Families in Psychiatry

Bob is in the kitchen, settling down his family to preparing a celebration dinner with produce from the communal garden. He is a tall, wiry man with a gray beard and kind gentle eyes. His current family includes his wife, who is a therapist in a nearby town; a tall, blonde Scandinavian man who is spending time "finding himself"; a young, eager couple who tend the garden and teach the intricacies of organic farming; and a reclusive artist who works with metals and found objects.

Bob bought the dilapidated commune buildings several years ago, after retiring from his fast-paced, stressful life as an internist in California. He has meticulously restored the adobe buildings using the expertise of traditional builders. There are different types of adobe throughout the compound, sparkling mica walls in the bedrooms, and deep, rich brown in the large circular communal living room. Bob conceptualizes this historic setting as a retreat for meditation and a place to teach organic farming to the next generation. As I observed during my visit a few months ago, Bob is the elder and wise man of this communal family who gently quiets the demons in the spider-phobic Scandinavian.

This is a "family" in the best sense: a group of people who share a spiritual belief in their connection to the land, the goodness of the human spirit, and the importance of connection between people. Like the hippies before them who established New Buffalo in Arroyo Hondo, N.M., the residents reject many Western values, at least for a few years, and try out this alternative way of living. The community’s website says it is no longer a commune but that members are "connected by a common sense of ideals and a strong sense of place."

Communes have always existed in the United States. Native Americans live communally but are not recognized as communes. The largest recognized U.S. communal living group is the Hutterite community. About 42,000 people live in rural Hutterite communities across the United States. They are derived from the Anabaptists, a Christian sect dating back to 16th century Austria, which also spawned Amish and Mennonite communities.

Whatever type of family our patients live in, be it a religious sect, a down-to-earth commune, or a traditional family, to run well, that family needs to be organized, to communicate well and to have good boundaries (Fam. Process 2003;42:1-18).

Why is this important to psychiatry? Good family functioning is associated with good outcomes for patients with all kinds of illnesses from medical to psychiatric (Families, Health, and Behavior: A Section of the Commissioned Report by the Committee on Health and Behavior, Institute of Medicine [Families, Systems & Health 2002;20:7-46]). In addition, "a growing body of research finds that healthy family processes ... matter more than family form for effective functioning...," writes Froma Walsh, Ph.D., (Normal Family Process [N.Y.: Guilford Press, 2003]). To cope well with illness, families need to be able to problem solve, communicate, and stay connected. However, good family functioning looks different in different cultures, from the highly organized rigid religious sects to the looser counterculture New Buffalo community. So how do we describe families and their functioning?

One easy approach is to look at the Global Assessment of Relational Functioning, or the GARF Scale, found in Appendix B of the DSM IV-TR (Washington: American Psychiatric Association, 2000). It has three subscales: problem solving, organization, and emotional climate. The choices for rating families range from 1-20 "Relational unit has become too dysfunctional to retain continuity of contact and attachment," to the 81-100 range in which the "relational unit is functioning satisfactorily from self-report of participants and from the perspective of observers." This scale is easy to learn and use. Also, the scale is independent of culture and can be used for any group of people who call themselves a family. So yes, after observing the New Buffalo community for a few days, I would rank it a solid 88.

Bob is in the kitchen, settling down his family to preparing a celebration dinner with produce from the communal garden. He is a tall, wiry man with a gray beard and kind gentle eyes. His current family includes his wife, who is a therapist in a nearby town; a tall, blonde Scandinavian man who is spending time "finding himself"; a young, eager couple who tend the garden and teach the intricacies of organic farming; and a reclusive artist who works with metals and found objects.

Bob bought the dilapidated commune buildings several years ago, after retiring from his fast-paced, stressful life as an internist in California. He has meticulously restored the adobe buildings using the expertise of traditional builders. There are different types of adobe throughout the compound, sparkling mica walls in the bedrooms, and deep, rich brown in the large circular communal living room. Bob conceptualizes this historic setting as a retreat for meditation and a place to teach organic farming to the next generation. As I observed during my visit a few months ago, Bob is the elder and wise man of this communal family who gently quiets the demons in the spider-phobic Scandinavian.

This is a "family" in the best sense: a group of people who share a spiritual belief in their connection to the land, the goodness of the human spirit, and the importance of connection between people. Like the hippies before them who established New Buffalo in Arroyo Hondo, N.M., the residents reject many Western values, at least for a few years, and try out this alternative way of living. The community’s website says it is no longer a commune but that members are "connected by a common sense of ideals and a strong sense of place."

Communes have always existed in the United States. Native Americans live communally but are not recognized as communes. The largest recognized U.S. communal living group is the Hutterite community. About 42,000 people live in rural Hutterite communities across the United States. They are derived from the Anabaptists, a Christian sect dating back to 16th century Austria, which also spawned Amish and Mennonite communities.

Whatever type of family our patients live in, be it a religious sect, a down-to-earth commune, or a traditional family, to run well, that family needs to be organized, to communicate well and to have good boundaries (Fam. Process 2003;42:1-18).

Why is this important to psychiatry? Good family functioning is associated with good outcomes for patients with all kinds of illnesses from medical to psychiatric (Families, Health, and Behavior: A Section of the Commissioned Report by the Committee on Health and Behavior, Institute of Medicine [Families, Systems & Health 2002;20:7-46]). In addition, "a growing body of research finds that healthy family processes ... matter more than family form for effective functioning...," writes Froma Walsh, Ph.D., (Normal Family Process [N.Y.: Guilford Press, 2003]). To cope well with illness, families need to be able to problem solve, communicate, and stay connected. However, good family functioning looks different in different cultures, from the highly organized rigid religious sects to the looser counterculture New Buffalo community. So how do we describe families and their functioning?

One easy approach is to look at the Global Assessment of Relational Functioning, or the GARF Scale, found in Appendix B of the DSM IV-TR (Washington: American Psychiatric Association, 2000). It has three subscales: problem solving, organization, and emotional climate. The choices for rating families range from 1-20 "Relational unit has become too dysfunctional to retain continuity of contact and attachment," to the 81-100 range in which the "relational unit is functioning satisfactorily from self-report of participants and from the perspective of observers." This scale is easy to learn and use. Also, the scale is independent of culture and can be used for any group of people who call themselves a family. So yes, after observing the New Buffalo community for a few days, I would rank it a solid 88.

Bob is in the kitchen, settling down his family to preparing a celebration dinner with produce from the communal garden. He is a tall, wiry man with a gray beard and kind gentle eyes. His current family includes his wife, who is a therapist in a nearby town; a tall, blonde Scandinavian man who is spending time "finding himself"; a young, eager couple who tend the garden and teach the intricacies of organic farming; and a reclusive artist who works with metals and found objects.

Bob bought the dilapidated commune buildings several years ago, after retiring from his fast-paced, stressful life as an internist in California. He has meticulously restored the adobe buildings using the expertise of traditional builders. There are different types of adobe throughout the compound, sparkling mica walls in the bedrooms, and deep, rich brown in the large circular communal living room. Bob conceptualizes this historic setting as a retreat for meditation and a place to teach organic farming to the next generation. As I observed during my visit a few months ago, Bob is the elder and wise man of this communal family who gently quiets the demons in the spider-phobic Scandinavian.

This is a "family" in the best sense: a group of people who share a spiritual belief in their connection to the land, the goodness of the human spirit, and the importance of connection between people. Like the hippies before them who established New Buffalo in Arroyo Hondo, N.M., the residents reject many Western values, at least for a few years, and try out this alternative way of living. The community’s website says it is no longer a commune but that members are "connected by a common sense of ideals and a strong sense of place."

Communes have always existed in the United States. Native Americans live communally but are not recognized as communes. The largest recognized U.S. communal living group is the Hutterite community. About 42,000 people live in rural Hutterite communities across the United States. They are derived from the Anabaptists, a Christian sect dating back to 16th century Austria, which also spawned Amish and Mennonite communities.

Whatever type of family our patients live in, be it a religious sect, a down-to-earth commune, or a traditional family, to run well, that family needs to be organized, to communicate well and to have good boundaries (Fam. Process 2003;42:1-18).

Why is this important to psychiatry? Good family functioning is associated with good outcomes for patients with all kinds of illnesses from medical to psychiatric (Families, Health, and Behavior: A Section of the Commissioned Report by the Committee on Health and Behavior, Institute of Medicine [Families, Systems & Health 2002;20:7-46]). In addition, "a growing body of research finds that healthy family processes ... matter more than family form for effective functioning...," writes Froma Walsh, Ph.D., (Normal Family Process [N.Y.: Guilford Press, 2003]). To cope well with illness, families need to be able to problem solve, communicate, and stay connected. However, good family functioning looks different in different cultures, from the highly organized rigid religious sects to the looser counterculture New Buffalo community. So how do we describe families and their functioning?

One easy approach is to look at the Global Assessment of Relational Functioning, or the GARF Scale, found in Appendix B of the DSM IV-TR (Washington: American Psychiatric Association, 2000). It has three subscales: problem solving, organization, and emotional climate. The choices for rating families range from 1-20 "Relational unit has become too dysfunctional to retain continuity of contact and attachment," to the 81-100 range in which the "relational unit is functioning satisfactorily from self-report of participants and from the perspective of observers." This scale is easy to learn and use. Also, the scale is independent of culture and can be used for any group of people who call themselves a family. So yes, after observing the New Buffalo community for a few days, I would rank it a solid 88.

Editors’ Note: Patients are part of family systems, and understanding these systems can help psychiatrists advance treatment. That’s why we’re launching a new column we are calling Families in Psychiatry. In this column, Dr. Alison M. Heru will examine issues faced by psychiatrists who are involved in family therapy and psychoeducation. She will also look at family research and at the impact that caring for patients with mental illness has on caregivers. Often, she will also offer a global perspective on these issues. If you have an idea for Dr. Heru, e-mail her at [email protected].

At age 7, Maggie Jarry watched her mother "walk around the apartment trying to catch her eyes because she believed they had floated out of her face." Her mother often locked herself in the bathroom and talked to herself in the mirror because she believed that had telepathic powers.

"We lived like this for a year, until a babysitter and her mother figured out what was going on" and got professional help for Maggie’s mother. Her mother was diagnosed with schizoaffective disorder, and after she died in 2007, Maggie Jarry felt free to share her experience (Psychiatr. Serv. 2009;60:1587-8). "During these years, no one asked me about my experiences of living with my mom while she was ill. I was expected to just go play and be a child while she was in the hospital," Maggie wrote.

Maggie, now a community organizer, is part of a new consumer organization that seeks to provide support and resources to those who have a parent with mental illness. In the organization’s blog, called "Daughters and Sons," one writer expressed the burden of children living with parents with mental illness this way:

"People can be told that your family member is ‘sick’ but until they have concrete examples of how a day becomes an eternity as a child sits unknowingly, waiting for a storm to pass that has no time limit, they really have no idea what it is like. Until people ‘get it,’ they won’t be inclined to help change it and deal with it on a societal level. Unlike the adults who can get away from dysfunction, the child growing up in a crooked house has no escape."

In Maggie’s case, when her mother was doing well, the two had a good relationship. The bond that existed between the two underscores the essential human role that parenting can have in helping patients with mental illness reach wellness.

Many resources are available for children of parents with mental illness, although there are more in Europe, Australia, and New Zealand than in the United States. In the Netherlands, an online group course for Parents With Mental Illness has been piloted, and in Finland, clinician training has been studied. In the United States, the National Research Council and the Institute of Medicine produced a report on Depression in Parents, Parenting and Children: Opportunities to Improve Identification, Treatment, and Prevention. In addition, excellent web resources are listed at end of the column.

What can individual adult psychiatrists do? We can include children in family meetings about the parent’s illness. We can answer their questions about psychiatric illness. Children can also provide great insight into family functioning – strengths and weaknesses. We can provide age-appropriate literature when they visit the hospital or come with their parent to our office. We can ask our patients, their spouses, and other caregiving adults about their children. We can ask if they need help with parenting, and provide appropriate resources. We can reassure our patients that we want to help them become better parents, not remove their children! Families can be referred for help and support. If you see your patient as being part of a family, then you have a family or systems perspective of health care.

There are many family psychiatrists and many of us are members of the Association of Family Psychiatrists, which is an organization allied with the American Psychiatric Association. We have a website and a newsletter. Family psychiatrists are found in diverse settings, such as child and adolescent inpatient units, geriatric clinics, and psychosomatic medicine services. Those of us in outpatient practice may use family therapy as a single modality. Most of us, however, incorporate a family approach in our care of the patient. We use medication, individual therapy, and family interventions.

Several international family psychiatry resources are available online. Among them are the "Mental Health and Growing Up" leaflets, the "Children of Parents With a Mental Illness" website, and the Effective Family Programme.

I look forward to bringing you updates on family psychiatry, the latest in evidence-based family interventions, and other information aimed at helping you keep an updated family systems approach in your practice. Let me hear from you.

Editors’ Note: Patients are part of family systems, and understanding these systems can help psychiatrists advance treatment. That’s why we’re launching a new column we are calling Families in Psychiatry. In this column, Dr. Alison M. Heru will examine issues faced by psychiatrists who are involved in family therapy and psychoeducation. She will also look at family research and at the impact that caring for patients with mental illness has on caregivers. Often, she will also offer a global perspective on these issues. If you have an idea for Dr. Heru, e-mail her at [email protected].

At age 7, Maggie Jarry watched her mother "walk around the apartment trying to catch her eyes because she believed they had floated out of her face." Her mother often locked herself in the bathroom and talked to herself in the mirror because she believed that had telepathic powers.

"We lived like this for a year, until a babysitter and her mother figured out what was going on" and got professional help for Maggie’s mother. Her mother was diagnosed with schizoaffective disorder, and after she died in 2007, Maggie Jarry felt free to share her experience (Psychiatr. Serv. 2009;60:1587-8). "During these years, no one asked me about my experiences of living with my mom while she was ill. I was expected to just go play and be a child while she was in the hospital," Maggie wrote.

Maggie, now a community organizer, is part of a new consumer organization that seeks to provide support and resources to those who have a parent with mental illness. In the organization’s blog, called "Daughters and Sons," one writer expressed the burden of children living with parents with mental illness this way:

"People can be told that your family member is ‘sick’ but until they have concrete examples of how a day becomes an eternity as a child sits unknowingly, waiting for a storm to pass that has no time limit, they really have no idea what it is like. Until people ‘get it,’ they won’t be inclined to help change it and deal with it on a societal level. Unlike the adults who can get away from dysfunction, the child growing up in a crooked house has no escape."

In Maggie’s case, when her mother was doing well, the two had a good relationship. The bond that existed between the two underscores the essential human role that parenting can have in helping patients with mental illness reach wellness.

Many resources are available for children of parents with mental illness, although there are more in Europe, Australia, and New Zealand than in the United States. In the Netherlands, an online group course for Parents With Mental Illness has been piloted, and in Finland, clinician training has been studied. In the United States, the National Research Council and the Institute of Medicine produced a report on Depression in Parents, Parenting and Children: Opportunities to Improve Identification, Treatment, and Prevention. In addition, excellent web resources are listed at end of the column.

What can individual adult psychiatrists do? We can include children in family meetings about the parent’s illness. We can answer their questions about psychiatric illness. Children can also provide great insight into family functioning – strengths and weaknesses. We can provide age-appropriate literature when they visit the hospital or come with their parent to our office. We can ask our patients, their spouses, and other caregiving adults about their children. We can ask if they need help with parenting, and provide appropriate resources. We can reassure our patients that we want to help them become better parents, not remove their children! Families can be referred for help and support. If you see your patient as being part of a family, then you have a family or systems perspective of health care.

There are many family psychiatrists and many of us are members of the Association of Family Psychiatrists, which is an organization allied with the American Psychiatric Association. We have a website and a newsletter. Family psychiatrists are found in diverse settings, such as child and adolescent inpatient units, geriatric clinics, and psychosomatic medicine services. Those of us in outpatient practice may use family therapy as a single modality. Most of us, however, incorporate a family approach in our care of the patient. We use medication, individual therapy, and family interventions.

Several international family psychiatry resources are available online. Among them are the "Mental Health and Growing Up" leaflets, the "Children of Parents With a Mental Illness" website, and the Effective Family Programme.

I look forward to bringing you updates on family psychiatry, the latest in evidence-based family interventions, and other information aimed at helping you keep an updated family systems approach in your practice. Let me hear from you.

Editors’ Note: Patients are part of family systems, and understanding these systems can help psychiatrists advance treatment. That’s why we’re launching a new column we are calling Families in Psychiatry. In this column, Dr. Alison M. Heru will examine issues faced by psychiatrists who are involved in family therapy and psychoeducation. She will also look at family research and at the impact that caring for patients with mental illness has on caregivers. Often, she will also offer a global perspective on these issues. If you have an idea for Dr. Heru, e-mail her at [email protected].

At age 7, Maggie Jarry watched her mother "walk around the apartment trying to catch her eyes because she believed they had floated out of her face." Her mother often locked herself in the bathroom and talked to herself in the mirror because she believed that had telepathic powers.

"We lived like this for a year, until a babysitter and her mother figured out what was going on" and got professional help for Maggie’s mother. Her mother was diagnosed with schizoaffective disorder, and after she died in 2007, Maggie Jarry felt free to share her experience (Psychiatr. Serv. 2009;60:1587-8). "During these years, no one asked me about my experiences of living with my mom while she was ill. I was expected to just go play and be a child while she was in the hospital," Maggie wrote.

Maggie, now a community organizer, is part of a new consumer organization that seeks to provide support and resources to those who have a parent with mental illness. In the organization’s blog, called "Daughters and Sons," one writer expressed the burden of children living with parents with mental illness this way:

"People can be told that your family member is ‘sick’ but until they have concrete examples of how a day becomes an eternity as a child sits unknowingly, waiting for a storm to pass that has no time limit, they really have no idea what it is like. Until people ‘get it,’ they won’t be inclined to help change it and deal with it on a societal level. Unlike the adults who can get away from dysfunction, the child growing up in a crooked house has no escape."

In Maggie’s case, when her mother was doing well, the two had a good relationship. The bond that existed between the two underscores the essential human role that parenting can have in helping patients with mental illness reach wellness.

Many resources are available for children of parents with mental illness, although there are more in Europe, Australia, and New Zealand than in the United States. In the Netherlands, an online group course for Parents With Mental Illness has been piloted, and in Finland, clinician training has been studied. In the United States, the National Research Council and the Institute of Medicine produced a report on Depression in Parents, Parenting and Children: Opportunities to Improve Identification, Treatment, and Prevention. In addition, excellent web resources are listed at end of the column.

What can individual adult psychiatrists do? We can include children in family meetings about the parent’s illness. We can answer their questions about psychiatric illness. Children can also provide great insight into family functioning – strengths and weaknesses. We can provide age-appropriate literature when they visit the hospital or come with their parent to our office. We can ask our patients, their spouses, and other caregiving adults about their children. We can ask if they need help with parenting, and provide appropriate resources. We can reassure our patients that we want to help them become better parents, not remove their children! Families can be referred for help and support. If you see your patient as being part of a family, then you have a family or systems perspective of health care.

There are many family psychiatrists and many of us are members of the Association of Family Psychiatrists, which is an organization allied with the American Psychiatric Association. We have a website and a newsletter. Family psychiatrists are found in diverse settings, such as child and adolescent inpatient units, geriatric clinics, and psychosomatic medicine services. Those of us in outpatient practice may use family therapy as a single modality. Most of us, however, incorporate a family approach in our care of the patient. We use medication, individual therapy, and family interventions.

Several international family psychiatry resources are available online. Among them are the "Mental Health and Growing Up" leaflets, the "Children of Parents With a Mental Illness" website, and the Effective Family Programme.

I look forward to bringing you updates on family psychiatry, the latest in evidence-based family interventions, and other information aimed at helping you keep an updated family systems approach in your practice. Let me hear from you.