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.     

The Effectiveness of Functional Family Therapy for Adolescent Behavioral and Substance Misuse Problems: A Meta‐Analysis

A systematic review of published and unpublished English language articles identified 14 studies containing 18 comparisons between functional family therapy (FFT) and another condition in the treatment of adolescent disruptive behavior and substance use disorders. In 11 of these comparisons, assignment to conditions was random, while nonrandom assignment occurred in seven studies. For both random and nonrandom comparisons, separate meta‐analyses were conducted for subgroups of studies depending on the type of comparison group used. Data from studies of untreated control groups (CTL), treatment as usual (TAU), and well‐defined alternative treatments (ALTs) were analyzed separately. Effect sizes from these six meta‐analyses were as follows: random assignment FFT versus CTL (k = 3, d = 0.48, p < .01); random assignment FFT versus TAU (k = 3, d = .20, ns); random assignment FFT versus ALT (k = 5, d = .35, p < .05); nonrandom assignment FFT versus CTL (k = 2, d = .90, ns); nonrandom assignment FFT versus TAU (k = 2, d = .08, ns); and nonrandom assignment FFT versus ALT (k = 3, d = .75, p < .001). These results provide support for the effectiveness of FFT compared with untreated controls and well‐defined ALTs, such as cognitive behavior therapy, other models of family therapy, and individual and group therapy for adolescents.     

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.     

Current Issues in the Practice of Integrative Couple and Family Therapy

This paper provides an overview of current issues in integration in couple and family therapy. It summarizes the evolution of integration in couple and family therapy, the various traditions in integration, the strengths of integrative approach, and the possible pitfalls involved. It highlights the extent to which most couple and family therapy is now integrative practice. It concludes with a consideration of an emerging trend toward methods of practice centered on modules of intervention that have been identified as effective with certain presenting phenomena. The example of therapy for high conflict divorce is utilized to illustrate how various components can be brought together to create a maximally effective intervention.     

Third‐Order Thinking in Family Therapy: Addressing Social Justice Across Family Therapy Practice

We contend that the field of family therapy is undergoing a notable shift from second‐ to third‐order thinking. We offer theoretical support and examples to demonstrate how third‐order thinking provides a framework for integrating heightened sociocultural attunement into family therapy practice. We discuss the importance of third‐order thinking relative to being prepared to invite families into third‐order change. Finally, we offer a case example to show specific guidelines for third‐order practice.     

Systematic Review of Self‐Report Family Assessment Measures

A systematic review of self‐report family assessment measures was conducted with reference to their psychometric properties, clinical utility and theoretical underpinnings. Eight instruments were reviewed: The McMaster Family Assessment Device (FAD); Circumplex Model Family Adaptability and Cohesion Evaluation Scales (FACES); Beavers Systems Model Self‐Report Family Inventory (SFI); Family Assessment Measure III (FAM III); Family Environment Scale (FES); Family Relations Scale (FRS); and Systemic Therapy Inventory of Change (STIC); and the Systemic Clinical Outcome Routine Evaluation (SCORE). Results indicated that five family assessment measures are suitable for clinical use (FAD, FACES‐IV, SFI, FAM III, SCORE), two are not (FES, FRS), and one is a new system currently under‐going validation (STIC).     

Psychometric Properties and Responsiveness to Change of 15‐ and 28‐Item Versions of the SCORE: A Family Assessment Questionnaire

The SCORE (Systemic Clinical Outcome and Routine Evaluation) is a 40‐item questionnaire for completion by family members 12 years and older to assess outcome in systemic therapy. This study aimed to investigate psychometric properties of two short versions of the SCORE and their responsiveness to therapeutic change. Data were collected at 19 centers from 701 families at baseline and from 433 of these 3–5 months later. Results confirmed the three‐factor structure (strengths, difficulties, and communication) of the 15‐ and 28‐item versions of the SCORE. Both instruments had good internal consistency and test–retest reliability. They also showed construct and criterion validity, correlating with measures of parent, child, and family adjustment, and discriminating between clinical and nonclinical cases. Total and factor scales of the SCORE‐15 and ‐28 were responsive to change over 3–5 months of therapy. The SCORE‐15 and SCORE‐28 are brief psychometrically robust family assessment instruments which may be used to evaluate systemic therapy.     

Pathways of Risk and Resilience: Impact of a Family Resilience Program on Active‐Duty Military Parents

Over the past decade, studies into the impact of wartime deployment and related adversities on service members and their families have offered empirical support for systemic models of family functioning and a more nuanced understanding of the mechanisms by which stress and trauma reverberate across family and partner relationships. They have also advanced our understanding of the ways in which families may contribute to the resilience of children and parents contending with the stressors of serial deployments and parental physical and psychological injuries. This study is the latest in a series designed to further clarify the systemic functioning of military families and to explicate the role of resilient family processes in reducing symptoms of distress and poor adaptation among family members. Drawing upon the implementation of the Families Overcoming Under Stress (FOCUS) Family Resilience Program at 14 active‐duty military installations across the United States, structural equation modeling was conducted with data from 434 marine and navy active‐duty families who participated in the FOCUS program. The goal was to better understand the ways in which parental distress reverberates across military family systems and, through longitudinal path analytic modeling, determine the pathways of program impact on parental distress. The findings indicated significant cross‐influence of distress between the military and civilian parents within families, families with more distressed military parents were more likely to sustain participation in the program, and reductions in distress among both military and civilian parents were significantly mediated by improvements in resilient family processes. These results are consistent with family systemic and resilient models that support preventive interventions designed to enhance family resilient processes as an important part of comprehensive services for distressed military families.     

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.     

A Conceptual Model and Clinical Framework for Integrating Mindfulness into Family Therapy with Adolescents

Individual and group‐based psychotherapeutic interventions increasingly incorporate mindfulness‐based principles and practices. These practices include a versatile set of skills such as labeling and attending to present‐moment experiences, acting with awareness, and avoiding automatic reactivity. A primary motivation for integrating mindfulness into these therapies is compelling evidence that it enhances emotion regulation. Research also demonstrates that family relationships have a profound influence on emotion regulation capacities, which are central to family functioning and prosocial behavior more broadly. Despite this evidence, no framework exists to describe how mindfulness might integrate into family therapy. This paper describes the benefits of mindfulness‐based interventions, highlighting how and why informal mindfulness practices might enhance emotion regulation when integrated with family therapy. We provide a clinical framework for integrating mindfulness into family therapy, particularly as it applies to families with adolescents. A brief case example details sample methods showing how incorporating mindfulness practices into family therapy may enhance treatment outcomes. A range of assessment modalities from biological to behavioral demonstrates the breadth with which the benefits of a family‐based mindfulness intervention might be evaluated.     

The Effectiveness of Functional Family Therapy in Reducing Adolescent Mental Health Risk and Family Adjustment Difficulties in an Irish Context

To evaluate the effectiveness of Functional Family Therapy (FFT) 42 cases were randomized to FFT and 55 to a waiting‐list control group. Minimization procedures controlled the effects of potentially confounding baseline variables. Cases were treated by a team of five therapists who implemented FFT with a moderate degree of fidelity. Rates of clinical recovery were significantly higher in the FFT group than in the control group. Compared to the comparison group, parents in the FFT group reported significantly greater improvement in adolescent problems on the Strengths and Difficulties Questionnaire (SDQ) and both parents and adolescents reported improvements in family adjustment on the Systemic Clinical Outcomes and Routine Evaluation (SCORE). In addition, 93% of youth and families in the treatment condition completed FFT. Improvements shown immediately after treatment were sustained at 3‐month follow‐up. Results provide a current demonstration of FFT's effectiveness for youth with behavior problems in community‐based settings, expand our understanding of the range of positive outcomes of FFT to include mental health risk and family‐defined problem severity and impact, and suggests that it is an effective intervention when implemented in an Irish context.     

The Effects of a Multiple Family Therapy on Adolescents with Eating Disorders: An Outcome Study

Multiple Family Therapy (MFT) has gained increasing popularity in the treatment of eating disorders and many programs have been developed over the past decade. Still, there is little evidence in the literature on the effectiveness on MFT for treating eating disorders. The present study examines the effects of a particular model of Multiple Family Therapy on eating disorder symptoms, quality of life, and percentage of Expected Body Weight (%EBW) in adolescents with eating disorders (ED). Eighty‐two adolescents with ED, aged between 11 and 19 years, were assessed before and after treatment using the Eating Disorders Inventory 2 (EDI‐2), the Outcome Questionnaire 45 (OQ‐45) and %EBW. Results showed a significant increase in %EBW between the beginning and end of treatment, with a large effect size. 52.4% of patients achieved an EBW above 85%. Symptoms relative to all EDI dimensions (except for bulimia) significantly decreased during treatment. The three dimensions related to quality of life assessment also improved over the course of MFT. At the end of treatment, 70.7% of patients had a total OQ‐45 score below clinical significance. This study suggests that Multiple Family Therapy may benefit adolescents with eating disorders, with improvement on several outcome measures (%EBW, ED symptoms, and quality of life). However, the lack of a comparison group entails caution when drawing conclusions.     

Family‐Based HIV and Sexually Transmitted Infection Risk Reduction for Drug‐Involved Young Offenders: 42‐Month Outcomes

This study tested a family‐based human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention approach integrated within an empirically supported treatment for drug‐involved young offenders, Multidimensional Family Therapy (MDFT). A randomized, controlled, two‐site community‐based trial was conducted with 154 youth and their parents. Drug‐involved adolescents were recruited in detention, randomly assigned to either MDFT or Enhanced Services as Usual (ESAU), and assessed at intake, 3, 6, 9, 18, 24, 36, and 42‐month follow‐ups. Youth in both conditions received structured HIV/STI prevention in detention and those in MDFT also received family‐based HIV/STI prevention as part of ongoing treatment following detention release. Youth in both conditions and sites significantly reduced rates of unprotected sex acts and STI incidence from intake to 9 months. They remained below baseline levels of STI incidence (10%) over the 42‐month follow‐up period. At Site A, adolescents who were sexually active at intake and received MDFT showed greater reduction in overall frequency of sexual acts and number of unprotected sexual acts than youth in ESAU between intake and 9‐month follow‐ups. These intervention differences were evident through the 42‐month follow‐up. Intervention effects were not found for STI incidence or unprotected sex acts at Site B. Intensive group‐based and family intervention in detention and following release may reduce sexual risk among substance‐involved young offenders, and a family‐based approach may enhance effects among those at highest risk. Site differences in intervention effects, study limitations, clinical implications, and future research directions are discussed.     

Reducing the Risk of Internalizing Symptoms among High‐risk Hispanic Youth through a Family Intervention: A Randomized Controlled Trial

Familias Unidas is an intervention that has been found to be efficacious in preventing and reducing substance use, sexual risk, and problem behaviors among Hispanic youth. While it does not specifically target youth internalizing symptoms, the intervention works to strengthen parenting and family factors associated with reduced risk of internalizing symptoms (i.e., depression, anxiety symptoms). This study examines the effects of Familias Unidas on internalizing symptoms among high‐risk youth, as well as the role of family level factors in the intervention's effects. A total of 242 12–17‐year‐old Hispanic youth with a history of delinquency and their primary caregivers were recruited from the school and juvenile justice systems, and randomly assigned to the Familias Unidas intervention or community practice control. A linear latent growth model was used to examine intervention effects on the trajectory of adolescent internalizing symptoms from baseline to 6 and 12 months post‐baseline. Results show that the Familias Unidas intervention was more efficacious than control in reducing youth internalizing symptoms. Baseline youth externalizing and internalizing symptoms did not moderate the intervention's effects on the trajectory of youth internalizing symptoms. While parent – adolescent communication did not significantly moderate the intervention's effects, changes in parent – adolescent communication mediated the intervention's effects on internalizing symptoms, showing stronger intervention effects for youth starting with poorer communication. Findings indicate that the Familias Unidas intervention can reduce internalizing symptoms among high‐risk Hispanic youth, and that improving parent – youth communication, a protective family factor, may be one of the mechanisms by which the intervention influences youth internalizing symptoms.     

Queer Youth in Family Therapy

Trends in popular belief about same‐sex relationships have undergone noteworthy change in the United States over the last decade. Yet this change has been marked by stark polarizations and has occurred at varying rates depending upon regional, community, racial, religious, and individual family context. For queer youth and their families, this cultural transformation has broadened opportunities and created a new set of risks and vulnerabilities. At the same time, youth's increasingly open and playful gender fluidity and sexual identity is complicated by unique intersections of class, race, religion, and immigration. Effective family therapy with queer youth requires practitioner's and treatment models that are sensitive to those who bear the burden of multiple oppressions and the hidden resilience embedded in their layered identities. We present case examples of our model of family therapy which addresses refuge, supports difficult dialogs, and nurtures queerness by looking for hidden resilience in the unique intersections of queer youths' lives. These intersections provide transformational potential for youth, their families and even for family therapists as we are all nurtured and challenged to think more complexly about intersectionality, sexuality, and gender.     

Treatment Efficacy of Multiple Family Therapy for Chinese Families of Children with Attention Deficit Hyperactivity Disorder

The treatment efficacy of multiple family therapy (MFT) for Chinese families of children with attention deficit hyperactivity disorder (ADHD) has not been studied in the past. In this paper, the effect of MFT on different aspects of the lives of the parents in the experimental group (n = 61) was compared with the effect of only the psychoeducational talks on parents in the control group (n = 53). The results of a MANOVA have shown that by the time they reached the posttreatment phase, the parents who had completed the full 42 hours of the MFT program perceived their children's ADHD symptoms as being less serious and less pathological than they had originally thought compared to the parents in the control group. The effect of MFT on parent–child relationships, parenting stress, parental efficacy, hope, and perceived social support was statistically insignificant. Contributions and limitations of our study are discussed.     

The Family Assessment Device: An Update

The current study set out to describe family functioning scores of a contemporary community sample, using the Family Assessment Device (FAD), and to compare this to a currently help‐seeking sample. The community sample consisted of 151 families who completed the FAD. The help‐seeking sample consisted of 46 families who completed the FAD at their first family therapy appointment as part of their standard care at an outpatient family therapy clinic at an urban hospital. Findings suggest that FAD means from the contemporary community sample indicate satisfaction with family functioning, while FAD scores from the help‐seeking sample indicate dissatisfaction with family functioning. In addition, the General Functioning scale of the FAD continues to correlate highly with all other FAD scales, except Behavior Control. The cut‐off scores for the FAD indicating satisfaction or dissatisfaction by family members with their family functioning continue to be relevant and the FAD continues to be a useful tool to assess family functioning in both clinical and research contexts.     

Experiences of Families Transmitting Values in a Rapidly Changing Society: Implications for Family Therapists

Intergenerational value transmission affects parent–child relationships and necessitates constant negotiation in families. Families with adolescents from rapidly changing societies face unique challenges in balancing the traditional collectivistic family values that promote harmony with emerging values that promote autonomy. Using modern Turkey as an example of such a culture, the authors examine the transmission process in families that hold more traditional and collectivistic values than their adolescent children. Special consideration is given to generational and cultural differences in the autonomy and relatedness dimensions.