teaching research informed systemic therapy. · 1 teaching research informed systemic therapy....
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TEACHING RESEARCH
INFORMED SYSTEMIC
THERAPY.
Director of Clinical Psychology Training
University College Dublin
Clinical Psychologist & Family Therapist, Clanwilliam Institute
Melbourne
36th Annual Australian Family Therapy Conference, Jasper Hotel, Melbourne, Australia, 6th – 7th November, 2015.
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FAMILY THERAPY TRAINING
ON THE UCD CLINICAL PSYCHOLOGY
PROGRAMME
• At UCD systemic thinking is taught
throughout the whole 3 year doctoral
programme in clinical psychology.
• FT skills training occurs in the 2nd
teaching block of the first year
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YEAR 1CHILD MENTAL
HEALTH
TEACHING BLOCK 1 6 weeks
CLINICAL PLACEMENT 1
16 weeks
TEACHING BLOCK 2 6 weeks
CLINICAL PLACEMENT 2
16 weeks
YEAR 3DISABILITY &SPECIALTIES
TEACHING BLOCK 5 6 weeks
CLINICAL PLACEMENT 5
16 weeks
TEACHING BLOCK 6 6 weeks
CLINICAL PLACEMENT 6
16 weeks
YEAR 2 ADULT MENTAL
HEALTH
TEACHING BLOCK 3 6 weeks
CLINICAL PLACEMENT 3
16 weeks
TEACHING BLOCK 4 6 weeks
CLINICAL PLACEMENT 4
16 weeks
UCD DOCTORAL PROGRAMME IN CLINICAL PSYCHOLOGY
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FAMILY THERAPY TRAINING
ON THE UCD CLINICAL PSYCHOLOGY PROGRAMME
• FT skills training occurs in the 2nd
teaching block of the first year
• At this point, from the Child HB
students have learned
• An individually focused DSM/ICD
‘syndromal’ approach to clinical
formulation
• Evidence-based individually focused
interventions such as parent training
and individual CBT
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PRECIPITATING FACTORS
PROTECTIVE FACTORS
PROBLEM OR SYNDROME
MAINTAINING FACTORS
PREDISPOSING FACTORS
INDIVIDUAL SYNDROMAL FORMULATION MODEL
SYNDROMAL FORMULATION MODEL
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PRECIPITATING FACTORS
PROTECTIVE FACTORS
PROBLEM OR SYNDROME
PERSONAL Biological
Psychological
CONTEXTUAL Treatment
system FamilyParents
Social network
MAINTAINING FACTORS
PERSONAL Biological
Psychological
CONTEXTUAL Treatment
system FamilyParents
Social network
StressesIllnessInjuryAbuse
PREDISPOSING FACTORS
PERSONAL Biological
Psychological
CONTEXTUAL Child-parent factors in early life
Family problems in early life Stresses in early life
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CASE EXAMPLE OF BILL - CONDUCT DISORDER
• Bill, aged 11, was referred by his social-worker after climbing onto the roof of his house and throwing stones at neighbours who ostracized his family because his father raped a girl in the village
• Bill smoked, drank alcohol, and stole from neighbours
• He had school problems (academic underachievement, defiance, rejection by peers, and repeated absence)
• Bill had a history of a difficult temperament, language delay and dyslexia
• His conduct problems were long-standing but had intensified in the six months preceding the referral when his father, Paul, was imprisoned for raping a young girl in the small rural village where the family lived
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• Bill was one of five boys who lived with his mother, Rita, in chaotic circumstances with no home routines
• All 5 boys had conduct problems but Bill's were by far the worst
• Prior to Paul's imprisonment, the children's defiance and rule-breaking was kept in check by their fear of physical punishment from their father
• Since his imprisonment, there were few house rules and these were implemented inconsistently by Rita
• Rita had developed intense coercive patterns of interaction with Bill and John (the second eldest)
• Rita supported the family with welfare payments and money earned illegally from farm-work & would sometimes take the boys to work with her to earn extra money
CASE EXAMPLE OF BILL- CONDUCT DISORDER
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• Rita had a history of school problems, conduct problems and ongoing depression
• Paul had a history of conduct problems and criminality
• The couple’s parents disapproved of their marriage and were in conflict about this
• Rita was ostracised by the village community who blamed her for driving her husband to commit rape.
CASE EXAMPLE OF BILL - CONDUCT DISORDER
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CASE EXAMPLE OF BILL- CONDUCT DISORDER
CASE EXAMPLE OF BILL - CONDUCT DISORDER
SYNDROMAL FORMULATION
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CASE EXAMPLE OF BILL - CONDUCT DISORDER
TREATMENT & OUTCOME
Treatment
• Behavioural parent training
• School attendance programme
• Social skills training
• Respite foster care
Outcome
• Did not become a saint
• Attended school more regularly
• Less aggressive
• Not placed in long-term residential care
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TEACHING METHOD
• Pre-class reading
• Have 6 hour classes (9am – 4 or 5 pm) with 7-12 in class
• Discuss chapter and implications of research and theory for practice
• In small groups formulate ‘paper cases’
• Accredited training in parent training (Incredible years & Parents plus)
• Training in child-focused CBT using ‘Pesky gNats’ programme
• Use skills on 16 week placement
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TEACHING METHOD
• During their first placement they
• Discover importance of changing family and school contexts to help young people overcome problems
• See limitations of individually-focused approach
• Become ready to see the relevance of a systemic model
• Towards the end of their 1st
placement they read FTCPP to prepare for FT skills training workshop
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FT MANUAL USED ON THE UCD CLIN
PSYCH PROGRAMME
Concepts – A review of the schools of FT
Process – A treatment manual based on an integrative 3-column model
Practice – Guidance on the clinical application of the model to common child and adult problems
• Research & Resources
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FT SKILLS TRAINING METHOD
• Read manual as ‘required reading’ prior to
3-4 day workshop.
• Overview discussion of model (and
limitations of individual-focused models)
• Video of FT model in action
• Role play FT exercises covering planning,
assessment, intervention and
disengagement phases
• Use of team, virtual screen, and ‘freeze’
technique to aid learning.
• Use FT skills on 16 week placement
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FT SKILLS TRAINING METHOD - ROLE PLAY ROUTINE
• Divide class into family and treatment team
• Read detailed family roles or team briefing and goals from FTCP&P
• Set up room with team behind therapist
• Roleplay FT session
• When ‘stuck’ therapist ‘freezes’ time and discusses this with team
• Therapist ‘unfreezes’ and continues role play
• After role play family give feedback on experiences that ‘worked’ for them
• Therapist and team rate degree to which session goals were achieved.
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STAGES OF FAMILY THERAPY
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CONTEXTS
THAT UNDERPIN BELIEFS &
BEHAVIOUR
HISTORICALStressful family-
of-origin experiences
CONTEXTUALStressful current
extra-familial experiences
CONSTITUTIONALBiological
vulnerabilities
THE 3 COLUMN FAMILY SYSTEMS FORMULATION MODEL FOR PROBLEMS –
HELPS PLANNING WHAT TO ASK
BELIEF SYSTEMS
THAT SUBSERVE THE BEHAVIOUR
PATTERN
Problematic beliefs about
finding solutions
Problematic beliefs about relationships
Problematic cognitive styles
BEHAVIOUR PATTERNS
THAT MAINTAIN THE PROBLEM
Problem-maintaining
solutions
Confused communication
Problematic relationships
CASE EXAMPLE OF RAD & SAD:
CAROLINE BARROW
REFERRAL
• She was concurrently
referred by
• A paediatricianfor chronic recurrent abdominal pain
• An educational psychologist for persistent school refusal
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• For almost year, she had
• Stomach aches & vomiting in the mornings
• Difficulty going to school
• Anxiety about her mother’s health
• Fear of leaving her mother alone
• The problems were getting worse
• The mother was very worried and the father
seemed to be uninvolved.24
CASE EXAMPLE OF RAD & SAD:
CAROLINE BARROW
PRESENTING PROBLEMS
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1.2. PRELIMINARY FORMULATION & PLANNING WHAT TO ASK
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WHERE DID THE 3 COLUMN FORMULATION MODEL COME
FROM ?
• We found that in the 1980s and 1990s
most of the major schools of family
therapy could be classified in terms of
their emphasis on three main themes
• Behaviour problems
• Beliefs systems / narratives
• Predisposing factors (historical,
contextual, biological)
• We used this 3 column model to
• Integrate ideas and research
findings from multiple schools of
family therapy
• Guide assessment, formulation and
treatment
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PREDISPOSINGHISTORICAL,
CONTEXTUAL & CONSTITUTIONAL
FACTORS
Transgenerational
Psychoanalytic
Attachment based
Experiential
Multisystemic
Psychoeducational
CLASSIFICATION OF SCHOOLS OF FAMILY THERAPY
ACCORDING TO THEIR EMPHASIS ON 3 THEMES
BELIEF SYSTEMS &
NARRATIVES
THAT SUBSERVE THE BEHAVIOUR
PATTERN
Constructivist
Original Milan School
Social constructionist
Solution-focused
Narrative
BEHAVIOUR PATTERNS
THAT MAINTAIN THE PROBLEM
MRI brief therapy
Strategic therapy
Structural therapy
Cognitive-behavioural
Functional
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2.3. COMPLETING THE ASSESSMENT -
TRACKING THE BEHAVIOUR PATTERN
AROUND THE PROBLEM
• Tell me, in detail, about the last time the
problem occurred?
• If I was watching a video of the last time
the problem happening what would I see in
the lead up to it, during it, and after it?
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Mat asks S to leave C alone.S shouts at M who then withdraws and is relieved
C has stomach cramps & vomits. S tells her to go to bed. Later C helps S with housework, & both are relieved
Dick is at work
Sheila and Caroline have an anxiety provoking conversation about how ill C feels, & whether to have breakfast
Dick phones & criticizes S’s management of C. S begins to worry again
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2.3. COMPLETING THE ASSESSMENT -
EXPLORING BELIEF SYSTEMS
• What explanation do you or others
give for this problem?
• What sort of solution goes with your
explanation of the problem?
• If your parents were here with us,
what advice would they give us about
managing this problem?
M thinks C is not ill and should do her duty & go to school
Mat asks S to leave C alone.S shouts at M who then withdraws and is relieved
C knows she has a history of gastro. and thinks she must be ill now if S is so worried about her
C has stomach cramps & vomits. S tells her to go to bed. Later C helps S with housework, & both are relieved
D believes that short term home absence will lead to him being based locally in the long term
Dick is at work
S believes that health is more important than anything and that the doctors may have misdiagnosed C, as they did her mother
Sheila and Caroline have an anxiety provoking conversation about how ill C feels, & whether to have breakfast
D thinks C is disobedient not ill, and S must make her do her duty and go to school
Dick phones & criticizes S’s management of C. S begins to worry again
• Genograms may be used to identify
contextual factors that underpin the
behaviour pattern and beliefs that
maintain the problem:
• Historical factors
• Contextual factors in the wider social
system (extended family, school,
work, professional network)
• Constitutional (psychobiological)
factors
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2.3. COMPLETING THE ASSESSMENT -
GENOGRAMS
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BARROW’S GENOGRAM
Caroline
14y
M. 18y
Left
When Dick
was 3y
Annie
81y
School
Nurse
Betty
Boyd
EWO
Phil
Hutchinson
Ed
Psych
David
Trellis
Best
Friend
Mary
Best
Friend
Kirsty
School
Doctor
Ed
Reed
Paediatrician
Tom
Walker
Family
Doctor
Brian
Wilson
Sheila
50y
Dick
56y
Billy
15y
John
55y
Rex
54y
Visits
every
4m
Tom
56yCaroline
52y
David
55y
Henry
10y
Sharon
12y
Died
1y
Ago
Cancer &
Depression
JuneTom
77y
Lives 100
miles away
Visits at
Easter
& Xmas
Grampy
Mat
17y
To go to
University in
September
Miscarriage
Occurred 1y
Before C’s
Birth
May
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M identifies with D’s values where duty is more important that health
M thinks C is not ill and should do her duty & go to school
Mat asks S to leave C alone.S shouts at M who then withdraws and is relieved
C has history of gastroenteritisIntergenerational pattern of close mother-daughter relationships
C knows she has a history of gastro. and thinks she must be ill now if S is so worried about her
C has stomach cramps & vomits. S tells her to go to bed. Later C helps S with housework, & both are relieved
D’s career path as a travelling salesman
D believes that short term home absence will lead to him being based locally in the long term
Dick is at work
Health was core value in S’s family S’s mother had undiagnosed cancer for a long time
S believes that health is more important than anything and that the doctors may have misdiagnosed C, as they did her mother
Sheila and Caroline have an anxiety provoking conversation about how ill C feels, & whether to have breakfast
Duty is a core value for D who took parental responsibility for his sibs. After his father left
D thinks C is disobedient not ill, and S must make her do her duty and go to school
Dick phones & criticizes S’s management of C. S begins to worry again
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2.3. COMPLETING THE ASSESSMENT –
RECAP OF 3 COLUMN PROBLEM
FORMULATION
• What is the behavioural pattern of interaction of
family members (and others) around the main
problem?
• What beliefs of family members (and others)
underpin their roles in the behavioural pattern of
interaction around the problem?
• What contextual factors subserve these beliefs and
behaviour patterns?
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CONTEXTS
THAT UNDERPIN BELIEFS &
BEHAVIOUR
HISTORICALStressful family-
of-origin experiences
CONTEXTUALStressful current
extra-familial experiences
CONSTITUTIONALBiological
vulnerabilities
3 COLUMN FAMILY SYSTEMS FORMULATION MODEL
FOR PROBLEMS
BELIEF SYSTEMS
THAT SUBSERVE THE BEHAVIOUR
PATTERN
Problematic beliefs about
finding solutions
Problematic beliefs about relationships
Problematic cognitive styles
BEHAVIOUR PATTERNS
THAT MAINTAIN THE PROBLEM
Problem-maintaining
solutions
Confused communication
Problematic relationships
EXCEPTIONS!
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• What is the behavioural pattern of interaction of
family members (and others) around exceptions to the
problem?
• What beliefs of family members (and others)
underpin their roles in the pattern of interaction
around exceptions to the problem?
• What contextual factors subserve these beliefs and
behaviour patterns?
2.3. COMPLETING THE ASSESSMENT –
3 COLUMN EXCEPTION FORMULATION
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CONTEXTS
THAT UNDERPIN EXCEPIONAL
BELIEFS & BEHAVIOUR
HISTORICALPositive family-of-origin experiences
CONTEXTUALSupportive current
extra-familial experiences
CONSTITUTIONALBiological strengths
3 COLUMN FAMILY SYSTEMS FORMULATION MODEL
FOR EXCEPTIONS
BELIEF SYSTEMS
THAT SUBSERVE EXCEPTIONS
Empowering beliefs about
solving problems
Empowering beliefs about relationships
Optimistic cognitive styles
BEHAVIOUR PATTERNS
AROUND EXCEPTIONS
Effectiveproblem-solving
Clear communication
Supportive relationships
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Intergenerational pattern of close mother-daughter relationships
C believes she is not ill because S is not worried about her
C ignores gastric discomfort, washes and has breakfast without anxiety
Kirsty and C have been friends for 10 years
Kirsty and C believe they are best friends
Kirsty calls for C and they walk to school together
D’s father was absent & he does not want to repeat that mistake
D believes its important for him to be at home when he can
Dick is at home
D & S have a supportive marriage
D believes C is OK, and S trusts D’s judgment
Sheila tells D she is worried about Caroline’s healthD reassures S and she worries lessS does not have an anxiety provoking conversation with C
3 COLUMN EXCEPTION FORMULATION
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2.5. FORMULATION AND
FEEDBACK
• Match complexity of formulation to family
members’ cognitive ability
• Present exceptions, highlight strengths, create
hope
• Empathize with each person’s position within the
problem formulation
• Feedback the formulation a bit at a time, and
check understanding
• Do not proceed to goal setting or contracting for
treatment, until formulation has been accepted
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HOW DO FAMILY SYSTEMS FORMULATIONS
HELP US DO THERAPY?
Move from behaviour, to beliefs, to contexts
• First, focus on changing problem-maintaining family behaviour
patterns
• If that is unsuccessful, focus on re-evaluating beliefs and
narratives that keep the family stuck in problem maintaining
behaviour patterns
• If that is unsuccessful, address the wider context that
underpins behaviour and beliefs (history, social systems and
constitutional factors)
• With the Barrow’s, we started by trying to give Caroline the
skill to autonomously manage her pain/anxiety, and invited
her parents to support her autonomy.45
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CONTEXTS
HISTORICALInsight
CONTEXTUALReducing
extrafamilial stress & building supports
CONSTITUTIONALPsychoeducation
about vulnerabilities
BELIEF SYSTEMS
Address ambivalence
Highlight strengths
Reframe problems
Multiple perspectives
Externalizing problems and
building on exceptions
BEHAVIOUR PATTERNS
Change behaviour pattern within
sessions
Change behaviour pattern between
sessions
HOW DO FAMILY SYSTEMS FORMULATIONS HELP US TO DO THERAPY?
Sequence interventions from behaviour to beliefs to contexts
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YEAR 1CHILD MENTAL
HEALTH
TEACHING BLOCK 1 6 weeks
CLINICAL PLACEMENT 1
16 weeks
TEACHING BLOCK 2 6 weeks
CLINICAL PLACEMENT 2
16 weeks
YEAR 3DISABILITY &SPECIALTIES
TEACHING BLOCK 5 6 weeks
CLINICAL PLACEMENT 5
16 weeks
TEACHING BLOCK 6 6 weeks
CLINICAL PLACEMENT 6
16 weeks
YEAR 2 ADULT MENTAL
HEALTH
TEACHING BLOCK 3 6 weeks
CLINICAL PLACEMENT 3
16 weeks
TEACHING BLOCK 4 6 weeks
CLINICAL PLACEMENT 4
16 weeks
UCD DOCTORAL PROGRAMME IN CLINICAL PSYCHOLOGY
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FAMILY THERAPY TRAINING
ON THE UCD CLINICAL PSYCHOLOGY PROGRAMME
• By the end of their first year PGs have
basic competencies in
• FT assessment, formulation,
intervention
• DSM/ICD ‘syndromal’ approach to
clinical assessment, formulation and
intervention
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THANK YOU.
Director of Clinical Psychology Training
University College Dublin
Clinical Psychologist & Family Therapist, Clanwilliam Institute
Melbourne
36th Annual Australian Family Therapy Conference, Jasper Hotel, Melbourne, Australia, 6th – 7th November, 2015.
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Carr, A (2015). Teaching research informed systemic therapy.
Paper presented at the 36th Annual Australian Family Therapy Conference, Jasper Hotel, Melbourne, Australia, 6th – 7th
November, 2015.
In this presentation the research-informed approach to teaching systemic practice on the UCD doctoral programme in clinical psychology will be described. Research informed systemic therapy is taught using the text: Family Therapy Concepts Process and Practice (by Alan Carr). The integrative approach described in this book conceptualizes family therapy as a staged process. It involves the use of a three-column model (covering behaviour, beliefs, and wider contextual factors) to formulate problems and exceptions, and guide interventions. This approach to systemic practice is taught once clinical psychologists in training have experience with a more traditional approach to practice described in the Handbook of Child and Adolescent Clinical Psychology(by Alan Carr) which adopts a syndromal, rather than a systemic approach to formulation.