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OUB 804

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  1. OUB 804 From Parent guidance to Family-oriented intervention

  2. Training framework • Systems-oriented • Relational framework • Evidence-based practice • Resiliency/Competency based

  3. Training competencies • COMPETENCIES • Application of scientific knowledgepractice • Psychological assessment • Psychological intervention • Consultation and collaboration • THEORETICAL PRINCIPLES • Integrative assimilation

  4. Training competencies • PROFESSIONAL DEVELOPMENT • Accurate self-assessment • ETHICAL ISSUES • Unique to families • Client • Confidentiality • Goals

  5. Biopsychosocial – Engel (1977) Body/Mind – Kandel (1998) Bio-ecological - Bronfenbrenner (1994) Developmental psychopathology - SYSTEMIC MODELS

  6. Bio-psychosocial model - Engel • Psychiatry has become a hodge-podge of unscientific opinions, assorted philosophies and “schools of thought”, mixed metaphors, role diffusion, propaganda and politicking for mental health and other esoteric goals. • Ludwig: “The medical model premises that sufficient deviation from normal represents disease, that disease is known to known or unknown natural causes, and that elimination of these causes will result in cure or improvement in an individual” • Engel and Von Bertallanfy – general systems theory

  7. Developmental psychopathology • Family as the central context for understanding the development of children’s adjustment problems • Focus: adjustment and maladjustment • Interrelation • Genetic proclivities • Family subsystems • Social contexts and ecologies

  8. Principles and assumptions • Concerned with individual differences in maladaptive patterns of functioning • Charting developmental trajectories in functioning • Explaining continuity and discontinuity in development • Attention: specific processes, developmental processes, normal and abnormal functioning

  9. Risk and protective factors • Dynamic mediating processes accounting for adaptation and maladaptation • More complexity in conceptualising process underlying normal development • Interaction of both risk and protective factors – transactional rather than linear • Mediational pathways – why risk factors lead to maladaptive outcomes

  10. Parent-child subsystem • Parenting – socialisation of child: desirable or non-desirable outcomes • Towards a process model – principles: • Transactional – process unfolds over time • Transformational/epigenetic: change is basic • Multivariate – multiple dimensions; horizontal and vertical stressors

  11. Systemic context for assessment – McGoldrick, Gerson, Petry (2008) • Vertical stressors: Family generational patterns, myths, triangles secrets, religious beliefs, addictions, violence, racism, politics • Horizontal stressors: Developmental (life transitions), unpredictable (accidents, chronic illness, unemployment, disasters) and historical (economic and political events)

  12. Systemic models • Integrating genetics, mind and social world • Mind/brain integration • Mental processes derive from the brain • Genes and protein products • Genes and social/developmental factors • Learning produces gene alterations • Nurture ultimately expressed as nature

  13. Body/mind integration • Mind is biologically based • Genes determine the biological base • Experience alters genetic expression • Reciprocity (Gene-experience)

  14. Propositions • Body – Mind – Social/Relational world • Integrated system • Co-evolve • Changes in one system will have impact • Genetic constraints • Set is sensitive to change by psychotherapy • Praxis: Entry points; affecting change; family-oriented intervention

  15. Implications • Therapist as agent of change • World unstable and in disequilibrium • Directional hypotheses • Interface is important • Genetics a proclivity not a destiny • Family task: calibrating a fit • Causes versus fitness

  16. Example: Emotion regulation • Emotions • Whole-bodied phenomena that involve changes in domains of central and peripheral physiology (body), subjective experience (mind) and behaviour (relational) • Intrinsic (temperament, biological maturation) and extrinsic (caregiver support and flexibility) factors

  17. Caregiver influences • Prenatal stress • Hyperactivity • Attention deficits • Maladaptive social behaviour • Mechanism • Stress hormones alter the developing hypothalamic-pituitary-adrenal axis: results in dysregulation of stress-response system

  18. Caregiver influences • Maternal depression • Diminished responsiveness and emotional animation by 2 – 3 months • More subdued with non-depressed strangers • Interaction with a depressed caregiver undermine healthy emotional functioning as well as the emergence of behavioural and neurobiological emotion regulatory capacity • Oppositional behaviour : coercive interaction cycles • Less parental support • Internal characteristics of the child

  19. Central to health + treatment Self-Concept Individual Relational Collectivist Relational orientation Internal representation Experience oneself Dimensions Focus Autonomy Connection Power Egalitarian Hierarchical Typologies Relational framework(Silverstein, 2006)

  20. Rule-directed • Hierarchical and connected • Responsibility to group • Within established rules and guidelines • Authority  common good • Response to societal change • Problems • Authority challenged • Abuse of power

  21. Position-directed • Hierarchical and autonomous • One up/one down in relationships • Determining/maintaining place in relationships • Know thyself, present own interests • Problems • Power struggles and own interests • Dominant person has limited empathy • Position through individual positioning of power not clear cultural rules

  22. Independence directed • Autonomous and egalitarian • Western ideal • Competing needs are managed • Compromise, give-and-take • Problems • Individuality is threatened • Agreed upon goals cannot be reached

  23. Relationship directed • Egalitarian and connected • Women’s psychology • Shared responsibilities and commitment • Personal authenticity – connection to others • Problems • Authentic expression is limited • Harmony at expense of conflict • Devitalised – conflict avoidance

  24. Evaluation • Keeps relationships central • Important to understand diversity • Worth • promoting stable, satisfying relationship • that support and facilitate • the well-being of each member • Ethical issues • Clinical goals set in collaboration

  25. Evidence based family intervention(Larner, 2004) • Family therapy works • Systemic family therapy • Language-based • Client-directed • Relationally focused • Context, narrative, relationships • Scientist-practioner vs systemic practitioner

  26. Criteria for evidence • Double-blind treatment with control groups and replication by at least two independent studies • Translated into a treatment manual • Treatment has been applied with specific client populations

  27. Family therapy • Relational process • Generic for approaches based on • Broad systemic principles • Specifics vary • Application is flexible and pragmatic with integrative models becoming the norm • Emphasis: who says what to whom • Collaborative and reflective form of therapy • Gender, culture, politics, spirituality • Ecological intervention

  28. Scientist-practitioner model • Lack of evidence for SPM itself • Research and implementation differs • Research setting vs clinical settings • “Why” and “How” – non-existent • Child psychiatric practice: interventions mostly psychosocial, contextual

  29. Other types of evidence • Client feedback and satisfaction • Practical clinical experience • Practice protocols - multiple sources of information • Common factors in therapy • Client resourcefulness – 40% • Relationship (empathic/collaborative) – 30% • Client expectations – 15% • Therapeutic approach – 15%

  30. Key tasks of the family therapist • Form collaborative relationships • Engage client’s hopes and expectations • More relational and client-driven than model driven

  31. Efficacy of family-oriented intervention • Good global evidence • Specific evidence lacking • Brief therapy: depressed and bereaved children • Narrative therapy: psychosomatic problems; more effective than behavioural • ADD: low-dose medication; structural family therapy; parental behaviour management; school behavioural programmes

  32. Efficacy of family-oriented intervention • Oppositional/conduct: Parent management intervention • Agoraphobia: CBT more effective in family context than individual • Schizophrenia: psycho-educational; medication; family counseling to manage stress

  33. Efficacy of family-oriented intervention • Campbell (1997) • Schizophrenia • Depression • Behaviour problems in children • Conduct disorder in adolescence • Substance abuse • Physical illness

  34. Efficacy of family-oriented intervention • Sandberg (1997) • Depression • Delinquency • Conduct disorder • Substance abuse • Eating disorders • Marital discord

  35. Efficacy of family-oriented intervention • Asen (2002) – FT major treatment of choice for • Anorexia, psychosis and mood disorders • Sprenkle (2003) – Family treatment for • Conduct disorder and delinquency • Substance abuse • Childhood behaviour disorders • Severe mental illness • Affective disorders • Schizophrenia • Marital problems

  36. Conclusion • Larner (2004) “In complex therapeutic systems evidence-based practice need to be applied in clinically relevant ways and family therapy is best practice. Especially in child and adolescent therapy.” • Kazdin and Weisz (1998) noted that all intervention with this age group is de facto family therapy whatever treatment is espoused.

  37. Integrative practice model • Reimers (2001) – three principles for user-friendly family therapy • Be open to use mixed therapeutic approaches • Therapy approach should be tailored to the needs of particular families • Therapy should be based on outcome research and therapeutic relationship • Art and science of therapy • Pragmatic, creative, intuitive and curious • Value scientific method and clinical wisdom

  38. Systemic practitioner model • What works for whom when – requires relational/systemic understanding • Relational work precursor for other EB treatments • Balance clinical experience, relational know-how and science • Research question: how to measure systemic progress in 1+a terms

  39. Transmodal family work - Bitter (2009) • Forming a relationship • Assessment • Hypothesizing and sharing meaning • Facilitating change

  40. Relationship forming • Common factors • Client characteristics – 40% • Relationship – 30% • Therapeutic model – 15% • Extraneous factors – 15% • Process and structure • Relationships, seating, talking • How rather than who, what, where questions

  41. Family Assessment – Bitter (2009) • Internal family systems • Structure, organisation, subsystems • Parts of the family • The differentiated self • Internal: rationality over emotion reactivity • External: Disengaging from patterned interactions

  42. Family Assessment – Bitter (2009) • Teleological lens • Future oriented, goals, endpoints, intentional self • Goals of dysfunctional communication • Goals of misbehaviour • Important in reframing • Changing the viewing of the problem • Pay-offs of the interactions, behaviours

  43. Family Assessment (Bitter, 2009) • Sequences: Patterns of interaction • Level One: Face to face sequences, including triangulation • Level Two: Routines that support functioning • Level Three: Ebb and flow – longer – developmental or outside forces • Level Four: Transgenerational. They provide continuity and pass on values and rules.

  44. Family Assessment (Bitter, 2009) • Organisation lens • Towards effective leadership, productive • Key is balance • Discipline • Emotion coaching • Firm but friendly • Understanding developmental needs and processes • Individuality and connection

  45. Family assessment (Bitter, 2009) • Developmental lens • Family life cycle approach (Carter & McGoldrick, 2005), framework for Level 3 and 4 sequences • Six transitions • Single, young adult leaves home • Individuals marry/couple and build a life together • Starting a family with young children • Adolescence • Launching • Later years

  46. Family assessment (Bitter, 2009) • Multicultural lens • Multicultural and gender lenses crucial • Access, influence, responsibility, decisionmaking • Dominant cultures arise • Reinforcing themselves • Minimising power and influence of other positions • Challenging supremacy/dominance • Membership, level of economic privilege/poverty, level of education; ethnicity; religion; gender; sexual orientation; age; health and ability; race; minority status; regional.

  47. Family Assessment (Bitter, 2009) • Gender lens • Patriarchy and feminism • Is marriage good for women? • Feminism: challenge the unequal status of women • Gender organisation: aware, polarised, transitional, balanced

  48. Family assessment (Bitter, 2009) • Process lens • Communication and metacommunication • Patterned communications in dysfunctional families • Process of change • Where is the family in the process of change? • How is therapy time being utilised?

  49. Formal family assessment • Sperry (2004) • 1. Interview the family • 2. Choose specific inventories • 3. Collect additional data • 4. Review assessment data and plan treatment • 5. Monitor clinical outcomes and modify treatment • 6. Evaluate outcomes

  50. Conceptualising a case • Diagnostic formulation (What happened?) • What brought family to treatment • How severe are the difficulties? • How are individuals coping? • Clinical formulation (Why did it happen?) • Eight lenses come into play • More diverse and wider than the family • Treatment formulation (What will be done?) • Goals for counseling • Length and duration