This article provides an overview of controlled trials research on treatment processes and outcomes in family-based approaches for adolescent substance abuse. Outcome research on engagement and retention in therapy, clinical impacts in multiple domains of adolescent and family functioning, and durability and moderators of treatment effects is reviewed. Treatment process research on therapeutic alliance, treatment fidelity and core family therapy techniques, and change in family processes is described. Several important research issues are presented for the next generation of family-based treatment studies focusing on delivery of evidence-based treatments in routine practice settings.
The editor of this journal has asked for our opinion on the article by Wilson (2012). In the interests of open dialogue we have agreed. We do not intend to critique the article in detail or to select specific sentences that we agree or disagree with. Our aim is to highlight what we consider important relevant issues.
In this article we describe a project which aims to ensure prevention and continued protection from violence for family members. We outline our theoretical approach to assessment and working with violence in family relationships and the associated ethical problems. We identify three recurrent themes: risk, collaboration, and responsibility. We focus on our work with couples, where the man is violent towards the woman. Within this discussion we identify other important clinical issues.
Frame (noun), an established order, plan or system, (verb), set in or provide with a frame; serve as a frame for; formulate or devise the essentials of (a complex thing, idea, theory, etc.).Framework (noun), an essential supporting structure; a basic system.(The Concise Oxford Dictionary)If the framework through which experience is viewed can be changed, then meaning can be changed and thus also the experiential and behavioural consequences of meaning. (Cade, 1980; p. 90)To the extent that cognitive factors are potent determinants of emotional states, it could be anticipated that precisely the same state of physiological arousal could be labelled joy' or ‘fury’ or ‘jealousy’ or any other of a great diversity of emotional labels depending on the cognitive aspects of the situation. (Schachter and Singer, 1962; p. 381)
This paper's aim is to enable family therapists from whatever approach to address family attachments during their work. It explores the role of attachment in the family, and how to enable therapists to increase security in the family so that family members can solve their own problems during and after therapy. The article gives a brief overview of the nature of family attachment relationships and the influence of secure and insecure attachments within the family and their narrative styles. This is described in language that a therapist might readily hold in mind and share the ideas in dialogue with families. The paper discusses the interplay between insecure attachments and other family problems, such as parental conflict and disagreements over authority. It also discusses ways of establishing a secure therapeutic base and the influence of the therapist's own attachment style. The implications for family therapy practice are described and illustrated by work with a specific family.
This paper describes an important recent development in American family therapy. Medical family therapy uses a biopsychosocial systems model to work with families who have a member with a chronic illness or disability. The authors maintain that family therapy has tended to embrace the mind–body split and to view itself too narrowly as a mental health specialty. Medical family therapists work collaboratively with physicians and other health professionals to help families achieve a sense of agency and communion in facing some of the greatest challenges that life brings.
This study represents the first UK national survey of family therapists and systemic practitioners. The aim was to provide demographic information of systemic practitioners/family therapists and also to describe their clinical practice. The sampling frame used was the UK Association of Family Therapy membership list and all members were sent a postal questionnaire. The response rate was 33% with 495 out of 1500 questionnaires returned. Among the major findings were: systemic practitioners/family therapists are most likely to work for an NHS trust, to use family therapy techniques/systemic ideas predominantly, and to treat a broad range of client issues. They are also most likely to work with families, and therapy is relatively short term (five to eight sessions) regardless of whether they treat families, couples or individuals. Most family therapists/systemic practitioners use some measure of outcome, although frequently this will be feedback from clients. Supervision is sought by the majority of AFT members. In spite of some methodological limitations, the study provides interesting insights into the training and practice of UK family therapists and systemic practitioners which appears to differ in some respects from our American colleagues. It also provides a baseline for future surveys, making it possible to describe the developments of family therapy and systemic practice in this country.
This review considers papers within the principal family therapy journals for the year 1998. The clearest themes that emerged were a considerable reflection on the influence of constructionism on the field, issues around femininism and family violence and techniques of working with children.
This paper reviews the principal family therapy journals for the year 1999. Of the themes that emerged, ‘reaching out’ with systemic practice, developing a political edge, gender issues and developments in theory will be discussed. The paper concludes with a resumé of the research reported in these journals for the review period.
This review considers papers that were published within the principal family therapy journals for the year 1997. The clearest themes that emerged were on the nature of love, gender and collaborative approaches.
This article reviews the principal English-language (including British) family therapy journals for the year 2001. Articles are clustered around various common themes which include marital therapy and cultural competency. There is also a discernible interest in working with populations that have received less attention from family therapists such as substance misusers. Within this literature there is also a trend to 'import' ideas and methods from other therapeutic traditions. Important research papers are noted from within these categories, rather than having a separate section. As this is the fifth in a series of reviews, a 'look back' at trends within the family therapy literature concludes the paper.
This article reviews the principal English–language (including British) family therapy journals for the year 2001. Articles are clustered around various common themes which include marital therapy and cultural competency. There is also a discernible interest in working with populations that have received less attention from family therapists such as substance misusers. Within this literature there is also a trend to ‘import’ ideas and methods from other therapeutic traditions. Important research papers are noted from within these categories, rather than having a separate section. As this is the fifth in a series of reviews, a ‘look back’ at trends within the family therapy literature concludes the paper.
This article reviews the principal English-language (including British) family therapy journals for the year 2002. A number of common themes and threads predominate within these journals. Articles relating to these themes are reported under distinct headings. These themes were: responding to 9/11; marital therapy and diversity practice. Significant research papers are incorporated into the relevant heading. This is the final thematic review undertaken by the current author.
In this paper the principal English-language family therapy journals published in 2003 are reviewed under the following headings: therapy effectiveness, therapy process, assessment, theory with specific reference to attachment resilience, practice with specific reference to trauma, and training.
In this paper the principal English-language family therapy journals published in 2004 are reviewed under the following headings: evidence-based practice, common factors in effective therapy, innovations in family therapy, innovations in couples therapy, training, gender, diversity, international developments, terrorism, and historical transitions.
In this article the contents of the principal English-language family therapy journals and key family therapy articles published in other journals in 2013 are reviewed under these headings: models of family therapy, developments in family therapy practice, couple therapy, training, diversity, international developments, research and DSM-5. Practitioner points Ecosystemic structural family therapy, FFT, MST, MDFT and other traditional systemic approaches, with recent adaptations, may be helpful for an increasing range of populations. Developments in research and practice support the value of father involvement in systemic therapy, conducting family therapy in medical settings and using family therapy to treat adolescent eating disorders. The integration of mindfulness into couple therapy, and new approaches to addressing infidelity are important developments to consider in treating couples.
In this paper the contents of the principal English-language family therapy journals, and family therapy papers from other journals published in 2008, are reviewed under the following headings: child-focused problems, adult-focused problems, couples, diversity, developments in systemic practice, training, research, and recent deaths of significant contributors to the field.
In this article the contents of the principal English-language family therapy journals published in 2009 are reviewed under these headings: narrative therapy, child-focused problems, adult-focused problems, substance abuse across the lifespan, illness across the lifespan, family violence, couples, diversity, developments in systemic practice, training and research.
In this paper the principal English-language family therapy journals published in 2005 are reviewed under the following headings: research in family therapy, couples, families and wider systems, parental alimentation syndrome, diversity, training, and deaths.
In this article the contents of the principal English-language family therapy journals, and key family therapy articles published in other journals in 2012 are reviewed under these headings: therapy processes in the treatment of child-focused problems, autism, adolescent substance use, human immunodeficiency virus, depression and grief, fragile families, mental health recovery, medical family therapy, family business and systemic practice, couple therapy, intimate partner violence, key issues in theory and practice, research, diversity, international perspectives, interviews, and deaths.
This article describes the development, in an Irish context, of a three-factor, twenty-eight-item version of the Systemic Clinical Outcome and Routine Evaluation (SCORE) questionnaire for assessing progress in family therapy. The forty- item version of the SCORE was administered to over 700 Irish participants including non-clinical adolescents and young adults, families attending family therapy, and parents of young people with physical and intellectual disabilities and cystic fibrosis. For validation purposes, data were also collected using brief measures of family and personal adjustment. A twenty-eight-item version of the SCORE (the SCORE-28) containing three factor scales that assess family strengths, difficulties and communication was identified through exploratory principal components analysis. Confirmatory factor analysis showed that the factor structure of the SCORE-28 was stable. The SCORE-28 and its three factor scales were shown to have excellent internal consistency reliability, satisfactory test-retest reliability and construct validity. The SCORE-28 scales correlated highly with the General Functioning Scale of the Family Assessment Device, and moderately with the Global Assessment of Relational Functioning Scale, the Kansas Marital and Parenting Satisfaction Scales, the Satisfaction with Life Scale, the Mental Health Inventory – 5, and the total problems scale of the Strengths and Difficulties Questionnaire. Correlational analyses also showed that the SCORE-28 scales were not strongly associated with demographic characteristics or social desirability response set. The SCORE-28 may routinely be administered to literate family members aged over 12 years before and after family therapy to evaluate therapy outcome.
This paper explores how ideas from first- and second-order cybernetics may be incorporated into the contemporary interest in social constructionist perspectives. We argue that it is possible to contemplate a third-order cybernetics which incorporates ideas from systems theory and social constructionism and that this may capture the reality of the ‘hands-on’ integration of ideas that many practitioners are currently exploring. A framework consisting of eight connecting threads is proposed as a way of helping us to clarify the continuities and discontinuities between the original and contemporary ideas. It is argued that this is an important and potentially useful endeavour, since many practitioners use a mixture of ideas and techniques in an eclectic way but are wary of potential criticisms of being ‘linear’, ‘expert’, ‘manipulative’ and ‘non-collaborative’. A case study is offered to illustrate a ‘hands-on’ integration of contemporary and pioneering ideas and to invite discussion of how concepts and techniques from first- , second- and the new ‘third-order’ cybernetics influenced by social constructionism might be further integrated.
This paper uses three clinical examples to illustrate the experience of feeling abandoned by theory – times when no one model has sufficient signposts to show the way. Therapy is considered to be an endlessly creative interpersonal encounter, to which the client brings the major resource for change. It is argued that the therapist is influenced by worldview, values and beliefs, and personal style, as well as by theoretical model. Further, it is suggested that there is a need to acknowledge and investigate the limitations of therapy. An argument is made for ‘going beyond the model’, for seeking an ethical practice based on what our clients tell us is important, and for sharing across models the common dilemmas and goals of therapy. Clinicians are encouraged to articulate their own ‘swampy lowland’ principles of practice.
Drawing on the author's Mental Health Trust experience, this paper explores and celebrates the diversity of multi-disciplinary, multi-model approaches within a National Health Service context and the challenges systemic practitioners encounter in fitting what they have to offer into these complex professional systems. It suggests that we can best meet these challenges both by looking for underlying similarities between approaches and finding ways to accommodate and celebrate the differences.
Twenty families are observed during the first interview for family therapy. In families where suicidal behaviour occurs there are three variables which distinguish them from families where no such behaviour occurs. These variables are;the threat of immediate break up of the family relationship i.e. someone is about to leave,a situation of mutual negative connotation where no matter what anyone tries to do it is seen as being ‘wrong’,a tradition of symptoms being used at times of crisis to keep the family together.Suicidal behaviour is seen as a strategic move to keep the family together in the face of developmental change.
Intra-familial sexual abuse of children is a peculiarly potent area for subsequent inter-agency responses and interventions to become inappropriate, irrational, and damaging. A major component of the damaging responses by the inter-agency system is the mirroring processes which occur between that system and the family.
A case example is presented in some detail to illustrate the ways in which such mirroring processes also effect therapeutic teams dealing with such families. Some therapeutic techniques from an experiential base are described. It is argued that productive therapeutic work can only occur if the mirroring processes within the inter-agency system, and the therapeutic team system, are considered systemically.
Three cases from a larger review of child abuse inquiry reports are discussed. The abuse the children suffered is termed ‘not-existing’ because they had been shut away until they perished. Interaction between the children's caretakers and the child protection professionals is examined within a revised framework of the double-bind.
Abusing and high-risk families have been seen over three years at a new treatment resource with a family therapy orientation. The families present with established resistance to any treatment intervention and many have defeated a succession of previous helping agencies. Initial typology and treatment strategies are described with the aim of more systematic selection of therapeutic techniques.
This article proposes that some perpetrators of domestic violence respond to their partners' apparent rejection of them with abusive behaviour, and that there exists a cycle of rejection and abuse. The model posits that some men, having experienced rejection within their families of origin or in relation to past partners, become sensitive to potential rejection in their current relationships. The cycle for rejection-sensitive men consists of an event that constitutes a threat to self, leading to a defence against this threat which in turn results in psychological or physical abuse. This model was tested on sixty-six male participants of perpetrator group programmes who completed a survey designed to measure each point in the proposed model through path analysis. There was support for the following model: rejection, threat to self-defence against threat, abuse. Other paths were tested, but were not significant. These results are discussed in terms of the implications for treating perpetrators.
As clinicians working with children who have been sexually abused we have observed that many children choose not to give the therapist a detailed account of their abuse.† Our hypothesis is that whether or not children tell their story to the therapist hinges upon several factors: whether they have been believed by their significant (non-abusing) carer(s); their developmental stage; the therapeutic context; and whether they feel their therapist is available to hear the distressing details of the abuse. We explore this through two case studies and conclude that while children's ability to use therapy is affected by multiple factors – societal, cultural, personal, life histories and beliefs about the value of therapy – telling their therapist the details of their abusive experiences is not necessarily a part of effective therapy.
In this article, the author points out the usefulness of applying an interactional approach to the treatment of alcoholic abuse. First, the relational significance of the symptom is discussed and an analysis is made of the principal communication patterns existing between the partners of the couple.
The essential contents of the therapeutic strategy are then described, as well as the homeostatic reactions of the system: two types of intervention were applied, paradoxical and structural, which were aimed at eliminating the symptom and gradually changing the couple's relationship.
In this paper five countertransference reactions, which may be experienced by workers on child abuse management teams, are described. Karpman's Drama Triangle is used as a framework within which to define these reactions. The reactions are: (i) rescuing the child; (2) rescuing the parents; (3) rescuing the mother and child while persecuting the father; (4) rescuing the father; and (5) persecuting the family.
The paper describes the changes in family dynamics that occur throughout the process of family-orientated treatment of families where father–daughter incest or stepfatherr–stepdaughter child sexual abuse has occurred. A detailed step-by-step analysis of the developing family process in incest families during therapy is given. The analysis establishes the nature of the original pattern of family relationships, explores the impact made by crisis intervention on the family structure and then outlines therapy and termination of treatment. Characteristic mechanisms in the family process during therapy are described. A detailed clinical example demonstrates the basic therapeutic moves and the mechanisms involved.
Among the various types of partner- and family-involved interventions used to treat adults with substance use disorders, Behavioural Couples Therapy (BCT) has garnered the strongest empirical support for its efficacy. During the past thirty years, multiple studies have consistently found married or cohabiting substance-abusing patients who engage in BCT, compared to traditional individual-based counselling or partner-involved attention control treatments, report significantly greater (1) reductions in substance use, (2) levels of relationship satisfaction, and (3) greater improvements in other areas of relationship and family adjustment (e.g. reductions in partner violence, improvements in custodial children's adjustment). In addition to discussing the theoretical rationale for BCT as a treatment of substance abuse, this article describes specific therapeutic techniques used as part of this intervention and summarizes the relevant evaluative empirical literature.
The longer-term emotional and interpersonal effects of sexual abuse in childhood are reviewed and approaches to treatment discussed. The notion of a ‘trauma organized system’ to account for the long-standing effects of abuse is described. A major potential issue in creating therapeutic change is confronting the abuser, and a case is described where a woman brought her family for therapy when it was feared that the father, who had abused her in childhood, might abuse his grandchildren. A focal family therapy approach was used: this takes into account the traumatic nature of abusive events and their long-term organizing effects on individual and family functioning. The process of therapeutic work is described, including the resolution of traumatic effects by confronting the abusive act.
Although recent reviews of the literature on families and substance misuse offer compelling evidence that inclusion of families significantly improves treatment engagement, retention and outcome, family therapy remains peripheral in most substance abuse treatment programmes. Furthermore, many of the treatment approaches that have been included under the term ‘family therapy’ continue to focus on the substance abuser as the sole target of treatment. Still conspicuously absent are treatment models based on family systems approaches, with outcomes targeted at non-abusing family members as well. This article presents an overview of one such family-focused substance abuse treatment model – systemic-motivational therapy – that combines a family systems approach with techniques derived from motivational interviewing, but this time is applied to work with the family as a unit. The background for the development of the model will be described, as well as the assessment/consultation, family-level action plan, and aftercare/relapse prevention phases of the treatment approach.
A psychiatric out-patient sample of forty-five teenage solvent abusers and their families is described. Most lived in socially deprived areas. In this necessarily unrepresentative clinic sample family psychopathology was characterized by (i) adult intimacy-avoidance and (ii) a powerful, collusive alliance between mother and adolescent. These were linked in a circular pattern of systemic dysfunction, social and generational influences tending to strengthen homeostatic rigidity. Structural and strategic treatment approaches are described with case illustrations and discussed. At the six-month follow-up a good outcome was recorded in three-quarters of the treated cases but the effects of sample bias and ‘soft’ evaluative data should be borne in mind.
Family therapy takes a special position in the therapeutic community for substance abusers (TC). In the early therapeutic communities, the family of origin was not considered as important for the substance abuser's recovery process, and was even labelled as part of the problem. It was only in the 1970s that the TC acknowledged the significance of family involvement in treatment. Nowadays, the contextual vision of Ivan-Boszormenyi-Nagy seems to have a strong impact on family counselling activities in Belgian TCs.
In this article, the integration of contextual thinking in the TC is discussed. By means of a case study, it is shown that there are some clear parallels between the treatment evolutions in family counselling and the peer group community. The central position of trust both in contextual therapy and the TC treatment model is an important common ground for stimulating integration. Some obstacles that can disrupt this integration process are discussed.
A family is presented where sexual abuse of one child had occurred but the family wished to stay together. Work with the family over 3 years, during which time the father served a prison sentence, is described.The problems, for professionals as well as the family, in deciding when a family is safe are discussed.
Patient satisfaction with treatment sheds light on the acceptability, disseminability and usefulness of treatments. This study aimed to assess the perspectives of families who completed treatment using a manual-driven family-based treatment for anorexia nervosa. We hypothesized that overall, manualized treatment would be viewed as acceptable and helpful, but that none the less, a proportion of patients would identify a wish for other types or additional therapy. A total of thirty-four families participated in the survey. Results suggest that patients and families viewed the treatment as highly effective and acceptable. However, approximately a quarter suggested that individual therapy, more family therapy, and focusing on other issues besides anorexia nervosa would improve treatment. These data suggest that a manual-driven family-based treatment for adolescents with anorexia nervosa is acceptable to adolescents and their parents, though modifications to include additional therapy and individual therapy might be considered in some cases.
The improving access to psychological therapies (IAPT) programme, which started with two pilot sites, has dramatically changed the provision of mental health services for depression and anxiety disorders in the National Health Service. The IAPT initiative has focused on the provision of cognitive behaviour therapy but incorporated a small systemic therapy service in the Newham pilot site. The outcomes of this systemic service are presented in this article. Most clients seen by the service suffered from depression and anxiety disorders. The response rate for the evaluation questionnaires was high. For the depression and anxiety measures the recovery rate was above 50 per cent and the effect sizes were large. Most of the clients were satisfied with the service. A trend towards employment was identified. The outcomes are discussed in comparison with those of the cognitive behaviour therapy service and recommendations for the process of further studies are made.
This paper examines the ways in which parents attending family therapy report how they discipline their children. The children are reported to have mental health problems and by the nature of their disorders present challenging behaviours. Within the family therapy setting, parents account for their methods of punishment which includes threatening, punching, hitting and smacking with belts. They report desires to inflict physical damage upon the child, contrast their punishment strategies against the extremeness of the child and co-construct the essential and necessary nature of the discipline. Investigating parental perspectives has wider implications for child discipline and child protection and the growing social impact of discipline techniques for policy-makers.