Family psychiatry was defined in 1963 x in the first book on family psychiatry as follows:
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 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.
This definition has stood the test of time. There has been, in some countries, a parallel movement whereby the general medical practitioner practices on a family basis and even refers to himself as a "family physician." It would be a logical development for a family practitioner to emerge in the future trained in both organic and psychological family medicines.
Over the past quarter century there has been an extension of the field of family psychiatry in at least two directions. At first, great attention was given to the child as the indicator of family psychopathology.2 With time, adulte were seen to be a channel for introduction to family psychopathology. Again, at first, attention was focused on emotional psychopathology in the presenting family member. Later, it was seen as inappropriate to treat psychotic conditions in the context of the family It is still unproven, despite a number of proponents, that family psychopathology causes schizophrenia,3 but there is now no doubt that schizophrenia is best managed as an element in the patient's family.
Family psychiatry must not be confused with family therapy. Family therapy has antecedents going back as far as family psychiatry to its originator Nathan Ackerman4 in the United States. This psychoanalyst conceived of the notion that an individual could be better treated in a family group situation rather than in an individual situation. Largely due to his publications and his films, this form of therapy rapidly gathered force in the USA and, post 1970, in Europe. It is the counterpart of family group therapy within family psychiatry. But there is an important difference. In family therapy, the object of treatment is often the individual. The patient's condition is improved by the process of family group treatment. In family psychiatry, the object of treatment is the family unit and not the individual presenting patient. The patient is the family and its welfare is addressed in treatment.
Family psychiatry is a way of practicing psychiatry,5 as the title implies. It is a procedure for psychiatrists. It is a medical movement. It aims at utilizing medical practitioners who have been given the most intensive and extensive training to give the emotionally ill the same standard of care as its related medical specialities. This concept, the family as patient, determines theory, clinical organization, views on family psychopathology, referral practices, family diagnoses, and family treatment.
Being a medical movement, family psychiatry places great emphasis on diagnosis. Treatment cannot be effective without a clear understanding of pathology. Hence the importance of family diagnosis. Again, to merely use the family group as the platform for treatment would greatly limit family treatment. Thus family psychiatry explores a whole range of approaches to treat the family unit. New methods of treatment have evolved, in particular, vector therapy. As in other medical fields, prevention is considered as important as treatment. Family psychiatry eschews speculative notions of psychopathology. It leans instead on experimental psychology using the experiential approach. Experience, reality, is all. Speculation and symbolism have no place. This slow, careful gathering of knowledge is proper as a part of medical science.
THE REFERRED PATIENT
Given that the unit of morbidity is the family, why does a particular part of it present at one moment in time? Why this husband, or this wife, or this child? Why not another? A number of mechanisms are at work to explain this occurrence as follows:
* The family member with the most obvious symptom (e.g., a tic) may be told to look for help.
* The family member with the most dangerous symptom may be forced to seek help (e.g., attempted suicide).
* The family member with the most inconvenient symptom (e.g., enuresis) may be pressured to seek help.
* A scapegoated member of the family, being under extra stress, may be the one to develop symptoms and thus be the subject of referral.
* The balance of the dynamics in the family at any particular moment may determine that the individual in the vulnerable position seeks help.
* Lastly, it may be the healthiest family member, with the greatest insight, who offers himself or herself as a patient in order to get help for the family. Insight is highly correlated with the degree of disturbance; the less insight, the more the disturbance. Thus, paradoxically, the healthiest member of the family could be under treatment in the psychiatric service while sicker members of the family are ignored.
An adequate intake procedure is always acceptance of any age group or dyad from the family or the whole family. In family psychiatry, whatever the family offers is accepted and, after initial investigation of the presenting patient, the family itself becomes the object of investigation.
It is an axiom in medicine that careful diagnosis precedes effective treatment. An incorrect diagnosis leads to the wrong choice of treatment. It is also a matter of medical experience that a carefully taken history of the development of a disorder is the most important element in the investigation. An examination for morbidity often confirms the result of the history-taking, and occasionally, may elucidate a situation where the historytaking has not led to a diagnosis. The central part of the investigation is the emotional aspects of pathology, but the physical part must be included so as to make a total and systematic appraisal of the individual.
At the first level, the clinician investigates the presenting individual. He then moves to every other family member. It is common to find the sickest member of the family is not the presenting family member.
The medium for exploration can be an interview with an individual alone, or with two family members (dyadic interview), or with the whole family group (a family diagnostic interview).
As the result of family diagnosis,6 the psychopathology ofthat family is revealed and it can be seen how it impinges on each family member and exposes the symptomatology in each. A crucial area of investigation is the life experience of each family member in their family of upbringing. Later, treatment will focus on this central area.
It is a matter for concern that, in many fields of family group therapy, what is termed "therapy" proves to be a mere recital of events in the experience of the individual. It is critical to appreciate that diagnosis is not treatment. For a process to be termed "therapeutic," it must be a positive process leading to a change that improves the welfare of the family. A mere recital of events carries no positive value.
The broad aim of family treatment is to produce a beneficial change in the family psychopathology, so as to bring family functioning to an optimum degree of harmony. When this is achieved, the symptoms of psychopathology will disappear. There are two main psychotherapeutic approaches, family psychotherapy and vector therapy. These are complementary.
Family psychotherapy is an intrainterview technique. An instrument, the personality and the expertise of the psychotherapist, is employed to effect change in the family psychopathology over a number of interviews. To claim to be effective, a therapist must achieve a positive change irrespective of the time over which the therapy proceeds. By time alone, positive change can occur in the family as its structure may change. For example, a destructive father leaves the family with a consequent improvement in the condition of the remaining family members.
The platform for effecting the change by the therapist can be a number of differently constructed interviews -individual, dyadic, or family group. Another group has tremendous potential for change - the multigenerational family interview; one or two families of upbringing join the parents in the family group. While it has great potential for change, to be handled constructively this interview technique needs a therapist of great experience.
The second therapeutic approach is that of vector therapy. Within the family there is a field of emotional forces between and involving every family member. Some of these forces are positive and constructive, some are negative and destructive. The purpose of vector therapy is to change the pattern of the forces so that they are maximally harmonious. In the previous example, a destructive father leaves the family. If it happens by accident, this cannot be claimed to be a therapeutic effort. But if it is planned, effected, and monitored within the interview, then it can be claimed to be a therapeutic effort. Vector therapy can often be more effective than family psychotherapy. The two approaches can be used together.
To effect a continuing and permanent improvement in the nation's families calls for a third approach, preventive psychiatry. Or to put it in a positive mold, creating a salutary health-creating society. Actions in the body of society can be health-promoting to the individual family, or they can be antagonistic to its health. The positive attitudes and efforts of society need promoting; the negative efforts and attitudes need eliminating. Almost no attention has been given to this movement in comparison to the efforts to improve the physical health and material resources of families. Emotional well-being has no importance in social and political planning despite pronouncements of its importance.
IN THIS ISSUE
In the following pages the role of family dysfunction in the production of a number of symptoms in the members will be illustrated.
Dr. Melvin Lansky focuses on a disruptive element in family life - the aggressive, violent, family member. He exposes the central feature of shame, and its linked mechanisms, in its pathogenesis and points to aspects of management.
Dr. Gabor Keitner and associates highlight the interaction in the family between the patient's vulnerability to depression and the family's competence to cope with it. They see family procedures as the best choice for effective treatment.
Drs. Brian Cook and George Winokur, while postulating a possible gene-induced mechanism in the alcoholic family member, go on to discuss its impact on family dysfunction. They see it as a matter of gene/family environment interaction. They also underline the need for a holistic, organic, and psychological approach.
Dr. Meissner centers on a stark physical symptom - cancer in a family member. Given a frank physical symptom, he postulates that the family system can support the patient's coping capacities or undermine them. Again, we see the need to take account of the organic and psychological functions in effective patient management in the family context.
1. Howells JG. Family Psychiatry. Edinburgh: Oliver & Lloyd; 1963.
2. Howells JG. Family Psychiatry for Child Psychiatrists. London: SCP Reports; 1972.
3. Howells JG, Guirguis WR. The Family and Schizophrenia. New York, NY: International Universities Press; 1985.
4. Ackerman NW. The Psychodynamics of Family Life. New York, NY: Basic Books; 1958.
5. Howells JG. Principles of Family Psychiatry. New York, NY: Brunner/Mazel; 1968.
6. Howells JG, Brown W. Family Diagnosis. New York, NY: International Universities Press; 1986.