Families in Psychiatry

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. 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).

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. 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).

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. 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).

Dr. Denis Fiallos Montero, who describes himself as "an old-time psychiatrist" who grew up during the Family Therapy days, wrote to me to point out "a great omission" in my recent discussion about some of the pioneers in our field ("Dr. Minuchin and the Ashtray," October 2012, p. 4).

Whom did I fail to mention? The late Dr. Murray Bowen.

Dr. Bowen was the originator of the American Family Therapy Association and served as the group’s first president, from 1978 to 1982. (See the Bowen Center website for details of his enduring legacy.)

This column is dedicated to these two gentlemen.

Individuation as a concept

The spirit of Murray Bowen sits in the corner at every family therapist’s family gathering and reminds us about triangulation! He told us clearly that one of the main tasks of individuation is finding the right level of differentiation from our parents.

Concepts of emotional fusion and emotional cutoff are helpful at this time of year, as many of us struggle with conflicted thoughts and feelings about our families of origin.

At one end of the differentiation spectrum is emotional fusion (overly close fused relationships); at the other end of the spectrum is emotional cutoff (disconnection between family members or refusal to engage with certain family members).

Bowen described emotional cutoffs as "the natural mechanisms people use to counter high anxiety or high emotional fusion that arise from unresolved issues with our family of origin" (Family Evaluation, New York: W.W. Norton and Co., 1988). He and his longtime colleague Dr. Michael E. Kerr noted that unresolved family issues get passed down through the generations, with successive generations being affected by seemingly mysterious emotional patterns and behaviors.

Common laments at this time of year are "I feel like a child when I go home," "I feel guilty when I go home," and "I want to take care of those parents of mine and make them do the right thing!" Or we think things like: "I feel angry that my parents do not understand or approve of me." Friends give advice: "Just go home for a short time. Try to avoid sensitive issues. Try to not get into things with them, and then you all will get along."

Gritting your teeth and powering through a family visit is exhausting. However, what is the alternative?

Bowen thought that to develop a healthy sense of self, you must be in good relation with your family of origin, and that all adults in the family should be in "comfortable emotional contact." A self-report scale called the Differentiation of Self Inventory (DSI) is based on Bowen’s theory, and measures emotional functioning, intimacy, and autonomy in interpersonal relationships.

Its subscales assess interpersonal (i.e., fusion and emotional cutoff) and intrapsychic dimensions of differentiation problems (i.e., emotional reactivity and difficulty taking an "I" position) (J. Counseling Psychol. 1998;45:235-46). The DSI has questions like: "I would never consider turning to any of my family members for emotional support," and "I often feel unsure when others are not around to help me make a decision."

Personal connections to theory

Bowen’s theories are helpful to me in thinking about my family of origin. I recently returned to Scotland to visit my Aunt Charlotte. My aunt is the living embodiment of an emotional cutoff.

The original family insult occurred before she was born. Her beloved brother Charlie, the first-born son, was killed in a car accident when he was a young child. Charlotte was the "replacement child," prescribed by the general practitioner to help my grandmother recover from the grief and loss of her son.

Of course, this was not a successful prescription, and the grief and sense of loss continued. However, more tragically, Aunt Charlotte’s mere presence triggered feelings of grief, anger, and guilt for her parents and sister.

Aunt Charlotte was the weakest and most sensitive member of our family. She suffered from asthma and, as an adult, was the victim of a car accident that left her cognitively impaired. (No one seemed to think it was ironic that the accident heightened the family’s anger and distaste for her, rather than provoke sympathy that she could now no longer live a productive life.)

Mentioning Aunt Charlotte’s name in our household raised everyone’s blood pressure. As a young teenager, I was acutely aware of the "unfairness" of the family’s responses to her. Although we all knew about Charlie’s death, we had little understanding of the connection between his death and how Aunt Charlotte was perceived.

I do remember the strong negative feelings in the house at holiday times, but neither my family nor I, as an adolescent, understood what was being enacted. As an adult, I have come to understand that the grief, anger, and emotional tension experienced by Charlie’s death were shifted and projected onto Aunt Charlotte.

Encouraged to seek a life of her own, she eventually moved away, to a small town, close to where her mother had been born and raised. She enjoyed volunteering at the house where Mary, Queen of Scots, had lived, a woman who herself was one of Scotland’s most tragic figures. The best way the family could function, it seemed, was to use emotional cutoff.

As an adult, I have been able to go back and talk with her and her friends, discussing the grief and trauma in the family. Understanding that an emotional cutoff was used to manage the unbearable emotional tensions in the family brings understanding and a way to think about what happened over the years. How much better if her parents and sister had been able to understand this, too!

Forerunner of the genogram

Bowen focused on helping family members develop emotional objectivity about their family relationships. Bowen would draw a family diagram, the forerunner of the genogram, and talk through the family influences on each member. His goal was to help the patient develop emotional object and a greater intellectual understanding about their family of origin. He wanted to help the patient understand the emotional tasks of differentiation.

In the case of Aunt Charlotte, therapy might not have been able to restore her to the family, but at least therapy would have given her and our family a deeper appreciation of the impact of trauma on family relationships and subsequent generations.

Healthy relationships with one’s family of origin mean having the right amount of differentiation. You know you have it when you can relate to your family members without regressing to the "child" position or the "parent" position – and when going home feels good, not fraught with angst, anger, or other strong and difficult emotions.

However, if it still doesn’t feel good because of unresolved problems, it is still possible to develop greater emotional objectivity and a deeper intellectual understanding.

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

Dr. Denis Fiallos Montero, who describes himself as "an old-time psychiatrist" who grew up during the Family Therapy days, wrote to me to point out "a great omission" in my recent discussion about some of the pioneers in our field ("Dr. Minuchin and the Ashtray," October 2012, p. 4).

Whom did I fail to mention? The late Dr. Murray Bowen.

Dr. Bowen was the originator of the American Family Therapy Association and served as the group’s first president, from 1978 to 1982. (See the Bowen Center website for details of his enduring legacy.)

This column is dedicated to these two gentlemen.

Individuation as a concept

The spirit of Murray Bowen sits in the corner at every family therapist’s family gathering and reminds us about triangulation! He told us clearly that one of the main tasks of individuation is finding the right level of differentiation from our parents.

Concepts of emotional fusion and emotional cutoff are helpful at this time of year, as many of us struggle with conflicted thoughts and feelings about our families of origin.

At one end of the differentiation spectrum is emotional fusion (overly close fused relationships); at the other end of the spectrum is emotional cutoff (disconnection between family members or refusal to engage with certain family members).

Bowen described emotional cutoffs as "the natural mechanisms people use to counter high anxiety or high emotional fusion that arise from unresolved issues with our family of origin" (Family Evaluation, New York: W.W. Norton and Co., 1988). He and his longtime colleague Dr. Michael E. Kerr noted that unresolved family issues get passed down through the generations, with successive generations being affected by seemingly mysterious emotional patterns and behaviors.

Common laments at this time of year are "I feel like a child when I go home," "I feel guilty when I go home," and "I want to take care of those parents of mine and make them do the right thing!" Or we think things like: "I feel angry that my parents do not understand or approve of me." Friends give advice: "Just go home for a short time. Try to avoid sensitive issues. Try to not get into things with them, and then you all will get along."

Gritting your teeth and powering through a family visit is exhausting. However, what is the alternative?

Bowen thought that to develop a healthy sense of self, you must be in good relation with your family of origin, and that all adults in the family should be in "comfortable emotional contact." A self-report scale called the Differentiation of Self Inventory (DSI) is based on Bowen’s theory, and measures emotional functioning, intimacy, and autonomy in interpersonal relationships.

Its subscales assess interpersonal (i.e., fusion and emotional cutoff) and intrapsychic dimensions of differentiation problems (i.e., emotional reactivity and difficulty taking an "I" position) (J. Counseling Psychol. 1998;45:235-46). The DSI has questions like: "I would never consider turning to any of my family members for emotional support," and "I often feel unsure when others are not around to help me make a decision."

Personal connections to theory

Bowen’s theories are helpful to me in thinking about my family of origin. I recently returned to Scotland to visit my Aunt Charlotte. My aunt is the living embodiment of an emotional cutoff.

The original family insult occurred before she was born. Her beloved brother Charlie, the first-born son, was killed in a car accident when he was a young child. Charlotte was the "replacement child," prescribed by the general practitioner to help my grandmother recover from the grief and loss of her son.

Of course, this was not a successful prescription, and the grief and sense of loss continued. However, more tragically, Aunt Charlotte’s mere presence triggered feelings of grief, anger, and guilt for her parents and sister.

Aunt Charlotte was the weakest and most sensitive member of our family. She suffered from asthma and, as an adult, was the victim of a car accident that left her cognitively impaired. (No one seemed to think it was ironic that the accident heightened the family’s anger and distaste for her, rather than provoke sympathy that she could now no longer live a productive life.)

Mentioning Aunt Charlotte’s name in our household raised everyone’s blood pressure. As a young teenager, I was acutely aware of the "unfairness" of the family’s responses to her. Although we all knew about Charlie’s death, we had little understanding of the connection between his death and how Aunt Charlotte was perceived.

I do remember the strong negative feelings in the house at holiday times, but neither my family nor I, as an adolescent, understood what was being enacted. As an adult, I have come to understand that the grief, anger, and emotional tension experienced by Charlie’s death were shifted and projected onto Aunt Charlotte.

Encouraged to seek a life of her own, she eventually moved away, to a small town, close to where her mother had been born and raised. She enjoyed volunteering at the house where Mary, Queen of Scots, had lived, a woman who herself was one of Scotland’s most tragic figures. The best way the family could function, it seemed, was to use emotional cutoff.

As an adult, I have been able to go back and talk with her and her friends, discussing the grief and trauma in the family. Understanding that an emotional cutoff was used to manage the unbearable emotional tensions in the family brings understanding and a way to think about what happened over the years. How much better if her parents and sister had been able to understand this, too!

Forerunner of the genogram

Bowen focused on helping family members develop emotional objectivity about their family relationships. Bowen would draw a family diagram, the forerunner of the genogram, and talk through the family influences on each member. His goal was to help the patient develop emotional object and a greater intellectual understanding about their family of origin. He wanted to help the patient understand the emotional tasks of differentiation.

In the case of Aunt Charlotte, therapy might not have been able to restore her to the family, but at least therapy would have given her and our family a deeper appreciation of the impact of trauma on family relationships and subsequent generations.

Healthy relationships with one’s family of origin mean having the right amount of differentiation. You know you have it when you can relate to your family members without regressing to the "child" position or the "parent" position – and when going home feels good, not fraught with angst, anger, or other strong and difficult emotions.

However, if it still doesn’t feel good because of unresolved problems, it is still possible to develop greater emotional objectivity and a deeper intellectual understanding.

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

Dr. Denis Fiallos Montero, who describes himself as "an old-time psychiatrist" who grew up during the Family Therapy days, wrote to me to point out "a great omission" in my recent discussion about some of the pioneers in our field ("Dr. Minuchin and the Ashtray," October 2012, p. 4).

Whom did I fail to mention? The late Dr. Murray Bowen.

Dr. Bowen was the originator of the American Family Therapy Association and served as the group’s first president, from 1978 to 1982. (See the Bowen Center website for details of his enduring legacy.)

This column is dedicated to these two gentlemen.

Individuation as a concept

The spirit of Murray Bowen sits in the corner at every family therapist’s family gathering and reminds us about triangulation! He told us clearly that one of the main tasks of individuation is finding the right level of differentiation from our parents.

Concepts of emotional fusion and emotional cutoff are helpful at this time of year, as many of us struggle with conflicted thoughts and feelings about our families of origin.

At one end of the differentiation spectrum is emotional fusion (overly close fused relationships); at the other end of the spectrum is emotional cutoff (disconnection between family members or refusal to engage with certain family members).

Bowen described emotional cutoffs as "the natural mechanisms people use to counter high anxiety or high emotional fusion that arise from unresolved issues with our family of origin" (Family Evaluation, New York: W.W. Norton and Co., 1988). He and his longtime colleague Dr. Michael E. Kerr noted that unresolved family issues get passed down through the generations, with successive generations being affected by seemingly mysterious emotional patterns and behaviors.

Common laments at this time of year are "I feel like a child when I go home," "I feel guilty when I go home," and "I want to take care of those parents of mine and make them do the right thing!" Or we think things like: "I feel angry that my parents do not understand or approve of me." Friends give advice: "Just go home for a short time. Try to avoid sensitive issues. Try to not get into things with them, and then you all will get along."

Gritting your teeth and powering through a family visit is exhausting. However, what is the alternative?

Bowen thought that to develop a healthy sense of self, you must be in good relation with your family of origin, and that all adults in the family should be in "comfortable emotional contact." A self-report scale called the Differentiation of Self Inventory (DSI) is based on Bowen’s theory, and measures emotional functioning, intimacy, and autonomy in interpersonal relationships.

Its subscales assess interpersonal (i.e., fusion and emotional cutoff) and intrapsychic dimensions of differentiation problems (i.e., emotional reactivity and difficulty taking an "I" position) (J. Counseling Psychol. 1998;45:235-46). The DSI has questions like: "I would never consider turning to any of my family members for emotional support," and "I often feel unsure when others are not around to help me make a decision."

Personal connections to theory

Bowen’s theories are helpful to me in thinking about my family of origin. I recently returned to Scotland to visit my Aunt Charlotte. My aunt is the living embodiment of an emotional cutoff.

The original family insult occurred before she was born. Her beloved brother Charlie, the first-born son, was killed in a car accident when he was a young child. Charlotte was the "replacement child," prescribed by the general practitioner to help my grandmother recover from the grief and loss of her son.

Of course, this was not a successful prescription, and the grief and sense of loss continued. However, more tragically, Aunt Charlotte’s mere presence triggered feelings of grief, anger, and guilt for her parents and sister.

Aunt Charlotte was the weakest and most sensitive member of our family. She suffered from asthma and, as an adult, was the victim of a car accident that left her cognitively impaired. (No one seemed to think it was ironic that the accident heightened the family’s anger and distaste for her, rather than provoke sympathy that she could now no longer live a productive life.)

Mentioning Aunt Charlotte’s name in our household raised everyone’s blood pressure. As a young teenager, I was acutely aware of the "unfairness" of the family’s responses to her. Although we all knew about Charlie’s death, we had little understanding of the connection between his death and how Aunt Charlotte was perceived.

I do remember the strong negative feelings in the house at holiday times, but neither my family nor I, as an adolescent, understood what was being enacted. As an adult, I have come to understand that the grief, anger, and emotional tension experienced by Charlie’s death were shifted and projected onto Aunt Charlotte.

Encouraged to seek a life of her own, she eventually moved away, to a small town, close to where her mother had been born and raised. She enjoyed volunteering at the house where Mary, Queen of Scots, had lived, a woman who herself was one of Scotland’s most tragic figures. The best way the family could function, it seemed, was to use emotional cutoff.

As an adult, I have been able to go back and talk with her and her friends, discussing the grief and trauma in the family. Understanding that an emotional cutoff was used to manage the unbearable emotional tensions in the family brings understanding and a way to think about what happened over the years. How much better if her parents and sister had been able to understand this, too!

Forerunner of the genogram

Bowen focused on helping family members develop emotional objectivity about their family relationships. Bowen would draw a family diagram, the forerunner of the genogram, and talk through the family influences on each member. His goal was to help the patient develop emotional object and a greater intellectual understanding about their family of origin. He wanted to help the patient understand the emotional tasks of differentiation.

In the case of Aunt Charlotte, therapy might not have been able to restore her to the family, but at least therapy would have given her and our family a deeper appreciation of the impact of trauma on family relationships and subsequent generations.

Healthy relationships with one’s family of origin mean having the right amount of differentiation. You know you have it when you can relate to your family members without regressing to the "child" position or the "parent" position – and when going home feels good, not fraught with angst, anger, or other strong and difficult emotions.

However, if it still doesn’t feel good because of unresolved problems, it is still possible to develop greater emotional objectivity and a deeper intellectual understanding.

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

BREB, ROMANIA – While strolling through this village in the Maramures region in the northwest corner of Romania, I ask Ileana, "How many live in this village?" Ileana has just come home from high school in the nearest town and is wearing brightly colored sneakers, blue jeans, and a pink sweatshirt with the word "LOVE" emblazed in sparkles across her chest. She is touring us proudly around her village.

"400."

"400 people?"

"No, 400 families."

"How many in each family?"

"About six or seven."

On the large ornate wooden gate to the family homestead is the inscription: "Familie Hermann." All seven members of the Hermann family live in a three-room traditional wooden house. The house has a large porch, where the family eats, works, and sometimes sleeps in the warm weather.

Courtesy David Naylor

Maria, the 82-year-old grandmother, sits outside the gate on a small bench and watches the villagers stroll home from the fields with scythes and rakes on their shoulders. She welcomes her daughter and son-in-law back home. It is spring, and the villagers are cleaning the fields in preparation for the summer grass growing. In the fall, they will harvest the grass to feed their animals throughout the winter.

On the porch, in the quiet of a late afternoon, as 9-year-old Ioanna is doing her homework, her mother, Raluca, works on the intricacies of beading the border of Ioanna’s traditional costume to be worn on Easter Sunday. Ioanna watches her mother pin the black velvet jacket to her skirt and load the needle with the gold beads to make the stems for the purple and red flowers. She sees how to turn the green rows into leaves. She shows her mother her school work, as equally neat and carefully calligraphied as her mother’s beading. Concern for accuracy and aesthetics are the skills and values passed down through the generations.

Maria comes in from the gate and resumes shelling beans on the front porch. She doesn’t do as much work in the fields anymore. Instead, she sweeps the house, tends to the flower garden, and helps with the two children. Maria takes the clothes down from the clothesline that stretches across the front of the porch. These handmade, intricately stitched works of art have been washed in preparation for Easter.

Maria shows us the gown she will wear at her funeral. She wove the linen, and smocked the neck and wrists with traditional village colors. She is proud of her work, and we admire it. She takes her gown inside, along with all the other freshly laundered white blouses that men and women will wear during the traditional events throughout the year.

After Easter, when the weather warms, most of the village will make the pilgrimage up the mountain accompanying the shepherds taking the sheep to summer grazing. The milking of the sheep is a defining village event, and precise measures are recorded in a book or on a stick to indicate each person’s anticipated portion of future milkings. This is Stina, a serious celebration, and the villagers wear traditional dress for the feasting, drinking, and dancing.

Life in rural villages is physically hard, and family and communal living are not idyllic. There is no privacy in the village, perhaps no secrets.

There is no privileging of the individual over the family. The family functions as a unit, getting work done by the seasons, so the family can eat throughout the year. The sense of belonging is irrefutable.

There is room for individual pride, however, and this is expressed as skill in raking a straight row, making the best plum brandy, wood carving, and doing embroidery. Everyone has an opinion on which family is the best at their craft in the village. The Hermann family is recognized for their skill in textiles – particularly their embroidery.

The village has its characters: the most devout, the "bad boy," the lazy person, and the man who can’t hold his liquor. This man, the village drunk, frequently makes a trip to the psychiatric hospital in the town of Sighetu Marmatieti, when he gets out of hand. After a few weeks, he comes home quieter, and his good behavior will last for the best part of a year. There is no physician or nurse in the village, only a veterinarian who visits, when called, to care for the animals.

The darker stories of the village lie hidden, because for now, it is early spring, and the village flows with optimism, celebration, and courtship. The white, hand-crafted blouses manifest the feelings of anticipation as they billow and dance on each clothesline throughout the village. Belonging to the village means feeling the seasons unfold intuitively. These feelings sustain and nourish the village families throughout their lives.

Outside of the village, in the "real world," we try to create a sense of belonging. As a country of immigrants, we in America have sense of belonging that is scattered. Still, connecting with our past is too often beyond our grasp. What is belonging? What are its components?

Ways to think about belonging

Studies on belonging extend across many disciplines: psychoanalysis, attachment psychology, social and cultural studies to philosophy. How does a family psychiatrist think about belonging? What aspects of belonging can be incorporated into psychiatric care?

An unmet need for belonging leads to loneliness and lower life satisfaction. This finding came from a study of 436 participants from the Australian Unity Wellbeing database who completed several measurements, including the Need to Belong Scale according to David Mellor, Ph.D., and his colleagues(Pers. Individ. Dif. 2008;45:213-8). Dr. Vincenzo Di Nicola, a psychiatrist who has written extensively about family relationships, also has offered valuable perspective on belongingness: "Belonging is a way of rethinking relational being, how we define mental health, how we understand the expression of its vicissitudes, and how we organize care and healing for sufferers. To do this, we need to recognize how belonging is experienced and negotiated, free of the constraints of our habitual patterns of practice and thought, to imagine belonging without borders for settlers, sojourners, and travelers in the 21st century."

Belongingness traditionally has been seen as a core of family life. If your values are different from those of your family, if you have moved from the village to the city and don’t want to be a farmer, what values do you uphold? Do you now have a new set of people and values? Do you belong to a group/club/school? Belonging to a guild or religious order means that the guild or order becomes your new family. However, belongingness is more transient and a less substantial part of life, as people change jobs and careers, get divorced and remarried, move to other countries.

Who serves as the family for people with psychiatric illness? In a recent study, people with serious mental illness were interviewed and asked about the "communities" to which they belonged (Psychiatr. Serv. [doi: 10.1176/appi.ps.201200235]). The researchers found four "patterns of experience" that made up communities for the respondents. Communities were places where people with mental illness could receive help, especially in times of vulnerability.

In addition, communities were places to manage risk and minimize the anxiety felt in public setting by people with mental illness. The stigma experienced in the general community or even within their families led many respondents to identify more strongly with peers who had mental illness.

Communities also were seen as places where those with serious mental illness could "give back" and help others. So perhaps, in the same way as these respondents defined belongingness for themselves, we can define belongingness for all our patients.

Several components must be satisfied for a person to have a sense of belongingness.

• A community in which the person’s beliefs and values are upheld as sacred (meaningfulness).

• Rituals that bring people together and support the meaningfulness of their lives (meaningfulness).

• People who provide emotional and practical support for others (attachment).

• People who allow others to provide them with support (sense of self-efficacy).

• Generational transmission of skills, crafts, values, and beliefs (generativity).

A sense of place is another component that has been associated with a sense of belonging. After the Boston Marathon bombings, some people affirmed that their sense of belonging was consolidated by that event. For others, a sense of belonging becomes fixed in their sense of tragedy as a victim of an event. We see many patients with posttraumatic stress disorder who have been bound by the traumatizing event(s), and who find it difficult or impossible to move beyond that experience.

For Americans, perhaps the notion of "family values" can be parsed to include the idea and study of belongingness. Understanding what belongingness encompasses can help us discuss relational being with our patients. Where do you find that sense of belonging? For Ioanna, her sense of belonging is felt in the seasonal ebb and flow of village life. Her sense of belonging shows in her skill as she works with her crafts with her hands. Breb belongs to her, even as it opens its large wooden doors to the world.

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.

BREB, ROMANIA – While strolling through this village in the Maramures region in the northwest corner of Romania, I ask Ileana, "How many live in this village?" Ileana has just come home from high school in the nearest town and is wearing brightly colored sneakers, blue jeans, and a pink sweatshirt with the word "LOVE" emblazed in sparkles across her chest. She is touring us proudly around her village.

"400."

"400 people?"

"No, 400 families."

"How many in each family?"

"About six or seven."

On the large ornate wooden gate to the family homestead is the inscription: "Familie Hermann." All seven members of the Hermann family live in a three-room traditional wooden house. The house has a large porch, where the family eats, works, and sometimes sleeps in the warm weather.

Courtesy David Naylor

Maria, the 82-year-old grandmother, sits outside the gate on a small bench and watches the villagers stroll home from the fields with scythes and rakes on their shoulders. She welcomes her daughter and son-in-law back home. It is spring, and the villagers are cleaning the fields in preparation for the summer grass growing. In the fall, they will harvest the grass to feed their animals throughout the winter.

On the porch, in the quiet of a late afternoon, as 9-year-old Ioanna is doing her homework, her mother, Raluca, works on the intricacies of beading the border of Ioanna’s traditional costume to be worn on Easter Sunday. Ioanna watches her mother pin the black velvet jacket to her skirt and load the needle with the gold beads to make the stems for the purple and red flowers. She sees how to turn the green rows into leaves. She shows her mother her school work, as equally neat and carefully calligraphied as her mother’s beading. Concern for accuracy and aesthetics are the skills and values passed down through the generations.

Maria comes in from the gate and resumes shelling beans on the front porch. She doesn’t do as much work in the fields anymore. Instead, she sweeps the house, tends to the flower garden, and helps with the two children. Maria takes the clothes down from the clothesline that stretches across the front of the porch. These handmade, intricately stitched works of art have been washed in preparation for Easter.

Maria shows us the gown she will wear at her funeral. She wove the linen, and smocked the neck and wrists with traditional village colors. She is proud of her work, and we admire it. She takes her gown inside, along with all the other freshly laundered white blouses that men and women will wear during the traditional events throughout the year.

After Easter, when the weather warms, most of the village will make the pilgrimage up the mountain accompanying the shepherds taking the sheep to summer grazing. The milking of the sheep is a defining village event, and precise measures are recorded in a book or on a stick to indicate each person’s anticipated portion of future milkings. This is Stina, a serious celebration, and the villagers wear traditional dress for the feasting, drinking, and dancing.

Life in rural villages is physically hard, and family and communal living are not idyllic. There is no privacy in the village, perhaps no secrets.

There is no privileging of the individual over the family. The family functions as a unit, getting work done by the seasons, so the family can eat throughout the year. The sense of belonging is irrefutable.

There is room for individual pride, however, and this is expressed as skill in raking a straight row, making the best plum brandy, wood carving, and doing embroidery. Everyone has an opinion on which family is the best at their craft in the village. The Hermann family is recognized for their skill in textiles – particularly their embroidery.

The village has its characters: the most devout, the "bad boy," the lazy person, and the man who can’t hold his liquor. This man, the village drunk, frequently makes a trip to the psychiatric hospital in the town of Sighetu Marmatieti, when he gets out of hand. After a few weeks, he comes home quieter, and his good behavior will last for the best part of a year. There is no physician or nurse in the village, only a veterinarian who visits, when called, to care for the animals.

The darker stories of the village lie hidden, because for now, it is early spring, and the village flows with optimism, celebration, and courtship. The white, hand-crafted blouses manifest the feelings of anticipation as they billow and dance on each clothesline throughout the village. Belonging to the village means feeling the seasons unfold intuitively. These feelings sustain and nourish the village families throughout their lives.

Outside of the village, in the "real world," we try to create a sense of belonging. As a country of immigrants, we in America have sense of belonging that is scattered. Still, connecting with our past is too often beyond our grasp. What is belonging? What are its components?

Ways to think about belonging

Studies on belonging extend across many disciplines: psychoanalysis, attachment psychology, social and cultural studies to philosophy. How does a family psychiatrist think about belonging? What aspects of belonging can be incorporated into psychiatric care?

An unmet need for belonging leads to loneliness and lower life satisfaction. This finding came from a study of 436 participants from the Australian Unity Wellbeing database who completed several measurements, including the Need to Belong Scale according to David Mellor, Ph.D., and his colleagues(Pers. Individ. Dif. 2008;45:213-8). Dr. Vincenzo Di Nicola, a psychiatrist who has written extensively about family relationships, also has offered valuable perspective on belongingness: "Belonging is a way of rethinking relational being, how we define mental health, how we understand the expression of its vicissitudes, and how we organize care and healing for sufferers. To do this, we need to recognize how belonging is experienced and negotiated, free of the constraints of our habitual patterns of practice and thought, to imagine belonging without borders for settlers, sojourners, and travelers in the 21st century."

Belongingness traditionally has been seen as a core of family life. If your values are different from those of your family, if you have moved from the village to the city and don’t want to be a farmer, what values do you uphold? Do you now have a new set of people and values? Do you belong to a group/club/school? Belonging to a guild or religious order means that the guild or order becomes your new family. However, belongingness is more transient and a less substantial part of life, as people change jobs and careers, get divorced and remarried, move to other countries.

Who serves as the family for people with psychiatric illness? In a recent study, people with serious mental illness were interviewed and asked about the "communities" to which they belonged (Psychiatr. Serv. [doi: 10.1176/appi.ps.201200235]). The researchers found four "patterns of experience" that made up communities for the respondents. Communities were places where people with mental illness could receive help, especially in times of vulnerability.

In addition, communities were places to manage risk and minimize the anxiety felt in public setting by people with mental illness. The stigma experienced in the general community or even within their families led many respondents to identify more strongly with peers who had mental illness.

Communities also were seen as places where those with serious mental illness could "give back" and help others. So perhaps, in the same way as these respondents defined belongingness for themselves, we can define belongingness for all our patients.

Several components must be satisfied for a person to have a sense of belongingness.

• A community in which the person’s beliefs and values are upheld as sacred (meaningfulness).

• Rituals that bring people together and support the meaningfulness of their lives (meaningfulness).

• People who provide emotional and practical support for others (attachment).

• People who allow others to provide them with support (sense of self-efficacy).

• Generational transmission of skills, crafts, values, and beliefs (generativity).

A sense of place is another component that has been associated with a sense of belonging. After the Boston Marathon bombings, some people affirmed that their sense of belonging was consolidated by that event. For others, a sense of belonging becomes fixed in their sense of tragedy as a victim of an event. We see many patients with posttraumatic stress disorder who have been bound by the traumatizing event(s), and who find it difficult or impossible to move beyond that experience.

For Americans, perhaps the notion of "family values" can be parsed to include the idea and study of belongingness. Understanding what belongingness encompasses can help us discuss relational being with our patients. Where do you find that sense of belonging? For Ioanna, her sense of belonging is felt in the seasonal ebb and flow of village life. Her sense of belonging shows in her skill as she works with her crafts with her hands. Breb belongs to her, even as it opens its large wooden doors to the world.

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.

BREB, ROMANIA – While strolling through this village in the Maramures region in the northwest corner of Romania, I ask Ileana, "How many live in this village?" Ileana has just come home from high school in the nearest town and is wearing brightly colored sneakers, blue jeans, and a pink sweatshirt with the word "LOVE" emblazed in sparkles across her chest. She is touring us proudly around her village.

"400."

"400 people?"

"No, 400 families."

"How many in each family?"

"About six or seven."

On the large ornate wooden gate to the family homestead is the inscription: "Familie Hermann." All seven members of the Hermann family live in a three-room traditional wooden house. The house has a large porch, where the family eats, works, and sometimes sleeps in the warm weather.

Courtesy David Naylor

Maria, the 82-year-old grandmother, sits outside the gate on a small bench and watches the villagers stroll home from the fields with scythes and rakes on their shoulders. She welcomes her daughter and son-in-law back home. It is spring, and the villagers are cleaning the fields in preparation for the summer grass growing. In the fall, they will harvest the grass to feed their animals throughout the winter.

On the porch, in the quiet of a late afternoon, as 9-year-old Ioanna is doing her homework, her mother, Raluca, works on the intricacies of beading the border of Ioanna’s traditional costume to be worn on Easter Sunday. Ioanna watches her mother pin the black velvet jacket to her skirt and load the needle with the gold beads to make the stems for the purple and red flowers. She sees how to turn the green rows into leaves. She shows her mother her school work, as equally neat and carefully calligraphied as her mother’s beading. Concern for accuracy and aesthetics are the skills and values passed down through the generations.

Maria comes in from the gate and resumes shelling beans on the front porch. She doesn’t do as much work in the fields anymore. Instead, she sweeps the house, tends to the flower garden, and helps with the two children. Maria takes the clothes down from the clothesline that stretches across the front of the porch. These handmade, intricately stitched works of art have been washed in preparation for Easter.

Maria shows us the gown she will wear at her funeral. She wove the linen, and smocked the neck and wrists with traditional village colors. She is proud of her work, and we admire it. She takes her gown inside, along with all the other freshly laundered white blouses that men and women will wear during the traditional events throughout the year.

After Easter, when the weather warms, most of the village will make the pilgrimage up the mountain accompanying the shepherds taking the sheep to summer grazing. The milking of the sheep is a defining village event, and precise measures are recorded in a book or on a stick to indicate each person’s anticipated portion of future milkings. This is Stina, a serious celebration, and the villagers wear traditional dress for the feasting, drinking, and dancing.

Life in rural villages is physically hard, and family and communal living are not idyllic. There is no privacy in the village, perhaps no secrets.

There is no privileging of the individual over the family. The family functions as a unit, getting work done by the seasons, so the family can eat throughout the year. The sense of belonging is irrefutable.

There is room for individual pride, however, and this is expressed as skill in raking a straight row, making the best plum brandy, wood carving, and doing embroidery. Everyone has an opinion on which family is the best at their craft in the village. The Hermann family is recognized for their skill in textiles – particularly their embroidery.

The village has its characters: the most devout, the "bad boy," the lazy person, and the man who can’t hold his liquor. This man, the village drunk, frequently makes a trip to the psychiatric hospital in the town of Sighetu Marmatieti, when he gets out of hand. After a few weeks, he comes home quieter, and his good behavior will last for the best part of a year. There is no physician or nurse in the village, only a veterinarian who visits, when called, to care for the animals.

The darker stories of the village lie hidden, because for now, it is early spring, and the village flows with optimism, celebration, and courtship. The white, hand-crafted blouses manifest the feelings of anticipation as they billow and dance on each clothesline throughout the village. Belonging to the village means feeling the seasons unfold intuitively. These feelings sustain and nourish the village families throughout their lives.

Outside of the village, in the "real world," we try to create a sense of belonging. As a country of immigrants, we in America have sense of belonging that is scattered. Still, connecting with our past is too often beyond our grasp. What is belonging? What are its components?

Ways to think about belonging

Studies on belonging extend across many disciplines: psychoanalysis, attachment psychology, social and cultural studies to philosophy. How does a family psychiatrist think about belonging? What aspects of belonging can be incorporated into psychiatric care?

An unmet need for belonging leads to loneliness and lower life satisfaction. This finding came from a study of 436 participants from the Australian Unity Wellbeing database who completed several measurements, including the Need to Belong Scale according to David Mellor, Ph.D., and his colleagues(Pers. Individ. Dif. 2008;45:213-8). Dr. Vincenzo Di Nicola, a psychiatrist who has written extensively about family relationships, also has offered valuable perspective on belongingness: "Belonging is a way of rethinking relational being, how we define mental health, how we understand the expression of its vicissitudes, and how we organize care and healing for sufferers. To do this, we need to recognize how belonging is experienced and negotiated, free of the constraints of our habitual patterns of practice and thought, to imagine belonging without borders for settlers, sojourners, and travelers in the 21st century."

Belongingness traditionally has been seen as a core of family life. If your values are different from those of your family, if you have moved from the village to the city and don’t want to be a farmer, what values do you uphold? Do you now have a new set of people and values? Do you belong to a group/club/school? Belonging to a guild or religious order means that the guild or order becomes your new family. However, belongingness is more transient and a less substantial part of life, as people change jobs and careers, get divorced and remarried, move to other countries.

Who serves as the family for people with psychiatric illness? In a recent study, people with serious mental illness were interviewed and asked about the "communities" to which they belonged (Psychiatr. Serv. [doi: 10.1176/appi.ps.201200235]). The researchers found four "patterns of experience" that made up communities for the respondents. Communities were places where people with mental illness could receive help, especially in times of vulnerability.

In addition, communities were places to manage risk and minimize the anxiety felt in public setting by people with mental illness. The stigma experienced in the general community or even within their families led many respondents to identify more strongly with peers who had mental illness.

Communities also were seen as places where those with serious mental illness could "give back" and help others. So perhaps, in the same way as these respondents defined belongingness for themselves, we can define belongingness for all our patients.

Several components must be satisfied for a person to have a sense of belongingness.

• A community in which the person’s beliefs and values are upheld as sacred (meaningfulness).

• Rituals that bring people together and support the meaningfulness of their lives (meaningfulness).

• People who provide emotional and practical support for others (attachment).

• People who allow others to provide them with support (sense of self-efficacy).

• Generational transmission of skills, crafts, values, and beliefs (generativity).

A sense of place is another component that has been associated with a sense of belonging. After the Boston Marathon bombings, some people affirmed that their sense of belonging was consolidated by that event. For others, a sense of belonging becomes fixed in their sense of tragedy as a victim of an event. We see many patients with posttraumatic stress disorder who have been bound by the traumatizing event(s), and who find it difficult or impossible to move beyond that experience.

For Americans, perhaps the notion of "family values" can be parsed to include the idea and study of belongingness. Understanding what belongingness encompasses can help us discuss relational being with our patients. Where do you find that sense of belonging? For Ioanna, her sense of belonging is felt in the seasonal ebb and flow of village life. Her sense of belonging shows in her skill as she works with her crafts with her hands. Breb belongs to her, even as it opens its large wooden doors to the world.

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.

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

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

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

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

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

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

Measuring relational functioning briefly

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

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

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

A daughter’s documentary about her father

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

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

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

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

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

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

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

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

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

Measuring relational functioning briefly

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

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

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

A daughter’s documentary about her father

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

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

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

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

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

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

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

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

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

Measuring relational functioning briefly

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

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

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

A daughter’s documentary about her father

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

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

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

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

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

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

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

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

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

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

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

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

In light of those allowances:

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

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

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

What to do if a patient objects

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In light of those allowances:

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

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

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

What to do if a patient objects

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In light of those allowances:

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

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

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

What to do if a patient objects

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

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

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

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

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

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

Intergenerational trauma often proves to be a prevailing feature of family systems.

The trauma of the Nazi concentration camps, for example, can be re-experienced in the lives of the children of camp survivors. Even the grandchildren of Holocaust survivors have been found to suffer from the effects of trauma. These effects manifest through characteristics such as increased suspiciousness of others, anger, and irritability in these individuals compared with controls (J. Relig. Health 2011;50:321-9).

Such intergenerational trauma has been found among urban American Indian and Alaska Native populations who have been involved in culturally specific sobriety maintenance programs (Am. Indian Alsk. Native Ment. Health Res. 2011;18:17-40). Likewise, a body of research supports the notion that untreated intergenerational trauma tied to generations of slavery in the United States continues to negatively affect many in the black community.

Other kinds of trauma can be passed down through the generations, as well. Take the trauma of a combat soldier; victim of or prisoner of war; survivor of a mass shooting or of child abuse; witness of genocide; or survivor of colonial suppression, slavery, or political totalitarianism. People who have experienced these traumas can pass down the consequences to subsequent generations.

We know that people who suffer trauma firsthand often develop posttraumatic stress disorder symptoms (PTSD) symptoms such as fearfulness, nightmares, flashbacks, sorrow, and difficulty with emotional closeness. However, it also is clear that compared with controls, the children of veterans with PTSD have shown an inability to experience appropriate emotional responses to situations and difficulty in solving problems effectively both within and outside the family unit (Aust. N.Z. J. Psychiatry 2001;35:345-51).

The trauma of childhood abuse also is transmitted down through the influences of the other members of the family, especially their children.

Another group known to suffer from the effects of intergenerational trauma is the children of alcoholics. This is a group that has demonstrated an increased need to care for others and keep secrets. They might use lying as a normal coping style and sometimes experience difficulty being children. Such behaviors are understood as a direct consequence of the experience of the family dysfunction. The question about trauma is: How do the symptoms of PTSD get "passed down" through the next generations, when the younger family members were not exposed to any trauma?

Various mechanisms have been considered, with individual psychological mechanisms and family dynamics being the most commonly cited mechanisms. Other factors have been suggested, such as the role of cultural and societal factors in the perpetuation of symptoms. Children and young adults might develop retaliatory fantasies "to right the wrongs done to their families." These types of beliefs and fantasies fuel many sectarian struggles around the world.

Individual psychological mechanisms commonly considered to be important are projection and identification. The parent with PTSD projects unwanted aspects of himself onto the child, who takes up the projection and identifies with it; this is called projective identification. Fear of the cold or the dark in the father then becomes the child’s fear instead. Children who are closest to the traumatized parent will be most affected.

Other postulated mechanisms focus on affect regulation. Parents who have difficulty with emotional regulation will have difficulty bonding appropriately with their child. On the other hand, emotional numbing might be present, which interferes with the development of a strong bond between parent and child.

One study of male Vietnam veterans found that "emotional numbing" and the quality of their relationship with their children remained significant even after investigators controlled for numerous factors, including the fathers’ family-of-origin stressors, combat exposure, depression, and substance abuse (J. Trauma Stress 2002;15:351-7). In other words, the children then suffer from secondary trauma.

Trauma-affected families also might have difficulty setting appropriate boundaries between parent and child so that the child becomes the caregiver of sorts and protector of the parent. The fears of the parent can become the fears of the child. It might be confusing for the child when a parent says: "Shh! Did you hear that noise," implying that "they" will get us, without really specifying the who and why, thus depriving the child of a rational explanation of his or her own experiences.

However, sometimes, trauma is not transmitted intergenerationally, a series of meta-analyses shows (Attach. Hum. Dev. 2008;10:105-21). Instead, these families are able to develop resilience and adapt well in the face of adversity – and achieve posttraumatic growth. How do we help the families with trauma become these resilient families?

Here is a list of nine points that can help guide the family psychiatrist:

1. The ability to regulate emotions, especially negative affect, is key to maintaining an understandable emotional climate for others in the family. Frequent unexplained emotional outbursts are difficult for other family members to understand. For children, it is especially important for them to understand that any emotional dysregulation is not caused by their behavior but by the parent’s experience of prior trauma.

2. The family should have an understanding of the meaning and cause of the traumatic events.

The traumatic events must be symbolized in a way that allows conversation and discussion about the past. The mention of wartime trauma can be phrased in a way that allows for the experience of pain, and then recovery, with hope and resilience as the message. A narrative story is important, with a good ending that the parent has survived, has overcome difficulties, and is here in the present with the child.

3. The parent must have "worked through" the trauma to the extent that he can internally symbolize his experiences enough to be able to talk about them and relay them to his

offspring in a coherent narrative with a positive message.

4. Open communication about the trauma prevents any unsymbolized, unspoken aspects of the trauma from being driven into unconsciousness, where they become dark fearful secrets that haunt the imagination and awaken the children, even as adults, at night.

5. Being able to access public accounts of the traumatic events is helpful to widen the family’s understanding of how others are affected, thus reducing the fearfulness of being alone with the trauma. Families should be encouraged to access these sources in order to understand the global aspects of trauma and the associated suffering and recovery.

6. For many families, having suffered trauma means that they must always be prepared for disaster. This, too, can be framed in a positive way, more like the scout motto of "be prepared," rather than the fearful posture of the survivalist.

7. A family fleeing from trauma might experience displacement through immigration and have no sense of home. This can be modulated by reestablishing and developing a new sense of community, and developing strong social and family rootedness. Sometimes, this involves a religious or spiritual group affiliation.

8. Family members who have suffered trauma often can identify skills that helped them survive. Hope, education, community, art – these values can be transmitted as the positive legacy of trauma. Helping families identify with positive resilient features of surviving trauma does not mean forgetting about the trauma but identifying the aspects that help the family go forward, enabling them to develop a narrative that allows recovery and growth.

9. If the child or other family members develop ongoing secondary PTSD or have enduring feelings of survivor guilt, persecution, and so on that are not resolved by family intervention, individual assessment might be needed.

In conclusion, despite the many illuminating case reports and anecdotes about the intergenerational transmission of trauma (for example, see J. Marital Fam. Ther. 2004;30:45-59), the message to families must be resilience focused. The question for these families becomes: "What did you do to manage the trauma and survive?"

Using a narrative framework, we can help these families identify the factors that can contribute to resilience, and build a future for the family that does not transmit traumatic symptoms but rather transmits the ability to move forward, despite traumatic symptoms.

 E-mail Dr. Heru at [email protected].

Intergenerational trauma often proves to be a prevailing feature of family systems.

The trauma of the Nazi concentration camps, for example, can be re-experienced in the lives of the children of camp survivors. Even the grandchildren of Holocaust survivors have been found to suffer from the effects of trauma. These effects manifest through characteristics such as increased suspiciousness of others, anger, and irritability in these individuals compared with controls (J. Relig. Health 2011;50:321-9).

Such intergenerational trauma has been found among urban American Indian and Alaska Native populations who have been involved in culturally specific sobriety maintenance programs (Am. Indian Alsk. Native Ment. Health Res. 2011;18:17-40). Likewise, a body of research supports the notion that untreated intergenerational trauma tied to generations of slavery in the United States continues to negatively affect many in the black community.

Other kinds of trauma can be passed down through the generations, as well. Take the trauma of a combat soldier; victim of or prisoner of war; survivor of a mass shooting or of child abuse; witness of genocide; or survivor of colonial suppression, slavery, or political totalitarianism. People who have experienced these traumas can pass down the consequences to subsequent generations.

We know that people who suffer trauma firsthand often develop posttraumatic stress disorder symptoms (PTSD) symptoms such as fearfulness, nightmares, flashbacks, sorrow, and difficulty with emotional closeness. However, it also is clear that compared with controls, the children of veterans with PTSD have shown an inability to experience appropriate emotional responses to situations and difficulty in solving problems effectively both within and outside the family unit (Aust. N.Z. J. Psychiatry 2001;35:345-51).

The trauma of childhood abuse also is transmitted down through the influences of the other members of the family, especially their children.

Another group known to suffer from the effects of intergenerational trauma is the children of alcoholics. This is a group that has demonstrated an increased need to care for others and keep secrets. They might use lying as a normal coping style and sometimes experience difficulty being children. Such behaviors are understood as a direct consequence of the experience of the family dysfunction. The question about trauma is: How do the symptoms of PTSD get "passed down" through the next generations, when the younger family members were not exposed to any trauma?

Various mechanisms have been considered, with individual psychological mechanisms and family dynamics being the most commonly cited mechanisms. Other factors have been suggested, such as the role of cultural and societal factors in the perpetuation of symptoms. Children and young adults might develop retaliatory fantasies "to right the wrongs done to their families." These types of beliefs and fantasies fuel many sectarian struggles around the world.

Individual psychological mechanisms commonly considered to be important are projection and identification. The parent with PTSD projects unwanted aspects of himself onto the child, who takes up the projection and identifies with it; this is called projective identification. Fear of the cold or the dark in the father then becomes the child’s fear instead. Children who are closest to the traumatized parent will be most affected.

Other postulated mechanisms focus on affect regulation. Parents who have difficulty with emotional regulation will have difficulty bonding appropriately with their child. On the other hand, emotional numbing might be present, which interferes with the development of a strong bond between parent and child.

One study of male Vietnam veterans found that "emotional numbing" and the quality of their relationship with their children remained significant even after investigators controlled for numerous factors, including the fathers’ family-of-origin stressors, combat exposure, depression, and substance abuse (J. Trauma Stress 2002;15:351-7). In other words, the children then suffer from secondary trauma.

Trauma-affected families also might have difficulty setting appropriate boundaries between parent and child so that the child becomes the caregiver of sorts and protector of the parent. The fears of the parent can become the fears of the child. It might be confusing for the child when a parent says: "Shh! Did you hear that noise," implying that "they" will get us, without really specifying the who and why, thus depriving the child of a rational explanation of his or her own experiences.

However, sometimes, trauma is not transmitted intergenerationally, a series of meta-analyses shows (Attach. Hum. Dev. 2008;10:105-21). Instead, these families are able to develop resilience and adapt well in the face of adversity – and achieve posttraumatic growth. How do we help the families with trauma become these resilient families?

Here is a list of nine points that can help guide the family psychiatrist:

1. The ability to regulate emotions, especially negative affect, is key to maintaining an understandable emotional climate for others in the family. Frequent unexplained emotional outbursts are difficult for other family members to understand. For children, it is especially important for them to understand that any emotional dysregulation is not caused by their behavior but by the parent’s experience of prior trauma.

2. The family should have an understanding of the meaning and cause of the traumatic events.

The traumatic events must be symbolized in a way that allows conversation and discussion about the past. The mention of wartime trauma can be phrased in a way that allows for the experience of pain, and then recovery, with hope and resilience as the message. A narrative story is important, with a good ending that the parent has survived, has overcome difficulties, and is here in the present with the child.

3. The parent must have "worked through" the trauma to the extent that he can internally symbolize his experiences enough to be able to talk about them and relay them to his

offspring in a coherent narrative with a positive message.

4. Open communication about the trauma prevents any unsymbolized, unspoken aspects of the trauma from being driven into unconsciousness, where they become dark fearful secrets that haunt the imagination and awaken the children, even as adults, at night.

5. Being able to access public accounts of the traumatic events is helpful to widen the family’s understanding of how others are affected, thus reducing the fearfulness of being alone with the trauma. Families should be encouraged to access these sources in order to understand the global aspects of trauma and the associated suffering and recovery.

6. For many families, having suffered trauma means that they must always be prepared for disaster. This, too, can be framed in a positive way, more like the scout motto of "be prepared," rather than the fearful posture of the survivalist.

7. A family fleeing from trauma might experience displacement through immigration and have no sense of home. This can be modulated by reestablishing and developing a new sense of community, and developing strong social and family rootedness. Sometimes, this involves a religious or spiritual group affiliation.

8. Family members who have suffered trauma often can identify skills that helped them survive. Hope, education, community, art – these values can be transmitted as the positive legacy of trauma. Helping families identify with positive resilient features of surviving trauma does not mean forgetting about the trauma but identifying the aspects that help the family go forward, enabling them to develop a narrative that allows recovery and growth.

9. If the child or other family members develop ongoing secondary PTSD or have enduring feelings of survivor guilt, persecution, and so on that are not resolved by family intervention, individual assessment might be needed.

In conclusion, despite the many illuminating case reports and anecdotes about the intergenerational transmission of trauma (for example, see J. Marital Fam. Ther. 2004;30:45-59), the message to families must be resilience focused. The question for these families becomes: "What did you do to manage the trauma and survive?"

Using a narrative framework, we can help these families identify the factors that can contribute to resilience, and build a future for the family that does not transmit traumatic symptoms but rather transmits the ability to move forward, despite traumatic symptoms.

 E-mail Dr. Heru at [email protected].

Intergenerational trauma often proves to be a prevailing feature of family systems.

The trauma of the Nazi concentration camps, for example, can be re-experienced in the lives of the children of camp survivors. Even the grandchildren of Holocaust survivors have been found to suffer from the effects of trauma. These effects manifest through characteristics such as increased suspiciousness of others, anger, and irritability in these individuals compared with controls (J. Relig. Health 2011;50:321-9).

Such intergenerational trauma has been found among urban American Indian and Alaska Native populations who have been involved in culturally specific sobriety maintenance programs (Am. Indian Alsk. Native Ment. Health Res. 2011;18:17-40). Likewise, a body of research supports the notion that untreated intergenerational trauma tied to generations of slavery in the United States continues to negatively affect many in the black community.

Other kinds of trauma can be passed down through the generations, as well. Take the trauma of a combat soldier; victim of or prisoner of war; survivor of a mass shooting or of child abuse; witness of genocide; or survivor of colonial suppression, slavery, or political totalitarianism. People who have experienced these traumas can pass down the consequences to subsequent generations.

We know that people who suffer trauma firsthand often develop posttraumatic stress disorder symptoms (PTSD) symptoms such as fearfulness, nightmares, flashbacks, sorrow, and difficulty with emotional closeness. However, it also is clear that compared with controls, the children of veterans with PTSD have shown an inability to experience appropriate emotional responses to situations and difficulty in solving problems effectively both within and outside the family unit (Aust. N.Z. J. Psychiatry 2001;35:345-51).

The trauma of childhood abuse also is transmitted down through the influences of the other members of the family, especially their children.

Another group known to suffer from the effects of intergenerational trauma is the children of alcoholics. This is a group that has demonstrated an increased need to care for others and keep secrets. They might use lying as a normal coping style and sometimes experience difficulty being children. Such behaviors are understood as a direct consequence of the experience of the family dysfunction. The question about trauma is: How do the symptoms of PTSD get "passed down" through the next generations, when the younger family members were not exposed to any trauma?

Various mechanisms have been considered, with individual psychological mechanisms and family dynamics being the most commonly cited mechanisms. Other factors have been suggested, such as the role of cultural and societal factors in the perpetuation of symptoms. Children and young adults might develop retaliatory fantasies "to right the wrongs done to their families." These types of beliefs and fantasies fuel many sectarian struggles around the world.

Individual psychological mechanisms commonly considered to be important are projection and identification. The parent with PTSD projects unwanted aspects of himself onto the child, who takes up the projection and identifies with it; this is called projective identification. Fear of the cold or the dark in the father then becomes the child’s fear instead. Children who are closest to the traumatized parent will be most affected.

Other postulated mechanisms focus on affect regulation. Parents who have difficulty with emotional regulation will have difficulty bonding appropriately with their child. On the other hand, emotional numbing might be present, which interferes with the development of a strong bond between parent and child.

One study of male Vietnam veterans found that "emotional numbing" and the quality of their relationship with their children remained significant even after investigators controlled for numerous factors, including the fathers’ family-of-origin stressors, combat exposure, depression, and substance abuse (J. Trauma Stress 2002;15:351-7). In other words, the children then suffer from secondary trauma.

Trauma-affected families also might have difficulty setting appropriate boundaries between parent and child so that the child becomes the caregiver of sorts and protector of the parent. The fears of the parent can become the fears of the child. It might be confusing for the child when a parent says: "Shh! Did you hear that noise," implying that "they" will get us, without really specifying the who and why, thus depriving the child of a rational explanation of his or her own experiences.

However, sometimes, trauma is not transmitted intergenerationally, a series of meta-analyses shows (Attach. Hum. Dev. 2008;10:105-21). Instead, these families are able to develop resilience and adapt well in the face of adversity – and achieve posttraumatic growth. How do we help the families with trauma become these resilient families?

Here is a list of nine points that can help guide the family psychiatrist:

1. The ability to regulate emotions, especially negative affect, is key to maintaining an understandable emotional climate for others in the family. Frequent unexplained emotional outbursts are difficult for other family members to understand. For children, it is especially important for them to understand that any emotional dysregulation is not caused by their behavior but by the parent’s experience of prior trauma.

2. The family should have an understanding of the meaning and cause of the traumatic events.

The traumatic events must be symbolized in a way that allows conversation and discussion about the past. The mention of wartime trauma can be phrased in a way that allows for the experience of pain, and then recovery, with hope and resilience as the message. A narrative story is important, with a good ending that the parent has survived, has overcome difficulties, and is here in the present with the child.

3. The parent must have "worked through" the trauma to the extent that he can internally symbolize his experiences enough to be able to talk about them and relay them to his

offspring in a coherent narrative with a positive message.

4. Open communication about the trauma prevents any unsymbolized, unspoken aspects of the trauma from being driven into unconsciousness, where they become dark fearful secrets that haunt the imagination and awaken the children, even as adults, at night.

5. Being able to access public accounts of the traumatic events is helpful to widen the family’s understanding of how others are affected, thus reducing the fearfulness of being alone with the trauma. Families should be encouraged to access these sources in order to understand the global aspects of trauma and the associated suffering and recovery.

6. For many families, having suffered trauma means that they must always be prepared for disaster. This, too, can be framed in a positive way, more like the scout motto of "be prepared," rather than the fearful posture of the survivalist.

7. A family fleeing from trauma might experience displacement through immigration and have no sense of home. This can be modulated by reestablishing and developing a new sense of community, and developing strong social and family rootedness. Sometimes, this involves a religious or spiritual group affiliation.

8. Family members who have suffered trauma often can identify skills that helped them survive. Hope, education, community, art – these values can be transmitted as the positive legacy of trauma. Helping families identify with positive resilient features of surviving trauma does not mean forgetting about the trauma but identifying the aspects that help the family go forward, enabling them to develop a narrative that allows recovery and growth.

9. If the child or other family members develop ongoing secondary PTSD or have enduring feelings of survivor guilt, persecution, and so on that are not resolved by family intervention, individual assessment might be needed.

In conclusion, despite the many illuminating case reports and anecdotes about the intergenerational transmission of trauma (for example, see J. Marital Fam. Ther. 2004;30:45-59), the message to families must be resilience focused. The question for these families becomes: "What did you do to manage the trauma and survive?"

Using a narrative framework, we can help these families identify the factors that can contribute to resilience, and build a future for the family that does not transmit traumatic symptoms but rather transmits the ability to move forward, despite traumatic symptoms.

 E-mail Dr. Heru at [email protected].

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

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

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

Individual resilience

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

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

Acquiring resilient qualities

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

Family resilience

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

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

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

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

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

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

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

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

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

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

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

Community resilience

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

Professional resilience

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

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

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

Further reading:

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

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

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

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

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

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

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

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

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

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

Individual resilience

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

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

Acquiring resilient qualities

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

Family resilience

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

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

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

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

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

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

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

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

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

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

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

Community resilience

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

Professional resilience

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

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

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

Further reading:

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

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

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

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

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

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

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

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

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

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

Individual resilience

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

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

Acquiring resilient qualities

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

Family resilience

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

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

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

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

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

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

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

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

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

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

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

Community resilience

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

Professional resilience

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

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

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

Further reading:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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