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Therapeutic Approaches to Working with Children and Families

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Therapeutic Approaches to Working with Children and Families. Workshop Notes . Goldsmiths College. Stephen Coulter. Queens University, Belfast . May 2014 – PowerPoint PPT presentation

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Title: Therapeutic Approaches to Working with Children and Families


1
Therapeutic Approaches to Working with Children
and Families
  • Workshop Notes
  • Goldsmiths College
  • Stephen Coulter
  • Queens University, Belfast
  • May 2014

2
Aspects of (Systemic) Family Therapy
3
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

4
Hierarchy of Evidence
5
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 Kings 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, 95100.
6
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

7
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
8
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
9
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)
10
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 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 Minuchin Collaborated with Braulio
Montalvo. Key pupil Harry Aponte
11
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.
  • Parents become fascinated by how their children
    perceive family relationships

In the Flesh
In Representative Form
12
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
13
The Milan Approach
  • The problem symptomatic behaviour in a family
    member helped maintain the systems 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

14
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

15
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

16
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.

17
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

18
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?

19
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?

20
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.

21
Originators
Michael White
David Epston
http//www.dulwichcentre.com.au/
22
  • 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

23
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

24
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?

25
References
Carr, 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, 95100. Minuchin, S. (1974)
Families and family therapy. Cambridge, MA
Harvard University Press.
26
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.
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