A number of comments may be made about the evidence reviewed in this paper. First, well-articulated systemic interventions are effective for a wide range of common adult mental health and relationship problems. Second, these interventions are brief and may be offered by a range of professionals on an outpatient or inpatient basis, as appropriate. Third, for many of these interventions, useful treatment manuals have been developed which may be flexibly used by clinicians in treating individual cases. Fourth, an important issue is the generalizability of the results of the studies reviewed in this paper to typical health service settings. It is probable that the evidence-based practices described in this paper are somewhat less effective when used in typical health service settings by busy clinicians, who receive limited supervision, and carry large case loads of clients with many co-morbid problems. This is because participants in research trials tend to have fewer co-morbid problems than typical service users, and most trials are conducted in specialist university-affiliated clinics where therapists carry small case loads, receive intensive supervision, and follow flexible manualized treatment protocols. Clearly, an important future research priority is to conduct treatment effectiveness trials in which evidence-based practices are evaluated in routine non-specialist health service clinics with typical clients and therapists. Fifth, controlled trials of systemic therapy for prevalent problems such as personality disorders have not been reported in the literature, although clinical models for their treatment have been developed (MacFarlane, 2004). Clearly these should be a priority for future research. Such trials should include relatively homogeneous samples, and involve the flexible use of treatment manuals. Sixth, the contribution of common factors (such as the therapeutic alliance) and specific factors (such as techniques specified in protocols) to therapy outcome have rarely been investigated, and future research should routinely build an exploration of this issue into the design of controlled trials (Sprenkle and Blow, 2004). Seventh, the bulk of systemic interventions which have been evaluated in control trials have been developed within the cognitive-behavioural, psychoeducational and structural-strategic psychotherapeutic traditions. More research is required on social constructionist and narrative approaches to systemic practice, which are very widely used in the UK, Ireland and elsewhere. Eighth, for some adult-focused problems such as schizophrenia and bipolar disorder, the research evidence shows that systemic therapy is particularly effective, not as an alternative to medication, but when offered as one element of a multi-modal treatment programme involving pharmacotherapy. A challenge for systemic therapists using such approaches in routine practice, and for family therapy training programmes, will be to develop coherent, overarching frameworks within which to conceptualize the roles of systemic therapy and pharmacotherapy in the multi-modal treatment of such conditions. Ninth, because there is so little evidence on the conditions under which systemic therapy is not effective for the adult-focused mental health problems covered in this paper, it is probably appropriate for practitioners to use evidence-based systemic interventions in situations where family members are available and willing to engage in therapy, to contribute to problem resolution and to disengage from family processes that maintain the identified patients presenting problems.
The results of this review are broadly consistent with the important role accorded to systemic interventions and family involvement in psychosocial treatment within NICE guidelines for a range of adult mental health problems including schizophrenia (NICE, 2003), depression (NICE, 2004), bipolar disorder (NICE, 2006) and OCD (NICE, 2005). In contrast, the potentially helpful role of family-based interventions found in this review is not reflected in NICE guidelines for the treatment of panic disorder with agoraphobia (NICE, 2007).
A broad definition of family therapy and systemic intervention has been adopted in this paper. There are pros and cons to this approach. On the positive side, it provides the widest scope of evidence on which to draw in support of systemic practice. This is important in a climate where there is increasing pressure to point to a large and significant evidence base to justify funding any particular type of psychotherapy service. However, the broad definition of systemic intervention taken in this paper potentially blurs the unique contribution of those practices developed within the tradition of marital and family therapy, as distinct from interventions where partners or other family members are included in an adjunctive role to facilitate individually focused therapy.
The findings of this review have clear implications for training and practice. Family therapy training programmes should include coaching in evidence-based practices in their curricula. Qualified family therapists should make learning evidence-based practices, relevant to the client group with whom they work, a priority when planning their own continuing professional development. Experienced clinicians working with clients who present with the types of problems discussed in this paper may benefit their clients by incorporating essential elements of effective family-based treatments into their own style of practice. To facilitate this, a list of accessible treatment manuals is included at the end of both papers. The incorporation of such elements into one's practice style is not incompatible with the prevailing social constructionist approach to family therapy, as I have argued elsewhere (Carr, 2006).