Multifamily Groups in the Treatment of Severe Psychiatric Disorders

by Tom Pyle

Multifamily Groups in the Treatment of Severe Psychiatric Disorders, by William R. McFarlane. New York: The Guilford Press, 2002. 403 pages.

[NOTE: For additional resources on the Multifamily Group modality, see PsychOdyssey Academy 360: Multifamily Groups.]


Mental illness shreds families. When a severe mental illness like schizophrenia strikes a loved one, the consequences are devastating. For both the loved one and the family, mental illness can be like a never-ending tornado, repeatedly inflicting untold emotional, financial, social, and psychological damage.

For the loved one’s benefit, the best means through such a maelstrom is family support. But it is not easy. If the onset doesn’t smash a family altogether, it marks the beginning of a Sisyphean odyssey. First are the loved one’s urgent treatments: emergency rooms, inpatient wards, outpatient clinics, stabilizing psych meds, assessments, psychiatric prescriptions, psychotherapeutic recommendations, discharge plans. Then follow his or her adjustments, pressures, emotional volatility, side-effects, and ostracization. Further along may come addiction complications, disability supports, housing issues, educational challenges, unemployment, legal problems, and stigma. At every turn for the family, there is anxiety, uncertainty, insecurity, and isolation. Extraordinary burden freights such families. They endure chronic sorrow. Many can’t take it. The mental illness breaks them apart. Afflicted loved ones sometimes fall by the wayside, untreated and addicted in shelters, on the streets, or in jail.

How can families in the maelstrom regroup, reconnect, and rebuild? How can they best work with their loved ones to stabilize their family circumstances and support the loved one’s recovery? They can engage in a modality called Family Psychoeducation, one of the five established evidence-based psychosocial practices for the treatment of severe mental illness. (The others are Illness Management and Recovery, Supported Employment, Integrated Dual Disorder Treatment, and Assertive Community Treatment.) They can specifically engage in the currently most effective method of Family Psychoeducation, the Multifamily Group approach as advanced by Dr. William R. McFarlane in his 2002 book Multifamily Groups in the Treatment of Severe Psychiatric Disorders.

Building on the earlier family psychoeducation work of Carol Anderson, Ian Falloon, Harriet Lefley, and Julian Leff, McFarlane’s Multifamily Group approach has both educational and psychotherapeutic components. It seeks to provide information about the mental illness and its treatments. It also seeks to teach strategies for coping with the illness, such as problem-solving skills, coping and communications skills, and crisis management. Its goals are to improve quality of life for both the family and the loved one, to improve the functioning of the family unit, and to reduce family stress.

Typically, the Multifamily Group approach consists of a closed group of five to eight families, including the loved ones with the mental illness, meeting biweekly for 90 minutes for up to 18 months. The approach is diagnosis specific, principally for schizophrenia but applicable to other illnesses. It is led by trained professionals and is centered primarily on the loved one’s outcomes. Focused on problem solving, cross parenting, and helping isolated families to rebuild what McFarlane calls “prosthetic” and “therapeutic” social networks, it has a strengths-based perspective and views family members as competent therapeutic agents in their own right.

McFarlane outlines four stages of the Multifamily Group psychoeducation. It begins with a “joining” phase of at least three meetings of the clinicians with family members individually to understand the process. The second phase is a one-day intensive education class about the mental illness itself for family members only without their loved ones. The third phase follows in the biweekly group meetings, where specific problems are reviewed and solutions developed. The final phase is a vocational and social rehabilitation phase in which the loved ones advance their recoveries with the benefit of work and social contact facilitated by the “prosthetic” social networks created by the Multifamily Group itself.

McFarlane traces the need for his Multifamily Group approach to the tragic consequences of dehospitalization in the 1970s. New antipsychotic medications of the 1950s and civil rights activism of the 1960s spawned the currently continuing evolution from the traditionally centralized custodial care model to community-based treatment. In the 1970s mental hospitals disgorged their patients into the communities, but the communities were hardly ready. Very serious gaps in service left patients in the lurch. Their families had to step in. But there was little professional or institutional support for the families, and the families were unprepared for the profound changes. Understandably, family stress increased dramatically, which often exacerbated the illnesses of their loved ones.

Sadly, academic clinicians who subsequently investigated such conditions did not pay proper attention to the recent social history and context. Instead, they questioned family attitudes and behavior as causal to the illnesses. As McFarlane notes, “The ironic, if not tragic, result was that families were held responsible for daily monitoring and care while they were excluded from participation in the treatment or decision-making process, and from information regardless of illness or intervention. They were held responsible for both care and cause.”

McFarlane likens the effects of mental illness to a bottomless sinkhole. The family coping with a severe mental illness needs an “extremely strong” system of support. “Expecting family members to respond in the most helpful manner to the often confusing and provocative symptoms of schizophrenia without some knowledge base and understanding is, at best, unrealistic.”  Since schizophrenia affects the entire personality, McFarlane concludes that targeting only the psychobiological and ignoring the psychosocial context is not sufficient. “[E]ffective treatment should address as many known aspects of the illness as possible, from as many perspectives as possible… [A] multifamily group satisfies the technical requirements for a natural social network.” At the same time, it “provides a nonintrusive alternative to the problem of family overinvolvement, an important element of high expressed emotion.”

The results of McFarlane’s Multifamily Group approach are compelling. Compared even to other Family Psychoeducation approaches, the Multifamily Group approach was shown to result in lower relapse and rehospitalization rates of loved ones after four years. Although a demanding family modality in terms of time, commitment, and professional resources, Multifamily Group is currently the most effective in helping families help their loved ones. For this important book and his many contributions to the advancement of effective treatment for severe mental illness, Dr. McFarlane is recognized among the titans of psychiatric rehabilitation. Amidst a fractured system of mental health services, his Multifamily Groups family psychoeducation modality represents an ideal which all families—as well as all public and private agencies seeking to serve them—should know and support.

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