Abstract
When John Bowlby wrote that ‘much psychiatric illness is an expression of pathological mourning’ he was continuing a line of thought reaching from the Freud of Mourning and melancholia through Erich Lindemann, Colin Parkes and Beverley Raphael. Now, in this important book, David Kissane and Sidney Bloch extend this legacy. They do this by, as Colin Parkes notes in his foreword, attending to ‘grief as a family event’. Usually, attention to the bereaved is provided on a one-to-one basis, in the aftermath of the death of a family member. This book presents a compelling argument for familycentred care starting earlier on in palliative care, and presents ways of both identifying and intervening with families during a terminal illness who are at risk for the later psychosocial complications of bereavement. It is an idea of considerable clinical and preventive possibilities. Buttressed by meticulous empirical studies, the model Kissane and Bloch propose has major implications for health policy and psychotherapy.
The first part of the book describes the development of Melbourne-based family grief studies over the past 10 years. From the 1980s on, the family therapy literature was emphasizing the importance of family as distinct from individual grief. Murray Bowen spoke of ‘the generational shockwave of death’. However, there was a dearth of systematic or longitudinal studies until the Melbourne studies. From study of families involved in palliative care the authors were able to define an empirical family typology that could consistently link psychosocial morbidity with family functioning and refine a screening instrument, the Families Relationship Index (FRI). The FRI is a 12-item questionnaire for family members which measures individual perceptions of family cohesiveness, conflict and expressiveness. In the studies about a half of the families showed high cohesion and open expression and minimal conflict (‘supportive or conflicting-resolving’). They were likely to manage grief well. One-fifth of the families revealed high or moderate conflict, low cohesion and poor expressiveness (‘hostile or sullen’), and one-third were ‘intermediate’. These two groups had poorer outcomes and higher levels of psychosocial morbidity postbereavement, and represented the obvious targets for family intervention.
These were important findings. As the authors comment ‘a clinically useful model to conceptualize families by reference to their functioning as a group thus emerged, a wonderful result’ (p.33).
Building on this empirical work, their next project was a pilot study of family therapy. Families identified by the FRI as at-risk, were offered interventions focusing on promoting cohesion, expression of feelings and conflict management. The feedback from families and therapists was promising. Maladaptive grieving was reduced and family coping responses improved. The culmination was a treatment manual for ‘family focused grief therapy’ (FFGT) that formed the base of a large randomised, controlled 5 year trial for families with a terminally ill member. This was a task Sid Bloch recently characterized as ‘both laborious and poignant’. The trial of FFGT is now completed. The baseline data are just published (they confirm the predictive validity of the model), and the intricate data analysis that family interactions demand is near to completion. We eagerly await the results, to see whether FFGT can meet the gold standard of the RCT.
In the meantime, and of great value whatever the RCT finally shows, is the step-by-step guide to FFGT in the second part of the book. The model is relatively brief and time-limited, requiring 6–10 sessions over 6–12 months, from the period of palliative care on through the death and funeral (for which they set guidelines for the therapist's attendance) to the later mourning of the family. Their model elegantly applies the core concepts and methods of family therapy, including working with genograms and multigenerational scripts, emphasizing family strengths and traditions (families are never labelled as ‘dysfunctional’), and encouraging mutual expression and forgiveness and completion of ‘unfinished business’. It is a well ordered manual, but absolutely written with heart, and avoids the strategic/ cognitive cleverness that sometimes afflicts family therapy. The authors illustrate the complications, challenges and ethical issues that arise in family work with vivid examples, and an account of a completed therapy.
These sections are for anyone who wants to expand their clinical skills in family therapy or grief counselling. and more than that, I would advocate the book to anyone wanting to reflect on mortality and family loss. I began this review during my father's palliative care and dying. I was tempted to beg off from writing the review, but I'm glad I didn't. The book gave me both consolation and clarity about what I was going through.
In the last section the authors wrestle intelligently with the problems of ‘making the psychosocial domain as natural a target of care as the relief of pain…’ (p.194). It is one thing to show the preventive, cost-effective and clinical value of family interventions. It is quite another to have such conversations heard in the din of all the other technologic and fiscal demands on the health system. Yet the quiet, persistent voice of this book must surely be heard. Family psycho-educational approaches are proving increasingly important in the management of chronic illnesses, from schizophrenia to diabetes and bulimia. The evidence is coming in. This book deepens the arguments for psychosocial care. It is amongst the most important health service and family therapy research produced in Australia.