2020: what COVID taught us about women in medicine.

As Vice Chair of Clinical Services of Psychiatry at the University of Colorado, I choose to work where clinical services need most attention. As a woman, I want to show up where we can be seen and show up in the best possible way. Just as COVID began, I found myself doing clinical shifts in the newly created psychiatry emergency room. I became part of a front-line team, where "I" became "We," facing an unknown enemy. Not only was my work life upended, but my personal life was too, as I rushed to help my daughter, a medical student, care for her son when his day-care closed. My commentary highlights the increased burden experienced by women during this time, an example of systemic bias in medicine.

Cultural research deconstructs the psychosocial construct 'expressed emotion'.

Expressed emotion (EE) is a highly researched psychosocial construct. Cultural research challenges the assumption that high family criticism is a universal determinant of poor outcome, especially for chronic illness. The concept of warmth, an original component of EE, was dropped owing to the complexity of its measurement. Warmth has now been resurrected as an important predictor of good patient outcome. Cultural scrutiny and appropriate adaptation of any psychosocial construct is necessary before its acceptance into the medical lexicon of healthcare.

The 'secret' source of 'female hysteria': the role that syphilis played in the construction of female sexuality and psychoanalysis in the late nineteenth and early twentieth centuries.

In the late nineteenth and early twentieth centuries, the unspoken fear of syphilis played a significant role in the development of beliefs about female sexuality. Many women were afraid of sexual relationships with men because they feared contracting syphilis, which was, at that time, untreatable. Women also feared passing this disease on to their children. Women's sexual aversion, or repression, became a focus for Freud and his colleagues, whose theory of psychosexual development was based on their treatment of women. This article examines the case of Dora, the memoirs of Mabel Dodge Luhan and other sources to argue that the fear of syphilis was a significant factor in upper- and middle-class women's avoidance of heterosexual relationships. The fear of syphilis, in turn, became a significant factor in the psychoanalytic construction of female sexuality. The social suppression of the fear of syphilis has had a profound impact on theories of women's development. The implication for psychiatry is that our models of psychological development occur within a sociocultural milieu and cannot escape suppressed aspects of our culture.

Family-centered Care in the Outpatient General Psychiatry Clinic.

Although family research supports family-centered care for all medical specialties, the benefit of family-centered care has not been fully realized in outpatient practice. Physicians, including psychiatrists, are not routinely taught how to work with families and may not be aware of the evidence-base for family interventions. However, some medical specialties, such as family medicine and palliative care, have a clinical practice that routinely includes the family. Clinicians working in medical clinics, such as diabetes clinics, know that successful management of chronic illness requires family involvement. Psychiatric clinics, such as The Family Center for Bipolar Disorder at Beth Israel Medical Center in New York City, also have a family-centered practice and show improved patient outcomes. This article provides guidelines, including clinical interview questions, to help psychiatrists practice family-centered care, either in a private office or in a general psychiatric outpatient clinic. The guidelines include questions that identify when to seek an in-depth family assessment or consultation. Family-centered care will become more useful when health care reimbursement focuses on patient outcome.

Teaching psychosomatic medicine using problem-based learning and role-playing.

OBJECTIVE: Problem-based learning (PBL) has been implemented in medical education world-wide. Despite its popularity, it has not been generally considered useful for residency programs. The author presents a model for the implementation of PBL in residency programs. METHOD: The author presents a description of a PBL curriculum for teaching psychosomatic medicine to PGY 2 members in a psychiatry training program. The goals of PBL are to encourage self-directed learning; enhance curiosity, using case-based, contextualized learning; promote collaborative practice; and support patient-centered care. The addition of role-playing exercises helps PGY 2 residents to develop their skills from simply developing a differential diagnosis to being able to construct biopsychosocial formulations, and it provides these residents an opportunity to practice presenting case formulations to the patient and family. RESULTS: Residents and faculty enjoyed the PBL role-playing sessions. Residents wanted the learning objectives given to them rather than generating their own learning objectives, to move through the cases faster, and to receive more information and more cases. CONCLUSION: Teaching psychosomatic medicine, using PBL and role-playing, allows many of the proposed Academy of Psychosomatic Medicine residency core competencies to be met. However, further refinement of the PBL method needs to take place in order to adapt its use to residency programs.

Family functioning in suicidal inpatients with intimate partner violence.

BACKGROUND: Intimate partner violence (IPV) is commonly bidirectional with both partners perpetrating and being victims of aggressive behaviors. In these couples, family dysfunction is reported across a broad range of family functions: communication, intimacy, problem solving, expression or control of anger, and designation of relationship roles. This study reports on the perceived family functioning of suicidal inpatients. METHOD: In this descriptive, cross-sectional study of adult suicidal inpatients, participants completed assessments of recent IPV and family functioning. Recruited patients were between 18 and 65 years of age and English fluent, had suicidal ideation, and were living with an intimate partner for at least the past 6 months. Intimate partner violence was assessed using the Conflict Tactics Scale-Revised, and family functioning was measured using the McMaster Family Assessment Device. The study was conducted from August 2004 through February 2005. RESULTS: In 110 inpatients with suicidal ideation and IPV, family functioning was perceived as poor across many domains, although patients did report family strengths. Gender differences were not found in the overall prevalence of IPV, but when the sample was divided into good and poor family functioning, women with poorer family functioning reported more psychological abuse by a partner. For both genders, physical and psychological victimization was associated with poorer family functioning. CONCLUSION: Among psychiatric inpatients with suicidal ideation, IPV occurred in relationships characterized by general dysfunction. Poorer general family functioning was associated with the perception of victimization for both genders. The high prevalence of bidirectional IPV highlights the need for the development of couples treatment for this population of suicidal psychiatric inpatients.

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.

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.

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 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.

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.

Self-disclosure in psychotherapy supervisors: gender differences.

OBJECTIVE: This article will explore the possible reasons for gender differences found in self-disclosure in psychotherapy supervisors. METHOD: Trainees and supervisors in the Brown University Department of Psychiatry and Human Behavior completed a questionnaire that asked about the appropriateness of the actions of a psychotherapy supervisor. RESULTS: On three items, male and female supervisors differed significantly in their perceptions of appropriate boundaries. These items were: interacting with the resident alone outside of supervision e.g. playing tennis (p = .0005), publishing identifiable content of supervision discussions with resident's consent (p = .0006), and disclosing the supervisor's prior struggles with substance abuse (p = .0008). Female supervisors answered "never" to these items in greater numbers than the male supervisors, who, for the most part answered "occasionally". CONCLUSION: Traditional gender role behaviors and differential gender socialization patterns are possible reasons for the gender difference in perception of boundaries by supervisors.