Family Therapy and

The Family Physician A.COMLEY,MD

SUMMARY The purpose of this research paper is to look at family therapy as a
technique for dealing with emotional problems in family medicine.
It consisted of a non-randomized cohort study utilizing the patients
at McMaster University Clinic. There were 42 families involved in
the study group and they were matched with a control group. The
results indicated that patients treated by means of family therapy
placed 50 percent fewer demands on the physician and clinic than
patients in the control groups treated with medication and/or
psychotherapy. It also revealed little difference in the mix of
complaints and diagnoses before and after family therapy.
The study looks at complaints before and after diagnosis, before
and after treatment, and the frequency of visits as a means of
indicating whether there has been some improvement in the patient.
It is hoped by this technique to provide a very easy method of
researching this type of problem in an active community practice.
Dr. Comley is an assistant professor in the Department of Family
Medicine at McMaster University. He is on the staff of the Smithville
- McMaster Family Medical Centre, Smithville, Ont.

PHYSICIANS INVOLVED in primary care and family deal with problems will economize on health resource
medicine are faced with an increasing number of utilization in the long run. The goal is to develop resources
patients presenting with emotional problems either recog- within the family for dealing with problems which have
nized by themselves or by the physician. These patients traditionally been brought to the physician as an emotional
present with emotional problems as their overt complaint complaint or as a masked somatic or psychosomatic
or indirectly with somatic or psychosomatic complaints. complaint. During the family session, the family decides on
There are several methods available to the physician for a method of dealing with the problem and usually reports
dealing with these problems. Traditionally, the emotional back in a few weeks. Most problems seem to be handled in
problem has been dealt with by medication and/or individ- one or two sessions and a decision to continue beyond this
ual psychotherapy. One of the newer methods available is point is dependent upon the progress made by that family
family therapy. This study is based on the experience at the after the initial session.
McMaster University Clinic using the technique of family
therapy to deal with emotional problems.1' 2, 3 Purpose of the Study
Family therapy may be a time-consuming procedure. It
Involvement of Family Members requires that the entire family come in for a session and
When the physician identifies an emotional problem, the utilizes approximately one hour of the therapist's time in
patient is advised to bring in the other family members for each visit. The first purpose of this study is to ascertain
a family session. The patient presents the problem as he whether family therapy has any effect on the pattern of
sees it to the members of the family. The physician then overall demands for health care made by the family
tries to get a better understanding of the nature of the following such therapy. In this study, two dependent
problem from the other members of the family, facilitated variables were examined. The first variable was the
by evaluating the function of the family unit as a system. frequency with which the family used the clinic before and
This is achieved by looking at the. roles the various members after family psychotherapy. The second variable consisted
take in the family, the method of communicating, the of the complaints and diagnoses of the family members
patterns of behavior and control, the family's problem- before and after therapy. It was considered important to
solving techniques, the degree of autonomy granted family measure the time expended in family therapy per family
members, and the resources available to the family.4 This because many physicians have stated that they would like
approach will help the physician determine the importance to do this kind of therapy but do not have the time. They
of the presenting problem in the economy of the patient's are far too busy with day-to-day care of their patients to
life and that of the family. devote one hour to one emotional problem. This study
Since this can be very time consuming, we hope that attempts to test the hypothesis that there would be an
time spent in improving the family's ability to function and actual time saving in the long run if health professionals
78 CANADIAN FAMILY PHYSICIAN/FEBRUARY, 1973
would invest the necessary time in family therapy. 10 percent increase in the demand for medical services
A non-randomized cohort study was done using the comparing the year before with the year after identification
records of the McMaster University Clinic as source data. of the emotional problem. Table II shows approximately
The McMaster University Clinic is a family medicine the same decrease in visits per year after family therapy for
teaching group of five practices. At the time of the study each group regardless of the number of sessions required to
there were approximately 1,500 families in the population. deal with the family problem.
Where similar types of data allow (size of family, ages Since family therapy is a major event in the family's life
within the family, religion, country of birth), comparisons requiring attendance by all family members, one could
have been made between the sample population at the postulate that the decrease in visits after family therapy was
clinic and the population of the metropolitan Hamilton due to the 'punishment' of family therapy. People would
area as described in the 1961 census. These comparisons subsequently not be willing to bring their problems to the
have indicated a close resemblance which makes us con- doctor. Therefore, one of the variables we examined was
fident that the patient population that we are studying is the category of the complaints. It seemed necessary to
representative of the population of Hamilton as a whole.5 establish if there was a change in the stimulus for demand
The medical data in this system is abstracted from the of services after family therapy. If family therapy acts as a
patients' charts, key punched and placed on a magnetic deterrent then one might expect a change or decrease in the
tape which is updated on a weekly basis. The data centers number of emotional problems seen by the physician.
into three areas: At the McMaster University Clinic, the reason for the
1. The symptoms and complaints (or problems) as visit is recorded in the patient's own words. These
presented by the patients. complaints, before and after therapy, were recorded. (Table
2. The diagnosis or diagnoses (or the physician's labels III). The results showed that there was very little change in
for the patients' complaints. the mix of complaints that were presented before and after
3. The management of their problem, including the the family therapy. There was some change in frequency
investigating procedures. for certain complaints. The families in the study group were
From this file, a search was made identifying patients bringing the same complaints to the physician but only half
with emotional problems. The clinical charts were then as frequently after family therapy. A further variable is the
reviewed to see if the problem was managed by family physician's diagnoses. (Table IV). The diagnoses are
therapy.
Those patients whose emotional problem was managed
with family therapy were then segregated. However, only
those families who had one year of records preceding and
following the psychotherapeutic intervention were finally TABLE I
selected for the study.
Frequency of Clinic Visits: Mean Number of Visits Per
Selection of Controls Person By Entire Family One Year Before And One Year
Families in which the emotional problem was not After Family Therapy
managed by family therapy were identified as potential
control families. Criteria for selection of control families Before Therapy After Therapy
was as follows:
1. That the demand for services in the year preceding the Study Group 4.03 visits/person 2.08 visits/person
emotional problem was comparable to the frequency of the (family therapy) per year per year
visits by the families in the study group. Control Group 3.52 visits/person 3.90 visits/person
2. According to the age of the parents and wherever (no family therapy) per year per year
possible, the number of children in the family.
Once the two groups were selected, the charts for the
entire family were reviewed and a record of the frequency
of visits for one year before and after the diagnosis of an
emotional problem was made and examined.
In an attempt to discover if the families were receiving TABLE 11
medical attention elsewhere, a series of interviews in 15 To Number of Family Therapy
families and a phone call questionnaire in the remaining Frequency of Visits Related Sessions
families was done in the family therapy group. In the
interview, inquiry was made about the volume of services 'Before' Visits 'After' Visits
they were receiving from the clinic. There were several Number of Per Family Per Family
questions in the inquiry, such as, "Were they using other Family Number of Member Member
medical services?" "Did they feel they were using the clinic Sessions Families Per Year Per Year
more frequently, less frequently, unchanged?"
or
5 Sessions
Results or More 7 5.14 2.30
The families which had family therapy in the manage- 4 3 3.12 1.94
ment of emotional problems made less use of the clinic 3 4 5.00 3.67
services in the year following intervention than in the year
prior intervention. (Table I) There was a 49 percent 2 11 4.68 2.31
decrease in the demand for medical services in the year 1 17 3.34 1.66
following family therapy. In the control group there was a
CANADIAN FAMILY PHYSICIAN/FEBRUARY, 1973 79
 TABLE III
A Comparison Of The Mix Of Complaints Before And After Family Therapy
Complaints Before Frequency of Percent Complaints After Frequency of Percent
Therapy Occurrence Total Therapy Occurrence Total
Depression 127 21% Depression 52 16%
Skin Rash 60 10 Cold 39 12
Abd. Pain 54 8 Throat soreness 32 10
Fatigue 50 8 Headaches 26 8
Headaches 47 7 Abd. Pain 26 8
Back Pain 44 7 Skin Rash 23 7
Cold 38 6 Cough 23 7
Sore Throat 31 5 Back Pain 16 5
Shoulder Pain 30 5 Fatigue 13 4
Cough 20 3 Fever 8 3
Other 132 Other 70 20
Totals 633 100 325 100

TABLE IV
A Comparison Of The Mix Of Diagnosis Before and After Family Therapy
Diagnosis Frequency of Total After Frequency of Total
Before Therapy Occurrence Percent Therapy Occurrence Percent
Depression 138 22% Acute Pharyngitis 65 20%
Anxiety 101 16 Depression 53 16
Acute Pharyngitis 90 14 Anxiety 46 14
Otitis Media 54 8 Otitis Media 26 8
Bronchitis 44 7 Obesity 24 7
Vaginitis 40 6 Vaginitis 20 6
Tonsillitis 32 5 Tonsillitis 16 5
Obesity 30 5 Tension Headache 15 5
26 4 Bronchitis 13 4
Tension Headaches 21 3 Family Dysfunction 12 4
Cellulitis 19 3 ASHD 6 2
ASHD 19 3 Hypertension 3 1
Other 49 2 Other 29 8

TABLE V
Patient's Response To Questions On Interview
Using Other Increased Decreased Did Not Total Number
Services Use? Use? Unchanged Know of Families
Families
I nterviewed 1 0 3 10 2 15
Families
Telephoned 2 2 4 10 4 20
Note: Five Families refused to be interviewed
Two Families could not be reached

80 CANADIAN FAMILY PHYSICIAN/FEBRUARY, 1973

approximately the same before and after family therapy, suggests that the families exposed to family therapy are
the only change being the decrease in number of visits. better able to handle medical problems, emotional or
otherwise, within the family.
Possibility of Service Elsewhere 5. In situations where family therapeutic intervention is
When the families exhibit such a reduction in the of three sessions or less for a family, it appears that
number of visits while presenting with the same complaints, expenditure of time by physicians in the management of
and being categorized by the same diagnosis, it is possible that family's problem during the year, is reduced.
that they are going elsewhere for services they previously The differences noted in medical service utilization are
received at the clinic. To investigate this point, 15 families of sufficient magnitude and of sufficient clinical signifi-
in the study group were interviewed. They were asked if cance in the practice of family medicine that a randomized
they were using other medical services besides the clinic. controlled trial of family therapy should be undertaken.
They were also asked if they were aware of any changes in The importance of follow-up study will be enhanced if
their use of the clinic. The results of the inquiry (Table V) assessment is made of which families are 'better off' or
indicated that the families were not using other services. It 'worse off' as a result of exposure to family therapy. Such
also showed that the families having substantial reductions determinations, added to measures of medical service used
in the number of visits were mostly unaware of the change. as data in a study, hopefully will establish more firmly what
Skeptics about this form of therapy state that they would the role of family therapy should be in the overall practice
like to do it in their practices but do not feel they have the of family medicine.
time. The time expended was measured to determine if
there was any time saving in one year if emotional problems Acknowledgements
were managed this way. (Table VI). This table shows that I would like to thank Dr. J. C. Reid, Dr. R. G. McAuley,
problems which could be handled in one or two sessions Dr. A. H. McFarlane and Dr. W. R. McMillan, physicians at
resulted in the greatest reduction of time expenditure. the McMaster University Clinic, for allowing access to their
patients and records for the study.
Conclusions I would also like to thank Dr. A. H. McFarlane, Dr. J.
Because of the process of self selection which results in a Cleghorn, Dr. W. 0. Spitzer and Dr. N. Epstein for their
non-randomized cohort study, definite conclusions of the technical advice and encouragement.
effect on utilization cannot be made. However, we have
gained useful impressions which should be substantiated References
with follow-up studies of somewhat different design. 1. EPSTEIN, N. B., WESTLEY, W. A.: The silent majority. San
Tentative conclusions stemming from this study are: Francisco Josee-Bass, 1969.
2. SIGALL, J. J., RAKOFF, V., EPSTEIN, N. B.: Indicators of
1. Emotional problems managed by family therapy therapeutic outcome in conjoint family therapy. Family Process 6,
resulted in fewer demands on the McMaster University 215-226, 1967.
Clinic in the year following the intervention than in the 3. SIGALL, J. J., RAKOFF, V., EPSTEIN, N. B.: Working through
year preceding the intervention. If one considers the year in1967. conjoint family therapy. Amer. J. Psychotherapy 21: 782-790,
prior to family therapy as a control period for the year 4. EPSTEIN, N. B., SIGALL, J. J., RAKOFF, V.: Family categories
following therapy, (i.e. families serve as their own controls) schema, unpublished.
the changes are remarkable, and highly significant statis- 5. McFARLANE, A. H., O'CONNELL, B. P.: Morbidity in family
tically. From this, we can infer that patients of a university practice. Canad. med. Assoc. J. 101: 259-263, 1969.
teaching family medical clinic who are willing to undergo
family therapy can be expected to reduce their demand for
medical services by approximately 50 percent.
2. Furthermore, in control families not treated by
family therapy for an emotional problem, we observed TABLE VI
slightly increased demands for medical service utilization,
comparing the year prior to the identification of the Decrease in Visits Related To Number of Family Therapy
emotional problem with the year after. Since it was Sessions
determined that 25 percent of the families in the control
group had in fact been offered family therapy but refused, Number of Sessions Total Number Decrease in
comparisons of medical service utilization between the two Per Family Of Sessions Visits
cohorts are risky and probably unwarranted. However, the 5 sessions or more 40 68
differences are striking enough and consistent enough with
before and after comparison of the study group to warrant 4 12 24
further studies. 3 12 15
3. The mix of complaints of patients in the study group 2 22 77
and the mix of diagnoses mtade by the physician remain 17 139
largely unchanged before and after family therapy inter- 1
vention. 103 sessions resulted in a decrease of 313 office visits.
4. The pattern of decreased use of medical services

CANADIAN FAMILY PHYSICIAN/FEBRUARY, 1973 81