Family Therapy of Schizophrenics with High Risk of Relapse

Three families that demonstrated factors associated with relapse of florid symptoms in a schizophrenic family member underwent a course of 25 sessions of behavioral therapy in a multi-family group. Details of the treatment and assessment procedures are presented along with evidence of significant beneficial change in two families. The problem of providing continuing care for schizophrenic patients and their families is discussed.     

Attachment relationships within a family system

Insecurity in attachment relationships may promote family interactions that involve (1) “capturing” an attachment figure, (2) turning to an inappropriate attachment figure, (3) inappropriate responding to attachment behavior, and/or (4) anticipating loss, similar to past loss. In a family with two small children, family therapy over all the sessions involved reducing the need to “capture” (point l), with the therapist acting as a secure base for each family member (point 2) and exploring the anticipation of past losses (point 4), so that the parents could become a secure base for each other and their children (point 3). Coding from videotapes focused on a few minutes of intervention concerning the problem child. The interactions formed a pattern suggestive of a pattern of attachment with each parent. How the family contributed to the origins and maintenance of each pattern was illuminated by the above four influences of insecurity.     

A linguist looks at “schizophrenic” language

The language of some patients diagnosed as schizophrenic is apparently caused by a disruption in the ability to order linguistic elements into meaningful structures. This disruption affects different levels of language at different times, even in the same patient, thus causing six definable characteristics of schizophrenic speech. These characteristics are discoverable only through a linguistic analysis of a corpus of such speech.     

ABSTRACTS OF LITERATURE

Schizophrenia is due to a combination of genetic and environmental factors. The author asserts that there has previously been an error in conceiving the patient as being molded completely by external circumstances. In fact, it is the patient's behavior, which is a transformation of family irrationality, that constitutes schizophrenia. In 75 per cent of cases of schizophrenia seen by the author in private practice, the mother did not fit the image of the so-called “schizophrenogenic mother.” In this technique for teaching family therapy, the students take the roles of the family. Procedures, selection of players, formulating the problem, the value of the experience, and ground rules are described. This is a case report and follow-up over nine years of an alcoholic woman. The patient and husband were treated for 35 sessions by cotherapists in conjoint marital therapy. Although there was improvement in the family patterns and in drinking behavior during the treatment, the improvement did not last after termination. The case suggests that marital therapy in the absence of other treatment interventions is ineffective in changing the long-run course of women alcoholics. Based on the author's practice on an inpatient unit that specializes in the study of aggressive behavior, he describes family dynamics and treatment when the identified patient suffers from “episodic violent behavior.” The sample focuses on adolescents, most of whom had episodes of suicidal behavior and who had some evidence of “organic involvement.” Typical family patterns include overly close alliances by the adolescent with one or both parents and transmission by parents of inconsistent values regarding aggression. Family therapy is seen as the preferred treatment approach and emphasizes family ways of handling dyscontrol episodes and the responsibility of the patient for his or her actions. No results are reported. This study attempts to link family variation and core relationships in types of families with the mental health of children. Sample was from a black, poor, urban community defined in terms of the adults present in the home. Eighty-six family types were found falling into ten major classes. Measures of mental health in children were done on psychological well-being of the children and on Social Adaptational Status. Results indicate that family type is strongly related over time to child's SAS and his or her psychological well-being. Mother-alone families entail the highest risk in terms of social maladaptation and psychological well-being of the child; the presence of certain second adults has important ameliorative functions—mother/grandmother families being nearly as effective as mother/father families, with mother/stepfather families similar to mother-alone in regard to risk. Inferences from this data and implications and interventions are discussed. This is a clinical essay on the role of family therapy for black families. In addition to the usual family stresses, black families are subject to the additional strain of discrimination. Support is achieved mostly from the family and from the kinship network, rather than the community. Treatment strategies for this situation are proposed. This essay reviews recent regulations concerning consent procedures and protection of privacy as they apply to children and their families. Rigorous sample selection, nearly complete follow-up, and objective assessment of outcome are virtually impossible at this point. It is concluded that compliance with current “subjects' rights” regulations sometimes seems potentially more harmful to the subjects than the research itself. One case example is presented in support of the hypothesis that brief family therapy has the potential to lead to individual personality changes that are long-lasting. The identified patient was a 15½ year old boy with the symptom of having a falsetto voice. Father, mother, and child were seen in twelve family therapy sessions with changes in the boy's self-image documented in “man-figure” drawings. Nine-month follow-up revealed no recurrence of the presenting symptom and an improvement in social and familial relationships of the identified patient. This is another in a series of papers from a divorce-counseling project. The focus in this paper is on preventive clinical interventions developed for children of various ages in divorcing families. Developmental assessment was achieved with a “brief” history from the parents, detailed information from school, and “direct observation” of the child. This paper covers treatment strategies, interventions, failures, therapist's role, and professional dilemmas in divorce counseling of 60 families with 131 children between the ages of 3 and 18 at the time of divorce. The technique of counseling was to see one parent and child separately by the same therapist three to six times over a three-month period. This is a research study to provide data on the question of whether the disturbed behavior of parents with a schizophrenic child preexists or is a response to an identified patient's pathology. Method was to administer a conceptual task called the Twenty Questions Task individually to each family member and to the family as a unit with a sample of 36 schizophrenic families, 13 non-schizophrenic controls, and 38 normal controls. Results “indicated that far more schizophrenic sons than control sons were much more efficient individually than with their families.” A number of schizophrenic sons performed competently as individuals, but the subsequent performance of parents and sons together on the same task was generally inferior to that of the son alone. Results suggest that the parental behavior plays a part in the etiology of schizophrenia.     

Effects of a Workplace Intervention on Parent–Child Relationships

This study tested whether effects of a workplace intervention, aimed at promoting employees’ schedule control and supervisor support for personal and family life, had implications for parent–adolescent relationships; we also tested whether parent–child relationships differed as a function of how many intervention program sessions participants attended. Data came from a group randomized trial of a workplace intervention, delivered in the information technology division of a Fortune 500 company. Analyses focused on 125 parent–adolescent dyads that completed baseline and 12-month follow-up home interviews. Results revealed no main effects of the intervention, but children of employees who attended 75 % or more program sessions reported more time with their parent and more parent education involvement compared to adolescents whose parents attended <75 % of sessions, and they tended to report more time with parent and more parental solicitation of information about their experiences compared to adolescents whose parents were randomly assigned to the usual practice condition.     

Context, categorization, and recall: The “change-of-standard” effect

A psycholinguistically based conception of the relation among context, categorization, and memory is tested by examining what happens to people's memory of an object when the object is initially categorized in terms of the context in which it appears, but, when the object is later recalled, this context is no longer salient. Subjects read about the sentencing decisions of a target trial judge in the context of other trial judges who consistently gave either higher sentences or lower sentences than the target judge. As predicted, subjects tended to categorize the target judge as “lenient” in the former, harsh context condition, and as “harsh” in the latter, lenient context condition. A week later, subjects read about the sentencing decisions of some additional judges, and then recalled the sentencing decisions of the target judge they had read about the week before. Across the two sessions, either a harsh, moderate, or lenient category norm for judges' sentencing decisions was established by having subjects read about decisions that involved either high, medium, or low sentences, respectively. The results indicated that subjects recalled the target judge's decisions by interpreting their prior categorization of his behavior in terms of the category norm established across the two sessions rather than the original context. Thus, subjects who were exposed to the same target in the same circumstances, and initially categorized the target in the same way, nevertheless remembered his behavior differently if their category norm was different at the moment of recall. Other types of “change of standard” and their implications for human judgment and memory are discussed.     

Family interaction and outcome IQ in high-risk boys

This study examined the relationship between measures of family interaction and outcome for 97 boys at risk for psychopathology from having one parent previously hospitalized for psychiatric illness. Measures of communication deviance and of activity, balance and warmth, derived from two family activities, correlated significantly with 3-yr. follow-up adaptive functioning, measured by IQ. Poor family interaction, in previous studies associated with schizophrenic symptomatology, was here correlated with poor cognitive/social/emotional functioning, suggesting that family interaction may be a broad predictor of adequacy of functioning.     

Engaging “Resistant” Families in Treatment

Many families, when presented with the option of family therapy, are less than eager to participate. This paper comprises the second and third parts of a series on engaging “resistant” families. ¹ 1 The first paper in this series, authored by J. M. Van Deusen, M. D. Stanton, S. M. Scott, and T. C. Todd, is entitled “Engaging “Resistant” Families in Treatment: I. Getting the Drug Addict to Recruit His Family Members” and appeared in the International Journal of the Addictions 15 (7): 1069–1089, 1980. A revised and expanded version of Part II is presented in M.D. Stanton, T. C. Todd, and Associates, The Family Therapy of Drug Abuse and Addictions New York, Guilford, in press.
Part II presents 21 principles and a number of techniques and strategies that have been developed for successfuly recruiting such families. These techniques should be applicable for engaging resistant families with all types of presenting problems. Part III provides an analysis of the important variables involved, along with data on cost efficiency and administrative costs. It was found that when therapists had administrative control of their cases, serving in dual roles as both therapists and drug counselors, the recruitment effort was (a) more effective (i.e., complete families, including both parents or parent surrogates, were recruited in 77 per cent of the cases), and (b) twice as cost efficient. Two-thirds of the non-engaged families were not recruited because the index patient would not allow family members to be contacted. Black families were more difficult to recruit than whites. Data on cost efficiency and on the actual administrative costs of recruiting families are also provided. We conclude that the engagement process requires a revision in therapeutic philosophy, since such families are often desperately in need of help but are unavailable unless therapists make a special effort to reach them.     

“Growing your own herbs” and “cooking from scratch”: Contemporary discourses around good mothering,food, and class‐related identities

In a cultural climate of “intensive parenting” and concerns about the “obesity epidemic,” parents are expected to take responsibility for their children's health, particularly through the provision of a “healthy” diet. This study involved intergenerational dyad interviews with both middle‐class and working‐class mothers and daughters from the United Kingdom. Analysing the data using discourse analysis informed by feminist poststructuralist theory, we found that mothers were positioned as having prime responsibility for the nurturing of family members, including the provision of a healthy diet. However, providing a healthy diet alone was insufficient; mothers needed to demonstrate that time and effort had been taken in the preparation of meals using fresh ingredients. Those who failed to do so were positioned as “lazy,” thus inviting the blaming of mothers for any current or future health problems encountered by family members (especially children). However, talk from some of the working‐class mothers pointed to the unattainable and “classed” ideals that are set by such cultural expectations.     

The effects of parental illness and other ill family members on youth caregiving experiences

Informed by a model of family role redistribution derived from the family ecology framework, this study examined differences in two proposed psychological components of role redistribution (youth caregiving experiences and responsibilities) between youth of a parent with illness and their peers from ‘healthy’ families controlling for the effects of whether a parent is ill or some other family member, illness type and demographics. Based on self-report questionnaire data, four groups of Australian children were derived from a community sample of 2474 youth (‘healthy’ family, n = 1768; parental illness, n = 336; other family member illness (OFMI), n = 254; both parental and OFMI, n = 116). The presence of any family member with a serious illness is associated with an intensification of youth caregiving experiences relative to peers from healthy families. This risk is elevated if the ill family member is a parent, if more illnesses are present and by certain youth and family demographics, and especially by higher caregiving responsibilities. The presence of a family member, particularly a parent, with a serious medical condition has pervasive increased effects on youth caregiving compared to healthy families, and these effects are not fully accounted for by illness type, demographics or caregiving responsibilities.     

Comparison of Schizophrenic Patients' Families and Normal Families in China,Using Chinese Versions of FACES-II and the Family Environment Scales

The lack of measures that systematically evaluate the characteristics and functioning of Chinese families is hindering the development of appropriate family interventions for schizophrenia in China. We assessed the reliability and validity of revised and adapted Chinese versions (CV) of the Family Adaptability and Cohesion Evaluation Scales (FACES-II-CV) and the Family Environment Scales (FES-CV) and administered these instruments to 120 respondents from families with a schizophrenic member and 126 respondents from control families. The psychometric properties of the FACES-II-CV and of the FES-CV Cohesion, Conflict, Intellectual-Cultural Orientation, and Active-Recreational Orientation scales are satisfactory, so they are appropriate for use in China; the remaining six FES-CV scales require further culturally appropriate revision. Compared to control families, families with schizophrenic patients in China have higher conflict, lower cohesion, poor adaptability, and are less likely to be involved in intellectual and recreational activities. These differences remained significant after adjusting for family and respondent characteristics.     

Communication Efficiency in Couples With and Without a Schizophrenic Offspring

A new, experimental method was developed to study language and communication in schizophrenia, employing the device of a map task. Two subjects are given what they believe are identical maps. Subject A is called upon to explain a route to Subject B, whose map has, in fact, an additional street marked on it. Comparing five parent dyads of schizophrenic patients (Group S) with a matched group of five parent dyads of normals (Group N), both groups performed equally well on the training route (for which the maps were identical), but on the experimental route, four out of the five Group S couples were unable to solve the problem. (As a side-light, it was learned subsequently that the fifth Group S couple had previously received some family therapy.) Further qualitative analysis was done on the data. The results have stimulated additional research using this experimental approach.     

A Case of the Blind Leading the “Blind”: Reframing a Physical Handicap as Competence

Structural and strategic family therapy inform the course of treatment of a family with a blind member. Alteration of the family's view of the problem through reframing the blindness as competence is reported.     

If It's Offered,Will They Come? Influences on Parents' Participation in a Community-Based Conduct Problems Prevention Program

This study examined influences on the rate and quality of parent participation in the Fast Track Program, a multi-system, longitudinal preventive intervention for children who are at risk for conduct problems. A theoretical model of the relations among family coordinator characteristics, parent characteristics, the therapeutic engagement between family coordinator and parent, and rate and quality of parent participation was the basis for this study. Family coordinators are the Fast Track program personnel who conduct group-based parent-training sessions and home visits. Participants in this study included 12 family coordinators (42% were African American, 58% European American) and 87parents (55% were African American, 45% European American). The level of therapeutic engagement between the parent and the family coordinator was positively associated with the rate of parent attendance at group training sessions. The extent of family coordinator-parent racial and socioeconomic similarity and the extent of the family coordinator's relevant life experiences were highly associated with the level of therapeutic engagement. The quality, but not the rate, of participation was lower for African American parents. Implications of these findings for preventive intervention with this population are discussed.     

Therapist Focus on Parent Involvement in Community-Based Youth Psychotherapy

Parent involvement in the treatment of childhood disruptive behavior problems is a critical component of effective care. Yet little is known about the amount of time therapists are involving parents in treatment and factors that predict therapists' efforts to involve parents in routine care. The purpose of this study is to examine therapists' within-session involvement of parents in community-based outpatient mental health treatment. The data are from a larger longitudinal observational study of psychotherapy for children ages 4-13 with disruptive behavior problems and include videotaped psychotherapy sessions coded for the therapeutic strategies delivered as well as measures of child, parent/family, and therapist characteristics at baseline. Parent involvement is defined as the proportion of time in the session that therapists direct treatment strategies towards parents. Results indicated that therapists directed treatment strategies towards parents an average of 44% of the time within a session. Multilevel modeling was used to examine client-level (child, parent, and family functioning) and provider-level (therapist experience and background) predictors of parent involvement. Therapists involved parents more when the child had higher levels of behavior problems, when the parent reported higher levels of internalized caregiver strain, and when the therapist was more experienced. The results highlight potential areas to target in efforts to increase parent involvement, including training less experienced therapists to increase their focus on directing strategies towards parents.     

Enhancing Family Communication: Examining the Impact of a Therapeutic Wilderness Program for Struggling Teens and Parents

Every year approximately 130 families participate in Intercept, a program for struggling teens and their families at the Voyageur Outward Bound School, because they are concerned about the loss of trust, poor communication, and/or other high-risk behaviors they are experiencing with their children. Though families hope for improvements in family functioning, little research has been done on the impact of this type of program on the parent/child relationship or how families function once they leave the program. This phenomenological study collected qualitative data from nine families to determine what positive relationship outcomes emerged between parent(s) and their adolescent child post-program, as well as what aspects of the program curriculum were helpful in improving the parent/child relationship. Results showed that communication among family members improved as a result of participation in the Outward Bound program, and families reported utilizing new skills they had learned, including the use of time-outs, improved listening, and other assertive communication tools. Families reported that the parent/child conference at the end of the program was the most helpful aspect of the Intercept curriculum for improving the parent/child relationship. Implications for family therapy include support for therapeutic wilderness programs as a viable intervention for families of high-risk teens struggling with communication.     

Introducing Novice Therapists to “Go-Between” Techniques of Family Therapy

The training of family therapists requires that learning objectives and expectations be specified in empirical terms so that the trainer and trainee can achieve clear goals, identify areas of progress, and meet the special needs of the trainee. This paper articulates the competencies, objectives, and criteria for evaluation used during a time-limited training program for therapists involved in family therapy research conducted at Centennial School of Lehigh University.     

Family Secrecy in Family Therapy Practice: An Explorative Focus Group Study

The aim of this focus group study was to explore the experiences of family therapists working with family secrecy. Our study highlights that family secrets present important and compelling challenges for family therapists. Furthermore, our study reveals that there seem to be some basic strategies family therapists use in dealing with these challenges in therapy sessions. One basic strategy is that family therapists try to guard their position of being a trustworthy therapist for each family member by avoiding becoming stuck in family secrecy. Furthermore, therapists explore ways to guide the family toward the disclosure of the secret in order to alleviate the toxicity of the secrecy. This highlights the importance of the systemic model and how influential this perspective is in family therapy practice. Some participants, however, have in addition a second strategy they sometimes use: talking with the family about secrecy without aiming to disclose the secret. In the discussion section of the article we reflect on the possibility that in the strategic choices family therapists make conceptual issues might be involved. Furthermore, we stress the importance of further research.     

Characteristics of Schizogenic Families During a Joint Story-Telling Task

For a joint family story-telling task, families with a schizophrenic offspring were compared to normal families on the completeness and clarity of the final composite stories and on their interactional behavior. The composite stories from schizogenic families were more “vague and confused”, fragmented, and less complete as to the five components required to satisfy the task instructions. Schizogenic families displayed more conflict, failure, and confusion during the interactional task than control families, and, fathers and mothers of schizophrenic offspring displayed more “anxiety and tension”, “depressive mood”, “evasiveness” and “lack of interest” than fathers and mothers of normal families. Mothers of schizophrenic offspring were also described as more “hostile” than control mothers. Comparing schizogenic families from which the patient was absent during the task with schizogenic families with the patient present, and with control families, indicated that the central findings were not attributable to the immediate presence and participation of the schizophrenic member.