A Community‐Responsive Adaptation to Reach and Engage Latino Families Affected by Maternal Depression

As family researchers and practitioners seek to improve the quality and accessibility of mental health services for immigrant families, they have turned to culturally adapted interventions. Although many advancements have been made in adapting interventions for such families, we have yet to understand how the adaptation can ensure that the intervention is reaching families identified to be in greatest need within a local system of care and community. We argue that reaching, engaging, and understanding the needs of families entails a collaborative approach with multiple community partners to ensure that adaptations to intervention content and delivery are responsive to the sociocultural trajectory of families within a community. We describe a cultural adaptation framework that is responsive to the unique opportunities and challenges of identifying and recruiting vulnerable families through community partnerships, and of addressing the needs of families by incorporating multiple community perspectives. Specifically, we apply these principles to the cultural adaptation of an intervention originally developed for low‐income African American and White families facing maternal depression. The new intervention, Fortalezas Familiares (Family Strengths), was targeted to Latino immigrant families whose mothers were in treatment for depression in mental health and primary care clinics. We conclude with key recommendations and directions for how family researchers and practitioners can design the cultural adaptation of interventions to be responsive to the practices, preferences, and needs of underserved communities, including families and service providers.     

Cultivating Resilience in Families Who Foster: Understanding How Families Cope and Adapt Over Time

Families who foster offer essential care for children and youth when their own parents are unable to provide for their safety and well‐being. Foster caregivers face many challenges including increased workload, emotional distress, and the difficulties associated with health and mental health problems that are more common in children in foster care. Despite these stressors, many families are able to sustain fostering while maintaining or enhancing functioning of their unit. This qualitative study applied an adaptational process model of family resilience that emerged in previous studies to examine narratives of persistent, long‐term, and multiple fostering experiences. Data corroborated previous research in two ways. Family resilience was again described as a transactional process of coping and adaptation that evolves over time. This process was cultivated through the activation of 10 family strengths that are important in different ways, during varied phases.     

Providing therapy to children and families in foster care: a systemic-relational approach

Foster care is a system created to protect children from an unsafe home environment yet multiple foster home placements, conflictual or nonexistent relationships between foster parents and birth parents, long, drawn out court battles, and living in an on-going state of not knowing when or if they will be going home are just some of the challenges many children in care are expected to manage. This paper presents a guide for therapists working with families involved in foster care. Utilizing ideas from the postmodern therapies and structural family therapy, suggestions will be provided about who needs to talk to whom about what, when to have these necessary conversations, and how to talk to people in a way that mobilizes adults to take action for the children, with the goal of minimizing postplacement trauma, strengthening and repairing relational bonds, and moving children out of foster care and into permanent homes as quickly as possible.     

Global Mental Health: A Call for Increased Awareness and Action for Family Therapists

Global mental health (GMH) is an emerging field that focuses on the need for culturally sensitive mental health services in low‐ and middle‐income countries (LMICs). While many new initiatives have been established worldwide to understand GMH needs and to provide care in LMICs, family therapists have primarily worked with families in high‐income countries. The few existing family‐based initiatives in GMH focus on psychoeducation and are typically not based on general systems theory. However, emerging trends in family therapy may enable family therapists to impact mental health issues in LMICs. These trends, which are shared interests of both family therapy and GMH, include collaborative care, a growing emphasis on the importance of culture in understanding and treating mental health issues, recognition of the ability of families to support or impede recovery from mental illness, and the use of strength‐based and evidence‐based treatments. This paper describes ways for family therapists to become active in the GMH community.     

Collaborative helping maps: a tool to guide thinking and action in family-centered services

This article highlights "disciplined improvisation" as a metaphor for community-based work with multi-stressed families. It introduces Collaborative Helping maps as a tool that both helps workers think their way through complex situations with families and provides a structure to support constructive conversations between workers and families about challenging situations. The article illustrates this map through a clinical vignette and uses interviews with workers to highlight ways in which the map can both enhance worker thinking and support constructive conversations between workers and families about problems that could easily divide them and lead to polarization and escalating tension.     

Integrated,Family‐based,Partial Hospital Treatment for Complex Pediatric Illness

This paper describes a unique treatment program for complex pediatric illness. The Hasbro Children's Partial Hospital Program uses a family systems orientation, integrated care, and a partial hospital setting to treat children with a wide range of pediatric illnesses that have failed outpatient and inpatient treatments. We have treated more than 2000 children with at least 80 different ICD‐9 diagnoses. The multidisciplinary treatment team functions as a meta‐family for children and their families who present with illness and family beliefs that impede successful outcomes with standard care. The three features: family systems orientation, integrated care, and partial hospital setting, hopefully interact to create an environment that helps families expand and modify their explanatory models regarding participating in effective medical care. The goal of treatment is for both children and their parents to feel empowered to take control of the illness. Parents completing standardized measures at intake describe their children and families as experiencing significant emotional distress, low levels of general family functioning, and poor quality of life. Although the children are described as having distinct behavioral differences, the families are described as responding to the experience of a seriously ill child in similar ways. A treatment program that addresses the noncategorical aspects of how families respond to illness while addressing the specific diseases of the children can allow children and their families to respond favorably to treatment.     

The marriage checkup: increasing access to marital health care

Despite the ongoing prevalence of marital distress, very few couples seek therapy. Researchers and clinicians have increasingly been calling for innovative interventions that can reach a larger number of untreated couples. Based on a motivational marital health model, the Marriage Checkup (MC) was designed to attract couples who are unlikely to seek traditional tertiary therapy. The objective of the MC is to promote marital health for as broad a population of couples as possible, much like regular physical health checkups. This first paper from the largest MC study to date examines whether the MC engaged previously unreached couples who might benefit from intervention. Interview and survey data suggested that the MC attracted couples across the distress continuum and was perceived by couples as more accessible than traditional therapy. Notably, the MC attracted a substantial number of couples who had not previously participated in marital interventions. The motivational health checkup model appeared to encourage a broad range of couples who might not have otherwise sought relationship services to deliberately take care of their marital health. Clinical implications are discussed.     

Understanding autism: how family therapists can support parents of children with autism spectrum disorders

The number of children diagnosed with an Autism Spectrum Disorder has increased dramatically in the last 20 years. Parents of children with autism experience a variety of chronic and acute stressors that can erode marital satisfaction and family functioning. Family therapists are well-suited to help parents stay connected to each other as they create a "new normal." However, family therapists need updated information about autism, and they need to understand how family therapy can help parents of children with autism. Because having a child with autism affects multiple domains of family life, this paper explores how family therapists can utilize an integrative approach with parents, enabling them to flexibly work with the domains of action, meaning, and emotion.     

Diagnoses,Relational Processes and Resourceful Dialogs: Tensions for Families and Family Therapy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM‐5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths‐based orientations, many tensions can follow when use of the DSM‐5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM‐5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.     

A Multi‐Family Group Intervention for Adolescent Depression: The BEST MOOD Program

Depression is the most common mental disorder for young people, and it is associated with educational underachievement, self‐harm, and suicidality. Current psychological therapies for adolescent depression are usually focused only on individual‐level change and often neglect family or contextual influences. The efficacy of interventions may be enhanced with a broader therapeutic focus on family factors such as communication, conflict, support, and cohesion. This article describes a structured multi‐family group approach to the treatment of adolescent depression: Behaviour Exchange Systems Therapy for adolescent depression (BEST MOOD). BEST MOOD is a manualized intervention that is designed to address both individual and family factors in the treatment of adolescent depression. BEST MOOD adopts a family systems approach that also incorporates psychoeducation and elements of attachment theories. The program consists of eight multifamily group therapy sessions delivered over 2 hours per week, where parents attend the first four sessions and young people and siblings join from week 5. The program design is specifically aimed to engage youth who are initially resistant to treatment and to optimize youth and family mental health outcomes. This article presents an overview of the theoretical model, session content, and evaluations to date, and provides a case study to illustrate the approach.     

Preparing the Field for Feasibility Testing of a Parenting Intervention for War‐Affected Mothers in Northern Uganda

In this article, we discuss the successful implementation of an adapted evidence‐based parenting intervention for families affected by two decades of war in Northern Uganda. The adaptation and adoption of such interventions to support mental health and family functioning is widely endorsed by prevention scientists and considered a priority in global mental health. The preparation and early adoption phases of engaging with a highly vulnerable community affected by war trauma are documented in this paper along with a discussion of the steps taken to adapt a parenting intervention for cultural and contextual fit. This study is a component of an overall program of research aimed at reducing the long‐term negative effects of war on parenting practices and childhood outcomes, which have considerable implications for preventing mental, neurological, and substance‐use disorders. The processes described here cover a 4‐year period culminating in the implementation of the nine‐session Enhancing Family Connection intervention piloted with a group of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility results promising for further testing the intervention.     

Pathways of Risk and Resilience: Impact of a Family Resilience Program on Active‐Duty Military Parents

Over the past decade, studies into the impact of wartime deployment and related adversities on service members and their families have offered empirical support for systemic models of family functioning and a more nuanced understanding of the mechanisms by which stress and trauma reverberate across family and partner relationships. They have also advanced our understanding of the ways in which families may contribute to the resilience of children and parents contending with the stressors of serial deployments and parental physical and psychological injuries. This study is the latest in a series designed to further clarify the systemic functioning of military families and to explicate the role of resilient family processes in reducing symptoms of distress and poor adaptation among family members. Drawing upon the implementation of the Families Overcoming Under Stress (FOCUS) Family Resilience Program at 14 active‐duty military installations across the United States, structural equation modeling was conducted with data from 434 marine and navy active‐duty families who participated in the FOCUS program. The goal was to better understand the ways in which parental distress reverberates across military family systems and, through longitudinal path analytic modeling, determine the pathways of program impact on parental distress. The findings indicated significant cross‐influence of distress between the military and civilian parents within families, families with more distressed military parents were more likely to sustain participation in the program, and reductions in distress among both military and civilian parents were significantly mediated by improvements in resilient family processes. These results are consistent with family systemic and resilient models that support preventive interventions designed to enhance family resilient processes as an important part of comprehensive services for distressed military families.     

Relationships,Environment, and the Brain: How Emerging Research is Changing What We Know about the Impact of Families on Human Development

Recent research is providing family therapists with new information about the complex interaction between an individual's biological makeup and his/her social and physical environment. Family and social relationships, particularly during sensitive periods early in life, can affect a child's biological foundation. Additionally, stress during the early years can have a lasting effect on an individual's physical and mental health and contribute to the onset of severe mental illness. Community programs have been developed to intervene early with families who have an at‐risk child to prevent or minimize the onset of mental illness including providing partnerships with at‐risk mothers of infants to shape attachment relationships. Programs are also developing individual and family interventions to prevent the onset of psychosis. Practicing family therapists can incorporate emerging neuroscience and early intervention research and leverage the growing base of community programs to enhance the effectiveness and sustainability of mental health outcomes for clients. Additionally, family therapy education programs should broaden student training to incorporate the growing body of information about how family relationships affect individual mental health development.     

A narrative evaluation of a psychoeducation and a therapeutic alliance intervention for parents of persons with a severe mental illness

Most attempts to study the impact of psychosocial interventions on parents of persons with severe mental illness (SMI) are quantitative. The purpose of the present study was to investigate the subjective experience of parents of persons with SMI who participated in either a psychoeducational intervention which emphasized providing information on the illness and support, or a therapeutic alliance focused intervention (TAFI) which emphasized the alliance between the group members and group leaders. Ninety-three parents, who participated in either one of these two interventions, were interviewed using the Narrative Evaluation of Intervention Interview. Results show that participants found both interventions to be beneficial with no statistical differences in the level of perceived change. Themes describing change in relating to illness were significantly more frequently mentioned by participants in the TAFI group, whereas significantly more participants in the family psychoeducation interventions reported that implementation and information provided contributed to positive change. Also participants in the TAFI reported significantly more often that group regulation contributed to change. As both interventions were perceived as contributing, the findings support the relationship orientation to psychosocial interventions, which stresses the quality of the social support and interpersonal interaction as the source of positive outcomes of intervention.     

Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families

Families of gender nonconforming children need to negotiate the interactions between two gender systems: a rigid gender binary imported from familial, social, and cultural experiences and a fluid gender spectrum articulated by their child. This article reviews parental reactions to nonconforming gender developments and poses that the parental mandates of protection and acceptance are problematized by the difference of gender norms between the child and the family, as well as the child and the environment. Through multiple therapeutic modalities-parental coaching and education, parent support group, and child and family therapy-the author illustrates interventions supporting both parents and prepubescent children in their negotiation of safety, connection, and fluidity. Case vignettes illustrate the method in action.     

Couples' cultural values, shared parenting, and family emotional climate within Mexican American families

This study tested a model of shared parenting as its centerpiece that incorporates cultural values as predictors and family emotional climate as the outcome variable of interest. We aimed to assess the predictive power of the Mexican cultural values of familismo and simpatia over couples' shared parenting practices. We anticipated that higher levels of shared parenting would predict family emotional climate. The participants were 61 Mexican American, low income couples, with at least one child between 3 and 4 years of age, recruited from a home-based Head Start program. The predictive model demonstrated excellent goodness of fit, supporting the hypothesis that a positive emotional climate within the family is fostered when Mexican American couples practice a sufficient level of shared parenting. Empirical evidence was previously scarce on this proposition. The findings also provide evidence for the role of cultural values, highlighting the importance of family solidarity and avoidance of confrontation as a pathway to shared parenting within Mexican American couples.     

What the family brings: gathering evidence for strengths-based work

Families attending child and adolescent mental health (CAMH) services are often assumed to have problems in key areas such as communication, belonging/acceptance and problem-solving. Family therapy is often directed towards addressing these difficulties. With increasing emphasis in family therapy and human services fields over the last decade on identifying and building from strengths, a different starting point has been advocated. This paper describes a large survey of the self-reported pre-therapy functioning of children and families using a public CAMH service (n=416). Before commencing family therapy parents identified family strengths across a range of key areas, despite the burden of caring for children with moderate to severe mental health problems. This evidence supports theoretical and clinical work that advocates a strengths perspective, and highlights how resilience framed in family (and social) rather than individual terms enables a greater appreciation of how strengths may be harnessed in therapeutic work.     

Speaking of privilege: family therapy educators' journeys toward awareness and compassionate action

This study explores how family therapy educators from privileged social locations understand issues of privilege and the process by which they integrate their personal and professional journeys to create and model equity in family therapy training and professional development. These educators developed awareness about issues of privilege and oppression and owned their privilege. Increased awareness involved personal struggles with guilt and managing internalized voices of prejudice that are constantly reinforced in society. These educators adopted a stance of action and accountability for equity. We hypothesize that the process leading to owning one's privilege involves the ability to be compassionate for others' suffering and one's own limitations.     

Developing an outcome-based assessment for family therapy training: the Rochester Objective Structured Clinical Evaluation (ROSCE)

This paper addresses a growing need for cost-effective, outcome-based assessment in family therapy training. We describe the ROSCE, a structured, evidence-informed, learner-centered approach to the assessment of clinical skills developed at the University of Rochester Medical Center. The ROSCE emphasizes direct observation of trainees demonstrating clinical competencies. The format integrates both formative and summative assessment methods. It can readily be adapted to a wide variety of educational and training settings.