thomas campbell improving health through family interventions

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Improving Health through Family Interventions

Thomas L. Campbell, M.D.

Professor of Family Medicine and Psychiatry

University of Rochester School of Medicine & Dentistry

885 South Ave, Rochester, NY 14620

585-442-7470 x701

[email protected]
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INTRODUCTION

A large body of research has demonstrated that families have a powerful influence

on physical health, including morbidity and mortality (Campbell.T.L., 1986;

Campbell.T.L. & Patterson, 1995; Kiecolt-Glaser & Newton, 2001; Burman & Margolin,

1992) . Numerous epidemiologic studies have demonstrated that social support,

particularly from the family, is health promoting(Berkman, 2000; Berkman, 1995). In an

1988 article in the journal Science, sociologist James House reviewed this research and

concluded:

The evidence regarding social relationships and health increasinglyapproximates the evidence in the 1964 Surgeon Generals report that

established cigarette smoking as a cause or risk factor for mortality and

morbidity from a range of disease. The age-adjusted relative risk ratios are

stronger than the relative risks for all cause mortality reported for cigarette

smoking(House, Landis, & Umberson, 1988).

Family support affects the outcome of many chronic medical illnesses. Berkman and

colleagues found that after suffering a myocardial infarction, women who are isolated

and have few or no family or social supports have two to three times the mortality rate

compared to other women(Berkman, Leo-Summers, & Horwitz, 1992). Many stresses

within the family, such as loss of a spouse and divorce, significantly impact morbidity

and mortality.

Marriage is the family relationship which has the strongest influence on physical

health. . Even after controlling for other factors, marital status affects overall

mortality, mortality from specific illnesses (e.g. cancer and coronary disease) and

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morbidity(Kiecolt-Glaser & Newton, 2001; Burman & Margolin, 1992). Married

individuals are healthier than the widowed, who are in turn healthier than either

divorced or never married individuals. Many large studies have shown that

bereavement or death of a spouse increases mortality, especially for men (Martikainen

& Valkonen, 1996; Osterweis, Solomon, & Green, 1984). Separation and divorce is

also associated with increased mortality.

The quality of marital relationships can influence morbidity and mortality from

chronic illnesses. Coyne et al (Coyne et al., 2001) found that marital quality, measured

by a composite of self report and observation of marital interaction, was predictive of survival from congestive heart failure, after controlling for the initial severity of the

heart failure. Marital quality was as strong a predictor of death as the severity of heart

failure itself and had a stronger effect for women than men. Dyadic negativity has

been shown to worsen survival in women who have end stage renal disease and are on

dialysis (Kimmel et al., 2000). Weihs (Weihs, Enright, Simmens, & Reiss, 2000)found

that women with early breast cancer who do not confide in their spouses have higher

recurrence rates than those who do have a confiding relationship. Marital stress has

been shown to worsen coronary artery disease in women (Orth-Gomer et al., 2000).

These findings suggest that loss of a spouse has the greatest health effects on men, but

the impact of poor marital quality may be greater for women.

Negative, critical, or hostile family relationships have a stronger influence on

health than positive or supportive relationships. In terms of health, being nasty is

worse than simply not being nice. Research in the mental health field with

schizophrenia and depression first demonstrated that family criticism was strongly

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predictive of relapse and poor outcome(Hooley, 1985; Hooley, Orley, & Teasdale,

1986; Kanter, Lamb, & Loeper, 1987; Hooley et al., 1986). Similar results have been

found with smoking cessation(Mermelstein, Lichtenstein, & McIntyre, 1983), weight

management(Fischmann-Havstad & Marston, 1984), diabetes(Klausner, Koenigsberg,

Skolnick, & Chung, 1995; Koenigsberg, Klausner, Pelino, & Rosnick, 1993), asthma

and migraine headaches. Physiological studies have shown that conflict and criticism

between family members can have negative influences on blood pressure(Ewart, Taylor,

Kraemer, & Agras, 1991) and diabetes control(Minuchin, Rosman, & Baker, 1978).

Although there is strong observational research demonstrating that familyrelationships influence physical health, there are few studies examining whether family

interventions improve physical health. This chapter will review the evidence that family

interventions be beneficial in the prevention or treatment of physical disorders. While it

has been clearly demonstrated that family therapy can improve the emotional health of

family members and family functioning, there is much less evidence that family

interventions can improve the physical health of family members. Studies, mostly

randomized controlled trials of family intervention will be reviewed using the family life

cycle as an organizing theme. After reviewing studies on the prevention of chronic

illness, research on the chronic illness in childhood, adult and the elderly will be

reviewed. Recommendations for future research and implications for family clinicians

will be presented.

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FAMILY INTERVENTIONS FOR PHYSICAL DISORDERS

Many types of family interventions have been developed and tested for a wide

range of physical disorders. ? more here

Prevention of Chronic Disease

Over one-third of all deaths in the United States can be directly attributable to

unhealthy behaviors, particularly smoking, lack of exercise, poor nutrition and alcohol

abuse, and are potentially preventable. These unhealthy behaviors account for much of

morbidity or suffering from chronic illnesses, such as heart disease, cancer, diabetes and

stroke. Health habits usually develop, are maintained and are changed within the context

of the family. Unhealthy behaviors or risk factors tend to cluster within families, since

family members tend to share similar diets, physical activities and use or abuse of

unhealthy substances, such as smoking. The World Health Organization (World Health

Organization, 1976) has characterized the family as the primary social agent in the

promotion of health and well-being(p. 17)

Nutrition and prevention of cardiovascular disease. Despite societal changes,

families still tend to eat together, share the same diets and consume similar amounts of

salt, calories, cholesterol and saturated fats (Doherty & Campbell, 1988; Nader et al.,

1983). If one family member changes his or her diet, other family members tend to

make similar changes (Sexton et al., 1987). However, most dietary interventions are

directed at individuals with little or no attention to the rest of the family.

Family intervention can change diet and promote a healthier lifestyle, but family

interventions have not been compared to an individual interventions. In the British

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Family Heart Study over 12,000 middle aged couples from 26 general received family-

based counseling by a trained nurse about healthy lifestyles and cardiac risk

reduction(Graham, Senior, Dukes, & Lazarus, 1993). At one-year follow-up, the the

couples receiving the intervention had reduced their smoking, blood pressure and

cholesterol level and had a 16% reduction in their overall cardiac risk score. Other

studies have found similar results with small, but significant improvements in healthy

behaviors (Knutsen & Knutsen, 1991; Perry et al., 1989).

Weight reduction Over 30% of the population is considered obese (more than

20% over ideal body weight) which contributes to numerous chronic illnesses, includingdiabetes, hypertension, coronary heart disease and arthritis. Obesity is a major public

health problem Overeating and obesity can play important homeostatic roles in families.

The parents of obese children are less likely to encourage exercise and more likely to

encourage their children to eat than other parents(Hanson, Klesges, Eck, & Cigrang,

1990; Waxman & Stunkard, 1980). The family plays an important role in both the

development and the treatment of eating disorders such as anorexia nervosa and bulimia

(Campbell & Patterson, 1995).

In obesity treatment programs, spousal support predicts successful weight loss

(Streja, Boyko, & Rabkin, 1982) and spousal criticism or high expressed emotion is

associated with little or no weight loss (Fischmann-Havstad et al., 1984). There are ten

randomized controlled trials of spouse or partner involvement in weight reduction

programs (Black, Gleser, & Kooyers, 1990a). The interventions are based upon

individual cognitive behavioral approaches in which a spouse is viewed as reinforcing

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desired behaviors. Spouses attend all the sessions and are instructed in basic behavior

modification techniques, especially giving positive reinforcement and avoiding criticism.

The results of the couple interventions were mixed. In approximately one half of

the studies, the intervention groups were able to maintain the weight loss for up to 3

years. A meta-analysis of these studies (Black, Gleser, & Kooyers, 1990) concluded that

couples interventions had a small, but significant, improvement in weight loss at the end

of the program, which persisted for 2 to 3 months, but was no longer apparent at lengthier

(1-3 years) follow-up.

When supportive behaviors were measured in these studies, there was little or noincrease in these behaviors. Obese subjects who reported higher satisfaction with their

marriage lost more weight (Dubbert & Wilson, 1984). In one study, the greatest weight

loss occurred in the group where the spouses were asked not to nag, criticize or otherwise

participate in their partners efforts at weight reduction. These studies suggest that

blocking partner criticism and addressing marital conflict and dissatisfaction may be

more important than trying to increase supportive behaviors.

Childhood obesity is a growing problem, but family interventions for this problem

are more encouraging. Parental involvement in weight reduction programs for children

results in greater weight loss for both the child and the parent, with a high correlation

between the parents and childs weight loss (Epstein, Wing, Koeske, Andrasik, & Ossip,

1981). One program for obese adolescents found the best results when the adolescent

and the parent received their own separate training, thus respecting the adolescents

growing independence (Brownell, Kelman, & Stunkard, 1983).

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Cigarette smoking . Smoking causes over 350,000 deaths per year, mostly from

heart disease and cancer and remains the number one public health problem in the US.

Smoking is strongly influenced by the family. Adolescents are five times more likely to

start smoking if a parent or older sibling smokes (Bewley & Bland, 1977). Smokers tend

to marry other smoker, to smoke the same number of cigarettes as their spouse and to quit

at the same time (Venters et al., 1984). Smokers married to non or ex-smokers are more

likely to quit and remain abstinent. Support from the smokers partner or spouse is

highly predictive of successful smoking cessation. Specific supportive behaviors such as

providing encouragement and positive reinforcement predict successful quitting, whilenegative behaviors such as nagging or criticism predict failure to quit or relapse

(Coppotelli et al., 1985; Mermelstein, 1986). The Agency for Healthcare Quality and

Research (AHRQ) recommends family and social support interventions as components of

effective smoking cessation (Fiore, 2000)

Nine randomized controlled trials involving over 1700 subjects have examined

the impact of partner support in smoking cessation, (Park, Schultz, Tudiver, Campbell, &

Becker, 2002). These studies add a social support intervention to a traditional smoking

cessation program which include nicotine replacement, behavioral therapy and relapse

prevention. The partner, usually the spouse, is given suggestions and feedback on

helpful and unhelpful behaviors for smoking cessation .

The results of these studies have been mixed and a meta-analysis found no overall

impact of partner support on smoking cessation(Park et al., 2002). In most of these

studies, the amount of partner support reported by the smokers continued to predict

successful smoking cessation, but few of the interventions had any impact on the level of

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partner support. These results suggest that partner support is important for smoking

cessation, but that it is difficult to increase levels of support.

The inability of these interventions to improve partner support or smoking

cessation may result from an overly simplistic and nonsystemic view of marriage. As

marital therapists know, ts. These behaviors are part of a complex marital relationship

and are affected by the history and quality of the marital relationship. asking partners or

spouses to be more supportive or less critical only occasionally has its desired effect

Unfortunately, none of these studies assessed the quality of the marriage. It may be

easier to increase supportive behaviors in couples that have higher levels of maritalsatisfaction. A more in-depth qualitative study of what happens to these couples when

they participate in these smoking cessation programs would be very helpful to better

understand the relationship between smoking behaviors and marital dynamics.

CHRONIC DISEASE THROUGH THE LIFECYCLE

Pediatric Chronic Illnesses

The course and outcome of most childhood illnesses are strongly influenced by

both family structure and function. Parents are responsible for the treatment of the most

pediatric illnesses. Many family variables are associated with health outcomes across a

broad range of chronic illnesses. For example, healthy family functioning is strongly

correlated with improved control of diabetes, while family conflict, parental indifference,

and low cohesion have all been associated with poor metabolic control in diabetes

(Anderson & Kornblum, 1984; Gustafsson, Kjellman, & Cederblad, 1986). In a

comprehensive literature review, Patterson (Patterson, 1991) identified nine aspects of

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family process which have been consistently associated with good outcomes in children

with chronic illness and disabilities: 1) balancing the illness with other family needs, 2)

maintaining clear boundaries, 3) developing communication competence, 4) attributing

positive meaning to the situation, 5) maintaining family flexibility; 6) maintaining family

cohesiveness, 7) engaging active coping efforts, 8) maintaining social supports and 9)

developing collaborative relationships with professionals. Many of these attributes have

been targeted by family interventions for pediatric illnesses.

Psychosomatic Families Salvador Minuchin, one of the founders of family

therapy, developed an early and well known family interventions in childhood chronicillness. In a series of studies, he and his colleagues at the Philadelphia Child Guidance

Clinic (Minuchin et al., 1975; Minuchin et al., 1978) studied poorly controlled diabetic

children and their families. These children had recurrent episodes of diabetic

ketoacidosis, but when hospitalized, the diabetes was easily managed. Stress and

emotional arousal within the family seem to directly affect the child's blood sugar.

Minuchin described a specific pattern of interaction in these psychosomatic families,

characterized by enmeshment (high cohesion), overprotectiveness, rigidity and conflict

avoidance.

Minuchin (Minuchin et al., 1975) studied the physiologic responses of these

diabetic children to a stressful family interview to determine how these family patterns

can affect diabetes,. During the family interview, the children from psychosomatic

families had a rapid rise in free fatty acids (FFA), a precursor to diabetic ketoacidosis,. .

Minuchin hypothesized that in psychosomatic families, parental conflict is detoured or

defused through the chronically ill child, and the resulting stress leads to exacerbation of

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the illness. Minuchin was the first investigator to demonstrate a link between family and

physiologic processes.

Minuchin and his colleagues (Minuchin et al., 1978) successfully treated

psychosomatic families using structural family therapy to help disengage the diabetic

child and establish more appropriate family boundaries. In 15 cases, the pattern of

recurrent ketoacidosis ceased and insulin doses were reduced. However, these early case

reports lacked any standardized outcome measures or control groups. In addition, the

psychosomatic family model has been criticized as blaming families for the childs illness

and lacking empirical validation. (Coyne & Anderson, 1989). Wood (Wood et al., 1989) proposed a more systemic and comprehensive biobehavioral model of childhood chronic

illness.

Insulin Dependent Diabetes Mellitus . Several different types of family

interventions have been studied in childhood (Type 1 insulin dependent) diabetes.

Family education and support groups (Anderson, Wolf, Burkhart, Cornell, & Bacon,

1989; Dougherty, Schiffrin, White, Soderstrom, & Sufrategui, 1999; McNabb, Quinn,

Murphy, Thorp, & Cook, 1994; Wing, Marcus, Epstein, & Jawad, 1991) and more

intensive psychoeducational programs that address collaborative problem solving and

problematic family interactions (Galatzer, Amir, Gil, Karp, & Laron, 1982; Wing et al.,

1991) have been studied. Mendenhall identified twelve RCTs of family interventions for

IDDM, ten of which used hemoglobin A1C (HBA1C) as an outcome measure, an

excellent measure of chronic blood sugar control, (Mendenhall, 1 A.D.). Seven of ten

studies demonstrated a significant improvement in diabetic control with a family

intervention. Blood sugar control worsened in two studies. . These interventions were

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effective in improving diabetic control, but it is unclear which interventions were more

effective.

These studies have also looked at the impact of the family interventions on other

diabetes related outcomes, including the patients emotional health and adherence to

diabetic treatment programs. Most of these programs have increased overall self care

and specific aspects of diabetes care, such as adherence with diet, exercise, blood sugar

testing and insulin. They have also reduced patients levels of distress and denial of the

illness and increased self-esteem, perceived quality of life, and acceptance of the illness.

It is not possible to determine which of these psychosocial improvements (diabetes-related behaviors or emotional health) contributed more to better blood sugar control.

This is an important issue for future research.

Asthma. Asthma has been strongly associated with psychosocial distress,

depression, and disturbed family relationships (Liebman, Minuchin, & Baker, 1974).

The only randomized controlled trials of family therapy for a childhood illness have been

conducted for severe childhood asthma. Two studies involved a total of 55 children with

moderately severe asthma and were based on structural family therapy models.

Strengthening of boundaries between generations and addressing hidden conflicts were

used to alter dysfunctional patterns of interaction. Both interventions improved asthma

symptoms, clinical evaluation and a number of measures of lung function (although they

differed in the two studies). A recent Cochrane review (considered by many to be the

gold standard of evidence based medicine) of these studies concluded that There is

some indication that family therapy may be a useful adjunct to medication for children

with asthma.(Panton & Barley, 2002).

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Numerous family psychoeducational programs have been designed and tested for

improving treatment of childhood asthma. In a review of this research, Benard-Bonnin

(Bernard-Bonnin, Stachenko, Bonin, Charette, & Rousseau, 1995) identified 11 well

designed randomized controlled trials of family psychoeducation for asthma. In their

meta-analysis, they found a significant improvement in several measures of asthma

severity. Although the overall effect sizes were small (


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psychoeducation may actually be able to extend the lives of those who suffer from this

disorder.

Congenital Heart Disease . Two studies have examine the impact of family

interventions to reduce the psychological morbidity associated with cardiac surgery for

congenital heart disease (Campbell, Kirkpatrick, Berry, & Lamberti, 1995; Campbell et

al., 1986). Both interventions provided separate informational and skills training

separately to the child and one parent before cardiac surgery. The children in the

intervention group were better adjusted at home and had higher functioning at school

after the procedure. There were no differences in the parents reports of anxiety, but the parents in the intervention group felt more competent in caring for their child.

These family interventions for childhood illnesses clearly demonstrate health

benefits for asthma, diabetes and cystic fibrosis and show promise for reducing the

psychosocial morbidity associated with cancer and cardiac surgery. They need to be

applied across a wider range of pediatric illnesses.

Childhood cancer . In childhood cancer, a few studies have used family

interventions to reduce the psychological morbidity associated with diagnosis and

treatment. Two interventions designed to improve parental coping with the stress of the

illness failed to show any significant decrease in parental distress (Hoekstra-Weebers,

Heuvel, Jaspers, Kamps, & Klip, 1998; Jay & Elliott, 799). Working with children with

leukemia and their families, Kazak and her colleagues were able to reduce the childs

distress related to painful procedure using a cognitive-behavioral, family-oriented

intervention (Kazak et al., 1996). In another study, Kazak and colleagues piloted a

multi-family group intervention for survivors of childhood cancer to reduce the post-

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traumatic stress symptoms related to the diagnosis and treatment of the cancer. In a pre-

post test design, they were able to show a decrease in posttraumatic stress and anxiety in

the survivors and their family members (Kazak, 1989).

Adult Chronic Diseases

Although there is a large body of research on the impact of marriage on

chronic illness and overall health, there are relative few family or marital intervention

studies in adult physical illness. Most of the research in this area has focused on the role

of the spouse as the primary caregiver. There are no randomized controlled trials for

marital or family therapy for adult illnesses. Gonzales, Steinglass and Reiss developedan innovative multifamily psychoeducational group intervention for families with chronic

medical illnesses. Based upon their clinical work, they found that in many of these

families the chronic illness tended to dominate family life and take over the familys

identity. The goal of these groups is to help families balance the needs of the illness with

the needs of the family by putting the illness in its appropriate place in family life

(Gonzalez, Steinglass, & Reiss, 1989). It is currently being studied as an intervention

with a wide range of illnesses, including HIV/AIDS, adult cancer and end stage renal

disease.

Non-insulin Dependant Diabetes Non-insulin dependent diabetes (NIDDM

or Type 2) afflicts over 15 million adults in the US and is ten times more common than

insulin dependent diabetes, a disease of children and young adults. Most patients with

NIDDM are overweight, and the major challenge for these patients is adherence with

recommended diet, exercise, medication and blood sugar monitoring. Only two studies

have examined the impact of a couples intervention on diabetes outcomes. Gilden

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Several studies have examined the impact of spouse involvement in cardiac

rehabilitation on psychosocial outcomes. In one ingenious controlled study, wives of

heart attack patients walked on the treadmill at the same workload as their husbands, 3

weeks after their husbands heart attack(Taylor, Bandura, Ewart, Miller, & DeBusk,

1985). These wives were much more confident and less anxious about their husbands

health and capability, than wives in the control group who merely observed their

husbands tests. When these women actually experienced what their husband were

capable of doing, they were less overprotective and the husbands had improved cardiac

functioning 11 and 26 weeks after the heart attack. Of the three studies that includedcouple counseling as part of cardiac rehabilitation (Dracup, Meleis, Baker, & Edlefsen,

1984; Thompson & Meddis, 1990; Gilliss, Neuhaus, & Hauck, 1990), only one was able

to show any improvement in the spouses emotional health (Dracup et al., 1984). Patient

outcomes were not examined.

Although observational research suggests that spouses play an important role

in recovery from heart attacks, few couple or family interventions have been tested, and

those that have, report mixed results.

Hypertension. Adherence with hypertension treatment remains a major

public health problem. Less than one half of adults with elevated blood pressure are

taking their medication as directed. Medication compliance has been shown to be

significantly correlated with marital satisfaction in married hypertensive patients

(Trevino, Young, Groff, & Jono, 1990). In experimental studies, blood pressure

reactivity has been linked to marital interaction and conflict. (Gottman, 1994). Ewart

and colleagues taught communication skills to 20 hypertensive patients and their spouses

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to help them reduce conflict and emotional and blood pressure reactivity during

arguments(Ewart, Taylor, Kraemer, & Agras, 1984). These couples showed less

hostility, fewer combative behaviors and a significant reduction in systolic blood

pressure.

Two randomized controlled trials have examined the impact of a family

intervention on adherence to hypertension treatment. Morisky and colleagues compared

three psychoeducation interventions (brief individual counseling, counseling the spouse

during a home visit and patient support group) to improve blood pressure treatment in an

inner city population (Morisky et al., 1983). The family intervention was included after a patient survey indicated that 70% of the hypertensive patients at the clinic wished that

their spouse or other family members knew more about their illness and were more

involved. Educating and counseling the spouse improved treatment adherence and

lowered both blood pressure and overall mortality. Overall the experimental groups had

a 57% reduction in mortality, and the family intervention seemed to have the greatest

effect. A similar study (Earp, Ory, & Strogatz, 1982) failed to demonstrate any benefits

from involving a family member during a home visit, but the followup may not have been

long enough to detect a difference

Chronic Diseases in the Elderly

In no other area of health has the family received as much attention as family

caregiving of persons with chronic disabling conditions. With the aging of the

population, the rising incidence of degenerative and disabling conditions in the elderly

and fewer resources for professional caregiving, a growing percentage of older

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individuals must rely on family members for care. For example, it is estimate that over

40% of the elderly over the age of 85 have some form of dementia and one half of those

individuals are cared for by family members in their own communities (Biegel, Sales, &

Schulz, 1991).

Research has demonstrated that caregiving exerts a heavy toll on family

members. Family caregivers have much higher morbidity and mortality than age

matched controls. One study (Schulz & Beach, 1999) found that caregivers over 65 who

were experiencing emotional strain were 63% more likely to die than age matched non-

caregivers over a 4 year period. Caregivers suffer higher rates of multiple physicalillnesses, depression and anxiety. The incidence of depression among caregivers of

persons with dementia has been estimated to between 40-50% (Gallagher, Rose, Rivera,

Lovett, & Thompson, 1989). They often restrict their social activities and reduce their

time at work. The financial impact of caregiving on families can be enormous, both in

terms of decreased wages of caregivers and the cost of providing equipment and services

in the home for the patient.

Family caregivers are essential members of the health care team. They

provide clinical observation, direct care, case management, and a range of other services.

In chronic illnesses, such as Alzheimer's Disease, these caregivers may devote years of

their own lives to caring for a loved one. Unfortunately, our current health care system

offers little in the way of institutional support for families who are burdened with

caregiving. Managed care has shifted many of the burdens of caregiving from

professionals in the hospital and other institutions to family members at home without

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providing adequate support. As hospital stays have shortened, elderly patients are being

discharged home sicker and with more health care needs than in the past

A number of effective interventions for the caregivers of patients with dementia

have been developed and tested, including psychoeducational and family counseling

interventions and family support/ education groups. No controlled trials of family

therapy for family caregivers could be found.

Family support groups for caregivers of patients with Alzheimer Disease have

become quite common and are promoted by advocacy groups. These are usually open

ended groups which are professionally or peer led and provide information and emotionalsupport to families. Studies of these groups suggest that participants learn new

information and report high levels of satisfaction, but the impact on the caregivers

emotional distress and sense of burden is inconsistent (Orleans, George, Houpt, &

Brodie, 1985; Haley, Brown, & Levine, 1987; Kahan, Kemp, Staples, & Brummel-Smith,

1985).

Family psychoeducational programs provide more intensive skills training to help

family caregivers manage many of the common problems presented by elders with

dementia (Chiverton & Caine, 1989; Goodman & Pynoos, 1990; Gallagher et al., 1989;

Toseland et al., 2001; Toseland, Labrecque, Goebel, & Whitney, 1992; Mittelman, Ferris,

Shulman, Steinberg, & Levin, 1996) (Marriott, Donaldson, Tarrier, & Burns, 2000).

These interventions usually include weekly group sessions led by a trained professional

and typically last for 8 to 10 weeks. In randomized controlled trials, they have

consistently reduced depressive symptoms, emotional distress and the sense of burden of

family caregivers.

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An excellent example of an effective, family psychoeducational intervention for

family caregivers of Alzheimer Disease (AD) patients has been developed by Mittelman

and tested in a randomized controlled trial(Mittelman et al., 1996). These families

attended individual and group instructional and problem-solving sessions where they

learned how to manage many of the troublesome behaviors of patients with AD. They

also attended an ongoing family support group and could access a crisis intervention

service to help them with urgent problems. In Mittelmans study, the caregivers who

received the intervention were less depressed and physically healthier than those that did

not, and AD patients were able to remain at home for almost a year longer than in thecontrol group. The savings in nursing home costs were several times the cost of the

interventions. Similar types of family support should be a part of the treatment of all

patients and families with Alzheimer Disease and other dementias.

Sorensen and colleagues (Sorensen, Pinquart, & Duberstein, 2002) recently

conducted a meta-analysis of 78 caregiver intervention studies representing six different

types of interventions for different illnesses. They found a significant improvement

(0.14-0.41 standard deviation units) across all six outcome variables (caregiver burden,

depression, subjective well-being, perceived caregiver satisfaction, ability/knowledge and

patient symptoms. The effects were the smallest for caregivers of dementia patients and

most consistent with the psychoeducational interventions. Caregiver ability/knowledge

improved more than subjective burden and depression. Group interventions had smaller

improvements than individual interventions.

These studies of family interventions for family caregivers suggest that

providing education and support for family caregivers is necessary, but not sufficient to

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reduce their burden and improve their emotional health. Family caregivers need more

intensive interventions that include skills training and assistance with problem solving.

Similar results have been found in the few interventions for patients who have suffered a

stroke and their families (Evans, Matlock, Bishop, Stranahan, & Pederson, 1988). Family

psychoeducational programs for family caregivers are effective in improving both the

physical and emotional health of the caregiver and can be cost-effective. These programs

have many similarities with psychoeducational programs that have been developed and

tested for schizophrenia and can be used as models for family interventions for other

physical disorders.

FUTURE DIRECTIONS FOR RESEARCH

Much more research on family interventions for physical disorders needs to be

done. This area of research is still in its infancy, at the stage where research on families

and schizophrenia was 30 years ago. This creates many opportunities for new family

researchers to become involved in this exciting area of research.

Very few of the family interventions for physical disorders have been designed by

family researchers or based on family science. Medical and nursing researchers have

been the principal investigators in most of these studies. Rarely is a particular family

characteristic or variable targeted by the intervention, and pre or post family assessment

is usually absent. There are very few trials of family therapy for any physical disorders.

Family researchers and therapists need to become involved in research on families and

health and help design and implement family interventions for physical disorders. in

this area.

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Although there is a large body of observational research on families and health,

more observational studies are needed. Few family variables have been shown to be

predictive of health outcomes, and the strength of this evidence is not strong. The most

promising recent research has focused on the role of family criticism, family conflict and

expressed emotion and its impact on physical health.

Family and health research needs to be based upon family theories and family

science. Most existing studies are atheoretical. Intervention strategies should be guided

by theoretical models that hypothesize relationships between family and health variables

and then measure these family variables before and after the intervention. For example,studies of spouse involvement in smoking cessation and weight loss should measure

marital satisfaction or quality as well as helpful and harmful behaviors before and after

the interventions. Pre-intervention family assessment will also allow researchers to

determine in which families the intervention is most effective.

Nearly all existing family intervention studies target a single disease with little

evidence that the results are generalizable to other disease. Family interventions should

be developed and targeted across several chronic diseases that have commonalities.

Interventions that have been shown to be effective for one disease (such as family

psychoeducation for caregivers of AD patients) should be tested with other similar

disease (such as stroke or Parkinsons Disease).

Intervention studies should measure multiple outcomes across several levels,

including patient physical and emotional health, family members physical and emotional

health, family functioning, marital satisfaction or quality, and health care and overall

costs. Many of the benefits of a family intervention may not be captured by traditional

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measures. For example, a family intervention may improve the health of other family

members and reduce their use of health care services. Family interventions should be

adaptable to meet specific needs and characteristics of individual families. For example,

families in which there is significant conflict, disengagement or dissatisfaction will need

a different and more intensive approach than more functional families. More attention

needs to be paid to the cost of family interventions and the potential financial benefits of

the intervention for the patient and other family members.

The family interventions need to be described in more detail, so that they can be

replicated and to determine what the most effective ingredients of the intervention are.This will help researchers determine why one intervention is effective and not another.

These interventions need to play close attention to gender effects. As noted earlier,

marriage has very different effects on the physical health of men and women(Kiecolt-

Glaser et al., 2001). Because marriage is often the primary source of social support for

men, the presence or absence of a wife has the greatest impact on health, where womens

health is most influenced by the quality of the relationship. Couple interventions are

therefore likely to have very different effects on men and womens health. Only one

intervention study has examined gender effects and found that women had better

outcomes (weight loss) in couples treatment and men did better alone.

Finally, family intervention studies need to include more diversity. Most of

current studies are conducted with white middle class families. Future studies should

include different family types (e.g. single parent families, gay families) and families from

different racial, ethnic and socioeconomic background.

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CONCLUSIONS

This review documents that there are effective family interventions for some

physical disorders and promising ones for others. No family interventions have been

developed or tested for many chronic physical illnesses. The most commonly studied

and effective type of family intervention is family psychoeducation. It has wide appeal

and applicability to numerous disorders. It appears to be more effective than programs

that only provide family support or education. Families need more intensive assistance

with specific problem solving and coping skills. Whether group family psychoeducation

is more effective than individual family psychoeducation for physical disorders is not

known and needs study. There are too few studies of family therapy for physical

disorders to comment on its effectiveness, although family therapy is likely to be directed

to a much more limited group of dysfunctional families.

The most effective family interventions have been in the treatment of family

caregivers of dementia patients. Not only did these family interventions improve the

physical and mental health of the caregivers, but were very cost effective. Mittelmans

comprehensive intervention for family caregivers should be adapted to other chronic

disorders(Mittelman et al., 1996). Family interventions for childhood disorders,

especially diabetes and asthma, are effective in improving medical (e.g. HBA1C levels

and pulmonary function), as well as psychosocial outcomes. Not surprisingly, family

interventions are most effective at each end of the life cycle when much of the care is

provided by family caregivers.

There is insufficient research on family interventions for adult illness to make any

firm conclusions. Although enhancing family support for adherence to chronic medical

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treatments appears to have a powerful effect on health outcomes (Morisky et al., 1983),

more research is needed to verify this. Studies of spouse involvement in cardiac

rehabilitation have demonstrated little effect. Family involvement for health promotion

and disease prevention programs offers great promise. Family-centered nutrition and

cardiovascular risk reduction programs are effective in improving the health of multiple

members, but have not been directly compared with individually oriented programs.

Family based programs for obesity in children are clearly more effective than individual

programs, but their effectiveness for adults is unclear. Partner or spouse involvement for

smoking cessation has been shown to be ineffective.

This research suggests that marriage and family therapists have an important, but

unmet role in the treatment of physical illness. Family therapists should be a part of most

health care teams, offering a family and systemic perspective that is so often missing.

Much has been written about family therapist working in primary care settings, helping

family physicians, pediatricians and primary care internists care for patients and their

families. There are also opportunities for working with medical specialties, especially

rehabilitation medicine, reproductive health, oncology, cardiac rehabilitation and

geriatrics(Seaburn, Lorenz, Gunn, & Gawinski, 1996).

Family therapy training programs need to provide the knowledge and skills for all

new family therapists to work in medical settings and with families with health problems.

These programs should offer courses on medical family therapy, collaboration with

medical providers, and psychopharmacology. Family therapy trainees should be

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provided with opportunities to work in medical settings under supervision during

graduate school and internship.

Overall one can conclude that there is some evidence that family interventions can

improve health outcomes in physical disorders. There is a need for more observational

and intervention research on families and health, and family researchers and clinicians

need to become more involved in this area of research. Only by better understanding

how families can be used as a resource in medical care will our health care system

become more family-oriented and higher quality.

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