Family Therapy and Mental Health University of Guelph Open Learning and Educational Support

Family Therapy and Mental Health

University of Guelph

Open Learning and Educational Support

Today: sadness and worry

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Review

Comments from last class Questions about assignments Areas not covered

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Presentation

Depression - Andrew and Dulcie

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Ordinary People

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Depressive Disorders

Disruptive mood dysregulation disorder Major depressive disorder Persistent depressive disorder Premenstrual dysphoric disorder Substance/medication-induced dd DD due to another medical condition Other specified DD Unspecified DD

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Disruptive Mood Dysregulation Disorder

To reduce overdiagnosis and treatment of bipolar disorder in children

Persistent irritability Frequent episodes of extreme behavioural

dyscontrol Up to age 12 Children of this pattern typically develop

unipolar depression or anxiety as adults, not bipolar disorder

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Major Depressive Disorder

At least two weeks’ duration Clear-cut changes in affect, cognition, and

neurovegetative functions Inter-episode remissions Bereavement is no longer excluded

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Persistent Depressive Disorder

At least 2 years in adults or 1 in children New in DSM-5 Combines chronic major depression and

dysthymia (DSM-IV)

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Premenstrual Dysphoric Disorder

Was in an appendix of DSM-IV Now in the main part of DSM-5 Specific and treatment-responsive form of

depressive disorder that begins after ovulation and remits after menses

Marked impairment of functioning

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Drugs and Medical Conditions

Substances of abuse Prescribed medications Medical conditions

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The Depression Map

A Holistic Approach to Understanding and Treating

Depression

The Depression Map(Randy J. Paterson, 2002)

Multi-causal No “one size fits all” Match strategies with cause & nature for

individual Understand how parts interact/effect each

other



Physiology Illness, disease, hormonal & metabolic disorders,

medication, alcohol/drugs, environmental toxins, nutritional deficiencies, sleep disorders, childbirth

Behaviour Diet, exercise, sleep, caffeine, sunlight, avoid

drugs/alcohol, having fun


Thinking Thought records, cognitive distortions,

attributional biases, perfectionism, worry, challenging negative thoughts, core beliefs

Emotion Stress, understanding & managing mood Fear, anger, guilt & shame

Current life situation Finding balance, goal setting, problem solving


Social setting Deepening current relationships Reviving old relationships Starting new friendships Social balance Being assertive Managing child care


Finding meaning Meaning inventory, welcoming the crisis,

spirituality, connecting to a larger cause Prevention

Managing stress Emergency action plan

Treatment

Treat the mood directly with antidepressant medication (or better music)

Treat the thinking with therapy

Medications for Anxiety and Depression

Improve the function of endogenous norepinephrine, serotonin and dopamine (neurotransmitters associated with mood)

Medications

Serotonin-Specific Reuptake Inhibitors (SSRI’s) 2-4 weeks response time suicide risk in children Generally much safer than TCA’s or MAOI’s

(below)

Medications

Heterocyclic (Tricyclic) Antidepressants (TCA’s) Amitriptyline, imipramine are examples 3-6 weeks response time Overdose very dangerous

Medications

Monoamine Oxidase Inhibitors (MAOI’s) Inhibit monoamine oxidase, so monoamines last

longer High blood pressure side effect ( tyramine)

Special diet 3-8 weeks’ response (must start at low dose) Overdose can be fatal E.g. Nardil, ENSAM, Parnate

Therapy

Behavioural (do pleasant or rewarding activities) Social skills (reduce social isolation) Cognitive (change thoughts, images,

interpretations) Interpersonal

Which works better?

Treatment of Depression Collaborative Research Program (1989) Historic multisite coordinated study 250 patients Randomly assigned

Interpersonal psychotherapy (IPT) Cognitive-Behavioural Therapy (CBT) Imipramine (tricyclic antidepressant) Placebo

TDCRP results

“no evidence of greater effectiveness of one of the psychotherapies as compared with the other and no evidence that either of the psychotherapies was significantly less effective than the standard reference treatment”

Severely depressed: imipramine>IPT>CBT>placebo Elkin et al, 1989, p. 980

Which therapy works best?

Why will almost anyone tell you that CBT is the “best practice” for treatment of depression if IPT>CBT?

See also Duncan and Miller (2000) The Heroic Client

Why is medication the treatment of choice for depression?

Depression

Segal 2002 Prevalence worldwide

17% -20% meet some criteria 10% major depression Twice as common in women

Suicide rate In recurrent depression: 15%

Recurrence

Defined as at least two episodes of major depression with a non-depressed period in between

About 20% of “first timers” will relapse Overall average rate of recurrence: 50% Two or more episodes: 80% risk Each recurrence worsens the disease

Relapse Prevention

Treat a major depressive episode with either medication or therapy (work equally well)

Stop treatment when the depressive episode is over

Who relapses?

Segal 2002, p. 24

Preventing Relapse

Therapy or medication appear to treat depression equally well (medication slightly better for severe depression)

Risk of relapse is significantly higher without therapy

The studies were done with cognitive behavioural therapy

The Power of Therapy After recovery from a depressive episode, all

subjects had “normal” thinking Introduce any stressful or traumatic event –

all people become sad, with concomitant cognitive triad (bad self, bad world, bad future)

Cognitive therapy seems to help people stay well after depression

Does it make them think better?

Mood affects thinking After depressive episode, thinking returns to

normal

Further studies

Induce a sad mood (country music) Thinking becomes distorted

People who ruminate on their thoughts (what’s wrong with me that my wife left me, stole my truck and ran over my dog?) stay depressed

People who distract themselves and move on, recover

Decentering of Thoughts from Self

Segal 2002 The essential ingredient in Cognitive Therapy

is not the content of the therapy, but the process of decentering

I have thoughts instead of I am my thoughts

Objectification of thoughts, or decentering of the self from thinking

CBT vs. other therapies

Self psychology is a form of decentering Interpersonal therapy works better than CBT Family therapy, narrative therapy, solution-

focused therapy – almost any form of therapy that encourages externalizing of problems or objective examination of thinking, ought to protect people from depression

Family Therapy for Depression

Gupta 2005 Bidirectional effects Marital stress depression

parenting problems

Family Therapy and Depression

Gupta 2005 Depression -> marital conflict

Individual and marital therapy both effective in treating depression and improving relationship

Marital conflict -> depression Marital therapy effectively treats both the

depression and the relationship Individual therapy makes the relationship worse

Treatment

Behavioural Marital Therapy BMT or BFT Conjoint marital IPT (IPT – CM) Parenting interventions (Barkley)

Suicide Stats

Approximately 4000 Canadians commit suicide each year; about 11/day

The World Health Organization estimates as many as 20 suicide attempts for every suicide death

Men are 4x more likely than women to complete suicide (lethal means)

Suicide Stats

Hospitalization rate for attempted suicide among females is highest aged 15 to 19

Among teens, girls are more likely than boys to have suicidal thoughts (8.4% vs. 4.6%)

Almost half of those admitted to hospital for attempted suicide have a major mental health issue

6 Steps to Suicide Intervention

1. Engage engage the person in conversation, listen,

empathize with feelings, be understanding, be honest and genuine

2. Identify identify warning signs

3. Inquire ask the person directly, “Are you having thoughts

of suicide?”

6 Steps to Suicide Intervention

4. Estimate have they attempted before? do they have a plan? (where, when, how) what supports do they have?

5. Contract negotiate a ‘no-suicide contract’, be specific about follow-up and what to do if they feel suicidal again, identify supports and resources with them

6. Follow through follow through on plans agreed upon

Cognitive Behavioural

Therapy (CBT)

Treatment Interventions for Depression

Origins of CBT

Epictetus, Greek Stoic philosopher (c.55 – c.135):

“Men are disturbed not by things, but by the view which they take of them.”

Origins of CBT

Alfred Adler, Austrian psychologist, 1870-1937:

“I am convinced that a person’s behaviour springs from his ideas.”

Development of CBT

Major influences: Albert Ellis, RET, mid-1950s, ABC model of

emotions Aaron Beck, Cognitive Therapy, 1960’s Don Meichenbaum, CBM, effective with children David Burns, popularized CBT with Feeling Good Marsha Linehan, DBT, integrates CBT with

mindfulness, effective w/BPD

CBT: General Principles

Present-oriented Structured Active Directed toward:

Solving current problems Modifying dysfunctional thinking and behaviour

Negative Cognitive Triad(A. Beck, 1963)

Look for negative beliefs about:SelfWorldFuture

Negative Explanatory Style for Bad Events (M. Seligman, 1991)

Internal vs. ExternalStable/Permanent vs. TemporaryGlobal vs. Specific

Cognitive Distortions(Burns, 1980)

1. All-or-Nothing Thinking

2. Overgeneralization

3. Mental Filter

4. Disqualifying the positive

5. Jumping to conclusions1. Mind reading

2. The fortune teller error

Cognitive Distortions(Burns, 1980)

6. Magnification and minimization

7. Emotional reasoning

8. Should statements

9. Labeling and mislabeling

10. Personalization

Triple-Column Technique (Burns, 1980)

1. Identify automatic thoughts2. Identify cognitive distortion

related to automatic thought3. Challenge distortion by writing a

rational response

Questions to Help Formulate a Rational Response

What is the evidence that the automatic thought is true/not true?

Is there an alternative explanation? What is the worst that could happen? How

likely is that? Would I live through it? What’s the best that could happen? What’s the most realistic outcome?

Questions to Help Formulate a Rational Response

What is the effect of my believing the automatic thought?

If my best friend was in this situation and had this thought, what would I tell him/her?

(the best-friend technique)

What are “Core Beliefs”?

Central ideas about self An absolute statement that seems

unchangeable (e.g. I’m unlovable) Formed early in life Act as a “fliter” Generally involve themes of helplessness or

unlovability Risk factors for future episodes

Identifying Core Beliefs

Find a general theme in negative automatic thoughts

Find underlying meaning of automatic thoughts by asking “what does this say about (me, others, or the world)?” (the downward arrow)

Challenging Core Beliefs

Make a list of evidence that a core belief is not 100% true

Test the belief with experiments Identify and strengthen alternative core

beliefs (e.g. affirmations) Historical tests of negative and alternative

core beliefs

For More Info. on CBT for Depression see:

Feeling Good by David Burns (1980)Mind Over Mood by Dennis

Greenberger & Christine Padesky (1995)

Cognitive Therapy of Depression by Beck, Rush, Shaw & Emery (1979)

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Presentation

Anxiety/OCD/Trauma - Inge and Heather

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Break

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What About Bob?

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Anxiety Disorders

Fear: emotional response to real or perceived imminent threat

Anxiety: anticipation of future threat Fear

Autonomic arousal: fight or flight Thoughts of immediate danger Escape Behaviours

Anxiety Muscle tension Vigilance Avoidant Behaviours

Developmentally Normal Fears

Age Normal Fear

Birth- 6 Months Loud noises, loss of physical support, rapid position changes, rapidly approaching other objects

7-12 Months Strangers, looming objects, unexpected objects or unfamiliar people

1-5 Year Strangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet

6-12 Year Supernatural, bodily injury, disease, burglars, failure, criticism, punishment

12-18 Performance in school, peer scrutiny, appearance, performance

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Developmentally Abnormal Fears

Separation Anxiety Disorder Excessive distress about separation Excessive worry about losing attachment figure

including by an untoward event Reluctance to go out Reluctance about being alone Refusal to sleep w/o attachment figure Nightmares on the theme of separation Physical symptoms

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Selective Mutism

Failure to speak in specific social situations Interferes with education or occupation At least 1 month Not attributable to not knowing the language Not better explained by a communication or

other (autism, schizophrenia) disorder

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Specific Phobia

Fear or anxiety about a specific object or situation

The object/situation almost always provokes fear/anxiety

Actively avoided or endured with intense fear/anxiety

Out of proportion to actual danger 6 months or more

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Social Anxiety Disorder

Social situations, exposed to possible scrutiny by others in peer settings

Fear of negative evaluation, including fear of showing anxiety symptoms

Almost always provoked Avoided or endured Out of proportion Six months or more

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Panic Disorder

Abrupt surge of intense fear with four of Palpitations Sweat Trembling Shortness of breath Choking Chest discomfort Nausea Dizziness Chills Tingling Derealization/depersonalization Fear of losing control Fear of dying

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Panic Disorder, continued

At least one attack followed by at least one month of one or both of Worrying about additional panic attacks Maladaptive behaviour to avoid panic attacks

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Panic Attack Specifier

Panic Attack as above, without the worry or avoidant behaviour

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Agoraphobia

Marked fear or anxiety about two or more: Using public transportation Being in open spaces Being in enclosed spaces Standing in line or being in a crowd Being outside of the home alone

Thoughts that escape might be difficult or embarrassing situation might occur

Situation(s) almost always provoke fear/anxiety Avoidance, companion, or extreme discomfort Out of proportion to the situation Six months or more

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Generalized Anxiety Disorder

Excessive anxiety and worry, more days than not, for at least 6 months, about a number of events or activities

Difficult to control Three or more:

Restlessness Fatigue Difficulty concentrating/mind going blank Irritability Muscle tension Sleep disturbance

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Substance/Medication-Induced Anxiety Disorder

Panic or anxiety Evidence

The symptoms started after substance use or withdrawal

The substance can produce anxiety Not better explained by another anxiety

disorder Not exclusively during delirium

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Anxiety Disorder due to Another Medical Condition

Panic or Anxiety Evidence that it is the direct effect of another

medical condition Not better explained by another mental

disorder Not exclusively during the course of delirium

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Anxiety Disorders - Prevalence

From: The Anxious Brain, M. Wehrenberg & S. Prinz, 2007: Nearly 26% of adult Americans suffer from

anxiety in a given year: 6.8% Social Anxiety Disorder 3.1% Generalized Anxiety Disorder 2.7% Panic Disorder

Anxiety Disorders - Comorbidities

Panic disorder: 25% also have GAD 15-30% also have SAD 10-20% also have specific phobia 8-10% also have OCD

50% with PD and GAD also have depression

SAD – Addressing Physiology

Rule out medical conditions e.g. heart, thyroid, hormone, hypoglycemia, adrenal fatigue

Teach diaphragmatic breathing and progressive muscle relaxation

Teach mindfulness skills “Three deep breaths and good preparation”

SAD – Medications

More use of PRNs with SAD than others Need for in vivo practice

Beta blockers: Propranolol (Inderal) & Atenolol (Tenormin)

Benzopiazepines: Clonazepam & Alprazolam MAOIs: Phenelzine SSRIs: Prozac

SAD – Addressing Behaviour

In Vivo exposure Assess social skill deficits Social skills training for specific fears,

assertiveness, anger and conflict management Systematic desensitization or EMDR

List every feared situation, rank from 0-100, imagery + coping skills

Create hierarchy for in vivo exposure then practice

SAD – Working with Families

Family members either push too hard or back off completely

Help them to find balance, matched with clients skill and developmental level

Remember that negative experiences reinforce fears

Help client negotiate practice with family Help family manage their own anxiety

Panic Disorder

Assessment &

Treatment

Panic Disorder(C. Padesky, 2011)

Catastrophic misinterpretation of physical and mental sensations

Seems to come out of nowhere → avoidance Panic attack ≠ panic disorder

Rule out medical conditions For PD to develop:

Vigilance for sensations Avoid situations that evoke sensations Use of safety behaviours


Assessment Choose recent, specific attack Identify sensations then review in detail Thoughts & images What was the worst thing that could have

happened? Use their words What would’ve happened if you couldn’t get out?


Hypothetical model:

trigger → sensations → automatic

thoughts → emotions → sensations →

focus on sensations → interpretation

of sensations → catastrophic

misinterpretation → PANIC


Treatment Need to induce sensations (“take the fear out of

panic”) Alternative explanation for sensations Differentiate between uncomfortable vs. fatal Medication may be contra-indicated re. therapy Do the induction, no safety behaviours, continue

until anxiety goes down Less than 10% relapse after 2 yrs.


Guidelines for Interoceptive Exposure Practices should be planned, structured,

predictable Pace can be gradual Subtle avoidance strategies should not be used Ritual prevention Use SUDS to rate fear throughout practice Practices should be repeated frequently Fighting Fear vs. Allowing Fear to Happen


Symptom Induction Exercises Shake head from side to side for 30 sec. Hold breath for as long as possible Breathe through a straw for 2 min. Overbreathe (hyperventilate) for 60 sec. Spin in a swivel chair for 30 sec. Tense every muscle in your body for 1 min. Jog on the spot for 2 min. Stare at a light for 2 min. Stare at someone’s mouth while they talk for 3 min.


Steps for Interoceptive Exposure

1. Present the rationale.

2. Assess for medical problems that might

affect the safety of certain exercises.

3. Conduct symptom induction testing.

4. Assign interoceptive exposure practices.

5. Combine with situational exposure.


Usually a narrow band of thoughts for PD No need for thought records, etc.

Focus more on sensations Treatment: 4 – 8 sessions, 12 at the most PD w/agoraphobia: 16 to 30 sessions

Systematic Desensitization

Create a hierarchy of exposure From easiest to hardest Usually begins with imagery Pair images with relaxation techniques

Exposure Procedure1. Enter the situation

2. Retreat only if anxiety is “out of control”

3. Recover, then continue

Exposure Therapy

What promotes success: Cooperation of your partner or spouse Willingness to tolerate some discomfort Ability to handle the initial symptoms of panic Ability to handle setbacks Willingness to practice regularly

GAD – Reid Wilson, 2009

PD is the easiest to treat, with the best outcome, whereas GAD is the hardest to treat

Worry about at least two of the following: Minor things – 91% Family/home – 79% Financial – 50% Work/school – 43% Illness/health/injury – 14%

GAD – Reid Wilson, 2009

It’s not the content of the worry, it’s the process that is problematic: They worry in order to try and prevent what they

are worrying about (to stay safe) Chronic worry leads to procrastination Becomes a self-perpetuating problem Nervous system is always on guard to threat and

they don’t know what it’s like to be relaxed

GAD – Treatment(R. Wilson, 2009)

“If it’s worth worrying about, it’s worth problem solving!” Teach them problem solving skills Help them make a decision w/reasonable risk and

follow through (e.g. cost/benefit analysis) Learn how to tolerate consequences/uncertainty Distinguish ‘signals’ from ‘noise’ Catch episodes and intervene early Mindfulness (present focused)

GAD – Treatment(R. Wilson, 2009)

Train in multiple relaxation techniques e.g. biofeedback, breathing, progressive muscle

relaxation, meditation, yoga, guided imagery Help them recognize the absence of relaxation as

a cue for skills Keep a worry log Cognitive restructuring Designate worry times – ‘worry free zones’

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Lunch

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As Good As It Gets

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Obsessive-Compulsive Disorder

Assessment &

Treatment

Obsessive-Compulsive Disorder(M. Antony, 2010)

Unwanted, repetitive thoughts, images or urges (obsessions)

Repetitive behaviours that occur in response to an obsession, to reduce anxiety (compulsions)

Causes significant distress or impairment Yale-Brown Obsessive-Compulsive Scale

Reduction ≥ 35% is considered success


Obsessions: Contamination Doubting (forgetting) Aggressive Accidentally harming others Religious Sexual


Compulsions Washing, cleaning Checking Repeating actions Repeating words, phrases, or prayers Counting Symmetry or exactness

Not just behaviours, can be thoughts too


Other features Avoid feared situations Varying levels of insight (poor insight = worse

prognosis) Thought-action fusion (thought is as bad as

action) Magical thinking Inflated sense of responsibility (↑guilt) Thought suppression & rituals maintain problem


Targets for treatment Compulsive rituals Avoidance of feared situations Cognitive avoidance and thought suppression Compulsions and safety behaviours Requests for reassurance Alcohol or drug use


Exposure & Ritual Prevention (ERP) Considered “gold standard” psychological

treatment for OCD Between 63 – 83% participants who complete

gain some benefit Benefits are maintained over long-term Exposure isn’t enough, have to prevent rituals too Metaphor:

“Every time you do the compulsion, you’re putting gas in the car”


Sample hierarchyItem Fear

Visit a cancer ward in a hospital 100

Shake hands with a person who has cancer 90

Talk to someone who has cancer 75

Eat in a hospital cafeteria 70

Walk through the halls of a hospital 60

Stand in front of a hospital 50

Read a library book about cancer 40

Talk to someone about cancer 25


Imaginal exposure With clients who fear images, thoughts,

memories, or other mental stimuli Can involve mental exposure, exposure to verbal

descriptions, or written exposure Imagery should be multi-sensory Record sessions and listen to them for homework

Measure success by doing, not feeling (may be uncomfortable)


If preventing rituals is impossible Eliminate certain rituals first (based on location,

time of day, ritual content) Delay the ritual Shorten the ritual Do the ritual differently (e.g. in a different order,

more quickly)


Cognitive features of OCD Beliefs about responsibility Overestimating probability and severity of danger Overimportance of thoughts Control of thoughts Desire for certainty Consequences of anxiety Fear of positive experiences Perfectionism


Cognitive strategies Thought records Countering probability overestimations Countering catastrophic thinking Responsibility pie chart (Mind Over Mood) Challenge meta-cognitions (vs. intrusive

thoughts) e.g. thinking about X means that I will do it

Best-friend technique (perspective taking) Cost-benefit analysis

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Treatment

Support Discuss the event Educate regarding coping mechanisms

(relaxation, diet, exercise, etc) e.g. CISM handout

Medications Therapies

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Medications

Imipramine - effective treatment of panic Amitriptyline - chronic pain, PTSD SSRIs, MAOIs, anticonvulsants, propranolol Xanax (but may introduce or exacerbate

substance-abuse disorder) in general, the drugs help with depression,

anxiety and hyperarousal but not with avoidance, denial and

emotional numbing Kaplan and Sadock 1998

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Break

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The Fisher King

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Trauma

Reactive Attachment Disorder Child rarely seeks comfort when distressed Minimal social contact, limited positive affect,

unexplained irritability, sadness, fear A pattern of extremes of insufficient care

Disinhibited Social Engagement Disorder Child is too friendly with unfamiliar adults Not just impulsive but socially disinhibited A pattern of extremes of insufficient care

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Posttraumatic Stress Disorder

Exposure to actual or threatened death direct experience witnessing hearing about it (new) repeated or extreme exposure to the details (e.g.

collecting body parts, hearing stories of child abuse) Intrusion symptoms, one or more

Recurrent, involuntary, intrusive, distressing memories Dreams Flashbacks (dissociative reactions) Distress from exposure to cues

Psychological, physiological 120

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PTSD, continued

Avoidance Memories, thoughts, feelings People, places, conversations, activities

Negative changes in thought and mood Amnesia Persistent and exaggerated negative beliefs Persistent distortions about cause Persistent negative emotional state Decreased interest in activities Detachment Inability to experience positive emotions

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PTSD, continued

Alterations in arousal Irritable/angry Reckless/self-destructive Hypervigilance Exaggerated startle response Problems concentrating Sleep disturbanc

Duration > 1 month With or w/o dissociative symptoms

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Acute Stress Disorder Exposure to actual or threatened death Nine or more:

intrusive memories distressing dreams dissociative reactions psychological distress/physiological reaction negative mood altered sense of reality amnesia avoiding thoughts avoiding reminders sleep disturbance irritable mood hypervigilance concentration startle

3 days to 1 month (PTSD lite)123

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Adjustment Disorders

Response to an identifiable stressor within 3 months

One or both Marked distress out of proportion Significant impairment

Not attributable to another mental disorder Not normal bereavement Resolves within 6 months of stressor ending

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Next Class Here again next week Sex, Drugs and Food

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Documents

Family Therapy and Mental Health University of Guelph Open Learning and Educational Support