TEACHING RESEARCH INFORMED SYSTEMIC THERAPY. · 1 TEACHING RESEARCH INFORMED SYSTEMIC THERAPY. Director of Clinical Psychology Training University College Dublin Clinical Psychologist

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TEACHING RESEARCH

INFORMED SYSTEMIC

THERAPY.

Director of Clinical Psychology Training

University College Dublin

Clinical Psychologist & Family Therapist, Clanwilliam Institute

Melbourne

36th Annual Australian Family Therapy Conference, Jasper Hotel, Melbourne, Australia, 6th – 7th November, 2015.

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FAMILY THERAPY TRAINING

ON THE UCD CLINICAL PSYCHOLOGY

PROGRAMME

• At UCD systemic thinking is taught

throughout the whole 3 year doctoral

programme in clinical psychology.

• FT skills training occurs in the 2nd

teaching block of the first year

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YEAR 1CHILD MENTAL

HEALTH

TEACHING BLOCK 1 6 weeks

CLINICAL PLACEMENT 1

16 weeks



16 weeks

YEAR 3DISABILITY &SPECIALTIES



16 weeks



16 weeks

YEAR 2 ADULT MENTAL

HEALTH



16 weeks



16 weeks

UCD DOCTORAL PROGRAMME IN CLINICAL PSYCHOLOGY

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ON THE UCD CLINICAL PSYCHOLOGY PROGRAMME

• FT skills training occurs in the 2nd

teaching block of the first year

• At this point, from the Child HB

students have learned

• An individually focused DSM/ICD

‘syndromal’ approach to clinical

formulation

• Evidence-based individually focused

interventions such as parent training

and individual CBT

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PRECIPITATING FACTORS

PROTECTIVE FACTORS

PROBLEM OR SYNDROME

MAINTAINING FACTORS

PREDISPOSING FACTORS

INDIVIDUAL SYNDROMAL FORMULATION MODEL

SYNDROMAL FORMULATION MODEL

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PRECIPITATING FACTORS

PROTECTIVE FACTORS

PROBLEM OR SYNDROME

PERSONAL Biological

Psychological

CONTEXTUAL Treatment

system FamilyParents

Social network

MAINTAINING FACTORS

PERSONAL Biological

Psychological

CONTEXTUAL Treatment

system FamilyParents

Social network

StressesIllnessInjuryAbuse

PREDISPOSING FACTORS

PERSONAL Biological

Psychological

CONTEXTUAL Child-parent factors in early life

Family problems in early life Stresses in early life

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CASE EXAMPLE OF BILL - CONDUCT DISORDER

• Bill, aged 11, was referred by his social-worker after climbing onto the roof of his house and throwing stones at neighbours who ostracized his family because his father raped a girl in the village

• Bill smoked, drank alcohol, and stole from neighbours

• He had school problems (academic underachievement, defiance, rejection by peers, and repeated absence)

• Bill had a history of a difficult temperament, language delay and dyslexia

• His conduct problems were long-standing but had intensified in the six months preceding the referral when his father, Paul, was imprisoned for raping a young girl in the small rural village where the family lived

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• Bill was one of five boys who lived with his mother, Rita, in chaotic circumstances with no home routines

• All 5 boys had conduct problems but Bill's were by far the worst

• Prior to Paul's imprisonment, the children's defiance and rule-breaking was kept in check by their fear of physical punishment from their father

• Since his imprisonment, there were few house rules and these were implemented inconsistently by Rita

• Rita had developed intense coercive patterns of interaction with Bill and John (the second eldest)

• Rita supported the family with welfare payments and money earned illegally from farm-work & would sometimes take the boys to work with her to earn extra money

CASE EXAMPLE OF BILL- CONDUCT DISORDER

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• Rita had a history of school problems, conduct problems and ongoing depression

• Paul had a history of conduct problems and criminality

• The couple’s parents disapproved of their marriage and were in conflict about this

• Rita was ostracised by the village community who blamed her for driving her husband to commit rape.


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CASE EXAMPLE OF BILL- CONDUCT DISORDER


SYNDROMAL FORMULATION

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TREATMENT & OUTCOME

Treatment

• Behavioural parent training

• School attendance programme

• Social skills training

• Respite foster care

Outcome

• Did not become a saint

• Attended school more regularly

• Less aggressive

• Not placed in long-term residential care

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TEACHING METHOD

• Pre-class reading

• Have 6 hour classes (9am – 4 or 5 pm) with 7-12 in class

• Discuss chapter and implications of research and theory for practice

• In small groups formulate ‘paper cases’

• Accredited training in parent training (Incredible years & Parents plus)

• Training in child-focused CBT using ‘Pesky gNats’ programme

• Use skills on 16 week placement

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TEACHING METHOD

• During their first placement they

• Discover importance of changing family and school contexts to help young people overcome problems

• See limitations of individually-focused approach

• Become ready to see the relevance of a systemic model

• Towards the end of their 1st

placement they read FTCPP to prepare for FT skills training workshop

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FT MANUAL USED ON THE UCD CLIN

PSYCH PROGRAMME

Concepts – A review of the schools of FT

Process – A treatment manual based on an integrative 3-column model

Practice – Guidance on the clinical application of the model to common child and adult problems

• Research & Resources

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FT SKILLS TRAINING METHOD

• Read manual as ‘required reading’ prior to

3-4 day workshop.

• Overview discussion of model (and

limitations of individual-focused models)

• Video of FT model in action

• Role play FT exercises covering planning,

assessment, intervention and

disengagement phases

• Use of team, virtual screen, and ‘freeze’

technique to aid learning.

• Use FT skills on 16 week placement

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FT SKILLS TRAINING METHOD - ROLE PLAY ROUTINE

• Divide class into family and treatment team

• Read detailed family roles or team briefing and goals from FTCP&P

• Set up room with team behind therapist

• Roleplay FT session

• When ‘stuck’ therapist ‘freezes’ time and discusses this with team

• Therapist ‘unfreezes’ and continues role play

• After role play family give feedback on experiences that ‘worked’ for them

• Therapist and team rate degree to which session goals were achieved.

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STAGES OF FAMILY THERAPY

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CONTEXTS

THAT UNDERPIN BELIEFS &

BEHAVIOUR

HISTORICALStressful family-

of-origin experiences

CONTEXTUALStressful current

extra-familial experiences

CONSTITUTIONALBiological

vulnerabilities

THE 3 COLUMN FAMILY SYSTEMS FORMULATION MODEL FOR PROBLEMS –

HELPS PLANNING WHAT TO ASK

BELIEF SYSTEMS

THAT SUBSERVE THE BEHAVIOUR

PATTERN

Problematic beliefs about

finding solutions

Problematic beliefs about relationships

Problematic cognitive styles

BEHAVIOUR PATTERNS

THAT MAINTAIN THE PROBLEM

Problem-maintaining

solutions

Confused communication

Problematic relationships

CASE EXAMPLE OF RAD & SAD:

CAROLINE BARROW

REFERRAL

• She was concurrently

referred by

• A paediatricianfor chronic recurrent abdominal pain

• An educational psychologist for persistent school refusal

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• For almost year, she had

• Stomach aches & vomiting in the mornings

• Difficulty going to school

• Anxiety about her mother’s health

• Fear of leaving her mother alone

• The problems were getting worse

• The mother was very worried and the father

seemed to be uninvolved.24

CASE EXAMPLE OF RAD & SAD:

CAROLINE BARROW

PRESENTING PROBLEMS

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1.2. PRELIMINARY FORMULATION & PLANNING WHAT TO ASK

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WHERE DID THE 3 COLUMN FORMULATION MODEL COME

FROM ?

• We found that in the 1980s and 1990s

most of the major schools of family

therapy could be classified in terms of

their emphasis on three main themes

• Behaviour problems

• Beliefs systems / narratives

• Predisposing factors (historical,

contextual, biological)

• We used this 3 column model to

• Integrate ideas and research

findings from multiple schools of

family therapy

• Guide assessment, formulation and

treatment

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PREDISPOSINGHISTORICAL,

CONTEXTUAL & CONSTITUTIONAL

FACTORS

Transgenerational

Psychoanalytic

Attachment based

Experiential

Multisystemic

Psychoeducational

CLASSIFICATION OF SCHOOLS OF FAMILY THERAPY

ACCORDING TO THEIR EMPHASIS ON 3 THEMES

BELIEF SYSTEMS &

NARRATIVES


PATTERN

Constructivist

Original Milan School

Social constructionist

Solution-focused

Narrative

BEHAVIOUR PATTERNS


MRI brief therapy

Strategic therapy

Structural therapy

Cognitive-behavioural

Functional

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2.3. COMPLETING THE ASSESSMENT -

TRACKING THE BEHAVIOUR PATTERN

AROUND THE PROBLEM

• Tell me, in detail, about the last time the

problem occurred?

• If I was watching a video of the last time

the problem happening what would I see in

the lead up to it, during it, and after it?

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Mat asks S to leave C alone.S shouts at M who then withdraws and is relieved

C has stomach cramps & vomits. S tells her to go to bed. Later C helps S with housework, & both are relieved

Dick is at work

Sheila and Caroline have an anxiety provoking conversation about how ill C feels, & whether to have breakfast

Dick phones & criticizes S’s management of C. S begins to worry again

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EXPLORING BELIEF SYSTEMS

• What explanation do you or others

give for this problem?

• What sort of solution goes with your

explanation of the problem?

• If your parents were here with us,

what advice would they give us about

managing this problem?

M thinks C is not ill and should do her duty & go to school


C knows she has a history of gastro. and thinks she must be ill now if S is so worried about her


D believes that short term home absence will lead to him being based locally in the long term

Dick is at work

S believes that health is more important than anything and that the doctors may have misdiagnosed C, as they did her mother


D thinks C is disobedient not ill, and S must make her do her duty and go to school


• Genograms may be used to identify

contextual factors that underpin the

behaviour pattern and beliefs that

maintain the problem:

• Historical factors

• Contextual factors in the wider social

system (extended family, school,

work, professional network)

• Constitutional (psychobiological)

factors

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GENOGRAMS

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BARROW’S GENOGRAM

Caroline

14y

M. 18y

Left

When Dick

was 3y

Annie

81y

School

Nurse

Betty

Boyd

EWO

Phil

Hutchinson

Ed

Psych

David

Trellis

Best

Friend

Mary

Best

Friend

Kirsty

School

Doctor

Ed

Reed

Paediatrician

Tom

Walker

Family

Doctor

Brian

Wilson

Sheila

50y

Dick

56y

Billy

15y

John

55y

Rex

54y

Visits

every

4m

Tom

56yCaroline

52y

David

55y

Henry

10y

Sharon

12y

Died

1y

Ago

Cancer &

Depression

JuneTom

77y

Lives 100

miles away

Visits at

Easter

& Xmas

Grampy

Mat

17y

To go to

University in

September

Miscarriage

Occurred 1y

Before C’s

Birth

May

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M identifies with D’s values where duty is more important that health

M thinks C is not ill and should do her duty & go to school


C has history of gastroenteritisIntergenerational pattern of close mother-daughter relationships

C knows she has a history of gastro. and thinks she must be ill now if S is so worried about her


D’s career path as a travelling salesman

D believes that short term home absence will lead to him being based locally in the long term

Dick is at work

Health was core value in S’s family S’s mother had undiagnosed cancer for a long time

S believes that health is more important than anything and that the doctors may have misdiagnosed C, as they did her mother


Duty is a core value for D who took parental responsibility for his sibs. After his father left

D thinks C is disobedient not ill, and S must make her do her duty and go to school


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2.3. COMPLETING THE ASSESSMENT –

RECAP OF 3 COLUMN PROBLEM

FORMULATION

• What is the behavioural pattern of interaction of

family members (and others) around the main

problem?

• What beliefs of family members (and others)

underpin their roles in the behavioural pattern of

interaction around the problem?

• What contextual factors subserve these beliefs and

behaviour patterns?

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CONTEXTS

THAT UNDERPIN BELIEFS &

BEHAVIOUR

HISTORICALStressful family-

of-origin experiences

CONTEXTUALStressful current


CONSTITUTIONALBiological

vulnerabilities

3 COLUMN FAMILY SYSTEMS FORMULATION MODEL

FOR PROBLEMS

BELIEF SYSTEMS


PATTERN

Problematic beliefs about

finding solutions

Problematic beliefs about relationships

Problematic cognitive styles

BEHAVIOUR PATTERNS


Problem-maintaining

solutions

Confused communication

Problematic relationships

EXCEPTIONS!

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• What is the behavioural pattern of interaction of

family members (and others) around exceptions to the

problem?

• What beliefs of family members (and others)

underpin their roles in the pattern of interaction

around exceptions to the problem?

• What contextual factors subserve these beliefs and

behaviour patterns?

2.3. COMPLETING THE ASSESSMENT –

3 COLUMN EXCEPTION FORMULATION

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CONTEXTS

THAT UNDERPIN EXCEPIONAL

BELIEFS & BEHAVIOUR

HISTORICALPositive family-of-origin experiences

CONTEXTUALSupportive current


CONSTITUTIONALBiological strengths

3 COLUMN FAMILY SYSTEMS FORMULATION MODEL

FOR EXCEPTIONS

BELIEF SYSTEMS

THAT SUBSERVE EXCEPTIONS

Empowering beliefs about

solving problems

Empowering beliefs about relationships

Optimistic cognitive styles

BEHAVIOUR PATTERNS

AROUND EXCEPTIONS

Effectiveproblem-solving

Clear communication

Supportive relationships

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Intergenerational pattern of close mother-daughter relationships

C believes she is not ill because S is not worried about her

C ignores gastric discomfort, washes and has breakfast without anxiety

Kirsty and C have been friends for 10 years

Kirsty and C believe they are best friends

Kirsty calls for C and they walk to school together

D’s father was absent & he does not want to repeat that mistake

D believes its important for him to be at home when he can

Dick is at home

D & S have a supportive marriage

D believes C is OK, and S trusts D’s judgment

Sheila tells D she is worried about Caroline’s healthD reassures S and she worries lessS does not have an anxiety provoking conversation with C

3 COLUMN EXCEPTION FORMULATION

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2.5. FORMULATION AND

FEEDBACK

• Match complexity of formulation to family

members’ cognitive ability

• Present exceptions, highlight strengths, create

hope

• Empathize with each person’s position within the

problem formulation

• Feedback the formulation a bit at a time, and

check understanding

• Do not proceed to goal setting or contracting for

treatment, until formulation has been accepted

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HOW DO FAMILY SYSTEMS FORMULATIONS

HELP US DO THERAPY?

Move from behaviour, to beliefs, to contexts

• First, focus on changing problem-maintaining family behaviour

patterns

• If that is unsuccessful, focus on re-evaluating beliefs and

narratives that keep the family stuck in problem maintaining

behaviour patterns

• If that is unsuccessful, address the wider context that

underpins behaviour and beliefs (history, social systems and

constitutional factors)

• With the Barrow’s, we started by trying to give Caroline the

skill to autonomously manage her pain/anxiety, and invited

her parents to support her autonomy.45

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CONTEXTS

HISTORICALInsight

CONTEXTUALReducing

extrafamilial stress & building supports

CONSTITUTIONALPsychoeducation

about vulnerabilities

BELIEF SYSTEMS

Address ambivalence

Highlight strengths

Reframe problems

Multiple perspectives

Externalizing problems and

building on exceptions

BEHAVIOUR PATTERNS

Change behaviour pattern within

sessions

Change behaviour pattern between

sessions

HOW DO FAMILY SYSTEMS FORMULATIONS HELP US TO DO THERAPY?

Sequence interventions from behaviour to beliefs to contexts

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YEAR 1CHILD MENTAL

HEALTH



16 weeks



16 weeks

YEAR 3DISABILITY &SPECIALTIES



16 weeks



16 weeks

YEAR 2 ADULT MENTAL

HEALTH



16 weeks



16 weeks

UCD DOCTORAL PROGRAMME IN CLINICAL PSYCHOLOGY

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ON THE UCD CLINICAL PSYCHOLOGY PROGRAMME

• By the end of their first year PGs have

basic competencies in

• FT assessment, formulation,

intervention

• DSM/ICD ‘syndromal’ approach to

clinical assessment, formulation and

intervention

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THANK YOU.

Director of Clinical Psychology Training

University College Dublin

Clinical Psychologist & Family Therapist, Clanwilliam Institute

Melbourne

36th Annual Australian Family Therapy Conference, Jasper Hotel, Melbourne, Australia, 6th – 7th November, 2015.

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Carr, A (2015). Teaching research informed systemic therapy.

Paper presented at the 36th Annual Australian Family Therapy Conference, Jasper Hotel, Melbourne, Australia, 6th – 7th

November, 2015.

In this presentation the research-informed approach to teaching systemic practice on the UCD doctoral programme in clinical psychology will be described. Research informed systemic therapy is taught using the text: Family Therapy Concepts Process and Practice (by Alan Carr). The integrative approach described in this book conceptualizes family therapy as a staged process. It involves the use of a three-column model (covering behaviour, beliefs, and wider contextual factors) to formulate problems and exceptions, and guide interventions. This approach to systemic practice is taught once clinical psychologists in training have experience with a more traditional approach to practice described in the Handbook of Child and Adolescent Clinical Psychology(by Alan Carr) which adopts a syndromal, rather than a systemic approach to formulation.

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TEACHING RESEARCH INFORMED SYSTEMIC THERAPY. · 1 TEACHING RESEARCH INFORMED SYSTEMIC THERAPY. Director of Clinical Psychology Training University College Dublin Clinical Psychologist