Nathan B. Epstein

The McMaster Approach to Families: theory, assessment, treatment and research

The McMaster Approach to Families is a comprehensive model of family assessment and treatment. This paper provides an overview of the McMaster Approach and consists of five major sections. First, the under-lying theoretical model (McMaster Model of Family Functioning) is described. Second, the three assessment instruments of the approach (Family Assessment Device, McMaster Clinical Rating Scale, McMaster Structured Interview of Family Functioning) and their psychometric properties are summarized. Third, the family treatment model (Problem Centered Systems Therapy of the Family) is presented. Fourth, the research conducted using the McMaster Approach is reviewed. Finally, the clinical uses and advantages of the McMaster Approach are discussed.

Family functioning in the families of psychiatric patients

Abstract The functioning of families of five psychiatric groups and a group of nonclinical families was assessed by the Family Assessment Device (FAD), a recently developed multidimensional measure of family functioning. The results indicated that families of patients with major depression, alcohol dependence, and adjustment disorder reported greater family dysfunction than nonclinical families. Families of schizophrenic and bipolar patients did not differ significantly from controls.

Depressed patients with dysfunctional families: Description and course of illness.

Sixty-eight depressed patients were subdivided according to their familys level of family functioning into functional and dysfunctional groups. Patients from dysfunctional families did not differ from those from functional families on measures of severity of depression, chronicity of depression, depression subtypes, other nonaffective psychiatric diagnoses, history of depression, or neuroendocrine functioning. Patients from dysfunctional families did have significantly higher levels of neuroticism. A 12-month follow-up of these patients indicated that depressed patients with dysfunctional families had a significantly poorer course of illness, as manifested by higher levels of depression, lower levels of overall adjustment, and a lower proportion of recovered patients. Thus, impaired family functioning appears to be an important prognostic factor in major depression.

Family functioning and the course of major depression

Abstract Thirty-eight psychiatric inpatients with major depression and their families were assessed during the acute phase of the depressive disorder and at remission or 12-month follow-up. They were matched to 28 nonclinical control families. Depressed families reported worse family functioning than control families, both during the acute episode and at remission. The depressive episode was significantly shorter (4.1 months) in those families that improved in family functioning during follow-up than in those that did not (8.1 months) improve. The familys perception of its functioning during the acute episode was not a good predictor of the length of depression for its family member.

Stroke: Morale, family functioning, health status, and functional capacity

Twenty-two stroke patients and their spouses were studied. All patients were living at home and had had a stroke at least one year previously. Of the 22 patients 14 were men and eight were women. Couples were assessed on the variables of morale, family functioning, health status, and patient functional capacity. For all variables, patient-spouse and husband-wife differences were tested. Couples from a previously studied random community sample were matched to the stroke couples on age and socioeconomic status (SES). Identical morale, family functioning, and health status data collected on these couples were compared to the stroke data. The results included the following: Stroke patients and their spouses were healthy on all variables. Members of the couple did not differ on most variables whether compared as husband-wife or patient-spouse. Wives from the two samples did not differ on any variable. Husbands from the stroke sample differed from the matched husbands on only one health variable--the number of doctor visits made in the past six months.

Family functioning and suicidal behavior in psychiatric inpatients with major depression

Family functioning was compared between suicide-attempting and nonsuicidal depressed inpatients in order to further understand psychosocial determinants of suicidal behavior. Suicidal behavior was strongly associated with a discrepancy between the patients perception of his/her family and the perception held by other family members. Suicide-attempting depressed inpatients perceived their family functioning to be worse than did their families. Suicidal patients also viewed their families more negatively than did depressed nonsuicidal inpatients, who actually viewed their family functioning more positively than did their family members. The clinical implications of these findings are discussed.

A cross-cultural study of major depression and family functioning

Patterns of family functioning in families with a depressed member from two cultures (North America and Hungary) were compared. In both cultural settings, families with a depressed member reported poorer family functioning than the control families. Comparisons between the two depressed groups, however, showed that the response to family dysfunction by the two cultures differed. While depressed families in Hungary reported difficulties in setting family rules and boundaries, those in North America experienced impaired functioning in solving problems, communicating, being involved with each other, and in overall functioning. These results are discussed in terms of the interplay between culture, depression and family functioning.

Family Functioning, Social Adjustment, and Recurrence of Suicidality

We examined suicidal and nonsuicidal patients with major depression during and subsequent to their hospitalization. Factors associated with suicidality at the index episode included psychosocial variables as well as measures of family functioning. Previous suicidality, inter-episodic adjustment, changes in family constellation, and perception of family functioning were instrumental in separating nonsuicidal patients at follow-up from patients exhibiting recurrent suicidal behavior. These results indicate that when assessing patients with major depression for suicidality, particular attention should be paid both to the social environment and to family functioning as perceived by the patient.

A Systems Therapy

Family therapy has become an increasingly popular mode of treatment over the last two decades (Epstein & Bishop, 1973; Group for the Advancement of Psychiatry, 1970; Gurman & Kniskern, 1978, 1981; Haley, 1971; Olson, 1970; Zuk, 1971). Its acceptance has not been limited to psychiatry and other mental health fields, for it is increasingly viewed as an important development by family medicine (Comley, 1973; Epstein & McAuley, 1978; McFarlane, Norman, & Spitzer, 1971; McFarlane, O’Connell, & Hay, 1971; Patriarche, 1974; Stanford, 1972), by pediatrics (Finkel, personal communciation, 1974; McClelland, Staples, Weisberg, & Bergin, 1973; Tomm, 1973), and by those working with the disabled (Bishop & Epstein, 1980). Training programs and study curricula in family therapy have grown tremendously in the last 10 years (Bishop & Epstein, 1979; Liddle & Halpin, 1978). Reports of a significant amount of research have also appeared (DeWitt, 1978; Glick & Haley, 1971; Gurman & Kniskern, 1978; Guttman, Spec-tor, Sigal, Rakoff, & Epstein, 1971; Olson, 1970; Santa-Barbara, Woodward, Levin, Streiner, Goodman, & Epstein, 1977, 1979; Wells, Dilkes, & Trivelli, 1972; Woodward, Santa-Barbara, Levin, & Epstein, 1978; Woodward, Santa-Barbara, Levin, & Epstein, 1978; Woodward, Santa-Barbara, Levin, Goodman, Streiner, Muzzin, & Epstein, 1974). Several authors have pointed to the need for clear descriptions of conceptual orientations and the specifics of the therapy process (Epstein & Bishop, 1973; Liddle & Halpin, 1978).