Towards a Metamorphosis: Current Developments in the Theory and Practice of Family Therapy
This paper reviews the current state of the theory and practice of family therapy. It proposes that the field is undergoing a radical metamorphosis in which its theory base is becoming characterised by less ideological ‘purity’, more attention to an evidence base and an integration within other treatment modalities. Like all such metamorphoses, this transformation of family therapy is not without its difficulties. In many ways, professional contexts, professional institutions and training programmes, at least in the UK, do not appear to have made the adjustment to this change. The paper will therefore highlight these contextual issues as a counter-point to the metamorphosis that is in process.
Key Practitioner Message:
- • Family therapy is changing into an evidenced based intervention
- • Family therapy is integrating aspects of other therapies into its approach
- • Guidelines exist which describe the content of family therapy for particular child and adolescent difficulties
In his short novel, Metamorphosis,Kafka (2000) describes how Gregor Samsa went to sleep in his bed as a human being and awoke, in the same bed, as a rather large ‘monstrous insect’ (p76). This paper will argue that family therapy as it is practiced and conceived is currently undergoing an equally radical transformation. However, the metamorphosis of family therapy consists, probably, of a change from a carapaced, independent insect to an interdependent, softer kind of insect: perhaps more like the sociable and productive bee.
There are a number of aspects that characterise this transformation. These can be summarised as: less ideological ‘purity’; greater attention to evidenced based practice; and a shift from an assumption that the generic skills of family therapy are ‘enough’ to a recognition that specific difficulties require specific applications from these generic skills. This transformation can be explained with reference to a number of contextual and institutional factors. Rivett and Street (2003) suggested that as family therapy reached a certain level of maturity, such changes became possible with the greater sense of confidence that experience brings. However, this paper will also suggest that it is outside forces that are predominantly driving this transformation and that because this is the case internal constraints on the metamorphosis still exist.
Family therapists, especially since the ‘discovery’ of the post-modern turn in therapy (Dallos & Draper, 2005), attend carefully to the way in which words construct reality. It therefore follows that many family therapy readers and their colleagues may disagree with the description of the metamorphosis that is proposed in this paper. Indeed Gregor Samsa’s family could not accept him as an insect and left him to die in a darkened room. It is therefore also important to establish that this change includes the ‘melding’ of many historical dualities (Rivett & Street, 2003). Family therapy is now constantly seeking to connect rather than divide with the phrase ‘both/and’ more common than that of ‘either/or’ (Goldner et al., 1990). Thus evidenced based practice does not necessarily stand in contradiction to creativity; nor need ideological merging, mean that what is uniquely systemic about family therapy has been lost. Some authors suggest that the changes described here are possible because the ‘systemic concept’ has become integrated within many other therapeutic traditions (Lebow, 2005). This means that integration and collaboration across disciplines becomes the norm rather than competition and divergence (Speed, 2004).
This paper is divided into three sections. The first section will explore the trend away from theoretical purity; the second will explore the growing evidence base for this trend and will point to the emergence of protocols and manuals; the last section will comment upon the current context in which family therapists work, which offers challenges and opportunities.
Previous reviews of family therapy have often concentrated on the developments within one or other ‘school’ of family therapy (Campbell, 1999; Dallos & Urry, 1999; Jenkins, 1990; Burck, 1995). Such discussions have been primarily centred upon the theoretical ‘trends’ of the time. Indeed, it used to be argued that this variety of philosophical adherence meant that there was no such thing as ‘family therapy’ only a number of ‘family therapies’ (Gurman & Kniskern, 1992; Rivett & Street, 2003). However, Lebow (2005) now argues that ‘family therapy is becoming more a single therapy than [at] any time since its beginning’. What Lebow means is that many of the historical divisions between family therapy schools are breaking down and increasingly family therapists are being taught to use a collection of techniques and ways of thinking from all of the different schools. This means that it is more possible to describe commonalities between family therapists than to concentrate upon differences.
The second significant theoretical development is that systemic therapy has begun to import and value the insights of other therapeutic traditions. Over the last two decades, this has constituted a journey of sorts. This journey could be demonstrated by reference to recent integrations of cognitive-behavioural therapy with systemic approaches (Dattilio & Epstein, 2005; Dummett, 2006), or by reference to the increasing interest of systemic practitioners with psycho-dynamic applications (Donovan, 2003; Larner, 2000; Pocock, 2005; 2006). Another example would be the burgeoning of clinical interest by family therapists into the value of attachment theory (Dallos, 2006; Hughes, 2007; Kozlowska & Hanney, 2002). Some have described this as an integration (Pinsof, 1995) in which different theoretical modalities are seen as helpful for different problems.
The interest in the therapeutic alliance in family therapy could be seen to be the example that most demonstrates the confluence of theory. It is certainly true that this interest has been implicit within family therapy perhaps since its pioneering days (Friedlander, Escudero & Heatherington, 2006). However, recent interest in this concept which has been most usually studied within the individual therapies (Safran & Muran, 2000) grew out of a dissatisfaction with the divisions within family therapy and between family therapy and other therapies (Hubble, Duncan, & Miller, 1999). Family therapy has awoken to the realisation that the therapeutic alliance between therapist and family has a significant bearing, if not an essential bearing, on the outcome of the therapy. This awareness has grown out of process research findings (Friedlander et al., 1994) and has been part of the debate which asserts that ‘common factors’ in therapy determine its outcome not the model by which the therapist works. For instance, Sprenkle & Blow (2004) argue that a focus on the common factors in all therapies ‘will contribute to the demise of whatever parochialism, triumphalism and divisiveness remains in family therapy on the basis of our sacred models’. Others however (Sexton, Ridley, & Kleiner, 2004; Sexton, 2007; Simon, 2007) argue that this ‘all size fits all’ view does not take into account the large number of variables that are involved in family therapy approaches.
Out of the study of the therapeutic alliance in family therapy has emerged a recent empirical model for analysing this aspect of family treatment. What makes this part of the metamorphosis of family therapy is that it proposes a set of therapist behaviours which transcend schools but which embody many of the generic skills taught across these schools. This is the System for Observing the Therapeutic Alliance (SOFTA) (Friedlander et al., 2006) which is an American/ Spanish collaboration. SOFTA provides both a self report scale (versions available for therapists and family members) and an observational system (again including therapist behaviours and family behaviours available from http://www.softa-soatif.com). The system describes four ‘dimensions’ within the therapeutic alliance. Two of these could be said to be common across all therapies and replicate previous methods of measuring the alliance. These dimensions are engagement in the therapeutic process and emotional connection with the therapist. SOFTA however, also has two dimensions that are hypothesised as having unique applications to family therapy: safety within the therapeutic system and shared sense of purpose within the family. These are unique because family therapy must enable all family members to feel safe whilst talking together (often about difficult issues) and must develop a shared sense of commitment to work on the difficulties together. SOFTA provides an empirical instrument which not only measures the alliance between therapist and family, but also provides indicators of behaviour which if maximised will increase the alliance. For instance, in order to increase the family’s shared sense of purpose in the therapy, SOFTA recommends that therapists encourage compromise, emphasise commonalities and encourage inter-family discussion. By adopting a trans-therapy theory (of the therapeutic alliance), family therapy is opening itself up to constructing pragmatic trans-theoretical behaviours which primarily attend to the alliance between family and therapist.
Such an emphasis does not ‘erase’ the old techniques and theories of family therapy. Rather it builds upon them. Thus SOFTA recognises that, for instance, circular questions, a traditional technique used by family therapists, may build a shared sense of purpose. It also values the use of enactment techniques (asking family members to demonstrate interactions within the therapeutic setting). SOFTA sees these as evidence of a good alliance and as a way of increasing engagement in the process of therapy. It is also important to note that this integrative version of family therapy incorporates the traditional skills of family therapists e.g. interviewing multiple family members, balancing multiple perspectives (in traditional terms ‘multi-partiality’, ‘neutrality’ or ‘curiosity’); de-focusing from ‘blaming’ interactions; and examining contextual influences on family life.
Towards an evidence based practice
It is beyond the scope of this brief paper to outline the caveats and criticisms that have been levelled against the concept of evidenced based research and the institutions that rely upon it (McArdle, 2007; Rowland & Goss, 2000). It is equally impossible for this paper to provide a thorough critical review of the evidence base for family therapy in child and adolescent mental health difficulties. Other publications provide such reviews (American Association for Marriage and Family Therapy, 2005; Carr, 2000; Sprenkle, 2002), though there is always controversy about making any robust conclusions (Roy & Frankel, 1995). The most thorough reviews have been undertaken in the United States where ‘managed care’ (limited insurance cover for therapies) creates a particular need for evidence. Henggeler and Sheidow (2002) for instance argue that the evidence for ‘certain family-based treatments…of conduct problems in adolescents’ has become so strong that federal agencies have identified them as ‘effective treatments’. Northey et al. (2002) comment that for childhood behavioural disorders ‘family-based treatments are the psycho-social treatments of choice’ whilst acknowledging that these must be designed to complement neuropsychological treatment (medication). Many of the more recent handbooks also outline specific models of family therapy that are designed to effect change for specific problems (Lebow, 2005; Sexton, Weeks, & Robbins, 2003). The literature most likely to be known to British family therapists is that which establishes the value of family therapy in the treatment of anorexia. The anorexia research undertaken by the Maudsley Hospital and Institute of Psychiatry team has now spanned three decades and has become increasingly subtle in its findings. The initial findings demonstrated the value of family therapy in early onset anorexia (Eisler, 2005). Later studies led to a critical re-evaluation of the early family therapy concept that the ‘family’ caused the anorexia and also suggested that there were appropriate circumstances where the family should not be worked with conjointly (Eisler, 2005; Eisler et al., 2007). Subsequently, the team have built on this evidence base rather than allowing it to limit them and have trialled the use of multi-family group treatment for anorexia (Eisler, 2005).
There are similar generally supportive reviews and studies which argue for the value of a form of family therapy in a number of child and adolescent difficulties. These span from interventions in depression (Cottrell, 2003; Diamond, 2005), in ADHD and anxiety (Northey et al., 2002), to behavioural problems (Henggeler & Sheidow, 2002; Horigian et al., 2005) and adolescent substance misuse (Liddle et al., 2005).
There are a number of aspects of the evidence base of family therapy which need to be emphasised. These aspects confirm the metamorphosis within family therapy. Firstly, all the research confirms that family therapy contributes to rather than constitutes the treatments that have value. Thus, as noted, Northey et al. (2002) comment that family based treatments are to be seen as complementing medication. Eisler (2005) also argues that within the treatment of anorexia, family therapy must include an element of psycho-education. All these studies confirm a model in which family therapy is one aspect of a multi-model intervention. The traditional conflict between family therapy and other models is subsumed within an approach which is predicated on the need for varied forms of intervention (Speed, 2004). Secondly, and possibly more controversially, this evidence base has led to the increasing adoption of ‘guidelines’ which describe the kind of family therapy or alternatively, the process and general content, of the family therapy that should be implemented within the treatment of these specific childhood difficulties.
These ‘guidelines’ exist within the literature for the treatment of depression (Jones & Asen, 2000), anorexia (Eisler, LeGrange, & Asen, 2002; Lock et al., 2001), ADHD (Orr, Miller, & Polson, 2005; Wells, 2005) and psychosis (Wright et al., 2004). Sometimes these guidelines have been created out of research studies where treatment has to fit a standard manual. But on the whole the guidelines are a series of recommendations about topics to explore in family sessions, and a number of loose ideas about how to help the family alter interactions, beliefs and behaviours. For instance, Wright et al. (2004) describe how they have integrated the family psycho-educational research (Fadden, 2006; Kuipers, 2006) within family therapy into a treatment programme for adolescent psychosis. They describe the important role of balancing conversations with family members about guilt and loss with the more structured sessions centred around family management of the young person. Reflecting many family therapy approaches, they value the role of spending time discussing the meanings that family members use to explain their teenager’s behaviour. This more traditional ‘meaning’ conversation will then be balanced with one exploring relapse prevention techniques. The description offered of their approach by Wright et al. (2004) blends the traditional family therapy techniques and concerns, with the new focused approach. For instance, they conduct conversations which seek to differentiate ‘adolescent behaviour’ from ‘illness behaviour’ and in these conversations demonstrate the ‘lightness’ of belief in diagnosis that often characterises family therapy interventions.
Summarising the last two sections, we can characterise contemporary family therapy in this way. It is more likely to draw on a varied theory base, it is more likely to be part of a treatment package, it is more likely to be describable via a series of guidelines, and it is more likely to be focused on a particular difficulty. However, this transformation retains the traditional skills and traditional concerns of family therapy. Thus the conversations that a family therapist might have will still centre upon beliefs, meanings, interactions and relationships. But these conversations will have an ‘edge’ which is informed by evidence. However, as one would expect in a therapy which maintains an awareness of context, it is important to turn to the contexts in which family therapy is practiced in order to consider how these changes in theory and practice are being played out within institutional contexts.
Contexts and the metamorphosis of family therapy
There are two contexts that have significance for the metamorphosis of family therapy. The first is the professional context including the professional organisation of family therapists (in the UK: The Association for Family Therapy and Systemic Practice). Within CAMHS agencies, many professionals have a degree of family therapy training (Rivett & Street, 2003) and the number of family therapists employed as family therapists remains relatively small. The professional body regulates the training of family therapists and accredits them to practice as family psychotherapists. Although the regulations for training (in the UK) do not yet reflect the changes described in this paper, there are models for training family therapists which do seek to train them for practice in this collaborative, evidence-based world of child and adolescent mental health. Wendel, Grouze and Lake (2005) for instance describe a training course in which therapists are taught a series of modules that cover the integration of psychiatric, developmental, and cognitive aspects of practice which are integrated into the research evidence. More ‘traditional’ family functioning aspects of knowledge are also taught.
The second crucial institutional context which will affect the metamorphosis of family therapy is that of the large institutions that employ family therapists. It is the National Health Service that generally comes to mind in this context. The NHS has been subject to a series of reorganisations (Hawkes, 2006) and most recently, these are leading to further integration of CAMHS professionals. This may support the changes to family therapy practice outlined in this paper. But the effect of the Agenda for Change process which has allocated family therapists onto a common skills and knowledge framework may paradoxically lead to fewer family therapists employed within the NHS. On the other hand, there has been a growth in family therapy within many of the specialist areas which the metamorphosis of family therapy would predict. Thus, the growth of treatment foster care services (Chamberlain, 2003) has meant that family therapists are required to work with birth families. Interestingly, this work conforms to many of the parameters outlined in this paper: the work is focused, has a manual and is drawn out of an evidence base.
This paper has proposed that family therapy has undergone or is undergoing a metamorphosis. This change has been driven not predominantly by internal theories but by external pressures in the form of research and accountability. The outcome of this process is a form of family therapy which combines traditional family therapy skills and theories with a sharper focus on the unique difficulties of a particular family. This sharper focus integrates knowledge from different therapeutic traditions and from the developing research evidence. This means that colleagues within CAMHS can expect family therapists to work confidently alongside them whilst integrating other therapeutic ideas. Further, they can expect family therapists to describe how their modality can improve the presenting difficulties and even refer to the guidelines for treatment within the literature.
This description of family therapy incorporates rather than rejects any of the previous models. It does reflect a change. Change cannot come without controversy and debate which will result in accommodation and integration. In the historical journey of family therapy, this metamorphosis will almost certainly only be a temporary staging post before other changes stimulate new developments.