3 Overview Evidence base for Systemic Family Therapy Some approaches/Techniques for working with Children (and others)Sculpting – Structural Family TherapyCircular Questioning – Milan AssociatesScaling – Solution-Focused Brief TherapyExternalisation – Narrative Therapy
5 RCT EXAMPLE: SYSTEMIC COUPLES THERAPY FOR DEPRESSION For chronic depression 1 and 2 years after treatment systemic couples therapy led to greater improvement in Beck Depression Inventory scores than antidepressant medication for depressed partners.Julian LeffKing’s College LondonLeff, J. et al (2000) The London Depression Intervention Trial. Randomised controlled trial of antidepressants versus couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcomes and costs. British Journal of Psychiatry, 177, 95–100.
6 The ‘Elephant (Dodo Bird) in the Room’ IMPROVEMENT RATES FROM META-ANALYSES OF FAMILY THERAPYSystemic therapy and other types of therapy are effective for 66-72% of children and adults
7 Cost Effective?Crane & Christenson (2008) - high users of services who participated in Marital and Family Therapy showed reduction of 68% for health screening visits, 38% for illness visits, 56% for laboratory/x-ray visits and 78% for urgent care visitsRussell Crane
8 Latest Meta-AnalysesSydow et al. (2013) - 47 trials from the United States, Europe, and China, published in English, German, and Mandarin, were identified. A total of 42 of them showed systemic therapy to be efficacious for the treatment of attention deficit hyperactivity disorders, conduct disorders, and substance use disorders. Results were stable across follow-up periods of up to 14 years.Retzlaff et al. (2013) – 38 trials were identified, with 33 showing ST to be efficacious for the treatment of internalizing disorders (including mood disorders, eating disorders, and psychological factors in somatic illness). There is some evidence for ST being also efficacious in mixed disorders, anxiety disorders, Aspergers disorder, and in cases of child neglect. Results were stable across follow-up periods of up to 5 years
9 WHAT SORT OF ST WORKS FOR SPECIFIC PROBLEMS? SYSTEMIC THERAPY WORKS WELL FOR THESE PROBLEMSCHILD & ADULT-FOCUSED PROBLEMSAlcohol and drug problemsMood disordersAnxiety disordersPsychosisAdjustment to illness and disabilityCHILD-FOCUSED PROBLEMSSleep, feeding & attachment problems in infancyElimination disordersChild abuseDisruptive behaviour disordersEating disordersADULT-FOCUSED PROBLEMSRelationship distressPsychosexual problemsIntimate partner violence(Carr, 2014a, 2014b)
10 Structural Family Therapy The problem – there is something untenable with the structure of the familyemphasis on structural change as the main goal of therapythe therapist as an active agent in the process of restructuring the familydelinquent boys from disorganized, multi-problem, poor families (rather than verbally articulate, middle-class patients besieged by intrapsychic conflicts)Later applied at the Philadelphia Child Guidance clinic to the whole range of problems typically brought for treatment to a child clinicSalvador MinuchinCollaborated with: Braulio Montalvo.Key pupil: Harry Aponte
11 In Representative Form SculptingThe Therapist is: A ‘stage director’, creating scenarios where problems are played according to different scripts.Distances and positions are prescribed by different family members, alternative arrangements tried.Parents become fascinated by how their children perceive family relationshipsIn the FleshIn Representative Form
12 The Milan AssociatesMara Selvini Palazzolitrained as a child psychoanalyst - specialized in eating disorders but frustrated with resultsblended psychoanalytical approach with approaches of Bateson, Haley, and Watzlawickformed the Centre for the Study of the Family in Milan, Italy in 1971.The two women split from the men in the early 1980sPalazzoli died in 1999And her colleagues - Gianfranco Cecchin, Giuliana Prata and Luigi BoscoloSaw themselves as a research team investigating Family patterns
13 The Milan ApproachThe problem: symptomatic behaviour in a family member helped maintain the system’s homeostatic balance through an unacknowledged network of coalitions and alliances, developed over generationsThe Therapists Role: to identify the ‘function of the symptom’ within the family system, initially prescribe it on the basis if a positive connotation and then help the family find ways that it longer requiredHypothesising and Circular Questioning are used towards these ends
14 Circular Questions Used to explore validity of hypotheses Focus on exploring differences:between peoplebetween relationshipsbetween behavioursbetween emotionsbetween ideas or beliefsin perception of eventstemporal differences
15 Benefits of Circular Questions Introduce new information - elicit different perspectivesPrompt answers which comment on relationships - reduce scape-goatingElicit patterns, including communicationBroaden or narrow focus as requiredNon-judgemental - maintain therapist neutralityHighlight changes which may have been unnoticedEncourage families to adopt an attitude of curiosity - generated options for change
16 Solution-Focused Brief Therapy Developed at brief Family Therapy Centre, Milwaulkee, USA in late 70s and 80sSteve De Shazer and Insoo Kim Berg(again) a research teamFound the modal number of sessions was ‘1’Change is happening all the time. Our job is to identify and amplify useful change.
17 SFBTis a short-term goal-focused therapeutic approach which helps clients change by constructing solutions rather than dwelling on problems.Explores current resources rather than present problemsExplores hopes rather than past causesPeople often resourceful - there are always exceptions to the problemDo more of what works
18 Scaling QuestionsOn a scale of where ten is that you achieve completely your goal and one is the furthest away you have ever been. Where would you place your self now?On a scale of 1- 10, where one is the worst things have been and ten is the best where would you place yourself today?What makes you think you got that far?What things have you done already that got you to four?What moved you from three to four?What do you think will move you one step further on?What would move you to five?
19 Scaling Questions for Others If I was to ask your partner where would they say you are between 1 and 10 in achieving your goal? What makes them more confident? Why do they think you have gone further? What would it take to convince them that you are moving towards your goal?Motivation/Confidence ScalingOn the scale between one to ten how willing are you to work to solve this problem? Who is most motivated to solve this problem ? Where would you put their motivation on the same scale? What makes them more motivated?
20 Narrative TherapyA philosophical Approach drawn from post-modern and social constructionist ways of understanding relationshipsPeople link events across time, according to a plot in order to explain or make sense of their livesOur conversations are continually creating our reality, rather than just reflecting itoptions for the telling and re-telling of, for the performance and re-performance of, the preferred stories of people's lives.
22 The Problem: the stories we chose to tell ourselves about our experience The Therapists role: creating opportunities for re-authoring’ conversations that seek out alternative stories identified by our clients as stories by which they would like to live their livesMoto: the person is not the problem, the problem is the problem
23 Externalising the Problem To make the problem visible- objectifying or personifying the problem – helping to disempower the problemTo separate the person from the problem, for example a ‘depressed person’ becomes a person who lives with the ‘voice of depression’, or is ‘troubled by depression’To decreases guilt and blame/pathologyTo open up other/ multiple descriptions of a person rather that internal problem saturated descriptions Opens pathways for action and enables the person and wider family to take a position in relation to the problem
24 Some Questions That Might Help Tell me about what does it look like?Who in your family first noticed it?Who gets on best with it?Who does it shy away fromWho manages it best?Where does it live?What does want of you and your family ?How does effect you and the life of your familyHow does make you feel about yourselves?If I asked your your best friend/ partner etc what could they tell me about ?“What do your friends think of trouble?”
25 ReferencesCarr, A. (2014a). The evidence base for family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 36(2),Carr, A. (2014b) The evidence base for couples therapy, family therapy and systemic interventions for adult-focused problems. Journal of Family Therapy, 36(2),Crane, D. R. & Christenson, J. D. (2008) The Medical offset Effect: patterns of Outpatient Services Reduction for High Utilisers of Health Care. Contemporary Family Therapy, 30(2), pde Shazer S (1991) Putting Differences To Work. Norton: New York.Leff, J. et al (2000) The London Depression Intervention Trial. Randomised controlled trial of antidepressants versus couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcomes and costs. British Journal of Psychiatry, 177, 95–100.Minuchin, S. (1974) Families and family therapy. Cambridge, MA: Harvard University Press.
26 References 2Morgan, A. (2000) What is Narrative Therapy? An easy to read introduction. Adelaide: Dulwich Centre Publications.Palazzoli, M., Boscolo, L., Cecchin, G. and Prata, G. (1980) Hypothesising, circularity and neutrality: three guidelines for the conductor of the session. Family Process, 19, Sydow, K., Retzlaff, R., Beher, S., Haun, M. W. and Schweitzer, J. (2013) The Efficacy of Systemic Therapy for Externalizing Disorders of Childhood and Adolescence: A Meta-Content Analysis of 46 Randomized Trials. Family Process, Article first published online: 11 Sep 2013 | DOI: /famp.12047Retzlaff, R., Sydow, K., Beher, S., Haun, M. W. and Schweitzer, J. (2013) The Efficacy of Systemic Therapy for Internalizing Disorders of Childhood and Adolescence: A Meta-Content Analysis of 46 Randomized Trials. Family Process, Article first published online: 5 Aug 2013 | DOI: /famp.12041White, M. (2008) Maps of narrative practice. New York: Norton.