The efficacy of systemic therapy with adult patients: a meta-content analysis of 38 randomized controlled trials

Systemic therapy is a widely used psychotherapy approach. Yet there exist few systematic reviews on its efficacy. A meta-content analysis was performed to analyze the efficacy of systemic therapy for the treatment of mental disorders in adulthood. All randomized (or matched) controlled trials (RCT) evaluating systemic/systems oriented therapy in various settings (family, couple, individual, group, multifamily group therapy) with adult index patients suffering from mental disorders were identified by database searches and cross-references in other reviews. Inclusion criteria were: index patient diagnosed with a DSM or ICD listed mental disorder, trial published in any language up to the end of 2008. The RCTs were content analyzed according to their research methodology, interventions applied, and results. Thirty-eight trials published in English, German, Spanish, and Chinese were identified, 34 of them showing systemic therapy to be efficacious for the treatment of mood disorders, eating disorders, substance use disorders, mental and social factors related to medical conditions and physical disorders, and schizophrenia. Systemic therapy may also be efficacious for anxiety disorders. Results were stable across follow-up periods of up to 5 years. There is a sound evidence-base for the efficacy of systemic therapy for adult index patients with mental disorders in at least five diagnostic groups.     

The Efficacy of Systemic Therapy for Internalizing and Other Disorders of Childhood and Adolescence: A Systematic Review of 38 Randomized Trials

Systemic therapy (ST) is one of the most widely applied psychotherapeutic approaches in the treatment of children and adolescents, yet few systematic reviews exist on the efficacy of ST with this age group. Parallel to a similar study on adults, a systematic review was performed to analyze the efficacy of ST in the treatment of children and adolescents. All randomized or matched controlled trials (RCT) evaluating ST in any setting with child and adolescent index patients were identified by database searches and cross‐references, as well as in existing meta‐analyses and reviews. Inclusion criteria were: index patient diagnosed with a DSM‐IV or ICD‐10 listed psychological disorder, or suffering from other clinically relevant conditions, and trial published by December 2011. Studies were analyzed according to their sample, research methodology, interventions applied, and results at end‐of‐treatment and at follow‐up. This article presents findings for internalizing and mixed disorders. Thirty‐eight trials were identified, with 33 showing ST to be efficacious for the treatment of internalizing disorders (including mood disorders, eating disorders, and psychological factors in somatic illness). There is some evidence for ST being also efficacious in mixed disorders, anxiety disorders, Asperger disorder, and in cases of child neglect. Results were stable across follow‐up periods of up to 5 years. Trials on the efficacy of ST for externalizing disorders are presented in a second article. There is a sound evidence base for the efficacy of ST as a treatment for internalizing disorders of child and adolescent patients.     

Benchmarking Community-Based Couple Therapy: Considering Measurement Reactivity

Couple therapy has been shown to be effective in randomized clinical trials; however, results from naturalistic couple therapy have been less consistent. This study utilized a benchmarking approach to compare the effectiveness of couple therapy in a community-based setting with findings from efficacy treatments, such as treatment within randomized clinical trials. The current study is the largest couple therapy sample published to date (N = 3,347 couples). Clients in couple therapy were asked to provide initial and weekly ratings of symptomology on the Outcome Questionnaire (OQ-45.2). We found that treatment effect sizes found at community clinics were smaller than efficacy studies (i.e., the benchmark). However, when taking into account measurement reactivity, the effect sizes were comparable. This is the first benchmarking study for community-based couple therapy, allowing for meaningful comparisons and understanding of outcomes in real-world couple therapy. Implications for the field are offered in terms of evaluating community-based psychotherapy studies with benchmarking for couple therapy. Results of this study provide clinicians and researchers a way to meaningfully compare couple therapy outcomes, accounting for differences in community-based practices and randomized clinical trials. This benchmark also underscores the impact of measurement sensitivity, an issue commonly overlooked in psychotherapy research and practice.     

Systemische Therapie bei Störungen des Erwachsenenalters

Background

Systemic therapy is a scientifically acknowledged form of psychotherapy in the US and many European countries, but not yet in Germany.

Method

All randomized (or parallelized) controlled trials (RCT) evaluating systemic couples/family/individual therapy with adult index patients published in English, German or Spanish up to the end of 2004 were identified via data base searches and cross-references in other meta-analyses and reviews. A meta-analysis of the identified RCT was performed.

Results

28 RCT (43 publications) evaluating systemic therapy with adult index patients suffering from clinical disorders (ICD-10) were identified. Systemic therapy is efficacious with regard to substance disorders, mental/social factors interacting with somatic disorders, schizophrenia, depression and eating disorders. The results are stable across follow-up periods of up to 5 years.

Conclusion

According to the criteria of the German Scientific Advisory Board Psychotherapy (Wissenschaftlicher Beirat Psychotherapie) there seems to be good evidence for the efficacy of systemic therapy in at least four fields of application of adult psychotherapy.     

Thematic review of Family Therapy Journals 2012

In this article the contents of the principal English‐language family therapy journals, and key family therapy articles published in other journals in 2012 are reviewed under these headings: therapy processes in the treatment of child‐focused problems, autism, adolescent substance use, human immunodeficiency virus, depression and grief, fragile families, mental health recovery, medical family therapy, family business and systemic practice, couple therapy, intimate partner violence, key issues in theory and practice, research, diversity, international perspectives, interviews, and deaths.     

The evidence base for couple therapy,family therapy and systemic interventions for adult‐focused problems

This review updates similar articles published in JFT in 2000 and 2009. It presents evidence from meta‐analyses, systematic literature reviews and controlled trials for the effectiveness of couple and family therapy for adults with various relationship and mental health problems. The evidence supports the effectiveness of systemic interventions, either alone or as part of multi‐modal programmes, for relationship distress, psychosexual problems, intimate partner violence, anxiety disorders, mood disorders, alcohol problems, schizophrenia and adjustment to chronic physical illness.     

Couple therapy,family therapy and systemic interventions for adult‐focused problems: the current evidence base

This paper updates previous similar reviews published in JFT in 2000, 2009 and 2014. It presents evidence from meta‐analyses, systematic literature reviews and controlled trials for the effectiveness of couple therapy, family therapy, and systemic interventions for adults with a range or relationship and mental health problems. The evidence supports the effectiveness of systemic interventions, either alone or as part of multimodal programmes, for relationship distress, psychosexual problems, intimate partner violence, anxiety disorders, mood disorders, alcohol problems, psychosis and adjustment to chronic physical illness.     

Family therapy and systemic interventions for child‐focused problems: the current evidence base

This review updates previous similar papers published in JFT in 2000, 2009 and 2014. It presents evidence from meta‐analyses, systematic literature reviews, narrative literature reviews and controlled trials for the effectiveness of systemic interventions for families of children and adolescents with common mental health problems and other difficulties. In this context, systemic interventions include both family therapy and other family‐based approaches such as parent training, or parent implemented behavioural programmes. The evidence supports the effectiveness of systemic interventions either alone or as part of multimodal programmes for sleep, feeding and attachment problems in infancy; recovery from child abuse and neglect; conduct problems, emotional problems, eating disorders, somatic problems, and first episode psychosis.     

Systemic Family Therapy Competences in Child and Adolescent Mental Health Care

This article is based on a doctoral research project aiming to identify a comprehensive and detailed outline of the systemic therapist competences in child and adolescent mental health care in Norway. Because of the growing demands to offer specialized services within child and adolescent mental health care, I intended the identified competences to target the psychosocial difficulties that are categorized as associated abnormal psychosocial situations (axis 5) in the multiaxial diagnostic system (WHO, Multiaxial classification of child and adolescent psychiatric disorders. The ICD-10 classification of mental and behavioural disorders in children and adolescents. Cambridge University Press, Cambridge, 1996). The project is based on twelve qualitative in-depth interviews with six experienced systemic family therapists, and fieldwork observations of the therapists (participants) in practice. The qualitative methodology is based on Grounded Theory and five overarching categories were identified through the analysis: (1): the importance of ethical and contextual awareness in systemic therapy; (2) the systemic therapist’s stance; (3) therapeutic processes; (4) therapeutic practices; and (5) session-specific features. Challenges, such as limiting the systemic approach to five overarching competences, are discussed alongside this strengths and limitations of the study. The detailed outline of systemic therapist competences is intended to offer a framework for delivering flexible, yet specialized systemic therapy in the context of child and adolescent mental health care. This research may therefore facilitate a “bridge-building process” between mental health’s biomedical focus and postmodern systemic ideas.     

We‐Language and Sustained Reductions in Drinking in Couple‐Based Treatment for Alcohol Use Disorders

Couple‐based treatments for alcohol use disorders (AUDs) produce higher rates of abstinence than individual‐based treatments and posit that active involvement of both identified patients (IPs) and significant others (SOs) is partly responsible for these improvements. Separate research on couples’ communication has suggested that pronoun usage can indicate a communal approach to coping with health‐related problems. The present study tested whether communal coping, indicated by use of more first‐person plural pronouns (“we” language), fewer second‐person pronouns (“you” language), and fewer first‐person singular pronouns (“I” language), predicted improvements in abstinence in couple‐based AUD treatment. Pronoun use was measured in first‐ and mid‐treatment sessions for 188 heterosexual couples in four clinical trials of alcohol behavioral couple therapy (ABCT). Percentages of days abstinent were assessed during treatment and over a 6‐month follow‐up period. Greater IP and SO “we” language during both sessions was correlated with greater improvement in abstinent days during treatment. Greater SO “we” language during first‐ and mid‐treatment sessions was correlated with greater improvement in abstinence at follow‐up. Greater use of IP and SO “you” and “I” language had mixed correlations with abstinence, typically being unrelated to or predicting less improvement in abstinence. When all pronoun variables were entered into regression models, only greater IP “we” langue and lower IP “you” language predicted improvements in abstinence during treatment, and only SO “we” language predicted improvements during follow‐up. Most pronoun categories had little or no association with baseline relationship distress. Results suggest that communal coping predicts better abstinence outcomes in couple‐based AUD treatment.     

Reflections under the lens: observations of a systemic therapist on the experience of participation and scrutiny in a research project

The London Depression Intervention Trial (LDIT) was set up in the early 1990s by Professor Julian Leff ( Leff et al., 2000 , and in this issue) to compare the relative efficacy and costs, in work with depressed adults, of systemic couple therapy, drug treatment and individual cognitive behaviour therapy (CBT). The research found that systemic therapy compared favourably with the other modalities in respect of fewer drop‐outs, improvement in measured depression at the end of therapy and on follow‐up after a second year without therapy, and was not – contrary to the usual assumptions – more expensive. I was one of the two therapists, together with Eia Asen ( Jones and Asen, 2000 , and Asen in this issue) practising systemic therapy with diagnosed depressed patients and their partners. In this paper I will discuss the experience of being the object of research scrutiny, and the reflections that have come to me during and subsequent to the research period. To put it more challengingly: What are the consequences for systemic psychotherapists of co‐operation with researchers? Can a circular epistemology survive being scrutinized through a lineal grid?     

A Multi‐Family Group Intervention for Adolescent Depression: The BEST MOOD Program

Depression is the most common mental disorder for young people, and it is associated with educational underachievement, self‐harm, and suicidality. Current psychological therapies for adolescent depression are usually focused only on individual‐level change and often neglect family or contextual influences. The efficacy of interventions may be enhanced with a broader therapeutic focus on family factors such as communication, conflict, support, and cohesion. This article describes a structured multi‐family group approach to the treatment of adolescent depression: Behaviour Exchange Systems Therapy for adolescent depression (BEST MOOD). BEST MOOD is a manualized intervention that is designed to address both individual and family factors in the treatment of adolescent depression. BEST MOOD adopts a family systems approach that also incorporates psychoeducation and elements of attachment theories. The program consists of eight multifamily group therapy sessions delivered over 2 hours per week, where parents attend the first four sessions and young people and siblings join from week 5. The program design is specifically aimed to engage youth who are initially resistant to treatment and to optimize youth and family mental health outcomes. This article presents an overview of the theoretical model, session content, and evaluations to date, and provides a case study to illustrate the approach.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

Externalizing Disorders in Adolescence Mediate the Effects of Maternal Depression on Substance Use Disorders

Maternal depression has been linked to increased risk of substance use disorders (SUDs) in offspring. Cross-sectional studies have identified relationships among maternal depression, externalizing disorders and SUDs, but no longitudinal examination of causality has been undertaken. In order to address this gap in the literature, depression and externalizing disorders at or prior to age 15 were tested as mediators of the relationship between maternal depression and SUDs diagnosed between ages 16 and 20 in a sample of 702 Australian youth (363 women) using path models. Mothers’ and fathers’ substance diagnoses and earlier onset of substance abuse in youth were controlled for in all analyses. Consistent with previous work, maternal depression predicted SUDs between ages 16 and 20. An indirect effect of maternal depression through youth externalizing disorders diagnosed by age 16 was detected for alcohol and cannabis use disorders, but not drug disorders. Early adolescent depression was not a mediator of the relationship between maternal depression and any of the substance outcomes measured. To our knowledge, this study is the first to examine depression and externalizing disorders in early adolescence as mediators of the effect of maternal depression on psychopathology in later adolescence. Further work is needed to understand how family environment and genetic factors may explain the mediation by externalizing disorders.     

Fidelity Failures in Brief Strategic Family Therapy for Adolescent Drug Abuse: A Clinical Analysis

As evidence‐based family treatments for adolescent substance use and conduct problems gain traction, cutting edge research moves beyond randomized efficacy trials to address questions such as how these treatments work and how best to disseminate them to community settings. A key factor in effective dissemination is treatment fidelity, which refers to implementing an intervention in a manner consistent with an established manual. While most fidelity research is quantitative, this study offers a qualitative clinical analysis of fidelity failures in a large, multisite effectiveness trial of Brief Strategic Family Therapy (BSFT) for adolescent drug abuse, where BSFT developers trained community therapists to administer this intervention in their own agencies. Using case notes and video recordings of therapy sessions, an independent expert panel first rated 103 cases on quantitative fidelity scales grounded in the BSFT manual and the broader structural‐strategic framework that informs BSFT intervention. Because fidelity was generally low, the panel reviewed all cases qualitatively to identify emergent types or categories of fidelity failure. Ten categories of failures emerged, characterized by therapist omissions (e.g., failure to engage key family members, failure to think in threes) and commissions (e.g., off‐model, nonsystemic formulations/interventions). Of these, “failure to think in threes” appeared basic and particularly problematic, reflecting the central place of this idea in structural theory and therapy. Although subject to possible bias, our observations highlight likely stumbling blocks in exporting a complex family treatment like BSFT to community settings. These findings also underscore the importance of treatment fidelity in family therapy research.     

Diagnoses,Relational Processes and Resourceful Dialogs: Tensions for Families and Family Therapy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM‐5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths‐based orientations, many tensions can follow when use of the DSM‐5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM‐5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.     

The effectiveness of family therapy and systemic interventions for adult-focused problems

This review updates a similar paper published in this Journal in 2000. It presents evidence from meta-analyses, systematic literature reviews and controlled trials for the effectiveness of couples and family therapy for adults with various relationship and mental health problems. The evidence supports the effectiveness of systemic interventions, either alone or as part of multimodal programmes, for relationship distress, psychosexual problems, domestic violence, anxiety disorders, mood disorders, alcohol abuse, schizophrenia and adjustment to chronic physical illness.     

Using telehealth to provide outpatient follow‐up to children with avoidant/restrictive food intake disorder

The COVID‐19 global health crisis compelled behavior analysts to consider alternatives to face‐to‐face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day‐treatment program; and transitioned to an outpatient follow‐up program. In Experiment 1, we analyzed the data of participants who received follow‐up both in‐clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow‐up either in‐clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in‐clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.     

The evidence base for family therapy and systemic interventions for child‐focused problems

This review updates similar articles published in the Journal of Family Therapy in 2001 and 2009. It presents evidence from meta‐analyses, systematic literature reviews and controlled trials for the effectiveness of systemic interventions for families of children and adolescents with various difficulties. In this context, systemic interventions include both family therapy and other family‐based approaches such as parent training. The evidence supports the effectiveness of systemic interventions either alone or as part of multi‐modal programmes for sleep, feeding and attachment problems in infancy; child abuse and neglect; conduct problems (including childhood behavioural difficulties, attention deficit hyperactivity disorder, delinquency and drug misuse); emotional problems (including anxiety, depression, grief, bipolar disorder and self‐harm); eating disorders (including anorexia, bulimia and obesity); somatic problems (including enuresis, encopresis, medically unexplained symptoms and poorly controlled asthma and diabetes) and first episode psychosis.