family therapy concepts process and practice phần 9 ppt

496 FAMILY THERAPY PRACTICE WITH ADULT-FOCUSED PROBLEMS schizophrenia emphasis is placed on blame-reduction, the positive role family members can play in the rehabilitation of the family member with schizophrenia and the degree to which the family intervention will alle- viate some of the family’s burden of care. These programmes include psychoeducation, communication and problem-solving skills training and a variety of techniques, such as reframing, externalising the problem, and so forth, to address problem-maintaining belief systems. Effective programmes also include sessions on recognition of prodromal symptoms and the development of a clear relapse management plan. FURTHER READING Falloon, I., Laporta, M., Fadden, G. & Graham-Hole, V. (1993). Managing Stress in Families. London: Routledge. Kuipers, L., Leff, J. & Lam, D. (2002). Family Work for Schizophrenia – A Practical Guide, 2nd edn. London: Gaskell. Kuipers, E. & Bebbington, P. (2005). Living with Mental Illness, 3rd edn. London: Souvenir Press. Part V RESEARCH AND RESOURCES Chapter 18 EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY An important question for clinicians and service funders is, ‘What type of family therapy approaches and practices are effective for specifi c clini- cal problems?’. An answer to this question, based on a review of available empirical research, is provided in this chapter. There is a growing body of empirical evidence that unequivocally sup- ports the effectiveness of marital and family therapy in the treatment of a wide range of problems (Sexton, Alexander & Leigh-Mease, 2004; Sprenkle, 2002). A review of 12 major meta-analyses confi rmed that for child-focused and adult-focused mental health problems and relationship diffi culties, marital and family therapy is highly effective in a signifi - cant proportion of cases (Shadish & Baldwin, 2003). Across the 12 meta- analyses, average effect sizes of 0.65 after treatment and 0.52 at follow-up were obtained. This indicates that the average treated case fared better than 74% of untreated cases after treatment and 70% of untreated cases at follow-up. Shadish and Baldwin (2003) also concluded that for 40–50% of cases treated with marital and family therapy, the gains made during therapy were clinically signifi cant (as well as statistically signifi cant) and refl ected important changes in the quality of clients lives. This global conclusion is important because it underlines the value of martial and family therapy as a viable intervention modality. Highlighting this overall conclusion is timely since currently increased emphasis is being placed on evidence-based practice by purchasers and providers of mental health services around the world. However, such broad conclusions are of lim- ited value to practicing clinicians in their day-to-day work. In addition to such broad statements about the global effectiveness of family therapy, there is a clear requirement for specifi c evidence-based statements about the precise types of family-based interventions which are most effective with particular types of problems. The present chapter addresses this question with particular reference to a number of common child-focused and adult-focused diffi culties. In many instances reference is made in this chapter to DSM-IV-TR (American Psychiatric Association, 2000) and ICD-10 (World Health Organisation, 1992) diagnostic categories. It is recognised that these are 500 RESEARCH AND RESOURCES premised on an individualistic medical model of family diffi culties and so may be ideologically unacceptable to many family therapists who adopt a systemic framework and a social constructionist epistemology as a basis for practice. Elsewhere (Carr, In press), I have argued on the basis of substantial empirical evidence that both the ICD and DSM systems have reliability, coverage and comorbidity diffi culties, which compromise their validity and that this is because most problems of living which come to the attention of mental health professionals, including family therapists, are not distributed within the population as disease-like categorical entities. Rather, they are more usefully socially constructed as either com- plex interactional problems involving identifi ed patients and members of their social networks or as dimensional psychological characteristics or combinations of both. However, the administration and funding of clini- cal services and research programmes is predominantly framed in terms of the ICD and DSM systems and so, in my opinion, it is expedient to review research on the effectiveness of treatment with reference to the prevailing medical-model framework. This pragmatic approach is also taken by many family therapy training programmes (Denton, Patterson & Van Meir, 1997). In the following sections, where possible, reference is made to important review papers and meta-analyses. When individual treatment outcome studies are cited, unless otherwise stated, these are controlled trials or comparative group outcome studies. Quantitative and qualita- tive treatment process studies are mentioned where they throw light on factors underpinning effective treatment of particular problems. Single case reports and single group outcome studies have been largely ex- cluded from this review because this type of evidence is less compel- ling than that provided by controlled studies, meta-analyses and review papers. The chapter is organised so that child-focused problems are considered fi rst and adult-focused problems are addressed second. Within subsec- tions the implications of research fi ndings for practice and service development are given. CHILD-FOCUSED PROBLEMS Evidence for the effectiveness of family therapy and family-based interventions for the following problems, which occur during childhood and adolescence, will be considered in this section: • physical child abuse and neglect • conduct problems • emotional problems • psychosomatic problems. EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 501 Physical Child Abuse and Neglect Child abuse and neglect have devastating effects on the psychological development of children (Kolko, 2002). The overall prevalence of physical child abuse during childhood and adolescence is 10–25%, depending on the defi nition used, the population studied, and the cut-off point for the end of adolescence (Wekerle & Wolfe, 2003). Community surveys in the USA, the UK and other European countries in the 1990s found that the annual incidence of physical child abuse was 5–9% (Creighton, 2004). The aim of family therapy for cases in which child abuse has occurred is to restructure relationships and prevailing belief systems within the child’s social system so that the interaction patterns that contributed to abuse or neglect will not recur. Signifi cant subsystems for intervention include the child, the parents, the marital subsystem, the extended family, the school system, and the wider professional network. The results of a number of controlled trials show that effective interventions for the family and wider system within which physical child abuse and neglect occurs entail coordinated intervention with problematic subsystems based on a clear assessment of interaction patterns and belief systems that may contribute to abuse or neglect (Edgeworth & Carr, 2000). For illustra- tive purposes two studies will be described. Nicol et al. (1988), in a UK study, compared the impact of social worker facilitated family-focused casework and individual child play therapy for cases at risk for physical abuse or neglect. Family casework was a home- based intervention which included behavioural family assessment and feedback followed by a programme of family-focused problem-solving therapy. This included parental instruction in behavioural child management principles, family crisis intervention and reinforcement of parents for engaging in the casework processes. As a result of the intervention, the average treated family was displaying less coercive behaviour than 76% of the untreated families. Brunk et al. (1987) compared the effectiveness of multisystemic family therapy and behavioural parent training with families where physical abuse or neglect had occurred. Multisystemic family therapy was based on an assessment of family functioning and involved conjoint family sessions, marital sessions, individual sessions and meetings with members of the wider professional network and extended family as appropriate (Henggeler & Borduin, 1990). Interventions included joining with family members and members of the wider system, reframing interaction patterns and prescribing tasks to alter problematic interaction patterns within specifi c subsystems. Therapists designed intervention plans on a case-by-case basis in light of family assessment, and received regular supervision to facilitate this process. In the behavioural parent training programme, parents received treatment within a group context. The programme involved instruction in child development and the principles 502 RESEARCH AND RESOURCES of behavioural management including the use of reward systems and time-out routines. Following treatment both groups showed signifi cant improvement in parental and family stress levels but cases who received multisystemic therapy showed greater improvements in family problems and parent–child interaction. In developing services for families in which physical abuse or neglect has occurred, programmes that begin with a comprehensive network assessment and include, along with regular family therapy sessions, the option of parent-focused and child-focused interventions should be pri- oritised. To maximise the impact of such programmes, given our current state of knowledge, they would probably need to run over a minimum of a six-month period. For such programmes to be practically feasible, at least two therapeutically trained staff would be required and they would need to be provided with adequate administrative support and therapeu- tic supervision. Conduct Problems in Childhood and Adolescence The effectiveness of family therapy and family-based interventions for the following four distinct but related categories of conduct problems will be considered in this section: • pre-adolescent children with oppositional behavioural diffi culties confi ned to the home and school • pre-adolescent children with attentional and overactivity problems • adolescents with pervasive conduct problems • adolescents with drug-related problems. Childhood Oppositional Behavioural Diffi culties Pre-adolescent children who present with oppositional behavioural problems, temper tantrums, defi ance, and non-compliance confi ned largely to the family, school and peer group constitute a third to a half of all refer- rals to child and family mental health clinics, and prevalence rates for clinically signifi cant levels of oppositional behavioural problems in the community vary from 4% to 14% (Carr, 1993; Meltzer et al., 2000). Op- positional behavioural problems are of particular concern because in the longer term they may lead to adolescent conduct problems and later life diffi culties. Oppositional behavioural diffi culties tend to develop gradually within the context of coercive patterns of parent–child interaction and a lack of mutual parental support (Patterson, 1982). When coercive interaction cycles occur the child repeatedly refuses in an increasingly aggressive way to comply with parents’ requests despite escalating parental demands. EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 503 Such cycles conclude with the parent withdrawing. The probability that the cycle will repeat is increased because the parent’s withdrawal offers relief to both the parent and the child. The parent is relieved that the child is no longer aggressively refusing to comply with parental requests and the child is relieved that the parent is no longer demanding compliance. As the frequency of such coercive interaction cycles increases, the frequency of positive parent–child interaction decreases. Coercive parent–child interaction patterns are commonly associated with low levels of mutual parental support or extrafamilial support and may be exacerbated by high levels of family stress. Coercive interaction cycles are also associated with belief systems in which parents attribute the child’s diffi cult behaviour to internal characteristics of the child rather than external characteristics of the situation. For childhood oppositional behavioural problems, behavioural parent training has been shown in many studies to be a highly effective treatment (Behan & Carr, 2000). Behavioural parent training focuses on helping parents develop the skills to monitor specifi c positive and negative behaviours and to modify these by altering their antecedents and consequences. For example, parents are coached in prompting their children to engage in positive behaviours and preventing children from entering situations that elicit negative behaviours. They are also trained to use reward systems such as star charts or tokens to increase positive behaviours and time-out to reduce negative behaviours. Behavioural parent training is probably so effective because it offers parents a highly focused way to supportively cooperate with each other in disrupting the coercive parent–child interaction patterns that maintain children’s oppositional behaviour problems. It also helps parents develop a belief system in which the child’s diffi cult behaviour is attributed to external situational characteristics rather than to intrinsic characteristics of the child. The impact of a variety of formats on the effectiveness of behavioural parent training have been investigated, and the results of these studies allow the following conclusions to be drawn. Behavioural parent training is most effective for families with children who present with oppositional behavioural problems when offered: intensively over at least 20 sessions; exclusively to one family rather than in a group format; and as part of a multisystemic and multimedia intervention package, which in- cludes concurrent individual child-focused problem-solving skills training with video-modeling for both parents and children (Kazdin, 2003; Webster-Stratton & Reid, 2003). Such intensive, exclusive, multisystemic, multimedia programmes are more effective than less intensive, group- based behavioural parent training alone, child-focused problem-solving skills training alone, or video modelling alone, with minimal therapist contact. Where a primary caregiver (typically a mother) is receiving little social support from her partner, then including a component to enhance the social support provided by the partner into a routine behavioural 504 RESEARCH AND RESOURCES parent training programme may enhance the programme’s effectiveness (Dadds, Schwartz & Sanders, 1987). These conclusions have implications for service development. Services should be organised so that comprehensive child and family assessment is available for cases referred where pre-adolescent conduct problems are the central concern. Where it is clear that cases have circumscribed oppositional behavioural problems without other diffi culties, behavioural parent training with video modelling may be offered to parents and child-focused problem-solving training may be offered to children. Each programme should involve at least 20 sessions over a period of 3–6 months. Where there is evidence of marital discord, both parents should be involved in treatment with the focus being on one parent supporting the other in implementing parenting skills in the home situation. Where service demands greatly outweigh available resources, cases on the wait- ing list may be offered video modelling-based behavioural parent training, with minimal therapist contact as a preliminary intervention. Fol- lowing this intervention, cases should be reassessed and if signifi cant behavioural problems are still occurring they should be admitted to a combined 40-session programme behavioural parent training with video modelling and child-focused problem-solving training. Childhood Attentional and Overactivity Problems Attention defi cit hyperactivity disorder is now the most commonly used term for a syndrome characterised by persistent overactivity, impulsivity and diffi culties in sustaining attention (American Psychiatric Association, 2000; Barkley, 2003; World Health Organisation, 1992). The syndrome is a particularly serious problem because youngsters with the core diffi culties of inattention, overactivity and impulsivity, which are usually present from infancy, may develop a wide range of second- ary academic and relationship problems. Available evidence suggests that vulnerability to attentional and overactivity problems, unlike oppositional behavioural problems discussed in the preceding section, is largely constitutional, although the precise role of genetic, prenatal and perinatal factors in the aetiology of the condition are still unclear. Using DSM IV criteria for attention defi cit hyperactivity disorder, a prevalence rate of about 3–7% has been obtained in community studies (American Psychiatric Association, 2000). In the UK about 1% of children, aged 5–15 years, meet the more stringent ICD-10 diagnostic criteria for hyperkinetic disorder (Meltzer et al., 2000). Multimodal programmes are currently the most effective for children with attentional and overactivity problems (Nolan & Carr, 2000). Multi- modal programmes typically include stimulant treatment of children with drugs such as methylphenidate combined with family therapy or parent training; school-based behavioural programmes; and coping skills EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 505 training for children (MTA Cooperative Group,1999). Family-based multimodal programmes are probably effective because they provide the family with a forum within which to develop strategies for managing a chronic disability. As in the case of oppositional behavioural problems discussed above, both behavioural parent training and structural family therapy help parents and children break out of coercive cycles of interaction and to develop mutually supportive positive interaction patterns. Both family therapy and parent training help parents develop benign belief systems where they attribute the child’s diffi cult behaviour to either the disability (attention defi cit hyperactivity disorder) or external situational factors rather than to the child’s negative intentions. School-based behavioural programmes have a similar impact on school staffs’ belief systems and behaviour. Stimulant therapy (e.g. methylphenidate/Ritalin) and coping skills training help the child to control both their attention to academic tasks and their activity levels. Stimulant therapy, when given in low dos- ages, helps children to both concentrate better and sit still in classroom situations. High dosage levels have a more marked impact on overactivity but impair concentration and so are not recommended. Coping skills training helps children to use self-instructions to solve problems in a systematic rather than an impulsive manner. In cases of attentional and overactivity problems, effective family therapy focuses on helping families to develop patterns of organisation condu- cive to effective child management (Barkley, Guevremont, Anastopoulos & Fletcher, 1992). Such patterns of organisation include a high level of parental cooperation in problem-solving and child management; a clear intergenerational hierarchy between parents and children; warm supportive family relationships; clear communication; and clear, moderately fl exible rules, roles and routines. Parent training, as described in the previous section on oppositional behavioural problems, focuses on helping parents develop the skills to monitor specifi c positive and negative behaviour and to modify these by altering their antecedents and consequences (e.g. Barkley, 1997). School- based behavioural programmes in cases of attentional and overactivity problems, involve the extension of home-based behavioural programmes into the school setting through home–school, parent–teacher liaison meetings (Braswell & Bloomquist, 1991; DuPaul & Eckert, 1997). Coping skills focus largely on coaching children in the skills required for sustained attention and systematic problem solving (Baer & Nietzel, 1991; Kendall & Braswell, 1985). These skills include identifying a problem to be solved; breaking it into a number of solvable sub-problems; tackling these one at a time; listing possible solutions; examining the costs and benefi ts of these; selecting the most viable solution; implementing this; monitoring prog- ress; evaluating the outcome; rewarding oneself for successful problem solving; modifying unsuccessful solutions; and monitoring the outcomes of these revised problem-solving plans. [...]... (Brent et al., 199 7; Cottrell, 2003; Harrington et al., 199 8a; Harrington, Whittaker & Shoebridge, 199 8b; Lewinsohn, Clarke, Hops & Andrews, 199 0; Lewinsohn et al., 199 6, Moore & Carr, 2000b) Effective family therapy and family- based interventions aim to decrease the family stress to which the youngster is exposed and enhance the availability of social support to the youngster within the family context... with nonalcoholic family members, particularly spouses, and include: family intervention (Liepman, Silvia & Nirenberg, 198 9); unilateral family therapy (Thomas & Ager, 199 3); community reinforcement and family training (Meyers, Smith & Miller, 199 8); and the pressure to change approach (Barber & Crisp, 199 5) These can help 57–86% of cases engage in treatment (either individual or family based) compared... show that family therapy is more effective than other treatments in engaging and retaining adolescents in therapy and also in reducing of drug abuse (Cormack & Carr, 2000; Rowe & Liddle, 2003; Stanton, 2004; Stanton & Shadish, 199 7) Family- based therapy is more effective in reducing drug abuse than individual therapy, peer group therapy and family psychoeducation Furthermore, family- based therapy leads... 2002; Sandler et al., 199 2) Such programmes focus on: engaging families in treatment; assessing and understanding the context of the loss; acknowledging the reality of the death; modifying the family s worldview so that it incorporates the loss; facilitating problem solving and reorganising the family system, and moving on With respect EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 515 to practice, ... during family therapy sessions Silver, Williams, Worthington 516 RESEARCH AND RESOURCES and Phillips ( 199 8) found that a treatment programme based on Michael White’s narrative therapy externalising procedure was more effective than traditional behavioural programmes for soiling (White & Epston, 198 9) In this type of family therapy, the soiling problem was externalised and defined as distinct and separate... into adolescence and adulthood are parental conflict and violence; a high level of intrafamilial and extrafamilial EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 507 stress; a low level of social support; and parental psychological adjustment problems such as depression or substance abuse Reviews of current outcome studies indicates that functional family therapy and multisystemic therapy are currently... approaches Family therapy can also be effectively combined with other individuallybased approaches and lead to positive synergistic outcomes Thus, family therapy can empower family members to help adolescents: engage in treatment; remain committed to the treatment process; and develop family rules, roles, routines, relationships, and belief systems that support a drug-free lifestyle In addition, family therapy. .. drug problems and the family therapy associated with this, and then framing invitations for resistant family members to engage in therapy so as to indicate that their goals will be addressed and feared outcomes will be avoided (Santiseban et al., 199 6; Szapocznik et al., 198 8) Once families engage in therapy, effective treatment programmes for adolescent drug abuse involve the following processes which,... dissatisfaction and conflict are extremely common problems and currently in western industrialised societies a third to a EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 5 19 half of marriages are ending in divorce (Johnson, 2003b) For couples’ relationship problems, behavioural marital therapy (with and without a cognitive component), emotionally-focused couples therapy, insightoriented marital therapy, and. .. management; family communication training; and family problem-solving training With routine pharmacological treatment, such as lithium carbonate (Keck, & McElroy, 2002), in the absence of family therapy, people with bipolar disorder commonly relapse in response to family- and workrelated stress and non-compliance with medication regimes (Craighead et al., 2002b) Inpatient family therapy, McMaster family therapy . (Brent et al., 199 7; Cottrell, 2003; Harrington et al., 199 8a; Harrington, Whittaker & Shoebridge, 199 8b; Lewinsohn, Clarke, Hops & Andrews, 199 0; Lewinsohn et al., 199 6, Moore &. structural and strategic family therapy traditions (Haley, 199 7; Minuchin, 197 4). In each case treated EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY 511 with multisystemic therapy, around. V RESEARCH AND RESOURCES Chapter 18 EVIDENCE-BASED PRACTICE IN MARITAL AND FAMILY THERAPY An important question for clinicians and service funders is, ‘What type of family therapy approaches and practices