The Development of Family Therapy and Systemic Practice in Europe: Some Reflections and Concerns

This paper outlines the development of pan European systemic thinking and practice. This development has been enabled and supported with the establishment of the European Family Therapy Association (EFTA). EFTA has evolved over the last decade from an organisation of individual members to an organisation of organisations—representing also national associations of family therapy and family therapy training institutes across 28 European countries. There are three sections to this paper: (1) a brief summary of the development of family therapy practice in Europe; (2) a brief summary of the work of the national associations of family therapy in EFTA; and (3) a brief summary of current concerns of some senior family therapists and family therapy trainers within the EFTA organisation.     

Couple and family therapists’ experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants’ initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients’ privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients’ raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a “participant observer” to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

     

Power and influence in the environment of family therapy

This paper explores some of the ways in which family therapy theory and practice limits an appreciation of the contexts of families and family therapists. It focuses particularly upon how the rules which underline patterns of relationships in social systems are made and maintained more by one part of a system than by another, and considers this (a) within families, (b) within various aspects of the social environment of families, and (c) within the organizational contexts of family therapists. It then proposes that the systemic thinking which family therapists apply to families is potentially applicable to wider contexts including international relationships.     

Power and influence in the environment of family therapy*

This paper explores some of the ways in which family therapy theory and practice limits an appreciation of the contexts of families and family therapists. It focuses particularly upon how the rules which underlie patterns of relationships in social systems are made and maintained more by one part of a system than by another, and considers this (a) within families, (b) within various aspects of the social environment of families, and (c) within the organizational contexts of family therapists. It then proposes that the systemic thinking which family therapists apply to families is potentially applicable to wider contexts including international relationships.     

Practising family therapy in India: how many people are there in a marital subsystem?

Systemic therapy would appear to be a viable form of treatment for people who exist in cultures that contain complex, extended family systems, such as those found in India. The practice of family therapy in India has evolved from Western concepts. These concepts appear to offer Indian therapists relevant and practical ways of working with families. However, some of these concepts need modifying before they can be used in an Indian context. Indian families may have very different worldviews and ideas of 'self' compared to families in the West, leading to different family organization. The situation can be further complicated by the cultural norms of therapists themselves. Therapists in India are often highly educated, come from upper-middle-class families and have been exposed to different cultures. They increasingly share many of the values of their counterparts in the West. At the same time, they retain aspects of their own cultural heritage, which is also the dominant culture for a large number of the families with whom they work. Thus, not only must Indian family therapists seek to work in culturally appropriate ways; they must also tolerate their own internalized conflicts regarding differing cultural norms. With the use of clinical data, this paper describes some of the personal and professional problems experienced by an Indian family therapist working with Western constructs of family organization.     

The Primacy of Discourse in the Study of Gender in Family Therapy

Family therapists and scholars increasingly adopt poststructural and postmodern conceptions of social reality, challenging the notion of stable, universal dynamics within family members and families and favoring a view of reality as produced through social interaction. In the study of gender and diversity, many envision differences as social constructed rather than as “residing” in people or groups. There is a growing interest in discourse or people's everyday use of language and how it may reflect and advance interests of dominant groups in a society. Despite this shift from structures to discourse, therapists struggle to locate the dynamics of power in concrete actions and interactions. By leaving undisturbed the social processes through which gendered and other subjectivities and relations of power are produced, therapists may inadvertently become complicit in the very dynamics of power they seek to undermine. In this article, we argue that discourse analysis can help family therapy scholars and practitioners clarify the link between language and power. We present published examples of discourse analytic studies of gender and sexism and examine the relevance of these ideas for family therapy practice and research.     

The Development of Systemic Family Therapy for Changing Times in the United Kingdom

In sketching the position of couples and family therapy and systemic practice in the United Kingdom of Great Britain and Northern Ireland (the UK) we have provided what we can of the development of the contexts of training and practice; the content of some of the theories and their applications; and the external realities within which we currently operate. The UK has a well developed structure for training and practice in systemic couples and family therapy. The history is of enthusiastic adoption of therapies from international sources which are generally then incorporated into an overarching systemic framework. Family therapy in the UK is currently subjected to a variety of pressures but is well regulated and is in a strong position to continue making its contribution to the welfare of families.     

The crucial roles of attachment in family therapy

This paper's aim is to enable family therapists from whatever approach to address family attachments during their work. It explores the role of attachment in the family, and how to enable therapists to increase security in the family so that family members can solve their own problems during and after therapy. The article gives a brief overview of the nature of family attachment relationships and the influence of secure and insecure attachments within the family and their narrative styles. This is described in language that a therapist might readily hold in mind and share the ideas in dialogue with families. The paper discusses the interplay between insecure attachments and other family problems, such as parental conflict and disagreements over authority. It also discusses ways of establishing a secure therapeutic base and the influence of the therapist's own attachment style. The implications for family therapy practice are described and illustrated by work with a specific family.     

Thinking and Working Relationally: Interviewing and Constructing Hypotheses to Create Compassionate Understanding

In the initial interviews of family therapy sessions, the therapist faces the challenge of obtaining and organizing the information that is most relevant toward understanding the essential concerns that families and couples bring to therapy. This article describes the process of clinical interviewing and case conceptualization used in training family therapists at the Ackerman Institute for the Family. This approach helps the therapist bring forward, and organize, specific information into relational hypotheses, or systemic‐relational conceptualizations, that allow both family members and the therapist to understand presenting problems within their relational contexts. While always provisional, relational hypotheses help anchor the therapist in a systemic‐relational frame and provide a conceptual through‐line to guide the ongoing work of the therapy. The process of interviewing and the construction of clear and complex conceptualizations of presenting problems are illustrated through case examples.     

Developing an indicator of family function and a practicable outcome measure for systemic family and couple therapy: the SCORE

There is a need for a measure of outcome in systemic family and couples therapy (SFCT) that reflects current theory and practice. To meet the needs of SFCT practice the measure needs to use self‐report by family members, take a short time to complete and be easy to understand. The development of such a measure, called the SCORE, is reported in this article. Substantial piloting, consultation and review in terms of clinical judgement led to the construction of the SCORE 40 which has forty items about how the family functions, rated by family members over 11 years of age on a Likert scale, in addition to independent ratings of the family and its difficulties. The SCORE 40 is shown to be a viable instrument but is too substantial for everyday clinical use. In a research project to reduce and refine the measure and determine its psychometric properties the SCORE 40 was administered to 510 members of 228 families at the start of their first appointment for family therapy at clinics throughout the UK. The scale has good psychometric properties and could operate with either three or four dimensions. The analyses of these data, combined with data from a convenience sample of 126 non‐clinical families, allowed a reduction to fifteen items while retaining most of the information provided by the SCORE 40. This version is offered with three dimensions of: (1) Strengths and adaptability; (2) Overwhelmed by difficulties; and (3) Disrupted communication. It is hoped that the ready availability of the SCORE 15 will encourage routine evaluation of outcomes in clinics as well as the SCORE being used flexibly for both therapy and research.     

Reasonable Hope: Construct, Clinical Applications, and Supports

To read this article's abstract in both Spanish and Mandarin Chinese, please visit the article's full-text page on Wiley InterScience ( http://interscience.wiley.com/journal/famp ).
Hope may be the most laden shorthand term of all time. Everyone wants it; few know how to articulate what it is. Although family therapists frequently work to restore hope with hopeless families, they have contributed little to the abundant literature on hope. I present a new conceptualization of hope—reasonable hope—that reflects how family therapists think and practice. By subscribing to reasonable hope, clinicians enhance their ability to offer accompaniment and bear witness to clients. I describe clinical practices that, informed by reasonable hope, also facilitate its cocreation. Finally, I suggest supports for clinicians who practice reasonable hope.     

Cause and responsibility: towards an interactional understanding of blaming and 'neutrality' in family therapy

This paper aims to shed light on the ways in which 'neutrality' is both produced and resisted by socially competent actors in family therapy sessions. It draws upon recent and previous papers in this journal ( Stancombe and White, 1997; Stratton, 2003a, 2003b ), which highlight the importance of blame in therapeutic encounters. When families come to therapy, individual members frequently deliver competing accounts about the family troubles and who is to blame for them. This produces particular challenges for the therapist. We examine the practices of therapists in managing accountability in the session and in their own discussions. Family therapists operate with a professional ethic of neutrality, or multi-partiality. This paper is concerned with the linguistic strategies used by therapists to deal with overtly blaming accounts, how these strategies are responded to by family members in talk-in-interaction and how therapists go about crafting accountability-neutral versions. We show that the social and moral context of family work makes the therapist's job of communicating multi-partiality precarious. In producing accountability-neutral versions of families' troubles, therapists are forced to make practical-moral evaluations of competing versions of events. We conclude by arguing for a more explicit engagement with the moral nature of therapeutic practice.     

Do primary care psychological therapists ‘think family’? Challenges and opportunities for couple and family therapy in the context of ‘Improving Access to Psychological Therapies’ (IAPT) services

Very little couple or family work takes place in primary care despite the advantages offered by the context. This pilot study investigated the experiences of primary care adult therapists regarding the place of families in their clinical work. Semi‐structured interviews with seven therapists were analysed using interpretative phenomenological analysis. The findings tentatively suggest that primary care psychological therapists ‘think family’ primarily from the perspective of their main therapeutic model when offering individual therapy. Some study participants questioned the appropriateness of their family/context focus. Family members were extremely rarely seen together. Facilitating factors included supervision and training. Barriers to family work were both external (the work setting) and internal (beliefs about it). The impact of the current dominance of cognitive behavioural therapy in National Health Service adult psychological therapy services and the development of Improving Access to Psychological Therapies (IAPT) services on the provision of couple and family therapy are discussed. Some challenges and opportunities presented by IAPT for couple and family therapy are explored.     

Development of Family Therapy in Ireland

In Ireland family therapy is a small profession, with under 200 registered therapists. The Irish family therapy movement began in the mid-1970s. By 1980 the Family Therapy Network of Ireland in the Republic of Ireland and the Northern Ireland Branch of the UK Association Family therapy had been founded. At present there are three main family therapy training centers in Ireland: two in the south (the Mater University Hospital, affiliated to University College Dublin and Clanwilliam Institute) and one in the north (at Queen’s University Belfast). There is no statutory registration and licensing of family therapists in Ireland. Accredited professional family therapy programs in Ireland are 4-year part-time courses culminating in masters level qualifications. A primary degree in medicine, nursing, psychology, social science or education is a prerequisite for entry. Family therapists in Ireland work in both private practice and the public health service. Most family therapists in the public sector are employed as social workers, psychologists, psychiatrists or nurses, and conduct family therapy as part of their broader professional roles. Couple therapy in Ireland is provided by family therapists, and also by voluntary couple counselors based in networks of local centers, some of which were originally religiously affiliated, without a formal connection to national family therapy associations. The three major future challenges for Irish family therapy are creating a research infrastructure, developing a career structure in the public health service, and introducing statutory registration.     

Developing Metacompetence in Low Intensity Cognitive‐Behavioural Therapy (CBT) Interventions: Evaluating a Self‐Practice/Self‐Reflection Programme for Experienced Low Intensity CBT Practitioners

Self‐practice/self‐reflection (SP/SR) is a targeted training and professional development strategy in which clinicians practice cognitive‐behavioural therapy (CBT) techniques and processes on themselves and then working through a structured process of self‐reflection. Previous studies with CBT trainees and experienced mental health practitioners have found that SP/SR or experiencing CBT “from the inside out” has been perceived by participants as increasing competency in a number of important areas and increasing therapist flexibility and artistry. Low intensity (LI) practitioners are identified as a relatively new addition to mental health service delivery in the UK. These workers are differentiated from traditional mental health practitioners by a shorter training period, the delivery of a circumscribed number of CBT interventions, and a very high weekly patient load. This study, the first of its kind, reports outcomes from an SP/SR programme undertaken by seven experienced LI CBT practitioners. Participants used the following measures to track their experience of the programme: time spent on programme, personal‐ and therapy‐related belief rating, goals attained, and perceived skill rated for average and most difficult patients. Results showed a positive change in work‐related skill and behaviour change, particularly when working with the more difficult patients. The findings are consistent with those found in other groups of therapists (e.g., trainee CBT therapists and highly experienced CBT therapists), suggesting that SP/SR may be a valuable addition to LI intensity training and professional development. These findings are discussed in the context of the particular needs of LI practitioners.     

Concurrent therapies: a model for collaboration between psychoanalysts and other therapists

Many psychoanalysts treat individuals who are simultaneously in couples therapy or whose partners are in individual therapy. If such cases stall, some analysts may seek consultation from a colleague, though most have accepted the tacit historical prohibition against communication between therapists treating members of the same family. Experience, however, suggests that a certain form of communication between such therapists can have a powerfully enhancing effect on the concurrent therapies. After a review of the literature, the advantages, disadvantages, and impediments to collaborative cross-communication are examined. A model is then presented for use in ongoing discussion between therapists, and is illustrated with two clinical examples. The proposed model centers on the transference-countertransference configurations within the therapeutic field, and serves as an organizer highlighting areas for discussion.     

The Profession of Family Therapy in South Korea: Current Status and Future Directions

The authors present a brief overview of the family therapy field in South Korea. Since its introduction in the late 1970s, family therapy has been developing into a professional field with education and training institutions, practice settings, credentials, and practitioners holding memberships in various professional organizations. While such issues as family values and types, filial piety, violence, interethnic marriage, and social polarization have resulted in an increased demand for family therapy, such services are not readily accessible to Korean families in need. Efforts should be made in increasing number of competent family therapists by strengthening both academic and clinical requirements for credentialing. Efforts are also needed in increasing accessibility of family therapy services by making them more available within a variety of human service contexts.     

Family Secrecy in Family Therapy Practice: An Explorative Focus Group Study

The aim of this focus group study was to explore the experiences of family therapists working with family secrecy. Our study highlights that family secrets present important and compelling challenges for family therapists. Furthermore, our study reveals that there seem to be some basic strategies family therapists use in dealing with these challenges in therapy sessions. One basic strategy is that family therapists try to guard their position of being a trustworthy therapist for each family member by avoiding becoming stuck in family secrecy. Furthermore, therapists explore ways to guide the family toward the disclosure of the secret in order to alleviate the toxicity of the secrecy. This highlights the importance of the systemic model and how influential this perspective is in family therapy practice. Some participants, however, have in addition a second strategy they sometimes use: talking with the family about secrecy without aiming to disclose the secret. In the discussion section of the article we reflect on the possibility that in the strategic choices family therapists make conceptual issues might be involved. Furthermore, we stress the importance of further research.     

Families and therapists achieve clinical outcomes,systems of care mediate the process

Conclusion The values articulated in the system of care philosophy (Stroul & Friedman, 1994) have been necessary elements of local, state, and national efforts to reform mental health care for children. The importance of the values of family collaboration, cultural competence, interagency coordination, individualized care, and use of the least restrictive treatment setting articulated by the system of care philosophy has been affirmed by practitioners, policy makers, and mental health services researchers. Such values, however, are likely not sufficient to achieve clinical outcome. Clinical outcomes are more likely to be achieved by family members and therapists when clinical practices are changed to reflect the demanding and comprehensive work of changing child and family social ecologies.