Clínica Dr. Carlos Durán Cartín

1. Clínica Dr. Carlos Durán Cartín Proyecto: “Apoyo a las familias con situaciones de depresión parental”

2. Marco de referencia • Clínica Dr. Carlos Durán Cartín • Centro de atención ambulatoria primaria y especializada • Población adscrita de 123.544 habitantes • Recurso básico de salud mental: • 1 médico- psiquiatra • 1 psicóloga • 3 trabajadoras sociales • Recurso de apoyo • 1 médico pediatra • 1 médico general

3. Grupo etario Curativas Promoción Rehabilitación Docencia Evaluaciones psicométricas con aplicación de pruebas Niño/as Clínica para la evaluación de trastornos del desarrollo Escuelas para padres Adolescentes Comisión para la atención de adolescentes Escuelas para padres Historias longitudinales Talleres (Técnicas de relajación Acondiciona- miento físico, manualidades) • Consulta individual • Psicoterapia grupal • Psicoterapia grupal adicciones • Clínica de adicciones (consulta individual) Adultos Grupos de autoayuda Marco de referencia • Modelo de atención que inicia su organización y desarrollo desde 1999 • Investigaciones de tipo exploratorio (niños, adicciones) Centro Diurno

4. Psicología Interdisciplinarias Psiquiatría Trabajo Social APSI Atención psicológica individual AINAD Atención interdisc. de adolescentes AIPSQ Atención psiquiátrica individual ACTSO Atención comunal por T.Social # atenciones #atenciones #atenciones PGPSI Psicoterapia grupal por psicóloga AINNI Atención interdisciplinaria de niños #intervenciones PGPSQ Psicoterapia grupal por psiquiatra # atenciones AGTSO Atención grupal por T.Social #atenciones AINAA Atención interdisciplinaria adicciones #atenciones EAPSI Evaluación con aplicación pruebas #intervenciones AEPSQ Atención psiquiátrica emergencias AITSO Atención individual por T.Social # evaluaciones #atenciones AICRI Atención interdisciplinaria de crisis SOPSI Salud ocupacional por psicóloga #atenciones #intervenciones #atenciones AAPSQ Atención adicciones por psiquiatra #atenciones CUTSO Capacitación de usuarios T. Social EINI Evaluación interdisc. de incapacidad LAPSI Psicología laboral #atenciones #intervenciones CAPSQ Capacitación y docencia # atenciones CATSO Capacitación de funcionarios T. Soc. #horas AINED Educación para la salud #horas AVPSI Atención víctimas de violencia #intervenciones #horas #atenciones AINNA At. interdisc. comité de niño agredido CAPSI Capacitación y docencia #atenciones #horas Tipificar las actividades incluidas en el programa de salud mental - (febrero 2003) Resultados

5. Resultados Tipificar las actividades incluidas en el programa de salud mental

6. A Depression Prevention Model for Latino Families: An Adaptation of the Beardslee Model Roxana Llerena-Quinn Rachel Shapiro Frances Colón March 15, 2006 Treatment of Depression Module

7. Rationale for the Prevention Project • Depression is a major cause of disability worldwide • Focus on children of families with depressed parents can help prevent depression in adolescence and adulthood • Depression can be prevented by reducing risk factors and • Enhancing protective factors associated with depression in youth

8. Risk for Depression in the General Population • Mood disorders are among the top 10 causes of worldwide disability, major depression ranks at the top (Murray & Lopez, 1996). • Major depression bears for the greatest burden of any disease among all illnesses in developed nations (NIMH, 2001) • 10-20% risk for a lifetime occurrence in the United States (Beardslee, 2002)

9. Major Risk Factors for Depression(Institute of Medicine, 1994) • Mood disorder in parent or close biological relative • Pessimistic cognitive style • Experiencing a severe distress: • Loss: bereavement, divorce, marital separation, unemployment, job dissatisfaction • Exposure to violence • Undergoing loss without support • Chronic physical or medical condition • In children, a learning disability, or other psychiatric illness

10. Major Risk Factors for Depression (Institute of Medicine, 1994) • Living in poverty • Low self-esteem, a sense of diminished self-efficacy, or a sense of hopelessness and helplessness; • Being female (Cumulative in nature)

11. Risks for Depression Among Children with A Depressed Parent • Children of parents with mood disorders are two to four times more likely to develop a mood disorder (Beardslee, Versage & Gladstone, 1998) • It is estimated that as many as 50% of these children will experience an episode of major depression by the end of adolescence or early adulthood (Beardslee & Podorefsky, 1988) • Poor outcome has been associated with a greater number of adversities. The greater the number of adversities, the increased likelihood the child will become depressed.

12. Efficacy studies for the Prevention of Childhood Depression • Three efficacy studies by Seligman, Clarke and Beardslee • They all have in common a strong theory with emphasis on cognitive changes • A focus on building strengths and resources • Manualized approaches and randomized trials

13. Some differences… • Clarke’s work focuses on correcting negative thinking and promoting cognitive restructuring of children already expressing depressive symptoms (groups in school). He has expanded this model to parents. • Seligman and his colleagues develop a district- wide, school base targeting 10-13 years old children at risk for depression based on elevated symptomatology, self-reports of parental conflict, or both. They identified core cognitive deficits associated with youth depression and were provided with cognitive training. • Beardslee and associates family approach targets developmental transaction between parents and children and focuses on resilience.

14. Depression Prevention Principles Beardslee Project • Depression (though biological) is also an interpersonal disorder with major effects on family functioning and relationships. • Parental depression is almost always associated with a constellation of other risk factors which may include disturbances in marital functioning, family functioning and parenting. • Targeting family: change in parental transactions can bring change in the child, focus on resilience (strengths/positivism).

15. Core Elements of the Preventive Intervention Program for Depression in Families • Assessment of family members • Presentation of psychoeducational material about mood disorders, risk, and resilience in children • Link psychoeducational material to family’s life experience (meaning-making) • Decrease guilt/blame in children and parents • Help children to develop relationships both within and outside of the family to promote independent functioning in school, community, & outside of the home

16. Healing Principles • Demystification of the illness • Modulation of shame and guilt • Increase the capacity for perspective taking • Development of hopeful perspective

17. Goals of the Current Project • Creation of a concept paper detailing the important features and considerations in developing and implementing an adaptation of an empirically-supported intervention for use in the Latino community • Develop a revised manual which is culturally and linguistically sensitive, has case illustrations based on experience with Latino families that can be used by a wide range of clinicians in the United States • Report about the safety and feasibility of the project and the adaptation process • Lay the groundwork for a larger effectiveness trial

18. Initial Adaptation of PIP for Use with a High Risk Population: The Dorchester Project • A focus on alliance building with the families, community, and caregivers • Flexibility as to where and how many sessions were conducted • Increased sensitivity to and acknowledgement of community experiences of marginalization and racism • Reconceptualized depression and resilience to include participants’ definitions and labeling of illness and strengths and thus modified the content and format of the intervention to include and/or acknowledge participants’ perspectives. (Podorefsky, McDonald-Dowell, & Beardslee, 2001)

19. Acculturative Stress (McKelney & Webb, 1996) • Language • Perceived discrimination • Perceived cultural in-competency • Intergeneration conflicts

20. Recruitment Criteria: • At least one parent with a current or past history of a Depressive Disorder. Diagnoses include Dysthymia, Depressive NOS and Major Depressive Disorder (within 3 years). • At least one child /adolescent between ages 8-17 years of age who may have a diagnosis of Adjustment Disorder with Depressed Mood or another clinical diagnosis excluding a psychotic disorder, significant neurological disorder, substance abuse or mental retardation.

21. The Pilot Study • Nine Latino families with a history of parental depression • Pre-assessment of parent(s) and children • Participation in the Six modules • Post-assessment interviews/rating scales regarding safety, satisfaction, and general issues of feasibility

22. Modules and Cultural Adaptations

23. Cultural Adaptations The process of establishing and maintaining the therapeutic relationship is central Personalismo: warm, personal, informal style Respeto: acknowledging and valuing the authority of the parent Confianza (trust) result from the first two A collaborative, rather than a hierarchical relationship with parents but respecting the hierarchical relationship between parents and children Establish therapeutic alliance & collaborative nature of the intervention Orienting the family to the intervention To construct the family history of the parental depression Module 1:Establishing the Therapeutic Relationship & Constructing the Family History of Depression

24. Module 1: Establishing the Therapeutic Relationship & Constructing the Family History of Depression (continued) Cultural Adaptations (continued) • Definition of family. Who is included? • Spouse/partner involvement? • “Secrets” may need to be considered (e.g., illegal status, etc) • Confidentiality becomes a major focus • Safety • Family history of depression, using family’s understanding of depression, and names used for sadness and depression. Listen for issues regarding stigma

25. Cultural Adaptations Not having a spouse modifies Module II Depression not seen as a illness, we needed to modify how we used the term with this sample Different understanding of depression and its etiology. Difficulties translating resilience Psycho-education not limited to depression Many parents reported “kids don’t know I am depressed” which required that preparation of the children be adapted. Review previous session: discuss reactions, questions and goals Continue to elicit history of family’s experience with affective illness, with particular attention to spouse’s/partner’s experience Psychoeducation about the etiology, symptoms, and treatment of the pertinent affective disorder Help parents review child’s current functioning and their worries about their children Help parent prepare child for meeting with clinician (i.e. worries about the interview) Module 2: Experience of Depression and Psycho-education

26. Module 2: Illness Experience and Psycho-education Adaptations (continued): • Flexible boundaries • Prepare to address other problems that may arise independent of depression. Parent may request assistance with general problem solving or case management (sign of confianza). • Focus on daily life, reduce crises: Concrete needs, crises addressed. Referral to medical, legal services or for concrete utility assistance. • Intervention rescheduled to attend crises. People cannot learn when in crises. • Materials for depression, resilience, ADHD, domestic violence, divorce, stress management, autism, etc. connected to concerns provided in Spanish, as much possible adapted to the cultural and literacy level.

27. Module 2: Illness Experience and Psycho-education Adaptations (continued): • Discussion about parenting beliefs and what makes a good parent (be aware of your own parental beliefs arising from a different culture and keep an open mind). • Inquire about parents worries and perspectives about raising children in this country and these communities. • Keep in mind the challenges of raising kids in cultural borderlands, with limited social power.

28. To acknowledge the importance of the child’s perspective & to develop a rapport with him/her Assess child’s current functioning & understanding/response to parental depression Help the child articulate questions or concerns for family meeting When appropriate, impart information about depression geared to child’s concerns and developmental level Cultural adaptation: Brief meeting with child and parent to review purpose of meeting and obtain parental sanction Emphasis on worries and concerns on self-and parent not limited to depression Psycho-education about topics related to family concerns in addition to depression Listen to children’s requests for assistance in negotiating generational differences without betraying parents best intentions. Interview all the children Module 3: The Meeting with the Child

29. Provide parents with a general review of their child’s functioning Link parents’ perception of depression with that of the child’s experience of their affective illness Facilitate participation in the joint task of planning a family meeting Cultural Adaptations A meaningful conversation about resilience can take place following the meeting with the children based on the children’s strengths. Discuss and prepare parents for difficult conversations about events the children have witnessed associated with the depression or contextual risk factors. Be prepare to follow family’s lead and work with sub-systems Module 4: Planning the Family Meeting

30. To review with the family the purpose of the family meeting(s) & information from last session about depression & resiliency Facilitate the creation of a shared understanding of parental illness, incorporating the affective experience of all family members Empower parents to conceptualize & present the depression to their children as an [illness] that may have affected the family in various ways & can now be discussed Cultural adaptations: Family conversation is the most important factor of the intervention keeping focus on strengths. The conversation does not always focus on depression but on the associated risks. Constructing a shared understanding about issues of common concern. Families learn each other’s experiences, their contexts and meanings Module 5: The Family Meeting: Facilitating the Creation of a Shared Understanding of the Parental Depression

31. Module 5: The Family Meeting: Facilitating the Creation of a Shared Understanding of the Parental Depression Cultural adaptations: • Clinician helps negotiate language and generational differences, learning each other’s worlds and experiences valuable. • Clinician will act both as generational and cultural liaison voicing children’s experiences when necessary (cultural ambassador). • Positively refrain concerns about children’s well-being so they reflect parents beliefs systems and children’s commitment to the well-being of the family unit. • Giving parents general information about adolescence in the U.S. and country of origin. • Strong value given to positive emotional expression • Greater importance given to parental love and obligation over the marital bond across many Latino families • Problem solving • Keep focus on strengths and gifts

32. Review with the parents the purpose of the family meeting & whether the purpose was met Review information shared with/by children and discuss their immediate and present reactions to openly discussing their affective disorder Review the purpose/ limitations of the intervention and assist them in making long-term plans to address the impact of parental depression on family functioning Ask parents: Did the intervention helped? What helped? What did they learn? Developing a plan for what still needs to be done beyond the intervention (problem solving) Anticipating future developmental challenges and helping them know what resources are available to them Review: Cultural transitions experienced by Latino families are part of the immigration experience not reflective of bad parenting The intervention is the first step in a journey toward “una mejor vida” Discussion of resources available both within and outside the family Module 6: The Review Meeting: Planning for the Future

33. What are we learning?

34. Different understanding of depression • Depression was not the focus of the sessions • Depression not viewed as an illness: “I was not born with it” • Experienced as caused by interpersonal and psychosocial stressors • Despite severe symptoms, most were not incapacitated because parenting came first “seguiendo con la lucha” (not giving up)

35. Language used to describe depression • Depression was best understood when explained in terms of an ailment of the soul that affected the body, spirit and the mind • Spiritual: sin animo, derrotada, demoralizada, no valgo nada, el alma arrastrando el cuerpo, desespero, un vacio grande • Physical: all kinds of somatic complaints • Mind: irritability, memory problems, “ya no se nada”

36. Causes • Involvement with an abusive partner • Financial hardships/unemployment • Having an ill child • Having a child at risk • Personal health issues • Isolation related to immigration • Acculturative stressors (negotiating systems, learning language) • Racism and discrimination discussed in terms of “me ignoran, no me escuchan—por el idioma creo.” Concept of “mal trato” and “buen trato.” Assault to personal dignity. Did not want to go back. • Over-burdened by multiple stressors

37. 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” • Aguantar (mixed reports-may be a problem)

38. Parental concerns worries and experiences: • Concern about the kids’ future: wanted a better life than theirs for their children, with less suffering, and for them to take advantage of the opportunities offered in this country, to study and to eventually develop better relationships with partners. • Concern about the impact of absent fathers • Parents felt isolated in this country but stayed for the opportunities for their children. Kids difficulties (disobedience, school problems) associated with fear dreams will not come true and sacrifice will be in vain. Often depressive feelings were associated with these fears.

39. Parents concerns, worries and experiences: • If children don’t do well, they felt they’ve failed as parents • Felt challenged in their traditional parental authority- intergenerational struggles: “ella quiere mandar, asi no es, no pueden haber dos mujeres en la casa” (she wants to make the rules, that is not how it works, there can’t be two women in the house). • Parents afraid of dangerous communities and of losing control over the children:“quieren mandarse, ir para la calle, no quieren ayudar” (they want to make their own rules, want to go out, and don’t help in the house).

40. Children’s concerns, worries and experiences • Most kids were unaware of parental depression, they thought symptoms were related to physical symptoms • Some adolescents over-functioning because of language and acculturation differences. Their strengths and gifts to the home not fully appreciated. • Kids felt trapped in the home. They wanted greater freedom (going to friends houses) • Kids wanted parents to have fun with their parents, do activities outside the home. • They wanted more family conversations: “I want to know what is going on, I want her to talk to me.” • Not having enough money

41. What kids hoped for… • More friends, or being able to visit friends • Less strictness • Equitable treatment

42. What helps kids build resilience? • Faith in God and in my children • Darles animo (give encouragement) • Meeting their needs • Discipline and setting limits • School support and emphasis on education • Activities: • Structured activities, preferably after school related (less trust about other activities) • Providing games, acitvities they can enjoy • Working and providing them with what they need • Buen ejemplo- good example

43. 10 Points to Build Resilience • Capacity to establish meaningful relationships • Viewing crisis as opportunities • Accepting change as a part of life • Having goals • Taking action, not avoiding problems • Seeking opportunities for self-understanding • Maintaining a positive view of self • Keeping problems in perspective • Not losing hope • Learning from the past and being flexible

44. Preliminary post-assessment findings • Four families that have completed the intervention, so far SAFE. • Positive feedback to assessors, intervention found a useful resource • Family meetings the most important part of the intervention.

45. Preliminary post-assessment findings • Dialogue continued post intervention, it opened up doors of communication (B. began weekly family meetings). • Most families did not speak as a family unit about their shared concerns and worries until being part of this intervention (“ I did not know my kids had a voice” -significant given belief in family secrets for protection).

46. Post-assessment findings • Psycho-education on resilience, depression, and other medical conditions related to the families were well received in this study. • Flexibility and availability of therapist was an important part of the success of this intervention. Therapists worked around patients schedules and met with families after hours, week-ends, early in the mornings, and at their homes. • Home visits: Families appreciated study therapist’s presence in their homes during some of the modules. • Resource assistance and advocacy needed outside of parent’s depression was a critical aspect of this intervention that families valued in this study.

47. Resilience • The capacity to rebound from adversity strengthened and more resourceful • …it is more than merely surviving…. • It does not assume faulty notions of “invulnerability” and “self-sufficiency” • It is forged through openness to experiences and interdependence with others. -Froma Walsh-

48. Grupo etario Curativas Promoción Rehabilitación Docencia Evaluaciones psicométricas con aplicación de pruebas Niño/as Adolescentes Historias longitudinales Talleres (Técnicas de relajación Acondiciona- miento físico, manualidades) Adultos Marco de referencia • Modelo de atención que inicia su organización y desarrollo desde 1999 Clínica para la evaluación de trastornos del desarrollo Escuelas para padres Comisión para la atención de adolescentes Escuelas para padres • Consulta individual • Psicoterapia grupal • Psicoterapia grupal adicciones • Clínica de adicciones (consulta individual)

49. Consulta individual Recursos • Psicoterapia grupal • PSIQUIATRIA • 4 grupos (32-40 personas) • Psicoterapia grupal • PSICOLOGIA • 2 grupos (20 personas) Sesiones psicoterapia - en curso - Medición del grado de depresión Presentación Fundamentos teóricos Consenso Alianza terapéutica Distorsiones cognitivas Criterios de inclusión (grupo) Grupo abierto de padres # de hijos 2-3 Explorar cuantos padres-madres por grupo actual Encuadre de intervención Construcción de la historia Material psicoeducativo Resiliencia Funcionamiento del hijo(s) Reunión con hijos Reunión familiar Seguimiento

50. Consulta individual Supervisión del equipo interdisciplinario Recursos Escuelas para Padres Niños n=20 Escuelas para Padres Adolescentes n=20 Medición del grado de depresión Evaluación (multidisciplinaria) Presentación Fundamentos teóricos Consenso Alianza terapéutica Distorsiones cognitivas Encuadre de intervención Construcción de la historia Material psicoeducativo Resiliencia Funcionamiento del hijo(s) Reunión con hijos Reunión familiar Seguimiento Equipo para la evaluación de trastornos del desarrollo Equipo para la atención de adolescentes