Therapeutic Approaches to Working

with Children and FamiliesWorkshop Notes

Goldsmiths College

Stephen CoulterQueens University, Belfast

May 2014

Aspects of (Systemic) Family Therapy

OverviewEvidence 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

Hierarchy of Evidence

5

RCT EXAMPLE: SYSTEMIC COUPLES THERAPY FOR DEPRESSIONFor 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.

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.

Julian LeffKing’s College London

The ‘Elephant (Dodo Bird) in the Room’IMPROVEMENT RATES FROM META-ANALYSES OF FAMILY THERAPY

Systemic therapy and other types of therapy are effective for 66-72% of children and adults

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 visits Russell Crane

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

WHAT SORT OF ST WORKS FOR SPECIFIC PROBLEMS?

SYSTEMIC THERAPY WORKS WELL FOR THESE PROBLEMS

CHILD & ADULT-FOCUSED PROBLEMS

• Alcohol and drug problems• Mood disorders• Anxiety disorders• Psychosis• Adjustment to illness and disability

CHILD-FOCUSED PROBLEMS

• Sleep, feeding & attachment problems in infancy

• Elimination disorders• Child abuse• Disruptive behaviour disorders• Eating disorders

ADULT-FOCUSED PROBLEMS

• Relationship distress• Psychosexual problems• Intimate partner violence

(Carr, 2014a, 2014b)

Structural Family TherapyThe 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 clinic

Salvador MinuchinCollaborated with: Braulio Montalvo.

Key pupil: Harry Aponte

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 relationships

In the Flesh

In Representative Form

The Milan Associates

Mara Selvini Palazzoli• trained as a child psychoanalyst - specialized in

eating disorders but frustrated with results• blended psychoanalytical approach with approaches

of Bateson, Haley, and Watzlawick• formed the Centre for the Study of the Family in

Milan, Italy in 1971.• The two women split from the men in the early

1980s• Palazzoli died in 1999

And her colleagues - Gianfranco Cecchin, Giuliana Prata and Luigi Boscolo

Saw themselves as a research team investigating Family patterns

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 generations

The 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 required

Hypothesising and Circular Questioning are used towards these ends

Circular QuestionsUsed to explore validity of hypothesesFocus on exploring differences:

between peoplebetween relationshipsbetween behavioursbetween emotionsbetween ideas or beliefsin perception of eventstemporal differences

Benefits of Circular QuestionsIntroduce new information - elicit different perspectives

Prompt answers which comment on relationships - reduce scape-goating

Elicit patterns, including communication

Broaden or narrow focus as required

Non-judgemental - maintain therapist neutrality

Highlight changes which may have been unnoticed

Encourage families to adopt an attitude of curiosity - generated options for change

Solution-Focused Brief TherapyDeveloped at brief Family Therapy Centre, Milwaulkee, USA in late 70s and 80s

Steve De Shazer and Insoo Kim Berg

(again) a research team

Found the modal number of sessions was ‘1’

Change is happening all the time. Our job is to identify and amplify useful change.

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

Scaling QuestionsOn a scale of 1- 10 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?

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?

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.

Originators

Michael White David Epston

http://www.dulwichcentre.com.au/

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 lives

Moto: the person is not the problem, the problem is the problem

Externalising the Problem

• To make the problem visible- objectifying or personifying the problem – helping to disempower the problem

• To 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

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 from

Who manages it best?

Where does it live?

What does ------- want of you and your family ?

How does -------effect you and the life of your family

How 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?”

ReferencesCarr, A. (2014a). The evidence base for family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 36(2), 107-157.

Carr, A. (2014b) The evidence base for couples therapy, family therapy and systemic interventions for adult-focused problems. Journal of Family Therapy, 36(2), 158-194.

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), p127-138.

de 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.

References 2

Morgan, 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, 3-12. 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: 10.1111/famp.12047

Retzlaff, 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: 10.1111/famp.12041

White, M. (2008) Maps of narrative practice. New York: Norton.