Family psychiatry originated in the years following the Second World War as my reaction to the then practice of child psychiatry. At the Institute of Psychiatry in London at that time, it was usual for the child to be regarded as sick in his own right and for the parents to be offered "guidance" on his management; it was not conceived that the child's emotional illness was the end product of a pathologic process involving the whole family. Once the latter viewpoint was accepted, it became a matter of daily frustration for me to use the traditional approach. To escape this frustration and to pursue my approach of family psychiatry, I moved to East Anglia in 1949. The Ipswich Hospital, with its affiliation to the University of Cambridge, provided virgin territory.
Ten years' work ( 1 949-59) culminated in a report to the Health Authority; this report, published in 1963, became the first book1 on family psychiatry. The book contained this definition of family psychiatry:
Family psychiatry is a clinical approach by which a child, an adolescent, or an adult, referred from a family because of emotional disorder, is regarded as an indication of family psychopathology. This concept leads to the employment of procedures for investigating the psychodynamics of the whole family in its social and cultural setting and to offering treatment on a family basis.
In family psychiatry a family is not regarded merely as a background to be modified in order to help the presenting patient alone. Family psychiatry accepts the family itself as the patient, the presenting member being viewed as a sign of family psychopathology.
The central principle of family psychiatry, then, is that the family is the patient. This is a simple notion in theory but a revolutionary approach in clinical application. What began as a reaction to traditional child psychiatry gradually developed as a reaction to the whole of individual psychiatry. Adolescent, adult, and geriatric psychiatry seemed equally outmoded. Thus, clinical practice at the Institute of Family Psychiatry in Ipswich was refashioned to accept any individual family member, a part, or the whole family as the initial patient and to move always to the assessment and management of the whole family as the patient.
The development of family psychiatry coincided with two other movements in the family field, both in the United States - family therapy and studies on the family and schizophrenia. In 1961, these three movements came together in a panel discussion at the World Congress of Psychiatry in Montreal. Family therapy was presented by its formative spirit, Nathan Ackerman, with his colleague Nathan Epstein. The study of the family and schizophrenia was presented by Theodore Lidz and Don Jackson, both commanding leaders in this field. I presented the paper on family psychiatry.
Family therapy owes much to Nathan Ackerman; his book The Psychodynamics of Family Life1 was a landmark in the field. A psychiatrist, Ackerman became convinced of the virtue of involving the whole family in psychotherapy, an approach that came to be termed "conjoint family therapy." His films, writings, and presentations at conferences, together with his work at the Jewish Family Agency in New York, gave immense impetus to this movement.
Family therapy has been defined by WaldronSkinner3 as "the psychotherapeutic treatment of a natural social system, the family, using as its basic medium, conjoint interpersonal interviews." The emphasis is on treatment by psychotherapy in a family group setting. As we shall see, it forms an important part of family treatment - in turn a part of family psychiatry. The practice of family therapy has spilled over into allied fields and ultimately has involved the general public. Such is its growth that it has become unwieldy and often confused, and the very laudable concentration on treatment has abandoned diagnosis, organization, and theory.
For many years, there was speculation about the link between the individual's psychopathology and schizophrenia. This was soon extended so that pathologic relationships between the mother and the schizophrenic and, later, the relationship between the parents and the schizophrenic were explored.
Inevitably, family psychopathology in time became the focus of investigation. The original worker was Murray Bowen,4 at the National Institute of Mental Health, who was also responsible for the innovative measure of bringing the whole family into the hospital for investigation. He was followed by Lyman C. Wynne,5 also at the National Institute of Mental Health; by John Spiegel,6 at Harvard; and, down the coast, at Yale, by Lidz7 and his colleagues. On the West Coast of the United States, Bateson, Jackson, Haley, and their co-workers8 had teamed up at what became the Mental Health Institute at Palo Alto. In the United Kingdom, Laing9 speculated in terms very similar to those used by Bateson and Jackson. Their collective work has made an immense contribution to the understanding of family psychopathology, but whether this is relevant to the etiology of schizophrenia is an open question. W. R. Guirguis will review the field in a subsequent issue of Psychiatric Annals.
Family psychiatry embraces more than family therapy. Once the principle is accepted that the family is the patient, the whole of psychiatric practice can turn around this principle. It affects theory, clinical organization, views on family psychopathology, referral practices, family diagnosis, and family treatment. In family treatment, family psychiatry uses conjoint family therapy as one of its techniques and thus touches on the field of family therapy. But, as will be seen, family treatment - to the family psychiatrist - embraces more than just conjoint family therapy.
Once the family is adopted as the unit in clinical practice (and resistance to its adoption comes more from psychiatrists than from families), the advantages multiply. For example, all too often in the individual approach to psychiatry the presenting patient is treated, given a measure of health, and then replaced as the sick person in the family by another family member who comes for treatment (although the second family member may not necessarily attend the same clinic as the first). In family psychiatry, the family is stabilized as a whole and remains healthy.
The individual approach is costly in resources, since different family members with different symptoms will usually attend a variety of clinics. In family psychiatry, all could attend one facility giving more effective as well as a more economical service. Individuals attending clinics often leave behind them at home resentful family members who, denied a relationship with the psychiatrist, work against him in the therapeutic process. In family psychiatry, the cooperation and collaboration of the whole family can be guaranteed. The individual, who gains health in the traditional individual approach, is still in a pathologic family and later reverts to ill health. In family psychiatry, the source of pathology is treated and changes are permanent. This is especially advantageous to children, who will become the families of the future. So family psychiatry makes a real contribution to social psychiatry.
As a prelude to the articles that follow, it may be useful to elaborate on some of the facets of family psychiatry. Readers wanting additional information are referred to two of my subsequent books on the subject.10,11
THE THEORY OF FAMILY PSYCHIATRY
Adopting the family as the clinical unit in family psychiatry does not mean that the individual is abandoned. The individual remains as a crucial figure, but as an integral part of a larger unit. Thus, the family psychiatrist continues to depend on the knowledge of individual functioning and dysfunctioning garnered over time and remains an eager contributor to, and receiver of, continuing knowledge.
But these three new ingrethents appear in family psychiatry:
1. Interaction between individuals are brought into focus both in and out of the family. (The most significant interactions are usually within.) Interaction and communication theory both come into their own. New relationships acquire significance. Not only a mother-child relationship but also a child-mother relationship is under scrutiny; it is not only mother-child but also father-child and childfather relationships that are observed. The interaction of husband and wife is considered important, but so is the interaction of sib and sib.
2. The family is a small group, and the theory applicable to the understanding of functioning and dysfunctioning in small groups applies to family psychiatry. Hence the interest in such concepts as systems theory, field theory, transactional processes, gestalt theory, homeostasis, etc.
3. The family is viewed as a part of a larger unit - society as a whole. Thus, the interaction of a large unit with a smaller and that of a smaller unit with a larger must become a field of study. One contribution to the theory of family psychiatry is made by Dr. Stephen Fleck in the article that follows.
Theory impinges on practice in many ways. One of the most cogent needs is to have a workable conceptual model for the assessment of families. At the Institute of Family Psychiatry, we have arrived at a five-dimensional model that is invaluable in marshaling data in clinical practice (Figure I)-By using this model, it is possible to assess the family in the present; this can lead to an accurate formulation for treatment and, later, to an assessment of progress.
Those working with persons who are emotionally ill have questioned the value of having a medical model. The same doubts have been expressed in relation to family psychiatry. The question is confused by the definition of the medical model given by critics; the medical model is equated with the understanding and treatment of somatic pathology. Such a definition is false: the medical model from time immemorial does not limit itself to the soma but also embraces the psyche. The morbid process is understood in terms of organic pathology, psychopathology, or, not uncommonly, the interaction of both. Given the correct definition, it soon becomes apparent that many of the principles in the understanding and the amelioration of organic pathology apply equally to psychopathology.
Figure 1. Conceptual model for the assessment of families.
THE ORGANIZATION OF FAMILY PSYCHIATRY
Interest in family psychiatry often starts in a psychiatric unit, with one person becoming committed to it. Such an interest can lead to the breakdown of the barriers between the children's, adolescent, and adult clinics. It can also lead to demarcation problems and tension. However, in many units the approach is acceptable as an experimental venture. Then colleagues move to the same position, and soon family psychiatry is the reigning ethos for the whole department; either this is tacitly accepted or there may be acknowledgment in the change of departmental designation.
Family psychiatry may also start in one particular field - e.g., child psychiatry. A psychiatrist may initially become aware that involvement of the parents in assessment and treatment leads to more efficacious treatment for the child. This could be termed child-and-parent psychiatry. He then moves to a position where acknowledgment of the whole family unit helps in the management of the individual patient. This, of course, is not family psychiatry but individual psychiatry, as the focus for help is the child; however, it is a step in the right direction. Later, the psychiatrist moves to the position where the child's problem is regarded as an introduction to the family, and thereafter the family becomes the patient. This is true family psychiatry. The same process can be seen at work in clinics for the aged or adults or adolescents.
Occasionally, the interest of a psychiatrist is linked with a particular clinical entity. Attention has already been drawn to the widespread interest in the relationship between family pathology and schizophrenia. Again, it could be psychosomatic disorder, as Dr. Walter W. Meissner points out in his article in this issue, or antisocial behavior, alcoholism, or some other form of addiction.
After a while it becomes clear to the clinician that this program, so useful in the management of one clinical group of patients, is equally valuable in the management of other clinical groups. A position is then reached in which all clinical categories - neurosis, personality problems, delinquency, antisocial behavior, and psychosomatic disorder, as well as psychosis - are accepted in the family psychiatry clinical program.
Fortunate is the family psychiatrist who starts off with a new department, and even more fortunate is the one who can start a new department in a new hospital.
If there were a maximum degree of understanding of family psychiatry on the part of both referral agencies and families, then, in the practice of family psychiatry, the whole family would always attend the initial interview. There are many mechanisms, however, that prevent a family from developing this complete attitude of cooperation and understanding. In day-to-day practice, for a variety of reasons, families often present as individuals. The mechanisms that determine which individual comes from the family at a particular moment include the following: the balance of the dynamics in the family at that moment, the nature of the psychiatric service, scapegoating mechanisms, folie à deux, and anniversary reactions. Furthermore, the person who comes first may be the least disturbed member of the family; disturbance is highly correlated with lack of insight, and the most insightful person will be the one who goes for help. Thus, paradoxically, adopting the individual approach may lead to a situation in which attention is given to the least sick member of the family.
It is necessary to accept whatever the family initially offers. At the Institute of Family Psychiatry we have intake clinics for children, for adolescents, for adults, and for the aged. Sometimes the presenting problem revolves around a dyad in the family, most frequently that of the marital relationship; thus, it is necessary to have a marital-problems-intake clinic. This is discussed by Dr. Peter A. Martin in the concluding article in this issue.
Finally, families may come to the clinic as a unit. This is true of 15 percent of those who come to the Institute of Family Psychiatry. Regardless of whether an individual, a dyad, or an entire family initially comes to family psychiatry, the important rule to adopt is that the person or persons coming first be regarded as an indicator of a disturbed family. It is the family itself that will be the patient.
In our service, we have found that about one-third of families can be involved very easily. Another third can be involved only after a period of time, sometimes extending to some months. As for the remaining third of the families, all the members of each family may never be involved; if, however, the clinician and the part of the family that does come continually take into account the missing part of the family, they will not be seriously handicapped in their efforts. The major obstacle in the involvement of families lies within the clinician himself; moving from the individual to the family model calls for a positive shift of emphasis, and it is easy to slip back to the individual model. Most families positively welcome coming as a whole.
This is the first of two issues on family psychiatry that will be published by PSYCHIATRIC ANNALS. In the second issue, I will continue my overview of family psychiatry with a discussion of family diagnosis and family psychotherapy, and articles will be presented on the teaching of family therapy, styles and strategies of using family therapy, and the family and schizophrenia.
1. Howells, J. G. Family Psychiatry. Edinburgh: Oliver & Boyd, 1963.
2. Ackerman, N. W. The Psychodynamics of Family Life. New York: Basic Books, 1958.
3. Waldron-Skinner, S. Family Therapy: The Treatment of Natural Systems. London: Routledge and Kegan Paul, 1976.
4. Bowen, M. A Family Concept of Schizophrenia: The Etiology of Schizophrenia. New York: Basic Books, 1960.
5. Wynne, L. C, Ryckoff, I. M., Day, ]., and Hirsch, S. I. Pseudomutuality in the family relations of schizophrenics. Psychiatry 21 (1958), 205.
6. Spiegel, J. P., and Bell, N. W. The family of the psychiatric patient. In Arieti, S. (ed.). The Handbook of American Psychiatry. New York: Basic Books. 1959.
7. Lidz, T., and Fleck, S. Family Studies and a Theory of Schizophrenia: The American Family in Crisis. Des Plaines, HL: Forest Hospital Publications, 1965.
8. Bateson, G., Jackson, D. D., Haley, J., and Weakland, J. H. Toward a theory of schizophrenia. Behav. Sci. 1 (1956), 251-264.
9. Laing, R. D., and Esterson, A. Sanity, Madness and the Family. Vol. 1. Families of Schizophrenics. New York: Basic Books, 1964.
10. Howells, J. G. Theory and Practice of Family Psychiatry. Edinburgh: Oliver & Boyd; New York: Brunner/Mazel, Publishers, 1968.
11. Howells, L G. Principles of Family Psychiatry. London: Pitman Medical. New York: Brunner/Mazel, Publishers, 1975.