Involving Family in Psychosocial Interventions for Chronic Illness
Department of Psychiatry, University of Pittsburgh School of Medicine, and University Center for Social and
Urban Research, University of Pittsburgh
ABSTRACT—Interactions with close family members have
consequences for the emotional and physical well-being of
individuals who are dealing with a chronic physical illness.
Therefore, inclusion of a close family member in psycho-
social interventions for chronic illnesses is a logical treat-
ment approach that has the potential to boost the effects
of intervention on the patient and also benefit the family
member. However, randomized, controlled studies indicate
that such family-oriented interventions generally have
small effects. The efficacy of these treatment approaches
might be enhanced by targeting specific interactions that
emerging research identifies as promoting or derailing
healthy behaviors and by better incorporating strategies
from family caregiver interventions. In addition, family-
oriented interventions should be more fully evaluated, by
assessing the benefits for both patients and family mem-
bers. Future research in this area can tell us much about
how and when to involve family in treatment of specific
chronic illnesses and, in turn, may inform conceptual
models of the impact of family interactions on health.
KEYWORDS: chronic illness, psychosocial interventions,
family, social support
Family is not an important thing, it’s everything.
—Michael J. Fox
Regardless of an individual’s celebrity, few circumstances in
adulthood are more stressful than a chronic illness, and family
plays an important role in psychological adjustment and symp-
tom management. Emotionally and instrumentally supportive
actions on the part of family members, as well as family conflict
and criticism, have been linked with patients’ emotional well-
being, health behaviors, immune function, blood pressure, and
illness events (Kiecolt-Glaser & Newton, 2001; Schmaling &
Sher, 2000). These associations have been observed across ill-
nesses as diverse as cardiovascular disease, chronic pain dis-
orders, arthritis, cancer, renal disease, and Type 2 diabetes, as
well as in healthy individuals who are at risk for illness. In turn,
illness in a loved one can erode family members’ psychological
and physical well-being over time and compromise their ability
to be supportive, especially when the illness is life threatening
or the patient requires assistance with daily activities.
Psychosocial or behavioral interventions for chronic illness,
such as patient education, support groups, and cognitive-
behavioral therapies, have been shown to have effects on health
and emotional well-being that surpass improvements attained
with usual medical care alone (i.e., medication or surgery).
Because of the links between family relationships and chronic-
illness management, some researchers have incorporated a close
family member such as the spouse in these interventions. The
rationale for involving a family member in treatment can be
found in the biopsychosocial model of health and illness and
specific marital and family-systems frameworks. These con-
ceptual models and frameworks have been supported by
empirical evidence showing that close social relationships, es-
pecially the marital relationship, affect biological systems,
health behaviors, and psychological well-being. Therefore,
improving the quality of interactions with a close family member
or involving that individual in disease management should
promote adjustment to chronic illness. Specific treatment ap-
proaches range from enlisting the family member’s help in
changing the patient’s health behaviors (e.g., training the spouse
of a patient with chronic pain to help the patient practice pro-
gressive muscle relaxation) to also addressing issues of how
spouses can provide effective emotional and instrumental sup-
port (e.g., counseling for couples dealing with the wife’s breast
cancer).
Incorporating a close family member in psychosocial treat-
ment may have a positive impact on patient health behaviors,
Address correspondence to Lynn M. Martire, 121 University Place, Room 508, University of Pittsburgh, Pittsburgh, PA 15260; e-mail: martire@pitt.edu.
CURRENT DIRECTIONS IN PSYCHOLOGICAL SCIENCE
90 Volume 16—Number 2Copyright r 2007 Association for Psychological Science
emotional well-being, and symptomatology as the result of
increased empathy and supportiveness of the family member. In
addition, the family member’s caregiving burden may be eased
by the validation of his or her caregiving experiences and im-
proved interactions with the patient. In the following sections,
we summarize our findings from two recent systematic reviews
of the literature that compared family-oriented psychosocial
intervention with usual medical care alone and with patient-
oriented psychosocial intervention.
ARE FAMILY INTERVENTIONS MORE BENEFICIAL
THAN USUAL MEDICAL CARE?
In our first review of the literature, we included studies that
compared family-oriented psychosocial interventions (which
included usual medical care) to usual medical care that did not
include a psychosocial component. We reviewed the findings of
70 randomized, controlled studies that compared these two
approaches and that recruited a family member, such as the
spouse or an adult son or daughter, for every patient (Martire,
Lustig, Schulz, Miller, & Helgeson, 2004). These interventions
focused on different illness populations; used psychological,
social, or behavioral approaches; and were targeted at either the
patient’s closest family member (the primary caregiver in some
studies) or both patient and family member. Because we in-
cluded different illnesses in this review, our focus was on out-
comes that were generalizable across illnesses, and we examined
effects on the patient (i.e., depressive and anxiety symptoms,
relationship satisfaction, physical disability, and mortality) as
well as on the family member (i.e., depressive and anxiety
symptoms, relationship satisfaction, and caregiving burden).
Almost half of the studies focused on populations with dementia;
the remainder focused on those with cardiovascular disease,
cancer, general medical frailty, chronic pain, stroke, rheumatoid
arthritis, and traumatic brain injury.
For patients, interventions that included only patients’ spou-
eses had small, positive effects on reducing depressive symp-
toms across various illnesses, but interventions that included
mixed groups of family members (e.g., spouses and adult chil-
dren) did not decrease depressive symptoms. In addition, fam-
ily-oriented interventions that focused on individuals dealing
with hypertension or cardiovascular disease resulted in a small
decreased risk for patient mortality, especially if the interven-
tions included mixed groups of family members and used be-
havioral treatment approaches. For family members, we found
that family-oriented interventions slightly reduced the psycho-
logical burden of caregiving, as well as depressive and anxiety
symptoms. This latter finding has important implications for
family members’ physical health because caregiver burden and
distress have been linked to an increased risk for morbidity and
mortality (Schulz & Beach, 1999).
ARE FAMILY INTERVENTIONS MORE BENEFICIAL
THAN PATIENT INTERVENTIONS?
From a behavioral-medicine perspective, the more interesting
question than whether family interventions are more beneficial
than usual medical care is whether targeting both the patient and
the family member with psychosocial or behavioral strategies is
better than targeting only the patient with these strategies (with
both treatment approaches including usual medical care; see
Fig. 1). In other words, is there an advantage to patient and
family member when the family member is included in a psy-
chosocial intervention? Unfortunately, few studies have been
Illness Parameters – Physical symptoms – Treatment side effects
Emotional Well-Being – Depressive symptoms – Anxiety – Perceived stress
Family Factors – Effective emotional support and assistance to patient
– Burden on family member
Health Behaviors – Diet, exercise – Smoking, alcohol use – Medication adherence
Biological Parameters – Cardiovascular, immune,
and neuroendocrine functioning
Functional Status – Overall illness severity – Physical disability
Patient-Oriented Psychosocial Intervention
Family-Oriented Psychosocial Intervention
Fig. 1. Heuristic model showing domains of functioning (i.e., emotional well-being, health behaviors, and family factors) that mediate parameters of chronic illness in their effects on a patient’s functioning. Intervention that incorporates or involves a close family member may have added benefit as compared to intervention aimed only at the patient, due to the former’s effects on the third domain of functioning (i.e., family factors). The type of family-oriented intervention depicted in this model includes standard content (e.g., education regarding illness etiology and cognitive-behavioral skills training for illness management) and incorporates a close family member by treating that individual as a collaborator in the patient’s inter- vention and/or by addressing his or her personal concerns, burden, and supportiveness of the patient. Examples of specific constructs are provided for each domain of functioning.
Volume 16—Number 2 91
Lynn M. Martire and Richard Schulz
designed to answer this question, and those show mixed findings
for patients and focus little attention on whether family members
benefited from being included.
The findings of 12 randomized, controlled studies comparing
family-oriented intervention to patient-oriented intervention
were recently reviewed (Martire, 2005). Approximately half of
these studies showed significant improvements over time for
those receiving family intervention or reported that there was
also a statistically significant advantage of family intervention
over patient intervention. For example, individuals with chronic
low back pain who attended exercise sessions in combination
with couple-oriented behavioral therapy showed greater less-
ening of pain and pain behavior (e.g., grimacing, limping,
groaning) and greater diminishment of the impact of pain on
their lives than did individuals who received only an exercise
intervention. Our own research with osteoarthritis patients and
their spouses showed that patients felt they managed their
arthritis more effectively if they received a couples-oriented
education and support intervention than if they received edu-
cation and support with other patients only (Martire et al., 2003).
Consistent with these positive findings, a more recent study
showed that problem-solving therapy for cancer patients and
their significant others reduced the patients’ psychological
distress more than did patient-focused problem-solving therapy
(Nezu, Nezu, Felgoise, McClure, & Houts, 2003). Significant
improvements over time as the result of family-oriented inter-
vention have also been reported regarding blood-pressure con-
trol in hypertension; stress and cardiovascular complications in
postcardiac surgery; and pain, psychosocial adjustment, and
number of medical visits in chronic pain.
In contrast to the positive findings for family-oriented inter-
ventions, an educational intervention for individuals with
rheumatoid arthritis and their significant others resulted in
decreased self-efficacy and increased fatigue, whereas a similar
patient-oriented intervention was found to enhance self-efficacy
and reduce fatigue (see review by Martire, 2005). Such unex-
pected negative effects of family-oriented intervention may oc-
cur in studies that do not address communication issues between
patients and partners, or partners’ personal concerns. We return
to this issue in the next section.
In the remaining studies, the more efficacious approach for
patients depended on factors such as patient gender and specific
type of intervention (i.e., educational versus behavioral
approach; see review by Martire, 2005). For example, a couple-
oriented behavioral program for obese individuals with Type 2
diabetes resulted in more weight loss for female patients than did
a patient-oriented program, whereas male patients lost more
weight in the patient-oriented program. (Spouses who partici-
pated in the couples program lost more weight than spouses of
individuals in the patient-oriented program, regardless of their
gender.) In addition, studies focused on rheumatoid arthritis or
osteoarthritis showed that family-oriented interventions that
used cognitive-behavioral rather than educational approaches
resulted in greater reductions in joint swelling or pain-related
outcomes than did cognitive-behavioral interventions for pa-
tients only.
These studies illustrate how research can reveal for whom and
under what conditions family intervention may be especially
beneficial, by identifying patient, family member, or intervention
characteristics that moderate the effects of family intervention.
A recent study showed that a couple-oriented intervention for
breast cancer patients that was designed to enhance support
exchanges (e.g., effective communication, problem solving as a
team, respecting differences in coping styles) was most helpful to
patients with unsupportive partners (Manne et al., 2005). This
study, as well as others (e.g., Helgeson, Cohen, Schulz, & Yasko,
2000), raises an important question about patient-oriented in-
terventions that have targeted individuals with unsupportive
relationships and have had small effects on patient outcomes:
Would the effects of these interventions have been stronger had
the interventions included a family member?
HOW CAN WE ENHANCE THE EFFICACY OF
FAMILY INTERVENTIONS?
As described above, the findings of randomized trials indicate
that family-oriented interventions do not consistently outper-
form patient-oriented psychosocial interventions. There are
several explanations why the promise of family interventions has
not been fulfilled. Methodological flaws, such as failing to ensure
the full participation of family members, may explain why this
approach has had null or weak effects in some studies. In
addition, family-oriented interventions have not consistently
targeted family interactions that affect health and issues sur-
rounding the burden of illness on a family. Interventions appear
to be more beneficial for patients (Martire et al., 2004) and for
family members (Martire, 2005) when they address such issues.
Research on family caregiver interventions illustrates the value
of particular strategies such as stress management, skills
training, and validation of the family member’s experiences as a
provider of support (Schulz et al., 2002).
But how can we explain the generally small effects of inter-
ventions targeting family support or the relationship between
patient and family member? One explanation may be found in
the empirical literature that is the foundation for many family-
oriented interventions for chronic illness. Early correlational
research revealed that patients sometimes perceive well-
intentioned family actions or communications as unhelpful, and
that overprotective or solicitous behaviors may be perceived as
helpful by patients but also cause them to be more physically
inactive and dependent (Lyons, Sullivan, Ritvo, & Coyne, 1995).
Thus, past family-oriented interventions may not have been
successful in (a) reducing the frequency of family actions or
communications that derail healthy behaviors and distress
patients or (b) bolstering interactions that promote healthy be-
haviors and emotional well-being.
92 Volume 16—Number 2
Family-Oriented Interventions
More recent conceptual and empirical work might be useful in
developing family interventions that have greater impact and
more consistent effects. Here, we provide examples of relevant
research in two of several useful areas: autonomy support and
social control. We chose to highlight these two areas of research
because they focus on health behaviors, and management of
today’s most common chronic illnesses often requires patients to
make substantial changes in diet and exercise and to adhere to a
medication regimen despite unpleasant side effects. Autonomy
support refers to behaviors that are characterized by warmth,
empathy, and understanding for an individual’s situation;
patient-centered communication; and the provision of choices
for making health behavior changes. A program of research on
individuals with Type 2 diabetes has shown that patients with
health-care providers who are more supportive of their autonomy
feel that they are better able to regulate their blood glucose and
show improved glucose control over 1 year (Williams, Freedman,
& Deci, 1998). Complementing these findings, our work has
demonstrated that older adults with disabling arthritis who feel
that they have no choice over the amount, timing, and manner
of physical assistance from their spouses experience increased
depressive symptoms over time (Martire, Stephens, Druley, &
Wojno, 2002).
Emerging work in the area of health-related social control also
might be useful to incorporate in family interventions. Social
control is thought to be distinct from social support and refers to
an individual’s attempts to regulate or influence the behaviors of
another person through actions, affective responses, and cor-
rective feedback. Early theory on social control suggested that it
may deter poor health practices but at the same time cause dis-
tress by evoking irritation, resentment, or guilt. However, more
recent research has identified tactics that may promote healthy
behaviors and also be appreciated by patients—tactics such
as persuasion (e.g., efforts to convince or motivate), modeling
(enacting the behavior), reinforcement, and using logic (e.g.,
pointing out positive consequences; Lewis & Butterfield, 2005).
As these lines of research move forward and are conceptually
and empirically synthesized with previous research, findings can
inform the development of psychosocial interventions for spe-
cific illness populations. Specifically, future interventions may
include content aimed at teaching family members how to sup-
port patients’ need to make their own choices and carry out daily
activities independently. This type of family-oriented interven-
tion may show stronger and more consistent advantages over
psychosocial treatments focused only on the patient.
CONCLUSIONS
There is not yet strong evidence for the efficacy of family-
oriented interventions. However, including family members in
health care is an approach that has much face validity. Moreover,
the small effects that have generally been observed across
studies, particularly with regard to the emotional well-being of
family members, make a compelling argument for further re-
search using well-designed studies that can more fully reveal
what type of patient may benefit from this approach.
Future research may better evaluate the added benefit of
family-oriented interventions by including specific features that
have often been disregarded in past studies, such as random
assignment of participants and adequate statistical power to
detect between-group differences. In this research, it would be
optimal to assess outcomes for both the patient and the family
member. Finally, we have much to learn about the causal
mechanisms linking positive and negative aspects of close social
relationships to physical health (e.g., psychological, behavioral,
and biological pathways), and such knowledge is critical for
developing family-oriented interventions that truly make a dif-
ference for patients and their families.
Recommended Reading Cohen, S., Underwood, L.G., & Gottlieb, B.H. (2000). Social support
measurement and intervention: A guide for health and social scientists. New York: Oxford University Press.
Lyons, R.R., Sullivan, M.J.L., Ritvo, P.G., & Coyne, J.C. (1995).
(See References)
Martire, L.M. (2005). (See References)
Martire, L.M., Lustig, A.P., Schulz, R., Miller, G.E., & Helgeson, V.S.
(2004). (See References)
Schmaling, K.B., & Sher, T.G. (2000). (See References)
Acknowledgments—Preparation of this manuscript was sup-
ported in part by National Institutes of Health Grants K01
MH065547, R24 HL076852-076858 (Pittsburgh Mind-Body
Center), and R01 NR008272.
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