Implementation of the McMaster Model in Family Therapy: Effects on Family Function in Married Couples.

Objective: Family function is one of the main effective factors on stability of the family. Family therapy can promote family function and performances. This study aimed to assess the effects of family therapy on family function among couples in Yazd province (Iran) based on the McMaster model. Method : The research population was selected from volunteer couples in Yazd in 2017 who were invited by publicity announcement to participate in this research. Finally, 40 couples were selected and randomly divided into 2 intervention and control groups. Participants answered to the demographic and Family Assessment Device (FAD) questionnaires. The acquired information was analyzed using inferential and descriptive statistics and SPSS 21 software.
Results: The outcomes showed significant differences between the intervention and control groups in problem-solving (p = 0.01), communication (p < 0.0001), emotional responsiveness (p = 0.01), emotional involvement (p < 0.0001), and general function (p = 0.04). The roles and behavior control domains were improved after the intervention in 2 groups, but the differences were not significant.
Conclusion: Family therapy based on McMaster model can promote the skills of problem- solving, family communication, emotional responsiveness, emotional involvement, and general function in couples. Healthy family functioning is a substantial domain of concern for mental health specialists who provide family interventions. Our findings enhance considerably to family professionals' knowledge about patterns of family function in Iranian families.

RCT Entities:   Population Interventions Outcomes

A desirable family is an open system whose members are emotionally interconnected, but they have also been encouraged to expand their individual identities. The atmosphere of such a family is full of love, in which each member is accepted unconditionally. Therefore, the family can solve the conflicts and respond to its members’ help requests with pleasure (1). Family function has internal and external dimensions. The criterion of family efficiency is not absence of psychological stress, problems, and conflicts in the family, but it is the ability of family to fulfill its tasks and functions. This ability, in turn, depends on the structure and compatibility power of couples (2). Ahluwalia et al (2018) stated that family therapy has been found to be an efficacious treatment for couples with some problems. Therapy programs, which have included spouses, have been found to be effective in motivating couples to enter and continue treatment. They have also been associated with better outcomes such as better family functioning. The theoretical framework underlying couples therapy is an understanding of marital discord. Problems in the marital relationship, poor communication, and poor problem-solving may precede dysfunctional relationships. Marital and family conflicts also have the propensity to facilitate relapse (3).

Family therapists attempt to decrease problems and difficults by improving interactions between members of family. Family therapy offers families a way to develop or maintain a healthy and functional family.

Families with more difficult and intractable problems require family interventions and therapy. The systemic framework approach offers advanced family therapy for such families (4).

Many theorists and researchers occupied for the study of the family and manners that affect family structures have changed during the past 2 decades. It appears the families in the 21st century have faced new challenges that threaten the family functioning (5). To survey about the family systems, several proceedings have been used. For instance, many researchers have offered the need for intervention methods to study family types and functions (6, 7). The factors that affect compatibility of family members are their attitude toward problems, especially in the domains of family functioning, such as communication, problem-solving, roles, behavior control, and ways to express one's interests and emotional responses. One of the models, which assess the family functions, is the McMaster Model (8). In this regard, using an educational model can help the couples.

McMaster model is one of the effective and appropriate models for studying healthy families in Iran, which can be used by family counselors to decrease familial problems in the country (9, 10, 11). It is an effective model in family studies, which increases the effectiveness of interventions in family stability and reduces marital conflicts and risk of divorce. This model can be used to help couples who have problems and want divorce. Furthermore, it promotes the quality of family relationships (12).

Continuous investigations that have been conducted since the development of McMaster's model are the main strengths of this approach (13). Unfortunately, little attention has been paid to the family functions in the Iranian people with different cultures. Due to the increasing divorce rate in our country, especially in Yazd, the damages caused by it, and the couples’ worries, this research was done to assess the effects of family therapy on family function among couples in Yazd province (Iran) based on the McMaster model to improve the dimensions of family function and marital satisfaction in the couples.

Materials and Methods

This semi-experimental study was based on a pretest-posttest design and investigated couples in Yazd in 2017. Based on the results of a preliminary study conducted by the researchers (S = 4.5) and considering the significant level of 5% and the test power of 80%, and to achieve a significant difference in the mean score of the domains, 40 participants (20 couples) were needed in each group (intervention and control).

The first 45 couples (90 persons) were registered as control and the intervention groups (Figure 1).

Figure 1

Consort Diagram of Randomization, Allocation, Follow-Up and Analysis

The couples were invited through publicity announcement and those willing to participate in this research were selected. We also sent letters to several psychological counseling centers and asked them to introduce couples who referred to these centers for treatment and had no therapeutic and educational sessions until the start of the research. The couples were selected based on the following criteria: having complete awareness, negative history of main psychological disorders, willingness to participate, having at least 1 child or more, and having full consciousness (absence of history of insanity and dementia, lack of mental retardation, and awareness of time, place, and person). Then, the selected couples were randomly divided into intervention and control groups. Randomization method was used to reduce bias and participants in both groups had an equal chance of being in each group. In addition, the lack of missing data was and effective way to reduce bias. At first, informed written consents, demographic and FAD questionnaires were collected from eligible families. Then, the training package and its content were adjusted based on the results of pretest questionnaires. Educational interventions were later performed for 7 sessions of 75-90 minutes for the intervention group. All intervention programs were approved by 5 professionals containing counselors, psychologists, and psychiatrists. The participants of both groups were asked to complete the FAD questionnaire 3 months after the intervention. Also, the control group was informed about the educational materials at the end of the study. Moreover, those families with severe problems were requested to refer to mental health specialists.

The content of the educational package, which was done through lectures by 6 psychologists, is presented in Table 1. In all training sessions, the couples asked their questions and the teachers took feedback.

Table 1

Content of the Educational Package of the McMaster Model in Family Therapy

Sessions 1	Title and goalsGetting to know and expressing of goalsRoles: improvement the proper roles and responsibilitiesEmotional responsiveness: increasing of emotional supportEmotional involvement: increasing of proper emotional involvementCommunication: empowerment for effective communicationProblem solving: improvement the effective strategies for problem solvingBehavior control: management of the stress and anger	ContentConcept and types of family, goals of family formation, healthy family characteristics, divorce statistics in IranRole delegation in the family, barriers of accepting responsibilities in family affaires, unbalanced distribution of roles and its effect on family functioningEmpathy and emotional support (intimacy, sympathy, and forgiveness), inappropriate emotional interactions with family members and emotional involvementEffective communication, the consequences of lack of communication skills, types of verbal and non-verbal communicationEffective problem-solving strategies, decision-making skills, consequences of using incorrect solutions on family functionAnger management, ways to cope with stress in crisis , extreme monitoring and negligence
2
3
4
5
6
7	Making conclusion, taking feedback, guiding couples for referring to the consultant if necessary	General function and summarization of all domains

The participants’ demographic characteristics, such as age, education, job, and similar subjects, were recorded using a questionnaire. Furthermore, FAD questionnaire developed by Epstein, Baldwin, and Bishop in 1950 was used based on the McMaster theory. The word of “family functioning” shows the ability of a family to work together as a unit to satisfy the basic needs of its members. The McMaster Family Function (MMFF) emphasizes the interrelations among the family members and family system. The McMaster model was developed at McMaster University and Brown University. It is a model of family counseling that accentuates the family unit as a setting for social, biological, and psychological development of its members. The 6 dimensions of the FAD correspond to dimensions of family functioning in the McMaster model (14). It contains 60 items and represents 6 dimensions of family functioning that are highly relevant in clinical practice. Each question is related to one of the dimensions and describes the healthy and unhealthy functions of the family. The family domains include problem-solving, communication, roles, emotional responsiveness, emotional involvement, and behavioral control (15, 16, 17).

The higher scores achieved by respondents indicate their worse levels of family functioning. Accordingly, individual scale scores range from 1 (the best function) to 4 (the worst function). This questionnaire has high levels of internal consistency(18). The validity of the applied questionnaires was evaluated within and out of Iran. In the Iranian version of the questionnaire, Cronbach’s alpha factor was 0.94 for all the instruments and the subscales were defined as problem-solving (0.86), communication (0.87), roles (0.87), emotional responsiveness (0.81), emotional involvement (0.89), and general functioning (0.82). The validity and reliability of FAD were also examined in other studies. In the research of ZadehMohammadi and Malekkhosravi (2011), Cronbach’s alpha for the entire scale was 0.90 and the test-retest coefficient was 0.82 (19-21).

All quantitative data were coded for statistical analysis using SPSS software version 21 (SPSS Inc, Chicago). The statistical tests including Chi-Square, Mann-Whitney U-test, independent sample t test, paired sample t test, and Univariate covariance analyses were used to evaluate and compare the subscales of family function in 2 groups of couples. P value < 0.05 was considered as statistically significant.

Ethical committee of Public Health School, Shahid Sadoughi University of Medical Sciences (Ethic code: IR.SSU.SPH.REC.1395.52) Yazd, Iran approved this study. Data were kept strictly confidential and personal identifiers were not put on the questionnaires. They had no limitation to participate in the study. The study purpose and objectives were explained to each participant. Informed consent was sought from all study participants before the commencement of study activity. No biological sample was obtained as a part of the data collection.

Results

The difference between the mean age of the intervention group (34.67 ± 5.70) and that of the control group (37.00 ± 7.66) was not statistically significant (P = 0.88). Moreover, the average duration of marriage in intervention group (9.90 ± 4.70) and control group (11.75 ± 7.75) was not statistically significant (P = 0.20). Other demographic variables, including education, job, income satisfaction, smoking, drinking, substance abuse, referring to a psychiatrist, referring to the court, and referring to the social emergency department, were not significant between the 2 groups (p> 0.05).

Table 2 represents the mean scores of FAD in the 2 groups before intervention. As it is shown in this table, in all domains, the intervention group had higher scores, indicating a worse family functioning.

Table 2

Participants’ FAD Mean scores Before Intervention of the McMaster Model in Family Therapy

Variable	Intervention		Control		P value
	Mean	SD	Mean	SD
Problem solving	12.90	2.47	11.90	1.98	0.18
Communication	20.15	3.94	18.60	3.46	0.08
Emotional responsiveness	13.67	2.54	12.07	2.37	0.10
Emotional involvement	17.95	2.68	17.22	2.16	0.14
Roles	25.50	3.00	23.20	2.86	0.05
Behavior control	22.02	3.82	20.52	3.99	0.07
General function	24.87	4.43	23.12	4.11	0.06

The results showed significant differences between the intervention and control groups in the domains of problem-solving (p = 0.01), communication (p < 0.0001), emotional responsiveness (p = 0.01), emotional involvement (p < 0.0001), and general function (p = 0.04). The scores of roles and behavior control domains were decreased after the intervention in both groups, but the differences were not significant (Table 3). Moreover, lower scores indicated a better function in FAD.

Table 3

Participants’ FAD Mean Scores after Intervention of the McMaster Model in Family Therapy

Variable	Intervention		Control		P value
	Mean	SD	Mean	SD
Problem solving	10.05	2.74	11.80	2.22	0.01
Communication	16.27	3.78	18.92	4.60	0.00
Emotional responsiveness	11.30	2.65	13.27	2.66	0.01
Emotional involvement	14.35	2.23	17.08	2.56	0.00
Roles	21.05	4.41	22.62	3.42	0.07
Behavior control	19.30	3.10	20.22	3.73	0.08
General function	21.25	4.37	23.22	4.73	0.04

The univariate covariance analysis was used to control the effect of pretest on the dependent variables in the posttest stage. There were significant differences between the 2 groups in roles (P < 0.0001) and behavior control (P < 0.001). This means that training was able to improve the 2 domains in the intervention group. To conduct covariance analysis, regression gradient equivalence and normality of data were considered as prerequisites (Table 4).

Table 4

Univariate Covariance Analysis on 2 Domains of FAD in Intervention and Control Groups at Posttest

Domains	Sum of squares	Degree of freedom	Mean of squares	F P value Statistical power
Roles	218.04	1	218.04	23.24 0.0001 1
Behavior control	110.21	1	110.21	12.99 0.001 1

Also, significant differences were observed in each domain before and after intervention in case group: problem-solving (P < 0.001), affective involvement (p < 0.002), behavior control (P < 0.001), and other domains (p < 0.0001) by paired sample t test. However, there were no significant differences in each domain before and after the intervention in control group: problem-solving (p = 0.593), communication (p = 0.245), emotional responsiveness (p = 0.615), emotional involvement (p = 0.853), roles (p = 0.191), behavioral control (p = 0.604), and general function (p = 0.889).

Discussion

The results of this study showed training can improve family function in couples in Yazd. Teaching them problem-solving strategies could improve this skill in couples. This result is in the same line with the findings of Markman and Hallweg (1993) in couples who were unable to solve problems (22). Cognitive training can increase problem-solving skills in couples and reduce their conflicts (23). The results of Tellado's study (1984) also confirmed the positive effect of educational intervention on increasing problem-solving skills and promoting solving family problems (24). In the domain of "communication", the results showed education was able to improve communication skills in couples. Usually the most common complaint mentioned by couples is the lack of proper and mutual communication (25). This conclusion is similar to findings of Robinson and Price (1980) as well as Eidelson and Epstein (1982), based on the fact that communication problems can be the main cause of marital conflicts (26, 27).

Moreover, educational intervention improved the "emotional responsiveness and emotionalinvolvement" in couples. These results also confirmed that educating couples to express their love, increased marital satisfaction (28, 29), promoted intimacy and improved the emotional relationships of couples (30). It seems that by improving the empathy skill, couples were able to express emotional responses appropriately. These results are in agreement with those reported by Deffenbaucher et al (1994); training can reduce anger and negative emotional manifestations (31).

In this study, the couples of the intervention group improved their roles compared with members of the control group, but the difference between the 2 groups was not significant in this regard. However, these findings are not confirmed by Dattilo and Epstein (2005) or Mousavi (2013) regarding the effect of teaching on role play, marital satisfaction, and family functioning (32, 33). Furthermore, the couples were able to control their behavior properly by learning the necessary skills. In fact, education was effective in improving couples’ behavior control, but there was no significant difference between the 2 groups. In this regard, Mousavi (2013) found a significant relationship between behavioral control and marital satisfaction at the level of 0.01.The efficiency of couples in different family dimensions, such as behavioral monitoring and controlling, requires an intimate atmosphere free of threats and existence of couples' agreement.This in turn leads to more efficiency and stability in the family (33). This was not integrated with our study results.

The training sessions help couples to acquire the most important skills needed to comply with each other, control anger, manage stress, and cope with their emotions (34). The results further showed that educational intervention improved the general family function of couples. The point to be made in explaining these results is that there is a mutual relationship between training and family function (35). Education is associated with marital satisfaction and family function change through making individual changes and affect each other simultaneously. On the other hand, with change in the performance of couples in the family, they feel better and this in turn improves the function and relationships among family members (36). Intact and balanced families will be generally functioning more adequately than unbalanced couples. For example, Coe, Davies, and Sturge-Apple (2018) stated that family cohesion balanced associations between maternal relationship inconstancy and increases in family’s problems (37). Clinical psychologists can use family therapy to improve psychological attributes, especially improving family function and marital agreement in divorce demandant couples (38). Given the important role of attitudes and functions in the intention to divorce, further educational interventions in this field are suggested to consider influencing constructs (39). The current findings enhance an appending body of literature on the effect of family therapy and education on family function.

Limitation

The results provided a better understanding of Iranian family function in life of couples. The literature review for this study did not recognize any systematic studies which assessed the function of family based on McMaster Model in Iranian couples, and this research determined this gap in the literature. Lack of complete control on confounding variables, such as the personality of persons, cultural and socioeconomic variables, lack of access to a representative sample, and sampling by a non-random method, were limitations of this study.

Considering the many problems about of family functioning, further investigations are suggested in other cities and based on other aspects of family life. Replication of this research is also recommended regarding culture of people in Iran. Counselors and psychologists should also identify families suffering from problems related to family function and treat them faster.

Conclusion

Family therapy based on McMaster model can promote the skills of problem- solving, family communication, emotional responsiveness, emotional involvement, and general function in couples. Healthy family functioning is a substantial domain of concern for mental health specialists who provide family interventions. Our findings enhance considerably to family professionals’ knowledge about patterns of family function in Iranian families