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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
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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,
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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
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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
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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
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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).
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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.,
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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.,
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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;
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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
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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.
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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.
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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.
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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
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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
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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
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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
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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.
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