Evaluating and Treating Families

The McMaster Approach

Christine E. Ryan, Nathan B. Epstein, Gabor I. Keitner, Ivan W. Miller, Duane S. Bishop

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136915840
• Edition: 1
• Topic: Psicología
• Subtopic: Relaciones interpersonales en psicología

This comprehensive text is organized into two parts, the first of which presents an overview of the history, development, and theory of the model, and its specific applications to treatment, training, assessment, and research. Part II includes the instruments and assessment tools originally developed by the authors during their extensive clinical and research experience. Clinical case examples drawn from over four decades of family therapy work enrich the text, and an entire chapter is devoted to the authors' own research findings, current research plans, and new directions in their work.

PART

I

CHAPTER

1

Development and Historical Background

The conceptual beginnings of the McMaster Model of Family Functioning (MMFF) originated at McGill University in Montreal, Canada more than 50 years ago. Under the direction of Nathan Epstein, a team of clinicians and researchers began their work in family therapy by focusing on two major areas: (1) research with nonclinical families and (2) research on the process and outcome of conducting family therapy. A nonclinical family refers to a family whose members have no diagnosed psychiatric illness. The family may or may not be healthy and may have good or poor family functioning.

The model that was conceptualized and tested from the mid 1950s through the 1970s, first at McGill and then at McMaster University in Hamilton, Ontario was refined, elaborated upon, and completed at Brown University in Providence, Rhode Island where Epstein had relocated and created the Family Research Program. The prototype for some instruments and manuals (i.e., the Family Assessment Device and the Problem Centered Systems Therapy of the Family (PCSTF)) had begun at McMaster and became finalized and ready for distribution after the team moved to Brown. Other measures used to assess family functioning (the McMaster Clinical Rating Scale and the McMaster Structured Interview of Family Functioning) were more fully developed at Brown. Today, members and associates of the Family Research Program continue to teach and study this model, and to use it daily for clinical as well as research purposes.

We thought that a useful way to introduce the McMaster approach to working with families was to present a brief historical background of the conceptual beginnings of the McMaster model. The easiest way to do so was to introduce the developer of the model and to discuss the specific schools of thought that influenced him and from which the model emerged.

Nathan Epstein, founder of the Family Research Program and the main developer of the model, first received training as an adult and a child psychiatrist. He underwent additional training in psychoanalysis, a highly valued component of every psychiatrist's repertoire during the 1950s and 1960s. Throughout his training, Epstein worked in the area of child psychiatry, seeing children, adolescents, and families. Epstein was interested in understanding a child's development—how he or she thought and behaved—not because he wanted to treat children, but because he wanted to better understand the thinking and development of the adults he treated. The training he received, his work with children and their families, and the ideas he was exposed to led to a change in Epstein's thinking and focus. Ultimately, the shift in direction resulted in a body of work that included the development of the McMaster model for assessing and treating families, the establishment of an interdisciplinary team of researchers who focused on family issues, and the creation of a training program for clinicians and therapists.

Although Epstein led the effort in developing the McMaster approach, many individual clinicians and researchers played key roles in designing the model, treatment, instruments, training, and research. Whether their contributions assisted the programs at McGill University, McMaster University, or here at Brown University, the work would not have progressed without their hard work, clinical insight, and research knowledge. In this chapter we first trace Epstein's development as a clinician and researcher, for it exemplifies how to intertwine clinical experience with research findings. We then highlight the unique features of the McMaster model, show how the clinical, teaching, and research components developed in concert, and introduce the philosophy and thinking which serve as the underpinning of the model and guide our approach in evaluating and treating families.

Early Training

By the early 1950s, workers in child psychiatry had begun to connect the role of the mother to the behavior of the child. Some therapists noted that other family members also had an effect on the identified patient. Nathan Ackerman, in particular, began to develop his ideas on working with the total family group in psychotherapy—a radical idea at the time.² Ackerman was drawn to families and the family environment through work with his own young patients. He reasoned that, since the family was the focus in a child's development, it did not make sense to expect a child to change in isolation from other family members.^2,3 By the time Epstein underwent training with him, Ackerman was already engaged in formulating family theories and family therapy techniques as a more effective way of understanding and treating patients.² The process he used had the significant actors in the patient's life attend the therapy session, thereby making it easier for the therapist to tease out family interactions that led to the behavior being treated.

Other leaders in the field of psychiatry and human development who were based at Columbia University also had an impact on Epstein's early thinking. Abram Kardiner, a pioneer in cultural psychiatry, examined the interplay between culture, economics, history, and social patterns and practices as they affect individual and group behavior.⁴ Two other noteworthy figures who stimulated further thought were Sandor Rado, whose work centered on adaptational psychodynamics⁵ and David Levy who taught research methodology and the process of integrating research findings with an understanding of human behavior.⁶ The interplay between the theoretical ideas he was exposed to and the clinical work he was engaged in led Epstein to the same realization that Ackerman had arrived at, that is, that he could not help children unless he worked with their families. He realized that if he just focused on the child, the treatment was not effective. He was convinced that, unless he saw the family, his understanding of the clinical issues were lacking. He decided to stop treating children unless the family was present.

Once Epstein determined to include the family in treatment, he began to experiment with different ways of involving family members and patients in the course of conducting therapy. He tried several approaches: (1) seeing the mother and child patient in play therapy; (2) having both parents in for occasional sessions, with or without the child or adolescent patient present; (3) having mothers participate in activity-group therapy with children and seeing the mothers in a separate weekly group without the children; (4) seeing both spouses together when only one of them was the presenting patient; and (5) bringing in different members of the individual patient's family at various times during the course of the patient's therapy. As time went on, the approach that was used most frequently and seen, at least clinically, as most effective was one in which all members were seen together for conjoint family therapy regardless of the presenting problem.

Theoretical Foundation

During these early years, the basic conceptual model that therapists used when working with families was intrapsychic while the therapeutic approach was psychoanalytic.⁷ For example, family interaction patterns that were thought responsible for the intrapsychic and behavioral pathologies in the identified patient were observed, stimulated, inferred, and interpreted. Then analytic concepts were used to interpret behavior seen in family meetings. The concepts might include role projection, displacement, incorporation and projection of part objects, oedipal strivings, sibling rivalry, denial, and affective repression. The primarily analytic approach changed gradually to one that focused more on interactional aspects of intrafamilial behavior. Therapists began to emphasize the importance of releasing affect underlying the presumed and significant family interactions and the associated intrapsychic conflicts and fantasies. The primary objective remained that of easing the intrapsychic conflicts of the identified patient that were inferred to result in the pathological symptoms or behavior for which treatment was undertaken.⁸

When Epstein returned to McGill after his training at Columbia, he and several colleagues began a series of family studies. The first studies involved nonclinical families and overlapped with later studies that focused on families with an identified patient. Whether family cases were nonclinical or clinical, the primary function of the family was conceived as providing an environment for the psychosocial development and maintenance of its members. Over time Epstein and his colleagues came to believe that the family as a system was more powerful than intrapsychic factors in determining the behavior of individual family members. This insight, which came out of the series of small research studies, led to a fundamental shift in his approach to family therapy.

In practice, the shift from viewing therapy as primarily a psychoanalytic-interactional mode to a systems mode was difficult at best. In the family systems approach the family is looked at as the factor to be evaluated; it is the family that is centrally involved in the difficulty and in the behavior being examined. The 15 years of training and experience that Epstein and colleagues had undergone had to be modified and a new approach had to be developed. The new approach was controversial, for it questioned previous assumptions of treating patients and families and because it made use of research data to alter clinical practice. Now, the idea of evidenced-based treatment is much in vogue, but in earlier periods the link between clinical practice and research findings was tenuous. During the transition period, before the new method was fully developed and established, there was a natural tendency for Epstein to slip back into a primarily psychoanalytic approach when conducting therapy. Today Epstein may consciously decide to use a psychoanalytic approach to generate another viewpoint that furthers understanding or therapeutic progress.

Approaches to Family Therapy

As noted, Epstein's psychoanalytic training had resulted in a strong interest in the interaction between personality and the surrounding environment.⁹ Given his additional training with Ackerman, Epstein paid increasing attention to the family as an important aspect of an individual's environment. Not surprisingly, therapists viewed the family from very different perspectives. At least three important conceptual approaches marked the early advances in the field of family therapy and set the stage for later model development. The approaches included: (1) an individual psychodynamic model, (2) an interaction model, and (3) a systems model. Epstein's thinking about these models evolved over time and included some overlap. The three models and examples are described below, roughly as occurring in three sequential phases.⁷

Phase 1

Individual Psychodynamic Model

The conceptual orientation which Epstein used in phase one of his clinical work with families was based on an individual psychodynamic model in which therapists saw the family as a backdrop for understanding the intrapsychic conflicts of the identified patient. The primary focus of the therapeutic work was on the patient; the family was seen only as the context in which the individual psychodynamic processes and structures were worked out. Significant family members were referred to and even seen on occasion, but the focus always remained on the individual.

Example:

Donald, 7 years old, was referred for treatment because of a severe crippling anxiety. The boy was involved in a strong symbiotic relationship with his mother. Examination revealed that the anxiety was related to extreme separation anxiety. He displayed a school phobia, but only as one aspect of his unwillingness to ever let his mother out of sight. The mother contributed strongly to the maintenance of this symbiotic relationship as a means of fulfilling her own intrapsychic needs.

Therapy focused on the boy, primarily in the form of individual play therapy sessions. Epstein occasionally spoke to the mother and received reports from her on the patient between sessions. During these brief meetings, he encouraged her to extricate herself from this over-intense relationship and to develop a healthier stance with her son. Epstein saw the father only after many months and only because the mother indicated some unhappiness in her relationship with him. Epstein saw the father alone and dealt with some of his intrapsychic problems on a rather superficial basis. He never saw the couple nor any other family member together. The patient and the mother gave reports of the family to the therapist, but these were not dealt with in detail nor used to any great extent in the treatment of the identified patient.

After several years of regular visits, the patient was relatively free of anxiety and had a close, warm relationship with his mother, yet both seemed to allow for autonomous functioning.

Epstein's intrapsychic orientation was so strong during this period of his career that treatment focused on the identified patient (with some supportive work done individually with both parents), despite the fact that family pathology indicated couple and family therapy might be helpful. Recognition of the impact that family members had on each other (including, but not limited to the patient) would later become a key concept in the McMaster model.

Phase 2

Interactional Model

The interactional phase of Epstein's work is distinct from the previous phase despite some overlap in both the temporal and conceptual sense. Interactions between several family members (usually two) are observed and interpreted to members during therapy sessions. The interactions are usually related to the intrapsychic processes of the interacting members, but they do not have the same degree of detail, frequency, and intensity as does the intrapsychic phase. The assumption underly...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Tables and Figures
• Acknowledgments
• Introduction
• Part I
• Part II
• Related Articles
• References
• Index