Depression,the Family,and Family Therapy

The potential contribution of family therapists to the treatment of depression remains underdeveloped. Family therapists need to articulate how changes in family functioning might benefit depressed persons, as well as how other problems in the families of depressed persons tend to go unrecognised. Furthermore, family therapists need to be alert to how undetected depression in adults and children may interfere with their ability to meet their goals with families who seek therapy for other persons. This article provides family therapists with (1) an overview of the nature and experience of depression; (2) an introduction to antidepressant medication; (3) a summary of research findings relating depression to its family context and (4) a brief overview of developments in the marital and family treatment of depression.     

THE EFFECTIVENESS OF FAMILY THERAPY IN THE TREATMENT OF ADOLESCENTS WITH CONDUCT DISORDERS AND DELINQUENCY

A literature review was conducted on recent studies using family therapy approaches to the treatment of conduct disorders in adolescents. Results from studies conducted since the Shadish et al. (1993) meta-analysis on the effects of family and marital therapies are included. Barriers to effective treatment are identified, costs of care are discussed, and a variety of systems of care in which family interventions are embedded are reviewed.     

Preliminary estimates of cost-effectiveness for marital therapy

Cost‐effectiveness of marital therapy was examined beginning with a simple question: If government or health insurers paid for the screening and, where indicated, empirically supported treatment of 100,000 randomly selected married persons (i.e., 50,000 couples) from the general population, would the financial benefits outweigh costs? Two empirically supported forms of marital therapy, behavioral marital therapy and emotionally focused therapy, were considered in aggregate as possible treatments of choice. Marital therapy appears to be cost‐effective when paid for by government to reduce public costs of divorce or when paid for by insurers to offset the increased health‐care expenses associated with divorce. Implications and specific needs for future research to substantiate these conclusions are discussed.     

The Case for Insurance Reimbursement of Couple Therapy

A case is made for why it may now be in the best interest of insurance companies to reimburse for marital therapy to treat marital distress. Relevant literature is reviewed with a considerable focus on the reasons that insurance companies would benefit from reimbursing marital therapy – the high costs of marital distress, the growing link between marital distress and a host of related physical and mental health problems, as well as the availability of empirically supported treatments for marital distress. This is followed by a focus on the major reasons insurance companies cite for not reimbursing marital therapy, along with a discussion of advances in several growing bodies of research to address these concerns. Main arguments include the direct medical offset costs of couple and family therapy (including for high utilizers of health insurance), and the fact that insurance companies already find it cost effective to reimburse for prevention of other health and psychological problems. This is followed by implications for practitioners and researchers.     

WHO'S DRAGGING THEIR FEET? HUSBANDS AND WIVES SEEKING MARITAL THERAPY

Despite its demonstrated efficacy, marital therapy's impact has been limited by couples' general reluctance to seek help until their problems become severe. To understand this delay, 147 married couples (294 individuals) in the process of seeking marital therapy were surveyed. Using multilevel confirmatory factor analysis, three relatively independent steps (problem recognition, treatment consideration, and treatment seeking) were identified. On average, wives were rated as completing all three steps before their husbands. Gender-role orientation, demographics, relationship satisfaction, and specific relationship problems (especially husbands' dissatisfaction with sex) were also predictive of the steps toward therapy. Implications for marital therapy are discussed.     

THE EFFECTIVENESS OF FAMILY INTERVENTIONS IN THE TREATMENT OF PHYSICAL ILLNESS

Although a large body of research demonstrates that the family has a powerful influence on physical health, the evidence for the effectiveness of family interventions in physical illness is less conclusive. Family therapy and other family interventions appear to be most effective in chronic childhood illnesses such as asthma and diabetes. Family interventions have also been shown to be effective in the management of some cardiovascular and neurologic disorders and for the treatment of obesity. Family therapy appears to be more effective than individual therapy for some groups of patients with anorexia nervosa. This research supports the increasingly important role of medical family therapy in the new health care system. Recommendations for future research are discussed.     

Anxiety Disorders and Family Therapy

The role of family therapy in anxiety disorders is controversial. Empirical data exist only in relation to agoraphobia and obsessive compulsive disorders. Experienced clinicians, generally working with complex cases, regard marital and family conflict as central to many cases, which require a family approach for optimal therapy. In contrast, research workers generally regard marital and family factors as irrelevant to treatment. This is because complex cases are usually excluded from empirical research. This leaves mainly uncomplicated cases without significant family conflicts, for which a family approach is rarely necessary. Techniques for treating anxiety disorders in a marital/family setting are outlined.     

THE EFFICACY OF MARITAL AND FAMILY THERAPY: AN EMPIRICAL OVERVIEW, CONCLUSIONS, AND RECOMMENDATIONS

Based primarily on the contributions to this Special Issue of JMFT, this article provides an overview of the empirical research on the efficacy of marital and family therapy for the following disorders and problems: schizophrenia; affective (mood) disorders; slected externalizing, internalizing, and pervasive developmental disorders of childhood; adolescent conduct disorder; marital distress and the prevention of divorce; alcoholism; adult and adolescent drug abuse; and various chronic adult, adolescent, and childhood physical disorders. Convincing scientific evidence supports the efficacy of broadly defined marital and family therapy for the treatment of many disorders, as well as its superiority to standard and individual treatments for certain disorders and populations. We conclude with recommendations for future research as well as for collaborative initiatives between marital/family therapists and other professionals working in the marriage and family field.     

A REVIEW AND EVALUATION OF MARITAL AND FAMILY THERAPIES FOR AFFECTIVE DISORDERS

Although the efficacy of individual treatments of affective disorders has been well-documented, there are also significant limitations to existing treatments. In the last decade attention has focused increasingley on the interpersonal context of affective illness, and on marital and family relationships in particular. As a result, a number of approaches have been developed which directly involve family members in treatment. In this article we evaluate the current status of marital and family therapies for affective illness. We begin with a discussion of several lines of research bearing on the relationships between family processes and affective illness. The available treatment outcome data evaluating the efficacy of marital and family interventions are then reviewed, with particular attention paid to predictors of treatment success and cost efficacy issues. Finally, we suggest several priorities for future research.     

Meta-analysis of MFT interventions

This article briefly reviews 20 meta-analyses of marital and family interventions. These meta-analyses support the efficacy of both MFT for distressed couples, and martial and family enrichment. Those effects are slightly reduced at follow-up, but still significant. Differences among kinds of marital and family interventions tend to be small. MFT produce clinically significant results in 40-50% of those treated, but the effects of MFT in clinically representative settings have not been much studied. The article also introduces the concept of meta-analytically supported treatments (MASTs), which are treatments that meet certain criteria for efficacy in meta-analysis, and which remedy certain problems in the empirically supported treatment (EST) literature. The article concludes with recommendations for doing better meta-analyses.     

Residency training and the later use of marital and family therapy in psychiatric practice

Marital and family therapy training during psychiatry residency was compared to later use, in practice, for 87 psychiatrists. Respondents reported modest to minimal amounts of training in residency but practiced marital and family therapy with a variety of problems, identified a spread of effect to other treatment modalities, and preferred marital and family therapy second only to individual therapy. These results suggest a trend towards incorporating marital and family therapy into psychiatry and also indicate levels of training which must be exceeded in order to achieve basic competency.     

Analysis of projective identification: An object-relations approach to marital treatment

Projective identification is an important construct to both analytic and family therapy practice approaches. It is an especially useful concept in marital therapy, and can be used as the foundation for assessment and intervention. This paper provides an overview of projective identification and an illustration of its use in marital treatment.     

Family Planning

In the past two decades, several fertility variables have been shown to have an effect on marital stability: presence or absence of children. child spacing, birth timing, and total number of children. Only one paper can be found that directly implicates the planning component of fertility, and then only from a theoretical perspective. This paper studies the effect on marital sta. bility of the planning of fertility. The research upon which this paper is based was done in Spokane County in Spring 1977. A random sample of divorced persons(N = 165) was compared to a matched group of persons who had not divorced (N = 102). It was found that it was not possible to predict marital stability from knowledge of number of children, presence or absence of children, or timing of childbirth in relationship to marriage date. A significant predictor of marital stability, however, was found to be whether or not the children were planned. Several implications of these findings for social work practice and for family planning clinics are discussed.     

TREATMENT ACCEPTABILITY OF ALTERNATIVE MARITAL THERAPIES: A COMPARATIVE ANALYSIS

Client acceptability of treatment procedures has recently become a significant concern in the assessment of psychotherapeutic effectiveness (Kazdin, French & Sherick, 1981; Wolf, 1978). Formally, acceptability refers to the fairness, appropriateness and intrusiveness of the treatment procedure as judged by clients, lay persons and nonprofessionals (Kazdin, 1980a). Unfortunately, marital and family therapists have yet to utilize this criterion in an evaluation of their psychotherapeutic interventions. Consequently, the purpose of the present investigation was to examine the acceptability of four differing therapeutic models (psychoanalytic, behavioral, systems and eclectic) used in the treatment of marital discord.     

Antecedents and consequences of negative marital stressors

Many couples seeking therapy report the occurrence of severe, negative marital stressors (e.g., infidelity, threats of marital dissolution). In addition, existing research has demonstrated that these marital stressors precipitate Major Depressive Episodes and psychological symptoms. This longitudinal study examines the antecedents and consequences of negative marital stressors to help clinicians and researchers develop interventions that might prevent these stressors and their outcomes. Forty-one women completed a semistructured interview and measures of marital discord and depressive symptoms within one month after experiencing a marital stressor (baseline) and at a 16-month follow up. The results indicate that baseline marital discorded contributes to the occurrence of additional marital stressors during the follow-up period. Although baseline depressive symptoms do not predict additional marital stressors, depressive symptoms along with marital discord predict future depressive symptoms. Finally, baseline marital discord and additional marital stressors contribute to future marital dissolution. Clinical and research implications are discussed.     

ARE GOALS AND TOPICS INFLUENCED BY GENDER AND MODALITY IN THE INITIAL MARRIAGE AND FAMILY THERAPY SESSION?

Establishment of a goal is crucial to therapy, but identification of therapeutic goals may be difficult in conjoint therapy because each participant may identify a different problem. We examined the influence of gender on ability to successfully introduce therapeutic topics in marital and family therapy by conducting two studies. The first study evaluates the ability of therapists to identify therapeutic goals that matched goals prioritized by both women and men clients on pretherapy questionnaires. The second study examines the process of initial therapy sessions to see whether gender influences a client's ability to introduce a therapeutic topic. Results suggest that therapeutic topic is influenced by the interaction of gender and treatment modality. Specifically, therapists were better able to match women's pretherapy stated goals in marital therapy than family therapy, men were more successful at introducing topics in family therapy, and women were more successful at introducing topics in marital therapy.     

EXAMINING MULTICULTURAL COUNSELING COMPETENCE AND RACE-RELATED ATTITUDES AMONG WHITE MARITAL AND FAMILY THERAPISTS

This study investigates the relative contributions of social desirability attitudes, previous number of multicultural counseling courses taken, and racism and White racial identity attitudes together in predicting marital and family therapists' self-reported multicultural counseling competence. Results revealed that, when controlling for social desirability attitudes and the number of multicultural courses taken, racism and White racial identity attitudes in consort accounted for a significant amount of the variance in self-perceived multicultural counseling competence. Implications for marital and family therapy training, practice, and research are discussed.     

Marital Therapy,EMDR, Herman's Model of Recovery from Trauma The Journey of One Woman and Her Family

Judith Herman (1992, page 183) delineates a three stage model of recovery from trauma: 1) Safety, 2) Remembrance and Mourning, 3) Reconnection. She criticises current treatment methods for their failure to make a difference in the “constrictive symptoms of numbing and social withdrawal … and marital, social and work problems do not necessarily improve”. Family therapy has been criticised often for insufficient focus on emotion and general sensations. This case analysis will illustrate how these shortcomings can be successfully addressed with the use of marital counselling and EMDR. The use of multiple treatment approaches contributed to one client's resolution of recent trauma due to a car accident, of past crises due to marital infidelity and early childhood abuse, with significant changes for her in her current family as well as in her family of origin. Theoretical implications for “family therapy” are raised.     

The Clinical Uses of Video Therapy in the Treatment of Childhood Sexual Trauma Survivors

The power of visual images, combined with the increased availability of video taping equipment, has dramatically expanded the use of recorded images in psychotherapy over the past three decades. However, it appears that earlier video feedback techniques may not have fully capitalized on this modality's potential for catalyzing therapeutic change. Further, we have found scant literature on the use of video therapy in the treatment of adult survivors of sexual trauma. Drawing conceptually from a trauma model, as well as from cognitive behavioral and systemic/cybernetic frameworks, this article describes the therapeutic use of video therapy in the treatment of childhood sexual abuse. In video therapy, the patient is directed to independently view video recordings of therapy sessions to help correct cognitive and affective distortions resulting from trauma. How these distortions develop within the context of an incest "family trance" and how they are connected with processes of conditioning and programming are discussed. Further, the use of video therapy for marital therapy, perpetrator confrontations, and addressing suicidal impulses is described. The need for further empirical research is highlighted.