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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.


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