Master ClassNational Harbor, Maryland
8 July 2013
William R. Beardslee, MDDepartment 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 shift2. Mental health and physical health are
inseparable3. Successful prevention is inherently
interdisciplinary4. Mental, emotional, and behavioral disorders
are developmental 5. Coordinated community level systems are
needed to support young people6. 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 MeetingFour 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 families3. Large scale approaches – collaborations in
Finland, Holland, and Australia4. Head Start – Program for parental adversity /
depression5. Blackfeet Nation – Head Start – Family
Connections
Different Implementations of the Family Talk Approach
(continued)
6. Costa Rica7. 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 Planning Narrative 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 services7. 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