Family interventions for mental disorders: efficacy and effectiveness.

Abstract

The physician Henry Richardson described the role of family care in the recovery from physical and mental health problems in 1948 (1). His landmark book entitled Patients have was read by a group of psychiatrists and social anthropologists at the Palo Alto Research Institute in California and became the basis of the systemic approach to family interventions (see 2 for details of this historical perspective). Unlike Richardson, these psychoanalytically trained professionals postulated that family influence was an etiological factor in serious mental disorders, rather than a key factor on the road to recovery. For many years the family system was thought to be the root of all evil and families were accused of inadvertently abusing their offspring through a variety of subtle communication strategies, such as the double-bind or communication deviance. However, these pioneers of family treatment spent considerable time with families and attempted to help them correct these defects. A special unit was opened at National Institutes of Health (NIH) in Bethesda where entire families lived for up to two years, with regular meetings to study their communication styles when faced with day to day life problems. The mere fact of convening family meetings on a regular basis, where families were encouraged to speak openly about their stresses and to attempt to find solutions to their most pressing problems, often appeared to have substantial therapeutic impact. Around the same time, a team of British sociologists and social psychiatrists began to study the outcome of relocating long-term mental hospital residents into community settings (3). Led by George Brown and John Wing, they noted that one of the predictors of successful resettlement was the interpersonal environment of the households where patients resided (4,5). The worst outcomes were in hostels where little warmth and support was provided. But the next worst situation was households where patients lived with close relatives, such as parents or spouses. This unexpected finding was explored in a series of studies using more and more sophisticated interviewing techniques to try to flesh out the specific features associated with success or failure of community care (6). The 1976 doctoral dissertation of Christine Vaughn compared the effects of family attitudes on the short-term rates of recurrence of major episodes of depression or psychosis in outpatients who had shown good recovery after acute hospital treatment. This study was summarised in a classic paper that established family factors as a key variable in achieving stable recovery from severe mental disorders. In her classic paper (7), co-authored by Julian Leff, Vaughn emphasised the value of the negative attitudes of emotive criticism and intrusiveness as predictors of a relapsing clinical course. However, in her unpublished thesis, greater emphasis was placed on the better clinical outcome associated with supportive comments and emotional warmth expressed by relatives towards the patient (8). Unfortunately the term 'expressed emotion' became synonymous with negative aspects of family care. Alternative hostels and residences were developed, despite the fact that the earlier studies had shown that they were associated with the highest rate of failure of community care. Fortunately not all those who studied this literature concluded that the best way forward was to seek alternatives to family care for people with serious mental disorders. A small group led by Robert Liberman set out on a different direction that aimed to help those families who were so burdened and stressed by the care of their relatives, that they were unable to demonstrate the positive caring behaviours that appeared to enhance the prognosis of patients. Detailed education about the nature of mental disorders and their optimal treatment was followed by practical problem solving about how to manage the everyday difficulties they encountered with patients' residual symptoms and interpersonal difficulties (9). Relatives and patients were encouraged to use effective communication skills to express their emotions in a manner not dissimilar to the methods developed by earlier family systems therapists. The focus was on increasing the expression of positive comments for efforts patients made, no matter how trivial they might seem, and on reducing nagging and hostile criticism, replacing this with attempts to clarify key problem issues in a way that would enhance patients' efforts to solve them. In simplistic terms, this psychoeducational approach aimed to convert harmful high expressed emotion to helpful low expressed emotion, or to teach family members some of the core skills of effective nursing and rehabilitation strategies. From these early beginnings in the mid 1970s, a series of random controlled trials was instigated, initially with schizophrenic disorders, but later with an increasing range of mental health problems. In the remainder of this paper we will review the results of this body of work in terms of evidence for the efficacy and the effectiveness of family interventions in adult mental health.

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