Celebrating 30 years of Medical Family Therapy: introduction to the Special Issue

Our final issue of 2022 celebrates the 30-year anniversary of the groundbreaking book Medical Family Therapy: A Biopsychosocial Approach to Families with Health Problems, written by Susan McDaniel, Jeri Hepworth, and William Doherty. The book was a culmination of the authors’ work in primary care medical settings over many years and provided a name to describe a specialization that was being practiced throughout the world. The term ‘medical family therapy’ deserves some explanation due to its tendency to be misunderstood.

We use the word “medical” to convey a focus on health problems such as chronic illness, disability, and health behaviors. We use “family therapy” to emphasize the family systems framework that informs our model. This label is consistent with other disciplines such as “medical anthropology” or “medical social work.” However convenient and descriptive, the label is not without ambiguity. We do not wish to convey that medical family therapy is ordinarily practiced by physicians or that it necessarily involves prescribing medications (McDaniel et al., 1992, p. xix).

Over time, medical family therapy has become synonymous with integrative family therapy, including the integration of family therapy models and the integration of multiple systems, which is closely linked to the biopsychosocial model.

The biopsychosocial (BPS) model, introduced in 1977 by George Engel at the University of Rochester (Engel, 1977), is an expansive, layered hierarchy of systems that are in constant interaction over time. Like Bronfenbrenner’s Ecological Systems Theory (Bronfenbrenner, 1977), the BPS model highlights the importance of context in understanding a client’s presenting concerns: One cannot fully understand a system (or part of a system) without understanding its relevant context. Engel proposed the biopsychosocial model in response to what he perceived as biomedical fixation in medicine:

[The biomedical model] assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. The biomedical model not only requires that disease be dealt with as an entity independent of social behavior, it also demands that behavioral aberrations be explained on the basis of disordered somatic (biochemical or neurophysiological) processes. Thus, the biomedical model embraces reductionism, the philosophical view that complex phenomena are ultimately derived from a single primary principle, and mind-body dualism, the doctrine that separates the mental from the somatic. (Engel, 1977, p. 130)

Engel’s writings suggest that he was worried medicine was marginalizing the patient’s experience of pain and suffering, as well as the factors that impact illness, such as family and community relationships. McDaniel et al. (1992) expressed a related concern for family therapists:

[F]amily therapists have not practiced within a biopsychosocial model but have tended to operate within their field of comfort — the family system — and to pay only minor attention to the individual biological or physical dimensions. By neglecting the other levels of organization, they are at risk for “psychosocial fixation”. (p. 14)

McDaniel et al. (1995) advocated for an integrated biopsychosocial model ‘that assumes that every psychosocial issue has some biological component, and every biological event has psycho – social consequences’ (p. 286). Over time, we’ve seen a gradual healing of the mind-body split. For example, research on the brain and its impact on human development has led to significant advances in how we understand and work with clients (Patterson & Vakili, 2014; Siegel, 2020).

A legacy for medical family therapy

From my perspective, medical family therapy’s enduring legacy is its emphasis on collaborative care and increasing access to systems-oriented mental health services for patients who have historically been left out. Collaborative care, which is now more commonly referred to as integrated care or integrated behavioral health, is characterized by two or more health care professionals (e.g., family physician, family therapist) who work closely with each other, patients, and their family members to collaboratively define problems, identify strengths, and develop treatment goals and actions (Bower et al., 2006; National Collaborating Centre for Mental Health, 2010). Ideally, these health care professionals are located in the same office and routinely communicate in person and through an electronic medical record.

Physicians and nurses in primary care medical settings, for example, have always seen mental health care as part of their treatment scope, along with the more traditional physical illnesses. Although intense demands on their time often make it difficult for primary care providers to treat the whole patient, including addressing mental health concerns, patients look to primary care providers for mental health care. In fact, research suggests that primary care is the de facto mental health system (McDaniel et al., 1995). In other words, if people seek care for mental health concerns, they are most likely to seek treatment from their physician, not a mental health specialist.

When a patient who is depressed, anxious, and/or has a family problem goes to see their primary care provider, they may not report depression, anxiety or a family problem on an intake questionnaire. Instead, they may report difficulty sleeping, headaches, and/or fatigue. It is left to the physician to decipher what these symptoms mean. When mental health concerns are identified and patients are referred to a mental health professional, patients have reported significant benefits (National Institute for Health and Clinical Excellence, 2004).

McDaniel, Hepworth, and Doherty inspired a new generation of family therapists to seek training in medical settings. Structured clinical internships emerged at the Chicago Center for Family Health and University of Rochester (Gawinski et al., 1999). Later, several universities began providing specialized training in medical family therapy, including doctoral degrees at East Carolina University and Saint Louis University (Tyndall et al., 2014). As the integration of mental health services into medical settings becomes commonplace, a continuing challenge remains: How do we keep a systems perspective alive in our consultations (‘Who does the patient live with?’) and daily clinical practice (‘Is there anyone else you’d like to include in our first meeting?’)? The articles in this special issue help advance the effort to think and practice from a culturally sensitive, systems perspective in a range of medical settings.

Disclosure statement

No potential conflict of interest was reported by the author(s).