Biomedical subjects
Alison M Heru
Publications and source records attributed to Alison M Heru.
Family psychiatry: from research to practice.
OBJECTIVE: The purpose of this article is to review current research evidence for clinicians involving families in the assessment and treatment of their patients. METHOD: Research on effects of family support on illness outcome and outcomes of family-centered treatment in medicine, pediatrics, and psychiatry are reviewed. RESULTS: Research in many medical fields shows that families have powerful influences on health that are equal to or surpass other risk factors and that brief family interventions increase health and decrease the risk of relapse in chronic illnesses. Research in psychiatry affirms that family interventions reduce the rate of relapse, improve recovery, and increase family well-being. CONCLUSIONS: Current evidence supports increased emphasis on family-oriented psychiatric practice.
Family functioning in the caregivers of patients with dementia: one-year follow-up.
Caregivers for relatives with dementia can maintain their quality of life without specific intervention. It is unclear which variables are protective and which variables are aggravating for the caregiver. To assess the impact of family functioning on caregiver burden over time, the authors had caregivers of out patients with dementia complete self-report questionnaires at recruitment and at 1 year. At recruitment, 63% of caregivers were female, with a mean age of 62 years. Mean patient age was 73 years. The average number of caregiving years was 3.1. Caregivers were more likely to be spouses (61%). After 1-year, caregivers who stayed in the study reported no change in burden, reward, quality of life, or overall family functioning, although the patient's activities of daily living and level of disability were perceived to have significantly deteriorated. Caregivers who reported poor family functioning at initial assessment had higher ratings of strain and burden.
Prevalence and severity of intimate partner violence and associations with family functioning and alcohol abuse in psychiatric inpatients with suicidal intent.
BACKGROUND: Many medical settings have conducted screenings for domestic violence, but no study has assessed the prevalence and frequency of intimate partner violence (IPV) within the acute psychiatric inpatient population. METHOD: This descriptive, cross-sectional study was conducted in adult inpatient acute care units at a psychiatric hospital. Participants completed questionnaire-based assessments of recent and lifetime history of IPV, family functioning, and alcohol use. Recruited patients were aged between 18 and 65 years, were English-fluent and literate, had suicidal ideation, and had been living with an intimate partner for at least the past 6 months. Acutely psychotic patients and patients who were too agitated to complete the questionnaires were excluded. 110 patients completed the assessments. Interpersonal violence was assessed using the Revised Conflict Tactics Scale (CTS2), family functioning was measured using the Family Assessment Device, and alcohol use was assessed with the Alcohol Use Disorders Identification Test. Data were gathered from August 2004 through February 2005. RESULTS: Over 90% of suicidal inpatients reported IPV perpetration and victimization in their relationships in the past year, with the overwhelming majority reporting severe IPV. Male and female patients did not differ significantly on any CTS2 violence perpetration or victimization subscale (all p values >.05). Poor family functioning predicted physical violence victimization in both male and female suicidal inpatients, even after controlling for alcohol use and demographic characteristics. CONCLUSION: Psychiatric inpatients with suicidal ideation or intent would benefit from screening for IPV. Information about IPV and treatment options should be made available to psychiatric inpatients with suicidal intent. Attention to the family functioning of these patients is recommended.
Understanding families: from criticalness to resilience.
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Supervisor-trainee relationship boundaries in medical education.
Despite concerns about the prevalence and ramifications of medical student mistreatment, the boundaries of faculty-student relationships have not been studied systematically in medical training programs. This study aimed to identify behaviours that occur with some frequency and potentially raise issues related to boundaries in the supervisor-trainee relationship. An anonymous questionnaire was distributed to the mailboxes of 154 residents in the departments of psychiatry, internal medicine, and obstetrics and gynaecology at four hospitals affiliated with Brown University Medical School. Residents were asked to report whether they had encountered specific behaviours from supervisors during medical training, the frequency of these experiences, and the professional status of the supervisor involved in each episode. There was a significant reported incidence of behaviours related to academic/professional boundaries, personal boundaries, and dating boundaries. Some of these behaviours raise issues related to exploitation. The major sources of these reported boundary behaviours were hospital-based clinical faculty, university-based academic faculty, and senior house staff. The potentially adverse effects of boundary behaviours on the individual student, the teacher-student relationship, and the doctor-patient relationship are discussed. Future research is recommended to clarify the limits of appropriate behaviour between supervisors and trainees in the medical learning environment
Family systems training in psychiatric residencies.
Both extensive research and common sense dictate that attention to families is necessary for appropriate care of psychiatric patients. However, training in family skills has often been difficult to integrate into psychiatric residency programs because of conflicting paradigms, turf battles, constraints of time and money, and confusion over whether family-centered care or family therapy should be taught. Current changes in residency accreditation mandate that family skills (not necessarily family therapy in its sophisticated form) be part of all residency programs. This article reviews the history of systems training in residencies, current accreditation requirements, and the GAP proposal for family systems skills, knowledge, and attitudes that that are teachable within the limited time available to residents. The application of these core skills is described using a case example and formulation. Challenges in teaching and ways of overcoming programmatic constraints are outlined.
Psychoeducation for caregivers of patients with chronic mood disorders.
Caregivers of patients with mood disorders report high levels of caregiver burden and poor family functioning. This study assessed the impact of educating caregivers about their symptoms and about community resources. Depressive symptoms were reported by 74% of caregivers, but only 37% of these caregivers accepted a referral and only 6% followed through. Similarly, of those with poor family functioning, 44% were offered a referral, 22% accepted, but only 5% followed through. Overall, 82% reported that the psychoeducational packet was useful.
Family functioning in the caregivers of patients with dementia.
BACKGROUND: Caregiver burden has been extensively studied in the dementia population. The marital relationship has been suggested as a mediational model through which variables influence the caregiver and contribute to the experience of burden or reward. OBJECTIVES: This study examines family functioning, caregiver burden and reward and quality of life in 38 family members caring for a relative with dementia. METHODS: Caregivers of out-patients with dementia completed self report questionnaires. RESULTS: 63% of caregivers were female with a mean age of 62 years. Patient mean age was 73 years. The average number of caregiving years was 3.1. Caregivers were more likely to be spouses (61%) than children (29%) or other relatives (11%). Despite the fact that caregivers reported that their relatives were moderately disabled, they perceived more reward than burden. Caregivers who reported poor family functioning had higher ratings of strain and burden. Family functioning in these caregivers was poorest in the dimensions of affective responsiveness, problem solving and communication but it was also impaired in roles and affective involvement. CONCLUSIONS: Assessing a family's functioning may be an important factor in the care of the dementia patient and his/her family.
Burden, reward and family functioning of caregivers for relatives with mood disorders: 1-year follow-up.
BACKGROUND: Longitudinal caregiver studies of patients with mood disorders report no consistent pattern in burden over time. This naturalistic study of caregivers of patients with mood disorders assesses caregiver perceptions of burden, reward and family functioning at hospitalization and at 1 year follow-up. METHODS: Thirty-nine caregivers of patients with mood disorders were recruited during their relative's in-patient psychiatric hospitalization. Caregivers were given an assessment packet to complete at the time of enrollment and identical assessment packets were mailed to the caregivers at 1 year. RESULTS: Caregivers of bipolar disorder relatives reported less reward, more subjective burden and worse family functioning than depression caregivers, at recruitment. Bipolar caregivers showed a significant reduction in burden 1 year after their relative was discharged from the hospital, whereas depression caregivers showed no change at 1 year. At 1 year, overall family functioning was unchanged and was in the unhealthy range in all dimensions except for behavior control. Limitations of the study include the small sample size, the selective recruitment from a hospital setting where family members did not actively seek out help and the high drop-out rate. CONCLUSIONS: Caregivers of relatives with mood disorders show a different pattern of burden and reward, over time, depending on the patient diagnosis. In all cases, however, family functioning was significantly impaired. CLINICAL RELEVANCE: Short-term family interventions can be offered at the time of hospitalization to try to reduce caregiver burden and increase caregiver reward.
Sexual harassment in medical education: liability and protection.
The prevalence and frequency of sexual harassment in medical education is well documented. On the graduation questionnaire administered by the Association of American Medical Colleges in 2003, 15% of medical students reported experiences of mistreatment during medical school. On items that specifically address sexual mistreatment, over 2% of students reported experiencing gender-based exclusion from training opportunities, and unwanted sexual advances and offensive sexist comments from school personnel. Sexual harassment of medical trainees by faculty supervisors is obviously unethical and may also be illegal under education discrimination laws. In two cases in 1998 and 1999, the U.S. Supreme Court clarified that schools may be held liable under Title IX of the Education Amendments of 1972 for the sexual harassment of their students. In 2001, the Office of Civil Rights of the Department of Education released revised policy guidelines on sexual harassment that reflect the Supreme Court rulings. Medical school administrators should undertake formal assessments of the educational environment in their training programs as a first step toward addressing the problem of sexual harassment. The authors recommend that medical schools implement measures to both prevent and remedy sexual harassment in their training programs. These constructive approaches include applying faculty and student education, establishing a system for notification and response, and creating an institutional structure to provide continuous evaluation of the educational environment.
Boundaries in psychotherapy supervision.
OBJECTIVE: This study examines the perceptions of trainees and supervisors on the boundaries of the supervisory relationship. METHOD: A 19-item questionnaire about the appropriateness of the actions of a psychotherapy supervisor was completed by 43 supervisors and 52 trainees. It was distributed at Grand Rounds and mailed out to psychotherapy supervisors in the community. RESULTS: Generally, trainees and supervisors agreed about the boundaries of supervision. Only one item indicated a significant difference between trainees and supervisors. Trainees considered the discussion of sexual fantasies as less appropriate than did supervisors. Using factor analysis, two scales accounted for 66% of the common variance. Supervisors scored higher than trainees on scale 1 (F = 5.14, df = 1.92, p = .03) and women scored lower than men on scale 2 (F = 9.88, df = 1.92, p = .002). CONCLUSION: Scale 1, a set of items related to sexual topics, revealed a significant difference in supervisor/trainee response with supervisors considering discussion of sexual items as appropriate compared to trainees. Scale 2, a set of items related to self-disclosure, revealed a significant difference with male respondents favoring looser boundaries and more self-disclosure than female respondents. The boundaries of the supervisory relationship are important concerns for our profession. This is the first study to provide an empirical evaluation of perceptions of trainees and supervisors on aspects of boundaries in the supervisory relationship. If the findings are replicated, they could contribute to future analysis of trainee/supervisor relationships. The maintenance of good boundaries between trainees and supervisors is crucial to the integrity of the supervisory relationship.
Quality of life and family functioning in caregivers of relatives with mood disorders.
This study examines the quality of life of caregivers of hospitalized relatives with mood disorders. Caregivers reported poor social, physical and emotional functioning. Family functioning was poor in the areas of roles, communication and affective involvement. It is significant that problem-solving, affective responsiveness and behavior control are within the normal range, indicating that these families do have strengths. Subjective burden but not objective burden was correlated with a poorer quality of life. Less than 30% of caregivers received help from other relatives and less than 5% sought help from outside organizations like NAMI, MDDA or VNA.
Using role playing to increase residents' awareness of medical student mistreatment.
The teacher-learner relationship is subject to both internal and external influences that may lead to mistreatment and harassment of the student. The student who is mistreated may mistreat students when he or she becomes a teacher. The author describes an experiential program for residents at Brown Medical School from 1999 to 2002 in which residents, through role playing, helped produce teaching videotapes on medical student mistreatment. Fourteen residents had participated in the program to date. They reported that they had benefited from an increased awareness of the effects of student mistreatment and had learned how to handle mistreatment more effectively. They also reported increased sensitivity to others and improved self-awareness, qualities that they planned to incorporate into their professional identities and that should help them avoid mistreatment of students and residents later in their careers. Because preventing mistreatment from being transmitted to the next generation is an important way to increase medical professionalism, the author recommends that role-playing exercises dealing with mistreatment be a part of all residency education.
Family skills for general psychiatry residents: meeting ACGME core competency requirements.
OBJECTIVE: The authors discuss the knowledge, attitudes, and skills needed for a resident to be competent in supporting and working with families, as mandated by the residency review committee (RRC) core competencies. METHODS: The RRC core competencies, as they relate to patients and their families, are reviewed. The Group for Advancement of Psychiatry (GAP) presents an operational version of these core competencies. RESULTS: Methods of assessment, challenges in teaching, and ways of overcoming programmatic constraints are outlined. Examples of training programs that offer ways of integrating the teaching of family skills into existing programs are described. CONCLUSIONS: The implications of the current RRC core competency requirements pertaining to families have the potential to change the training environment substantially. The GAP Family Committee proposes recommendations to facilitate the training of residents in family skills.
Overcoming barriers in working with families.
OBJECTIVE: The Accreditation Council for Graduate Medical Education and the Residency Review Committee for psychiatry outline the expected competencies for residents. These competencies include working with families. This article describes barriers that residents face when working with families, and offers ways to overcome these barriers. METHOD: In 23 years of combined experience teaching family therapy to psychiatry residents, the authors have identified typical barriers that residents face when beginning to work with families. RESULTS: Six clinical vignettes, with the resident's concerns, the supervisor's intervention and the resident's response, illustrate these barriers. CONCLUSIONS: In order for residents to become skilled in working with families, barriers should be made explicit and ways of overcoming these barriers should be discussed clearly with residents.