Family Therapy and
Mental Health
University of Guelph
Open Learning and Educational
Support
Review
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
Comments from last class
Questions about assignments
2
Day Three – Agenda
1.
2.
3.
4.
5.
6.
Panic Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
Lunch
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
3
Presentation

Panic Disorder – Purple
4
Anxiety Disorders
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Fear: emotional response to real or perceived
imminent threat
Anxiety: anticipation of future threat
Fear
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Autonomic arousal: fight or flight
Thoughts of immediate danger
Escape Behaviours
Anxiety

Muscle tension, vigilance, avoidant behaviours
Developmentally Normal Fears
Age
Normal Fear
Birth- 6 Months
Loud noises, loss of physical support,
rapid position changes, rapidly
approaching other objects
7-12 Months
Strangers, looming objects,
unexpected objects or unfamiliar
people
1-5 Year
Strangers, storms, animals, dark,
separation from parents, objects,
machines loud noises, the toilet
6-12 Year
Supernatural, bodily injury, disease,
burglars, failure, criticism, punishment
12-18
Performance in school, peer scrutiny,
appearance, performance
Developmentally Abnormal
Fears
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Separation Anxiety Disorder
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Excessive distress about separation
Excessive worry about losing attachment figure
Reluctance to go out or be alone
Refusal to sleep w/o attachment figure
Nightmares about separation
Physical symptoms
4 weeks (children), 6 months (adults)
7
Specific Phobia
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Fear or anxiety about a specific object or
situation
The object/situation almost always provokes
fear/anxiety
Actively avoided or endured with intense
fear/anxiety
Out of proportion to actual danger
6 months or more
8
Anxiety Disorders
Prevalence

From: The Anxious Brain, M. Wehrenberg & S.
Prinz, 2007:
 Nearly 26% of adult Americans suffer from
anxiety in a given year:
 6.8% Social Anxiety Disorder
 3.1% Generalized Anxiety Disorder
 2.7% Panic Disorder
Anxiety Disorders
Comorbidities

Panic disorder:
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25% also have GAD
15-30% also have SAD
10-20% also have specific phobia
8-10% also have OCD
50% with PD and GAD also have depression
Panic Disorder
Assessment & Treatment
Panic Disorder

Abrupt surge of intense fear with four of
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Palpitations, sweat, trembling
Shortness of breath, choking
Chest discomfort, nausea
Dizziness, chills, tingling
De-realization/depersonalization
Fear of losing control
Fear of dying
13
Panic Disorder

At least one attack followed by at least one
month of one or both of
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Worrying about additional panic attacks
Maladaptive behaviour to avoid panic attacks
14
Agoraphobia
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Marked fear or anxiety about two or more:
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Using public transportation
Being in open spaces/enclosed spaces
Standing in line or being in a crowd
Being outside of the home alone
Thoughts that escape might be difficult or
embarrassing situation might occur
Situation(s) almost always provoke fear/anxiety
Avoidance, companion, or extreme discomfort
Out of proportion to the situation
Six months or more
15
Panic Disorder
(C. Padesky, 2011)
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Catastrophic misinterpretation of physical
and mental sensations
Seems to come out of nowhere → avoidance
Panic attack ≠ panic disorder

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Rule out medical conditions
For PD to develop:
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Vigilance for sensations
Avoid situations that evoke sensations
Use of safety behaviours
Panic Disorder
(C. Padesky, 2011)

Assessment
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Choose recent, specific attack
Identify sensations then review in detail
Thoughts & images
What was the worst thing that could have
happened?
Use their words
What would’ve happened if you couldn’t get out?
Panic Disorder
(C. Padesky, 2011)

Hypothetical model:
trigger → sensations → automatic thoughts
→ emotions → sensations → focus on
sensations → interpretation of sensations →
catastrophic misinterpretation → PANIC
Panic Disorder
(C. Padesky, 2011)

Treatment

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Need to induce sensations (goal: “take the fear
out of panic”)
Alternative explanation for sensations
Differentiate between uncomfortable vs. fatal
Medication may be contra-indicated re. therapy
Do the induction, no safety behaviours, continue
until anxiety goes down
Less than 10% relapse after 2 yrs.
Panic Disorder
(C. Padesky, 2011)
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Guidelines for Interoceptive Exposure
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Practices should be planned, structured,
predictable
Identify and challenge avoidance strategies
Ritual prevention
Use SUDs to rate fear throughout practice
Practices should be repeated frequently
Fighting fear vs. allowing fear to happen (Reid
Wilson – “love the mat”)
Panic Disorder
(C. Padesky, 2011)
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Symptom Induction Exercises
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Shake head from side to side for 30 sec.
Hold breath for as long as possible
Breathe through a straw for 2 min.
Overbreathe (hyperventilate) for 60 sec.
Spin in a swivel chair for 30 sec.
Tense every muscle in your body for 1 min.
Jog on the spot for 2 min.
Stare at a light for 2 min.
Stare at someone’s mouth while they talk for 3 min.
Panic Disorder
(C. Padesky, 2011)

Steps for Interoceptive Exposure
1.
2.
3.
4.
5.
Present the rationale.
Assess for medical problems that might affect
the safety of certain exercises.
Conduct symptom induction testing.
Assign interoceptive exposure practices.
Combine with situational exposure.
Panic Disorder
(C. Padesky, 2011)

Usually a narrow band of thoughts for PD
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No need for thought records, etc.
Focus more on sensations
Treatment: 4 – 8 sessions, 12 at the most
PD w/agoraphobia: 16 to 30 sessions
Systematic Desensitization
Create a hierarchy of exposure
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From easiest to hardest
Usually begins with imagery
Pair images with relaxation techniques
Exposure Procedure
1. Enter the situation
2. Retreat only if anxiety is “out of control”
3. Recover, then continue
Exposure Therapy

What promotes success:
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Cooperation of your partner or spouse
Willingness to tolerate some discomfort
Ability to handle the initial symptoms of panic
Ability to handle setbacks
Willingness to practice regularly
PD – Working with Families
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Psychoeducation
Assist with exposure
Identify and challenge safety/reassurance
behaviours
Assess for patterns of “Expressed Emotion”:
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High conflict, criticism, over-protection
Discuss and challenge patterns
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Assertiveness, complaints vs. criticism (e.g. Gottman),
dependency/co-dependency, caring about vs.
caring for
26
Social Anxiety Disorder
Assessment & Treatment
Social Anxiety Disorder
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Social situations, exposed to possible
scrutiny by others in peer settings
Fear of negative evaluation; fear of showing
symptoms
Almost always provoked
Avoided or endured
Out of proportion
Six months or more
28
Social Anxiety
Physiology
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Rule out medical conditions e.g. heart,
thyroid, hormone, hypoglycemia, adrenal
fatigue
Teach diaphragmatic breathing and
progressive muscle relaxation
Teach mindfulness skills
“Three deep breaths and good preparation”
SAD – Medications

More use of PRNs with SAD than others
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Need for in vivo practice
Beta blockers: Propranolol (Inderal) &
Atenolol (Tenormin)
Benzopiazepines: Clonazepam & Alprazolam
MAOIs: Phenelzine
SSRIs: Prozac
SAD – Addressing Behaviour

In Vivo exposure
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Assess social skill deficits
Social skills training for specific fears,
assertiveness, anger and conflict management
Systematic desensitization
Hierarchy of feared situations, rank order
0-100, imaginal exposure + coping skills
Hierarchy for in vivo exposure then practice
SAD – Assertive Defense of
Self (C. Padesky, 1997)
a)
b)
c)
d)
e)
f)
g)
Predict others reactions
Develop assertive responses
In session practice
Debrief and coach
Increase difficulty in session
Practice outside session
Practice, debrief, plan future behavioural
experiments
32
SAD – Assertive Defense of
Self (C. Padesky, 1997)

Client: If I try to sign my name, my anxiety will
show and I will be humiliated
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It’s true (I blush) but that doesn’t mean (I’m hiding
something)
I know (my hands are sweaty) because I get nervous
when (I meet new people)
(You might think) that’s weird (but actually) being
anxious (is quite common)
(There’s nothing to be concerned about) my hand
always shakes like that
33
SAD – Working with Families
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Family push too hard or back off completely
Help them find balance, match with client’s
skill and developmental level
Remember that negative experiences
reinforce fears
Help client negotiate practice with family
Help family manage their own anxiety
Identify and address safety and reassurance
behaviours
Generalized Anxiety
Disorder
Assessment & Treatment
Generalized Anxiety Disorder
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Excessive anxiety and worry, more days than
not, for at least 6 months, about a number of
events or activities
Difficult to control
Three or more:
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Restlessness, fatigue
Difficulty concentrating/mind going blank
Irritability, muscle tension
Sleep disturbance
36
Generalized Anxiety Disorder
(Reid Wilson, 2009)

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PD is the easiest to treat, with the best
outcome, whereas GAD is the hardest to
treat
Worry about at least two of the following:
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Minor things – 91%
Family/home – 79%
Financial – 50%
Work/school – 43%
Illness/health/injury – 14%
Generalized Anxiety Disorder
(Reid Wilson, 2009)

It’s not the content of the worry, it’s the
process that is problematic:
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They worry in order to try and prevent what they
are worrying about (to stay safe)
Chronic worry leads to procrastination
Becomes a self-perpetuating problem
Nervous system is always on guard to threat and
they don’t know what it’s like to be relaxed
GAD – Treatment
(Reid Wilson, 2009)

“If it’s worth worrying about, it’s worth
problem solving!”
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Teach them problem solving skills (turn “What
if…?” into “If…then”)
Help them make a decision w/reasonable risk and
follow through (e.g. cost/benefit analysis)
Learn how to tolerate consequences/uncertainty
Distinguish ‘signals’ from ‘noise’
Catch episodes and intervene early
Mindfulness (present focused)
GAD – Treatment
(Reid Wilson, 2009)
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Train in multiple relaxation techniques
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e.g. biofeedback, breathing, progressive muscle
relaxation, meditation, yoga, guided imagery
Help them recognize the absence of relaxation as
a cue for skills
Keep a worry log
Cognitive restructuring
Designate worry times – ‘worry free zones’

The “worry box”
Obsessive-Compulsive
Disorder
Assessment & Treatment
Presentation

Justin & Jenna
42
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Unwanted, repetitive thoughts, images or
urges (obsessions)
Repetitive behaviours that occur in response
to an obsession, to reduce anxiety
(compulsions)
Causes significant distress or impairment
Yale-Brown Obsessive-Compulsive Scale

Reduction ≥ 35% is considered success
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Obsessions:
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Contamination
Doubting (forgetting)
Aggressive
Accidentally harming others
Religious
Sexual
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Compulsions
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Washing, cleaning
Checking
Repeating actions
Repeating words, phrases, or prayers
Counting
Symmetry or exactness
Not just behaviours, can be thoughts too
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Other features
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Avoid feared situations
Varying levels of insight (poor insight = worse
prognosis)
Thought-action fusion (thought is as bad as
action)
Magical thinking
Inflated sense of responsibility (↑guilt)
Thought suppression & rituals maintain problem
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Targets for treatment
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Compulsive rituals
Avoidance of feared situations
Cognitive avoidance and thought suppression
Compulsions and safety behaviours
Requests for reassurance
Alcohol or drug use
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Exposure & Ritual Prevention (ERP)
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Considered “gold standard” psychological
treatment for OCD
Between 63 – 83% participants who complete
gain some benefit
Benefits are maintained over long-term
Exposure isn’t enough, have to prevent rituals too
Metaphor:

“Every time you do the compulsion, you’re putting gas
in the car”
Obsessive-Compulsive Disorder
(M. Antony, 2010)

Sample hierarchy
Item
Visit a cancer ward in a hospital
Shake hands with a person who has cancer
Talk to someone who has cancer
Eat in a hospital cafeteria
Walk through the halls of a hospital
Stand in front of a hospital
Read a library book about cancer
Talk to someone about cancer
Fear
100
90
75
70
60
50
40
25
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Imaginal exposure
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With clients who fear images, thoughts,
memories, or other mental stimuli
Can involve mental exposure, exposure to verbal
descriptions, or written exposure
Imagery should be multi-sensory
Record sessions and listen to them for homework
Measure success by doing, not feeling (may
be uncomfortable)
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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If preventing rituals is impossible
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Eliminate certain rituals first (based on location,
time of day, ritual content)
Delay the ritual
Shorten the ritual
Do the ritual differently (e.g. in a different order,
more quickly)
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Cognitive features of OCD
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Beliefs about responsibility
Overestimating probability and severity of danger
Overimportance of thoughts
Control of thoughts
Desire for certainty
Consequences of anxiety
Fear of positive experiences
Perfectionism
Obsessive-Compulsive Disorder
(M. Antony, 2010)
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Cognitive strategies
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Thought records
Countering probability overestimations
Countering catastrophic thinking
Responsibility pie chart (Mind Over Mood)
Challenge meta-cognitions (vs. intrusive
thoughts)
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e.g. thinking about X means that I will do it
Best-friend technique (perspective taking)
Cost-benefit analysis
Medications
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Imipramine - effective treatment of panic
Amitriptyline - chronic pain, PTSD
SSRIs, MAOIs, anticonvulsants, propranolol
Xanax (but may introduce or exacerbate
substance-abuse disorder)
in general, the drugs help with depression,
anxiety and hyperarousal
but not with avoidance, denial and emotional
numbing
(Kaplan and Sadock 1998)
54
OCD – Family Support
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Psychoeducation
Assess for safety/reassurance seeking
behaviours
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Educate
Identify patterns
Coach in responses
Assist with skills cueing/coaching
Reinforcement

“scratch the good dog, not the bad one”
55
Post-Traumatic Stress
Disorder
Assessment & Treatment
Presentation

Sarah & Geoff
57
Trauma
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Reactive Attachment Disorder
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Child rarely seeks comfort when distressed
Minimal social contact, limited positive affect,
unexplained irritability, sadness, fear
A pattern of extremes of insufficient care
Disinhibited Social Engagement Disorder
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Child is too friendly with unfamiliar adults
Not just impulsive but socially disinhibited
A pattern of extremes of insufficient care
58
Posttraumatic Stress Disorder

Exposure to actual or threatened death
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direct experience
witnessing
hearing about it (new)
repeated or extreme exposure to the details (e.g.
collecting body parts, hearing stories of child abuse)
Intrusive symptoms (one or more)
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Recurrent, involuntary, intrusive, distressing memories
Dreams
Flashbacks (dissociative reactions)
Distress from exposure to cues
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Psychological, physiological
59
PTSD, continued
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Avoidance
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Memories, thoughts, feelings
People, places, conversations, activities
Negative changes in thought and mood
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Amnesia
Persistent and exaggerated negative beliefs
Persistent distortions about cause
Persistent negative emotional state
Decreased interest in activities
Detachment
Inability to experience positive emotions
60
PTSD, continued
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Alterations in arousal
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Irritable/angry
Reckless/self-destructive
Hypervigilance
Exaggerated startle response
Problems concentrating
Sleep disturbanc
Duration > 1 month
With or w/o dissociative symptoms
61
Acute Stress Disorder
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Exposure to actual or threatened death
Nine or more:
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intrusive memories, distressing dreams
dissociative reactions
psychological distress/physiological reaction
negative mood, altered sense of reality
amnesia, avoiding thoughts/reminders
sleep disturbance, irritable mood
hypervigilance, lack of concentration
exaggerated startle response
3 days to 1 month (PTSD lite)
62
Adjustment Disorders
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Response to an identifiable stressor within 3
months
One or both
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Marked distress out of proportion
Significant impairment
Not attributable to another mental disorder
Not normal bereavement
Resolves within 6 months of stressor ending
63
PTSD – Treatment

Trauma & Recovery (2015) J. Herman
1.
2.
3.
Safety
Remembrance and mourning
Connection
64
Phase 1: Safety
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Not a linear sequence
Being prepared for hyperarousal, intrusion,
and numbing
Offer adaptive coping strategies
May not connect traumatic history with
present problems
Knowledge is power
Normal human response to extreme
circumstances
65
Phase 1: Safety
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Reframe accepting help as an act of courage
From days to weeks to months to years
Naming symptoms, daily charting
Development of concrete safety plans
Mobilizing natural support systems
Accessing self-help organizations
Begin by focusing control over the body and
gradually moving out to the environment
66
Phase 1: Safety
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Sleep, eating and exercise
Management of symptoms
Control of self-destructive behaviours
Safe living situation
Financial security
Medication
Education for loved ones on PTSD
Crisis may prompt the family to deal with
issues that have been ignored
67
Phase 1: Safety
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Assess self-soothing strategies
(e.g. self-harm)
Attending to care of victim’s children as well
Carefully explore current family relationships
re. boundary issues
“Without freedom, there can be no safety and
no recovery” (p. 172)

May have to give up everything else for freedom
68
Phase 1: Safety
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“Recovery, like a marathon, is a test of
endurance” (p. 174)
Shift to phase 2:
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Client no longer feels completely vulnerable and
isolated
Confidence in the ability to protect self
Knows how to control most symptoms
Knows on whom to rely for support
69
Phase 2:
Remembrance & Mourning
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Tell the story of the trauma – in detail
Reconstruction transforms traumatic memory
so it can be integrated
Therapist is witness and ally
“Speak the unspeakable”
Balance need for safety with need to face the
past
Avoiding leads to stagnation of recovery
70
Phase 2:
Remembrance & Mourning
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Monitor intrusive symptoms
Review client’s life before the trauma
Reconstruct the traumatic event as a
recitation of fact first
Narrative must include vivid description of
traumatic imagery – “like watching a movie”
Goal is to put story (including imagery) into
words
Recollection without affect produces no result
71
Phase 2:
Remembrance & Mourning
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Systematic review of the meaning of the
event
Articulate values and beliefs that the trauma
destroyed
Examine guilt and responsibility
Normalize client’s responses
Construct new interpretation of the event
affirming dignity and value of survivor
Make no assumptions
72
Phase 2:
Remembrance & Mourning
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“The more I talk about it, the more I have
confidence that it happened, the more I can
integrate it” (p. 179)
Living with ambiguity – may not have
complete knowledge
Be a witness, not a detective
“The goal of recounting the trauma is
integration, not exorcism” (p. 181)
73
Phase 2:
Remembrance & Mourning
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In the telling, the trauma story becomes a
testimony – a ritual of healing
Context, facts, emotion, and meaning
Produces a change in the abnormal
processing of the traumatic memory
View photographs, construct a family tree,
visiting sites of childhood experiences
Flashbacks and nightmares are also helpful
Leave time in session for decompression
74
Phase 2:
Remembrance & Mourning
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Trauma inevitably brings loss
Fear of grieving
Reframe mourning as an act of courage vs,
humiliation
Reclaiming the ability to feel is an act of
resistance
The revenge fantasy
Moving to quick to forgiveness – bypassing
anger
75
Phase 2:
Remembrance & Mourning
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“Mourning is the only way to give due honour
to loss” (p. 190)
Hope is in the ability to form loving
connections
Second stage has a timeless quality, but will
not go on forever
Shift to stage 3:

Renewed hope and energy for engaging with life
76
Phase 3: Reconnection

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Creating a future
Develop a new self, new relationships
Taking risks, engaging fears
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Attempts to master the traumatic experience
Disciplined, controlled challenges to fear;
learn how to live with it
Breaking the silence, challenge family secrets
How the family responds is immaterial; the
goal is telling the truth
77
Phase 3: Reconnection
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To become the person you want to be –
reinvent yourself
Letting go, self-forgiveness, acceptance, selfcompassion
Identifying positive aspects of the traumatic
experience
Feeling autonomous and being connected
(i.e. differentiation)
78
Phase 3: Reconnection


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
Ready for greater intimacy, incl. sexual
intimacy
Social action – public truth-telling
Taking public action against perpetrator
Resolution of the trauma is never final

Symptoms may re-occur under stress
79
Phase 3: Reconnection

Criteria for resolution (Mary Harvey, 1990)
1.
2.
3.
4.
5.
6.
7.
Physiological symptoms are within manageable
limits
Able to bear feelings associated with trauma
Person has authority over memories – can
remember or put aside
Memory is a coherent narrative, linked with
feelings
Self-esteem has been restored
Important relationships have been re-established
Has a coherent system of meaning and belief
that incorporates story of the trauma
80
Closing


Q&A
Evaluations for Day 3
81