Families in Psychiatry

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

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

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

First Situation

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

Which answer is correct?

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

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

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

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

Second Situation

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

Which answer is correct?

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

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

5c. Neither of the above choices is correct.

5d. Not sure

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D: "Do you think he knows?"

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

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

P: "Maybe, yes, perhaps."

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

P: "I guess so."

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

P: "Okay, I’ll talk to him."

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

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

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

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

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

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

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

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

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

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

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

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

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

First Situation

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

Which answer is correct?

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

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

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

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

Second Situation

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

Which answer is correct?

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

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

5c. Neither of the above choices is correct.

5d. Not sure

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D: "Do you think he knows?"

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

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

P: "Maybe, yes, perhaps."

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

P: "I guess so."

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

P: "Okay, I’ll talk to him."

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

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

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

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

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

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

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

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

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

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

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

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

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

First Situation

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

Which answer is correct?

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

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

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

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

Second Situation

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

Which answer is correct?

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

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

5c. Neither of the above choices is correct.

5d. Not sure

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D: "Do you think he knows?"

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

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

P: "Maybe, yes, perhaps."

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

P: "I guess so."

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

P: "Okay, I’ll talk to him."

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

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

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

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

• Can you ask your spouse for help and support?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

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

• Can you ask your spouse for help and support?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

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

• Can you ask your spouse for help and support?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

©Dmytro Panchenko/iStockphoto.com

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

Family-Focused Interventions

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

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

Community Reinforcement Approach Family Training (CRAFT)

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

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

A Relational Intervention Sequence for Engagement (ARISE)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

©Dmytro Panchenko/iStockphoto.com

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

Family-Focused Interventions

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

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

Community Reinforcement Approach Family Training (CRAFT)

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

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

A Relational Intervention Sequence for Engagement (ARISE)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

©Dmytro Panchenko/iStockphoto.com

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

Family-Focused Interventions

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

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

Community Reinforcement Approach Family Training (CRAFT)

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

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

A Relational Intervention Sequence for Engagement (ARISE)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Enabling Behaviors

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

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

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

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

Enabling Beliefs

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

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

What Should the Clinician Do?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Enabling Behaviors

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

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

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

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

Enabling Beliefs

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

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

What Should the Clinician Do?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Enabling Behaviors

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

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

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

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

Enabling Beliefs

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

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

What Should the Clinician Do?

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

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

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

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

"My Story: Blogs by Four Military Teens" is a book that gives voice to military teens by highlighting their feelings and experiences before, during, and after parental deployment. The four youths in "My Story" are fictional, but the stories are real in that the posts are a compilation of real life experiences of military kids.

"Adam" blogs, "My dad is one of the coolest, smartest, bravest men I’ve ever met, but sometimes I just can’t stand being around him. He’s a doctor – a surgeon – and is in the Air Force Reserves. He just returned from a second tour in Iraq, and he sure acts different. After his first tour, it took us some time to get caught up, but just when things got normal again, he got his orders to go back to Iraq. Now he’s finally home (for good?), but he just isn’t the same. He gets mad over the stupidest things and spends most of his time in his bedroom or in front of the computer.

Photo courtesy Michelle D. Sherman, Ph.D. and DeAnne M. Sherman, Ph.D.

"He’s still in ‘military mode,’ and orders us around way too much. He doesn’t joke around like before, and sometimes just hangs out in the garage by himself. We don’t talk much. I almost liked it better when he was gone. It was a lot quieter and less stressful around the house. Ashley, Lisa, and I just stay out of his way. Derrick is lucky – he’s leaving for college soon."

This book also provides support and education for military teens and preteens by honoring their unique joys and sacrifices, addressing their fears and hopes, and exploring how parental deployment affects their lives.

The book was written by Michelle D. Sherman, Ph.D., and her mother, DeAnne M. Sherman. Together, Dr. Sherman and her mother – a teacher – have written other books for teens, including "Finding My Way: A Teen’s Guide to Living with a Parent Who has Experienced Trauma" (Waco, Tex.: Seeds of Hope Publishers, 2005).

Dr. Sherman is a clinical psychologist at the Oklahoma City VA Medical Center, where she directs its Family Mental Health Program. She has dedicated her career to supporting families affected by mental illness and posttraumatic stress disorder, and has a special interest in the impact of parental mental illness and PTSD on youth.

"Think about the ... challenges facing our military teens," she writes in a guest post on the blog of an organization called Veterans Children. "Their parent(s) may be deployed once, twice, or even multiple times to a war zone. The parent may miss out on important events, such as prom, the school play, the state basketball tournament, and birthdays."

These young people are resilient, Dr. Sherman writes, but some are struggling with increased rates of anxiety, sleeping and behavioral problems, and the use of psychotropics.

"What does this tell us? ...They are affected by their parent’s deployment. We need to listen to them, provide resources, and make services available," writes Dr. Sherman, also is a clinical professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center and a research affiliate with the South Central Mental Illness Research, Education and Clinical Center (MIRECC).

In her work with veterans and families, Dr. Sherman has developed educational and support programs. Operation Enduring Families is a 5-session family education curriculum for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans/families, developed with Ursula B. Bowling, Psy.D., and Alan L. Doerman, Psy.D. This program is based on her S.A.F.E (Support and Family Education) program, an 18-session curriculum for those who care about someone with a mental illness/PTSD.

Dr. Sherman has developed an extensive resource list for OEF/OIF service members, and veterans and their families. (See box.) For a complete list, you can e-mail her at michelle-sherman@ouhsc.edu.

This column, "Families in Psychiatry," regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor 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 following list of books and websites can be used to help military children of all ages cope with parental deployment:

Books

• "After the War Zone: A Practical Guide for Returning Troops and Their Families" (Cambridge, Mass.: Da Capo Press, 2008).

• "Back from the Front: Combat Trauma, Love, and the Family" (Brooklandville, Md.: Sidran Institute Press, 2007).

• "Courage After Fire: Coping Strategies for Returning Soldiers and Their Families" (Berkeley, Calif.: Ulysses Press, 2005).

• "I Miss You!: A Military Kid’s Book About Deployment" (Amherst, N.Y.: Prometheus Books, 2007).

• "Night Catch" (Jamestown, N.D.: Bubble Gum Press, 2005).

• "100 days and 99 nights" (New York: Little, Brown and Co. Books for Young Readers, 2008).

• "Sometimes We Were Brave" (Honesdale, Pa.: Boyds Mills Press, 2010).

• "The Fathers Are Coming Home" (New York: Margaret K. McElderry Books, 2010).

Websites

• "Courage to Care, Courage to Talk About War Injuries," developed by the Center for the Study of Traumatic Stress.

• "Military Child Bill of Rights."

• National Military Family Association.

• Operation Child Care.

• Operation: Military Kids.

• Song and video: "The Price of Peace."

• Video (58 minutes): "Returning From the War Zone: A Guide for Families of Military Members," created by the National Center for PTSD.

• Salute Our Services.

• SOAR (Student Online Achievement Resources).

• Students at the Center: An Education Resource for Families, the Military, and Schools.

• "Talk, Listen, Connect: Deployments, Homecomings, Changes."

• United Through Reading.

• Veteran Parenting Toolkit, created by the Oklahoma City VA Family Mental Health Program.

• "Welcome Back Parenting: A Guide for Reconnecting Families After Military Deployment."

• DVD: "Young Children on the Homefront: Family Stories, Family, Strengths," developed by the nonprofit organization Zero to Three: National Center for Infants, Toddlers, and Families.

• "Operation: Military Kids."

• "Young Heroes: Military Deployment Through the Eyes of Youth."

"My Story: Blogs by Four Military Teens" is a book that gives voice to military teens by highlighting their feelings and experiences before, during, and after parental deployment. The four youths in "My Story" are fictional, but the stories are real in that the posts are a compilation of real life experiences of military kids.

"Adam" blogs, "My dad is one of the coolest, smartest, bravest men I’ve ever met, but sometimes I just can’t stand being around him. He’s a doctor – a surgeon – and is in the Air Force Reserves. He just returned from a second tour in Iraq, and he sure acts different. After his first tour, it took us some time to get caught up, but just when things got normal again, he got his orders to go back to Iraq. Now he’s finally home (for good?), but he just isn’t the same. He gets mad over the stupidest things and spends most of his time in his bedroom or in front of the computer.

Photo courtesy Michelle D. Sherman, Ph.D. and DeAnne M. Sherman, Ph.D.

"He’s still in ‘military mode,’ and orders us around way too much. He doesn’t joke around like before, and sometimes just hangs out in the garage by himself. We don’t talk much. I almost liked it better when he was gone. It was a lot quieter and less stressful around the house. Ashley, Lisa, and I just stay out of his way. Derrick is lucky – he’s leaving for college soon."

This book also provides support and education for military teens and preteens by honoring their unique joys and sacrifices, addressing their fears and hopes, and exploring how parental deployment affects their lives.

The book was written by Michelle D. Sherman, Ph.D., and her mother, DeAnne M. Sherman. Together, Dr. Sherman and her mother – a teacher – have written other books for teens, including "Finding My Way: A Teen’s Guide to Living with a Parent Who has Experienced Trauma" (Waco, Tex.: Seeds of Hope Publishers, 2005).

Dr. Sherman is a clinical psychologist at the Oklahoma City VA Medical Center, where she directs its Family Mental Health Program. She has dedicated her career to supporting families affected by mental illness and posttraumatic stress disorder, and has a special interest in the impact of parental mental illness and PTSD on youth.

"Think about the ... challenges facing our military teens," she writes in a guest post on the blog of an organization called Veterans Children. "Their parent(s) may be deployed once, twice, or even multiple times to a war zone. The parent may miss out on important events, such as prom, the school play, the state basketball tournament, and birthdays."

These young people are resilient, Dr. Sherman writes, but some are struggling with increased rates of anxiety, sleeping and behavioral problems, and the use of psychotropics.

"What does this tell us? ...They are affected by their parent’s deployment. We need to listen to them, provide resources, and make services available," writes Dr. Sherman, also is a clinical professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center and a research affiliate with the South Central Mental Illness Research, Education and Clinical Center (MIRECC).

In her work with veterans and families, Dr. Sherman has developed educational and support programs. Operation Enduring Families is a 5-session family education curriculum for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans/families, developed with Ursula B. Bowling, Psy.D., and Alan L. Doerman, Psy.D. This program is based on her S.A.F.E (Support and Family Education) program, an 18-session curriculum for those who care about someone with a mental illness/PTSD.

Dr. Sherman has developed an extensive resource list for OEF/OIF service members, and veterans and their families. (See box.) For a complete list, you can e-mail her at michelle-sherman@ouhsc.edu.

This column, "Families in Psychiatry," regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor 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 following list of books and websites can be used to help military children of all ages cope with parental deployment:

Books

• "After the War Zone: A Practical Guide for Returning Troops and Their Families" (Cambridge, Mass.: Da Capo Press, 2008).

• "Back from the Front: Combat Trauma, Love, and the Family" (Brooklandville, Md.: Sidran Institute Press, 2007).

• "Courage After Fire: Coping Strategies for Returning Soldiers and Their Families" (Berkeley, Calif.: Ulysses Press, 2005).

• "I Miss You!: A Military Kid’s Book About Deployment" (Amherst, N.Y.: Prometheus Books, 2007).

• "Night Catch" (Jamestown, N.D.: Bubble Gum Press, 2005).

• "100 days and 99 nights" (New York: Little, Brown and Co. Books for Young Readers, 2008).

• "Sometimes We Were Brave" (Honesdale, Pa.: Boyds Mills Press, 2010).

• "The Fathers Are Coming Home" (New York: Margaret K. McElderry Books, 2010).

Websites

• "Courage to Care, Courage to Talk About War Injuries," developed by the Center for the Study of Traumatic Stress.

• "Military Child Bill of Rights."

• National Military Family Association.

• Operation Child Care.

• Operation: Military Kids.

• Song and video: "The Price of Peace."

• Video (58 minutes): "Returning From the War Zone: A Guide for Families of Military Members," created by the National Center for PTSD.

• Salute Our Services.

• SOAR (Student Online Achievement Resources).

• Students at the Center: An Education Resource for Families, the Military, and Schools.

• "Talk, Listen, Connect: Deployments, Homecomings, Changes."

• United Through Reading.

• Veteran Parenting Toolkit, created by the Oklahoma City VA Family Mental Health Program.

• "Welcome Back Parenting: A Guide for Reconnecting Families After Military Deployment."

• DVD: "Young Children on the Homefront: Family Stories, Family, Strengths," developed by the nonprofit organization Zero to Three: National Center for Infants, Toddlers, and Families.

• "Operation: Military Kids."

• "Young Heroes: Military Deployment Through the Eyes of Youth."

"My Story: Blogs by Four Military Teens" is a book that gives voice to military teens by highlighting their feelings and experiences before, during, and after parental deployment. The four youths in "My Story" are fictional, but the stories are real in that the posts are a compilation of real life experiences of military kids.

"Adam" blogs, "My dad is one of the coolest, smartest, bravest men I’ve ever met, but sometimes I just can’t stand being around him. He’s a doctor – a surgeon – and is in the Air Force Reserves. He just returned from a second tour in Iraq, and he sure acts different. After his first tour, it took us some time to get caught up, but just when things got normal again, he got his orders to go back to Iraq. Now he’s finally home (for good?), but he just isn’t the same. He gets mad over the stupidest things and spends most of his time in his bedroom or in front of the computer.

Photo courtesy Michelle D. Sherman, Ph.D. and DeAnne M. Sherman, Ph.D.

"He’s still in ‘military mode,’ and orders us around way too much. He doesn’t joke around like before, and sometimes just hangs out in the garage by himself. We don’t talk much. I almost liked it better when he was gone. It was a lot quieter and less stressful around the house. Ashley, Lisa, and I just stay out of his way. Derrick is lucky – he’s leaving for college soon."

This book also provides support and education for military teens and preteens by honoring their unique joys and sacrifices, addressing their fears and hopes, and exploring how parental deployment affects their lives.

The book was written by Michelle D. Sherman, Ph.D., and her mother, DeAnne M. Sherman. Together, Dr. Sherman and her mother – a teacher – have written other books for teens, including "Finding My Way: A Teen’s Guide to Living with a Parent Who has Experienced Trauma" (Waco, Tex.: Seeds of Hope Publishers, 2005).

Dr. Sherman is a clinical psychologist at the Oklahoma City VA Medical Center, where she directs its Family Mental Health Program. She has dedicated her career to supporting families affected by mental illness and posttraumatic stress disorder, and has a special interest in the impact of parental mental illness and PTSD on youth.

"Think about the ... challenges facing our military teens," she writes in a guest post on the blog of an organization called Veterans Children. "Their parent(s) may be deployed once, twice, or even multiple times to a war zone. The parent may miss out on important events, such as prom, the school play, the state basketball tournament, and birthdays."

These young people are resilient, Dr. Sherman writes, but some are struggling with increased rates of anxiety, sleeping and behavioral problems, and the use of psychotropics.

"What does this tell us? ...They are affected by their parent’s deployment. We need to listen to them, provide resources, and make services available," writes Dr. Sherman, also is a clinical professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center and a research affiliate with the South Central Mental Illness Research, Education and Clinical Center (MIRECC).

In her work with veterans and families, Dr. Sherman has developed educational and support programs. Operation Enduring Families is a 5-session family education curriculum for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans/families, developed with Ursula B. Bowling, Psy.D., and Alan L. Doerman, Psy.D. This program is based on her S.A.F.E (Support and Family Education) program, an 18-session curriculum for those who care about someone with a mental illness/PTSD.

Dr. Sherman has developed an extensive resource list for OEF/OIF service members, and veterans and their families. (See box.) For a complete list, you can e-mail her at michelle-sherman@ouhsc.edu.

This column, "Families in Psychiatry," regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor 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 following list of books and websites can be used to help military children of all ages cope with parental deployment:

Books

• "After the War Zone: A Practical Guide for Returning Troops and Their Families" (Cambridge, Mass.: Da Capo Press, 2008).

• "Back from the Front: Combat Trauma, Love, and the Family" (Brooklandville, Md.: Sidran Institute Press, 2007).

• "Courage After Fire: Coping Strategies for Returning Soldiers and Their Families" (Berkeley, Calif.: Ulysses Press, 2005).

• "I Miss You!: A Military Kid’s Book About Deployment" (Amherst, N.Y.: Prometheus Books, 2007).

• "Night Catch" (Jamestown, N.D.: Bubble Gum Press, 2005).

• "100 days and 99 nights" (New York: Little, Brown and Co. Books for Young Readers, 2008).

• "Sometimes We Were Brave" (Honesdale, Pa.: Boyds Mills Press, 2010).

• "The Fathers Are Coming Home" (New York: Margaret K. McElderry Books, 2010).

Websites

• "Courage to Care, Courage to Talk About War Injuries," developed by the Center for the Study of Traumatic Stress.

• "Military Child Bill of Rights."

• National Military Family Association.

• Operation Child Care.

• Operation: Military Kids.

• Song and video: "The Price of Peace."

• Video (58 minutes): "Returning From the War Zone: A Guide for Families of Military Members," created by the National Center for PTSD.

• Salute Our Services.

• SOAR (Student Online Achievement Resources).

• Students at the Center: An Education Resource for Families, the Military, and Schools.

• "Talk, Listen, Connect: Deployments, Homecomings, Changes."

• United Through Reading.

• Veteran Parenting Toolkit, created by the Oklahoma City VA Family Mental Health Program.

• "Welcome Back Parenting: A Guide for Reconnecting Families After Military Deployment."

• DVD: "Young Children on the Homefront: Family Stories, Family, Strengths," developed by the nonprofit organization Zero to Three: National Center for Infants, Toddlers, and Families.

• "Operation: Military Kids."

• "Young Heroes: Military Deployment Through the Eyes of Youth."

Ms. Suarez, a 48-year-old married Hispanic woman, came to her appointment at the outpatient psychiatry clinic asking for a second opinion. She told the admitting resident that she had had depression for years, and that nothing had helped. She said she had tried many medications and individual therapy, and she was feeling hopeless and frustrated. She worried that her husband would leave her. She was still working, but felt that the quality of her work was poor.

The psychiatric resident wondered whether to put her in the psychopharmacology clinic or in the psychotherapy clinic. What should the resident do? The American Psychiatric Association Symposium No. 81, from 9 a.m. to noon on May 8 in Philadelphia, will answer this question.

The symposium is called "Improving Quality of Care for Patients with Psychiatric Illness: Combining and Integrating Psychopharmacological, Individual, and Family Therapy." I will be presenting the symposium with Dr. Alan F. Schatzberg, Dr. Glen O. Gabbard, and Dr. Gabor I. Keitner as panelists, and Dr. Ira D. Glick as the discussant. We’ll be looking at the following topics:

• Dr. Schatzberg will discuss "Combining Pharmacotherapy With Other Modalities."

Psychopharmacology has become a major approach in the treatment of patients with psychiatric disorders. The discipline has evolved from its humble beginnings with a limited number of classes of agents that had a relatively narrow range of mechanisms of action, to the current host of classes and agents, many with disparate effects. This development demands considerable knowledge of the basic biology of the disorder, as well as the specific pharmacology of specific agents.

The development of this field, however, is not the only one in psychiatric treatment. Rather, parallel developments have taken place in the psychotherapies – as well as in devices – such that the practitioner needs to be able to incorporate advances in all of them to most optimally help his or her patient.

As models of other areas in psychiatry, recent developments in psychopharmacology and stimulatory device treatment of major depression will be reviewed, with data from studies on the biology of early abuse and cognitive deficits in depression and with an eye toward understanding how these various approaches can be integrated optimally to treating particular patients.

Early child abuse is associated with an increased risk for developing increased responsiveness to stress, as well as major depression in adulthood, and this risk interacts with specific genetic vulnerability. These patients might respond to medication, but do best when medications are combined with psychotherapy. Optimally, effective treatment outcomes will require the sophisticated application of knowledge of biology, pharmacology, and psychotherapy. In addition, training and education need to incorporate such approaches.

• Dr. Gabbard will discuss "Combining Individual Therapy With Other Modalities."

In the practice of general psychiatry, it inevitably becomes necessary to combine medication and psychotherapy techniques. However, this combination is undertheorized in our literature. In this presentation, the practice of combining individual therapy strategies and pharmacotherapy will be systematically considered from the standpoint of adherence, meanings of medication, enhancement of outcome, and different modes of therapeutic action. This presentation will address the practical matter of sequencing of the two modalities overall and within sessions.

• Dr. Keitner will discuss "Family Intervention by Psychiatrists as a Routine Component of Patient Care."

Illnesses begin and evolve in a social context, and affect friends and relatives of the ill person. The ways in which the patient’s significant others, in turn, deal with the illness influence its course and outcome.

It is necessary, therefore, to involve the families of patients in the assessment and treatment process. Family interventions can be stand-alone treatments or adjuncts to pharmacotherapy and psychotherapy. Numerous family-assessment and family-therapy models have been tested for use in many different illnesses. In general, family interventions have been found to be useful in the management of many chronic medical conditions as well as in major depression, bipolar disorder, anxiety disorders, schizophrenia, and substance abuse.

Most psychiatrists are not comfortable with or skilled in working with families, despite the evidence for its usefulness. This presentation will outline ways in which psychiatrists can systematically involve the families of patients in their assessment and treatment, and ways to combine and integrate family interventions with pharmacotherapy and psychotherapy.

For many decades, a biopsychosocial approach to patient care has meant a comprehensive assessment of the patient and the family environment. However, little discussion has occurred regarding what follows. What should follow is an extensive discussion with the patient and family about treatment. Clinical decision making should be done with the patient and the family, and should include a discussion of the biopsychosocial components that contribute to the illness, followed by a discussion of treatment options. The expected changes for each modality must be provided to the patient and family.

This symposium will address how to combine modalities, and how to discuss doing so with the patient and family. Each panelist will discuss how to combine modalities and will apply their expertise to Ms. Suarez’s situation.

Bring your clinical cases and questions, and pose them to the experts! See you there!

Ms. Suarez, a 48-year-old married Hispanic woman, came to her appointment at the outpatient psychiatry clinic asking for a second opinion. She told the admitting resident that she had had depression for years, and that nothing had helped. She said she had tried many medications and individual therapy, and she was feeling hopeless and frustrated. She worried that her husband would leave her. She was still working, but felt that the quality of her work was poor.

The psychiatric resident wondered whether to put her in the psychopharmacology clinic or in the psychotherapy clinic. What should the resident do? The American Psychiatric Association Symposium No. 81, from 9 a.m. to noon on May 8 in Philadelphia, will answer this question.

The symposium is called "Improving Quality of Care for Patients with Psychiatric Illness: Combining and Integrating Psychopharmacological, Individual, and Family Therapy." I will be presenting the symposium with Dr. Alan F. Schatzberg, Dr. Glen O. Gabbard, and Dr. Gabor I. Keitner as panelists, and Dr. Ira D. Glick as the discussant. We’ll be looking at the following topics:

• Dr. Schatzberg will discuss "Combining Pharmacotherapy With Other Modalities."

Psychopharmacology has become a major approach in the treatment of patients with psychiatric disorders. The discipline has evolved from its humble beginnings with a limited number of classes of agents that had a relatively narrow range of mechanisms of action, to the current host of classes and agents, many with disparate effects. This development demands considerable knowledge of the basic biology of the disorder, as well as the specific pharmacology of specific agents.

The development of this field, however, is not the only one in psychiatric treatment. Rather, parallel developments have taken place in the psychotherapies – as well as in devices – such that the practitioner needs to be able to incorporate advances in all of them to most optimally help his or her patient.

As models of other areas in psychiatry, recent developments in psychopharmacology and stimulatory device treatment of major depression will be reviewed, with data from studies on the biology of early abuse and cognitive deficits in depression and with an eye toward understanding how these various approaches can be integrated optimally to treating particular patients.

Early child abuse is associated with an increased risk for developing increased responsiveness to stress, as well as major depression in adulthood, and this risk interacts with specific genetic vulnerability. These patients might respond to medication, but do best when medications are combined with psychotherapy. Optimally, effective treatment outcomes will require the sophisticated application of knowledge of biology, pharmacology, and psychotherapy. In addition, training and education need to incorporate such approaches.

• Dr. Gabbard will discuss "Combining Individual Therapy With Other Modalities."

In the practice of general psychiatry, it inevitably becomes necessary to combine medication and psychotherapy techniques. However, this combination is undertheorized in our literature. In this presentation, the practice of combining individual therapy strategies and pharmacotherapy will be systematically considered from the standpoint of adherence, meanings of medication, enhancement of outcome, and different modes of therapeutic action. This presentation will address the practical matter of sequencing of the two modalities overall and within sessions.

• Dr. Keitner will discuss "Family Intervention by Psychiatrists as a Routine Component of Patient Care."

Illnesses begin and evolve in a social context, and affect friends and relatives of the ill person. The ways in which the patient’s significant others, in turn, deal with the illness influence its course and outcome.

It is necessary, therefore, to involve the families of patients in the assessment and treatment process. Family interventions can be stand-alone treatments or adjuncts to pharmacotherapy and psychotherapy. Numerous family-assessment and family-therapy models have been tested for use in many different illnesses. In general, family interventions have been found to be useful in the management of many chronic medical conditions as well as in major depression, bipolar disorder, anxiety disorders, schizophrenia, and substance abuse.

Most psychiatrists are not comfortable with or skilled in working with families, despite the evidence for its usefulness. This presentation will outline ways in which psychiatrists can systematically involve the families of patients in their assessment and treatment, and ways to combine and integrate family interventions with pharmacotherapy and psychotherapy.

For many decades, a biopsychosocial approach to patient care has meant a comprehensive assessment of the patient and the family environment. However, little discussion has occurred regarding what follows. What should follow is an extensive discussion with the patient and family about treatment. Clinical decision making should be done with the patient and the family, and should include a discussion of the biopsychosocial components that contribute to the illness, followed by a discussion of treatment options. The expected changes for each modality must be provided to the patient and family.

This symposium will address how to combine modalities, and how to discuss doing so with the patient and family. Each panelist will discuss how to combine modalities and will apply their expertise to Ms. Suarez’s situation.

Bring your clinical cases and questions, and pose them to the experts! See you there!

Ms. Suarez, a 48-year-old married Hispanic woman, came to her appointment at the outpatient psychiatry clinic asking for a second opinion. She told the admitting resident that she had had depression for years, and that nothing had helped. She said she had tried many medications and individual therapy, and she was feeling hopeless and frustrated. She worried that her husband would leave her. She was still working, but felt that the quality of her work was poor.

The psychiatric resident wondered whether to put her in the psychopharmacology clinic or in the psychotherapy clinic. What should the resident do? The American Psychiatric Association Symposium No. 81, from 9 a.m. to noon on May 8 in Philadelphia, will answer this question.

The symposium is called "Improving Quality of Care for Patients with Psychiatric Illness: Combining and Integrating Psychopharmacological, Individual, and Family Therapy." I will be presenting the symposium with Dr. Alan F. Schatzberg, Dr. Glen O. Gabbard, and Dr. Gabor I. Keitner as panelists, and Dr. Ira D. Glick as the discussant. We’ll be looking at the following topics:

• Dr. Schatzberg will discuss "Combining Pharmacotherapy With Other Modalities."

Psychopharmacology has become a major approach in the treatment of patients with psychiatric disorders. The discipline has evolved from its humble beginnings with a limited number of classes of agents that had a relatively narrow range of mechanisms of action, to the current host of classes and agents, many with disparate effects. This development demands considerable knowledge of the basic biology of the disorder, as well as the specific pharmacology of specific agents.

The development of this field, however, is not the only one in psychiatric treatment. Rather, parallel developments have taken place in the psychotherapies – as well as in devices – such that the practitioner needs to be able to incorporate advances in all of them to most optimally help his or her patient.

As models of other areas in psychiatry, recent developments in psychopharmacology and stimulatory device treatment of major depression will be reviewed, with data from studies on the biology of early abuse and cognitive deficits in depression and with an eye toward understanding how these various approaches can be integrated optimally to treating particular patients.

Early child abuse is associated with an increased risk for developing increased responsiveness to stress, as well as major depression in adulthood, and this risk interacts with specific genetic vulnerability. These patients might respond to medication, but do best when medications are combined with psychotherapy. Optimally, effective treatment outcomes will require the sophisticated application of knowledge of biology, pharmacology, and psychotherapy. In addition, training and education need to incorporate such approaches.

• Dr. Gabbard will discuss "Combining Individual Therapy With Other Modalities."

In the practice of general psychiatry, it inevitably becomes necessary to combine medication and psychotherapy techniques. However, this combination is undertheorized in our literature. In this presentation, the practice of combining individual therapy strategies and pharmacotherapy will be systematically considered from the standpoint of adherence, meanings of medication, enhancement of outcome, and different modes of therapeutic action. This presentation will address the practical matter of sequencing of the two modalities overall and within sessions.

• Dr. Keitner will discuss "Family Intervention by Psychiatrists as a Routine Component of Patient Care."

Illnesses begin and evolve in a social context, and affect friends and relatives of the ill person. The ways in which the patient’s significant others, in turn, deal with the illness influence its course and outcome.

It is necessary, therefore, to involve the families of patients in the assessment and treatment process. Family interventions can be stand-alone treatments or adjuncts to pharmacotherapy and psychotherapy. Numerous family-assessment and family-therapy models have been tested for use in many different illnesses. In general, family interventions have been found to be useful in the management of many chronic medical conditions as well as in major depression, bipolar disorder, anxiety disorders, schizophrenia, and substance abuse.

Most psychiatrists are not comfortable with or skilled in working with families, despite the evidence for its usefulness. This presentation will outline ways in which psychiatrists can systematically involve the families of patients in their assessment and treatment, and ways to combine and integrate family interventions with pharmacotherapy and psychotherapy.

For many decades, a biopsychosocial approach to patient care has meant a comprehensive assessment of the patient and the family environment. However, little discussion has occurred regarding what follows. What should follow is an extensive discussion with the patient and family about treatment. Clinical decision making should be done with the patient and the family, and should include a discussion of the biopsychosocial components that contribute to the illness, followed by a discussion of treatment options. The expected changes for each modality must be provided to the patient and family.

This symposium will address how to combine modalities, and how to discuss doing so with the patient and family. Each panelist will discuss how to combine modalities and will apply their expertise to Ms. Suarez’s situation.

Bring your clinical cases and questions, and pose them to the experts! See you there!

When Ms. A. visited with her son’s psychiatrist, she broke into tears: "I don’t know what to do! My son hates us! He calls us ‘messengers of the devil!’ His sister is getting teased at school. Her classmates won’t talk to her, and they say her family is "really messed up." No one understands our problems, and I feel so alone. I am too ashamed to confide in any of our family friends. Our friends’ kids all seem to be doing so well. What should I do?"

Fortunately, the psychiatrist was aware of the NAMI Family-to-Family Education Program, which provided her with a free, 12-week course for family caregivers of individuals with severe mental illnesses. Family members who had been trained to run the program taught the course. It afforded Ms. A. the opportunity to learn current information about the biology of schizophrenia, medication, and strategies for medication adherence. She also got a chance to meet others who had experienced the maelstrom that mental illness can have on families. From another mother in the group, Ms. A. learned strategies aimed at managing her son when he became angry.

More importantly, however, she learned not to blame herself and to take time to look after her own health and well-being. She got advice about how to help her daughter manage the teasing at school. In addition, she took educational material into the school and gave it to her daughter’s homeroom teacher.

Families of individuals who suffer from mental illness experience a myriad of emotions: anger, frustration, hopelessness, sadness, fear, anxiety, shame, and loss. Psychiatrists must maintain a nonjudgmental and empathic stance with patients and their families.

In addition, we must be mindful of the profound influence mental illness has on the family system. Relatives might become psychologically distressed from the burden of caretaking and the social stigma of mental illness (J. Fam. Psychol. 2001;15:225-40). Recognizing that caregivers and families are often under stress and might have depression or anxiety must be a paramount goal of the clinician (J. Affect. Disord. 2010;121:10-21). Caregiver burden itself impairs the support that the caregiver can provide (Expressed Emotion in Families: Its Significance for Mental Illness, New York: The Guilford Press, 1985).

Psychiatrists are in the position to identify resources in the community that can help families build a knowledge base, which can be a tool for families to assist their loved ones and themselves. Support groups empower families to advocate for their loved ones, can alleviate the burdens of caregiving, and give family members a sense of community (Family Relations 1999;48:405-10).

The websites below contain helpful information, including support groups for families dealing with the mental illness of a loved one. We encourage clinicians to recommend these sites to families.

Many institutions provide patients and family education, so local or state resources can be of additional help. Please let us know about any websites that are not on our list that you would recommend to family members.

The following websites might help patients cope with family members who have mental illness:

P The Crooked House

P National Family Caregivers Association

P American Foundation for Suicide Prevention

P Family Connections: Coordinated by the National Education Alliance for Borderline Personality Disorder

P Families for Depression Awareness

P Families Together

P Depression and Bipolar Support Alliance

P Mental Health America

P The Children’s Society’s Include Project

P The National Alliance on Mental Illness Family-to-Family Education Program

P Support and Education Program for Families

P Network of Care

P Children and Adults with Attention Deficit/Hyperactivity Disorder

P Active Minds

P Substance Abuse and Mental Health Services Administration Resources for Military Families

P Compeer

P National PLAN (Planned Lifetime Assistance Network) Alliance

Dr. Heru is an associate professor 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. Ascher is a resident in psychiatry, department of psychiatry and behavioral sciences at Beth Israel Medical Center, New York. He is the Dear Abby Fellow, Group for the Advancement of Psychiatry (GAP) Family Committee. This commentary appears in Clinical Psychiatry News, a publication of Elsevier.

When Ms. A. visited with her son’s psychiatrist, she broke into tears: "I don’t know what to do! My son hates us! He calls us ‘messengers of the devil!’ His sister is getting teased at school. Her classmates won’t talk to her, and they say her family is "really messed up." No one understands our problems, and I feel so alone. I am too ashamed to confide in any of our family friends. Our friends’ kids all seem to be doing so well. What should I do?"

Fortunately, the psychiatrist was aware of the NAMI Family-to-Family Education Program, which provided her with a free, 12-week course for family caregivers of individuals with severe mental illnesses. Family members who had been trained to run the program taught the course. It afforded Ms. A. the opportunity to learn current information about the biology of schizophrenia, medication, and strategies for medication adherence. She also got a chance to meet others who had experienced the maelstrom that mental illness can have on families. From another mother in the group, Ms. A. learned strategies aimed at managing her son when he became angry.

More importantly, however, she learned not to blame herself and to take time to look after her own health and well-being. She got advice about how to help her daughter manage the teasing at school. In addition, she took educational material into the school and gave it to her daughter’s homeroom teacher.

Families of individuals who suffer from mental illness experience a myriad of emotions: anger, frustration, hopelessness, sadness, fear, anxiety, shame, and loss. Psychiatrists must maintain a nonjudgmental and empathic stance with patients and their families.

In addition, we must be mindful of the profound influence mental illness has on the family system. Relatives might become psychologically distressed from the burden of caretaking and the social stigma of mental illness (J. Fam. Psychol. 2001;15:225-40). Recognizing that caregivers and families are often under stress and might have depression or anxiety must be a paramount goal of the clinician (J. Affect. Disord. 2010;121:10-21). Caregiver burden itself impairs the support that the caregiver can provide (Expressed Emotion in Families: Its Significance for Mental Illness, New York: The Guilford Press, 1985).

Psychiatrists are in the position to identify resources in the community that can help families build a knowledge base, which can be a tool for families to assist their loved ones and themselves. Support groups empower families to advocate for their loved ones, can alleviate the burdens of caregiving, and give family members a sense of community (Family Relations 1999;48:405-10).

The websites below contain helpful information, including support groups for families dealing with the mental illness of a loved one. We encourage clinicians to recommend these sites to families.

Many institutions provide patients and family education, so local or state resources can be of additional help. Please let us know about any websites that are not on our list that you would recommend to family members.

The following websites might help patients cope with family members who have mental illness:

P The Crooked House

P National Family Caregivers Association

P American Foundation for Suicide Prevention

P Family Connections: Coordinated by the National Education Alliance for Borderline Personality Disorder

P Families for Depression Awareness

P Families Together

P Depression and Bipolar Support Alliance

P Mental Health America

P The Children’s Society’s Include Project

P The National Alliance on Mental Illness Family-to-Family Education Program

P Support and Education Program for Families

P Network of Care

P Children and Adults with Attention Deficit/Hyperactivity Disorder

P Active Minds

P Substance Abuse and Mental Health Services Administration Resources for Military Families

P Compeer

P National PLAN (Planned Lifetime Assistance Network) Alliance

Dr. Heru is an associate professor 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. Ascher is a resident in psychiatry, department of psychiatry and behavioral sciences at Beth Israel Medical Center, New York. He is the Dear Abby Fellow, Group for the Advancement of Psychiatry (GAP) Family Committee. This commentary appears in Clinical Psychiatry News, a publication of Elsevier.

When Ms. A. visited with her son’s psychiatrist, she broke into tears: "I don’t know what to do! My son hates us! He calls us ‘messengers of the devil!’ His sister is getting teased at school. Her classmates won’t talk to her, and they say her family is "really messed up." No one understands our problems, and I feel so alone. I am too ashamed to confide in any of our family friends. Our friends’ kids all seem to be doing so well. What should I do?"

Fortunately, the psychiatrist was aware of the NAMI Family-to-Family Education Program, which provided her with a free, 12-week course for family caregivers of individuals with severe mental illnesses. Family members who had been trained to run the program taught the course. It afforded Ms. A. the opportunity to learn current information about the biology of schizophrenia, medication, and strategies for medication adherence. She also got a chance to meet others who had experienced the maelstrom that mental illness can have on families. From another mother in the group, Ms. A. learned strategies aimed at managing her son when he became angry.

More importantly, however, she learned not to blame herself and to take time to look after her own health and well-being. She got advice about how to help her daughter manage the teasing at school. In addition, she took educational material into the school and gave it to her daughter’s homeroom teacher.

Families of individuals who suffer from mental illness experience a myriad of emotions: anger, frustration, hopelessness, sadness, fear, anxiety, shame, and loss. Psychiatrists must maintain a nonjudgmental and empathic stance with patients and their families.

In addition, we must be mindful of the profound influence mental illness has on the family system. Relatives might become psychologically distressed from the burden of caretaking and the social stigma of mental illness (J. Fam. Psychol. 2001;15:225-40). Recognizing that caregivers and families are often under stress and might have depression or anxiety must be a paramount goal of the clinician (J. Affect. Disord. 2010;121:10-21). Caregiver burden itself impairs the support that the caregiver can provide (Expressed Emotion in Families: Its Significance for Mental Illness, New York: The Guilford Press, 1985).

Psychiatrists are in the position to identify resources in the community that can help families build a knowledge base, which can be a tool for families to assist their loved ones and themselves. Support groups empower families to advocate for their loved ones, can alleviate the burdens of caregiving, and give family members a sense of community (Family Relations 1999;48:405-10).

The websites below contain helpful information, including support groups for families dealing with the mental illness of a loved one. We encourage clinicians to recommend these sites to families.

Many institutions provide patients and family education, so local or state resources can be of additional help. Please let us know about any websites that are not on our list that you would recommend to family members.

The following websites might help patients cope with family members who have mental illness:

P The Crooked House

P National Family Caregivers Association

P American Foundation for Suicide Prevention

P Family Connections: Coordinated by the National Education Alliance for Borderline Personality Disorder

P Families for Depression Awareness

P Families Together

P Depression and Bipolar Support Alliance

P Mental Health America

P The Children’s Society’s Include Project

P The National Alliance on Mental Illness Family-to-Family Education Program

P Support and Education Program for Families

P Network of Care

P Children and Adults with Attention Deficit/Hyperactivity Disorder

P Active Minds

P Substance Abuse and Mental Health Services Administration Resources for Military Families

P Compeer

P National PLAN (Planned Lifetime Assistance Network) Alliance

Dr. Heru is an associate professor 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. Ascher is a resident in psychiatry, department of psychiatry and behavioral sciences at Beth Israel Medical Center, New York. He is the Dear Abby Fellow, Group for the Advancement of Psychiatry (GAP) Family Committee. This commentary appears in Clinical Psychiatry News, a publication of Elsevier.

Julie Totten was 24 years old when her brother Mark took his life. Shortly after, she helped her father, who had been suffering from undiagnosed depression all his life, get treated for the illness. In dealing with the depression that afflicted her father and brother, she felt alone, lost, and responsible. She thought there must be a lot of other families like hers.

So, 10 years after Mark’s death, Julie founded Families for Depression Awareness, a nonprofit organization to help families, including family caregivers like her, recognize and cope with depressive disorders to get people well and prevent suicides. The organization’s website, helps families recognize and cope with depression, and focuses on getting people into treatment to prevent suicide.

Dr. Bill Beardslee, chairman of psychiatry at Children’s Hospital Boston, lost an older sister to suicide when he was in medical school. "The depression took her over and after a valiant struggle against it, she took her own life some years later.

"It has taken me many years to deal with that and many conversations with my father, my mother and my wife, my friends, and, more recently, my children. Above all, it has given me a sense of how awful this illness can be for families," he wrote on the Hachette Book Group website. In his book, Out of the Darkened Room (New York: Little, Brown & Co., 2002), he describes the experiences of families with depression and strategies that families find helpful. It is highly recommended to psychiatrists to share with their patients and families.

Parents with depression worry that their children are suffering. Dr. Beardslee, who also is the Gardner-Monks Professor of Child Psychiatry at Harvard Medical School, Boston, has developed interventions with his colleagues aimed at helping these families. A major goal is "breaking the silence and helping the family talk together about depression." He conceptualizes depression as a chronic medical illness but also a family calamity and has developed an intervention to help families talk together and make meaning together.

His website, Families Preventing and Overcoming Depression provides details on the Family Talk Preventive Intervention. This is a public health, strength-based, and family-centered intervention designed to support families in which one or both parents have depression. This evidence-based practice partners with families to improve relationships and functioning by educating families on depression risk factors and understanding the benefits of applying protective factors to promote resilience.

Dr. Beardslee has many international collaborators in many different countries: Australia, Finland, the Netherlands, Norway, Sweden, Columbia, Costa Rica, and Iceland. Family interventions in these countries are supported by government, and in the public health, and medical and mental health systems. Interventions in these countries are more widespread and systematically available than they are in the United States.

A symposium on this topic will be held at the American Psychiatric Association’s annual meeting in Philadelphia, moderated by Dr. Ellen Berman. It is called "When Your Patient Is a Parent: Supporting the Family and Addressing the Needs of Children." As part of that symposium, Dr. Beardslee will present "Clinical Implications of Evidence-Based Preventive Interventions for Families With Parental Depression." Finally, Ms. Totten will present "A Family Perspective," and I will present "Overview of Needs of the Children of Parents With Mental Illness." See you there!

Dr. Heru is an associate professor 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

Julie Totten was 24 years old when her brother Mark took his life. Shortly after, she helped her father, who had been suffering from undiagnosed depression all his life, get treated for the illness. In dealing with the depression that afflicted her father and brother, she felt alone, lost, and responsible. She thought there must be a lot of other families like hers.

So, 10 years after Mark’s death, Julie founded Families for Depression Awareness, a nonprofit organization to help families, including family caregivers like her, recognize and cope with depressive disorders to get people well and prevent suicides. The organization’s website, helps families recognize and cope with depression, and focuses on getting people into treatment to prevent suicide.

Dr. Bill Beardslee, chairman of psychiatry at Children’s Hospital Boston, lost an older sister to suicide when he was in medical school. "The depression took her over and after a valiant struggle against it, she took her own life some years later.

"It has taken me many years to deal with that and many conversations with my father, my mother and my wife, my friends, and, more recently, my children. Above all, it has given me a sense of how awful this illness can be for families," he wrote on the Hachette Book Group website. In his book, Out of the Darkened Room (New York: Little, Brown & Co., 2002), he describes the experiences of families with depression and strategies that families find helpful. It is highly recommended to psychiatrists to share with their patients and families.

Parents with depression worry that their children are suffering. Dr. Beardslee, who also is the Gardner-Monks Professor of Child Psychiatry at Harvard Medical School, Boston, has developed interventions with his colleagues aimed at helping these families. A major goal is "breaking the silence and helping the family talk together about depression." He conceptualizes depression as a chronic medical illness but also a family calamity and has developed an intervention to help families talk together and make meaning together.

His website, Families Preventing and Overcoming Depression provides details on the Family Talk Preventive Intervention. This is a public health, strength-based, and family-centered intervention designed to support families in which one or both parents have depression. This evidence-based practice partners with families to improve relationships and functioning by educating families on depression risk factors and understanding the benefits of applying protective factors to promote resilience.

Dr. Beardslee has many international collaborators in many different countries: Australia, Finland, the Netherlands, Norway, Sweden, Columbia, Costa Rica, and Iceland. Family interventions in these countries are supported by government, and in the public health, and medical and mental health systems. Interventions in these countries are more widespread and systematically available than they are in the United States.

A symposium on this topic will be held at the American Psychiatric Association’s annual meeting in Philadelphia, moderated by Dr. Ellen Berman. It is called "When Your Patient Is a Parent: Supporting the Family and Addressing the Needs of Children." As part of that symposium, Dr. Beardslee will present "Clinical Implications of Evidence-Based Preventive Interventions for Families With Parental Depression." Finally, Ms. Totten will present "A Family Perspective," and I will present "Overview of Needs of the Children of Parents With Mental Illness." See you there!

Dr. Heru is an associate professor 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

Julie Totten was 24 years old when her brother Mark took his life. Shortly after, she helped her father, who had been suffering from undiagnosed depression all his life, get treated for the illness. In dealing with the depression that afflicted her father and brother, she felt alone, lost, and responsible. She thought there must be a lot of other families like hers.

So, 10 years after Mark’s death, Julie founded Families for Depression Awareness, a nonprofit organization to help families, including family caregivers like her, recognize and cope with depressive disorders to get people well and prevent suicides. The organization’s website, helps families recognize and cope with depression, and focuses on getting people into treatment to prevent suicide.

Dr. Bill Beardslee, chairman of psychiatry at Children’s Hospital Boston, lost an older sister to suicide when he was in medical school. "The depression took her over and after a valiant struggle against it, she took her own life some years later.

"It has taken me many years to deal with that and many conversations with my father, my mother and my wife, my friends, and, more recently, my children. Above all, it has given me a sense of how awful this illness can be for families," he wrote on the Hachette Book Group website. In his book, Out of the Darkened Room (New York: Little, Brown & Co., 2002), he describes the experiences of families with depression and strategies that families find helpful. It is highly recommended to psychiatrists to share with their patients and families.

Parents with depression worry that their children are suffering. Dr. Beardslee, who also is the Gardner-Monks Professor of Child Psychiatry at Harvard Medical School, Boston, has developed interventions with his colleagues aimed at helping these families. A major goal is "breaking the silence and helping the family talk together about depression." He conceptualizes depression as a chronic medical illness but also a family calamity and has developed an intervention to help families talk together and make meaning together.

His website, Families Preventing and Overcoming Depression provides details on the Family Talk Preventive Intervention. This is a public health, strength-based, and family-centered intervention designed to support families in which one or both parents have depression. This evidence-based practice partners with families to improve relationships and functioning by educating families on depression risk factors and understanding the benefits of applying protective factors to promote resilience.

Dr. Beardslee has many international collaborators in many different countries: Australia, Finland, the Netherlands, Norway, Sweden, Columbia, Costa Rica, and Iceland. Family interventions in these countries are supported by government, and in the public health, and medical and mental health systems. Interventions in these countries are more widespread and systematically available than they are in the United States.

A symposium on this topic will be held at the American Psychiatric Association’s annual meeting in Philadelphia, moderated by Dr. Ellen Berman. It is called "When Your Patient Is a Parent: Supporting the Family and Addressing the Needs of Children." As part of that symposium, Dr. Beardslee will present "Clinical Implications of Evidence-Based Preventive Interventions for Families With Parental Depression." Finally, Ms. Totten will present "A Family Perspective," and I will present "Overview of Needs of the Children of Parents With Mental Illness." See you there!

Dr. Heru is an associate professor 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 the comfort of the Gottmans’ own island home, learn research-based tools for building and maintaining relationship intimacy. Have you ever planned a wonderful romantic vacation, complete with a lovely room, candle-lit dinners, and white sand beaches, only to have your dream become a nightmare when tense quarrels and silence spoil the sunset? We have been listening to painful stories like these for nearly 35 years.

"Now you can restore your relationship while having a world-class romantic holiday. In an exclusive, small group two-day couples retreat (there will be no more than six couples in each retreat), we offer you research-based skills for deepening intimacy, managing conflicts, and enhancing your sense of shared meaning in a private, comfortable, and beautiful setting."

That is a description from the brochure and website of the Gottman Relationship Institute, a marital therapy retreat conducted on Orcas Island off the coast of Washington, and run by an academic who has crossed over to the public sector: John M. Gottman, Ph.D.

Dr. Gottman is a psychologist who has received National Institute of Mental Health grants and numerous awards, and has authored or coauthored 119 academic articles and 37 books. In addition, Dr. Gottman is cofounder with his wife, Julie Gottman, also a Ph.D psychologist, of the Gottman Relationship Institute in Seattle. (Another personalized marriage counseling retreat is called Marriage Quest.* This one is held in Cabot, Vt., and is run by Israel Helfand, Ph.D., and his wife, Cathie Helfand, M.S. The Helfands are marriage counselors and sex therapists who have been working together with couples since 1983.)

We are all familiar with Dr. Gottman’s relationship interaction ratios. In happy couples, there are 20 positive interactions to 1 negative interaction, in conflicted couples the ratio is 5 to 1, and in soon-to-divorce couples the ratio is 0.8 to 1. Unhappy couples have a filter that screens out positive events and makes even neutral events negative. Happy couples have a filter that screens out negative events and makes neutral events positive.

Dr. Gottman’s research involves a quantitative mathematical approach to understanding the changes in the marital dyad and the relative influence that each has on the other. This model predicts changes in the relationship of a couple in his research laboratory.

His relational ratios and equations are now being applied to the dynamics of psychotherapy (Cogn. Neurodyn. 2011;5:265-75). The influence that the client has on the therapist and the influence that the therapist has on the client are mathematically mapped. Without going into the mathematical computations, I can say that the findings are that the therapist or client who is most responsive to the other ends up being the most positive, often through a series of emotional ups and downs. In other words, being positive, either on the part of the therapist or the client, yields positive outcomes. However, being too responsive to clients produces mediocre outcomes, and being negative to patients produces negative outcomes.

The authors do not claim any major theoretical advances. But they do believe that understanding the dynamic emotional states that exist between the therapist and the patient holds clues to the good therapeutic relationship.

For their part, Dr. Gottman and his wife certainly have balanced out the positives with the negatives when it comes to work and lifestyle balance. They’ve got an island home, the gratification of a successful practice, the avoidance of the health care system, and a continued ability to influence the field of relational psychology. In fact, he has developed a Relationship Vision Quest based on extensive research laboratory findings. One critical question has always been: Does this research translate into clinical practice?

Dr. Gottman now has his utopian island where he can put his research to the test – and he is looking for volunteers.

This column, Families in Psychiatry, appears in Clinical Psychiatry News. Dr. Heru is an associate professor 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 author of numerous articles on this topic.

*Correction, 1/9/2012: An earlier version of this column inadvertently referred to the Gottmans' retreat as Marriage Quest.

"In the comfort of the Gottmans’ own island home, learn research-based tools for building and maintaining relationship intimacy. Have you ever planned a wonderful romantic vacation, complete with a lovely room, candle-lit dinners, and white sand beaches, only to have your dream become a nightmare when tense quarrels and silence spoil the sunset? We have been listening to painful stories like these for nearly 35 years.

"Now you can restore your relationship while having a world-class romantic holiday. In an exclusive, small group two-day couples retreat (there will be no more than six couples in each retreat), we offer you research-based skills for deepening intimacy, managing conflicts, and enhancing your sense of shared meaning in a private, comfortable, and beautiful setting."

That is a description from the brochure and website of the Gottman Relationship Institute, a marital therapy retreat conducted on Orcas Island off the coast of Washington, and run by an academic who has crossed over to the public sector: John M. Gottman, Ph.D.

Dr. Gottman is a psychologist who has received National Institute of Mental Health grants and numerous awards, and has authored or coauthored 119 academic articles and 37 books. In addition, Dr. Gottman is cofounder with his wife, Julie Gottman, also a Ph.D psychologist, of the Gottman Relationship Institute in Seattle. (Another personalized marriage counseling retreat is called Marriage Quest.* This one is held in Cabot, Vt., and is run by Israel Helfand, Ph.D., and his wife, Cathie Helfand, M.S. The Helfands are marriage counselors and sex therapists who have been working together with couples since 1983.)

We are all familiar with Dr. Gottman’s relationship interaction ratios. In happy couples, there are 20 positive interactions to 1 negative interaction, in conflicted couples the ratio is 5 to 1, and in soon-to-divorce couples the ratio is 0.8 to 1. Unhappy couples have a filter that screens out positive events and makes even neutral events negative. Happy couples have a filter that screens out negative events and makes neutral events positive.

Dr. Gottman’s research involves a quantitative mathematical approach to understanding the changes in the marital dyad and the relative influence that each has on the other. This model predicts changes in the relationship of a couple in his research laboratory.

His relational ratios and equations are now being applied to the dynamics of psychotherapy (Cogn. Neurodyn. 2011;5:265-75). The influence that the client has on the therapist and the influence that the therapist has on the client are mathematically mapped. Without going into the mathematical computations, I can say that the findings are that the therapist or client who is most responsive to the other ends up being the most positive, often through a series of emotional ups and downs. In other words, being positive, either on the part of the therapist or the client, yields positive outcomes. However, being too responsive to clients produces mediocre outcomes, and being negative to patients produces negative outcomes.

The authors do not claim any major theoretical advances. But they do believe that understanding the dynamic emotional states that exist between the therapist and the patient holds clues to the good therapeutic relationship.

For their part, Dr. Gottman and his wife certainly have balanced out the positives with the negatives when it comes to work and lifestyle balance. They’ve got an island home, the gratification of a successful practice, the avoidance of the health care system, and a continued ability to influence the field of relational psychology. In fact, he has developed a Relationship Vision Quest based on extensive research laboratory findings. One critical question has always been: Does this research translate into clinical practice?

Dr. Gottman now has his utopian island where he can put his research to the test – and he is looking for volunteers.

This column, Families in Psychiatry, appears in Clinical Psychiatry News. Dr. Heru is an associate professor 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 author of numerous articles on this topic.

*Correction, 1/9/2012: An earlier version of this column inadvertently referred to the Gottmans' retreat as Marriage Quest.

"In the comfort of the Gottmans’ own island home, learn research-based tools for building and maintaining relationship intimacy. Have you ever planned a wonderful romantic vacation, complete with a lovely room, candle-lit dinners, and white sand beaches, only to have your dream become a nightmare when tense quarrels and silence spoil the sunset? We have been listening to painful stories like these for nearly 35 years.

"Now you can restore your relationship while having a world-class romantic holiday. In an exclusive, small group two-day couples retreat (there will be no more than six couples in each retreat), we offer you research-based skills for deepening intimacy, managing conflicts, and enhancing your sense of shared meaning in a private, comfortable, and beautiful setting."

That is a description from the brochure and website of the Gottman Relationship Institute, a marital therapy retreat conducted on Orcas Island off the coast of Washington, and run by an academic who has crossed over to the public sector: John M. Gottman, Ph.D.

Dr. Gottman is a psychologist who has received National Institute of Mental Health grants and numerous awards, and has authored or coauthored 119 academic articles and 37 books. In addition, Dr. Gottman is cofounder with his wife, Julie Gottman, also a Ph.D psychologist, of the Gottman Relationship Institute in Seattle. (Another personalized marriage counseling retreat is called Marriage Quest.* This one is held in Cabot, Vt., and is run by Israel Helfand, Ph.D., and his wife, Cathie Helfand, M.S. The Helfands are marriage counselors and sex therapists who have been working together with couples since 1983.)

We are all familiar with Dr. Gottman’s relationship interaction ratios. In happy couples, there are 20 positive interactions to 1 negative interaction, in conflicted couples the ratio is 5 to 1, and in soon-to-divorce couples the ratio is 0.8 to 1. Unhappy couples have a filter that screens out positive events and makes even neutral events negative. Happy couples have a filter that screens out negative events and makes neutral events positive.

Dr. Gottman’s research involves a quantitative mathematical approach to understanding the changes in the marital dyad and the relative influence that each has on the other. This model predicts changes in the relationship of a couple in his research laboratory.

His relational ratios and equations are now being applied to the dynamics of psychotherapy (Cogn. Neurodyn. 2011;5:265-75). The influence that the client has on the therapist and the influence that the therapist has on the client are mathematically mapped. Without going into the mathematical computations, I can say that the findings are that the therapist or client who is most responsive to the other ends up being the most positive, often through a series of emotional ups and downs. In other words, being positive, either on the part of the therapist or the client, yields positive outcomes. However, being too responsive to clients produces mediocre outcomes, and being negative to patients produces negative outcomes.

The authors do not claim any major theoretical advances. But they do believe that understanding the dynamic emotional states that exist between the therapist and the patient holds clues to the good therapeutic relationship.

For their part, Dr. Gottman and his wife certainly have balanced out the positives with the negatives when it comes to work and lifestyle balance. They’ve got an island home, the gratification of a successful practice, the avoidance of the health care system, and a continued ability to influence the field of relational psychology. In fact, he has developed a Relationship Vision Quest based on extensive research laboratory findings. One critical question has always been: Does this research translate into clinical practice?

Dr. Gottman now has his utopian island where he can put his research to the test – and he is looking for volunteers.

This column, Families in Psychiatry, appears in Clinical Psychiatry News. Dr. Heru is an associate professor 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 author of numerous articles on this topic.

*Correction, 1/9/2012: An earlier version of this column inadvertently referred to the Gottmans' retreat as Marriage Quest.

Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).

Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).

Dr. Sali, the resident, asks his attending: Dr. Biba, are you saying that you can tell if a patient has marital problems in the first 5 minutes of an interview?

Dr. Biba: Yes. In fact, Jill Hooley says that you just need to ask one question of a patient: "How critical is your spouse of you?"

Dr. Sali: Okay, so I asked Jeanie "the Critical Question" at our first meeting. She said yes. Now what?

Dr. Biba: Now you bring in the husband and try to understand what is going on.

A week later:

Dr. Sali: So I met with Jeanie and her husband. He started right in with "So what’s wrong with my wife?" When I explained about depression, he said "What do you mean she’s depressed? She’s never said that before! Jeanie, why are you saying this stuff? Don’t you want to go to work?"

Dr. Biba: Wow, that sounds bad. What did you do then?

Dr. Sali: I explained some more about depression, all its symptoms and signs. I asked the husband to listen and said that we needed to work together to help Jeanie. Then he said, "That’s how her mother was!" He completely changed! He still was a bit agitated but he was okay and said, "So, let’s get this illness treated!" I am not sure I trust his quick change, but at least he has some idea of what needs to be done.

Dr. Biba: What did you tell him he needs to do?

Dr. Sali: I didn’t know what to tell him. I gave him a handout about depression and families that I found on the Internet. Can you meet with them and me next week?

High criticalness in families is often tied to a lack of understanding about illness. In the scenario described above, the patient’s husband thought he was being a good husband by standing tough with his wife. His intentions were good, but he did not understand the extent to which depression impairs energy and motivation.

High criticalness is a component of the concept of expressed emotion (EE), a robust research construct in family psychiatry. High levels of EE are found in patient-family interactions when patients relapse sooner and more frequently. EE was first described with schizophrenia, but high EE is associated with early relapse in many other psychiatric and medical illnesses (Arch. Gen. Psychiatry 1998;55:547-52).

EE consists of three components: criticalness, overt hostility, and emotional overinvolvement. It originally was measured with the 2-hour Camberwell Family Interview ("Expressed Emotion in Families." New York: Guilford Press, 1985). But shorter tools now exist, such as the critical question conceptualized by Jill Hooley, D.Phil., and the Five-Minute Speech Sample (FMSS). The FMSS consists of asking a family member to speak freely about the patient’s character and their relationships, without disturbance from the interviewer, for 5 minutes (Psychiatry Res. 1986;17:203-12).

Dr. Hooley measured marital distress and patients’ perceptions of criticism from spouses in hospitalized patients with major depression. EE and marital distress predicted the same relapse rates at 9 months. However, a patient’s response to the question, "How critical is your spouse of you?" accounted for more of the variance in relapse rates than did EE and marital distress combined (J. Abnorm. Psychol. 1989;98:229-35).

The good news is that EE is reduced with psychoeducational family interventions. In addition, many interventions that reduce EE are evidence based, and are effective across many illnesses and cultures. For example, a recent study of a family work intervention in Catalonia, Spain, found improvements in the clinical status as well as global and social functioning of patients with schizophrenia (Int. J. Soc. Psychiatry 2011 Aug. 1 [doi:10.1177/00207640114155]).

Dr. Julian Leff, one of the social psychiatrists who delineated EE, is still hard at work reducing EE, this time in the auditory hallucination of patients with schizophrenia in a new therapy called Avatar Therapy for people with persistent auditory hallucinations (Department of Psychiatry Grand Rounds, University of Colorado at Denver, Oct. 19, 2011).