Peter Stratton and Judith Lask UKCP Research Conference July 2015

What is particular about Systemic Therapy? What are the research challenges ?

A broad range of approaches and methods Family Therapy, Couple Therapy, individual Systemic Therapy, Narrative therapy, Brief Solution Focused Therapy, Structural Therapy, Strategic Therapy, Dialogic Therapy, Post Milan Therapy, Milan Therapy, Social Constructionist Therapy, Attachment/Narrative Therapy, Contextual Therapy and so on…………… Raises issues about the nature of change that is sought by therapist What is useful to measure?

Passion Therapists can be very passionate about their approach fall in love with their particular “brand of therapy” make assumptions about efficacy that they do not want to open to scrutiny Assume the complexity of what they do could never be measured Worry that the process of measurement can be a straightjacket on the therapy.

Collaborative Approach We are interested in client’s views We know professionals may measure change in a different way from families and family members may have differing views about what they want to change and different experiences of the change process Sometimes the problem may not change but relationships to the problem may change.

Challenges to the Systemic Researcher What do you measure? What family processes are associated with positive change ( whatever that might be). Are changes in family processes necessary or relevant? What kind of measure can appeal to researchers and clinicians so it will be used? How can family members be fully participant in the process of understanding what happens in therapy and what is useful change?

Political Context Emphasis on evidence based practice Most Systemic Psychotherapists employed in services which rely on government funding. Increased emphasis on individualised diagnostic categories Narrowing of range of psychological therapies available outside private sector. Some polarisation of the art and science of therapy.

How can we find out what we need to know in order to be more effective ? An important gap was the lack of an easy to administer self report measure that makes sense for systemic work and can be used clinically as well as for research. We reviewed existing measures and found that none really did this job We were familiar with CORE and appreciated what it was trying to do and decided to create a measure which honored CORE but with a focus on family function.

9 So how about a systemic version of CORE? © Peter Stratton N'hampton CAMHS June 2014

Why Family Processes? Some systemic therapists are interested in how symptoms develop in an attempt to cope with the way the family has operated its relationships. Others are more focused on building the underused capabilities of patients and their families. All believe that healthy family processes will help a designated patient to overcome their difficulties and maintain therapeutic change. So the ways the family members describe their life at home should be a crucial indicator of the resources the patients have. 10

Some crucial Areas of Interest backed up by research 1. communication 2. management of emotions in families/ expression and containment 3. attachment/ safety, intimacy, love,care 4. Family and individual beliefs and narratives 5. Patterns of Behaviour/ 6. interaction with outside world 7. Validation 8.Individual and family life cycle. Needs and transitions 9 Family strengths and resilience. 10 Problem solving capacity.

First Steps along the way Reviewed current measures and measures used in FT research Convened an expert reference group of Systemic Psychotherapists and trainers to develop a 45 item measure and develop the structure of the questionnaire. This was with the aim of trialing the longer measure and eventually developing a 15 item measure

Some Underpinnings The measure would focus on family strengths and resilience as well as potential problem areas. It would respect differences within families ( that is each family member would have a voice to express their experience) It would respect different family forms and cultural contexts. We asked families to define themselves. It would respect that families are experts on themselves and be self report

Some Underpinnings It would draw from clinical and research knowledge about families as well as well developed theory. It would be qualitative but also contain space for quantitative data. Although it is developed for work with families – changes in family function are pertinent to many psychological interventions. It would be relevant across a range of families at different life cycle stages and with different presentations

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

Some Clinical uses of SCORE 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 Discussing differences between perceptions od different family members 16© Peter Stratton N'hampton CAMHS June 2014

Developments We realised the need for translations of the measure – for both language and cultural reasons and we have organised a programme of translations into a range of languages across Europe and beyond. We wanted these to be meaningful to local populations but stay close to the standard 15 item measure to make cross cultural research and comparisons possible/ Peter has worked hard with EFTA in Europe and the translations have by and large been done with a standard protocol.

Translation Commission 5 translations from the English version by fluent English speakers who have the target language as their first language ( or one of their first languages). These 5 should include: at least one mental health professional with systemic training, at least two lay persons differing in age, ( over 12) gender or social class and someone who has significant experience of translation. 18

Test in clinical context Translate according to protocol Establish ethics and gain family consent Administer at 1 st, 4 th and final session Have therapist rate change at 4 th and last session Record all consecutive families Send data anonymously Keep a copy for own use. 19

Increasing the Use of the measure It is difficult to encourage people who are not used to it to use measure – lots of anxieties about effect on families The CYP –IAPT developments have led many people previously resistant to value ROMS and the Systemic Family Practice students and practitioners use Score. This increased use throws up different issues and concerns

Recent developments Tom Jewell has developed a version for 8-12 year olds Yang Yang The trialed it with a group from the LGBT community and professionals working with them and made some suggestions for alteration of wording to increase acceptability. We are working on a version specifically for couples.

So what does SCORE look like? And why? And how? clients rating concrete aspects of their lives that are relevant to what will be needed for the therapy to be effective. 22

23 For each line, would you say this describes our family: 1. Describes us: Very well 2. Describes us: Well 3. Describes us: Partly 4. Describes us: Not well 5. Describes us: Not at all 1)In my family we talk to each other about things which matter to us 1)People often don’t tell each other the truth in my family 1)Each of us gets listened to in our family 1)It feels risky to disagree in our family 1)We find it hard to deal with everyday problems 1)We trust each other

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Consultation stage A 16 item Likert scale created Formal and informal expert consultation Service user consultation Lay consultation, including deliberate sampling of people from diverse ethnic backgrounds 25

Qualitative PRN Piloting an early version Three therapists each interviewed three experienced therapists about SCORE Thematic analysis of therapeutic judgements. Pooling of analyses Tape recording responses to individual items See what we found in the Australian & New Zealand Journal of Family Therapy Responses of 33 FT trainees simulating family members. Clear difference between functional and not. Etc etc. 26

Ethical Approval NRES Ethical approval was granted in January 2006 for multi-site piloting of SCORE. Each pilot site needs to register with COREC to initiate application. Close attention to confidentiality, patient information, informed consent, data storage & custodianship. 28

Expand and contract and test Qual and quant data used to generate items, reduced to 55. Piloted on therapists and non-clinical samples Reduced to 40 items. Advice that the development should be in the context of how we plan for it to be used. So applied to families as they come for systemic therapy. Recruited clinics throughout the UK. 29

The families-in-therapy project SCORE 40 given to individual family members at start of first session. 228 families, 510 SCORE 40s. Cronbach Alpha, is.934, and Split-half reliability is a correlation of.833. It is coherent. Every item correlates with the corrected average. High levels of acceptability of all items The SCORE 40 works Now we really got going. 30

Now we make it more practicable Can we do with far fewer items? Yes we can Items were checked for how well they correlated with the total SCORE; whether they distinguished clinical and non-clinical, how they worked in MR and FA. The ‘weaker items’ were examined for clinical significance. We ended up with 15 items that factor into 3 clear dimensions 31

Characteristics of the SCORE 15 Factor 1. Strengths and adaptability Factor2. Overwhelmed by difficulties Factor 3. Disrupted communication In the full sample of 608 cases SCORE 15 explained 95% of the variance in the means of the full SCORE 40. Alan Carr and his researchers in Dublin conducted a similar process with >700 mostly non-therapy individuals and has created a 28 item version that correlates highly with several family measures, especially the Family Assessment Device. It has the same factor structure. 32

Factor 1. Strengths and adaptability In my family we talk to each other about things that matter to us We are good at finding new ways to deal with things that are difficult 33

Factor2. Overwhelmed by difficulties We seem to go from one crisis to another in my family Things always seem to go wrong for my family It feels miserable in our family 34

Factor 3. Disrupted communication People often don’t tell each other the truth in my family It feels risky to disagree in our family People in the family are nasty to each other 35

Rating helpfulness of FT session 1&4 36© Peter Stratton N'hampton CAMHS June

Family descriptions of those with highest scores 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 37

Hoped for change daughter's behaviour family life work/life: my husband getting his interest back blame & competition over our son understanding each other dependence would like to be independence f part's health daughter's ill health tolerance of each other's different opinions the way we deal with our problems 38

A simple question: can you tell us how you felt about filling in this questionnaire Ok, fine etc horrible, vulnerable, frightening. selfharm v hitting very sad, upset ok, hopefully helpful answers should be on scale of thoughtful my back hurts so I was irritable anxious & tearful useful to assess family life, helpful to confirm in writing very helpful to analyse our family dynamics 39

Some issues we need to think about evaluating outcome. Through real life aspects that the theory of therapy indicates. Status of family member reports of life at home. Issue of the therapy choosing what its objectives are and then measuring them. Therefore needs validation outside of judgements made by the faithful. Are we repeating the old pattern e.g. with Beck constructing a measure of the kinds of cognitive changes that his form of therapy tried to achieve. 40

Suggestions of research uses of SCORE Generating an evidence base appropriate to relational therapies Examining effects of therapy with: Different lengths Different client groups Different approaches Collaboration across countries. Multi-country collaboration through the European Family Therapy Association A national data-base Practitioner Networks of researchers Exploring cultural differences between families ……………. 41

A wellbeing measure Overall, how satisfied are you with your life nowadays? not at all completely 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

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

Research is not about digging for nuggets of truth It is about creating new meanings (Silverman) GOD © Peter Stratton Birmingham April 2014

45 We need: Psychological health systems that recognise that there is an enormous amount still to learn about psychotherapy and about fostering better relationships. This means supporting research that will release the benefit of what has been learned in the full range of relevant therapeutic practice, and service provision that maintains the variety of promising therapies which are researched every whichway.