Therapeutic Approaches to
Working with Children and
Families
Workshop Notes
Goldsmiths College
Stephen Coulter
Queens University, Belfast
May 2014
Aspects of (Systemic) Family Therapy
Overview
Evidence base for Systemic Family Therapy
Some approaches/Techniques for working
with Children (and others)
Sculpting – Structural Family Therapy
Circular Questioning – Milan Associates
Scaling – Solution-Focused Brief Therapy
Externalisation – Narrative Therapy
Hierarchy of Evidence
RCT EXAMPLE: SYSTEMIC COUPLES THERAPY FOR DEPRESSION
For 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.
Julian Leff
King’s College London
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.
5
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-Analyses
Sydow 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
•
ADULT-FOCUSED PROBLEMS
Sleep, feeding & attachment
problems in infancy
•
Relationship distress
•
Psychosexual problems
•
Elimination disorders
•
Intimate partner violence
•
Child abuse
•
Disruptive behaviour disorders
•
Eating disorders
(Carr, 2014a, 2014b)
Structural Family Therapy
The problem – there is something
untenable with the structure of the
family
emphasis on structural change as the
main goal of therapy
the therapist as an active agent in the
process of restructuring the family
delinquent boys from disorganized,
multi-problem, poor families (rather than
verbally articulate, middle-class patients Salvador Minuchin
besieged by intrapsychic conflicts)
Collaborated with: Braulio Montalvo.
Key pupil: Harry Aponte
Later applied at the Philadelphia Child
Guidance clinic to the whole range of
problems typically brought for treatment
to a child clinic
Sculpting
The 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.
In the Flesh
Parents become fascinated by
how their children perceive
family relationships
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 Approach
The 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 Questions
Used to explore validity of hypotheses
Focus on exploring differences:
between people
between relationships
between behaviours
between emotions
between ideas or beliefs
in perception of events
temporal differences
Benefits of Circular Questions
Introduce 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 Therapy
Developed 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.
SFBT
is 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 problems
Explores hopes rather than past causes
People often resourceful - there are always
exceptions to the problem
Do more of what works
Scaling Questions
On 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 Scaling
On 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 Therapy
A philosophical Approach drawn from post-modern
and social constructionist ways of understanding
relationships
People link events across time, according to a plot
in order to explain or make sense of their lives
Our conversations are continually creating our
reality, rather than just reflecting it
options 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/pathology
To 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?”
References
Carr, A. (2014a). The evidence base for family therapy and systemic
interventions for child-focused problems. Journal of Family Therapy, 36(2), 107157.
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.