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
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.
2.
3.
4.
5.
6.
7.
Taking a history
Psychoeducation and the family’s story
Seeing the children
Planning the family meeting
Holding the family meeting
One week follow-up, check-in
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.
2.
3.
4.
To reassure your children that you will be okay and that the
illness will not overwhelm the family
To emphasize that no one is guilty or to blame
To speak to the positives, the strengths that exist and will be
enhanced
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
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; familystrengthening intervention in Rwanda; webbased 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
Traumatic Stress Research:
Children and Families
Evidence Based
Prevention
Interventions
Family Resilience Models
FOCUS Resiliency
Certain
family behaviors are
Training
especially likely to be found
in resilient families
Public Health
Implementation with
COSC Model
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
Three foundational interventions:
1.

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
Partnerships
Partnerships
Training &
Adaptations
Operations
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: Individual Family Resiliency Training
Sessions 1 & 2
Parents Only
Sessions 3 & 4
Children Only
Narrative Construction
Session 5
Parents Only
Sessions 6  8
Family Sessions
Parent Planning
Narrative Sharing
& Skills Practice
•Collect family
history
•Teach emotion
regulation skills
•Strengthen parents’
leadership roles
•Share family
narrative
•Construct parent
narrative
•Construct child
narrative
•Strategize for
family sessions
•Practice skills
•Real time check-up
•Real time check-up
Psychoeducation and Skills Building
•Plan future
FOCUS Suite of Services: Public Health
Strategy for Implementation
Universal
Community and
Leadership Briefs
Educational
Workshop
Provider
Consultation
Skill Building
Group
Family
Consultation
Individual
Family
Resiliency
Training
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
www.focusproject.org

California






Hawaii





MCB Camp Pendleton
MCAGCC Twentynine Palms
Naval Base Ventura County
Naval Base San Diego
NSW/EOD West
MCB Hawaii
Joint Base Pearl Harbor-Hickam
Schofield Barracks
Wheeler Army Airfield
Japan



MCB Okinawa
Kadena AB
Torii Station

Mississippi




North Carolina


MCB Camp Lejeune
Virginia




Naval CBC Gulfport
Keesler Air Force Base
Camp Shelby
MCB Quantico
NAVSTA Norfolk
NSW/EOD East
Washington


NAS Whidbey Island
Joint Base Lewis-McChord
Participation in FOCUS Suite of Services
2008-2012
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 Building
Groups
2,707
23,773
Multi Session
Training
5,510 Adults*
5,310 Children
FOCUS Family Resiliency
Training
*Includes all enrolled family members, including in-progress.
Perception of Change
After FOCUS Family Resiliency Training
Service Members
Civilian Parents
Family support/strength enhancement
Management of stress reminders/triggers
Family goal setting
Parent-child communications
Emotional regulation
Understanding combat operational stress
reactions
1.00
Less than
before
2.00
3.00
4.00
Same
5.00
6.00
7.00
Much more
than before
Estimated Time Trends Parent Outcomes
Pre
GSI
Global Severity
Index
Exit
FU1
FU2
SOM
Somatization
0.7
0.6
0.5
0.4
0.3
Estimate
0.2
ANX
Anxiety
DEP
Depression
0.7
0.6
0.5
0.4
0.3
0.2
Pre
Exit
FU1
FU2
Visit
Time Trends of Child SDQ Assessments
Pro-SocialPSBehaviors
• Study Sample:
included in these analyses; 54% were
boys.
– 98% had the intake assessment and ≥
1 post-intervention assessment.
Estimate
– 1,888 children ages 3-18 were
8.5
8.0
• Primary Outcome Measures:
– SDQ Pro-Social Behaviors
Pre
– SDQ Total Difficulties
FU1
FU2
Visit
Total Difficulties
• Analytical Approach:
TDS
– Same as for the adult BSI measures
12
– 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.
Estimate
• Results:
11
10
9
8
Pre
FU1
Visit
FU2
FOCUS Adaptations
FOCUS
Couples
FOCUS Early
Childhood
Wounded
Warrior
FOCUS World
Purple
Implementation
Partnerships
FOCUS World:
Online Resiliency Training
FOCUS Core Elements
FOCUS Family Resilience FOCUS Family Resilience
Training
Training for Wounded, ill &
injured
Core Elements
FOCUS – Early Childhood
Key Characteristics (Activities/Delivery) for Target Populations
Family Psychological
Assessment includes core
Health Check-in to
symptom clusters, caregiver
assess areas of challenge burden, functional assessment
Assessment tailored to
accommodate young
children.
Family specific psychoeducation 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 parentchild 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