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Working Systemically with Families

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Systemic theory offers a valuable framework for integrating the diverse ideas found throughout the mental health arena in both theory and clinical practice. With this accessible book, the authors take you on an enjoyable and coherent journey through systemic theory. They then review the body of research into family therapy and conclude with a critical review of major recent developments in theory and application. At the end of several chapters are reflexive notes containing exercises that relate to the ideas and processes found within the chapter to further develop the reader's understanding. The conclusion draws together the ideas found throughout the book, with particular emphasis on the interlocking triangle of formulation, intervention and evaluation and how this will impact on systemic practice in the future. While this book will be an invaluable introduction to family systems theory and practice for clinical psychology training courses, plugging a gap that Vetere and Dallos have identified as one of their motives for writing it, its remit runs much wider. It will prove an essential companion for any professional working in the public services, whether systemically trained or not. It covers an impressive range of theory, practice and research and, as such, is firmly grounded both in the application to different client groups and in the necessity for most practitioners of integrating different therapeutic approaches.

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CHAPTER ONE. What is family therapy and systemic practice?

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From the intra-psychic to the trans-personal

The central organizing thesis of the systemic paradigm is the focus on interpersonal relationships and the move to thinking about relationships as the cradle and web of human experience and development. For us, the excitement of this paradigm shift lies in understanding and explaining individual experiences in relational terms and in understanding individual processes in the context of emotionally significant relationships. Thus, individual distress can no longer be seen only as the product of the individual’s psychology, but rather as a complex iterative process that is understood in terms of relational dynamics at many levels of contextual understanding. Applied psychologists’ preference for (ongoing) formulation maps well on to systemic thinking, so that the particular circumstances of the people seeking our help will dictate how much relative importance is attached to individual, relational, group, cultural, and societal levels of explanation. Making the connections between these levels of explanation and their relationship over time, connecting past to present to future, is the powerful contribution that systemic thinking can make to psychotherapy formulation and ensuing practice. Thus, when we use the term “systemic”, we are using it in the wider sense of its meaning as rooted in developments in family systems theories (Dallos & Urry, 1999; Vetere & Gale, 1987), rather than in the narrower definition adopted by practitioners of a particular approach in family therapy, based on the developments in the Milan school of family systemic psychotherapy (e.g., Campbell, 1999).

 

CHAPTER TWO. Enduring and helpful techniques in systemic thinking and practice

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Family therapy has developed action techniques, such as enactment and sculpting, which help make patterns between people visible, and questioning techniques, such as circular questions, which help to evaluate systemic hypotheses.

Systemic hypothesizing

A systemic hypothesis is an attempt to develop the connections between information gained from family members during a family interview. It will often include information about life-cycle transitions and inter-generational patterns; relationship patterns (closeness and distance) and recent changes in those patterns; family beliefs and the relationship to the presenting difficulties; dilemmas around change; and issues of gender and culture. Systemic hypotheses are developed and discarded as new information emerges or is elaborated in subsequent family meetings. Cecchin (1987) has suggested that when practitioners consider themselves stuck in their work with families, it is either because they have fallen in love with one hypothesis or because they are thinking at one level of the system. Under such circumstances, his advice is to challenge ourselves by broadening the contextual frame for our thinking.

 

CHAPTER THREE. Systemic formulation

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Formulation in clinical practice

The skills of assessment and formulation have been fundamental in the development of many of the therapeutic professions. For example, from the start clinical psychology nailed its colours to the positivist traditions of science and promised to provide a rigorous and evidence-based approach to clinical work. In the early days of the profession clinical psychologists often worked alongside psychiatrists to provide detailed “objective” assessments, frequently employing standardized tests that shaped clinical formulation. The purpose of the assessments was largely to diagnose with accuracy deficits in functioning with the aim of clarifying their extent and nature. Once established, this was employed to indicate the direction of treatment. For example, a psychologist might assess the extent of impairment in a young child apparently demonstrating learning disability. Based on the assessment particular regimes of interventions might be attempted such as, behavioural programmes to improve the level of independence or communication.

 

CHAPTER FOUR. Integrative practice: research on process and outcomes

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In this chapter we shall overview some of the helpful findings from family therapy process and outcome research, as the empirical base for family therapy and systemic practice.

Does family therapy work?

This question is often asked by clinical managers who may be worried that a systemic approach will be too expensive to implement. The straightforward answer is yes, it does work, and the cost effectiveness advantages of family based interventions are beginning to emerge from a few studies. For example, Pinsof & Wynne (1995) review preliminary data that indicate family therapy is more cost effective than alternative interventions for adult alcohol problems and adolescent substance misuse. It seems that family therapy is more cost effective than standard in-patient and residential treatment for people with a diagnosis of schizophrenia and severe adolescent conduct disorders and delinquency.

Bergin and Garfield (1994) assert that the marital and family therapies have been subjected to rigorous scrutiny, with only a few other models of psychotherapy studied as often. The outcome literature typically reviews the couple/marital and family therapies together. Outcome studies have reported the use of controlled and uncontrolled group comparison designs across different psychotherapy modalities, single case designs, and outcome studies that compare the relative efficacy of different schools of family therapy. The findings from the research reviews and the meta-analytic studies are that family therapy works compared with untreated control groups, with some demonstrated superior effects over standard and individualized treatments for some psychological problems and groups of people (Pinsof & Wynne, 1995). The meta-analytic studies show moderate, statistically significant effects, and often with clinically significant effects. The research literature in support of these conclusions is as robust as it is for the other modes of psychotherapy studied as often (Carr, 2000a,b; Cottrell & Boston, 2002).

 

CHAPTER FIVE. Integrative practice: developments in theory

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The impact of social constructionism and critical theory

Social constructionists argue that our social world, unlike our physical world is not a pre-given but is actively created. In effect this argument is part of a wider philosophical debate in psychology and the social sciences about whether a positivist version of science can legitimately be applied to the study of human experience and action. Similarly, constructivism had argued that meaning is central and that a psychology that focused predominantly on behaviour was fundamentally limited. However, further to constructivism, social constructionism gives priority to language and argues that language contains the “building blocks”, the materials from which we construct our experiences (Foucault, 1975). Like systemic theory, social constructionism also sees interaction and communication as central. Through the processes of conversation, meanings are mutually shaped. Rather than being seen as essentially located within individuals, meanings are seen to be co-constructed, so that with each conversation new meanings, interpretations, and nuances are developed. Importantly, it is suggested that even in our private moments our thinking features internalized conversations with ourselves and with others. I may rehearse conversations that I wish to have with people, or attempt to edit conversations that I have had to get my point across better, and so on.

 

CHAPTER SIX Specific applications: integrative practice—context and method

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This section explores some of the applications of systemic ideas and practices across a range of service settings and with specific issues.

Working systemically with couples

The work of Zimmerman and Dickerson (1993) will be described in some detail as it illustrates nicely an attempt to converge social constructionism, family systems thinking, and second order cybernetics with White and Epston’s (1990) ideas as a narrative model for working with couples. This posits that people choose specific incidents from their past experience to justify and explain their present behaviour, constructing meanings which become small stories, scripts, and myths (Bruner, 1990). It is suggested that any new events that confirm or conform to the story are added over time, so that the stories become treated as if true, and people can be influenced by them or act in accordance with them. Some accounts we hold are said to be problem-saturated. At first sight, this model seems to suggest that people are not reflective, or that they do not notice disconfirming events. Rather, the model suggests that people’s accounts and explanations can be influenced by prevailing socialization processes, gender training, cultural, economic, and political conditions, that may operate outside full conscious attention. Zimmerman and Dickerson’s model suggests that couples’ reciprocal patterns of interaction connect both the socially constructed meanings and the habits of the couple. It does not assume, however, that partners in a couple relationship have equity in their relationship and equal influence on these patterns.

 

CHAPTER SEVEN Integrative practice: thinking in the future

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In this chapter we try to draw together the recursive themes of formulation, intervention, and evaluation. As we say at the outset, these three themes can be seen as an interlocking triangle in which each point of the triangle informs the other. Systemic thinking provides us with the framework within which we integrate diverse ideas. For us, the recursive loops between thinking and practice are grounded in pragmatic considerations of best fit and theory has never been about a search for a once-and-for-all understanding. Rather, it is more how we best describe and explain the circumstances under consideration, in terms of what we think we know, ever alert to new and disconfirmatory information. Our chief criterion for the evaluation of theory used for formulation is usefulness: how does this formulation best explain what is happening? from whose perspective? does it help us think further? does it guide our practice?

We have tried to present systemic formulation as a case study approach to practice-based evidence. We have argued that formulation offers a case by case approach to making theory evident in our clinical practice. For example, how our clinical observations are developed and evolve into progressive hypotheses that recursively inform our practice from the ground up, so to speak, much as in a grounded theory approach to practice, is made known through the practice of formulation. Formulation as a process thus enables evaluation, which itself is rooted in actual day to day practices. The collaborative approaches promoted within these pages parallel recent Department of Health research directives concerning user involvement in evaluation research. Arguably, a systemic approach helps us move beyond paying lip service to collaboration if formulation itself can be shown to be collaborative in nature.

 

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