Outdated Practitioner Views about Family Culpability and Severe Mental Disorders

Current theories and research about the etiology and treatment of psychotic disorders increasingly point to the importance of biological factors. Only about two decades ago these disorders were attributed by mental health professionals and the public at large to flaws in parenting and family interactions, whereas the scientific literature now emphasizes such things as genetics, early (perhaps prenatal) physical illnesses and brain traumas, and other physiological forces that produce neurochemical abnormalities in the brain (Gottesman, 1991, 1996; Maziade & Raymond, 1995; McFarlane, 1996; Torrey, 1994). Accompanying this shift in the etiological literature has been an accumulation of evidence indicating the need to move away from treatment modalities that cause families of people with psychotic disorders to feel culpable for the causation or perpetuation of their relatives' disorders. Research has indicated that family systems therapies that tend to attribute psychotic disorders to parental or family dysfunction not only are ineffective in alleviating symptoms or preventing relapse but also may exacerbate both (Lefley, 1994; McFarlane, 1996). The latter can happen when the treatment intensifies the guilt and sense of blame felt by the family, which in turn increases family members' anxiety and preoccupation with their relative's problems. Increased anxiety and preoccupation are likely to intensify the level of expressed emotion in the family and the level of criticism and over-involvement by family members who, feeling blamed for causing the disorder, are less able to be supportive and philosophical in the face of its long-term persistence (Kuipers & Bebbington, 1990). Research has indicated that people with psychotic disorders are more vulnerable to relapse at higher levels of expressed emotion, anxiety, overinvolvement, and criticism. They are less vulnerable when family members can be more supportive and not act on needs or misunderstandings that induce unrealistic hopes for a full and early recovery (Hogarty, Reiss, & Anderson, 1990; McFarlane, 1996). In addition to illuminating the counter-therapeutic effects of standard therapies that induce a sense of blame, current research has supported the efficacy of newer treatment approaches. These approaches - generally termed family psychoeducation - provide families with support, educate them about the disorder in a way that identifies biological causation and alleviates their sense of guilt or shame, foster the development of their social support network, and train them in skills to help them cope with their relative's unusual and perhaps provocative behavior (Falloon, 1990; Gingerich & Bellack, 1996; Hogarty et al., 1990; Hugen, 1993; Leff, 1995; McFarlane, 1996; Stern & Drummond, 1991). Quite unlike refuted family systems approaches with these families, psychoeducational interventions attempt to build an alliance between the practitioner and family members (Gingerich & Bellack, 1996). McFarlane (1996) noted that family psychoeducation assumes that "family members are not only blameless but in fact secondary victims of a biological illness" and regards them "as partners in treatment and rehabilitation - a group of lay collaborators with special knowledge of the patient" (p. 12). Given all the literature that has appeared since the mid-1970s along the foregoing lines, it may seem reasonable to suppose that family members with a psychotic relative entering the mental health services delivery system today will no longer be made to feel culpable for generating or precipitating the disorder, will no longer receive debunked and ineffectual treatments, and instead will receive psychoeducational interventions consistent with current theory and research. We have encountered well-informed colleagues who scoff at the notion that mental health practitioners continue to perpetuate outdated beliefs and treatments that imply family blame for psychotic disorders. …