FAMILY RESILIENCE AND THE

MANAGEMENT OF FIBROMYALGIA:
IMPLICATIONS FOR FAMILY THERAPISTS
J. Cameron Preece
Jonathan G. Sandberg

ABSTRACT: Fibromyalgia Syndrome (FMS) is one of the most trou-

bling rheumatic disorders for patients, significant others, and the
health care providers who treat them. Responses from 150 partici-
pants provided valuable information on the relationship between
family resilience and the management of fibromyalgia. Self reported
family stressors, strains, and distress were significantly associated
with an increase in health problems/functional disability, whereas
family hardiness and family social support were associated with a
decrease. Family stressors and family strains were also positively
associated with the frequency of medication use. Medical family
therapy interventions that consider the familial context are recom-
mended for treatment. Additional implications for clinical practice and
future research are discussed.
KEY WORDS: fibromyalgia; family resilience; family therapy; medical internet re-
search

Fibromyalgia Syndrome (FMS) is a non-inflammatory rheumatic

disorder characterized by chronic, widespread, musculoskeletal pain
punctuated by painful flare-ups in concentrated areas. The symp-
toms of fibromyalgia include chronic pain, stiffness, persistent fati-
gue, poor sleep quality, and multiple low pain-threshold sites known

J. Cameron Preece, PhD, Sage Health Care, PLLC, 339 Allumbaugh Street, Boise,
ID 83704. Jonathan G. Sandberg, PhD, Department of Marriage and Family Therapy,
Syracuse University, Syracuse, NY 13244. (jgandbe@syr.edu)
Special thanks go to Linda Stone Fish, PhD, for her support and guidance throughout
the study.

Contemporary Family Therapy 27(4), December 2005 Ó 2005 Springer Science+Business Media, Inc. 559
DOI: 10.1007/s10591-005-8242-x
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CONTEMPORARY FAMILY THERAPY

as ‘‘tender points,’’ which are symmetrically distributed throughout

the body. Most patients also experience co-morbid bouts of depres-
sion, headaches, bladder irritation, Raynaud’s phenomenon, restless
legs, and atypical numbness and tingling (Bennett, 1993; Fitz-
charles, DeCosta, & Poyhia, 2003; Shuer, 2003; Wolf, Smythe, &
Yunus, 1990). The syndrome is further complicated by the fact that
these symptoms seem to surface at random and are co-morbid with
anxiety and depression (Marcus, 2003). Women are much more
likely to be diagnosed with FMS than men (Alonso, Loevinger,
Muller, & Coe, 2004).
Because no direct links have been discovered between pathologi-
cal tissue or neurological abnormalities and symptoms, a typical FMS
patient will generally move from physician to physician and be sub-
jected to a multitude of tests over a number of years before receiving a
diagnosis of fibromyalgia (Aaron et al., 1997; Alfici, Sigal, & Landau,
1989; Bennett, 1986; Goldenberg, 1989; Lash, Ehrlich-Jones, &
McCoy, 2003; Yunus, 1994). Yunus (1994), a prominent leader in fi-
bromyalgia research, has speculated that ‘‘biophysiological mecha-
nisms in FMS are likely to involve a complex interaction of multiple
factors, e.g. genetic, neuroendocrine, psychological, poor sleep and
environmental’’ (p. 814). Repeated attempts to solve their medical
problems may cause FMS patients to utilize high levels of medical
services. With an estimated 3.7 million Americans affected with FMS,
a lack of clarity regarding of effective treatment, and patients’ fre-
quent use of medical services, fibromyalgia has rapidly become a
serious public health concern (Bennett, Smythe, & Wolfe, 1992; Fitz-
charles, DaCosta, & Poyhia, 2003; Goldenberg, 1989; Lash, Ehrlich-
Jones, & McCoy, 2003; Rossy et al., 1999; Unger, 1996).
The current health care context that emphasizes cost containment
provides compelling reasons for developing cost effective interventions
for treating FMS. Longitudinal studies have found that FMS patients
averaged approximately 10 outpatient medical visits per year (Wolfe
et al., 1997). These researchers also report that a typical FMS patient
is hospitalized one time every three years and receives medical ser-
vices representing a total annual cost of $2274 (in 1996 dollars) for
FMS-related care alone. In addition, compared with patients with
other rheumatic disorders, those with fibromyalgia were more likely to
have lifetime surgical interventions (i.e., back or neck surgery,
appendectomy, carpal tunnel surgery, gynecologic surgery) (Wolfe
et al., 1997).
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J. CAMERON PREECE AND JONATHAN G. SANDBERG

TREATMENT

To date there are no medical or non-medical treatment protocols

that have proven completely effective at reversing FMS symptoms; al-
though a number of studies have claimed some success at reducing
symptoms over time (Burckhardt & Bjelle, 1994; Gordon & Morrison,
1998; McCain, 1990; Rossy et al., 1999; Russell, 1996). However, it
should be noted that recent longitudinal research has shown that
standard care in fibromyalgia treatment resulted in improvements for
less than half of the participants (Fitzcharles, Da Costa, & Poyhia, 2003).
Existing treatment programs typically utilize individually based
interventions focused on enhancing ‘‘self-efficacy’’ or the ‘‘sense of
control’’ resulting from perceived success in managing symptoms
(Bennett, 1996; Burckhardt & Bjelle, 1994). In order to increase cost
effectiveness, patients are usually instructed in groups. Programs
frequently may include the following critical elements: (a) information
about fibromyalgia, (b) physical training (e.g., stretching, exercise,
conditioning), (c) cognitive behavioral therapy (e.g., self-efficacy
training, relaxation techniques, and coping techniques), and (d) com-
munication (provider–patient relationship, assertiveness training,
and family and social support) (Buckhardt & Bjelle, 1994; Rossy et al.,
1999).

Marriage and Family Therapy Interventions

Only one study has considered the effectiveness of using marriage
and family therapy for treatment of FMS. Over a period of nine
months, de Voogd, Knipping, de Blecourt, and van Rijswijk (1993)
offered 10 group psychomotor therapy sessions and 10 marital coun-
seling sessions to 50 FMS patients and their spouses. The marital
sessions focused on improving communication between partners and
on coping with FMS. Unfortunately, 34% of the subjects dropped out of
the study before completion, resulting in no significant differences on
any measure between treatment and control group and generating
serious questions about the methodology of the study.

The Family and Health

It can be argued that the success of current interventions for FMS
has been constrained by a lack of clear etiological indicators. However,
we also assert that the success or failure of extent treatments and
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CONTEMPORARY FAMILY THERAPY

studies may have been mediated by family systems dynamics, a

compelling variable that has not yet been fully considered in treat-
ment of FMS. Family systems based approaches were noticeably ab-
sent from the literature addressing symptom reduction of FMS. This
lack of a systems and developmental based framework regarding
chronic illness may prove costly in terms of human suffering and
dollars spent (Rolland, 1990). Specifically, the failure to recognize
marriage and family therapy as a viable clinical option is surprising
considering the abundant body of research linking marital and family
dynamics and health (Campbell, 2003; Kiecolt-Glaser & Newton, 2001;
Patterson & Garwick, 1994; Revenson, 1994).
Family stress and family resiliency theories provide some insight
into how family structures, behaviors, and capabilities may act as a
buffer, thereby reducing the impact of stressful life events on those
coping with chronic illness (McCubbin, Thompson, & McCubbin, 1996;
Walsh, 1996). McCubbin et al. (1996) described resilient families as
those who:

are better able to negotiate their way through transitions

and crises and to cope with and even thrive on life’s hard-
ships, while other families, faced with similar if not identi-
cal stressors, give up, are easily exhausted or deteriorate in
the face of adversity (p. 2).

It is our assertion that family resilience may play an important

mediating role in managing FMS symptoms and possibly predict
health care utilization. A better understanding of how family resil-
iency affects FMS patients’ use of the health care system could be
critical in developing appropriate cost effective interventions.

Research Aims
This study is designed to help researchers and clinicians under-
stand the links between family resilience and the effective manage-
ment of fibromyalgia symptoms. It also assesses the relationship
between family resilience and three key outcome variables: (a) re-
ported number of health problems and overall functional disability, (b)
use of positive pain coping strategies proven effective in reducing
symptoms severity, and (c) frequency of medication intake and health
care utilization.
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J. CAMERON PREECE AND JONATHAN G. SANDBERG

METHODS

Participants
Participants in this study were recruited via Internet postings to
major FMS websites, e-mail list serves, and electronic bulletin boards
on the Internet. During the six-week recruitment period, a nonran-
domized convenience sample of 150 completed surveys was secured.
Each of the participants (n=150) returning complete surveys also
indicated they had been officially diagnosed with fibromyalgia by a
practicing physician. At the time of completing the survey, partici-
pants reported experiencing fibromyalgia symptoms for an average
duration of 14.19 years (SD = 12.8). Participants ranged in age from
19 to 81 years of age with a mean age of 45.7 years (SD = 12.35). As is
typical of those diagnosed with FMS, the vast majority of participants,
were female (93.1%). Only 5.5% (7) identified themselves as nonwhite.
Forty three percent (62) of the participants were currently employed;
55.9% (81) were not. The demographic characteristics of this sample
are very similar to other large sample Fibromyalgia studies
(Fitzcharles et al., 2003).

Procedure
Conducting research on the Internet has tremendous potential as
a research tool but also presents unique challenges to researchers.
Harris and Dersch (1999) and Schaefer and Dillman (1998) provided
helpful guidelines for designing the present study such as providing
multiple electronic means for subjects to return completed data; pro-
viding consistent follow-up reminders; and taking measures to ensure
confidentiality and anonymity. Participants were directed to a web
page set up exclusively for this study that introduced them to the
parameters of the study and gave them several options for down-
loading, completing, and returning the survey. Respondents could
download the survey directly from the web page or ask for an e-mail or
regular mail version to be sent to them. Those asking for regular mail
versions received a packet via the US Postal Service that included a
self-addressed stamped envelope. Those who preferred to respond
electronically were given the option to fax or e-mail completed surveys
directly to the primary investigator.
Each respondent received a research packet that included an
introductory letter, consent form, and a series of questionnaires. The
questionnaire packet included demographic items, the Fibromyalgia
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CONTEMPORARY FAMILY THERAPY

Impact Questionnaire (FIQ), the Chronic Pain Coping Strategies

Questionnaire (CPCS), Health Care Utilization Survey (HCUS), and
the Family Index of Regenerativity and Adaptation-General (FIRA-G).
An e-mail message was sent one week after the initial mailing to en-
sure that the respondent had received the packet, to offer to answer
any questions, and to thank them for helping with the research. Re-
minder e-mails were then sent out on a weekly basis to respondents
who had not returned surveys until one week before the completion of
participant recruitment. Reminder notices were also posted on the
primary Web page.

Instruments
Health Care Utilization Survey (HCUS). The items comprising
this measure were taken from Wolfe et al. (1997) longitudinal, multi-
site study of fibromyalgia, which was based on the Arthritis, Rheu-
matism and Aging Medical Information System (ARAMIS). Questions
used in this study focused on the number of visits to health care
providers, type of medical procedures performed, hospitalization, and
the number and dosage of medications taken for FMS related symp-
toms. The psychometric properties of this shortened survey have yet to
be published.

Fibromyalgia Impact Questionnaire. This survey, developed by

Burckhardt, Clark, and Bennett (1991), consists of 10 items that
measure physical, psychological, and social and global well being. The
participant is asked to answer the questions based on the past seven
days. The 10 items are standardized, resulting in a possible high score
of 100. The average FMS patient scores about 50 while a severely
impaired patients would typically score 70 or higher. The FIQ has
demonstrated good validity and reliability scores (Burckhardt et al.,
1991; Pfeiffer et al., 2003).

Chronic Pain Coping Inventory (CPCI). The CPCI was developed

by Jensen, Turner, Romano, and Strom (1995) and seeks to determine
how frequently the participant uses each of 11 different coping strat-
egies to manage his or her FMS pain. The CPCI consists of eight scales
(64 total items) that measure the coping skills of guarding, resting,
asking for assistance, relaxation, task persistence, exercise or
stretching, seeking social support, and coping self-statements. All of
the scales have proven reliable and valid with internal reliability
coefficients ranging from 0.70 to 0.93 (median of .84).
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J. CAMERON PREECE AND JONATHAN G. SANDBERG

Family Index of Regenerativity and Adaptation-General (FIRA-G).

The Family Index of Regenerativity and Adaptation-General (FIRA-G)
includes seven brief self-report indices (McCubbin, 1987). These
indices operationalize the Resiliency Model by providing data about
resiliency that enable researchers to make predictions about a family
unit, its structure, function, capabilities and responses to crisis and
stressful life events (McCubbin, Thompson, & McCubbin, 1996). The
FIRA-G has good validity scores ranging from 0.23 to 0.99. It also has
excellent reliability scores ranging from 0.69 to 0.82.

Data Analysis
The purpose of the analysis was to investigate the relationship
between family resilience (stress, strains, distress, hardiness, social
support and coherence) and health problems/functional disability,
chronic pain coping, and health care utilization. Therefore, the sum
score of each of the six family resilience indices was individually re-
gressed onto total Fibromyalgia Impact Questionnaire (FIQ), Chronic
Pain Coping Inventory (CPCI), and Health Care Utilization Survey
(HCUS) scores. Mean and standard deviation scores for the key vari-
ables in the study are listed in Table 1.

TABLE 1
Means and Standard Deviations of Variables in the Model

Variable Mean SD

Family stress 16.07 10.91

Family strains 15.08 10.46
Family distress 9.38 8.04
Family social supporta 82.59 16.15
Family cohesion 15.19 3.09
Family hardiness 39.47 11.57
Health problems/Functional disability 62.64 18.16
Pain coping strategies 3.22 0.70
Provider visits 18.43 16.66
Medication use 4.05 2.90
a
This variable reflects the composite score of family social support and family relative
and friend support.
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RESULTS

Family Resilience and Health Problems/Functional Disability

The results of the statistical analyses suggest that elevated levels
of family stress (e.g., illness, retirement, death, birth, and so on) were
significantly associated with higher FIQ scores (e.g., reported health
problems and functional disability) (R2 = .05; p =. 009). Elevated
scores on family strain measures (e.g., conflict in marriage, between
parents and children, between children and children) were also sig-
nificantly associated with higher FIQ scores (R2 = 0.11, p < 0.000).
Consistent with the previous two findings, the data suggests that
elevated reports of family distress (e.g., emotional problems, alcohol/
drug abuse, sexual dysfunction, etc.) are significantly associated with
greater FIQ scores (R2=0.07, p=0.002). As predicted, both family social
support (R2 = 0.06, p = 0.002), and family hardiness (R2 = 0.08,
p < 0.000) were significantly associated with a lower FIQ scores (see
Table 2).

Family Resilience and Use of Chronic Pain Coping Strategies

Table 3 displays the results of the six family resilience indices
individually regressed on pain coping strategies. Contrary to prior
research and theoretical indicators, self reported family stress,
strains, and distress were not associated at significant levels with
chronic pain coping skills. Family social support (R2 = 0.06, p <

TABLE 2
Regression Results: Patient Family Resilience Indices on the Fibrom-
yalgia Impact Questionnaire (Health Problems/Functional Disability)

Variable B SE B Beta p R2

1. Family stressors 0.36 0.14 0.22 0.009* 0.05

2. Family strains 0.57 0.14 0.33 0.000* 0.11
3. Family distress 0.58 0.18 0.26 0.002* 0.07
4. Family social support 0.28 0.09 )0.25 0.002* 0.06
5. Family coherence )0.21 0.49 )0.04 0.665 0.00
6. Family hardiness )0.44 0.13 )0.27 0.000* 0.08

* Significance of F ratio at p < 0.05.

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J. CAMERON PREECE AND JONATHAN G. SANDBERG

TABLE 3
Regression Results: Patient Family Resilience Indices on Chronic
Pain Coping Strategies

Variable B SE B Beta p R2

1. Family stressors 0.00 0.00 0.08 0.34 0.00

2. Family strains 0.00 0.00 )0.09 0.29 0.00
3. Family distress 0.00 0.00 0.06 0.44 0.00
4. Family social support 0.01 0.00 0.24 0.00* 0.06
5. Family coherence 0.04 0.02 0.18 0.04* 0.03
6. Family hardiness 0.02 0.01 0.31 0.00* 0.10

* Significance of F ratio at p<0.05.

0.000), family coherence (R2=.03, p<.05) and family hardiness

(R2 = 0.10, p < 0.000) were all significantly associated with the use of
pain coping strategies.

Family Resilience and Health Care Utilization

For the purposes of this study, two different indices of health care
usage were utilized: (1) the number of fibromyalgia related health care
provider visits (PUI) over a six-month period, and (2) the number of
fibromyalgia related medications (MUI) taken during that same time
period. Participants in the study reported an average use of four dif-
ferent types of medication to treat FMS symptoms and an average of
18 physician visits during the same six-month period. Contrary to
predictions, none of the six family indices was significantly associated
with provider utilization.
However, results did show that elevated levels of family stress
(R2 =0.06, p < 0.05) and family strains (R2 = 0.05, p < 0.05) were as-
sociated with elevated medication use (see Table 4). Family hardiness
was inversely associated with medication use at a significant level
(R2 = 0.05, p 0.< 008). Family distress, family support, and family
coherence were not significantly related to medication use

DISCUSSION

The results of this study highlight the potential utility of a bio-

psychosocial systems perspective to better understand how differing
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CONTEMPORARY FAMILY THERAPY

TABLE 4
Regression Results: Patient Family Resilience Indices on Medication
Usage

Variable B SE B Beta p R2

1. Family stressors 0.06 0.02 0.24 0.003* 0.06

2. Family strains 0.06 0.02 0.22 0.009* 0.05
3. Family distress 0.05 0.03 0.13 0.112 0.02
4. Family social support )0.00 0.01 )0.04 0.560 0.00
5. Family coherence )0.04 0.08 )0.05 0.537 0.00
6. Family hardiness )0.05 0.02 )0.22 0.008* 0.05

* Significance of F ratio at p < 0.05.

family dynamics influence individual patients’ management of FMS

symptoms.

Family Strains and Patient Health Problems/Functional

Disability
The apparent association between family stress, family strains,
family distress, and FMS symptoms lends initial support to a number
of clinical and research hypotheses; that is, when a family experiences
a pile-up of stressors and strains in the system, there may be a
breaking point at which the demands of the system exceed the avail-
able resources (McCubbin et al., 1996). When this phenomenon occurs
it might lead to a breakdown in the system as systemic and individual
needs go unmet. When fibromyalgia symptoms are present, insuffi-
cient family resources may combine with an overload of the individ-
ual’s own resources to result in what is called a ‘‘flare’’, where tender
points become activated and pain is magnified. Many FMS patients
link acute stressors to the onset or flares of their symptoms (Aaron
et al., 1997; Greenfield, Fitzcharles, & Esdaile, 1992).
One novel finding in the study is the link between family strains
and self reported health problems. There is a growing body of research
documenting the association between marital conflict and compro-
mised endocrine and immune systems functioning (Kiecolt-Glaser &
Newton, 2001; Robles & Keicolt-Glaser, 2003). It is possible that
family conflict as measured in this study contributes to the complex
neuroendocrine-immune functioning (Yunus, 1992) that is thought to
be a primary factor in the generation of FMS symptoms.
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J. CAMERON PREECE AND JONATHAN G. SANDBERG

Family Hardiness and Patient Health Problems/Functional

Disability
A solid body of research has shown that individual hardiness can
be a significant predictor of health status and may act as a buffer in
stress related illness (Drory & Florian, 1991; Kobasa, 1979, Kobasa,
Maddi, & Kahn, 1982; Lawler & Schmied, 1992). Kobasa et al. (1982)
three-pronged conceptualization of hardiness proposes:

hardy people...feel they can control or influence the events

of their experience, feel involved or committed to the activi-
ties of their lives, and see change as an exciting challenge
to further development (Campbell, Swank, & Vincent, 1991,
p. 54).

Expanding the existing research, this study found that increased

levels of family hardiness were associated with fewer self-reported
health problems/functional disability. These findings are not surpris-
ing considering FMS patients score lower on some hardiness measures
when compared to rheumatoid arthritis patients (Gusteborgs &
Gaston-Johansson, 1996). Also, Nicassio, Schuman, Radojevic, and
Weisman (1999), found that lower ‘‘individual’’ hardiness scores cor-
responded with poorer health status for FMS patients.
However, it should be noted that at least one study has suggested
that stress may influence the relationship between hardiness and
health related outcomes. Hull, Van Treuren, and Virnelli (1987) sug-
gest that a lack of hardiness may contribute to increased psychological
stress, thereby making an individual more vulnerable to illness. It
might be that the psychological stress (generated by feeling out of
control or helpless in the battle to manage symptoms) buffers the
association between hardiness and health problems in this study.

Family Hardiness and Patient’s Use of Pain Coping Strategies

Because of no known distinctive pathophysiologic entity and
resultant medical intervention, FMS patients are faced with learning
how to cope with chronic pain. Though there is some research to
suggest that certain pain coping techniques are more effective than
others (Jensen et al., 1995; Jenson & Karoly, 1991) little is known
about the relationship between family dynamics and certain tech-
niques. Results from this study suggest that family hardiness may be
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CONTEMPORARY FAMILY THERAPY

associated with the use of positive pain coping skills. This finding
invites practitioners and clinicians to consider if individually based
treatment programs can adequately attend to patients’ context, spe-
cifically the dynamics and structures that foster or stifle ‘‘family har-
diness’’.

Family Resilience and Patient’s Use of Medication

Many practitioners work within a managed care environment
that increasingly demands proof of effective and economical treatment
that also leads to an overall medical cost offset. Because the Wolf and
associates’ study showed that medication use accounted for 32% ($731)
of the total annual cost for treating FMS patients, results linking
family variables to decreased need for or use of medication could be of
great interest to many players in the health care community. Family
hardiness was the only family resilience index that had a significant
negative relationship with medication use. Perhaps hardy families
perceive going to a physician or using medication prescribed by a
physician as outside their locus of control, in contrast to using pain
coping strategies, as also suggested in this study (McCubbin et al.,
1996). It is interesting to note that family hardiness was also posi-
tively associated with the use of alternative medication such as herbs,
vitamins, and other supplements.
It may be that FMS patients who report higher levels of family
stress and strain manage symptoms with medication rather than
seeking relief through visits with physicians. This idea would be
consistent with anecdotal evidence supplied by post hoc follow up
questioning of participants in this study, as well as clinical experience.
It would also seem plausible that FMS patients who have received an
official diagnosis and have recognized that current treatments can
only focus on symptom relief could find some comfort in managing pain
with medication. This explanation is supported by the work of Wayl-
onis and Perkins (1994) who studied health care utilization in 176
FMS patients. The authors reported health care utilization data that
showed a dramatic decrease in visits to physicians at follow up while
54% continued using over the counter medications and 39% were
using antidepressants. The current study provides initial evidence
that family resilience may be associated with medication use, thus
providing clinicians with a theoretical foundation for developing
interventions that result in medical cost offset.
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J. CAMERON PREECE AND JONATHAN G. SANDBERG

Implications for Clinical Practice

Because medical treatment alone of fibromyalgia has proven
ineffective and FMS patients are often left to managing the trouble-
some symptoms on their own, fibromyalgia patients likely will seek
collaborative care (treatment from a more holistic or multidisciplinary
approach where physicians, physical therapists, and mental health
professionals work collaboratively) in increasing numbers. Treatment
from a biopsychosocial approach may be particularly useful in helping
patients and families deal with a variety of FMS related issues
including: (1) learning pain coping techniques, (2) dealing with FMS
related depressive symptoms, (3) addressing marital problems pre-
cipitated by FMS symptoms (e.g., complaints about sexual intimacy
inhibited by chronic pain), (4) fostering emotional support, and (5)
setting up a recovery program. Furthermore, because comorbid
affective disorders and interpersonal relationship problems are so
common in the lives of FMS patients, marital and family therapy may
be an appropriate treatment approach to these complex problems.
The results of the present study invite family therapists to con-
sider a number of specific clinical implications that may be helpful
when treating FMS patients and their families. First, the literature
reviewed in this study alerts readers to the complexity of the biopsy-
chosocial variables involved with treating fibromyalgia. It is hoped
that a firm grasp of the key symptoms of the syndrome, the multile-
veled systems involved, the current treatment protocols, and the
controversial nature of FMS symptoms will provide clinicians with the
sensitivity and empathy FMS patients deserve.
Second, this study links stress, particularly interpersonal conflict
in the family, with more severe symptoms for FMS patients in the
sample. This finding sheds initial light on why cognitive behavioral
group therapies focusing on symptom management for FMS patients
have been marginally effective in reducing symptom severity (Kaplan,
Goldenberg, & Galvin-Nadeau, 1993). Perhaps clinicians who treat
FMS patients individually using cognitive behavioral techniques to
manage pain, may see even greater results by combining this ap-
proach with the assessment and treatment of those interpersonal
family stressors that the patient perceives as leading to magnified
symptoms.
In addition, the findings suggest that one reason some patients do
not follow through on using helpful pain coping strategies may be
related to deficits in family social support, family coherence, and
family hardiness as opposed to failure in the cognitive behavioral
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CONTEMPORARY FAMILY THERAPY

approach. One way to improve such programs is to include a family

systems element where family resilience is assessed and appropriate
interventions are applied to deficit areas. These recommendations are
consistent with the findings of Turk, Okifuji, Sinclair, and Starz (1998)
that noted FMS patients experiencing the most interpersonal distress
were also the most resistant to the individually based treatment.
Clinicians treating FMS patients within a group therapy format
might consider inviting significant family members to some sessions or
abandoning the group format altogether and using couple therapy or
multiple family groups in order to effectively address the impact of
family stress on the patient and the impact of FMS symptoms on the
family. The potential utility of multiple family or couple groups as a
means for treating chronic illness has already been noted in the clin-
ical literature (Steinglass, 1998).
Third, family hardiness and family social support were the only
family resilience components that were significantly associated with a
reduction in health problems and functional disability. This suggests
that in addition to teaching basic symptom management skills to pa-
tients, and transforming conflictual family interactions, clinicians may
consider helping the family develop other resiliency qualities. For
example, family therapy sessions could be used to develop communi-
cation and problem solving skills, to increase flexibility, and to learn
and utilize familial and community resources differently. Developing
familial hardiness may also include an assessment of how much the
family has become organized around the illness. Families that allocate
an inordinate amount of resources to managing the illness may neglect
important family hardiness-building exercises such as recreation,
family traditions and rituals, and family work. Steinglass (1998)
warns against letting the chronic illness becoming the ‘‘central orga-
nizing principal’’ and works with families to ‘‘find a place for the illness
in the family and to keep the illness in its place’’ (p. 62).

Implications for Future Research

The most fundamental limitation of this study is its generaliz-
ability due to the fact that a convenience sample was taken from
Internet active fibromyalgia patients. This immediately excludes all
persons not using the Internet from the study. The results of the US
Department of Commerce study (2000) notes that although there are
equal numbers of men and women using the Internet, there continue
to be deficits in Internet access for groups defined by income, age,
and race. Obviously, such deficits exist in any self-selected sample
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J. CAMERON PREECE AND JONATHAN G. SANDBERG

when efforts are not made to obtain a stratified set of subjects.

However, the demographics listed above do suggest using caution
when generalizing these results to a diverse age, racial, and ethnic
population.
An additional drawback of using FMS websites as a recruiting and
data gathering vehicle is that participants in the study may be more
likely to share their stories of dissatisfaction with traditional medical
treatment than other FMS patients. Because many of the websites
used are created by FMS patients to share experiences and informa-
tion with other patients, and because FMS patients often experience
invalidating and disbelieving behavior and attitudes from family and
medical professionals when reporting symptoms, the results from this
study may represent the experience of more severe and chronically
dissatisfied FMS patients. As with any survey research, there is
no way to verify the validity of critical information such as whether
patients were indeed diagnosed by a physician, how many clinical
visits were made, exactly how many procedures were performed, and
how much medication was prescribed and consumed. Future research
that relies on direct access to medical records would ensure greater
accuracy in the data collection process.
This study has punctuated a reciprocal relationship between
family resilience and FMS symptoms and looked only at the associ-
ation between the two variables. Because of this, caution must be
used in assuming linear cause and effect relationships between
family resilience and management of FMS symptoms, especially in
the presence of low R square scores. Patterson and Garwick (1994)
remind ‘‘most descriptive and empirical findings are really punctu-
ations in a process involving feedback across many levels of sys-
tem—the family system, the individual, organ systems, and so on’’ (p.
133). The next logical step is to begin looking at the systemic rela-
tionship between these variables and using more sophisticated
models and methods of statistical analysis to assess such relation-
ships. Such models would allow for the gathering of family based
data, instead of interpreting one member’s assessment of family
functioning and generalizing to larger family dynamics, a limitation
of the current study.
A number of critical questions remain. For example, the results
highlight an observed relationship between family resilience and
coping skills; but is there also a relationship between coping skills
and medical utilization or health problems? In addition, results
showed that decreased levels of family resilience were associated
with increased health problems and greater physical disability. Do
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these increased limitations necessarily result in increased medical

utilization? Longitudinal studies could also be utilized to help dis-
entangle the reciprocal relationship between family resilience and
FMS symptoms.
Another question raised by this study is which types of stressors
and strains are significant and whether the chronology of their arrival
in the system seems to be linked to FMS symptoms? This study
measured stress as major life events as opposed to looking at how
specific daily stressors were related to changes in symptoms. Because
some FMS patients report daily micro-exacerbations of symptoms, it
seems reasonable to focus future research on how daily stressors and
disease-specific stress influence symptoms. Prospective research that
measures symptom severity before, during, and after these stressors
could fill this gap in the literature.
We need to move beyond addressing general resilient qualities in
families to developing concepts and subsequent psychometric assess-
ments that consider the idiosyncrasies of family resiliency in specific
chronic illness conditions. In other words, it is impossible to capture
the resilient characteristic in families with a chronic illness without
finding ways to measure and describe the reciprocal relationships
between the symptom bearer, family members, and the unique attri-
butes of the illness itself on the family. The paucity of biopsychosocial
systems based interventions for fibromyalgia patients has led us to
believe that as a field MFT probably has provided no better treatment
for other high maintenance chronic illnesses. Certainly this uncharted
territory is worthy of serious and sustained investigation.

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