘preexisting conditions’ are commonly framed as the "cause" of a worker’s emotional response to injury, and therefore, [the worker’s] current psychiatric conditions are not accepted as a consequence of the original injury event.

"Be careful that we do not enable this distortion further in our efforts to include context and history."

How should we include patient contexts such as violence, abuse, trauma, poverty, injustice, or relational dysfunction? How do we acknowledge that these factors play a significant role in the lives of our patients? For children, this is especially important as treatment often focuses on changing or stabilizing their environment, and ensuring that there is adequate attachment and nurturance.

How do we ensure that these relationships and contexts are adequately defined so we can monitor the effectiveness (or not) of interventions? AFTA supports the creation of a work group that will focus on developing an alternative to the DSM for the conceptualization of emotional distress. David Elkins, Ph.D., is planning an international summit in 2013 with representatives from all therapist groups to discuss the feasibility of such a system.

Another way forward is to develop a diagnostic system that focuses on health. The Global Assessment of Functioning (GAF), describes with reasonable accuracy a person’s individual level of functioning on a scale of 1 to 100. The Global Assessment of Relational Functioning (GARF) describes the health of a relationship on a scale of 1-100. Using these scales, pathology and health coexist on a continuum, with anchors throughout the scale. These systems are currently crude instruments, but imagine how much better they could become if they were the focus of research, clinical trials, etc.

There will always be the need for individual diagnoses, where the melancholic continues to suffer despite having an excellent social and family context, and there will always be cases where we cannot decide if the patient is ill unto himself or if his illness is informed by the context of his life.

But consider the inverse, the person who is optimistic and functional in spite of the dire context of his life, people who hold beliefs, convictions, and so on that raise them above their life circumstances. (Think of visionaries like Gandhi or Mandela). In the same way, there are relationships that function well, despite the presence of adversity. How do we develop a system that aspires to "health" instead of pathology? The American health care system (or rather its illness care system) needs to morph into true health care with a focus on prevention on both an individual and relational front.

For additional information, see Relational Processes and DSM-V: Neuroscience, Assessment, Prevention, and Treatment (Washington: American Psychiatric Association Publishing, 2006).

Dr. Alison Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

In our understanding of family systems, we have long known that dysfunctional relational patterns often lie at the root of our patients’ problems. But to what extent should family diagnoses be incorporated into the DSM?

I sat down with Dr. Marianne Z. Wamboldt to explore these issues. Dr. Wamboldt, a child psychiatrist, is chair of the board of the Family Process Institute. She also holds the Leslie and William Vollbracht Family Chair in Stress and Anxiety Disorders at the University of Colorado, Denver, and serves as professor and vice chair in the department of psychiatry in the medical school.

Marianne Wamboldt: So why exactly do you oppose the inclusion of family diagnoses in the DSM?

Alison Heru: I don’t like the labeling of families. I like helping families understand their strengths and helping them work out their problems. I don’t see family problems as psychiatric problems.

MW: I think it is important that we have a way of measuring and classifying what we see, so that we know what we are talking about and that we can measure whether or not we have success in what we are doing.

AH: I agree that these goals are important. However, I think we can use tools like the GARF (Global Assessment of Relational Functioning) or other measuring devices, to do this. I don’t think we need to go as far as including measurements of family functioning in the DSM.

MW: Did you know the GARF is included in DSM-IV-TR already? What is the difference between the GARF and the DSM?

AH: The GARF is good and useful, like the GAF (Global Assessment Scale) in that it gives you a way to describe functioning on a range from healthy to unhealthy, without defining a pathological state. When you put something in the DSM, you are saying it is a disease. You are saying something about etiology.

MW: Not necessarily. In the DSM-IV, ADHD is a description of behavior; there is no attempt to talk about causality. We had hoped that the DSM-5 could start talking about causality, but most of the research is not yet ready. In the meantime, having a clear definition of what we are treating is useful for researchers as well as clinicians. Having a universal description is helpful for everyone.

AH: I agree that a universal description is good, but I still think that more harm than good comes from including family diagnoses in the DSM. I just don’t see families needing to be labeled as pathological. I understand your point, but I think that the repercussions of having a family diagnosis in the DSM outweigh the benefits. The DSM is used in all kinds of ways. In the court system, it is described as "The Psychiatrist’s Bible." If a family diagnosis is in the DSM, then it becomes an "illness" with all the repercussions that come from that label.

MW: However, if it is not in the DSM, many insurance companies won’t pay for the treatment, and persons in the family get labeled with some other diagnosis in order to get therapy. Moreover, if you label something and talk about it, stigma is reduced. Think about cancer and how we used to think about it. It used to be feared, and people with cancer were isolated. That is not what we want for psychiatry and family problems.

AH: I understand that view, but I think that the analogy with cancer is not accurate. Cancer research is well funded, and cancer in many instances can be cured. Mental illnesses have not seen this kind of support, funding, or understanding. In fact, funding has been drastically cut, and the prisons are full of people with mental illness. People now think about mental illness and crime together.

MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.

AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.

MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?

AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.

MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.

AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.

MW: How are we going to measure and be scientific about our work?

AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.

MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!

AH: A good question is, "What is the DSM for?"

MW: To provide a framework for us to diagnose and treat mental illness.

AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.

MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.

AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.

MW: So how do you see us communicating and working on this problem without a good system of description?

AH: Well, I think we can continue as we have, using these constructs but not embedding them in the DSM. I don’t think that is necessary. I think it might be better to get diagnoses that are subjective or significantly influenced by the prevailing culture out of the DSM.

MW: I would argue that many illnesses, let alone psychiatric disorders in the DSM, are significantly influenced by the prevailing culture. Read "The Spirit Catches You and You Fall Down" (New York: Farrar, Straus and Giroux, 2012), which illustrates the different cultural beliefs of the Hmong (who think the spirit moves a child) from Western medicine (which diagnoses epilepsy). If relational diagnoses are not in the DSM, many therapists will not think about relationships and will not have them as a focus for change.

AH: I think that is an assumption that is not proven.

MW: If relational disorders are in the DSM, then practitioners are more likely to think of them, and faculty are more likely to teach them to new clinicians.

AH: Yes, but think of them as a pathological entity and then we are back where we were 50 years ago – pathologizing families.

MW: I disagree with that. With education and knowledge about effective family interventions, stigma can be reduced, and people can access the treatments they need!

AH: This is a good argument that our field needs to engage in. Better measurement and reduced stigma are the benefits that you see from including relational problems in the DSM.

MW: Yes, and you see this as unnecessary labeling that might be used against families.

AH: Yes. I also think that relational diagnoses are more fluid than biological diagnoses and that we are not ready, and may never be ready, to carve these out as definitive immutable constructs.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

In our understanding of family systems, we have long known that dysfunctional relational patterns often lie at the root of our patients’ problems. But to what extent should family diagnoses be incorporated into the DSM?

I sat down with Dr. Marianne Z. Wamboldt to explore these issues. Dr. Wamboldt, a child psychiatrist, is chair of the board of the Family Process Institute. She also holds the Leslie and William Vollbracht Family Chair in Stress and Anxiety Disorders at the University of Colorado, Denver, and serves as professor and vice chair in the department of psychiatry in the medical school.

Marianne Wamboldt: So why exactly do you oppose the inclusion of family diagnoses in the DSM?

Alison Heru: I don’t like the labeling of families. I like helping families understand their strengths and helping them work out their problems. I don’t see family problems as psychiatric problems.

MW: I think it is important that we have a way of measuring and classifying what we see, so that we know what we are talking about and that we can measure whether or not we have success in what we are doing.

AH: I agree that these goals are important. However, I think we can use tools like the GARF (Global Assessment of Relational Functioning) or other measuring devices, to do this. I don’t think we need to go as far as including measurements of family functioning in the DSM.

MW: Did you know the GARF is included in DSM-IV-TR already? What is the difference between the GARF and the DSM?

AH: The GARF is good and useful, like the GAF (Global Assessment Scale) in that it gives you a way to describe functioning on a range from healthy to unhealthy, without defining a pathological state. When you put something in the DSM, you are saying it is a disease. You are saying something about etiology.

MW: Not necessarily. In the DSM-IV, ADHD is a description of behavior; there is no attempt to talk about causality. We had hoped that the DSM-5 could start talking about causality, but most of the research is not yet ready. In the meantime, having a clear definition of what we are treating is useful for researchers as well as clinicians. Having a universal description is helpful for everyone.

AH: I agree that a universal description is good, but I still think that more harm than good comes from including family diagnoses in the DSM. I just don’t see families needing to be labeled as pathological. I understand your point, but I think that the repercussions of having a family diagnosis in the DSM outweigh the benefits. The DSM is used in all kinds of ways. In the court system, it is described as "The Psychiatrist’s Bible." If a family diagnosis is in the DSM, then it becomes an "illness" with all the repercussions that come from that label.

MW: However, if it is not in the DSM, many insurance companies won’t pay for the treatment, and persons in the family get labeled with some other diagnosis in order to get therapy. Moreover, if you label something and talk about it, stigma is reduced. Think about cancer and how we used to think about it. It used to be feared, and people with cancer were isolated. That is not what we want for psychiatry and family problems.

AH: I understand that view, but I think that the analogy with cancer is not accurate. Cancer research is well funded, and cancer in many instances can be cured. Mental illnesses have not seen this kind of support, funding, or understanding. In fact, funding has been drastically cut, and the prisons are full of people with mental illness. People now think about mental illness and crime together.

MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.

AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.

MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?

AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.

MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.

AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.

MW: How are we going to measure and be scientific about our work?

AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.

MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!

AH: A good question is, "What is the DSM for?"

MW: To provide a framework for us to diagnose and treat mental illness.

AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.

MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.

AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.

MW: So how do you see us communicating and working on this problem without a good system of description?

AH: Well, I think we can continue as we have, using these constructs but not embedding them in the DSM. I don’t think that is necessary. I think it might be better to get diagnoses that are subjective or significantly influenced by the prevailing culture out of the DSM.

MW: I would argue that many illnesses, let alone psychiatric disorders in the DSM, are significantly influenced by the prevailing culture. Read "The Spirit Catches You and You Fall Down" (New York: Farrar, Straus and Giroux, 2012), which illustrates the different cultural beliefs of the Hmong (who think the spirit moves a child) from Western medicine (which diagnoses epilepsy). If relational diagnoses are not in the DSM, many therapists will not think about relationships and will not have them as a focus for change.

AH: I think that is an assumption that is not proven.

MW: If relational disorders are in the DSM, then practitioners are more likely to think of them, and faculty are more likely to teach them to new clinicians.

AH: Yes, but think of them as a pathological entity and then we are back where we were 50 years ago – pathologizing families.

MW: I disagree with that. With education and knowledge about effective family interventions, stigma can be reduced, and people can access the treatments they need!

AH: This is a good argument that our field needs to engage in. Better measurement and reduced stigma are the benefits that you see from including relational problems in the DSM.

MW: Yes, and you see this as unnecessary labeling that might be used against families.

AH: Yes. I also think that relational diagnoses are more fluid than biological diagnoses and that we are not ready, and may never be ready, to carve these out as definitive immutable constructs.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

In our understanding of family systems, we have long known that dysfunctional relational patterns often lie at the root of our patients’ problems. But to what extent should family diagnoses be incorporated into the DSM?

I sat down with Dr. Marianne Z. Wamboldt to explore these issues. Dr. Wamboldt, a child psychiatrist, is chair of the board of the Family Process Institute. She also holds the Leslie and William Vollbracht Family Chair in Stress and Anxiety Disorders at the University of Colorado, Denver, and serves as professor and vice chair in the department of psychiatry in the medical school.

Marianne Wamboldt: So why exactly do you oppose the inclusion of family diagnoses in the DSM?

Alison Heru: I don’t like the labeling of families. I like helping families understand their strengths and helping them work out their problems. I don’t see family problems as psychiatric problems.

MW: I think it is important that we have a way of measuring and classifying what we see, so that we know what we are talking about and that we can measure whether or not we have success in what we are doing.

AH: I agree that these goals are important. However, I think we can use tools like the GARF (Global Assessment of Relational Functioning) or other measuring devices, to do this. I don’t think we need to go as far as including measurements of family functioning in the DSM.

MW: Did you know the GARF is included in DSM-IV-TR already? What is the difference between the GARF and the DSM?

AH: The GARF is good and useful, like the GAF (Global Assessment Scale) in that it gives you a way to describe functioning on a range from healthy to unhealthy, without defining a pathological state. When you put something in the DSM, you are saying it is a disease. You are saying something about etiology.

MW: Not necessarily. In the DSM-IV, ADHD is a description of behavior; there is no attempt to talk about causality. We had hoped that the DSM-5 could start talking about causality, but most of the research is not yet ready. In the meantime, having a clear definition of what we are treating is useful for researchers as well as clinicians. Having a universal description is helpful for everyone.

AH: I agree that a universal description is good, but I still think that more harm than good comes from including family diagnoses in the DSM. I just don’t see families needing to be labeled as pathological. I understand your point, but I think that the repercussions of having a family diagnosis in the DSM outweigh the benefits. The DSM is used in all kinds of ways. In the court system, it is described as "The Psychiatrist’s Bible." If a family diagnosis is in the DSM, then it becomes an "illness" with all the repercussions that come from that label.

MW: However, if it is not in the DSM, many insurance companies won’t pay for the treatment, and persons in the family get labeled with some other diagnosis in order to get therapy. Moreover, if you label something and talk about it, stigma is reduced. Think about cancer and how we used to think about it. It used to be feared, and people with cancer were isolated. That is not what we want for psychiatry and family problems.

AH: I understand that view, but I think that the analogy with cancer is not accurate. Cancer research is well funded, and cancer in many instances can be cured. Mental illnesses have not seen this kind of support, funding, or understanding. In fact, funding has been drastically cut, and the prisons are full of people with mental illness. People now think about mental illness and crime together.

MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.

AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.

MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?

AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.

MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.

AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.

MW: How are we going to measure and be scientific about our work?

AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.

MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!

AH: A good question is, "What is the DSM for?"

MW: To provide a framework for us to diagnose and treat mental illness.

AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.

MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.

AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.

MW: So how do you see us communicating and working on this problem without a good system of description?

AH: Well, I think we can continue as we have, using these constructs but not embedding them in the DSM. I don’t think that is necessary. I think it might be better to get diagnoses that are subjective or significantly influenced by the prevailing culture out of the DSM.

MW: I would argue that many illnesses, let alone psychiatric disorders in the DSM, are significantly influenced by the prevailing culture. Read "The Spirit Catches You and You Fall Down" (New York: Farrar, Straus and Giroux, 2012), which illustrates the different cultural beliefs of the Hmong (who think the spirit moves a child) from Western medicine (which diagnoses epilepsy). If relational diagnoses are not in the DSM, many therapists will not think about relationships and will not have them as a focus for change.

AH: I think that is an assumption that is not proven.

MW: If relational disorders are in the DSM, then practitioners are more likely to think of them, and faculty are more likely to teach them to new clinicians.

AH: Yes, but think of them as a pathological entity and then we are back where we were 50 years ago – pathologizing families.

MW: I disagree with that. With education and knowledge about effective family interventions, stigma can be reduced, and people can access the treatments they need!

AH: This is a good argument that our field needs to engage in. Better measurement and reduced stigma are the benefits that you see from including relational problems in the DSM.

MW: Yes, and you see this as unnecessary labeling that might be used against families.

AH: Yes. I also think that relational diagnoses are more fluid than biological diagnoses and that we are not ready, and may never be ready, to carve these out as definitive immutable constructs.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

A pod of family psychiatrists is sitting around and chatting about the state of family psychiatry. They are preparing for a plenary at the Group for the Advancement of Psychiatry with the goal of showing how far family psychiatry has come since the first psychiatrists embraced the paradigm of systemic thinking. They also debate why family psychiatry is ignored in current practice, especially since the evidence shows that family treatment dramatically improves recovery rates for many illnesses.

When family therapy had its first wave of popularity, the charismatic leaders were out front wowing the crowds. Dr. Sal Minuchin’s sessions were heavily focused on structure and boundary making, and involved much chair rearranging and pulling family members, especially children, out from between the couple dyad and into their own space and chairs in the room. One of his most famous tapes involved putting an ashtray between the chairs of two family members to literally increase the distance between them!

Jay Haley, Ph.D., delivered strategic barbed arrows that pierced the hearts of the family members. Virginia Satir demonstrated the theater of families, sculpting organic shapes that pulsed with the gestalt of the family. There was much smoking of cigarettes during the sessions, by both the family psychiatrists and the family members. Psychiatry was exciting. The possibilities for change were endless. It was the 1960s.

Unfortunately, in those early days, family therapy was oversold as the sole treatment for schizophrenia and other mental illnesses. As a result, families have felt blamed by the negative attention and are still hesitant to engage in traditional family therapy. Nevertheless, quiet pioneers, like Carol M. Anderson, Ph.D., continue to research and practice a measured educational and collaborative approach aimed at involving families in mental health treatment. Indeed, current American Psychiatric Association guidelines for many psychiatric illnesses recommend that families be brought into the treatment process.

Family research has become much more sophisticated, with Dr. Minuchin’s early research on asthma and "psychosomatic families" being refined by teams led by Betsy Wood in New York, and Dr. Fred Wamboldt and Dr. Marianne Z. Wamboldt in Denver. Family research covers a broad territory, from studies on the impact of care giving on the caregiver’s immune function, to the role of expressed emotion in the outcome of illnesses – medical and psychiatric – to the efficacy of family treatments.

However, the Big Question still remains: Which model is the best? Structural? Strategic? Experiential?

While the arguments among devotees continue, studious researchers are quietly extracting the common factors found in the original family therapy models. These common factors are defined as the variables associated with positive clinical outcomes and are shared by several or all approaches. Andrew Christensen, Ph.D., suggests five principles that evidence-based couple interventions share: a systemic rather than an individual orientation of problems; modification of emotion-driven dysfunctional behaviors by teaching partners constructive ways to deal with differences, problems, and emotions; making both partners aware of avoided, emotion-based, private behaviors of each other, and making these internal experiences accessible to each other; enhancement of constructive communication in speaking and listening; and emphasis on strengths and positive behaviors (Enhancing Couples, Cambridge, Mass.: Hogrefe Publishing, 2009).

For couples and family therapies, common factors are conceptualizing the problems in relational terms, disrupting relational patterns, expanding treatment to include family members of the identified patient and an expanded therapeutic alliance (Common Factors in Couple and Family Therapy: The Overlooked Foundation for Effective Practice, New York: Guilford Press, 2009). Relational patterns have cognitive, behavioral, and affective domains, all of which can be targets of intervention. The therapeutic alliance is with the relationship and the family, rather than with the individual family members.

Patients, families, and psychiatrists all demand treatments that have been shown to work well. Family psychiatry has moved from theatrical showmanship to evidence-based treatments. Within a broad range of family interventions are different levels of family involvement. Family inclusion is the easiest intervention – simply involving the family members as historians, supporters, and allies in treatment.

Second, family psychoeducation has amassed a substantial evidence base showing its efficacy in the treatment of schizophrenia, bipolar disorder, and many medical illnesses, such as diabetes.

Last, but certainly not least, are the family systemic therapies, which in a meta-analysis of family systems therapies, were defined as "any couple, family, group, multifamily group, or individual focused therapeutic intervention that refers to either one of the following systems-oriented authors (Tom Andersen, Dr. Ivan Böszörményi-Nagy, Steve de Shazer, Jay Haley, Ph.D., Dr. Minuchin, Ms. Satir, Dr. Mara Selvini Palazzoli, Dr. Helm Stierlin, Paul Watzlawick, Ph.D., Michael White, Gerald H. Zuk, Ph.D.) or specified the intervention by use of at least one of the following terms: systemic, structural, strategic, triadic, Milan, functional, solution focused, narrative, resource/strength oriented, McMaster model" (Fam. Process 2010;49:457-85).

Family systems therapy has come a long way from the early days. We are very clear that for serious mental illness, family therapy alone is not enough, but neither are medications. Combination treatment produces symptom reduction AND good quality of life.

However, most psychotherapies – of the individual and family variety – are delivered by non-psychiatrists. Psychiatry is in danger of losing itself, as primary care physicians prescribe medications and refer patients to psychotherapists who are often co-located in their offices. Psychiatrists, however, are still the only professionals who have the potential to see the whole person and oversee the entire treatment: medications, individual, and family interventions.

It is to our advantage to be knowledgeable about all psychotherapeutic interventions AND to use them. We must make family therapy more visible and easier to teach in residencies. Psychiatrists have been reluctant to identify themselves as family psychiatrists because our enthusiastic charismatic leaders took the promise of family therapy too far. We hope that the solid family research now available will encourage all psychiatrists to learn and implement family interventions.

Dr. Minuchin and the ashtray, however, remain potent symbols of how creativity and genius created a new paradigm in psychiatry.

Dr. Heru is with the department of psychiatry at the University of Colorado, Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

A pod of family psychiatrists is sitting around and chatting about the state of family psychiatry. They are preparing for a plenary at the Group for the Advancement of Psychiatry with the goal of showing how far family psychiatry has come since the first psychiatrists embraced the paradigm of systemic thinking. They also debate why family psychiatry is ignored in current practice, especially since the evidence shows that family treatment dramatically improves recovery rates for many illnesses.

When family therapy had its first wave of popularity, the charismatic leaders were out front wowing the crowds. Dr. Sal Minuchin’s sessions were heavily focused on structure and boundary making, and involved much chair rearranging and pulling family members, especially children, out from between the couple dyad and into their own space and chairs in the room. One of his most famous tapes involved putting an ashtray between the chairs of two family members to literally increase the distance between them!

Jay Haley, Ph.D., delivered strategic barbed arrows that pierced the hearts of the family members. Virginia Satir demonstrated the theater of families, sculpting organic shapes that pulsed with the gestalt of the family. There was much smoking of cigarettes during the sessions, by both the family psychiatrists and the family members. Psychiatry was exciting. The possibilities for change were endless. It was the 1960s.

Unfortunately, in those early days, family therapy was oversold as the sole treatment for schizophrenia and other mental illnesses. As a result, families have felt blamed by the negative attention and are still hesitant to engage in traditional family therapy. Nevertheless, quiet pioneers, like Carol M. Anderson, Ph.D., continue to research and practice a measured educational and collaborative approach aimed at involving families in mental health treatment. Indeed, current American Psychiatric Association guidelines for many psychiatric illnesses recommend that families be brought into the treatment process.

Family research has become much more sophisticated, with Dr. Minuchin’s early research on asthma and "psychosomatic families" being refined by teams led by Betsy Wood in New York, and Dr. Fred Wamboldt and Dr. Marianne Z. Wamboldt in Denver. Family research covers a broad territory, from studies on the impact of care giving on the caregiver’s immune function, to the role of expressed emotion in the outcome of illnesses – medical and psychiatric – to the efficacy of family treatments.

However, the Big Question still remains: Which model is the best? Structural? Strategic? Experiential?

While the arguments among devotees continue, studious researchers are quietly extracting the common factors found in the original family therapy models. These common factors are defined as the variables associated with positive clinical outcomes and are shared by several or all approaches. Andrew Christensen, Ph.D., suggests five principles that evidence-based couple interventions share: a systemic rather than an individual orientation of problems; modification of emotion-driven dysfunctional behaviors by teaching partners constructive ways to deal with differences, problems, and emotions; making both partners aware of avoided, emotion-based, private behaviors of each other, and making these internal experiences accessible to each other; enhancement of constructive communication in speaking and listening; and emphasis on strengths and positive behaviors (Enhancing Couples, Cambridge, Mass.: Hogrefe Publishing, 2009).

For couples and family therapies, common factors are conceptualizing the problems in relational terms, disrupting relational patterns, expanding treatment to include family members of the identified patient and an expanded therapeutic alliance (Common Factors in Couple and Family Therapy: The Overlooked Foundation for Effective Practice, New York: Guilford Press, 2009). Relational patterns have cognitive, behavioral, and affective domains, all of which can be targets of intervention. The therapeutic alliance is with the relationship and the family, rather than with the individual family members.

Patients, families, and psychiatrists all demand treatments that have been shown to work well. Family psychiatry has moved from theatrical showmanship to evidence-based treatments. Within a broad range of family interventions are different levels of family involvement. Family inclusion is the easiest intervention – simply involving the family members as historians, supporters, and allies in treatment.

Second, family psychoeducation has amassed a substantial evidence base showing its efficacy in the treatment of schizophrenia, bipolar disorder, and many medical illnesses, such as diabetes.

Last, but certainly not least, are the family systemic therapies, which in a meta-analysis of family systems therapies, were defined as "any couple, family, group, multifamily group, or individual focused therapeutic intervention that refers to either one of the following systems-oriented authors (Tom Andersen, Dr. Ivan Böszörményi-Nagy, Steve de Shazer, Jay Haley, Ph.D., Dr. Minuchin, Ms. Satir, Dr. Mara Selvini Palazzoli, Dr. Helm Stierlin, Paul Watzlawick, Ph.D., Michael White, Gerald H. Zuk, Ph.D.) or specified the intervention by use of at least one of the following terms: systemic, structural, strategic, triadic, Milan, functional, solution focused, narrative, resource/strength oriented, McMaster model" (Fam. Process 2010;49:457-85).

Family systems therapy has come a long way from the early days. We are very clear that for serious mental illness, family therapy alone is not enough, but neither are medications. Combination treatment produces symptom reduction AND good quality of life.

However, most psychotherapies – of the individual and family variety – are delivered by non-psychiatrists. Psychiatry is in danger of losing itself, as primary care physicians prescribe medications and refer patients to psychotherapists who are often co-located in their offices. Psychiatrists, however, are still the only professionals who have the potential to see the whole person and oversee the entire treatment: medications, individual, and family interventions.

It is to our advantage to be knowledgeable about all psychotherapeutic interventions AND to use them. We must make family therapy more visible and easier to teach in residencies. Psychiatrists have been reluctant to identify themselves as family psychiatrists because our enthusiastic charismatic leaders took the promise of family therapy too far. We hope that the solid family research now available will encourage all psychiatrists to learn and implement family interventions.

Dr. Minuchin and the ashtray, however, remain potent symbols of how creativity and genius created a new paradigm in psychiatry.

Dr. Heru is with the department of psychiatry at the University of Colorado, Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

A pod of family psychiatrists is sitting around and chatting about the state of family psychiatry. They are preparing for a plenary at the Group for the Advancement of Psychiatry with the goal of showing how far family psychiatry has come since the first psychiatrists embraced the paradigm of systemic thinking. They also debate why family psychiatry is ignored in current practice, especially since the evidence shows that family treatment dramatically improves recovery rates for many illnesses.

When family therapy had its first wave of popularity, the charismatic leaders were out front wowing the crowds. Dr. Sal Minuchin’s sessions were heavily focused on structure and boundary making, and involved much chair rearranging and pulling family members, especially children, out from between the couple dyad and into their own space and chairs in the room. One of his most famous tapes involved putting an ashtray between the chairs of two family members to literally increase the distance between them!

Jay Haley, Ph.D., delivered strategic barbed arrows that pierced the hearts of the family members. Virginia Satir demonstrated the theater of families, sculpting organic shapes that pulsed with the gestalt of the family. There was much smoking of cigarettes during the sessions, by both the family psychiatrists and the family members. Psychiatry was exciting. The possibilities for change were endless. It was the 1960s.

Unfortunately, in those early days, family therapy was oversold as the sole treatment for schizophrenia and other mental illnesses. As a result, families have felt blamed by the negative attention and are still hesitant to engage in traditional family therapy. Nevertheless, quiet pioneers, like Carol M. Anderson, Ph.D., continue to research and practice a measured educational and collaborative approach aimed at involving families in mental health treatment. Indeed, current American Psychiatric Association guidelines for many psychiatric illnesses recommend that families be brought into the treatment process.

Family research has become much more sophisticated, with Dr. Minuchin’s early research on asthma and "psychosomatic families" being refined by teams led by Betsy Wood in New York, and Dr. Fred Wamboldt and Dr. Marianne Z. Wamboldt in Denver. Family research covers a broad territory, from studies on the impact of care giving on the caregiver’s immune function, to the role of expressed emotion in the outcome of illnesses – medical and psychiatric – to the efficacy of family treatments.

However, the Big Question still remains: Which model is the best? Structural? Strategic? Experiential?

While the arguments among devotees continue, studious researchers are quietly extracting the common factors found in the original family therapy models. These common factors are defined as the variables associated with positive clinical outcomes and are shared by several or all approaches. Andrew Christensen, Ph.D., suggests five principles that evidence-based couple interventions share: a systemic rather than an individual orientation of problems; modification of emotion-driven dysfunctional behaviors by teaching partners constructive ways to deal with differences, problems, and emotions; making both partners aware of avoided, emotion-based, private behaviors of each other, and making these internal experiences accessible to each other; enhancement of constructive communication in speaking and listening; and emphasis on strengths and positive behaviors (Enhancing Couples, Cambridge, Mass.: Hogrefe Publishing, 2009).

For couples and family therapies, common factors are conceptualizing the problems in relational terms, disrupting relational patterns, expanding treatment to include family members of the identified patient and an expanded therapeutic alliance (Common Factors in Couple and Family Therapy: The Overlooked Foundation for Effective Practice, New York: Guilford Press, 2009). Relational patterns have cognitive, behavioral, and affective domains, all of which can be targets of intervention. The therapeutic alliance is with the relationship and the family, rather than with the individual family members.

Patients, families, and psychiatrists all demand treatments that have been shown to work well. Family psychiatry has moved from theatrical showmanship to evidence-based treatments. Within a broad range of family interventions are different levels of family involvement. Family inclusion is the easiest intervention – simply involving the family members as historians, supporters, and allies in treatment.

Second, family psychoeducation has amassed a substantial evidence base showing its efficacy in the treatment of schizophrenia, bipolar disorder, and many medical illnesses, such as diabetes.

Last, but certainly not least, are the family systemic therapies, which in a meta-analysis of family systems therapies, were defined as "any couple, family, group, multifamily group, or individual focused therapeutic intervention that refers to either one of the following systems-oriented authors (Tom Andersen, Dr. Ivan Böszörményi-Nagy, Steve de Shazer, Jay Haley, Ph.D., Dr. Minuchin, Ms. Satir, Dr. Mara Selvini Palazzoli, Dr. Helm Stierlin, Paul Watzlawick, Ph.D., Michael White, Gerald H. Zuk, Ph.D.) or specified the intervention by use of at least one of the following terms: systemic, structural, strategic, triadic, Milan, functional, solution focused, narrative, resource/strength oriented, McMaster model" (Fam. Process 2010;49:457-85).

Family systems therapy has come a long way from the early days. We are very clear that for serious mental illness, family therapy alone is not enough, but neither are medications. Combination treatment produces symptom reduction AND good quality of life.

However, most psychotherapies – of the individual and family variety – are delivered by non-psychiatrists. Psychiatry is in danger of losing itself, as primary care physicians prescribe medications and refer patients to psychotherapists who are often co-located in their offices. Psychiatrists, however, are still the only professionals who have the potential to see the whole person and oversee the entire treatment: medications, individual, and family interventions.

It is to our advantage to be knowledgeable about all psychotherapeutic interventions AND to use them. We must make family therapy more visible and easier to teach in residencies. Psychiatrists have been reluctant to identify themselves as family psychiatrists because our enthusiastic charismatic leaders took the promise of family therapy too far. We hope that the solid family research now available will encourage all psychiatrists to learn and implement family interventions.

Dr. Minuchin and the ashtray, however, remain potent symbols of how creativity and genius created a new paradigm in psychiatry.

Dr. Heru is with the department of psychiatry at the University of Colorado, Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

"My husband is an alcoholic. They tell me I am an enabler! They say I am codependent," Ms. Jasper stated to the nurse as her husband was being admitted for alcohol detox.

"What do they mean?" she continued. "What am I supposed to do when my husband drinks? Wrestle the bottle from him? Then he would just slug me. If I don’t give him what he wants, he starts, you know, getting aggressive with me. I don’t think I am the problem here. He is the one with the problem. I am not to blame for his drinking!"

What is codependency? Who is an enabler? Why would spouses encourage their partners to keep on drinking? Think of these issues from Ms. Jasper’s point of view. It is easier to allow her alcohol-dependent husband to continue drinking rather than confront the problem and face either violence or a break-up of the family.

If he is the main breadwinner, the stakes are even higher. Ms. Jasper might encourage him to continue going to work – and might be eager to make excuses for him so he won’t lose his job.

Besides, people with alcohol dependence might gain sobriety and do well for periods of time, leading the family to believe that the problem is solved.

Another factor that can lead to this dysfunctional way of relating is a desire on the part of the family to preserve its image. As a result, family members might try to hide the problem. In time, they might forget about their own needs and devote their lives to trying to maintain a calm family atmosphere, hoping that the person with alcohol dependence will feel less stress and become sober.

Essentially, families cope as best they can. Whatever behaviors they demonstrate can be understood as normal reactions to the stress of trying to cope with a spouse who has alcohol dependency.

What are the best coping behaviors that provide a supportive environment for recovery without family members becoming overly responsible for their ill relative?

One way to determine this is to use the Behavioral Enabling Scale (BES), a clinically derived instrument that assesses enabling behaviors. The BES emphasizes observable behaviors rather than inferred motives. The BES has two components: the enabling behaviors scale and the enabling beliefs scale. The enabling behaviors scale includes items such as giving money to the patient to buy alcohol, buying alcohol, and taking over neglected chores because she or he was drinking. Enabling behaviors can be subtle, such as making excuses to family or friends. The enabling beliefs scale includes items such as, ‘‘I need to do whatever it takes to hold my relationship with my partner together’’ and ‘‘I should do my best to protect my partner from the negative consequences of his/her alcohol use.’’

Family research can tell us quite a bit about enabling behaviors in families with alcohol dependence. One such study was conducted by Robert J. Rotunda, Ph.D., and his colleagues (J. Subst. Abuse Treat. 2004;26:269-76).

That study looked at 42 couples in which one partner met DSM-IV criteria for alcohol dependence. In all, 29 patients were men, and 13 were women. The mean age of the patients was 43.9 years, and their partners’ mean age was 44.3 years. Some 95% of the couples were legally married and had been cohabiting for an average of 13 years. Investigators administered the BES to both partners.

Enabling Behaviors

The study found that enabling behaviors are prevalent but not consistent. For example, "specific items of strong endorsement [that is, collapsing the response categories of sometimes, often, and very often] arising from the partners themselves included admission ... to lying or making excuses to family or friends (69%), performing the client’s neglected chores (69%), threatening separation but then not following through ... (67%), changing or canceling family plans or social activities because of the drinking (49%), and making excuses for the client’s behavior (44%)," the investigators wrote.

"Notably, 30% of the partners sampled indicated they gave money to the client to buy alcohol, or drank in the client’s presence."

All of the enabling behaviors had occurred over the past year, and only one partner of the 42 clients who participated in the survey denied engaging in any of the 20 enabling behaviors.

This study shows the extent to which most partners have engaged in some enabling behavior.

Enabling Beliefs

Another concept that the study explored was the relationship between specific partner beliefs and enabling behaviors. The investigators identified 13 "partner belief items" that factor into the partner’s enabling behaviors.

Examples of enabling beliefs include ‘‘My partner can’t get along without my help’’ and ‘‘It is my duty to take on more responsibility for home and family obligations than my partner in times of stress.’’

What Should the Clinician Do?

How can we help families cope with the psychological and physical strain that might result from interaction with those struggling with alcohol dependence? Enabling behavior might reflect hopelessness, and partners should be assessed for depression or at least demoralization. Clinicians should assess which particular spousal behaviors reinforce drinking or interfere with recovery, and which behaviors are supportive of recovery. As always, it is important to let partners know what they are doing well, and to encourage them to continue.

The couple can be encouraged to enroll in marital family therapy (MFT), which can have excellent results for treating alcohol dependence, according to Timothy J. O’Farrell, Ph.D. (J. Marital Fam. Ther. 2012;38:122-44). Even if the spouse with alcohol dependence is unwilling to seek help, MFT is effective in helping the family cope better and in motivating alcoholics to enter treatment.

In addition, spouse coping-skills training promotes improved coping by family members, as can involvement with groups such as Al-Anon. Behavioral couples therapy is more effective than individual treatment at increasing abstinence and improving relationship functioning.

Take a look Dr. O’Farrell’s program. It is easy to implement some of his couples therapy exercises into your clinical practice.

"My husband is an alcoholic. They tell me I am an enabler! They say I am codependent," Ms. Jasper stated to the nurse as her husband was being admitted for alcohol detox.

"What do they mean?" she continued. "What am I supposed to do when my husband drinks? Wrestle the bottle from him? Then he would just slug me. If I don’t give him what he wants, he starts, you know, getting aggressive with me. I don’t think I am the problem here. He is the one with the problem. I am not to blame for his drinking!"

What is codependency? Who is an enabler? Why would spouses encourage their partners to keep on drinking? Think of these issues from Ms. Jasper’s point of view. It is easier to allow her alcohol-dependent husband to continue drinking rather than confront the problem and face either violence or a break-up of the family.

If he is the main breadwinner, the stakes are even higher. Ms. Jasper might encourage him to continue going to work – and might be eager to make excuses for him so he won’t lose his job.

Besides, people with alcohol dependence might gain sobriety and do well for periods of time, leading the family to believe that the problem is solved.

Another factor that can lead to this dysfunctional way of relating is a desire on the part of the family to preserve its image. As a result, family members might try to hide the problem. In time, they might forget about their own needs and devote their lives to trying to maintain a calm family atmosphere, hoping that the person with alcohol dependence will feel less stress and become sober.

Essentially, families cope as best they can. Whatever behaviors they demonstrate can be understood as normal reactions to the stress of trying to cope with a spouse who has alcohol dependency.

What are the best coping behaviors that provide a supportive environment for recovery without family members becoming overly responsible for their ill relative?

One way to determine this is to use the Behavioral Enabling Scale (BES), a clinically derived instrument that assesses enabling behaviors. The BES emphasizes observable behaviors rather than inferred motives. The BES has two components: the enabling behaviors scale and the enabling beliefs scale. The enabling behaviors scale includes items such as giving money to the patient to buy alcohol, buying alcohol, and taking over neglected chores because she or he was drinking. Enabling behaviors can be subtle, such as making excuses to family or friends. The enabling beliefs scale includes items such as, ‘‘I need to do whatever it takes to hold my relationship with my partner together’’ and ‘‘I should do my best to protect my partner from the negative consequences of his/her alcohol use.’’

Family research can tell us quite a bit about enabling behaviors in families with alcohol dependence. One such study was conducted by Robert J. Rotunda, Ph.D., and his colleagues (J. Subst. Abuse Treat. 2004;26:269-76).

That study looked at 42 couples in which one partner met DSM-IV criteria for alcohol dependence. In all, 29 patients were men, and 13 were women. The mean age of the patients was 43.9 years, and their partners’ mean age was 44.3 years. Some 95% of the couples were legally married and had been cohabiting for an average of 13 years. Investigators administered the BES to both partners.

Enabling Behaviors

The study found that enabling behaviors are prevalent but not consistent. For example, "specific items of strong endorsement [that is, collapsing the response categories of sometimes, often, and very often] arising from the partners themselves included admission ... to lying or making excuses to family or friends (69%), performing the client’s neglected chores (69%), threatening separation but then not following through ... (67%), changing or canceling family plans or social activities because of the drinking (49%), and making excuses for the client’s behavior (44%)," the investigators wrote.

"Notably, 30% of the partners sampled indicated they gave money to the client to buy alcohol, or drank in the client’s presence."

All of the enabling behaviors had occurred over the past year, and only one partner of the 42 clients who participated in the survey denied engaging in any of the 20 enabling behaviors.

This study shows the extent to which most partners have engaged in some enabling behavior.

Enabling Beliefs

Another concept that the study explored was the relationship between specific partner beliefs and enabling behaviors. The investigators identified 13 "partner belief items" that factor into the partner’s enabling behaviors.

Examples of enabling beliefs include ‘‘My partner can’t get along without my help’’ and ‘‘It is my duty to take on more responsibility for home and family obligations than my partner in times of stress.’’

What Should the Clinician Do?

How can we help families cope with the psychological and physical strain that might result from interaction with those struggling with alcohol dependence? Enabling behavior might reflect hopelessness, and partners should be assessed for depression or at least demoralization. Clinicians should assess which particular spousal behaviors reinforce drinking or interfere with recovery, and which behaviors are supportive of recovery. As always, it is important to let partners know what they are doing well, and to encourage them to continue.

The couple can be encouraged to enroll in marital family therapy (MFT), which can have excellent results for treating alcohol dependence, according to Timothy J. O’Farrell, Ph.D. (J. Marital Fam. Ther. 2012;38:122-44). Even if the spouse with alcohol dependence is unwilling to seek help, MFT is effective in helping the family cope better and in motivating alcoholics to enter treatment.

In addition, spouse coping-skills training promotes improved coping by family members, as can involvement with groups such as Al-Anon. Behavioral couples therapy is more effective than individual treatment at increasing abstinence and improving relationship functioning.

Take a look Dr. O’Farrell’s program. It is easy to implement some of his couples therapy exercises into your clinical practice.

"My husband is an alcoholic. They tell me I am an enabler! They say I am codependent," Ms. Jasper stated to the nurse as her husband was being admitted for alcohol detox.

"What do they mean?" she continued. "What am I supposed to do when my husband drinks? Wrestle the bottle from him? Then he would just slug me. If I don’t give him what he wants, he starts, you know, getting aggressive with me. I don’t think I am the problem here. He is the one with the problem. I am not to blame for his drinking!"

What is codependency? Who is an enabler? Why would spouses encourage their partners to keep on drinking? Think of these issues from Ms. Jasper’s point of view. It is easier to allow her alcohol-dependent husband to continue drinking rather than confront the problem and face either violence or a break-up of the family.

If he is the main breadwinner, the stakes are even higher. Ms. Jasper might encourage him to continue going to work – and might be eager to make excuses for him so he won’t lose his job.

Besides, people with alcohol dependence might gain sobriety and do well for periods of time, leading the family to believe that the problem is solved.

Another factor that can lead to this dysfunctional way of relating is a desire on the part of the family to preserve its image. As a result, family members might try to hide the problem. In time, they might forget about their own needs and devote their lives to trying to maintain a calm family atmosphere, hoping that the person with alcohol dependence will feel less stress and become sober.

Essentially, families cope as best they can. Whatever behaviors they demonstrate can be understood as normal reactions to the stress of trying to cope with a spouse who has alcohol dependency.

What are the best coping behaviors that provide a supportive environment for recovery without family members becoming overly responsible for their ill relative?

One way to determine this is to use the Behavioral Enabling Scale (BES), a clinically derived instrument that assesses enabling behaviors. The BES emphasizes observable behaviors rather than inferred motives. The BES has two components: the enabling behaviors scale and the enabling beliefs scale. The enabling behaviors scale includes items such as giving money to the patient to buy alcohol, buying alcohol, and taking over neglected chores because she or he was drinking. Enabling behaviors can be subtle, such as making excuses to family or friends. The enabling beliefs scale includes items such as, ‘‘I need to do whatever it takes to hold my relationship with my partner together’’ and ‘‘I should do my best to protect my partner from the negative consequences of his/her alcohol use.’’

Family research can tell us quite a bit about enabling behaviors in families with alcohol dependence. One such study was conducted by Robert J. Rotunda, Ph.D., and his colleagues (J. Subst. Abuse Treat. 2004;26:269-76).

That study looked at 42 couples in which one partner met DSM-IV criteria for alcohol dependence. In all, 29 patients were men, and 13 were women. The mean age of the patients was 43.9 years, and their partners’ mean age was 44.3 years. Some 95% of the couples were legally married and had been cohabiting for an average of 13 years. Investigators administered the BES to both partners.

Enabling Behaviors

The study found that enabling behaviors are prevalent but not consistent. For example, "specific items of strong endorsement [that is, collapsing the response categories of sometimes, often, and very often] arising from the partners themselves included admission ... to lying or making excuses to family or friends (69%), performing the client’s neglected chores (69%), threatening separation but then not following through ... (67%), changing or canceling family plans or social activities because of the drinking (49%), and making excuses for the client’s behavior (44%)," the investigators wrote.

"Notably, 30% of the partners sampled indicated they gave money to the client to buy alcohol, or drank in the client’s presence."

All of the enabling behaviors had occurred over the past year, and only one partner of the 42 clients who participated in the survey denied engaging in any of the 20 enabling behaviors.

This study shows the extent to which most partners have engaged in some enabling behavior.

Enabling Beliefs

Another concept that the study explored was the relationship between specific partner beliefs and enabling behaviors. The investigators identified 13 "partner belief items" that factor into the partner’s enabling behaviors.

Examples of enabling beliefs include ‘‘My partner can’t get along without my help’’ and ‘‘It is my duty to take on more responsibility for home and family obligations than my partner in times of stress.’’

What Should the Clinician Do?

How can we help families cope with the psychological and physical strain that might result from interaction with those struggling with alcohol dependence? Enabling behavior might reflect hopelessness, and partners should be assessed for depression or at least demoralization. Clinicians should assess which particular spousal behaviors reinforce drinking or interfere with recovery, and which behaviors are supportive of recovery. As always, it is important to let partners know what they are doing well, and to encourage them to continue.

The couple can be encouraged to enroll in marital family therapy (MFT), which can have excellent results for treating alcohol dependence, according to Timothy J. O’Farrell, Ph.D. (J. Marital Fam. Ther. 2012;38:122-44). Even if the spouse with alcohol dependence is unwilling to seek help, MFT is effective in helping the family cope better and in motivating alcoholics to enter treatment.

In addition, spouse coping-skills training promotes improved coping by family members, as can involvement with groups such as Al-Anon. Behavioral couples therapy is more effective than individual treatment at increasing abstinence and improving relationship functioning.

Take a look Dr. O’Farrell’s program. It is easy to implement some of his couples therapy exercises into your clinical practice.