For those curious about family therapy... Current Trends and Practices in Family Therapy Taken From C. Franklin & C. Jordan, (2001). Guidelines for Conducting Family Therapy. In A. Roberts and G. Greene ( Eds.). Social Workers Desk Reference. Oxford University Press. Family therapy is a relationship form of therapy and it has always been practiced in a systems framework. Family models view individual problems in relationship to other people in the family and work with family members to change dysfunctional family patterns. Some current practices are summarized below. 1. Family therapy practice has expanded in its viewpoint on how to practice family therapy. Family therapy is no longer viewed as only conjoint work between family members. Therapists practice family therapy with individuals alone, as well as various combinations of people from family groups and other significant people who may be involved with individuals who need help. For example, a family therapist might work with an individual client, a live-in couple, a foster family, a social services agency representative, or a teacher. Family therapists work with anyone who is in a relationship with the person who has the presenting problem and is either participating in the problem or could be a resource to a solution. The idea of “problem- determined system” is sometimes used to describe this process of helping. The system that the therapist works with is determined by who is defining and participating in the client’s life around the problem issues. 2. Family therapists currently utilize a more ecological systems perspective and expand their relationship emphasis beyond the nuclear and extended family to include other societal systems and cultural issues that impact individuals and families. For example, a family’s relationship with a social service delivery system, race, gender, and socioeconomic status have become important issues to consider when formulating therapeutic strategies. 3. In recent years there has been a critique of traditional family models and a dissatisfaction with family systems theory as the sole basis for understanding individual problems. This critique has caused therapists to reevaluate family theory and methods for helping in the following manner: • Families are no longer held responsible for causing severe and persistent mental disorders in their family members. The etiology of serious and persistent mental disorders is now viewed from the perspective of stress-diathesis model, which recognizes the role of biology in the development of mental disorders and does not blame the family interactions for these problems. Newer, family-based, psychoeducation treatments are offered to family members to help educate them about mental disorders and to provide support in coping with and managing a mental disorder of a family member. • Division between the medical model and family approaches has diminished. Older family models are revamped to be more flexible and to work with medical professionals and diverse systems of care when helping clients. Family therapists encourage diverse treatments such as medications, Eye Movement Desensitization, or whatever appears to be the best practice available when helping clients. • Increase in popularity of family approaches that rejects the notions of systems theory. Postmodern approaches, narrative therapy, and solution-focused brief therapy have become popular alternatives for the practice of family therapy. These newer approaches developed in reaction to traditional systems models and each model disavows allegiance to the family systems theory. 4. There is less allegiance to the practice of one type of family therapy model. Practicing therapists use a combination of techniques when working with families. Integrationism and technical eclecticism are the preferred ways to practice family therapy (Lebow, 1997). Multi-component treatment programs, which emphasize more than one approach being delivered at the same time, are the preferred way to work with various client populations. Family researchers are combining strategies across models to design empirically-based treatments for hard-to-serve clients such as serious juvenile offenders and substance-abusing youths (Henggeler, 1999). 5. Feminist, postmodern, and multicultural perspectives are at the forefront of discussions about family models and have redefined our understanding of family systems. Feminist viewpoints emphasize the unequal power relations between men and women and how that these larger societal issues impact family life and problem solving. Postmodern viewpoints emphasize the constructed nature of reality and the need for collaborative relationships between client and therapist. Postmodern family therapists examine sociocultural issues such as how client problems and beliefs become socially constructed, the need for empowerment of marginalized clients, the political nature of therapy, and a need for social justice. Multicultural perspectives emphasize race and culture and why these variables are important to therapeutic work. Multicultural, postmodern, and solution-focused practices also emphasize non-pathological approaches to clients. These perspectives have helped therapists learn to respect diversity and see strengths in the families they serve. All practicing therapists trained in family therapy are challenged to become culture and gender sensitive and to practice therapy recognizing the importance of the strengths of their clients. Each therapist is also expected to develop responsive interventions that take into account social justice issues. 6. Family therapists have generally worked with clients using practice methods that focus on changing behavioral patterns, cognitive-beliefs, and social context as their major means of helping. In recent years, however, family therapists are emphasizing the importance of working with attachment processes and emotional states. The use of acceptance strategies is one of the major means of helping families resolve their differences. Therapies that use emotion-focused techniques have offered effective results for distressed couples (Jacobson & Christensen, 1996; Johnson, Hunsley, Greenberg, & Schindler, 1999). Research has also shown that a positive ratio of positive to negative emotions is important to marital satisfaction and the health of family relationships. Research has repeatedly shown that couples who are defensive, criticize, show contempt, and stonewall their partners are the most distressed couples and the ones who are most likely to divorce (Gottman, 1998). Acceptance is believed to be equally important to couple and family change as directed behavioral change strategies such as skills training and contracting. Acceptance strategies emphasize the reframing of hard emotions such as anger into soft emotions such as sadness and uses discussions about behavioral patterns learned in one’s family of origin as a way to help couples gain insight, empathy, and acceptance for each other’s behavior. One research study has shown that acceptance strategies increase the effectiveness of traditional behavioral marital therapies for some clients, such as those who are angry with their partner and are demanding changes (Jacobson & Christensen, 1996). 7. There has been increasing concern over the effectiveness of family therapy models and concerns about how that family therapy will be judged by funding sources such as managed behavioral health care companies. In the past ten years, family therapy researchers and other advocates of these therapeutic methods have given attention to documenting the brief nature of family therapy and its efficacy with client populations. Shadish (1993) conducted a meta-analysis of 163 randomized clinical trials and concludes that the positive results found demonstrate that marital and family therapies work (Shadish, 1995, as cited in Pinsof & Wynne, 1995). Since Shadish published his meta-analysis, a number of other clinical trials and effectiveness studies have accumulated. Recent studies also show that family therapy reduces client utilization of the health care system (Law & Crane, 2000). Most schools of family therapy currently qualify as effective and brief forms of therapy and easily meet the demands of current practices (Franklin & Jordan, 2000). Effective Approaches Several recent reviews of effective marital and family therapy approaches have been written for practitioners (e.g. Corcoran, 2000; Frazer, Nelson & Rivard, 1997; Hogue & Liddle, 1999; Johnson & Lebow, 2000; Lebow, 2000; Pinsof & Wynne, 1995; 2000). Social workers may consult these authors for more comprehensive reviews of marital and family therapy process and outcome studies. This chapter summarizes some of the major conclusions from these reviews about what models work best. Results from meta-analysis suggest that it is difficult to distinguish between different models of family therapy when comparing their overall effectiveness against one another (Shadish, 1993). All models are more effective than not receiving any therapy at all and show similar statistical effect sizes indicating that differing approaches get about the same results. Even so, certain models of family therapy present better outcome research and evidence has accumulated suggesting that these therapies have clinical efficacy with certain client populations. At the present time, behavioral, functional, psychoeducational, multisystemic, and structural models of family therapy present the best evidence for their effectiveness. Each one of these approaches also has well-developed clinical protocols, procedures, and treatment manuals to help therapists learn how to do the interventions. Other promising interventions, which undoubtedly will receive more research, are the emotion-focused therapy for couples, strategic therapy models, intensive family preservation approaches, and solution-focused, brief therapies. Research studies on emotion-focused therapy is progressing and there is evidence for its effectiveness with distressed couples including those who experience trauma. Additional replications and follow-ups will place this model among the best in terms of its empirical basis. Intensive family preservation has shown some positive, but mixed, results with high-risk families, such as those involved in child welfare services. This model appears to work best when combined with other family therapy methods (e.g. structural, behavioral) and implemented by a highly proficient clinical staff. In order to assure the appropriateness and effectiveness of intensive family preservation, a therapist must also give careful attention to risk assessment and work within the framework of multi-component treatment programs. Strategic models have limited studies that show effectiveness, but there is promising work in the area of substance abuse and behavioral disordered youths. Some of the evidence for the strategic model, however, combines strategic methods with structural family therapy. Scott Sells (1998) conducted process outcome research in developing a strategic model for the treatment of behavioral disordered adolescents. Sell’s strategic model is very promising and awaits further outcome studies. Solution-focused, brief therapy is a newer model that has just started to investigate its effectiveness. In the past five years, however, several small, quasi-experimental studies have shown that solution-focused therapy is an effective and promising model with a wide range of problems. Choosing the Best of the Best for Your Clients Behavioral models provide some of the best outcome studies suggesting their effectiveness. Behavioral models work with childhood behavioral disorders and autism. Parent management training is one of the primary components of effective treatment programs. Functional family therapy, which integrates systems theory and behavioral methods into its own unique relationship therapy, works with juvenile offenders and their families. There is also evidence to show that functional family therapy reduces arrests in younger siblings. Skills training approaches based on behavioral therapies work in prevention of substance use and antisocial behaviors. These approaches all emphasize learning skills through a four-step process: (a) therapist modeling the skill, (b) clients role playing and practicing skill in session, (c) clients being assigned homework to continue practicing the skill in their daily lives, and (d) therapist gaining feedback from clients about their success in learning the skills and adjusting the training to accommodate individual differences when learning is not successful. Multisystemic therapy, which uses ecological approaches, intensive family preservation, and structural family therapy, works with hard-to-reach juvenile delinquents and dependent substance abusers. This approach also offers sophisticated protocols for engaging hard-to-reach clients and manuals for maintaining the treatment adherence of therapists. Psychoeducation, multi-family group interventions are the treatment of choice when working with severe and persistent mental disorders such as schizophrenia and bi-polar disorder. A combination of education and social support appears to most efficacious when conducting psychoeducational programs. Structural family therapy interventions work with Hispanic youths who abuse substances and evidence also exists that structural approaches can be effectively used to engage hard-to reach-families in treatment. There is also some evidence that structural family therapy methods may work with eating disorders. Behavioral marital therapies and emotion-focused therapies are the most effective treatments for distressed couples (Johnson, 2000). Behavioral marital therapy is also the treatment of choice for women with Major Depressive Disorder who are also experiencing marital discord. Behavioral marital therapy has been shown to be more effective in ameliorating depressive symptoms than individual treatment, for example. References Corcoran, J. (2000). Evidence-based social work practice with families: A lifespan approach. New York: Springer. Franklin, C., & Jordan, C. (2000). Family practice: Brief systems methods for social work. Pacific Grove, CA: Brooks/Cole. Fraser, M. W., Nelson, K. E., & Rivard, J.C. (1997). Effectiveness of family preservation services. Social Work Research, 21, 138-53. Gottman, J. M. (1999). The marriage clinic. New York: Guilford Press. Henggeler, S. W. (1999). Multisystemic therapy: An overview of clinical procedures, outcomes, and policy implications. Child Psychology and Psychiatry Review, 4, 2-10. Hogue, A., & Liddle, H. A. (1999). Family-based preventive intervention: An approach to preventing substance abuse and antisocial behavior. The American Journal of Orthopsychiatry, 69, 278-290. Jacobson, N. S., & Christensen, A. (1996). Integrative couple therapy. New York: Norton. Johnson, S. M., & Lebow, J. (2000). The coming of age of couple therapy: A decade review. Journal of Marital and Family Therapy, 26, 23-38. Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler, D. (1999). Emotion focused couples therapy: Status and challenges. Clinical Psychology: Science and Practice, 6, 67-79. Law, D. D. & Crane, D. S. (2000). The influence of marital and family therapy on health care utilization in a health-maintenance organization. Journal of Marital and Family Therapy, 26, 281-291. Lebow, J. (1997). The integrative revolution in couple and family therapy. Family Process, 36, 1-17. Lebow, J. (2000). What does the research tell us about couple and family therapies? Psychotherapy in Practice, 56, 1083-1094. Pinsof, W. M. & Wynne, L. C. (1995). The efficacy of marital and family therapy: An empirical overview, conclusions, and recommendations. Journal of Marital and Family Therapy, 21, 585-613. Pinsof, W. M. & Wynne, L. (2000). Toward progress research: Closing the gap between family therapy practice and research. Journal of Marital and Family Therapy, 26, 1-8. Shadish, R., Montgomery, L. M., Wilson, P., Wilson, M. R., Bright, I. & Okwumabua, T. (1993). Effects of family and marital psychotherapies: A meta-analysis. The Journal of Consulting and Clinical Psychology, 61, 992-1002. Sells, S. P. (1998). Treating the tough adolescent: A family-based, step by step guide. New York: Guilford.
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