Outcome Research In Family Therapy

A Review of Article By Tom Smith, Ph.D.

“Outcome research in family therapy” by Eia Asen was originally published in Advances in Psychiatric Treatment (2002), vol. 8, pp. 230-238

The full text of this article is available at no charge to the public because the journal publisher has provided open access to it in one of these ways: Some of the older articles are freely available after a period of time or this particular article has been made available in the public interest. The original article may be found at the following site: http://apt.rcpsych.org/cgi/content/full/8/3/230

This article is particularly useful in that it provides a multiple choice test at its conclusion offering aid to the reader to evaluate comprehension.

 

The author begins his article regarding outcome research by first questioning what the nature of “family” is in the twenty-first century. It used to be that we understood the family to be Dad, Mom and a girl and boy: The nuclear family. Not so anymore. There are single parent families, same-sexed parents raising children, blended families brought together through death or divorce and remarriage again, childless couples who are a “family” nevertheless. There are now many acceptable committed relationships that are considered family.

Additionally, what used to be considered an aberration is now normal. What a “family” used to go to therapy for is no longer considered to be amenable to or require “therapy”. Therapy was once considered to be stigmatic. The family does not have a problem, but maybe dad or mom or one of the kids does. Family Therapy seemed to have to blame some one. A new name was needed.

With this in mind, many therapists choose to treat the family “in context”; hence, the development of the systemic approach that really dates back to the 1950s, Gregory Bateson and the treatment of the “schizophrenic family” and the “identified patient”. A new terminology was developed that used such terms as hierarchies, boundaries, covert conflicts, dysfunctional communications and the destabilization of homeostatic conditions. Now, instead of working on the “family” or a “patient” we are now working with a system. No blame. No shame.

Thus, the major systemic approaches were developed: Structural, strategic, the Milan system, postmodern narrative approaches and psycho educational and behavioral approaches.

Salvador Minuchin introduced the world to his Systemic approach. Family structure, clear hierarchies and authority, established limits and flexible boundaries that permit an up and down communication flow is important to the composition of the “normal” family.

The Strategic system is a brief therapy that based on the hypothesis that symptoms are maintained by the very behaviors that seek to quell them. Once the symptoms begin to change, the whole system will follow.

The Milan system developed by Pazzoli and others uses a questioning technique that explores the perceptions, beliefs and relationships t of the various family members. Everyone’s view is valid and no one is to “blame” for anything.

The social constructionist, narrative approach emphasizes that reality is “invented” by the stories we tell and the social context within which we live. Change the social setting and tell a different story and the family can experience a different outcome to its difficulties.

Solution focused therapy says that the problem is the problem and let us find a solution. The focus is on the positive and that everyone involved should keep a “solution-focused mind”.

Psycho educational approaches address the deficit of psychological education in the schools and in the general public. If there is a psychiatric problem, those that are involved are educated about the illness, how it may run its course, if it is going to be a permanent or transitional situation, etc. This education gives the family a sense of control and reduces the emotional intensity that accompanies psychiatric illness.

Finally, the behavioral therapies are just that: The focus is on functional and dysfunctional behaviors, enhancing the former and extinguishing the latter.

Systemic approaches are somewhat circular and and were once thought to be not always open to linear research approaches. Nevertheless, therapists work in an evidence based climate regarding the efficacy of treatment (especially in the current age of managed care and stringent requirements for reimbursement), and the “linear tools” of research can indeed be applied to develop a proper criteria for evidence.

Criteria for evidence outlined in the article here reviewed as promulgated by the National Service Framework in the United Kingdom include: Type I evidence (a systematic review and a random controlled trial), Type II evidence (a quality random controlled trial), Type III evidence (a well designed intervention study without randomization), Type IV evidence (an observational study) and Type V evidence (expert opinion including service users and caregivers).

Using these categories of evidence, systemic therapies have proven to be effective. Some of the therapies are effective as they are, but also in conjunction with other therapies they can treat a wide range of different conditions and presentations including conduct problems in children, eating disorders (anorexia nervosa and bulimia nervosa) and drug and alcohol misuse in adolescents and marital distress. The article here reviewed cites a number of studies according to the criteria for evidence identified above that show systemic therapies as useful and effective.

With the development of vastly improved psychiatric medications, it is sometimes thought that family intervention for psychosis; i.e., a family member suffering from schizophrenia, bipolar disorder or major depression may be a waste of time and effort. This is a hasty conclusion that is not supported by research.

For example, as reported in the Cochrane Review, randomized controlled trials were carried out in variety of settings in Europe, Australia, Canada, China and the United States of America, employing a large number of outcome scales used to focus primarily on suicide, relapse and hospital admission. Other criteria were considered, including employment status, compliance with treatment, expressed emotion in the home and relative family burden.

Although there were some adverse outcomes; for example, 4% suicides, family intervention was found to have no relationship to this particular outcome. Family intervention though was found to prevent relapse (defined in a variety of different ways) and improved compliance with medication regimens. The fundamental conclusion drawn was that family intervention (therapy) results in “significant net savings in the overall costs of managing patients in the community”.

Regarding mood disorders, research evidence generated in the year 2000 indicates that conjoint interpersonal or marital or family therapy is effective when one of the partners has depression and prevents relapse rates. This is consistent with research in the United States that medication with Cognitive Behavioral Therapy is better than just medication alone. Additionally, it seems that CBT or couples counseling is more acceptable to the patient than just drug therapy alone.

In conclusion, it has been found that systemic therapy is effective in the treatment of psychotic disorders, mood disorder, eating disorders in adolescents, drug and alcohol abuse, conduct problems in children and marital distress.