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PROBLEMS IN FAMILY THERAPY RESEARCH
LETTERS
TO
THE
EDITOR
PROBLEMS IN FAMILY THERAPY RESEARCH
than 18 years), it cannot be claimed that this intervention has been demonstrated to be effective with this group.
To the Editor:
I read with interest the timely review by Diamond et al. (1996) regarding the family therapy research. There has been rapid growth in this field, and the complexity and diversity of the research was not well covered in the review. I would like to comment on three important issues. First, the structure of the article implies that family risk factors, in terms of deviant interaction and processes, need to have been identified for the development of effective family intervention. This is neither logical nor empirically justified. For example, the most important family etiological risk factors for disorders such as anorexia nervosa and schizophrenia are genetic factors. This does not detract from the usefulness of family treatment in management. Models of etiology are different from models of treatment (Dare, 1993). Second, the reviewis condensed to the point of inaccuracy. For example, it is stated that only one controlled clinical trial of family therapy for eating disorders has been carried out, but three others have been published (Crisp et al., 1991; Le Grange et al., 1992; Robin et al., 1994). These have found that family therapy, which may take different forms, but includes directive and psychoeducational elements, is very helpful for anorexia nervosa in younger patients. No controlled trials have been carried out for family therapy of bulimia nervosa. There are also problems that may be helped, on the basis of findings from controlled trials, that are not mentioned here. Problems such as grief, asthma, and physical child abuse are examples. The third limitation of the article is the lack of qualification about which group of patients, with respect to age, gender, ethnicity, and other psychosocial variables, are helped by family therapy. For example, all studies investigating the family treatment of schizophrenia, that I am aware of, have adults as subjects. In many of the studies, for a significant proportion of patients the key relative is a spouse, and intervention is marital therapy. Although it would seem reasonable to include family treatment as an ingredient in the management of young sufferersof schizophrenia (younger
Matthew Hodes, M.B.B.S, M.R.C.Psych. St. Mary's Hospital Medical School London Crisp AH, Norton K, Gowers S et al. (1991), A controlled study of the effect of the therapies aimed at adolescent and family psychopathology in anorexia nervosa. Br J Psychiatry 159:325-333 Dare C (1993), Etiological models and the psychotherapy of psychosomatic disorders. In: Psychological Treatment in Disease and Illness, Hodes M, Moorey S, eds. London: Gaskell Diamond GS, Serrano AC, Dickey M, Sonis WA (1996), Current status of family-based outcome and process research. JAm Acad ChildAdolesc
Psychiatry 35:6-16 Le Grange D, Eisler I, Dare C, Russell GFM (1992), Evaluation offamily treatments in adolescent anorexia nervosa: a pilot study. Int J Eat Disord 12:347-357 Robin AL, Siegel PT, Koepke T, Moye AW, Tice S (1994), Family therapy versus individual therapy for adolescent females with anorexia nervosa. J Dev Behav Pediatr 15:111-116
Dr. Diamond replies:
In response to Dr. Hodes' letter, I would like to clarify our position on risk factors. In an empirically based, intervention science, information from basic psychopathology and developmental research is used to enhance model development and evaluation. These bodies of literature have identified individual and family risk, mediator and moderator factors that can serve as primary targets of assessment and intervention and as outcome criteria. Generally, family-based treatments first target relevant and accessible family risk factors (e.g., disengagement) and then use adjunctive treatments (e.g., skills training, medications) to target other individual parent or child factors associated with the disorder. All interventions are intended to promote family competency, in order to avoid symptom exacerbation and to help buffer against relapse. Guy Diamond, Ph.D. University of Pennsylvania School of Medicine Philadelphia MALE-FEMALE REFERRAL PATTERNS To the Editor:
Cuffe et al. (1995) reviewed some race and gender differences in the treatment of psychiatric disorders in young
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996
1105
TO
THE
EDITOR
PROBLEMS IN FAMILY THERAPY RESEARCH
than 18 years), it cannot be claimed that this intervention has been demonstrated to be effective with this group.
To the Editor:
I read with interest the timely review by Diamond et al. (1996) regarding the family therapy research. There has been rapid growth in this field, and the complexity and diversity of the research was not well covered in the review. I would like to comment on three important issues. First, the structure of the article implies that family risk factors, in terms of deviant interaction and processes, need to have been identified for the development of effective family intervention. This is neither logical nor empirically justified. For example, the most important family etiological risk factors for disorders such as anorexia nervosa and schizophrenia are genetic factors. This does not detract from the usefulness of family treatment in management. Models of etiology are different from models of treatment (Dare, 1993). Second, the reviewis condensed to the point of inaccuracy. For example, it is stated that only one controlled clinical trial of family therapy for eating disorders has been carried out, but three others have been published (Crisp et al., 1991; Le Grange et al., 1992; Robin et al., 1994). These have found that family therapy, which may take different forms, but includes directive and psychoeducational elements, is very helpful for anorexia nervosa in younger patients. No controlled trials have been carried out for family therapy of bulimia nervosa. There are also problems that may be helped, on the basis of findings from controlled trials, that are not mentioned here. Problems such as grief, asthma, and physical child abuse are examples. The third limitation of the article is the lack of qualification about which group of patients, with respect to age, gender, ethnicity, and other psychosocial variables, are helped by family therapy. For example, all studies investigating the family treatment of schizophrenia, that I am aware of, have adults as subjects. In many of the studies, for a significant proportion of patients the key relative is a spouse, and intervention is marital therapy. Although it would seem reasonable to include family treatment as an ingredient in the management of young sufferersof schizophrenia (younger
Matthew Hodes, M.B.B.S, M.R.C.Psych. St. Mary's Hospital Medical School London Crisp AH, Norton K, Gowers S et al. (1991), A controlled study of the effect of the therapies aimed at adolescent and family psychopathology in anorexia nervosa. Br J Psychiatry 159:325-333 Dare C (1993), Etiological models and the psychotherapy of psychosomatic disorders. In: Psychological Treatment in Disease and Illness, Hodes M, Moorey S, eds. London: Gaskell Diamond GS, Serrano AC, Dickey M, Sonis WA (1996), Current status of family-based outcome and process research. JAm Acad ChildAdolesc
Psychiatry 35:6-16 Le Grange D, Eisler I, Dare C, Russell GFM (1992), Evaluation offamily treatments in adolescent anorexia nervosa: a pilot study. Int J Eat Disord 12:347-357 Robin AL, Siegel PT, Koepke T, Moye AW, Tice S (1994), Family therapy versus individual therapy for adolescent females with anorexia nervosa. J Dev Behav Pediatr 15:111-116
Dr. Diamond replies:
In response to Dr. Hodes' letter, I would like to clarify our position on risk factors. In an empirically based, intervention science, information from basic psychopathology and developmental research is used to enhance model development and evaluation. These bodies of literature have identified individual and family risk, mediator and moderator factors that can serve as primary targets of assessment and intervention and as outcome criteria. Generally, family-based treatments first target relevant and accessible family risk factors (e.g., disengagement) and then use adjunctive treatments (e.g., skills training, medications) to target other individual parent or child factors associated with the disorder. All interventions are intended to promote family competency, in order to avoid symptom exacerbation and to help buffer against relapse. Guy Diamond, Ph.D. University of Pennsylvania School of Medicine Philadelphia MALE-FEMALE REFERRAL PATTERNS To the Editor:
Cuffe et al. (1995) reviewed some race and gender differences in the treatment of psychiatric disorders in young
j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:9, SEPTEMBER 1996
1105