Family therapy and psychopathology: developments in research and approaches to treatment

Journal of Family Therapy (1993) 15: 113-146 0163-4445 $3.00

Family therapy and psychopathology: developments in research and approaches to treatment

Alfred Lange,* Cas Schaapt and Brigit van Widenfeltt

The impact of family approaches in understanding and treating psychopathology is reviewed for the following disorders: schizophrenia, mood disorders, anxiety disorders, psychoactive substance use disorders, eating disorders, and conduct disorders in children. Family-oriented interventions are concluded to be useful in treating disorders when applied flexibly and multi-dimensionally and when used in conjunction with psychopharmacological or other valid individual treatment approaches.

As early as 1921, Flugel postulated a relationship between psychopathology and the way family members interact (Flugel, 1921). The elaboration of this conceptual perspective, however, took place only some thirty years later in the late 1950s and 1960s. Concomitantly, various schools of family therapy emerged.

At the beginning of the 1980s) Lansky observed that the gap between family therapy and individual therapy was widening, causing family therapists to concentrate on treating interactional problems within the family instead of committing themselves to the treatment of major psychopathology (Lansky, 1981; pp. 7-8). He warned of the detrimental effects of this development, that it would keep the best possible treatment away from many patients. In the later part of the 1980s, this development was further strengthened by the development of the DSM 111 and the DSM III-R (APA, 1980; 1987). Although both DSM 111’s do not explicitly refer to etiology of psychopathology, many family therapists are not comfortable with the bias towards individual symptomatology which it expresses (Denton, 1989; 1990). Denton (1990) therefore proposes a new axis which should appear in

* Department of Clinical Psychology, University of Amsterdam, Roetersstraat 15, 1018 WB Amsterdam, the Netherlands (address for reprint requests). (E-Mail address: [email protected].)

t University of Nijmegen, the Netherlands.

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the DSM IV, expressing family and relational disorders in addition to the description of individual symptomatology.

By criticizing the individual focus of the DMS 111, family therapists make themselves vulnerable. Since many family systems theorists state that major psychopathology is based on family dynamics, family therapy should have a record of successful treatment in this area. We have, therefore, reviewed the empirical contribution of the different family therapy schools in the treatment of psychiatric disorders, such as schizophrenia, depression, anxiety disorders, addictions, eating disorders and conduct disorders of children and adolescents. In the discussion, attention is focused on the fact that the best results of family therapy were achieved when that therapy is conducted in an eclectic way. This is in agreement with the growing emphasis on integration of family therapy schools (Wynne, 1988).

Schizophrenia

In the 1950s and early 1960s, the Palo Alto group, led by the anthropologist Gregory Bateson, introduced the construct ‘double bind’. This purported to explain the family climate of schizophrenic patients, in which the mother of the patient was described as sending unclear and ambiguous messages to the patient (Bateson et al . , 1956; 1963). Empirical research on the double bind concept never substanti- ated these claims (Mishler and Waxler, 1968). Nevertheless, many systems-oriented therapists have long clung to the notion that schizophrenia is not a psychopathological condition of the individual, but a signal of destructive communication within a family (e.g. Haley, 1980). However, outcome studies of family therapy inspired by such ideas have remained rather meagre (Gurman et a l . , 1986). In a literature review by Berkowitz (1988), only one systematic study was found on the cybernetic (Milan) approach. In this study by Palazzoli and Prata (1983), family therapy conducted with 19 families with members suffering from different forms of schizophrenia was evaluated. The treatment did not include any medication and consisted of vaguely described interventions, such as advising parents to create a secret and keep it from the rest of the family. For ten families a dramatic success was apparently achieved. The outcome criteria used and whether or not follow-ups were done, however, remain unclear according to Berkowitz.

The psychoeducational approach (Anderson et al . , 1980; Berkowitz, 1984) which resulted from uulnerubility theory (Sturgeon et a l . , 198 1)

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appears to be more useful. This approach is based on research on Expressed Emotion (EE) from the 1970s, which revealed that persons with Schizophrenia whose families were characterized by over- involvement, hostility and criticism towards the patient, had higher rates of relapse than if the family climate was characterized as relatively warm and quiet (Hogarty et al., 1986; Leff and Vaughn, 1985). Whereas the EE studies mentioned above are aimed at attitudes expressed by relatives (in interviews), other studies have investigated the actual interaction within families of schizophrenics. These findings suggest that high-EE relatives are characterized by a negative affective style (criticism, intrusiveness) and an unclear, amorphous or fragmented expression of these attitudes during interaction with the patient (Doane et al., 1985; Miklowitz et al., 1984; Miklowitz et al., 1986). Furthermore, these researchers concluded that family therapy, in which little structure was offered during the first sessions and which was relatively confrontational and emotional, led to deterioration of the patients’ functioning (Anderson et al., 1981; Berkowitz et al., 1981 ; Falloon et al., 1984; Leff and Vaughn, 1985).

In contrast to the earlier Pal0 Alto school researchers, the EE researchers assumed that schizophrenia had an organic basis, an attention deficit that renders the patient vulnerable to (socially) complex stimuli. If the family climate is relatively warm and quiet, in combination with pharmacological treatment, the probability of relapse would decrease dramatically. These observations and this conceptualization resulted in the psycho-emotional or f a m i b educational approach (Anderson et al., 1980; Anderson, Reiss and Hogarty, 1986; Berkowitz, 1988; Falloon et al., 1981; Snyder and Liberman, 1981).

Apart from providingrelatives with information about schizophrenia, this approach combines family therapeutic interventions such as joining, establishing boundaries, contingency contracting, and enhancement of communicational and problem-solving skills. Evalua- tion studies have shown that such programmes do have significant effects: for instance, a reduction in the feelings of guilt of relatives with high EE and increased feelings of support (Cozolino et al. 1988). The authors of the latter study conclude that family education programmes should be adapted to the needs, expectations and previously held theories of the participants (see also Tarrier and Barrowclough, 1986).

There is a consensus in the literature that family members have far more difficulty in coping with the negative symptoms of schizophrenia, such as isolation and apathy, than with the positive symptoms, such

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as loose associations, hallucinations and bizarre behaviour of the patient (Creer and Wing, 1974; Maccarthy et al., 1986; Runions and Prudo, 1983; Vaughn, 1977). Also, a spouse7s positive symptoms have less detrimental effects on the quality of the marital relationship than negative symptoms (Hooley et al., 1986).

Research by Glynn et al. (1988) suggests that family members attribute the positive and negative symptoms of schizophrenia to different external and internal causes. The negative symptoms are attributed to internal factors of patients and thus it is assumed by family members that patients have control over their withdrawal from social interaction. In contrast, the positive symptoms of hallucinations and agitation are attributed by the family members to the illness itself. Moreover, it is suggested that high ratings of EE are associated with negative symptoms, suggesting that a finer diagnosis is needed in EE research.

Despite the popularity of EE research, the studies are characterized by considerable methodological weaknesses. For instance, the dimensions constituting the construct hardly intercorrelate and in most of the studies the critical attitude of the mother seems to be the only relevant variable. This leads to the question whether EE is different from what is called ‘punishment’ by social learning theorists. Also, the description of the family in terms of EE ratings is based on interviews and not on actual family interaction. Finally, the studies differ in who is seen as ‘the significant other to the patient’. Nevertheless, the EE research has led to a reasonably successful family therapy approach. For instance, the London group (Berkowitz et al., 1981; Leff et al., 1982) found that families rated high in EE showed little relapse after a combined treatment consisting of neuroleptic medication and psychoeducative ingredients. They reported an associated reduction in EE with 70 per cent of the families. If the families were low in EE, the drugs made no such differences. Falloon et al. (1985) report similar results based on a treatment programme including information, interpersonal conflict management and interpersonal skills training. Further evidence for the effectiveness of the psychoeducative family approach is provided by Stein (1989) in his comment on Haley (1989), who favours dismissing psychopharmacological treatment for schizophrenics in favour of verbal therapy.

That psychoeducative family therapy is important not only for the treatment of adult schizophrenics is argued in an impressive review by Konstantareas (1990). She shows how orthodox family therapy has dramatically failed to help families with autistic children. A combina-

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tion of psychoeducation, behaviour therapy and family therapy is shown to yield the probability of improvement in this area.

Mood disorders Major depression

A series of studies has been conducted investigating the marital and family relationships of depressed persons. Early studies were essen- tially descriptive and correlational and repeatedly showed distressed marriages to be characteristic of depressed persons. For example, Weissman and Paykel (1974) conducted interviews with 40 depressed female outpatients and 40 non-depressed non-patient controls and found a great deal of marital distress in the depressed sample. Poor communication, hostility, guilt, dependency, resentment, and diminished sexual satisfaction were reported by the depressed women. Likewise, Coleman and Miller (1975) found a correlation between depression and marital maladjustment in a sample of 154 couples. These studies, however, may have been subject to response biases, and required the confirmation of observational data.

Hinchcliffe et al. (1975) conducted the first observational study on persons with mood disorders and their spouses. Ten depressed inpatients were observed with their spouses and with a stranger at two phases in their illness. These couples were matched with surgical patients and their spouses. Results showed that interactions of depressed couples were characterized by more negative expressiveness and tension than were the interactions of surgical patients and their spouses. Interestingly, depressed patients demonstrated a significant reduction in negative expressiveness when interacting with strangers. The authors interpreted their findings as indicative of the depressed persons’s behaviour being part of a social familial system that produces and maintains depressive symptomatology, rather than viewing the depression as a consistent behaviour within the depressed person. These findings were confirmed in a second study (Hinchcliffe et al., 1978). Ruscher and Gotlib (1988) also conducted an observational study on depressed couples and found the interactions of these couples to be more verbally negative than those of non-depressed couples and to be characterized by lower rates of positive verbal behaviour. In another observational study, Biglan et al. (1985) found lower rates of self-disclosure for couples with a depressed partner and higher rates of aggressive behaviour compared to control couples. As

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in the Biglan study, Kahn et al. ( 1985) found depressed persons and their spouses to report less constructive problem-solving and more destructive behaviour than couples without a depressed member.

From these studies, the relationship between depression and marital distress is compelling. However, in most of the studies there were no psychiatric control groups to control for general factors in the interaction between psychopathology and marital distress, and since these studies all used correlational methods, a causal relationship between marital distress and depression cannot be inferred.

After evaluating a number of longitudinal studies, Barnett and Gotlib (1988) conclude that marital difficulties may lead to depression. Whisman and Jacobson (1989) also mention a number of studies indicating that marital problems often antecede depression. Accord- ing to these authors, discontent about role division in the marriage is often the conflicting issue. Beach et al. (1990) provide an elaborate model which shows that a range of marital variables such as loss of trust, lack of intimacy and lack of cohesion often precede depression. Consequently, they describe specific marital interventions when dealing with depressed distressed couples (see also Beach and O’Leary, 1986). The causal relationship might, however, be reversed: depression of a spouse, a parent or a child may lead to marital or family distress. Several studies do indeed suggest that depression in one of the spouses constitutes a factor that significantly increases the probability of marital distress and divorce (Fadden et al., 1987; Jacobs et al., 1987).

That social environmental factors can also play a role in the genesis of depression was demonstrated in an impressive study by Ilfeld (1977). About 25 per cent of the variance in complaints among 2,299 depressive persons was accounted for by social stressors, in particular family variables. Barnett and Gotlib (1988) conclude that marital and family problems form a chronic undermining of positive self-esteem. This in turn could lead to a reduction in the ability to cope with other social problems, eventually causing a depressive episode. Brown and Harris (1978) found in their study of depressed and non-depressed women that the lack of a confiding relationship with their husband or boyfriend was found to be the strongest vulnerability factor related to depression in these young women. Interestingly, this relationship with an intimate other was not compensated for by confiding relationships with friends or relatives.

However, the literature also offers support for the contention that the starting point of the vicious circle lies in the depressive person who

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prompts responses from the spouse and other family members that may have a negative influence on his or her self-esteem and ideas about life in general (i.e., the depressive triad). Haas and Clarkin (1988) conclude that there is not always an evident social cause of depression, but the better the social system, the better the prognosis. This conclusion is supported by the findings of Vaughn and Leff (1976). Depressed patients who after hospitalization returned to relatives that were rated as high in EE were significantly more likely to relapse during a nine-month follow-up period then depressed patients who returned to relatives rated low on EE. The critical attitude of the spouses was more predictive of relapse than the symptomatology of the depressed person. These findings were replicated in a study of 39 hospitalized depressed patients by Hooley et al. (1986). Of these patients with spouses rated high in EE, 59 per cent relapsed within a nine-month follow-up period, while none of the patients with low-EE spouses relapsed.

Keitner et al. (1990) discuss a series of studies concerned with family functioning of depressed inpatients compared to that of non- clinical control families. Significant dysfunction was reported in the depressed families during the acute episode of the patient, especially in terms of poor communication and problem solving, but also with the regulation and appropriate expression of affect by family members. Furthermore, members within depressed families reported dificulties in dealing with family role issues such as the allocation of household tasks and responsibilities.

In an attempt to examine whether the family dysfunctioning during the acute episode of the depressed person is a response to the episode or is of a more chronic nature, the authors report on an earlier study conducted by their research team (Keitner et al., 1987, cited in Keitner et al., 1990). In that study 28 families of depressed persons were assessed during the acute phase and during remission. The findings suggest that ‘depressed families’, though showing some improvement in family functioning from the acute phase of remission, reported overall significantly poorer functioning than controls, especially in terms of communication and problem solving.

Given the association between family dysfunction and depression, it is recommended to involve the family when treating depressed patients, in order to maintain treatment effects and prevent relapse. Coyne (1986), an exponent of strategic family therapy, proposes a treatment approach for depression consisting of family interventions using techniques such as relabelling and paradoxical assignments.

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These interventions are aimed at breaking up the vicious circle between depression of the individual and behaviour of the family members. Haas et al. (1985), however, conclude on the basis of their study of the literature that depression should be treated in a multidimensional, eclectic context. This view should be adopted as early as the assessment phase, in which individual aspects of the depression should be evaluated, as well as the way the depression is woven into the relationships between the family members. Treatment could then be focused on both the individual and the interactions between the family members.

Haas and his colleagues offer different recommendations for endogenous versus exogenous depression (Haas et al., 1985). For endogenous depression, they recommend a combination of anti- depressant medication and family approach, emphasizing coping with the stress resulting from the transactions within the family. They emphasize the mobilization of the support of the family for the medical compliance. Falloon et al. (1988) describe a model of psychoeducational family therapy that is similar to their model of treating families with schizophrenic patients. However, several authors conclude that in the case of (endogenous) depression family interventions should be more than education only. Teichman (1986) calls for a combination of medication and structural family therapy. Others stress changing misperceptions, mutual misunderstanding, ineffective communication, ineffective problem-solving and mutual expectations (see Rounsaville et al., 1985) for what might aptly be called ‘short-term interpersonal psychotherapy for depression’.

In spite of the realization that family factors influence the genesis and course of major depression, there are few controlled studies on the effects of family therapy in this area. In a review of the literature, Berkowitz (1988) found only two studies. I n one investigation, Glick and colleagues studied a multidimensional approach with hospitalized patients in which few positive results were detected (Glick et al., 1985). The second study by Anderson, Griffin et al. (1986) compared multiple family therapy in combination with self-help groups with pure psychoeducation. They did not find differences between the two approaches which might have been due to the heterogeneity of the samples. In any case, both studies show that psychoeducation had to be adapted to the nature ofthe depression. In contrast to schizophrenia, depression may be less suited to a standardized programme of information and stress reduction. This in turn might explain the lack of controlled research in this area.


Bipolar depression

Although lithium has proved to be quite effective in the treatment of patients with bipolar disorders (Goodwin and Zis, 1979), the long- term effects are only moderate. Almost half of the patients display a clinically significant relapse within a year of being treated (Prien et al., 1984). Therefore, researchers and clinicians have started to consider the importance of environmental factors, including family environ- ment.

Hoover and Fitzgerald (1981) investigated both persons with depression and with bipolar disorder. Marriages of patients with bipolar disorders were found to be rated higher in perceived conflict and disagreement than those of controls. Miklowitz et al. (1988) studies 23 recently hospitalized bipolar patients and their key relatives (parents or spouses). The family members were interviewed using the Camberwell Family Interview (CFI) during hospitalization and two weeks following discharge. Within nine months, 16 of the 23 patients relapsed. Measures of Expressed Emotion and Affective Style (AS) jointly predicted the likelihood of relapse at follow-up. It is important to note that EE and AS were both unrelated to medication compliance and that non-compliance itself did not account for relapse. This encourages the hypothesis that the emotional atmosphere of the patient’s family during the post-discharge period is an important predictor for relapse in patients with bipolar disorders.

Although concerned with the negative effect of labelling the patient as a depressed person, Coyne (1987) supports a combined treatment approach consisting of medication and family interventions, particularly with bipolar disorders. Clarkin et al. (1988) compared an individual treatment with a ‘family-oriented’ therapy approach for inpatients with unipolar and bipolar mood disorders. The family approach, which consisted mostly of psychoeducation, was more effective with bipolar patients than with patients with major depression, for which it was not more successful than individual therapy. These findings were underlined by Clarkin et al. (1990) in the presentation of the final results of their research project. The inpatients with bipolar disorder and major depression were randomly assigned to multimodal hospital treatment (including medication, individual and group therapy) either with Inpatient Family Interven- tion or without Inpatient Family Intervention (IF1 and non-IFI, respectively). The family intervention consisted of providing the family with psychoeducational information concerning the symptoms,


course and treatment of affective disorders. At discharge the women in the IF1 group scored significantly better on global functioning. Furthermore, at discharge the family attitude towards the patient was significantly better in the IF1 group than in the non-IF1 group. At follow-up, however, there were no main effects for the treatments on the family measures. When comparing the effect of IF1 on patients with bipolar versus major depression, the treatment had a significant beneficial effect on bipolar patients but a negative effect on patients with major depression, who did better with the non-family treatment.

The results of the studies on bipolar and major depression, as described above, lead to the conclusion that psychoeducation is not enough for families with depressed patients. A number of case studies support the view that a more active involvement by the family members is needed in the treatment (e.g., Coyne, 1986; Lange and IJzerman, 1989; Rush et al., 1980).

Anxiety disorders

Agoraphobia

For many years the question has been discussed whether the quality of a marriage is an important determinant in the onset, maintenance and treatment of panic disorder with agoraphobia. O n the basis of clinical observations, Fry (1962) was one of the first to suggest that the phobic patient was often ‘protecting’ the healthy partner, especially in those cases where the ‘healthy’ partner was extremely jealous.

Although there is some literature supporting this view (Hafner, 1979, 1982; Vandereycken, 1983), there is little empirical evidence that the marital relationship is a significant factor in the development of agoraphobia. Arrindell and Emmelkamp ( 1 985) even conclude to the contrary, based on a study in which they found that the partners of agoraphobics were no more disturbed than partners in a control group. In a second study, these authors showed that agoraphobic women were no less satisfied with their marital relationship than women with other psychiatric problems, and that they were more satisfied with their marriage than women who had applied for marital therapy (Arrindell and Emmelkamp, 1986). They conclude that the agoraphobic women were just as happy with their partners as the women who belonged to the group of couples who reported having a happy marriage.


Kleiner and Marshall (1987) provide different arguments for rejecting the hypothesis of functionality of agoraphobic symptoms. They conducted retrospective structured interviews with 50 agoraphobics. These interviews revealed that a stressful relationship with the partner and persistent conflicts in the marriage nearly always preceded the onset of agoraphobic symptoms. There was no indication of a reduction in marital stress following the onset of the agoraphobic symptoms, as one would expect if the symptom was functional in the relationship. Conclusions should, however, be drawn with caution, since the level of marital stress observed in the study of Kleiner and Marshall might have been still worse in the absence of agoraphobic symptoms on the part of either spouse.

A number of studies have examined the effect of a purely individual approach versus an individually focused ‘spouse-aided’ treatment on both the reduction in complaints and the quality of the marital relationship. The results are equivocal. Cobb et al. (1984) reported that exposing patients to the feared situations led to improvement in the phobic complaints as well as in the marital relationship, while marital therapy affected the quality of the relationship but not the avoidance behaviour. Lange and Van Dyck (1392) demonstrated, by means of a controlled group study, that after individual behavioural treatment of agoraphobia the marital relationship improved, even to the extent that with regard to solving their problems the couples came close to the level observed in the ‘normal’ population. These results suggest that marital distress does not lead to agoraphobia but agoraphobia may rather lead to marital distress.

Milton and Hafner (1979), on the contrary, report that an individual behaviourally oriented treatment of agoraphobia leads to a deterioration of the relationship between the spouses or to complaints by the ‘healthy’ spouse. This finding was, however, not replicated in a study by Bland and Hallam (1981).

A possible explanation for these findings lies in the distinction made by Chambless and Goldstein (1980) between ‘simple’ and ‘complex’ agoraphobia. Simple panic disorder with agoraphobia can be explained entirely by panic and fear of panic, indicating that treatment should focus on breaking the spiral of anticipation anxiety (fear of panic). Complex panic disorder with agoraphobia is characterized by the presence of a number of stressors, of both an intrapsychic as well as an interpersonal nature. A number of case studies support this conclusion (Lange and De Beurs, 1992; Stronkman et al., 1987). At present, the most likely, but as yet unproven

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hypothesis is that marital distress increases the chance of agoraphobia in persons who are vulnerable in that respect, but it is unlikely that agoraphobia serves a function in safeguarding the relationship by protecting the ‘healthy’ spouse.

If individual therapy can have harmful effects on the relationship, as it seems possible in complex agoraphobia, it appears sound to involve the spouse in the treatment. The result of comparative studies in this area are inconclusive, however. Some authors report no significant differences between treatment approaches, whereas others report favourable results of an individual, ‘spouse-aided’ approach (Badenoch et al., 1984; Cobb et al., 1984; Hafner et al., 1983).

One may conclude that in relatively simple cases of panic disorder with agoraphobia, individual intervention programmes are necessary. Involving the spouse does not seem to be a prerequisite for successful treatment outcome. However, for more complex cases of agoraphobia, involving the spouse does increase the probability of successful treatment outcome (Lange and De Beurs, 1992). In any case, involving the spouse will enable the therapist to change interaction patterns that may control avoidance behaviour (Lange et al., 1987).

Our conclusions coincide with the ‘foot in the door’ principle, already advocated by Hand and Lamontagne ( 1976) and Vandereycken ( 1983). The partner should be involved from the very beginning of treatment even if the treatments consists mainly of exposure or other individual interventions focused on the panic disorder. In some cases, this may lead to a reduction of complaints while the marital relationship does not deteriorate and may even improve. With some complex cases, however, the symptoms might not be reduced or problems in the marriage might emerge or get worse. In those cases, the fact that the partner is already involved increases the chance of motivating the patients to continue treatment, with their relationship as a target of therapy. Hafner ( 1986) describes how the partner can be motivated to co-operate in this sort of treatment.

Obsessive-comfiulsiue disorder

With regard to obsessive-compulsive disorder, the situation is not very different from panic disorder with agoraphobia. Emmelkamp et al. (1990) found that involving the partner in the treatment of patients with obsessive-compulsive disorder does not influence the outcome. However, it is not clear what ‘involving the partner’ meant in their study. O n the other hand there are several studies claiming evidence


that changing the reactions of the spouse to compulsive behaviour or compulsive questioning is crucial to the outcome of treatment (Hoogduin, 1986; Hoogduin and Duivenvoorden, 1988; Pauly and Vandereycken, 1990). It therefore appears to be a sensible therapeutic practice to ‘involve’ the spouse in treatment, particularly if he or she is part of the compulsive ritual and avoidance behaviour.

Social phobia

There are some suggestions that the behaviour of family members is a controlling factor in social phobia. Individual therapy has been found to result in little effect if the patient is in a family situation where the self-confidence of the patient is undermined by other family members (Huffngton and Sevitt, 1989). However, an extensive literature review by Scholing and Emmelkamp (1990) strongly suggests that next to family and marital therapy, breaking the anxiety spiral requires individually aimed interventions such as exposure, cognitive restructuring and social skills training.

Addictions Illegal drug abuse

Until clinicians started to consider family backgrounds, illegal drug abuse was considered an individual problem accompanied by a poor prognosis. Reilly (1976) studied families with adolescent drug abusers and observed a negative family interaction in which positive behaviour of the abuser was hardly reinforced and illegal drug abuse received a great deal of negative attention from other family members. Moreover, the parents were not able to set limits on the abuser’s behaviour. Reilly (1976) suggests that the abuser’s behaviour had the function of eliciting this behaviour on the part of the parents. He describes the atmosphere within these families as dull, lifeless and superficial, where hostility is not expressed.

Kaufman (1981) stresses the overprotection of the mother, the weak position of the father, who often appears to have a drinking problem, and the weak boundaries between the subsystems in families of drug abusers. He suggests that the abuser’s behaviour functions to provide the parents with a problem that conceals the lack of intimacy in their own relationship. Similar descriptions, based on clinical observations rather than empirical research, have been made (Alexander and Dibb, 1975; Klagsbrun and Davis, 1977; Noone and Reddig, 1976).

126 Ayred Lunge et al. According to these observations, family therapy appears a promising

treatment. Unfortunately, the ensuing traditional empirical research (Ziegler-Driscoll, 1977; Hirsch and Imhof, 1975; Noone and Reddig, 1976; Kempler and Mackenna, 1975; Kaufman, 1981; Szapocznik et al., 1983; Vallum and Fossheim, 1980) suffers from serious methodological weaknesses. For instance, Kempler and Mackenna (1975) treated 12 families with a family therapy approach, consisting of identification and restructuring of dysfunctional interaction patterns, and though they report changes in the desired direction with regard to family interaction they fail to report the effects on drug abuse. Additionally, all the studies suffer from enormous drop-out rates. For instance, Entin and Schuman (1972) report that six families who received a number of explorative intergenerational ‘Bowenian’ family therapy sessions refused to continue treatment. Szapocznik et al. (1983) started treatment with only 15 per cent of their original referrals.

Stanton and Todd (1982), in a methodologically more sophisticated study, report on the effects and effectiveness of structural-strategic family therapy with young male heroin addicts who had used heroin for at least two years and who kept frequent contact (at least once a week) with their family of origin. All were veterans of the Vietnam war and varied in age between 20 and 34 years. Stanton and his colleagues compared four treatment conditions: paid family therapy (n = 21), unpaid family therapy (n = 25), a control condition consisting of families watching some movies with a cultural-anthropological content (n = 19), and individual treatment of the addict (n = 53). Both family therapy conditions yielded the best results in terms of reduction in illegal drug use, as measured six and twelve months after the termination of treatment. There were no differences between the two family therapy groups and no differences between family therapy and individual therapy with regard to the use of legal drugs and social integration (days spent in work or at school).

Although this is by far the strongest study reported on family therapy and drug abuse, the improvement criteria used can be criticized (Romijn, 1989). A study in the Netherlands, using a comparable programme of structural strategic interventions, yielded as the most interesting result that family therapy was effective for relatively young abusers who were still living at home and had a short history of abuse. ‘Thc programme also led to an improvement in the relationship between the parents (Romijn et al . , 1992). The methodic spin-off of these results is important. Both the Stanton group and the Dutch ‘replication’ group found that a strictly paradigmatic approach was


counter-productive. Their structural and strategic approach which was combined with interventions in the sphere of communication and social skills offered a good starting point for the treatment of drug abusers, particularly if they were young and still living at home. Furthermore, Lange (1987) demonstrated that such an approach may effectively be enhanced by using individual behaviour therapeutic interventions to increase self-control as well.

Alcohol

During the last decade, the influence of the family research field has been growing steadily in alcohol studies (Schaap et al., 1991). Some studies have focused on communication patterns between the alcoholic and the family members. Gorad (1971a, 1971b) assumed that male alcoholics transmit two messages simultaneously. The first message is one of deviant, aversive behaviour. The second message is a disqualification of the first: ‘I may be mean, nasty, aggressive, etc., but I am not responsible for my behaviour; i t is the result of the alcohol.’ In doing so, alcoholics keep their family in a firm grip: they can do things for which they are not accountable. In the literature, this behaviour is referred to as deviance disavowal or time-out (MacAndrew and Edgerton, 1969). By consuming alcohol, the alcoholics create opportunities for expressing strong negative feelings that would otherwise be expressed only partially or not at all. There is indeed some evidence in the empirical literature that corroborates this responsibility-avoiding behaviour of alcoholics (Drewery and Rae, 1969; Hanson et al., 1968; Jacob and Seilhamer, 1987). This pattern of responsibility avoidance is also stressed in the literature on alcohol-related wife-battering (Christensen, 1989). The abusing husband convinces his wife that his battering of her is his ‘shadow-side’, emerging only when he is drunk.

For nearly 20 years, a group of investigators led by Steinglass have been studying the relationship between alcoholism and family processes. Their primary contribution is a theoretical framework for viewing alcoholism as embedded in family interactions (Steinglass et al., 1987). One particularly interesting finding demonstrated that during intoxication, interactions were exaggerated and more restricted in range; thus more extreme yet more predictable. I t was concluded by Steinglass and his colleagues that the alcohol served a short-term adaptive problem-solving function in the marriage (Steinglass et al., 1977). These clinical findings are provocative but should also be


viewed cautiously given the small sample size (n = 10) and absence of a control group.

I t has been suggested by Jacob and his colleagues that, when interpreting the role ofalcohol abuse in marital and family interaction, it is important to distinguish different types of alcoholics (Jacob, 1987; Jacob et al., 1985; Jacob and Krahn, 1988; Jacob and Leonard, 1988; Jacob and Seilhamer, 1987). Style of drinking and where the alcohol is consumed appear to be relevant dimensions. ‘Binge drinkers’ (B) and ‘steady drinkers’ (S) are distinguished, and also ‘in-home’ (IH) and ‘out-of-home’ (OH) drinkers. These dimensions suggest four types of alcoholics, of which one combination (binge, at home) hardly ever occurs.

According to Jacob (1987), the family’s response to the B-drinker differs from that to the S-drinker, particularly the S/IH-drinker. B- drinking enables the alcoholic to express negative feelings without accountability or sanctions. The ‘steady in-home drinkers’ show less disruption in their lives. In some cases positive effects may even be observed. In this group, a positive correlation between alcohol consumption and marital satisfaction is sometimes found. Compared to B-drinkers, S/IH-drinkers are generally less disturbed, score relatively high on marital satisfaction, and experience fewer problems in social interaction as a result of the alcohol problem. The communication of the S/IH-group is also less negative and is on the same level as that of depressive and normal husbands. Although a laboratory-induced change from no-drinking to drinking resulted in a slight increase in negativity in the S/IH groups, this was far less than that of the B-group. Moreover, their problem-solving ability increased a little in the drink condition, while the positive nature of their communication increased dramatically. This might explain the positive correlation with marital satisfaction. The steady out-of-home (S/OH) drinkers appear to be characterized by a middle position. Sometimes they resemble the B-group, at other times they are quite similar to the steady in-home group.

These findings seem to suggest that it is important to achieve an integration of alcohol-focused and marriage-focused approaches in the treatment of (male) alcoholics. A relational approach is relevant for engaging the alcoholic in treatment (Sission and Azrin, 1986). Studies by O’Farrell and colleagues (O’Farrell e t al., 1985; O’Farrell and Cowles, 1989) indicate that by adding a marital treatment programme to an individually oriented programme for male alcoholics, marital satisfaction noticeably increases.


Although these reviews do suggest interactional mechanisms in the control of alcoholism, at least for some types of alcoholics, family therapy has laid little claim in this area. There are only a small number ofcase studies (e.g. Carter, 1977) and a few controlled studies where the impact of family therapy on alcoholism is investigated (O’Farrell et al., 1985). The latter study showed that the nature of the family therapy (behavioural versus insight-oriented) was not very important. Although marital satisfaction increased, both therapy programmes, as well as a control condition, consisting of a combination of individual behaviour therapy and Antabuse, only reduced alcohol consumption temporarily. Modest results are also reported by Bennun ( 1988) in a study in which ‘Milan Family Therapy’ was compared to a ‘Standard Therapy’ consisting of behavioural and cognitive interventions. Both groups showed improvement but there was no post-treatment difference in symptomatology between the groups.

Eating disorders and psychosomatics In the early 1960s, the Pal0 Alto group expressed interest in family influences on psychosomatic complaints, reflected in the publication of a number of case studies (i.e. Jackson and Yalom, 1966). It was, however, the structural family therapy approach that laid the most claims to successful treatment regarding psychosomatic and eating problems. Exemplary is the study of Minuchin, Rosman and Baker (1978) which presented data on the treatment of 53 families with an anorexic patient together with four very detailed case descriptions. They also described a study regarding diabetics in which a therapeutic family task was used. These results have gained much publicity since they suggest that a ‘psychosomatic family’ does indeed exist, i.e. a family characterized by enmeshment, over-protection, rigidity and a lack of problem-solving skills, and also because the authors claimed a high success rate.

After a careful analysis of the original data, Coyne and Anderson (1988), however, leave little doubt about the illusory character of Minuchin et al.’s original publication. Coyne and Anderson ( 1 988) demonstrate that the data were analysed statistically in an unaccept- able way. Moreover, the conclusions of Minuchin and his colleagues were based on a report whch was given as ‘in press’ but which was never published. Reanalyses showed that there was no basis in their data for the concept of ‘a psychosomatic family’ and that the patients


did not protect the family with their symptoms. What Minuchin and his colleagues describe as over-protection and enmeshment should probably be perceived as the adequate responses of a system to the metabolic crises of the patients. Similarly, rigidity may be perceived as the understandable resistance of the family to the interpretations of the therapist that the problems are more the result of their dysfunctional interactions than of the medical crises. Coyne and Anderson (1989) also conclude that the family factors distinguished, such as problems between the parents, over-protection and psychiatric symptoms with the parents, are by no means specific for families with a diabetic or anorexic patient. Although they do not criticize the Minuchin study for the confusion it brought about by mixing up (psycho)somatic disorders and eating disorders, they do warn against the use of the term ‘psychosomatic family’ because it may keep the therapist from helping the families in a practical way with the medical crises. I t is also striking that the results of Minuchin et al. (1978) have never been validated in a replication. When replication was attempted, results were less convincing (e.g. Kog et al., 1989).

Studies by Grigg and Friesen (1989) and by Marcus and Wiener (1989), which focused entirely on eating disorders, offer additional support to the contentions by Coyne and Anderson (1988, 1989). Although they found that families with an anorexic child did differ from control families on a number of dimensions, this could by no means be interpreted as evidence for the existence of an anorexogenic family structure. The latter authors are in accordance with the contention of Garfinkel and Garner (19829, that there exists no unique family interaction pattern with anorectic symptoms. The term ‘anorectic family’ should therefore be avoided or only used with the greatest of care. In a review, Kog and Vandereycken (1989) conclude that some family patterns seem to occur quite often in families of patients with eating disorders. With anorexia it is the interdependence to which they react with submission, while the bulimics, react in a more hostile way. However, the authors also notice that the research on eating disorders is not rich in methodologically sound studies and that the results are often contradictory. Meijer (1987) found that the medical treatment for asthma of children was more successful when the parents reported a good marital relationship. Furth (1991) found in an experimental study that the degree of Expressed Emotion of the mothers of anorexia was predictive for the success of the treatment.

Summarizing, there is clinical evidence and there are some controlled studies suggesting that family factors do influence the


emergence and maintenance of somatic disorders and eating disorders. For eating disorders, family therapy, if the therapy is not applied too rigidly, is obviously of importance, if only because the identified patient is usually a child. This is also concluded by Gurman et al. (1986) on the basis, amongst others, of the study by Schwartz, Barrett and Saba (1983, quoted in Gurman et al.). In this study, certain elements of structural family therapy were combined with individual sessions in the treatment of bulimia patients. Of the 29 cases that were completed, 66 per cent had almost complete control over their symptoms, even after a relatively long follow-up period of three and a half years.

Dare et al. (1990) show that structural/strategic family therapy is especially effective in comparison to individual supportive treatment with young anorexics with a relatively short duration of illness. On the basis of a non-controlled group study, of a review of the outcome literature and of their extensive clinical experiences, Vandereycken and Vanderlinden recommend an eclectic approach combining family therapy with individual interventions (Vanderlinden and Vander- eycken, 1989; Vandereycken and Vanderlinden, 1989).

It can be concluded that with regard to what have originally been labelled as psychosomatic disorders, (structural) family therapy has claimed an important place with respect to treatment. However, an exclusive focus on family dimensions appears to be one-sided and thus not of maximum effect (Root et al., 1986). A multidimensional approach where symptoms-focused interventions are combined with educational material, information given to the parents and attempts to change dysfunctional interaction patterns appears to be the indicated treatment.

Conduct disorders with children and adolescents

In 1967 the book Families of the Slums received much attention. It contained a number of case studies on the treatment of families from lower socio-economic classes with a delinquent child (Minuchin et al., 1967). The structural approach advocated in this book, consisting of drawing boundaries and adapting the roles within the family, has constituted the face of treating conduct disorders of children and adolescents. Under the influence of a popular book by Haley consisting of clinical descriptions (Haley, 1980), attention was focused on the lack of a hierarchical structure within the family of acting out adolescents. This has certainly been an important factor. However,

132 Alfred Lange et al .

Haley formulated his concepts so rigidly that replications based exclusively on his paradigm frequently ended disastrously (Wever et al., 1983).

There are several studies showing the unfavourable family back- ground of children with conduct disorders (Dadds, 1987; Kolko, 1989; Patterson et al., 1989; Reid and Crisafulli, 1990). The variables which seem important vary between lack of agreement between the parents; depression of the mother; minimal involvement of the father (sometimes combined with alcoholism and a criminal inclination on the part of the father); harsh and inconsistent discipline; little positive involvement with the child; and poor supervision of the child’s activities. An impressive study on the relation between family factors and conduct disorder with children was recently carried out by Frick et al. (1992). Their sample consisted of 177 clinic-referred children. Initially, they found an association between conduct disorder of the children, and parenting by the mother (the way discipline was carried out) and parental adjustment (parental antisocial personality disorder and parental substance abuse). However, further analysis showed that when both factors were analysed together, only parental antisocial personality disorder appeared to be significantly associated with conduct disorder, and there were no correlations between parental adjustment and negative parenting. The authors conclude that their study seems to suggest an inherited predisposition to severe childhood conduct problems, but they do not rule out that these risk factors may interact with the psychosocial family factors described above, such as parental modelling or selective reinforcement of antisocial behaviour.

The approach of the ‘Oregon group’ (Forgatch and Patterson, 1989; Patterson, 1971, 1982; Patterson and Forgatch, 1987) is based on social learning principles (modelling, changing reinforcement patterns). They specialized in detailed ‘parent management training programs’. One could argue that coaching parents how to raise their children or how to handle conduct problems in children is hardly family therapy. However, its impact was tremendous, stimulating family therapists to choose the whole family as the target of their interventions. The method is described as the best studied and best founded method of treatment for children with conduct problems (Kazdin, 1984). An extensive review of ‘parent behavioural training’ is provided by Graziano and Diament (1992), showing that i t is not only a very effective method for treating conduct disorders, but also for treating children with fears, enuresis, obesity and stuttering. In an


experimental study with 97 children (ages 7-13 years) referred for severe antisocial behaviour, Kazdin et al. (1992) also show that parental mangement training improves the children’s functioning. However, significantly better results were obtained when it was combined with training the children in cognitive problem-solving skills.

In a controlled study, Simpson (1991) compared the treatment of child psychopathology by ‘Milan Family Therapy’ (MFT) and individual therapy, containing behavioural, cognitive or psycho-

’ analytical elements, with a six-month follow-up. The sample of subjects was heterogenous in age (3-16 years) and in symptomatology. According to the principles of MFT, the experimental therapy was carried out by a team using a one-way screen, every member in rotation acting as primary therapist. Each session was preceded by pre-session hypothesizing and included mid-session rounds of hypothesizing as well. Besides established scales, measurement included semi-structured interviews by independent interviewers and a record of the therapy. Both treatment groups appeared to be effective in reducing symptomatology (there was no group without treatment, controlling for spontaneous remission, however). As expected, MFT resulted in more change in family relations and fewer sessions were needed to achieve this. The degree to which the father could be involved in the family treatment was found to be crucial for the outcome.

A somewhat broader approach is described by Barton and Alexander ( 1981). Their ‘functional’ family therapy consists of an integration between behavioural techniques such as modelling and contracting, and strategic interventions such as paradoxes. In an extensive study with young delinquents and their families, these authors showed that the application of this eclectic approach leads to less recidivism than other forms of family therapy. I t also showed a favourable effect on the siblings. Gordon et al. (1988) evaluated this therapy model in a controlled group study with juvenile delinquents of low socio-economic status. The treatment was time-unlimited with an average of 16 sessions. The control group only received probation. Recidivism in the treatment group was 11 per cent against 66 per cent in the control group, with a follow-up of 2.5 years.

Discussion

The contributions of the best-known approaches within family therapy for the treatment of different psychiatric disorders have been

134 Alfred Lunge et al.

reviewed. Even ifwe limit ourselves to the contribution of marital and family therapy in the context of psychopathological disorders, not including marital interaction as the presented complaint, the field is broad. Family therapy approaches differ not only with regard to their theories and techniques; the criteria for evaluating the effects and effectiveness oftreatment aredifferent too. Cybernetic family therapists, such as Tomm ( 1983), argue that focusing on the changes in the identified patient does injustice to the circular causality involved. Outcome should, according to this view, be assessed by family variables. Carr (1991) discusses several studies in which this is the case. However, the experiences with the measurement of family variables are not very encouraging. The instruments which, for instance, were developed by structural family therapists with regard to cohesion and adaptation (Olson and Portner, 1983) reflect individual opinions of family members rather than providing a description of the family (Edman et al., 1990; Jacob and Tennenbaum, 1989). More promising are the ‘Family Assessment Scales’ (Skinner et al., 1983), which describe a11 the dyads within a family on the interactional level. The complexity of these scales, however, will deter many researchers and clinicians from using them.

On both theoretical and practical grounds, Gurman et al . (1986) conclude that when assessing the outcome of family therapy, it is a sound practice to start with changes in the complaints of the identified patient.

What about the overall effect offamily therapy on psychopathology? Hazelrigg et al. (1987) conclude from a meta-analysis that family therapy is more effective than no-treatment or alternative treatments. Perhaps more interesting than their conclusion is the fact that these authors could trace only 20 studies that complied with their not too high methodological standards. Most studies focused on children with conduct disorders and were mainly behaviourally oriented. Markus et al. ( 1990) came to similar conclusions and expressed their concern at the lack of studies with regard to multidimensional family treatment. This reflects the gap between research and clinical practice as described by Emmelkamp (1986). This may be due to the fact that it is easier to investigate relatively strict treatment protocols than complex treatment models.

Although Milan family therapy is still quite popular, both comparative studies as well as case studies do suggest that a mono- method family therapy is in actuality too meagre in the treatment of psychiatric disorders (Anderson, 1986; Kaffman, 1987; Konstantareas,


1990; Mashal et al., 1989; Treacher, 1988). One of the early leading family therapists, Lyman Wynne, concluded that the emphasis on ‘identified patient’, ‘homeostasis’ and other system concepts have brought family therapists to a state of ignoring other relevant etiological factors (Wynne, 1988). The same concern about relying on rigid concepts was strongly expressed in an extensive review by Liddle, another leading family therapist (Liddle, 1991).

We agree with Gurman et al. (1986), who conclude on the basis of their review that some family constellations contribute to a situation in which vulnerable family members develop psychiatric symptoms or in which existing problems are resistant to treatment:

They suggest that there exist a number of adult (and perhaps child and adolescent) psychiatric disorders that may improve significantly in treatment that explicitly and systematically maintains a focus on the symptomatic person as ‘the patient’ without attempting to defocus the ‘patient’ by redefining that person’s problem as a ‘family’ or ‘marital’ problem, all the while remaining sensitive to the contribution of family members’ behavior to the persistence and modification of the index patient’s symptoms. While these data do not-inherently disconfirm hypotheses about the often-assumed systemic function of certain adult psychiatric symptoms, they do challenge the clinical necessity of routinely reframing such problems in this fashion. In this way, these data are consistent with the views of certain other family therapists who argue that persistent symptoms reflect the unwitting and recurrent application of misguided ‘solutions’ to problems by both the patient and those people with whom the patient regularly interacts about the problem. (Gurman et al . , 1986; p. 582).

Family therapists should not be too eager to relabel individual psychiatric disorders as family problems but choose a treatment based on the presenting problem. Assessing and treating the ways in which the family creates tension and reinforces the symptomatic behaviour can be combined with this. Interventions aimed at the individual level can thus be integrated into one treatment plan with interventions at the interactional level.

Nevertheless, there are some differences with regard to the different symptomatologies and syndromes. With schizophrenia, as is probably the case with bipolar disorder, treatment should consist of providing educational information and reducing tension and confrontation within the family, in conjunction with pharmacological treatment. In the treatment of addiction, individual self-control programmes seem necessary, although involving the family or spouse seems sensible in order to change and control reinforcement mechanisms. With simple


agoraphobia, the role of the family or spouse seems negligible. In complex agoraphobia, however, as with obsessive-compulsive disorders and depression, family members might be involved as ‘co-therapists’. However, it might also prove to be necessary to evaluate and intervene with regard to their behaviour if they contribute to the dysfunctional behaviour of the patients or if their relationship with the patient should be the unit of treatment. It is crucial that during the assessment procedure with the whole family, the different interactional and individual factors are assessed and that symptom-oriented interventions are integrated in a treatment which provides enhancement of skills to solve family problems. Even in those aspects of therapy in which family members are not the subject of treatment, they should be involved as much as possible and shown respect instead of confrontation (Anderson, 1986; Konstantareas, 1990; Methorst and Diekstra, 1987; Treacher, 1988).

Conclusion

For most of the disorders we have reviewed, family approaches appear to have relevant contributions, especially for schizophrenia (psychoeducation), mood disorders (especially unipolar depression), conduct disorders with children, addiction to drugs, and eating disorders. The impact of family therapy on anxiety disorders and addictions to alcohol is less clear. Wherever the strength of family therapy in the treatment of psychiatric disorders lies, it is not based on a rigid use of system concepts but rather on combining techniques from different theoretical frameworks including individual interventions. Family therapists have had opportunities to learn from the developments in individual (behaviour) therapy in order to create a broader and more practical, realistic approach. I t is not surprising that Garfield (1986) describes the integration of different theoretical frameworks as the most important development in psychotherapy.

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Family therapy and psychopathology: developments in research and approaches to treatment