Master Class National 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 future shall 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 :Risk Assessment - Children of Parents with Mood Disorders :Resiliency Studies and Intervention Development :Pilot Comparison of Public Health Interventions :Randomized Trial Comparing Psychoeducational Family Interventions for Depression :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 history 2. Psychoeducation and the family’s story 3. Seeing the children 4. Planning the family meeting 5. Holding the family meeting 6. One week follow-up, check-in 7. 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 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 Families Who 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 The Family Connections program is available at

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 Lester Lee Klosinski William R. Beardslee William Saltzman Kirsten Woodward William Nash Catherine Mogil Robert Koffman Robert Pynoos Stephen J. Cozza Gregory 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

Chronology 1. 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 : Navy Bureau of Medicine and Surgery funded FOCUS for selected USN and USMC installations..

FOCUS Implementation 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

FOCUS Suite of Services: Public Health Strategy for Implementation Universal 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 Sites  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 EventsEnrollment Community/ Group Briefings6,267308,423 FOCUS Workshops185541,451 FOCUS Consultations2,0044,623 FOCUS Skill Building Groups 2,70723,773 FOCUS Family Resiliency Training Multi Session Training 5,510 Adults* 5,310 Children Participation in FOCUS Suite of Services *Includes all enrolled family members, including in-progress.

Perception of Change After FOCUS Family Resiliency Training

Estimated Time Trends Parent Outcomes Global Severity IndexSomatization AnxietyDepression

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. Pro-Social Behaviors Total Difficulties

FOCUS Adaptations Partnerships

FOCUS World: Online Resiliency Training

FOCUS Core Elements FOCUS Family Resilience Training FOCUS Family Resilience Training for Wounded, ill & injured FOCUS – Early Childhood Core ElementsKey Characteristics (Activities/Delivery) for Target Populations Family 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