Evidence-Based Family Therapy

Evidence-Based Family Therapy Per A Gustafsson Div. of Child and Adolescent Psychiatry Dept of Health and Environment University Hospital S-581 85 Linköping Sweden tel: +46 13 22 41 93, fax: +46 13 22 42 34 e-mail: [email protected] Three components: EBM is the ... use of current best evidence in making decisions about the care of individual patients… integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sachet DL, Centre for EBM Oxford, BMJ 1996). Evidence for a family therapy approach: It allows us to see the individual in a context It then becomes obvious that the context influences the individual (and that influence measured i.e. in time is much more important than psychotherapy sessions) The family and the informal social network constitute the most important environment for the child, both in psychological and social aspects In that environment the child develops, learns social skills and how to cope with life Evidence for a family therapy approach: Resilience research has found that this is favourable for development: a clear family structure with clear rules and roles; shared values between family members; experience of well-functioning cognitive processing and coping models; a positive, open and intimate relation between parents and children; parents supervising and monitoring activities, limiting exposure to risks; positive interaction experiences (as compared to "negative chain reactions"); reduction of impact of adversity on the child (Hansson & Cederblad 1995, Rutter 1999) Evidence for a family therapy approach: A basic assumption: If interaction patterns in the family system could be changed this would have an impact on the individual child and its psychiatric symptoms Interaction forces could be compared to the gravitation force – they are invisible but work even over long distance, i.e. when a child is triangulated between divorced parents Family therapy In child psychiatry (as in paediatrics) one has always been aware of the fact that children live with parents and considered that in treatment John Bowlby in 1947: "it was striking that the children’s problems could be understood as a reflection of the parents’ problems" When family therapy appeared in the 1960-ies the new concept was "conjoint" family therapy. Instead of meeting the child and the mother (or parents) separately discussing rearing conflicts, marital problems, unclear communication, dysfunctional coalitions, unclear structure/hierarchy, etc were dealt with directly in the family Family therapy Treatment of the entire family or parts of it, with psychological and/or pedagogical methods aimed at changing interaction patterns and interpersonal relations In family therapy the systems view has always been a theoretical base Focus is on changing interaction patterns between family members (and with people outside the family) with the assumption that if interaction changes, hidden resources would be freed and amazing things could happen Family therapy From focus on development and "growth" in interpersonal relations to management of difficulties in child rearing, psychiatric symptoms, criminality, etc A multi-systemic approach with interventions in the individual child, the family and the social network comes as natural for a person trained in family therapy Family therapy with good evidence of treatment effects is often based in a multi-systemic approach Evidence-based family therapy Carr A. Evidence-based practice in family therapy and systemic consultation. J Fam Therapy 2000;22:29-60 (Meta-analysis of controlled studies) Family based interventions have been shown to be effective for a wide range of child-focused problems These interventions are brief (as compared to psychodynamic therapy) The bulk of evidence based treatments come from the cognitive-behavioural, structural and strategic traditions, but there are some studies of systemic family therapy. There are few or non- existing of psychodynamic family therapy Evidence-based family therapy Child abuse and neglect Conduct problems Emotional problems Psychosomatic problems Aims and interventions in effective treatment Evidence-based family therapy Child abuse and neglect Aim: to restructure relationships and prevailing belief systems within the child's social system so that interaction patterns that contributed to abuse and neglect will not recur Intervention subsystems: child, parents, marital subsystem, extended family, school, professional network Evidence-based family therapy Oppositional behaviour difficulties (> 100 studies) Aim: helping parents develop the skills to monitor positive and negative behaviours and to modify these by altering their antecedents and consequences Intervention subsystems: parent's training, often in group format with video-illustrations, social skills training for children Evidence-based family therapy Attention and overactivity problems Aim: develop strategies for managing a chronic disability, develop monitoring and modifying skills Intervention subsystems: Multi-modal and multi-systems approaches are more effective including parent's training, often in group format with video-illustrations, social skills training for children combined with stimulants and school-based behavioural programmes (token economy) Evidence-based family therapy Conduct disorder and drug abuse Aim: counter risk factors; child characteristics (impulsivity, inattention and overactivity), parenting practices (ineffective monitoring and supervision, inconsistent and harsh discipline (high EE), failing reinforcement for positive behaviour) and family organization problems (parental conflict and violence, high intra- and extrafamilial stress, low social support, parental abuse and psychiatric disorder) Intervention subsystems: Multi-modal and multi-systems approaches are more effective: functional family therapy (FFT, reduce disorganization, modify chaotic family routines and communication patterns), multi-systemic therapy in addition addresses factors within the adolescent (i.e. using ART) and the wider social system with individualized packages of interventions Evidence-based family therapy Anxiety disorders Fewer studies Aims: creating a context within family therapy that allows the child to eventually enter into anxiety-provoking situations Interventions: parental support, encouragement and developing personal coping skills. Parental engagement significantly enhances the effects of CBT Evidence-based family therapy Depression Family interventions as good as individual approaches in several studies Aim: to decrease the family stress to which the youngster is exposed and to enhance social support within the family context Interventions: conjoint family therapy or concurrent parent and child sessions. Clear parent child communication, family-based problem solving, lowering negative critical high EE Evidence-based family therapy Psychosomatic problems Family therapy has the best research evidence, much less studies on individual approaches Evidence-based family therapy Astma There is some indication that family therapy may be a useful adjunct to medication for children with asthma is the conclusion of a Cochrane systematic review . Obesity Family therapy seems to be effective in preventing progression to severe obesity during adolescence if the treatment starts at 10 to 11 years of age. Recurrent abdominal pain Family therapy more effective than standard medical care Eating disorders Family therapy and combined individual therapy and parent counselling are effective in treating anorexia nervosa Evidence-based family therapy Aims: viewing the illness in a family context, addressing parents (and siblings) as partners in medical treatment, preventing that the illness disrupts family life Interventions: conjoint family therapy sessions, often sometimes including the paediatrician, structural family therapy interventions using i.e. the father working with the child in relaxation training sessions to diminish the dependence on the mother, etc Evidence-based family therapy Family based interventions have been shown to be effective for a wide range of child-focused problems The bulk of evidence based treatment come from the cognitive-behavioural, structural and strategic traditions, but there are some studies of systemic family therapy. There are few or non- existing of psychodynamic family therapy Family therapy with good evidence of treatment effects is often based in a multi-systemic approach Referenser Carr A. Evidence-based practice in family therapy and systemic consultation. J Fam Therapy 2000;22:29-60. Diamond, G. S., Serrano, A. C., Dickey, M., & Sonis, W. A. (1996). Current status of family- based outcome and process research [see comments]. J Am Acad Child Adolesc Psychiatry, 35(1), 6-16. Flodmark, C. E., Ohlsson, T., Ryden, O., & Sveger, T. (1993). Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy. Pediatrics, 91(5), 880-884. Gustafsson, P. A., Kjellman, N. I., & Cederblad, M. (1986). Family therapy in the treatment of severe childhood asthma. J Psychosom Res, 30(3), 369-374. Hansson K. Familjebehandling på goda grunder. Gothia, 2000 (in press). Hansson, K., & Cederblad, M. (1995). Salutogen familjeterapi. Fokus på familien, 23. Panton, J., & Barley, E. A. (2000). Family therapy for asthma in children. Cochrane Database Syst Rev(2), CD000089. Rutter, M. (1999). Resilience concepts and findings: implications for family therapy. J Fam Therapy, 21, 119-144.