Using Family Therapya

Using Family Therapy^a

LEONARD WOODS

^aPortions of the material come from my collaboration with colleagues and fellow trainers at Western Psychiatric Institute and Clinic of UPMC Presbyterian-Shadyside. Credits to the Family Based Mental Health Training Services: Patricia Johnston QCSW, BCD, Robert Sheen, MA, LMFT, Cynthia Stone, MS, LMFT, and Robert Sukolsky, MS, NCC; as well as colleagues at Western Psychiatric Institute and Clinic, Center for Children and Families who worked with me on preparation of the Family Therapy Treatment Manual for our Child and Adolescent Outpatient Clinic: Amy Chisholm, MA, Amy DeMario, LCSW, Bradley Sanders, LCSW.

KEY POINTS

Most risk factors for onset, relapse, and recurrence of depression in children and adolescents occur in the family context (e.g., parental depression, poor bonding, divorce, parent–child conflict, abuse, or trauma).
Instead of prescribing family therapy because “it must be the family causing the depression,” family therapy assists the family to cope with the illness and to modify individual, psychological, and interactive factors that may be at play.
Clinicians should be careful when implying that parental rearing practices, relationships, or psychiatric disorders are the cause of dysfunctional interactions because these problems may be driven, in part, by the child’s current psychopathology.
A family treatment approach seeks to reduce risk factors and enhance protective factors by increasing positive interactions between parents and children, and by increasing understanding of the illness for everyone in the family.
Providing psychoeducation to the family about the mutual influence between illness, individual and family may facilitate engagement in family treatment.
Be aware of your beliefs or assumptions about families. They will greatly influence your ability to engage or use the family as a resource to treat a child’s or adolescent’s depression.
Obtain the family’s perspective and beliefs about the risk factors in their unique situation; a pie chart may be the simplest and quickest way to accomplish this.
Identify and address risk factors for this unique family.
Block or interrupt patterns of interaction that are not working.
Create a space to experience alternative interactions with better outcomes.
Use in-session enactments to facilitate the direct experience of interacting differently that may result in family members’ experiencing successful relationship outcomes.
Increase supportive mechanisms that serve as protective factors.
Provide psychoeducation on possible signs of recurrence of the depression and ways to address these if they occur.
Sensitivity toward issues of race, culture, ethnicity, and gender for specific groups is imperative to treat families from different cultural backgrounds.

Introduction

The two most consistent risk factors for adolescent major depressive disorder (MDD) are being female and a history of MDD in the family.1,2 A 20-year follow up study by Pilowsky3 showed that “parental depression is associated with family discord and is a consistent risk factor for offspring major depressive disorder.” It further concluded that “family discord factors may be a risk factor for major depressive disorder in offspring of non-depressed parents.” Further studies have shown that treating parental depression reduces diagnoses and symptoms in the children.4 These matters are described in detail in Chapter 2. However, it is worth highlighting that factors predicting or contributing to onset, recurrence, and relapse of MDD in children and adolescents are mostly adverse family environments, such as absence of supportive interactions, poor parental bonding or attachment, harsh discipline, parental divorce, family and parent–child conflict, abuse, rejection, and high expressed emotion.5,6,7,8 Most findings suggest that stresses in young persons’ social environment—whether family, peer, or school network—influence the emergence, amelioration, or exacerbation of a depressive episode. Conversely, once adolescents are depressed, they themselves become a significant influence on their own social environment.9,10

EVIDENCE ABOUT EFFECTIVENESS OF FAMILY THERAPY

“It is virtually impossible to successfully treat a child or adolescent patient without the close involvement of parents.”10 Given that most risk factors occur within the family context, it would appear the family would be the natural focus of intervention for most depressed children and adolescents.11,12,13

Diamond and Siqueland conducted a review of randomized clinical trials in which parents were included as primary participants in the treatment of child and adolescent psychiatric disorders. They concluded that “for many disorders, family treatment can be an effective stand-alone intervention or an augmentation to other treatments.”14 Trowell et al.15 studied the use of family therapy and individual psychodynamic therapy in a group of clinically depressed youth. They reported significant reductions in the rate of disorders with both therapies and a reduction in comorbid conditions. Changes in both treatment groups persisted at the 6-month follow-up. An attachment-based family therapy16 was more effective in adolescent depression than wait list or no treatment, and improvement was maintained at 6-month follow-up. An influential study of depressed youth, which compared the use of cognitive behavioral therapy (CBT), nondirective supportive therapy (NST), and systemic behavioral family therapy (SBFT), showed that all three interventions were effective.17 Although CBT performed better for acute treatment, CBT was not superior to SBFT or NST when the effects of maternal depression were taken into account. At 2-year follow-up, SBFT had impacted on family conflict and parent–child relationship problems more than CBT or NST.

Although randomized controlled trials (RCTs) of family therapy are scarce and the empirical evidence weak, what there is indicates that intervening at the level of family risk factors can influence the course and outcome of youth depressive episodes.12,16,18,19,20,21,22

SYSTEMS THEORY

Before discussing how to use family therapy, it is important to review briefly some of the theoretical underpinnings of this treatment modality. Family therapy has largely evolved from the concepts of systems theory,23 which conceptualize the family as a system and propose that components of a system are interconnected and interactions regulated by means of “recursive feedback loops,” the system attempting always to maintain a balance. That is, individual family members respond to each other to maintain the balance or “homeostasis” within the family system. Any behavior or symptom would thus be understood within the context of the system. Earlier practitioners saw the individual’s symptoms as a reflection of dysfunction in the larger system; modifying factors within the family system was the route to eliminating symptoms in the individual. This simplistic view, which used mechanical systems as a model, can easily move from “recursive feedback loops” to “circular causality,” and to the covert or overt assumption that because symptoms exist in a family context, interactions
within the family cause the mental illness, ignoring biologic factors that may also be at play. This type of thinking was quite off-putting to many families.

RECIPROCAL INFLUENCE VERSUS CAUSALITY

Most contemporary family therapy theorists of childhood disorders acknowledge reciprocal influences among genetic, personality, cognitive, behavioral, familial, interpersonal, and sociocultural factors in the emergence and maintenance of the depressive illness.24,25 Although temperament, personality, and internalized meanings of individual experiences are at play in us all and may become predisposing factors for psychopathology, a person’s biologic or genetic makeup also influences and is influenced by systemic interactions. In that context, children can be seen as positively and negatively influencing their families and vice versa—families influencing their children.

Most researchers are also aware of the larger sociocultural influences at play.26 How we are acculturated to social expectations regarding gender, status as a majority or minority member of our society, our beliefs about mental illness, and so on, influence the range of options we instinctively believe are available to us.

Rather than focusing on causality (i.e., deciding whether the chicken or the egg came first), clinicians can take what already exists and engage families in treatment. Instead of prescribing family therapy because “it must be the family causing the depression,” this approach views family treatment as assisting the family to cope with the illness and to modify individual, psychological, and interactive factors that may be at play. This is similar to the situation in families struggling to deal with chronic medical conditions like diabetes.

Research seems to support the view of reciprocal influence versus causality. For example, a study of factors that may influence a group of children and adolescents at risk of developing MDD did not find any that were highly predictive.27 The authors concluded that “family and peer interactions of the high risk youth were similar to the interactions of the healthy controls” and that dysfunctional family patterns seemed to depend mainly on the child’s depressive symptoms. “Clinicians should be careful when implying that parental rearing practices, relationships, and/or psychiatric disorders are the cause of family dysfunctional interactions because these problems may be driven, in part, by the child’s current psychopathology” was one of the conclusions.27

SKILL LEVELS FOR FAMILY INTERVENTION

Family treatments are broader than just formalized family therapy. Irrespective of the context in which clinicians work (primary care physician, school counselor, inpatient unit, emergency room, etc.), there will be opportunities to engage families. Job context and responsibilities, training and comfort level will all influence the role that one may take with a family, but families can be used in different forms to assist a young person struggling with depression. A continuum of levels of intervention and generic skills necessary to be successful at each level follows.

Giving feedback and information to the family about depression and the treatment of the individual family member (psychoeducation). One must be willing and open to talk with families and give information about the present diagnosis and treatment of the family member. This includes education about biologic influences, effects of depression on cognitions and of cognitions on depression, influences of depression on relationships (family, marriage, work, school, and social) and of relationships on depression. One needs to remain open and honest to build trust and rapport, as well as to deal with naturally occurring fear and reluctance on the part of family members.
Taking a history to better understand what is happening and make recommendations or referral. One needs the skills listed in number 1 and the ability to ask questions respectfully about family structure, family’s history (biologic, psychological, interactional), strengths, attempted solutions, internal and external resources, and family’s beliefs about the illness, the patient, and therapy. One needs the ability to listen empathically, a basic knowledge of family development and transitions, and confidence in identifying and stopping harmful interactions among family members.
Single session using the family as a consultant to the treatment. Such a session would require the skills described in numbers 1 and 2, as well as the ability to summarize and give feedback to the
family about the content of what they shared with the clinician, and possible hypotheses or additional insights they may have given regarding understanding and treating the patient’s depression.
Family meeting to problem-solve interactional issues influencing or being influenced by the depression. An intervention at this level would require the skills mentioned in the previous headings as well as confidence in clarifying issues and problem solving in a family context. One should also have the ability to recognize when problems are above one’s head (e.g., related to “how stuck” a family is in their interactional patterns and in need of referral to someone with more expertise).
Family therapy. To conduct family therapy, one requires all the skills listed in the previous headings as well as having the training, experience, and supervision in a method of family therapy.

DRAWING A PIE CHART OF THE AREAS OF INFLUENCE

One simple tool for discussing and assessing areas of influence and risk factors that can be used across all levels of intervention is to engage the patient and/or family in drawing a pie chart of the areas of influence (biologic, psychological [thinking], social [interactive]), as seen by them, or to assess their effect in the present situation. This provides a way of educating patients about the complex factors at play simply and efficiently. This task allows clinicians to work with the patient collaboratively by finding about the young person’s belief system and to prescribe a treatment consistent with the patient’s experience and beliefs rather than reinforcing the clinician’s own thinking.

When young persons (or family) recognize that family or interactional patterns are affecting the emergence or maintenance of depression—or that depression is affecting the family—they may be open to family treatment. Similarly, if a patient or family is able to identify a strong biologic component as well as interactional patterns, using medication and family therapy concurrently would not only be consistent with research findings but also match the belief system of the patient and family, thus increasing the probability of adherence.

ENGAGEMENT

Effectiveness research is increasingly showing the strength of the alliance between therapist and client, rather than the model of treatment, is one of the most important factors influencing outcome.28 Most family therapists pay particular attention to establishing a strong therapeutic alliance with the family as a whole or with particular subsystems like the adolescent or parents. If the therapist is able to maintain a positive view, this will increase the ability to engage a family in a true therapeutic alliance. To engage a family (especially parents) effectively, clinicians must be able to believe in the positive intent of most family interactions (even in the midst of some terrible situations) and view interactions as becoming “stuck” rather than judging individuals for their behaviors.

CORE BELIEFS

One of the most difficult aspects when dealing with families is maintaining a strength-focused or positive perspective. Much of the current health training centers predominantly on disease, dysfunction, illness, and pathology, partly as a result of health insurance reimbursement demands. A biomedical view has become the most commonly held. This creates ambiguous situations (e.g., when a patient does not respond to first-line treatment, usually medication or individual psychotherapy). It is at this point that a referral for family therapy is usually considered, often with the simplistic message (overt or covert) that “if the individual and pharmacological treatments didn’t work, it must be the family that is influencing the patient’s depression.” The next small but unhelpful step is to believe that the family is causing the depression or, at the very least, interfering with our efforts to treat it. Conversely, the longer family members struggle unsuccessfully with a child’s depression, the more stuck they can become in mutually reinforcing ineffective patterns that can lead the treatment team to see the family in a negative light.

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