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Improving Health through Family Interventions

Thomas L. Campbell, M.D. Professor of Family Medicine and Psychiatry University of Rochester School of Medicine & Dentistry 885 South Ave, Rochester, NY 14620 585-442-7470 x701 Tom_Campbell@urmc.rochester.edu

INTRODUCTION A large body of research has demonstrated that families have a powerful influence on physical health, including morbidity and mortality (Campbell.T.L., 1986; Campbell.T.L. & Patterson, 1995; Kiecolt-Glaser & Newton, 2001; Burman & Margolin, 1992) . Numerous epidemiologic studies have demonstrated that social support, particularly from the family, is health promoting(Berkman, 2000; Berkman, 1995). In an 1988 article in the journal Science, sociologist James House reviewed this research and concluded: The evidence regarding social relationships and health increasingly approximates the evidence in the 1964 Surgeon Generals report that established cigarette smoking as a cause or risk factor for mortality and morbidity from a range of disease. The age-adjusted relative risk ratios are stronger than the relative risks for all cause mortality reported for cigarette smoking(House, Landis, & Umberson, 1988). Family support affects the outcome of many chronic medical illnesses. Berkman and colleagues found that after suffering a myocardial infarction, women who are isolated and have few or no family or social supports have two to three times the mortality rate compared to other women(Berkman, Leo-Summers, & Horwitz, 1992). Many stresses within the family, such as loss of a spouse and divorce, significantly impact morbidity and mortality. Marriage is the family relationship which has the strongest influence on physical health. . Even after controlling for other factors, marital status affects overall mortality, mortality from specific illnesses (e.g. cancer and coronary disease) and

morbidity(Kiecolt-Glaser & Newton, 2001; Burman & Margolin, 1992).

Married

individuals are healthier than the widowed, who are in turn healthier than either divorced or never married individuals. Many large studies have shown that bereavement or death of a spouse increases mortality, especially for men (Martikainen & Valkonen, 1996; Osterweis, Solomon, & Green, 1984). Separation and divorce is also associated with increased mortality. The quality of marital relationships can influence morbidity and mortality from chronic illnesses. Coyne et al (Coyne et al., 2001) found that marital quality, measured by a composite of self report and observation of marital interaction, was predictive of survival from congestive heart failure, after controlling for the initial severity of the heart failure. Marital quality was as strong a predictor of death as the severity of heart failure itself and had a stronger effect for women than men. Dyadic negativity has been shown to worsen survival in women who have end stage renal disease and are on dialysis (Kimmel et al., 2000). Weihs (Weihs, Enright, Simmens, & Reiss, 2000)found that women with early breast cancer who do not confide in their spouses have higher recurrence rates than those who do have a confiding relationship. Marital stress has been shown to worsen coronary artery disease in women (Orth-Gomer et al., 2000). These findings suggest that loss of a spouse has the greatest health effects on men, but the impact of poor marital quality may be greater for women. Negative, critical, or hostile family relationships have a stronger influence on health than positive or supportive relationships. In terms of health, being nasty is worse than simply not being nice. Research in the mental health field with schizophrenia and depression first demonstrated that family criticism was strongly

predictive of relapse and poor outcome(Hooley, 1985; Hooley, Orley, & Teasdale, 1986; Kanter, Lamb, & Loeper, 1987; Hooley et al., 1986). Similar results have been found with smoking cessation(Mermelstein, Lichtenstein, & McIntyre, 1983), weight management(Fischmann-Havstad & Marston, 1984), diabetes(Klausner, Koenigsberg, Skolnick, & Chung, 1995; Koenigsberg, Klausner, Pelino, & Rosnick, 1993), asthma and migraine headaches. Physiological studies have shown that conflict and criticism

between family members can have negative influences on blood pressure(Ewart, Taylor, Kraemer, & Agras, 1991) and diabetes control(Minuchin, Rosman, & Baker, 1978). Although there is strong observational research demonstrating that family relationships influence physical health, there are few studies examining whether family interventions improve physical health. This chapter will review the evidence that family interventions be beneficial in the prevention or treatment of physical disorders. While it

has been clearly demonstrated that family therapy can improve the emotional health of family members and family functioning, there is much less evidence that family interventions can improve the physical health of family members. Studies, mostly

randomized controlled trials of family intervention will be reviewed using the family life cycle as an organizing theme. After reviewing studies on the prevention of chronic illness, research on the chronic illness in childhood, adult and the elderly will be reviewed. Recommendations for future research and implications for family clinicians will be presented.

FAMILY INTERVENTIONS FOR PHYSICAL DISORDERS

Many types of family interventions have been developed and tested for a wide range of physical disorders. ? more here Prevention of Chronic Disease Over one-third of all deaths in the United States can be directly attributable to unhealthy behaviors, particularly smoking, lack of exercise, poor nutrition and alcohol abuse, and are potentially preventable. These unhealthy behaviors account for much of morbidity or suffering from chronic illnesses, such as heart disease, cancer, diabetes and stroke. Health habits usually develop, are maintained and are changed within the context of the family. Unhealthy behaviors or risk factors tend to cluster within families, since family members tend to share similar diets, physical activities and use or abuse of unhealthy substances, such as smoking. The World Health Organization (World Health Organization, 1976) has characterized the family as the primary social agent in the promotion of health and well-being(p. 17) Nutrition and prevention of cardiovascular disease. Despite societal changes,

families still tend to eat together, share the same diets and consume similar amounts of salt, calories, cholesterol and saturated fats (Doherty & Campbell, 1988; Nader et al., 1983). If one family member changes his or her diet, other family members tend to make similar changes (Sexton et al., 1987). However, most dietary interventions are directed at individuals with little or no attention to the rest of the family. Family intervention can change diet and promote a healthier lifestyle, but family interventions have not been compared to an individual interventions. In the British

Family Heart Study over 12,000 middle aged couples from 26 general received familybased counseling by a trained nurse about healthy lifestyles and cardiac risk reduction(Graham, Senior, Dukes, & Lazarus, 1993). At one-year follow-up, the the couples receiving the intervention had reduced their smoking, blood pressure and cholesterol level and had a 16% reduction in their overall cardiac risk score. Other studies have found similar results with small, but significant improvements in healthy behaviors (Knutsen & Knutsen, 1991; Perry et al., 1989). Weight reduction Over 30% of the population is considered obese (more than 20% over ideal body weight) which contributes to numerous chronic illnesses, including diabetes, hypertension, coronary heart disease and arthritis. Obesity is a major public health problem Overeating and obesity can play important homeostatic roles in families. The parents of obese children are less likely to encourage exercise and more likely to encourage their children to eat than other parents(Hanson, Klesges, Eck, & Cigrang, 1990; Waxman & Stunkard, 1980). The family plays an important role in both the development and the treatment of eating disorders such as anorexia nervosa and bulimia (Campbell & Patterson, 1995). In obesity treatment programs, spousal support predicts successful weight loss (Streja, Boyko, & Rabkin, 1982) and spousal criticism or high expressed emotion is associated with little or no weight loss (Fischmann-Havstad et al., 1984). There are ten randomized controlled trials of spouse or partner involvement in weight reduction programs (Black, Gleser, & Kooyers, 1990a). The interventions are based upon individual cognitive behavioral approaches in which a spouse is viewed as reinforcing

desired behaviors. Spouses attend all the sessions and are instructed in basic behavior modification techniques, especially giving positive reinforcement and avoiding criticism. The results of the couple interventions were mixed. In approximately one half of the studies, the intervention groups were able to maintain the weight loss for up to 3 years. A meta-analysis of these studies (Black, Gleser, & Kooyers, 1990) concluded that couples interventions had a small, but significant, improvement in weight loss at the end of the program, which persisted for 2 to 3 months, but was no longer apparent at lengthier (1-3 years) follow-up. When supportive behaviors were measured in these studies, there was little or no increase in these behaviors. Obese subjects who reported higher satisfaction with their marriage lost more weight (Dubbert & Wilson, 1984). In one study, the greatest weight loss occurred in the group where the spouses were asked not to nag, criticize or otherwise participate in their partners efforts at weight reduction. These studies suggest that blocking partner criticism and addressing marital conflict and dissatisfaction may be more important than trying to increase supportive behaviors. Childhood obesity is a growing problem, but family interventions for this problem are more encouraging. Parental involvement in weight reduction programs for children results in greater weight loss for both the child and the parent, with a high correlation between the parents and childs weight loss (Epstein, Wing, Koeske, Andrasik, & Ossip, 1981). One program for obese adolescents found the best results when the adolescent and the parent received their own separate training, thus respecting the adolescents growing independence (Brownell, Kelman, & Stunkard, 1983).

Cigarette smoking. Smoking causes over 350,000 deaths per year, mostly from heart disease and cancer and remains the number one public health problem in the US. Smoking is strongly influenced by the family. Adolescents are five times more likely to start smoking if a parent or older sibling smokes (Bewley & Bland, 1977). Smokers tend to marry other smoker, to smoke the same number of cigarettes as their spouse and to quit at the same time (Venters et al., 1984). Smokers married to non or ex-smokers are more likely to quit and remain abstinent. Support from the smokers partner or spouse is highly predictive of successful smoking cessation. Specific supportive behaviors such as providing encouragement and positive reinforcement predict successful quitting, while negative behaviors such as nagging or criticism predict failure to quit or relapse (Coppotelli et al., 1985; Mermelstein, 1986). The Agency for Healthcare Quality and Research (AHRQ) recommends family and social support interventions as components of effective smoking cessation (Fiore, 2000) Nine randomized controlled trials involving over 1700 subjects have examined the impact of partner support in smoking cessation, (Park, Schultz, Tudiver, Campbell, & Becker, 2002). These studies add a social support intervention to a traditional smoking cessation program which include nicotine replacement, behavioral therapy and relapse prevention. The partner, usually the spouse, is given suggestions and feedback on helpful and unhelpful behaviors for smoking cessation . The results of these studies have been mixed and a meta-analysis found no overall impact of partner support on smoking cessation(Park et al., 2002). In most of these studies, the amount of partner support reported by the smokers continued to predict successful smoking cessation, but few of the interventions had any impact on the level of

partner support. These results suggest that partner support is important for smoking cessation, but that it is difficult to increase levels of support. The inability of these interventions to improve partner support or smoking cessation may result from an overly simplistic and nonsystemic view of marriage. As marital therapists know, ts. These behaviors are part of a complex marital relationship and are affected by the history and quality of the marital relationship. asking partners or spouses to be more supportive or less critical only occasionally has its desired effect Unfortunately, none of these studies assessed the quality of the marriage. It may be easier to increase supportive behaviors in couples that have higher levels of marital satisfaction. A more in-depth qualitative study of what happens to these couples when they participate in these smoking cessation programs would be very helpful to better understand the relationship between smoking behaviors and marital dynamics.

CHRONIC DISEASE THROUGH THE LIFECYCLE Pediatric Chronic Illnesses The course and outcome of most childhood illnesses are strongly influenced by both family structure and function. Parents are responsible for the treatment of the most pediatric illnesses. Many family variables are associated with health outcomes across a broad range of chronic illnesses. For example, healthy family functioning is strongly correlated with improved control of diabetes, while family conflict, parental indifference, and low cohesion have all been associated with poor metabolic control in diabetes (Anderson & Kornblum, 1984; Gustafsson, Kjellman, & Cederblad, 1986). In a comprehensive literature review, Patterson (Patterson, 1991) identified nine aspects of

family process which have been consistently associated with good outcomes in children with chronic illness and disabilities: 1) balancing the illness with other family needs, 2) maintaining clear boundaries, 3) developing communication competence, 4) attributing positive meaning to the situation, 5) maintaining family flexibility; 6) maintaining family cohesiveness, 7) engaging active coping efforts, 8) maintaining social supports and 9) developing collaborative relationships with professionals. Many of these attributes have been targeted by family interventions for pediatric illnesses. Psychosomatic Families Salvador Minuchin, one of the founders of family therapy, developed an early and well known family interventions in childhood chronic illness. In a series of studies, he and his colleagues at the Philadelphia Child Guidance Clinic (Minuchin et al., 1975; Minuchin et al., 1978) studied poorly controlled diabetic children and their families. These children had recurrent episodes of diabetic ketoacidosis, but when hospitalized, the diabetes was easily managed. Stress and emotional arousal within the family seem to directly affect the child's blood sugar. Minuchin described a specific pattern of interaction in these psychosomatic families, characterized by enmeshment (high cohesion), overprotectiveness, rigidity and conflict avoidance. Minuchin (Minuchin et al., 1975) studied the physiologic responses of these diabetic children to a stressful family interview to determine how these family patterns can affect diabetes,. During the family interview, the children from psychosomatic families had a rapid rise in free fatty acids (FFA), a precursor to diabetic ketoacidosis,. . Minuchin hypothesized that in psychosomatic families, parental conflict is detoured or defused through the chronically ill child, and the resulting stress leads to exacerbation of

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the illness. Minuchin was the first investigator to demonstrate a link between family and physiologic processes. Minuchin and his colleagues (Minuchin et al., 1978) successfully treated psychosomatic families using structural family therapy to help disengage the diabetic child and establish more appropriate family boundaries. In 15 cases, the pattern of recurrent ketoacidosis ceased and insulin doses were reduced. However, these early case reports lacked any standardized outcome measures or control groups. In addition, the psychosomatic family model has been criticized as blaming families for the childs illness and lacking empirical validation. (Coyne & Anderson, 1989). Wood (Wood et al., 1989) proposed a more systemic and comprehensive biobehavioral model of childhood chronic illness. Insulin Dependent Diabetes Mellitus. Several different types of family interventions have been studied in childhood (Type 1 insulin dependent) diabetes. Family education and support groups (Anderson, Wolf, Burkhart, Cornell, & Bacon, 1989; Dougherty, Schiffrin, White, Soderstrom, & Sufrategui, 1999; McNabb, Quinn, Murphy, Thorp, & Cook, 1994; Wing, Marcus, Epstein, & Jawad, 1991) and more intensive psychoeducational programs that address collaborative problem solving and problematic family interactions (Galatzer, Amir, Gil, Karp, & Laron, 1982; Wing et al., 1991) have been studied. Mendenhall identified twelve RCTs of family interventions for IDDM, ten of which used hemoglobin A1C (HBA1C) as an outcome measure, an excellent measure of chronic blood sugar control, (Mendenhall, 1 A.D.). Seven of ten studies demonstrated a significant improvement in diabetic control with a family intervention. Blood sugar control worsened in two studies. . These interventions were

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effective in improving diabetic control, but it is unclear which interventions were more effective. These studies have also looked at the impact of the family interventions on other diabetes related outcomes, including the patients emotional health and adherence to diabetic treatment programs. Most of these programs have increased overall self care and specific aspects of diabetes care, such as adherence with diet, exercise, blood sugar testing and insulin. They have also reduced patients levels of distress and denial of the illness and increased self-esteem, perceived quality of life, and acceptance of the illness. It is not possible to determine which of these psychosocial improvements (diabetesrelated behaviors or emotional health) contributed more to better blood sugar control. This is an important issue for future research. Asthma. Asthma has been strongly associated with psychosocial distress, depression, and disturbed family relationships (Liebman, Minuchin, & Baker, 1974). The only randomized controlled trials of family therapy for a childhood illness have been conducted for severe childhood asthma. Two studies involved a total of 55 children with moderately severe asthma and were based on structural family therapy models. Strengthening of boundaries between generations and addressing hidden conflicts were used to alter dysfunctional patterns of interaction. Both interventions improved asthma symptoms, clinical evaluation and a number of measures of lung function (although they differed in the two studies). A recent Cochrane review (considered by many to be the gold standard of evidence based medicine) of these studies concluded that There is some indication that family therapy may be a useful adjunct to medication for children with asthma.(Panton & Barley, 2002).

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Numerous family psychoeducational programs have been designed and tested for improving treatment of childhood asthma. In a review of this research, Benard-Bonnin (Bernard-Bonnin, Stachenko, Bonin, Charette, & Rousseau, 1995) identified 11 well designed randomized controlled trials of family psychoeducation for asthma. In their meta-analysis, they found a significant improvement in several measures of asthma severity. Although the overall effect sizes were small (<.2), the results of these interventions were significantly better when limited to children with more severe asthma. This is an obvious issue that is worth highlighting across all disorders. Family interventions are more likely to improve health outcomes with more severe illness. Patients with mild disease are unlikely to need or benefit from family interventions. . Cystic fibrosis. Cystic fibrosis (CF) is a lethal, genetic disorder in which children are missing a key enzyme in the lungs resulting in progressive deterioration in lung function over several decades and eventual death. Complex treatment programs involving frequent chest physical therapy (cupping and drainage), aggressive treatment of infections with antibiotics and use of synthetic enzymes have dramatically improved the survival of these children and young adults. Yet these treatments are very demanding upon families. Patterson demonstrated that family variables predict the rate of decline of pulmonary function over a 10 year period(Patterson, Budd, Goetz, & Warwick, 1993). Bartholomew and colleagues developed separate psychoeducational groups for children and adolescents with CF and their parents (Bartholomew & Schneiderman, 1982). In a randomized controlled trial, they found that the children and adolescents in the families that received the intervention reported improved knowledge, self-efficacy, self management of the illness and overall health status. This study suggests that family

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psychoeducation may actually be able to extend the lives of those who suffer from this disorder. Congenital Heart Disease. Two studies have examine the impact of family interventions to reduce the psychological morbidity associated with cardiac surgery for congenital heart disease (Campbell, Kirkpatrick, Berry, & Lamberti, 1995; Campbell et al., 1986). Both interventions provided separate informational and skills training separately to the child and one parent before cardiac surgery. The children in the intervention group were better adjusted at home and had higher functioning at school after the procedure. There were no differences in the parents reports of anxiety, but the parents in the intervention group felt more competent in caring for their child. These family interventions for childhood illnesses clearly demonstrate health benefits for asthma, diabetes and cystic fibrosis and show promise for reducing the psychosocial morbidity associated with cancer and cardiac surgery. They need to be applied across a wider range of pediatric illnesses. Childhood cancer. In childhood cancer, a few studies have used family interventions to reduce the psychological morbidity associated with diagnosis and treatment. Two interventions designed to improve parental coping with the stress of the illness failed to show any significant decrease in parental distress (Hoekstra-Weebers, Heuvel, Jaspers, Kamps, & Klip, 1998; Jay & Elliott, 799). Working with children with leukemia and their families, Kazak and her colleagues were able to reduce the childs distress related to painful procedure using a cognitive-behavioral, family-oriented intervention (Kazak et al., 1996). In another study, Kazak and colleagues piloted a multi-family group intervention for survivors of childhood cancer to reduce the post-

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traumatic stress symptoms related to the diagnosis and treatment of the cancer. In a prepost test design, they were able to show a decrease in posttraumatic stress and anxiety in the survivors and their family members (Kazak, 1989). Adult Chronic Diseases Although there is a large body of research on the impact of marriage on chronic illness and overall health, there are relative few family or marital intervention studies in adult physical illness. Most of the research in this area has focused on the role of the spouse as the primary caregiver. There are no randomized controlled trials for marital or family therapy for adult illnesses. Gonzales, Steinglass and Reiss developed an innovative multifamily psychoeducational group intervention for families with chronic medical illnesses. Based upon their clinical work, they found that in many of these families the chronic illness tended to dominate family life and take over the familys identity. The goal of these groups is to help families balance the needs of the illness with the needs of the family by putting the illness in its appropriate place in family life (Gonzalez, Steinglass, & Reiss, 1989). It is currently being studied as an intervention with a wide range of illnesses, including HIV/AIDS, adult cancer and end stage renal disease. Non-insulin Dependant Diabetes Non-insulin dependent diabetes (NIDDM or Type 2) afflicts over 15 million adults in the US and is ten times more common than insulin dependent diabetes, a disease of children and young adults. Most patients with NIDDM are overweight, and the major challenge for these patients is adherence with recommended diet, exercise, medication and blood sugar monitoring. Only two studies have examined the impact of a couples intervention on diabetes outcomes. Gilden

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(Gilden, Hendryx, Casia, & Singh, 1989) included the wives of elderly diabetic patients in a 6 week diabetes education program. Patients with participating spouses showed greater improvement in knowledge, increase in family involvement and more improvement in diabetic control than those without spouse involvement. Wing and colleagues enrolled obese diabetic patients and their obese spouses in a behavioral weight reduction program(Wing et al., 1991). Patients and their spouses were randomly assigned to an individual or couples program. At one year followup, there was no difference in overall weight loss in the two groups, but the women lost more weight in the couples groups and the men lost more weight when treated alone. There was no report of changes in blood sugar control. This study emphasizes the importance of examining gender effects in couples intervention. Marital interactions and interventions are likely to have very different effects on women than men. . Cardiac Rehabilitation Although there is evidence that families have a

powerful influence on recovery and survival after a myocardial infarction, there are very few family interventions in cardiac rehabilitation. Spouses of heart attack patients have high levels of depression, anxiety and guilt, and experience similar levels of overall distress as the patients (Bedsworth & Molen, 1982). Many male cardiac patients feel overprotected by their wives (Fiske, Coyne, & Smith, 1991). Emotional support provided by a family member (usually spouse) or confident is a very strong predictor of survival after a myocardial infarction, stronger than any of the usually physiologic measures. For example, in the three months after a heart attack, elderly women who lack a confidant are three times more likely to die than women who have a confidant (Berkman et al., 1992)

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Several studies have examined the impact of spouse involvement in cardiac rehabilitation on psychosocial outcomes. In one ingenious controlled study, wives of heart attack patients walked on the treadmill at the same workload as their husbands, 3 weeks after their husbands heart attack(Taylor, Bandura, Ewart, Miller, & DeBusk, 1985). These wives were much more confident and less anxious about their husbands health and capability, than wives in the control group who merely observed their husbands tests. When these women actually experienced what their husband were capable of doing, they were less overprotective and the husbands had improved cardiac functioning 11 and 26 weeks after the heart attack. Of the three studies that included couple counseling as part of cardiac rehabilitation (Dracup, Meleis, Baker, & Edlefsen, 1984; Thompson & Meddis, 1990; Gilliss, Neuhaus, & Hauck, 1990), only one was able to show any improvement in the spouses emotional health (Dracup et al., 1984). Patient outcomes were not examined. Although observational research suggests that spouses play an important role in recovery from heart attacks, few couple or family interventions have been tested, and those that have, report mixed results. Hypertension. Adherence with hypertension treatment remains a major public health problem. Less than one half of adults with elevated blood pressure are taking their medication as directed. Medication compliance has been shown to be significantly correlated with marital satisfaction in married hypertensive patients (Trevino, Young, Groff, & Jono, 1990). In experimental studies, blood pressure reactivity has been linked to marital interaction and conflict. (Gottman, 1994). Ewart and colleagues taught communication skills to 20 hypertensive patients and their spouses

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to help them reduce conflict and emotional and blood pressure reactivity during arguments(Ewart, Taylor, Kraemer, & Agras, 1984). These couples showed less hostility, fewer combative behaviors and a significant reduction in systolic blood pressure. Two randomized controlled trials have examined the impact of a family intervention on adherence to hypertension treatment. Morisky and colleagues compared three psychoeducation interventions (brief individual counseling, counseling the spouse during a home visit and patient support group) to improve blood pressure treatment in an inner city population (Morisky et al., 1983). The family intervention was included after a patient survey indicated that 70% of the hypertensive patients at the clinic wished that their spouse or other family members knew more about their illness and were more involved. Educating and counseling the spouse improved treatment adherence and

lowered both blood pressure and overall mortality. Overall the experimental groups had a 57% reduction in mortality, and the family intervention seemed to have the greatest effect. A similar study (Earp, Ory, & Strogatz, 1982) failed to demonstrate any benefits from involving a family member during a home visit, but the followup may not have been long enough to detect a difference

Chronic Diseases in the Elderly In no other area of health has the family received as much attention as family caregiving of persons with chronic disabling conditions. With the aging of the

population, the rising incidence of degenerative and disabling conditions in the elderly and fewer resources for professional caregiving, a growing percentage of older

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individuals must rely on family members for care. For example, it is estimate that over 40% of the elderly over the age of 85 have some form of dementia and one half of those individuals are cared for by family members in their own communities (Biegel, Sales, & Schulz, 1991). Research has demonstrated that caregiving exerts a heavy toll on family members. Family caregivers have much higher morbidity and mortality than age matched controls. One study (Schulz & Beach, 1999) found that caregivers over 65 who were experiencing emotional strain were 63% more likely to die than age matched noncaregivers over a 4 year period. Caregivers suffer higher rates of multiple physical illnesses, depression and anxiety. The incidence of depression among caregivers of persons with dementia has been estimated to between 40-50% (Gallagher, Rose, Rivera, Lovett, & Thompson, 1989). They often restrict their social activities and reduce their time at work. The financial impact of caregiving on families can be enormous, both in terms of decreased wages of caregivers and the cost of providing equipment and services in the home for the patient. Family caregivers are essential members of the health care team. They provide clinical observation, direct care, case management, and a range of other services. In chronic illnesses, such as Alzheimer's Disease, these caregivers may devote years of their own lives to caring for a loved one. Unfortunately, our current health care system offers little in the way of institutional support for families who are burdened with caregiving. Managed care has shifted many of the burdens of caregiving from professionals in the hospital and other institutions to family members at home without

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providing adequate support. As hospital stays have shortened, elderly patients are being discharged home sicker and with more health care needs than in the past A number of effective interventions for the caregivers of patients with dementia have been developed and tested, including psychoeducational and family counseling interventions and family support/ education groups. No controlled trials of family therapy for family caregivers could be found. Family support groups for caregivers of patients with Alzheimer Disease have become quite common and are promoted by advocacy groups. These are usually open ended groups which are professionally or peer led and provide information and emotional support to families. Studies of these groups suggest that participants learn new information and report high levels of satisfaction, but the impact on the caregivers emotional distress and sense of burden is inconsistent (Orleans, George, Houpt, & Brodie, 1985; Haley, Brown, & Levine, 1987; Kahan, Kemp, Staples, & Brummel-Smith, 1985). Family psychoeducational programs provide more intensive skills training to help family caregivers manage many of the common problems presented by elders with dementia (Chiverton & Caine, 1989; Goodman & Pynoos, 1990; Gallagher et al., 1989; Toseland et al., 2001; Toseland, Labrecque, Goebel, & Whitney, 1992; Mittelman, Ferris, Shulman, Steinberg, & Levin, 1996) (Marriott, Donaldson, Tarrier, & Burns, 2000). These interventions usually include weekly group sessions led by a trained professional and typically last for 8 to 10 weeks. In randomized controlled trials, they have consistently reduced depressive symptoms, emotional distress and the sense of burden of family caregivers.

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An excellent example of an effective, family psychoeducational intervention for family caregivers of Alzheimer Disease (AD) patients has been developed by Mittelman and tested in a randomized controlled trial(Mittelman et al., 1996). These families attended individual and group instructional and problem-solving sessions where they learned how to manage many of the troublesome behaviors of patients with AD. They also attended an ongoing family support group and could access a crisis intervention service to help them with urgent problems. In Mittelmans study, the caregivers who received the intervention were less depressed and physically healthier than those that did not, and AD patients were able to remain at home for almost a year longer than in the control group. The savings in nursing home costs were several times the cost of the interventions. Similar types of family support should be a part of the treatment of all patients and families with Alzheimer Disease and other dementias. Sorensen and colleagues (Sorensen, Pinquart, & Duberstein, 2002) recently conducted a meta-analysis of 78 caregiver intervention studies representing six different types of interventions for different illnesses. They found a significant improvement (0.14-0.41 standard deviation units) across all six outcome variables (caregiver burden, depression, subjective well-being, perceived caregiver satisfaction, ability/knowledge and patient symptoms. The effects were the smallest for caregivers of dementia patients and most consistent with the psychoeducational interventions. Caregiver ability/knowledge improved more than subjective burden and depression. Group interventions had smaller improvements than individual interventions. These studies of family interventions for family caregivers suggest that providing education and support for family caregivers is necessary, but not sufficient to

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reduce their burden and improve their emotional health. Family caregivers need more intensive interventions that include skills training and assistance with problem solving. Similar results have been found in the few interventions for patients who have suffered a stroke and their families (Evans, Matlock, Bishop, Stranahan, & Pederson, 1988). Family psychoeducational programs for family caregivers are effective in improving both the physical and emotional health of the caregiver and can be cost-effective. These programs have many similarities with psychoeducational programs that have been developed and tested for schizophrenia and can be used as models for family interventions for other physical disorders.

FUTURE DIRECTIONS FOR RESEARCH

Much more research on family interventions for physical disorders needs to be done. This area of research is still in its infancy, at the stage where research on families

and schizophrenia was 30 years ago. This creates many opportunities for new family researchers to become involved in this exciting area of research. Very few of the family interventions for physical disorders have been designed by family researchers or based on family science. Medical and nursing researchers have been the principal investigators in most of these studies. Rarely is a particular family characteristic or variable targeted by the intervention, and pre or post family assessment is usually absent. There are very few trials of family therapy for any physical disorders.

Family researchers and therapists need to become involved in research on families and health and help design and implement family interventions for physical disorders. in this area.

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Although there is a large body of observational research on families and health, more observational studies are needed. Few family variables have been shown to be predictive of health outcomes, and the strength of this evidence is not strong. The most promising recent research has focused on the role of family criticism, family conflict and expressed emotion and its impact on physical health. Family and health research needs to be based upon family theories and family science. Most existing studies are atheoretical. Intervention strategies should be guided by theoretical models that hypothesize relationships between family and health variables and then measure these family variables before and after the intervention. For example, studies of spouse involvement in smoking cessation and weight loss should measure marital satisfaction or quality as well as helpful and harmful behaviors before and after the interventions. Pre-intervention family assessment will also allow researchers to determine in which families the intervention is most effective. Nearly all existing family intervention studies target a single disease with little evidence that the results are generalizable to other disease. Family interventions should be developed and targeted across several chronic diseases that have commonalities. Interventions that have been shown to be effective for one disease (such as family psychoeducation for caregivers of AD patients) should be tested with other similar disease (such as stroke or Parkinsons Disease). Intervention studies should measure multiple outcomes across several levels, including patient physical and emotional health, family members physical and emotional health, family functioning, marital satisfaction or quality, and health care and overall costs. Many of the benefits of a family intervention may not be captured by traditional

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measures. For example, a family intervention may improve the health of other family members and reduce their use of health care services. Family interventions should be adaptable to meet specific needs and characteristics of individual families. For example, families in which there is significant conflict, disengagement or dissatisfaction will need a different and more intensive approach than more functional families. More attention needs to be paid to the cost of family interventions and the potential financial benefits of the intervention for the patient and other family members. The family interventions need to be described in more detail, so that they can be replicated and to determine what the most effective ingredients of the intervention are. This will help researchers determine why one intervention is effective and not another. These interventions need to play close attention to gender effects. As noted earlier, marriage has very different effects on the physical health of men and women(KiecoltGlaser et al., 2001). Because marriage is often the primary source of social support for men, the presence or absence of a wife has the greatest impact on health, where womens health is most influenced by the quality of the relationship. Couple interventions are therefore likely to have very different effects on men and womens health. Only one intervention study has examined gender effects and found that women had better outcomes (weight loss) in couples treatment and men did better alone. Finally, family intervention studies need to include more diversity. Most of current studies are conducted with white middle class families. Future studies should include different family types (e.g. single parent families, gay families) and families from different racial, ethnic and socioeconomic background.

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CONCLUSIONS
This review documents that there are effective family interventions for some physical disorders and promising ones for others. No family interventions have been developed or tested for many chronic physical illnesses. The most commonly studied and effective type of family intervention is family psychoeducation. It has wide appeal and applicability to numerous disorders. It appears to be more effective than programs that only provide family support or education. Families need more intensive assistance

with specific problem solving and coping skills. Whether group family psychoeducation is more effective than individual family psychoeducation for physical disorders is not known and needs study. There are too few studies of family therapy for physical disorders to comment on its effectiveness, although family therapy is likely to be directed to a much more limited group of dysfunctional families. The most effective family interventions have been in the treatment of family caregivers of dementia patients. Not only did these family interventions improve the physical and mental health of the caregivers, but were very cost effective. Mittelmans comprehensive intervention for family caregivers should be adapted to other chronic disorders(Mittelman et al., 1996). Family interventions for childhood disorders, especially diabetes and asthma, are effective in improving medical (e.g. HBA1C levels and pulmonary function), as well as psychosocial outcomes. Not surprisingly, family interventions are most effective at each end of the life cycle when much of the care is provided by family caregivers. There is insufficient research on family interventions for adult illness to make any firm conclusions. Although enhancing family support for adherence to chronic medical

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treatments appears to have a powerful effect on health outcomes (Morisky et al., 1983), more research is needed to verify this. Studies of spouse involvement in cardiac rehabilitation have demonstrated little effect. Family involvement for health promotion and disease prevention programs offers great promise. Family-centered nutrition and cardiovascular risk reduction programs are effective in improving the health of multiple members, but have not been directly compared with individually oriented programs. Family based programs for obesity in children are clearly more effective than individual programs, but their effectiveness for adults is unclear. Partner or spouse involvement for smoking cessation has been shown to be ineffective.

This research suggests that marriage and family therapists have an important, but unmet role in the treatment of physical illness. Family therapists should be a part of most health care teams, offering a family and systemic perspective that is so often missing. Much has been written about family therapist working in primary care settings, helping family physicians, pediatricians and primary care internists care for patients and their families. There are also opportunities for working with medical specialties, especially rehabilitation medicine, reproductive health, oncology, cardiac rehabilitation and geriatrics(Seaburn, Lorenz, Gunn, & Gawinski, 1996). Family therapy training programs need to provide the knowledge and skills for all new family therapists to work in medical settings and with families with health problems. These programs should offer courses on medical family therapy, collaboration with medical providers, and psychopharmacology. Family therapy trainees should be

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provided with opportunities to work in medical settings under supervision during graduate school and internship. Overall one can conclude that there is some evidence that family interventions can improve health outcomes in physical disorders. There is a need for more observational and intervention research on families and health, and family researchers and clinicians need to become more involved in this area of research. Only by better understanding how families can be used as a resource in medical care will our health care system become more family-oriented and higher quality.

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