USE OF FAMILY IN THE TREATMENT OF SCHIZOPHRENIC AND PSYCHOPATHIC PATIENTS*

Editor's Note. Occasionally, the Journal of Marital and Family Therapy will publish papers of major historical significance to the field of family therapy which, though written long before their appearance in the Journal, have remained unpublished and received little public circulation or attention. Such papers are those which, in the view of the Editor, would have been certain “classics” in the literature of family therapy had they been published when they were written, and which, despite their overdue appearance, are of significant enduring value. The first of these papers, by Dr. C. F Midelfort, appears here. Though essentially isolated from the family therapy movement that was soon to follow, Dr. Midelfort, in fact, published the first book on family therapy. The present article grows out of what was probably the first paper on family therapy ever presented at a psychiatric convention in the United States. In this paper, originally written almost exactly thirty years ago, Dr. Midelfort articulately presents a creative interweaving of an appreciation of the psychodynamics of family relationships with an ego-oriented family approach to severe psychiatric disturbance in one family member. It is an innovative presage of the flexible use of the principles of family dynamics, social psychiatry and biological psychiatry that has been “discovered” only very recently in family therapy with schizophrenics. The paper is introduced by Dr. John E. Bell, to whom the Journal is grateful for bringing it to light.     

GROWTH BEHIND THE MIRROR:, THE FAMILY THERAPY CONSORTIUM'S GROUP PROCESS

An earlier paper (Wendorf, 1984) presented the pragmatic aspects and theoretical model of The Family Therapy Consortium, a group set up to provide supervision and continuing education in family therapy. The emphasis was on the development of each individual therapist's competency, the isomorphic relationship between the supervisor, group, therapist, and family levels of the therapeutic system, and the legitimacy of the term "peer supervision." Beginning under the leadership of an expert supervisor hired from outside the group, the Family Therapy Consortium has developed into a peer supervision group with a "floating," rather than fixed, supervisory hierarchy. The present paper charts this development and explores the peer supervision process as it currently works in the Consortium. The focus is on the growth of the individual behind the mirror as therapist, person, leader and group member, and on the growth of the group as a "mature sibling subsystem" no longer in need of outside supervision. Individual and group development are seen as complementary aspects of the same growth process.     

EMERGENCY PSYCHIATRY AND THE FAMILY: THE DECISION TO ADMIT

The author's work with families presenting to a psychiatric emergency service points to the prominence of families' wishes that one family member be hospitalized. The pressure on the cliniciancan be extreme. A number of studies in the literature on the decision to admit contain similar observations emerging from varied methodologies and vantages. The author draws from clinical practiceand the literature to focus on an interpersonal dimension to emergency interventions. Awareness ofinterpersonal forces upon mental health clinicians is crucial to allow mature balancing of the many factors involved in the decision making process. An integration of family and systems thinking into the practice of emergency psychiatry can enhance comfort and effectiveness in many difficult crisis situations.     

STAGES OF FAMILY INVOLVEMENT IN THE RESIDENTIAL TREATMENT OF ADOLESCENTS

A strong case has been made in the literature that the effective treatment of adolescents in long-term psychiatric hospitals or residential treatment centers must include treatment of the family. This highlights the need for a family treatment model that integrates a long-term psychodynamically oriented residential treatment approach with family systems theory. Such a model must take into account the stages of inpatient treatment and must address therapeutic management of the physical, emotional and psychological aspects of separation between the adolescent and the family. A bridge between family systems theory and psychoanalytic theory can be found in object relations theory. A four-stage model for working with families having a hospitalized adolescent member is described in which each stage builds upon the previous one. Progress through the stages depends upon the establishment of a relationship in which the family perceives the hospital as supportive, nonjudgmental, helpful and trustworthy.     

An Endangered Species: The Female as Addict or Member of an Addict Family*

When a woman is the identified addict or a member of a drug/alcohol abusing family system she often experiences considerably more psychiatric abuse than her male cohorts. This paper surveys some of the representative literature reflecting attitudes and practices imposed on these women. Explanations based on a study of healthy family systems are given with interpretations anchored in cultural rather than sexist phenomena. It is suggested that women need to be understood according to the complex interlocking transactions within family systems.     

THE JAPANESE TANSHIN FUNIN

This paper examines the tanshin funin, the Japanese commuter family. As a topic that has received little coverage in academia, this paper defines and explains the unique tanshin funin family structure that is found in Japan. Data were gathered from numerous sources, including interviews that were conducted in the Kansai region in 2000 and 2002, as well as secondary interviews and research that has been published by Japanese scholars and the media during the last two decades. First the absence of the tanshin funin from past family research is discussed, followed by the historical development of this family structure and the factors that enable and maintain its existence. The purpose of this paper is to recognize and explore the tanshin funin in Japan, as it is yet to be identified in Western academia.     

Maladaptive Coping as a Mediator of Family Stress

Family members of women substance users may be at risk for stress-related problems. Family coping responses may affect outcomes for both families and women in treatment. Eighty-two women in treatment for substance use disorders (56 with comorbid psychiatric conditions) and 82 family members were interviewed. Stressors related to women's disorders were significantly related to increased family member burden. Women's behavioral problems predicted greater family member Worry, Displeasure, and Impact. Extent of women's drug or alcohol use predicted greater family member Stigma and Impact. Family member maladaptive coping partially mediated relationships between family member stressors and family member Displeasure and Impact. Family member maladaptive coping also functioned as a moderator between the stressors and Impact.     

FAMILY ASSESSMENT IN CHILD CUSTODY DISPUTES*

This paper has operationalized family systems theory to explicate the interfacing dynamics between family dissolution and child custody disputes. The authors suggest that clinical assessment and intervention in these matters which focus solely on individual and marital, or child dimensions, fail to recognize the powerful influences of systemic family process. A family assessment model, evolved from clinical work with over 200 court-referred custody cases, is described. The model involves a cross-sex therapy team with each member responsible for a specific family subsystem. The role of each therapist and the functioning of the team is outlined. Specific criteria for determining custody recommendations are identified based on patterns of family process and dissolution.     

Parental Grief and Serious Mental Illness: A Narrative

Serious mental illness is associated with substantial personal and interpersonal distress and life disruption for the sufferer and for his/her family. A common response to having and caring for a family member with a serious mental illness is feeling loss and grief. This paper presents a representative narrative that attempts to capture the essence of the experience as conveyed by 22 parents of adult children with a serious mental illness. The implication of the narrative is examined.     

Treading the Path of Anticipatory Bereavement: Working with Families with a Dying Member in an Acute Care Medical Setting

The aim of this paper is to consider issues related to working with families with a dying member in an acute medical setting, using the framework of the Bower Place family therapy approach. The literature on individual and family anticipatory bereavement processes is reviewed and the Bower Place methodology of family therapy is outlined. A case example is used to illustrate the application of the methodology to a family facing the death of one of its members. The author highlights the need for therapists to consider second order cybernetic issues when working in this context.     

Depression movement in family therapy with depressed adolescents

Family therapists presume, observe, and predict that depression can move from member to member in the family system depending upon the dynamics of the system as a whole. When an adolescent who is depressed begins to improve in family treatment, many family therapists have reported that the parents will often begin to experience an increase in their level of depression. This observation has been reported but has not been objectively measured. In this clinical study of four families, adolescent and parental depression during family therapy is measured to determine if depression movement does occur during family treatment. Results indicate that in three of the four families the parents did initially show depression level increases reactive to improvement in the adolescent. Such findings are supportive to the idea that some forms of adolescent depression often do serve a family system function.     

A COMPARISON OF THE McMASTER AND CIRCUMPLEX FAMILY ASSESSMENT INSTRUMENTS*

This study compared clinical rating scales and self-report scales from the McMaster and Circumplex models of family functioning. Forty-one families were given self-report measures, while clinicians assessed the families using clinical rating scales. There are three main findings: (a) The McMaster instruments have superior sensitivity (i.e., ability to correctly identify clinical families based on instrument scores); (b) there is greater correspondence between clinical rating scales and family member self-report inventories on the McMaster instruments; (c) there is lack of support for the curvilinear model of pathology suggested by the Circumplex model, as evidenced by unequal and linear distribution of scores on the Circumplex dimensions.     

Adult child and elderly parent household

Intergenerational households—adult child and elderly parents—are an alternative lifestyle. A review of the literature suggests that several factors are related to the level of stress in these households. A number of structural, individual family member and family factors which may influence the stress level in intergenerational households are explicated. It is suggested that community resources mediate the linkages between the structural factors, individual family member factors, family factors, and the level of stress in intergenerational households. A number of practice strategies for preventing and dealing with stress are discussed.     

Reconstructing a Sense of Relational Agency in Family Therapy

The concept of agency is relevant in family therapy. As family therapists we approach each family member as a full agent, which means that what each person thinks and feels, makes sense, and that each person contributes in a significant way to the construction of a relationship. A person's sense of relational agency is constructed in relationships through processes of relational influence. Thus, agency is a relational construct and is dependent on bidirectional transactions in a relationship. A person's sense of relational agency refers to the belief a person has about being able to influence another person, that this influence is significant for the other, makes a difference for the other, and contributes to the construction of the relationship. Many family members who enter therapy have lost their sense of relational agency. In this paper we discuss ideas how to reconstruct family members’ sense of relational agency in therapeutic practice.     

Traumatic Stress and Affect Management in Military Families

The war-time deployment of a service member creates significant stress for the family system that supports that person’s transition into combat, combat duty, and readjustment into civilian and family life upon return. The stressors associated with the deployment cycle are significant and can lead to depression, anxiety, and behavioral concerns for all family members including the children and partners. A family’s adaptation to these stressors can also impact the functioning of the service member during the phases of mobilization, deployment, sustainment, and reintegration. Social work interventions that offer support to the military family can reduce levels of distress within and between the members and improve overall family functioning. A case vignette will be presented that highlights some of the salient interpersonal challenges that can develop in a military family when a veteran returns home with posttraumatic stress that is left untreated. Recommendations for interventions will be considered through the application of psychoeducational approaches for managing traumatic stress in families.     

Predictors of Burden of Family Caregivers of Women with Substance Use Disorders or Co-Occurring Substance and Mental Disorders

ABSTRACT

This study examined the impact of having a female family member with a substance use or co-occurring disorders on family caregivers. Predictors of subjective burden (worry, stigma, and displeasure) and objective burden (family disruption) on caregivers and on types of burden were explored. Subjects were 82 women receiving substance abuse treatment and their family member providing most social support. Behavioral problems of the recipient and lack of social support for caregivers predicted higher levels of family member burden, with different types of social support predicting different types of burden. Having a dual disorder did not predict family member burden. Implications of findings for treatment are discussed.     

How are we doing? Results of receiving family-driven feedback on alliances between families and residential treatment staff over time

Developing working alliances and actively engaging families is essential for youth success in residential treatment. Ideally, these alliances can be fostered by sharing feedback with residential staff about their alliances with families over time to encourage more family engagement and better outcomes for families of youth in treatment. This study measured alliances between families and residential treatment family workers and assessed the effectiveness of an unobtrusive method of sharing working alliance feedback with residential treatment staff. Results revealed that family members rated the working alliance higher than family workers, and that these discrepancies in scores converged over time. In addition, higher family member ratings of the alliance predicted higher family functioning, and longer time in treatment resulted in higher family functioning scores. Lastly, receiving feedback about the working alliance resulted in higher family member ratings of the alliance with their family worker.     

Too sick to move: distant ‘crisis’ care in transnational families

This paper examines the crisis of acute and chronic illness, death, and dying in transnational families. These are the stages in the family life-course when physical co-presence is required to deliver hands-on care and intimate emotional support for the sick family member. It is a time when distant kin feel they need ‘to be there’, including for their own sense of well-being. This period of ‘crisis’ (in the anthropological sense) makes visible all of the impediments to transnational family caregiving that often remain hidden during those periods when ‘routine’ forms of distant care are adequate. Of particular relevance are the macro-level factors generated by national borders and the policies that define them, including those that govern employment, travel, visa, health, and aged care provisions. It is in these family life phases of crisis that nation-state structures can work to constrain individual agency and rights, making compellingly evident the growing need for transnational structures and policy. At issue are the largely invisible (in a policy sense) but increasingly common micro-level responses of family and individuals that characterize ‘crisis distant care’, which are characterized by the urgent need to visit and to intensify use of ICTs. The paper examines the experiences of migrants living in Australia who are trying to care for acutely unwell family members abroad.     

Problematic Integration and Family Communication about Decisions at the End of Life

Making a decision on behalf of a family member at the end of life (EOL) is a highly uncertain and anxiety-ridden experience. To examine how families navigate this complex, emotionally stressful situation, Problematic Integration theory was applied as a lens for understanding EOL decision experiences managed in the context of the family. Drawing on qualitative data from interviews with 22 family members who participated in family conversations about an end-of-life decision, this study demonstrated that family members encounter multiple sources of uncertainty and divergence, including questions regarding whether or not a family member’s life is ending, what the decision should be, and who should make or participate in the decision. Family members’ stories also identified ways in which medical professionals and communication about the wishes of the patient helped family members manage problematic integration. Finally, findings revealed experiences where problematic orientations were not transformed after family members made an EOL decision.