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NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES (INI)

DEPARTMENTAL COLLOQUIUM

SEMINAR ON
FAMILY THERAPY

CHAIR PERSON:

PRSENTER:

DR.PRASANTHI NATTALA

NEETHU ROSE JOHN

ASSOCIATE PROFESSOR

MSc NURSING 1ST YR

DEPT. OF NURSING

DEPT. OF NURSING

NIMHANS

NIMHANS

DATE: 19/4/16
VENUE:

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TIME:2-3pm
SL. NO
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INDEX
PAGE NUMBER
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3-4
4-5
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TABLE OF CONTENTS
Introduction
Historical development
Purposes
Indications
Contraindications
Characteristics of the
therapist
Functions of the therapist
Education to the family
Types of family therapy
Stages of family therapy

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Goals of family therapy

16-18

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Guidelines for the therapist 19-21

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Nurses role

21-22

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Conclusion

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14
15

References
Appendices

22-23
23-31

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11-13
13-15

1. INTRODUCTION1
The term family therapy was coined by the American Psychiatrist Nathan Ackerman in the 1950s. Family
therapy is a method drawn from one or more of a range of schools, and the intervention may involve "the
individual alone, the nuclear family or an extended family network; however the focus is more on relationships
between people rather than on individual alone.
It assumes that the family as a whole is larger than the sum of its parts. Family therapy is a form
of psychotherapy that involves all the members of a nuclear or extended family.
2. HISTORICAL DEVELOPMENT 2
Marriage and family therapy (MFT) had its origins in the 1950s, adding a systemic focus to
previous understandings of the family. Systems theory recognizes that

A whole system is more than the sum of its parts.

Parts of a system are interconnected.

Certain rules determine the functioning of a system.

Systems are dynamic, carefully balancing continuity against change.

Promoting or guarding against system entropy (i.e., disorder or chaos) is a powerful


dynamic in the family system balancing change of the family roles and rules.

The strategic school of family therapy introduced two of the most powerful insights in all of
family therapy: that family members often perpetuate problems by their own actions; and that
directives tailored to the needs of a particular family can sometimes bring about sudden and
decisive change .
One major model that emerged during the 1970s was cognitivebehavioral family and couples
therapy. It grew out of the early work in behavioral marital therapy and parenting training, and
incorporated concepts developed by Aaron Beck. Beck reasoned that people react according to
the ways they think and feel, so changing maladaptive thoughts, attitudes, and beliefs would
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eliminate dysfunctional patterns and the triggers that set them in motion (Beck 1976). This union
of cognitive and behavioral therapies in a family setting was new and useful. The therapist
considers not only how peoples thoughts, feelings, and emotions influence their behavior, but
also the impact they have on spouses and other family members. Cognitivebehavioral family
therapy and behavioral couples therapy are two models that have strong empirical support.
In the early part of the 21st century, MFT seems poised to undergo another change, focused on
empirically demonstrating the effectiveness of different approaches to therapy. The few models
that have been tested empirically have shown promising results. Among the models known to
have reduced marital distress and psychological problems are emotionally focused couples
therapy, cognitivebehavioral couples therapy, behavioral couples therapy, integrative couples
therapy, and systemic couples therapy.

3. PURPOSES OF FAMILY THERAPY1

Improve self-awareness and enhance self-worth and


confidence

Develop meaningful short-term and long-term life goals

Improve emotional regulation, coping, and problem-solving


skills

ADOLESCENT

Improve communication skills

Promote success in school/work

Promote pro-social peer relations and activities

Reduce substance use, delinquency, and problem behaviors

Improve and stabilize mental health problems


Strengthen parental teamwork

PARENT

Improve parenting skills & practices

DOMAIN

Rebuild parent-teen emotional bonds

Enhance parents' individual functioning

DOMAIN

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FAMILY

Improve family communication and problem-solving skills

Strengthen emotional attachments and feelings of love and

DOMAIN

connection among family members

Improve everyday functioning of the family unit

Improve family members' relationships with social systems

COMMUNITY
DOMAIN

such as school, court, legal, workplace, and neighborhood

Build family member capacity to access and actualize


needed resources

4. INDICATIONS

When problems exist across generational boundaries: Grandparents feeling excluded from
access to grandchildren; conflicts between a father and a son or a daughter working together

in a family business; sharing the living space with more than one generation in the family.
At significant transition times in the family life cycle: Leaving home; the birth of a child;

contemplating a geographical move; death in the extended family.


Whenever a child or adolescent is symptomatic and designated as the problem: An
adolescent acting out with drugs, alcohol, and promiscuity; cutting; children who refuse to

attend school and/or have psychosomatic symptoms.


When a couple or family calls or comes in requesting a family therapy format.
When serious medical or psychiatric illness is present in a family member: Cancer,

schizophrenia, bipolar disorder.


Families stressed due to cultural or religious heritage differences: Interfaith and interracial

partnerships.
Issues that stem from recombined or blended families: Friction between step-parent and
biological child; problems with role definition as parents; children who feel in a loyalty bind

between divorced parents.


Families in which someone intrudes or sabotages another member's individual
psychotherapy: Intrusive parents threatened by the independence of the adolescent or young
adult in individual therapy; parental abuse of power by refusing to pay for treatment.

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Families or couples in which societal pressure and prejudice have significant emotional
spillover into family life: Homosexual parents with children; older couples contemplating the

adoption of a child; common-law partnerships.


When sibling issues are beyond the control of the parent(s): Physical assault on a younger
sibling; bullying behavior; excessive competition for parental attention and affection.

5. CONTRAINDICATIONS

When a family has an emotionally unstable member or members and the risk of stimulating
intense affect in session might lead to decompensation or other adverse effects:
Schizophrenia, major depression, impulse control disorders, addictions, and dementia.

When there is a history of violence in the family: Elder abuse; domestic violence; drug and
alcohol dependence.

When a family is collusive, rigidly unified, and inflexible in considering that there may be a
problem in the family/couple.

When therapy runs counter to the belief system in the family: Sense of shame; religious or
cultural beliefs that discourage therapy.

When essential members of the family cannot or refuse to be included in the sessions: The
father feels that real men handle problems on their own; a family member offers work
schedule as a reason for being unable to participate.

When family therapy should not be the first-line treatment: The detoxification of addicted
family members should precede a decision for family/couple therapy; a family member with
psychosis who is not adequately medicated.

6. CHARACTERISTICS OF THE FAMILY THERAPIST14,15,19


6.1 Education:

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The therapist needs to have a masters degree in family therapy or they have to undergo a short
term course in counseling and family therapy. In India the courses available are Masters of
Science in Counseling and Family Therapy (MSCCFT) offered by IGNOU, a two year training
program and various short term courses of three and six months duration. In NIMHANS, a
three months training program is given to the psychology students during their training.

6.2 Self awareness:

The therapist who works with families needs to understand her own family system and her
role in that system. This gives the therapist an understanding of how her family background
has both hindered and facilitated her own goals. This understanding aids the therapist in her

development as an effective person, family member and professional.


For the beginning family therapist, the goal of working with and seeing the family as a
system rather than as individuals who live together needs to be a constant focus. The
therapist needs to be aware of her biases and prejudices and the special issues that affect her
daily life. Otherwise the therapists process can be blocked; family members must be
accepted for themselves. Knowing the developmental stages of a family and being alert to
the therapists own strengths and weaknesses can prove to be invaluable. Having this self
awareness allows the family therapist to join with the family and become a part of the
system yet maintain a sense of separateness and objectivity. With this sense of self, the
structure and dynamics of the family system can be accurately assessed within a
generational and multigenerational perspective.

6.3 Verbal and non verbal behavior

Clients of effective therapists feel understood, trust the therapist, and believe the therapist
can help him or her. The therapist creates these conditions in the first moments of the
interaction through verbal and importantly non-verbal behavior. In the initial contacts,
clients are very sensitive to cues of acceptance, understanding, and expertise. Although

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these conditions are necessary throughout therapy, they are most critical in the initial
interaction to ensure engagement in the therapeutic process.
6.4 Working alliance

Effective therapists are able to form a working alliance with a broad range of clients. The
working alliance involves the therapeutic bond, but also importantly agreement about the
task of goals of therapy. The working alliance is described as collaborative, purposeful
work on the part of the client and the therapist. The effective therapist builds on the clients
initial trust and belief to form this alliance and the alliance becomes solidly established
early in therapy.

6.5 Acceptance

Effective therapists provide an acceptable and adaptive explanation for the clients distress.
There are several considerations involved in providing the explanation. First, the
explanation must be consistent with the healing practice: in medicine, the explanation is
biological whereas in psychotherapy the explanation is psychological. Second, the
explanation must be acceptable and accepted by the client, a process that involves
compatibility with clients attitudes, values, culture, and worldview. That is, treatments are
adapted for patients. Third, the explanation must be adaptive that is, the explanation
provides a means by which the client can overcome his or her difficulties. This induces
positive expectations that the client can master what is needed to resolve difficulties.
Fourth, the scientific truth of the explanation is unimportant relative to its acceptance by the
client. The therapist is aware of the context of the patient (e.g., issues of culture, socio
economic status, race, ethnicity) in the development and presentation of the explanation.
Acceptance of the explanation leads to purposeful collaborative work.

6.6 Influential, persuasive, and convincing.

The therapist presents the explanation and the treatment plan in a way that convinces the
client that the explanation is correct and that compliance with the treatment will benefit the
patient. This process leads to client hopefulness, increased expectancy for mastery, and

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enactment of healthy actions. These characteristics are essential for forming a strong
working alliance.
6.7 Uses difficulties therapeutically

The effective therapist does not avoid difficult material in therapy and uses such difficulties
therapeutically. It is not unusual that the client will avoid material that is difficult. The
effective therapist can infer when such avoidance is taking place and does not collude to
avoid the material; rather the therapist will facilitate a discussion of the difficult material
and in therapy will address core client problems. Such discussions are typically emotional
and thus effective therapists are comfortable with interactions with strong affect. When the
difficult material involves the relationship between the therapist and the client, the effective
therapist addresses the interpersonal process in a therapeutic way.

6.8 Hope and optimism

The effective therapist communicates hope and optimism. This communication is relatively
easy for motivated clients who are making adequate therapeutic progress. However, those
with severe and/or chronic problems typically experience relapses, lack of consistent
progress, or other difficulties. The effective therapist acknowledges these issues but
continues to communicate hope that the client will achieve realistic goals in the long run.
Effective therapists mobilize client strengths and resources to facilitate the clients ability to
solve his or her own problems. Moreover, the effective therapist creates client attributions
that it is the client, through his or her work, who is responsible for therapeutic progress,
creating a sense of mastery.

6.9 Aware of clients characteristics

Effective therapists are aware of the clients characteristics and context. Characteristics of
the client refer to the culture, race, ethnicity, spirituality, sexual orientation, age, physical
health, motivation for change, and so forth. The context involves available resources (e.g.
socio economic status), family and support networks, vocational status, cultural milieu, and
concurrent services (e.g., psychiatric, case management, etc.). The therapist works to
coordinate care of the client with other psychological, psychiatric, physical, or social

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services. Furthermore, the effective therapist is aware of how his or her own background,
personality, and status interacts with those of the patient, in terms of the clients reaction to
the therapist, the therapist reaction to the client, and to their interaction.
7. FUNCTIONS OF THE FAMILY THERPIST 1,16,17
(i)
(ii)

Establishes a rapport, empathy and communication among family members.


Evolves the major conflicts and ways of coping and clarifies by dissolving barriers,
confusions and misunderstandings. Helps to bring more mutual and accurate

(iii)

understanding.
Extends emotional support. Plays a role of a true parent-figure-a controller of

(iv)
(v)

danger.
Serves as a personal instrument of reality testing for the family.
Serves as an educator and a personifier of useful models of family health.

8. EDUCATION TO THE FAMILY


i)

Families need to understand that hospitals are not the proper places for long-term

ii)

treatment. The crisis care that hospitals provide is not recovery oriented.
Rehabilitation and effective treatment are more likely to occur in community settings,

iii)

under normalized condition.


The current developments of enhanced supports for community living are allowing the

iv)

patient to live more normal lives and experience full rehabilitation.


Education will help families understand how to resolve their conflicts over accepting a

v)
vi)

more detached role.


Dependency cripples the functioning of both families and consumers.
Help the patient relearn how to live again. Recovery from mental illness involves the re-

vii)

learning of many skills and is essentially development of a new life.


A regressed patient has great difficulty in relating to other people and in meeting adult

viii)

needs for safety, security, and continuity in living.


Families need to learn that relapse and regression are normal parts of the recovery and

ix)

not evidence of failure.


Families need to learn to accept risks and changes. Risks may lead temporarily to

x)

relapse and re hospitalization, but a static environment is deadly to recovery.


Sickness is static. Recovery is change. Families need to accept the lifelong challenges
of impairment and change.

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xi)

Family education focus on a change in perspective. Person with mental illness needs to
be seen with new eyes. Instead of dysfunction, incompetency, and disease, one needs to

xii)

see a person who can function, competent and have ability and potential.
The families need to make the patient experience that families are their support system,
lifelines in the years of struggles, hardship and pain.

9. TYPES OF FAMILY THERAPY3,4,5


9.1 Psychodynamic Family Therapy (Freud Erik Erikson Nathan Ackerman: 1870s)
It helps family members to solve relational problems by understanding better how emotional process
influence the perception, feelings and actions of those involved. This therapy concentrate on
motivations, conflicts, defenses and the relationships from the past that are currently influence the
present. Therapeutic change is sought through family members gaining conscious insight into previously
unconscious process that have been generating problem in family relationships.
9.2 Structural Family Therapy (Salvador Minchin: 1974)
It considers problems involving two particular family members linked to the organizational context of the entire
family.
In this, the therapist observes closely the flow of family structure as family members talk about and interact
together around the presenting problem of the therapy He observes how boundaries, hierarchy, alliances and
coalitions are associated with the presenting symptoms, as well as repetitive behavioral sequences that involves
symptomatic behaviour.
Therapist ameliorates symptoms by shifting family structure. Boundaries can be strengthened or weakened by
behavioral assignment that educate a particular family member from certain moments of family life or include a
particular family member where that person had been absent.
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9.3 Strategic Family Therapy (Jay Haley, Mitton Erickson:1976)


It is built upon the premise that a therapist is responsible for planning a strategy that solves successfully the
family's presenting problem. The therapist sets clear goals that intervene by changing relational and
communicational process in family.
Therapist commonly view clinical problems as emerging out of difficult lifestyle transitions both
predictable ones e.g. marriage, childbirth, separating individuating of an adolescent and
unpredictable ones. E.g. loss of job, sudden illness, a death in the family.
The central aim of therapist is to motivate family members to try novel solutions, rather than,
repeating what has been tried in the past. Psycho education, direct behavioral directives such as reframing the symptoms, prescribing the symptoms, restraining the system, positions.
9.4 Cognitive Behavior Family Therapy (Norman Epstein and Donald Baucom:2002)
It applies principles of learning theory to help family members solve problems by modifying
cognitive distortions and repetitive problem inducing interactions and by learning new knowledge
and skills. Cognitive behavior family therapy relies heavily upon family psycho education and
teaching a coaching stance of the therapist.
It is based on the influence family members hold by offering positive and negative reinforcement to
other family members. Parents and spouses are trained to eliminate reinforcement contingencies I'm'
undesirable behaviors. Cognitive interventions engage family members as co investigators who
study the ecology of family problems and symptoms and discern new thoughts, feelings and
behaviors interplay. A therapist assists family members in identifying when such cognitive
distortions as catastrophic thinking, over generalization or misattribution lead to conflict in
relationships. The therapy

involves psycho education, communication training, and problem

solving training, operant conditioning strategies, contingency contracting, thought diaries.


9.5 Post Modern Family Therapies (Anderson:1997)
These are group of therapies which include narrative, solution focused, collaborative language systems and
feminist family therapies. Innovation introduced by post modern therapies have opened new ways for families
to solve problems by valuing and learning from their own experiences, histories, traditions, values and
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identities, instead of seeking answers from mental health experts. The post modern therapies have sought to
empower families by helping them develop reflective processes for exercising choice to build supportive
communities with other families, and to clarify undesirable ways in which cultural influences have limited
appreciation and utilization of the family's own practical wisdom.
9.6 Narrative Family Therapy (Michael White and David Epston: 1970s)
In a narrative approach, the therapist aims to adopt a collaborative therapeutic posture
rather than imposing ideas on people by giving them advice. The therapist seeks to help
the person co-author a new narrative about themselves by investigating the history of
those qualities. Both the therapist and the people who consult them are seen as having
valuable information both in terms of the process of therapeutic conversation and in
terms of the content of these conversations. When people develop solutions to their own
problems on the basis of their own values, they become much more committed to
implementing these solutions.
10 STAGES OF FAMILY THERAPY20
Engagement
The goals of this phase involve enhancing family members' perceptions of therapist
responsiveness and credibility. Therapists work hard to demonstrate a sincere desire to listen,
help, respect and "match" to family members in a way that is sensitive and respectful of
individual, family and cultural beliefs, perspectives and values. The therapist's focus is on
immediate responsiveness to family needs and maintaining a strength-based relational focus.
Activities include high availability, telephone outreach, appropriate language and dress, contact
with as many family members as possible, "matching" and a respectful attitude.
Motivation
The goals of this phase include creating a positive motivational context by decreasing family
hostility, conflict and blame, increasing hope and building balanced alliances with family
members. Therapists work to change the meaning of family relationships by emphasizing
possible hopeful alternatives, maintaining a nonjudgmental approach and conveying acceptance
and sensitivity to diversity. The therapist's focus is on the relationship process, separating blame
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from responsibility while remaining strength-based. Activities include the interruption of highly
negative interaction patterns, changing meaning through a strength-based relational focus,
pointing process, sequencing and reframing of the themes by validating negative impact of
behavior while introducing possible benign/ noble (but misguided) motives for behavior. The
introduction of themes and sequences that imply a positive future are important activities of this
phase.

Relational Assessment
The goal of this phase is to identify the patterns of interaction within the family to understand the
relational "functions" or interpersonal payoffs for individual family members' behaviors. The
therapist focuses on eliciting and analyzing information pertaining to relational processes, and
assess each dyad in the family using perception and understanding of relational processes. The
focus is directed to intra family and extra family context and capacities (e.g., values, attributions,
functions, interaction patterns, sources of resistance, resources and limitations). Therapist
activities involve observation, questioning, inferences regarding the functions of negative
behaviors, and switching from an individual problem focus to a relational perspective. This sets
the stage for planning in Behavior change and Generalization, where all interventions are
matched to the families' relational functions.
Behavior Change
The goal of this phase is to reduce or eliminate referral problems by improving family
functioning and individual skill development. Behavior Change often includes formal behavior
change strategies that specifically address relevant family processes, individual skills or clinical
domains (such as depression, truancy, substance use). Skills such as structuring, teaching,
organizing and understanding behavioral assessment are required. Therapists focus on
communication training, using technical aids, assigning tasks, and training in conflict resolution.
Techniques and strategies often include evidence-based cognitive-behavioral strategies for
addressing family functioning and referral problems. Phase activities are focused on modeling
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and prompting positive behavior, providing directives and information, developing creative
programs to change behavior, all while remaining sensitive to family member abilities and
interpersonal needs.
Generalization Phase
The primary goals in this phase are to extend the improvements made during Behavior Change
into multiple areas and to plan for future challenges. This often involves extending positive
family functioning into new situations or systems, planning for relapse prevention, and
incorporating community systems into the treatment process (such as teachers, Probation
Officers). Skills include a multisystemic/systems understanding and the ability to establish links,
maintain energy, and provide outreach into community systems. The primary focus is on
relationships between family members and multiple community systems. Generalization
activities involve knowing the community, developing and maintain contacts, initiating clinical
linkages, creating relapse prevention plans, and helping the family develop independence.
11. GOALS OF FAMILY THERAPY6,7,8
11.1 FOR INITIAL SESSIONS
The first family consultation occurs soon after the patient's illness is identified and treatment
has begun. The mail goals during this phase include:
11.1.1 Outline Therapy Boundaries & Structure
During the initial stages of therapy it is important for the therapist to set the boundaries of
therapy by sharing only needed information with the family / professional system which informs
them about the process of therapy, and orientates them to the first meeting.
11.1.2 Engage and Involve all family members
Supportive environment:
Initially it is very important for the therapist to provide a warm, supportive and empathic
environment, to increase trust and rapport and to build the therapeutic relationship. The therapist
must work to help the family feel understood, accepted, comfortable and less anxious. This may

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include making the room comfortable and safe for younger children, and making it clear they are
free to play/draw during the session.
Hear from everyone:
Therapists should try to hear from all members of the system/family, initially connecting with
them all at an individual level, and assessing the level of contribution they feel they are able to
make to the discussion, from either verbal or non-verbal cues. The therapist should try to make
sure that everyone in the system is able to contribute to the discussion if they wish.
Neutrality:
The therapist is trying not only to hear everyones views but also to establish their interest in
different perspectives that may be held within the system. At this point unless serious concerns
arise regarding safety/confidentiality the therapist should remain neutral to the difficulties and
issues that the family is presenting and their views about them.
11.1.3 Gather and Clarify Information
Information should be gathered by the therapist to orientate them to the system and enable them
to hear more about the issues the family is bringing to therapy. Information should be obtained
on the following topics: the context, the system and presenting difficulties.
11.1.4 Establish Goals and Objectives of Therapy
The establishment of goals should be achieved in a way which expresses the Possibility of
Change, and should convey the expectation that change is possible, and likely to occur, that the
therapy team may be able to work with the family towards this. This intention is to build the
familys confidence in their ability to make changes.
11.2 FOR MIDDLE SESSIONS
11.2.1 Develop engagement
The therapist should pay particular attention to developing a therapeutic relationship. In addition
to attending to the three aspects of engagement from the initial meeting (supportive
environment/hearing from everyone/neutrality), attention should be paid to:

Creating and offering choices about the process of therapy

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Resolving issues in the family-therapist-team system as they arise. This will require therapists
to allow sufficient time for team discussions pre and post and time within sessions to discuss the
process of therapysessions ( with families and any concerns or questions they have in relation
to this.
11.2.2 Gather Information & Focus Discussion
Information is still gathered by the therapist, but more emphasis should be paid to discussion, so
that issues and areas for discussion from the initial broad discussions may be looked in a greater
detail or from different perspectives. The therapist plays a role in developing this discussion to
develop themes and keep the discussion focused.
11.2.3 Identify & Explore Beliefs
The therapist should identify and explore the familys thoughts, beliefs, myths or attitudes, which
may be contributing to their dilemmas and difficulties. The therapist should begin to develop a
picture of the ideas and beliefs that influence behaviour, as they are gathering a description of the
difficulties with which the family are struggling.
11.2.4 Work towards change at the level of beliefs and behaviors
Challenge existing patterns and assumptions:
To move with the family to a position where they are able to query their own beliefs, perceptions
and feelings. The therapist should actively query the familys existing beliefs, assumptions or
behaviors.
Provide distance between the family and the problem:
Providing distance to try and free the family from the pressure of the difficulties, so that they are
more able to consider and reflect upon them.
Externalize
One specific way of providing distance between the family and the difficulties, which is
particularly useful if the difficulties are seen to reside within one family member is to externalize
the problem. That is to give the problem an external, objective reality outside of the person. This
can be useful in mobilizing the familys resources to unite in working towards solutions and new
ways of thinking which challenge the difficulties.
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Elicit Solutions:
It will be helpful to gather information from the family about solutions for the difficulties that
they have tried or would consider useful.
11.3 FOR END SESSIONS
11.3.1 Develop family understanding about behaviors and beliefs
As therapy ends it will be important for the therapist to work with the family to develop and
encourage their understanding of the process of the development of difficulties. This may be
helpful in equipping the family with the ability to recognize the development of such processes
in the future. Particular attention should be paid to:

Underlying family interactional patterns.

Motivations for assumptions, behaviors and feelings.


Understanding of a family members reactions to others behaviors.
11.3.2 Collaborative ending decision
The timing of ending is not always obvious and in aiming to make the ending process a
collaborative process the therapist and therapy team should be alert to a number of signals in
sessions which may indicate that therapy may soon draw to a close. These include:
Positive feedback from the family:
The family situation or the issues they presented are reported as improved or improving. The
family report having made changes in other areas of their lives.
Therapist notices changes:
Missed sessions by the family and changes in the level of engagement in therapy. Therapist
notices positive changes in the way the family are interacting during sessions, for example they
are beginning to use new narratives, or are beginning to comment in a different way on their
relationships and the issues with which they are struggling.
11.3.3 Review the process of therapy

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It will be helpful for the therapist to invite the family to review the process of therapy. This may
be useful for the team and family in relation to prevention of future difficulties, and to empower
the family in any future contact with therapeutic services
12. GUIDELINE FOR THE THERAPIST11,12,13
12.1 Address the families concern to work together with family therapists:
This demonstrates that he/she is sensitive to possible difference and is willing to discuss their
views on topic.
12.2 Orient family to the therapy process through role induction:
Nalitzer, Dermen and Connors (1999) note that role inductions have been found to be useful in
improving therapy outcomes and session dependence particularly for clients with low income
and education. Other advantages of role induction include more relevant comments and more
active participation by clients (Friedander and Kaul, 1983).

12.3 Do not assume familiarity with clients in the first session:


Therapist should ask family members how they would be like to be addressed and not call
clients by their first names, as this can be disrespectful. It is important not to assume familiarity

prematurely, especially with older family members because the misuse of given

names and disregard for paper titles such as Mr. and Ms.
12.4 Join with the family before gathering sensitive information:
Families that come in for therapy are sometimes weighed down by secrets and have difficult
time discussing sensitive topics such as paternity, absent family members and legal or
substance abuse problems. For this reason it is recommended that therapist work to join with
the family while being considerate of their need for privacy. Boyd- Franklin(1989 )observed
that the family secrets that are silent to treatment will be revealed over time as the therapist and
family continue to work together to find solution to family problems.
12.5 Maintain a broad definition of family when assessing family structure and role:

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In gathering information about who lives in the home and who fulfills family roles, it is
important to assess for the involvement of extended family and non blood kin. Presence of
these ties to the extended family has been shown to be related to better psychological
functioning in men and women.
12.6 Assess and intervene multi systematically:
When addressing the needs of family system, therapists are encouraged to view the family in
relation to their school, church, neighborhood and or community. This multi systemic or eco
structural perspective allows for more contextually sensitive assessment of the familys
situation and how that is related to societal problems. In addition, it allows therapist the chance
to join with the family around real life problems such as housing, food, clothing, financial help
and medical care.
12.7 Report to family members who are unable or unwilling to attend:
Consistent with the multi systemic emphasis, therapist should be prepared to use phone calls or
letters to contact family members that are unable or unwilling to attend as their non- attendance
can be representative of their true status or power in the family. Decision regarding contact with
absent family members should be made by those involved in treatment, with attention in
treatment, with attention to clients confidentiality.
12.8 Do home visits:
Home based therapy has been a central part of the treatment of families for some time. Home
visits can aid in the process and progress of therapy because they have an opportunity to meet
and engage family member that are hesitant to come to therapy; they to engage the family in
their environment; and they permit more clear assessment of the contextual factors that play a
role in the lives of the family. Before making home visit, therapist should explain the rationale
for the home therapy sessions. This can help address any concerns about the purpose of the visit
and clarify that it is not for the purpose of checking upon them "or evaluating household
management or financial need.
12.9 Use a Problem Solving Focus in Treatment:

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It is often advantageous to approach family therapy with a focus on problem resolution and/or
symptom alleviation. When families are able to address their biggest concern, and if they
experience an immediate benefit to therapy, they are more likely to trust the therapy process.
12.10 Use Scriptural Reference / Metaphors:
Religious writing and/or metaphors from Bible, Kuran or other resources can be used to join
with clients, foster family cohesion, challenge rigidity and punctuate important realization.
12.11 Be Creative and Flexible when Involving Male Family Member in Therapy:
Involvement of both parents has both effective and instrumental roles that are crucial to role
development, functioning and positive child well-being outcomes.

12.12 Acknowledge Strengths, Resources and Success:


It is often difficult for families to see their abilities and resources when they are overwhelmed
with a "problem or feeling ashamed for having it. These feelings of embarrassment can be
prevented from being able to appreciate their individual success and/ or their ethnic heritage of
strength and survival specifically. Therapists are encouraged to use cultural resources such as
strong kinship bonds, role flexibility, strong religious orientation, and strong education/ work
ethnic while working with families. E.g. therapy can draw on role flexibility in helping the
family to make role substitutions or adjustments when family members are unable to fulfill
their usual responsibilities due to prolonged illness.
13. NURSES ROLE IN FAMILY WORK:1,18
To co-ordinate treatment- everyone is working towards same goals in a collaborative
supportive way.
To pay attention to the social and clinical needs of patient and family.
To provide optimum medication management.
To listen to families and treat them as equal partners.

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To explore family expectations from the therapy and help them in having realistic
expectations.
To assess family's strengths, problems and goals.
To provide initial intensive education programme followed by continuing education

targeted at needs.
To provide explicit crisis plan and professional response.
To promote clear communication and active listening.
To provide training in structured problem solving technique.
To help resolve family conflict and sensitive response to emotions.
To help family come to terms with feelings of loss.
To encourage family to expand social support networks.
To be flexible in meeting the needs of the family.
To provide follow up contacts foe future access to support if work with family ceases.

12. CONCLUSION
Family therapy doesn't automatically solve family conflicts or make an unpleasant situation go
away. But it can help the family members understand one another better and it can provide them
with skills to cope with challenging situations in a more effective way. Family therapy sessions
can teach the skills to deepen family connections and get through stressful times, even after
ending the therapy sessions.
13. REFERENCES
1. Lalitha KL. Mental health and psychiatric nursing an Indian perspective. 2 nd edition.VMG
book house.2011;117-29
2. Townsend C Mary. Essentials of Psychiatric Mental Health Nursing. 4 th edition. Davis Plus
Publishers(p) ltd;2008
3. Ackerman NW: Treating the Troubled Family. New York: Basic Books; 1966.
4. Anderson CM, Reiss D, Hogarty B: Schizophrenia and the Family. New York: Guilford
Press; 1986.
5. Atkinson BJ: Emotional Intelligence in Couple Therapy: Advances from Neurobiology and
the Science of Intimate Relationships. New York: WW Norton; 2005.
6. Boszormenyi-Nagy I, Spark GM: Invisible Legalities: Reciprocity in Intergenerational
Family Therapy. New York: Harper & Row; 1973.
7. Bowen M: Family Therapy in Clinical Practice. Northvale, NJ: Jason Aronson; 1978.
8. De Shazer S: Keys to Solutions in Brief Therapy. New York: Norton; 1985.
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9. Fields L, Morrison TL, Beels CC: Couple and family therapy. In: Hales RE, Yusofsky SC.
The American Psychiatric Publishing Textbook of Psychiatry. 4th ed. Washington, DC:
American Psychiatric Publishing; 2003:1373.
10. Framo JL: Family-of-Origin Therapy: An Intergenerational Approach. New York:
Brunner/Mazel; 1992.
11. Glick ID, Berman EM, Clarkin JF, Rait DS. Marital and Family Therapy. 4th ed. Washington,
DC: American Psychiatric Press; 2000.
12. Gurman AS: Clinical Handbook of Couple Therapy. 4th edition. New York:

The Guilford

Press, 2008.
13. Gurman AS, Jacobson N. Clinical Handbook of Couple Therapy. 3rd ed. New York: Guilford
Press; 2003.
14. Sholevar GP, Schwoeri, LD, Textbook of Family and Couple Therapy: Clinical Applications.
Washington, DC: American Psychiatric Publishing; 2003:797.
15. Lebow JL.U.S. Bureau of Labor Statistics, American Association for Marriage and Family
Therapy, Occupational Information Network. New York: Wiley; 2002.
16. McCrady BS, Epstein EE: Couples Therapy for Alcohol Use Problems: A CognitiveBehavioral Treatment Workbook. New York: Oxford University Press, 2008.
17. McGoldrick M, Hardy KV: Re-Visioning Family Therapy and Nurses role: Race, Culture,
and Gender in Clinical Practice. 2nd edition. New York: The Guilford Press, 2008.
18. Nakonezny PA, Denton WH: Marital relationships: A social exchange theory perspective. Am
J Fam Therapy. 2008;36(5):402.
19. Nichols, MP, Schwartz, RC: Family Therapy: Concepts and Methods. 7th ed. Boston:
Pearson Education; 2006.
20. http://www.fftllc.com/about-fft-training/clinical-model.html

14. APPENDICES
14.1 APPENDIX- 1- LITRATURE REVIEW
1. Experiential Family Therapy
This review identified thirty-six refereed journal articles and books on experiential family
therapy, but only three of those make a direct reference to outcomes or effectiveness. This is
partly because the goals of experiential family therapy are often difficult to define, for example,
goals such as self-actualisation and expressing innermost thoughts. The nature of this approach is
not prescriptive and it is dependent on the needs of particular families and the expert decision-

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making of the therapist. Therefore, it is difficult to generalise about effectiveness independently


of the family or the therapist.
Byrne, Carr and Clark (2004) reviewed thirteen studies on short term behavioural couples
therapy (BCT) and seven studies on the longer-term emotionally-focused therapy (EFT), both
directed towards couples. They concluded that the outcomes for EFT were positive and in some
cases better than BCT, but cautioned that the results need replication.
2. Structural Family Therapy
Structural family therapy (SFT) was developed by Salvador Minuchin during the 1960s. SFT is
described as primarily a way of thinking about and operating in three related areas: (a) the
family, (b) the presenting problem, and (c) the process of change (Minuchin, Lee, & Simon,
1996).
Few studies within the prescribed date ranges exclusively using a SFT model were located. As
noted by McFarlane et al, (2003), elements of SFT can be found in other family therapy
modalities, particularly within psycho-educational family therapies. SFT concepts have been
built on and amalgamated into newer therapies. Family-Directed Structural Therapy (FDST)
utilises similar definitions of the family unit (McLendon, McLendon and Petr, 2005) and the
structural component of Brief Strategic Family Therapy (BSFT) draws on the work of Minuchin
(1974).
Despite an exhaustive search into recent research with SFT utilised as the primary modality, the
only research that has been undertaken in the last decade was case study research. Thus, given
the limitations with this methodology and inability to generalise the findings of these studies to
wider populations, no definitive statement will be given as to the effectiveness of SFT.
Carter (2011) provides an example of the type of case study research which has been undertaken
on SFT. He undertook single case study research with a young man and his family where the
primary diagnosis was schizophrenia. The family was randomly selected to participate in this
intervention and sixteen Personality Questionnaires were administered over the fifteen week
treatment. Carter reports significant change in the individual from pre-test to post-test. Sim
(2007) describes a case study involving an adolescent and their family in Hong Kong, where

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drug and alcohol use of the young person was identified as the primary issue. A Chinese SelfReport Inventory was administered pre- and post-treatment.

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The author tentatively concluded that there was improvement in both individual and family
functioning.
Going outside the scope of the specified timeframe, two key studies utilising SFT were located.
Szapocznik et al. (1988) undertook a randomised controlled study assigning families in which an
adolescent was suspected of, or observed, using drugs. Subjects were randomly assigned to a
strategic structural systems engagement (experimental) condition or to an engagement-as-usual
(control) condition. The two conditions were operationalised by establishing therapist behaviours
that were permitted within each treatment group. The outcome measures of this study were
difficult to ascertain and focused on establishing the level of rapport between the therapist and
client. The authors of this study noted that this cohort of young people was particularly difficult
to engage in treatment. Thus, one of their key findings was that subjects in the experimental
condition were engaged at a dramatically higher rate than subjects in the control condition. The
authors conceded that, although not intended, the study design was limited by the fact that one
therapist administered both the control and experimental intervention, making clear differences
in the modalities difficult to discern or attribute to the model of the individual therapist.
Szapocznik et al. (1989) undertook a further randomised control study, assigning participants to
one of three interventions: structural family therapy, psychodynamic child therapy, and a
recreational control condition. Participants included sixty-nine Hispanic boys (aged 6-12 years),
who presented with behavioural and emotional problems. Five outcome measures were utilised
in this study, administered pre- and post-intervention and at a one year follow up. The control
condition was found to be significantly less effective in retaining cases than the two treatment
conditions. Interestingly, the most significant finding in this study that supported the position and
intervention of family therapists was the dramatic effect on the family functioning measure with
the Family Therapy condition improving, the Child Therapy condition deteriorating, and the
Control group remaining the same.
SFT has attracted numerous criticisms in recent years, of which much stems from the use of
confrontation and the impact this has on the therapeutic alliance (Hammond & Nichols 2008).

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The Maudsley model of family therapy is an eclectic model of intervention specifically designed
for the treatment of children and adolescents with anorexia nervosa. Although this model notes
strong influences from both narrative and strategic family therapy it embraced the work of
Minuchins structural work with anorexia (Rhodes, 2003) which is evident in its three clear
phases of intervention. The primary focus of the intervention is to empower the family to take
control of the re-feeding aspect of intervention over a 6 to 12 month time period (The National
Eating Disorders Callaboration, 2010). Developed at the Maudsley Hospital in London, the
Maudsely model of family therapy has received empirical support internationally.
Robin et al (1995) conducted a randomised control study comparing the impact of a family
systems therapy (FST) (with similar underpinnings to the Maudsely model) to individual therapy
(IT) amongst 22 adolescents diagnosed with anorexia nervosa. Each group received an average
15 months therapy with a 12-month follow-up period. Both groups improved significantly over
time on body mass index. At post-treatment, 64% in the FST and 64% of IT had achieved target
weight. At 12-month follow-up, 82% of the FST and 50% of the IT were at or above target
weight.
Authors reported that other measured outcomes, such as measures of family functioning,
generally favoured those treated with behavioural family systems therapy.
The support for the model was not as influential when comparing it to another family therapy.
Eisler et al., (2007) conducted a randomised control study with a 5 year follow-up period.
Families were allocated to either conjoint family therapy or separated family therapy (an early
variation of the Maudsley model). The authors found that 72.2% of patients in CFT group and
80% of patients in SFT had good outcome further concluding that there were no differences in
the long-term outcome between the two treatment groups, though noting the efficacy of family
therapy with regard to treating anorexia nervosa.
3. Cognitive Behaviour Therapy (CBT)
Today, cognitive-behavioural therapy (CBT) has become a conventional part of psychotherapy
and aims to alter an individuals thoughts and actions by modifying their conscious thought
patterns (Goldenberg & Goldenberg, 2008). The distinct influence of this approach has been its
determination to employ a rigorous, scientific set of methods that is regularly and consistently
scrutinised (Goldenberg & Goldenberg, 2008).

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Behavioural Couple Therapy (BCT)


Two very recent systematic reviews that examine behavioural-couple therapy (BCT) have been
published in the USA. The most recent of these examines BCT outcomes as part of a larger
review of controlled studies of marital and family therapy (MFT) treatment outcomes for
alcoholism (see OFarrell & Clements, 2011). The review includes mostly randomised studies
and some quasi-experimental studies, published between 2002 and mid-2010, which compare
MFT to one or more comparison situations (OFarrell & Clements, 2011). Results of the study
were reported at two main stages of change: (a) when a person dependent on alcohol is unwilling
to seek help, and (b) when such person has sought help. No specific outcomes of BCT were
noted at the first stage of change, but the authors conclude that in the second stage, MFT and
BCT are more effective than individual treatment for increasing abstinence and improving
relationship function (OFarrell & Clements, 2011). BCT also appeared efficacious with women,
gay and lesbian alcoholics and showed promise in treating male alcoholic veterans with
comorbid combat-related post-traumatic stress disorder (PTSD) (OFarrell & Clements, 2011).
The second systematic review examined outcomes of a specific program of BCT developed by
Fals-Stewart, OFarrell and colleagues (see Ruff et al. 2010). Twenty-three studies, published in
peer-reviewed journals that examined this version of BCT, were included in the review. The
authors made the general finding that couple-based treatment for substance abuse was
consistently more efficacious that individual treatment (Ruff et al. 2010). The authors concluded
that the literature demonstrated BCT was linked to positive outcomes for children and reduced
intimate partner violence (IPV) (Ruff et al., 2010).
Integrative Behavioural Couple Therapy (IBCT)
In an American study that compared how traditional behavioural couple therapy (TBCT) and
integrative behavioural couple therapy (IBCT) affected relationship satisfaction during and after
therapy, Christensen et al. ( 2010) followed up one-hundred and thirty-four distressed married
couples for five years after they participated in a clinical trial. In the original trial, couples had
been randomly assigned to approximately eight months of either TBCT or IBCT (Christensen et
al. 2004). Treatment outcomes were based on participant self-reports every three months during
the treatment and for five years after treatment (Christensen et al. 2010). The study concluded
that TBCT and IBCT were both effective, but that IBCT produced marginally, but significantly,
improved outcomes for the first two years following treatment termination (Christensen et al.)
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Cognitive Behavioural Therapy (CBT) and Multi-Dimensional Family Therapy (MDFT)


A recent American study involved secondary analysis of two randomised control trials using
growth mixture modelling (GMM) to examine diversity in treatment response (Henderson et al.,
2010). Of these studies, one is of particular interest to this review, as it compared the
effectiveness of individually delivered CBT with multi-dimensional family therapy (MDFT) for
treating adolescent substance abuse and delinquency (Henderson et al., 2010). The study
involved two-hundred and twenty-four primarily male African-American adolescents (aged 12 to
17.5 years), with substance abuse issues not requiring detoxification. Young people were
excluded from the study if they were actively suicidal. Participants were randomly assigned to
either CBT or MDFT. Treatment outcomes were assessed using baseline, post-treatment and
follow-up assessments at six and twelve months after terminating treatment. The secondary
analysis of this study concluded that individually delivered CBT produced inferior treatment
outcomes for young people with more severe substance abuse and greater psychiatric
comorbidity than MDFT (Henderson et al., 2010).
It is perhaps worth noting that in addition to this study, there is a large and growing body of
literature related to the effectiveness of interventions or what works to reduce recidivism and
delinquency in children, adolescents and adults that demonstrates the efficacy of CBT
approaches in this regard (see Dowden & Andrews, 2003; McGuire, Kinderman & Hughes,
2002; Sallybanks, 2002; Sexton & Alexander, 2002).
4. Multi-Systemic Therapy (MST)
Multi-Systemic Therapy (MST) is sometimes described as a form of family therapy, however
there are key differences from traditional models of intervention. MST is a home-based model of
service delivery, which aims to overcome barriers that families and young people may face to
services access, with the purpose of increasing the chances that families will adhere to the
treatment. It is a holistic intervention, addressing several key systems in which the individual and
family are involved, including educational/ vocational systems, peer and wider social groups,
and neighbourhoods. In consultation with each family member, the therapist identifies welldefined treatment goals, assigns the tasks required to accomplish these goals, and monitors the
progress in regular family sessions at least once a

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week. The goals of the treatment are family-driven, rather than therapist-driven, and the
treatment is highly individualised.
The goal of MST is to provide an integrative, cost-effective, family-based treatment that results
in positive outcomes for adolescents who demonstrate serious antisocial behaviour (PerkinsDock, 2001). MST focuses on altering the young persons natural settings in the home, school
and locality in order to support positive conduct and behaviours (Henggeler et al., 1997). MST is
usually provided for three to five months and therapists carry caseloads of four to six families.
Therapists are seen as experts, and are available round-the-clock to respond to families and crises
(Henggeler et al., 1998). MST draws on a number of family therapy modalities included in this
review, such as strategic family therapy, structural family therapy, behavioural parent training
and cognitive therapies.
MST has a strong research tradition with research assessing its effectiveness being undertaken
since its inception in the 1990s. Research pertaining to the effectiveness of MST has
predominately been undertaken with offending adolescents. The results of these outcome studies
clearly support the efficacy of MST in treating relatively serious, psychosocial difficulties with
juvenile offenders and their multi-problem families. MST has demonstrated decreased criminal
activity and incarceration in studies with violent and chronic juvenile offenders (Rowland et al.,
2005; Timmons-Mitchell et al., 2006; Ogden & Halliday-Boykins, 2004; Perkins-Dock, 2001).
Painter (2009) evaluated a pilot project designed to use MST with youth who were seriously and
emotionally disturbed, who had no history of juvenile justice involvement. The author compared
MST services with intensive case management and parent skills training. Preliminary results
indicated that youth involved in MST improved to a statistically significant degree with lessened
symptoms and improved functioning.
Henggeler et al. (2003) undertook another study that moved beyond the scope of offending
adolescents and their families, and examined the efficacy of treating adolescents with a serious
emotional disturbance and their families with MST. According to several outcome measures,
including placement and youth-report outcomes measures, MST was initially more effective than
emergency hospitalisation and usual services at decreasing adolescents symptoms and out-ofhome placements and increasing school attendance and family structure. These differences,
however, were generally not maintained at one-year follow-up.

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5. Family Problem Solving


Family problem solving has its origins in models of problem solving, which have been used by
workers in the human services for many years. This model has been utilised by social workers,
psychologists, family support workers and family therapists working with clients in a wide array
of settings including child welfare, youth justice, mental health, drug treatment, school welfare,
community and hospitals. Typically, the family problem solving model is an eight-step approach,
specifically designed for client/s to understand the nature and purpose of the intervention and the
roles of the worker and each family member. Briefly, the model encompasses role clarification,
problem survey, problem ranking, problem exploration, setting goals, developing a contract,
developing tasks/strategies and an on-going review process (Trotter, 2010).
There has been some research on the effectiveness of this approach with families. Wade et al
(2006) undertook a study with families where a young person (aged 5 to 16 years) was
recovering from traumatic brain injury. Sixteen families were given family problem solving and
sixteen control group families received no treatment. The experimental group were offered seven
bi-weekly core sessions with family members followed by four individualised sessions using the
problem solving model. They used the acronym ABCDE to describe the steps in the model Aim, Brainstorm, Choose, Do it, Evaluate. Sessions focused on general goals as well as goals
relating directly to the brain injury, based on the evidence that brain injury impacts on multiple
issues for family members. This study found positive results for the use of family problem
solving with families with a young person (aged 5 to 16 years) recovering from brain injury. The
young people in the treated families subsequently showed significant reductions in levels of
behaviour problems, depression and anxiety.
Ahmadi et al (2010) undertook research in Tehran using a family problem model with married
couples studying the effects of family problem-solving on decreasing the couples dissatisfaction.
Four hundred and fifty couples were recruited and participated in the study,

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and were randomly assigned to the experimental or control group. Ahmadi (2010) found
increased levels of marital satisfaction following around fifteen sessions of family problem
solving with maladjusted couples, compared to a matched control group with no treatment. The
model included several steps: an introduction to the model, prioritizing issues and increasing
optimism, creating solutions evaluating solutions, solving problems and evaluation.
A meta-analysis of thirteen randomised studies of the use of problem solving therapy (PST) for
depression concluded that there is no doubt that PST can be an effective treatment for
depression, although they also suggest that more research is needed to determine when and in
what circumstances it is most effective (Cuijpers, van Straten, and Warmerda, 2007). They
defined PST as:
[A] psychological intervention in which the following elements had to be included: definition of
personal problems, generation of multiple solutions to each problem, selection of the best
solution, the working out of a systematic plan for this solution, and evaluation as to whether the
solution has resolved the problem. (Cuijpers et al., 2007:10)
In addition, family problem solving models have been shown to be effective with depressed older
adults in methadone maintenance treatment (see Rosen, Morse and Reynolds, 2011). Those
undertaking the study have argued that PST is particularly suitable for this group, as it is less
cognitively demanding than other therapies. Family problem solving models also appear to be
effective in reducing suicidal behavior and depression, as demonstrated in a study with young
people in Sri Lanka (Perera & Kathriarachchi, 2011).
In another study, a twelve-session family problem solving intervention was offered to families
recruited from a head start program in Canada (Drummond, Fleming, McDonald & Kysela,
2005). They used a model based on three steps: evaluate options, can anyone help and agree
and notice the difference. They found improvements in the length of time that children in the
experimental group engaged in play therapy and further co-operation within the parent / child
relationship was also evident. Problem solving also proved to be effective in an Australian study
by Trotter (2010) of thirty-one families, most of which had been referred for family work by
juvenile justice or child protection agencies. Seventy four percent of the family members
reported that they were getting along much better following the family counselling, with only
one person saying that things were worse.

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