Master Class National Harbor, Maryland 8 July 2013 William R. Beardslee, MD Department of Psychiatry Boston Children’s Hospital and Harvard Medical School.

Master ClassNational Harbor, Maryland

8 July 2013

William R. Beardslee, MD

Department of Psychiatry

Boston Children’s Hospital and Harvard Medical School

“The child is the bearer of whatever the futureshall be … At this center … his incomparable tenderness to experience, his malleability,

the almost unimaginable nakedness and defenselessness of this wondrous

five-windowed nerve and core.”

James Agee, “Let Us Now Praise Famous Men”

“The pediatrician can regard the family as carrying the ‘chromosomes’ that perpetuate the

culture and also form the cornerstone of emotional development.”

Beardslee & Richmond. Mental Health of the Young: An Overview

Envisioning the Future

What should a heath care system look like that fully meets the needs of families, both military and nonmilitary, incorporates prevention and treatment, and reflects cultural competence and cultural humility?

Envisioning the Future

What should a network of preventive family-based services look like to best serve the needs of active duty military families and Guard and Reserve families in all branches of the service?

IOM 2009

Key Core Concepts of Prevention

1. Prevention requires a paradigm shift

2. Mental health and physical health are inseparable

3. Successful prevention is inherently interdisciplinary

4. Mental, emotional, and behavioral disorders are developmental

5. Coordinated community level systems are needed to support young people

6. Developmental perspective is key

Prevention AND Promotion

IOM, 2009

Mental Health Promotion Aims to:

Enhance individuals’– ability to achieve developmentally appropriate

tasks (developmental competence) – positive sense of self-esteem, mastery, well-being,

and social inclusion Strengthen their ability to cope with adversity

IOM 2009

“If you always do what you’ve always done, you’ll always get what you’ve always got.”

~ Albert Einstein

Health care reform must challenge existing paradigms and develop new

paradigms.

Component Studies

1979 - 1985: Risk Assessment - Children of Parents with Mood Disorders

1983 - 1987: Resiliency Studies and Intervention Development

1989 - 1991: Pilot Comparison of Public Health Interventions

1991 - 2000: Randomized Trial Comparing Psychoeducational Family Interventions for Depression

1997 - 1999: Family CORE in Dorchester

1998: Narrative Reconstruction

2000: Efficacy to Effectiveness

Characteristics of Resilient Youth

Activities - Intense Involvement in Age Appropriate Developmental Challenges - in School, Work, Community, Religion, and Culture

Relationships - Deep Commitment to Interpersonal Relationships - Family, Peers, and Adults Outside the Family

Self-Understanding - Self-Reflection and Understanding in Action

Resilience in Parents

Commitment to parenting

Openness to self-reflection

Commitment to family connections and growth of shared understanding

Core Elements of the Intervention

1. Assessment of all family members

2. Presentation of psychoeducational material (e.g., affective disorder, child risk, and child resilience)

3. Linkage of psychoeducational material to the family’s life experience

4. Decreasing feelings of guilt and blame in the children

5. Helping the children develop relationships (inside and outside the family) to facilitate independent functioning in school and in activities outside the home

Seven modules

1. Taking a history2. Psychoeducation and the family’s story3. Seeing the children4. Planning the family meeting5. Holding the family meeting6. One week follow-up, check-in7. Long-term follow-up

Session 1 – taking a history

1. If possible, include both parents. 2. Elicit the history of the illness and a history of

strengths and positives in the marriage or partnership.

3. After asking one partner his/her experience, ask the other, “What was it like for you?” Then ask, “What was it like for your child?”

Session 2 – psychoeducation and the family’s story

1. Cognitive information is presented. Resilience is possible; treatment is useful.

2. Recognizing how vitally important the child is to the family.

Three Randomized Trials of Family Talk

High rankings - 3.5 out of a possible 4.0 in the National Registry of Evidence-based Programs and Practices for strength of evidence, SAMHSA.

Six Principles for a Successful Family Meeting

1. Pay attention to the timing of the meeting.

2. Gain commitment to the process from the entire family.

3. Begin by identifying specific major concerns and addressing them.

4. Bring together and reknit the family history.

5. Plan to talk more than once.

6. Draw on all the available resources to get through depression.

Holding the Family Meeting

Four key objectives of the family meeting:

1. To reassure your children that you will be okay and that the illness will not overwhelm the family

2. To emphasize that no one is guilty or to blame

3. To speak to the positives, the strengths that exist and will be enhanced

4. To present some knowledge about depression and treatment

Narrative Project for FamiliesWho Sustained Changes

1. The emergence of the healer within

2. The need to understand depression anew across development

• Children’s growth

• Vicissitudes of parental illness

Making Peace and Moving On

Seeing the Continuity and One’s Place in It

Becoming Part of the Story Again

Web-based training in Family Talk available at www.fampod.org.

The Family Connections program is available at www.childrenshospital.org/familyconnections.

Different Implementations of the Family Talk Approach

1. Randomized trial pilot – Dorchester for single parent families of color

2. Development of a program for Latino families

3. Large scale approaches – collaborations in Finland, Holland, and Australia

4. Head Start – Program for parental adversity / depression

5. Blackfeet Nation – Head Start – Family Connections

Different Implementations of the Family Talk Approach

(continued)

6. Costa Rica

7. Collaboration with other investigators in new preventive interventions – Project Focus; Chicago city-wide training; family-strengthening intervention in Rwanda; web-based training – FamPod.org

8. International collaborations – COPMI

9. Core principles across project

Latino Adaptation Familismo

Allocentric orientation

Kinds of separation in immigrant families

Differing involvement of parents and children in the mainstream culture

Immigration narrative

What helps parents cope with depression?

Focus on the children Visualizations. Envisioning a better future Prayer, songs, religion, church community, spiritual healing Support groups Helping others, sharing information Focusing in the present: “viviendo de dia a dia” (living day to day) Not giving up: “seguir la lucha” Alternative medicine Humor: “al mal tiempo buena cara” “yo no lloro, yo me rio”

Applying Evidence Based Interventions for Military Families: Partnered Implementation with Military Communities

Certain family behaviors are especially likely to be found

in resilient families

Family Resilience Models

FOCUS Resiliency Training

Public Health Implementation with

COSC Model

Evidence Based Prevention

Interventions

Traumatic Stress Research: Children and Families

Key Collaborators in the Evaluation of the Dissemination Effort

Patricia LesterLee Klosinski

William R. BeardsleeWilliam Saltzman Kirsten Woodward

William NashCatherine MogilRobert KoffmanRobert Pynoos

Stephen J. CozzaGregory Leskin

Alignment of FOCUS with Military Organizational Goals

FOCUS: Adaptation of UCLA-Harvard Team’s Evidence Based Prevention Interventions for Military Families during Wartime

Families are important gateway to services, given the multiple barriers to care

Opportunity for screening, prevention and intervention

Integration with Combat Operational Stress Continuum Model

Destigmatizing framework for promoting psychological health

Supporting readiness, recovery, and reintegration

Chronology1. Three foundational interventions:

Project Talk (teens and adults learning to communicate) for families with parental medical illness including HIV/aids leadership

UCLA Trauma Grief Intervention – a cognitive behavioral program

Family Talk: family based preventive intervention for parental depression

2. From the beginning, intervention development and deployment was a partnership between academic and clinical mental health professionals, military mental health professionals, and other military personnel.

3. The initial FOCUS manual based on key informative interviews, family focus groups, environmental assistance assessment, or piloting with USMC families at Camp Pendleton, CA.

4. 2007-2008: Navy Bureau of Medicine and Surgery funded FOCUS for selected USN and USMC installations. .

FOCUS Implementation

Evaluation Innovation/ Technology

OperationsTraining & Adaptations

Partnerships Partnerships

FOCUS Resilience Training Core Components

Family web based check-up

Family level education: Stress continuum model, Parenting, Developmental guidance

Individual and Family narrative timelines Link skills to family (and child) narrative Gives voice to child’s experience Develop shared family meaning Bridge estrangements Co-parenting

Family level resiliency skills across the deployment cycle Emotional regulation Problem solving Communication Goal setting Managing deployment reminders

Sessions 1 & 2 Sessions 3 & 4 Session 5 Sessions 6 8Parents Only Parents OnlyChildren Only Family Sessions

FOCUS: Individual Family Resiliency Training

•Collect family history

•Construct parent narrative

•Real time check-up

•Teach emotion regulation skills

•Construct child narrative

•Real time check-up

•Strengthen parents’ leadership roles

•Strategize for family sessions

•Share family narrative

•Practice skills

•Plan future

Psychoeducation and Skills Building

Narrative Construction Parent PlanningNarrative Sharing & Skills Practice

Community and Leadership Briefs

Educational Workshop

Provider Consultation

Skill Building Group

Family Consultation

Individual Family

Resiliency Training

FOCUS Suite of Services: Public Health Strategy for Implementation

prev

entio

nUniversal

Indicated

Personnel Outreach and Engagement II

5. Personnel selection and training.

6. Framing and positioning of services

7. Data management and evaluation strategies.

8. Network of well supported team leaders and resiliency trainers in close communication with each other and other teams.

9. Effective partnerships with active duty personnel at multiple levels and with other military caregiving professionals on each base.

10. Effective core leadership of overall project

BUMED FOCUS Project Siteswww.focusproject.org

California MCB Camp Pendleton MCAGCC Twentynine Palms Naval Base Ventura County Naval Base San Diego NSW/EOD West

Hawaii MCB Hawaii Joint Base Pearl Harbor-Hickam Schofield Barracks Wheeler Army Airfield

Japan MCB Okinawa Kadena AB Torii Station

Mississippi

Naval CBC Gulfport Keesler Air Force Base Camp Shelby

North Carolina MCB Camp Lejeune

Virginia MCB Quantico NAVSTA Norfolk NSW/EOD East

Washington NAS Whidbey Island Joint Base Lewis-McChord

Community Outreach and Education

Events Enrollment

Community/ Group Briefings 6,267 308,423

FOCUS Workshops 1855 41,451

FOCUS Consultations 2,004 4,623

FOCUS Skill BuildingGroups

2,707 23,773

FOCUS Family Resiliency Training

Multi Session Training

5,510 Adults* 5,310 Children

Participation in FOCUS Suite of Services 2008-2012

*Includes all enrolled family members, including in-progress.

Perception of Change After FOCUS Family Resiliency

Training

Understanding combat operational stress reactions

Emotional regulation

Parent-child communications

Family goal setting

Management of stress reminders/triggers

Family support/strength enhancement

1.00 2.00 3.00 4.00 5.00 6.00 7.00

Service Members Civilian Parents

Less than before

Same as before

Much more than before

Estimated Time Trends Parent Outcomes

Visit

Est

imat

e

0.2

0.3

0.4

0.5

0.6

0.7

Pre Exit FU1 FU2

ANX DEP

GSI

Pre Exit FU1 FU2

0.2

0.3

0.4

0.5

0.6

0.7

SOMGlobal Severity Index Somatization

Anxiety Depression

Time Trends of Child SDQ Assessments• Study Sample:

– 1,888 children ages 3-18 were included in these analyses; 54% were boys.– 98% had the intake assessment and ≥ 1 post-intervention assessment.

• Primary Outcome Measures:– SDQ Pro-Social Behaviors– SDQ Total Difficulties

• Analytical Approach: – Same as for the adult BSI measures

• Results:– Significant reduction in the SDQ total difficulties (3.81 ± 0.16, P < .0001) and significant improvement in pro-social behaviors (0.74 ± 0.05, P < .0001) were observed.

Visit

Est

imat

e

8.0

8.5

Pre FU1 FU2

PS

Visit

Est

imat

e8

9

10

11

12

Pre FU1 FU2

TDS

Pro-Social Behaviors

Total Difficulties

FOCUS Adaptations

FOCUS Couples

FOCUS Early Childhood

Wounded Warrior

Purple Implementatio

n

FOCUS World

Partnerships

FOCUS World: Online Resiliency Training

FOCUS Core ElementsFOCUS Family Resilience Training

FOCUS Family Resilience Training for Wounded, ill & injured

FOCUS – Early Childhood

Core Elements Key Characteristics (Activities/Delivery) for Target PopulationsFamily Psychological Health Check-in to assess areas of challenge

Assessment includes core symptom clusters, caregiver burden, functional assessment

Assessment tailored to accommodate young children.

Family specific psycho-education to support informed parenting

Content tailored to highlight injury communication.

Content tailored to accommodate young children.

Family narrative timeline to promote perspective taking and meaning making

Timeline anchored to key experiences in injury recovery chain of events for all family members

Tailored to incorporate age appropriate play and parent-child interactions.

Family level skills tailored to the needs of participants

Sessions, pacing & skill training tailored to accommodate needs & capacity of injured.

Tailored to be age and developmentally appropriate; focus on promoting those skills.

Core Principles Across Projects

Self-understanding and shared understanding

Individual and shared narratives.

Self care and shared support

Long-term commitment to long-term partnerships - several years at a minimum

Shared values

Envisioning the Future

1. Families and children have ready access to the best available evidence-based preventive interventions delivered in their own communities in a culturally competent and respectful (nonstigmatizing way).

2. Services are coordinated and integrated with multiple points of entry for children and their families (e.g., schools, health care settings, and youth centers).

3. Families are informed that they have access to resources when they need them without barriers of culture, cost, or type of service.

4. Families and communities are partners in the development and implementation of preventive interventions.

5. The development and application of preventive intervention strategies contribute to narrowing rather than widening health disparities in individuals and families.

“Ours was a profoundly shared mission. Throughout our work, we came to have an enormous admiration for the courage and

remarkable strengths of personnel and families. The service members, their caregivers and the

families themselves became our partners in intervention development and in understanding

how to help other families. We are deeply grateful to them.”

US Navy Bureau of Medicine and Surgery

UCLA Semel Institute for Neuroscience and Human Behavior