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Managing family differences
What is it about families that makes our patients so upset? Why can our patients not just walk away from conflict? Why do they get so bent out of shape when family members do not say or do what they expect them to do? We all have families that are less than ideal and struggle with how to manage difference.
This column gives psychiatrists a framework for thinking with families about the universal dilemma of managing difference. This dilemma can be viewed from the perspectives of the individual, the family, and society: Identity is formed in the crucible of the family, where parental introjects become a model for the child’s development and can be rejected as an adolescent or adult as individuals shape their own identity. Processes within the family shape family members’ relationships and, therefore, their expectations of one another. Strong boundaries provide safety for those inside the family versus those outside the family.
Individual perspective
Family members’ perspective and expectations of others depend on their family position. Children or young adults want to please the parent, and to be accepted and recognized for who they are. They want their unique qualities to be valued, they want to be loved, and they want to feel that they belong.
Parents want their young adult to reach what they consider a successful life, and to be fulfilled and healthy. When their child strikes out on his or her own, the parent may not understand, and may feel let down or angry. The parent may say: “She married him to get back at me.” “Why is my son so rejecting of the business our family spent generations to build?” “How can my child reject our family values that we brought from the old country?” “How did it happen that my son is gay?”
Siblings have an idea of who their sibling should be, and this idea often is fixed and immutable. They may ask, “Why won’t my sister help me out?” “Why can’t she be a good sister?” “Why is my brother so jealous of me?”
Family elders may wonder why their adult children do not want to return home to care for them or why they want their parents to go into a nursing home.
These dilemmas are easy to understand as conscious expectations. More difficult to understand are the unconscious projections that tangle up families.
Unconscious psychological processes
The two main unconscious psychological processes that tangle up families are projection and projective identification. Projective identification is an unconscious process in which aspects of the self are split off and projected onto another person. In 1946, Melanie Klein introduced the term “projective identification” as follows: “Much of the hatred against parts of the self is now directed toward the mother. This leads to a particular form of identification which establishes the prototype of an aggressive object-relation. I suggest for these processes the term ‘projective identification’ ” (Int J Psychoanal. 1946;27[pt 3-4]:99-110).
Mutual projective processes can occur in committed relationships. The following scenario helps illustrate this: Ms. A. projects onto her husband her own feared and unwanted aggressive, dominating aspects of herself. The result is that she fears and respects him. He, in turn, comes to feel aggressive and dominating toward her, not only because of his own resources but because of her projections, which she forces onto him. He may, in turn, despise and disown timid and fearful aspects of his own personality and by a similar mechanism of projective identification force these unwanted aspects of himself onto his wife. Ms. A. is then composed of timid unaggressive parts of herself as well as his projections, and she carries these feelings as her part in the relationship. Some couples, like Mr. and Ms. A., live in such locked systems, dominated by mutual projections, with each not truly married to the other person but to the unwanted, split-off, and projected parts of themselves.
In this scenario, the husband becomes dominant and cruel, and the wife becomes stupidly timid and respectful. These marriages are stable, because each partner needs the other for narcissistic pathologic purposes (see “Some Psychodynamics of Large Groups” in “The Large Group: Dynamics and Therapy” [London: Karnac Books, 1975] and “The Ailment and Other Psychoanalytic Essays” [London: Free Association Books, 2015]).
Marriage offers an opportunity for individuals to work out these types of issues, or, in the case of Mr. and Ms. A, not work through them. Instead, they exist in tight mutual projections.
Family process perspective
Families function as a system or unit, and each person in the family has a role or function. When change occurs, basic rules of systems theory apply. For example, if the mother functions as the emotional barometer, no one else needs to pay attention to emotions, as that is the mother’s job. If she leaves or becomes ill, someone else will take on that role or the family will fall apart. If the father becomes depressed and unable to function in his role as a parent, the oldest child may have to step up to become the parent. When he gets better and his depression resolves, there may be tension – as the older child may not want to give up that role. There may be a disagreement in the family vision.
When the children grow and develop their own identities and lifestyles, the family has to adjust to include the adult children or cut them off. Individuals also may cut themselves off from the family if there are significant disagreements. There are variations, such as “semi-cutoffs,” where there is little contact except at ritualized holidays and significant family events. Therefore, tensions arise most clearly at these times when family members come together.
Boundaries protect the family
A family functions like a pack. As with most species, families and parents protect the young until they are able to care for themselves. The marriage contract specifies that spouses care for each other but additionally that they join extended families together. Family cares for family before caring for strangers. It is the elder’s role and responsibility to keep the family together, or the family members may drift apart or be subsumed into other family groups.
A clan is made up of related families that form a larger extended family unit. Historically, strong alliances, as in clans or family dynasties, become dominant socially. In recent history, the idea of clans has become less attractive as the idea of individualism has become the American ideal.
Modern families tend to be individually oriented and do not need their families for protection as much as primitive tribes did. Modern families have fairly loose boundaries, and problems can arise when the family tries to define boundaries and values.
Families also change composition with the impact of sociocultural influences, such as migration. However, the primitive social drive still forces us to form families and clans. This drive can explain much of the need for identifying people as “in or out” of the family. The Amish intentionally address this dilemma. At adolescence, the ritual of Rumspringa allows the young person to experience 1 year out of Amish life in Western life. The adolescent can then decide to be in or out. If the adolescent decides to be in, conformity to Amish lifestyle is required (“Serving the Amish,” Baltimore: Johns Hopkins University Press, 2014).
Lastly, our families provide memories of where we have come from and where we are going, both as individuals and as a clan. Powerful stories serve the next generation with a sense of belonging and a specific orientation to the world. The studies of third-generation Holocaust survivors attest to the power of family narratives. Individuals can choose to embrace the family narrative or alter it to allow individual growth.
Explaining families to families
When helping patients work through issues with their families, it is helpful to provide them with context. Among the important points we can make are:
● Families came into existence as a way to protect our young; this is true across the animal kingdom. Humans congregated into clans or tribes that demanded conformity and obedience to the chief. There was a clear sense of who was in and who was out. Many of the difficulties that we experience are tied to the primitive tension of needing to decide who is in and who is out. This is a normal function of families.
● These days, families have much looser boundaries, and individuals have the freedom to strike out on their own. Families have to grapple with their collective identity only when they get together at holiday times or transitional events like marriages, births, and deaths. So, is it worth getting upset about this? If so, ask patients what they would like to change – and why.
● With this background, the family can dive deeper. Ask your patients, “Is the issue a problem with roles within the family? Has there been a role transition? Has there been a death, serious illness, or birth? Has someone left, retired, or joined the family? How would you as a family like to proceed?”
● Lastly, is there a complicated tangled web or relationship that might be explained by mutual projective identifications? If so, refer to a colleague with family therapy skills.
Key points to keep in mind
1. Families should be placed in the context of clans and tribes.
2. Transitions and family events cause families to question their family identity, boundaries, and values.
3. Patients should explore their individual expectations about what families should do. This conversation can be extensive, and include cultural and generational flash points.
4. If there is a tangled web that makes no sense to you, refer to a colleague with family therapy skills.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
What is it about families that makes our patients so upset? Why can our patients not just walk away from conflict? Why do they get so bent out of shape when family members do not say or do what they expect them to do? We all have families that are less than ideal and struggle with how to manage difference.
This column gives psychiatrists a framework for thinking with families about the universal dilemma of managing difference. This dilemma can be viewed from the perspectives of the individual, the family, and society: Identity is formed in the crucible of the family, where parental introjects become a model for the child’s development and can be rejected as an adolescent or adult as individuals shape their own identity. Processes within the family shape family members’ relationships and, therefore, their expectations of one another. Strong boundaries provide safety for those inside the family versus those outside the family.
Individual perspective
Family members’ perspective and expectations of others depend on their family position. Children or young adults want to please the parent, and to be accepted and recognized for who they are. They want their unique qualities to be valued, they want to be loved, and they want to feel that they belong.
Parents want their young adult to reach what they consider a successful life, and to be fulfilled and healthy. When their child strikes out on his or her own, the parent may not understand, and may feel let down or angry. The parent may say: “She married him to get back at me.” “Why is my son so rejecting of the business our family spent generations to build?” “How can my child reject our family values that we brought from the old country?” “How did it happen that my son is gay?”
Siblings have an idea of who their sibling should be, and this idea often is fixed and immutable. They may ask, “Why won’t my sister help me out?” “Why can’t she be a good sister?” “Why is my brother so jealous of me?”
Family elders may wonder why their adult children do not want to return home to care for them or why they want their parents to go into a nursing home.
These dilemmas are easy to understand as conscious expectations. More difficult to understand are the unconscious projections that tangle up families.
Unconscious psychological processes
The two main unconscious psychological processes that tangle up families are projection and projective identification. Projective identification is an unconscious process in which aspects of the self are split off and projected onto another person. In 1946, Melanie Klein introduced the term “projective identification” as follows: “Much of the hatred against parts of the self is now directed toward the mother. This leads to a particular form of identification which establishes the prototype of an aggressive object-relation. I suggest for these processes the term ‘projective identification’ ” (Int J Psychoanal. 1946;27[pt 3-4]:99-110).
Mutual projective processes can occur in committed relationships. The following scenario helps illustrate this: Ms. A. projects onto her husband her own feared and unwanted aggressive, dominating aspects of herself. The result is that she fears and respects him. He, in turn, comes to feel aggressive and dominating toward her, not only because of his own resources but because of her projections, which she forces onto him. He may, in turn, despise and disown timid and fearful aspects of his own personality and by a similar mechanism of projective identification force these unwanted aspects of himself onto his wife. Ms. A. is then composed of timid unaggressive parts of herself as well as his projections, and she carries these feelings as her part in the relationship. Some couples, like Mr. and Ms. A., live in such locked systems, dominated by mutual projections, with each not truly married to the other person but to the unwanted, split-off, and projected parts of themselves.
In this scenario, the husband becomes dominant and cruel, and the wife becomes stupidly timid and respectful. These marriages are stable, because each partner needs the other for narcissistic pathologic purposes (see “Some Psychodynamics of Large Groups” in “The Large Group: Dynamics and Therapy” [London: Karnac Books, 1975] and “The Ailment and Other Psychoanalytic Essays” [London: Free Association Books, 2015]).
Marriage offers an opportunity for individuals to work out these types of issues, or, in the case of Mr. and Ms. A, not work through them. Instead, they exist in tight mutual projections.
Family process perspective
Families function as a system or unit, and each person in the family has a role or function. When change occurs, basic rules of systems theory apply. For example, if the mother functions as the emotional barometer, no one else needs to pay attention to emotions, as that is the mother’s job. If she leaves or becomes ill, someone else will take on that role or the family will fall apart. If the father becomes depressed and unable to function in his role as a parent, the oldest child may have to step up to become the parent. When he gets better and his depression resolves, there may be tension – as the older child may not want to give up that role. There may be a disagreement in the family vision.
When the children grow and develop their own identities and lifestyles, the family has to adjust to include the adult children or cut them off. Individuals also may cut themselves off from the family if there are significant disagreements. There are variations, such as “semi-cutoffs,” where there is little contact except at ritualized holidays and significant family events. Therefore, tensions arise most clearly at these times when family members come together.
Boundaries protect the family
A family functions like a pack. As with most species, families and parents protect the young until they are able to care for themselves. The marriage contract specifies that spouses care for each other but additionally that they join extended families together. Family cares for family before caring for strangers. It is the elder’s role and responsibility to keep the family together, or the family members may drift apart or be subsumed into other family groups.
A clan is made up of related families that form a larger extended family unit. Historically, strong alliances, as in clans or family dynasties, become dominant socially. In recent history, the idea of clans has become less attractive as the idea of individualism has become the American ideal.
Modern families tend to be individually oriented and do not need their families for protection as much as primitive tribes did. Modern families have fairly loose boundaries, and problems can arise when the family tries to define boundaries and values.
Families also change composition with the impact of sociocultural influences, such as migration. However, the primitive social drive still forces us to form families and clans. This drive can explain much of the need for identifying people as “in or out” of the family. The Amish intentionally address this dilemma. At adolescence, the ritual of Rumspringa allows the young person to experience 1 year out of Amish life in Western life. The adolescent can then decide to be in or out. If the adolescent decides to be in, conformity to Amish lifestyle is required (“Serving the Amish,” Baltimore: Johns Hopkins University Press, 2014).
Lastly, our families provide memories of where we have come from and where we are going, both as individuals and as a clan. Powerful stories serve the next generation with a sense of belonging and a specific orientation to the world. The studies of third-generation Holocaust survivors attest to the power of family narratives. Individuals can choose to embrace the family narrative or alter it to allow individual growth.
Explaining families to families
When helping patients work through issues with their families, it is helpful to provide them with context. Among the important points we can make are:
● Families came into existence as a way to protect our young; this is true across the animal kingdom. Humans congregated into clans or tribes that demanded conformity and obedience to the chief. There was a clear sense of who was in and who was out. Many of the difficulties that we experience are tied to the primitive tension of needing to decide who is in and who is out. This is a normal function of families.
● These days, families have much looser boundaries, and individuals have the freedom to strike out on their own. Families have to grapple with their collective identity only when they get together at holiday times or transitional events like marriages, births, and deaths. So, is it worth getting upset about this? If so, ask patients what they would like to change – and why.
● With this background, the family can dive deeper. Ask your patients, “Is the issue a problem with roles within the family? Has there been a role transition? Has there been a death, serious illness, or birth? Has someone left, retired, or joined the family? How would you as a family like to proceed?”
● Lastly, is there a complicated tangled web or relationship that might be explained by mutual projective identifications? If so, refer to a colleague with family therapy skills.
Key points to keep in mind
1. Families should be placed in the context of clans and tribes.
2. Transitions and family events cause families to question their family identity, boundaries, and values.
3. Patients should explore their individual expectations about what families should do. This conversation can be extensive, and include cultural and generational flash points.
4. If there is a tangled web that makes no sense to you, refer to a colleague with family therapy skills.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
What is it about families that makes our patients so upset? Why can our patients not just walk away from conflict? Why do they get so bent out of shape when family members do not say or do what they expect them to do? We all have families that are less than ideal and struggle with how to manage difference.
This column gives psychiatrists a framework for thinking with families about the universal dilemma of managing difference. This dilemma can be viewed from the perspectives of the individual, the family, and society: Identity is formed in the crucible of the family, where parental introjects become a model for the child’s development and can be rejected as an adolescent or adult as individuals shape their own identity. Processes within the family shape family members’ relationships and, therefore, their expectations of one another. Strong boundaries provide safety for those inside the family versus those outside the family.
Individual perspective
Family members’ perspective and expectations of others depend on their family position. Children or young adults want to please the parent, and to be accepted and recognized for who they are. They want their unique qualities to be valued, they want to be loved, and they want to feel that they belong.
Parents want their young adult to reach what they consider a successful life, and to be fulfilled and healthy. When their child strikes out on his or her own, the parent may not understand, and may feel let down or angry. The parent may say: “She married him to get back at me.” “Why is my son so rejecting of the business our family spent generations to build?” “How can my child reject our family values that we brought from the old country?” “How did it happen that my son is gay?”
Siblings have an idea of who their sibling should be, and this idea often is fixed and immutable. They may ask, “Why won’t my sister help me out?” “Why can’t she be a good sister?” “Why is my brother so jealous of me?”
Family elders may wonder why their adult children do not want to return home to care for them or why they want their parents to go into a nursing home.
These dilemmas are easy to understand as conscious expectations. More difficult to understand are the unconscious projections that tangle up families.
Unconscious psychological processes
The two main unconscious psychological processes that tangle up families are projection and projective identification. Projective identification is an unconscious process in which aspects of the self are split off and projected onto another person. In 1946, Melanie Klein introduced the term “projective identification” as follows: “Much of the hatred against parts of the self is now directed toward the mother. This leads to a particular form of identification which establishes the prototype of an aggressive object-relation. I suggest for these processes the term ‘projective identification’ ” (Int J Psychoanal. 1946;27[pt 3-4]:99-110).
Mutual projective processes can occur in committed relationships. The following scenario helps illustrate this: Ms. A. projects onto her husband her own feared and unwanted aggressive, dominating aspects of herself. The result is that she fears and respects him. He, in turn, comes to feel aggressive and dominating toward her, not only because of his own resources but because of her projections, which she forces onto him. He may, in turn, despise and disown timid and fearful aspects of his own personality and by a similar mechanism of projective identification force these unwanted aspects of himself onto his wife. Ms. A. is then composed of timid unaggressive parts of herself as well as his projections, and she carries these feelings as her part in the relationship. Some couples, like Mr. and Ms. A., live in such locked systems, dominated by mutual projections, with each not truly married to the other person but to the unwanted, split-off, and projected parts of themselves.
In this scenario, the husband becomes dominant and cruel, and the wife becomes stupidly timid and respectful. These marriages are stable, because each partner needs the other for narcissistic pathologic purposes (see “Some Psychodynamics of Large Groups” in “The Large Group: Dynamics and Therapy” [London: Karnac Books, 1975] and “The Ailment and Other Psychoanalytic Essays” [London: Free Association Books, 2015]).
Marriage offers an opportunity for individuals to work out these types of issues, or, in the case of Mr. and Ms. A, not work through them. Instead, they exist in tight mutual projections.
Family process perspective
Families function as a system or unit, and each person in the family has a role or function. When change occurs, basic rules of systems theory apply. For example, if the mother functions as the emotional barometer, no one else needs to pay attention to emotions, as that is the mother’s job. If she leaves or becomes ill, someone else will take on that role or the family will fall apart. If the father becomes depressed and unable to function in his role as a parent, the oldest child may have to step up to become the parent. When he gets better and his depression resolves, there may be tension – as the older child may not want to give up that role. There may be a disagreement in the family vision.
When the children grow and develop their own identities and lifestyles, the family has to adjust to include the adult children or cut them off. Individuals also may cut themselves off from the family if there are significant disagreements. There are variations, such as “semi-cutoffs,” where there is little contact except at ritualized holidays and significant family events. Therefore, tensions arise most clearly at these times when family members come together.
Boundaries protect the family
A family functions like a pack. As with most species, families and parents protect the young until they are able to care for themselves. The marriage contract specifies that spouses care for each other but additionally that they join extended families together. Family cares for family before caring for strangers. It is the elder’s role and responsibility to keep the family together, or the family members may drift apart or be subsumed into other family groups.
A clan is made up of related families that form a larger extended family unit. Historically, strong alliances, as in clans or family dynasties, become dominant socially. In recent history, the idea of clans has become less attractive as the idea of individualism has become the American ideal.
Modern families tend to be individually oriented and do not need their families for protection as much as primitive tribes did. Modern families have fairly loose boundaries, and problems can arise when the family tries to define boundaries and values.
Families also change composition with the impact of sociocultural influences, such as migration. However, the primitive social drive still forces us to form families and clans. This drive can explain much of the need for identifying people as “in or out” of the family. The Amish intentionally address this dilemma. At adolescence, the ritual of Rumspringa allows the young person to experience 1 year out of Amish life in Western life. The adolescent can then decide to be in or out. If the adolescent decides to be in, conformity to Amish lifestyle is required (“Serving the Amish,” Baltimore: Johns Hopkins University Press, 2014).
Lastly, our families provide memories of where we have come from and where we are going, both as individuals and as a clan. Powerful stories serve the next generation with a sense of belonging and a specific orientation to the world. The studies of third-generation Holocaust survivors attest to the power of family narratives. Individuals can choose to embrace the family narrative or alter it to allow individual growth.
Explaining families to families
When helping patients work through issues with their families, it is helpful to provide them with context. Among the important points we can make are:
● Families came into existence as a way to protect our young; this is true across the animal kingdom. Humans congregated into clans or tribes that demanded conformity and obedience to the chief. There was a clear sense of who was in and who was out. Many of the difficulties that we experience are tied to the primitive tension of needing to decide who is in and who is out. This is a normal function of families.
● These days, families have much looser boundaries, and individuals have the freedom to strike out on their own. Families have to grapple with their collective identity only when they get together at holiday times or transitional events like marriages, births, and deaths. So, is it worth getting upset about this? If so, ask patients what they would like to change – and why.
● With this background, the family can dive deeper. Ask your patients, “Is the issue a problem with roles within the family? Has there been a role transition? Has there been a death, serious illness, or birth? Has someone left, retired, or joined the family? How would you as a family like to proceed?”
● Lastly, is there a complicated tangled web or relationship that might be explained by mutual projective identifications? If so, refer to a colleague with family therapy skills.
Key points to keep in mind
1. Families should be placed in the context of clans and tribes.
2. Transitions and family events cause families to question their family identity, boundaries, and values.
3. Patients should explore their individual expectations about what families should do. This conversation can be extensive, and include cultural and generational flash points.
4. If there is a tangled web that makes no sense to you, refer to a colleague with family therapy skills.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
Helping patients bring an end to domestic violence
As healers trained to address some of the psychosocial issues facing our patients, we need to understand various forms of domestic violence – and what we can do to stop it. One form, honor killings, remains pervasive across the globe.
In a sample of 856 ninth-grade students from 14 schools in Amman, Jordan, for example, about 40% of boys and 20% of girls believed that killing a daughter, sister, or wife who had dishonored the family was justified (Aggress Behav. 2013 Sep-Oct;39[5]:405-17). The schools were representative of students from different religions, socioeconomic statuses, and upbringings. The proportions are broadly in line with the religious affiliation of Jordanians, with 92% of the population identifying themselves as Muslims, 6% as Christians, and 2% as affiliated with other religions.1 However, researchers found that support for honor killings was more widespread among adolescents from poorer and more traditional family backgrounds.
What are honor killings?
According to Sally Elakkary, MD, and her colleagues, honor killings are “violence implicated against a female for the deviancy of her activities from the traditional cultural norms.”2 The perpetrators in these crimes are usually male relatives but may be other family members, including women. Males also can be victims of honor crimes. For example, a male can become a victim if he is the female’s lover in an extramarital relationship or if he is homosexual.
Most honor killings are reported from countries in the Maghreb region of North Africa; the Middle East (Palestine, Lebanon, Syria, Jordan, and Turkey); and Western and Central Asia (Iraq, Pakistan, Afghanistan, and India). However, honor killings also occur in countries with strong minorities from those origins. A report3 published in 2000 by the United Nations Population Fund estimated that 5,000 honor killings were carried out worldwide per year, with the largest absolute numbers reported for Pakistan and India (about 1,000 cases per year in each country).
Until the 1960s in the United States, penal codes in some states, such as Georgia, New Mexico, Texas, and Utah, justified a husband killing his wife’s lover. In those states, the law was formulated to protect the male’s honor. Honor killings are culture-based practices that are supported indirectly by that country’s legal system. In a recent New York Times op-ed4 piece, Bina Shah stated that “upending misogynistic tribal codes is the real key to finally ending the most egregious gender crime.” The Pakistan Parliament recently stiffened the punishment for honor killings. The new anti–honor killing law mandates a minimum lifetime jail sentence for perpetrators and closes a legal loophole that allowed an honor killer to walk free if the family of the victim forgave him.
However, in rural areas, a Pakistani woman accused of violating family or tribal honor can be sentenced to death by an informal village court or a gathering of tribal elders. Women have been killed by stoning, shooting, or being buried alive. Sometimes, the woman’s relatives condemn her to death without a trial. Women are killed for reasons such as wanting to marry of their own choice, divorcing abusive husbands, or speaking to a man or boy outside the family; “in one case, four young girls who were filmed dancing in a rain shower were executed by their cousin for immorality,” Ms. Shah said.
Range of behaviors
Abusive behavior can take many forms, including:
• Isolating a person from her friends and family.
• Depriving her of basic needs.
• Monitoring her time.
• Monitoring her use of online communication tools or spyware.
• Taking control over aspects of her everyday life, such as where she can go, whom she can see, what she can wear, and when she can sleep.
• Depriving her of access to support services, such as specialist support or medical services.
• Repeatedly putting her down, such as telling her that she is worthless.
• Enforcing rules and activities that humiliate, degrade, or dehumanize the victim.
• Forcing the victim to take part in criminal activity such as shoplifting, and neglecting or abusing children to encourage self-blame and prevent disclosure to authorities.
• Abusing finances, including controlling resources so that the person is allowed only a punitive allowance.
• Threatening to hurt or kill her.
• Threatening a child.
• Threatening to reveal or publish private information (for example, threatening to “out” someone).
• Assaulting the person.
• Causing criminal damage (such as destruction of household goods).
• Engaging in rape.
• Preventing a person from having access to transportation or from working.
New domestic violence law in the United Kingdom
Meanwhile, domestic violence laws in England and Wales now consider emotional and psychological abuse as legally actionable. The new legislation targets those who subject spouses, partners, and family members to psychological and emotional torment, but stop short of violence. The new law5 follows a Home Office consultation showing that 85% of participants said the existing law did not provide sufficient protection and a Citizens Advice report showing a 24% rise in people seeking advice for domestic abuse.
The new law falls under the Serious Crime Act 2015 of England and Wales. The act creates a new offense of “controlling or coercive behavior in intimate or familial relationships.” The act states: “The new offence closes a gap in the law around patterns of controlling or coercive behavior in an ongoing relationship between intimate partners or family members.”
Breaking the law carries a maximum sentence of 5 years’ imprisonment, a fine, or both. The behavior must have had a “serious effect” on the victim, meaning that it has caused the victim to fear violence will be used against them on “at least two occasions,” or it has had a “substantial adverse effect on the victim’s day to day activities.”
The alleged perpetrator must have known that his behavior would have a serious effect on the victim, or the behavior must have been such that he “ought to have known” it would have that effect.
The new law includes honor-based violence, female genital mutilation, and forced marriage. The law explicitly states that the victim may fear that the perpetrator has asked another person to commit violence against them, thus including family honor killings.
Gendered nature of domestic controlling or coercive behavior
While all legislation is gender neutral, women and girls are disproportionately affected by crimes of domestic violence and abuse. Women from black and minority ethnic backgrounds may experience barriers to reporting, such as a distrust of the police, concerns about racism, language barriers, concerns about family finding out, or fear of rejection by the wider community. A victim might be fearful about her children being taken away if she makes a report. Lesbian, gay, bisexual, and transgender individuals in relationships may be subjected to threats to reveal sexual orientation to family or others.
Interestingly, the U.K. guidelines state that victims of controlling or coercive behavior may not recognize themselves as victims. Therefore, it is important that the new offense be considered by the police and other authorities in attendance at all call-outs. Police are encouraged to ask questions about rules, decision making, norms, and fear in the relationship, rather than just what happened. The guidelines provide specific comments about handling perpetrators who are described as being “particularly adept” at manipulating professionals, agencies, and systems, and may use a range of tactics in relation to this offense, including targeting people who might be vulnerable (there may be evidence of this from previous relationships) and using the system against the victim by making false or vexatious allegations to agencies.
The Authorized Professional Practice on Investigating Domestic Abuse issued by the College of Policing states: “A manipulative perpetrator may be trying to draw the police into colluding with their coercive control of the victim. Police officers must avoid playing into the primary perpetrator’s hands and take account of all available evidence when making the decision to arrest.” Such evidence includes attempting to frustrate or interfere with the police investigation; making counterallegations against the victim; and using threats of manipulation against the victim – such as telling the victim that he will make a counterallegation against her, that the victim will not be believed by the police or other agencies, that he will inform social services, or that he will inform immigration officials where the victim does not have a right to remain.
How can psychiatrists raise awareness?
• Individual change. Abusive controlling behavior can have its origin in childhood psychological experiences, in the same way that honor killings and wife beating can have their roots in the perpetrator’s cultural experience. As a child, the adult perpetrator may have been a direct victim of violence or may have been a witness to domestic violence. Controlling abusive behavior also can occur as a choice in perpetrators with personality disorders unrelated to childhood experiences. It can occur in a person with both exposure and personality disorder. It is important to understand the origins and reasoning behind the behavior in order to understand how best to intervene.
If the behavior is based on the childhood experience of the prevailing sociocultural practice, the psychiatrist can explore values and beliefs, identifying those that are based on family and cultural factors. Beliefs that have been present during a person’s entire life can appear as the unexamined “background” of their lives. Bringing those beliefs to the fore can allow discussion. For example, does the individual hold the belief that women are possessions? What is the basis of holding such a belief? How does he account for the differences between societies?
• Family change. Individuals in the family may differ in their support of honor killings. Those who do not support honor killings may have difficulty speaking out for fear of becoming a future target. When we meet with families who have a belief in honor killings, we can discuss how patriarchal societies have encouraged families to maintain a firm hand on the behavior of their members. This practice encourages repression of women’s individuality and also may consider women to be possessions. Patriarchal societies control their populations by supporting values and beliefs in their citizens that support the patriarchal structure. In this way, they can exert social control easily by having members of the society act as enforcers. Open and clear discussion with families about the ways in which cultural practice affects individual behavior may allow families that are unsure to explore alternative new beliefs.
Families must understand that, under U.S. law, perpetrators of honor killings and domestic violence can be prosecuted.
• System change. According to the U.S. Justice Department, 9 out of 10 honor killings were victims who had become “too Westernized.” Leaders of the American Muslim community and members of the Council on American-Islamic Relations have condemned all honor killings, stating that the practice stems from sexism and tribal behavior that predates the religion. In February 2009, after the high-profile killing of Aasiya Zubair Hassan in New York, Muslim leaders began a nationwide effort entitled, “Imams Speak Out: Domestic Violence Will Not Be Tolerated in Our Communities,” asking all imams and religious leaders to discuss domestic violence in their weekly sermon or their Friday prayer services. The group, “Muslim Men Against Domestic Violence,” was founded soon after the murder, which came just a few days after she had filed for divorce. (After a 3-week trial, Mrs. Hassan’s estranged husband, Muzzammil “Mo” Hassan, was found guilty of second-degree murder and received a 25-year to life sentence).
Our laws reflect our values as a society. As citizens, we must actively work for the enforcement of domestic violence laws. Our mental health organizations can support the training of police and health agencies to identify victims and perpetrators.
References
1. The World Factbook, Central Intelligence Agency, 2009.
2 Forensic Sci Med Pathol. 2014;10(1):76-82.
3. “Lives Together, Worlds Apart: Men and Women in a Time of Change,” United Nations Population Fund report, 2000.
4. “Pakistan’s Honor-Killing Law Isn’t Enough,” The New York Times, Oct. 27, 2016.
5. “Controlling or Coercive Behaviour in an Intimate or Family Relationship,” Home Office, December 2015.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
As healers trained to address some of the psychosocial issues facing our patients, we need to understand various forms of domestic violence – and what we can do to stop it. One form, honor killings, remains pervasive across the globe.
In a sample of 856 ninth-grade students from 14 schools in Amman, Jordan, for example, about 40% of boys and 20% of girls believed that killing a daughter, sister, or wife who had dishonored the family was justified (Aggress Behav. 2013 Sep-Oct;39[5]:405-17). The schools were representative of students from different religions, socioeconomic statuses, and upbringings. The proportions are broadly in line with the religious affiliation of Jordanians, with 92% of the population identifying themselves as Muslims, 6% as Christians, and 2% as affiliated with other religions.1 However, researchers found that support for honor killings was more widespread among adolescents from poorer and more traditional family backgrounds.
What are honor killings?
According to Sally Elakkary, MD, and her colleagues, honor killings are “violence implicated against a female for the deviancy of her activities from the traditional cultural norms.”2 The perpetrators in these crimes are usually male relatives but may be other family members, including women. Males also can be victims of honor crimes. For example, a male can become a victim if he is the female’s lover in an extramarital relationship or if he is homosexual.
Most honor killings are reported from countries in the Maghreb region of North Africa; the Middle East (Palestine, Lebanon, Syria, Jordan, and Turkey); and Western and Central Asia (Iraq, Pakistan, Afghanistan, and India). However, honor killings also occur in countries with strong minorities from those origins. A report3 published in 2000 by the United Nations Population Fund estimated that 5,000 honor killings were carried out worldwide per year, with the largest absolute numbers reported for Pakistan and India (about 1,000 cases per year in each country).
Until the 1960s in the United States, penal codes in some states, such as Georgia, New Mexico, Texas, and Utah, justified a husband killing his wife’s lover. In those states, the law was formulated to protect the male’s honor. Honor killings are culture-based practices that are supported indirectly by that country’s legal system. In a recent New York Times op-ed4 piece, Bina Shah stated that “upending misogynistic tribal codes is the real key to finally ending the most egregious gender crime.” The Pakistan Parliament recently stiffened the punishment for honor killings. The new anti–honor killing law mandates a minimum lifetime jail sentence for perpetrators and closes a legal loophole that allowed an honor killer to walk free if the family of the victim forgave him.
However, in rural areas, a Pakistani woman accused of violating family or tribal honor can be sentenced to death by an informal village court or a gathering of tribal elders. Women have been killed by stoning, shooting, or being buried alive. Sometimes, the woman’s relatives condemn her to death without a trial. Women are killed for reasons such as wanting to marry of their own choice, divorcing abusive husbands, or speaking to a man or boy outside the family; “in one case, four young girls who were filmed dancing in a rain shower were executed by their cousin for immorality,” Ms. Shah said.
Range of behaviors
Abusive behavior can take many forms, including:
• Isolating a person from her friends and family.
• Depriving her of basic needs.
• Monitoring her time.
• Monitoring her use of online communication tools or spyware.
• Taking control over aspects of her everyday life, such as where she can go, whom she can see, what she can wear, and when she can sleep.
• Depriving her of access to support services, such as specialist support or medical services.
• Repeatedly putting her down, such as telling her that she is worthless.
• Enforcing rules and activities that humiliate, degrade, or dehumanize the victim.
• Forcing the victim to take part in criminal activity such as shoplifting, and neglecting or abusing children to encourage self-blame and prevent disclosure to authorities.
• Abusing finances, including controlling resources so that the person is allowed only a punitive allowance.
• Threatening to hurt or kill her.
• Threatening a child.
• Threatening to reveal or publish private information (for example, threatening to “out” someone).
• Assaulting the person.
• Causing criminal damage (such as destruction of household goods).
• Engaging in rape.
• Preventing a person from having access to transportation or from working.
New domestic violence law in the United Kingdom
Meanwhile, domestic violence laws in England and Wales now consider emotional and psychological abuse as legally actionable. The new legislation targets those who subject spouses, partners, and family members to psychological and emotional torment, but stop short of violence. The new law5 follows a Home Office consultation showing that 85% of participants said the existing law did not provide sufficient protection and a Citizens Advice report showing a 24% rise in people seeking advice for domestic abuse.
The new law falls under the Serious Crime Act 2015 of England and Wales. The act creates a new offense of “controlling or coercive behavior in intimate or familial relationships.” The act states: “The new offence closes a gap in the law around patterns of controlling or coercive behavior in an ongoing relationship between intimate partners or family members.”
Breaking the law carries a maximum sentence of 5 years’ imprisonment, a fine, or both. The behavior must have had a “serious effect” on the victim, meaning that it has caused the victim to fear violence will be used against them on “at least two occasions,” or it has had a “substantial adverse effect on the victim’s day to day activities.”
The alleged perpetrator must have known that his behavior would have a serious effect on the victim, or the behavior must have been such that he “ought to have known” it would have that effect.
The new law includes honor-based violence, female genital mutilation, and forced marriage. The law explicitly states that the victim may fear that the perpetrator has asked another person to commit violence against them, thus including family honor killings.
Gendered nature of domestic controlling or coercive behavior
While all legislation is gender neutral, women and girls are disproportionately affected by crimes of domestic violence and abuse. Women from black and minority ethnic backgrounds may experience barriers to reporting, such as a distrust of the police, concerns about racism, language barriers, concerns about family finding out, or fear of rejection by the wider community. A victim might be fearful about her children being taken away if she makes a report. Lesbian, gay, bisexual, and transgender individuals in relationships may be subjected to threats to reveal sexual orientation to family or others.
Interestingly, the U.K. guidelines state that victims of controlling or coercive behavior may not recognize themselves as victims. Therefore, it is important that the new offense be considered by the police and other authorities in attendance at all call-outs. Police are encouraged to ask questions about rules, decision making, norms, and fear in the relationship, rather than just what happened. The guidelines provide specific comments about handling perpetrators who are described as being “particularly adept” at manipulating professionals, agencies, and systems, and may use a range of tactics in relation to this offense, including targeting people who might be vulnerable (there may be evidence of this from previous relationships) and using the system against the victim by making false or vexatious allegations to agencies.
The Authorized Professional Practice on Investigating Domestic Abuse issued by the College of Policing states: “A manipulative perpetrator may be trying to draw the police into colluding with their coercive control of the victim. Police officers must avoid playing into the primary perpetrator’s hands and take account of all available evidence when making the decision to arrest.” Such evidence includes attempting to frustrate or interfere with the police investigation; making counterallegations against the victim; and using threats of manipulation against the victim – such as telling the victim that he will make a counterallegation against her, that the victim will not be believed by the police or other agencies, that he will inform social services, or that he will inform immigration officials where the victim does not have a right to remain.
How can psychiatrists raise awareness?
• Individual change. Abusive controlling behavior can have its origin in childhood psychological experiences, in the same way that honor killings and wife beating can have their roots in the perpetrator’s cultural experience. As a child, the adult perpetrator may have been a direct victim of violence or may have been a witness to domestic violence. Controlling abusive behavior also can occur as a choice in perpetrators with personality disorders unrelated to childhood experiences. It can occur in a person with both exposure and personality disorder. It is important to understand the origins and reasoning behind the behavior in order to understand how best to intervene.
If the behavior is based on the childhood experience of the prevailing sociocultural practice, the psychiatrist can explore values and beliefs, identifying those that are based on family and cultural factors. Beliefs that have been present during a person’s entire life can appear as the unexamined “background” of their lives. Bringing those beliefs to the fore can allow discussion. For example, does the individual hold the belief that women are possessions? What is the basis of holding such a belief? How does he account for the differences between societies?
• Family change. Individuals in the family may differ in their support of honor killings. Those who do not support honor killings may have difficulty speaking out for fear of becoming a future target. When we meet with families who have a belief in honor killings, we can discuss how patriarchal societies have encouraged families to maintain a firm hand on the behavior of their members. This practice encourages repression of women’s individuality and also may consider women to be possessions. Patriarchal societies control their populations by supporting values and beliefs in their citizens that support the patriarchal structure. In this way, they can exert social control easily by having members of the society act as enforcers. Open and clear discussion with families about the ways in which cultural practice affects individual behavior may allow families that are unsure to explore alternative new beliefs.
Families must understand that, under U.S. law, perpetrators of honor killings and domestic violence can be prosecuted.
• System change. According to the U.S. Justice Department, 9 out of 10 honor killings were victims who had become “too Westernized.” Leaders of the American Muslim community and members of the Council on American-Islamic Relations have condemned all honor killings, stating that the practice stems from sexism and tribal behavior that predates the religion. In February 2009, after the high-profile killing of Aasiya Zubair Hassan in New York, Muslim leaders began a nationwide effort entitled, “Imams Speak Out: Domestic Violence Will Not Be Tolerated in Our Communities,” asking all imams and religious leaders to discuss domestic violence in their weekly sermon or their Friday prayer services. The group, “Muslim Men Against Domestic Violence,” was founded soon after the murder, which came just a few days after she had filed for divorce. (After a 3-week trial, Mrs. Hassan’s estranged husband, Muzzammil “Mo” Hassan, was found guilty of second-degree murder and received a 25-year to life sentence).
Our laws reflect our values as a society. As citizens, we must actively work for the enforcement of domestic violence laws. Our mental health organizations can support the training of police and health agencies to identify victims and perpetrators.
References
1. The World Factbook, Central Intelligence Agency, 2009.
2 Forensic Sci Med Pathol. 2014;10(1):76-82.
3. “Lives Together, Worlds Apart: Men and Women in a Time of Change,” United Nations Population Fund report, 2000.
4. “Pakistan’s Honor-Killing Law Isn’t Enough,” The New York Times, Oct. 27, 2016.
5. “Controlling or Coercive Behaviour in an Intimate or Family Relationship,” Home Office, December 2015.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
As healers trained to address some of the psychosocial issues facing our patients, we need to understand various forms of domestic violence – and what we can do to stop it. One form, honor killings, remains pervasive across the globe.
In a sample of 856 ninth-grade students from 14 schools in Amman, Jordan, for example, about 40% of boys and 20% of girls believed that killing a daughter, sister, or wife who had dishonored the family was justified (Aggress Behav. 2013 Sep-Oct;39[5]:405-17). The schools were representative of students from different religions, socioeconomic statuses, and upbringings. The proportions are broadly in line with the religious affiliation of Jordanians, with 92% of the population identifying themselves as Muslims, 6% as Christians, and 2% as affiliated with other religions.1 However, researchers found that support for honor killings was more widespread among adolescents from poorer and more traditional family backgrounds.
What are honor killings?
According to Sally Elakkary, MD, and her colleagues, honor killings are “violence implicated against a female for the deviancy of her activities from the traditional cultural norms.”2 The perpetrators in these crimes are usually male relatives but may be other family members, including women. Males also can be victims of honor crimes. For example, a male can become a victim if he is the female’s lover in an extramarital relationship or if he is homosexual.
Most honor killings are reported from countries in the Maghreb region of North Africa; the Middle East (Palestine, Lebanon, Syria, Jordan, and Turkey); and Western and Central Asia (Iraq, Pakistan, Afghanistan, and India). However, honor killings also occur in countries with strong minorities from those origins. A report3 published in 2000 by the United Nations Population Fund estimated that 5,000 honor killings were carried out worldwide per year, with the largest absolute numbers reported for Pakistan and India (about 1,000 cases per year in each country).
Until the 1960s in the United States, penal codes in some states, such as Georgia, New Mexico, Texas, and Utah, justified a husband killing his wife’s lover. In those states, the law was formulated to protect the male’s honor. Honor killings are culture-based practices that are supported indirectly by that country’s legal system. In a recent New York Times op-ed4 piece, Bina Shah stated that “upending misogynistic tribal codes is the real key to finally ending the most egregious gender crime.” The Pakistan Parliament recently stiffened the punishment for honor killings. The new anti–honor killing law mandates a minimum lifetime jail sentence for perpetrators and closes a legal loophole that allowed an honor killer to walk free if the family of the victim forgave him.
However, in rural areas, a Pakistani woman accused of violating family or tribal honor can be sentenced to death by an informal village court or a gathering of tribal elders. Women have been killed by stoning, shooting, or being buried alive. Sometimes, the woman’s relatives condemn her to death without a trial. Women are killed for reasons such as wanting to marry of their own choice, divorcing abusive husbands, or speaking to a man or boy outside the family; “in one case, four young girls who were filmed dancing in a rain shower were executed by their cousin for immorality,” Ms. Shah said.
Range of behaviors
Abusive behavior can take many forms, including:
• Isolating a person from her friends and family.
• Depriving her of basic needs.
• Monitoring her time.
• Monitoring her use of online communication tools or spyware.
• Taking control over aspects of her everyday life, such as where she can go, whom she can see, what she can wear, and when she can sleep.
• Depriving her of access to support services, such as specialist support or medical services.
• Repeatedly putting her down, such as telling her that she is worthless.
• Enforcing rules and activities that humiliate, degrade, or dehumanize the victim.
• Forcing the victim to take part in criminal activity such as shoplifting, and neglecting or abusing children to encourage self-blame and prevent disclosure to authorities.
• Abusing finances, including controlling resources so that the person is allowed only a punitive allowance.
• Threatening to hurt or kill her.
• Threatening a child.
• Threatening to reveal or publish private information (for example, threatening to “out” someone).
• Assaulting the person.
• Causing criminal damage (such as destruction of household goods).
• Engaging in rape.
• Preventing a person from having access to transportation or from working.
New domestic violence law in the United Kingdom
Meanwhile, domestic violence laws in England and Wales now consider emotional and psychological abuse as legally actionable. The new legislation targets those who subject spouses, partners, and family members to psychological and emotional torment, but stop short of violence. The new law5 follows a Home Office consultation showing that 85% of participants said the existing law did not provide sufficient protection and a Citizens Advice report showing a 24% rise in people seeking advice for domestic abuse.
The new law falls under the Serious Crime Act 2015 of England and Wales. The act creates a new offense of “controlling or coercive behavior in intimate or familial relationships.” The act states: “The new offence closes a gap in the law around patterns of controlling or coercive behavior in an ongoing relationship between intimate partners or family members.”
Breaking the law carries a maximum sentence of 5 years’ imprisonment, a fine, or both. The behavior must have had a “serious effect” on the victim, meaning that it has caused the victim to fear violence will be used against them on “at least two occasions,” or it has had a “substantial adverse effect on the victim’s day to day activities.”
The alleged perpetrator must have known that his behavior would have a serious effect on the victim, or the behavior must have been such that he “ought to have known” it would have that effect.
The new law includes honor-based violence, female genital mutilation, and forced marriage. The law explicitly states that the victim may fear that the perpetrator has asked another person to commit violence against them, thus including family honor killings.
Gendered nature of domestic controlling or coercive behavior
While all legislation is gender neutral, women and girls are disproportionately affected by crimes of domestic violence and abuse. Women from black and minority ethnic backgrounds may experience barriers to reporting, such as a distrust of the police, concerns about racism, language barriers, concerns about family finding out, or fear of rejection by the wider community. A victim might be fearful about her children being taken away if she makes a report. Lesbian, gay, bisexual, and transgender individuals in relationships may be subjected to threats to reveal sexual orientation to family or others.
Interestingly, the U.K. guidelines state that victims of controlling or coercive behavior may not recognize themselves as victims. Therefore, it is important that the new offense be considered by the police and other authorities in attendance at all call-outs. Police are encouraged to ask questions about rules, decision making, norms, and fear in the relationship, rather than just what happened. The guidelines provide specific comments about handling perpetrators who are described as being “particularly adept” at manipulating professionals, agencies, and systems, and may use a range of tactics in relation to this offense, including targeting people who might be vulnerable (there may be evidence of this from previous relationships) and using the system against the victim by making false or vexatious allegations to agencies.
The Authorized Professional Practice on Investigating Domestic Abuse issued by the College of Policing states: “A manipulative perpetrator may be trying to draw the police into colluding with their coercive control of the victim. Police officers must avoid playing into the primary perpetrator’s hands and take account of all available evidence when making the decision to arrest.” Such evidence includes attempting to frustrate or interfere with the police investigation; making counterallegations against the victim; and using threats of manipulation against the victim – such as telling the victim that he will make a counterallegation against her, that the victim will not be believed by the police or other agencies, that he will inform social services, or that he will inform immigration officials where the victim does not have a right to remain.
How can psychiatrists raise awareness?
• Individual change. Abusive controlling behavior can have its origin in childhood psychological experiences, in the same way that honor killings and wife beating can have their roots in the perpetrator’s cultural experience. As a child, the adult perpetrator may have been a direct victim of violence or may have been a witness to domestic violence. Controlling abusive behavior also can occur as a choice in perpetrators with personality disorders unrelated to childhood experiences. It can occur in a person with both exposure and personality disorder. It is important to understand the origins and reasoning behind the behavior in order to understand how best to intervene.
If the behavior is based on the childhood experience of the prevailing sociocultural practice, the psychiatrist can explore values and beliefs, identifying those that are based on family and cultural factors. Beliefs that have been present during a person’s entire life can appear as the unexamined “background” of their lives. Bringing those beliefs to the fore can allow discussion. For example, does the individual hold the belief that women are possessions? What is the basis of holding such a belief? How does he account for the differences between societies?
• Family change. Individuals in the family may differ in their support of honor killings. Those who do not support honor killings may have difficulty speaking out for fear of becoming a future target. When we meet with families who have a belief in honor killings, we can discuss how patriarchal societies have encouraged families to maintain a firm hand on the behavior of their members. This practice encourages repression of women’s individuality and also may consider women to be possessions. Patriarchal societies control their populations by supporting values and beliefs in their citizens that support the patriarchal structure. In this way, they can exert social control easily by having members of the society act as enforcers. Open and clear discussion with families about the ways in which cultural practice affects individual behavior may allow families that are unsure to explore alternative new beliefs.
Families must understand that, under U.S. law, perpetrators of honor killings and domestic violence can be prosecuted.
• System change. According to the U.S. Justice Department, 9 out of 10 honor killings were victims who had become “too Westernized.” Leaders of the American Muslim community and members of the Council on American-Islamic Relations have condemned all honor killings, stating that the practice stems from sexism and tribal behavior that predates the religion. In February 2009, after the high-profile killing of Aasiya Zubair Hassan in New York, Muslim leaders began a nationwide effort entitled, “Imams Speak Out: Domestic Violence Will Not Be Tolerated in Our Communities,” asking all imams and religious leaders to discuss domestic violence in their weekly sermon or their Friday prayer services. The group, “Muslim Men Against Domestic Violence,” was founded soon after the murder, which came just a few days after she had filed for divorce. (After a 3-week trial, Mrs. Hassan’s estranged husband, Muzzammil “Mo” Hassan, was found guilty of second-degree murder and received a 25-year to life sentence).
Our laws reflect our values as a society. As citizens, we must actively work for the enforcement of domestic violence laws. Our mental health organizations can support the training of police and health agencies to identify victims and perpetrators.
References
1. The World Factbook, Central Intelligence Agency, 2009.
2 Forensic Sci Med Pathol. 2014;10(1):76-82.
3. “Lives Together, Worlds Apart: Men and Women in a Time of Change,” United Nations Population Fund report, 2000.
4. “Pakistan’s Honor-Killing Law Isn’t Enough,” The New York Times, Oct. 27, 2016.
5. “Controlling or Coercive Behaviour in an Intimate or Family Relationship,” Home Office, December 2015.
Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
Belonging and grieving: Lessons from Orlando
We belong in our family, in our group, and in our community. Belonging is a basic human need, and we work throughout our lives to seek or create safe places where we can belong. For the LGBTQ+ community, the Pulse nightclub was one of those rare places where they could feel like they truly belonged. It was a place where they did not need to pretend to be someone else or to keep their guard up against insults or criticism. For survivors of the shooting, the families, and the LGBTQ+ community, that sense of belonging is now fractured.
Pulse reportedly represented every LGBTQ+’s queer bar, where a safe environment is sought – an environment in which to grow and express identity. For the LGBTQ+ community, the June 12 massacre threatened all safe havens – where few currently exist – especially in the night scene, where the increased risk of violence is a constant factor in deciding where to party. There are few gay bars.
What must psychiatrists understand about the impact of the event, besides the regular work of grieving? Some specifics pertinent to this attack must be understood: the preponderance of Latinos1, the youthfulness of most victims, and the impact and reverberations throughout the LGBTQ+ community. This column highlights the unique aspects of this tragedy, and the complexity of the grieving that will take place in these families and communities.
Grief, illness, and resilience: What do we know?
Grieving after sudden and violent deaths, compared with natural deaths, is more likely to be associated with mental health disorders and a slower recovery (Psychiatry. 2012 Spring;75[1]:76-97). Traumatic loss can cause incapacitating grief and a search for meaning that can continue for years, especially in those who identify closely with the victims (J Trauma Stress. 2016 Feb;29[1]41-8).
The LGBTQ+ community identifies strongly with the victims of the Orlando shooting, and so is more likely to have a prolonged and difficult grieving process. Feelings of “it could have been me” or “this might happen to me or my loved ones,” can result in symptoms of anxiety and survivor guilt. The LGBTQ+ community also is grieving the loss of a safe place and that associated sense of belonging. Loss of safety and feelings of reduced control over one’s life result in a more difficult grieving process, irrespective of the cause of death (Death Stud. 2006;30[5]:403-28). It is as if the loss provides further evidence of life’s injustices and unpredictability, provoking feelings of helplessness and fear.
Being able to make sense or make meaning after a disaster is a key component of developing resilience (J Clin Psychol. 2016 Feb 22. doi: 10.1002/jclp.22270). To make meaning out of a loss, people inevitably will examine their own lives for meaning and purpose. Meaning-making also can result in post-traumatic growth, such as an increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths.
The meaning-making process, often facilitated by psychotherapy, plays a critical role in recovery. Meaning-making takes different forms. For some people, the record-breaking turnout at NYC Pride, in which the owner of Pulse and others rode on a float and received great support, was a significant event. Meanwhile, another person who might be scared might want to see his family, regardless of whether or not the family is fully accepting.
Grief as a social process
Coping with grief is the working out of “the meaning of the loss,” both personally and in community. Grieving is a social process, and eulogies, grief accounts in popular literature, and elegies help construct the identity of the loved one and the meaning of the event. Grieving involves reviewing the relationship to the lost loved one and establishing a sense of continuity between life before and life after the loss (Death Stud. 2014 Jul-Dec; 38[6-10]:485-98).
One challenge for the LGBTQ+ community is how to direct the meaning of the loss. What is the meaning of this loss and how will the dead be remembered? The outpouring of support across the world is heartwarming and reflects how the LGBTQ+ community has become more accepted in the world at large.
The LGBTQ+ community experiences much less stigma than 50 years ago. In 1973, after the firebombing of a club in New Orleans, some relatives reportedly refused to claim the bodies of their gay sons. However, there remains much variation in how communities/societies view LGBTQ+ individuals and relationships.
Cultural considerations of being LGBTQ+
Nonbinary gender identity is recognized in several cultures around the world. The word “Mahu” in Polynesian culture and the concept of being Two-Spirit in some Native American cultures describe those who do not identify as their assigned sex at birth, play out gender roles opposite their assigned sex, or are attracted to same-sex partners, according to biologist Joan Roughgarden, PhD, (“Evolution’s Rainbow: Diversity, Gender and Sexuality in Nature and People” Los Angeles: University of California Press, 2004). In Dr. Roughgarden’s 2010 book, “The Genial Gene” (Los Angeles: University of California Press), she promotes social-selection theory as an alternative to the Darwinian selfish gene theory. She lists 26 phenomena, not explained by current sexual-selection theory, that are better explained by social selection, a population-based explanation of partner selection. Those ideas are beginning to reach a wider audience in mainstream culture, although for many communities and religions, those ideas are seen as “wrong” or “blasphemous.”
For all minority groups, the importance of belonging to a safe, accepting community ranks highly. The pressure for all minority group members to conform to mainstream society is strong and persistent. A good parallel is found when thinking about race and the pressure of dark-skinned individuals to conform to white society. Skin bleaching remains a common practice; some people turn dark skin whiter in order to conform to a societal ideal. Similarly, in order to fit in and avoid discrimination or persecution, many LGBTQ+ individuals work hard to keep their gender conforming face forward. Pulse offered an opportunity for LGBTQ+ individuals and couples to feel like they could be themselves, express themselves, and forget about the societal pressures of conformity. Belonging to a safe community is, therefore, vital to maintaining a sense of self and self-worth.
The acknowledgment of LGBTQ+ status varies by culture. Ninety percent of the Pulse shooting victims reportedly were gay Latino men; a group that expresses its gender identity differently from gay white men. Verbal disclosure benefits gay white men’s well-being but doesn’t affect gay Latino men’s well-being, either positively or negatively. For gay white men, the more they verbally disclose their gay identity to others, the more they feel they are showing their true, feelings of authenticity, research shows). Additionally, LGBTQ+ members may be out in English but not in their Spanish-speaking church, according to Marianne Duddy-Burke, executive director of Dignity/USA, the largest national lay movement of LGBTQ Catholics, their families, and friends. Sadly, many of the Latino families of the Pulse shooting victims are Spanish-speaking only and reportedly had difficulty finding someone to explain what had happened.
Family considerations of being LGBTQ+.
Some families may know privately that they have an LGBTQ member but do not publicly acknowledge the fact. Family members may say things like “being married is maybe not for you, and that’s OK,” or “People should be allowed to be whoever they are.” This communication, while masked, is supportive and illustrates “an understanding” in the family. It may be some time before a family can say “we support our child, regardless” or “I know you are gay, and that’s OK.”
Gender identity can, therefore, be communicated nonverbally and behaviorally. For example, gay Puerto Rican and gay Dominican men in New York City discussed how they disclosed their gender identity by bringing their same-sex partner to family functions without the direct verbalization of a romantic relationship. This strategy, by which gay identity is implied and unspoken, is known as “tacit subjectivity,” or “tacitness.” The authors of this study postulated that for gay Latino men, their relationships in the family and Latino community are more important than the acknowledgment of individual difference and the expression of authenticity.
This perspective is consistent with the importance of community and family identity, a common aspect of non-Western cultures. At the extreme, some communities are very hostile to LGBTQ+ individuals, including in the United States. After sending “thoughts and prayers” to Orlando, the GOP House chair blocked legislation aimed at making sure that federal contractors cannot discriminate based on gender identity or sexual orientation.
Meanwhile, in Pakistani Muslim families, an LGBTQ+ member threatens the marriage prospects of the girls and may place the family in danger of being killed. Yet, 50 top Pakistani clerics recently issued a religious decree, or fatwa, declaring that transgender people have full marriage, inheritance, and funeral rights under Islamic law. The fatwa stated that a female-born transgender person having “visible signs of being a male” may marry a woman or a male-born transgender with “visible signs of being a female,” and vice versa. However, it ruled that a transgender person carrying “visible signs of both genders” – or intersex – may not marry anyone.
Currently in Pakistan, gay marriage is punishable by life imprisonment. The new fatwa also declared that any act intended to “humiliate, insult, or tease” the community was “haraam” (forbidden). The fatwa also states that transgender people should not be deprived of family inheritances, nor the right to be buried in Muslim ceremonies and that parents who deprived their transgender sons or daughters of inheritances were “inviting the wrath of God.”
Complexity of grieving after Pulse
The unique cultural and family aspects of the Pulse shooting makes the process of grieving complex. The cultural aspects of LGBTQ+ identity, both within that community and within Latino culture, bring new variables to the grieving process. Many of the previously held truths about grieving may turn out to be unimportant in this tragedy, and new factors may emerge.
Previously held findings on complex grief include:
• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.
• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.
• Low perceived social support associated with depression after disaster-related bereavement.
• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.
• Finding meaning in the loss is related to lower mental distress and grief after violent losses.
• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.
After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.
An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.
In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).
Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).
DSM-5 diagnosis of persistent complex bereavement disorder
How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).
PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.
Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.
In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.
Summary of proposed PCBD in DSM-5
• Criterion A requires that the individual has experienced the death of a loved one.
• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.
• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.
• Criterion D requires clinically significant distress or functional impairment.
• Criterion E requires that distress or impairment is outside of sociocultural norms.
Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.
Source: Dr. Heru
Thank you to Shiona Heru, JD, for her comments.
References
1. Gender-inclusive version is to use either Latinx (the x symbol represents the absence of o/a) or Latin@ (using the @ symbol mixes the o and @).
2. For more on “The Singular Experience of the Queer Latin Nightclub”: http://www.theatlantic.com/entertainment/archive/2016/06/orlando-shooting-pulse-latin-queer-gay-nightclub-ramon-rivera-servera-intrerview/487442/
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest to disclose. .
We belong in our family, in our group, and in our community. Belonging is a basic human need, and we work throughout our lives to seek or create safe places where we can belong. For the LGBTQ+ community, the Pulse nightclub was one of those rare places where they could feel like they truly belonged. It was a place where they did not need to pretend to be someone else or to keep their guard up against insults or criticism. For survivors of the shooting, the families, and the LGBTQ+ community, that sense of belonging is now fractured.
Pulse reportedly represented every LGBTQ+’s queer bar, where a safe environment is sought – an environment in which to grow and express identity. For the LGBTQ+ community, the June 12 massacre threatened all safe havens – where few currently exist – especially in the night scene, where the increased risk of violence is a constant factor in deciding where to party. There are few gay bars.
What must psychiatrists understand about the impact of the event, besides the regular work of grieving? Some specifics pertinent to this attack must be understood: the preponderance of Latinos1, the youthfulness of most victims, and the impact and reverberations throughout the LGBTQ+ community. This column highlights the unique aspects of this tragedy, and the complexity of the grieving that will take place in these families and communities.
Grief, illness, and resilience: What do we know?
Grieving after sudden and violent deaths, compared with natural deaths, is more likely to be associated with mental health disorders and a slower recovery (Psychiatry. 2012 Spring;75[1]:76-97). Traumatic loss can cause incapacitating grief and a search for meaning that can continue for years, especially in those who identify closely with the victims (J Trauma Stress. 2016 Feb;29[1]41-8).
The LGBTQ+ community identifies strongly with the victims of the Orlando shooting, and so is more likely to have a prolonged and difficult grieving process. Feelings of “it could have been me” or “this might happen to me or my loved ones,” can result in symptoms of anxiety and survivor guilt. The LGBTQ+ community also is grieving the loss of a safe place and that associated sense of belonging. Loss of safety and feelings of reduced control over one’s life result in a more difficult grieving process, irrespective of the cause of death (Death Stud. 2006;30[5]:403-28). It is as if the loss provides further evidence of life’s injustices and unpredictability, provoking feelings of helplessness and fear.
Being able to make sense or make meaning after a disaster is a key component of developing resilience (J Clin Psychol. 2016 Feb 22. doi: 10.1002/jclp.22270). To make meaning out of a loss, people inevitably will examine their own lives for meaning and purpose. Meaning-making also can result in post-traumatic growth, such as an increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths.
The meaning-making process, often facilitated by psychotherapy, plays a critical role in recovery. Meaning-making takes different forms. For some people, the record-breaking turnout at NYC Pride, in which the owner of Pulse and others rode on a float and received great support, was a significant event. Meanwhile, another person who might be scared might want to see his family, regardless of whether or not the family is fully accepting.
Grief as a social process
Coping with grief is the working out of “the meaning of the loss,” both personally and in community. Grieving is a social process, and eulogies, grief accounts in popular literature, and elegies help construct the identity of the loved one and the meaning of the event. Grieving involves reviewing the relationship to the lost loved one and establishing a sense of continuity between life before and life after the loss (Death Stud. 2014 Jul-Dec; 38[6-10]:485-98).
One challenge for the LGBTQ+ community is how to direct the meaning of the loss. What is the meaning of this loss and how will the dead be remembered? The outpouring of support across the world is heartwarming and reflects how the LGBTQ+ community has become more accepted in the world at large.
The LGBTQ+ community experiences much less stigma than 50 years ago. In 1973, after the firebombing of a club in New Orleans, some relatives reportedly refused to claim the bodies of their gay sons. However, there remains much variation in how communities/societies view LGBTQ+ individuals and relationships.
Cultural considerations of being LGBTQ+
Nonbinary gender identity is recognized in several cultures around the world. The word “Mahu” in Polynesian culture and the concept of being Two-Spirit in some Native American cultures describe those who do not identify as their assigned sex at birth, play out gender roles opposite their assigned sex, or are attracted to same-sex partners, according to biologist Joan Roughgarden, PhD, (“Evolution’s Rainbow: Diversity, Gender and Sexuality in Nature and People” Los Angeles: University of California Press, 2004). In Dr. Roughgarden’s 2010 book, “The Genial Gene” (Los Angeles: University of California Press), she promotes social-selection theory as an alternative to the Darwinian selfish gene theory. She lists 26 phenomena, not explained by current sexual-selection theory, that are better explained by social selection, a population-based explanation of partner selection. Those ideas are beginning to reach a wider audience in mainstream culture, although for many communities and religions, those ideas are seen as “wrong” or “blasphemous.”
For all minority groups, the importance of belonging to a safe, accepting community ranks highly. The pressure for all minority group members to conform to mainstream society is strong and persistent. A good parallel is found when thinking about race and the pressure of dark-skinned individuals to conform to white society. Skin bleaching remains a common practice; some people turn dark skin whiter in order to conform to a societal ideal. Similarly, in order to fit in and avoid discrimination or persecution, many LGBTQ+ individuals work hard to keep their gender conforming face forward. Pulse offered an opportunity for LGBTQ+ individuals and couples to feel like they could be themselves, express themselves, and forget about the societal pressures of conformity. Belonging to a safe community is, therefore, vital to maintaining a sense of self and self-worth.
The acknowledgment of LGBTQ+ status varies by culture. Ninety percent of the Pulse shooting victims reportedly were gay Latino men; a group that expresses its gender identity differently from gay white men. Verbal disclosure benefits gay white men’s well-being but doesn’t affect gay Latino men’s well-being, either positively or negatively. For gay white men, the more they verbally disclose their gay identity to others, the more they feel they are showing their true, feelings of authenticity, research shows). Additionally, LGBTQ+ members may be out in English but not in their Spanish-speaking church, according to Marianne Duddy-Burke, executive director of Dignity/USA, the largest national lay movement of LGBTQ Catholics, their families, and friends. Sadly, many of the Latino families of the Pulse shooting victims are Spanish-speaking only and reportedly had difficulty finding someone to explain what had happened.
Family considerations of being LGBTQ+.
Some families may know privately that they have an LGBTQ member but do not publicly acknowledge the fact. Family members may say things like “being married is maybe not for you, and that’s OK,” or “People should be allowed to be whoever they are.” This communication, while masked, is supportive and illustrates “an understanding” in the family. It may be some time before a family can say “we support our child, regardless” or “I know you are gay, and that’s OK.”
Gender identity can, therefore, be communicated nonverbally and behaviorally. For example, gay Puerto Rican and gay Dominican men in New York City discussed how they disclosed their gender identity by bringing their same-sex partner to family functions without the direct verbalization of a romantic relationship. This strategy, by which gay identity is implied and unspoken, is known as “tacit subjectivity,” or “tacitness.” The authors of this study postulated that for gay Latino men, their relationships in the family and Latino community are more important than the acknowledgment of individual difference and the expression of authenticity.
This perspective is consistent with the importance of community and family identity, a common aspect of non-Western cultures. At the extreme, some communities are very hostile to LGBTQ+ individuals, including in the United States. After sending “thoughts and prayers” to Orlando, the GOP House chair blocked legislation aimed at making sure that federal contractors cannot discriminate based on gender identity or sexual orientation.
Meanwhile, in Pakistani Muslim families, an LGBTQ+ member threatens the marriage prospects of the girls and may place the family in danger of being killed. Yet, 50 top Pakistani clerics recently issued a religious decree, or fatwa, declaring that transgender people have full marriage, inheritance, and funeral rights under Islamic law. The fatwa stated that a female-born transgender person having “visible signs of being a male” may marry a woman or a male-born transgender with “visible signs of being a female,” and vice versa. However, it ruled that a transgender person carrying “visible signs of both genders” – or intersex – may not marry anyone.
Currently in Pakistan, gay marriage is punishable by life imprisonment. The new fatwa also declared that any act intended to “humiliate, insult, or tease” the community was “haraam” (forbidden). The fatwa also states that transgender people should not be deprived of family inheritances, nor the right to be buried in Muslim ceremonies and that parents who deprived their transgender sons or daughters of inheritances were “inviting the wrath of God.”
Complexity of grieving after Pulse
The unique cultural and family aspects of the Pulse shooting makes the process of grieving complex. The cultural aspects of LGBTQ+ identity, both within that community and within Latino culture, bring new variables to the grieving process. Many of the previously held truths about grieving may turn out to be unimportant in this tragedy, and new factors may emerge.
Previously held findings on complex grief include:
• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.
• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.
• Low perceived social support associated with depression after disaster-related bereavement.
• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.
• Finding meaning in the loss is related to lower mental distress and grief after violent losses.
• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.
After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.
An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.
In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).
Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).
DSM-5 diagnosis of persistent complex bereavement disorder
How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).
PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.
Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.
In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.
Summary of proposed PCBD in DSM-5
• Criterion A requires that the individual has experienced the death of a loved one.
• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.
• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.
• Criterion D requires clinically significant distress or functional impairment.
• Criterion E requires that distress or impairment is outside of sociocultural norms.
Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.
Source: Dr. Heru
Thank you to Shiona Heru, JD, for her comments.
References
1. Gender-inclusive version is to use either Latinx (the x symbol represents the absence of o/a) or Latin@ (using the @ symbol mixes the o and @).
2. For more on “The Singular Experience of the Queer Latin Nightclub”: http://www.theatlantic.com/entertainment/archive/2016/06/orlando-shooting-pulse-latin-queer-gay-nightclub-ramon-rivera-servera-intrerview/487442/
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest to disclose. .
We belong in our family, in our group, and in our community. Belonging is a basic human need, and we work throughout our lives to seek or create safe places where we can belong. For the LGBTQ+ community, the Pulse nightclub was one of those rare places where they could feel like they truly belonged. It was a place where they did not need to pretend to be someone else or to keep their guard up against insults or criticism. For survivors of the shooting, the families, and the LGBTQ+ community, that sense of belonging is now fractured.
Pulse reportedly represented every LGBTQ+’s queer bar, where a safe environment is sought – an environment in which to grow and express identity. For the LGBTQ+ community, the June 12 massacre threatened all safe havens – where few currently exist – especially in the night scene, where the increased risk of violence is a constant factor in deciding where to party. There are few gay bars.
What must psychiatrists understand about the impact of the event, besides the regular work of grieving? Some specifics pertinent to this attack must be understood: the preponderance of Latinos1, the youthfulness of most victims, and the impact and reverberations throughout the LGBTQ+ community. This column highlights the unique aspects of this tragedy, and the complexity of the grieving that will take place in these families and communities.
Grief, illness, and resilience: What do we know?
Grieving after sudden and violent deaths, compared with natural deaths, is more likely to be associated with mental health disorders and a slower recovery (Psychiatry. 2012 Spring;75[1]:76-97). Traumatic loss can cause incapacitating grief and a search for meaning that can continue for years, especially in those who identify closely with the victims (J Trauma Stress. 2016 Feb;29[1]41-8).
The LGBTQ+ community identifies strongly with the victims of the Orlando shooting, and so is more likely to have a prolonged and difficult grieving process. Feelings of “it could have been me” or “this might happen to me or my loved ones,” can result in symptoms of anxiety and survivor guilt. The LGBTQ+ community also is grieving the loss of a safe place and that associated sense of belonging. Loss of safety and feelings of reduced control over one’s life result in a more difficult grieving process, irrespective of the cause of death (Death Stud. 2006;30[5]:403-28). It is as if the loss provides further evidence of life’s injustices and unpredictability, provoking feelings of helplessness and fear.
Being able to make sense or make meaning after a disaster is a key component of developing resilience (J Clin Psychol. 2016 Feb 22. doi: 10.1002/jclp.22270). To make meaning out of a loss, people inevitably will examine their own lives for meaning and purpose. Meaning-making also can result in post-traumatic growth, such as an increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths.
The meaning-making process, often facilitated by psychotherapy, plays a critical role in recovery. Meaning-making takes different forms. For some people, the record-breaking turnout at NYC Pride, in which the owner of Pulse and others rode on a float and received great support, was a significant event. Meanwhile, another person who might be scared might want to see his family, regardless of whether or not the family is fully accepting.
Grief as a social process
Coping with grief is the working out of “the meaning of the loss,” both personally and in community. Grieving is a social process, and eulogies, grief accounts in popular literature, and elegies help construct the identity of the loved one and the meaning of the event. Grieving involves reviewing the relationship to the lost loved one and establishing a sense of continuity between life before and life after the loss (Death Stud. 2014 Jul-Dec; 38[6-10]:485-98).
One challenge for the LGBTQ+ community is how to direct the meaning of the loss. What is the meaning of this loss and how will the dead be remembered? The outpouring of support across the world is heartwarming and reflects how the LGBTQ+ community has become more accepted in the world at large.
The LGBTQ+ community experiences much less stigma than 50 years ago. In 1973, after the firebombing of a club in New Orleans, some relatives reportedly refused to claim the bodies of their gay sons. However, there remains much variation in how communities/societies view LGBTQ+ individuals and relationships.
Cultural considerations of being LGBTQ+
Nonbinary gender identity is recognized in several cultures around the world. The word “Mahu” in Polynesian culture and the concept of being Two-Spirit in some Native American cultures describe those who do not identify as their assigned sex at birth, play out gender roles opposite their assigned sex, or are attracted to same-sex partners, according to biologist Joan Roughgarden, PhD, (“Evolution’s Rainbow: Diversity, Gender and Sexuality in Nature and People” Los Angeles: University of California Press, 2004). In Dr. Roughgarden’s 2010 book, “The Genial Gene” (Los Angeles: University of California Press), she promotes social-selection theory as an alternative to the Darwinian selfish gene theory. She lists 26 phenomena, not explained by current sexual-selection theory, that are better explained by social selection, a population-based explanation of partner selection. Those ideas are beginning to reach a wider audience in mainstream culture, although for many communities and religions, those ideas are seen as “wrong” or “blasphemous.”
For all minority groups, the importance of belonging to a safe, accepting community ranks highly. The pressure for all minority group members to conform to mainstream society is strong and persistent. A good parallel is found when thinking about race and the pressure of dark-skinned individuals to conform to white society. Skin bleaching remains a common practice; some people turn dark skin whiter in order to conform to a societal ideal. Similarly, in order to fit in and avoid discrimination or persecution, many LGBTQ+ individuals work hard to keep their gender conforming face forward. Pulse offered an opportunity for LGBTQ+ individuals and couples to feel like they could be themselves, express themselves, and forget about the societal pressures of conformity. Belonging to a safe community is, therefore, vital to maintaining a sense of self and self-worth.
The acknowledgment of LGBTQ+ status varies by culture. Ninety percent of the Pulse shooting victims reportedly were gay Latino men; a group that expresses its gender identity differently from gay white men. Verbal disclosure benefits gay white men’s well-being but doesn’t affect gay Latino men’s well-being, either positively or negatively. For gay white men, the more they verbally disclose their gay identity to others, the more they feel they are showing their true, feelings of authenticity, research shows). Additionally, LGBTQ+ members may be out in English but not in their Spanish-speaking church, according to Marianne Duddy-Burke, executive director of Dignity/USA, the largest national lay movement of LGBTQ Catholics, their families, and friends. Sadly, many of the Latino families of the Pulse shooting victims are Spanish-speaking only and reportedly had difficulty finding someone to explain what had happened.
Family considerations of being LGBTQ+.
Some families may know privately that they have an LGBTQ member but do not publicly acknowledge the fact. Family members may say things like “being married is maybe not for you, and that’s OK,” or “People should be allowed to be whoever they are.” This communication, while masked, is supportive and illustrates “an understanding” in the family. It may be some time before a family can say “we support our child, regardless” or “I know you are gay, and that’s OK.”
Gender identity can, therefore, be communicated nonverbally and behaviorally. For example, gay Puerto Rican and gay Dominican men in New York City discussed how they disclosed their gender identity by bringing their same-sex partner to family functions without the direct verbalization of a romantic relationship. This strategy, by which gay identity is implied and unspoken, is known as “tacit subjectivity,” or “tacitness.” The authors of this study postulated that for gay Latino men, their relationships in the family and Latino community are more important than the acknowledgment of individual difference and the expression of authenticity.
This perspective is consistent with the importance of community and family identity, a common aspect of non-Western cultures. At the extreme, some communities are very hostile to LGBTQ+ individuals, including in the United States. After sending “thoughts and prayers” to Orlando, the GOP House chair blocked legislation aimed at making sure that federal contractors cannot discriminate based on gender identity or sexual orientation.
Meanwhile, in Pakistani Muslim families, an LGBTQ+ member threatens the marriage prospects of the girls and may place the family in danger of being killed. Yet, 50 top Pakistani clerics recently issued a religious decree, or fatwa, declaring that transgender people have full marriage, inheritance, and funeral rights under Islamic law. The fatwa stated that a female-born transgender person having “visible signs of being a male” may marry a woman or a male-born transgender with “visible signs of being a female,” and vice versa. However, it ruled that a transgender person carrying “visible signs of both genders” – or intersex – may not marry anyone.
Currently in Pakistan, gay marriage is punishable by life imprisonment. The new fatwa also declared that any act intended to “humiliate, insult, or tease” the community was “haraam” (forbidden). The fatwa also states that transgender people should not be deprived of family inheritances, nor the right to be buried in Muslim ceremonies and that parents who deprived their transgender sons or daughters of inheritances were “inviting the wrath of God.”
Complexity of grieving after Pulse
The unique cultural and family aspects of the Pulse shooting makes the process of grieving complex. The cultural aspects of LGBTQ+ identity, both within that community and within Latino culture, bring new variables to the grieving process. Many of the previously held truths about grieving may turn out to be unimportant in this tragedy, and new factors may emerge.
Previously held findings on complex grief include:
• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.
• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.
• Low perceived social support associated with depression after disaster-related bereavement.
• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.
• Finding meaning in the loss is related to lower mental distress and grief after violent losses.
• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.
After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.
An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.
In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).
Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).
DSM-5 diagnosis of persistent complex bereavement disorder
How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).
PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.
Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.
In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.
Summary of proposed PCBD in DSM-5
• Criterion A requires that the individual has experienced the death of a loved one.
• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.
• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.
• Criterion D requires clinically significant distress or functional impairment.
• Criterion E requires that distress or impairment is outside of sociocultural norms.
Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.
Source: Dr. Heru
Thank you to Shiona Heru, JD, for her comments.
References
1. Gender-inclusive version is to use either Latinx (the x symbol represents the absence of o/a) or Latin@ (using the @ symbol mixes the o and @).
2. For more on “The Singular Experience of the Queer Latin Nightclub”: http://www.theatlantic.com/entertainment/archive/2016/06/orlando-shooting-pulse-latin-queer-gay-nightclub-ramon-rivera-servera-intrerview/487442/
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest to disclose. .
Family psychiatry considers key issues
These are exciting times for family psychiatry. In this column, I would like to sum up some of the key themes from the recent American Psychiatric Association meeting in Atlanta and how family fits in.
The Association of Family Psychiatrists (AFP), which has been in existence for about 40 years as an APA Allied organization, met last month during the APA annual meeting. Dr. Greg Miller is our representative on the Assembly Committee of Representatives of Subspecialties and Sections (ACROSS). This representation gives us an opportunity to ensure that family is considered in APA initiatives.
Who are we?
AFP psychiatrists are chairs of departments, residency directors, medical directors of general and psychiatric hospitals, child psychiatrists, and psychiatrists in private practice. Our members also are residents and allied members, such as psychologists, and directors of family and consumer organizations. One such organization is Families for Depression Awareness (familyaware.org). Its current executive director, Marlin W. Collingwood II and director of development, Valerie Cordero, attended our meeting, and encouraged us to include patient and family advocates in our presentations and activities.
Our meeting was sponsored by the Family Process Institute (FPI), most widely known for its journal, Family Process, the preeminent family therapy journal worldwide. We were pleased that Nadine J. Kaslow, Ph.D., attended. Not only is she a former director of FPI, but also she is the former editor of the Journal of Family Psychology. Dr. Kaslow, professor and vice chair for faculty development in the department of psychiatry and behavioral sciences at Emory University, Atlanta, also is the 2014 president of the American Psychological Association.
What do we do?
We discussed the changes in our specialty, mainly the broadening of family psychiatry to include family inclusion and family psychoeducation, and community involvement of families. We identified many opportunities to include in global health, integrated care in primary care, and specialty care. We announced a new book that I wrote with three other AFP members: Dr. Ira D. Glick; Douglas S. Rait, Ph.D.; and Dr. Michael S. Ascher. The book is called “Couples & Family Therapy in Clinical Practice,” 5th Edition (see www.wiley.com).
Also, at this meeting, we presented the 2016 winners for the Residency Recognition Award for Excellence in Family-Oriented Care:
• Dr. Jessica Abellard, Cooper Medical School of Rowan University, Camden, N.J.
• Dr. Aislinn Bird, Stanford (Calif.) University.
• Dr. Oliver Harper, NYU Langone Medical Center.
• Dr. Randi Libbon, University of Colorado at Denver, Aurora.
• Dr. Richa Maheshwari, NYC Langone Medical Center.
• Dr. Josh Nelson, University of Rochester, New York
• Dr. Mitali Patnaik, Drexel University, Philadelphia.
• Dr. Puneet Sahota, University of Pennsylvania, Philadelphia.
AFP’s presence at the APA
Many members of AFP and other psychiatrists interested in family care presented at the APA.
Dr. Sarah A. Nguyen and her colleagues, Dr. Daniel Patterson, social worker Madeleine S. Abrams, and Dr. Andrea Weiss, from Montefiore Medical Center, New York, presented a poster: “Importance and Utilization of Family Therapy in Training: Resident Perspectives.” Dr. Nguyen and her colleagues noted that only eight residency programs nationwide provide in-depth training in family skills and therapy. Their poster provided a PGY-4 resident perspective on the significance that family therapy training has in understanding the ways in which the context of family and larger systems has an impact on the individual.
An understanding of the resident’s own family, cultural, and social context also serves as the springboard to broaden the individual biopsychosocial conceptualization. This personal development was an essential turning point for continued professional development, as the progression of each year of training allowed for a greater appreciation of the complexity of the individual within the family and larger systems context.
Working with cultural psychiatrists
Several cultural psychiatrists are members of AFP and the Society for the Study of Psychiatry and Culture (SSPC). Psychiatry has evolved from the study of the individual to the study of culture, with minimal discussion of the family that mediates between the individual and the culture. Two APA workshops addressed this gap in theory and practice: “Contextualizing the patient interview” (which I conducted this with Dr. Ellen M. Berman) and “Cultural Family Therapy” (Dr. Vincenzo Di Nicola and Dr. Berman). The theme of SSPC’s 38th annual meeting, which will run from April 27-29, 2017, in Philadelphia, will focus on the role of family in culture (See psychiatryandculture.org) for details.
Dr. Francis G. Lu, presenting at his 32nd consecutive APA, gave the APA Distinguished Psychiatrist Lecture on Cultural Psychiatry. He also held a media session called “The Resilience of Family in Film: Aparajito.” This movie by Indian director Satyajit Ray depicts love, loss, tragedy, and resilience in the family of Apu. Dr. Lu led the audience through a nuanced discussion about the power of film to enhance our understanding of “other” and culture, and its impact on our practice.
“Liminal” or “threshold” people are terms that Dr. Di Nicola uses to describe people at the margins of society. These are people who are most at risk for illness. Immigrants, one type of threshold people, tend to congregate in close family communities. Addressing the family as a unit acknowledges the family’s role as the bearer of culture, and as the bearer and interpreter of illness and health. Dr. Di Nicola states: “I believe that each family is the bearer of the culture within which it is embedded and the vehicle for intergenerational transmission, for maintaining culture, and for generating its own small scale cultural adaptations, yielding three yoked family functions: cultural transmissions, cultural maintenance/coherence, and cultural adaptation” (For details, see http://www.slideshare.net/PhiloShrink/cultural-family-therapy-integrating-family-therapy-with-cultural-psychiatry).
Working in global mental health
Once again, psychiatry is beginning to recognize the importance of the social determinants of health. Severe stress tied to rapid and massive culture change, social trauma that occurs with immigration, and the experience of refugees, war, incarceration, all affect the health of the family and individuals.
Dr. James Griffith, chair of the department of psychiatry at George Washington University, Washington, promotes the inclusion of families in global mental health. Few mental health providers are on the global stage, and so families essentially act as health care extenders. Prior to current hospital practice, families would stay in hospital waiting rooms and sleep by the patient’s bedside. Families took care of patients, feeding and changing them, and assisting the nurses. Families provided reassurance, support and comfort to their sick relatives and acted as their advocates. In China, in American mission-run hospitals, families were indispensable (“Family-Centred Care in American Hospitals in Late-Qing China,” Clio Medica, 2009;86:55). In the 19th century, fear of infectious diseases prompted hospitals to discourage this practice.
Today, in developing countries, families are still indispensable – both for medical and psychiatric care. Families can be educated and welcomed as members of the treatment team.
Understanding the patient’s family system and its relationship to the culture at large is indispensable when developing effective interventions. Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, and set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
Integrating families into health care
Dr. Eliot Sorel, an internationally recognized global health leader, educator, and health systems policy expert, advocates for moving mental health into public health. The fragmentation of the health care system makes it imperative that families understand the challenges of navigating the health care system. APA public health position papers can be amended to include the wording “patient- and family-centered care.” The integration of physical and mental health in the delivery of general health care allows for many opportunities for family involvement. Dr. Atul Gawande, the foremost physician spokesperson for health care reform, focuses on the need for team-based health care reform, from the bedside to population management. Family members are key people on the health care team.
Relational psychiatry and the DSM
Family psychiatry is sometimes referred to as relational psychiatry. The study of relationships range from courting behaviors, attraction, marriage, child rearing, interpersonal violence, and grieving. Attachment theory helps us understand the strong bonds between family members, and the formation of individual and family identity. At a social level, the bonds between the family and society/culture/community are looser but still strong and contribute to a sense of belonging.
There has been a strong push for including relational diagnoses in the DSM. The rationale for inclusion is twofold: to bring attention to relational difficulties and to bring validation to those diagnoses tied to insurance coverage and payment. For a debate with Dr. Marianne Z. Wamboldt about the pros and cons of the inclusion of relational diagnoses in the DSM see “Relational Diagnoses and the DSM,” Clinical Psychiatry News, Families in Psychiatry, Oct. 19, 2012).
Currently as psychiatrists, we bill family meetings and consultations using codes 90846 and 90847. Meeting families occurs as part of the initial assessment of the patient. This interview assesses for strengths and stressors in the family system, and can be billed as part of the initial assessment. With the move to population health care, we will begin to see changes in physician reimbursement and increased recognition of the role of families in contextualizing the patient’s experience.
Families and advocacy
The Mental Health Parity and Addiction Equity Act of 2008, or the Parity Act, requires health insurance carriers to achieve coverage parity between Mental Health/Substance Use Disorders (MH/SUD) and medical/surgical benefits. The MHPAEA originally applied to group health plans and group health insurance coverage, and was amended by the Affordable Care Act to apply also to individual health insurance coverage. The Parity Act was the signature achievement of former Rep. Patrick J. Kennedy’s 16 years in Congress. At the APA, Mr. Kennedy said: “The brain is an organ – a part of the body – and needs to be covered like all other organs.” He encouraged us to continue to advocate for the rights of people with mental illness. In his writing and advocacy work, he frequently references his own family. His is one of the many ways of doing family work.
Looking for allies
AFP has allies in all areas of psychiatry. Family psychiatrists think family in all subspecialties, from child psychiatry, psychosomatic medicine, global health to geriatric psychiatry. Where ever we work, we emphasize the importance of including families in patient care, and educating and supporting families, and when needed, providing family therapy or access to family therapy. Our activities are described on our website, www.familypsychiatrists.org. We welcome any psychiatrists interested in integrating family care into their specialty area. Those interested in joining us should contact our president, Dr. Berman, at [email protected].
Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
As psychiatry continues to evolve and become more evidence-based, let us research how to use the strengths that lie within the family system, acknowledging the support that patients find among their families and communities. As former Rep. Kennedy states: “Our country is a young country, and we are still finding out who we are.” In a similar way, psychiatry is a young medical specialty. Let us become a specialty that truly honors families.
The Family Process Institute offers a writing workshop to emerging writers in family therapy that is open to all residents and early career psychiatrists. See www.familyprocess.org/newwriters for details.
Dr. Heru is professor of psychiatry at the University of Colorado, Denver. She is the author of several books, including “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013).
These are exciting times for family psychiatry. In this column, I would like to sum up some of the key themes from the recent American Psychiatric Association meeting in Atlanta and how family fits in.
The Association of Family Psychiatrists (AFP), which has been in existence for about 40 years as an APA Allied organization, met last month during the APA annual meeting. Dr. Greg Miller is our representative on the Assembly Committee of Representatives of Subspecialties and Sections (ACROSS). This representation gives us an opportunity to ensure that family is considered in APA initiatives.
Who are we?
AFP psychiatrists are chairs of departments, residency directors, medical directors of general and psychiatric hospitals, child psychiatrists, and psychiatrists in private practice. Our members also are residents and allied members, such as psychologists, and directors of family and consumer organizations. One such organization is Families for Depression Awareness (familyaware.org). Its current executive director, Marlin W. Collingwood II and director of development, Valerie Cordero, attended our meeting, and encouraged us to include patient and family advocates in our presentations and activities.
Our meeting was sponsored by the Family Process Institute (FPI), most widely known for its journal, Family Process, the preeminent family therapy journal worldwide. We were pleased that Nadine J. Kaslow, Ph.D., attended. Not only is she a former director of FPI, but also she is the former editor of the Journal of Family Psychology. Dr. Kaslow, professor and vice chair for faculty development in the department of psychiatry and behavioral sciences at Emory University, Atlanta, also is the 2014 president of the American Psychological Association.
What do we do?
We discussed the changes in our specialty, mainly the broadening of family psychiatry to include family inclusion and family psychoeducation, and community involvement of families. We identified many opportunities to include in global health, integrated care in primary care, and specialty care. We announced a new book that I wrote with three other AFP members: Dr. Ira D. Glick; Douglas S. Rait, Ph.D.; and Dr. Michael S. Ascher. The book is called “Couples & Family Therapy in Clinical Practice,” 5th Edition (see www.wiley.com).
Also, at this meeting, we presented the 2016 winners for the Residency Recognition Award for Excellence in Family-Oriented Care:
• Dr. Jessica Abellard, Cooper Medical School of Rowan University, Camden, N.J.
• Dr. Aislinn Bird, Stanford (Calif.) University.
• Dr. Oliver Harper, NYU Langone Medical Center.
• Dr. Randi Libbon, University of Colorado at Denver, Aurora.
• Dr. Richa Maheshwari, NYC Langone Medical Center.
• Dr. Josh Nelson, University of Rochester, New York
• Dr. Mitali Patnaik, Drexel University, Philadelphia.
• Dr. Puneet Sahota, University of Pennsylvania, Philadelphia.
AFP’s presence at the APA
Many members of AFP and other psychiatrists interested in family care presented at the APA.
Dr. Sarah A. Nguyen and her colleagues, Dr. Daniel Patterson, social worker Madeleine S. Abrams, and Dr. Andrea Weiss, from Montefiore Medical Center, New York, presented a poster: “Importance and Utilization of Family Therapy in Training: Resident Perspectives.” Dr. Nguyen and her colleagues noted that only eight residency programs nationwide provide in-depth training in family skills and therapy. Their poster provided a PGY-4 resident perspective on the significance that family therapy training has in understanding the ways in which the context of family and larger systems has an impact on the individual.
An understanding of the resident’s own family, cultural, and social context also serves as the springboard to broaden the individual biopsychosocial conceptualization. This personal development was an essential turning point for continued professional development, as the progression of each year of training allowed for a greater appreciation of the complexity of the individual within the family and larger systems context.
Working with cultural psychiatrists
Several cultural psychiatrists are members of AFP and the Society for the Study of Psychiatry and Culture (SSPC). Psychiatry has evolved from the study of the individual to the study of culture, with minimal discussion of the family that mediates between the individual and the culture. Two APA workshops addressed this gap in theory and practice: “Contextualizing the patient interview” (which I conducted this with Dr. Ellen M. Berman) and “Cultural Family Therapy” (Dr. Vincenzo Di Nicola and Dr. Berman). The theme of SSPC’s 38th annual meeting, which will run from April 27-29, 2017, in Philadelphia, will focus on the role of family in culture (See psychiatryandculture.org) for details.
Dr. Francis G. Lu, presenting at his 32nd consecutive APA, gave the APA Distinguished Psychiatrist Lecture on Cultural Psychiatry. He also held a media session called “The Resilience of Family in Film: Aparajito.” This movie by Indian director Satyajit Ray depicts love, loss, tragedy, and resilience in the family of Apu. Dr. Lu led the audience through a nuanced discussion about the power of film to enhance our understanding of “other” and culture, and its impact on our practice.
“Liminal” or “threshold” people are terms that Dr. Di Nicola uses to describe people at the margins of society. These are people who are most at risk for illness. Immigrants, one type of threshold people, tend to congregate in close family communities. Addressing the family as a unit acknowledges the family’s role as the bearer of culture, and as the bearer and interpreter of illness and health. Dr. Di Nicola states: “I believe that each family is the bearer of the culture within which it is embedded and the vehicle for intergenerational transmission, for maintaining culture, and for generating its own small scale cultural adaptations, yielding three yoked family functions: cultural transmissions, cultural maintenance/coherence, and cultural adaptation” (For details, see http://www.slideshare.net/PhiloShrink/cultural-family-therapy-integrating-family-therapy-with-cultural-psychiatry).
Working in global mental health
Once again, psychiatry is beginning to recognize the importance of the social determinants of health. Severe stress tied to rapid and massive culture change, social trauma that occurs with immigration, and the experience of refugees, war, incarceration, all affect the health of the family and individuals.
Dr. James Griffith, chair of the department of psychiatry at George Washington University, Washington, promotes the inclusion of families in global mental health. Few mental health providers are on the global stage, and so families essentially act as health care extenders. Prior to current hospital practice, families would stay in hospital waiting rooms and sleep by the patient’s bedside. Families took care of patients, feeding and changing them, and assisting the nurses. Families provided reassurance, support and comfort to their sick relatives and acted as their advocates. In China, in American mission-run hospitals, families were indispensable (“Family-Centred Care in American Hospitals in Late-Qing China,” Clio Medica, 2009;86:55). In the 19th century, fear of infectious diseases prompted hospitals to discourage this practice.
Today, in developing countries, families are still indispensable – both for medical and psychiatric care. Families can be educated and welcomed as members of the treatment team.
Understanding the patient’s family system and its relationship to the culture at large is indispensable when developing effective interventions. Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, and set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
Integrating families into health care
Dr. Eliot Sorel, an internationally recognized global health leader, educator, and health systems policy expert, advocates for moving mental health into public health. The fragmentation of the health care system makes it imperative that families understand the challenges of navigating the health care system. APA public health position papers can be amended to include the wording “patient- and family-centered care.” The integration of physical and mental health in the delivery of general health care allows for many opportunities for family involvement. Dr. Atul Gawande, the foremost physician spokesperson for health care reform, focuses on the need for team-based health care reform, from the bedside to population management. Family members are key people on the health care team.
Relational psychiatry and the DSM
Family psychiatry is sometimes referred to as relational psychiatry. The study of relationships range from courting behaviors, attraction, marriage, child rearing, interpersonal violence, and grieving. Attachment theory helps us understand the strong bonds between family members, and the formation of individual and family identity. At a social level, the bonds between the family and society/culture/community are looser but still strong and contribute to a sense of belonging.
There has been a strong push for including relational diagnoses in the DSM. The rationale for inclusion is twofold: to bring attention to relational difficulties and to bring validation to those diagnoses tied to insurance coverage and payment. For a debate with Dr. Marianne Z. Wamboldt about the pros and cons of the inclusion of relational diagnoses in the DSM see “Relational Diagnoses and the DSM,” Clinical Psychiatry News, Families in Psychiatry, Oct. 19, 2012).
Currently as psychiatrists, we bill family meetings and consultations using codes 90846 and 90847. Meeting families occurs as part of the initial assessment of the patient. This interview assesses for strengths and stressors in the family system, and can be billed as part of the initial assessment. With the move to population health care, we will begin to see changes in physician reimbursement and increased recognition of the role of families in contextualizing the patient’s experience.
Families and advocacy
The Mental Health Parity and Addiction Equity Act of 2008, or the Parity Act, requires health insurance carriers to achieve coverage parity between Mental Health/Substance Use Disorders (MH/SUD) and medical/surgical benefits. The MHPAEA originally applied to group health plans and group health insurance coverage, and was amended by the Affordable Care Act to apply also to individual health insurance coverage. The Parity Act was the signature achievement of former Rep. Patrick J. Kennedy’s 16 years in Congress. At the APA, Mr. Kennedy said: “The brain is an organ – a part of the body – and needs to be covered like all other organs.” He encouraged us to continue to advocate for the rights of people with mental illness. In his writing and advocacy work, he frequently references his own family. His is one of the many ways of doing family work.
Looking for allies
AFP has allies in all areas of psychiatry. Family psychiatrists think family in all subspecialties, from child psychiatry, psychosomatic medicine, global health to geriatric psychiatry. Where ever we work, we emphasize the importance of including families in patient care, and educating and supporting families, and when needed, providing family therapy or access to family therapy. Our activities are described on our website, www.familypsychiatrists.org. We welcome any psychiatrists interested in integrating family care into their specialty area. Those interested in joining us should contact our president, Dr. Berman, at [email protected].
Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
As psychiatry continues to evolve and become more evidence-based, let us research how to use the strengths that lie within the family system, acknowledging the support that patients find among their families and communities. As former Rep. Kennedy states: “Our country is a young country, and we are still finding out who we are.” In a similar way, psychiatry is a young medical specialty. Let us become a specialty that truly honors families.
The Family Process Institute offers a writing workshop to emerging writers in family therapy that is open to all residents and early career psychiatrists. See www.familyprocess.org/newwriters for details.
Dr. Heru is professor of psychiatry at the University of Colorado, Denver. She is the author of several books, including “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013).
These are exciting times for family psychiatry. In this column, I would like to sum up some of the key themes from the recent American Psychiatric Association meeting in Atlanta and how family fits in.
The Association of Family Psychiatrists (AFP), which has been in existence for about 40 years as an APA Allied organization, met last month during the APA annual meeting. Dr. Greg Miller is our representative on the Assembly Committee of Representatives of Subspecialties and Sections (ACROSS). This representation gives us an opportunity to ensure that family is considered in APA initiatives.
Who are we?
AFP psychiatrists are chairs of departments, residency directors, medical directors of general and psychiatric hospitals, child psychiatrists, and psychiatrists in private practice. Our members also are residents and allied members, such as psychologists, and directors of family and consumer organizations. One such organization is Families for Depression Awareness (familyaware.org). Its current executive director, Marlin W. Collingwood II and director of development, Valerie Cordero, attended our meeting, and encouraged us to include patient and family advocates in our presentations and activities.
Our meeting was sponsored by the Family Process Institute (FPI), most widely known for its journal, Family Process, the preeminent family therapy journal worldwide. We were pleased that Nadine J. Kaslow, Ph.D., attended. Not only is she a former director of FPI, but also she is the former editor of the Journal of Family Psychology. Dr. Kaslow, professor and vice chair for faculty development in the department of psychiatry and behavioral sciences at Emory University, Atlanta, also is the 2014 president of the American Psychological Association.
What do we do?
We discussed the changes in our specialty, mainly the broadening of family psychiatry to include family inclusion and family psychoeducation, and community involvement of families. We identified many opportunities to include in global health, integrated care in primary care, and specialty care. We announced a new book that I wrote with three other AFP members: Dr. Ira D. Glick; Douglas S. Rait, Ph.D.; and Dr. Michael S. Ascher. The book is called “Couples & Family Therapy in Clinical Practice,” 5th Edition (see www.wiley.com).
Also, at this meeting, we presented the 2016 winners for the Residency Recognition Award for Excellence in Family-Oriented Care:
• Dr. Jessica Abellard, Cooper Medical School of Rowan University, Camden, N.J.
• Dr. Aislinn Bird, Stanford (Calif.) University.
• Dr. Oliver Harper, NYU Langone Medical Center.
• Dr. Randi Libbon, University of Colorado at Denver, Aurora.
• Dr. Richa Maheshwari, NYC Langone Medical Center.
• Dr. Josh Nelson, University of Rochester, New York
• Dr. Mitali Patnaik, Drexel University, Philadelphia.
• Dr. Puneet Sahota, University of Pennsylvania, Philadelphia.
AFP’s presence at the APA
Many members of AFP and other psychiatrists interested in family care presented at the APA.
Dr. Sarah A. Nguyen and her colleagues, Dr. Daniel Patterson, social worker Madeleine S. Abrams, and Dr. Andrea Weiss, from Montefiore Medical Center, New York, presented a poster: “Importance and Utilization of Family Therapy in Training: Resident Perspectives.” Dr. Nguyen and her colleagues noted that only eight residency programs nationwide provide in-depth training in family skills and therapy. Their poster provided a PGY-4 resident perspective on the significance that family therapy training has in understanding the ways in which the context of family and larger systems has an impact on the individual.
An understanding of the resident’s own family, cultural, and social context also serves as the springboard to broaden the individual biopsychosocial conceptualization. This personal development was an essential turning point for continued professional development, as the progression of each year of training allowed for a greater appreciation of the complexity of the individual within the family and larger systems context.
Working with cultural psychiatrists
Several cultural psychiatrists are members of AFP and the Society for the Study of Psychiatry and Culture (SSPC). Psychiatry has evolved from the study of the individual to the study of culture, with minimal discussion of the family that mediates between the individual and the culture. Two APA workshops addressed this gap in theory and practice: “Contextualizing the patient interview” (which I conducted this with Dr. Ellen M. Berman) and “Cultural Family Therapy” (Dr. Vincenzo Di Nicola and Dr. Berman). The theme of SSPC’s 38th annual meeting, which will run from April 27-29, 2017, in Philadelphia, will focus on the role of family in culture (See psychiatryandculture.org) for details.
Dr. Francis G. Lu, presenting at his 32nd consecutive APA, gave the APA Distinguished Psychiatrist Lecture on Cultural Psychiatry. He also held a media session called “The Resilience of Family in Film: Aparajito.” This movie by Indian director Satyajit Ray depicts love, loss, tragedy, and resilience in the family of Apu. Dr. Lu led the audience through a nuanced discussion about the power of film to enhance our understanding of “other” and culture, and its impact on our practice.
“Liminal” or “threshold” people are terms that Dr. Di Nicola uses to describe people at the margins of society. These are people who are most at risk for illness. Immigrants, one type of threshold people, tend to congregate in close family communities. Addressing the family as a unit acknowledges the family’s role as the bearer of culture, and as the bearer and interpreter of illness and health. Dr. Di Nicola states: “I believe that each family is the bearer of the culture within which it is embedded and the vehicle for intergenerational transmission, for maintaining culture, and for generating its own small scale cultural adaptations, yielding three yoked family functions: cultural transmissions, cultural maintenance/coherence, and cultural adaptation” (For details, see http://www.slideshare.net/PhiloShrink/cultural-family-therapy-integrating-family-therapy-with-cultural-psychiatry).
Working in global mental health
Once again, psychiatry is beginning to recognize the importance of the social determinants of health. Severe stress tied to rapid and massive culture change, social trauma that occurs with immigration, and the experience of refugees, war, incarceration, all affect the health of the family and individuals.
Dr. James Griffith, chair of the department of psychiatry at George Washington University, Washington, promotes the inclusion of families in global mental health. Few mental health providers are on the global stage, and so families essentially act as health care extenders. Prior to current hospital practice, families would stay in hospital waiting rooms and sleep by the patient’s bedside. Families took care of patients, feeding and changing them, and assisting the nurses. Families provided reassurance, support and comfort to their sick relatives and acted as their advocates. In China, in American mission-run hospitals, families were indispensable (“Family-Centred Care in American Hospitals in Late-Qing China,” Clio Medica, 2009;86:55). In the 19th century, fear of infectious diseases prompted hospitals to discourage this practice.
Today, in developing countries, families are still indispensable – both for medical and psychiatric care. Families can be educated and welcomed as members of the treatment team.
Understanding the patient’s family system and its relationship to the culture at large is indispensable when developing effective interventions. Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, and set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
Integrating families into health care
Dr. Eliot Sorel, an internationally recognized global health leader, educator, and health systems policy expert, advocates for moving mental health into public health. The fragmentation of the health care system makes it imperative that families understand the challenges of navigating the health care system. APA public health position papers can be amended to include the wording “patient- and family-centered care.” The integration of physical and mental health in the delivery of general health care allows for many opportunities for family involvement. Dr. Atul Gawande, the foremost physician spokesperson for health care reform, focuses on the need for team-based health care reform, from the bedside to population management. Family members are key people on the health care team.
Relational psychiatry and the DSM
Family psychiatry is sometimes referred to as relational psychiatry. The study of relationships range from courting behaviors, attraction, marriage, child rearing, interpersonal violence, and grieving. Attachment theory helps us understand the strong bonds between family members, and the formation of individual and family identity. At a social level, the bonds between the family and society/culture/community are looser but still strong and contribute to a sense of belonging.
There has been a strong push for including relational diagnoses in the DSM. The rationale for inclusion is twofold: to bring attention to relational difficulties and to bring validation to those diagnoses tied to insurance coverage and payment. For a debate with Dr. Marianne Z. Wamboldt about the pros and cons of the inclusion of relational diagnoses in the DSM see “Relational Diagnoses and the DSM,” Clinical Psychiatry News, Families in Psychiatry, Oct. 19, 2012).
Currently as psychiatrists, we bill family meetings and consultations using codes 90846 and 90847. Meeting families occurs as part of the initial assessment of the patient. This interview assesses for strengths and stressors in the family system, and can be billed as part of the initial assessment. With the move to population health care, we will begin to see changes in physician reimbursement and increased recognition of the role of families in contextualizing the patient’s experience.
Families and advocacy
The Mental Health Parity and Addiction Equity Act of 2008, or the Parity Act, requires health insurance carriers to achieve coverage parity between Mental Health/Substance Use Disorders (MH/SUD) and medical/surgical benefits. The MHPAEA originally applied to group health plans and group health insurance coverage, and was amended by the Affordable Care Act to apply also to individual health insurance coverage. The Parity Act was the signature achievement of former Rep. Patrick J. Kennedy’s 16 years in Congress. At the APA, Mr. Kennedy said: “The brain is an organ – a part of the body – and needs to be covered like all other organs.” He encouraged us to continue to advocate for the rights of people with mental illness. In his writing and advocacy work, he frequently references his own family. His is one of the many ways of doing family work.
Looking for allies
AFP has allies in all areas of psychiatry. Family psychiatrists think family in all subspecialties, from child psychiatry, psychosomatic medicine, global health to geriatric psychiatry. Where ever we work, we emphasize the importance of including families in patient care, and educating and supporting families, and when needed, providing family therapy or access to family therapy. Our activities are described on our website, www.familypsychiatrists.org. We welcome any psychiatrists interested in integrating family care into their specialty area. Those interested in joining us should contact our president, Dr. Berman, at [email protected].
Providers who can initiate discussions with families about the stigma of mental illness, etiology, and relapse prevention, set the stage for better patient outcomes. Families with cell phones can be given access to Internet educational and patient care programs.
As psychiatry continues to evolve and become more evidence-based, let us research how to use the strengths that lie within the family system, acknowledging the support that patients find among their families and communities. As former Rep. Kennedy states: “Our country is a young country, and we are still finding out who we are.” In a similar way, psychiatry is a young medical specialty. Let us become a specialty that truly honors families.
The Family Process Institute offers a writing workshop to emerging writers in family therapy that is open to all residents and early career psychiatrists. See www.familyprocess.org/newwriters for details.
Dr. Heru is professor of psychiatry at the University of Colorado, Denver. She is the author of several books, including “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013).
Psychiatry can promote growth amid chronic illness
Promoting resilience, benefit finding, and post-traumatic growth help patients and families cope well with chronic illness. A resilient family has good problem-solving skills and communication, and a shared belief system (Fam Process. 2003; 42:1-18). Benefit finding coexists with feelings of burden, grief, and loss, and post-traumatic growth can occur despite grief and loss. Convening family meetings, for example, is a way to provide a therapeutic space for families and an opportunity to reflect on ways that chronic illness has affected the family, both negatively and positively.
What is coping well?
Resilient families cope well by identifying and solving illness-related problems, communicating about symptoms, negotiating role changes, and developing new interests as a family and new ways of emotionally being together. In addition, resilient families are able to adapt or change their life goals or health behaviors, such as improving diet, increasing exercise, and stopping smoking. A family member may work fewer hours, for example, and older children may give up some childhood activities to take on caregiving responsibilities.
Families do not usually think about how they cope; they just get along the best they can. Families may not consider how each family member’s individual coping style meshes with the coping styles of other family members. Illness management often is punctuated by crises where change happens quickly, without the family having time to deliberate on what coping styles might work best. Family changes can become fixed, therefore, not by choice, but by happenstance.
The initial stage of coping is “assimilative.” This is when the impact of the illness is being understood and absorbed. Emotional coping occurs when distress is highest, for example, at the beginning of an illness – when uncertainty exists about the diagnosis. Another characteristic of emotional coping is that it is characterized by attempts to regulate negative emotions. For example, family members may blame themselves or others, engage in wishful thinking, or become avoidant.
At later stages of illness, coping becomes “accommodative” after attempts to change or cure the illness have been found to be ineffective. Emotional coping can then be replaced with a problem-based coping style, allowing a stressor to be discussed and a solution chosen from several alternatives. Reflective coping, a related concept, is the ability to generate and consider coping options, and to recognize the usefulness of a particular coping strategy in a particular situation.
Psychiatric imperatives
While providing psychotherapy with these couples, it is helpful to:
• Help families differentiate between emotional difficulties such as “I am the primary caregiver, and I feel overburdened,” and more general practical problems, such as “I am happy to be the primary caregiver, but I need some extra help.”
• Describe coping to the family. Coping is a dynamic process, and coping styles change over time. Each person copes in their own way, depending on their experiences of illness and expectations of living with illness. In a family, the experiences and behaviors of all the individuals influence the way the family unit functions as a whole.
• Promote a balance between acceptance and change.
• Encourage the family to talk about their experience with others who are experiencing the same stressors.
• Give the family a handout that outlines different coping styles to get the discussion started.
• Provide a therapeutic space for family members to think together about how they want to cope and what coping well means to their family.
Developing dyadic coping
When dyadic coping takes place, couples cope as a single entity. Dyadic coping research is relatively new; most studies have been conducted in the past 15 years. Couples who use positive dyadic coping employ joint problem solving, joint information seeking, sharing of feelings, mutual commitment, and relaxing together. Meanwhile, couples who use negative dyadic coping hide concerns from each other and avoid shared discussion. A systemic review of dyadic coping in couples with cancer found that couples using positive dyadic coping styles experienced higher relationship functioning (Br J Health Psychol. 2015 Feb;20[1]:85-114).
Couples with good dyadic coping view the illness as “our problem.” This approach necessitates a shared understanding of the illness. The couple usually has prior experience working together as a team, for example, parenting and dividing roles within the house. They are able to relax together and provide emotional support, such as mutual calming and expressions of solidarity. Talking together about one’s worries and needs allows couples to share the experience more adequately. Dyadic coping is reflected in the amount of “we” talk.
The person in the family who copes “best” may provide the model for developing the family coping style. In a study of 66 couples faced with the stress of forced relocation, nearly all the couples adapted to the stress “as a couple,” rather than “as individuals” (Fam Process. 1991 Sep;30[3]:347-61). At the 2-year follow-up, each husband and wife developed similar coping styles, with one individual’s coping ability driving the adjustment of his or her partner. The need to adjust together or to adapt as a couple lessened the stress of relocation. Adaptation occurred through the development of shared meaning of the relocation that emerged from conversation within the couples. In other words, the couple developed a shared worldview. The coping style of the person who coped best was the strongest predictor of adjustment for both members of the couple. For most couples, the style of the person who coped best dominated.
Questions to ask during therapy
While working with these couples, assess their motivation to develop dyadic coping, by asking:
• “Do either of you feel that the patient should do this alone?” If the answer is yes, it will be difficult, if not impossible, to move the couple to a dyadic coping style.
• “Do your efforts to work together result in greater conflict?”
• “How much do you want this to change?” This questions clarifies their motivation to work together.
• “When you think about problems related to your heart condition, to what extent do you view those as ‘our problem’ [shared by the patient and the spouse equally] or mainly as ‘your own problem?’ ”
• “When a problem related to your heart condition arises, to what extent do you and your partner work together to solve it?”
• “When you both talk about the illness, how much do you use ‘we-talk’?”
• “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?”
• “How do you respond when your spouse becomes 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?”
‘Benefit finding’ and PTG
Benefit finding emerges later in the adjustment to chronic illness. For example, caregivers may develop a greater appreciation of their own health and ability to enjoy their own pursuits. Family connectedness is a frequent source of meaning, and a critical aspect of well-being and benefit finding. Seven factors make up benefit finding: compassion/empathy, spiritual growth, mindfulness, family relations growth, lifestyle gains, personal growth, and new opportunities (Psychol Health. 2009 Apr;24[4]:373-93). Benefit finding is associated with higher marital adjustment, improved life satisfaction, and a more positive affect, especially at high levels of stress.
Post-traumatic growth, or PTG, refers to positive changes that occur after traumatic life events. People who experience PTG are transformed by their struggles with adversity. It is the struggle after the trauma, not the trauma itself, that produces PTG. In contrast to resilience, PTG refers to changes that go beyond pretrauma levels of adaptation and beyond benefit finding. Relational benefits in the aftermath of a cancer diagnosis are well recognized. An instrument used to assess these outcomes is called the Post-traumatic Growth Inventory, or PTGI (J Trauma Stress. 1996 Jul;9:455-71).
Interventions for couples coping with cancer resulted in improvements in communication, dyadic coping, quality of life, psychosocial distress, sexual functioning, and marital satisfaction (Psychooncology. 2014 Apr;23[7]:731-9). PTG may, however, be more apparent in patients than spouses.
Potential interventions
Promoting dyadic coping is effective if the couple wants to engage in intervention. According to one study, a partner-assisted emotional disclosure improved relationship functioning and intimacy (J Marital Fam Ther. 2012 Jun;38 Suppl 1:284-95). Couples therapy improves relational functioning in couples coping with cancer, at 1-year follow-up (Psychooncology. 2009 Mar;18[3]:276-83). Most important, as a first step, the couple must agree that they want to develop dyadic coping. The concept of individual versus dyadic coping may be novel for couples, and it is worth spending time on this review before offering couples intervention.
A psychoeducational program also can teach dyadic coping. The Resilient Partners discussion group developed in collaboration with the Multiple Sclerosis Society focused on developing couples’ strengths in coping with multiple sclerosis (Rolland, J., McPheters, J., and Carbonell, E., 2008). This multifamily group program is based on the Family Systems Illness Model, which integrates the demands of multiple sclerosis over time within a family developmental framework. In a comparison of a couple skills intervention with a psychoeducation program, women in the couple skills intervention benefited more in terms of their relationship functioning (Ann Behav Med. 2012 Apr;43[2]:239-52).
Dr. John S. Rolland’s Family Systems Illness (FSI) model provides a framework for the psychoeducation, assessment, and intervention with families dealing with chronic illness. This model, developed in clinical experience with more than 1,000 families, views families as valued partners and resources, and emphasizes resilience and growth. The FSI model takes into account the interaction of an illness with the individual’s development and the family’s development, the multigenerational ways of coping with illness, the family’s health/illness belief system, available resources, and relationships between health care providers.
The PTGI includes five domains: improved relationships, new possibilities for one’s life, a greater appreciation for life, a greater sense of personal strength, and spiritual development. Several family oriented themes within the PTGI can be used by the psychiatrist to inquire about positive change. These themes are:
• Knowing that I can count on people in times of trouble.
• A sense of closeness with others.
• Having compassion for others.
• Putting effort into my relationships.
• I learned a great deal about how wonderful people are.
• I accept needing others.
To promote PTG, the psychiatrists can listen for accounts of the experience of growth, label the experience, decide when the patient is ready for more focused questioning, and recognize that a life narrative including the aftermath of a trauma has value. In order to get the patient to recognize PTG, the psychiatrist can state and ask: “You may have heard people say that they have found some benefit in their struggle with trauma. Given what has happened to you, do you think that is possible?” Another exchange might flow like this: “You mentioned last time that you noticed that you and your wife have grown closer since this happened. Can you tell me more about this closeness. What is it about this struggle that has produced this closeness?”
Conclusion
Strengths, resilience, and post-traumatic growth are distinct constructs that share conceptual overlap. Using these constructs, the psychiatrist can help the patients and their families move forward. At the time of diagnosis/trauma/bereavement, family and couple interventions provide support, education, and symptom management. Specific psychoeducational interventions or family therapy can be used if needed. As the illness progresses and the family moves from an assimilative stance to an accommodative stance, and as problem-solving moves from emotional problem solving to reflective problem solving, the possibility of benefit finding and PTG emerge. Most importantly, the psychiatrist can provide the family with a therapeutic space to consider their coping styles, and offer the family a path forward through discussion of dyadic coping and family growth.
Further reading
1. Tedeschi and Kilmer, “Assessing Strengths, Resilience, and Growth to Guide Clinical Interventions,” Professional Psychology: Research and Practice. 2005;36(3), p. 230-7.
2. Heru A.M., “Working With Families in Medical Settings,” (New York: Routledge), 2013.
3. Rolland J.S. “Families, Illness, & Disability: An Integrative Treatment Model,” (New York: Basic Books), 1994. New edition in press.
Thank you to Dr. Jennifer Caspari for assisting with resources for this article.
Dr. Heru is with the department of psychiatry at the University of Denver, Aurora. She has no conflicts of interest to disclose.
Promoting resilience, benefit finding, and post-traumatic growth help patients and families cope well with chronic illness. A resilient family has good problem-solving skills and communication, and a shared belief system (Fam Process. 2003; 42:1-18). Benefit finding coexists with feelings of burden, grief, and loss, and post-traumatic growth can occur despite grief and loss. Convening family meetings, for example, is a way to provide a therapeutic space for families and an opportunity to reflect on ways that chronic illness has affected the family, both negatively and positively.
What is coping well?
Resilient families cope well by identifying and solving illness-related problems, communicating about symptoms, negotiating role changes, and developing new interests as a family and new ways of emotionally being together. In addition, resilient families are able to adapt or change their life goals or health behaviors, such as improving diet, increasing exercise, and stopping smoking. A family member may work fewer hours, for example, and older children may give up some childhood activities to take on caregiving responsibilities.
Families do not usually think about how they cope; they just get along the best they can. Families may not consider how each family member’s individual coping style meshes with the coping styles of other family members. Illness management often is punctuated by crises where change happens quickly, without the family having time to deliberate on what coping styles might work best. Family changes can become fixed, therefore, not by choice, but by happenstance.
The initial stage of coping is “assimilative.” This is when the impact of the illness is being understood and absorbed. Emotional coping occurs when distress is highest, for example, at the beginning of an illness – when uncertainty exists about the diagnosis. Another characteristic of emotional coping is that it is characterized by attempts to regulate negative emotions. For example, family members may blame themselves or others, engage in wishful thinking, or become avoidant.
At later stages of illness, coping becomes “accommodative” after attempts to change or cure the illness have been found to be ineffective. Emotional coping can then be replaced with a problem-based coping style, allowing a stressor to be discussed and a solution chosen from several alternatives. Reflective coping, a related concept, is the ability to generate and consider coping options, and to recognize the usefulness of a particular coping strategy in a particular situation.
Psychiatric imperatives
While providing psychotherapy with these couples, it is helpful to:
• Help families differentiate between emotional difficulties such as “I am the primary caregiver, and I feel overburdened,” and more general practical problems, such as “I am happy to be the primary caregiver, but I need some extra help.”
• Describe coping to the family. Coping is a dynamic process, and coping styles change over time. Each person copes in their own way, depending on their experiences of illness and expectations of living with illness. In a family, the experiences and behaviors of all the individuals influence the way the family unit functions as a whole.
• Promote a balance between acceptance and change.
• Encourage the family to talk about their experience with others who are experiencing the same stressors.
• Give the family a handout that outlines different coping styles to get the discussion started.
• Provide a therapeutic space for family members to think together about how they want to cope and what coping well means to their family.
Developing dyadic coping
When dyadic coping takes place, couples cope as a single entity. Dyadic coping research is relatively new; most studies have been conducted in the past 15 years. Couples who use positive dyadic coping employ joint problem solving, joint information seeking, sharing of feelings, mutual commitment, and relaxing together. Meanwhile, couples who use negative dyadic coping hide concerns from each other and avoid shared discussion. A systemic review of dyadic coping in couples with cancer found that couples using positive dyadic coping styles experienced higher relationship functioning (Br J Health Psychol. 2015 Feb;20[1]:85-114).
Couples with good dyadic coping view the illness as “our problem.” This approach necessitates a shared understanding of the illness. The couple usually has prior experience working together as a team, for example, parenting and dividing roles within the house. They are able to relax together and provide emotional support, such as mutual calming and expressions of solidarity. Talking together about one’s worries and needs allows couples to share the experience more adequately. Dyadic coping is reflected in the amount of “we” talk.
The person in the family who copes “best” may provide the model for developing the family coping style. In a study of 66 couples faced with the stress of forced relocation, nearly all the couples adapted to the stress “as a couple,” rather than “as individuals” (Fam Process. 1991 Sep;30[3]:347-61). At the 2-year follow-up, each husband and wife developed similar coping styles, with one individual’s coping ability driving the adjustment of his or her partner. The need to adjust together or to adapt as a couple lessened the stress of relocation. Adaptation occurred through the development of shared meaning of the relocation that emerged from conversation within the couples. In other words, the couple developed a shared worldview. The coping style of the person who coped best was the strongest predictor of adjustment for both members of the couple. For most couples, the style of the person who coped best dominated.
Questions to ask during therapy
While working with these couples, assess their motivation to develop dyadic coping, by asking:
• “Do either of you feel that the patient should do this alone?” If the answer is yes, it will be difficult, if not impossible, to move the couple to a dyadic coping style.
• “Do your efforts to work together result in greater conflict?”
• “How much do you want this to change?” This questions clarifies their motivation to work together.
• “When you think about problems related to your heart condition, to what extent do you view those as ‘our problem’ [shared by the patient and the spouse equally] or mainly as ‘your own problem?’ ”
• “When a problem related to your heart condition arises, to what extent do you and your partner work together to solve it?”
• “When you both talk about the illness, how much do you use ‘we-talk’?”
• “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?”
• “How do you respond when your spouse becomes 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?”
‘Benefit finding’ and PTG
Benefit finding emerges later in the adjustment to chronic illness. For example, caregivers may develop a greater appreciation of their own health and ability to enjoy their own pursuits. Family connectedness is a frequent source of meaning, and a critical aspect of well-being and benefit finding. Seven factors make up benefit finding: compassion/empathy, spiritual growth, mindfulness, family relations growth, lifestyle gains, personal growth, and new opportunities (Psychol Health. 2009 Apr;24[4]:373-93). Benefit finding is associated with higher marital adjustment, improved life satisfaction, and a more positive affect, especially at high levels of stress.
Post-traumatic growth, or PTG, refers to positive changes that occur after traumatic life events. People who experience PTG are transformed by their struggles with adversity. It is the struggle after the trauma, not the trauma itself, that produces PTG. In contrast to resilience, PTG refers to changes that go beyond pretrauma levels of adaptation and beyond benefit finding. Relational benefits in the aftermath of a cancer diagnosis are well recognized. An instrument used to assess these outcomes is called the Post-traumatic Growth Inventory, or PTGI (J Trauma Stress. 1996 Jul;9:455-71).
Interventions for couples coping with cancer resulted in improvements in communication, dyadic coping, quality of life, psychosocial distress, sexual functioning, and marital satisfaction (Psychooncology. 2014 Apr;23[7]:731-9). PTG may, however, be more apparent in patients than spouses.
Potential interventions
Promoting dyadic coping is effective if the couple wants to engage in intervention. According to one study, a partner-assisted emotional disclosure improved relationship functioning and intimacy (J Marital Fam Ther. 2012 Jun;38 Suppl 1:284-95). Couples therapy improves relational functioning in couples coping with cancer, at 1-year follow-up (Psychooncology. 2009 Mar;18[3]:276-83). Most important, as a first step, the couple must agree that they want to develop dyadic coping. The concept of individual versus dyadic coping may be novel for couples, and it is worth spending time on this review before offering couples intervention.
A psychoeducational program also can teach dyadic coping. The Resilient Partners discussion group developed in collaboration with the Multiple Sclerosis Society focused on developing couples’ strengths in coping with multiple sclerosis (Rolland, J., McPheters, J., and Carbonell, E., 2008). This multifamily group program is based on the Family Systems Illness Model, which integrates the demands of multiple sclerosis over time within a family developmental framework. In a comparison of a couple skills intervention with a psychoeducation program, women in the couple skills intervention benefited more in terms of their relationship functioning (Ann Behav Med. 2012 Apr;43[2]:239-52).
Dr. John S. Rolland’s Family Systems Illness (FSI) model provides a framework for the psychoeducation, assessment, and intervention with families dealing with chronic illness. This model, developed in clinical experience with more than 1,000 families, views families as valued partners and resources, and emphasizes resilience and growth. The FSI model takes into account the interaction of an illness with the individual’s development and the family’s development, the multigenerational ways of coping with illness, the family’s health/illness belief system, available resources, and relationships between health care providers.
The PTGI includes five domains: improved relationships, new possibilities for one’s life, a greater appreciation for life, a greater sense of personal strength, and spiritual development. Several family oriented themes within the PTGI can be used by the psychiatrist to inquire about positive change. These themes are:
• Knowing that I can count on people in times of trouble.
• A sense of closeness with others.
• Having compassion for others.
• Putting effort into my relationships.
• I learned a great deal about how wonderful people are.
• I accept needing others.
To promote PTG, the psychiatrists can listen for accounts of the experience of growth, label the experience, decide when the patient is ready for more focused questioning, and recognize that a life narrative including the aftermath of a trauma has value. In order to get the patient to recognize PTG, the psychiatrist can state and ask: “You may have heard people say that they have found some benefit in their struggle with trauma. Given what has happened to you, do you think that is possible?” Another exchange might flow like this: “You mentioned last time that you noticed that you and your wife have grown closer since this happened. Can you tell me more about this closeness. What is it about this struggle that has produced this closeness?”
Conclusion
Strengths, resilience, and post-traumatic growth are distinct constructs that share conceptual overlap. Using these constructs, the psychiatrist can help the patients and their families move forward. At the time of diagnosis/trauma/bereavement, family and couple interventions provide support, education, and symptom management. Specific psychoeducational interventions or family therapy can be used if needed. As the illness progresses and the family moves from an assimilative stance to an accommodative stance, and as problem-solving moves from emotional problem solving to reflective problem solving, the possibility of benefit finding and PTG emerge. Most importantly, the psychiatrist can provide the family with a therapeutic space to consider their coping styles, and offer the family a path forward through discussion of dyadic coping and family growth.
Further reading
1. Tedeschi and Kilmer, “Assessing Strengths, Resilience, and Growth to Guide Clinical Interventions,” Professional Psychology: Research and Practice. 2005;36(3), p. 230-7.
2. Heru A.M., “Working With Families in Medical Settings,” (New York: Routledge), 2013.
3. Rolland J.S. “Families, Illness, & Disability: An Integrative Treatment Model,” (New York: Basic Books), 1994. New edition in press.
Thank you to Dr. Jennifer Caspari for assisting with resources for this article.
Dr. Heru is with the department of psychiatry at the University of Denver, Aurora. She has no conflicts of interest to disclose.
Promoting resilience, benefit finding, and post-traumatic growth help patients and families cope well with chronic illness. A resilient family has good problem-solving skills and communication, and a shared belief system (Fam Process. 2003; 42:1-18). Benefit finding coexists with feelings of burden, grief, and loss, and post-traumatic growth can occur despite grief and loss. Convening family meetings, for example, is a way to provide a therapeutic space for families and an opportunity to reflect on ways that chronic illness has affected the family, both negatively and positively.
What is coping well?
Resilient families cope well by identifying and solving illness-related problems, communicating about symptoms, negotiating role changes, and developing new interests as a family and new ways of emotionally being together. In addition, resilient families are able to adapt or change their life goals or health behaviors, such as improving diet, increasing exercise, and stopping smoking. A family member may work fewer hours, for example, and older children may give up some childhood activities to take on caregiving responsibilities.
Families do not usually think about how they cope; they just get along the best they can. Families may not consider how each family member’s individual coping style meshes with the coping styles of other family members. Illness management often is punctuated by crises where change happens quickly, without the family having time to deliberate on what coping styles might work best. Family changes can become fixed, therefore, not by choice, but by happenstance.
The initial stage of coping is “assimilative.” This is when the impact of the illness is being understood and absorbed. Emotional coping occurs when distress is highest, for example, at the beginning of an illness – when uncertainty exists about the diagnosis. Another characteristic of emotional coping is that it is characterized by attempts to regulate negative emotions. For example, family members may blame themselves or others, engage in wishful thinking, or become avoidant.
At later stages of illness, coping becomes “accommodative” after attempts to change or cure the illness have been found to be ineffective. Emotional coping can then be replaced with a problem-based coping style, allowing a stressor to be discussed and a solution chosen from several alternatives. Reflective coping, a related concept, is the ability to generate and consider coping options, and to recognize the usefulness of a particular coping strategy in a particular situation.
Psychiatric imperatives
While providing psychotherapy with these couples, it is helpful to:
• Help families differentiate between emotional difficulties such as “I am the primary caregiver, and I feel overburdened,” and more general practical problems, such as “I am happy to be the primary caregiver, but I need some extra help.”
• Describe coping to the family. Coping is a dynamic process, and coping styles change over time. Each person copes in their own way, depending on their experiences of illness and expectations of living with illness. In a family, the experiences and behaviors of all the individuals influence the way the family unit functions as a whole.
• Promote a balance between acceptance and change.
• Encourage the family to talk about their experience with others who are experiencing the same stressors.
• Give the family a handout that outlines different coping styles to get the discussion started.
• Provide a therapeutic space for family members to think together about how they want to cope and what coping well means to their family.
Developing dyadic coping
When dyadic coping takes place, couples cope as a single entity. Dyadic coping research is relatively new; most studies have been conducted in the past 15 years. Couples who use positive dyadic coping employ joint problem solving, joint information seeking, sharing of feelings, mutual commitment, and relaxing together. Meanwhile, couples who use negative dyadic coping hide concerns from each other and avoid shared discussion. A systemic review of dyadic coping in couples with cancer found that couples using positive dyadic coping styles experienced higher relationship functioning (Br J Health Psychol. 2015 Feb;20[1]:85-114).
Couples with good dyadic coping view the illness as “our problem.” This approach necessitates a shared understanding of the illness. The couple usually has prior experience working together as a team, for example, parenting and dividing roles within the house. They are able to relax together and provide emotional support, such as mutual calming and expressions of solidarity. Talking together about one’s worries and needs allows couples to share the experience more adequately. Dyadic coping is reflected in the amount of “we” talk.
The person in the family who copes “best” may provide the model for developing the family coping style. In a study of 66 couples faced with the stress of forced relocation, nearly all the couples adapted to the stress “as a couple,” rather than “as individuals” (Fam Process. 1991 Sep;30[3]:347-61). At the 2-year follow-up, each husband and wife developed similar coping styles, with one individual’s coping ability driving the adjustment of his or her partner. The need to adjust together or to adapt as a couple lessened the stress of relocation. Adaptation occurred through the development of shared meaning of the relocation that emerged from conversation within the couples. In other words, the couple developed a shared worldview. The coping style of the person who coped best was the strongest predictor of adjustment for both members of the couple. For most couples, the style of the person who coped best dominated.
Questions to ask during therapy
While working with these couples, assess their motivation to develop dyadic coping, by asking:
• “Do either of you feel that the patient should do this alone?” If the answer is yes, it will be difficult, if not impossible, to move the couple to a dyadic coping style.
• “Do your efforts to work together result in greater conflict?”
• “How much do you want this to change?” This questions clarifies their motivation to work together.
• “When you think about problems related to your heart condition, to what extent do you view those as ‘our problem’ [shared by the patient and the spouse equally] or mainly as ‘your own problem?’ ”
• “When a problem related to your heart condition arises, to what extent do you and your partner work together to solve it?”
• “When you both talk about the illness, how much do you use ‘we-talk’?”
• “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?”
• “How do you respond when your spouse becomes 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?”
‘Benefit finding’ and PTG
Benefit finding emerges later in the adjustment to chronic illness. For example, caregivers may develop a greater appreciation of their own health and ability to enjoy their own pursuits. Family connectedness is a frequent source of meaning, and a critical aspect of well-being and benefit finding. Seven factors make up benefit finding: compassion/empathy, spiritual growth, mindfulness, family relations growth, lifestyle gains, personal growth, and new opportunities (Psychol Health. 2009 Apr;24[4]:373-93). Benefit finding is associated with higher marital adjustment, improved life satisfaction, and a more positive affect, especially at high levels of stress.
Post-traumatic growth, or PTG, refers to positive changes that occur after traumatic life events. People who experience PTG are transformed by their struggles with adversity. It is the struggle after the trauma, not the trauma itself, that produces PTG. In contrast to resilience, PTG refers to changes that go beyond pretrauma levels of adaptation and beyond benefit finding. Relational benefits in the aftermath of a cancer diagnosis are well recognized. An instrument used to assess these outcomes is called the Post-traumatic Growth Inventory, or PTGI (J Trauma Stress. 1996 Jul;9:455-71).
Interventions for couples coping with cancer resulted in improvements in communication, dyadic coping, quality of life, psychosocial distress, sexual functioning, and marital satisfaction (Psychooncology. 2014 Apr;23[7]:731-9). PTG may, however, be more apparent in patients than spouses.
Potential interventions
Promoting dyadic coping is effective if the couple wants to engage in intervention. According to one study, a partner-assisted emotional disclosure improved relationship functioning and intimacy (J Marital Fam Ther. 2012 Jun;38 Suppl 1:284-95). Couples therapy improves relational functioning in couples coping with cancer, at 1-year follow-up (Psychooncology. 2009 Mar;18[3]:276-83). Most important, as a first step, the couple must agree that they want to develop dyadic coping. The concept of individual versus dyadic coping may be novel for couples, and it is worth spending time on this review before offering couples intervention.
A psychoeducational program also can teach dyadic coping. The Resilient Partners discussion group developed in collaboration with the Multiple Sclerosis Society focused on developing couples’ strengths in coping with multiple sclerosis (Rolland, J., McPheters, J., and Carbonell, E., 2008). This multifamily group program is based on the Family Systems Illness Model, which integrates the demands of multiple sclerosis over time within a family developmental framework. In a comparison of a couple skills intervention with a psychoeducation program, women in the couple skills intervention benefited more in terms of their relationship functioning (Ann Behav Med. 2012 Apr;43[2]:239-52).
Dr. John S. Rolland’s Family Systems Illness (FSI) model provides a framework for the psychoeducation, assessment, and intervention with families dealing with chronic illness. This model, developed in clinical experience with more than 1,000 families, views families as valued partners and resources, and emphasizes resilience and growth. The FSI model takes into account the interaction of an illness with the individual’s development and the family’s development, the multigenerational ways of coping with illness, the family’s health/illness belief system, available resources, and relationships between health care providers.
The PTGI includes five domains: improved relationships, new possibilities for one’s life, a greater appreciation for life, a greater sense of personal strength, and spiritual development. Several family oriented themes within the PTGI can be used by the psychiatrist to inquire about positive change. These themes are:
• Knowing that I can count on people in times of trouble.
• A sense of closeness with others.
• Having compassion for others.
• Putting effort into my relationships.
• I learned a great deal about how wonderful people are.
• I accept needing others.
To promote PTG, the psychiatrists can listen for accounts of the experience of growth, label the experience, decide when the patient is ready for more focused questioning, and recognize that a life narrative including the aftermath of a trauma has value. In order to get the patient to recognize PTG, the psychiatrist can state and ask: “You may have heard people say that they have found some benefit in their struggle with trauma. Given what has happened to you, do you think that is possible?” Another exchange might flow like this: “You mentioned last time that you noticed that you and your wife have grown closer since this happened. Can you tell me more about this closeness. What is it about this struggle that has produced this closeness?”
Conclusion
Strengths, resilience, and post-traumatic growth are distinct constructs that share conceptual overlap. Using these constructs, the psychiatrist can help the patients and their families move forward. At the time of diagnosis/trauma/bereavement, family and couple interventions provide support, education, and symptom management. Specific psychoeducational interventions or family therapy can be used if needed. As the illness progresses and the family moves from an assimilative stance to an accommodative stance, and as problem-solving moves from emotional problem solving to reflective problem solving, the possibility of benefit finding and PTG emerge. Most importantly, the psychiatrist can provide the family with a therapeutic space to consider their coping styles, and offer the family a path forward through discussion of dyadic coping and family growth.
Further reading
1. Tedeschi and Kilmer, “Assessing Strengths, Resilience, and Growth to Guide Clinical Interventions,” Professional Psychology: Research and Practice. 2005;36(3), p. 230-7.
2. Heru A.M., “Working With Families in Medical Settings,” (New York: Routledge), 2013.
3. Rolland J.S. “Families, Illness, & Disability: An Integrative Treatment Model,” (New York: Basic Books), 1994. New edition in press.
Thank you to Dr. Jennifer Caspari for assisting with resources for this article.
Dr. Heru is with the department of psychiatry at the University of Denver, Aurora. She has no conflicts of interest to disclose.
Storytelling that heals: Movies and families
Movies are storytelling in high definition. Have you ever used movies to teach your students or residents? Have you ever prescribed therapeutic movie watching to your patients, families, or couples? Movie watching helps us to understand and process the challenges we face. Movie watching helps us to imagine new stories for ourselves.
Stories connect us to our own families. The experiences of our elders and other family members are the story of our family and give coherence to our own life story. We may identify with a family member whose life experience resonates with our life experience; maybe it is the relative who perseveres, or the black sheep, or the one with depression, or the pioneer, or the one who settles for happiness or the alcoholic or workaholic. Maybe we cherish stories that connect us to our generation rather than our family, such as stories about a generational war experience or the stories and camaraderie of Alcoholics Anonymous meetings.
Stories help us understand ourselves. Stories give us scripts, maps, mental models, metaphors, and narratives to help us navigate through our lives. Stories are how we explain our lives to others, reach decisions, understand our place in the world, create our identities, and define and teach social and moral values. Many children come to understand the morals of the world by reading about the lives of animals in Aesop’s Fables. How often do parents have to read the same story over and over to their child? Familiar stories give our lives a narrative structure that is familiar, predictable, and comforting.
Storytelling is fundamental to all cultures. Stories live in our imagination. We can rehearse imagined experiences and imagine our life story in many different ways. Stories help us step out, step forward, see the world and ourselves. Story reading and movie watching help us imagine. Psychotherapy is a therapeutic way to help patients relinquish old stories and begin to construct a new story about themselves.
Movie watching can be used in therapy and has been studied as a therapeutic tool. Cinema therapy, or movie therapy, is considered a form of supplemental therapy and a form of self-help. Cinema therapy was popularized by Gary Solomon, Ph.D., the first to write on using movies as therapy (“The Motion Picture Prescription: Watch This Movie and Call Me in the Morning.” Santa Rosa, Calif.: Aslan Publishing,1995).
Watching movies was used in one arm of the first long-term investigation to compare different types of early marriage intervention programs. In this study, 174 couples in their first 3 years of marriage were enrolled in one of three treatment arms: conflict management, compassion and acceptance training, or relationship awareness through film. Each arm was equally effective in reducing the 3-year divorce/separation rate for newlyweds from 24% to 11%.
The first arm
The conflict management group learned “active listening” or the “speaker-listener technique.” This technique slows down communication and helps individuals focus on what their partner is saying. The practice requires one spouse to listen and then paraphrase back to the partner what the spouse heard to ensure the message has been properly understood. This technique has been shown to be effective at promoting happier and more satisfying relationships for 3-5 years (see the Prevention and Relationship Enhancement Program). This model provides couples with training in communication and problem-solving skills, as well as relationship expectations, friendship, and commitment.
The second arm
The compassion and acceptance training cohort focused on couples working as a team. Through a series of lectures and exercises, couples were taught to approach their relationships with more compassion and empathy by doing things like listening as a friend, practicing random acts of kindness and affection, and using the language of acceptance. Both programs involved weekly lectures, supervised practice sessions, and homework assignments over the course of a month, for a total investment of roughly 20 hours, with 18 hours of therapy time.
The third arm
The movie-and-talk group attended a 10-minute lecture on the importance of relationship awareness and how watching couples in movies could help spouses pay attention to their own behavior, both constructive and destructive. They spent 10 hours on “movie and talk” with 4 hours outside of the home. After each movie, the couple discussed a list of 12 questions about the screen couple’s interactions. Questions included: “How did the movie partners handle arguments? Were they able to open up and tell each other how they really felt, or did they tend to just snap at each other with anger? Did they try using humor to keep things from getting nasty?” The couple was asked to consider in what way the movie relationship was “similar to or different from your own relationship in this area.”
All couples in the third arm met with a therapist to watch “Two for the Road,” a 1967 romantic comedy about the joys and strains of young love, infidelity, and professional pressures across 10 years of a marriage. They were then led by the therapist in a guided discussion. They went home with a list of 47 movies with intimate relationships as a major plot focus, and were asked to watch 1 a week for the next month, followed by a guided discussion for about 45 minutes. For couples interested in trying the film discussions for themselves, the website ofRonald D. Rogge, Ph.D., offers interactive tools to help with the process, including lists of movies and the discussion questions used.
What happened?
The couples invested in their relationship and began to examine their own behavior. Watching a movie together and having a discussion was therapeutic but did not pathologize their relationship, nor did the partners seek to blame each other. The therapist-led marriage intervention programs available usually require trained therapists, and are expensive and intensive. Can couples work on their relationships on their own? The assumption has been that you need to teach couples skills to manage conflict; this might not be true. This study indicates that relationship storytelling can be a step that couples and families can take, on their own.
Movies also can be used in teaching
Family medicine teachers Catherine M. Weber, Ph.D., and Dr. Hugh J. Silk (Fam Med. 2007;39[5]:317-9) developed a movie-watching curriculum to deepen trainees’ understanding of patients and their families. The curriculum was divided into sections. The family and illness section focused on how family members find a will to help their loved ones, even in the midst of a lack of resources or medical futility. They watched “Lorenzo’s Oil” (1992), “The Straight Story” (2006), and “A River Runs Through It” (1992). The family and loss section examined how families become dysfunctional in the presence of the loss of a loved one and what it takes to heal. They watched “Ordinary People” (1980), “The Barbarian Invasions” (2003), and “The Trip to Bountiful” (1985). The section on family and caregiving identifies the strain of illness on family members who provide direct care to ill patients. They watched “Marvin’s Room” (1996) and “Iris” (2001). The section on the family and substance abuse identified how family members got caught in roles and included “When a Man Loves a Woman” (1994) and “The Days of Wine and Roses” (1962). The section on the extended family and illness illustrated how illness brings people together. They watched “Flawless” (1999), “My House in Umbria” (2003), “Beaches” (1988), and “The Barbarian Invasions (2003).
A more specific look at family systems is provided by the curriculum of Dr. Robin O. Winter and Bruce A. Birnberg (Fam Med. 2005;37[2]:96-8) in a series called “Family Systems at the Movies.” Their overarching objective was to promote an understanding of multigenerational issues, the impact of family secrets and family dynamics, the effect of stress on family life, and the attributes of a functional family. Concepts such as homeostasis, boundaries, coalitions, and scapegoating were then applied to the clinical setting. Selected scenes were chosen from three works: “The Joy Luck Club” (1993), “Shine” (1996), and a TV series called “Secrets and Lies” (2015-).
Regarding early marriage, Dr. Salman Ahktar and Dr. Zoe Billinkoff (Am J Psychoanal. 2011; 71[2]:110-20) used movies to discuss how identity, the development of mutuality, and the synthesis of affection and sensuality develop in early marriage. Their goal was to help therapists develop greater empathy with newly married individuals. They focused on three movies: “Barefoot in the Park” (1967), “Raising Arizona” (1987), and “The Quiet Man” (1952). Regarding divorce, Toni Mandelbaum(Am J Psychoanal. 2011;71[2]:121-33) used movies to illustrate the interplay between dependence and independence using “Eat Pray Love” (2010) and “Kramer vs. Kramer” (1979).
Many psychiatry residency programs have journal clubs and film clubs that use movies as a jumping-off point to deepen trainees’ understanding of psychopathology. Implementing these curricula is a simple way of beginning family training in residency, especially when the use of family videos are curtailed by strict confidentiality rules.
Future ‘family and film’ events
Dr. Francis G. Lu, (www.francislumd.com), a regular presenter at many conferences, including the American Psychiatric Association annual meetings, uses film to promote a deeper understanding of the world around us and within us. In 2007, he and Brother David Steindl-Rast, Ph.D., a Benedictine monk, co-led a 7-day seminar entitled, “Families in Film, Now and Forever” at Esalen Institute (go to www.gratefulness.org, then search “films”). From July 10-17, 2016, Dr. Lu and Dr. Steindl-Rast will co-lead “The Resilience of the Family in Film: Epics of Love, Loss, and Recovery” and from July 17-24, 2016, “Through Compassion to Serenity in the Mindful Viewing of Japanese and Western Films.” Registration opens in January 2016 at www.esalen.org. If you have ever attended one of Dr. Lu’s seminars at the APA, then you know you will be in for a rich experience at Esalen.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).
Movies are storytelling in high definition. Have you ever used movies to teach your students or residents? Have you ever prescribed therapeutic movie watching to your patients, families, or couples? Movie watching helps us to understand and process the challenges we face. Movie watching helps us to imagine new stories for ourselves.
Stories connect us to our own families. The experiences of our elders and other family members are the story of our family and give coherence to our own life story. We may identify with a family member whose life experience resonates with our life experience; maybe it is the relative who perseveres, or the black sheep, or the one with depression, or the pioneer, or the one who settles for happiness or the alcoholic or workaholic. Maybe we cherish stories that connect us to our generation rather than our family, such as stories about a generational war experience or the stories and camaraderie of Alcoholics Anonymous meetings.
Stories help us understand ourselves. Stories give us scripts, maps, mental models, metaphors, and narratives to help us navigate through our lives. Stories are how we explain our lives to others, reach decisions, understand our place in the world, create our identities, and define and teach social and moral values. Many children come to understand the morals of the world by reading about the lives of animals in Aesop’s Fables. How often do parents have to read the same story over and over to their child? Familiar stories give our lives a narrative structure that is familiar, predictable, and comforting.
Storytelling is fundamental to all cultures. Stories live in our imagination. We can rehearse imagined experiences and imagine our life story in many different ways. Stories help us step out, step forward, see the world and ourselves. Story reading and movie watching help us imagine. Psychotherapy is a therapeutic way to help patients relinquish old stories and begin to construct a new story about themselves.
Movie watching can be used in therapy and has been studied as a therapeutic tool. Cinema therapy, or movie therapy, is considered a form of supplemental therapy and a form of self-help. Cinema therapy was popularized by Gary Solomon, Ph.D., the first to write on using movies as therapy (“The Motion Picture Prescription: Watch This Movie and Call Me in the Morning.” Santa Rosa, Calif.: Aslan Publishing,1995).
Watching movies was used in one arm of the first long-term investigation to compare different types of early marriage intervention programs. In this study, 174 couples in their first 3 years of marriage were enrolled in one of three treatment arms: conflict management, compassion and acceptance training, or relationship awareness through film. Each arm was equally effective in reducing the 3-year divorce/separation rate for newlyweds from 24% to 11%.
The first arm
The conflict management group learned “active listening” or the “speaker-listener technique.” This technique slows down communication and helps individuals focus on what their partner is saying. The practice requires one spouse to listen and then paraphrase back to the partner what the spouse heard to ensure the message has been properly understood. This technique has been shown to be effective at promoting happier and more satisfying relationships for 3-5 years (see the Prevention and Relationship Enhancement Program). This model provides couples with training in communication and problem-solving skills, as well as relationship expectations, friendship, and commitment.
The second arm
The compassion and acceptance training cohort focused on couples working as a team. Through a series of lectures and exercises, couples were taught to approach their relationships with more compassion and empathy by doing things like listening as a friend, practicing random acts of kindness and affection, and using the language of acceptance. Both programs involved weekly lectures, supervised practice sessions, and homework assignments over the course of a month, for a total investment of roughly 20 hours, with 18 hours of therapy time.
The third arm
The movie-and-talk group attended a 10-minute lecture on the importance of relationship awareness and how watching couples in movies could help spouses pay attention to their own behavior, both constructive and destructive. They spent 10 hours on “movie and talk” with 4 hours outside of the home. After each movie, the couple discussed a list of 12 questions about the screen couple’s interactions. Questions included: “How did the movie partners handle arguments? Were they able to open up and tell each other how they really felt, or did they tend to just snap at each other with anger? Did they try using humor to keep things from getting nasty?” The couple was asked to consider in what way the movie relationship was “similar to or different from your own relationship in this area.”
All couples in the third arm met with a therapist to watch “Two for the Road,” a 1967 romantic comedy about the joys and strains of young love, infidelity, and professional pressures across 10 years of a marriage. They were then led by the therapist in a guided discussion. They went home with a list of 47 movies with intimate relationships as a major plot focus, and were asked to watch 1 a week for the next month, followed by a guided discussion for about 45 minutes. For couples interested in trying the film discussions for themselves, the website ofRonald D. Rogge, Ph.D., offers interactive tools to help with the process, including lists of movies and the discussion questions used.
What happened?
The couples invested in their relationship and began to examine their own behavior. Watching a movie together and having a discussion was therapeutic but did not pathologize their relationship, nor did the partners seek to blame each other. The therapist-led marriage intervention programs available usually require trained therapists, and are expensive and intensive. Can couples work on their relationships on their own? The assumption has been that you need to teach couples skills to manage conflict; this might not be true. This study indicates that relationship storytelling can be a step that couples and families can take, on their own.
Movies also can be used in teaching
Family medicine teachers Catherine M. Weber, Ph.D., and Dr. Hugh J. Silk (Fam Med. 2007;39[5]:317-9) developed a movie-watching curriculum to deepen trainees’ understanding of patients and their families. The curriculum was divided into sections. The family and illness section focused on how family members find a will to help their loved ones, even in the midst of a lack of resources or medical futility. They watched “Lorenzo’s Oil” (1992), “The Straight Story” (2006), and “A River Runs Through It” (1992). The family and loss section examined how families become dysfunctional in the presence of the loss of a loved one and what it takes to heal. They watched “Ordinary People” (1980), “The Barbarian Invasions” (2003), and “The Trip to Bountiful” (1985). The section on family and caregiving identifies the strain of illness on family members who provide direct care to ill patients. They watched “Marvin’s Room” (1996) and “Iris” (2001). The section on the family and substance abuse identified how family members got caught in roles and included “When a Man Loves a Woman” (1994) and “The Days of Wine and Roses” (1962). The section on the extended family and illness illustrated how illness brings people together. They watched “Flawless” (1999), “My House in Umbria” (2003), “Beaches” (1988), and “The Barbarian Invasions (2003).
A more specific look at family systems is provided by the curriculum of Dr. Robin O. Winter and Bruce A. Birnberg (Fam Med. 2005;37[2]:96-8) in a series called “Family Systems at the Movies.” Their overarching objective was to promote an understanding of multigenerational issues, the impact of family secrets and family dynamics, the effect of stress on family life, and the attributes of a functional family. Concepts such as homeostasis, boundaries, coalitions, and scapegoating were then applied to the clinical setting. Selected scenes were chosen from three works: “The Joy Luck Club” (1993), “Shine” (1996), and a TV series called “Secrets and Lies” (2015-).
Regarding early marriage, Dr. Salman Ahktar and Dr. Zoe Billinkoff (Am J Psychoanal. 2011; 71[2]:110-20) used movies to discuss how identity, the development of mutuality, and the synthesis of affection and sensuality develop in early marriage. Their goal was to help therapists develop greater empathy with newly married individuals. They focused on three movies: “Barefoot in the Park” (1967), “Raising Arizona” (1987), and “The Quiet Man” (1952). Regarding divorce, Toni Mandelbaum(Am J Psychoanal. 2011;71[2]:121-33) used movies to illustrate the interplay between dependence and independence using “Eat Pray Love” (2010) and “Kramer vs. Kramer” (1979).
Many psychiatry residency programs have journal clubs and film clubs that use movies as a jumping-off point to deepen trainees’ understanding of psychopathology. Implementing these curricula is a simple way of beginning family training in residency, especially when the use of family videos are curtailed by strict confidentiality rules.
Future ‘family and film’ events
Dr. Francis G. Lu, (www.francislumd.com), a regular presenter at many conferences, including the American Psychiatric Association annual meetings, uses film to promote a deeper understanding of the world around us and within us. In 2007, he and Brother David Steindl-Rast, Ph.D., a Benedictine monk, co-led a 7-day seminar entitled, “Families in Film, Now and Forever” at Esalen Institute (go to www.gratefulness.org, then search “films”). From July 10-17, 2016, Dr. Lu and Dr. Steindl-Rast will co-lead “The Resilience of the Family in Film: Epics of Love, Loss, and Recovery” and from July 17-24, 2016, “Through Compassion to Serenity in the Mindful Viewing of Japanese and Western Films.” Registration opens in January 2016 at www.esalen.org. If you have ever attended one of Dr. Lu’s seminars at the APA, then you know you will be in for a rich experience at Esalen.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).
Movies are storytelling in high definition. Have you ever used movies to teach your students or residents? Have you ever prescribed therapeutic movie watching to your patients, families, or couples? Movie watching helps us to understand and process the challenges we face. Movie watching helps us to imagine new stories for ourselves.
Stories connect us to our own families. The experiences of our elders and other family members are the story of our family and give coherence to our own life story. We may identify with a family member whose life experience resonates with our life experience; maybe it is the relative who perseveres, or the black sheep, or the one with depression, or the pioneer, or the one who settles for happiness or the alcoholic or workaholic. Maybe we cherish stories that connect us to our generation rather than our family, such as stories about a generational war experience or the stories and camaraderie of Alcoholics Anonymous meetings.
Stories help us understand ourselves. Stories give us scripts, maps, mental models, metaphors, and narratives to help us navigate through our lives. Stories are how we explain our lives to others, reach decisions, understand our place in the world, create our identities, and define and teach social and moral values. Many children come to understand the morals of the world by reading about the lives of animals in Aesop’s Fables. How often do parents have to read the same story over and over to their child? Familiar stories give our lives a narrative structure that is familiar, predictable, and comforting.
Storytelling is fundamental to all cultures. Stories live in our imagination. We can rehearse imagined experiences and imagine our life story in many different ways. Stories help us step out, step forward, see the world and ourselves. Story reading and movie watching help us imagine. Psychotherapy is a therapeutic way to help patients relinquish old stories and begin to construct a new story about themselves.
Movie watching can be used in therapy and has been studied as a therapeutic tool. Cinema therapy, or movie therapy, is considered a form of supplemental therapy and a form of self-help. Cinema therapy was popularized by Gary Solomon, Ph.D., the first to write on using movies as therapy (“The Motion Picture Prescription: Watch This Movie and Call Me in the Morning.” Santa Rosa, Calif.: Aslan Publishing,1995).
Watching movies was used in one arm of the first long-term investigation to compare different types of early marriage intervention programs. In this study, 174 couples in their first 3 years of marriage were enrolled in one of three treatment arms: conflict management, compassion and acceptance training, or relationship awareness through film. Each arm was equally effective in reducing the 3-year divorce/separation rate for newlyweds from 24% to 11%.
The first arm
The conflict management group learned “active listening” or the “speaker-listener technique.” This technique slows down communication and helps individuals focus on what their partner is saying. The practice requires one spouse to listen and then paraphrase back to the partner what the spouse heard to ensure the message has been properly understood. This technique has been shown to be effective at promoting happier and more satisfying relationships for 3-5 years (see the Prevention and Relationship Enhancement Program). This model provides couples with training in communication and problem-solving skills, as well as relationship expectations, friendship, and commitment.
The second arm
The compassion and acceptance training cohort focused on couples working as a team. Through a series of lectures and exercises, couples were taught to approach their relationships with more compassion and empathy by doing things like listening as a friend, practicing random acts of kindness and affection, and using the language of acceptance. Both programs involved weekly lectures, supervised practice sessions, and homework assignments over the course of a month, for a total investment of roughly 20 hours, with 18 hours of therapy time.
The third arm
The movie-and-talk group attended a 10-minute lecture on the importance of relationship awareness and how watching couples in movies could help spouses pay attention to their own behavior, both constructive and destructive. They spent 10 hours on “movie and talk” with 4 hours outside of the home. After each movie, the couple discussed a list of 12 questions about the screen couple’s interactions. Questions included: “How did the movie partners handle arguments? Were they able to open up and tell each other how they really felt, or did they tend to just snap at each other with anger? Did they try using humor to keep things from getting nasty?” The couple was asked to consider in what way the movie relationship was “similar to or different from your own relationship in this area.”
All couples in the third arm met with a therapist to watch “Two for the Road,” a 1967 romantic comedy about the joys and strains of young love, infidelity, and professional pressures across 10 years of a marriage. They were then led by the therapist in a guided discussion. They went home with a list of 47 movies with intimate relationships as a major plot focus, and were asked to watch 1 a week for the next month, followed by a guided discussion for about 45 minutes. For couples interested in trying the film discussions for themselves, the website ofRonald D. Rogge, Ph.D., offers interactive tools to help with the process, including lists of movies and the discussion questions used.
What happened?
The couples invested in their relationship and began to examine their own behavior. Watching a movie together and having a discussion was therapeutic but did not pathologize their relationship, nor did the partners seek to blame each other. The therapist-led marriage intervention programs available usually require trained therapists, and are expensive and intensive. Can couples work on their relationships on their own? The assumption has been that you need to teach couples skills to manage conflict; this might not be true. This study indicates that relationship storytelling can be a step that couples and families can take, on their own.
Movies also can be used in teaching
Family medicine teachers Catherine M. Weber, Ph.D., and Dr. Hugh J. Silk (Fam Med. 2007;39[5]:317-9) developed a movie-watching curriculum to deepen trainees’ understanding of patients and their families. The curriculum was divided into sections. The family and illness section focused on how family members find a will to help their loved ones, even in the midst of a lack of resources or medical futility. They watched “Lorenzo’s Oil” (1992), “The Straight Story” (2006), and “A River Runs Through It” (1992). The family and loss section examined how families become dysfunctional in the presence of the loss of a loved one and what it takes to heal. They watched “Ordinary People” (1980), “The Barbarian Invasions” (2003), and “The Trip to Bountiful” (1985). The section on family and caregiving identifies the strain of illness on family members who provide direct care to ill patients. They watched “Marvin’s Room” (1996) and “Iris” (2001). The section on the family and substance abuse identified how family members got caught in roles and included “When a Man Loves a Woman” (1994) and “The Days of Wine and Roses” (1962). The section on the extended family and illness illustrated how illness brings people together. They watched “Flawless” (1999), “My House in Umbria” (2003), “Beaches” (1988), and “The Barbarian Invasions (2003).
A more specific look at family systems is provided by the curriculum of Dr. Robin O. Winter and Bruce A. Birnberg (Fam Med. 2005;37[2]:96-8) in a series called “Family Systems at the Movies.” Their overarching objective was to promote an understanding of multigenerational issues, the impact of family secrets and family dynamics, the effect of stress on family life, and the attributes of a functional family. Concepts such as homeostasis, boundaries, coalitions, and scapegoating were then applied to the clinical setting. Selected scenes were chosen from three works: “The Joy Luck Club” (1993), “Shine” (1996), and a TV series called “Secrets and Lies” (2015-).
Regarding early marriage, Dr. Salman Ahktar and Dr. Zoe Billinkoff (Am J Psychoanal. 2011; 71[2]:110-20) used movies to discuss how identity, the development of mutuality, and the synthesis of affection and sensuality develop in early marriage. Their goal was to help therapists develop greater empathy with newly married individuals. They focused on three movies: “Barefoot in the Park” (1967), “Raising Arizona” (1987), and “The Quiet Man” (1952). Regarding divorce, Toni Mandelbaum(Am J Psychoanal. 2011;71[2]:121-33) used movies to illustrate the interplay between dependence and independence using “Eat Pray Love” (2010) and “Kramer vs. Kramer” (1979).
Many psychiatry residency programs have journal clubs and film clubs that use movies as a jumping-off point to deepen trainees’ understanding of psychopathology. Implementing these curricula is a simple way of beginning family training in residency, especially when the use of family videos are curtailed by strict confidentiality rules.
Future ‘family and film’ events
Dr. Francis G. Lu, (www.francislumd.com), a regular presenter at many conferences, including the American Psychiatric Association annual meetings, uses film to promote a deeper understanding of the world around us and within us. In 2007, he and Brother David Steindl-Rast, Ph.D., a Benedictine monk, co-led a 7-day seminar entitled, “Families in Film, Now and Forever” at Esalen Institute (go to www.gratefulness.org, then search “films”). From July 10-17, 2016, Dr. Lu and Dr. Steindl-Rast will co-lead “The Resilience of the Family in Film: Epics of Love, Loss, and Recovery” and from July 17-24, 2016, “Through Compassion to Serenity in the Mindful Viewing of Japanese and Western Films.” Registration opens in January 2016 at www.esalen.org. If you have ever attended one of Dr. Lu’s seminars at the APA, then you know you will be in for a rich experience at Esalen.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).
Family-centered care in the NICU
Hospitals are slow to change, especially when changes – such as the inclusion of families in patient care – are not big money makers. Even so, in a competitive marketplace, hospitals are beginning to realize that patient and family satisfaction develops loyal customers.
When patients and families have a good experience, they are likely to return to the hospital and recommend the hospital to others. From a business perspective, it makes sense to develop family-oriented care in hospital specialty units such as the neonatal intensive care unit.
Involving families in the NICU also reduces the neonate’s length of stay (Nurs Adm Q. 2009 Jan-Mar;33[1]32-7).
COPE is a manualized intervention program comprising DVDs and a workbook.
The DVDs provide parents with educational information about the appearance and behavioral characteristics of their premature infants and about how they can participate in their infants’ care, meet their needs, enhance the quality of interaction with their infants, and facilitate their development.
The workbook skills-building activities assist parents in implementing the educational information (for example, learning how to read their infants’ awake states and stress cues, keeping track of important developmental milestones, determining what behaviors are helpful when their infants are stressed).
Parents listen to the COPE educational information on DVDs as they read it in their workbooks. The first intervention in COPE is delivered to the parents 2-4 days after the infant is admitted to the NICU. The second COPE intervention is delivered 2-4 days after the first intervention, and the third intervention is delivered to parents 1-4 days prior to the infant’s discharge from the NICU. Parents receive the fourth COPE intervention 1 week after the infant is discharged from the hospital. Each of the four DVDs has corresponding skills-building activities that parents complete after they listen to the educational information on the DVDs.
The problem
In NICUs, families are not the primary focus of care. To nursing staff, parents are an unknown factor. Parents may silence alarms or open cribs to touch the baby, not realizing that by doing so, they are dysregulating the neonate’s delicate environment. They see nurses moving things around, and so feel they should be able to do it, too. Parents come in many varieties. Some parents sit quietly and appear overwhelmed. Some parents behave erratically. Some parents may smell of alcohol or marijuana, putting everyone in the NICU on alert. Assessing and intervening with parents is helpful to nurses, reduces tension between nurse and parent, and ensures that the daily caring for the neonate is smooth and optimal. Nurses are eager to help with parents.
Nursing perspective
From the nurses’ perspective, the parents are not the patient! Nurses have not been trained to assess and manage distressed parents. Nurses can provide basic education about the baby’s medical condition but do not have time to explain the details that overanxious parents might demand. The nurses recognize that some parents are under severe stress and do not want to leave the bedside, even to care for their own needs. The nurses recognize that some parents have their own health conditions but are unsure how to approach this issue. Nurses welcome education about how to intervene and how to refer parents to appropriate resources.
Parental perspective
Parents are distressed and uncertain about the fate of their newborns. There is an immediate need to gain as much information as possible about the baby’s medical condition and to understand what the nurses are “doing to our baby.” There may be concern that the nurse seems more bonded to the baby than the parents. There may be a lack of understanding of when the babies can be handled and what and when they can be fed. There is significant emotional distress about “not being able to take the baby home.” Parents may want to assign blame or may feel overwhelmed with guilt. For families with poor coping skills, fear and anger may predominate and can be directed at the nurses – an immediate and ever available target. Generally, parents want to be included as much as possible in the care of their children.
Postpartum disorders in the NICU
It is expected that having a baby in the NICU is stressful. However, a meta-analysis of 38 studies of stress in parents of preterm infants, compared with term infants, found that parents of preterm children experience only slightly more stress than do parents of term children. There is decreasing parental stress from the 1980s onward, probably because of the increased quality of care for preterm infants. These studies included 3,025 parents of preterm and low-birth-weight infants (PLoS One 2013;8[2]:e54992).
Over the long term, the psychological functioning of NICU parents is no different from that of control parents. A prospective randomized controlled study defined psychological distress as meeting one or more of the following criteria: any psychiatric diagnosis on the Mini-International Neuropsychiatric Interview at 2 years; Edinburgh Postnatal Depression Scale score more than 12.5 at 2 years; Hospital Anxiety and Depression Scale score more than 11.0 at 2 years, receiving treatment with antidepressants/psychotherapy/counseling over the previous 15 months (Psychosomatics 2014;55[6]:613-20).
In the short term, NICU parents are at risk for postpartum depression (PPD) with the resultant difficulty in establishing good attachment with their babies. The prevalence of PPD in mothers of term newborns is 10%-15%, compared with 28%-70% among NICU mothers (Int J Womens Health. 2014;2014[6]:975-87).
Fathers are known as the forgotten parents and experience a high prevalence of depressive symptoms. Fathers of term newborns experience depression at rates of 2%-10%, but rates of up to 60% have been reported in NICU fathers (Adv Neonatal Care. 2010 Aug;10[4]:200-3).
Prevention of psychiatric illness in family members
The NICU environment is often dimly lighted, and improving lighting prevents depression in NICU mothers. A 3-week bright-light therapy intervention improved the sleep and health outcomes of NICU mothers, who experienced less morning fatigue and depressive symptoms, and improved quality of life, compared with the control group (Biol Res Nurs. 2013 Oct;15[4] 398-406). An architect on our team is designing “quiet spaces” for parents and creating more ambient light and daylighting in our NICU.
For parents who do not want to leave the NICU, mobile computer terminals can bring education to the bedside. For parents who can leave the bedside, family educational interventions are well received (Adv Neonatal Care. 2013 Apr;13[2]:115-26).
In current practice, in our labor and delivery suite and in many NICUs, mothers are screened for postpartum depression via the Edinburgh Postnatal Depression Scale (EPDS) (Br J Psychiatry 1987 Jun;150[6]:782-6). If mothers score over 13, they are referred for further assessment. Treatment often consists of referral for individual intervention for the mother (usually sertraline and disclosures/instructions about breastfeeding, as well as supportive psychotherapy).
What does family-centered care look like?
A family perspective supports the screening of both parents, using the EPDS. This can occur on admission of the baby to the NICU and at 2-week intervals thereafter and again at discharge (J Perinatol 2013 Oct;33[10]748-53). Ideally, family functioning also can be assessed, and if needed, intervention can be offered to the whole family system.
Family screening occurs in other pediatric medical settings. High-risk families can be identified with the Psychosocial Assessment Tool (PAT) (Acta Oncol. 2015 May;54[5]:574-80).
The PAT is a brief parent self-report composed of items that assess risk associated with the child, family, and broader systems. It is currently used at 50 sites in 28 states in the United States. The PAT has been translated into Spanish, Columbian Spanish, Dutch, Brazilian Portuguese, Hebrew, Greek, Polish, Italian, Japanese, Chinese, and Korean, and is used internationally. English adaptations for Canada, the United Kingdom, Australia, New Zealand, and Singapore also are available. It has been modified for use in NICUs.
The screening enables health care providers to refer families to the appropriate service: support groups (low risk), psychoeducation (medium risk), or intensive outpatient services (high risk). This stratification allows for the appropriate use of services.
Likewise, family interventions can be thought about in tiers, similar to the risk stratification of the PAT. Tier 1 is a universal educational intervention for all parents, tier 2 parents have higher needs, and tier 3 parents need immediate intervention. The following descriptions show how this might work in practice.
Family intervention: Tier 1
•All families can be given educational material about the mental health needs of parents with a newborn in the NICU. Ideally, this material can be provided through handouts, references for further reading, and through websites accessed in the NICU. For parents who are willing to leave the NICU, they can attend support groups.
•All parents can be screened at initial contact in the NICU and then on discharge from the NICU. If the neonate stays an extended time, the parents can be screened at 2-week intervals. A high score on the EPDS screen indicates an immediate need to refer a parent. A family assessment tool, such as the PAT, can identify high-risk families for immediate referral.
•NICU nursing staff can actively address coparenting struggles. Our NICU nurses provide formal letters between nurses and parents to establish the parameters of the care of the baby, and provide direction for coparenting.
Family intervention: Tier 2
Parents identified on the PAT as having higher needs can be enrolled in psychoeducational groups, led by staff members who have behavioral health training and experience.
Family intervention: Tier 3
These parents are identified on the PAT as high risk and need significant health care services. The NICU social worker can actively work on consultation with addiction medicine, mental health, or social services.
In summary, a family approach in the NICU improves nurse-parent interactions. A focus on coparenting sets the stage for cooperation, trust, and better family outcomes. Some basic training in systems concepts and family dynamics can provide NICU staff with basic clinical skills to provide psychoeducation. Adequate screening can triage high-risk parents appropriately. For NICUs that want to implement a psychoeducational program, Melnyk’s COPE program is an evidenced-based program that is well worth implementation.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She thanks other members of the NICU team at the University of Colorado Hospital: Christy Math, Katherine Perica, and John J. White.
Hospitals are slow to change, especially when changes – such as the inclusion of families in patient care – are not big money makers. Even so, in a competitive marketplace, hospitals are beginning to realize that patient and family satisfaction develops loyal customers.
When patients and families have a good experience, they are likely to return to the hospital and recommend the hospital to others. From a business perspective, it makes sense to develop family-oriented care in hospital specialty units such as the neonatal intensive care unit.
Involving families in the NICU also reduces the neonate’s length of stay (Nurs Adm Q. 2009 Jan-Mar;33[1]32-7).
COPE is a manualized intervention program comprising DVDs and a workbook.
The DVDs provide parents with educational information about the appearance and behavioral characteristics of their premature infants and about how they can participate in their infants’ care, meet their needs, enhance the quality of interaction with their infants, and facilitate their development.
The workbook skills-building activities assist parents in implementing the educational information (for example, learning how to read their infants’ awake states and stress cues, keeping track of important developmental milestones, determining what behaviors are helpful when their infants are stressed).
Parents listen to the COPE educational information on DVDs as they read it in their workbooks. The first intervention in COPE is delivered to the parents 2-4 days after the infant is admitted to the NICU. The second COPE intervention is delivered 2-4 days after the first intervention, and the third intervention is delivered to parents 1-4 days prior to the infant’s discharge from the NICU. Parents receive the fourth COPE intervention 1 week after the infant is discharged from the hospital. Each of the four DVDs has corresponding skills-building activities that parents complete after they listen to the educational information on the DVDs.
The problem
In NICUs, families are not the primary focus of care. To nursing staff, parents are an unknown factor. Parents may silence alarms or open cribs to touch the baby, not realizing that by doing so, they are dysregulating the neonate’s delicate environment. They see nurses moving things around, and so feel they should be able to do it, too. Parents come in many varieties. Some parents sit quietly and appear overwhelmed. Some parents behave erratically. Some parents may smell of alcohol or marijuana, putting everyone in the NICU on alert. Assessing and intervening with parents is helpful to nurses, reduces tension between nurse and parent, and ensures that the daily caring for the neonate is smooth and optimal. Nurses are eager to help with parents.
Nursing perspective
From the nurses’ perspective, the parents are not the patient! Nurses have not been trained to assess and manage distressed parents. Nurses can provide basic education about the baby’s medical condition but do not have time to explain the details that overanxious parents might demand. The nurses recognize that some parents are under severe stress and do not want to leave the bedside, even to care for their own needs. The nurses recognize that some parents have their own health conditions but are unsure how to approach this issue. Nurses welcome education about how to intervene and how to refer parents to appropriate resources.
Parental perspective
Parents are distressed and uncertain about the fate of their newborns. There is an immediate need to gain as much information as possible about the baby’s medical condition and to understand what the nurses are “doing to our baby.” There may be concern that the nurse seems more bonded to the baby than the parents. There may be a lack of understanding of when the babies can be handled and what and when they can be fed. There is significant emotional distress about “not being able to take the baby home.” Parents may want to assign blame or may feel overwhelmed with guilt. For families with poor coping skills, fear and anger may predominate and can be directed at the nurses – an immediate and ever available target. Generally, parents want to be included as much as possible in the care of their children.
Postpartum disorders in the NICU
It is expected that having a baby in the NICU is stressful. However, a meta-analysis of 38 studies of stress in parents of preterm infants, compared with term infants, found that parents of preterm children experience only slightly more stress than do parents of term children. There is decreasing parental stress from the 1980s onward, probably because of the increased quality of care for preterm infants. These studies included 3,025 parents of preterm and low-birth-weight infants (PLoS One 2013;8[2]:e54992).
Over the long term, the psychological functioning of NICU parents is no different from that of control parents. A prospective randomized controlled study defined psychological distress as meeting one or more of the following criteria: any psychiatric diagnosis on the Mini-International Neuropsychiatric Interview at 2 years; Edinburgh Postnatal Depression Scale score more than 12.5 at 2 years; Hospital Anxiety and Depression Scale score more than 11.0 at 2 years, receiving treatment with antidepressants/psychotherapy/counseling over the previous 15 months (Psychosomatics 2014;55[6]:613-20).
In the short term, NICU parents are at risk for postpartum depression (PPD) with the resultant difficulty in establishing good attachment with their babies. The prevalence of PPD in mothers of term newborns is 10%-15%, compared with 28%-70% among NICU mothers (Int J Womens Health. 2014;2014[6]:975-87).
Fathers are known as the forgotten parents and experience a high prevalence of depressive symptoms. Fathers of term newborns experience depression at rates of 2%-10%, but rates of up to 60% have been reported in NICU fathers (Adv Neonatal Care. 2010 Aug;10[4]:200-3).
Prevention of psychiatric illness in family members
The NICU environment is often dimly lighted, and improving lighting prevents depression in NICU mothers. A 3-week bright-light therapy intervention improved the sleep and health outcomes of NICU mothers, who experienced less morning fatigue and depressive symptoms, and improved quality of life, compared with the control group (Biol Res Nurs. 2013 Oct;15[4] 398-406). An architect on our team is designing “quiet spaces” for parents and creating more ambient light and daylighting in our NICU.
For parents who do not want to leave the NICU, mobile computer terminals can bring education to the bedside. For parents who can leave the bedside, family educational interventions are well received (Adv Neonatal Care. 2013 Apr;13[2]:115-26).
In current practice, in our labor and delivery suite and in many NICUs, mothers are screened for postpartum depression via the Edinburgh Postnatal Depression Scale (EPDS) (Br J Psychiatry 1987 Jun;150[6]:782-6). If mothers score over 13, they are referred for further assessment. Treatment often consists of referral for individual intervention for the mother (usually sertraline and disclosures/instructions about breastfeeding, as well as supportive psychotherapy).
What does family-centered care look like?
A family perspective supports the screening of both parents, using the EPDS. This can occur on admission of the baby to the NICU and at 2-week intervals thereafter and again at discharge (J Perinatol 2013 Oct;33[10]748-53). Ideally, family functioning also can be assessed, and if needed, intervention can be offered to the whole family system.
Family screening occurs in other pediatric medical settings. High-risk families can be identified with the Psychosocial Assessment Tool (PAT) (Acta Oncol. 2015 May;54[5]:574-80).
The PAT is a brief parent self-report composed of items that assess risk associated with the child, family, and broader systems. It is currently used at 50 sites in 28 states in the United States. The PAT has been translated into Spanish, Columbian Spanish, Dutch, Brazilian Portuguese, Hebrew, Greek, Polish, Italian, Japanese, Chinese, and Korean, and is used internationally. English adaptations for Canada, the United Kingdom, Australia, New Zealand, and Singapore also are available. It has been modified for use in NICUs.
The screening enables health care providers to refer families to the appropriate service: support groups (low risk), psychoeducation (medium risk), or intensive outpatient services (high risk). This stratification allows for the appropriate use of services.
Likewise, family interventions can be thought about in tiers, similar to the risk stratification of the PAT. Tier 1 is a universal educational intervention for all parents, tier 2 parents have higher needs, and tier 3 parents need immediate intervention. The following descriptions show how this might work in practice.
Family intervention: Tier 1
•All families can be given educational material about the mental health needs of parents with a newborn in the NICU. Ideally, this material can be provided through handouts, references for further reading, and through websites accessed in the NICU. For parents who are willing to leave the NICU, they can attend support groups.
•All parents can be screened at initial contact in the NICU and then on discharge from the NICU. If the neonate stays an extended time, the parents can be screened at 2-week intervals. A high score on the EPDS screen indicates an immediate need to refer a parent. A family assessment tool, such as the PAT, can identify high-risk families for immediate referral.
•NICU nursing staff can actively address coparenting struggles. Our NICU nurses provide formal letters between nurses and parents to establish the parameters of the care of the baby, and provide direction for coparenting.
Family intervention: Tier 2
Parents identified on the PAT as having higher needs can be enrolled in psychoeducational groups, led by staff members who have behavioral health training and experience.
Family intervention: Tier 3
These parents are identified on the PAT as high risk and need significant health care services. The NICU social worker can actively work on consultation with addiction medicine, mental health, or social services.
In summary, a family approach in the NICU improves nurse-parent interactions. A focus on coparenting sets the stage for cooperation, trust, and better family outcomes. Some basic training in systems concepts and family dynamics can provide NICU staff with basic clinical skills to provide psychoeducation. Adequate screening can triage high-risk parents appropriately. For NICUs that want to implement a psychoeducational program, Melnyk’s COPE program is an evidenced-based program that is well worth implementation.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She thanks other members of the NICU team at the University of Colorado Hospital: Christy Math, Katherine Perica, and John J. White.
Hospitals are slow to change, especially when changes – such as the inclusion of families in patient care – are not big money makers. Even so, in a competitive marketplace, hospitals are beginning to realize that patient and family satisfaction develops loyal customers.
When patients and families have a good experience, they are likely to return to the hospital and recommend the hospital to others. From a business perspective, it makes sense to develop family-oriented care in hospital specialty units such as the neonatal intensive care unit.
Involving families in the NICU also reduces the neonate’s length of stay (Nurs Adm Q. 2009 Jan-Mar;33[1]32-7).
COPE is a manualized intervention program comprising DVDs and a workbook.
The DVDs provide parents with educational information about the appearance and behavioral characteristics of their premature infants and about how they can participate in their infants’ care, meet their needs, enhance the quality of interaction with their infants, and facilitate their development.
The workbook skills-building activities assist parents in implementing the educational information (for example, learning how to read their infants’ awake states and stress cues, keeping track of important developmental milestones, determining what behaviors are helpful when their infants are stressed).
Parents listen to the COPE educational information on DVDs as they read it in their workbooks. The first intervention in COPE is delivered to the parents 2-4 days after the infant is admitted to the NICU. The second COPE intervention is delivered 2-4 days after the first intervention, and the third intervention is delivered to parents 1-4 days prior to the infant’s discharge from the NICU. Parents receive the fourth COPE intervention 1 week after the infant is discharged from the hospital. Each of the four DVDs has corresponding skills-building activities that parents complete after they listen to the educational information on the DVDs.
The problem
In NICUs, families are not the primary focus of care. To nursing staff, parents are an unknown factor. Parents may silence alarms or open cribs to touch the baby, not realizing that by doing so, they are dysregulating the neonate’s delicate environment. They see nurses moving things around, and so feel they should be able to do it, too. Parents come in many varieties. Some parents sit quietly and appear overwhelmed. Some parents behave erratically. Some parents may smell of alcohol or marijuana, putting everyone in the NICU on alert. Assessing and intervening with parents is helpful to nurses, reduces tension between nurse and parent, and ensures that the daily caring for the neonate is smooth and optimal. Nurses are eager to help with parents.
Nursing perspective
From the nurses’ perspective, the parents are not the patient! Nurses have not been trained to assess and manage distressed parents. Nurses can provide basic education about the baby’s medical condition but do not have time to explain the details that overanxious parents might demand. The nurses recognize that some parents are under severe stress and do not want to leave the bedside, even to care for their own needs. The nurses recognize that some parents have their own health conditions but are unsure how to approach this issue. Nurses welcome education about how to intervene and how to refer parents to appropriate resources.
Parental perspective
Parents are distressed and uncertain about the fate of their newborns. There is an immediate need to gain as much information as possible about the baby’s medical condition and to understand what the nurses are “doing to our baby.” There may be concern that the nurse seems more bonded to the baby than the parents. There may be a lack of understanding of when the babies can be handled and what and when they can be fed. There is significant emotional distress about “not being able to take the baby home.” Parents may want to assign blame or may feel overwhelmed with guilt. For families with poor coping skills, fear and anger may predominate and can be directed at the nurses – an immediate and ever available target. Generally, parents want to be included as much as possible in the care of their children.
Postpartum disorders in the NICU
It is expected that having a baby in the NICU is stressful. However, a meta-analysis of 38 studies of stress in parents of preterm infants, compared with term infants, found that parents of preterm children experience only slightly more stress than do parents of term children. There is decreasing parental stress from the 1980s onward, probably because of the increased quality of care for preterm infants. These studies included 3,025 parents of preterm and low-birth-weight infants (PLoS One 2013;8[2]:e54992).
Over the long term, the psychological functioning of NICU parents is no different from that of control parents. A prospective randomized controlled study defined psychological distress as meeting one or more of the following criteria: any psychiatric diagnosis on the Mini-International Neuropsychiatric Interview at 2 years; Edinburgh Postnatal Depression Scale score more than 12.5 at 2 years; Hospital Anxiety and Depression Scale score more than 11.0 at 2 years, receiving treatment with antidepressants/psychotherapy/counseling over the previous 15 months (Psychosomatics 2014;55[6]:613-20).
In the short term, NICU parents are at risk for postpartum depression (PPD) with the resultant difficulty in establishing good attachment with their babies. The prevalence of PPD in mothers of term newborns is 10%-15%, compared with 28%-70% among NICU mothers (Int J Womens Health. 2014;2014[6]:975-87).
Fathers are known as the forgotten parents and experience a high prevalence of depressive symptoms. Fathers of term newborns experience depression at rates of 2%-10%, but rates of up to 60% have been reported in NICU fathers (Adv Neonatal Care. 2010 Aug;10[4]:200-3).
Prevention of psychiatric illness in family members
The NICU environment is often dimly lighted, and improving lighting prevents depression in NICU mothers. A 3-week bright-light therapy intervention improved the sleep and health outcomes of NICU mothers, who experienced less morning fatigue and depressive symptoms, and improved quality of life, compared with the control group (Biol Res Nurs. 2013 Oct;15[4] 398-406). An architect on our team is designing “quiet spaces” for parents and creating more ambient light and daylighting in our NICU.
For parents who do not want to leave the NICU, mobile computer terminals can bring education to the bedside. For parents who can leave the bedside, family educational interventions are well received (Adv Neonatal Care. 2013 Apr;13[2]:115-26).
In current practice, in our labor and delivery suite and in many NICUs, mothers are screened for postpartum depression via the Edinburgh Postnatal Depression Scale (EPDS) (Br J Psychiatry 1987 Jun;150[6]:782-6). If mothers score over 13, they are referred for further assessment. Treatment often consists of referral for individual intervention for the mother (usually sertraline and disclosures/instructions about breastfeeding, as well as supportive psychotherapy).
What does family-centered care look like?
A family perspective supports the screening of both parents, using the EPDS. This can occur on admission of the baby to the NICU and at 2-week intervals thereafter and again at discharge (J Perinatol 2013 Oct;33[10]748-53). Ideally, family functioning also can be assessed, and if needed, intervention can be offered to the whole family system.
Family screening occurs in other pediatric medical settings. High-risk families can be identified with the Psychosocial Assessment Tool (PAT) (Acta Oncol. 2015 May;54[5]:574-80).
The PAT is a brief parent self-report composed of items that assess risk associated with the child, family, and broader systems. It is currently used at 50 sites in 28 states in the United States. The PAT has been translated into Spanish, Columbian Spanish, Dutch, Brazilian Portuguese, Hebrew, Greek, Polish, Italian, Japanese, Chinese, and Korean, and is used internationally. English adaptations for Canada, the United Kingdom, Australia, New Zealand, and Singapore also are available. It has been modified for use in NICUs.
The screening enables health care providers to refer families to the appropriate service: support groups (low risk), psychoeducation (medium risk), or intensive outpatient services (high risk). This stratification allows for the appropriate use of services.
Likewise, family interventions can be thought about in tiers, similar to the risk stratification of the PAT. Tier 1 is a universal educational intervention for all parents, tier 2 parents have higher needs, and tier 3 parents need immediate intervention. The following descriptions show how this might work in practice.
Family intervention: Tier 1
•All families can be given educational material about the mental health needs of parents with a newborn in the NICU. Ideally, this material can be provided through handouts, references for further reading, and through websites accessed in the NICU. For parents who are willing to leave the NICU, they can attend support groups.
•All parents can be screened at initial contact in the NICU and then on discharge from the NICU. If the neonate stays an extended time, the parents can be screened at 2-week intervals. A high score on the EPDS screen indicates an immediate need to refer a parent. A family assessment tool, such as the PAT, can identify high-risk families for immediate referral.
•NICU nursing staff can actively address coparenting struggles. Our NICU nurses provide formal letters between nurses and parents to establish the parameters of the care of the baby, and provide direction for coparenting.
Family intervention: Tier 2
Parents identified on the PAT as having higher needs can be enrolled in psychoeducational groups, led by staff members who have behavioral health training and experience.
Family intervention: Tier 3
These parents are identified on the PAT as high risk and need significant health care services. The NICU social worker can actively work on consultation with addiction medicine, mental health, or social services.
In summary, a family approach in the NICU improves nurse-parent interactions. A focus on coparenting sets the stage for cooperation, trust, and better family outcomes. Some basic training in systems concepts and family dynamics can provide NICU staff with basic clinical skills to provide psychoeducation. Adequate screening can triage high-risk parents appropriately. For NICUs that want to implement a psychoeducational program, Melnyk’s COPE program is an evidenced-based program that is well worth implementation.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She thanks other members of the NICU team at the University of Colorado Hospital: Christy Math, Katherine Perica, and John J. White.
Families in Psychiatry: Parental alienation and shared delusional disorders
Disturbances in family emotional involvement are best understood at the extremes. At one end, there is extreme cutoff in the controversial diagnosis of parental alienation. At the other end is the extreme enmeshment in shared delusional disorders. What are the mechanisms that allow these conditions to develop? Helping families understand these mechanisms can help them change the trajectory of the family, by moving toward the middle, toward appropriate family emotional involvement.
How does enmeshment begin?
Good parents want to instill good morals, values, and behaviors in their children. Good parents want to teach their children to be good citizens, have good manners, and to treat others with respect. However, sometimes parents desire something more from their children; they want their children to continue a family business, be part of their religious organization, or to be “just like us.” Parental influence is easier when communities are isolated. When shared family beliefs are pervasive and impede the individuation of thoughts, feelings, and behaviors, these families are considered enmeshed and undifferentiated. Enmeshed families are more susceptible to indoctrination. Indoctrination is easier when there is a high level of emotional involvement, meaning that children are kept close, and differentiation and individuation are discouraged.
Using a child for one’s own needs is exploitative;however, many parents might not understand how their own unconscious psychological needs affect their children. This is seen clearly when children are rejected because they are “different.” For example, some parents have stated that a lesbian, gay, bisexual, and transgender sexual orientation is “against their religion,” and demand that their child conform to the family beliefs and norms. In these cases, the adolescent or young adult has to decide whether to leave the family, conform to its beliefs, or hide his or her identity.
Enmeshment
Emotional overinvolvement in undifferentiated enmeshed families is central to the diagnosis of shared delusional disorder. One example of a shared delusion is delusional parasitosis. This is a rare delusional disorder where the patient is convinced of being infested with worms, insects, parasites, or bacteria while no objective evidence exists to support this belief. Somatic delusions are shared with one or more members of a family in 5%-15% of cases (J. Behav. Health 2014;3:200-2).
Salvador Minuchin, Ph.D., and his colleagues outlined the impact of enmeshment in families where a child has an eating disorder. They described children so overprotected that there was a virtual moat around the family system, blocking out the world. Interpersonal differentiation in an enmeshed family system was poor, with identity fusion between parent and child. In this dynamic, the child is unable to establish a clear identity apart from the parent. Orthorexia, a term coined in 1997 by Dr. Steven Bratman, is defined as an obsession with “healthy or righteous eating.” The obsession with healthy foods can be structured within family habits. When enmeshment and family isolation are present, orthorexia can show up as a folie à famille (Heru, personal experience).
More exotic examples are known by the French terms folie à deux and folie à famille. Dr. Ernest-Charles Lasegue (Ann. Med. Psychol. 1877;18:321) was the first person to describe folie à deux. He stated that the inducer created the delusions from his/her psychosis and imposed them upon a “passive” individual; the induced subject was not truly psychotic but instead “absurdly credulous.” Several varieties are described. Folie imposée is the one we typically think of, where the naive individual has a resolution of symptoms when removed from the dominant person. Folie simultanée is where simultaneous and identical psychoses occur in two predisposed people who have had a long and intimate association with each other. There is usually no dominant partner, and separation does not alleviate the symptomatology. Folie communiquée involves the transfer of psychotic delusions after a long period of resistance by the passive partner. The recipient of the delusions subsequently develops his own delusions, independent of the primary subject’s, and these persist following separation.
Folie induite, a variant of folie communiquée, is diagnosed when new delusions are added to old ones under the influence of another deluded patient. The secondary person enriches the newly acquired delusions. Another method of classification is based on the number of individuals involved: folie à trois (three), folie à quatre (four), folie à cinq (five), and, as mentioned earlier, folie àfamille.
What is the mechanism for enmeshment? Several predisposing factors can occur: social isolation, the presence of a naive or “absurdly credulous” person, and in the case of relatives, a shared genetic predisposition. It is most common for the dominant person to drive the belief that is then accepted by dependent family members. In the case of children, there is also identification with a parent and a lack of drive for separation.
Role of alienation
At the opposite end of the spectrum is alienation, most publicly described in the disputed diagnosis of parental alienation syndrome (PAS) (The Parental Alienation Syndrome, 2nd ed., Cresskill, N.J.:Creative Therapeutics Inc., 1998). PAS sometimes arises in the context of child-custody disputes. The primary manifestation is the child’s unjustified denigration of one parent. According to Dr. William Bernet and Amy J.L. Baker, Ph.D., PAS features “abnormal, maladaptive behavior (refusal to have a relationship with a loving parent) that is driven by an abnormal mental state (the false belief that the rejected parent is evil, dangerous, or unworthy of love)” (J. Am. Acad. Psychiatry Law 2013;41:98-104). There is considered to be brainwashing of the child by one parent against the other parent in order to gain leverage in a court of law.
What is the mechanism in alienation? Enmeshment and overidentification of the child with the favored custodial parent is common. The child depends on this adult for his survival. The process of divorce can increase enmeshment with the custodial parent. The parent might reinforce the enmeshment by instilling fear of the “other” parent. The belief that the “other parent” is “bad” is transmitted through conscious and unconscious mechanisms.
The conscious mechanism is direct expression of anger toward the alienated parent. The anger might be motivated by rejection or as revenge for rejection with a desire to punish. The unconscious mechanisms include projective identification. In this situation, anger is seen as being embodied within the “other.” The projecting parent who continues to “hate” keeps the children tied to her out of projected fear of the “other.” The parent who uses projection is likely to have a primitive character structure. The child of the narcissistic custodial parent then acts out the shame and rage at the failure of the marriage.
These domestic tragedies have been around since the beginning of time. In Greek mythology, Medea, having been abandoned by Jason, took her revenge by murdering her two children. “Hell hath no fury like a woman scorned” is a paraphrase from William Congreve’s The Mourning Bride (1697).
What does the DSM-5 say?
Are these disorders and syndromes “real” psychiatric illnesses? The DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.
Those who advocated for inclusion of PAS cited the benefits that follow from a legitimate diagnosis such as legitimatizing problems that family therapists and psychotherapists encounter, allowing insurance coverage, and stimulating research. However, PAS was rejected as not having a good enough scientific basis.
Managing affective involvement
How does the psychiatrist manage families where emotional involvement is extreme? Psychiatrists first need to decide whether the family is capable of making changes and is willing to work on structural change within the family. If not, we can help patients remove themselves from destructive family situations. If the patient in your office wants to leave the family system or minimize the impact of the family system, individual psychotherapy that identifies the impact of family dysfunction, such as cognitive-behavioral therapy, can be used as a type of deprogramming. Exit strategies also can be discussed.
Al-Anon, for example, clarifies the influence of the family system on family members’ well-being by asking several questions, including:
Do you tell lies to cover up for someone else’s drinking?
Do you feel that if they cared about you, they would stop drinking to please you?
Do you make threats, such as, “If you don’t stop drinking, I’ll leave you?”
Are you afraid to upset someone for fear it will set off a drinking bout?
Have you considered calling the police for help in fear of abuse?
Do you feel like a failure because you can’t control the drinking?
Do you think that if they stopped drinking, your other problems would be solved?
If you think there is capacity for family change, the following strategies are helpful:
1. Education about appropriate differentiation
According to Dr. Murray Bowen, one of the main tasks of individuation is finding the right level of differentiation from parents. At one end of the differentiation spectrum is emotional fusion, and at the other end is emotional cutoff (disconnection between family members or refusal to engage with certain family members) (see “Family Evaluation,” New York: W.W. Norton & Co., 1988).
When family enmeshment is present, we can educate the family about individuation. In this way, the family develops a greater intellectual understanding of how they function, compared to their cultural norm. The family may benefit from creating a genogram that clarifies patterns of emotional involvement in their family of origin. Look for intergenerational patterns, and discuss how emotional differentiation occurred in prior generations. Teach the family about the emotional tasks of differentiation.
2. If there is alienation, parse out the reasons
Clarify conscious mechanisms that force the child to reject the other parent. Help the parent understand the consequences for the child in having no access to the other parent. Again, using a genogram helps identify intergenerational patterns, such as emotional cutoffs. Explore the reason for prior family emotional cutoffs. Identify typical patterns in the family for managing anger and conflicts.
In cases of divorce of the custodial parent, look at how anger is managed and stages of grief. Look for the presence of narcissistic injury. Discuss what a good divorce is and the healthiest way for the child to grow up. Help the parent manage and process her own affect without contaminating the child. It is not the role of the child to be the parental caregiver.
Help the child see that there was a loving relationship in the past and that new family goals can be created. The child also might experience anger and grief, and it is important to educate the child about how to manage those feelings appropriately rather than using blame and alienation. Help the child be empowered by positive ideals rather than negative emotions.
Psychiatrists often avoid working with these families, and perceive them as stuck and unable to change. This might be true for some families but certainly not all. Many families find themselves in situations that they do not understand and with problems they need help resolving. Educating and working with families who are stuck and who ask for and want change can change the life trajectory of many people.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).
Disturbances in family emotional involvement are best understood at the extremes. At one end, there is extreme cutoff in the controversial diagnosis of parental alienation. At the other end is the extreme enmeshment in shared delusional disorders. What are the mechanisms that allow these conditions to develop? Helping families understand these mechanisms can help them change the trajectory of the family, by moving toward the middle, toward appropriate family emotional involvement.
How does enmeshment begin?
Good parents want to instill good morals, values, and behaviors in their children. Good parents want to teach their children to be good citizens, have good manners, and to treat others with respect. However, sometimes parents desire something more from their children; they want their children to continue a family business, be part of their religious organization, or to be “just like us.” Parental influence is easier when communities are isolated. When shared family beliefs are pervasive and impede the individuation of thoughts, feelings, and behaviors, these families are considered enmeshed and undifferentiated. Enmeshed families are more susceptible to indoctrination. Indoctrination is easier when there is a high level of emotional involvement, meaning that children are kept close, and differentiation and individuation are discouraged.
Using a child for one’s own needs is exploitative;however, many parents might not understand how their own unconscious psychological needs affect their children. This is seen clearly when children are rejected because they are “different.” For example, some parents have stated that a lesbian, gay, bisexual, and transgender sexual orientation is “against their religion,” and demand that their child conform to the family beliefs and norms. In these cases, the adolescent or young adult has to decide whether to leave the family, conform to its beliefs, or hide his or her identity.
Enmeshment
Emotional overinvolvement in undifferentiated enmeshed families is central to the diagnosis of shared delusional disorder. One example of a shared delusion is delusional parasitosis. This is a rare delusional disorder where the patient is convinced of being infested with worms, insects, parasites, or bacteria while no objective evidence exists to support this belief. Somatic delusions are shared with one or more members of a family in 5%-15% of cases (J. Behav. Health 2014;3:200-2).
Salvador Minuchin, Ph.D., and his colleagues outlined the impact of enmeshment in families where a child has an eating disorder. They described children so overprotected that there was a virtual moat around the family system, blocking out the world. Interpersonal differentiation in an enmeshed family system was poor, with identity fusion between parent and child. In this dynamic, the child is unable to establish a clear identity apart from the parent. Orthorexia, a term coined in 1997 by Dr. Steven Bratman, is defined as an obsession with “healthy or righteous eating.” The obsession with healthy foods can be structured within family habits. When enmeshment and family isolation are present, orthorexia can show up as a folie à famille (Heru, personal experience).
More exotic examples are known by the French terms folie à deux and folie à famille. Dr. Ernest-Charles Lasegue (Ann. Med. Psychol. 1877;18:321) was the first person to describe folie à deux. He stated that the inducer created the delusions from his/her psychosis and imposed them upon a “passive” individual; the induced subject was not truly psychotic but instead “absurdly credulous.” Several varieties are described. Folie imposée is the one we typically think of, where the naive individual has a resolution of symptoms when removed from the dominant person. Folie simultanée is where simultaneous and identical psychoses occur in two predisposed people who have had a long and intimate association with each other. There is usually no dominant partner, and separation does not alleviate the symptomatology. Folie communiquée involves the transfer of psychotic delusions after a long period of resistance by the passive partner. The recipient of the delusions subsequently develops his own delusions, independent of the primary subject’s, and these persist following separation.
Folie induite, a variant of folie communiquée, is diagnosed when new delusions are added to old ones under the influence of another deluded patient. The secondary person enriches the newly acquired delusions. Another method of classification is based on the number of individuals involved: folie à trois (three), folie à quatre (four), folie à cinq (five), and, as mentioned earlier, folie àfamille.
What is the mechanism for enmeshment? Several predisposing factors can occur: social isolation, the presence of a naive or “absurdly credulous” person, and in the case of relatives, a shared genetic predisposition. It is most common for the dominant person to drive the belief that is then accepted by dependent family members. In the case of children, there is also identification with a parent and a lack of drive for separation.
Role of alienation
At the opposite end of the spectrum is alienation, most publicly described in the disputed diagnosis of parental alienation syndrome (PAS) (The Parental Alienation Syndrome, 2nd ed., Cresskill, N.J.:Creative Therapeutics Inc., 1998). PAS sometimes arises in the context of child-custody disputes. The primary manifestation is the child’s unjustified denigration of one parent. According to Dr. William Bernet and Amy J.L. Baker, Ph.D., PAS features “abnormal, maladaptive behavior (refusal to have a relationship with a loving parent) that is driven by an abnormal mental state (the false belief that the rejected parent is evil, dangerous, or unworthy of love)” (J. Am. Acad. Psychiatry Law 2013;41:98-104). There is considered to be brainwashing of the child by one parent against the other parent in order to gain leverage in a court of law.
What is the mechanism in alienation? Enmeshment and overidentification of the child with the favored custodial parent is common. The child depends on this adult for his survival. The process of divorce can increase enmeshment with the custodial parent. The parent might reinforce the enmeshment by instilling fear of the “other” parent. The belief that the “other parent” is “bad” is transmitted through conscious and unconscious mechanisms.
The conscious mechanism is direct expression of anger toward the alienated parent. The anger might be motivated by rejection or as revenge for rejection with a desire to punish. The unconscious mechanisms include projective identification. In this situation, anger is seen as being embodied within the “other.” The projecting parent who continues to “hate” keeps the children tied to her out of projected fear of the “other.” The parent who uses projection is likely to have a primitive character structure. The child of the narcissistic custodial parent then acts out the shame and rage at the failure of the marriage.
These domestic tragedies have been around since the beginning of time. In Greek mythology, Medea, having been abandoned by Jason, took her revenge by murdering her two children. “Hell hath no fury like a woman scorned” is a paraphrase from William Congreve’s The Mourning Bride (1697).
What does the DSM-5 say?
Are these disorders and syndromes “real” psychiatric illnesses? The DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.
Those who advocated for inclusion of PAS cited the benefits that follow from a legitimate diagnosis such as legitimatizing problems that family therapists and psychotherapists encounter, allowing insurance coverage, and stimulating research. However, PAS was rejected as not having a good enough scientific basis.
Managing affective involvement
How does the psychiatrist manage families where emotional involvement is extreme? Psychiatrists first need to decide whether the family is capable of making changes and is willing to work on structural change within the family. If not, we can help patients remove themselves from destructive family situations. If the patient in your office wants to leave the family system or minimize the impact of the family system, individual psychotherapy that identifies the impact of family dysfunction, such as cognitive-behavioral therapy, can be used as a type of deprogramming. Exit strategies also can be discussed.
Al-Anon, for example, clarifies the influence of the family system on family members’ well-being by asking several questions, including:
Do you tell lies to cover up for someone else’s drinking?
Do you feel that if they cared about you, they would stop drinking to please you?
Do you make threats, such as, “If you don’t stop drinking, I’ll leave you?”
Are you afraid to upset someone for fear it will set off a drinking bout?
Have you considered calling the police for help in fear of abuse?
Do you feel like a failure because you can’t control the drinking?
Do you think that if they stopped drinking, your other problems would be solved?
If you think there is capacity for family change, the following strategies are helpful:
1. Education about appropriate differentiation
According to Dr. Murray Bowen, one of the main tasks of individuation is finding the right level of differentiation from parents. At one end of the differentiation spectrum is emotional fusion, and at the other end is emotional cutoff (disconnection between family members or refusal to engage with certain family members) (see “Family Evaluation,” New York: W.W. Norton & Co., 1988).
When family enmeshment is present, we can educate the family about individuation. In this way, the family develops a greater intellectual understanding of how they function, compared to their cultural norm. The family may benefit from creating a genogram that clarifies patterns of emotional involvement in their family of origin. Look for intergenerational patterns, and discuss how emotional differentiation occurred in prior generations. Teach the family about the emotional tasks of differentiation.
2. If there is alienation, parse out the reasons
Clarify conscious mechanisms that force the child to reject the other parent. Help the parent understand the consequences for the child in having no access to the other parent. Again, using a genogram helps identify intergenerational patterns, such as emotional cutoffs. Explore the reason for prior family emotional cutoffs. Identify typical patterns in the family for managing anger and conflicts.
In cases of divorce of the custodial parent, look at how anger is managed and stages of grief. Look for the presence of narcissistic injury. Discuss what a good divorce is and the healthiest way for the child to grow up. Help the parent manage and process her own affect without contaminating the child. It is not the role of the child to be the parental caregiver.
Help the child see that there was a loving relationship in the past and that new family goals can be created. The child also might experience anger and grief, and it is important to educate the child about how to manage those feelings appropriately rather than using blame and alienation. Help the child be empowered by positive ideals rather than negative emotions.
Psychiatrists often avoid working with these families, and perceive them as stuck and unable to change. This might be true for some families but certainly not all. Many families find themselves in situations that they do not understand and with problems they need help resolving. Educating and working with families who are stuck and who ask for and want change can change the life trajectory of many people.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).
Disturbances in family emotional involvement are best understood at the extremes. At one end, there is extreme cutoff in the controversial diagnosis of parental alienation. At the other end is the extreme enmeshment in shared delusional disorders. What are the mechanisms that allow these conditions to develop? Helping families understand these mechanisms can help them change the trajectory of the family, by moving toward the middle, toward appropriate family emotional involvement.
How does enmeshment begin?
Good parents want to instill good morals, values, and behaviors in their children. Good parents want to teach their children to be good citizens, have good manners, and to treat others with respect. However, sometimes parents desire something more from their children; they want their children to continue a family business, be part of their religious organization, or to be “just like us.” Parental influence is easier when communities are isolated. When shared family beliefs are pervasive and impede the individuation of thoughts, feelings, and behaviors, these families are considered enmeshed and undifferentiated. Enmeshed families are more susceptible to indoctrination. Indoctrination is easier when there is a high level of emotional involvement, meaning that children are kept close, and differentiation and individuation are discouraged.
Using a child for one’s own needs is exploitative;however, many parents might not understand how their own unconscious psychological needs affect their children. This is seen clearly when children are rejected because they are “different.” For example, some parents have stated that a lesbian, gay, bisexual, and transgender sexual orientation is “against their religion,” and demand that their child conform to the family beliefs and norms. In these cases, the adolescent or young adult has to decide whether to leave the family, conform to its beliefs, or hide his or her identity.
Enmeshment
Emotional overinvolvement in undifferentiated enmeshed families is central to the diagnosis of shared delusional disorder. One example of a shared delusion is delusional parasitosis. This is a rare delusional disorder where the patient is convinced of being infested with worms, insects, parasites, or bacteria while no objective evidence exists to support this belief. Somatic delusions are shared with one or more members of a family in 5%-15% of cases (J. Behav. Health 2014;3:200-2).
Salvador Minuchin, Ph.D., and his colleagues outlined the impact of enmeshment in families where a child has an eating disorder. They described children so overprotected that there was a virtual moat around the family system, blocking out the world. Interpersonal differentiation in an enmeshed family system was poor, with identity fusion between parent and child. In this dynamic, the child is unable to establish a clear identity apart from the parent. Orthorexia, a term coined in 1997 by Dr. Steven Bratman, is defined as an obsession with “healthy or righteous eating.” The obsession with healthy foods can be structured within family habits. When enmeshment and family isolation are present, orthorexia can show up as a folie à famille (Heru, personal experience).
More exotic examples are known by the French terms folie à deux and folie à famille. Dr. Ernest-Charles Lasegue (Ann. Med. Psychol. 1877;18:321) was the first person to describe folie à deux. He stated that the inducer created the delusions from his/her psychosis and imposed them upon a “passive” individual; the induced subject was not truly psychotic but instead “absurdly credulous.” Several varieties are described. Folie imposée is the one we typically think of, where the naive individual has a resolution of symptoms when removed from the dominant person. Folie simultanée is where simultaneous and identical psychoses occur in two predisposed people who have had a long and intimate association with each other. There is usually no dominant partner, and separation does not alleviate the symptomatology. Folie communiquée involves the transfer of psychotic delusions after a long period of resistance by the passive partner. The recipient of the delusions subsequently develops his own delusions, independent of the primary subject’s, and these persist following separation.
Folie induite, a variant of folie communiquée, is diagnosed when new delusions are added to old ones under the influence of another deluded patient. The secondary person enriches the newly acquired delusions. Another method of classification is based on the number of individuals involved: folie à trois (three), folie à quatre (four), folie à cinq (five), and, as mentioned earlier, folie àfamille.
What is the mechanism for enmeshment? Several predisposing factors can occur: social isolation, the presence of a naive or “absurdly credulous” person, and in the case of relatives, a shared genetic predisposition. It is most common for the dominant person to drive the belief that is then accepted by dependent family members. In the case of children, there is also identification with a parent and a lack of drive for separation.
Role of alienation
At the opposite end of the spectrum is alienation, most publicly described in the disputed diagnosis of parental alienation syndrome (PAS) (The Parental Alienation Syndrome, 2nd ed., Cresskill, N.J.:Creative Therapeutics Inc., 1998). PAS sometimes arises in the context of child-custody disputes. The primary manifestation is the child’s unjustified denigration of one parent. According to Dr. William Bernet and Amy J.L. Baker, Ph.D., PAS features “abnormal, maladaptive behavior (refusal to have a relationship with a loving parent) that is driven by an abnormal mental state (the false belief that the rejected parent is evil, dangerous, or unworthy of love)” (J. Am. Acad. Psychiatry Law 2013;41:98-104). There is considered to be brainwashing of the child by one parent against the other parent in order to gain leverage in a court of law.
What is the mechanism in alienation? Enmeshment and overidentification of the child with the favored custodial parent is common. The child depends on this adult for his survival. The process of divorce can increase enmeshment with the custodial parent. The parent might reinforce the enmeshment by instilling fear of the “other” parent. The belief that the “other parent” is “bad” is transmitted through conscious and unconscious mechanisms.
The conscious mechanism is direct expression of anger toward the alienated parent. The anger might be motivated by rejection or as revenge for rejection with a desire to punish. The unconscious mechanisms include projective identification. In this situation, anger is seen as being embodied within the “other.” The projecting parent who continues to “hate” keeps the children tied to her out of projected fear of the “other.” The parent who uses projection is likely to have a primitive character structure. The child of the narcissistic custodial parent then acts out the shame and rage at the failure of the marriage.
These domestic tragedies have been around since the beginning of time. In Greek mythology, Medea, having been abandoned by Jason, took her revenge by murdering her two children. “Hell hath no fury like a woman scorned” is a paraphrase from William Congreve’s The Mourning Bride (1697).
What does the DSM-5 say?
Are these disorders and syndromes “real” psychiatric illnesses? The DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.
Those who advocated for inclusion of PAS cited the benefits that follow from a legitimate diagnosis such as legitimatizing problems that family therapists and psychotherapists encounter, allowing insurance coverage, and stimulating research. However, PAS was rejected as not having a good enough scientific basis.
Managing affective involvement
How does the psychiatrist manage families where emotional involvement is extreme? Psychiatrists first need to decide whether the family is capable of making changes and is willing to work on structural change within the family. If not, we can help patients remove themselves from destructive family situations. If the patient in your office wants to leave the family system or minimize the impact of the family system, individual psychotherapy that identifies the impact of family dysfunction, such as cognitive-behavioral therapy, can be used as a type of deprogramming. Exit strategies also can be discussed.
Al-Anon, for example, clarifies the influence of the family system on family members’ well-being by asking several questions, including:
Do you tell lies to cover up for someone else’s drinking?
Do you feel that if they cared about you, they would stop drinking to please you?
Do you make threats, such as, “If you don’t stop drinking, I’ll leave you?”
Are you afraid to upset someone for fear it will set off a drinking bout?
Have you considered calling the police for help in fear of abuse?
Do you feel like a failure because you can’t control the drinking?
Do you think that if they stopped drinking, your other problems would be solved?
If you think there is capacity for family change, the following strategies are helpful:
1. Education about appropriate differentiation
According to Dr. Murray Bowen, one of the main tasks of individuation is finding the right level of differentiation from parents. At one end of the differentiation spectrum is emotional fusion, and at the other end is emotional cutoff (disconnection between family members or refusal to engage with certain family members) (see “Family Evaluation,” New York: W.W. Norton & Co., 1988).
When family enmeshment is present, we can educate the family about individuation. In this way, the family develops a greater intellectual understanding of how they function, compared to their cultural norm. The family may benefit from creating a genogram that clarifies patterns of emotional involvement in their family of origin. Look for intergenerational patterns, and discuss how emotional differentiation occurred in prior generations. Teach the family about the emotional tasks of differentiation.
2. If there is alienation, parse out the reasons
Clarify conscious mechanisms that force the child to reject the other parent. Help the parent understand the consequences for the child in having no access to the other parent. Again, using a genogram helps identify intergenerational patterns, such as emotional cutoffs. Explore the reason for prior family emotional cutoffs. Identify typical patterns in the family for managing anger and conflicts.
In cases of divorce of the custodial parent, look at how anger is managed and stages of grief. Look for the presence of narcissistic injury. Discuss what a good divorce is and the healthiest way for the child to grow up. Help the parent manage and process her own affect without contaminating the child. It is not the role of the child to be the parental caregiver.
Help the child see that there was a loving relationship in the past and that new family goals can be created. The child also might experience anger and grief, and it is important to educate the child about how to manage those feelings appropriately rather than using blame and alienation. Help the child be empowered by positive ideals rather than negative emotions.
Psychiatrists often avoid working with these families, and perceive them as stuck and unable to change. This might be true for some families but certainly not all. Many families find themselves in situations that they do not understand and with problems they need help resolving. Educating and working with families who are stuck and who ask for and want change can change the life trajectory of many people.
Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013).
The practice of caring
“To look deep into your child’s eyes and see in him both yourself and something utterly strange, and then to develop a zealous attachment to every aspect of him, is to achieve parenthood’s self-regarding, yet unselfish, abandon. It is astonishing how often such mutuality had been realized – how frequently parents who had supposed that they couldn’t care for an exceptional child discover that they can. The parental predisposition to love prevails in the most harrowing of circumstances. There is more imagination in the world than one might think.”
Andrew Solomon, “Far from the Tree: Parents, Children, and the Search for Identity” (New York: Scribner, 2012).
In his most recent book, writer and lecturer Andrew Solomon describes a deep love that leads to redemption. His case histories describe parents becoming virtuous through the practice of caring. Solomon records both their loving and their suffering. He does not see caring, necessarily, as an inherent trait but rather sees virtue emerging from the act of caring. The philosophical study of caring and virtue is known as the “ethics of care.” This column considers the ethics of care in relation to our patients and their families.
‘Ethics of care’ origins
Care ethics emerged as a distinct moral theory when psychologist Carol Gilligan, Ph.D., and philosopher Nel Noddings, Ph.D., labeled traditional moral theory as biased toward the male gender. They asserted the “voice of care” as a female alternative to Lawrence Kohlberg’s male “voice of justice.”
Originally, therefore, care ethics were described as a feminist ethic. To drive home this point, the suffragettes argued that granting voting rights to (white) women would lead to moral, social improvements! The naive assumption was that women by nature had traits of compassion, empathy, nurturance, and kindness, as exemplified by the good mother. This is known as feminist essentialism. Taking this gendered view further, Nel Noddings states that the domestic sphere is the originator and nurturer of justice, in the sense that the best social policies are identified, modeled, and sustained by practices in the “best families.” This is a difficult position: Who decides on the characteristics of “best families?”
Practice of caring vs. ethics
The practice of caring can be described as actions performed by the carer, or as a value, or as a disposition or virtue that resides in the person who is caring. The following points summarize the current positions of philosophers who identify themselves as care ethicists.
• Care reflects a specific type of moral reasoning. This is the Kohlberg-Gilligan argument of male vs. female reasoning. Although care and justice have evolved as distinct ethical practices and ideals, they are not necessarily incompatible. As gender roles soften and gender as a concept becomes more blurry, care and justice can be intertwined. Reasoning does not have to be either justice based or care based.
• Care is the practice of caring for someone (Andrew Solomon’s case histories). This stance does not romanticize the practice of caring. This stance does not consider caring as a trait or disposition. This stance acknowledges the suffering and hardship in caring that can coexist with love. This stance points to the potential for individual spiritual and personal growth that can accompany caregiving. Andrew Solomon would agree to the notion of stages of caring (“Moral Boundaries: A Political Argument for an Ethic of Care,” New York: Routledge, 1994). These stages are: (1) attentiveness, becoming aware of need; (2) responsibility, a willingness to respond and take care of need; (3) competence, the skill of providing good and successful care; and (4) responsiveness, consideration of the position of others as they see it and recognition of the potential for abuse in care. The practice of caring is more of a daily reality than the abstract virtue.
• Care is an inherent virtue. This stance includes both feminist essentialism and feminist care ethics. In feminist essentialism, the process of moral development follows gender roles. The prototypical caregiving mother and a care-receiving child romanticize and elevate motherhood to the ideal practice of care. Feminist care ethicists avoid this essentialism by situating caring practices in place and time. They describe care as the symbolic practice rather than actual practice of women. Feminist care ethicists explore care as a gender neutral activity, advancing a utopian vision of care as a gender-neutral activity and virtue. Cognitive capacities and virtues associated with mothering, (better described as being associated with parenting), are seen as essential to the concept of care. These virtues are preservative love (work of protection with cheerfulness and humility), fostering growth (sponsoring or nurturing a child’s unfolding), and training for social acceptability (a process of socialization that requires conscience and a struggle for authenticity). This position also is reflected in Solomon’s ethics of care.
• Care is an inherent character trait or disposition. This stance understands care ethics as a form of virtue ethics, with care being a central virtue. There is an emphasis on relationship as fundamental to being, and the parent-child relationship as paramount. Virtue ethics views emotions such as empathy, compassion, and sensitivity as prerequisites for moral development and the ethics of care.
• Care as social justice and political imperative. One of the earliest objections to an ethics of care was that it valorized the oppression of women. Nietzsche held that those who are oppressed develop moral theories that reaffirm subservient traits as virtues. Women who perform the work of care often perform this care to their own economic disadvantage. A social justice perspective implies that the voice of care is the voice of an oppressed person, and eschews the idea that moral maturity means self-sacrifice and self-effacement. Care ethics informed by a social justice perspective asks who is caring for whom and whether this relationship is just.
When care ethics are applied to domestic politics, economic justice, international relations, and culture, interesting ideas emerge. Governments and businesses become responsible for support in sickness, disability, old age, bad luck, and reversal of fortune, for providing protection, health care, and clean environments, and for upholding the rights of individuals. A focus on autonomy, independence, and self-determination, which traditionally are seen as male traits, devalues interdependence and relatedness, which traditionally are seen as female values. Care ethics suggest that we replace hierarchy and domination that is based on gender, class, race, and ethnicity with cooperation and attention to interdependency. Interdependency is ubiquitous, and care ethics is a political theory with universal application. The practice of caring has no political affiliation; however, if we had founding mothers instead of founding fathers, would the United States be based more on ethics of care?
•The caring professions. The practice of caring is a practice that helps individuals meet their basic needs, maintain capabilities, and alleviate pain and suffering, so they can survive and function in society. Using this definition, the practice of care does not require any emotional attachment. Using this definition, the activity itself is a virtuous moral position. The health care professions mostly provide “services” rather than “care.” Is empathy a necessary ingredient for the practice of care? Many people believe so, and organizations such as the Watson Caring Science Institute (watsoncaringscience.org) are dedicated to putting the caring back into health care.
Meaning for the psychiatrist
When caregivers of patients with dementia were asked how they felt about caregiving, they responded positively. Caregiving felt good. Here is a listing of some their responses:
“Feeling needed and responsible.”
“Feeling good inside, doing for someone what you want for yourself and knowing I’ve done my best.”
“Being able to help.”
“To brighten her days.”
“I know he is being cared for the way he is used to.”
“I feel that she is loved and not alone.”
These caregivers were mostly spouses (61%), with an average of 3.1 caregiving years. Caregivers reported that their relatives were moderately disabled, but they perceived more reward than burden (Int. J. Geriatr. Psychiatry, 2004;19:533-7). The caregivers’ quality of life also proved similar to those in an age-controlled normal community sample. So if caregiving can be carried out without significantly affecting quality of life, caregiving can be more rewarding than burdensome.
Questions for the family psychiatrist:
• How am I caring for my patients and their families?
• What does it mean to care rather than provide a service?
• How has my psychiatric training changed how I perceive caring? Do I now care in a different way?
• Has the way I care developed through my practice of caring?
• Where am I in the stages of caring?
• When does caring mean advocacy?
Questions to ask patients and their families:
• Do you experience reward in caregiving?
• Are there ways to sustain and enhance the satisfaction and reward of caring?
• How might you explore the practice of caring?
• Has caring been redeeming for you?
• Has caring brought individual growth for you, despite the hardships?
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 Professionals” (New York: Routledge, 2013). Some of the research for this article came from The Internet Encyclopedia of Philosophy.
“To look deep into your child’s eyes and see in him both yourself and something utterly strange, and then to develop a zealous attachment to every aspect of him, is to achieve parenthood’s self-regarding, yet unselfish, abandon. It is astonishing how often such mutuality had been realized – how frequently parents who had supposed that they couldn’t care for an exceptional child discover that they can. The parental predisposition to love prevails in the most harrowing of circumstances. There is more imagination in the world than one might think.”
Andrew Solomon, “Far from the Tree: Parents, Children, and the Search for Identity” (New York: Scribner, 2012).
In his most recent book, writer and lecturer Andrew Solomon describes a deep love that leads to redemption. His case histories describe parents becoming virtuous through the practice of caring. Solomon records both their loving and their suffering. He does not see caring, necessarily, as an inherent trait but rather sees virtue emerging from the act of caring. The philosophical study of caring and virtue is known as the “ethics of care.” This column considers the ethics of care in relation to our patients and their families.
‘Ethics of care’ origins
Care ethics emerged as a distinct moral theory when psychologist Carol Gilligan, Ph.D., and philosopher Nel Noddings, Ph.D., labeled traditional moral theory as biased toward the male gender. They asserted the “voice of care” as a female alternative to Lawrence Kohlberg’s male “voice of justice.”
Originally, therefore, care ethics were described as a feminist ethic. To drive home this point, the suffragettes argued that granting voting rights to (white) women would lead to moral, social improvements! The naive assumption was that women by nature had traits of compassion, empathy, nurturance, and kindness, as exemplified by the good mother. This is known as feminist essentialism. Taking this gendered view further, Nel Noddings states that the domestic sphere is the originator and nurturer of justice, in the sense that the best social policies are identified, modeled, and sustained by practices in the “best families.” This is a difficult position: Who decides on the characteristics of “best families?”
Practice of caring vs. ethics
The practice of caring can be described as actions performed by the carer, or as a value, or as a disposition or virtue that resides in the person who is caring. The following points summarize the current positions of philosophers who identify themselves as care ethicists.
• Care reflects a specific type of moral reasoning. This is the Kohlberg-Gilligan argument of male vs. female reasoning. Although care and justice have evolved as distinct ethical practices and ideals, they are not necessarily incompatible. As gender roles soften and gender as a concept becomes more blurry, care and justice can be intertwined. Reasoning does not have to be either justice based or care based.
• Care is the practice of caring for someone (Andrew Solomon’s case histories). This stance does not romanticize the practice of caring. This stance does not consider caring as a trait or disposition. This stance acknowledges the suffering and hardship in caring that can coexist with love. This stance points to the potential for individual spiritual and personal growth that can accompany caregiving. Andrew Solomon would agree to the notion of stages of caring (“Moral Boundaries: A Political Argument for an Ethic of Care,” New York: Routledge, 1994). These stages are: (1) attentiveness, becoming aware of need; (2) responsibility, a willingness to respond and take care of need; (3) competence, the skill of providing good and successful care; and (4) responsiveness, consideration of the position of others as they see it and recognition of the potential for abuse in care. The practice of caring is more of a daily reality than the abstract virtue.
• Care is an inherent virtue. This stance includes both feminist essentialism and feminist care ethics. In feminist essentialism, the process of moral development follows gender roles. The prototypical caregiving mother and a care-receiving child romanticize and elevate motherhood to the ideal practice of care. Feminist care ethicists avoid this essentialism by situating caring practices in place and time. They describe care as the symbolic practice rather than actual practice of women. Feminist care ethicists explore care as a gender neutral activity, advancing a utopian vision of care as a gender-neutral activity and virtue. Cognitive capacities and virtues associated with mothering, (better described as being associated with parenting), are seen as essential to the concept of care. These virtues are preservative love (work of protection with cheerfulness and humility), fostering growth (sponsoring or nurturing a child’s unfolding), and training for social acceptability (a process of socialization that requires conscience and a struggle for authenticity). This position also is reflected in Solomon’s ethics of care.
• Care is an inherent character trait or disposition. This stance understands care ethics as a form of virtue ethics, with care being a central virtue. There is an emphasis on relationship as fundamental to being, and the parent-child relationship as paramount. Virtue ethics views emotions such as empathy, compassion, and sensitivity as prerequisites for moral development and the ethics of care.
• Care as social justice and political imperative. One of the earliest objections to an ethics of care was that it valorized the oppression of women. Nietzsche held that those who are oppressed develop moral theories that reaffirm subservient traits as virtues. Women who perform the work of care often perform this care to their own economic disadvantage. A social justice perspective implies that the voice of care is the voice of an oppressed person, and eschews the idea that moral maturity means self-sacrifice and self-effacement. Care ethics informed by a social justice perspective asks who is caring for whom and whether this relationship is just.
When care ethics are applied to domestic politics, economic justice, international relations, and culture, interesting ideas emerge. Governments and businesses become responsible for support in sickness, disability, old age, bad luck, and reversal of fortune, for providing protection, health care, and clean environments, and for upholding the rights of individuals. A focus on autonomy, independence, and self-determination, which traditionally are seen as male traits, devalues interdependence and relatedness, which traditionally are seen as female values. Care ethics suggest that we replace hierarchy and domination that is based on gender, class, race, and ethnicity with cooperation and attention to interdependency. Interdependency is ubiquitous, and care ethics is a political theory with universal application. The practice of caring has no political affiliation; however, if we had founding mothers instead of founding fathers, would the United States be based more on ethics of care?
•The caring professions. The practice of caring is a practice that helps individuals meet their basic needs, maintain capabilities, and alleviate pain and suffering, so they can survive and function in society. Using this definition, the practice of care does not require any emotional attachment. Using this definition, the activity itself is a virtuous moral position. The health care professions mostly provide “services” rather than “care.” Is empathy a necessary ingredient for the practice of care? Many people believe so, and organizations such as the Watson Caring Science Institute (watsoncaringscience.org) are dedicated to putting the caring back into health care.
Meaning for the psychiatrist
When caregivers of patients with dementia were asked how they felt about caregiving, they responded positively. Caregiving felt good. Here is a listing of some their responses:
“Feeling needed and responsible.”
“Feeling good inside, doing for someone what you want for yourself and knowing I’ve done my best.”
“Being able to help.”
“To brighten her days.”
“I know he is being cared for the way he is used to.”
“I feel that she is loved and not alone.”
These caregivers were mostly spouses (61%), with an average of 3.1 caregiving years. Caregivers reported that their relatives were moderately disabled, but they perceived more reward than burden (Int. J. Geriatr. Psychiatry, 2004;19:533-7). The caregivers’ quality of life also proved similar to those in an age-controlled normal community sample. So if caregiving can be carried out without significantly affecting quality of life, caregiving can be more rewarding than burdensome.
Questions for the family psychiatrist:
• How am I caring for my patients and their families?
• What does it mean to care rather than provide a service?
• How has my psychiatric training changed how I perceive caring? Do I now care in a different way?
• Has the way I care developed through my practice of caring?
• Where am I in the stages of caring?
• When does caring mean advocacy?
Questions to ask patients and their families:
• Do you experience reward in caregiving?
• Are there ways to sustain and enhance the satisfaction and reward of caring?
• How might you explore the practice of caring?
• Has caring been redeeming for you?
• Has caring brought individual growth for you, despite the hardships?
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 Professionals” (New York: Routledge, 2013). Some of the research for this article came from The Internet Encyclopedia of Philosophy.
“To look deep into your child’s eyes and see in him both yourself and something utterly strange, and then to develop a zealous attachment to every aspect of him, is to achieve parenthood’s self-regarding, yet unselfish, abandon. It is astonishing how often such mutuality had been realized – how frequently parents who had supposed that they couldn’t care for an exceptional child discover that they can. The parental predisposition to love prevails in the most harrowing of circumstances. There is more imagination in the world than one might think.”
Andrew Solomon, “Far from the Tree: Parents, Children, and the Search for Identity” (New York: Scribner, 2012).
In his most recent book, writer and lecturer Andrew Solomon describes a deep love that leads to redemption. His case histories describe parents becoming virtuous through the practice of caring. Solomon records both their loving and their suffering. He does not see caring, necessarily, as an inherent trait but rather sees virtue emerging from the act of caring. The philosophical study of caring and virtue is known as the “ethics of care.” This column considers the ethics of care in relation to our patients and their families.
‘Ethics of care’ origins
Care ethics emerged as a distinct moral theory when psychologist Carol Gilligan, Ph.D., and philosopher Nel Noddings, Ph.D., labeled traditional moral theory as biased toward the male gender. They asserted the “voice of care” as a female alternative to Lawrence Kohlberg’s male “voice of justice.”
Originally, therefore, care ethics were described as a feminist ethic. To drive home this point, the suffragettes argued that granting voting rights to (white) women would lead to moral, social improvements! The naive assumption was that women by nature had traits of compassion, empathy, nurturance, and kindness, as exemplified by the good mother. This is known as feminist essentialism. Taking this gendered view further, Nel Noddings states that the domestic sphere is the originator and nurturer of justice, in the sense that the best social policies are identified, modeled, and sustained by practices in the “best families.” This is a difficult position: Who decides on the characteristics of “best families?”
Practice of caring vs. ethics
The practice of caring can be described as actions performed by the carer, or as a value, or as a disposition or virtue that resides in the person who is caring. The following points summarize the current positions of philosophers who identify themselves as care ethicists.
• Care reflects a specific type of moral reasoning. This is the Kohlberg-Gilligan argument of male vs. female reasoning. Although care and justice have evolved as distinct ethical practices and ideals, they are not necessarily incompatible. As gender roles soften and gender as a concept becomes more blurry, care and justice can be intertwined. Reasoning does not have to be either justice based or care based.
• Care is the practice of caring for someone (Andrew Solomon’s case histories). This stance does not romanticize the practice of caring. This stance does not consider caring as a trait or disposition. This stance acknowledges the suffering and hardship in caring that can coexist with love. This stance points to the potential for individual spiritual and personal growth that can accompany caregiving. Andrew Solomon would agree to the notion of stages of caring (“Moral Boundaries: A Political Argument for an Ethic of Care,” New York: Routledge, 1994). These stages are: (1) attentiveness, becoming aware of need; (2) responsibility, a willingness to respond and take care of need; (3) competence, the skill of providing good and successful care; and (4) responsiveness, consideration of the position of others as they see it and recognition of the potential for abuse in care. The practice of caring is more of a daily reality than the abstract virtue.
• Care is an inherent virtue. This stance includes both feminist essentialism and feminist care ethics. In feminist essentialism, the process of moral development follows gender roles. The prototypical caregiving mother and a care-receiving child romanticize and elevate motherhood to the ideal practice of care. Feminist care ethicists avoid this essentialism by situating caring practices in place and time. They describe care as the symbolic practice rather than actual practice of women. Feminist care ethicists explore care as a gender neutral activity, advancing a utopian vision of care as a gender-neutral activity and virtue. Cognitive capacities and virtues associated with mothering, (better described as being associated with parenting), are seen as essential to the concept of care. These virtues are preservative love (work of protection with cheerfulness and humility), fostering growth (sponsoring or nurturing a child’s unfolding), and training for social acceptability (a process of socialization that requires conscience and a struggle for authenticity). This position also is reflected in Solomon’s ethics of care.
• Care is an inherent character trait or disposition. This stance understands care ethics as a form of virtue ethics, with care being a central virtue. There is an emphasis on relationship as fundamental to being, and the parent-child relationship as paramount. Virtue ethics views emotions such as empathy, compassion, and sensitivity as prerequisites for moral development and the ethics of care.
• Care as social justice and political imperative. One of the earliest objections to an ethics of care was that it valorized the oppression of women. Nietzsche held that those who are oppressed develop moral theories that reaffirm subservient traits as virtues. Women who perform the work of care often perform this care to their own economic disadvantage. A social justice perspective implies that the voice of care is the voice of an oppressed person, and eschews the idea that moral maturity means self-sacrifice and self-effacement. Care ethics informed by a social justice perspective asks who is caring for whom and whether this relationship is just.
When care ethics are applied to domestic politics, economic justice, international relations, and culture, interesting ideas emerge. Governments and businesses become responsible for support in sickness, disability, old age, bad luck, and reversal of fortune, for providing protection, health care, and clean environments, and for upholding the rights of individuals. A focus on autonomy, independence, and self-determination, which traditionally are seen as male traits, devalues interdependence and relatedness, which traditionally are seen as female values. Care ethics suggest that we replace hierarchy and domination that is based on gender, class, race, and ethnicity with cooperation and attention to interdependency. Interdependency is ubiquitous, and care ethics is a political theory with universal application. The practice of caring has no political affiliation; however, if we had founding mothers instead of founding fathers, would the United States be based more on ethics of care?
•The caring professions. The practice of caring is a practice that helps individuals meet their basic needs, maintain capabilities, and alleviate pain and suffering, so they can survive and function in society. Using this definition, the practice of care does not require any emotional attachment. Using this definition, the activity itself is a virtuous moral position. The health care professions mostly provide “services” rather than “care.” Is empathy a necessary ingredient for the practice of care? Many people believe so, and organizations such as the Watson Caring Science Institute (watsoncaringscience.org) are dedicated to putting the caring back into health care.
Meaning for the psychiatrist
When caregivers of patients with dementia were asked how they felt about caregiving, they responded positively. Caregiving felt good. Here is a listing of some their responses:
“Feeling needed and responsible.”
“Feeling good inside, doing for someone what you want for yourself and knowing I’ve done my best.”
“Being able to help.”
“To brighten her days.”
“I know he is being cared for the way he is used to.”
“I feel that she is loved and not alone.”
These caregivers were mostly spouses (61%), with an average of 3.1 caregiving years. Caregivers reported that their relatives were moderately disabled, but they perceived more reward than burden (Int. J. Geriatr. Psychiatry, 2004;19:533-7). The caregivers’ quality of life also proved similar to those in an age-controlled normal community sample. So if caregiving can be carried out without significantly affecting quality of life, caregiving can be more rewarding than burdensome.
Questions for the family psychiatrist:
• How am I caring for my patients and their families?
• What does it mean to care rather than provide a service?
• How has my psychiatric training changed how I perceive caring? Do I now care in a different way?
• Has the way I care developed through my practice of caring?
• Where am I in the stages of caring?
• When does caring mean advocacy?
Questions to ask patients and their families:
• Do you experience reward in caregiving?
• Are there ways to sustain and enhance the satisfaction and reward of caring?
• How might you explore the practice of caring?
• Has caring been redeeming for you?
• Has caring brought individual growth for you, despite the hardships?
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 Professionals” (New York: Routledge, 2013). Some of the research for this article came from The Internet Encyclopedia of Philosophy.
Families in Psychiatry: Successful strategies for fraught family gatherings
The variations of family tensions at family gatherings are endless: reenactments of sibling rivalry; favoritism; disappointments; unmet needs; failed expectations; feelings of rejection, abandonment, underappreciation. These tensions often are accompanied by a desire to right old wrongs and protect the vulnerable. Then there are the toxic or personality-disordered family members patients do not want to spend time with, the grieving for family members who have died or have been cut off from the family, managing the impact of divorce or job loss, handling the family member who has an untreated illness such as alcoholism. The list goes on and on.
Successfully navigating these rapids leads to positive self-regard and a sense of accomplishment. For patients with an illness, either medical and/or psychiatric, successful management might be crucial to their health. Those with diabetes need to be able to control their intake of sugars and calories or to say “no” to the pushy aunt when pressed to take more. For patients with epilepsy, increased ER visits were predicted by several factors, including holidays (Eur. J. Neurol. 2013;20:1411-6). There are more deaths from natural causes on Christmas and New Year’s than on any other day of the year (Soc. Sci. and Medicine 2010;71;1463-71). In contrast, suicide rates are actually lower at Thanksgiving and Christmas (J. Emerg. Med. 2014;46:776-81) and (Eur. J. Public Health 2014;pii:cku169). Stressful life events are known to be triggers for mood disorders (J. Affect. Disord. 2012;143:196-202), and tense holiday gatherings qualify as stressful.
As psychiatrists, we shape our discussions with patients with the goal of helping them identify situations that worsen other illnesses and situations that act as triggers. We might offer additional doses of medications to “help them through.” We caution against overeating or using substances to manage stress. We direct patients to one of many websites that provide helpful tips for managing the holidays.
We also help co-parents negotiate an amicable division of time with the children, and assist in getting adults and children come to terms with the “less than perfect family.” We help stepparents come into their new role. We remind blended families that new families need new traditions.
We are trained to resist providing specific advice for patients. However, we can employ strategic and educational interventions. Our patients are dealing with family issues AND mental illness. Discussing strategies helps our patients manage the stress of family gatherings.
Strategy 1: Differentiating levels of knowledge
Help the patient to think about her family’s understanding of mental illness. The public at large, including family members, can be very uninformed about mental illness. For those family members who have some understanding, they may be unsure about the best way to handle a relative with mental illness. They may feel that they should just treat them “the same” or “be tough” or “baby” them, or make special accommodations. Any strategy or intervention depends upon the family member’s level of understanding.
Each family member can be at different stages of acceptance of the illness. These different stages can sharpen division or create divisions in the family. This fracturing of the family will most likely occur along lines that show prior strain. Once this is known, the psychiatrist and the patient can have a more nuanced discussion about the best way to manage specific family members. The strategies can range from ignoring Uncle Bert when he makes ignorant comments, to helping Aunt Sadie who really wants to understand and be helpful.
It helps to remind patients that mental illness is common. According to the National Institute of Mental Health, one in four people will have an episode of mental illness in their lifetime. Also making statements like “My illness is as a common as diabetes” or “my treatment is quite specific” shows a mastery of the situation, rather than shame. If patients can use stock phrases with which they feel comfortable, the family will be more easily settled down.
Handouts on the patient’s specific mental illness that describe facts, such as prevalence and signs and symptoms, are useful. Family members can be very receptive to hospital or clinic educational information. These steps normalize the medical treatment and reduce the fear of the unknown illness. There is no need to make a big production around giving them these. Just have them on hand, in case someone asks. Inviting relatives to meet for an educational session with the psychiatrist can open up the dark and hidden aspects of mental illness, so having your business card on hand is a supportive gesture. Holiday gatherings are neither the time to clear up misunderstandings nor to work on resolving conflicts.
Strategy 2: Managing stigma
Some family members might react negatively because of the stigma of mental illness. A way to help the patient manage a relative who wants to discuss topics that are difficult is through role play. The psychiatrist plays the patient. The patient acts out the responses of the relative. The psychiatrist models good coping styles, using helpful stock phrases that the patient can then practice.
Relatives may say they do not “believe” in mental illness. As if illness could be a matter of belief! Do some relatives think that God and prayer, or hypnosis, or acupuncture and herbal medications are the cure? Help the patient be prepared through role play.
Strategy 3: Managing specific illnesses and symptoms
Patients with depression, bipolar disorder, or anxiety who experience family events as stressful can say to family members: “My doctor told me it is important to reduce my stress/maintain a low stress level. I will therefore take walks/naps or just be able to stay for a short time.” For patients and families that need more specific help to understand, the psychiatrist can provide the patient with a written list of instructions that the patient can present, like a prescription.
Strategy 4: Abusive or angry families
For families in which there is an abusive relative or past history of trauma, special considerations include making a decision about whether or not the patient should actually go. If they do decide to go, a short-time, limited visit works best. The psychiatrist can help the patient identify triggers to pay attention to, so that they can leave when needed.
Strategy 5: Advice about family members who seem to have their own illness
If a patient gives you information that leads you to believe that a family member has an untreated psychiatric illness or a personality disorder, offering some general advice is helpful. Recommend the avoidance of family drama. If other family members get into a scrap, it is not worth getting involved unless someone is in danger.
General comments are helpful: “While I cannot tell you what the issue is with your uncle, from what you are saying, it seems that he has a lifelong pattern of making a scene or provoking others or overreacting to benign comments. If I were in that situation, I would try not to take it personally, disengage, perhaps go to the bathroom, clear the dishes, or go outside for a breath of fresh air. Holidays are not the time to “try to sort things out” or “clear things up.” If there is a need to do this, a separate occasion or a visit to the psychiatrist can be suggested. A polite “ I am feeling tired, exhausted’ is an easy excuse to offer.
Strategy 6: When you don’t know the family dynamic
Often, there are issues that go back several generations, in which family members take sides. A daughter may look or behave like her father who perpetrated violence. This daughter can be unfairly treated. These types of situations can be difficult to ferret out. It is best to say something like: “This seems complicated and too difficult to sort out. Sorry, I cannot do better.”
One technique that can be helpful for the patient is the preparation of a family genogram. The timing of the genogram is important. It is worth considering whether this should be delayed to a time where the patient can be thoughtful and not prior to going to a family gathering that is anticipated to be stressful.
A genogram can help the patient see patterns that extend back through generations. It also can highlight people in the family system who are sympathetic or likely to know about mental illness. If 1 in 4 people have a serious mental illness in their lifetime, the genogram can shed light on these relatives. A genogram also can identify family strengths, thus changing the focus for the patient, from anticipation of conflict to anticipation of renewing and strengthening relationships.
Lastly, providing aphorisms is disarming. Aphorisms bring humor and wisdom to difficult situations. “Our family has its difficulties, but we also have our strengths.” “We have some issues right now, but thinking back through the generations, we have a lot to be thankful for,” or “Mental illness treatment will soon cure all ills.”
In summary, even if patients do not use this advice, the mere fact of thoughtful exploration and practice can help them feel more in control at stressful family gatherings.
Remember, if your patient decides not to attend a family gathering, provide strategies to manage spending the holidays alone. Avoiding these events can lead to feelings of isolation, abandonment, and loss. A plan to work or volunteer, or spend time with friends mitigates the emotional pain of the “not good enough” family.
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 Professionals” (New York: Routledge, 2013).
The variations of family tensions at family gatherings are endless: reenactments of sibling rivalry; favoritism; disappointments; unmet needs; failed expectations; feelings of rejection, abandonment, underappreciation. These tensions often are accompanied by a desire to right old wrongs and protect the vulnerable. Then there are the toxic or personality-disordered family members patients do not want to spend time with, the grieving for family members who have died or have been cut off from the family, managing the impact of divorce or job loss, handling the family member who has an untreated illness such as alcoholism. The list goes on and on.
Successfully navigating these rapids leads to positive self-regard and a sense of accomplishment. For patients with an illness, either medical and/or psychiatric, successful management might be crucial to their health. Those with diabetes need to be able to control their intake of sugars and calories or to say “no” to the pushy aunt when pressed to take more. For patients with epilepsy, increased ER visits were predicted by several factors, including holidays (Eur. J. Neurol. 2013;20:1411-6). There are more deaths from natural causes on Christmas and New Year’s than on any other day of the year (Soc. Sci. and Medicine 2010;71;1463-71). In contrast, suicide rates are actually lower at Thanksgiving and Christmas (J. Emerg. Med. 2014;46:776-81) and (Eur. J. Public Health 2014;pii:cku169). Stressful life events are known to be triggers for mood disorders (J. Affect. Disord. 2012;143:196-202), and tense holiday gatherings qualify as stressful.
As psychiatrists, we shape our discussions with patients with the goal of helping them identify situations that worsen other illnesses and situations that act as triggers. We might offer additional doses of medications to “help them through.” We caution against overeating or using substances to manage stress. We direct patients to one of many websites that provide helpful tips for managing the holidays.
We also help co-parents negotiate an amicable division of time with the children, and assist in getting adults and children come to terms with the “less than perfect family.” We help stepparents come into their new role. We remind blended families that new families need new traditions.
We are trained to resist providing specific advice for patients. However, we can employ strategic and educational interventions. Our patients are dealing with family issues AND mental illness. Discussing strategies helps our patients manage the stress of family gatherings.
Strategy 1: Differentiating levels of knowledge
Help the patient to think about her family’s understanding of mental illness. The public at large, including family members, can be very uninformed about mental illness. For those family members who have some understanding, they may be unsure about the best way to handle a relative with mental illness. They may feel that they should just treat them “the same” or “be tough” or “baby” them, or make special accommodations. Any strategy or intervention depends upon the family member’s level of understanding.
Each family member can be at different stages of acceptance of the illness. These different stages can sharpen division or create divisions in the family. This fracturing of the family will most likely occur along lines that show prior strain. Once this is known, the psychiatrist and the patient can have a more nuanced discussion about the best way to manage specific family members. The strategies can range from ignoring Uncle Bert when he makes ignorant comments, to helping Aunt Sadie who really wants to understand and be helpful.
It helps to remind patients that mental illness is common. According to the National Institute of Mental Health, one in four people will have an episode of mental illness in their lifetime. Also making statements like “My illness is as a common as diabetes” or “my treatment is quite specific” shows a mastery of the situation, rather than shame. If patients can use stock phrases with which they feel comfortable, the family will be more easily settled down.
Handouts on the patient’s specific mental illness that describe facts, such as prevalence and signs and symptoms, are useful. Family members can be very receptive to hospital or clinic educational information. These steps normalize the medical treatment and reduce the fear of the unknown illness. There is no need to make a big production around giving them these. Just have them on hand, in case someone asks. Inviting relatives to meet for an educational session with the psychiatrist can open up the dark and hidden aspects of mental illness, so having your business card on hand is a supportive gesture. Holiday gatherings are neither the time to clear up misunderstandings nor to work on resolving conflicts.
Strategy 2: Managing stigma
Some family members might react negatively because of the stigma of mental illness. A way to help the patient manage a relative who wants to discuss topics that are difficult is through role play. The psychiatrist plays the patient. The patient acts out the responses of the relative. The psychiatrist models good coping styles, using helpful stock phrases that the patient can then practice.
Relatives may say they do not “believe” in mental illness. As if illness could be a matter of belief! Do some relatives think that God and prayer, or hypnosis, or acupuncture and herbal medications are the cure? Help the patient be prepared through role play.
Strategy 3: Managing specific illnesses and symptoms
Patients with depression, bipolar disorder, or anxiety who experience family events as stressful can say to family members: “My doctor told me it is important to reduce my stress/maintain a low stress level. I will therefore take walks/naps or just be able to stay for a short time.” For patients and families that need more specific help to understand, the psychiatrist can provide the patient with a written list of instructions that the patient can present, like a prescription.
Strategy 4: Abusive or angry families
For families in which there is an abusive relative or past history of trauma, special considerations include making a decision about whether or not the patient should actually go. If they do decide to go, a short-time, limited visit works best. The psychiatrist can help the patient identify triggers to pay attention to, so that they can leave when needed.
Strategy 5: Advice about family members who seem to have their own illness
If a patient gives you information that leads you to believe that a family member has an untreated psychiatric illness or a personality disorder, offering some general advice is helpful. Recommend the avoidance of family drama. If other family members get into a scrap, it is not worth getting involved unless someone is in danger.
General comments are helpful: “While I cannot tell you what the issue is with your uncle, from what you are saying, it seems that he has a lifelong pattern of making a scene or provoking others or overreacting to benign comments. If I were in that situation, I would try not to take it personally, disengage, perhaps go to the bathroom, clear the dishes, or go outside for a breath of fresh air. Holidays are not the time to “try to sort things out” or “clear things up.” If there is a need to do this, a separate occasion or a visit to the psychiatrist can be suggested. A polite “ I am feeling tired, exhausted’ is an easy excuse to offer.
Strategy 6: When you don’t know the family dynamic
Often, there are issues that go back several generations, in which family members take sides. A daughter may look or behave like her father who perpetrated violence. This daughter can be unfairly treated. These types of situations can be difficult to ferret out. It is best to say something like: “This seems complicated and too difficult to sort out. Sorry, I cannot do better.”
One technique that can be helpful for the patient is the preparation of a family genogram. The timing of the genogram is important. It is worth considering whether this should be delayed to a time where the patient can be thoughtful and not prior to going to a family gathering that is anticipated to be stressful.
A genogram can help the patient see patterns that extend back through generations. It also can highlight people in the family system who are sympathetic or likely to know about mental illness. If 1 in 4 people have a serious mental illness in their lifetime, the genogram can shed light on these relatives. A genogram also can identify family strengths, thus changing the focus for the patient, from anticipation of conflict to anticipation of renewing and strengthening relationships.
Lastly, providing aphorisms is disarming. Aphorisms bring humor and wisdom to difficult situations. “Our family has its difficulties, but we also have our strengths.” “We have some issues right now, but thinking back through the generations, we have a lot to be thankful for,” or “Mental illness treatment will soon cure all ills.”
In summary, even if patients do not use this advice, the mere fact of thoughtful exploration and practice can help them feel more in control at stressful family gatherings.
Remember, if your patient decides not to attend a family gathering, provide strategies to manage spending the holidays alone. Avoiding these events can lead to feelings of isolation, abandonment, and loss. A plan to work or volunteer, or spend time with friends mitigates the emotional pain of the “not good enough” family.
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 Professionals” (New York: Routledge, 2013).
The variations of family tensions at family gatherings are endless: reenactments of sibling rivalry; favoritism; disappointments; unmet needs; failed expectations; feelings of rejection, abandonment, underappreciation. These tensions often are accompanied by a desire to right old wrongs and protect the vulnerable. Then there are the toxic or personality-disordered family members patients do not want to spend time with, the grieving for family members who have died or have been cut off from the family, managing the impact of divorce or job loss, handling the family member who has an untreated illness such as alcoholism. The list goes on and on.
Successfully navigating these rapids leads to positive self-regard and a sense of accomplishment. For patients with an illness, either medical and/or psychiatric, successful management might be crucial to their health. Those with diabetes need to be able to control their intake of sugars and calories or to say “no” to the pushy aunt when pressed to take more. For patients with epilepsy, increased ER visits were predicted by several factors, including holidays (Eur. J. Neurol. 2013;20:1411-6). There are more deaths from natural causes on Christmas and New Year’s than on any other day of the year (Soc. Sci. and Medicine 2010;71;1463-71). In contrast, suicide rates are actually lower at Thanksgiving and Christmas (J. Emerg. Med. 2014;46:776-81) and (Eur. J. Public Health 2014;pii:cku169). Stressful life events are known to be triggers for mood disorders (J. Affect. Disord. 2012;143:196-202), and tense holiday gatherings qualify as stressful.
As psychiatrists, we shape our discussions with patients with the goal of helping them identify situations that worsen other illnesses and situations that act as triggers. We might offer additional doses of medications to “help them through.” We caution against overeating or using substances to manage stress. We direct patients to one of many websites that provide helpful tips for managing the holidays.
We also help co-parents negotiate an amicable division of time with the children, and assist in getting adults and children come to terms with the “less than perfect family.” We help stepparents come into their new role. We remind blended families that new families need new traditions.
We are trained to resist providing specific advice for patients. However, we can employ strategic and educational interventions. Our patients are dealing with family issues AND mental illness. Discussing strategies helps our patients manage the stress of family gatherings.
Strategy 1: Differentiating levels of knowledge
Help the patient to think about her family’s understanding of mental illness. The public at large, including family members, can be very uninformed about mental illness. For those family members who have some understanding, they may be unsure about the best way to handle a relative with mental illness. They may feel that they should just treat them “the same” or “be tough” or “baby” them, or make special accommodations. Any strategy or intervention depends upon the family member’s level of understanding.
Each family member can be at different stages of acceptance of the illness. These different stages can sharpen division or create divisions in the family. This fracturing of the family will most likely occur along lines that show prior strain. Once this is known, the psychiatrist and the patient can have a more nuanced discussion about the best way to manage specific family members. The strategies can range from ignoring Uncle Bert when he makes ignorant comments, to helping Aunt Sadie who really wants to understand and be helpful.
It helps to remind patients that mental illness is common. According to the National Institute of Mental Health, one in four people will have an episode of mental illness in their lifetime. Also making statements like “My illness is as a common as diabetes” or “my treatment is quite specific” shows a mastery of the situation, rather than shame. If patients can use stock phrases with which they feel comfortable, the family will be more easily settled down.
Handouts on the patient’s specific mental illness that describe facts, such as prevalence and signs and symptoms, are useful. Family members can be very receptive to hospital or clinic educational information. These steps normalize the medical treatment and reduce the fear of the unknown illness. There is no need to make a big production around giving them these. Just have them on hand, in case someone asks. Inviting relatives to meet for an educational session with the psychiatrist can open up the dark and hidden aspects of mental illness, so having your business card on hand is a supportive gesture. Holiday gatherings are neither the time to clear up misunderstandings nor to work on resolving conflicts.
Strategy 2: Managing stigma
Some family members might react negatively because of the stigma of mental illness. A way to help the patient manage a relative who wants to discuss topics that are difficult is through role play. The psychiatrist plays the patient. The patient acts out the responses of the relative. The psychiatrist models good coping styles, using helpful stock phrases that the patient can then practice.
Relatives may say they do not “believe” in mental illness. As if illness could be a matter of belief! Do some relatives think that God and prayer, or hypnosis, or acupuncture and herbal medications are the cure? Help the patient be prepared through role play.
Strategy 3: Managing specific illnesses and symptoms
Patients with depression, bipolar disorder, or anxiety who experience family events as stressful can say to family members: “My doctor told me it is important to reduce my stress/maintain a low stress level. I will therefore take walks/naps or just be able to stay for a short time.” For patients and families that need more specific help to understand, the psychiatrist can provide the patient with a written list of instructions that the patient can present, like a prescription.
Strategy 4: Abusive or angry families
For families in which there is an abusive relative or past history of trauma, special considerations include making a decision about whether or not the patient should actually go. If they do decide to go, a short-time, limited visit works best. The psychiatrist can help the patient identify triggers to pay attention to, so that they can leave when needed.
Strategy 5: Advice about family members who seem to have their own illness
If a patient gives you information that leads you to believe that a family member has an untreated psychiatric illness or a personality disorder, offering some general advice is helpful. Recommend the avoidance of family drama. If other family members get into a scrap, it is not worth getting involved unless someone is in danger.
General comments are helpful: “While I cannot tell you what the issue is with your uncle, from what you are saying, it seems that he has a lifelong pattern of making a scene or provoking others or overreacting to benign comments. If I were in that situation, I would try not to take it personally, disengage, perhaps go to the bathroom, clear the dishes, or go outside for a breath of fresh air. Holidays are not the time to “try to sort things out” or “clear things up.” If there is a need to do this, a separate occasion or a visit to the psychiatrist can be suggested. A polite “ I am feeling tired, exhausted’ is an easy excuse to offer.
Strategy 6: When you don’t know the family dynamic
Often, there are issues that go back several generations, in which family members take sides. A daughter may look or behave like her father who perpetrated violence. This daughter can be unfairly treated. These types of situations can be difficult to ferret out. It is best to say something like: “This seems complicated and too difficult to sort out. Sorry, I cannot do better.”
One technique that can be helpful for the patient is the preparation of a family genogram. The timing of the genogram is important. It is worth considering whether this should be delayed to a time where the patient can be thoughtful and not prior to going to a family gathering that is anticipated to be stressful.
A genogram can help the patient see patterns that extend back through generations. It also can highlight people in the family system who are sympathetic or likely to know about mental illness. If 1 in 4 people have a serious mental illness in their lifetime, the genogram can shed light on these relatives. A genogram also can identify family strengths, thus changing the focus for the patient, from anticipation of conflict to anticipation of renewing and strengthening relationships.
Lastly, providing aphorisms is disarming. Aphorisms bring humor and wisdom to difficult situations. “Our family has its difficulties, but we also have our strengths.” “We have some issues right now, but thinking back through the generations, we have a lot to be thankful for,” or “Mental illness treatment will soon cure all ills.”
In summary, even if patients do not use this advice, the mere fact of thoughtful exploration and practice can help them feel more in control at stressful family gatherings.
Remember, if your patient decides not to attend a family gathering, provide strategies to manage spending the holidays alone. Avoiding these events can lead to feelings of isolation, abandonment, and loss. A plan to work or volunteer, or spend time with friends mitigates the emotional pain of the “not good enough” family.
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 Professionals” (New York: Routledge, 2013).
