Folie à Famille: A Family Therapist's Perspective

Over the last century there have been reports in the psychiatric journals of an unusual disorder, folie ä famille, yet the syndrome has been neglected by family theorists. In this paper the literature on delusions shared by families is examined from the perspective of a family therapist. The role the disorder plays in defining the continuum of functional/dysfunctional shared familial beliefs is described, and a case example demonstrating that folie ä famille may be underreported is presented.     

Lessons for an Outsider:A Family Therapist's Experience in Bolivia

This is a reflection on cross-cultural therapy from the perspective of a practitioner and trainer who is an outsider to the culture in which she is working. The context is work in Bolivia. The therapist's own position, the process of interaction and the influences on the family of its context are considered. Cultural notes are provided to highlight what an outsider may represent, and the legitimacy of his involvement and intervention in family situations. Themes frequently encountered in therapy are reviewed including jealousy, violence and the changing societal relationship between men and women. The usefulness of getting to know the cultural background of such themes, including the possibility of exploring them anew in therapy, is examined. Finally, a case study is presented related to the themes which also illustrates the adaptation of process to fit patient's culturally related expectations.     

Bipolar Disorder and the Family: An Integrative Model

The relationship between major mental illness and the family is complex. This article describes a model that recognizes biological, individual, and familial aspects of illness, and the interaction and reciprocal effects of these different levels. This model is illustrated using the example of bipolar illness, with particular emphasis on the effects of the illness on the family. Many characteristics previously noted in bipolar families can be understood as consequences, rather than causes, of the illness. A framework for integrated treatment is also described.     

Family Focused Treatment for Patients with Bipolar Disorder in Turkey: A Case Series

Family-focused therapy (FFT) is a 9-month, 21-session structured psychoeducational treatment for bipolar disorder. Several US-based studies have documented its efficacy as adjunctive to medication for depression stabilization and relapse prevention. However, FFT has never been applied outside of the United States. The objective of this case series is to explore the applicability of FFT in a non-Western culture. Ten patients with bipolar disorder and their family members attended the 9-month FFT as adjunctive to pharmacotherapy in an outpatient specialty clinic in Izmir, Turkey. Patients improved in Global Assessment of Functioning Scores and Clinical Global Impression Scores from pre- to posttreatment. Case studies are given, which illustrate the differences between Western and non-Western families coping with bipolar disorder. FFT was easily applied to a Turkish sample with few changes in format or focus. Adaptations included substitution of oral for written therapeutic tasks or homework assignments. Randomized controlled trials are needed to test the clinical effectiveness of FFT and other psychosocial interventions in non-Western cultures.     

An Occupational Therapist's Interdisciplinary Approach to a Geriatric Psychiatry Activity Group: A Case Study

Occupational therapy has long recognized the usefulness of activity groups to promote functional outcomes for clients in mental-health settings. An occupational therapist used an interdisciplinary approach (working with a psychiatric nurse practitioner and a manual arts therapist) to conduct a biweekly geriatric psychiatry activity group. A case study is presented to demonstrate the success and longevity of the interdisciplinary activity group. Each clinician contributed unique skills to provide occupation which provided positive outcomes for the clients. Practically, the employing of different disciplines allowed group coverage for each other in times of cost-containment and limited resources.     

Evaluating Therapist Competency and Adherence to Behavioral Family Management with Bipolar Patients

The present study assessed fidelity to the behavioral family management (BFM) model for treating bipolar disorder patients and their families. The BFM Therapist Competency/Adherence Scale (BFM-TCAS) was developed to evaluate clinicians' competency and adherence to BFM, as outlined by Miklowitz' (1989) BFM Manual for use with bipolar patients. Therapist competency and treatment adherence was also evaluated with regard to two family characteristics: overall level of family difficulty and family expressed emotion (EE) status. The BFM-TCAS was used to code 78 videotaped sessions of 26 families with a bipolar member, selected from a larger treatment study of bipolar disorder patients. The findings suggest that, overall, clinicians adhered closely to the BFM manual. Specific areas in which there was high competency and treatment adherence were (a) skill in conveying factual information about bipolar illness, (b) establishment of a therapeutic environment, and (c) ability to take command of therapy sessions. The one area in which there was less compotency and relatively weak adherence to the manual was the use of between-session homework assignments to assist families in mastering the BFM exercises. Results of this study also suggest that, for the most part, therapist competency and adherence ratings were not related to overall level of difficulty or to family EE status.     

Sorrow: A Therapist's Reflection on the Inevitable and the Unknowable

People who live with a painful gap between who they have been and who they are now, of who they dreamt themselves to be and who they still long to be, are living with chronic sorrow. Chronic sorrow is a normal, nonpathological state of pervasive, continuing, periodic, and resurgent sadness related to the ongoing losses associated with illness and disability, in this case not loss of an other, but loss of self (Roos, 2002). Focusing on the lives of four women, one of whom committed suicide, I explore the macroprocesses that invade the experience of even so personal an experience as self‐loss. The role of the therapist is made transparent through anecdotes and by discussing implications for clinical practice.     

A Witness Breaks His Silence: The Meaning of a Therapist's Response to an Adolescent's Self-Destruction

I describe the case of a self-mutilating adolescent girl and my dilemma, as her therapist, about telling her parents about her self-abuse. I use two complementary, mutually enhancing relational theories of trauma—Ferenczi's (1933) and Davies and Frawley's (1994)—to help understand the minefield I was in. Davies and Frawley describe certain relational configurations that are typical of trauma victims. I believe that it is not only unavoidable but therapeutically vital for therapists to participate in these configurations so they can know the patient's experience in a personal way. It is also crucial that they be witnesses who provide recognition for the patient's pain and, in so doing, relieve the intolerable feeling of isolation that Ferenczi proposed was the most basic trauma. In addition, I discuss the observation that some people who have not been previously traumatized in any gross way manifest characteristics of trauma.     

Preventing Mania: A Preliminary Examination of the GOALS Program

There is strong evidence of a relationship between goal dysregulation and mania. Building on these findings, we examined the feasibility of developing a mania prevention treatment program designed to improve goal regulation skills for those with bipolar disorder. Here, we describe the process of developing a manual, delivering the intervention to a series of cases, and then conducting a small open uncontrolled trial. All participants met diagnostic criteria for bipolar I disorder based on the Structured Clinical Interview for DSM-IV and were not currently experiencing episodes of depression or mania. Ten participants (8 female, mean age = 46.7 years) were enrolled in the GOALS program and completed an average of 13.2 weekly sessions. Participants were administered the Bech-Rafaelson Mania Scale (BRMS) and the Modified Hamilton Rating Scale for Depression at baseline and termination. Some participants completed self-report scales including the Altman Self-Rating Mania Scale, the Beck Depression Inventory, and the Willingly Approached Set of Statistically Unrealistic Pursuits at baseline and termination. In addition, participants were administered a consumer satisfaction questionnaire at termination. At termination, all 10 participants found the program highly relevant and helpful. Most importantly, even though levels of mania were low initially, mean levels of manic symptoms on the BRMS decreased significantly from baseline to termination, and all 10 participants were within a healthy range (BRMS < 7) at termination. Although the lack of control group or follow-up data limits this study, preliminary evidence suggests that it is feasible to identify treatment targets by drawing from the basic research literature in bipolar disorder. Findings await replication and more careful testing within a randomized controlled trial.     

Greek Thought: A Guide to Classical Knowledge

Book Information Greek Thought: A Guide to Classical Knowledge. By Jacques Bruschwig and Geoffrey, E. R. Lloyd. MA, Belnap Press. Cambridge. 2000. Pp. xv + 1024. Hardback, US$49.00.     

The Anorectic Process in the Family: A Six-Stage Model as a Guide for Individual Therapy

This article presents a conceptual framework for individual treatment with chronic anorectic patients. In the first part of the article, the six-stage model for the anorectic process developed over the past years by M. Selvini-Palazzoli and her team is briefly explained. After presenting the model, we then discuss some related concepts, namely, "family game," "rule," and "strategy." Finally, the therapeutic technique in individual treatment is discussed. Two basic assumptions underlie this technique: first, the therapeutic relationship is instrumental, its main purpose being to improve the patient's personal relations outside therapy; second, the focus of the treatment is on the strategic incapacity of the patient who is caught up in and unable to cope with the "concealed family game."     

Social Exchange Theory: Dynamics of a System Governing the Dysfunctional Family and Guide to Assessment

Examined is a social psychological model of family discordance. Theories derive in part from exchange theory and from operant principles of behavior. First reviewed are tenets of social exchange theory based in traditional systems analysis (ecosystems). Conceptually presented is how human relations are interdependent on resources of supply and demand. Family patterns are shared by unspoken rules governing givers and takers of resources, forming an imperfect market economy that balances or imbalances family life. Properties of family ecology clearly specify intervening variables contributing to family breakdown. Second, an application of social exchange theory integrates operant principles of reinforcement and punishment as predictors of family disintegration. Punishing and rewarding exchanges are explored in alcoholic families. Operant contingencies significantly magnify the inequity and nonreciprocity of love, affection, and general nurturing between parent and child. Implications are offered for clinical assessment.