Family And Psychiatric Illness Research Paper

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The term family therapy refers to the involvement of family members in the treatment of the patient. One participating member, as in the case of a spouse or partner, is sufficient to justify the use of the term. Family members included in the therapy may share the same household with the patient or live apart, and may be seen by therapists with or without the patient. Family therapy was introduced as a means of altering family relationships that were believed to contribute to the development of the patient’s illness. Recently, interventions have been mounted to help relatives cope better with long lasting illnesses without any implication that they have played a part in their causation.

1. Theories Of Family Causation Of Schizophrenia

Schizophrenia is one of the most severe mental illnesses and although relatively uncommon, affecting 1 percent of the population, can cause lifetime disability. Its causes are still unknown, although there is strong evidence for a contribution from inheritance. This evidence was scanty in the 1940s when psychoanalysts began to identify features of parental behavior that they linked to the development of schizophrenia. One of the earliest papers was by Hajdu-Gaines (1940), based on his psychoanalysis of four women with schizophrenia. He characterized their mothers as cold, rigorous, and sadistic and their fathers as soft, indifferent, and passive. Fromm-Reichman (1948), when discussing the problems patients with schizophrenia pose in psychoanalysis, coined the term ‘schizophrenogenic mother,’ which became common currency among psychiatric professionals. Coming from a similar background, Lidz et al. (1957) studied 14 families with a member suffering from schizophrenia and concluded that the parents’ marriages were either unbalanced in terms of power (‘marital skew’) or exhibited an emotional distance between the partners (‘marital schism’). Bateson et al. (1956) developed a theory that the irrational thinking of people with schizophrenia was induced by exposure to contradictory messages from their parents. They worked on the theory and came up with the term ‘the double bind’ that was an early formulation of catch 22. The double bind was defined carefully as a contradiction within the verbal content of a message, or between the words used and the feelings expressed. In addition, the recipient of the message is not allowed to comment on the contradiction (the doubling of the bind). Like FrommReichman’s term, double bind rapidly infiltrated the psychiatric vocabulary, and indeed went beyond into usage by the lay public. The basis of its popular appeal was in fact its greatest weakness as an explanation for the origin of schizophrenia, namely the fact that it was recognized immediately as occurring in everyday interchanges.

All the foregoing theorists were American, but Britain produced its own charismatic figure, R. D. Laing, who achieved popular fame during his lifetime. His formulation of schizophrenia was that it was a completely understandable response to the family’s efforts to drive one of its members mad (Laing and Esterson 1964). He believed the family selected one of its number as a scapegoat to bear the brunt of the family’s emotional tangles. His ideas also spread far beyond his colleagues to be taken up by young people in particular, who found the role of being their parents’ victim immensely appealing. A film based on his theory, called Family Life, was a popular success.

All four theories described above are flawed for the same reason: they were developed from clinical experience with highly selected groups of patients, and were not subjected to scientific tests of their validity by their originators. This would have entailed developing reliable measures of the phenomenon described, e.g., cold, rejecting mothers; double bind messages; and comparing their occurrence in representative samples of families of people with schizophrenia and in control families. One pair of theorists did just this: Lyman Wynne and Margaret Singer. Like Bateson’s group, they focused on distorted communication in the family, only they developed an extensive schema for rating varieties of what they termed ‘communication deviance.’ Using this method to rate transcripts of subjects’ speech they were able to distinguish parents of people with schizophrenia from parents of people with other psychiatric disorders and from normal subjects with uncanny accuracy (Singer and Wynne 1966). The results were so striking that they demanded replication and Hirsch and Leff (1971) attempted to do this using a British sample. They learned to make ratings of communication deviance reliably and assessed transcripts of parents of patients with schizophrenia and of parents of patients with neuroses. The former scored significantly higher than the latter but there was substantial overlap in the scores of the two groups. Thus, the parents of people with schizophrenia do seem to have an increased tendency to communicate in an unclear fashion, but this finding by no means proves that this lack of clarity induces schizophrenia in their offspring. An equally plausible explanation is that deviant communication in the parents is a manifestation of the genes they share with the ill family member. As a consequence of shared inheritance, 10 percent of parents of people with schizophrenia develop the illness themselves.

The theories presented address different parental qualities: their emotional responsiveness, the balance of power in their relationship, their ability to communicate. Each group of theorists has tended to formulate schizophrenia in terms of the particular abnormality they have focused on in the parents, rather than starting with a generally agreed concept of the nature of the illness. For example, Bateson’s group conceptualized schizophrenia as a disturbance of logical thinking, while Laing saw it as an attempt to escape from the role of victim. In fact schizophrenia produces pervasive disturbances in the entire mental life of the sufferer: thinking, feeling, perception, and communication may all be affected. None of the theories accounts for all the varied manifestations of this puzzling condition.

2. Family Therapy

2.1 The Introduction Of Family Therapy

Family therapy developed initially in relation to schizophrenia, fuelled by the widely held view among psychiatric professionals that parents induced the illness in their offspring. Experienced psychoanalysts brought their expertise to bear on families caring for a person with schizophrenia. This in itself was an unconventional use of psychoanalysis, which was traditionally centered on the relationship between the analyst and a single client. Although scientific evaluations of this adaptation of psychoanalysis are almost nonexistent, the pioneers realized after some years that they were making little impact on the illness. Rubinstein (1974), one of the most respected therapists in the field, wrote that ‘One of our earliest preconceptions, which proved to be unwarranted with the passage of time and our increase in experience, was that schizophrenic behavior could easily be modified if we treated the family conjointly, and if we helped the members sort out some of their distorted interpersonal dynamics.’ The disillusionment of therapists with this work can be documented by calculating the decline over time in the number of papers on schizophrenia in one of the premier journals dedicated to family therapy. In the first volume of Family Process, published in 1962, exactly half the papers were concerned with schizophrenia. By 1975, the proportion of papers dealing with this condition had dropped to 10 percent, and by 1990 to 6 percent.

While psychoanalytic therapists turned their attention to families with other types of problems, a few charismatic individuals continued the work with schizophrenia, developing their own approaches and techniques, which often departed radically from the tenets of psychoanalysis. Therapists who are convinced of the value of their work rarely submit their efforts to scientific evaluation and no rigorous studies have been conducted of these individualistic therapists.

2.2 Shift From Schizophrenia To Other Diagnostic Groups

The focus of family therapy shifted to disorders of children, such as bedwetting, tantrums, and school refusal. These disturbances proved to be much more responsive to a family approach than schizophrenia, partly because there is not likely to be a biological basis to these behavioral problems, and partly because children are much more under the influence of their parents than young adults. This point is underscored by the results of family therapy for eating disorders. This has beneficial results when the patient is a child or adolescent, but is less effective for adult patients, who do better with individual therapy (Russell et al. 1987).

2.3 The Influence Of Systems Theory

While psychodynamic approaches to family work continue to have their adherents, they have been eclipsed by the rise of systemic family therapy. This was based on systems theory as enunciated by Bertalanffy (1968). The family is conceptualized as a system that attempts to maintain its integrity by responding to change in one part of the system with compensatory changes in other parts. Homeostasis, then, is the overriding concern of the family system (Jackson 1957). When a child develops a disturbance such as bedwetting, this is seen as compensating for a disturbance between other members of the family, say a conflictual relationship between the parents. When the parents bring the child for treatment, the child’s symptoms are taken to signify dysfunction in the family system as a whole. For this reason the individual presenting for treatment is often termed the ‘designated patient,’ with the implication that this person has been selected by the family (unconsciously) as a messenger to the health professional that the whole family is in need of help. There is an echo here of Laing’s view of the person with schizophrenia as the scapegoat for the rest of the family.

2.4 Family Therapy Approaches

Structural family therapy was developed by Minuchin and co-workers and entailed a basic assumption about the way in which a normative family should function (Minuchin 1974). The therapist takes an active role in trying to mold the family as closely as possible to this ideal image. As it involved a view of the father as the head of the household, it was criticized as gender biased and ethnocentric. In response to this, structural therapists now request families to state how they would like to function, and then help them to achieve the necessary changes, thus incorporating cultural sensitivity.

Strategic therapy, by contrast with systemic therapy, takes the presenting symptom at face value and involves a narrow focus and a time-limited intervention. An important innovation of strategic therapists is ‘reframing,’ in which the problem as presented by the family is reformulated, often changing its negative connotations into positive ones. This can free the family from established patterns of behavior and enable them to respond to the ‘problematic’ member in a different way.

Systemic family therapy received a boost from a group working in Italy who became known as the Milan School. The key therapists were Selvini Palazzoli, Boscolo, and Cecchin. They introduced innovative techniques such as paradoxical injunctions, and focused on patients with eating disorders and with schizophrenia (Selvini Palazzoli et al. 1978). They developed an interviewing technique of circular questioning, which has become recognized by family therapists as a useful tool. An example would be the therapist asking one member to describe the relationship between two other family members. This will produce responses from all concerned and will prompt the therapist to formulate the next question. This process makes evident to the family the circularity of interaction, as hypothesized by systems theory. The fame of the Milan therapists was such that clients came to them from all over Italy. This made follow-up very difficult and no convincing outcome research has been conducted on their patients.

2.5 Research On Family Therapy

In fact systemic formulations about the family’s contribution to mental illness are difficult, though not impossible, to test scientifically. A number of instruments have been devised to measure the ways in which family members function when together, but these are not entirely satisfactory in grappling with the problem, since when several people are interacting they produce a vast amount of data. As an example, Mishler and Waxler (1967) recorded interactions between two parents and a single offspring. The recording, transcribing, coding, and scoring of the interviews required 129 hours of staff time for every hour of interview. For this reason greater success has been achieved by focusing on specific aspects of family interactions. The introduction of videotaping of family sessions, allowing replay, pausing, and slow motion, facilitated the study of interactions in great detail. One of the most productive lines of research has developed from the use of a measure of relatives’ emotional response to a sick family member, known by the term Expressed Emotion (EE).

3. Relatives Expressed Emotion

This assessment instrument was introduced to investigate one of the consequences of deinstitutionalization. In the UK it was found that patients discharged from psychiatric hospitals to live with close relatives were more likely to be readmitted than those who went to live with more distant kin or with landlords. George Brown, a sociologist, had a hunch that it was to do with the emotional relationship between patients and their close relatives, and with Michael Rutter, a child psychiatrist, developed a technique to measure these. It is based on a semistructured interview with the relative enquiring about the patient’s behavior and symptoms in the previous three months. The interview is audiotaped and ratings are made later from the tape. These depend partly on what the relative says and partly on the way their voice is used to convey emotion. The key ratings are of critical comments, reflecting how angry the relative is with the patient, hostility, representing rejection of the patient, overinvolvement, comprising overprotection and overidentification, and warmth.

3.1 Relatives EE And Schizophrenia

The initial studies were of patients with schizophrenia, since this was the most common diagnosis in patients discharged from long-term hospital care (Leff and Vaughn 1985). It was found that relatives’ negative emotions—critical comments, hostility, and over involvement—were each associated with a greater likelihood of the patients to relapse. Consequently, they were combined into an index of Expressed Emotion (EE) and relatives were classified as high or low EE. In most parental households both parents were congruent in being either high or low EE. When they differed in their ratings, the highest rating was taken as characterizing the household. By contrast with the ratings of negative emotion, warmth was associated with a better outcome for the patients. Thus, it appeared that the family members could influence the course of schizophrenia either in a positive or a negative way.

The early studies of EE aroused a great deal of interest since they demonstrated that family members’ emotional relationship with the patient could be measured reliably, and furthermore that these relationships appeared to determine the outcome of the patient’s illness. It should be emphasized that, unlike the theories of causality reviewed above, it was not claimed that high levels of EE antedated the appearance of schizophrenia or played any part in its etiology. If there was any causal influence, it was on the subsequent course of the illness once it was established. Many groups have replicated the link between EE and the outcome of schizophrenia, with the result that it is now one of the best evidenced associations in psychiatry (Butzlaff and Hooley 1998). These replications have been carried out in a number of languages and cultures, including India, China, and Japan, showing that the association is independent of variations in family structure and function.

3.2 Family Interventions For Schizophrenia

The research on relatives’ emotional responses and schizophrenia led to a revival of interest in working with the families of such patients. However the approach was quite different from that of the earlier generation of therapists. Instead of viewing the family as pathogenic and in need of treatment, the new attitude was one of respect for the carers and a genuine desire to work with them as allies in the struggle against the illness. This in itself was revolutionary since for decades family members had been subject to vilification and rejection by mental health professionals. Instead of the patients being scapegoated by their families, as Laing had claimed, it was the relatives who were treated as scapegoats by the professionals. Relatives were denied information about the patient’s illness on the grounds of confidentiality, which unnecessarily hindered their attempts to understand what was happening to the patient. Partly as a response to this treatment, relatives formed national organizations, such as the National Schizophrenia Fellowship in the UK and the National Alliance for the Mentally Ill in the US. This development raised the profile of relatives, gave them access to political power, and increased their confidence in dealing with professionals.

Controlled trials of family interventions for schizophrenia began to appear in print in 1978 and over the next two decades more than a dozen such studies were published (Lam 1991). They all employed the same design, namely a comparison of family intervention plus antipsychotic medication against medication alone. This design reflects the important assumption that antipsychotic medication is an essential basis for the treatment and maintenance of a person with schizophrenia, but that working with the family to improve the management of the condition confers an added benefit. Indeed, this series of studies provided strong evidence for that proposition. Patients’ relapse rate over one year was reduced from an average of 50 percent with medication alone to 20 percent or less by the addition of family interventions.

Despite a multiplicity of names, the interventions share much in common. They all start with an educational program which conveys to the family information about the causes of schizophrenia, the symptoms, the likely outcome, and the treatment and management. This is followed by instruction in problem solving, improving communication, reducing the intensity of negative emotions, utilizing the family’s natural support networks, and developing realistic expectations for the patient. The general aim of the approach is to build on the family’s strengths and to facilitate their mutual co-operation in coping with the illness.

3.3 Testing Systems Theory

Some programs were delivered by sessions in the family’s own home, a radical departure from traditional family therapy, in which treatment often took place in a special clinic room equipped with a one-way mirror to allow the whole team to monitor the interactions between therapist and family. Home visits are an effective way of engaging families, as well as enabling the therapists to observe families in their natural surroundings. These advantages have to be weighed against the extra staff time taken up by travel. Other programs set up groups for relatives that were run by professionals on the same lines as the family sessions. Voluntary organizations for families often establish self-help groups, but when they invite professionals along it is to provide information and not to institute therapy. Indeed they reject the term ‘family therapy’ as implying that relatives are pathological and in need of treatment themselves.

One American therapist, Bill McFarlane, based his program on multifamily groups that included patients as well as relatives. He has produced some evidence that these are more effective than groups comprising only relatives (McFarlane et al. 1993). Relatives groups provide the opportunity to test one of the basic tenets of systems theory, namely that altering one part of the system can effect change in the entire system. In the course of evaluating family interventions for schizophrenia, Leff et al. (1989) compared the effectiveness of family sessions with a relatives group from which patients were excluded. They found that relatives who attended the group showed a significant reduction in EE and this was accompanied by a lowered relapse rate for the patients. Hence, altering one component of the system, the relatives, led to the desired change in another component, the patient.

3.4 Relatives EE And Other Illnesses

Since the original research on schizophrenia, the measurement of EE has been applied to a variety of other conditions, both psychiatric and physical. In the realm of psychiatry, high levels of EE have been found in relatives of patients with manic-depressive psychosis, depressive neurosis, dementia, learning difficulties, alcoholism, eating disorders, and post-traumatic stress disorder, and in families in which children have suffered physical or sexual abuse. High EE has been found to be linked with outcome in all these conditions, with the exception of dementia and learning difficulties. In the domain of physical illness, high EE attitudes have been recorded in relatives of patients with epilepsy, heart disease, diabetes, inflammatory bowel disease, and Parkinson’s disease. From this it appears that high EE attitudes can develop in response to any long-standing or recurrent illness, be it psychiatric or physical. However, an association with outcome is much stronger for psychiatric than for physical disorders. Regarding the latter, only for diabetes has a link been demonstrated and the evidence is equivocal.

It seems from this series of studies that the emotional attitudes of family members have a much greater impact on people suffering from disorders with an emotional basis than on people with physical illnesses where there is a demonstrable pathology. The exception might seem to be schizophrenia, in which brain abnormalities have been demonstrated. However, a high proportion of patients with schizophrenia experience depressive symptoms and they are responsive to the same adverse events in their life as are people with a depressive illness. Hence, the underlying brain disorder does not negate their sensitivity to the social environment.

4. Couple Therapy For Depression

Marital therapy, as it used to be called before marriage went out of fashion, has a long history, and developed to help couples resolve their relationship difficulties or to part amicably. In the UK, a voluntary organization, Relate, trains counselors in the skills needed for couple therapy. However, there is not usually an identifiable psychiatric illness in either member of the partnership. In recent years, a small number of studies have tested the value of couple therapy for people with a depressive illness. In most of these, couple therapy has been compared with cognitive therapy, a treatment of known effectiveness for depression that focuses on the individual patient. In general, couple therapy has been found to be as effective as cognitive therapy for improving depression, but has stronger effects on the couple’s relationship.

A recent study tested couple therapy against the best possible regime of antidepressant medication for depressed patients who were in a stable relationship. Both treatments were continued for one year and then stopped, after which the subjects were followed up for a further year. This design was chosen because most treatments in use improve depressive symptoms: the challenge is to reduce the liability for the symptoms to recur. The couple therapy was given by two systemic therapists who focused on the relationship between the partners as being the means by which the depression was maintained. The patients who received couple therapy showed a greater improvement in depression than those assigned to medication, and this advantage for couple therapy persisted over the second year after treatment had been stopped (Leff et al. 2000). Hence, changing the relationship between patient and partner was more effective both for treatment and prevention than altering the biochemistry in the patient’s brain.

5. The Family As A Therapeutic Resource

Since family therapy was first introduced, there has been a major shift in professional attitudes from holding relatives responsible for the patient’s illness to viewing them as allies in a struggle to help the patient overcome symptoms and disabilities. Alongside this sea change, western families have been altering in their composition, structure, and function, requiring a greater flexibility in professional inputs. Several schools of family therapy have developed, each with their own distinctive concepts of the family, and have introduced novel techniques. Not all of these have proved their worth, but the emerging evidence of family influences on the course of a wide range of psychiatric disorders is a spur to test existing methods of working with families and to develop innovative ones.

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