Helping children and young people within their families: Perspectives from systemic therapy and research. Peter Stratton Emeritus Professor of Family Therapy Leeds Family Therapy and Research Centre Inst. of Health Sciences, Leeds University, UK

© Peter Stratton N'hampton CAMHS June 2014

© Peter Stratton N'hampton CAMHS June 2014

“not fully born until 4 weeks” (Gesell) “In the first weeks mother cannot know him. He has not got himself into .. knowable shape” (Leach, 1974) © Peter Stratton N'hampton CAMHS June 2014

LFTRC therapy team © Peter Stratton N'hampton CAMHS June 2014

AIMS To provide an idea of current knowledge in systemic family therapy show why we believe that people with social, psychological and mental health problems can sometimes best be helped by working with them and their families together indicate the knowledge that is available from family therapy research and practice about how to help families towards greater happiness © Peter Stratton N'hampton CAMHS June 2014

Aims and objectives Research and practice are often directed to basing interventions on deficiencies of parents or children, which can lead to a culture of blame To offer approaches that have developed within systemic family therapy that may be helpful to all practitioners © Peter Stratton N'hampton CAMHS June 2014

Overall orientation giving families messages of pathology and deficit is undermining, and encourages agencies to concentrate on professional expertise. If we give messages of resilience and empowerment we potentiate the orientations we need in families, while encouraging agencies to work with them collaboratively © Peter Stratton N'hampton CAMHS June 2014

Language, understanding and feeling must be consistent Language, understanding and feeling must be consistent. With each other, among professionals and across contexts. We need a shared culture for working with families. And some proven techniques. © Peter Stratton N'hampton CAMHS June 2014 9

Political issues NICE informs IAPT’s choice of CBT Savoy setup to broaden IAPT. Says IAPT is OK New Ways of Working sets up to broaden IAPT. Says IAPT must do what NICE says, but NICE should change NICE says it should be broader. But does not change. Return to top. © Peter Stratton N'hampton CAMHS June 2014

The politics of randomised controlled trials ‘The system’ has, perhaps rather lazily, applied a research methodology designed for other purposes to psychotherapy. The therapy that looks most like a drug treatment for a diagnosed illness, CBT, has acquired reasonable evidence within this paradigm. There is a danger that all other therapies will be excluded from the NHS and social care. © Peter Stratton N'hampton CAMHS June 2014

Other political orientations: skills4Health  systemic competences  NOS Social Care Institute for Excellence: “the factors which determine how well a child copes with their parent’s mental health problem are related to: • their relationships with other family members • the immediate environment in which they live” Think Family -> troublesome families Green paper on families and relationships, competition between the parties. © Peter Stratton N'hampton CAMHS June 2014

A high-quality service that incorporates a think family model is one that: • Incorporates a strengths and resilience-led perspective • Intervenes early to avoid crises, stops them soon after they start and continues to provide support once the crisis has been resolved. • Is built upon a thorough understanding of the developmental needs of children, the capacities of parents (or caregivers) to respond appropriately to these needs, the impact of wider family and environmental factors on parenting capacity, The combined impact of parental mental health problems and environmental factors on children, and the impact of parenting on a parent’s mental health. © Peter Stratton N'hampton CAMHS June 2014

SFT works OK ‘marriage and family therapy is now an empirically supported therapy in the plain English sense of the phrase - it clearly works, both in general and for a variety of specific problems.’ More specifically, they conclude: M & F interventions are clearly efficacious compared to no treatment. At least as efficacious as other modalities such as individual therapy, and may be more effective in at least some cases. There is little evidence for differential efficacy among the various approaches within marriage and family interventions. Shadish & Baldwin (2003) © Peter Stratton N'hampton CAMHS June 2014

Conditions with effectiveness evidence Carr, 2014 Journal of Family Therapy von Sydow et al, 2013 Family Process © Peter Stratton N'hampton CAMHS June 2014

Williams et al 2006 Panning For Gold: A Clinician’s Guide To Using Research. The gap between research and clinical practice is one of the key challenges facing family therapy. Clinicians often fail to incorporate research findings into their practice because they do not know how to search, evaluate, or apply research to their clinical work. © Peter Stratton N'hampton CAMHS June 2014

Williams’ conclusion “Eventually, most clinicians can overcome the challenges inherent in using research to inform clinical practice. ... Research has the potential to improve client services if it supplements (but does not replace) a clinician’s wisdom and judgment. ..the field as a whole will benefit if clinicians are willing to examine how their practice is both supported and challenged by the research. These benefits, we believe, are worth their weight in gold.” © Peter Stratton N'hampton CAMHS June 2014

The language of outcome research: efficacy studies – investigates outcome under controlled conditions, such as a randomised clinical trial, with a control/comparison group effectiveness studies – naturalistic outcome studies, reflecting everyday practice; no control groups practice-based evidence – a variant of effectiveness research, where a measure (e.g., SCORE) is routinely administered to all clients © Peter Stratton N'hampton CAMHS June 2014

Best Available Research Patient Characteristics, Culture, & Prefs Clinical Expertise EBP Decisions John Norcross, UKCP 2011 © Peter Stratton N'hampton CAMHS June 2014

So what did researchers ever do for us? A few interesting kinds of research findings: There are very small differences in measured effectiveness between different therapies. Experienced therapists draw on resources from several therapies. No therapist is below average (self report, N=634). clients consistently identify “being respected, being understood and being cared for” as core elements in their experience of their therapy. © Peter Stratton N'hampton CAMHS June 2014

Some therapists are consistently much more effective… patient characteristics, practitioner qualities and therapy relationship determine the outcome of a therapeutic process. Some therapists are consistently much more effective… One factor is belief by the therapist in the approach they are using A shared belief by client and therapist may be even more powerful. We don’t really know why ANY therapy works © Peter Stratton N'hampton CAMHS June 2014

There is a very easy way to make your practice better Research has shown that when therapists monitor their outcomes, clients value it, and therapists work more effectively. So the alliance and the shared belief in the approach are both strengthened. It is increasingly recognised that we need an alliance with clients in research as well as in therapy. © Peter Stratton N'hampton CAMHS June 2014

You can dig for gold in research publications (Williams 2006). But Research is not about digging for nuggets of truth It is about creating new meanings (Silverman) GOD © Peter Stratton Birmingham April 2014

If therapies are all similarly effective, what makes the difference? Research has consistently shown that the therapeutic relationship, or alliance, is a major factor. Other factors are a shared belief between therapist and client that the approach will work. And there is clear evidence that therapists differ in effectiveness (even though none are below average) Elaborate the final © Peter Stratton Birmingham April 2014

The SOFTA approach to alliance Engagement in the therapeutic process Emotional connection to the therapist Safety within the therapeutic system Shared sense of purpose within the family. Elaborate the final © Peter Stratton Birmingham April 2014

An alliance with several family members at the same time is difficult Which is why we have systemic methods like Neutrality Curiosity and irreverence vs. prejudice Circular questioning to expose differing views Constructing positive causal spirals Reflexive reference to therapist emotional reactions Etc etc © Peter Stratton N'hampton CAMHS June 2014

Family therapists always did work through relationships But research is pushing SFT to work most directly on the relationship between the therapist and the family members. Blow and Sprenkle (2001) identified the following therapist factors as common to the major models of family therapy: © Peter Stratton Birmingham April 2014

Would all of these be on your list? Empathy Acceptance Respect Support Caring Warmth self-awareness authenticity. © Peter Stratton Birmingham April 2014

Is the research being carried out in family therapy consistent with our experiences of the best ways of working? Most reviews are restricted to: Only particular therapies Only specific (DSM5) diagnoses Only good quality RCTs. Suppose we examined all outcome studies of broadly defined couple and family therapy over a decade? © Peter Stratton N'hampton CAMHS June 2014

The AFT Systematic Research Review 224 outcome studies from yr. 2000 to 2009. Extensively coded with good reliability 14 broad headings giving 125 potential classifications for each article For example: 75% some kind of controlled comparison 58% assessed more than one family member Only 24% used a family systems measure © Peter Stratton N'hampton CAMHS June 2014

Types of Study Design 224 Studies Reviewed 72% RCTs 15% Non-Controlled Outcome Studies 5% Quasi-experimental pre- post- test Average no. participants (families/couples) = 106 28% non RCT RCT mostly in Adult mood, substance misuse, schizophrenia, adolescent substance misuse, eating dis and conduct disorder. Sanderson found 53% RCTs (experimental design) © Peter Stratton N'hampton CAMHS June 2014

Child & Adolescent 54% of all studies Mean age=12.5 yr Mood 8% Mix 4% Child & Adolescent 54% of all studies Mean age=12.5 yr Mood 8% Behaviour Problems 25% Substance misuse 19% Anxiety Disorders 11% L.D 2% 56% male Age range Health 16% Eating disorders 15% © Peter Stratton N'hampton CAMHS June 2014

Does research relate to our therapy practice? Only 3 studies with adults > 65 years (2 dementia, 1 cancer) Only 4 studies where the referred patient was between 16 and 22 years Child Learning Disabilities - 2 studies Adult Learning Disabilities - ? More adult psychosis than adult mood disorders No it does not OA and LD services in north London are working predominantly systemically (lots of CP systemic training placements and a large proportion of systemic teaching on UCL and UEL CP courses comes from clinicians based in these services) Context April 2011 - SIG systemic practice people with LD. Proposal for RCT - exploring use of systemic FT with clients whose behaviour challenges the system, as compared to management as usual. Adolescent to Adult lack of services Child LD - mostly narrative research? More adults suffer with depression than psychosis - but perhaps EE psycho-education means FT research gets funded with psychosis more? © Peter Stratton N'hampton CAMHS June 2014

What we found… By accepted standards of research publication, the articles reviewed present a strong case for effectiveness of Family Therapy Research is disproportionately available in areas of societal concern, resulting in other areas of good and effective practice being without research support and vulnerable to being denied to clients in systems of managed care or state provision. © Peter Stratton N'hampton CAMHS June 2014

Very few of the studies used measures of effectiveness that told them anything useful about the families. Our proposition that change in family interaction is essential in SFCT and maybe in other therapies too. © Peter Stratton N'hampton CAMHS June 2014

Solutions in generating evidence for everyday practice The CORE (Clinical Outcomes in Routine Evaluation) system has worked well to gather data from practitioners doing individual psychotherapy. So how about a systemic version of CORE? SCORE © Peter Stratton N'hampton CAMHS June 2014

Overview The SCORE is a recently developed outcome measure Specific to family therapy but could be of wider interest because of its novel approach to indicating the effectiveness of therapy. It is now approved for use within CORC+ / CYP-IAPT And might be appropriate for use with other therapies. It is also being found to be useful in indicating the quality of life within the family, and as a tool for use by families and therapists during the therapy itself. © Peter Stratton N'hampton CAMHS June 2014

SCORE a quant and qual indicator Which fills a gap for a general measure that respects the findings and approaches of Systemic Family Therapy: that collaboration with the family is a powerful way of achieving therapeutic change. And therapeutic gain will show in improved family relating; and it is changes in the way the family relate and live their lives together that give the best chance of positive change being sustained. © Peter Stratton N'hampton CAMHS June 2014

Requirements of a family SRM So we wanted a measure based on self report, (FTs have always seen the family as the only expert on how it lives its life) which indicated a selection of the more important aspects of life at home, that would fit the generic form of most SFT practice. Which means being relevant for a very wide range of families and referrals. In the process it is informative about how family members see their lives together © Peter Stratton N'hampton CAMHS June 2014

9 SCORE questions You could rate your family Now or when you were 16 © Peter Stratton N'hampton CAMHS June 2014

9 SCORE questions It feels miserable in our family When people in my family get angry they ignore each other on purpose We seem to go from one crisis to another in my family When one of us is upset they get looked after within the family Things always seem to go wrong for my family People in the family are nasty to each other People in my family interfere too much in each other’s lives In my family we blame each other when things go wrong We are good at finding new ways to deal with things that are difficult © Peter Stratton N'hampton CAMHS June 2014

9 SCORE questions Would knowing the answers given by each family member 1. set you up for working with them? 2. be useful to know about a family your are seeing? Would you expect their answers to become more positive if the work was going well? © Peter Stratton N'hampton CAMHS June 2014

Capture of idiosyncratic (qualitative) data The latter 5 items in SCORE ask the respondent to: describe their family; identify what they feel the main problem is for the family and rate how bad it is; say what change they would most hope for; whether they feel FT is likely to be helpful. At followup, the therapist is also asked to rate the family and the helpfulness of therapy. © Peter Stratton N'hampton CAMHS June 2014

Highest scores on SCORE40 broken down, lonely, unsupportive, lacks trust and regard, a war zone hurt, bitter, cruel, painful, distrusting, crushed disjointed, undisciplined, nasty at times unhappy, unable to communicate and find a compromise miserable,bad environment,stressful, upsetting,overprotective, acrimonious, disharmonious, distrustful egg shells nightmare, bullying and control in crisis, son's violence intensity of love & despair, logic seen as right, feelings wrong © Peter Stratton N'hampton CAMHS June 2014

October Context (2011) says: “But happiness is what systemic therapy is about. The whole enterprise of working with, through, and for our clients’ systems of relationships can be conceptualised as working for greater happiness in these relationships.” Is SCORE a measure of (possibility of) happiness? © Peter Stratton N'hampton CAMHS June 2014

Dimension 2 overwhelmed by difficulties boring, mean, cheap, poor, sad, angry me and my mum don't get along very well inclusive suicide attempt close-knit, insular me great but struggling dealing with my wife's depression loving, confused, busy anorexia nervosa © Peter Stratton N'hampton CAMHS June 2014

Perceptions of family therapy In the SCORE the question at the start of therapy: Do you think the therapy here will be/has been helpful? Generally positive, especially women and older clients Correlation with measures of level of difficulty at the start were all very low. © Peter Stratton N'hampton CAMHS June 2014

Rating helpfulness of FT session 1&4 5 5 © Peter Stratton N'hampton CAMHS June 2014

29 therapists using SCORE in a research network 40% had not used any outcome measure before using SCORE. There was some concern about the effect using SCORE might have on the therapy; generally it took about 4 times using it before it became an ‘unproblematic routine’ but for some it never did. Effect on the therapy ranged from neutral to very positive. 82% were sure they would continue to use it; only one definitely would not. © Peter Stratton N'hampton CAMHS June 2014

Suggested uses of SCORE with families Pre-treatment information and screening Discussing the items that are significant for clients Indicating major areas of change, and of no change, between sessions A context for discussions of usefulness Using the items to alert family members to disregarded aspects Checking for difference between therapist and client perceptions © Peter Stratton N'hampton CAMHS June 2014

Systemics provides us with many resources We have manuals that describe what we do We have used manuals to specify the many competences of systemic therapists We have Governments that claim to be concerned for the wellbeing and happiness of their people. We know about happiness because we spend all our time with families that want help to become happier. © Peter Stratton N'hampton CAMHS June 2014

Wellbeing An overall objective for all psychotherapies The 4 items – please rate yourself at this moment © Peter Stratton N'hampton CAMHS June 2014

A wellbeing measure Overall, how satisfied are you with your life nowadays? not at all completely 0 -----------------------------------------------------------------10 Overall, to what extent do you feel the things you do in your life are worthwhile? Overall, how happy did you feel yesterday? Overall, how anxious did you feel yesterday? © Peter Stratton N'hampton CAMHS June 2014

a simple quantitative project the SCORE-15 and the Government’s wellbeing measures were given (in the German translation) to 90 citizens of a small German town. SCORE had a reasonable correlation with overall wellbeing but the strongest association was with people’s rating of how worthwhile their life is. Happiness had a much weaker connection. Thinking of what SCORE questions ask, why might that be? © Peter Stratton N'hampton CAMHS June 2014

Valuing Mental Health UKCP commissioned a report from econometricians. the subjective wellbeing approach, found that having either depression or anxiety is around five times worse for people's wellbeing than the worst physical health condition. Further, depression and anxiety are over ten times worse for people than the average impact of all the other physical health conditions considered. © Peter Stratton N'hampton CAMHS June 2014

Manualising LFTRC It was when we sat down to specify our ways of working that we found we needed a serious research project to do the job properly. We obtained a grant from the UK Medical Research Council that employed Helen Pote in LFTRC for a year. © Peter Stratton N'hampton CAMHS June 2014

Research Process Literature Review Interviews with Therapists Other Therapists Team Literature Review Interviews with Therapists Video Observations/Ratings Analyse therapy sessions Draft Manual Use of Manual in Practice Adherence Protocol development Review by major UK clinics Final Manual/Adherence Protocol Sticking to it : In relation to the development of manuals adherence measures for systemic therapists have been absent or not of high quality. It has been rare that observational methods have been used, with researchers often relying on the less reliable post session self report measures. We need to improve the quality of our adherence measures. Real Co-constructed practice? : In answering specific questions in outcome research facilitated by manuals, we may have something to add to the debates about power and co-constructed practice that are prolific in the family therapy literature and training at present. In Foucault’s language knowledge may be power, and this could be our chance to equip our client’s with real information about what we have to offer, for whom it is effective, and engage in discussion about whether this therapy or some other would be the one to suit their needs and wishes. Maybe this would be truly co-constructed practice? The future : The futre holds a number of possibilities in terms of manualised outcome research. Specific questions, specific answers. Research-Practice links. Successful & Unsuccessful. Core outcome measures. Client’s views. In terms of our project we are hoping to use the manual in an open trial comparing manualised and non-manualised family therapy, and develop this for a full randomised treatment trial. © Peter Stratton N'hampton CAMHS June 2014

Guiding Principles Systems Focus Circularity Connections & Patterns Narratives & Language Constructivism Social Constructionism Cultural Context Power Co-Constructed Therapy Self-Reflexivity Strengths & Solutions Interviews with therapists were analysed qualitatively to ascertain the important theoretical principles and overarching beliefs that guided their work. The list produced was this. Ranging from general systemic principles here at the beginning, such as circularity to more specific principles related to current theory and practice here, for example self-reflexivity. © Peter Stratton N'hampton CAMHS June 2014

Therapy Goals Also in the interviews therapists outlined the aims they have in their therapeutic practice. These are obviously broad aims that have been broken down further for the purposes of the manual. Talk through. Consider these goals for therapy for a moment, and discuss with the person sitting next to you. What other broad things are you trying to achieve as a systemic therapist. Think about this from the perspective of the beginning, middle and end of therapy. © Peter Stratton N'hampton CAMHS June 2014

Questioning © Peter Stratton N'hampton CAMHS June 2014

Therapist Activity Sets boundaries of therapy Actively works to engage all family members Identifies and defines goals for the therapy Actively addresses any engagement issues Creates distance between family and problem Challenges existing patterns and assumptions Reviews progress and utility of therapy © Peter Stratton N'hampton CAMHS June 2014

Item from the Adherence Manual 1 Item from the Adherence Manual 1.6 Was the therapist taking a self-reflexive stance? the therapist was able to apply systemic thinking to themselves and thus reject any thinking about families and their processes that does not also apply to therapists and therapy. Self-reflexivity focuses especially on the effect of the therapy process on the therapist and the way that this is a source of (resource for) change in the family. … Therapists should be rated at or above sufficient adherence level if they label the origins of ideas they are sharing with the family, and share with the family some of the reasoning behind their ideas or questioning. © Peter Stratton N'hampton CAMHS June 2014

Uses of the LFTRC Manual Used in US RCT for eating disorders (Lock et al) Specific version developed for RCT in adolescent self harm (SHIFT, Paula Boston, Ivan Eisler and David Cottrell) Content used in training, especially the prescriptive adherence manual (!) Giving SFT political credibility. © Peter Stratton N'hampton CAMHS June 2014

© Peter Stratton N'hampton CAMHS June 2014 Attachment sequence Baby: Hunger cry fed assuaged play General formulation: Stress demand care latitude explore A therapist: New pre-session manual confident creative Family anxiety Stratton, P. (1991) Back to the basics of attachment theory. Human Systems. 2. 139-142. © Peter Stratton N'hampton CAMHS June 2014

Conclusion A properly researched manual makes real practice open to inspection and improvement. Gives therapists a secure basis from which they can confidently and creatively adapt their practice. Is an essential basis for researching effectiveness. Shows we are serious about evidencing our practice. © Peter Stratton N'hampton CAMHS June 2014

What did manuals do for us? A major UK government initiative created definitions of competences in three major forms of therapy: CBT, psychoanalytic, and systemic (hurrah for AFT). Based entirely on manuals used in successful RCTs (so the content of these manuals was proven effective). 36 headings containing 254 specific evidenced competences that should be usable by all accredited systemic therapists. Stratton, P., Reibstein, J., Lask, J., Singh, R., & Asen, E. (2011) Competences and occupational standards for systemic family and couples therapy. Journal of Family Therapy. 33: 123–143 © Peter Stratton N'hampton CAMHS June 2014

A research based analysis of SCFT competences We have a comprehensive analyses, in detail, of the systemic competences that were used in successful therapies. This mapping can be used in planning courses and also for answering questions like “what can systemic therapists do and is there evidence that it is effective?” Stratton et al (2011) Access through the AFT website www.aft.org.uk © Peter Stratton N'hampton CAMHS June 2014

© Peter Stratton N'hampton CAMHS June 2014

Basic Systemic competence: An ability to engage and involve all members of the system through:   Establishing a system of concern that is warm, empathetic and enables the development of a therapeutic alliance Ensuring that the different developmental needs of the individual members of the system are considered ……………. ………………… © Peter Stratton N'hampton CAMHS June 2014

Ability to work in a reflective manner An ability of the therapist(s) to apply systemic thinking to their own work including:   The impact of the intervention on the therapist and the potential resource this presents to support change for the client(s) An awareness and use of the therapist’s own constructions, functioning and prejudices ….. © Peter Stratton N'hampton CAMHS June 2014

A position on therapist wellbeing When we are free from anxiety and need, we become playful. And so can be creative. Families need our playfulness and creativity to help them take less reverent and more creative positions about their problems. Support for taking a systemic position, and research-based systemic expertise provide the secure base for therapist wellbeing. © Peter Stratton N'hampton CAMHS June 2014

CONCLUSION: reasons to include systemic therapeutic approaches in practice: They have proven effectiveness for those conditions for which they have been properly researched. Very substantial supportive evidence from diverse research and clinical experience. Trained family therapists draw on a good range of approaches with clear theoretical rationales. Explicit attention to issues of culture, ethnicity, gender, discrimination and wider physical and societal contexts. Properly trained family therapists have transferable skills in relation to team working, consultation, organisation etc. Family therapists can support other professionals in their work with families © Peter Stratton N'hampton CAMHS June 2014