Family Interventions in Health Care

Author(s): William J. Doherty

Source: Family Relations, Vol. 34, No. 1, The Family and Health Care (Jan., 1985), pp. 129-137
Published by: National Council on Family Relations
Stable URL: http://www.jstor.org/stable/583766
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Family Interventions in Health Care
J. DOHERTY*
WILLIAM

In this article the author discusses the background and present status of family in-
terventions in health care. He notes the convergence of interest occurring in this
area among several health care disciplines during the 1970s and 1980s. He also sum-
marizes his and colleague Macaran Baird's model for primary care family interven-
tions in health care, which distinguishes between primary care interventions and
specialized family therapy interventions. The author then describes new work on
delineating levels of professional involvement with families in health care, and
discusses curriculum implications of these levels. Finally, he offers advice and warn-
ings about collaboration among different professional groups in this emerging area.

Family interventions in health care can be
defined as efforts by health care professionals
to work systematically with the patient's family
for the purposes of prevention, treatment,
management, or rehabilitation of biopsycho-
social problems. The focus of such interven-
tions may be: (a) on the individualpatient, with
the family playing a supportive role; or (b) on
the family itself, as when the patient's condi-
tion places severe stress on the family or when
the intervention is aimed at behavior patterns
in the whole family.This paper covers family in-
terventions centering on physical health
issues and the efforts of health care profes-
sionals to involve families in the treatment of
these problems.
The discussion begins with a brief overview
of the background and current status of family
interventions in health care, including the ex-
isting' research base. Then a model is pre-
sented for primary care family interventions.
The paper concludes with a discussion of inter-
professional collaboration in family-centered
health care.
Historical Background
Ransom (1981)has presented a fine overview entered the war in 1941.
of the early family-centered health care proj-
*WilliamJ. Dohertyis an Associate Professor, Department 100 families and controls. Study families were
of Family Medicine, University of Oklahoma, 800 N.E. 15th
Street, OklahomaCity, OK 73190.
Key Concepts: collaboration, family interventions, health disease prevention through working with the
care, primary care.
(Family Relations, 1985, 34, 129-137.)
ects in medicine. The following summary is
based on Ransom's work. The first organized
effort in this area was the Peckham Experiment
in the southeast London borough of Camber-
well (Pearse &Crocker, 1943). From 1926-1939,
an interdisciplinary team led by physicians
conducted a health center whose unit of in-
tervention was the family. The goal was to
study and promote health by strengthening the
family. Many of the team's activities were
social and recreational, but it also did physical
evaluations and recommended "family health
overhauls." The Peckham Experiment ended
with World War II.
The Cornell Project in New York City began
the same year the Peckham Experimentended.
It was a two-year study of 15 families to explore
the interaction between health and family pat-
terns and ways to treat families in interdiscipli-
nary teams. In his book, Patients Have Fami-
lies, Henry Richardson (1945) presents a
systems description of family and health
issues and shows the influence of Margaret
Mead on the Cornell Project. Like its predeces-
sor in England, this project was a casualty of
World War II, ending when the United States
Inspired by the Peckham Experiment, The
Family Health Maintenance Demonstration of
the Montefiore Medical Group conducted a
study and service project from 1950-1959 on
seen by a team consisting of an internist, a
pediatrician,a public health nurse, and a social
worker. The Montefiore Group emphasized
family unit (Silver,1963).As Ransom notes, this
project never fulfilled its potential because of
"difficulties of team coordination and the

January 1985 FAMILY RELATIONS 129

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 reluctance of professionals to try out new
roles" (p. 36). In addition, this project used an
individual intrapsychic orientation in guiding
the organization of services.
Unfortunately, none of these innovative
multidisciplinary family intervention projects
influenced the mainstream of health care ser-
vices in North America. Medicine continued on
its post World War II course of increased
specialization and emphasis on the biomedical
aspects of patient care. The advent of the new
specialty of Family Medicine in 1969 brought
the idea of family-centered care at least
nominally to the forefront, but only in the
1980's has this discipline begun to find models
for integrating families into patient care
(Christie-Seeley, 1984; Doherty & Baird, 1983).
The last decade has also witnessed a
resurgence of interest within nursing and
social work in family interventions. Nursing
historically has been especially sensitive to the
patient's physical and social environment
(Newman, 1983), and in many health care set-
tings the nurse is the primaryproviderof health
education to the family. In recent years, study
of the family system has become integrated in-
to the core nursing curriculum in many pro-
grams. However, it was only in 1984 that the
first comprehensive text on family-centered
nursing care was published (Wright& Leahey,
1984).
Sanctioned in 1906 to practice in the health
care field, social work had over 45,000 profes-
sionals practicing in this field in the early
1980s (Miller& Rehr, 1983). Social work defines
its specialty as dealing with the patient's
social and environmental stressors. However,
as Hartmanand Laird(1983) have observed in
their book Family-CenteredSocial WorkPrac-
tice, social work was founded with a family em-
phasis, but lost it during the discipline's mid-
dle years. Starting in the 1920s, social workers
relied on the mental hygiene and psychoanaly-
tic movements for inspiration, and later wit-
nessed deep rifts within social work ranks be-
tween individually oriented caseworkers and
systems-oriented community workers. Only
with the emergence of family-systems theory
into national prominence in the 1970s did
social work regain a family emphasis (Hartman
& Laird,1983). Now, social workers function on
many health care teams as the key profes-
sional assigned to work with the patient's fami-
ly.
Most health care interventions with in-
dividual patients also involve a family interven-
tion-whether or not the health professional
intends it. All but the most episodic of patient
encounters involve a strong element of the pa-
tient's social context (e.g., a biomedically
oriented surgeon is continually meeting with
families after surgery and making complex bio-
ethical decisions in consultation with families).
130 FAMILY RELATIONS
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However, the conceptual and clinical bases of
family interventions in health care did not
begin to develop systematically until family
systems theory and family therapy broke new
ground in the 1950s in the treatment of families
experiencing psychosocial problems. Coupled
with the growing research literaturepointing to
family factors in health and illness, the devel-
opment of these family therapy intervention
techniques has brought the issue of family in-
terventions in health care to the forefront of in-
terest in family medicine, nursing, social work,
and family therapy itself.
Research Base
Despite the large quantity of research ac-
cumulated over 30 or more years on the family
and health care, studies of family interventions
are sparse indeed and the research designs in
many cases are rudimentary. In two studies
based in primarycare office settings, Comley
(1973), and Huygen and Smits (1983) docu-
mented declines in health care utilization
among patients who received family therapy
for emotional problems as compared to
matched controls. Neither study used random
assignment to experimental conditions, but
they are rare examples of family intervention
research conducted in primarycare settings.
Compliance interventions have provided the
largest number of studies of the outcomes of
family interventions. Two published studies
have recently reported that family support in-
terventions for compliance with hypertensive
regimens were effective in promoting blood
pressure control (Earp, Ory, & Strogatz, 1982;
Moriskyet al., 1983). The study by Moriskyand
colleagues yielded striking findings for the ef-
ficacy of family interventions. At five-year
follow up of hypertensive patients who re-
ceived combinations of individual, group, and
family support interventions, the authors
reported a significant 65% increase in blood
pressure control for the interventions groups
versus a 22% increase for the routine care con-
trol group. The five-year mortality findings
showed 57% less mortality in the intervention
groups when compared with the controls. The
investigators noted the strong impact of the
brief family intervention, which showed as
strong an effect as the combined individual-
plus-family intervention.
A second prominent area of research on
family interventions concerns the effect of
family support (typically spouse support) on
weight loss in weight reduction clinics (Bar-
barin &Tirado, 1984). Although results are not
always consistent across studies, the bulk of
the evidence suggests that spouse support is
helpful to a person who is trying to lose weight
in a formal program. Barbarinand Tirado (this
issue) have moved this research area a step fur-
ther with evidence that spouse support is ef-
January1985
 fective only in the context of a cohesive marital
relationship. More work is needed to delineate
the specific family behaviors that are helpful
and not helpful for individuals trying to change
their health habits and lifestyles.
A third emerging area of research deals with
preventive health interventions for cardio-
vascular risk reduction. Several large National
Institute of Health-funded studies are in prog-
ress. Pilot results from one of these sites, the
University of Texas Medical Branch in Gal-
veston (Naderet al., 1983), indicated short-term
significant differences between randomly as-
signed family treatment and control groups for
family consumption of foods high in sodium
and saturated fats. Research in this area has
been boosted by a report from the American
Medical Association's Council on Scientific Af-
fairs (1983) on "Dietary and Pharmacologic
Therapy for Lipid Risk Factors." One of the
Council's conclusions: "Because of the
familial nature of many hyperlipidemias and
because dietary management is a family affair,
a good case can be made for extending dietary
recommendations to the entire family of the
patient" (p. 1877). Preventive family interven-
tions may well become the flagship for family
intervention research in the next decade.
Finally, the well-known work by Minuchin
and colleagues (Minuchin, Rosman, & Baker,
1978) on family therapy for psychosomatically
ill diabetic, asthmatic, and anorexic children
has made a significant case for family treat-
ment of these seemingly intractable medical
problems. Unfortunately, this groundbreaking
study has not been replicated by researchers
at other treatment centers.
Despite the promising work cited above,
research on family interventions in health care
is still quite limited. Although there is persua-
sive evidence that family factors are important
in health, illness, and health care utilization
(Litman, 1974), still lacking is similarly persua-
sive empirical evidence that systematically in-
tervening with families in medical settings aids
in the prevention or treatment of physical ill-
ness.
One possible reason why families interven-
tion research has been slow to develop in
health care is the lack of models for interven-
tions that are less intensive than family
therapy, and that can be delivered by health
professionals who are not trained as family
therapists. Family interventions in research
projects generally have been assigned either to
specialized therapists or to mental health pro-
fessionals trained in the psychoeducational
approach. While there will always be need for
interventions by therapists and other mental
health professionals in health care settings,
these efforts by specialists constitute a small
proportion of the family interventions that
could be available to families with health prob-
January 1985 FAMILY RELATIONS
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lems. An alternative, complementary approach
to family interventions in health care has
recently been developed by several authors, in-
cluding Doherty and Baird's model of primary
care family counseling (Doherty & Baird, 1983);
Christie-Seely and Talbot's model for "working
with families," (Christie-Seely, 1984) and
Wright and Leahey's (1984) distinction for
nurses between family interviewing and family
therapy. The following discussion will present
the Doherty and Baird model for primarycare
family counseling interventions.
A Model for PrimaryCare Family Interventions
Since most provider/patientcontacts occur
in a one-to-one context, it can be difficult for
both parties to view the social context of this
therapeutic relationship. However, as Haley
(1976) maintains, a dyad is inherently in-
complete without a third party as a referent
point. Hence, Doherty and Baird refer to the
provider/patient relationship as a triangle
rather than as a dyad. Because of the preemi-
nence of the family in the health of most in-
dividuals, the core therapeutic triangle con-
sists of the health professional, the patient,
and the patient's family. Of course, the key
"outside" partyto the provider/patientrelation-
ship can be other persons and institutions in
addition to the family. But, Doherty and Baird
have found the basic professional/patient/fami-
ly triangle model quite useful in helping health
care professionals begin to think in systems
terms about everyday health care.
Figure 1 outlines the therapeutic triangle in
health care. The arrows denote the mutual in-
fluences among the provider,the patient, and
the family. Each partyeither supports or under-
mines the relationship between the other two.
Each is affected by what happens elsewhere in
the triangle. The most important implication of
this framework for intervention is that the pa-
tient cannot be treated in isolation from the
family, since the family influences both the pa-
tient's behavior and the provider/patient rela-
tionship. Because patients generally live in
family or other intimate social contexts-or
have relatives living farther away who care
about their well-being-it can be said that
every individual patient intervention in health
care is simultaneously a family intervention.
This is true particularly when the illness is
serious and when the patient is asked to
modify his or her life style. Importantchanges
in the health or life style of one family member
reverberate within the family as it tries to ad-
just to or resist the change. Because the pro-
vider is part of a system with the patient and
family, the provider's interventions affect the
family and in turn are affected by the family.
If all health care interventions are in some
sense family interventions, when should the
family dimension of the intervention be con-
131
Figure 1. The therapeutic triangle in health
care.
Patient
Health Family
Professional
ducted systematically instead of implicitly?
Figure 2 presents Doherty and Baird's view of
the continuum of urgency to work directly with
the patient's family by calling a family con-
ference. The left end of the continuum repre-
sents common, minor self-limiting conditions
where assembling the family in the office or
clinic does not seem routinely practical or
necessary. As one moves across the con-
tinuum to recurrentminor problems, preventive
and educational situations, and serious and
chronic problems, the usefulness of a planned
family intervention becomes more apparent. In
many cases, this intervention may consist of
one or two meetings with the patient and
spouse or other family members. In other
cases, such as when a nursing home place-
ment is being contemplated, the meeting
might include all available family members.
A main hindrance to family interventions in
health care has been the notion that only
trained family therapists are equipped to help
families experiencing difficulties. In the Doher-
ty and Baird model, however, family interven-
tions can be viewed on a continuum from pri-
mary care to specialized therapy, with most
health professionals functioning toward the
primary care end of the continuum. Figure 3
outlines the continuum and the characteristics
that distinguish primarycare from specialized
care in the family area. Basically, more severe
and chronic psychosocial problems are best
handled by trained therapists, whereas many
health-related and life cycle issues could be
handled by a primarycare health professional
who has appropriate training.
Primarycare family interventions in Doherty
and Baird's model center around four func-
tions-education, prevention, support, and
challenge-whereas specialized therapy
focuses more on restructuring dysfunctional
relationships. Education involves teaching
families about issues such as health problems,
medical treatment, stress, coping with illness,
and handling a difficult child. Prevention refers
to providinganticipatory help before problems

Figure 2. When to assemble the family in health care.

Generally see Family conferences Family conferences
patient alone desirable essential

minor acute routine treatment routine chronic illness

problems self-limiting failure or preventive/ serious acute illness
problems regular educational psychosocial problems
recurrence care lifestyle problems
of symptoms death

Figure 3. Family treatment continuum.

PRIMARY CARE SPECIALIZED CARE

Problem Severity and Chronicity

Physician Skill
Physician Time and Resources
--Family's Adaptability
Typical Problems Typical Problems
Illness-related Chemical dependency
Life cycle transitions Chronic depression or anxiety
Recent onset problems Chronic family dysfunction
Serious acute problems
(e.g., physical abuse, incest)

132 FAMILY RELATIONS January19B5

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arise (e.g., by health promotion education and physicians start at the lower levels during their
by counseling about what to expect from life early training. Other health professionals may
cycle transitions such as pregnancy or the begin their clinical work at more advanced
death of a family member). Support refers to levels and, therefore, the lower levels may not
helping families cope with the demands of accurately describe their behavior. However,
health problems and other stressors. This sup- we believe that the levels describe a range of
port can take many forms, including extra avail- distinguishable activities that can be applied
ability to the family, empathetic listening, or to all primarycare health disciplines.
helping the family gain access to community For each level Dohertyand Bairdhave deline-
resources. Challenge involves the primarycare ated their current thinking about the knowl-
task of urging families to make changes or to edge base, personal development, and skills re-
accept a referralto a therapist, as in the exam- quired of the professional. Personal develop-
ple of a family with an alcoholic member. ment is the most difficult area to specify, but
In summary, Doherty and Baird have pro- nevertheless it seems an essential component
posed that family interventions by health pro- of the ability to deal with families in distress.
fessionals are a pervasive aspect of practice The levels are described from the profession-
because of the triangular context of health al's viewpoint to reflect what he or she sets out
care, that primarycare family interventions can to do with the family. For example, a Level 2 in-
be distinguished from family therapy, and that volvement in sharing information and advice
the former focus primarilyon education, pre- with the family might stimulate major family
vention, support, and challenge. The next sec- systems change. However, based on the inten-
tion presents Doherty and Baird's recent analy- tions and behavior of the health professional,
sis of levels of involvement by health profes- the intervention would still be at Level 2.
sionals in primarycare family counseling inter- Movement through the levels represents
ventions. shifts in the professional's paradigm for
health, illness, and health care. The move from
Levels of Primary Care Involvement
Level 1 to Level 2 represents a new awareness
with Families
that families are important parts of biomedical
Doherty and Baird elaborate on the primary health care, and a new willingness to collabo-
care end of the family interventions continuum rate with patients and their families in provid-
by distinguishing among level of depth and ing health care. The move from Level 2 to Level
scope. These levels may be used either 3 represents a shift from a primarilybiomedical
descriptively to distinguish types of family in- paradigm to a more humanistic one that em-
terventions or prescriptively to define desired phasizes affective care of patients and their
levels of competent performance by health pro- families in addition to treating and preventing
fessionals who are not trained as therapists. medical illness. We suggest that such a devel-
Finally, the levels are intended to reflect opment requires seeing oneself as a person
developmental phases that many health pro- with feelings and vulnerability.The move from
fessionals experience as they learn to deal Level 3 to Level 4 represents a paradigm shift
with families in patient care. into a systems perspective where one sees pa-
Figure 4 outlines the levels of involvement in tients and oneself as members of larger
primarycare family counseling. The flow of the systems. At all levels, however, the health pro-
levels goes from minimal involvement to infor- fessional may have acquired the relevant
mation exchange to feelings to systems, with knowledge base and personal development,
each succeeding level embracing and tran- but not yet the behavioral skills in dealing with
scending the priorone. This sequence reflects families.
the maturationalprocess that many physicians The levels represent a range of options avail-
have experienced. First, there is the focus dur- able to the health professional rather than a
ing early training on the biomedical needs of prescription for any particular situation. The
the individual patient, with the family being professional must judge the appropriateness
quite peripheral. Next, is an awareness that of different levels of family intervention based
families need information about the patient on the specific patient and family situation, in-
and can, in fact, provide useful information to cluding time availability and the presence of
the physician. Then, there is a gradual move- other resources for helping the family. Similar-
ment toward adding a focus on the patient and ly, when taken as levels of competency, the
family as persons with feelings and interper- levels represent one's professional ability
sonal bonds that need attention. Finally, for rather than one's performance in every situa-
some physicians, there is a more serious atten- tion; sometimes not doing all one is trained to
tion to the nuances of the family system and do is the best care.
the professional's own role in the family and There are strategic advantages of delineat-
other systems. The four levels are phrased here ing these levels. First, since many health pro-
and in Figure 4 as levels of "physician" involve- fessionals can identify themselves as already
ment because we are conf ident that many performing confidently at some point on the

January 1985 FAMILY RELATIONS 133

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 or
the
level as
most This Level
ment
where tegral Figure
patient families 1: 4.
sole to reasons,
practical
physician
municating on
care. medical to the butand only baseline
involving consists
presumably not as of
with Minimal
Levels
biomedical Familyof
level
conscious
school skills
develop. of
issues forphysician's
viewing
families dealing
focus This necessary Emphasis
medical/legal
of are theroleas
training involve- physician
characterizesin-com-forwith

5. 4. ily3. 2. ily 1.
and
how and thethe
bers. ness ship. Level
For to Skills:
channel
through patient.
families, to 2: involvement
concerns.formation.Asking
questions Personal medical,
Advising diagnostic municating Knowledge
one large members' members.Regularly
Attentively collaborative triangular
plus with
or handle andthat treatment
and family engage
knowing rehabilitation and Base: Ongoing
the way. formation
two families elicit medical
physician-patient
how
keycommunication listening
questions options Development: and families.
needs clearly families dimension
awareness
to to treatment to Medical
about
of medical members in
demanding and in-relevant findings of of Primarily
mem- a In-
the fam- fam-com- Open- relation- Advice

5. a 4. 3. 2. of 1.
the as to ily
and bers it If tion
them lated ness Level
in family family. family Skills: family.
family family's
problem. feelings, andto of 3:
Asking Personal stress.
unique
Tailoring preliminary itstheconcerns Knowledge
feelings their
with relates where relationship
level and one's
of to
Encouraging to
of members' andmembers' development
needs, their appropriate,Empathetically Base: Feelings
the the effect theown
medical efforts questions and
to family onpatient's and
assessment Development:
appropriate.
formingnormalizingthe feelings that
family. of a concerns patient Normal
advice cope listening condi- feelings
mem- patient's
situation.
concerns, functioning re-expressions
to as the andto elicit andin Aware- fam- Support
reactions

6. of 5. 4. 3. a in 2. 1. of
their its while even own
forms family Skills: Level
a cluding munity
of problem family's such triangle,
one's
systems 4:
chance
a Personal
Helping family Knowledge
to Engaging the own
Reframing
problem level
Supporting waypoorly
difficulty
the avoiding Structuring
solving
in the of a
as Systematically reluctant systems. Planned
Base:
a that conference.
family including
express system, Systematic
family
more all medical
collaborative way the Development:
Continued individual ones, and
coalitions.
family's in Family
on requiringthat participation
assessing
functioning. a
conference
efforts. communicating
members,larger in
system, Intervention
next newmembers members
the themselves.
achievable. members with in- Assessment
makes therapeutic
one's Awareness systems.
view definition family planned com-
page have and

134 FAMILY RELATIONS Januaryl985

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 continuum of family interventions, they may be
open to the prospect of learning to do more. It
Level is easier to think of expanding one's familiar
Figure
1: skills than of learning foreign ones from
4.
on scratch. In fact, the initial impetus for these
levels came from a discussion with a family
medicine resident who said that he was intimi-
Minimal
Levels dated by family counseling because he had
Familyof never "done any." When asked by Bairdabout
his previous day in the hospital, he replied that
of course he had met with lots of families to
Emphasis discuss the patient's condition. When it was
physician pointed out that he was thereby doing primary
care family counseling, he seemed pleased and
relieved. And Dohertyand Bairdfelt the need to
6. make more explicit the range of primarycare
pist. with activities with families.
Level
Second, the levels can be used to formulate
referring 2: involvement curriculum goals for training programs. The
dysfunction program could include required and desired
themedicalIdentifying with levels of competency for trainees at the end of
that their training period and at various points dur-
Ongoing
formation ing the training. For example, a family practice
family gross residency could require Level 2 competency by
to and the end of the internship year and Level 3 by
a treatment,
Medical the time of graduation, with Level 4 being an
family
interferes elective competency. In general, Doherty and
and In-
thera- Advice Bairdpropose Level 2 as a minimumcompeten-
cy standard for all health professionals who
deal with patients (including medical subspe-
families-Continued.
6. cialists) and Level 3 as a minimumcompetency
tion
Level standard for all primary care health profes-
unique 3: sionals, specifically, primarycare physicians,
and
nurses, and physicians associates. Level 4 is a
desirable, but elective competency for primary
Identifying care professionals and one that they should be
fitting
situation
recommendation
a Feelings exposed to during their training. Health social
of to workers presumably should be trained to at
family and least Level 4.
thethe Finally, family intervention beyond Level 4
referral
would require more indepth knowledge about
how families organize themselves dysfunction-
family.dysfunc-Support ally and more advanced skills in treating fami-
lies in acute crises or in chronic dysfunction.
9. 8. 7. This refers to specialized family therapy requir-
pist that their
their ing training beyond that offered to generalist
ment Level health care professionals.
allows
another. lies anyone's 4:
and generate
difficulty.
educating
about Helping
Helpingacceptable Professional Collaboration in
coping
various Family Interventions
the Identifying
what beyond support waysfamilyPlanned
Just as the knowledge base of the family and
to rolesfamily health area is larger than any one discipline,
efforts
autonomy. to alternative,Systematic the demands of family interventions require
family family in
a by
without
orchestrating the coordinated efforts of a variety of health
a primary
and
expect cope care professionals, most notably, physicians,
way members members nurses, health social workers, and family thera-
the care mutuallyIntervention
with pists. While most people would agree in prin-
from that ciple with this statement, collaboration among
dysfunction calibrating
referral Assessment
sacrificing these professional groups can be difficult to
onethera-
bytreat- balancetheir and achieve in practice. The key problems seem to
lie in the professional differences and rivalries
between physicians and other professional
groups.

January1985 FAMILY RELATIONS 135

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 After centuries of struggle, American medi-
cine in the 20th century has achieved an un-
precedented degree of professional control
over the delivery of health care (Starr,1983). As
Ransom (1981) recounts, medicine, with the ex-
ception of several notable experiments, gener-
ally ignored the family as a unit intervention un-
til the 1970s. Interestingly, the two American
experiments in family-centered care described
earlier in this paper were multidisciplinary in
nature. And one of them-the Montefiore Proj-
ect-floundered because of professional turf
issues. The emergence in 1969 of family medi-
cine as a specialty that is philosophically com-
mitted to family-centered medical care (Gey-
man, 1977) has moved medicine toward both
greater opportunities and clear dangers in the
area of family interventions. The opportunities
relate to physicians' ready access to the family
system because of their professional authority
and their involvement with patients and fami-
lies at many points during the life cycle. A prin-
ciple danger is that physicians will try to "own"
family interventions to the exclusion of other
professionals who have their own contribu-
tions to make. Fortunately, in current practice
most physicians readily perceive their need for
help and collaboration in dealing with patients'
families.
The nursing profession is currently strug-
gling to establish its professional autonomy
vis A vis medicine in the delivery of health ser-
vices. Christman (1978) contends that nurses
must move in the direction of "parity" with
physicians: "Parity connotes equality and is
crucial to having much influence on the deci-
sion-making power" (p. 362). Nurses are justifi-
ably proud of their profession's emphasis on
health promotion in the context of the family. A
danger is that they will try to exclude physi-
cians from family intervention work because of
the sometimes-expressed view that the real
role of physicians is simply to diagnose and
treat diseases and disabilities (Schlotfeldt,
1978). A corresponding opportunity emerging
from the modern development of a better-
trained and more confident nursing profession
is the greater leadership nurses are taking in
family-centered health care, particularlyin the
area of health promotion. In addition, since no
one discipline owns family interventions, this
area might serve as an exemplar for profes-
sional collaboration between nurses and physi-
cians.
With its traditional emphasis on the social
context of patient care, health social work has
the experience to enrich its professional col-
laborators, in particular by its skills in assess-
ing and intervening in the family's larger social
and environmental context. Many social work-
ers are also trained in family therapy or at least
in primarycare family interventions at Level 4
(Figure 4). In some medical settings, unfortu-
136 FAMILY RELATIONS
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nately, the family is assigned to a social worker
without meaningful involvement with the
physician and nurse, a procedure which can in-
dicate to the family that they are being
"shunted off" to the social worker for prob-
lems that are not really a part of health care,
and send a message to the social worker that
the "real" treatment is done with the patient
alone. In these situations, the social worker
may not be given adequate opportunity to in-
fluence the way that physicians and nurses are
dealing with the patient and family. The same
danger applies to social work as to medicine
and nursing in that social workers could try to
own the family and thereby keep other profes-
sionals away from family interventions. On the
positive side, the recent blurringof the distinc-
tion between psychiatric social work and
medical social work-the new term is health
social work-portends an admirable movement
away from the mind/body dualism that has
dominated most health disciplines.
It is somewhat harder to discuss the role of
family therapists as a profession, because
family therapists come not only from the new
discipline of family therapy, but also from a
variety of primary disciplines including
psychology, psychiatry, social work, and in-
creasingly nursing and primarycare medicine.
But, for present purposes, the role of family
therapist can be defined as the professional
whose job is providing family consultations
and family therapy in health care settings. The
opportunities for family therapists to con-
tribute to family interventions in health are
quite large and quite underdeveloped. Family
therapists are trained in the process of inter-
viewing and intervening with dysfunctional
families and for understanding the interaction
between the professional and the family. On
the other hand, a principal danger accompany-
ing the involvement of family therapists in
health care settings, one documented well by
Glenn, Atkins, and Singer (1984), is that they
will fail to join the culture of the health care
system enough to influence it. Since systems
thinking outside the biological realm is foreign
to medical settings, family therapists must
learn the paradigm and language of these set-
tings in order to function collaboratively and
effectively.
Involved at every level of interprofessional
collaboration are issues of identity, economic
well being, and power. However, as with bio-
logical relationships in families, the dissolu-
tion of interprofessional collaboration is an il-
lusory solution, since families cannot be
handled by one profession alone without that
profession losing its identity in the spectrum
of biopsychosocial disciplines. On the positive
side, just as child care depends on respectful
collaboration between parents, optimal care
for families rests on respectful collaboration
January1985
among health professionals. The treatment
system must be consistent in order for family
systems interventions to be successful over
the long run in health care settings.
Conclusion
Health care is a fundamentally practical
enterprise. Theories tend to be tolerated only
as long as they explain what happens in health
care and what works. Research is attended to
mainly when it can be translated into daily
work with patients. Furthermore, front line
health professionals generally operate by
assessment and intervention protocols that ex-
press professional consensus about how to ap-
proach patient problems, for example, by ask-
ing a definite list of questions in order to
establish a diagnosis, and by prescribing or
carrying out a standard treatment regimen us-
ing standard procedures.
This approach is foreign both to social scien-
tists, who tend to like theory and research even
when practical value is not evident, and to fami-
ly therapists, whose practice modes tend to be
less structured and less tied to consensual
procedures. If these two fields are to influence
health care in this country, social scientists
will have to become more involved in research
on health care practice, both descriptively to
develop more understanding of what goes on
between professionals, patients, and families,
and experimentally to show evidence that in-
tervening with families makes a difference in
the health and well-being of patients. Family
therapists will have to work with health profes-
sionals to develop concrete and practical fami-
ly intervention protocols that can be used by
front line providers in their everyday work.The
continued development of the family and
health area of professional interest depends on
collaborative efforts to change the way health
professionals deal with families in health care
and to evaluate scientifically the advantages
and disadvantages of these changes.
January1985 FAMILY RELATIONS
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