Warning: Non-family Tx may be hazardous to your (family’s) health

A clever article in the September 2007 issue of the Journal of Family Psychology by Jose Szapocznik and Guillermo Prado suggests that "psychosocial treatments with vulnerable populations have the potential to produce negative side effects on families."

The authors reported unexpected findings from three separate studies that compared the efficacy of a family and non-family treatment. In brief, they found that family-level outcomes measured after applying non-family treatments didn't just remain static (as they had expected), they actually declined. This relationship is correlational and does not necessarily mean that the treatments in question caused the decline, but the authors argue that the findings are striking enough to raise the question about whether unintended side effects psychosocial treatments should be subject to "safety monitoring" along the lines that biomedical products are. Something like a black box label: "Warning: This treatment manual may be hazardous to your family."

In the discussion section, Szapocznik and Prado hypothesize about the systemic mechanism for the results they found:

"The family is a system that must be viewed as composed of interdependent or interrelated members.... Family members tend to develop habitual patterns of behavior over time such that each individual in the family is accustomed to act in a certain way that in turn elicits specific predictable behaviors from others. One possible hypothesis is that if an individual is changed by an intervention that is design to change individual and not help the family adjust to these changes....the family may be negatively affected...."

Nothing in these studies relate directly to suicide. But I think there are implications for how we think about intervention, especially in light of what I've been reflecting on lately about suicide as a family issue (see posts related to family therapy)

  • Need for more systemic work on suicide. With respect to suicide, this article emphasized to me the need for greater conceptual clarity among systems thinkers about suicide in the context of the family system. We need to articulate in what ways suicidality might be a property of the system in which it resides, and what are the mechanisms by which family relationships might reduce the likelihood of suicide.



  • The complexity of defining "evidence-based practice." I've posted before (vis-à-vis the ambulatory redesign aspirations in our department) about my concerns that "evidence-based" can get too narrowly defined. What is evidence-based depends a lot on what evidence you look at, and, more to the point here, on what outcomes are measured in the studies that provide supporting evidence for an intervention. Given the documented importance of family functioning for long-term outcomes of many kinds, perhaps one of the criteria we should consider in evaluating the utility of a given treatment approach is its ability to promote family functioning.



  • This relates to suicide because of the ways in which I have heard distressed individuals conceptualize their presenting problem. When people seek help it is usually with a functional outcome in mind, often one that has to do with their relationships. Research studies measure symptom reduction, people care about love, work, and play. In delivering a human service, we should organize ourselves in congruence with human concerns. If we organize ourselves around "reducing depression" we run the risk that our language will become reified in our practice-the result of which could be a less connected stance toward a suicidal individual who sees his relationships, finances, or health as the primary problem, not his "symptoms." As one person I worked with paradoxically stated, "I don't care about feeling better, I just want all of these problems to go away."


Ideas around evidence-based practice are evolving. In our department, a vibrant conversation is underway. Simplistic views of what is evidence-based seem to be disappearing, as everyone realizes that "evidence-based" is a much broader and trickier term than we might like. Ultimately, I suspect that the way out of the dilemmas inherent in the term is for clinicians to collect evidence (in informal and formal ways) about change in their own cases. This kind of internal monitoring process will probably promote effectiveness more than selecting the right branded treatment, which may have aggregate data that allows it to be certified as "evidence based," but which may or may not be helping the particular individual and family we're working with.

Reference


Szapocznik, J. & Prado, G. (2007) Negative effects on family functioning from psychosocial treatments: A recommendation for expanded safety monitoring. Journal of Family Psychology. Vol 21, p. 468-478.