Family Therapy and COVID-19 (C-19)

There are strange parallels and a vital lesson between the successful prevention of Covid-19 and the central theory of family therapy's successful outcomes. Before I begin, I need to emphasize that in no way do I want to diminish the tragic consequences of the Covid-19 Pandemic. This global plague, killing millions worldwide, wrecking economies, leading to unemployment and poverty across our planet, trivializes for many the importance of family therapy. That said, there are still lessons here for us clinicians.

The epidemiologist's advice to avoid this infection is simple: keep your distance, wash hands frequently, wear face masks and, if necessary, shelter in place. It is so clear. Take the common cold: if someone is contagious, you keep your distance… or you'll catch it. With C-19, across the world, countries demonstrate this linear correlation: follow this advice and keep your case numbers down, even way down, to zero.

In those countries that did not follow this counsel, the disease rampaged. This wisdom is not new. Over a hundred years ago, America was ravaged by the Spanish Flu pandemic. Despite their best efforts, often the epidemiologists were unsuccessful in getting citizens to shelter.

Philadelphia did not establish an organized system. In the above photo, taken on September 28, 1918, 200,000 people—about one-ninth of the city's population—packed into downtown for a rousing procession of floats and troops. War widows held court on street corners. Schoolgirls, in white, marched arm in arm. The virus spread and spread among the packed crowd. Two days later, the Mayor acknowledged that the city was in the throes of an epidemic—but it was too late: the city did not have a chance. Hundreds of police officers came down with a "blue flu," impeding law enforcement. Telephone switchboard operators fell ill, disrupting communication. Schools and public venues closed, funeral processions competed for street space and church bells tolled incessantly, mourning the dead. The parade was the coup de grâce—afterwards, the disease the spiked, taking as many as 20,000 lives.

With due respect to the profound difference between the catastrophic pandemic and relative banality of psychotherapy, from a systems perspective, there is commonality. Our job is to similarly create what the mayor of Philadelphia failed to effect: a congruent system.

With the virus, systems that are successful in containing the disease create an organized system of care, like the NZ Prime Minister's Team of Five Million.

In the 1950s, Don Jackson, one of the founders of our movement, famously wrote, to paraphrase, that for positive change, an organized system must be established (Jackson, 1957). Everybody in the system has to cooperate and work together toward a common goal. Indeed, that is the power of family therapy.

In my clinical work, over many decades, I've found that clients, especially children and adolescents, rarely have concomitant neurological problems in syndromes such as ADHD—the problem is in their context, usually their family system. To the extent the family therapy successfully produces congruence in the family system, the presenting problems disappear.

For example, when treating anorexia nervosa, when the parents cooperate in feeding their child, the youngster eats. The corollary is also true — whenever there is a lack of cooperation between the parents, even subtly, for example, as when the mother says, "Take a bite of your sandwich." The father demurs, so the child refuses to eat. Similarly, the Family Psychoeducation treatment of schizophrenia: to the extent the family's expressed emotion is mitigated, the psychotic symptomatology mitigates.

With COVID-19, when there are splits in the system such as citizens refusing to wear masks in large congregations, the cases spike

Lessons Learned

Another practical lesson for those of us toiling on the front lines seeking to transform families is to consider how epidemiologists track their progress:

We can do the same thing as we work with families. In my upcoming book Performance Based Family Therapy: A Therapist’s Guide to Measurable Change, I introduce Results-Based Accountability, a framework developed by Mark Friedman that is widely used by many governmental agencies in the US and abroad to improve programmatic outcomes. One of RBA's central tools is Turning the Curve from the baseline, where the numerical progress of clinical data is tracked.

Take, for example, in the treatment of Anorexia Nervosa, a Turning the Curve.

As the epidemiologists invaluably learned, the same is true for us clinicians, working on the front lines struggling to transform families. We can easily use Turning the Curve to track our clinical progress. Indeed, as Peter Drucker, the father of business journalism said, "if you can't measure it, you can't manage it."

Jackson, D. (1957). “The question of family homeostasis.” The Psychiatric Quarterly Supplement, 31 (part 1), 79-90. Presented as the Frieda Fromm-Reichmann Lecture, V. A. Hospital in Menlo Park, January 1954; also presented May 7, 1954 at the American Psychiatric Association Meeting, St. Louis, MO. See also Jackson, D. D. (1981). “The question of family homeostasis.” International Journal of Family Therapy, 3(1), 5–15.

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