effectiveness of family interventions in the treatment of physical illness, The
Campbell, Thomas L
Until recently, family therapists and family researchers have largely ignored physical illness and its relationship to the family. This is partly a result of our cultural split between mind and body and biology and psychology, as well as the tendency of family therapists to avoid the biological aspects of family life. Exceptions to this trend have been the pioneering work of Bowen (1976), Minuchin (Minuchin et al., 1975) (described below), Weakland (1977), and Wynne (Wynne, Cromwell, & Matthysee, 1978). More recently, there has been a growing interest in the role of family therapists working in medical settings, caring for patients with physical illnesses and collaborating with medical providers (Seaburn, Gunn, Mauksch, Gawinski, & Lorenz, in press). In 1983, Donald Bloch(1983) began the journal, Family Systems Medicine, which addresses the interface of family therapy and medicine. In 1992, McDaniel, Hepworth, and Doherty (1992) coined the term medical family therapy to refer to “biopsychosocial treatment of individuals and families who are dealing with medical problems” (p. 2). More recently, family therapists, family nurses, family physicians, and others have come together to form the Collaborative Family Health Care Coalition to help promote a more family-centered and collaborative model of health care delivery (Bloch, 1994).
The U.S. health care system is in the midst of enormous changes, unlike any that have been seen since the early part of this century. Under tremendous pressure to control rising health care costs, most health care services are being reorganized into large, vertically integrated, managed care systems in which providers must demonstrate that they are offering the most cost-effective services available. Although this new health care system will provide many challenges to family therapists, it does offer new opportunities to demonstrate how collaborative health care that integrates traditional medical care with psychosocial services can provide the most effective and cost-efficient services. With these health care changes rapidly spreading across the country, it seems to be an important time to review the evidence that family interventions can lead to better health outcomes in the treatment of physical illness.
In the past two decades, a substantial body of research has been published exploring the relationships between family factors and health, accompanied by increasing recognition of the importance of the family in all aspects of health care (Campbell, 1986; Doherty & Campbell, 1988; Fisher, Ransom, Terry, Lipkin, & Weiss, 1992; Turk & Kerns, 1985). This family and health research has clearly demonstrated that the family has a powerful impact on an individual’s physical health. Despite these advances in our understanding of the relationships between family factors and health, research on family interventions in health care remains in its infancy. There are very few randomized controlled trials of family therapy in health care. Most of the studies are case reports or uncontrolled trials of family interventions. Part of the reason for this lack of research is that we are just beginning to understand what family variables are important in physical health and how they exert their influence. For example, there is strong evidence that social support, particularly from the family, profoundly influences overall morbidity and mortality and the course of most chronic illnesses (Cohen & Syme, 1985; House, Landis, & Umberson, 1988). In a comprehensive review of this research, House et al. (1988) conclude:
The evidence regarding social relationships and health increasingly approximates the evidence in the 1964 Surgeon General’s report that established cigarette smoking as a cause or risk factor of morbidity and mortality from a range of diseases. The age-adjusted relative risk ratios are stronger than the relative risks for all causes of mortality reported for cigarette smoking. (p. 543)
In 1964 it was not known what elements of cigarette smoke were carcinogenic, and there were few studies to demonstrate that smoking cessation resulted in improved health. In 1995 we are in an analogous situation with family and health research. It is not known what the most important aspects of family relationships are, how support from within the family and external to the family relate to each other, and how the processes of family support influence health. Some have even suggested that it may not be support but rather the absence of family conflict that is a key variable in physical health (Coyne, 1990). The results of social support intervention studies have been disappointing, partly because they have been unable to increase the levels of family support (Gottlieb, 1988).
In this paper we review the literature on Family interventions in child and adult physical illness and in health promotion and disease prevention. Among published studies, the concept of “family intervention” or “working with families” is often used loosely and is not always well-defined. For example, providers of services to children usually think of their work as involving the family since children’s access to and use of health care services depends largely on parent(s) or other family caregivers.
For this review we have defined a family intervention as any intervention that includes at least two members of a family, usually the patient and another family member. We chose not to restrict our focus to family therapy interventions for several reasons. First, there are very few controlled trials of interventions that are labeled as family therapy or conducted by family therapists. Second, the distinction between what is considered family therapy and what is not is not always clear. Many of the interventions reviewed are types of family psychoeducation and include elements of family education, family support, and problem solving. However, they have not often been labeled as family therapy or carried out by family therapists.
Third, even when family interventions in health care are not considered family therapy, they are relevant to family therapists who are working in health care and to the field of family therapy as a whole. Family therapists, with their systemic orientation and knowledge of family process, can expand their work beyond narrowly defined family therapy and play an important role in the design, implementation, and study of family interventions of all types. Often these interventions are designed and implemented by researchers and clinicians who have little understanding of families and family systems concepts. This knowledge should enable family therapists to expand their methods of intervention to deal with physical illness if their approach is not so constricted as to exclude biological systems.
Finally, any evidence that a family approach to health care and physical illness is more effective than an individual approach provides strong support for the need to have family professionals involved in the training of health care professionals, as well as being an essential member of health care teams (McDaniel, Campbell, & Seaburn, 1990). Research on family interventions can support the role of family therapists as direct care providers, health care consultants, educators of health care professionals, and researchers in the field.
We recognize that the distinction between physical and mental disorders is an artificial and culturally determined one. There are no purely physical or mental disorders, but all diseases have been demonstrated to be biopsychosocial entities which can be influenced by biomedical and psychosocial processes.
To conduct as comprehensive a review as possible, we conducted a computer search of Index Medicus and Psychological Abstracts using the following search terms: family, family intervention, family support, marriage, physical health, chronic illness and the name of each of the specific disorders reviewed. We checked the references of the studies we reviewed and several comprehensive reviews of the family and health literature. We also reviewed the contents of selected journals that frequently include studies related to family and health (e.g., Family Systems Medicine, Family Process, Journal of Family Psychology, Journal of Pediatric Psychology). Finally, we solicited references from numerous experts in the field. We were impressed by the broad range of disciplines involved in the field, including family therapy, nursing, medicine (especially family medicine, pediatrics, geriatrics, rehabilitation medicine, behavioral medicine, and psychiatry), psychology, nutrition, behavior therapy, and social work. Intervention studies from over 100 different journals are included.
In general, we included all intervention studies in which there was some attempt to provide a control group. Although we believe that case studies and case series play an important role in expanding our understanding of what types of family interventions may be effective, we excluded most of them from this review, in which we attempt to evaluate the overall effectiveness of family interventions for physical disorders. In most of the areas reviewed, there are just a few studies of family interventions, usually with different types of interventions or target populations. As a result, it is not feasible or meaningful to attempt a meta-analysis of family interventions in physical illness as a whole or for most individual health problems.
Most of the family interventions in the literature can be loosely classified into one of four categories based upon the intensity of the family intervention and the level of knowledge and skill needed to provide the intervention. There is considerable overlap among these categories, but we have found them helpful for organizing the literature and understanding what types of effects different types of interventions have across different studies.
The categories are:
1. Family therapy. Family therapy interventions are usually conducted by a family therapist, using one of the family systems models or theories. In general, the problem is considered to reside within the dysfunctional family, and therapy is provided to individual families for a limited number of sessions.
2. Family psychoeducation. Family psychoeducation is generally focused on helping the family to cope more effectively with an illness or disorder, although there are many family therapists who incorporate a psychoeducation component in their work. Family psychoeducation assumes that the family is healthy and that family problems result largely from ineffective coping. Therefore, interventions usually include providing specific guidelines for illness management, assistance with problem-solving skills, and expanding the patient’s and family’s social network (McFarlane, 1992). Although family psychoeducation with mental disorders is often provided by family therapists who consider this a type of family therapy, most of the psychoeducational interventions reviewed here were not conducted by family therapists or labeled as family therapy and are not systemic in their approach.
3. Family information and support programs. These programs may be led by professional counselors, rarely family therapists, or nonprofessionals, often trained peer counselors who have experienced similar illnesses in their families. In general these programs provide informational, instrumental, and/or emotional support to individual families or groups of families who are dealing with a specific disorder. They do not provide systematic assessment of problem-solving and coping skills or specific interventions, as do family psychoeducational programs.
4. Direct provision of services to the family. This category includes programs that deliver services directly to the entire family, often in the home.
The first three categories correspond roughly to Doherty and Baird’s five levels of health care professionals’ involvement with families (Doherty & Baird, 1987). Level 5 is family therapy. Family psychoeducation is similar to their Level 4 (systematic assessment and planned intervention), and family information and support programs incorporate components of their Level 2 (ongoing medical information and advice) and Level 3 (feelings and support).
FAMILY INTERVENTIONS IN PEDIATRIC ILLNESSES
There is an accumulating body of research documenting the relationship between family structure and functioning and health-related outcomes for children (see reviews by Kazak, 1989; Patterson & Garwick, 1994; Pokorni, Katz, & Long, 1991). While some of the earliest work emphasized aspects of family dysfunction associated with health problems in children, there has been an increasing emphasis in the literature on the strengths of families that are associated with good outcomes. In an integrative literature review, nine aspects of resilient family process associated with good outcomes in children with chronic illnesses and disabilities were identified: (a) balancing the illness with other family needs, (b) maintaining clear family boundaries, (c) developing communication competence, (d) attributing positive meanings to the situation, (e) maintaining family flexibility, (f) maintaining family cohesiveness, (f) engaging in active coping efforts, (g) maintaining social support, and 0l) developing collaborative relationships with professionals (Patterson, 1991). Findings from descriptive studies have guided family interventions such as family therapy, psychoeducational programs, parent and family support groups, and delivery of pediatric services in the family’s home environment.
Family Therapy Interventions
Although family therapy increasingly is used in pediatric settings, there are only a few reported studies of its effectiveness for children with physical illnesses (see Table la). Of the conditions studied, asthma and diabetes have received the most attention, perhaps because these conditions are known to be exacerbated by emotional distress and the family may be one source of distress. In the classic work of Minuchin and his colleagues (Minuchin et al., 1975; Minuchin, Rosman, & Baker, 1978), characteristics of the “psychosomatic family” were used to explain poor medical outcomes in children with diabetes and asthma. In this model, psychosomatic families showed enmeshment, rigidity, overprotection of the child, and inability to resolve family (especially marital) conflict.
Based on this psychosomatic family model, structural family therapy was used for children with superlabile diabetes or intractable asthma (Liebman, Minuchin, & Baker, 1974; Minuchin et al., 1975). Following 2 to 22 months of treatment, all children showed improved health status and decreased school absences and hospitalizations. Although these early case reports of family therapy were encouraging, no standardized measures of outcome were used and the absence of a control group posed a major threat to the internal validity of these findings.
In an improved research design, 18 children with severe asthma were randomly assigned to family therapy. Significant improvements in health status, school attendance, and daily activity were reported for the treatment group (Gustafsson, Kjellman, & Cederblad, 1986). Part of the focus of therapy was on changing family patterns where time and energy were disproportionately organized around illness-related needs and strong emotional reactions were repressed out of fear of provoking asthma attacks. In a similar controlled trial with 37 children with asthma, family therapy was used to reduce stress by encouraging the family to deal with their emotional reactions to asthma and helping them develop more realistic attitudes (Lask & Matthew, 1979). Children in the experimental group showed significant improvements in some outcomes (wheezing and lung overinflation), but no significant differences on other measures (pulmonary function and activity limitations).
In a study of psychodynamic, problem-centered family therapy for conversion disorders in children(e.g., pseudoseizures, muscle contractions, etc.), all 89 children showed improvement(Turgay, 1990). The target child also received individual psychotherapy. This study presents a near-perfect success rate, but it is not possible to determine what contributed to the outcome-individual or family therapy or some other factor(s)-since there was no comparison group. In addition, there were no standardized measures of outcome or any long-term follow-up.
Although the results of these studies are promising, confidence in the efficacy and effectiveness of family therapy in treating children’s physical illnesses is still limited be cause of inadequate study designs: no control group, no randomization, very small sample sizes, no standardized measures of impact, inadequate follow-up, and/or lack of control of other confounding variables.
Family Psychoeducational Interventions
In the studies of family psychoeducational interventions for pediatric illnesses, there is no assumption of underlying dysfunction in the family. They usually involve teaching specific skills for managing the added demands associated with chronic conditions and/or providing support and information to the parents and children. A variety of chronic conditions have been included in these studies (see Table 1b).
Diabetes. In a randomized trial of 32 families with an adolescent with diabetes, Satin, LaGreca, Zigo, and Skyler(1989) used a multifamily approach focused on diabetes education, emotional reactions, and support. Metabolic control of the diabetes was significantly better for those in the multifamily group. Adolescents’ attitudes and self-care behaviors also improved, although there were no significant differences between the groups in family functioning or parents’ attitudes.
The relationship of family stress to disease exacerbation was the basis of a study using biofeedback relaxation training to ameliorate parents’ distress as a way to reduce stress in their child with diabetes, thereby improving his/her metabolic control (Guthrie, Sargent, Speelman, & Parks, 1990). This study purports a family systems perspective in showing the relationship between parent functioning and child health outcome. In addition, they selected their sample based on a high score on a stress scale, increasing the chance of showing significant effects.
The timing of an intervention is another factor that has been considered. In a study of families who received education and support from a multidisciplinary team and another more experienced diabetic family at the time of diagnosis of their child’s diabetes, significantly better family relationships, social skills, and compliance were observed 3 to 15 years later compared to families who did not get this crisis intervention (Galatzer, Amir, Gil, Karp, Laron, 1982). Although the overall intensity of the intervention was relatively modest, the timing of its delivery makes it significant. The opportunity to incorporate strong emotional responses to the diagnosis with learning about the disease and making the necessary behavioral changes for managing diabetes may have allowed these families to establish more adaptive patterns of functioning at the beginning, thereby preventing the psychosocial problems associated with maladaptive coping. This intervention included support from another family living with the same condition for a longer period, but the study design does not allow determination of whether it was that support or other aspects of the intervention that contributed to the outcome. It is interesting that the intervention was not significant for families with low socioeconomic status who, the authors suggest, may need a more intensive intervention.
Asthma. Many chronic conditions require ongoing daily management. A central issue for families is who is responsible for this management, and especially at what ages a child should take responsibility for which tasks associated with his/her health. In the evaluation of a six-session family asthma program teaching child and family coping skills for disease management, children in the treatment group showed significant improvement in responsibility for their daily health care and scored higher on a measure of independence (Tal, Gil-Spielberg, Antonovsky, Tal, & Moaz, 1990). Given the importance of co-regulation of behavior for preadolescents and their parents, especially when the tasks of a chronic illness are added to normal developmental tasks, these findings are encouraging and clearly call for long-term follow-up (with a larger sample) to understand more fully the adolescent transition, which is often problematic for children with chronic illnesses.
Recurrent abdominal pain. In a randomized trial of a cognitive-behavioral intervention for children with recurrent abdominal pain (RAP), mothers were taught to respond differently to their children’s pain symptoms and the children were taught coping skills, such as relaxation, distraction, and so forth (Sanders, Shepherd, Cleghorn, & Woolford, 1994). The intervention group showed significant reductions in pain and activity limitations. Most of the children in this study lived in families that included fathers (93%) and siblings; however, the intervention directly involved only the child with RAP and his/her mother. From the data collected, there was no way to know if and how fathers’ behaviors in response to the child’s pain were changed or how family functioning may have been influenced by the intervention.
Severe disabilities. Behavioral management of children with severe disabilities involving the neurologic system (such as autism, neuromuscular disorders, mental retardation, epilepsy, cerebral palsy) is often a major challenge for parents (Cole & Reiss, 1993). Cognitive-behavioral strategies have been used effectively to help these parents cope with feelings of self-blame, guilt, depression, and demoralization, which are believed to affect parenting ability and family functioning (Nixon & Singer, 1993; Singer, Irvin, & Hawkins, 1988). Although some fathers participated in these intervention studies, they were excluded from the analyses because it was not possible to demonstrate the independence of their scores from those of their wives. In addition, no effort was made to link measures of mothers’ psychological health to parenting abilities or family functioning. Inclusion of father and family data would increase our understanding of the family impact of these interventions.
Preterm infants. Uncertainty is a major factor in the stress experienced by parents of children with chronic conditions (Jessop & Stein, 1985). This is particularly true when a baby is born prematurely. This stress and anxiety is believed to be associated with maladaptive coping responses in parents, which can set in motion a cycle of poor child outcomes and increased distress and lack of competence in parents. Education and support for parents in the early phases of adaptation has been shown to reduce parenting stress and increase parental competence (Affleck, Tennen, Rowe, Roscher, & Walker, 1989; Pokorni et al., 1991). However, all mothers did not benefit equally. Only those mothers who perceived a high need for support before the intervention actually showed improvements in outcome measures of parent competence, control, and responsiveness to the infant (Affleck et al., 1989). When mothers had low need for support predischarge, the program actually had negative effects on those outcomes. Another interaction effect was that the intervention positively affected mothers’ mood when the infants had severe medical problems but had a negative effect when the infants had below-average medical severity. This study is important in identifying the moderating effects on outcomes of variables such as perceived need for support and severity of child’s medical problems.
Chronic illnesses. In the field of chronic pediatric conditions, several investigators are calling for a noncategorical approach in studying the patient and family impact of conditions as well as in demonstrating how to deliver psychosocial services (Perrin et al., 1993; Stein, Bauman, Westbrook, Coupey, & Ireys, 1993). The rationale for this approach is that the psychosocial impact on the family and on the child’s development are more similar across conditions than between conditions. Even within a given chronic illness, there can be extreme variability in how a condition manifests itself. From a program and policy perspective, a stronger case can be made for interventions that work for multiple conditions, rather than for just one illness. In addition, some family therapists have argued that working with families in groups that involve several different conditions encourages a focus on family issues rather than just the disease itself(Gonzalez, Steinglass, & Reiss, 1989).
Pless and his colleagues have conducted a series of studies focused on reducing the negative psychosocial sequelae often present in children with chronic illnesses by varying who provides the intervention to families. In a recent report of a randomized trial of 332 children with a variety of chronic illnesses, nurses worked with parents to reduce their stress and enhance competence and family functioning (Pless et al., 1994). Children in the intervention group showed significantly less anxiety and depression and better scholastic competence, behavioral conduct, and global self-worth. However, in an earlier randomized trial where a pediatric social worker delivered a similar intervention, there were no significant differences between the groups on any of the measures of child or family maladjustment (Nolan, Zvagulis, & Pless, 1997). While the lack of significant results may be due, in part, to using a different professional to deliver the intervention, it is also possible that other factors contributed to nonsignificant findings, such as insufficient treatment dose (amount and intensity of services), doing the posttest before the long-term impact could be observed, or failure to examine the interaction between preexisting risk factors in the families (e.g., high stress and/or low support) and the impact of the intervention.
Parent and Family Support Programs
When considering the continuum of family interventions, comment needs to be made about the extensive use of support programs for families who have children with chronic conditions. The role of professionals in the implementation of these programs varies from simply encouraging families to use this kind of support, to providing training for volunteers, to actually being present and facilitating the support group. For example, in the crisis intervention program for diabetes described above (Galatzer et al., 1982), support from another diabetic parent/family was a major component of the intervention.
Pless and Satterwhite (1972) assessed the impact of support provided by parent and paraprofessional counselors who had a child with a chronic condition (see Table 1c). Although the initial intent of the program was to help the parents improve the child’s psychological adjustment, reports of actual activities suggested that considerable effort was devoted to dealing with other family issues, which in turn contributed to the child’s well-being. After 1 year, the psychologic well-being of children in the program was significantly improved compared to the control group. When this study is considered together with the other two studies reported by Pless and his colleagues, the issue of who provided the psychological services emerges as an important variable which needs further study. Best results were obtained from lay counselors (primarily other parents) and nurses. When the counseling was provided by a social worker, there were no significant differences in outcome. This may reflect the clinical observation that many parents of children with chronic illnesses resist mental health services because they view them as stigmatizing, as a failure at coping, or as one more pathological label assigned by the medical system they must contend with so frequently.
It is unfortunate that more systematic efforts have not been made to evaluate the effectiveness of support programs for families who have children with chronic illnesses and disabilities. The existing evaluations report the history of the program’s formation and the satisfaction of participants without any effort to determine impact (Santelli, Turnbull, Lerner, & Marquis, 1993). Ideally, studies will be undertaken that use quasi-experimental designs to examine the effect of this kind of intervention, both on those providing the support and on those receiving it.
In-Home Ambulatory Pediatric Services
Interventions involving the delivery of ambulatory pediatric services in the home environment have been included in this review because a more systemic view of the family appears to guide the orientation and style of the services delivered. This approach to service delivery has emerged for pediatric patients whose health needs have not been well met in standard outpatient clinics. These efforts are intended to bring needed preventive and other services to children with chronic conditions and their families as a way to reduce the overreliance on emergency room services for the acute crises that emerge when at-home routines and management of chronic illnesses are compromised.
In a well-designed study using this approach, the parent(s) of children with diverse conditions (such as, asthma, seizure disorder, congenital heart disease, diabetes) were randomly assigned to monthly home visits providing education, support, and advocacy by an interdisciplinary team (Stein & Jessop, 1984) (see Table 1d). Most of the families were minority, poor, and single parent(60%). The child’s psychological adjustment, mother’s psychiatric status, and satisfaction with care were significantly better for the home care group at the 6-month follow-up. Benefits of home care were greatest when the family’s social, educational, financial, and personal coping resources were low, particularly when low family resources were combined with low illness burden (Jessop & Stein, 1991). When the family had more abundant resources and the illness burden was low, standard care led to better child and family outcomes. The implications of these findings are that families who have ample resources manage well on their own and do not benefit from intensive services. It is possible that too much intervention, especially in the home environment, may violate the family’s boundaries and undermine their inherent competence. The lack of effectiveness of this intervention for the most severe conditions raises other questions. Is it reasonable to expect any family to manage a medically complex child at home continuously over the child’s life span? Do families of medically complex children need other kinds of interventions, such as respite care? These findings emphasize the need for more research to determine which interventions work best for which families, and under which conditions.
It is also unclear what the long-term impact of in-home interventions might be. Hughes, McLeod, Garner, and Goldbloom (1991) reported early improvement in medical and functional outcomes for children with asthma who received a home management program compared to standard outpatient care. However, 1 year after discontinuing the home visits from the pediatric nurse, the differences between the standard care and home care groups disappeared, suggesting that the intervention may have provided information and support to make the initial behavior changes, but other factors interfered with maintaining the changed behavior.
The mechanisms by which in-home interventions influence child and family outcomes are not clear from these data. From a larger systems perspective, the nature of the family-provider interaction may be changed when services are provided on the family’s turf, so that it is more egalitarian and less hierarchically dominated by the health care professional. Or perhaps the parent(s) of these children feel more social support, which in turn is associated with less depression. Or perhaps the guidance and education for managing the chronic condition are more individualized to the family’s unique circumstances, making it more possible for them to follow through. More studies are needed to determine the process by which change is brought about, including measures of the behavior of those providing the services.
FAMILY INTERVENTIONS IN ADULT PHYSICAL ILLNESS
Although a great deal of research has been done on how couples and families cope with and adapt to chronic illness in adults, there are no controlled trials of family therapy for chronic adult physical illnesses. Based upon their clinical work, Gonzales, Steinglass, and Reiss developed an innovative multifamily psychoeducational group intervention for families with chronic medical illnesses. They found that in many of these families, the chronic illness dominates family life and often takes over the family’s identity. The goal of these groups is to help families balance the needs of the illness and the needs of the family by putting the illness in its appropriate place in family life (Gonzales, Steinglass, & Reiss, 1989). These researchers are currently testing this intervention for families with several chronic illnesses.
Most of the relevant studies of family interventions in adult chronic illness have been done in the areas of cardiovascular disease, especially hypertension and cardiac rehabilitation (see Table 2), and chronic neurologic disease, especially dementia (see Table 3).
Compliance with hypertension treatment is a major health problem. It is estimated that less than one half of hypertensive patients under treatment take their medications as directed and have their blood pressure adequately controlled (American Heart Association, 1979). Trevino and colleagues (Trevino, Young, Groff, & Jono, 1990) found a significant correlation between marital satisfaction and medication compliance in a sample of 200 married hypertensive patients.
Researchers at Johns Hopkins developed a family intervention to improve blood pressure medication compliance after 70% of their clinic’s hypertensive patients indicated on a survey that they wished that family members knew more about hypertension (Levine et al., 1979). Morisky et al. (1983) compared three different psychoeducational interventions (brief individual counseling, counseling the spouse during a home visit, and patient support groups) in improving appointment keeping, weight control, and medication compliance. Counseling the spouse not only improved overall compliance but also contributed to a significant lowering of blood pressure and mortality. Overall the experimental groups experienced a 57% reduction in mortality, and the groups that included family counseling tended to do the best. A similar study (Earp, Ory, & Strogatz, 1982) failed to demonstrate any additional benefit from involving family members during a home visit, but the patients may not have been followed long enough to detect any effect.
In a series of elegant studies, Levenson and Gottman (1983, 1985; Gottman, 1994) have demonstrated close linkages between physiologic reactivity (including blood pressure) and marital interaction. However, only one study has examined the impact of a marital intervention on hypertension. Ewart and colleagues (Ewart, Taylor, Kraemer, & Agras, 1984) taught 20 hypertensive patients and their spouses communication skills to reduce conflict and blood pressure reactivity during arguments. Compared to controls, these couples exhibited less hostility, fewer combative behaviors and a significant reduction in systolic blood pressure.
Considerable research has been conducted to demonstrate that cardiovascular disease, particularly myocardial infarction, has a powerful impact on families and that the family influences the course of heart disease. In general, the spouses of cardiac patients experience as much or more distress than the patient. Studies have documented high levels of anxiety, depression, and guilt in these spouses (Bedsworth & Melon, 1992; Stern & Pascale, 1979). Many male cardiac patients report feeling overprotected by their wives (Jenkins, Stanton, Savageau, Denlinger, & Klein, 1983). However, other studies have reported improvement in marital relationships and family functioning after a myocardial infarction or coronary artery bypass surgery (CABG) (Laerum, Johnsen, Smith, & Larsen, 1987).
The amount and quality of social support, particularly from the family, has been shown to be a powerful predictor of survival after a heart attack.
Several studies have shown that emotional support from a family member or confidant is a stronger predictor of survival in cardiac patients than any physiological variables, such as the severity of the disease or the amount of damage to the heart (Bucher, 1994). For example, Berkman and colleagues (Berkman, Leo-Summers, & Horwitz, 1992) found that elderly women who lacked a confidant were three times more likely to die in the 6-month period after a heart attack than women with a confidant.
Although many researchers and clinicians have claimed that involvement of family members in cardiac rehabilitation programs leads to better psychosocial and medical outcomes for the patient, there are few controlled studies to demonstrate this. In an ingenious controlled study, Taylor and his colleagues (Taylor, Bandura, Ewart, Miller, & DeBusk, 1985) were able to show that the wives of heart attack patients who actually walked on the treadmill at the same workload as their husbands 3 weeks after a heart attack had higher levels of confidence in their husbands’ cardiac capabilities than wives who simply observed the test. When these women actually experienced the amount of exertion that their husbands could safely engage in, they were more confident of their recovery, which was predictive of the patients’ cardiovascular functioning 11 and 26 weeks after the heart attack. Presumably, this confidence helped to reduce overprotectiveness.
Since most deaths from heart attacks occur outside the hospital and can be prevented by prompt cardiopulmonary resuscitation, many have argued that family members of cardiac patients should be trained in CPR. Others have suggested that such training might lead to higher levels of anxiety and overprotectiveness in these family members, who might feel responsible for keeping the patient alive. Several studies report that most family members report positive feelings from learning CPR, say that they would perform CPR if required to do so, and deny feeling burdened by it (Dracup, Heaney, Taylor, Guzy, & Breu, 1989; Dracup, Moser, Guzy, Taylor, & Marsden, 1994). A small percentage of family members report feeling too responsible for the cardiac patient. One study found that the couples in which the spouse of the cardiac patient learned CPR reported higher levels of anxiety and depression than the control group, suggesting that there may be some deleterious effects of such training (Dracup, Guzy, Taylor, & Barry, 1986). None of these studies has examined the impact of this training on family relationships or cardiac rehabilitation.
Several studies have examined the impact of family and couple interventions to improve psychosocial outcomes after a myocardial infarction. Thompson and Meddis (1990) were able to show an improvement in anxiety but not depression in the wives of cardiac patients who received four sessions of couples counseling. Dracup (1985) was unable to demonstrate any significant differences in anxiety, anger, depression, or marital adjustment in a 10-week post-myocardial infarction couples versus individual counseling program. Gilliss and her colleagues (Gilliss, Neuhaus, & Hauck, 1990) conducted the only randomized trial of a family nursing intervention to improve family functioning after a myocardial infarction. The family intervention group received a brief couples counseling session prior to discharge from the hospital and a series of follow-up phone calls over 8 weeks. At 3-month follow-up, all the families reported significant declines in family functioning and marital adjustment, but there were no significant differences between this minimal intervention group and the control group.
Although research suggests that cardiac patients and their spouses experience significant levels of stress, anxiety, and depression, which are accompanied by a decline in marital satisfaction, the few marital or family interventions that have been tested have not been shown to be more effective than usual care. However, these studies involve a small number of families and lack the statistical power to detect measurable improvements in outcomes.
Family Caregiving of Neurologically Impaired Elderly
The research on family caregiving of elderly individuals has exploded over the past decade. In no other area of health has the family received as much attention as in family caregiving. With the aging of the U.S. population and increasing prevalence of dementias and other chronic debilitating disorders of the elderly, a growing percentage of elderly individuals must rely upon family members for care. It is estimated that over 40% of the elderly over the age of 85 have some form of dementia, and one half of those individuals are cared for by family members in their own communities (Evans, Funkelstein, & Albert, 1989)
An extensive body of research on family caregivers has documented the enormous burden and strain they experience in caring for impaired elderly family members. Overall, family caregivers have poorer emotional and physical health than age-matched controls (Biegel, Sales, & Schulz, 1991) . The incidence of depression is estimated to be between 40% and 50%, with high self-reported levels of anger, hostility, and guilt (Gallagher, Rose, Rivera, Lovett, & Thompson, 1989).
A wide variety of interventions to assist family caregivers have been developed and tested, including psychoeducational and family counseling interventions, family support and education groups, and the direct provision of services, such as respite care, to caregiving families. We could find no controlled trials of family therapy for family caregivers of elderly patients.
All of these studies have found high levels of satisfaction by the family caregivers with the programs offered. The interventions have had variable impact on other outcomes, including caregiver burden and depression, the caregivers’ physical health, and the length of time the elderly family member remains in the community. A number of family psychoeducational programs have taught family caregivers the skills to deal with many of the common problems presented by elderly with dementia (Chiverton & Caine, 1989; Goodman & Pynoos, 1990; Lovett & Gallagher, 1988; Mittelman, Ferris, & Schulman, in press; Quayhagen & Quayhagen, 1989; Toseland, Rossiter, Peak, & Smith, 1990; Zarit, Anthony, & Boutselis, 1987). These interventions usually involve group sessions led by a trained professional (nurse, social worker, but not family therapists) that meet weekly for 8 to 10 weeks. These controlled trials have consistently shown an improvement in the emotional distress and level of depression in the family caregivers who received the intervention. Findings regarding the impact on the caregivers’ subjective and objective sense of burden have been less consistent and not as great. A few studies that have provided psychoeducational interventions for individual families have had a greater impact on both emotional distress and burden (Toseland et al., 1990).
Family support groups for caregivers have become very popular and are being actively promoted by many advocacy groups such as the Alzheimer’s Disease and Related Disorders Association (ADRDA). These are usually open-ended groups that are professionally or peer led and provide information and emotional support to families. Four controlled studies of support groups for family caregivers of dementia patients have examined the impact of these groups (Farran & Keane-Hagerty, in press; George & Gwyther, 1988; Haley, Brown, & Levine, 1987; Kahan, Kemp, Staples, & Brummel-Smith, 1985). All participants reported high levels of satisfaction with the group and increased knowledge about dementia. The impact on caregiver well-being was less consistent, with one study reporting a decrease in burden and depression (Kahan et al., 1985), one study finding no effect (Haley et al., 1987), and a third reporting higher levels of distress in the intervention group (Farran & Keane-Hagerty, in press). The fourth study found lower levels of loneliness but did not measure burden or depression (George & Gwyther, 1988). Thus, although family support groups are well-received by participants and result in higher levels of knowledge, they have an inconsistent impact on caregivers’ emotional distress and sense of burden and do not appear to be as effective as more intensive and focused family psychoeducational interventions.
In one study of families caring for stroke patients, the researchers compared the impact of providing information about the illness to the family to more comprehensive family psychoeducation and patient counseling (Evans, Matlock, Bishop, Stranahan, & Pederson, 1988). Although both interventions resulted in less worsening of family functioning than the control group, only the counseling group showed any effect on family behavior or sustained benefit for family functioning. The authors concluded that family education alone is a “necessary but not a sufficient criterion for influencing families” (Evans et al., 1992, p. 1248). This conclusion seems to be supported by similar studies of caregivers of Alzheimer’s patients.
A number of studies have examined the impact of direct provision of services to the families of Alzheimer’s patients. Respite care is a commonly provided service in which professional caregivers temporarily take over the care of the patient in the home or an institution to provide family caregivers with some respite or vacation from their responsibilities. The results of controlled trials of respite care have shown inconsistent effects on caregiver burden and distress, with some studies showing no effect (Hughes et al., 1990; Lawton, Brody, & Saperstein, 1989; Silliman, McGarvey, Raymond, & Fretwell, 1990) and others demonstrating a mild to moderate improvement in the caregivers’ mental health (Burdz, Eaton, & Bond, 1989; Mohide et al., 1990; Montgomery & Borgatta, 1989). In general, providing longer respite care resulted in greater improvements in caregiver well-being (Knight, Lutzky, & Macofsky-Urban, 1993). One carefully controlled study of respite care (Lawton et al., 1989) found that it delayed nursing home placement, even though it had no impact on caregiver distress. Because of the high cost of nursing homes, this finding has important implications regarding the cost effectiveness of respite care. However, in Lawton et al.’s study, many family members were reluctant to use respite services.
From this research, one can conclude that family psychoeducational interventions for the caregivers of dementia and stroke patients can improve the mental health of the caregivers and are more effective than either family support groups or the direct provision of services. These psychoeducational programs are quite similar to those that have been developed and tested for schizophrenia. Family support groups and respite programs are well-received by family caregivers, but their effect on caregivers is less clear.
FAMILY INTERVENTIONS IN HEALTH PROMOTION AND DISEASE PREVENTION
Most of the current suffering and mortality from physical illnesses result from chronic, degenerative diseases such as cardiovascular disease and cancer, which are partially the result of unhealthy lifestyles and are potentially preventable. A large body of research has shown that the family has a strong influence on lifestyle and health behaviors. These behaviors are usually developed, maintained, or changed within the family setting. Health risk factors cluster within families since family members tend to share similar diets, physical activities, and the use and abuse of unhealthy substances, such as tobacco, alcohol, and illicit drugs (Campbell, 1991). Parents’ health behaviors and lifestyle have a strong influence on whether a child or adolescent will adopt healthy behaviors. A 1985 Gallup poll found that most adults report that their spouse or significant other is more likely to influence their health habits than anyone else, including their family doctor (cited in Public Health Service, 1990, p. 258). The World Health Organization (1976) has characterized the family as the “primary social agent in the promotion of health and well being” (p. 17).
Family Interventions in Smoking Cessation
Cigarette smoking remains the number one health problem in the United States today, with over 350,000 deaths each year directly attributable to smoking. A recent Surgeon General’s report (Department of Health and Human Services, 1988) documented that nicotine is an addictive drug and that many smokers (generally those who smoke more than one pack per day) are addicted to cigarettes.
The initiation, maintenance, and cessation of smoking are strongly influenced by other family members. An adolescent who has a parent and an older sibling who smoke is five times more likely to smoke than one from a nonsmoking family (Bewley & Bland, 1977). Smokers are more likely to many smokers, to smoke the same number of cigarettes as their spouse, and to quit at the same time (Venters, Jacobs, Luepker, Maiman, & Gillum, 1984). Smokers who are married to nonsmokers or ex-smokers are more likely to quit and remain abstinent (Price, Chen, & Cavallii, 1981). Several studies have demonstrated that support from the spouse is highly predictive of successful smoking cessation (Graham & Gibson, 1971; Ockene, Benfari, Nuttall, Hurwitz, & Ockene, 1982). In particular, supportive behaviors involving cooperative behaviors, such as talking the smoker out of smoking the cigarette, and reinforcement, such as expressing pleasure at the smoker’s efforts to quit, predict successful quitting (Coppotelli & Orleans, 1985; Mermelstein, Lichtenstein, & McIntyre, 1983). Negative behaviors, such as nagging the smoker and complaining about smoking are predictive of relapse.
Based upon this research, a number of smoking cessation studies have attempted to use partner support as an adjunct to their programs (see Table 4).
These studies have tried to combine or integrate a social support intervention with standard cognitive-behavioral programs to increase abstinence from smoking. Five different studies involving a total of over 250 subjects have tested a partner-support program in randomized trials (Abrams et al., 1985; Glasgow & Lichtenstein, 1987; Lichtenstein, Glasgow, & Abrams, 1986; Malott, Glasgow, O’Neill, & Klesges, 1984; McIntyre-Kingsolver, Lichenstein, & Mermelstein, 1986). Most of these programs involved an individual smoking cessation program which included nicotine replacement, self-management training, and relapse prevention. In the partner support groups, the partner, usually the spouse, participated in all the treatment sessions and the couples were given suggestions and feedback on helpful and unhelpful behaviors. Couples were encouraged to problem solve about how to encourage smoking cessation and, in some programs, were given homework assignments.
The results of these trials were quite consistent and discouraging. The smoking cessation rates in the partner support groups were not significantly different from the standard individually treated subjects, either at the end of the trials or at 6- to 12-month follow-ups. The results of only one study favored the partner support group, but the results were not statistically significant (McIntyre-Kingsolver et al., 1986). In each of the studies the amount of spousal or partner support reported by the smokers was predictive of the successful cessation, and the absence of negative or unsupportive behaviors was generally more important than the presence of supportive behaviors. However, these interventions failed to increase significantly the amount of support provided by the spouse. Thus, these studies confirm the hypothesis that spousal support and the absence of spousal criticisms are important for smoking cessation but also indicate that these behaviors are not easily changed through education and problem solving.
The failure of these interventions to increase smoking cessation may result partly from their lack of systemic orientation. Smoking is a complex behavior that is influenced by biological factors (nicotine addiction), individual psychological issues, extrafamilial social relationships and pressures, as well as the marital relationship. Supportive behaviors by the spouse are part of a complex marital relationship and are probably related to overall marital quality and satisfaction. Unfortunately, none of these observational or experimental studies of smoking cessation has measured any marital variables (other than spousal support), such as marital communication or satisfaction. Some of these studies do support the general finding in marital research that negative spousal interactions have a greater impact on outcomes than positive interactions (Coppotelli & Orleans, 1985; Mermelstein et al., 1983).
Weight Reduction Programs
Obesity is a major public health problem: over 30% of the adult population weighs more than 20% over their ideal body weight. Obesity contributes to higher rates of hypertension, diabetes, arthritis, coronary heart disease, and numerous other disorders. Studies have shown how eating behaviors and obesity can play important homeostatic functions within families (Stuart & Davis, 1972). Twenty-five percent of mothers report that they use food as a reward for their children, and 10% use it as punishment (Bryan & Lowenberg, 1958). Parents of obese children are more likely to encourage their children to eat (Klesges et al., 1983) and less likely to encourage exercise (Waxman & Stunkard, 1980). The family plays an important role in the development and treatment of the major eating disorders, anorexia nervosa and bulimia.
The research on family involvement in weight reduction programs for adults parallels that of smoking cessation (see Table 5). Observational studies have shown that spousal support predicts successful weight loss (Mahoney & Mahoney, 1976; Streja, Boyka, & Rabkin, 1 982); criticism and nagging (including high levels of expressed emotion) from the spouse are associated with poor outcomes (Fischman-Havstad & Marston, 1984). A number of randomized controlled trials have examined the effect of spouse involvement in weight reduction programs (Brownell, Heckerman, Westlake, Hayes, & Monti, 1978; Brownell & Stunkard, 1981; Heckerman & Zitter, 1979; Israel & Saccone, 1979; O’Neill et al., 1979; Pearce, LeBow, & Orchard, 1981; Saccone & Israel, 1978; Weisz & Bucher, 1980; Wilson & Brownell, 1978; Zitter & Fremeaw, 1978). Similar to the smoking studies, these trials have been based upon a cognitive behavioral model in which the spouse is seen as a reinforcer of the desired behavior. In general, spouses attend all training sessions, varying from 6 to 18 sessions, and are instructed in basic behavior modification techniques. They are trained to give positive reinforcement and instructed not to criticize their partner’s weight or eating behaviors.
The results of these studies have been mixed, with approximately one half of the studies demonstrating a positive effect of spouse involvement, particularly on the maintenance of weight loss after the end of the intervention. The most successful programs (Brownell et al., 1978; Heckerman & Zitter, 1979) have reported two to three times greater weight loss in the spouse-involved groups at 3-month and 3-year follow-ups. Pearce et al. (1981)demonstrated the greatest weight loss in the group in which the spouses were asked not to nag or otherwise participate in their partners’ weight loss efforts. This study emphasizes the importance of spousal criticism in weight reduction and suggests that blocking negative marital interactions may be more important than promoting supportive behaviors.
Because several well-designed studies have failed to demonstrate any effect from spouse involvement, it is difficult to draw any overall conclusions from this research. Black, Gleser, and Kooyers (1990) conducted a meta-analysis of couples weight loss programs and found that, based upon effect sizes, the couples programs were slightly but significantly superior to subject-alone programs at posttreatment. At 2- to 3-month follow-up, the couples programs maintained a nearly significant = .06) improvement, but that improvement disappeared at lengthier follow-up.
Several studies have looked at family variables that may help explain these findings. One study found that higher marital adjustment scores correlated with more weight loss in the spouse involvement group (Dubbert & Wilson, 1984) . Another found that spousal support in weight reduction was more important in highly cohesive than in disengaged families (Barbarin & Tirado, 1984). Women have been found to be more supportive of their husbands’ losing weight than vice versa (Burke & Weir, 1974). Similar to the smoking studies, several intervention studies that measured supportive behaviors pre- and postintervention showed no significant increase in these behaviors.
Studies of family intervention in pediatric obesity are more encouraging (see Table 6). In several studies of preadolescent obese children (ages 5- 11), involvement of parents in a structured behavior modification program resulted in greater weight loss in both the children and the involved parents (Argona, Cassady, & Drabman, 1975; Brownell, Kelman, & Stunkard, 1983; Coates, Killen, & Slinkard, 1982; Epstein, Wing, Steranchak, Dickson, & Michelson, 1980; Epstein, Wing, Koeske, Andrasik, & Ossip, 1981; Kingsley & Shapiro, 1977; Wheeler & Hess, 1976). The interventions varied considerably across studies but generally involved self-monitoring of eating behaviors and exercise, with training in reinforcement procedures and other behavioral techniques. However, the results of these studies are not completely consistent. One study found no benefit from parental involvement (Kingsley & Shapiro, 1977). Another found no difference between parent education and parental involvement in behavior management (Brownell et al., 1983). Some studies have found an effect of parental involvement on the parent’s weight (Kingsley & Shapiro, 1 977) and a high correlation (.75) between the parent and child’s weight loss (Epstein et al., 1980). A 5-year follow-up of one of these studies (Epstein et al., 1981 ) demonstrated greater weight reduction in the family-based intervention.
Only one study has examined the effect of parent involvement in the treatment of adolescent obesity. Brownell et al. (1983) compared three groups in a cognitive-behavioral weight reduction program: parent-child trained together, parent-child trained separately, and the child trained alone. The adolescents whose parents were trained separately had the greatest weight loss and were the only group that maintained their weight loss at l-year follow-up. The authors suggest that obese adolescents benefit from a moderate level of parental involvement, encouraging the parents to be supportive of the weight reduction while supporting the adolescent’s age-appropriate independence.
These studies demonstrate that parental involvement increases the effectiveness of the treatment of childhood and adolescent obesity but that the parental involvement must be developmentally appropriate. The effectiveness of couples-based weight reduction programs is not so clear, especially for long-term weight loss. More understanding is needed of the role of obesity in marital dynamics.
Nutrition and Cardiovascular Risk Reduction
Nutrition is an obvious family activity. Despite changes in traditional family roles, women still do most of the meal preparation and planning for the entire family. Family members consume similar amounts of salt, calories, cholesterol, and saturated fats (Baranowski & Nader, 1985). A number of studies have shown that interventions directed at individuals within a family have a spin-off effect on other family members, resulting in improvement in their health. For example, in the cardiovascular Multiple Risk Factor Intervention Trial (MR FITT), the wives of the men who were involved in the intervention made significant improvements in their diets and other risk factors even though they were not directly involved in the study (Sexton et al., 1987). Some studies of school-based child nutrition programs have resulted in improvements in the parents’ diets (Perry, Crockett, & Pirie, 1987). Because diet is a family activity, several dietary intervention programs have focused on the family rather than on individuals. Most of these family heart studies have dealt with cardiovascular risk reduction and have focused either on high-risk families or on the general population. A number have developed from child-focused, school-based programs to which a family component has been added.
A number of intervention studies have demonstrated that a family intervention to improve nutrition is effective and results in better outcomes than no intervention. The largest and most ambitious trial, the British Family Heart Trial (Family Heart Study Group, 1994), included over 12,000 middle-aged couples recruited from 26 general practices in Britain. Couples were screened for cardiovascular risk factors (smoking, elevated blood pressure, cholesterol and glucose, and obesity) and received family-centered counseling by a trained nurse about healthy lifestyles and cardiac risk reduction. Families received variable follow-up depending upon the level of cardiac risk. After 1 year, the men and women in the intervention group had a 16% overall reduction in their cardiac risk score, mostly resulting from reduced smoking, blood pressure, and cholesterol levels. The authors estimate that such a level of risk reduction would reduce heart attacks and cardiac deaths in Britain by approximately 8%.
Several smaller studies have compared the effectiveness of family approaches to more traditional individual approaches to cardiovascular risk reduction. Researchers from the University of Minnesota’s School of Public Health compared the effectiveness of a school-based nutritional program to reduce diet fat and sodium with a home-based program that included the parents (Perry et al., 1989). Over 1,000 families of third graders participated in a 5-week course in which parents and children participated in family games that used a baseball motif and rewarded healthy nutrition activities. Students who participated in the family-based intervention reported more behavioral changes and greater reduction in fat consumption than the students in a similar school-based program. Unfortunately, these differences had disappeared at a l-year follow-up.
In the Tromso Family Intervention Study (Knutsen & Knutsen, 1991), 1,373 men with elevated cholesterol levels and their families were randomly assigned to a family counseling or control group. Seven years after the family intervention, the men and their wives who received family counseling about diet, exercise, and smoking had significantly lower risk-factor levels than the controls. The differences in the children’s risk factors were not significant.
These studies demonstrate that a family approach to cardiovascular risk reduction, especially nutritional changes, is more effective than an individual approach. This remains a promising area for future research.
Anorexia Nervosa and Bulimia
Although anorexia nervosa and bulimia are usually classified as mental disorders (American Psychiatric Association, 1994), we have included them here because patients with these disorders often present in the medical setting and are usually managed collaboratively by medical providers and mental health professionals. Although family therapists have had a long-standing interest in eating disorders, there is little empirical research and only three randomized controlled studies on the outcome of family therapy with eating disorders (Friedrich, 1995). Both Minuchin et al. (1978) and Selvini-Palazzoli (1978) described the families of patients with anorexia nervosa as enmeshed, conflict avoidant, and rigid. However, empirical research has failed to confirm most of these observations and has found wide variations in the types of families with anorexic children (Kog, Vandereyecken, & Vertommen, 1985; Kog, Vertommen, & Vandereyecken, 1987).
Early reports of the use of family therapy for anorexia nervosa (Minuchin et al., 1978; Selvini-Palazzoli, 1978) were uncontrolled case series. Three randomized controlled trials suggest that family therapy is effective with certain populations of patients with eating disorders (see Table 7). Russell and his colleagues (Russell, Szmukler, Dare, & Eisler, 1987) randomly assigned 80 eating disorder patients (57 anorectics, 23 bulimics) to family therapy or individual therapy at the end of a hospitalization. Before randomization, the patients were divided into four prognostic groups based upon their age of onset (before or after age 18), duration of illness (more or less than 3 years), and their diagnoses (anorexia or bulimia). Each patient received approximately monthly sessions of family or individual therapy. Four therapists provided both the individual and family therapy. The family therapy approach was similar to that used by Minuchin et al. (1978). At the end of 1 year, the younger anorectic patients with a shorter duration of illness did dramatically better with family therapy than with individual therapy. Six of the 10 patients in this subgroup had a good outcome with family therapy, compared to only 1 of 11 in the individual therapy group. There were no significant differences between therapy outcomes for the patients with bulimia or the other anoretic patients. They also found that patients from families with high levels of expressed emotion (EE) were much more likely to drop out of family therapy (but not individual therapy) than those from low EE families (Dare, Eisler, Russell, & Szmukler, 1990).
In another study, Crisp et al. (1991) randomly assigned 90 patients with severe anorexia nervosa to one of three treatment groups (inpatient treatment, outpatient individual and family therapy, and outpatient group therapy with separate groups for patients and parents) and a control group. The family therapy group received 12 sessions over a year. At the end of 1 year and 2 years (Gowers, Norton, Halek, & Crisp, 1994), all three treatment groups had significantly better outcomes than the control group, but there were no significant differences in outcome among the three treatment groups.
In the most recent study, Robin and colleagues (Robin, Siegal, Koepke, Moye, & Tice, 1994) compared behavioral family systems therapy with ego-oriented individual therapy in a randomized controlled trial involving 22 adolescents with anorexia nervosa. After 16 months of outpatient therapy (individual or family), the patients in the family therapy group gained significantly more weight than the individual therapy group. There were no differences in other outcomes, including depressive symptoms, family conflict, or attitudes about eating or body shape.
In summary, this outcome research suggests that family therapy is more effective than individually oriented therapy for adolescents with anorexia of less than 3 years duration and probably equally effective for other patients with anorexia. Some older patients with more severe and long-standing disease may not benefit from family therapy. The only controlled study of family therapy with bulimia demonstrated equally poor outcomes for individual and family therapy (Russell et al., 1987). Much more research is needed to examine the optimal length of therapy, the effective components of treatment, and its impact on different groups of patients with eating disorders.
Although there is solid evidence that the family has a powerful impact on health across different age groups and illnesses, the results of family intervention studies are promising but not conclusive. This research demonstrates that family interventions are more effective than individual approaches for some chronic childhood diseases, especially asthma and diabetes. Family therapy improves the medical outcome in dysfunctional families who have an asthmatic child.
Enhancing family support for hypertension compliance appears to have a powerful effect on health outcomes, but more research is needed to verify Morisky et al.’s (1983) dramatic results. Family interventions in cardiac rehabilitation have been able to demonstrate little effect. Interventions for family caregivers of dementia and stroke patients clearly reduce caregiver burden and depression and may delay institutionalization of these patients.
Examining outcomes from family interventions across age groups and disorders, it is evident that family psychoeducation is the most commonly studied and consistently the most effective type of family intervention. It has been demonstrated to be more effective than family support groups or the direct provision of services to families. There is insufficient research to compare family therapy to family psychoeducation, and these approaches tend to be directed toward different populations (dysfunctional versus distressed but functional families).
Dietary interventions to reduce cardiac risk factors are more effective if directed at entire families rather than individuals. Family-based approaches to the treatment of obesity in childhood are more effective than those that do not involve parents. Couples-based weight reduction programs are slightly more effective than individual approaches, but these effects do not seem to persist over time. Involving spouses in smoking cessation programs does not seem to improve outcomes.
There are many parallels between this literature and the research on family psychoeducation in schizophrenia and other chronic illnesses. Negative family interactions, including spousal criticism, conflict, marital dissatisfaction, and family expressed emotion seem to play a more important role than positive interactions in these physical disorders, similar to findings in chronic mental illness (Rook, 1984) and marital outcomes (Gottman, 1994). In some physical disorders, such as Alzheimer’s Disease, family criticism (and high EE) may result from misinterpretation of disease symptoms (forgetfulness, incontinence, etc.) as willful, similar to what has been described in schizophrenia and depression. Family psychoeducation seems to be effective in educating the family about the physical illness, providing specific problem-solving skills, and decreasing isolation through improved social supports. One significant difference between physical and mental disorders is that group family psychoeducation appears to be less effective than individual family psychoeducation for dementia caregivers. The opposite has been found for schizophrenia (McFarlane et al., 1995). It may be that families with chronic physical illness suffer less isolation and stigma but need more specific problem-solving skills that may be better provided in individual family sessions.
It should be noted that very few of these interventions are directed at the entire family or are based upon a family systems perspective. Some of the lack of effectiveness of these interventions, particularly in smoking cessation and adult weight reduction, may result from a failure to understand the marital dynamics that underlie many health behaviors. In pediatric studies, “family” interventions are usually directed toward the mother, and the father is often ignored. With one exception (Gilliss et al., 1990) the outcomes of interest have been individual physical and mental health and not marital or family variables.
Family interventions need to be tailored to the differences in families–to their unique vulnerabilities–as well as to take account of unique strengths (Affleck et al., 1989). For example, some of these studies (Galatzer et al., 1982; Jessop & Stein, 1991 ) reported different outcomes for families with fewer socioeconomic resources. Some families may need more intensive interventions, such as in-home family therapy or other family interventions. Other families faced with physical illnesses may need very little help from service delivery systems. Many families do not want family therapy and view it as a label of a pathology in the family when they are already struggling with the patient’s illness. In a study designed to provide group counseling to parents on a range of issues associated with their child’s epilepsy, only 35% of 108 parents expressed an interest in the program and only 13% attended even one session (Hoare & Kerley, 1992). Of those who attended, only two families were interested in the effect of epilepsy on family life.
Many families who have a member with chronic illness are resilient and in the face of chronic stress discover their own resources for managing. Some of these families want and need timely information, prefer to read books, and/or to talk with their friends and family. There are other families who more or less manage, but often at a price that includes high levels of distress, sadness, and unhappiness (Singer & Yovanoff, 1992). These families could benefit from psychoeducational interventions, including programs that link them with others like themselves for support.
Recommendations for Future Research
Although this research provides some evidence that family interventions, particularly family psychoeducation, result in better outcomes in the prevention and treatment of physical illness, much more research is needed. Family therapists need to become more involved in the design and implementation of these intervention trials. Based upon our review of this intervention research, we recommend that the following issues be addressed in future studies:
1. Intervention strategies should be guided by theoretical models that hypothesize the relationship between variables that the intervention is intended to affect. These variables need to be assessed systematically at several points in time, pre- and postintervention, to determine the pathway of effects. Designs should include variables at multiple levels–biomedical status of the physical illness itself; individual functioning of the patient and other family members, as well as the functioning of the whole family system; and the function of the patient and family in relation to the health care system. Careful attention should be given to defining conceptually those aspects of family functioning that are related to illness. Reliable and valid operational measures of these variables should be used.
2. There is a need for more studies on the impact of family interventions on all kinds of physical health. In addition to conducting more randomized controlled trials, clinicians and researchers should publish case reports and case series of family interventions in physical health. These kinds of studies help to expand our theories and develop new interventions.
3. Family interventions need to be developed and studied in a wider range of physical disorders, especially common disorders that have enormous impact on families. These include cancer of all types, adult diabetes, chronic lung disease, end-stage renal disease, and HIV disease.
4. Study samples need to be large enough to provide adequate power to detect differences when they occur. More long-term follow-up after the intervention would allow researchers to determine which effects are long-lasting and whether some effects occur later. For example, a family intervention may lead to improved family functioning that results in improved psychological health or health behaviors but may not translate into better physical health outcomes for many months.
5. More attention should be paid to the selection of family variables and outcome variables. Because many of the studies lack any input from family therapists or scientists, family variables are often absent or unreliable measures are used. Studies should look at the impact of an intervention on the family as well as specific health outcomes. Studies conducted by family therapists often lack valid health outcome measures. A number of measures of functional health can be used as valid measures of general health.
6. Studies should provide better descriptions of the family interventions so that others can replicate them. Who delivers the intervention needs to be assessed more systematically. Patients with physical illnesses are already being seen in medical settings by nurses, social workers, occupational therapists, physical therapists, as well as physicians. Several of the studies reviewed used one or more of these health providers to deliver family interventions, and the results are mixed in terms of effectiveness. In addition, quasi-experimental studies of informal support in promoting health and adaptation to chronic illnesses need to be done.
7. Cost effectiveness studies that include health care costs for the whole family need to be undertaken. In the current health care environment, there is a constant demand to demonstrate that interventions not only are effective but also reduce overall health costs. Research on family-based cardiovascular risk reduction and family caregiving offer the most promise for showing cost savings.
8. Studies need to include diverse types of families, representing different races, cultures, socioeconomic statuses, structural types, and so forth. The sample size needs to be adequate to assess differences among these diverse types.
IMPLICATIONS FOR FAMILY THERAPISTS
This research on the effectiveness of family interventions in the treatment of physical illness suggests that family therapists have an important role to play in the management of physical health problems. Family therapists need to see themselves and be viewed by others as health care providers and essential members of the health care team. Health care providers and family therapists need to improve their skills for collaboration and develop effective models for working together (Seaburn, Gunn, Mauksch, Gawinski, & Lorenz, in press).
Family therapy training programs must provide adequate training for new family therapists to work in the rapidly evolving health care system. Courses should be offered in collaboration with medical providers, medical family therapy, working in a managed care setting, and psychopharmacology. There are also opportunities for family therapists to help train health care professionals to be more family and systematically oriented. Currently, there are family therapists teaching in many family medicine residency programs and a few pediatric programs, but there is a great need for family therapists to become more involved in teaching in medical and nursing schools and with other medical specialties and health professions.
The current crisis and rapid change in the health care system represents both a threat and an opportunity for the field of family therapy. It will become increasingly difficult to practice “business as usual” as more and more of health care becomes capitated under managed care. However, this new system will encourage innovative, cost-effective approaches that provide integrated mental and physical health care for families. The current research demonstrates that there are effective family interventions for some physical disorders and suggests promising family interventions for many others.
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Thomas L. Campbell, MD, is an Associate Professor of Family Medicine and Psychiatry, Primary Care Institute of Highland Hospital, University of Rochester School of Medicine, 885 South Avenue, Rochester, NY 14620.
Joan M. Patterson, PhD, is an Associate Professor of Maternal and Child Health in the School of Public Health, University of Minnesota, Box 97 UMHC, Minneapolis, MN 55455.
Copyright American Association for Marriage and Family Therapy Oct 1995
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