How and Why Do Family and Systemic Therapies Work?

My reviews of the evidence base for family therapy conducted over the past 15 years have been guided by four key questions. Does systemic therapy work? What sorts of systemic therapy work for specific problems? What processes occur in effective systemic therapy? Is systemic therapy cost‐effective? In this paper answers to these questions are given. Systemic interventions are effective for about two out of three cases. Specific models of effective systemic therapy have been developed for most common mental health problems. There are many processes shared by evidence‐based models of practice that can be incorporated into the routine practice of research‐informed family therapy. Systemic therapy is cost‐effective and in many cases leads to medical cost‐offsets. Available evidence indicates that family therapy can make a very significant contribution to alleviating suffering and making the world a better place to be.     

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.     

Significant Conversations or Reduced Relational Capacity? Exploring Couple and Family Therapists' Expectations for Including a Client Feedback Procedure

Little information exists on the specific reflective processes that precede therapists' choice of including or not including a structured feedback procedure in their established practice. In the present study, we aim to describe and explore experienced couple and family therapists' expectations for how the comprehensive therapy feedback procedure Systemic Therapy Inventory of Change might influence their practices. Through a thematic analysis of six focus group interviews, two main themes were elicited. The first main theme involved values embedded in current practice, with the following subthemes: (1) balance between the therapist's expert knowledge and the client's experience‐based knowledge; and (2) making time to build alliances. The second main theme concerned the presumed influence on current practice, with the following subthemes: (1) ‘Systemic Therapy Inventory of Change will disturb the therapist's capacity to stay present’; (2) ‘Systemic Therapy Inventory of Change will shape conversations’; and (3) ‘Systemic Therapy Inventory of Change will contribute to increased qualitative depth’. We discuss these results in relation to the notion of Systemic Therapy Invention of Change as a ‘third party in the room’. We also discuss the results in relation to implications for collaborative practices, and for client and therapist autonomy.     

Tapping your way to success: using Emotional Freedom Techniques (EFT) to reduce anxiety and improve communication skills in social work students

By the nature of their professional training and practice placements, social work students are prone to situations provoking the onset of anxiety. A programme of academic and placement support, termed the ‘Skills Lab’, provides help and support for students to develop their communication skills and prepare for their practice placements and transition into professional social work practice. Skills Lab evaluations indicated a high level of appreciation, linked with a strong sense of apprehension and anxiety, which some students report has negatively affected their performance. To address student anxiety, a pilot study using Emotional Freedom Techniques (EFT) was developed. EFT is an intervention, which may potentially be effective in reducing academic anxiety and enhancing public speaking. This mixed-methods pilot study measured participants’ (n = 45) subjective distress and anxiety before and after using EFT. Subjective distress/anxiety was invoked through a 15-min assignment lecture. Twelve of the 45 students also participated in one-one interviews to elaborate on their experiences of EFT. Quantitative findings indicated participants reported significantly less subjective distress and anxiety after using EFT. Qualitative findings indicated three themes whereby participants found EFT calming, relaxing and helpful; considered the transferability of EFT in other settings; and proposed some of the mechanisms of EFT’s action.     

Is There a Place for Biopsychosocial Formulation in a Systemic Practice?

There is a long history of literature concerning integrative practice and how a systemic practice can fit with other models of therapy Much of this literature has focused on establishing a space for systemic therapy within the dominant medical paradigm, and exploring how the medical model can be enhanced by systemic ideas. The outcome has been better practice, especially in child and adolescent mental health. Interestingly, however, there has been less discussion of the converse: the family therapy literature has rarely considered whether or not systemic practice itself can be enhanced by ideas from the dominant medical model. This article proposes that a biopsychosocial formulation can enhance systemic practice by: (I) holding clinicians accountable for their thinking; (2) facilitating a rigour and attention to detail that may prove useful when therapy falters; (3) opening up other possibilities for intervention; and (4) providing a way to engage with the dominant medical paradigm and support clients in negotiating their way through this system. Potential problems nevertheless arise when integrating a biopsychosocial formulation into a systemic framework. This article identifies these problems and presents ideas for how they can be managed in practice.     

Frameworks for Practice in the Systemic Field: Part 1 — Continuities and Transitions in Family Therapy Knowledge

This is the first of two articles to map the landscape of practice theory in systemic family therapy. In this first article, the representation of knowledge for practice is explored, and an argument is made that while frameworks remain important, the relationship to them is now more conditional and pragmatic. A particular chronology is offered of the development of family therapy practice theory frameworks, beginning with the frameworks that emerged in the 1960s to the 1970s. An analysis is given of the important transitions in the 1980s and three sets of influences in this decade — ecosystemic epistemology, the feminist challenge and postmodernism — are identified. This reading emphasises hidden continuities in the transition, despite the seemingly discontinuous shifts in practice theory from the beginning of the 1980s to the beginning of the 1990s. Context and relationship are identified as the enduring parameters of systemic family therapy knowledge, though understandings of context and relationship have been recast in the contemporary (post‐1990s) practice theory. The second article will explore the four contemporary influential approaches in Australian family therapy — the Milan‐systemic, narrative and solution‐focused frameworks, and the dialogical perspective — and point to intersections in practice ideas and integrative movements.     

Practice Learning and the Development of Professional Practice

The development of professional practice is based on practice learning, yet there is no consensus about its definition. The currently evolving use of the term ‘practice learning’ provides us with an opportunity to consider the nature of learning for professional practice at initial entry through to post qualifying stages of development. A number of streams of thought are influencing the understanding of practice learning and we aim to consider some of these and how they inform those involved in supporting and guiding practice learners at different stages of their professional development.

In presenting our conceptualisation of practice learning we argue against oversimplified dualities of classroom‐based academic learning concerned with theory and workplace‐based practice learning concerned with practice. Additionally we make explicit the career‐long nature of practice learning which is as embedded in continuing professional development as it is in the requirements for qualifying programmes.

Having established what we mean by ‘practice learning’ we consider the impact of organisational learning theory on the management of practice learning. The consideration of the characteristics of organisations which learn leads to a brief examination of approaches to teaching and learning which promote knowledge creation in a way which is meaningful to practitioners. We will argue that the development of understandings of organisational learning and knowledge creation should become part of the knowledge base for those supporting and guiding practice learners, in addition to the traditional knowledge base of adult learning theory.

Before exploring the nature of practice learning it would be helpful to consider briefly what we mean by professional practice for which practice learning is preparing people.

Professional practice in social work is a complex set of activities which involve direct work with service users, and their families, as well as work with other professionals and agencies. A range of knowledge and skills are used with a firm value base which recognises diversity and oppression as key elements in UK society.

Such professional practice is learned and developed in a range of ways over time through training, practice, understanding, analysis and reflection. However, the nature of just what practice learning is and where it occurs has become a focus of debate in the UK as a result of recent developments in initial professional education and training for social work.     

Systems thinking: fostering collaboration and connections to strengthen the field. A conversation with Umberta Telfener

Umberta Telfener is a highly respected figure known for her diverse contributions to various facets of family and systemic therapy. Her leadership style has earned her a reputation as somewhat of a ‘cultural anthropologist,’ reflecting her aptitude for creating connections, establishing relationships, and developing partnerships. Her unique ‘Umberta style’ is known for boundless energy, active leadership, and fierce commitment to challenging the status quo. Despite being in office for just a year at the European Family Therapy Association (EFTA), Umberta has conceived and developed numerous projects, establishing networks with practitioners, and systemic thinkers across the world. Rooted in classical philosophical training, her pursuit aligns with the systematic study of fundamental questions about existence, reason, knowledge, value, mind, and language. Umberta's role reminds one of a ‘Chasqui,’ a Quechua term for a ‘messenger,’ which aptly describes her agile networking skills. She actively communicates and shares vital messages, supporting the international community of systemic practitioners. This paper is based on an in-person conversation held in July 2023 at Umberta's country home in Tuscany. Our discussion delves into her extensive professional experience, from training at the Philadelphia Child Guidance Clinic, being mentored by Boscolo and Cecchin in Milan, to her leadership role as the current EFTA president. Umberta reflects on early pioneers who influenced her thinking and her impactful work with systems.     

Family Constellation — A Therapy Beyond Words

Family Constellation, a psychotherapeutic approach associated with the name Bert Hellinger, has become a popular yet also controversial form of systemic therapy in the German‐speaking therapy community. ‘Family Constellation’ (Familienstellen) means the individual client's physical‐emotional positioning and re‐positioning of substitute family members in relation to each other, with help of a therapeutic group. Family Constellation is a one‐session approach that addresses family‐of‐origin issues. The therapeutic process is highly experiential, utilising multiple sensory modalities. Hellinger locates his model within phenomenology, and his practice has roots in several therapy schools. His model offers complementary therapeutic techniques in our ‘languaged’ world of family therapy.     

Evaluating Training to Promote Critical Thinking Skills for Determining Children’s Safety

This study examined changes in training participants’ satisfaction with the instruction, knowledge gain, transfer of new skills, and beliefs about family involvement and engagement in working with families to help ensure children have safety. One hundred and forty-five practitioners participated in the training. Findings revealed shifts in knowledge and use of certain kinds of safety and risk assessment. Qualitative training feedback revealed that caseworkers and supervisors are now talking more about their practice and how they are trying new strategies to help children and families rather than how they complete a list of procedural tasks. The combination of workshop-based training followed by agency-based coaching appears to be a promising approach to professional learning in this practice area of child welfare.     

Stages of Change Theory in Family Therapy for Sibling Sexual Assault

Family therapy understands the benefits of therapeutically supported dialogue amongst family members when there are challenging themes and topics that need to be discussed. This paper is an attempt to explore ways that family therapists can work with family members who are thrust into therapy rather than ‘voluntarily’ signing up for it. It applies ideas from the drug and alcohol field such as Stages of Change theory and Motivational Interviewing. The paper explores how these ideas and approaches might help family therapists to formulate a concept of resistance and to make helpful dialogue more likely. They are applied to families experiencing sibling sexual assault, where they become involved with a legal response that necessitates a therapeutic intervention.     

Being neither Pollyanna nor Henny Penny: Responding to McDonald and Jones

Abstract

This paper provides an account of the earliest contributions to family theory and practice by social workers, beginning in the late nineteenth century. The paper argues that the first widespread practice of ‘family work’ by the helping professions was carried out by social workers, primarily women, despite this being rarely acknowledged in the family therapy literature. An analysis of gender and its place in the development of professional status and the ownership of ideas is provided.

Summary

This paper has traced the place of the family in social work theory and practice since the beginnings of the profession, with a particular focus on theoretical developments in social work in the United States. A number of points have been argued. Firstly, there is significant historical evidence that social workers, most of them women, pioneered family work many decades before the term ‘family therapy’ was invented. This directly challenges the claim made by a number of family therapy historians that work with families was pioneered by psychiatrists in the 1950s and 1960s. It is argued here that this discrepancy is largely a result of differences in professional power and gender status.

Secondly, it is argued that the impact of psychoanalytic theory on social work was profound, not only in terms of how it might have distracted the profession from further developing its early family systems focus, but also in how its multidisciplinary practice tended to place social workers, again mostly women, in somewhat limited and prescribed positions.

In addition, it is argued that social work's emphasis on the family and family intervention has waxed and waned due to these concepts not appearing to fit neatly into divisions between fields of practice, such as casework, group work and Community development. While social work struggled with finding a place for the further development of family social work theory, the rapidly growing domain of family therapy quickly colonised this field of practice, giving little credit to the ground already laid by social workers.     

The Origins of Family Work: The Theory and Practice of Family Social Work Since 1880

This paper provides a detailed literary and historical account of the earliest beginnings of family theory and practice by social workers, beginning in the 1880's. The paper argues that the first widespread practice of family work’ by the helping professions was carried out by social workers, primarily women, despite this being rarely acknowledged in the family therapy literature. An analysis of gender and its place in the development of professional status and the ownership of ideas is provided.     

Women as Workers and as Carers under Communism and After: The Case of Bulgaria

This paper reviews the work-family policy of Bulgaria before and after the transition. Before the transition the family policy was one of earner–carer where women were given support to combine work-force participation with childcare and men were at least encouraged to help with carework. After the transition women's access to help with carework became so limited that the family policy, by default, became one of dual earner, but with extremely high levels of unemployment. A survey of 349 women by the Varna Employment Office indicates how devastating the loss of employment was during the transition. Today policies that support family caregiving still exist on paper but are not enforced. This is due, in part, to the lack of organized broad-based women's groups. Such organizations would be necessary for women to effectively claim the rights and entitlements to caregiving support. But there is continuing pressure from the International Monetary Fund (IMF) and others to eliminate any state support for caregiving.     

‘What shall I pack in my suitcase?’: the role of work-integrated learning in sustaining social work students’ professional identity

Interest in the reflective practitioner as a model of a ‘good professional’ has increased in several professional fields and is also valued within social work education as a key aspiration to address the uncertainties and challenges encountered in contemporary working environments. Reflecting on their own professional identity, as well as theories, values, and devices used in professional practice, can help practitioners deal with complex work demands and help students be better equipped to transition from university to work. Work-integrated learning (WIL) provides students with an opportunity to integrate academic learning with ‘real-world’ experiences to develop both valuable self-monitoring and professional self-constructive ability. This paper presents a case study in social work higher education in which WIL class-based teaching was combined with the use of reflective journals to explore the role of WIL in developing reflective practices for professional identity formation. 21 reflective journals by social work students are analysed. The findings suggest that teaching practices based on WIL enable professional identity formation by developing reflective practices, and that different learning conditions sustain specific dimensions of professional identity, i.e. professional expertise, membership to a professional community and sense of professional self.     

Therapy and Ecology: Viewing the Natural World Through Systemic Lenses

Over the past fifty years systems theory has had a significant influence on numerous disciplines. Ecology and some models of therapy have integrated these systemic ideas, thereby opening up new meanings and new ways of responding respectively to environmental concerns and to emotional distress . Parallels can be drawn between how the two disciplines have developed systemic ideas and applied them for the purpose of change, and each has a contribution to make to the other. Systemic therapy has developed tools of inquiry that can assist in raising awareness of environmental issues. Ecology, in its turn, challenges therapy to include an ecological context in its understanding of the human condition.     

The Impact of Family Therapists’ Adult Attachment Styles on Their Career Choice and Approach to Therapy: An Interpretive Phenomenological Analysis

Attachment theorists have highlighted the role of the therapist in providing a ‘secure base’ for therapy. This raises the question of how therapists with insecure as well as secure attachment styles manage the integration of their personal experience and their therapeutic work. This study explored the relationship between family therapists’ adult attachment styles, influences on their career choice and their approach to therapy. Participants’ (n = 11) attachment styles were previously assessed using the self-report Experiences in Close Relationship questionnaire. Three participants were assessed as having a ‘secure’ attachment style; three were ‘preoccupied’, three ‘fearful’ and two ‘dismissing’. They were interviewed about their practice and the impact of past or current relationships on their development as therapists. Interpretive Phenomenological Analysis was used to analyse the verbatim accounts into cluster of master themes and subthemes. The analysis identified two master themes: understanding one’s self and the impact of family of origin experiences, and the integration between personal experiences and therapeutic work. There were differences in responses relating to the therapists’ attachment styles. Therapists with ‘secure’ adult attachment styles were aware of their challenges and able to utilise their experiences in their practice and respond sensitively to their clients. Conversely, those with ‘insecure’ styles have difficulties in mentalisation and in using counter-transference responses in their practice. We suggest that family therapists, social workers and others engaged in therapeutic work with families should undertake an exploration of the ‘self’ of the therapist in the context of their own family relationships and adult attachment styles as part of their training and continuing professional development.     

Gregory Bateson at 100

Gregory Bateson (1904–1980) was a founding figure of family therapy. The centenary of his birth offers a chance to look again at his life and work for ‘the patterns that connect’. Family therapy may have turned out to be a receding part of that pattern, but it remains important to place Bateson and his thinking in the larger contexts of knowledge; the 19th century history of Darwin and evolution, and 20th century developments in genetics, anthropology, cybernetics and psychotherapy. Bateson swam in all these vast currents, moving towards new aesthetic, holistic and contextual forms of systemic wisdom. His ideas are still very relevant to therapists, but even more, they may be vital to our very survival as a planet in this new century.     

Working with Stepfamilies

Stepfamilies are complex family systems that warrant a specific model to guide therapy practice. Once a stepfamily has formed it's easy to overlook the lack of an attachment history that is commonly embedded in a biologically connected nuclear family. This can result in stepparents picking up parental responsibility for their stepchildren, which often may not go well. This paper highlights the need for clarity concerning the different levels of connection within a stepfamily, and the importance of avoiding ‘nuclear family‐style’ solutions and assumed attachments. This is especially important in the early stages of the relationship when everyone is adjusting to changing circumstances, which is often a time when issues of loyalty and betrayal fuel many of the actions taken. A range of family therapy techniques can be helpfully adapted to working with stepfamilies, especially as relationships with children often bring them to therapy. In particular, therapists can utilise ideas from structural family therapy to help guide the stepfamily to navigate the complexities of everyday life.     

Challenge and Urgency in Defining Doctoral Education in Marriage and Family Therapy: Valuing Complementary Models

In this overview, I comment on the strong theme of the need to define and improve the quality of doctoral education in marriage and family therapy that pervades the three essays. Deficits in research training are the central concern, although the essayists take different perspectives on the nature of the research training needed. The different perspectives can be understood in terms of three different models of doctoral education. The institutional model focuses on professional training with little financial support for students and lower expectations for faculty research. The community of scholars model emphasizes a balance of research and practice with students required to attend full-time and financial support provided. Research is a mix of faculty- and student-driven and is often focused on professional issues. The star researcher model often held out as the ideal, although not yet represented in marital and family therapy (MFT), emphasizes faculty externally funded programmatic research with students working on and supported by faculty grant funding. The value and role of all three models in MFT doctoral education are described and discussed.