Clínica Dr. Carlos Durán Cartín

Clínica Dr. Carlos Durán Cartín

Proyecto: “Apoyo a las familias con situaciones de depresión parental”

Marco de referenciaMarco de referencia

Clínica Dr. Carlos Durán Cartín • Centro de atención ambulatoria primaria y especializada• Población adscrita de 123.544 habitantesRecurso básico de salud mental:1 médico- psiquiatra1 psicóloga3 trabajadoras socialesRecurso de apoyo1 médico pediatra1 médico general

Marco de referencia• Modelo de atención que inicia su organización y

desarrollo desde 1999 • Investigaciones de tipo exploratorio (niños, adicciones)

Grupo etario

Niño/as

Adolescentes

Adultos

Clínica para la evaluación de trastornos del desarrollo

Comisión para la atención de adolescentes

Consulta individualPsicoterapia grupalPsicoterapia grupal adiccionesClínica de adicciones (consulta individual)

Escuelas parapadres

Escuelas parapadres

Grupos de autoayuda

Centro Diurno

Curativas RehabilitaciónPromoción Docencia

Evaluaciones psicométricas con aplicación de pruebas

Historias longitudinales

Talleres(Técnicas

de relajaciónAcondiciona-

miento físico,

manualidades)

ResultadosResultadosTipificar las actividadesactividades incluidas en el programa de salud mental - (febrero 2003)

AIPSQAtención psiquiátrica individual

PGPSQPsicoterapia grupal por psiquiatra

AEPSQAtención psiquiátrica emergencias

AAPSQAtención adicciones por psiquiatra

CAPSQCapacitación y docencia

#atenciones

#atenciones

#atenciones

#atenciones

#horas

Psiquiatría

AITSOAtención individual por T.Social

ACTSOAtención comunal por T.Social

AGTSOAtención grupal por T.Social

CUTSOCapacitación de usuarios T. Social

CATSOCapacitación de funcionarios T. Soc.

#intervenciones

#intervenciones

#intervenciones

Trabajo Social

#intervenciones

#intervenciones

Psicología

#atenciones

SOPSISalud ocupacional por psicóloga

EAPSIEvaluación con aplicación pruebas

# evaluaciones

APSIAtención psicológica individual

PGPSIPsicoterapia grupal por psicóloga

# atenciones

# atenciones

AVPSIAtención víctimas de violencia

CAPSICapacitación y docencia

#horas

#atenciones

LAPSIPsicología laboral

#horas

Interdisciplinarias

EINIEvaluación interdisc. de incapacidad

AINEDEducación para la salud

AINAAAtención interdisciplinaria adicciones

AINADAtención interdisc. de adolescentes

AINNIAtención interdisciplinaria de niños

#atenciones

#atenciones

#atenciones

#horas

# atenciones

AICRIAtención interdisciplinaria de crisis

#atenciones

AINNAAt. interdisc. comité de niño agredido

#atenciones

ResultadosResultadosTipificar las actividadesactividades incluidas en el programa de salud mental

A Depression Prevention Model for A Depression Prevention Model for Latino Families: An Adaptation of the Latino Families: An Adaptation of the

Beardslee ModelBeardslee Model

Roxana Llerena-QuinnRachel ShapiroFrances Colón

March 15, 2006Treatment of Depression Module

Rationale for the Prevention Rationale for the Prevention ProjectProject

– 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

Risk for Depression in the Risk for Depression in the General PopulationGeneral 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)

Major Risk Factors for DepressionMajor Risk Factors for Depression(Institute of Medicine, 1994)(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

Major Risk Factors for Depression Major Risk Factors for Depression (Institute of Medicine, 1994)(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)

Risks for Depression Among Risks for Depression Among Children with A Depressed ParentChildren 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.

Efficacy studies for the Efficacy studies for the Prevention of Childhood Prevention of Childhood

DepressionDepression– 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

Some differences…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.

Depression Prevention Principles Depression Prevention Principles Beardslee ProjectBeardslee 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).

Core Elements of the Preventive Core Elements of the Preventive Intervention Program for Depression in Intervention Program for Depression in

FamiliesFamilies 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

Healing PrinciplesHealing Principles

– Demystification of the illness – Modulation of shame and guilt

– Increase the capacity for perspective taking

– Development of hopeful perspective

Goals of the Current ProjectGoals 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

Initial Adaptation of PIP for Use with a Initial Adaptation of PIP for Use with a High Risk Population: The High Risk Population: The

Dorchester ProjectDorchester 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)

Acculturative Stress (McKelney & Acculturative Stress (McKelney & Webb, 1996)Webb, 1996)

– Language– Perceived discrimination– Perceived cultural in-competency– Intergeneration conflicts

Recruitment 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.

The Pilot StudyThe Pilot StudyNine Latino families with a history of

parental depressionPre-assessment of parent(s) and childrenParticipation in the Six modulesPost-assessment interviews/rating scales

regarding safety, satisfaction, and general issues of feasibility

Modules and Cultural Adaptations

Module 1:Module 1: Establishing the Therapeutic Establishing the Therapeutic Relationship & Constructing the Family History Relationship & Constructing the Family History

of Depression of Depression 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 Module 1: Establishing the Therapeutic Relationship & Constructing the Family History Relationship & Constructing the Family History

of Depression (continued)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

Module 2: Experience of Depression Module 2: Experience of Depression and Psycho-educationand Psycho-education

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: Illness Experience and Module 2: Illness Experience and Psycho-educationPsycho-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.

Module 2: Illness Experience and Module 2: Illness Experience and Psycho-educationPsycho-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.

Module 3: The Meeting with Module 3: The Meeting with the Childthe Child

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 4: Planning the Family Module 4: Planning the Family MeetingMeeting

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 5: The Family Meeting: Module 5: The Family Meeting: Facilitating the Creation of a Shared Facilitating the Creation of a Shared

Understanding of the Parental DepressionUnderstanding of the Parental Depression 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: Module 5: The Family Meeting: Facilitating the Creation of a Shared Facilitating the Creation of a Shared

Understanding of the Parental DepressionUnderstanding of the Parental DepressionCultural 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

Module 6: The Review Meeting: Module 6: The Review Meeting: Planning for the FuturePlanning for the Future

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

What are we learning?What are we learning?

Different understanding of Different understanding of depressiondepression

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)

Language used to describe Language used to describe depressiondepression

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”

CausesCauses 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

What helps parents cope with What helps parents cope with depression?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)

Parental concerns worries and Parental concerns worries and experiences: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.

Parents concerns, worries and Parents concerns, worries and experiences: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).

Children’s concerns, worries and Children’s concerns, worries and experiencesexperiences

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

What kids hoped for…What kids hoped for…

More friends, or being able to visit friendsLess strictnessEquitable treatment

What helps kids build resilience?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

10 Points to Build Resilience10 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

Preliminary post-assessment Preliminary post-assessment findingsfindings

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.

Preliminary post-assessment Preliminary post-assessment findingsfindings

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).

Post-assessment findingsPost-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.

ResilienceResilience 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-

Marco de referencia• Modelo de atención que inicia su organización y desarrollo desde 1999

Grupo etario

Niño/as

Adolescentes

Adultos

Clínica para la evaluación de trastornos del desarrollo

Comisión para la atención de adolescentes

Consulta individualPsicoterapia grupalPsicoterapia grupal adiccionesClínica de adicciones (consulta individual)

Escuelas parapadres

Escuelas parapadres

Curativas RehabilitaciónPromoción Docencia

Evaluaciones psicométricas con aplicación de pruebas

Historias longitudinales

Talleres(Técnicas

de relajaciónAcondiciona-

miento físico,

manualidades)

RecursosPsicoterapia grupal PSIQUIATRIA 4 grupos (32-40 personas)

Psicoterapia grupal PSICOLOGIA 2 grupos (20 personas)

Sesiones psicoterapia - en curso -Medición del grado de depresiónPresentaciónFundamentos teóricosConsensoAlianza terapéuticaDistorsiones cognitivas

Encuadre de intervenciónConstrucción de la historiaMaterial psicoeducativoResilienciaFuncionamiento del hijo(s)Reunión con hijosReunión familiarSeguimiento Consulta individual

Criterios de inclusión (grupo)Grupo abierto de padres# de hijos 2-3Explorar cuantos padres-madres por grupo actual

Recursos

Medición del grado de depresión

PresentaciónFundamentos teóricosConsensoAlianza terapéuticaDistorsiones cognitivas Encuadre de intervenciónConstrucción de la historiaMaterial psicoeducativoResilienciaFuncionamiento del hijo(s)Reunión con hijosReunión familiarSeguimiento Consulta individual

Supervisión del equipo interdisciplinario

Escuelas paraPadresNiñosn=20

Escuelas paraPadres

Adolescentesn=20

Equipo para la evaluación de trastornos del desarrollo

Equipo para la atención de adolescentes

Evaluación (multidisciplinaria)

Ventajas - desventajasVentajas - desventajas 80 padres/madres expuestos 60-70 familias 120 niños Intervenciones en curso Evaluación y seguimiento

interdisciplinario Bajo costo (unitario) Inicio (en 1 mes) Lugar para entrenamiento de otro

personal de salud (mediano plazo)

Novedad Primera experiencia Diseño del proceso

evaluativo Carga adicional de trabajo

(el mismo recurso humano)

Muestra - sampleMuestra - sample

hijo(a) hijo(a) hijo(a) hijo(a)nombre edad nombre edad nombre edad nombre edad nombre edad

1 victor 50 johan 10 mauro 122 oscar 40 katerin 14 david 2.53 marta 43 roberto 11 tamara 20 sebastian 264 elizabeth 50 luis 75 isidro 50 alex 9 laura 126 aura 40 juan 8 adriana 17 susana 237 thelma 33 karol 8 daniel 48 roxana 39 roxana 69 luz 50 maria 14 melisa 20

10 manuel 47 karen 14 18

Edad promedio 44.2 10.1 13.2 24.5Min 33 6 2.5 23

Max 50 14 20 26

PREVENCION DE LA DEPRESION EN NIÑOSPrimera sesión ( ) realizada en forma: individual grupal Encuadre de la intervención Historia de la enfermedad del paciente identificado Principales temores de la familia y metas de la intervención Alianza terapéuticaSegunda sesión - reunión con los padres ( ) Perspectiva del padre no enfermo Experiencia de la enfermedad y material psicoeducativo Perspectivas sobre el funcionamiento de los hijosTercera sesión – reunión con los niños ( ) Propósito de la intervención valoración del funcionamiento (escolar, familiar, social) comprensión de la enfermedad de los padres intereses y preguntas para la reunión familiarCuarta sesión ( ) revisión del funcionamiento de los hijos planificación de la reunión familiarQuinta sesión - reunión familiar- ( ) revisión de información sobre depresión y resilencia material aplicado a la familia preguntas entre unos y otros perspectivas individualesSexta reunión – familiar - ( ) revisión de la reunión familiar intervención como proceso familiar revisión de los propios objetivosSéptima reunión –segumiento- ( ) reforzamiento de material socioeducativo funcionamiento familiar en el periodo valoración de la intervención preguntas e intereses

1 victor 50 johan 10 mauro 12

psicoterapia


psicoterapia

2 oscar 40 katerin 14 david 2.5


psicoterapia

3 marta 43 roberto 11 tamara 20 sebastian 26

Marta 42 años. Reacción de ajuste de tipo depresivo asociado a enfermedad del cáncer de útero diagnosticada en 2003, con cirugía posterior. Refiere cambios de humor, enojo, irritabilidad, llanto fácil, temor y ansiedad. Con trastorno del sueño y disminución del apetito. Se identificó un episodio depresivo severo en mayo del 2006. Identifica temores familiares por su muerte y externa preocupación por la condición emocional de su hijo de 11 años.


psicoterapia


Describe a su hijo de 11 años, ansioso, temeroso a partir de varias pérdidas experimentadas. Los hijos mayores tienden a evadir sus problemas emocionales y físicos. Los mantiene informados sobre su condición y tratamiento.

Cónyuge, 48 años Observó irritabilidad en su cónyuge y que "se aprovechaba" de su condición para demandar atención de la familia. Reconoce que los síntomas son depresivos. Sus principales temores están asociados a muerte de su esposa y problemas económicos. Observó que algunos de sus hijos no se involucraron con la situación de la madre, negando su enfermedad. Preocupación por rendimiento académico y estado emocional de su hijo menor (Roberto,11 a.)


psicoterapia


Hijo, 26 años.Refiere que la familia ha tenido que enfrentar pérdidas significativas en los últimos meses: enfermedad de abuela, suicidio de prima, enfermedad de cáncer de la madre, y problemas académicos en hermano menor. Conciencia de la depresión de su madre. Refiere conflictos en la relación entre su madre y su hermana, 21a. Propone como objetivos a trabajar en familia, abrir más espacios de comunicación familiar, abordar el suicidio de la prima, y mejorar la relación entre su madre y hermana.


psicoterapia


Hija 20 años. No se presenta, aduce razones laborales.

Hijo 11 años. Presentó ansiedad de separación hacia su madre. Refiere sentimientos de tristeza. Manejaba temor a la posibilidad de muerte de su madre y observó preocupaciones económicas en la familia a raíz de la enfermedad. Manifestó deseos de estar informado sobre el tx. de su madre.


psicoterapia

4 elizabeth 50 luis 75 isidro 50 alex 9 laura 126 aura 40 juan 8 adriana 17 susana 237 thelma 33 karol 8 daniel 48 roxana 39 roxana 69 luz 50 maria 14 melisa 20

10 manuel 47 karen 14 18

Clínica Dr. Carlos Durán Cartín

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