Evaluating Family Mental Health: History, Epidemiology, and Treatment Issues

445 Pages·1993·10.995 MB·English

by  John J. Schwab M.D., Judith J. Stephenson S.M., John F. Ice M.D. (auth.)

Evaluating FaIDily
Mental Health
History,
Epidemiology, and
Treatment Issues
CRITlCAL ISSUES IN PSYCHIATRY
An Educational Series for Residents and Clinicians
Series Editor: Sherwyn M. Woods, M.n., Ph.n.
UnitImitJ ojS outINm CalijomüI Sdwol 0/ MItlieiM
Los A"""", CalijomüI
Recent volumes in the series:
CASE STUDms IN INSOMNIA
Edited by Peter J. Hauri, Ph.n.
CHILD AND ADULT DEVELOPMENT: A Psychoanalytic Introduction for Clinicians
Calvin A. Colarusso, M.n.
CLINICAL nISORDERS OF MEMORY
Aman U. Khan, M.n.
CONTBMPORARY PERSPBCTIVBS ON PSYCHOTHBRAPY WlTH LBSBIANS
ANDGAYMBN
Edited by Terry S. Stein, M.n., and Carol J. Coben, M.n.
nBCIPHBRING MOTIVATION IN PSYCHOTIIERAPY
navid M. Allen, M.n.
nRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment,
Third Edition
Mare: A. Schuckit, M.n.
BTHNIC PSYCIßATRY
Edited by Charles B. Wilkinson, M.n.
BV ALUATING FAMILY MENTAL HBALTII: History, Bpidemiology, and
Treatment Issues
John J. Schwab, M.n., Judith J. Stepbenson, S.M., and John F. Ice, M.n.
BVA LUATION OF THB PSYClßATRIC PATIENT: A Primer
Seymour L. Halleck, M.n.
THB FRBEDOM OF THB SBLF: The Bio-Existential Treatment of Character Problems
Eugene M. Abroms, M.n.
HANDBOOK OF BBHA VIOR TIlERAPY IN THB PSYCIßATRIC SETTING
Edited by Alan S. Bellack, Ph.n., and Michel Hersen, Ph.n.
NBUROPSYClßATRIC FEATURES OF MENTAL nISORDERS
James W. Jefferson, M.n., and John R. Marshall, M.n.
RESEARCH IN PSYCIßATRY: Issues, Strategies, and Methods
Edited by L.K. George Hsu, M.n., and Michel Hersen, Ph.n.
SEXUAL LIFB: A Clinician's Guide
Stephen B. Levine, M.n.
STATES OF MIND: Configurational Analysis of Individual Psychology, Second Edition
Mardi J. Horowitz, M.n.
A Continuation Order Plan is available for Ibis series. A continuation order will bring delivery of
each new volume immediarely upon publication. Volumes aJe billcd only upon actual shipment.
For further information p1ease contact the publisber.
Evaluating FaDlily
Mental Health
History,
Epidemiology, and
Treatment Issues
JohnJ. Sehwab, M.D.
JudithJ. Stephenson, S.M.
John F. lee, M.D.
University 0/ Louisville
Louisville, Kentuclcy
Springer Science+ Business Media, LLC
Library of Congress Cataloging-in-Publication Data
Schwab, John J.
Evaluating faniiy mental health : history, epidemiology, and
treatment Issues / John J. Schwab, Judith J. Stephenson, John F.
Ice.
p. cm. — (Critical Issues In psychiatry)
Includes bibliographical references and index.
ISBN 978-1-4899-1261-9
1. Family—Mental health. 2. Family—Mental health—Kentucky-
-Lou1sv1lle—Longitudinal studies. 3. Fam1ly—Mental health-
-Research. 4. Family—History. I. Stephenson, Judith J. II. Ice,
John F. III. Title. IV. Series.
[DNLM: 1. Family. 2. Mental Health. 3. Mental Disorders.
4. Interpersonal Relations. MM 105 S398e 1993]
RC455.4.F3S385 1993
616.89*156—dc20
DIMLM/DLC
for Library of Congress 93-28471
CIP_
ISBN 978-1-4899-1261-9 ISBN 978-1-4899-1259-6 (eBook)
DOI 10.1007/978-1-4899-1259-6
© 1993 Springer Science+Business Media New York
Originally published by Plenum Press, New York in 1993
Softcover reprint of the hardcover 1st edition 1993
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise,
without written permission from the Publisher
Foreword
At the time of this writing, there is much uncertainty about the form of
this country's future healthcare system and the role of psychiatry and
other mental health disciplines in that system. Current experience with
various managed healthcare programs is not encouraging. Most often
patients with severe psychiatrie disturbances receive, at best, so me form
of crisis intervention or brief treatment. Marital and family approaches
to treatment receive even less support.
This discouraging socioeconomic context makes the work of John
Schwab and his colleagues even more important than it would be in
more favorable times. Their message is clear: The family is crucial to an
understanding of psychiatrie disorders and must often be the major
focus in the treatment of these disorders.
This book is unique in its direct reflection of the senior author's
long-term professional interests-the family, epidemiology, and history.
A careful reading provides family therapists and researchers with won
derful opportunities to examine the ways in which history, socio
economie and politieal contexts, and epidemiology can be used to in
crease understanding of the family.
This his tory of the family is unusually thorough; in particular, I
found fascinating the information about early Egyptian families (3000
B.C.) and their accordance of high status of women.
The pilot study of a small group chosen as a representative sam pie
of families in Louisville, Kentucky, provides important leads to be ex
plored in a larger study. Over 50 percent of the families were considered
symptomatie, and although the risk factors (low socioeconomic status,
single parenthood, and high levels of stress) for family symptomatic
status are not surprising, it is intriguing that in many families different
members are symptomatic at different times. This finding lends cred
ence to the family system construct that so me families may "require" a
patient, even if the person occupying the patient role varies over time.
v
vi roREWORD
The third feature of this work is the analysis of child guidance dinic
records from a 65-year period. The findings support the existence of
increasing levels of particular individual and marital-family disorders,
as weil as much that has recendy been of widespread concem about the
current state of the American family.
At a time when bookstores are filled with pop psychology and self
help manuals, this scholarly work will be most welcome to those profes
sionals who embrace complex models of human behavior, probability
approaches to causality, and an appreciation of how much we have yet to
learn.
Jerry
M. Lewis, M.D.
Timberlawn Psychiatrie Research Foundation
Dallas, Texas
Preface
Anxiety about the well-being of the family mounted steadily during the
1980s and now extends to indude concerns about the character of our
society and its moral fabric. But there is confusion about what is wrong
and what needs to be rectified. The worries about the family and fears of
its possible disintegration are matched by both veiled and loud denun
ciations of its having failed, with consequences being drug abuse, defec
tive education, violence, poor-quality manufactured goods, and an in
dulged and cynical (if not narcissistic) generation of young persons.
But the family does not need blame; it needs help. After the manu
script of this book was prepared, our data showing that increasing per
centages of families receiving psychiatric care had multiple problems
were supported by the winter 1992 report from Family Service America
in the Family Album, with its headline, "American Families in Trouble":
"The majority of families seeking help from family service agencies ...
are suffering from multiple problems and require several kinds of ser
vices" (p. 1). The re port on 16,000 families that have used family service
agencies states that "the average number of serious problems families
faced was three. Since 1970, problems that have increased among clients
indude drug/alcohol abuse, abuse-violence, single-parenting, work
related problems, and physical health problems" (p. 1). The most fre
quent problems also induded marital and parenting concerns. In com
menting on the report, Dan Fax, the executive director of the Family
and Children's Agency of Metropolitan Louisville, stated that "we have
definitely seen an increasing trend toward families who are facing more
than one problem" (p. 1).
Thus, the widespread concerns about the family are confirmed by
reports of families' multiple problems and indicators that the high
vii
viü PREFACE
divorce-remarriage-redivorce rates have had destabilizing, if not deleteri
ous, effects on a generation of young persons. Inasmuch as many of the
multiple problems faced by Ameriean families are paralleled by a host of
national problems-especially the deficit, unemployment, epidemie vio
lence, and pervasive distrust of leaders and institutions-our studies of
family mental health are aimed at two objectives. One is to gain a historieal
as weIl as scientific perspective on the status and weIl-being of the contem
porary family. Some historians have found associations between the rise
and fall of great civilizations and the health and instability of the family as
a sodal unit. Therefore, we think that an in-depth historical view of the
family and the social scene is timely as we approach the end of both a
century and a millenium. The other objective is to attempt to clarify the
interactions and influences ofthree levels ofbiosocial organization upon
each other: the wider society and the community, the family, and the
individual. Many works on the family present it as an almost singular
entity or institution, witho'ut a past and existing in isolation, uninfluenced
by other institutions and the social climate.
We view the family in Aristotelian terms as the basie social unit; its
two traditional functions are to produce children who will become au
tonomous members of society and to stabilize the parents' emotional and
sexual lives. In our opinion, the family can best be understood as a
system that operates according to the principles of generalliving systems
theory, as elaborated by James Grier Miller (1978). We hope that our
research efforts will simplify some of the confusion about the weIl-being
and fate of the family and enhance appreciation of the reciprocal effects
of the society, the family, and the individual. To do so, we have focused
on the family and mental disorder; accumulating evidence points both to
a possible increase in mental illness and to the intergenerational conti
nuity of mental health and illness.
In Chapter 1, we look at "the crisis": the American family in the
1980s, when the key words related to it were divorce, stepfamilies, domestic
partners, homeless families (almost a contradietion in terms), and single
parent families. In a decade that is now seen as characterized by an orgy of
American self-indulgence, not Emersonian "self-reliance," the family
was blamed for society's ills; the traditional, institutionally based family
was considered out of fashion, if not derided as obsolete, by many of our
nation's leaders and others of the elite. As the 1990s began, some of the
concerns changed to cries of alarm as the working poor and poverty
became common household realities and an economie recession failed to
recede before President Bush's pronouncements ofits being over,just as
the waves did not heed Canute's commands to become calm a thousand
years ago.
PREFACE ix
To place the concerns about the family in perspective, in Chapter 2
we look at the long his tory of the family, from its origins in the recesses
of prehistory to its battered, torn nuelear existence in the United States
as the twentieth century draws to a elose. Our historical research shows
that the Egyptians prized families and family sentiments at least 1,500
years be fore Moses, and that family stability waxed and waned in accord
with the vitality of the society and its leaders hip. We then trace the three
roots of the modern Western family (its elassical legacy, its Judeo
Christian heritage, and its Anglo-Saxon traditions) that culminated in
the emergence of the nuelear family in England during the eleventh and
twelfth centuries-not during the Industrial Revolution in the eigh
teenth century, as had been postulated. Also, new research has provided
substantial evidence of there being strong sentiments of love in Western
nuelear family relationships for hundreds of years.
In Chapter 3, we see that concern about the well-being of the family
as an institution in Western society surfaced in the 1880s and was mani
fest by 1900. We look at scholars' views of the family in every decade of
the twentieth century and relate the many changes taking place in family
life to the social history of the particular decade or era. A dominant
group of scholars argued that the family was merely adapting to the
challenges and opportunities of life in the twentieth century; in contrast,
others expressed concern about the increasing appearance of family
pathologies and indicators of family disorganization. From an erudite
historical perspective, Carle Zimmerman (1947) saw that the vitality of
the state and the well-being of the family marched in step. As early as the
mid-1930s, Zimmerman anticipated that the increasing family instability
would reach crisis proportions in the last decades of this century.
Chapter 4 is devoted to a summary of research on the family. We
offer a review of the beginnings of research, such as Le Play's studies of
family types and budgets in the 1850s, and also of such topics in this
century as marital adjustment. We review studies of stress and the family
and of family functioning and competence. Then we look at the chang
ing view of the family and mental disorder, especially studies of the
family and schizophrenia and of the manifold aspects of depression and
the family.
In Chapter 5, we turn to a succinct description of our other ap
proaches to the study of the family. We supply a short description of the
research setting (Louisville and Jefferson County, Kentucky) that in
cludes its his tory, and then we describe the methods used in our three
studies. The first was a straightforward 3-year review of almost 1,000
articles and books on the family, mainly in Western society. The second
was our epidemiological study of a random sam pie of families from the