It’s likely that few philosophers
who consult this service know about the unusually effective mental health
treatment described in this book: psychoeducational multiple family groups for
persons suffering from schizophrenia and other severe psychiatric disorders. The
disappointing fact is that the majority of mental health professionals fail to
provide this treatment for patients with schizophrenia.  Many randomized
research studies show that psychoeducational multiple family groups (or PMFG’s)
are one of the most effective non-pharmacological interventions available for
reducing re-hospitalization rates and promoting recovery for people with
schizophrenia. Similar but fewer studies show that PMFG’s are nearly as
effective for people with other severe psychiatric disorders. McFarlane’s MultiFamily
Groups is a detailed account of the empirical research that demonstrates
the effectiveness of PMFG’s, the theoretical presuppositions of neurobiology
and psychopathology, the social sciences that explain the effectiveness of the
groups, and the component interventions that make up PMFG’s. In  I summarize the
empirical findings, theoretical presuppositions, and components of the
intervention; in  I discuss problems associated with implementing PMFG’s; in  I
discuss some philosophically interesting issues the book raises.

2. Summary of Multifamily Groups in the Treatment of
Severe Psychiatric Disorders

2.1. Empirical studies of effectiveness

McFarlane has led efforts to
evaluate the empirical and clinical effectiveness of PMFG’s for over two
decades, building on the work of Peter Laqueur, Carol Anderson, Gerald Hogarty,
Julian Leff, Lyman Wynne, Ian Falloon and others. In severe psychiatric
illnesses, the primary criterion for evaluating treatment effectiveness is
relapse reduction. Fewer relapses result in fewer hospitalizations, less disruption
of the mentally ill person’s interaction with their social network, and more
time for the mentally ill person to take advantage of skill-building and
life-sustaining opportunities such as psychiatric rehabilitation. McFarlane
mentions the "striking consistency of therapeutic effects" in
descriptions of early investigations of family groups, behavioral training, and
educational programs for single families (p. 49) where the severe psychiatric
disorder is schizophrenia.  He notes that investigation of which factors made
these different interventions effective is absent. As a result, he and his
colleagues undertook to study factors that seemed responsible for their effectiveness,
including: educational presentations about mental illness, families and
patients meeting in groups, and social network expansion. He recounts two
long-term controlled studies: the first evaluated educational PMFG’s in
comparison to family groups, emphasizing interventions in family dynamics and
single-family education; the second evaluated educational PMFG’s in comparison
to single family education.

The first study showed that people
with schizophrenia had fewer relapses, longer periods without relapses, and
greater improvement in areas like employment. The second study showed similar
results on relapse rates and improvement. The second study also showed the need
for antipsychotic medication decreases for patients in PMFG’s and increases for
patients in single-family educational groups. Given that side-effects of
antipsychotic medications include increased risk of diabetes and socially
stigmatizing parkinsonian effects, there is a significant advantage to PMFG’s.

Due to the effects of
deinstitutionalization with inadequate outpatient treatment, the
criminalization of the mentally ill, and increased advocacy for rehabilitation
of people with psychiatric illnesses, McFarlane and his co-workers sought to
show the effectiveness of PMFG’s in specialized treatment modalities. As a
result, he cites studies showing that PMFG’s combined with assertive community
treatment and PMFG’s aimed at helping people with psychiatric illness find
employment also were successful.

McFarlane lists five conclusions
from the various studies he and his collaborators have conducted.

• Psychoeducational-problem-solving PMFG’s are more
  effective than individual therapy and/or medication alone.
• PMFG’s consistently yield lower relapse rates and higher
  employment rates than single-family psychoeducation.
• PMFG’s are more effective than single-family
  psychoeducation for first-episode and high-risk patients and for highly
  stressed families.
• PMFG’s result in higher employment rates than
  single-family psychoeducation even if both are combined with assertive
  community treatment.
• The benefits of PMFG’s increase over time up to four
  years.

2.2. Theoretical Explanation of the Effectiveness of PMFG’s

            To explain the empirical and clinical
effectiveness of PMFG’s, McFarlane turns to a theoretical model combining
studies from neuropsychiatry and social networks of schizophrenics and their
families. He summarizes it as follows:

The state of the individual with
schizophrenia is determined by a continuous interaction of specific biological
dysfunctions of the brain with social processes (p. 75).

Clinicians who expect McFarlane to re-hash the familiar bio-psycho-social
approach would be mistaken. The bio-psycho-social model is often presented to
clinicians as an equalizer, as if the fact that mental illness has biological,
psychological and social factors implies that all perspectives on the cause,
course and treatment of mental illness are equally correct, or even equally
effective. McFarlane’s account is more specific, arguing that biological factors
are the primary causal factors and that the effects of neurobiology in
schizophrenia cause cognitive and psychological deficits that result in social
impairment. The treatment recommendation that results is not the uncoordinated
mélange of medicines and therapies often found in public mental health systems
but a prescription for systematic social interventions that compensate for the
deficits caused by the neurobiology.

            McFarlane’s opening chapters summarize
neurological changes and social problems of people with schizophrenia. The
neurological changes that occur in schizophrenia cause psychological deficits.
The most important psychological deficits in his view are arousal dyscontrol,
in which the person with schizophrenia cannot adjust the content and intensity
of multiple repeated stimuli, resulting in cognitive confusion; impaired
executive functioning that affects problem-solving, planning, and self-care;
and negative symptoms, in which the person with schizophrenia suffers loses affective
expressiveness, capacity for abstract thought and motivation to participate in
formerly desired activities. Impaired executive functioning and decreased
motivation result in many persons with schizophrenia being unable to manage
their illness without considerable supports from family members and mental
health workers. The social problems on which McFarlane focuses are decreased
ability to cope with stress, reduced size of the schizophrenic’s social
network, and decreased quality of life.

            The prescriptive aim of McFarlane’s work emerges
when he discusses the need for compensatory environments that not only protect
schizophrenics from stressors and intense stimulation but also help them regain
skills lost to the neurological effects of the illness. The compensatory
environment has the family at its center, and he prescribes specific skills,
guidelines, and management strategies for protective and rehabilitative
functions. The clinician together with the family members and people with
schizophrenia form a therapeutic network. Some of those skills, guidelines, and
strategies are described in the section 2.3.

2.3. The Components of PMFG’s

            PMFG’s consist of structured interventions
intended to develop a bond between the clinician and family members, between
the clinician and the patient, and assist the family members in creating the
compensatory environment described above. The series of interventions begins
with joining, in which the clinician engages with families in a manner
specifically designed to address their guilt without blaming the family,
discover family strengths, and instill hope for recovery. Clinicians then lead
an educational workshop for several families and patients, where
clinicians present information about the biology of mental illness, psychotherapeutic
and pharmacological treatments, optimal compensatory environments and
guidelines for managing a family member’s mental illness. The educational
workshop is followed by meetings of multiple family groups. The initial
groups are organized around two contrasting goals: developing relationships
that are not centered on mental illness and sharing common experiences of what each
person has been affected by mental illness. Subsequent groups are devoted to problem-solving
in which clinicians follow and teach a structured method of problem-solving,
including problem-definition, brainstorming solutions, selecting solutions,
planning implementation and evaluating success.

            The description of PMFG’s ongoing groups, which
last from 9 months to 4 years, might sound unremarkable from this summary.
However, what happens in PMFG’s is noteworthy. McFarlane describes the process
of the groups that clinicians are required to learn and lead: relating problems
to illness management guidelines, managing difficult problems without eliciting
intensity that can precipitate relapse, interfamily assistance or ‘cross-parenting’,
in which family members from one family guide members of another to change some
behavior or learn some skill related to living with mental illness and
developing social networks that persist outside scheduled group meeting times. Many
clinicians learn and value skills that are not put to use in PMFG’s. The skills
of dynamic interventions, interpretation of psychological phenomena, ventilation
of feelings and probing memories for the sources of behavior patterns are not
effective and are often harmful in treating schizophrenia. PMFG’s require
clinicians to present themselves as partners in a recovery process, presenters
of specialized information to families, and receivers of specialized
information from family members. However, the requirement that clinicians who
would lead PMFG’s significantly alter the skills they have acquired gets little
emphasis in McFarlane’s text.

3. Implementation Failures

            There are two directions to consider when evaluating
efforts to implement an intervention as effective in controlled studies and
clinical research settings as PMFG’s. One direction to consider is whether PMFG’s
are as effective with other illnesses as with schizophrenia. A treatment that
is effective across multiple illnesses is considered robust. Call this
direction breadth because success with other illnesses would indicate the
intervention is effective with a broad range of illnesses and disorders. The
second direction is to ask whether a demonstrably effective intervention has
been widely adopted in ordinary clinical practice. Call this direction depth
since it would indicate that the intervention has roots in the culture and
practice of mental health treatment outside locations that specialize in the
intervention.

McFarlane has enlisted able
collaborators who show the multiple family group intervention has breadth. The book
includes chapters on implementing PMFG’s in community housing programs where ‘families’
are not biological and legal relatives or preferred companions. Rather, ‘families’
are staff members who work in group homes and other residential programs. Another
chapter describes combining PMFG’s with assertive community treatment teams who
specialize in work with mentally ill people who are detached from treatment
systems, whose mental  illnesses are  severe, and whose symptoms are often
exacerbated by addiction, homelessness and STI’s. This chapter describes
clinicians working to adapt the structured problem-solving method to difficult problems,
such as preventing patients from stealing from family members to buy drugs,
preparing for the return of a mentally ill person from prison and helping a
person with psychosis avoid contracting HIV during intravenous drug use.

Another indication of breadth is
the development of PMFG’s for the treatment of other severe psychiatric
illnesses and chronic medical illnesses. The PMFG method has been adapted for
bipolar disorder, major depression, borderline personality disorder and
obsessive-compulsive disorder. Use of PMFG’s for these disorders has not been
researched as thoroughly as it has for schizophrenia, but these chapters are
signs of hope. In addition, the method has been adapted for chronic medical
disorders, indicating that the problems and needs of families and patients, and
theoretical presuppositions that McFarlane capably outlines for mental illness,
also apply in some way to chronic medical conditions. 

There has been limited depth in the
implementation of PMFG’s and the results reported by McFarlane’s collaborators
and elsewhere are disappointing. As reported in this book, attempts to
implement PMFG’s statewide in mental health systems have failed. The authors of
this chapter identify organizational cultural issues, systems issues and
training issues as contributors to the failure. Organizational-cultural issues
that contributed to failed implementation efforts are that PMFG’s are
reportedly more complex than therapies with which clinicians are familiar, the
advantages of PMFG’s are reportedly not observable quickly enough to reinforce
sustained use, and PMFG’s are too different from clinicians’ familiar methods
to be easily adopted. Systems issues that contributed to failed implementation
efforts are the lack of financial support for the treatment and inadequate
commitment from mental health agency leaders to compel clinicians to adopt PMFG’s.
Training issues that contributed to failed implementation efforts are an over-reliance
on information transfer alone to alter clinical practice from other
interventions to use of PMFG’s.

The statewide implementation
efforts reported in this chapter ended seven years ago in Ohio and fifteen
years ago in New York. Implementation programs are underway in New York, Maryland and Michigan, and a study of PMFG’s in culturally diverse groups has been funded
by SAMHSA. At least some of the recent implementation programs have adopted
training methods designed to avoid the failures reported in this book and attempt
to effect institutional changes that would avoid the failures noted above. Attempts
have been made to secure Medicaid payment, identify leaders who will encourage
and/or compel staff to use PMFG’s, and provide consultants who can guide
agencies and clinicians in developing PMFG’s as a regular part of clinical
practice. We await reports on these implementation projects.

4. Philosophically Interesting Issues

            I shall mention four issues arising from
McFarlane’s work that should interest philosophers. The first concerns the
phenomena on which philosophers could profitably focus their interest in the
mind. The second is a similarity between McFarlane’s work and the capabilities
approach to human development. The third is to suggest that the failed
implementation efforts are a potential case study in implementation ethics. The
fourth is an implication of McFarlane’s work for disability studies. 

(1) Philosophers who are interested
in schizophrenia and mental illness are usually interested in what happens ‘inside’
the mind of the person with the mental illness. We want to learn about
consciousness, the self and rationality by understanding the mind when consciousness
is disordered by hallucination, self-awareness is fragmented by paranoia and
rationality is disturbed by delusion. McFarlane’s research on the effectiveness
of intervening in schizophrenia by means of compensatory social environments,
in families, friends and professionals, should give us pause to wonder what we
have missed by focusing on cognitive and perceptual processes and what we might
find if we investigated interactional processes. A common metaphor among
contemporary philosophers of mind is the idea of an ”extended mind”. That is,
the mind is not merely something ‘inside’ the person but is a set of functional
relationships constituted by interactions between persons and the instruments
and objects they use, and between the person and the environment. McFarlane’s
multiple family groups are an instance of another kind of extended mind, in
which groups of families create a ‘mind’ distinct from any individual person’s
mind that functions for the benefit of the group’s ill members.

(2) When McFarlane describes the
compensatory environment schizophrenics need as ”optimal but atypical” (p.
42; also p. 199) he reminds me of the capabilities approach to social justice
and human development championed by Martha Nussbaum and Amartya Sen. The
capabilities approach recognizes that not every person is born with the
capacity to learn the same skills to use resources to attain individual well-being,
and asks what people need to effectively use environmental resources to attain
well-being. McFarlane and his collaborators seem to have developed a method
that responds to the particular needs of people with severe mental illness that
helps them effectively use their capabilities. It would be interesting for
someone expert in the capabilities approach to study PMFG’s and for McFarlane
to take advantage of the theoretical resources of the capabilities approach.

(3) Few medical ethicists have
written about ”implementation ethics”, reflection on ethical principles,
practices, and pitfalls of implementing effective treatments in ordinary
clinical settings. Implementing new treatments ethically requires attention to
resource distribution, leadership, and sustainability rather than to protecting
subjects and assuring voluntary consent, as in research ethics.[1]
Inadequate support of effective treatments is an ethical failure that easily
goes unrecognized since it is difficult to identify a single responsible agent.
Here is an area in which subtle ethical issues could benefit from
investigation.

(4) McFarlane mentions a principle
that could be of interest for disabilities studies. Many theorists in
disabilities studies criticize ‘biomedical’ concepts of disability and favor the
view that disability is socially constructed. One reason given for rejecting
biomedical concepts of disability is the belief that an effect of biomedical
concepts is to deprive people classified as disabled in biomedical models of
their ability to choose and flourish. McFarlane’s work is solidly within the
biomedical tradition and he is aware of stigmatization and disempowerment. In
contrast to those who deny that mental illnesses are disabilities and the claims
of the disempowering effects of the biomedical concept of disability, he cites
a guiding principle of his work that contravenes such views:

The more that the partial
disabilities of schizophrenia are acknowledged, respected and accommodated, the
less they impede the path to recovery (p. 80).

Recovery here means many of the same things disability theorists
say they want: choice of goals in life, employment and freedom from
hospitalization. The principle of accepting partial disability as a biomedical
fact, rather than a social construction, in order to reduce the power of the
disabling condition to impede recovery suggests that the means of choosing and attaining
well-being is to manage the effects of a disabling condition rather than deny
the fact that some condition is disabling. There is no doubt that mental health
systems exercise great power in the lives of people they are charged to assist,
and many activities required of their charges have little connection to
individual choice and well-being. However, McFarlane’s ”devil’s pact”
suggests that accepting disability as a biomedical fact is a means by which
people with disabilities and those who work with them can increase choice and
well-being. McFarlane seems to suggest the importance of a certain sort of
psychological jujitsu: if you stop pushing against a force it has less power to
harm you. If you increase your force by joining with others in a multiple
family group, you gain the assistance of others and improve your chances of
reducing the impediments associated with disability.

    

© 2006 Robert L.
Muhlnickel

 

Robert L.
Muhlnickel, MSW, has been a clinician and teacher in the University of
Rcohester Department of Psychiatry and is completing his Ph.D. dissertation in
Philosophy at the University of Rochester. He also works on a grant training
clinicians in evidence-based family practices forpeople with serious and
persistent mental illness, co-sponsoredby the NYS Office of Mental Health and
University of Rochester Medical Center.