Couple and Family Interventions for High Mortality Health Conditions

Based on: Couple and family interventions for high mortality health conditions: A strategic review (2010-2019) Angela Lamson, PhD, Jennifer Hodgson, PhD, Keeley Pratt, PhD, Tai Mendenhall, PhD, Alison Wong, PhD, Erin Sesemann, PhD, Braden Brown, PhD, Erika Taylor, MS, Jacqueline Williams-Reade, PhD, Daniel Blocker, PhD, Jennifer Caspari, PhD, Max Zubatsky, PhD, and Matthew Martin, PhD,  January 2022 Journal of Marital and Family Therapy

An introduction from Angela Lamson, PhD

What inspired you all to evaluate family interventions related to medical conditions with the highest mortality rates?

Lamson: As MedFTs, we see health, wellness, illness, trauma, and death in the context of families as they interface with larger systems such as healthcare, schools, and military systems. A group of 13 MedFTs came together with the task of identifying and evaluating the empirical evidence of couple and family interventions in relation to health. Health, as you imagine, encompasses so many conditions. Therefore, we contemplated many places to begin with our search and decided upon the conditions with the highest mortality in the United States.

After all, the earliest practice and research in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. Our article captures an evaluation of efficacy for couple and family interventions with a focus on the most prevalent health conditions that lead to mortality in the United States.

Hodgson: We needed to be creative in our search strategies, looking beyond traditional ways in which we define and operationalize family, health, and health outcomes. Historically, much of the literature and protocols that were implemented with families only measured individual outcomes. To truly engage in relational and systemic research, you need to know that the researchers took care to study the biopsychosocial and spiritual outcomes with the family as the unit of measurement. 

This was such an expansive survey—which age groups and health conditions did you decide to include in your evaluation, and why?

Lamson: Age Groups (Health Conditions)

• Infants and children 0-4 years (chromosomal abnormalities, accidents, assault/homicide),  
• Children 5-14 years (accidents, cancer, intentional self-harm/ suicide), 
• Adolescents 15-24 years (accidents/unintentional injuries, intentional self-harm/ suicide, assault/homicide), and 
• Adults over 25 years (heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer’s disease, diabetes, influenza/pneumonia, nephritis/nephrosis, intentional self-harm/suicide)

We needed to start somewhere. We wanted to make sure we were capturing the lifespan and so we selected the top three conditions for infants, children, and adolescents, as well as the top 10 conditions for adults 25 and older. We could have chosen the World Health Organization’s lists to have a more global perspective on health, however that would have been incredibly complex because a different list of health conditions are listed for every nation in the world. We strategically evaluated the empirical evidence of couple and family interventions for conditions with the highest mortality in the United States, we chose to rely on the list of conditions according to the Centers for Disease Control and Prevention (CDC).

We also chose to include obesity in our review even though it was not in the top three mortality conditions for children or the ten mortality conditions for adults; we chose obesity for those 5 years of age and older because the CDC and National Institutes of Health (NIH) have consistently listed obesity as a leading precursor to preventable death.

While suicide and/or homicide were present in all age groups, we did not include these in our search because we were aware another JMFT Special Issue article would be covering these topics specifically.

What were some of the key interventions that appeared to be most effective among the various age groups?

Age 0-4
Taylor: Congenital malformations, deformations, and chromosomal anomalies
Nearly 3000 articles (n = 2937) were assessed for eligibility (i.e., couple and family intervention articles focused on children with a chromosomal anomaly aged 0-4). Of those reviewed, only three met full inclusion criteria. One included a probably efficacious intervention (i.e., Congenital Heart disease Intervention Program [CHIP-School] with high family inclusion; McCusker et al., 2012). A second CHIP intervention was labeled possibly efficacious with moderate family inclusion (McCusker et al., 2010), and one intervention was deemed experimental with moderate family inclusion (i.e., Enhanced Pilot-Early Start Denver Model [P-ESDM]; Vismara et al., 2019). It is likely that the CHIP program would be considered a well-established intervention if this search allowed for articles to be captured for children beyond the 0–4 age group.

Age 5-14
Cancer/Malignant neoplasms
While several studies stated that family approaches were utilized, the interventions were often individually focused and behavioral in nature, and thus did not adequately capture family interventions.

Accidents
Consistent with younger age groups, no couple or family intervention study emerged from the strategic review for those aged 15-24.

Age 25 and older
Heart disease
Overall, the CBT models, particularly the couples-CBT intervention, offered a promising option for positively influencing health behaviors and relational satisfaction.

Wong: Cancer
Of all the CDC’s top 10 health conditions that lead to mortality (2019), couple and family therapy interventions for cancer offered the most promising efficacy. Three interventions published across four articles were indicated as probably efficacious: FOCUS, Family Focused Grief Therapy (Kissane et al., 2016), and Intimacy Enhancing Therapy. 

Overall, studies found that the inclusion of the couple or family in the intervention resulted in improvements in psychosocial functioning for all participants.”

With obesity being such a common problem in the U.S., and the resulting heath issues a major concern for so many families, were there any take-aways that might be of particular interest to clinicians in helping their clients with these challenges?

Pratt (on clinical recommendations): The biggest take away is that despite the volume of research focused on family-based weight management interventions, there are very few family therapy interventions addressing existing dynamics for families with obesity. The most evidence for clinical intervention is around behaviorally-based interventions focused on changing individual or dyad (parent-child, spouse) behavior, patterns, and/or routines around eating and activity. Given current evidence, MFTs should prioritize collaboration with professionals with skills around nutrition (registered dietitians) and physical activity specialists, and referrals to these professionals as indicated. In their own practice, MFTs should (a) identify concrete eating and/or activity behaviors to address, and existing family dynamics that may interfere with behavior change, (b) assess and find way to encourage family support for individual member’s behavior change, (c) note existing strengths of the family that can be extended to modifying health behaviors and routines, and (d) the cultural and intergenerational context of eating and activity behaviors for the family.

Pratt (on research recommendations): There is a need for multi-tier, family-based approaches to weight management intervention. In light of the scarcity of intervention work in pediatric and adult weight management meeting high family inclusion criteria, future research should focus on: (a) manualizing family therapy approaches with patients and their family members in weight management; (b) assessment of family dynamics consistent with the family therapy approach used in interventions, such as family functioning, chaos, and stress; (c) establishing family-level outcomes that associate with weight loss and behavior change in weight management; and (d) determining family-level outcomes that are sensitive to change over time and mediators or moderators of change in family-level outcomes.

You mention in the article, in relation to research implications, that the review is clearly missing well-established couple and family interventions. What recommendations do you have for MFTs as a way to advance future couple and family intervention research gaps?

Lamson and Pratt:
1. Theory should ground the development and implementation of any couple and family intervention.

2. Researchers seeking to advance the empirical base for couple and family interventions in the context of health conditions should work to integrate behavioral and systemic theories into their designs to address both individual behaviors and the interpersonal dynamics affecting behavior change.

3. MFTs can work toward advancements in intervention science applied to health conditions. Specifically, more early-stage interventions need to be developed and rigorously tested. 

4. There continues to be a lack of attention devoted to the contextual details of intervention populations. We must ensure we are including more than just the identified patient or participant in a study. We need to include a partner, parent, sibling or other relational support person into research studies. Furthermore, we must be more aware of how we are attending to representation of our sample in comparison to the population. Often studies that we reviewed provided frequencies in a demographic table but were not intentional about representation by race, sexual orientation, gender identities, ability, etc. Most researchers did not attend to demographic differences in their intervention or analyses and therefore results were generalized for all participants in the sample rather than identifying how social location influences or is influenced by family measures, interventions, or outcomes. 

Pratt: To advance research in this area, MFTs should take a staged approach to development, testing, and implementation of family interventions with health conditions. First, given the strong foundation for behaviorally-based theories in family interventions for health conditions, additional development and testing of behavioral plus family therapy interventions are needed. This research is likely best served as pilot or early-stage intervention studies to (a) establish and test the integration of theories, (b) clearly outline the targeted outcomes and interventive components to get to those outcomes, (c) explore acceptability to families, and (d) determine feasibility of implementing the approach in different settings and with diverse families.

We chose obesity for those 5 years of age and older because the CDC and National Institutes of Health (NIH) have consistently listed obesity as a leading precursor to preventable death.

Of all the CDC’s top 10 health conditions that lead to mortality (2019), couple and family therapy interventions for cancer offered the most promising efficacy. Three interventions published across four articles were indicated as probably efficacious.

Across the spectrum of studies, what did you learn about their inclusivity, cultural awareness and diversity? Is there a trend showing movement toward inclusivity or did you find this to be somewhat in need of improvement?

Lamson: Among the articles reviewed, only 22 specifically mentioned samples that included Black participants and only 19 included samples with Hispanic participants. Even though 13.4% of the U.S. identifies as Black and 18.5% identify as Hispanic (U.S. Census, 2019), only 11 studies had samples with at least 13.4% participants identifying as Black and only six had samples with at least 18.5% participants identifying as Hispanic. Further, of the articles that included more than one race or ethnicity in the sample, only two tested the efficacy of the intervention with participants of color. Even more apparent are the gaps in representation of other social locations. In fact, there are clear omissions of additional identifying factors by the CDC (2019) (e.g., gender identity, sexual orientation, ability; Institute of Medicine, 2011) which likely influence the lack of representation in health interventions and subsequently contribute to health disparities.

Some of the studies demonstrated that attention is increasing regarding diversity and intersectionality. However, clinicians are encouraged to implement the findings carefully because not all researchers included in this review addressed or approached their studies from a position of cultural awareness and humility, as witnessed in the lack of representation for diversity in their samples and analyses.

Were there any components in this evaluation that were surprising to you all, or something you hadn’t expected?

Some of the things that were most striking to us were the diversity and equity concerns listed in the previous response.

Also, out of the 87 articles that were in our review, only 4 named an interventionist (as part of the research team) that was trained in family therapy. This told us that there is more we need to do to advocate for MFTs to work in healthcare. We need to do more to train MFTs in how to initiate or join research teams that incorporate couple and family therapy in context of high mortality health conditions. We hope that by the next 10-year review on couple and family therapy interventions with health that we see more publications that include MFTs as part of the research team.

Do you all have any recommendations related to clinical training as a result of what you learned during this evaluation?

Lamson:
1. Intervention and implementation science training is necessary in MFT/MedFT programs.

2. Knowledge about the biopsychosocial-spiritual framework must extend beyond readings about the original model, moving toward assessments and interventions that recognize the ways physical health can exacerbate psychosocial health and vice versa in couple and family relationships

3. Trainers should teach about efficacious interventions as part of their courses or supervision and ask trainees to apply theory and understand the efficacy of intervention research in relation to the diverse populations they serve and their health conditions

4. Recognize the importance of identifying as a scientist–practitioner who can discern how their clinical theories may translate to culturally indicated couple and family interventions, and also forward thinking in what data they need to track to enhance clinical fidelity and evidence-based research

5. Emphasis should be given to teaching MFTs about ways to secure external federal, foundation, and local funding.

Mendenhall: We should train students to be comfortable working in the comparatively messy worlds of interdisciplinary and collaborative clinics, hospitals, and community sites—understanding medical language(s) and terminology(ies), coordinating the care and contributions that we collectively offer, rubbing shoulders with our biomedical colleagues—and working together in teams.

Out of the 87 articles in our review, only 4 named an interventionist (as part of the research team) that was trained in family therapy. This told us that there is more we need to do to advocate for MFTs to work in healthcare.

Are there any “next steps” for you all as the authors? Anything related to your practice or research that you can implement/improve/further study from this evaluation?

Lamson: Determining ways to include, not just an identified patient, but other family members, in both our treatment and our evaluation of treatment. Furthermore, we need to construct well designed dyadic and family research with important considerations in our sampling, assessment, and analyses of findings.

• More early-stage interventions need to be developed and rigorously tested. 
• Developmentally, the field of MFT appears to be at the stage where the rigorous assessment of early-stage implementation (Aarons et al., 2011) acceptability, appropriateness, feasibility, and adoption of couple and family interventions is needed, prior to applying more advanced experimental designs (i.e., RCTs).
• We must be accountable to representation in our science and practice. 

Martin: Many agencies and clinics have limited resources, including limited time with families struggling with a chronic disease, injury, or other medical ailment. That is why evidence-based practice is essential in healthcare today! This article can help our clients receive the right care at the right time. This article can also advance the development of practice standards for specific clinical cases. I plan to use this review many times in the years to come.

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