Family Therapy and Mental Health

Innovations in Theory and Practice

Malcolm M Macfarlane

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780789008800
• eBook ISBN: 9781135788391
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Use these interventions and treatments to help people with mental health problems and their families!Family Therapy and Mental Health: Innovations in Theory and Practice explores the application of family therapy approaches to the treatment of a variety of mental health problems. A variety of treatment modalities are used with patients and their families to address these problems, including family psychoeducational approaches, the McMaster Model, cognitive behavioral family therapy, brief therapy, and systemic and narrative approaches. Each chapter of Family Therapy and Mental Health examines the gender and cultural issues that are relevant to the population and model it describes, and includes a case example. In addition, each chapter describes how the model is integrated with psychiatric services and examines the use of medication in each case. For complete contents, and to see our distinguished roster of contributors, please visit our Web site at http://www.haworthpress.comThis volume presents a variety of family therapy approaches to conditions that include:

• schizophrenia
• bipolar disorder
• anxiety
• depression
• personality disorders
• suicide
• addictionsThere are also complete chapters describing family therapy approaches to special issues such as:
• women and mental health
• brain injury
• aging

The text of Family Therapy and Mental Health: Innovations in Theory and Practice is written with a strong clinical focus and will be helpful and informative for frontline clinicians as well as students in graduate programs. The book's broad range, covering the mental health issues that clinicians typically encounter in the real world, ensures that they will find information they can use today and every day, and wisdom that students can carry with them through their careers.

PART I:
OVERVIEW

Chapter 1

Family Therapy and Mental Health: Historical Overview and Current Perspectives

William C. Nichols
Malcolm M. MacFarlane

INTRODUCTION

In North America, dealing with the mentally ill traditionally has been marked by a preference toward focusing on the individual and largely ignoring the family or treating it with indifference, ambivalence, or sometimes outright hostility. Although a small number of texts and other writings emphasize the importance of integrating individual and family perspectives in major mental illness (Hatfield, 1994; Lansky, 1981, 1985; Perlmutter, 1996), the important role of family therapy in the treatment of mental health problems continues to be underrepresented in the literature.

As Keefler notes in Chapter 8 of this text, the lack of attention to family therapy approaches is somewhat surprising, since ample research exists to indicate that family interventions have many positive effects in the treatment of mental health problems, including reducing relapse rates, reducing hospital admissions, encouraging compliance with medication, improving outcome, and reducing family burden and the cost of outpatient treatment (Azrin and Teichner, 1998; Droogan and Bannigan, 1997; Goldstein and Miklowitz, 1995; Penn and Mueser, 1996). Indeed, even if family interventions were not beneficial to family members with mental health problems, the beneficial impact of family therapy for families of the mentally ill would likely justify greater attention to this modality. Caregivers who live with a mentally ill relative indicate that caring for the relative can be a major burden. Gallagher and Mechanic (1996) and Song, Beigel, and Milligan (1997) have reported a variety of negative effects on the physical and psychological health of caregivers. Research indicates, however, that the coping abilities of families improve with the quality and quantity of social support from both professionals and their own social support system (Jutras and Veilleux, 1991; Solomon and Draine, 1995).

Eric Johnson, in Chapter 2 of this text, notes that many mental health professionals continue to overlook a rich resource for improving the community functioning of individuals with mental illness by not including family members’ information and insights into the problem. In his interviews with family members, Johnson found that many family members felt ignored by the mental health community and felt that their experiences were disregarded or dismissed as irrelevant by mental health professionals. Family members seemed to attribute this poor treatment to professionals being overinvested in a medical model of illness as an intrapersonal biological phenomenon, which seemingly exists without a social context.

Johnson's findings fit well with recent research by Dixon and associates (1999) on the utilization of family therapy in the treatment of schizophrenia. Dixon and colleagues found that only .7 percent of a Medicare sample, and 7.1 percent of a Medicaid sample received family therapy. Further, only 30 percent of the field study participants affirmatively answered the question, “Did anyone in your family receive information about your illness or your treatment, or advice or support for families about how to be helpful to you?” These findings are very disconcerting given that psychoeducational family therapy for schizophrenia has been demonstrated in research to be an effective treatment approach (Goldstein and Miklowitz, 1995).

The current picture, in terms of the integration of family therapy approaches with traditional individually focused mental health treatments, appears to be very mixed. Although there are a few encouraging signs of an increasing recognition of the important contributions family therapy can make in the treatment of mental illness, it is obvious that the historical struggle between individual and family orientations in diagnosing and assessing mental disorders and psychological problems, and in providing treatment, continues into the present.

THE ROAD TO THE TWENTY-FIRST CENTURY

A brief look back to the eighteenth century and forward to the present seems essential for understanding what is occurring today in the treatment of the mentally ill and psychologically disturbed. During the colonial days and into the early years of the United States as a nation, virtually no facilities were provided for the severely mentally ill, who largely lived with their families, were homeless, or were in prison (Hatfield, 1987).

The Asylum Period of Institutionalization

Taking the mentally ill out of the home and placing them in special facilities began in the mid-eighteenth century. When America's first general hospital, the Pennsylvania Hospital in Philadelphia, opened during that period, it provided housing for the mentally ill in its basement. The first state “asylum” for the mentally ill in the United States was opened in 1773 in Williamsburg, Virginia (Hatfield, 1987). The asylum pattern prevailed until approximately the 1860s, with psychotics, in particular, often housed in such institutions. Some continued to live in poorhouses with other individuals, including dependent children. Efforts to provide treatment were launched in the United States around the beginning of the nineteenth century. The most popular approach was “moral treatment,” which referred to the application of psychologically oriented therapy in an effort to return the disturbed individual to a state of reason. Introduced from Europe by Dorothea Dix, Horace Mann, and others, it involved placing the person in an asylum in a controlled atmosphere of “moral” sensibility or reason, in which he or she received a combination of somatic and psychosocial treatments. This approach was expected to restore mental health and avoid the development of chronic mental illness, but it did not prevent chronicity (U.S. Department of Health and Human Services, 1999; Grob, 1983, 1991, 1994).

The Mental Hospital Period of Institutionalization

The “mental hygiene” or public health movement appeared near the end of the nineteenth century. As the states were given the responsibility for providing care for the mentally ill, local communities tended to send them, along with some dependent persons, to state institutions. The asylums were renamed mental hospitals. Their development coincided with growing urbanization and, in light of the problems created by and for the mentally ill in cities, the hospitals were largely placed in rural areas (as were prisons), separating the patients from their families. Presumably the hospitalized mentally ill were to receive treatment as well as housing in the hospitals. In reality, the picture was quite mixed; large numbers continued to receive primarily custodial care and remain “warehoused” in mental hospitals once they were admitted. By 1955, there were approximatel559,000 psychiatric patients in state and county mental hospitals (Adamce, 1996). The National Committee on Mental Hygiene (currently the National Mental Health Association) advocated for moving mental health care into the mainstream of health care in a variety of ways, including outpatient treatment (U.S. Department of Health and Human Services, 1999).

The Community Mental Health Movement and Deinstitutionalization

During the 1940s, the concept of community mental health developed. Within a few years, partly due to the introduction of antipsychotic drugs that significantly reduced symptoms, state hospitals began to reverse the perpetual institutionalization pattern and to release some patients into the community. The recent surgeon general's report (U.S. Department of Health and Human Services, 1999) indicates that “The advent of chlorpromazine in 1952 and other neuroleptic drugs was so revolutionary that it was one of the major historical forces behind the deinstitutionalization movement” (p. 7).

With the passage of some state legislation on community mental health services and the 1963 enactment of the Community Mental Health Act, the deinstitutionalization period arrived full force. Some state mental hospitals were closed, others were downsized, and the movement to place the mentally ill in community placements (halfway houses and group homes) was fully underway. Community mental health centers were opened on a wide-scale basis to provide care not only for the seriously mentally ill who formerly had been hospitalized but also for others suffering from mental and psychological difficulties that impaired their functioning.

Graham (1988) describes a similar movement toward a community mental health focus in Canada. He notes that as a result of the continuing process of deinstitutionalization that began in the 1950s, in combination with improved treatment methods, the majority of people with chronic mental illnesses now live in the general community. He further estimates that in Ontario two-thirds of all psychiatric patients admitted to inpatient units stay for less than two weeks, and 90 percent stay for less than a month. With the implementation in Ontario of the Adult Community Mental Health Services Program in 1976, there was a major and positive shift toward locally based care and support of the mentally ill in the community.

In the United States, the mentally ill hospital population dropped to 193,435 by 1976 (Hatfield, 1987) and below 100,000 by the 1990s (Bachrach, 1996). Patients were outside mental hospitals, but families were not significantly involved with them. As Adamce (1996) has pointed out, “large numbers who were not in the care of their families were homeless or in prison,” as had been the situation in the eighteenth century (p. 13).

The Community Support Movement

During the mid-1970s, a new reform movement emerged out of the community mental health movement. The new community support movement (U.S. Department of Health and Human Services, 1999) advocated acute treatment and prevention and added the new dimension of providing for the social welfare needs of individuals incapacitated by mental illness, with a view to returning them to adequate functioning as citizens (Goldman, 1998). The concept of recovery became an important part of the picture. Beginning in the late 1970s, as former mental patients and their families became active regarding mental illness, new organizations such as the National Alliance for the Mentally Ill (NAMI) began to advocate for adequate services to help the most seriously mentally ill.

FAMILY THERAPY

The conscious emergence and flowering of family therapy also marked the 1950s and 1960s. Family therapy, therefore, began to attract many professionals at approximately the same time that the community mental health approach was adopted. During the period in which family therapy was developing, professionals generally were reluctant to acknowledge that they were working with families. The individual was the focus of treatment. Psychoanalytic theory largely shaped the therapy world and provided strictures against working therapeutically with more than one person at a time. It was in the late 1950s, particularly after some disclosures at the 1957 annual conference of the American Psychiatric Association in Chicago, that many psychiatrists and psychologists began to acknowledge openly that they had been working with families, instead of simply with individuals.

Family therapy, which has a much more varied and complex background than is frequently recognized, developed and emerged from several different sources. It came from marital therapy roots, the child guidance movement, the social work emphasis on working with families, family life education and counseling developments, and—the source typically cited—researchers and clinicians seeking a cure for major mental illnesses, especially schizophrenia (Broderick and Schrader, 1981, 1991; Nichols and Everett, 1986; Nichols, 1996). Many family therapists were working with a wide range of other types of mental illness and psychological and relationship disturbances; they were not primarily or even incidentally, in some instances, concerned with schizophrenia.

One of the major pioneers of family therapy, counseling psychologist John Elderkin Bell, began working with total families after mistakenly concluding from a conversation with a colleague in England that John Bowlby at London's Tavistock Clinic was working with complete families at all sessions. (Bowlby actually was working with family members individually and seeing them together for an occasional conference.) Some who had been working with families and family systems under the rubric of “counseling”—the term “psychotherapy” being largely restricted to psychiatrists prior to that time—nevertheless were doing serious therapeutic work with problem populations, although they were not attracting much attention.

The early days of trying to introduce family therapy into the treatment programs of community mental health centers and other outpatient treatment facilities were marked sometimes by tremendous conflict. Some of these are reflected in the trenchant article of Jay Haley (1975) titled, “Why a Mental Health Clinic Should Avoid Family Therapy.” Others have described, in informal anecdotal accounts, being ordered to refrain from working with families and to destroy films and recordings they were using to train therapists. At the core of many conflicts were disagreements over focusing on an individual versus a family systems orientation.

In 1970, the committee on the family of the Group for the Advancement of Psychiatry (GAP)—which included Murray Bowen, Ivan Boszormenyi-Nagy, Norman Paul, and Lyman C. Wynne—highlighted part of the issues with a reference to diagnostic evaluation in family or conjoint marital treatment:

The traditional terminology used for individuals in individual psychotherapy does not apply to a group of patients. One cannot label the psychological maladaptations with one term; the malfunctioning and problems may vary sharply from one member to another. What is needed, then, is a new nomenclature, a new method whereby the problems of an entire family can be diagnosed systematically and validly, (pp. 545-546)

Unfortunately, support for the development of such a nomenclature has been slow in developing. Other sources of conflict pertained to medical versus nonmedical therapy and therapists and political (i.e., power) issues.

FAMILIES AND THEORIES OF CAUSATION OF MENTAL ILLNESS

According to Walsh (1996), opinion in the field of mental health has tended to alternate between dichotomous assumptions of biological and social causation. Walsh indicates that simplistic either/or arguments for genetic versus environmental explanations have been common regarding the transmission of schizophrenia and have bred controversy regarding the family's role in its etiology and course as well as family involvement in treatment. In this polarization, some argue that schizophrenia is a myth, symptomatic of a problem family that has caused or needs to maintain schizophrenia to serve a family function, and oppose diagnosis, hospitalization, or medication. At the opposite pole, biological determinists have relied primarily on psychopharmacological treatment and tended to keep families out of treatment.

Families and Etiological Explanations

Starting with psychoanalytic theories and assumptions that produced such ideas as “the schizophrenogenic mother” (Fromm-Reichman, 1948), a considerable amount of professional opinion moved along to a more general blaming of the family for illness among its offspring. Socially, also, the family tended to be viewed in pathological terms. A variety of illnesses and disorders manifested by individuals came to be viewed as stemming from family deficits and negative influences.

In the 1950s, schizophrenia was defined by some theorists and researchers as a learned pattern of communication instead of an illness of the mind. The now familiar double-bind hypothesis set forth by Bateson, Jackson, Haley, and Weakland (1956) in an influential article titled “Towards a Theory of Schizophrenia,” attracted a considerable amount of attention and elevated hopes for a breakthrough in understanding and treating that disease. Eventually scholars and clinicians concluded that double-bind communication was no more prevalent in families of schizophrenics than in other families (Hatfield, 1987, p. 11); the theory was dropped as an etiological explanation.

Other attempts to explain schizophrenia in terms of family patterns and interactions that were advanced included the constructs of marital schism and skew (Lidz, Fleck, and Cornelison, 1965), other family communication disorders (Wynne, 1978), and disorganized family behavior and hierarchical incongruities (Haley, 1980; Madanes, 1981). Optimistic claims on the part of some early family therapists regarding a presumed discovery of the etiology of schizophrenia were not supported.

Biopsychosocial Model of Disease

George Engel (1977) offered the biopsychosocial model of disease, a framework which theorizes that biological, psychological, or social factors may be causes, correlates, and/or consequences in relation to mental health and mental illness (U.S. Department of Health and Human Serv...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Table of Contents
• About the Editor
• Contributors
• Foreword
• Preface
• Acknowledgments
• Part I: Overview
• Part II: Traditional Populations
• Part III: Special Populations
• Index