The main purpose of this study is to evaluate the importance of family systems interventions in the treatment of depression. Biomedical treatment which focuses on system resolution is the most commonly applicable model for assessing and treatment of depression. The Biomedical treatments of depression include pharmacotherapy and psychological treatment ( Carr, 2014 ). In spite of the efficacy of contemporary psychiatric treatment, a significant portion of patients with depression are irresponsive to such treatments and continue experiencing problematic residual symptoms ( Butler et al., 2015 ). A case study on the outpatients with mild-to-moderate depression showed that the remission rates were 46% for psychotherapy, 46% for medication, and 24% for control conditions, meaning approximately 50% of patients are left with some degree of persistent symptoms ( Becvar & Becvar, 2017 ). Therefore, it is essential to resort to other forms of depression treatment and management to improve the general results of treatment. For instance, a biopsychological model which mainly focuses on the social environment in which the depressive episode evolves can be an effective way to approach the management of depression ( Carr, 2014 ). It is necessary to pay attention to the insufficient effectiveness of biomedical treatment among other reasons when dealing with depression ( Butler et al., 2015 ).
Over 50% of patients with chronic depression are normally associated with distressing and problematic family functioning ( Butler et al., 2015 ). Like patients, families of patients with major depression also experience the same levels of family dysfunction ( Butler et al., 2015 ). Depression is associated with the changes in the social environment as well as the level of social support ( Becvar & Becvar, 2017 ). For instance, one of the most regularly reported incident leading to depression is marital arguments ( Mistik, Unalan & Tokgoz, 2017 ). The lack of support by a partner, or the inability to confide in a spouse can lead to depression ( Carr, 2014 ). Families with one individual with depression or couples with one depressed partner experience the lowest level of family/marital cohesion ( Butler et al., 2015 ). A study on individuals with depression and their partners reveals that majority experience negativity, hostility, mistrusting, and detachment ( Butler et al., 2015 ). Depressed patients usually exert aversive control over their partners’ behaviors ( Mistik et al., 2017 ). Family/ marital/ social conflicts increase the risk of depression which causes family stresses and burdens ( Carr, 2014 ).
Delegate your assignment to our experts and they will do the rest.
During the acute phase of a depressive episode, marital/family dysfunction is very common, always associated with difficulties in most family domains ( Butler et al., 2015 ). Some of the areas affected during this phase include role functioning, communication, and problem-solving ( Becvar & Becvar, 2017 ). The family burden increases significantly as a result of financial worries, fears of recurrence, loss of status, social isolation, and chronic tension ( Mistik et al., 2017 ). Family dysfunction during this phase of depression not only affects family distress but also has a great impact on the general depression management ( Butler et al., 2015 ). Patients who experience family/ marital distress respond slowly to depression treatment. Thus, family dysfunction has a negative effect on the short- and long-term recovery from depression ( Mistik et al., 2017 ). However, patients who are able to improve their family functioning may recover from depression quicker than those with family problems ( Mistik et al., 2017 ).
Family functioning is also associated with a higher likelihood of relapse or recovery ( Butler et al., 2015 ). For example, family criticism towards the depressed patient or marital distress is strongly associated with the relapse. The way the patient’s family or spouse respond to and deal with depression is essential in managing and recovery from depression ( Becvar & Becvar, 2017 ). When a depressive illness is responded to effectively at its onset, it can be brief, and the patient might take a short time recovering. However, if the family does not respond effectively to the depressive illness, it might a long time to recover since the chances of recovering are low, and there is a high possibility the patient will relapse into subsequent episodes ( Thoburn & Sexton, 2015 ). Pharmacotherapy and psychotherapy treatments may be effective when dealing with genetic vulnerability, current life stresses, and early life experiences, while family intervention is essential in increasing the family’s responsibility in responding to illness ( Butler et al., 2015 ).
Family Systems Theory and Models of Intervention and Treatment
The family systems theory or the Bowen Family Systems Theory was developed by Murray Bowen who was a pioneer of family psychotherapy ( Becvar & Becvar, 2017 ). Bowen worked at Menninger Clinic, Kansas between 1946 and 1954 where he studied the relationship between patients with schizophrenia and their mothers ( Smith, Hill & Kokanovic, 2015 ). He continued his research study in the National Institute of Mental Health between 1954 and 1959 where the whole family stayed in the ward with patients ( Smith et al., 2015 ). It is the study of these families and their relationship pattern that led to the development of family theory ( Smith et al., 2015 ). After concluding his study at NIMH, Bowen continued developing his theoretical concepts and refining the theory at Georgetown University ( Becvar & Becvar, 2017 ).
There are eight interlocking concepts of family systems theory including differentiation of self, the family project process, an emotional triangle, the multigenerational transmission process, sibling position, the emotional cutoff, the nuclear family emotional process and the societal process ( Smith et al., 2015 ). The core concept of Bowen’s theory is the differentiation of self which is the ability of an individual to cope with changes, respond to anxiety, and separate thoughts from goals while pursuing personal goals ( Butler et al., 2015 ). People with high level of differentiation are better at maintaining individuality as well as emotional contact with the group at the same time while individuals with low level of differentiation feel what the group feels and usually, experience emotional fusion ( Smith et al., 2015 ). An emotional triangle is the network of human relationship ( Becvar & Becvar, 2017 ). For instance, a two-person dyad may exist but eventually destabilize when anxiety is introduced. However, a three-person system offers more resources for management and reduction of anxiety ( Carr, 2014 ).
The family projection process involves transferring of parent’s anxiety, relationship problems, and emotional issues to the child within the emotional triangle, a process which may lead to the development of emotional concerns and other issues in the child ( Smith et al., 2015 ). The multigenerational transmission process entails individuals seeking out spouses with a same level of differentiation which potentially leading to certain traits being passed on through generations ( Smith et al., 2015 ). For example, when both partners have high levels of differentiation, there is a chance that their children will also have higher levels of differentiation ( Becvar & Becvar, 2017 ).
An emotional cutoff is an incidence whereby an individual deals with emotional issues or other difficulties within the family system by cutting emotional connections from other members of the family ( Smith et al., 2015 ). Sibling position is the habit of oldest, middle, or youngest children to adopt certain roles within the family as a result of the difference in expectation and other factors ( Butler et al., 2015 ). For instance, oldest siblings normally act like miniature adults within the family setting. The societal emotional process shows how the factors influencing the emotional system of the family also impact the emotional system of the society ( Becvar & Becvar, 2017 ). The nuclear family emotional process elaborates Bowen’s belief that the nuclear family normally counters issues in emotional distance, intimate partner conflict, impaired functionality in children, and problematic concerns in one partner ( Smith et al., 2015 ).
Family Systems Therapy Approaches
Most forms of family therapy follow Bowen’s family systems theory. The family systems therapy approaches are mainly classified under strategic, structural, or intergenerational ( Thoburn & Sexton, 2015 ). Structural family therapy focuses on family behaviors, relationships, and patterns as they are demonstrated during the therapy session to assess the structure of the family ( Butler et al., 2015 ). Therapists also evaluate subsystems within the family structure through the employment of activities such as role play during the therapy session ( Thoburn & Sexton, 2015 ). Strategic family therapy involves assessment of family processes and functions like problem-solving patterns or communication through examination of family behavior outside the session ( Becvar & Becvar, 2017 ). The therapist can utilize therapeutic methodologies such as using paradoxical interventions or reframing problem scenario to make the desired change. Intergenerational family therapy takes into account the generational impact on family and individual behavior ( Carr, 2014 ). Determining multigenerational behavioral patterns like anxiety management is essential in enabling individuals to see how their current issues/ concerns may be rooted in the previous generations ( Butler et al., 2015 ).
Application of Bowen’s Theory in Family Therapy
Bowen’s therapy techniques are widely applicable by nurse practitioners during family therapy sessions ( Butler et al., 2015 ). Family systems therapy starts with a family assessment of their emotional processes, tensions, closeness, triangles, and distance which remain unresolved form the family origin ( Butler et al., 2015 ). Bowen’s family systems therapy helps family members to attain differentiation of self to avoid blaming and emotional reactivity. Therapists’ main role in this process is to connect with family and trigger families to be active in the healing process, as well as prevent being drawn into a triangle ( Carr, 2014 ). Therapists should stay neutral and objective during the session to avoid being bias towards one side of the family ( Becvar & Becvar, 2017 ). According to Bowen, the role of the therapist is to coordinate family conversations during therapy sessions and assist family members in accepting individual responsibilities for a change ( Thoburn & Sexton, 2015 ).
The key objective of Bowen’s theory is to facilitate the dissolution of the dysfunction triangling process by assisting the individuals to be aware of the emotional process they are applying as well as encouraging examination of these behaviors ( Butler et al., 2015 ). Bowen also encourages dialogue during the session which enables family members to make suggestions regarding future activities and changes to the current behaviors ( Thoburn & Sexton, 2015 ).
Issues of Gender, Diversity and Sociocultural Aspects of Family Therapy
Bowen’s Family Systems Theory has been a successful systematic perspective since its earliest development in the field of family science guiding research and practices. ( Butler et al., 2015 ) The theory was implemented successfully due to the empirical support for its key concepts and premises ( Thoburn & Sexton, 2015 ). Despite its success, Bowen’s theory was no exception to criticism, especially from the feminists and multicultural activists. Several theorists have questioned the inclusivity of the family therapy theory concerning ethnicity and race, gender, and culture ( Carr, 2014 ). Bowen’s theory is specific to a given race/ethnic group/ gender in the interpretation of family life cycle across generations ( Thoburn & Sexton, 2015 ). For instance, Bowen’s theory specifically refers to American families in the United States. There is little evidence proving that the concepts of Bowen’s theory are examined in a cross-cultural way ( Carr, 2014 ). Most of the empirical supports for the Bowen’s concepts are research studies carried out in the United States ( Thoburn & Sexton, 2015 ). Few studies which have examined Bowen’s concepts in the non-US contexts have presented mixed results. Early pioneers of cross-cultural psychology questioned generalizability, validity, replicability, and utility of Western psychological study and its concepts in the majority of the world ( Thoburn & Sexton, 2015 ).
The continuum of individualism-collectivism is a dimension in re-conceptualizing the differentiation of self ( Thoburn & Sexton, 2015 ). Cultures of separateness or individualistic societies such as UK, US, and Germany uphold the culture of autonomy and independence of the individual and focus on individual goals and success over those of groups ( Butler et al., 2015 ). Conversely, cultures of relatedness/ collectivistic societies like China, Japan, and India foster in-group goals and achievements over personal goals ( Carr, 2014 ). Thus, in collectivistic societies, people tend to shape their behaviors on the basis of group norms and expectations ( Thoburn & Sexton, 2015 ). This difference in culture explains why studies of Bowen theory in other parts of the world gives mixed results. Bowen theory use of specific gender, ethnicity, race, and culture remains its major shortcoming ( Thoburn & Sexton, 2015 ). The theory lacks universality regarding culture, gender, ethnicity, and race ( Thoburn & Sexton, 2015 ).
Methods of Assessing Family Functioning
There are several developed and described family assessment tools which are designed for research purposes. These instruments are either self-reported or interview-based instruments. They are designed to measure family functioning numerically. The numerical results are then analyzed systematically for clinical use or other reasons.
Self-report Scales
Self-report scales are assessment instruments which enable family members to evaluate their functioning. These tools are cost-effective to administer. They include the Dyadic Adjustment Scale (DAD), the Family Environment Scale (FES), the Family Questionnaire (FQ), and the Family Assessment Device (FAD) among others ( Butler et al., 2015 ). The Dyadic Adjustment Scale (DAD) measures the marital adjustment and marital adjustment and marital quality ( Butler et al., 2015 ). It contains 32 items and four subscales which measures cohesion, affective expression, marital satisfaction, and consensus ( Butler et al., 2015 ). The Family Environment Scale (FES) is a true/false tool. It contains 90 items ( Butler et al., 2015 ). This type of measure assesses how family members perceive their family environment concerning personal growth, relationships, and system maintenance. The Family Questionnaire assesses the perceived criticism and over-involvement. The 60-item FAD evaluates the six dimensions of the McMaster Model of Family Functioning ( Carr, 2014 ). These dimensions include roles, communication, affective involvement, behavior control, affective responsiveness, and problem-solving. The FAD has good discriminative validity, acceptable levels of test-retest reliability, high level of internal consistency, and low correlations with social desirability ( Thoburn & Sexton, 2015 ).
Interview-based Family Assessment Instruments
Interview-based assessment tools are a bit complicated to use, require rater training, and labor intensive. These assessment tools compare how a family functions to other families. They include Camberwell Family Interview, The Five Minute Speech Sample, and The McMaster Clinical Rating Scale (MCRS) among others ( Carr, 2014 ). The Camberwell Family Interview evaluates the level of criticism and over-involvement. This measurement requires excessive training. Like FAD, MCRS also assess the six dimensions of family functioning. The Five Minute Speech assesses the emotions of depressed patients’ relatives ( Carr, 2014 ).
Evidence-Based Research in Family/ Marital Therapy for Depression
There are several schools of marital therapy including inpatient family intervention, cognitive marital therapy, the problem-centred systems therapy of family and many others ( Gladding, 2015) . Studies of family therapy for depression face similar limitations as for depression treatment studies, thus comparing the various types of therapies is very difficult ( Carr, 2014 ). The limitations of the studies of marital therapy for depression include the difference in the studied group concerning gender, severity, level of marital distress, diagnosis, and chronicity, as well as the difference in study designs used ( Gladding, 2015) . In spite of the limitations, various studies evaluating family/marital therapy interventions for depressive illness have been conducted in previous years ( Gladding, 2015) .
In a study, a randomized, controlled trial of 77 couples, whereby one spouse had mild-to-moderate depression was assigned to two groups, couples therapy and antidepressant medication ( Haefner, 2014) . The treatment for both groups was conducted for one year. After the one year, point treatment was discontinued ( Haefner, 2014 ). The treated groups were then followed for another year ( Haefner, 2014 ). The results of the study reveal that couples therapy was widely accepted among the subjects in the study as compared to medication ( Haefner, 2014 ). The dropout rate from antidepressant medication was 57%, while that of couple’s therapy was 15% ( Haefner, 2014 ). There was a significant improvement during the first year for both treatment groups with couple’s therapy showing higher improvement than drug treatment in the Beck Depression Inventory (BDI) ( Haefner, 2014 ). It was observed that the advantage of the couple’s therapy continued even in the second year ( Haefner, 2014 ). There was no significant difference in improvement between the two treatment groups in The Hamilton Rating Scale of Depression (HAM-D) ( Haefner, 2014) . In HAM-D, couples therapy was as effective as antidepressant medication for depression treatment and in preventing relapse ( Haefner, 2014 ).
Another study involved 121 patients with more severe depression ( Carr, 2014 ). The patients who were recruited from hospital units were randomly assigned to combined pharmacotherapy and family therapy, pharmacotherapy alone, combined pharmacotherapy, combined pharmacotherapy and cognitive therapy, cognitive therapy and family therapy ( Carr, 2014 ). The family therapy applied in this study was the Problem-Centered Systems Therapy of the Family (PCSFT) which follows the McMaster Model of Family Functioning ( Carr, 2014 ). The PCSFT family systems intervention is a short-term intervention system which emphasizes the macro stages of treatment, that is, assessment, contracting, treatment, and closure ( Carr, 2014 ). This type of family system intervention is opposed to idiosyncratic micro stages of each therapist. The result of the study reveals that there was a significant difference in treatment outcomes between groups with family therapy treatment and those without family therapy treatment ( Carr, 2014 ). The addition to family therapy treatment to cognitive therapy and pharmacotherapy resulted in a significant increase in patient improvement as well as the reduction in participant depression and suicide ideation ( Haefner, 2014 ).
Legal and Ethical Issues Associated with Family Therapy
Given the rising number of psychotherapists involved in marital and family therapy, it is important to have ethical guidelines that consider issues arising during therapy. The specialty guidelines for clinicians and ethical standards for psychologists are mainly formulated concerning a therapeutic relationship involving one therapist and one client ( Gladding, 2015) . APA guidelines for group therapy provide general guidelines for therapies involving multiple clients of more than one family member ( Carr, 2014 ). Some of the major legal and ethical issues associated with family therapy include therapist responsibility, confidentiality, patient privilege, informed consent and right to refuse treatment, children’s right to consent, preservation of families, and training and supervision ( Gladding, 2015) . The main therapist responsibility is protecting the right promoting the welfare of the client. The therapist must also maintain the confidentiality of the disclosed patient’s information; the information should not be disclosed to unauthorized personnel ( Gladding, 2015) .
It is important to consider some useful principles when connecting with families of a patient with depression. First, the therapist should meet every available and interested members of the family. Also, the therapist should be supportive and nonjudgmental. It is important to conduct a thorough assessment of family by encouraging dialogue and listening to all perspectives as well as exploring a wide range of family functions such as communication, emotional engagement, problem-solving, allocation of roles, set rules and expectations ( Gladding, 2015) . It is advisable to identify the major area of interest instead of dealing with every problem raised by the family. Sharing of critical information such as information about the illness, treatment progress, relapse signs and symptoms is essential to the family members ( Carr, 2014 ).
Conclusion
There are several ways of treating depression including pharmacotherapy, cognitive therapy, family therapy and many others. It is important to recommend the best treatment for depression based on the type of patient’s vulnerability to depression. A patient’s vulnerability to depression includes persistent family conflicts, genetic predisposition, current life events, personality variables, and life experiences among others. Pharmacotherapy or antidepressant and cognitive therapy medication are essential in controlling depression resulting from genetic predisposition, life experiences, and personality variables, while family events/ current life events depression is best treated through family therapy. It is difficult to decide on which treatment method is best for depression because they complement each other. Therefore, family therapy should be used together with antidepressant medication to achieve the best result in depression treatment.
References
Becvar, R. J., & Becvar, D. S. (2017). Systems theory and family therapy: A primer . Rowman & Littlefield.
Butler, J., Champagne, F. A., Curley, J., Crews, D., Donley, M. G., Farinelli, M., ... & Harrison, V. (2015). The family emotional system: An integrative concept for theory, science, and practice . Lexington Books.
Carr, A. (2014). The evidence base for couple therapy, family therapy and systemic interventions for adult‐focused problems. Journal of Family Therapy , 36 (2), 158-194.
Gladding, S. T. (2015). Family therapy: History, theory, and practice . Pearson.
Haefner, J. (2014). An application of Bowen family systems theory. Issues in Mental Health Nursing , 35 (11), 835-841.
Mistik, S., Unalan, D., & Tokgoz, B. (2017). The Effect of Depression and Perceived Social Support Systems on Quality of Life in Dialysis Patients. TURKISH NEPHROLOGY DIALYSIS AND TRANSPLANTATION JOURNAL , 26 (1), 23-28.
Smith, L., Hill, N., & Kokanovic, R. (2015). Experiences of depression, the role of social support and its impact on health outcomes. Journal of mental health , 24 (6), 342-346.
Thoburn, J. W., & Sexton, T. L. (2015). Family Psychology: Theory, Research, and Practice: Theory, Research, and Practice . ABC-CLIO.
