‘Somebody Else's Roadmap’: Lived Experience of Maudsley and Family‐based Therapy for Adolescent Anorexia Nervosa

The Maudsley and more recent family‐based therapy manualised approaches are positioned by some as the gold standard, evidence‐based therapy for adolescent anorexia nervosa (AN). However, a significant proportion of adolescents and their families either discontinue this therapy and/or find that it simply does not work for them. These adolescents and families are under‐represented in the literature on therapeutic interventions for adolescent AN. This paper begins to address this gap with an in‐depth qualitative case study that explores the lived experience of Maudsley family therapy (MFT)/family‐based therapy (FBT) for one female adolescent (age 14 years) and her family over the period of 3 years (ages 11–14). Although initially handing over the responsibility for her eating was comforting and reinstated a sense of control in the family system, these experiences were not maintained. When she did not progress past the first phase of FBT, she and her family experienced the approach as blaming. She felt silenced and family alliances were weakened. This paper analyses how the family members negotiated and preserved their identities within this disabling context.     

Commentary on Studying Circular Questioning “In Situ”

In their discursive study of circular questioning in a systemic family therapy session, the authors raise some interesting perspectives on the original Milan therapy team's guidelines for the therapist as the conductor of therapy. By emphasizing circularity from a discourse point of view, they suggest these guidelines can be used to help family members hypothesize about their own perspectives on themselves and the other family members in circular terms, and, drawing upon Cecchin's notion of neutrality, by creating a state of curiosity in their talk and maybe in their minds. Their emphasis on circularity also helps us to become more sensitive to ways in which the natural recursion in language can help us to appreciate the new guiding lines circular questions can suggest with previously spoken elements. If we follow this line of argument, then circular questions can be seen as a critical part of a therapy we can call recursive family therapy in which we use the recursive element of all natural living languages to help our clients to recursively change their language and lives naturally.     

Relationship Education and Therapy for Same‐Sex Couples

The gay and lesbian community suffers higher rates of discrimination, mental health problems, and relationship break‐up than their heterosexual counterparts. In this paper we analyse the challenges confronting same‐sex couples, and the implications for couple education and therapy with same‐sex couples. We describe some similarities in the challenges confronting heterosexual and same‐sex couples (e.g., negotiation of shared realistic relationship expectations, effective communication). These similarities suggest existing evidence‐based approaches to couple therapy and relationship education are likely to assist same sex couple relationships. We also describe distinctive challenges for same‐sex couples (e.g., homophobic discrimination, internalised homophobia, and low support from many families for same sex relationships). These distinctive challenges suggest some adaptation of existing approaches to couple education and therapy could enhance their relevance and effectiveness to same sex couples.     

Family Therapy in Child and Adolescent Mental Health Practice: Integrating Family Therapy in Child and Adolescent Mental Health Practice: An Ethic of Hospitality

This article integrates family therapy in contemporary child and adolescent mental health services as an evidence‐based practice. An integrative practice model is proposed where contextual approaches like systemic and narrative therapy complement and enrich individual problem‐focused models such as biological psychiatry and cognitive therapy. This is based on an ethic of hospitality towards all therapy discourses and the following best practice guideline: ‘To make optimum space for a systemic and narrative understanding contributes to evidence‐based practice in a contemporary mental health service.’ After discussing some dilemmas of integrative practice, I illustrate the therapeutic process by a detailed example of integrative family therapy with a depressed suicidal adolescent.     

Discernment Counseling for “Mixed‐Agenda” Couples

This article describes discernment counseling, an approach to working with couples where one partner is leaning toward divorce and the other wants to preserve the relationship and work on it in couples therapy. These “mixed‐agenda” couples are common in clinical practice but have been neglected in the literature. The goal of discernment counseling is clarity and confidence regarding the next steps for the relationship, based on a deeper understanding of each partner's contributions. Sessions emphasize individual conversations with each partner. An analysis of 100 consecutive cases found that about half of the couples chose to start couples therapy in order to reconcile, with most of the rest choosing the divorce path. Longer term follow‐up information is also presented.     

“Being a Therapist Doesn't Exclude You From Real Life”: Family Therapists’ Beliefs and Barriers to Political Action

A crucial and overlooked facet of social justice in family therapy is political and policy advocacy. Family therapists have unique insight into how social policies and political discourse shapes clients’ lives and the life of our profession. Such knowledge can inform policymakers and political debate, yet few family therapists are trained to engage in political action. In this randomized, national survey of licensed family therapists’ (N = 174), we explore beliefs about and barriers to engagement in political and policy processes. The findings suggest that there are significant barriers and uncertainties surrounding family therapists’ engagement, including time, feelings of efficacy, and interest. Given these barriers we discuss practical suggestions for clinicians and family therapy training programs.     

“Family Matters”: A Systematic Review of the Evidence For Family Psychoeducation For Major Depressive Disorder

The first aim of this systematic review was to evaluate the evidence for family psychoeducation (FPE) interventions for major depressive disorder (MDD). A second aim was to compare the efficacy of different modes of delivering face‐to‐face FPE interventions. Ten studies (based on nine distinct samples) were identified comprising four single‐family studies, four multifamily studies, one single versus multifamily comparative study, and one peer‐led, mixed‐diagnosis study. Seven studies measured patient functioning and six reported positive outcomes. Six studies measured carer's well‐being and four reported positive outcomes. Results provide preliminary evidence that FPE leads to improved outcomes for patient functioning and family–carer's well‐being for persons with depression. The implications for future development and delivery of FPE interventions for MDD are discussed.     

Between “Families in Trouble” and “Children at Risk”: Historicising “Troubled Family” Policy in England since 1945

The launch of the Troubled Families Programme in 2011 has thrown into sharp relief how governments develop policies and practices to intervene in the lives of so‐called ‘troubled families’. Commentators were quick to make comparisons with historic efforts to rehabilitate ‘problem families’ in the post‐war period. However, beyond discursive similarities, there are also marked continuities in how family policies have been developed and implemented. This review narrates the rise, fall and rise of concern about ‘problem’ and ‘troubled’ families in England in the context of anxieties about child and family welfare, and the appropriate response of the state.     

Getting Comfortable as “Fish Out of Water”: Using Qualitative Research Methods Training to Enhance the Technical Capacity of Family Therapy Trainees

This article describes a qualitative research methods training project undertaken in a COAMFTE‐accredited family therapy master’s‐level program. Graduate students were trained to collect research data for a qualitative study on the resilience of families displaced to the United States because of war and politically motivated violence in their country of origin. By involving trainees in a research project with refugees, the project was intended to address a gap in clinicians’ training, specific to the refugee population (Miller, Muzurovic, Worthington, Tipping, and Goldman, American Journal of Orthopsychiatry 2002; 72 : 341). However, the training process was also a way to increase the students’ skills at interviewing in complex situations, develop their cultural sensitivity beyond awareness, enhance their capacity for routine self‐reflection, and introduce them to basic practices of qualitative research methodology. In this article, we focus on the students’ experience of the training and discuss the potential implications of their feedback for family therapy training.     

Single Mothers “Do” Family

This paper explores how single mothers both incorporate others into family life (e.g., when they ask others to care for their children) and simultaneously “do families” in a manner that holds out a vision of a “traditional” family structure. Drawing on research with White, rural single mothers, the author explores the manner in which these women both endorse their children’s attachment to other caregivers and maintain boundaries around issues of discipline and attachment vis‐à‐vis these others. The author demonstrates that single mothers are willing to share this protected realm of family life with a new man (a fiancé or cohabiting boyfriend) as they pursue the goal of what has been called the “Standard North American Family.”     

Frameworks for Practice in the Systemic Field: Part 2 — Contemporary Frameworks in Family Therapy

This is the second of two articles to map the landscape of practice theory in systemic family therapy. The first article gave a particular chronology of the development of family therapy practice theory, beginning with the frameworks that emerged in the 1960s‐1970s and then tracing the transitional decade of the 1980s. The convergences of three sets of influences — ecosystemic epistemology, the feminist challenge and postmodernist ideas — led to the changed landscape of post‐1990 practice theory. This second article picks up at this point, mapping four contemporary influential approaches in Australian family therapy — the Milan‐systemic, narrative and solution‐focused frameworks, and the dialogical perspective. Social constructionist and narrative ideas together constitute the dominant common theory influence in the post‐1990 practice frameworks, although intersected and used in different ways in the different frameworks. Throughout the history of the development of practice theory, context and relationship remain the enduring parameters of the systemic family therapy field.     

“I'm Not Supporting His Kids”: Nonresident Fathers' Contributions Given Mothers' New Fertility

The authors examined whether nonresident fathers provide informal support to their children and whether support stops if their ex‐partner goes on to have a child with a new man. A logistic regression analysis of longitudinal survey and administrative data for 434 women who received welfare in Wisconsin showed that fathers are less likely to provide informal support when their ex‐partner has a child with a new partner. Alternative models that control for unobserved characteristics suggest somewhat different results, providing stronger evidence of declines in support that can be shared across family members than in support that can be directed to a particular child.     

FAMILY THERAPY RESEARCH AND THE “NEW EPISTEMOLOGY”*

Epistemological critiques of the theory and practice of family therapy recently have also been brought to bear on mainstream strategies and methods of research in family therapy. In this paper, it is argued that standard research methods are the only ethically responsible means presently available by which we can assess the efficacy of family therapy. It is also argued that standard research models have already provided data of practical relevance to clinicians, patients and public policy makers and should not be abandoned in haste. Finally, it is argued that there are insufficient grounds for divorce between the “new epistemology” and standard research, since commonplace research designs and methods are far more compatible with systemic thinking than some observers have suggested.     

THE FAMILY CRISIS INTERVENTION LITERATURE: WHAT IS MEANT BY “FAMILY”?*

Family crisis intervention is a rapidly growing area of clinical care in family therapy which lacks clear conceptualization, especially with respect to how “family” fits into crisis intervention theory. This paper integrates recent concepts from the family therapy literature into three views: family as background, family as context, and family as a unit. The family crisis intervention literature (56 publications) is reviewed and categorized according to these three views. Clarity in how “family” is viewed and consistency between theory and practice are examined. Recommendations for improving the conceptualization of “family” in family crisis intervention theory and practice are made.     

Integrative Family Therapy With Childhood Chronic Illness: An Ethics of Practice

A challenge for contemporary family therapists is negotiating differences between modern and postmodern frameworks in the practice context. Modernists espouse a systemic metaphor; use evidence‐based and interventive approaches, including strategic, structural‐ or solution‐focused techniques, and believe in the therapist's knowledge, expertise and power to influence individuals or families to change. On the other hand, postmodernists follow a social constructionist, dialogical or narrative paradigm, which identifies the main ingredient of therapy as language, conversation, understanding and the therapist's ‘not knowing’ stance in eliciting a person's expertise and story Yet many practitioners adopt a middle way between these paradigm polarities, one that is less theory‐driven and more pragmatic, flexible, integrative and practice‐based. This is consistent with evidence‐based practice and research demonstrating common factors across all therapies. The value of preserving systemic thinking in family therapy is recognised while reaching forward to a postmodern social constructionist and dialogical approach. The article describes this integrative stance in family therapy as paramodern based on an ethics of practice. This is illustrated by a detailed case study of integrative family therapy, which addresses anxiety, anger and sleeping issues associated with a chronic childhood illness called Perthe's disease.     

Family Therapy … What's in a Name?*

The 2nd Australian and New Zealand Family Therapy Conference, held in Melbourne in July 1992, invited those making presentations to address the Conference theme Family Therapy … what's in a name? In a closing address to a plenary session of the Conference, I used the metaphor of first names (family) and surnames (therapy) to suggest that names are central to issues of identity. Our first name of “family” differentiates us within the larger group who share the surname “therapy”; but what does it mean to belong to the larger group sharing the name “therapy”? Historically, much of family therapy's energy has gone into issues concerned with establishing difference — difference within family therapy in terms of models and approaches, and difference from other approaches to therapy. Yet now perhaps family therapy would benefit from exploring what it shares in common with others who hold the same surname of “therapy”, with the possibility such dialogue could lead to mutual enrichment.     

Attachment and the Repetition of Trauma: A Case Study of Attachment‐Based Crisis Intervention

This article explores the difficult case of a 16‐year‐old who was causing a great deal of anxiety by presenting with dramatic behaviour, such as leaping off buildings, swallowing needles and poisons, and jumping in front of cars. The case study explores a six‐month period of crisis intervention, which focused on the unique kind of attachment relationship that existed between the teenager and his mother. The mother had experienced recurrent traumatisation prior to his birth, and it was found that the aftereffects of this traumatisation must have influenced the teenager's early attachment experiences and subsequent development. The attachment‐based therapy treated the crises as primarily ‘relational crises’. The therapy involved investigating and sharing formulations about their attachment history, cultivating an insight into the relational or dynamic determinants of the teenager's crises. Broader suggestions are made concerning the application of attachment theory to different approaches in family therapy, as well as to our understanding of phenomena such as transgenerational traumatisation.