Psychoeducation Family Therapy and Medical Family Therapy

Family therapy was originally created to treat schizophrenia, but this approach fell into disrepute after the double bind hypothesis for schizophrenia was unsupported and after no research support emerged for other family theories of the etiology of schizophrenia. There was also concern about blaming families for their children with mental illness. Subsequently twin studies and other biological studies established a strong biological factor in schizophrenia. But in the 1970s, many professionals were dissatisfied with the long-term results of drug-only treatment for schizophrenia (usually accompanied with some form of supportive individual psychotherapy). At the same time, deinstitutionalization policies left families burdened by care for their members with chronic mental illness. On the professional front, biopsychosocial explanations and multimodal therapies became more acceptable during the 1980s as the field of therapy moved away from single models.

A number of psychiatrists and other family therapists working in mental hospital settings followed up on clinical observations about family influences on relapse and rehospitalization among young adult schizophrenics. Major figures included Ian Faloon, William MacFarlane, Carol Anderson, and J. P. Leff (see a discussion of this work in chap. 5, this volume). They produced a series of studies showing that psychoeducational family treatment was effective in preventing relapse and rehospitalization among people with schizophrenia (Anderson, Reiss, & Hogarty, 1986).

These therapists and researchers accepted the biological base for major mental illness. Reflecting earlier work by Lyman Wynne, they viewed the family environment as important as a possible precipitant and as a risk or supportive factor for maintaining treatment gains. The theory behind psychoeducational family treatment centered on expressed emotion, or critical overinvolvement of parents vis à vis their children with mental illness. As measured by the Camberwell Family Interview, expressed emotion was found to predict relapse and rehospitalization in schizophrenia.

Family psychoeducation works with individual families but is mostly done with family groups of relatives of the patient. The therapists present to families the biological theory of serious mental illness, along with findings for how families can best cope. They help families to learn low-key, nonreactive limit setting and problem solving, along with other behavioral strategies to support a healthy family environment. This treatment is combined with medication, social/vocational, and community-based interventions. Family psychoeducation for serious mental illness has an anomalous status in the field today: It is the best validated family treatment for serious mental disorder, and yet it is not widely practiced in psychiatric settings that are dominated by medical treatments.

Like family psychoeducation, medical family therapy embraces a biospsychosocial framework for health problems: body, mind, family, community, and wider environments. With roots in earlier work by pioneers such as Wynne and Minuchin, medical family therapy was crystallized by family therapists in the 1980s who worked in medical settings. The authors of this book were among a group that included Jeri Hepworth, John Rolland, Alexander Blount, and others. The term medical family therapy was originally coined by McDaniel, Hepworth, and Doherty in their 1992 book of that name. The authors criticized the family therapy field for abandoning early efforts (by Bateson, Bowen, Wynne, Minuchin, and others) to understand how biology works with family systems. Medical family therapy expanded the scope of family therapy beyond work with mental health problems to include the whole scope of health problems, especially chronic medical illness. Like other medical family therapists, McDaniel, Hepworth, and Doherty (1992) emphasized close collaborative work between therapists, physicians, and other providers. They formulated goals of this work as promoting agency and communion (autonomy and connectedness) in patients, families, and provider systems.

Medical family therapy is a metamodel, which means it is an overarching framework within which a therapist can use her or his preferred therapy model. This overarching framework emphasizes taking medical illness seriously instead of perpetuating the mind–body split; taking families seriously as a locus of health, illness, and coping; and seeing oneself as working as part of a team of multidisciplinary providers rather than a solo operator or part of a mental health team.

There were other important developments in second generation family therapy that did not lead to specific or enduring therapy models. For example, the Milan model of family therapy flourished for a time as a further development of strategic family therapy. It influenced leaders in the field but did not endure as a therapy model (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1980). Of special note is feminist family therapy, which emerged during the 1980s as a critique of male-oriented assumptions in the first generation models (Goldner, 1986). Feminists pointed out that the field came slowly to be influenced by second wave feminism and therefore carried biases about male power and female subordination in families and in the therapy room. They also noted the shortage of prominent women leaders in the field, a problem that was corrected in the decade of the 1990s. While not leading to a specific model of feminist family therapy, this second generation development has had a strong and enduring impact on the field.

THIRD GENERATION

Contemporary family therapists are more integrative and eclectic than their forebears, and emerging models reflect this shift. Two research-based, integrative family therapy models have become prominent in the treatment of children and adolescents with serious behavioral problems. They use many of the first and second generation family therapy tools but add an ecological perspective by working with multiple systems in the child’s life. They are also more explicitly research and evidence based.