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Article Excerpt
This study used a grounded theory approach to examine and describe the process of conducting Medical Family Therapy (MedFT) in an inpatient psychiatric system. Fifteen clinical cases were analyzed from the point of view of the patient, family/support member, referring providers, and MedFTs. In this study, MedFT appears to function well when there are high levels of collaboration with the patient, family, and referring provider. The participants in this study reported that MedFT was effective in helping them deal with complex family dynamics that often surround psychiatric hospitalization, and in helping patients and their families initiate systemic changes that help to reduce the possibility of further hospitalization for psychiatric issues. Effective MedFT approaches used in this setting are included.
Keywords: medical family therapy, inpatient psychiatry, process research grounded theory
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Many of the early pioneers of marriage and family therapy envisioned the useful ness of their work in treating both mental and physical health problems, and did not conceptualize mental health care and physical health care as segregated entities (e.g., Bowen, 1976; Madanes, 1980; Minuchin, Baker, Rosman, Liebman, Milman, & Todd, 1975; Minuchin, Rosman, & Baker, 1978). Traditionally, marriage and family therapists (MFTs) have been trained to focus on how family dynamics contribute to or cause a presenting problem to develop. At times MFTs may unintentionally minimize or even exclude consideration of the biological influences that may play a role in the client's presenting problem.
An increasing amount of literature in the MFT field has begun to give attention to the importance of biological components to presenting problems (e.g., Glick & Spencer, 1980; Kok & Lesekla, 1996; Piercy & Sprenkle, 1990) and to the significance of effective collaboration between all health care providers (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). These changes have coincided with shifting trends in medical environments, with efforts being made to both simplify and increasingly humanize the practice of medicine and bridge the gap between biomedical and psychosocial care (McDaniel et al., 1992).
Medical family therapy (MedFT) was developed in response to these emerging needs as a way to "increase the relative importance of primary care medicine and to strengthen and redefine the place of psychosocial providers in the health care system (McDaniel et al., 1992, p. ix)." McDaniel and associates (1992) use the term "medical family therapy" to refer to the "biopsychosocial treatment of individuals and families who are dealing with medical problems" (p. 2). The primary framework used by MedFTs is a combination of systems theory and a biopsychosocial approach--which some authors (e.g., Wright, Watson, & Bell, 1996) have expanded to a biopsychosocial-spiritual framework--which helps to conceptualize problems as having biological, psychological, social, and spiritual components that are best dealt with from a holistic and collaborative framework. Training in and proficiency at collaborating with the larger health care system effectively is one of the factors that sets MedFT training and practice apart from training within its parent discipline, marriage and family therapy. Underlying whatever the specific goals of therapy may be, MedFTs maintain two general meta-goals: promoting agency, defined as commitment to and active involvement in one's own care (Totman, 1970) and communion, defined as important emotional bonds, which can often be negatively affected by the strains of disease and disability (McDaniel et al., 1992).
MEDICAL FAMILY THERAPY FOR PSYCHIATRIC CONDITIONS
Not only has family therapy proven to be effective in the treatment of relational difficulties, but has also been shown to be an effective modality for several major mental health disorders, including schizophrenia, major depression, bipolar disorder, anorexia and other eating disorders, and so forth (McFarlane, Dixon, Lukens, & Lucksted, 2003; National Institute of Health & Clinical Excellence, 2002, 2004a, 2004b). In an extensive review of literature, evaluating more than 30 randomized clinical trials, MacFarlane and associates (2003) demonstrated that patients and families who participated in family interventions for schizophrenia, such as family psychoeducation, showed improved patient recovery, reduced relapse rates, and improved family well-being. They also examined a large amount of research indicating increased employment rates for people who were treated, decreased psychiatric symptoms, improved social functioning, decreased family illness and medical utilization, and reduced costs for care for patients and families who received family based interventions as a part of treatment for major psychiatric disorders.
In addition to the clinical benefits of utilizing family based interventions to treat psychiatric disorders, practitioners who have utilized family-based approaches such as family psychoeducation reported an increase in professional satisfaction, as well as an increase in expressions of gratitude from patients and families (McFarlane et al., 2003) suggesting that the utilization of family based interventions benefits all levels involved in the treatment: providers, patients, and families. Reduced relapse rates (e.g., Bustillo, Lauriello, Horan, & Keith, 2001; McFarlane et al., 2003) and reductions in medical costs (e.g., Cardin, McGill, & Falloon, 1985; Law & Crane, 2000; McFarlane, Link, Duschay, Marchal, & Crilly, 1995; Rund et al., 1994; Tarrier, Lowson, & Barrowclough, 1991) also provided incentives to third-party payment providers for the inclusion of family-based treatment in psychiatric disorders. Notwithstanding the multitude of data that provide compelling reasons for including MedFT in the treatment of major psychiatric disorders, the inclusion of MedFT in standard inpatient psychiatric treatment programs has been extremely limited (MacFarlane et al., 2003).
MODELS OF MEDFT IN PSYCHIATRIC SETTINGS
Existing research regarding collaboration between psychiatry and MedFT may be used to highlight the need for the development of "efficient collaborative models that include the breadth of biomedical and psychosocial providers with patients and their families" (Rolland & Walsh, 2005, p. 300). Various researchers have shown the usefulness of integrating family therapy techniques into psychiatric training programs and residencies (e.g., Berman & Heru, 2005; Carter, 1989; Guttman, Feldman, Engelsmann, Spector, & Buonvino, 1999; Slovik, Griffith, Forsythe, & Polles, 1997), but relatively little has been written about the collaborative inclusion of MedFT within inpatient psychiatric units.
Practicing psychiatrists who have received family therapy training have recognized the utility of MedFT in psychiatric treatments. According to Harvard Medical School researchers, practicing psychiatrists trained in family therapy "can make unique contributions to the knowledgebase and repertoire of skills of a biopsychosocial clinician that often are not provided by other components of residency training" (Slovik et al., 1997, p. 40).
Teaching psychiatric residents a set of basic family skills has become a priority recommendation by the Family Committee of the Group for the Advancement of Psychiatry (GAP; Berman et al., 2006). However, few current psychiatric residencies teach family skills, and there are various barriers to teaching these skills that require a focused effort to overcome (Heru & Drury, 2006). Berman and colleagues (2006) have provided descriptions of several training programs in which family skills are being successfully taught. Heru and Drury (2007) also provide rich descriptions of family-based techniques that psychiatrists may use. As a whole, however, family skills have been identified by former psychiatric residents as the least taught but the most needed. (Guttman et al., 1999; Slovik et al., 1997). Enhancing the teaching of these skills is highly recommended (Berman et al., 2006; Heru, 2004; Heru & Drury, 2006, 2007). At the same time, because psychiatry residents do not receive 2 to 4 years of education concentrating on family therapy training, as do MFT and MedFT students, cooperation between the two disciplines is necessary for the full implementation of MedFT in psychiatric clinical practice (Berman & Heru, 2005). In a report delineating the need for psychiatrists to develop competency in working with families, Berman and colleagues (2006) suggest that collaborative work with multiple therapists deserves attention in psychiatric residency programs. Indeed, the core family competencies suggested for psychiatric residents (Heru, 2004) include not only developing the ability to intervene in simple family problems, but also the ability to refer complicated problems to a more specialized provider. So, while efforts to teach psychiatric residents family skills shows promise in meeting the biopsychosocial needs of patients and families, the possibility of integrating a specialized MedFT practitioner in psychiatric treatment should be considered as a way to further enhance family services which are available.
Indeed, although earlier literature focused on the incorporation of family therapy techniques into inpatient psychiatric practice (e.g., Berman & Heru, 2005; Carter, 1989; Guttman et al., 1999; Slovik et al., 1997), many current theorists have advocated interdisciplinary collaboration (e.g., Edwards, Patterson, Grauf-Grounds, & Groban, 2001; Rolland & Walsh, 2005; Walsh & Fortner, 2002). In their article on an existing joint family therapy and psychiatry training program, Walsh and Fortner (2002) emphasized the utility and increased effectiveness of MFTs operating as separate professional entities working collaboratively with psychiatrists in inpatient behavioral health units, rather than merely trying to equip psychiatrists with ancillary and secondary training in family therapy techniques. Several articles (e.g., Edwards et al., 2001; Walsh & Fortner, 2002) have been written about MedFT in collaboration with psychiatric care, but they are primarily descriptive in nature, and while useful in that sense, they focus more on the structure of the programs and have little information on the actual process of the MedFT...
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