Mental Health
Resources

 email page    print page

All Topic Reviews
50 Signs of Mental IllnessA Beautiful MindA Beautiful MindA Bright Red ScreamA Casebook of Ethical Challenges in NeuropsychologyA Corner Of The UniverseA Lethal InheritanceA Mood ApartA Research Agenda for DSM-VA Slant of SunA War of NervesAbnormal Psychology in ContextADD-Friendly Ways to Organize Your LifeAddiction Recovery ToolsAdvance Directives in Mental HealthAggression and Antisocial Behavior in Children and AdolescentsAl-JununAlmost a PsychopathAlterations of ConsciousnessAm I Okay?American ManiaAmerican Psychiatric Publishing Textbook of Neuropsychiatry and Clinical NeurosciencesAn American ObsessionAngelheadAnger, Madness, and the DaimonicAnthology of a Crazy LadyApproaching NeverlandAs Nature Made HimAsylumAttention-Deficit Hyperactivity DisorderAttention-Deficit/Hyperactivity DisorderBeing Mentally Ill: A Sociological Theory Betrayal TraumaBetrayed as BoysBetter Than ProzacBetter Than WellBeyond AppearanceBeyond ReasonBinge No MoreBiological UnhappinessBipolar DisorderBipolar DisorderBipolar Disorder DemystifiedBlack-eyed SuzieBlaming the BrainBleeding to Ease the PainBluebirdBlueprints Clinical Cases in PsychiatryBody Image, Eating Disorders, and ObesityBorderline Personality DisorderBrain Circuitry and Signaling in PsychiatryBrave New BrainBreakdown of WillBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerCalm EnergyCassandra's DaughterCaught in the NetChild and Adolescent Treatment for Social Work PracticeChildren Changed by TraumaChronic Fatigue Syndrome (The Facts)Clinical Handbook of Psychological DisordersClinical Manual of Women's Mental HealthCognitive Theories of Mental IllnessCommonsense RebellionCommunity and In-Home Behavioral Health TreatmentComprehending SuicideConcise Guide to Child and Adolescent PsychiatryConquering Post-Traumatic Stress DisorderConscience and ConvenienceConsciousnessConsole and ClassifyContesting PsychiatryCoping With TraumaCopshockCrazy for YouCrazy in AmericaCrazy Like UsCreating HysteriaCritical PsychiatryCruel CompassionCultural Assessment in Clinical PsychiatryCulture and Mental HealthCulture and Psychiatric DiagnosisCultures of NeurastheniaDaddy's GirlsDante's CureDarwinian PsychiatryDaughter of the Queen of ShebaDaughters of MadnessDeinstitutionalization And People With Intellectual DisabilitiesDelivered from DistractionDepression In Later LifeDepression SourcebookDepression-Free for LifeDescriptions and PrescriptionsDestructive Trends in Mental HealthDevil in the DetailsDiagnosis: SchizophreniaDiagnostic and Statistical Manual of Mental Disorders DSM-IV-TRDirty Filthy Love DVDDisorders Of DesireDisrupted LivesDissociative ChildrenDivided MindsDr. Andrew Weil's Guide to Optimum HealthDr. Weisinger's Anger Work-Out BookDSM-IV SourcebookDSM-IV-TR CasebookDSM-IV-TR in ActionDSM-IV-TR Mental DisordersE-TherapyEccentricsElectroshockEmergencies in Mental Health PracticeEmergency PsychiatryEmotional and Behavioral Problems of Young ChildrenEmotions and LifeEmpowering People with Severe Mental IllnessEssential PsychopharmacologyEssentials of Cas AssessmentEssentials of Wais-III AssessmentEthics and Values in PsychotherapyEthics in Mental Health ResearchEthics in Psychiatric ResearchEthics, Culture, and PsychiatryEverything In Its PlaceFamily Experiences With Mental IllnessFatigue as a Window to the BrainFear of IntimacyFinding Iris ChangFinding Meaning in the Experience of DementiaFlorid StatesFolie a DeuxFor the Love of ItForensic Nursing and Multidisciplinary Care of the Mentally Disordered OffenderFountain HouseFrom Madness to Mental HealthFrom Trauma to TransformationGandhi's WayGender and Its Effects on PsychopathologyGender and Mental HealthGenes, Environment, and PsychopathologyGetting Your Life BackGracefully InsaneGrieving Mental IllnessHandbook of AttachmentHandbook of DepressionHandbook of Self and IdentityHealing the SplitHerbs for the MindHidden SelvesHigh RiskHope and DespairHow Clients Make Therapy WorkHow People ChangeHow to Become a SchizophrenicHow We Think About DementiaHughes' Outline of Modern PsychiatryHumanizing MadnessHysterical MenHystoriesI Hate You-Don't Leave MeI Never Promised You a Rose GardenI Thought I Could FlyI'm CrazyImagining RobertImpulse Control DisordersIn Others' EyesIn Two MindsInsanityIntegrated Behavioral Health CareIntegrative MedicineIntegrative Mental Health CareIntuitionJust CheckingKarl JaspersKissing DoorknobsKundalini Yoga Meditation for Complex Psychiatric DisordersLaw and the BrainLaw, Liberty, and PsychiatryLegal and Ethical Aspects of HealthcareLiberatory PsychiatryLife at the BottomLife at the Texas State Lunatic Asylum, 1857-1997Life Is Not a Game of PerfectLithium for MedeaLiving Outside Mental IllnessLiving with AnxietyLiving With SchizophreniaLiving with SchizophreniaLiving Without Depression and Manic DepressionLost in the MirrorLove's ExecutionerLoving Someone With Bipolar DisorderMad in AmericaMad TravelersMad, Bad and SadMadhouseMadnessMadness at HomeMadness in Buenos AiresManaged Care ContractingMandated Reporting of Suspected Child AbuseManic Depression and CreativityMary BarnesMasters of the MindMeasuring PsychopathologyMedia MadnessMedicine As MinistryMelancholy And the Care of the SoulMemory, Brain, and BeliefMental HealthMental Health At The CrossroadsMental Health Issues in Lesbian, Gay, Bisexual, and Transgender Communities Mental Health MattersMental Health Policy in BritainMental Health Policy in BritainMental Health Professionals, Minorities and the PoorMental IllnessMental Illness and Your TownMental Illness, Medicine and LawMental SlaveryMindfulness in Plain EnglishModels of MadnessMothers Who Kill Their ChildrenMozart's Brain and the Fighter PilotMultifamily Groups in the Treatment of Severe Psychiatric DisordersMuses, Madmen, and ProphetsMyths of ChildhoodNapkin NotesNeural MisfireNew Hope For People With Bipolar DisorderNight Falls FastNo Enemies WithinNolaNormalNot CrazyNovember of the SoulOf Two MindsOn Being Normal and Other DisordersOn Our Own, TogetherOn The Stigma Of Mental IllnessOrigins of Human NatureOut of Its MindOut of the ShadowsOvercoming Compulsive HoardingPathologies of BeliefPathways through PainPersonal Recovery and Mental IllnessPersonality Disorder: Temperament or Trauma?Pillar of SaltPoints of ViewPoppy ShakespearePosttraumatic Stress DisorderPsychiatric Cultures ComparedPsychiatric Diagnosis and ClassificationPsychiatric Genetics and GenomicsPsychiatric Illness in WomenPsychiatrists and Traditional HealersPsychiatryPsychiatry and ReligionPsychiatry in SocietyPsychological Dimensions of the SelfPsychology and the MediaPsychopathia SexualisPsychopathologyPsychopathyPsychotic DepressionQuitting the Nairobi TrioRaising a Moody ChildRapid Cognitive TherapyRebuilding Shattered LivesReclaiming Soul in Health CareReclaiming the SoulRecollection, Testimony, and Lying in Early ChildhoodRecovery from SchizophreniaRecovery in Mental IllnessRedressing the EmperorRelational Mental HealthRemembering TraumaRepressed SpacesResearch Advances in Genetics and GenomicsRestricted AccessRethinking the DSMReviving OpheliaRewarding Specialties for Mental Health CliniciansSaints, Scholars, and Schizophrenics: Mental Illness in Rural IrelandSchizophreniaSchizophrenia RevealedSchizophrenia: A Scientific Delusion?Self-Determination Theory in the ClinicShunnedShynessSigns of SafetySilencing the VoicesSlackjawSocial Cognition and SchizophreniaSocial Inclusion of People with Mental IllnessSoul Murder RevisitedSounds from the Bell JarSpeaking Our MindsSpontaneous HealingStop PretendingStraight Talk about Psychological Testing for KidsStranger Than FictionStreet CrazyStudy Guide to the DSM-IV-TRSurviving Manic DepressionSurviving SchizophreniaSurviving SchizophreniaTaking Charge of ADHD, Revised EditionTaking the Fear Out of ChangingTalking Back to PsychiatryTarnationTeen LoveTelling Is Risky BusinessTelling SecretsThe Age of InsanityThe American Psychiatric Press Textbook of PsychiatryThe American Psychiatric Publishing Textbook Of Child And Adolescent PsychiatryThe Anger WorkbookThe Anorexic SelfThe Behavioral Medicine Treatment PlannerThe Betty Ford Center Book of AnswersThe Bipolar ChildThe Bipolar Disorder Survival GuideThe Body in PsychotherapyThe Borderline Personality Disorder Survival GuideThe Broken MirrorThe Burden of SympathyThe Cambridge Medical Ethics WorkbookThe Case for Pragmatic PsychologyThe Center Cannot HoldThe Chemical Dependence Treatment Documentation SourcebookThe Chemical Dependence Treatment PlannerThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Condition of MadnessThe Construction of Power and Authority in PsychiatryThe Couples Psychotherapy Treatment PlannerThe Criminal BrainThe Cultural Context of Health, Illness, and MedicineThe Day the Voices StoppedThe Death of PsychotherapyThe Depression WorkbookThe Difficult-to-Treat Psychiatric PatientThe Early Stages of SchizophreniaThe Employee Assistance Treatment PlannerThe Employee Assistance Treatment PlannerThe Epidemiology of SchizophreniaThe Essential Family Guide to Borderline Personality DisorderThe Essentials of New York Mental Health LawThe Ethical WayThe Evolution of Mental Health LawThe Explosive ChildThe Fall Of An IconThe Fasting GirlThe Forensic Documentation SourcebookThe Forgotten MournersThe Gift of Adult ADDThe Good EaterThe Green ParrotThe Healing Power of PetsThe Heart of AddictionThe Heroic ClientThe Insanity OffenseThe Invisible PlagueThe Last Time I Wore a DressThe Limits of Autobiography The LobotomistThe Madness of Our LivesThe Mark of ShameThe Meaning of AddictionThe Meaning of MindThe Medical AdvisorThe Mind/Mood Pill BookThe Most Solitary of AfflictionsThe Mozart EffectThe Naked Lady Who Stood on Her HeadThe Older Adult Psychotherapy Treatment PlannerThe OutsiderThe Pastoral Counseling Treatment PlannerThe PDR Family Guide to Natural Medicines & Healing TherapiesThe Places That Scare YouThe Plural SelfThe Problem of EvilThe Psychology of Religion and CopingThe Quiet RoomThe Real World Guide to Psychotherapy PracticeThe Right to Refuse Mental Health TreatmentThe Rise of Mental Health NursingThe Roots of the Recovery Movement in PsychiatryThe Savage GirlThe Self-Help SourcebookThe Talking CureThe Trick Is to Keep BreathingThe Unwell BrainThe Virtuous PsychiatristThe Way of TransitionThe Wing of MadnessThe Wisdom in FeelingTheoretical Evolutions in Person-Centered/Experiential TherapyTherapy's DelusionsTheraScribe 3.0 for WindowsThis is Madness TooThoughts Without a ThinkerThrough the Looking GlassTo Have Or To Be?Toxic PsychiatryTransforming MadnessTraumaTraumatic PastsTraumatic Relationships and Serious Mental DisordersTreating Affect PhobiaTreating Chronic and Severe Mental DisordersTreating Self-InjuryTreatment and Rehabilitation of Severe Mental IllnessTreatment Plans and Interventions for Depression and Anxiety DisordersTwinsUnderstanding and Treating Violent Psychiatric PatientsUnderstanding Child MolestersUnderstanding DepressionUnderstanding ParanoiaUnderstanding the Stigma of Mental IllnessUnderstanding Treatment Without ConsentUnholy MadnessUnspeakable Truths and Happy EndingsUsers and Abusers of PsychiatryViolence and Mental DisorderVoices of MadnessVoices of RecoveryVulnerability to PsychopathologyWarning: Psychiatry Can Be Hazardous to Your Mental HealthWashing My Life AwayWhen History Is a NightmareWhen Someone You Love Is BipolarWhen the Body SpeaksWhen Walls Become DoorwaysWitchcrazeWomen and Borderline Personality DisorderWomen and Mental IllnessWomen Who Hurt ThemselvesWomen's Mental HealthWrestling with the AngelYou Must Be DreamingYour Drug May Be Your ProblemYour Miracle Brain

Related Topics
Multifamily Groups in the Treatment of Severe Psychiatric DisordersReview - Multifamily Groups in the Treatment of Severe Psychiatric Disorders
by William R. McFarlane
Guilford Press, 2004
Review by Robert L. Muhlnickel, M.S.W., Ph.D. (Candidate)
Jul 18th 2006 (Volume 10, Issue 29)

It's likely that few philosophers who consult this service know about the unusually effective mental health treatment described in this book: psychoeducational multiple family groups for persons suffering from schizophrenia and other severe psychiatric disorders. The disappointing fact is that the majority of mental health professionals fail to provide this treatment for patients with schizophrenia.  Many randomized research studies show that psychoeducational multiple family groups (or PMFG's) are one of the most effective non-pharmacological interventions available for reducing re-hospitalization rates and promoting recovery for people with schizophrenia. Similar but fewer studies show that PMFG's are nearly as effective for people with other severe psychiatric disorders. McFarlane's MultiFamily Groups is a detailed account of the empirical research that demonstrates the effectiveness of PMFG's, the theoretical presuppositions of neurobiology and psychopathology, the social sciences that explain the effectiveness of the groups, and the component interventions that make up PMFG's. In  I summarize the empirical findings, theoretical presuppositions, and components of the intervention; in  I discuss problems associated with implementing PMFG's; in  I discuss some philosophically interesting issues the book raises.

2. Summary of Multifamily Groups in the Treatment of Severe Psychiatric Disorders

2.1. Empirical studies of effectiveness

McFarlane has led efforts to evaluate the empirical and clinical effectiveness of PMFG's for over two decades, building on the work of Peter Laqueur, Carol Anderson, Gerald Hogarty, Julian Leff, Lyman Wynne, Ian Falloon and others. In severe psychiatric illnesses, the primary criterion for evaluating treatment effectiveness is relapse reduction. Fewer relapses result in fewer hospitalizations, less disruption of the mentally ill person's interaction with their social network, and more time for the mentally ill person to take advantage of skill-building and life-sustaining opportunities such as psychiatric rehabilitation. McFarlane mentions the "striking consistency of therapeutic effects" in descriptions of early investigations of family groups, behavioral training, and educational programs for single families (p. 49) where the severe psychiatric disorder is schizophrenia.  He notes that investigation of which factors made these different interventions effective is absent. As a result, he and his colleagues undertook to study factors that seemed responsible for their effectiveness, including: educational presentations about mental illness, families and patients meeting in groups, and social network expansion. He recounts two long-term controlled studies: the first evaluated educational PMFG's in comparison to family groups, emphasizing interventions in family dynamics and single-family education; the second evaluated educational PMFG's in comparison to single family education.

The first study showed that people with schizophrenia had fewer relapses, longer periods without relapses, and greater improvement in areas like employment. The second study showed similar results on relapse rates and improvement. The second study also showed the need for antipsychotic medication decreases for patients in PMFG's and increases for patients in single-family educational groups. Given that side-effects of antipsychotic medications include increased risk of diabetes and socially stigmatizing parkinsonian effects, there is a significant advantage to PMFG's.

Due to the effects of deinstitutionalization with inadequate outpatient treatment, the criminalization of the mentally ill, and increased advocacy for rehabilitation of people with psychiatric illnesses, McFarlane and his co-workers sought to show the effectiveness of PMFG's in specialized treatment modalities. As a result, he cites studies showing that PMFG's combined with assertive community treatment and PMFG's aimed at helping people with psychiatric illness find employment also were successful.

McFarlane lists five conclusions from the various studies he and his collaborators have conducted.

  • Psychoeducational-problem-solving PMFG's are more effective than individual therapy and/or medication alone.
  • PMFG's consistently yield lower relapse rates and higher employment rates than single-family psychoeducation.
  • PMFG's are more effective than single-family psychoeducation for first-episode and high-risk patients and for highly stressed families.
  • PMFG's result in higher employment rates than single-family psychoeducation even if both are combined with assertive community treatment.
  • The benefits of PMFG's increase over time up to four years.

2.2. Theoretical Explanation of the Effectiveness of PMFG's

            To explain the empirical and clinical effectiveness of PMFG's, McFarlane turns to a theoretical model combining studies from neuropsychiatry and social networks of schizophrenics and their families. He summarizes it as follows:

The state of the individual with schizophrenia is determined by a continuous interaction of specific biological dysfunctions of the brain with social processes (p. 75).

Clinicians who expect McFarlane to re-hash the familiar bio-psycho-social approach would be mistaken. The bio-psycho-social model is often presented to clinicians as an equalizer, as if the fact that mental illness has biological, psychological and social factors implies that all perspectives on the cause, course and treatment of mental illness are equally correct, or even equally effective. McFarlane's account is more specific, arguing that biological factors are the primary causal factors and that the effects of neurobiology in schizophrenia cause cognitive and psychological deficits that result in social impairment. The treatment recommendation that results is not the uncoordinated mélange of medicines and therapies often found in public mental health systems but a prescription for systematic social interventions that compensate for the deficits caused by the neurobiology.

            McFarlane's opening chapters summarize neurological changes and social problems of people with schizophrenia. The neurological changes that occur in schizophrenia cause psychological deficits. The most important psychological deficits in his view are arousal dyscontrol, in which the person with schizophrenia cannot adjust the content and intensity of multiple repeated stimuli, resulting in cognitive confusion; impaired executive functioning that affects problem-solving, planning, and self-care; and negative symptoms, in which the person with schizophrenia suffers loses affective expressiveness, capacity for abstract thought and motivation to participate in formerly desired activities. Impaired executive functioning and decreased motivation result in many persons with schizophrenia being unable to manage their illness without considerable supports from family members and mental health workers. The social problems on which McFarlane focuses are decreased ability to cope with stress, reduced size of the schizophrenic's social network, and decreased quality of life.

            The prescriptive aim of McFarlane's work emerges when he discusses the need for compensatory environments that not only protect schizophrenics from stressors and intense stimulation but also help them regain skills lost to the neurological effects of the illness. The compensatory environment has the family at its center, and he prescribes specific skills, guidelines, and management strategies for protective and rehabilitative functions. The clinician together with the family members and people with schizophrenia form a therapeutic network. Some of those skills, guidelines, and strategies are described in the section 2.3.

2.3. The Components of PMFG's

            PMFG's consist of structured interventions intended to develop a bond between the clinician and family members, between the clinician and the patient, and assist the family members in creating the compensatory environment described above. The series of interventions begins with joining, in which the clinician engages with families in a manner specifically designed to address their guilt without blaming the family, discover family strengths, and instill hope for recovery. Clinicians then lead an educational workshop for several families and patients, where clinicians present information about the biology of mental illness, psychotherapeutic and pharmacological treatments, optimal compensatory environments and guidelines for managing a family member's mental illness. The educational workshop is followed by meetings of multiple family groups. The initial groups are organized around two contrasting goals: developing relationships that are not centered on mental illness and sharing common experiences of what each person has been affected by mental illness. Subsequent groups are devoted to problem-solving in which clinicians follow and teach a structured method of problem-solving, including problem-definition, brainstorming solutions, selecting solutions, planning implementation and evaluating success.

            The description of PMFG's ongoing groups, which last from 9 months to 4 years, might sound unremarkable from this summary. However, what happens in PMFG's is noteworthy. McFarlane describes the process of the groups that clinicians are required to learn and lead: relating problems to illness management guidelines, managing difficult problems without eliciting intensity that can precipitate relapse, interfamily assistance or 'cross-parenting', in which family members from one family guide members of another to change some behavior or learn some skill related to living with mental illness and developing social networks that persist outside scheduled group meeting times. Many clinicians learn and value skills that are not put to use in PMFG's. The skills of dynamic interventions, interpretation of psychological phenomena, ventilation of feelings and probing memories for the sources of behavior patterns are not effective and are often harmful in treating schizophrenia. PMFG's require clinicians to present themselves as partners in a recovery process, presenters of specialized information to families, and receivers of specialized information from family members. However, the requirement that clinicians who would lead PMFG's significantly alter the skills they have acquired gets little emphasis in McFarlane's text.

3. Implementation Failures

            There are two directions to consider when evaluating efforts to implement an intervention as effective in controlled studies and clinical research settings as PMFG's. One direction to consider is whether PMFG's are as effective with other illnesses as with schizophrenia. A treatment that is effective across multiple illnesses is considered robust. Call this direction breadth because success with other illnesses would indicate the intervention is effective with a broad range of illnesses and disorders. The second direction is to ask whether a demonstrably effective intervention has been widely adopted in ordinary clinical practice. Call this direction depth since it would indicate that the intervention has roots in the culture and practice of mental health treatment outside locations that specialize in the intervention.

McFarlane has enlisted able collaborators who show the multiple family group intervention has breadth. The book includes chapters on implementing PMFG's in community housing programs where 'families' are not biological and legal relatives or preferred companions. Rather, 'families' are staff members who work in group homes and other residential programs. Another chapter describes combining PMFG's with assertive community treatment teams who specialize in work with mentally ill people who are detached from treatment systems, whose mental  illnesses are  severe, and whose symptoms are often exacerbated by addiction, homelessness and STI's. This chapter describes clinicians working to adapt the structured problem-solving method to difficult problems, such as preventing patients from stealing from family members to buy drugs, preparing for the return of a mentally ill person from prison and helping a person with psychosis avoid contracting HIV during intravenous drug use.

Another indication of breadth is the development of PMFG's for the treatment of other severe psychiatric illnesses and chronic medical illnesses. The PMFG method has been adapted for bipolar disorder, major depression, borderline personality disorder and obsessive-compulsive disorder. Use of PMFG's for these disorders has not been researched as thoroughly as it has for schizophrenia, but these chapters are signs of hope. In addition, the method has been adapted for chronic medical disorders, indicating that the problems and needs of families and patients, and theoretical presuppositions that McFarlane capably outlines for mental illness, also apply in some way to chronic medical conditions. 

There has been limited depth in the implementation of PMFG's and the results reported by McFarlane's collaborators and elsewhere are disappointing. As reported in this book, attempts to implement PMFG's statewide in mental health systems have failed. The authors of this chapter identify organizational cultural issues, systems issues and training issues as contributors to the failure. Organizational-cultural issues that contributed to failed implementation efforts are that PMFG's are reportedly more complex than therapies with which clinicians are familiar, the advantages of PMFG's are reportedly not observable quickly enough to reinforce sustained use, and PMFG's are too different from clinicians' familiar methods to be easily adopted. Systems issues that contributed to failed implementation efforts are the lack of financial support for the treatment and inadequate commitment from mental health agency leaders to compel clinicians to adopt PMFG's. Training issues that contributed to failed implementation efforts are an over-reliance on information transfer alone to alter clinical practice from other interventions to use of PMFG's.

The statewide implementation efforts reported in this chapter ended seven years ago in Ohio and fifteen years ago in New York. Implementation programs are underway in New York, Maryland and Michigan, and a study of PMFG's in culturally diverse groups has been funded by SAMHSA. At least some of the recent implementation programs have adopted training methods designed to avoid the failures reported in this book and attempt to effect institutional changes that would avoid the failures noted above. Attempts have been made to secure Medicaid payment, identify leaders who will encourage and/or compel staff to use PMFG's, and provide consultants who can guide agencies and clinicians in developing PMFG's as a regular part of clinical practice. We await reports on these implementation projects.

4. Philosophically Interesting Issues

            I shall mention four issues arising from McFarlane's work that should interest philosophers. The first concerns the phenomena on which philosophers could profitably focus their interest in the mind. The second is a similarity between McFarlane's work and the capabilities approach to human development. The third is to suggest that the failed implementation efforts are a potential case study in implementation ethics. The fourth is an implication of McFarlane's work for disability studies. 

(1) Philosophers who are interested in schizophrenia and mental illness are usually interested in what happens 'inside' the mind of the person with the mental illness. We want to learn about consciousness, the self and rationality by understanding the mind when consciousness is disordered by hallucination, self-awareness is fragmented by paranoia and rationality is disturbed by delusion. McFarlane's research on the effectiveness of intervening in schizophrenia by means of compensatory social environments, in families, friends and professionals, should give us pause to wonder what we have missed by focusing on cognitive and perceptual processes and what we might find if we investigated interactional processes. A common metaphor among contemporary philosophers of mind is the idea of an ''extended mind''. That is, the mind is not merely something 'inside' the person but is a set of functional relationships constituted by interactions between persons and the instruments and objects they use, and between the person and the environment. McFarlane's multiple family groups are an instance of another kind of extended mind, in which groups of families create a 'mind' distinct from any individual person's mind that functions for the benefit of the group's ill members.

(2) When McFarlane describes the compensatory environment schizophrenics need as ''optimal but atypical'' (p. 42; also p. 199) he reminds me of the capabilities approach to social justice and human development championed by Martha Nussbaum and Amartya Sen. The capabilities approach recognizes that not every person is born with the capacity to learn the same skills to use resources to attain individual well-being, and asks what people need to effectively use environmental resources to attain well-being. McFarlane and his collaborators seem to have developed a method that responds to the particular needs of people with severe mental illness that helps them effectively use their capabilities. It would be interesting for someone expert in the capabilities approach to study PMFG's and for McFarlane to take advantage of the theoretical resources of the capabilities approach.

(3) Few medical ethicists have written about ''implementation ethics'', reflection on ethical principles, practices, and pitfalls of implementing effective treatments in ordinary clinical settings. Implementing new treatments ethically requires attention to resource distribution, leadership, and sustainability rather than to protecting subjects and assuring voluntary consent, as in research ethics.[1] Inadequate support of effective treatments is an ethical failure that easily goes unrecognized since it is difficult to identify a single responsible agent. Here is an area in which subtle ethical issues could benefit from investigation.

(4) McFarlane mentions a principle that could be of interest for disabilities studies. Many theorists in disabilities studies criticize 'biomedical' concepts of disability and favor the view that disability is socially constructed. One reason given for rejecting biomedical concepts of disability is the belief that an effect of biomedical concepts is to deprive people classified as disabled in biomedical models of their ability to choose and flourish. McFarlane's work is solidly within the biomedical tradition and he is aware of stigmatization and disempowerment. In contrast to those who deny that mental illnesses are disabilities and the claims of the disempowering effects of the biomedical concept of disability, he cites a guiding principle of his work that contravenes such views:

The more that the partial disabilities of schizophrenia are acknowledged, respected and accommodated, the less they impede the path to recovery (p. 80).

Recovery here means many of the same things disability theorists say they want: choice of goals in life, employment and freedom from hospitalization. The principle of accepting partial disability as a biomedical fact, rather than a social construction, in order to reduce the power of the disabling condition to impede recovery suggests that the means of choosing and attaining well-being is to manage the effects of a disabling condition rather than deny the fact that some condition is disabling. There is no doubt that mental health systems exercise great power in the lives of people they are charged to assist, and many activities required of their charges have little connection to individual choice and well-being. However, McFarlane's ''devil's pact'' suggests that accepting disability as a biomedical fact is a means by which people with disabilities and those who work with them can increase choice and well-being. McFarlane seems to suggest the importance of a certain sort of psychological jujitsu: if you stop pushing against a force it has less power to harm you. If you increase your force by joining with others in a multiple family group, you gain the assistance of others and improve your chances of reducing the impediments associated with disability.

    

© 2006 Robert L. Muhlnickel

 

Robert L. Muhlnickel, MSW, has been a clinician and teacher in the University of Rcohester Department of Psychiatry and is completing his Ph.D. dissertation in Philosophy at the University of Rochester. He also works on a grant training clinicians in evidence-based family practices forpeople with serious and persistent mental illness, co-sponsoredby the NYS Office of Mental Health and University of Rochester Medical Center.

 



[1] S. Rennie and F. Behets, "AIDS Care and Treatment in Sub-Saharan Africa: Implementation Ethics," Hastings Center Report 36, 3 (2006), pp. 23-31.


Share

Welcome to MHN's unique book review site Metapsychology. We feature over 7900 in-depth reviews of a wide range of books and DVDs written by our reviewers from many backgrounds and perspectives. We update our front page weekly and add more than thirty new reviews each month. Our editor is Christian Perring, PhD. To contact him, use one of the forms available here.

Can't remember our URL? Access our reviews directly via 'metapsychology.net'


Metapsychology Online reviewers normally receive gratis review copies of the items they review.
Metapsychology Online receives a commission from Amazon.com for purchases through this site, which helps us send review copies to reviewers. Please support us by making your Amazon.com purchases through our Amazon links. We thank you for your support!


Join our e-mail list!: Metapsychology New Review Announcements: Sent out monthly, these announcements list our recent reviews. To subscribe, click here.

Interested in becoming a book reviewer for Metapsychology? Currently, we especially need thoughtful reviewers for books in fiction, self-help and popular psychology. To apply, write to our editor.

Metapsychology Online Reviews

Promote your Page too

Metapsychology Online Reviews
ISSN 1931-5716