The McMaster Approach to Families: theory, assess- ment

The McMaster Approach to Families: theory, assess-ment, treatment and research ... The McMaster Model of Family Functioning has evolved over a...
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 The Association for Family Therapy 2000. Published by Blackwell Publishers, 108 Cowley Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA. Journal of Family Therapy (2000) 22: 168–189 0163–4445

The McMaster Approach to Families: theory, assessment, treatment and research Ivan W. Miller,a Christine E. Ryan, Gabor I. Keitner, Duane S. Bishop and Nathan B. Epsteinb 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 underlying 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.

Overview Our major goal in developing the McMaster Approach to Families was to delineate the basic concepts of family functioning and family treatment, which, if consistently applied, would allow therapists to provide effective treatment for families. These methods were developed to be readily teachable, transferable to different settings, applicable to a variety of clinical family problems, and capable of empirical verification and validation. To attain this goal, we developed a comprehensive approach to families which integrates: (1) a multi-dimensional theory of family functioning, (2) assessment instruments to assess these constructs, and (3) a well-defined method of family treatment. In order to facilitate comprehension and application of the McMaster Approach, we have emphasized clarity, operationally defined constructs and empirical validation. This empirical emphasis enhances the precision of the our approach as well as providing a Department of Psychiatry and Human Behavior, Brown University, Potter 3, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.

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evidence for the utility of the approach. We believe the resulting approach to the family is a unique blend of comprehensiveness and simplicity, which captures the essential features necessary to describe and change a family system. This paper will give a brief overview of the major portions of the McMaster Approach and its applications. We will begin by describing the theoretical model, followed by sections outlining: (1) the assessment instruments, (2) the family treatment, and (3) research uses and findings. We will conclude with a short discussion of the potential clinical and research uses of the model. The McMaster Model of Family Functioning has evolved over a period of thirty years. The development of the model has involved conceptualizing and then testing concepts in clinical work, research and teaching. Problems discovered in these applications have led to reformulations of the model. The result of this pattern of development has been that the model is pragmatic. More detailed descriptions of the model are found in previous publications (Epstein et al., 1978, 1982, 1993). Basic assumptions The McMaster Model is based on a systems theory. The crucial assumptions of systems theory which underlie the model are as follows: 1 All parts of the family are interrelated. 2 One part of the family cannot be understood in isolation from the rest of the family system. 3 Family functioning cannot be fully understood by simply understanding each of the individual family members or subgroups. 4 A family’s structure and organization are important factors that strongly influence and determine the behaviour of family members. 5 The transactional patterns of the family system strongly shape the behaviour of family members. Dimensions of family functioning The McMaster Model does not cover all aspects of family functioning but identifies a number of dimensions which we have found important in dealing with clinically presenting families. A family  2000 The Association for Family Therapy and Systemic Practice

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can be evaluated to determine the effectiveness of its functioning with respect to each dimension. To understand the family structures, organization and transactional patterns associated with family difficulties, we focus on assessing and formulating six dimensions of family life: problem-solving, communication, roles, affective responsiveness, affective involvement, and behaviour control. The McMaster Model does not focus on any one dimension as the foundation for conceptualizing family behaviour. We argue that many dimensions need to be assessed for a fuller understanding of such a complex entity as the family. However, the dimensions are not an exhaustive listing of all aspects of family functioning, but only those that are expected to be useful in a clinical context. We also wanted the dimensions to be conceptualized and operationalized in a manner that allowed them to be easily taught and useful in research. Although we feel we have clearly defined and delineated the dimensions, we recognize that overlap and/or possible interaction may occur between them. Further clarification may result from our continuing research. The dimensions of family functioning are discussed in more detail below. Problem-solving. The problem-solving dimension is defined as a family’s ability to resolve problems at a level that maintains effective family functioning. A family problem is seen as an issue for which the family has trouble finding a solution, and the presence of which threatens the integrity and functional capacity of the family. Not all ‘problems’ are considered, since some families have continuing, unresolved difficulties that do not threaten their integrity and functioning. Problems are subdivided conceptually into instrumental and affective types. Instrumental problems are the mechanical problems of everyday life, such as money management or deciding on a place to live. Affective problems are those related to feelings and emotional experience. Communication. We define communication as how information is exchanged within a family. The focus is on verbal exchange. Nonverbal aspects of family communication are obviously important but are excluded here because of their potential for misinterpretation and the methodological difficulties of collecting and measuring such data for research purposes. Communication is also subdivided into instrumental and affective areas. As in problem-solving,  2000 The Association for Family Therapy and Systemic Practice

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although there can be overlap between the two areas, some families exhibit marked difficulties with affective communication, while functioning very well with instrumental communication. In addition, two other independent aspects of communication are also assessed: Is the communication clear or masked? Is it direct or indirect? The former distinction focuses on the clarity with which the content of the information is exchanged. Is the message clear, or is it camouflaged, muddied, vague and masked? The latter distinction considers whether the message is clearly directed to the person for whom it is intended. Roles. We define family roles as the recurrent patterns of behaviour by which individuals fulfil family functions. These are routine family tasks, such as cooking or taking out the garbage. Our model divides family functions into instrumental and affective areas, as noted above. In addition, the functions are subdivided into two further spheres: necessary family functions and other family functions. Necessary family functions include those with which the family must be repeatedly concerned if it is to function well. These functions may be instrumental, affective, or a combination of the two. Other family functions are those that are not necessary for effective family functioning but arise, to a varying degree, in the life of every family. Consideration of each group of functions is important. Affective responsiveness. Affective responsiveness is defined as the ability of the family to respond to a range of stimuli with the appropriate quality and quantity of feelings. In terms of quality, we are concerned with two questions. First, do family members respond with the full spectrum of feelings experienced in human emotional life? Second, is the emotion experienced consonant with the stimulus and situational context? The quantity aspect focuses on the degree of response and is viewed as extending along a continuum from non- or under-responsiveness to reasonable or expected responsiveness, to over-responsiveness. For an effective affective family life, we expect to find the potential for the full range of affective experiences that are appropriate in quality and quantity of response. Affective involvement. The dimension of affective involvement is defined as the degree to which the family as a whole shows interest in and values the activities and interests of individual family  2000 The Association for Family Therapy and Systemic Practice

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members. The focus is on how much, and in what way, family members show an interest and invest themselves in each other. However, affective involvement does not simply refer to what the family does together, but rather the degree of involvement among family members. Behaviour control. The behaviour control dimension is defined as the pattern a family adopts for handling behaviour in three types of situations. First, there are physically dangerous situations where the family will have to monitor and control the behaviour of its members. Second, there are situations which involve meeting and expressing psychobiological needs or drives such as eating, drinking, sleeping, eliminating, sex and aggression. Finally, there are situations involving interpersonal socializing behaviour both among family members and with people outside the family. It is important to consider the behaviour of all family members in each type of situation. In the course of assessing the appropriateness of the rules and standards of the family, the age and status of the individuals concerned must be considered. Families develop their own standards of acceptable behaviour, as well as the degrees of latitude they will permit in relation to these standards. The nature of these standards and the amount of latitude for acceptable behaviour determine degree of behaviour control in the family. Dysfunctional transactional patterns In addition to the six major dimensions of family functioning, the McMaster Model recognizes dysfunctional transactional patterns. Dysfunctional transactional patterns refer to characteristic or common interactions between family members which are associated with impaired functioning in one or more of the dimensions of family functioning described above. Generally, these dysfunctional transactional patterns serve to decrease anxiety in the family as a whole or in some subset of family members, at the expense of overall family functioning. The relationship between transactional patterns and other dimensions of the McMaster Model is a complex one. We do not believe that dysfunctional transactional patterns are necessarily the primary cause of family dysfunction, for true ‘causes’ are difficult to ascertain in complex systems such as families. However, it is our experience that dysfunctional transactional patterns are associated  2000 The Association for Family Therapy and Systemic Practice

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with family impairment, and change in dysfunctional transactional patterns is usually necessary for improved family functioning. While certain dysfunctional transactional patterns may be associated with problems in one particular dimension, some dysfunctional transactional patterns may create difficulties in a number of dimensions. Similarly, some transactional patterns may be dysfunctional for one family and highly adaptive for another. Assessment instruments As noted above, one of the basic tenets of the McMaster Approach is an emphasis on constructs and procedures which can be empirically measured and verified. Following this principle, after having developed our models of family functioning and family treatment, we turned to the issue of providing empirical measurement of the constructs of our model. We began with development of a selfreport questionnaire, the Family Assessment Device (FAD). We then developed the McMaster Clinical Rating Scale (MCRS), designed to be completed by a therapist or a trained rater after an interview with the entire family. Finally, we developed the McMaster Structured Interview of Family Functioning (McSIFF), a structured family interview schedule, which can be used by para-professionals or newly trained family clinicians to conduct a comprehensive family interview. We believe these three types of measures are complementary and offer a comprehensive assessment of family functioning according to the McMaster Model. Family assessment device Description. The Family Assessment Device (Epstein et al., 1983) was designed to assess the dimensions of the McMaster Model according to family members’ perceptions. It consists of subscales assessing the six dimensions of the McMaster Model as well as a general functioning scale which assesses the overall level of family functioning. The FAD consists of a total of sixty statements describing various aspects of family functioning, with the number of items in the subscales ranging from 6 to 12. Family members rate how well each statement describes their family by selecting from among four alternative responses: strongly agree, agree, disagree and strongly disagree. The questionnaire is designed to be completed by all  2000 The Association for Family Therapy and Systemic Practice

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family members over the age of 12 and takes fifteen to twenty minutes to complete. The FAD is scored by summing the endorsed responses (1–4) for each subscale (negatively worded items are reversed) and dividing by the number of items in each scale. Thus individual scale scores range from 1.0 (best functioning) to 4.0 (worse functioning). Psychometric properties. The psychometric properties of the FAD have been described in detail in three previous publications (Epstein et al., 1983; Kabacoff et al., 1990; Miller et al., 1985). Briefly, the FAD has been found to have high levels of internal consistency across a variety of different types of families (Epstein et al., 1983), and acceptable levels of test–retest reliability (Miller et al., 1985). While the seven FAD scales have been found to be moderately correlated (r =.4 –.6), this level of intercorrelation is consistent with our theoretical perspective that all aspects of family functioning are interrelated. When the effects of overall level of family functioning (as measured by the general functioning scale) are removed statistically, the correlations between dimension scales approach zero. Confirmatory factor analysis has supported the hypothesized underlying model of the FAD (Kabacoff et al., 1990). The FAD has been found to have low correlations with social desirability (r=.06 –.19), moderate correlations with global measures of marital functioning such as the Dyadic Adjustment Scale and the Locke-Wallace Marital Satisfaction Scale (r =.47, .59), and theoretically consistently correlations with other measures of family functioning (Miller et al., 1985). The FAD has been found to correlate moderately (r=.4-.6) with the observer-rated McMaster Clinical Rating scale (Miller et al., 1994) The FAD has been translated into fourteen languages, with empirical evidence of its utility in different cultures (Keitner et al., 1990, 1991; Morris, 1990; Wenniger et al., 1993) and has been used in over forty research studies. In general, these studies support the discriminative validity of the FAD and its utility as a research instrument (see research section). In addition, the FAD has been extensively used as an assessment tool by family clinicians (See clinical implications section). The twelve items comprising the general functioning scale of the FAD have been used alone as a brief measure of overall family functioning, with excellent psychometric properties (Byles et al., 1988).  2000 The Association for Family Therapy and Systemic Practice

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McMaster Clinical Rating Scale (MCRS) While it is important to have self-report inventories for assessing theoretical constructs, some difficulties may arise in their use with families. The decision on how to combine individual family scores into an overall rating can be problematic. In addition, there are interactional data and non-verbal cues available in interview settings that are not available with paper and pencil reports. To further increase the utility of the McMaster Model in clinical and research settings, we thought it would be useful to have a clinical rating instrument for assessing the functioning of families along the dimensions of the model. A detailed description of the MCRS and its psychometric properties can be found in Miller et al. (1994). Description. The MCRS is a seven-item rating scale which includes ratings of each of the six dimensions of the McMaster Model as well as an overall health-pathology rating. The MCRS is designed to be completed by either a rater who observes a suitable in-depth family interview or by the clinician who carries out such an interview. Each rating is made on a seven-point scale. A rating of 1 is made for the most ineffective or disturbed functioning and a rating of 7 represents the most effective or healthy functioning possible. A manual defines each dimension, explains the scaling system, and outlines concise anchor descriptions for points 1, 5 and 7 on the scales. These descriptions are in operational and behavioural terms and describe the type of functioning that should be present to qualify for a score on the various levels on the scale. Psychometric properties. The psychometric properties of the MCRS have been reported in Miller et al. (1994). Briefly, the MCRS has been found to have acceptable interrater (.68 –.87) and test–retest reliability (.81–.87). Correlations among the different scales of the MCRS mirror those of the FAD. There are moderate interscale correlations (.17 to .85, with a mean of .53.), which approach zero when the effects of the overall family functioning scale are removed. The available evidence concerning the validity of the MCRS provides proof of its utility in a number of different situations. Concurrent validity of the MCRS was documented by studies demonstrating good correspondence between the MCRS scales and the self-report FAD (Fristad, 1989; Hayden et al., 1998; Miller et al.,  2000 The Association for Family Therapy and Systemic Practice

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1994). In a study assessing discriminative validity (Keitner et al., 1992), the MCRS differentiated between families with a member in the acute and recovered phases of a depressive episode. The MCRS has also been shown to correlate significantly with independently rated family behaviour during mealtimes in the home (Hayden et al., 1998). Finally, studies by Maziade and his group (Maziade et al., 1985, 1987) indicated that the scales of the MCRS can make important contributions to predicting a child’s emotional and intellectual functioning. Training. As reported in Miller et al. (1994), reliable MCRS ratings have been obtained with experienced clinicians, relatively novice clinicians and undergraduate students with five hours of didactic instruction. Thus it appears that minimal training is required to accurately rate the MCRS. However, the skills required to conduct a family interview which provides sufficient information to make a MCRS rating is considerably more complex and led to the development of the McMaster Structured Interview for Family Functioning. McMaster Structured Interview for Family Functioning (McSIFF) The development of a structured interview of family functioning was stimulated by both our research and clinical training activities. From a research perspective, the need for a structured family interview was driven by two related issues. First, as we utilized the MCRS, it became apparent that the clinical interview of the family was a critical element in conducting a reliable and valid MCRS. However, use of an unstandardized family interview introduced considerable variability into the MCRS ratings. Many researchers and clinicians who desired to use the MCRS did not have high levels of experience with the McMaster Model and were thus unable to conduct adequate clinical interviews for MCRS ratings. A second research reason for developing a structured interview concerned the level of specificity available in the MCRS and FAD. The MCRS and FAD provide a single score for each dimension. They do not specify the particular areas within each dimension that contribute to a single score on each dimension. Single scores for each dimension, as generated by the FAD and MCRS, do not allow differentiation among these more specific family processes. Description. For these reasons, we developed the McMaster Structured Interview of Family Functioning (McSIFF) (Bishop et al.,  2000 The Association for Family Therapy and Systemic Practice

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1980). Our goal was to develop an instrument for families that was analogous to the SCID interview (First et al., 1994) for psychiatric diagnosis. We wanted to design a structured interview that clinicians and researchers could use to conduct reliable and valid family interviews based on the McMaster Model. As with the SCID, we tried to balance the sometimes conflicting issues of structure versus clinical judgement and flexibility. The McSIFF begins with an orientation to the interview process. The interviewer then obtains a listing of problems which the family identifies, and determines what steps the family had taken to solve these problems. Following this discussion of the family’s presenting problems, the interview shifts to each of the McMaster Model dimensions in the following order: (1) roles, (2) behaviour control, (3) problem-solving, (4) communication, (5) affective responsiveness and (6) affective involvement. Parallel but separate formats for the McSIFF are available for intact families, single-parent families and couples only. Training. A variety of interviewers with some clinical experience with families, but no formal training in family therapy or the McMaster Model, have been trained to reliably administer the McSIFF. Typically, interviewers require between ten and twenty hours of training, depending upon previous experience. Approximately five hours of this training is didactic instruction regarding the McMaster Model and the McSIFF. The remaining training time consists of practice interviews with supervision and feedback from experienced McSIFF interviewers. Evaluation. The McSIFF has been used in several large-scale studies investigating various aspects of psychiatric disorder, including: (1) a longitudinal study of family functioning and the course of illness in ninety-three patients with major depression (Keitner et al., 1987a; Miller et al., 1992), (2) a treatment outcome study investigating the efficacy of combined individual, family and pharmacological treatment for 120 depressed inpatients (Miller et al., in preparation a), (3) a treatment outcome project studying the efficacy of adding family treatments (family therapy or multi-family psycho-educational group) to pharmacotherapy for ninety bipolar patients (Miller et al., in preparation b)and (4) a longitudinal study examining intergenerational transmission of psychopathology in a sample of 182 families with young children (Dickstein et al., 1998; Hayden et al., 1998;  2000 The Association for Family Therapy and Systemic Practice

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Seifer et al., submitted). Since all these studies involve longitudinal assessment of family functioning in combination, close to 1,000 McSIFF interviews have been conducted. Overall, we have been extremely pleased with the use of the McSIFF in these studies. The training time required for mastery of the McSIFF is substantially less than complete family therapy training. The MCRS ratings based on the McSIFF interviews have produced interesting and clinically relevant data (Dickstein et al., 1998; Hayden et al., 1998; Max et al., 1997, 1998). As we had hoped, use of the McSIFF has virtually eliminated the problem of insufficiency of interview data in making reliable ratings on the MCRS. Limitations While we believe that the assessment instruments from the McMaster Model offer a comprehensive, reliable and valid assessment of the family, we are aware of several limitations. First, none of the assessment measures have the range of ‘normative’ data that would be ideal. While the FAD has been used with large numbers of non-clinical families, these families were largely Caucasian and middle class (See Kabacoff et al., 1990). The MCRS and McSIFF have been used less widely. Although the McMaster Model is based on a clinical health model which defines family health and normality by level of functioning rather than by statistical terms (Epstein et al., 1978, 1981, 1982, 1993), greater ethnic, racial and socioeconomic variability among non-clinical groups would still be helpful in verifying the utility of the McMaster Model instruments with these populations. Second, as noted above, the dimensions of the McMaster Model assessment instruments are correlated with each other. From a traditional psychometric perspective, the instruments may be criticized because their scales are not sufficiently independent of each other to be considered separate dimensions. We disagree with this viewpoint. As discussed in previous papers (Epstein et al., 1983; Kabacoff et al., 1990; Miller et al., 1985), McMaster Model assessment instruments are not based on traditional purist psychometric assumptions, such as orthogonality of scales. Rather, they were developed from a ‘rational-theoretical’ perspective to assess interrelated constructs specified in the McMaster Model. The McMaster Model hypothesizes that the dimensions of family functioning should be related to one  2000 The Association for Family Therapy and Systemic Practice

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another. The model predicts that there is a large, general, underlying health–pathology dimension which accounts for a large proportion of the variance in family functioning. This healthy–unhealthy dimension reflects the reality that when families have difficulty on one dimension it usually creates problems in other dimensions as well. Third, despite the large number of translations of the FAD and its use in non-English-speaking countries, the reliability and validity of these translated versions of the FAD have typically not been established, with the Dutch version (Wenniger et al., 1993) being a notable exception. Family treatment approach The Problem Centered Systems Therapy of the Family (PCSFT) has been described by Epstein and Bishop (1981; Epstein et al., 1990) and in a detailed treatment manual (Epstein et al., 1988). The PCSFT is a highly structured, multi-dimensional and systemsoriented treatment which allows the integration and co-ordination of a number of different treatment approaches, depending upon the specific clinical presentation. The PCSFT model is usually a short-term intervention which is designed to be delivered in a costeffective manner. Basic principles The PCSFT is based on ten basic principles: (1) emphasis on ‘Macro’ stages of treatment; (2) establishment of a collaborative set between therapist and family members; (3) open, direct communication with the family; (4) focus on the family’s responsibility for change; (5) emphasis on current problems; (6) focus on behavioural change; (7) emphasis on assessment; (8) focus on family strengths; (9) inclusion of the entire family, and (10) time-limited nature. Stages of treatment The Problem Centered Systems Therapy of the Family is composed of four major stages: (1) Assessment; (2) Contracting; (3) Treatment, and (4) Closure (see Table 1). Each stage contains a set of specific goals and a sequence of substages.  2000 The Association for Family Therapy and Systemic Practice

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TABLE 1 Stages and steps in Problem Centered Systems Therapy of the Family 1 Assessment (1) Orientation (2) Data-gathering (3) Problem description (4) Problem clarification (5) Formulation 2 Contracting (1) Orientation (2) Outlining options (3) Negotiating expectations (4) Contracting signing 3 Treatment (1) Orientation (2) Clarifying priorities (3) Setting tasks (4) Task evaluation 4 Closure (1) Orientation (2) Summary of treatment (3) Long-term goals (4) Follow-up

1 Assessment stage. The first major stage, and in many ways the most important stage, is the assessment stage. This stage has three major goals. First, the therapist should orient the family to the beginning of the treatment process and establish an open, collaborative relationship with the family. Second, the therapist should identify all current problems in the family, including the presenting problem as well as those identified during the course of the assessment. Third, the therapist must formulate specific hypotheses regarding the variables and/or processes that appear to be causally associated with the family’s identified problems. The assessment stage consists of four steps: (1) orientation; 2() data-gathering; (3) problem description; (4) clarifying and agreeing on a problem list, and (5) formulation.  2000 The Association for Family Therapy and Systemic Practice

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2 Contracting stage. The second macro stage is contracting. The goal is for the therapist and family to prepare a written contract that delineates the mutual expectations, goals and commitments regarding therapy. The steps in this stage are: (l) orientation; (2) outlining options; (3) negotiating expectations, and (4) contract signing. 3 Treatment stage. The third macro stage is treatment. The goals of the treatment stage should follow on closely from the previous assessment and contracting stages. Thus the goals should be to develop and implement problem-solving strategies to change the identified problems. There are two major types of therapeutic techniques utilized in PCSFT to accomplish these goals. First, the major treatment interventions are focused on producing behavioural change in the family through task-setting – the therapist setting tasks for the family to accomplish between sessions and subsequently evaluating the success or failure of these tasks. Second, a variety of techniques can be used in the therapy session to promote cognitive and behavioural changes which will increase the family’s abilities to successfully address their problems. The treatment stage consists of four steps: (1) orientation; (2) clarifying priorities; (3) setting tasks, and (4) task evaluation. 4 Closure stage. The final stage is closure, consisting of four steps: (1) orientation; (2) summary of treatment; (3) long-term goals, and (4) follow-up (optional). Research As noted above, the concepts and assessment instruments from the McMaster Approach have been used extensively in a variety of research contexts. A majority of these studies have used the Family Assessment Device as the principal measure of family functioning. More recent studies have also used the McSIFF and MCRS as part of their assessment battery. Finally, three large-scale studies have investigated the efficacy of the PCSFT treatment model. The largest number of studies using the McMaster Approach have focused on adult psychiatric populations, particularly on patients with mood disorders. Other areas of significant research activity focus on: (1) adult chronic medical disorders, (2) children, and (3) treatment. We will briefly review each of the major areas of research with the MMFF.  2000 The Association for Family Therapy and Systemic Practice

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Adult psychiatric patients Over twenty studies have utilized the McMaster Approach and its assessment instruments to investigate family functioning among psychiatric patients. A majority of these studies have focused on family functioning among patients with major depression. The results from these studies have indicated that: (1) families of depressed patients report severe levels of family dysfunction during the depressive episode (Keitner et al., 1986, 1987b), with some studies suggesting that the level of family impairment is more severe in depressive disorders than in any other psychiatric diagnostic group (Miller et al., 1986); (2) level and type of family dysfunction have been found to be associated with an increased risk for suicide (Keitner et al., 1987b, 1990; McDermut et al., submitted); (3) impairments in family functioning, while improving somewhat, still remain, even after remission of the acute depressive episode (Keitner et al., 1991, 1992, 1995) and (4) impaired family functioning is associated with a longer recovery time and increased risk for relapse (Keitner et al., 1991, 1992, 1995). Other studies have used the FAD to assess family functioning with a variety of clinical groups, including: (1)multiple diagnostic conditions (Friedmann et al., 1997; Miller et al., 1986), (2) substance abuse (Liepman et al., 1989), (3) eating disorders (North et al., 1997; Waller et al., 1990), and (4) obsessive-compulsive disorders (Livingston et al., 1988). Adult medical patients A number of studies have utilized the McMaster Approach and the Family Assessment Device in studies of the families of medical patients. The Family Assessment Device has been reported to predict future adjustment in a variety of chronic illnesses (Arpin et al., 1990; Bishop et al., 1987; Browne et al., 1990). Other studies have focused on more specific disorders, such as stroke (Bishop et al., 1986; Evans et al., 1986, 1987b, 1987c, 1988, 1991), traumatic brain injury (Bishop and Miller, 1988; Kreutzer et al., 1994; Zarski et al., 1988), and chronic pain (Roy, 1990). The studies focusing on stroke are particularly illustrative. In a series of studies, Evans, Bishop and their colleagues (Bishop et al., 1986; Evans, 1984, 1986, 1987a, 1987b, 1987c, 1988, 1991) demonstrated that family functioning predicts: (1) adherence to treatment  2000 The Association for Family Therapy and Systemic Practice

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following stroke, (2) healthcare utilization and (3) a larger degree of variance of post-stroke functioning than do medical variables. These findings led to a family treatment intervention based on the MMFF which produced significant improvements in functioning (see section on treatment below). Children Several studies have utilized the McMaster Approach and its assessment instruments to study family functioning and children. These studies have focused on a wide range of issues and populations. Joffe et al. (1988) used the general functioning scale from the FAD and found that it predicted subsequent adjustment and suicidal behaviour in a large epidemiological study of children. Several studies report data indicating that the FAD can be used to identify families which are dysfunctional and where children might be at risk for maladjustment (Akister and Stevenson-Hinde, 1991; Saayman and Saayman, 1988; Sawyer et al., 1988). Maziade et al. found that the communication and behaviour control scales from the MCRS predicted development of psychiatric disorders (Maziade et al., 1985, 1987). Max et al. used the FAD, MCSIFF and MCRS to assess family functioning in a sample of children with traumatic brain injury (Max et al., 1997, 1998). The family variables predicted the subsequent development of psychiatric disorders in these children. Another study used the McSIFF, MCRS and FAD to assess family functioning in an investigation of young children whose mothers were depressed, anxious or non-psychiatric (Dickstein et al., 1998; Hayden et al., 1998). They reported that the McMaster Model family assessments correlated well with observational measures of family functioning in the home and laboratory and that the level of family functioning was related to current maternal illness. Other studies have used the FAD in investigations of children who were psychiatric inpatients (McKay et al., 1991), children with ADHD (Cunningham et al., 1988) and outpatients at a child psychiatric clinic (Goodyear et al., 1982). Treatment Although the number of treatment outcome studies based on the McMaster Approach and the Problem Centered Systems Therapy of the Family is relatively small, the results have been highly  2000 The Association for Family Therapy and Systemic Practice

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encouraging. In an early study, 279 families which entered treatment at an outpatient children’s clinic for behavioural or academic problems were administered the PCSFT treatment. The results provided strong support for the effectiveness of this treatment method, with over 65% of the families showing positive effects (Woodward et al., 1978). More recent studies have utilized the PCSFT treatment as part of a multi-modal treatment programme in controlled trials for inpatients with major depression and patients with bipolar disorder (Miller et al., in preparation a and b). Preliminary analyses suggest that the PCSFT is an efficacious treatment adjunct for these disorders. More specifically, in a sample of 121 depressed inpatients treated for six months after discharge from hospital, a treatment programme composed of PCSFT, individual psychotherapy and pharmacotherapy produced better response rates than pharmacotherapy alone (Miller et al., in preparation a). In another study of bipolar patients, early analyses suggest that for patients admitted with a manic episode, a combination of pharmacotherapy and PCSFT is more effective than pharmacotherapy alone (Miller et al., in preparation a). Finally, as mentioned above, based on the MMFF, we have developed a telephone administered intervention for stroke patients and their caregivers (Family Intervention-Telephone Tracking) (Bishop et al., 1997). This intervention has been tested in one study and found to produce significant improvements in family functioning, health status and overall adjustment in the six months following a stroke (Bishop et al., in preparation). Clinical implications The McMaster Approach is a comprehensive model of family theory, assessment and treatment. As such, it provides clinicians with consistent, practical and empirically validated methods to assess and treat families. In addition to the specific uses and advantages described below, the McMaster Approach has several overall advantages for clinicians. First, since it is a comprehensive model the McMaster Approach provides the clinician with an integrated set of assessment and treatment approaches. This integration facilitates learning, consistency and outcomes. Second, the McMaster Approach was developed as a clinical model, with constructs and procedures based in clinical experience. Third, the McMaster  2000 The Association for Family Therapy and Systemic Practice

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Approach was deliberately designed to be clear and operationally defined, thus allowing easy understanding and implementation of the various aspects of the model. The Family Assessment Device has been used, and is appropriate for use, in a number of clinical situations. First, the FAD (or the general functioning scale alone) can be used as a screening assessment to identify families which are having problems. Second, the FAD can be used by clinicians to identify particular areas of difficulty within the family (e.g. problems with communication but not behaviour control). Finally, the FAD can be used to assess change in families following treatment. Similarly, the MCRS and McSIFF have a number of potential clinical uses. The MCRS provides the clinician with specific descriptions of levels of family functioning, which allow accurate assessment and delineation of problem areas. The McSIFF offers the clinician a rich and detailed assessment of the family. This interview can be used as part of the first stage of family treatment and provides the clinician with a broad overview of the family’s strengths and weaknesses. The structure and comprehensiveness of the McSIFF is also very useful for training new clinicians in family interviewing. Finally, the Problem Centered Systems Therapy of the Family Approach has several advantages for clinical use. First, the PCSFT model is a highly structured treatment which has been extensively described, and procedures to train and evaluate new therapists have been developed and tested (Bishop et al., 1984a, 1984b; Byles et al., 1983). Second, the PCSFT model is a multi-dimensional and systems-oriented treatment which allows the integration and coordination of a number of different treatment approaches, depending upon the specific clinical presentation. Third, the PCSFT model is usually a short-term intervention which can be delivered in a costeffective manner. Fourth, while still requiring training and supervision, the PCSFT is a relatively straightforward, easy-to-learn approach to family treatment. It provides a high degree of structure and guidance to the clinician, which is often essential with less experienced family clinicians. Conclusion In summary, the McMaster Approach to Families is a comprehensive model with an integrated set of theoretical constructs, assessment instruments and treatment methods. The McMaster  2000 The Association for Family Therapy and Systemic Practice

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Approach has been used successfully in numerous settings, and provides researchers and clinicians with an empirically validated approach to assessing and treating families. References Akister, J. and Stevenson-Hinde, J. (1991) Identifying families at risk: exploring the potential of the McMaster Family Assessment Device. Family Therapy, 13: 63–73. Arpin, K., Fitch, M., Browne, G. and Corey, C. (1990) Prevalence and correlates of family dysfunction and poor adjustment to chronic illness in speciality clinics. Journal of Clinical Epidemiology, 43: 373–383. Bishop, D. and Miller, I. (1988) Traumatic brain injury: empirical family assessment techniques. Journal of Head Trauma and Rehabilitation, 3: 16–30. Bishop, D., Epstein, N., Keitner, G., Miller, I. and Zlotnick, C. (1980) The McMaster Structured Interview for Family Functioning. Providence, RI: Brown University Family Research Program. Bishop, D., Byles, J. and Horn, D. (1984a) Family therapy training methods: minimal contact with an agency. Journal of Family Therapy: 6: 323–334. Bishop, D., Epstein, N., Gilbert, R., VanderSpuy, H., Levin, S. and McClemont, S. (1984b) Training family physicians to treat families: unexpected compliance problems. Family Systems Medicine, 2: 380–386. Bishop, D., Epstein, N., Keitner, G., Miller, I. and Srinivasan, S. (1986) Stroke: morale, family functioning, health status and functional capacity. Archives of Physical Medicine and Rehabilitation, 67: 84–87. Bishop, D., Evans, R., Minden, S., McGowan, M., Marlowe, S., Andreoli, N., Trotter, J. and Williams, C. (1987) Family functioning across different chronic illness/disability groups. Archives of Physical Medicine and Rehabilitation, 68: 79–87. Bishop, D., Evans, R., Miller, I., Epstein, N., Keitner, G., Ryan, C., Weiner, D. and Johnson, B. (1997) Family Intervention: Telephone Tracking: A Treatment Manual for Acute Stroke. Providence, Rhode Island, Brown University Family Research Program. Bishop, D., Miller, I., Weiner, D. and Albro, J. (in preparation) Telephone administered family intervention following stroke. Browne, G., Arpin, K., Corey, P., Fitch, M. and Cafni, A. (1990) Individual correlates of health service utilization and the cost of poor adjustment to chronic illness. Medical Care, 28: 43–58. Byles, J., Bishop, D. and Horn, D. (1983) Evaluation of a family therapy training program. Journal of Family and Marital Therapy, 9: 299-304. Byles, J., Byrne, C., Boyle, M. and Offord, D. (1988) Ontario Child Health Study – reliability and validity of the general functioning subscale of the McMaster Family Assessment Device. Family Process, 27: 97–104. Cunningham, C., Benness, B. and Siegel, L. (1988) Family functioning, time allocation, and parental depression in the families of normal and ADDH children. Journal of Clinical Child Psychology, 17: 169–177. Dickstein, S., Seifer, R., Hayden, L., Schiller, M., Sameroff, A., Keitner, G., Miller, I., Rasmussen, S., Matzko, M. and Magee, K. (1998) Levels of family assessment II: Impact of maternal psychopathology on family functioning. Journal of Family Psychology, 12: 23–34.  2000 The Association for Family Therapy and Systemic Practice

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Joffe, R., Offord, D. and Boyle, M. (1988) Ontario Child Health Study: Suicidal behavior in youth age 12–16 years. American Journal of Psychiatry, 145: 1420–1423. Kabacoff, R., Miller, I., Bishop, D., Epstein, N. and Keitner, G. (1990) A psychometric study of the McMaster Family Assessment Device in psychiatric, medical and nonclinical samples. Journal of Family Psychology, 3: 431–439. Keitner, G., Miller, I., Epstein, N. and Bishop, D. (1986) The functioning of families in patients with major depression. International Journal of Family Therapy, 18: 203–208. Keitner, G., Miller, I., Epstein, N., Bishop, D. and Fruzzetti, A. (1987a) Family functioning and the course of major depression. Comprehensive Psychiatry, 28: 54–64. Keitner, G., Miller, I., Fruzzetti, A., Epstein, N., Bishop, D. and Norman, W. (1987b) Family functioning and suicidal behavior in psychiatric inpatients with major depression. Psychiatry, 50: 242–255. Keitner, G., Ryan, C., Miller, I., Epstein, N., Bishop, D. and Norman, W. (1990) Family functioning, social adjustment and recurrence of suicidality. Psychiatry, 53: 17–30. Keitner, G., Ryan, C., Miller, I., Kohn, R. and Epstein, N. (1991) 12-month outcome of patients with major depression and comorbid psychiatric or medical illness. American Journal of Psychiatry, 148: 345–350. Keitner, G., Ryan, C., Miller, I. and Norman, W. (1992) Recovery and major depression: factors associated with 12 month outcome. American Journal of Psychiatry, 149: 93–99. Keitner, G., Ryan, C., Miller, I., Kohn, R., Bishop, D. and Epstein, N. (1995) Role of the family in recovery and major depression. American Journal of Psychiatry, 152: 1002–1008. Kreutzer, J., Gervasio, A. and Camplair, P. (1994) Patient correlates of caregivers’ distress and family functioning after traumatic brain injury. Brain Injury, 8: 211–230. Liepman, M., Nierenberg, T. and Doolittle, R. (1989) Family functioning of male alcoholics and their female partners during periods of drinking and abstinence. Family Process, 28: 239–249. Livingston, B., Rasmussen, S., Eisen, J. and McCartney, L. (1988) Family function and treatment in OCD. In M. Jenikes (ed.) Obsessions and Compulsions (pp. 248–259). New York: Yearbook Medical Publishers. McDermut, W., Miller, I., Solomon, D., Ryan, C. and Keitner, G. (submitted) Family functioning and clinical correlates of suicidality in families of depressed suicidal and depressed nonsuicidal adults. McKay, J., Murphy, R., Rivinus, T. and Maisto, S. (1991) Family dysfunction and alcohol and drug use in adolescent psychiatric inpatients. Journal of American Academy of Child & Adolescent Psychiatry, 30: 967–972. Max, J., Robin, D., Lindren, S., Smith, D., Sato, M., Mattheis, P., Stierwalt, J. and Castillo, C. (1997) Traumatic brain injury in children and adolescents: psychiatric disorders at two years. Journal of American Academy of Child & Adolescent Psychiatry, 36: 1278–1285. Max, J., Castillo, C., Robin, D., Lindgren, S., Smith, W., Sato, Y., Mattheis, P. and Stierwalt, J. (1998) Predictors of family functioning after traumatic brain injury in children and adolescents. Journal of American Academy of Child & Adolescent Psychiatry, 37: 83–90. Maziade, M., Caperaa, P., Laplante, B. et al. (1985) Value of difficult temperament  2000 The Association for Family Therapy and Systemic Practice

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