Evaluating and Treating Families: The McMaster Approach

Evaluating and Treating Families: The McMaster Approach by Christine E. Ryan, Nathan B. Epstein, Gabor I. Keitner, Ivan W. Miller, Duane S. Bishop, New York: Routledge, 2005, 340 pp. $39.95, softcover. Until recently clinicians who practiced family therapy, and researchers who studied families barely spoke to one another. Each seemed oblivious to the advisability of subjecting clinical “truths” to rigorous testing, and, conversely, making research clinically relevant. A prominent exception has been Nate Epstein and the group associated with the McMaster Model of family functioning. In this extraordinary book the team describes its journey over the past 40 years. The group moved with Epstein from his time at McGill, to McMaster University, from which the model derives its name, and eventually arrived at Brown University in Providence, RI, in the late 1970s where they carry on their work today. Dr. Epstein, now in his mid-80s continues to collaborate closely with the team and also maintains his own clinical practice working with severely ill, hospitalized patients. The book reflects the singular focus of the group. It is not just a book about family systems theory, or the development of instruments to measure empirically what is taking place in treatment, or how to proceed with family therapy, or what the research shows. It is all of the above. It begins with how family systems theory evolved from psychodynamic concepts in the 1960s and how this was translated into the McMaster Model. The team studied families, both with identified pathology and “nonpathological families.” It identified features it felt were found in most families, traits or organizational concepts that could be measured. The book goes on to describe the principal research instruments developed by the team: The Family Assessment Device (FAD), the McMaster Clinical Rating Scale (MCRS), and the McMaster Structured Interview of Family Functioning (McSIFF). It describes how the treatment approach based on the theoretical model and these measurement devices evolved in tandem. The authors explain that they set out to develop broadly relevant measures that could describe normal as well as pathological family processes. For example, the FAD is a brief, easy to administer, paper and pencil measure that can be given to anyone with an eighth grade reading level. The FAD has been translated into 23 languages and used in hundreds of studies. It has a General Family Functioning scale as well as subscales that measure communication, family roles, affective responsiveness, affective involvement, and behavior control. While these dimensions may only partly describe family functioning, they clearly represent some of the most important aspects of family life. The MCRS is the clinician rating scale based on the same dimensions of family functioning. It provides a clinician's expert impression of how the family is functioning on the various dimensions, and gives a contrasting view to the subjective view of family members. The McSIFF is a structured interview that allows clinically unsophisticated researchers to arrive at reliable assessments of families using the same concepts. The authors unapologetically describe the treatment approach as problem focused and directive. They assume that open, honest and direct communication between family members is a good thing, and that families function better when roles are clearly defined and carried out. They give a positive value to clear, unambiguous setting of fair limits of behavior among family members. And they address the importance of affective dimensions in family life. The authors acknowledge that others practice family therapy using different techniques but maintain that the benefits of being able to measure what one is trying to accomplish is hugely valuable. The last major section of the book details some of the many research findings based on the instruments and the treatment. The group did cross sectional and longitudinal studies on a diverse group of populations. They examined non-clinical families. They studied families with an index patient with a variety of medical conditions. They did numerous studies on families with a member presenting with major mental illness as well. They looked at the effect of family functioning on the outcome of illness, both medical and emotional. And they looked at how illness in one member can effect family functioning. The results of these studies are spelled out in remarkably clear language. The answers to major questions, as is the case in any good research, generate as many questions as they answer. The book represents a current view of a process, a snapshot in the life of a dedicated group of professionals that will obviously continue for many more years. Thomas Roesler, MD Division of Child and Adolescent Psychiatry Brown-Alpert Medical School Providence, RI

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