Parental Involvement: Contribution to Childhood Anxiety and Its Treatment

Anxiety disorders are prevalent in youth. Despite demonstrated efficacy of cognitive behavioral therapy (CBT), approximately 40 % of anxiety-disordered youth remain unresponsive to treatment. Because developmental and etiological models suggest that parental factors are relevant to the onset and maintenance of childhood anxiety, researchers have proposed and investigated family-based interventions with increased parent work in treatment, aiming to improve the efficacy of treatment for childhood anxiety. However, contrary to what theoretical models suggest, data to date did not indicate additive benefit of family-based CBT in comparison with child-centered modality. Is parent/family involvement unnecessary when treating childhood anxiety disorders? Or could there be the need for specificity (tailored family-based treatment) that is guided by a revised conceptualization that improves the implementation of a family-based intervention? The current review examines (1) relevant parental factors that have been found to be associated with the development and maintenance of childhood anxiety and (2) interventions that incorporate parental involvement. Relevant findings are integrated to formulate a “targeted” treatment approach for parental involvement in CBT for youth anxiety. Specifically, there is potential in the assessment of parent/family factors prior to treatment (for appropriateness) followed by a target-oriented implementation of parent training.     

Sculpting Present and Future: A Systemic Intervention Model Applied to Psychosomatic Families

We present a therapeutic intervention model for use with psychosomatic families. This method, the result of our extensive research on various psychosomatic disorders, uses family sculptures of the "present" and "future": each family member is requested to represent the family as it now "is," and how it "will be" in the future. We discuss the theoretical reasons for our choice of this method: (a) the opportunity to use a therapeutic language that is similar to the nonverbal language of the psychosomatic symptom, and (b) the usefulness of reinserting temporal dimensions into family systems that seem to have lost their evolutionary potential and to be in a sort of "time lock." Two clinical cases are discussed (a child with chronic asthma and an anorexic adolescent); the use of sculptures in both cases revealed the underlying problems and made positive therapeutic interventions possible. Finally, we point out how the use of sculpture as a therapeutic technique enables therapists to deal with multiple systemic levels.     

Comparison of the Family Therapy Educational and Experience Requirements for Licensure or Certification in Six Mental Health Disciplines

In a review of literature on clinical licensure programs and certified mental health disciplines, no studies specifically compared didactic methods and clinical training standards for family-based interventions. Consequently, consumers and insurers of these services have no basis from which to evaluate the relative competency of each of the mental health disciplines in providing family-based interventions. This study used content analysis to examine the amount of family based training that is required by six core mental health disciplines (Clinical Psychology, Psychiatry, Psychiatric Nursing, Professional Counseling, Marriage and Family Therapy, and Social Work) in each of the 50 United States. Results indicate that a marriage and family therapist is required to have three times more family therapy coursework than any other professional mental health discipline. Also, before becoming licensed a marriage and family therapist, must complete 16 times more face-to-face family therapy hours than a mental health professional from any other discipline. Implications for consumers and practitioners are discussed.     

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.     

Chaotic attractors in the therapeutic system 1

Because little research had been done on the presence and role of latent communication in the context of team‐conducted family therapy, the writers set out to monitor unconscious responses generated under these conditions. Specifically, they investigated an ongoing family treatment situation conducted according to the “reflecting team model.” One team of therapists handles the actual treatment session, while the other observes from behind a one‐way mirror. During the course of a session, the second team makes suggestions to the treatment team either by telephone or by calling the therapists out of the treatment room.

As the project developed, the writers found that the unconscious responses of both family and treatment teams indicated a process at work beyond the conscious intentions of the participants. That is, the therapeutic enterprise was functioning as a dynamical system, whose increasing complexity suggested a self organizing principle at work. This paper traces the development of the system's movement toward greater complexity, identifies the specific interventions that indicate this process, describes how all participants demonstrated a high degree of resonance and synchronization with this overarching‐self organizing pattern. This paper serves to alert therapists to the role of unconscious communication within the therapeutic system and postulates that the generation of form within psychotherapy follows many of the same self organizing processes found in other human and non human systems.     

Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes

Family affect was examined as a predictor of difficulty implementing a 9-month, manual-based, psychoeducational family therapy for recently manic bipolar patients. Prior to therapy, family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task. Following family treatment, both therapists and independent observers rated the overall difficulty of treating the family, and therapists also rated each participant's problem behaviors during treatment, in the areas of affect, communication, and resistance. Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family. Relatives' critical behavior toward patients during the pretreatment interaction task predicted both independent observers' ratings of overall treatment difficulty and therapists' perceptions of relatives' affective problems during treatment. Moreover, patients' residual symptoms predicted independent observers' ratings of overall difficulty and therapists' perceptions of patients' resistance to the family intervention. Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic, pretreatment family and clinical assessment.     

Parent Training for Childhood Anxiety Disorders: The SPACE Program

Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.     

Engaging multiproblem families in treatment: lessons learned throughout the development of multisystemic therapy.

Multisystemic therapy (MST) is a family-based treatment model that has achieved high rates of treatment completion with youths who present serious clinical problems, and their families. The success of MST in engaging challenging families in treatment is due to programmatic commitments to family collaboration and partnership as well as to a conceptual process that delineates barriers to family engagement, develops and implements strategies to overcome these barriers, and evaluates the success of these strategies. This article provides an overview of the nonspecific/universal engagement strategies used by MST therapists, frequently observed barriers to achieving therapist-family engagement, and specific strategies to overcome a sampling of these barriers.     

Fostering Client Creativity in Family Therapy: A Process Research Study

Creativity has been shown to enhance problem solving, and to increase flexibility and adaptability—qualities associated with positive therapeutic outcomes. Literature related to therapist and/or client creativity is primarily anecdotal. Empirical literature addressing how therapists can facilitate the creativity of their clients in family therapy is scarce. In this study, the researchers used process methodology to code the behavior of therapists and clients in 31 videotaped family therapy sessions. Results show a significant positive correlation between interventions that induce positive affect and the creative client behaviors of optimism and playfulness.     

Potential Mediators in Parenting and Family Intervention: Quality of Mediation Analyses

Parenting and family interventions have repeatedly shown effectiveness in preventing and treating a range of youth outcomes. Accordingly, investigators in this area have conducted a number of studies using statistical mediation to examine some of the potential mechanisms of action by which these interventions work. This review examined from a methodological perspective in what ways and how well the family-based intervention studies tested statistical mediation. A systematic search identified 73 published outcome studies that tested mediation for family-based interventions across a wide range of child and adolescent outcomes (i.e., externalizing, internalizing, and substance-abuse problems; high-risk sexual activity; and academic achievement), for putative mediators pertaining to positive and negative parenting, family functioning, youth beliefs and coping skills, and peer relationships. Taken as a whole, the studies used designs that adequately addressed temporal precedence. The majority of studies used the product of coefficients approach to mediation, which is preferred, and less limiting than the causal steps approach. Statistical significance testing did not always make use of the most recently developed approaches, which would better accommodate small sample sizes and more complex functions. Specific recommendations are offered for future mediation studies in this area with respect to full longitudinal design, mediation approach, significance testing method, documentation and reporting of statistics, testing of multiple mediators, and control for Type I error.     

A Feminist Approach to Family Therapy

Although family therapy recognizes the importance of the social context as a determiner of behavior, family therapists have not examined the consequences of traditional socialization practices that primarily disadvantage women. The unquestioned reinforcement of stereotyped sex roles takes place in much of family therapy. A feminist therapy orientation that considers the consequences of stereotyped sex roles and the statuses prescribed by society for females and males should be part of family therapy practice. This paper describes the ways in which family therapists who are aware of their own biases and those of the family can change sexist patterns through applying feminist principles to such areas as the contract, shifting tasks in the family, communication, generational boundaries, relabeling deviance, modeling, and therapeutic alliances.     

The hidden meanings of metaphors in family therapy

This study investigates how two therapists' beliefs and practices influence the therapeutic process when they organize social interaction according to a metaphor of a royal family. The therapeutic process is described through the case of a boy called Pelle. He comes to therapy together with his family. It is shown how the therapists collaborate in the process of implementing the worldview of the predefined normative standard for family life. In the short term the therapists' use of the metaphor can be seen as an intervention to accomplish immediate change in a non-threatening way. In the long term the cost of using the metaphor was that the mother got a confirmation about herself as a less powerful parent and the child got an image of being a failure. This study points out that metaphors as therapeutic tools have to be analyzed critically before they are used or more specifically the therapists have to examine what kind of values and meanings are hidden in the metaphor and who will gain and loose if it is used as an intervention.     

Perinatal Posttraumatic Stress Disorder: Implications for Occupational Therapy in Early Intervention Practice

The purpose of this article is to present literature regarding perinatal posttraumatic stress disorder and to describe the implications of research findings for occupational therapy screening and treatment in early intervention practice. Changes in legislation regarding early intervention practice and family centered care are presented as a rationale for including maternal mental health screening as a standard practice in the field of early intervention. A case study illustrates symptoms of perinatal posttraumatic stress disorder and the effect on maternal-infant co-occupational engagement. The Model of Human Occupation is used to guide clinical reasoning about potential occupational therapy interventions.     

For all we Know: Clinical Creativity as a Dialectic Between Knowledge and Unknownness

Musical thought is an essential instrument for grasping the most secret stirrings of the human heart. Contemporary psychoanalysis has been exploring implicit communication for some time now; I believe that the way in which music communicates is remarkably connected with these matters issues. I speak of musical thought to indicate the ways in which music thinks. In this article I offer a contribution in which I could dare to use musical thought as an essential element of the clinical relationship between my patient Ernesto and me.     

The psychotherapy of genetics

The evolution of genomic science and its effect on medicine and health care offer opportunities for family therapists to participate in the comprehensive care of patients and families with genetic disorders. This article provides an overview of what we now know about the psychological and interpersonal experience of patients and families facing some of these illnesses. Case examples illustrate the process of decision-making about testing and treatment, and the importance of understanding developmental issues and transgenerational family dynamics in any related psychotherapy. Challenging emotional issues include managing anger, ambivalence, and guilt; challenging interpersonal issues include dealing with differing coping and communication styles, decisions about disclosure and secrets, and conflict resolution. Family-oriented interventions include individual, couple, and family therapy, and psychoeducational groups. Recommendations are made for family therapists to participate as part of the genetic healthcare team.     

Media reviews

Abstract

Dr. Maurizio Andolfi is Director of the Family Institute in Rome, Italy. He was trained in family therapy in the United States and now frequently returns to give seminars and demonstrations of his particularly gifted systems approach in the treatment of families, and in supervision of family therapists. Dr. Joel Bergman, a member of the senior faculty at the Ackerman Family Institute, reviews two of Andolfi's videotapes dealing with the supervisory process, and illustrated by actual clinical material.

The mirroring and reduplication of patterns often occurs when systems interface. Family dynamics repeat themselves across generations, and therapists and therapeutic teams easily become enmeshed in the powerful intricacies of family systems. The work of Andolfi highlights the importance of using the therapist's self-experience to illuminate and effect change in the family interactions, and the awareness of the contextual complexities of the supervisory process provides further possibilities for more enlightened intervention.—I. A.     

Integrative problem-centered metaframeworks therapy II: planning, conversing, and reading feedback

This is the second of 2 articles presenting Integrative Problem Centered Metaframeworks (IPCM) Therapy, a multisystemic, integrative, empirically informed, and common factor perspective for family, couple, and individual psychotherapy. The first article presented IPCM's foundation concepts and Blueprint for therapy, focusing on the first Blueprint component—Hypothesizing or assessment. This article, focusing on intervention, presents the other 3 Blueprint components—Planning, Conversing, and Feedback. Articulated through the Blueprint, intervention is a clinical experimental process in which therapists formulate hypotheses about the set of constraints (the Web) within a client system that prevents problem resolution, develop a therapeutic Plan based on those hypotheses, implement the Plan through a coconstructed dialogue with the clients, and then evaluate the results. If the intervention is not successful, the results become feedback to modify the Web, revise the Plan, and intervene again. Guided by the therapeutic alliance, this process repeats until the presenting problems resolve. IPCM Planning sequentially integrates the major empirically and yet‐to‐be empirically validated therapies and organizes their key strategies and techniques as common factors. Conversing and Feedback employ empirical STIC^® (Systemic Therapy Inventory of Change) data collaboratively with clients to formulate hypotheses and evaluate interventions. This article emphasizes the art and science of IPCM practice.     

Family Therapy With Irish-Americans

This paper presents a paradigm for understanding the cultural values and family patterns of Irish-American families and offers suggestions for clinical intervention. Families' correspondence to the model described will depend upon their level of acculturation, socioeconomic status, and other contextual factors. The paradigm suggests a number of issues that may create difficulties for the therapist and for the family in therapy. In general, behavioral techniques, Bowen systems therapy, and strategic interventions may be more useful than techniques emphasizing expression of emotions in therapy or direct attempts to alter communication or family behavior in therapy sessions, as used in structural therapy.