Rutter's Child and Adolescent Psychiatry Book 2

ratings of flexible adaptation of intervention activities were not related to intervention outcome. In addition, flexible adaptation was not found to be related to client characteristics such as their age, sex, race, family income, specific anxiety diagnosis or comorbid diagnoses. Thus, it appears that the combination of requiring strict adherence to session goals while permitting careful flexibility in adapting specific activities meant to address the session goals can lead to successful implementation of programs in “real-world” settings. Therapeutic Alliance Later studies have suggested that a rigid adherence to a manual could have a negative effect on the therapeutic alliance, because as therapists’ technical competence increased their attention to the relationship decreased (Herschell, McNeil, & McNeil, 2004). The therapeutic alliance has been found in a meta-analysis to be significantly, albeit modestly, associated with outcomes in child and adolescent therapy (Shirk & Karver, 2003). Historically, the therapeutic relationship has been viewed as a key change mechanism in child psychotherapy (Shirk & Karver, 2003). Currently, the majority of child psychologists and psychiatrists report in surveys that the therapeutic alliance and other non-specific processes are critical for change in child treatment (Chu, Choudhury, Shortt et al., 2004; Kazdin, Siegel, & Bass, 1990). Therapeutic alliance can be conceptualized as (Chu, Choudhury, Shortt et al., 2004): 1 A means to an end, such as the working alliance in psychoanalytic therapy; 2 A necessary and sufficient mechanism for therapeutic change, as in play therapy and client-centered therapy; or 3 In CBT, the therapist serves as an active “coach,” with an emphasis on a collaborative process. Thus, therapeutic alliance is assumed to be necessary but not sufficient in CBT. Therapeutic alliance may be especially important in child intervention, because children do not initiate treatment. The affiliative bond between client and therapist and the agreement and involvement in intervention tasks may be key in child interventions. These dimensions are expected to be inter-related (Shirk & Saiz, 1992), and are assessed in one of the few therapeutic alliance measures available for children (Shirk & Russell, 1996). There is minimal research to date, but a meta-analysis (Shirk & Karver, 2003) and literature review (Green, 2006) indicated: 1 A small but significant effect for therapeutic alliance (0.21), with somewhat greater effect for disruptive behavior (0.30) than emotional (0.10) problems; 2 Measures of therapeutic alliance taken late in treatment are more strongly associated with outcome than measures taken early in treatment; and 3 There was little support for the predictive effect of therapeutic alliance. However, recent research has found that a positive alliance between parents and therapists in parent management training for antisocial children has predicted improvements in parenting practices (Kazdin & Whitley, 2006b) and positive child–therapist alliance has predicted improvements in children’s behavior (Kazdin, Whitley, & Marciano, 2006). To address a lack of examination of therapeutic alliance in group forms of CBT, Lochman, Barth, and Czopp (2005, June) examined therapeutic alliance in a sample of 80 children screened as being in the top 30% of children according to 4th grade teachers. The children received the Coping Power group CBT program. Findings indicated that children’s baseline behavior problems predicted poor therapeutic alliances, and weak therapeutic alliances are related to higher levels of children’s problem behaviors at the end of intervention. However, the therapeutic alliance was not a very good predictor of change in children’s disruptive behavior during intervention, suggesting that therapeutic alliance was not the primary mechanism accounting for CBT effects in group interventions with children. Potential Iatrogenic Effects: The Example of Deviancy Training Before widespread dissemination of evidence-based CBT interventions occurs, it is critical to understand who the interventions successfully influence, and whether there are intervention characteristics that can produce iatrogenic effects or subgroups of youth who are vulnerable to iatrogenic effects of a given intervention program. Within the field of youth violence prevention, a critical such concern that has arisen is the potential iatrogenic effect resulting from working with antisocial children in group formats where they may escalate, rather than reduce, their behavior problems. Research results were sufficiently alarming to lead some researchers to recommend that practitioners must be cautious in how they provide group-based interventions (Dishion, McCord, & Poulin, 1999). In one of the seminal articles on this form of iatrogenic effect, Dishion and Andrews (1995) randomly assigned high-risk young adolescents to one of four conditions varying in whether the youths received 12 youth-only sessions, their parents received 12 parent-only sessions, the youths and the parents both received combined intervention, or the youths and parents received no intervention. All three of the Adolescent Transition program (ATP) intervention cells had some positive effects at post-intervention, and the conditions providing youth intervention produced reductions in negative family interactions and good acquisition of the concepts presented in the intervention. However, by the time of a 1-year follow-up, the youths who had received youth sessions had higher rates of tobacco use and of teacher-rated delinquent behaviors than did the control children, and these iatrogenic effects were evident even if the parents had also received intervention in the combined condition. At a 3-year follow-up, the teen intervention conditions continued to have more tobacco use and delinquency (Poulin, Dishion, & Burraston, 2001). Analyses of the iatrogenic group conditions revealed that subtle dynamics of deviancy training during unstructured transitions in the groups predicted growth in self-reported smoking and growth in teacher ratings of delinquency. A recent meta-analysis by Weiss, Caron, Ball et al. (2005) concluded that the risk for iatrogenic effects may currently be CHAPTER 63 1038 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1038

overstated. Weiss, Caron, Ball et al. (2005) updated their prior treatment metaanalysis datasets with new studies, and found that there was no difference in effect size for group versus individual treatment (group effect size 0.79, individual effect size 0.68). Surprisingly, group intervention studies had a significantly lower likelihood of creating negative effect sizes than did individual intervention studies, although the log odds for having a negative effect size peaked at age 11 for children in groups versus age 8.6 for individual interventions. This suggests that groups tend to have worse effects as children approach adolescence, consistent with prior concerns that group iatrogenic effects may be most noticeable as children move into early adolescence. This meta-analysis suggests that iatrogenic effects of group interventions are not universal effects, and suggests that it is critically important to research further the potential iatrogenic effects of group interventions at key developmental points. In addition to developmental issues, the therapists’ behaviors may have a key role in whether deviancy training emerges in CBT groups. Carefully managed and supervised groups may avoid iatrogenic effects (Dishion & Dodge, 2006). The adult group leaders’ abilities to manage and structure peer interactions can assist in redirecting or stopping peers’ reinforcement of deviant behaviors. The deviancy effects may be substantially reduced or eliminated if group leaders exercise adequate control over deviancy training behaviors in the group sessions. Implications for Training and Implementation in Clinic and School Settings An issue that increases the difficulty of detecting the effects of interventions, especially cognitive–behavioral preventive interventions, is that they are typically implemented at a number of sites (Raudenbush & Willms, 1991). The degree to which the intervention is implemented fully, and the context in which the intervention is embedded, can vary markedly from site to site. With school interventions, contextual factors such as the characteristics of the schools and the school climate can be markedly different across schools. Raudenbush and Willms (1991) argue that this variation, rather than being a nuisance which must be controlled in analyses, can provide critical information and is more important than the overall average effectiveness of the intervention. Variations in the adoption, success and maintenance of interventions across sites can have major implications for the effective dissemination of preventive interventions. In studies of organizational structure and climate, the level of analysis of organization effects should be both at the group level (i.e., school level) and at the individual level (i.e., individual school staff implementing the intervention; Rowan, Raudenbush, & Kang, 1991). Organizational Influences at the School Level New interventions and programs need organizational support to be adequately implemented (Berwick, 2003; Henggeler, Lee, & Burns, 2002). One of the central influences within Rogers’ (1995) model of the diffusion of innovations involves characteristics of the social system in which the innovation will be embedded, including how decisions are made to adopt innovations and the organizational norms of the setting. The social environment of the organization, and the relationships between individuals in the work setting, are critical characteristics of the organization and are evident in the patterns of leadership, control, autonomy and communication among workers and supervisors (Mowdy & Sutton, 1993; O’Reilly, 1991; Pfeffer, 1983; Porras & Robertson, 1992; Turnipseed, 1994; Weich & Quinn, 1999; Wilport, 1995). The work environment can be conceptualized as having certain systematic characteristics (Moos, 1974, 2002; Trickett & Moos, 1973), consisting of a relationship dimension (involvement, peer cohesion, staff support), a personal growth and development dimension (autonomy, task orientation, work pressure) and a system maintenance and change dimension (clarity, control, innovation, physical comfort). School personnel who perceive that their school climate is negative have been found to think that innovations introduced into their schools are burdens, and they have more burn out (McClure, 1980). In contrast, positively perceived school climate has been found to lead to successful implementation of new reforms in schools (Bulach & Malone, 1994), and collegiality, shared authority among colleagues and positive leadership by principals have been linked to the ability to facilitate change in schools and to continue school improvements (Peterson, 1997). In addition, school-level factors that have been found to influence those perceived environment factors that operate at the school level, and which can affect the implementation of interventions and students’ behavior, are school size, school-wide achievement levels, the ethnic composition of schools, the socioeconomic level of the student body and school-wide aggression levels among students (Barth, Dunlap, Dane, Lochman, & Wells, 2004; Kellam, Ling, Merisca, Brown, & Ialongo, 1998; Rowan, Raudenbush, & Kang, 1991). Effects of Training The characteristics of the training process and the integrity of the intervention implementation can influence the outcomes of intervention and can contribute to weaker effects of an intervention when it is transported to new settings (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). Metaanalyses of the child treatment literature have found that a higher degree of provision of structure (through intervention manuals) and monitoring (through review of intervention session tapes) in treatments offered in a variety of university and community settings were directly linked to superior intervention effectiveness (Weisz, Donenberg, Han et al., 1995a; Weisz, Donenberg, Han et al., 1995b). Although rarely examined in the intervention literature, the degree of intensity of training can be anticipated to affect intervention outcomes. Henggeler, Schoenwald, Borduin et al. (1998) have advocated that Multisystemic Therapy (MST) can COGNITIVE–BEHAVIORAL THERAPIES 1039 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1039

only have maximal impact when training is both intense (5-day initial training), ongoing (weekly supervision by MST trained supervisors) and carefully specified. With sufficient intensity, training can achieve its primary purpose of enabling high levels of adherence to the intervention protocol, and producing high levels of intervention integrity (Henggeler, Schoenwald, Borduin et al., 1998). For example, adherence to MST intervention principles has been found to be an important predictor of key outcomes of criminal activity, incarceration and psychiatric symptoms for adolescents receiving MST (Henggeler, Schoenwald, Borduin et al., 1998). Future Development and Refinement of Cognitive–Behavioral Interventions Comorbidity Structured manualized CBT may ignore the complexities of individual cases and neglect the individual idiographic nature of each client (Henry, 1998; Herschell, McNeil, & McNeil, 2004). Thus, the manual may be targeted at the average client with the particular disorder being addressed, but it may not permit a focus on comorbid problems or on individuals with extremely serious versions of the disorder (Weisz, Donenberg, Han et al., 1995b). Range of Acceptable Adaptation The clinician may perceive that a CBT manual’s predetermined intervention components have to be presented in a linear, invariant order, limiting the efficiency of the program (Weisz, Donenberg, Han et al., 1995b). If so, a manual may limit the clinician’s flexibility in addressing issues that go beyond the scope of the portion of the manual currently being used in a given session, but that are still relevant to the treatment plan and the specific issues being raised in the session (Kendall & Chu, 2000; Weissman, Rounsaville, & Chevron, 1982). Booster Interventions The current intervention literature indicates that one of the greatest difficulties with interventions for children with disruptive behavior problems is that the children’s improved changes in behavior tend to erode over time (McMahon & Wells, 1998), because following intervention the children remain in the same peer, family and neighborhood settings that may have contributed to the child’s baseline level of problems. Thus, gains are not positively reinforced, and others, such as teachers, still expect that the formerly aggressive child will continue to behave in antisocial ways. One solution to this problem has been to consider the use of booster interventions, which have been found to assist in maintaining intervention effects (Bry, Catalano, Kumpfer, Lochman, & Szapocznik, 1998). In research on the Anger Coping program, Lochman (1992) found that earlier intervention-produced reductions in children’s disruptive off-task behavior in school settings was maintained at a 3-year follow-up only for aggressive children who had received a booster intervention. Technology and Internet Use Empirical evidence indicates that individuals pay more attention to and learn more deeply from multimedia presentations than from verbal-only messages, resulting in greater problemsolving transfer (Eveland, Seo, & Marton, 2002; Lieberman, 2001; Mayer, 2003; van der Molen & van der Voort, 2000). Given this and the popularity of computers and video games among children and adolescents (Vorderer & Ritterfeld, 2003), it is not surprising that electronic media have become a popular modality for youth preventive interventions. Indeed, children and adolescents indicate that their preferred method of learning involves interactive multimedia (Lieberman, 2001). Multimedia programs have been developed to prevent youth violence. One such program, SMART Talk (Students Managing Anger and Resolution Together) aims to teach middle school students anger management and conflict resolution skills through a similar set of computer-based activities. While no significant changes in the frequency of aggressive behavior were found in a randomized controlled study of SMART Talk, significant effects were observed on several mediating factors associated with violence. In particular, students in the intervention condition were less likely to value violence as a solution to conflict, were more likely to report intentions to use non-violent strategies and reported more self-awareness about their response to anger in conflict situations than students in the control group (Bosworth, Espelage, & DuBay, 2000). Thus, multimedia programs display promising effects on risk and protective factors for negative youth outcomes, and may have effects on their actual behavior, especially for children already motivated to change. Research will need to explore whether multimedia programs can produce effective behavior change in children without a therapist, and without a therapeutic alliance, or whether multimedia programs can best be considered to be adjuncts to therapist-provided CBT. References Akhutina, T. V. (1997). The remediation of executive functions in children with cognitive disorders: The Vygotsky–Luria neuropsychological approach. Journal of Intellectual Disability Research, 41, 144–151. Asarnow, J. R., & Callan, J. W. (1985). Boys with peer adjustment problems: Social cognitive processes. Journal of Consulting and Clinical Psychology, 53, 80– 87. Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston. Bandura, A. (1973). 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1046 Advice on how to rear children has been around for a long time. Socrates (435 bc) reports on how a girl should be brought up “so she might see, hear, and speak as little as possible”; both sexes should be brought up to be schooled in modesty and self-control, a girl’s physique is designed for indoor work (childcare, breadmaking and woolworking), whereas a boy’s was designed for outdoor activity (ploughing, planting and herding) so their rearing should be focused towards these skills. Thus, from early on we have a notion of raising children to function well in their future worlds, taking into account their characteristics. This is usually believed to be reasonably successful – in the Bible it is written “Train up a child in the way he should go: and when he is old, he will not depart from it” (Proverbs 22:6). However, the question is how best to do this: should one use plenty of physical chastisement “Spare the rod and spoil the child” (Samuel Butler, 1660); or should one believe in the virtue of rewards, “And he who gives a child a treat/makes joy-bells ring in Heaven’s street” (John Masefield, 1908). Beliefs about how children should be raised vary enormously, within the same culture over time, and across differing cultures at any one time, including the present. Designing materials for parenting programs for disruptive children is not new; Jonathan Swift (1708) stated: “I conceived some scattered notions about a superior power to be of singular use for the common people, as furnishing excellent materials to keep children quiet when they grow peevish.” Because of the wide range of theoretical ideas about how children should be brought up, this chapter first reviews evidence concerning parenting styles in relation to child outcomes. Then programs based on attachment theory and social learning theory are described in detail, and their effectiveness reviewed. Finally, factors that affect their effectiveness are discussed, including what predicts outcome, what are the mechanisms of change and the role of therapist factors in making programs work. Theoretical Basis Theories Linking Parenting to Child Outcomes Whereas many theories link parenting to child outcomes, two perspectives – attachment theory and social learning theory – have been especially influential in recent times and have led to rather different types of parenting programs. Attachment theory has led to interventions mainly for babies and infants, and social learning theory has led to interventions mainly for children from around 3 years upwards. Attachment Theory Attachment theorists (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1969/1982; Cassidy & Shaver, 1999) developed a model of parent–child relationships from a broad theoretical base, including ethology, cognitive psychology and control systems (see chapter 55). Bowlby was particularly interested in identifying the nature, significance and function of a child’s (or animal offspring’s) tie to his or her parent. Although the theory had its roots in clinical observations of children who experienced severely compromised, disrupted or deprived caregiving arrangements, it has been applied as a model for normal and abnormal development. “Parent–child attachment” is not synonymous with “parent–child relationship” insofar as the former was conceptualized as being far more limited in scope. Attachment theory is concerned with fundamental issues of safety and protection; in psychological terms, attachment theory focuses on the extent to which the relationship provides the child with protection against harm and with a sense of emotional security or, to use the term made famous by Bowlby, a “secure base” for exploration. Many components of the parent–child relationship are not central to an attachment assessment, such as cognitive stimulation or discipline. The theory proposes that the quality of care provided to the child, particularly sensitivity and responsiveness, leads to a secure or insecure attachment. Attachment theorists use the term “pathway” to make explicit that early attachment experiences do not shape subsequent development in a fixed deterministic manner (Bowlby, 1988). Insecure attachment is not synonymous with disturbance, and neither is a secure attachment a guarantee against disturbance. Indeed, long-term followup studies suggest that it is family relationships that are more important for child functioning than attachment insecurity per se (Grossman, Grossman, & Waters, 2005). However, we now know that a particular form of non-secure attachment in infants and young children termed “disorganized” is strongly related to risk for psychopathology and is a marker of particular risk in the caregiving environment (Greenberg, 1999; Lyons-Ruth, 1996), although it is important to note that it occurs in 15% or more of normal populations. Attachment Parenting Programs 64 Stephen Scott 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1046 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

relationships are, it is suggested, internalized and carried forward to influence expectations for other important relationships, a process mediated by what Bowlby referred to as an “internal working model.” A history of consistent and sensitive care with the parent is therefore expected to lead to the child developing a model of self and others as lovable and loving and helpful. Effective attachment-based interventions have been developed and validated for a range of clinical problems (Bakermans-Kranenburg, van Ijzendoorn, & Juffer, 2003; Cicchetti, Rogosch, & Toth, 2000). Social Learning Theory Social learning theory evolved from different roots in general learning theory and behaviorism (Bandura, 1977). Broadly put, the notion behind social learning theory is that children’s reallife experiences and exposures directly or indirectly shape behavior; processes by which this learning occurs can be diverse. For many, there is a focus on traditional behavioral principles of reinforcement and conditioning, and so there is a near-exclusive focus on observed behavior (Patterson, 1969, 1996). The fundamental tenet is that moment-to-moment exchanges are crucial; if a child receives an immediate reward for their behavior, such as getting parental attention or approval, then they are likely to do the behavior again, whereas if they are ignored (or punished) then they are less likely to do it again. Other advocates of social learning models have expanded this focus to consider the cognitive or “mindful” processes such as attributions and expectations that underlie the parent’s behavior (Bugental, Blue, & Cruzcosa, 1989; Dix, 1992) and its effects on children (Dodge, Pettit, Bates, & Valente, 1995). Thus, social learning theory can be applied to behavior, cognitions, or both. Whether the assessment and conceptual focus is on behavior or cognitions, the model suggests that children learn strategies about managing emotions, resolving disputes and engaging with others, not only from their experiences, but also from the way their own reactions were responded to. For younger children especially, the primary source of these experiences is in the context of the parent– child relationship and the family environment. Furthermore, children take these strategies and apply them to other settings, for example to relationships with peers and teachers. This means that there will be a carrying forward of the effects of parent– child relationships across setting and time. Given its historical emphasis on altering negative, aggressive behavior in the child, social learning theory-based models of parenting traditionally emphasized the harmful effects of parent–child conflict, coercion and inconsistent discipline. The focus was on the extent to which children’s aggressive behaviors were learned from and reinforced by parallel negative behaviors by the parents. More recently, social learning theory has explicitly incorporated positive dimensions of parenting as a way of promoting child positive behavior and affect, improving the pleasurable nature of parents’ and children’s interactions with one another, and providing a more positive and effective relationship context for parental disciplinary interventions (Gardner, 1987). Research on social learning theory-based approaches to parenting interventions, especially as applied to antisocial children, is most closely associated with the work of Patterson (1969), founder of the Oregon Social Learning Center. Also influential was Hanf (1969), who developed play therapy based on rewarding child behavior through attention. Many leading current interventions directly incorporate social learning principles, notably the programs of McMahon and Forehand (2003), Brinkmeyer and Eyberg (2003), Forgatch and DeGarmo (1999) and Webster-Stratton (1981). Several interventionists expanded the social learning model to incorporate consideration of the parents’ social setting that may contribute to poor parenting, including Wahler, Winkel, Peterson, and Morrison (1965), whose program recognized the particular needs of isolated “insular” mothers. They were instrumental in showing, with hard evidence, that “insular” mothers were harsher to their children on those days when the few other adults with whom they had contact – such as local government officials or their own mothers – had been rejecting of them. Parenting Styles There are many other theories of parenting, some with a considerable evidence base. One is mentioned here, as it has been influential, even though to date it has not led to specific interventions. This is what can broadly be described as the parenting styles approach, and is associated with the work of Baumrind (e.g., 1991) and elaborated by others (Hetherington, Henderson, & Reiss, 1999; Maccoby & Martin, 1983; Steinberg, Lamborn, Darling, Mounts, & Dournbusch, 1994). Baumrind observed interactions between parents and young children. Several important dimensions of parenting were measured and repeatedly found in subsequent studies carried out by successive generations of researchers. Core dimensions were warmth (versus conflict or neglect) and control strategies. Parenting typologies were thus constructed from a cross of warmth/conflict and control: authoritative (high warmth, positive/assertive control, and in adolescence high expectations), authoritarian (low warmth, high conflict, and coercive, punitive control attempts), permissive (high warmth coupled with low control attempts) and neglectful/disengaged (low warmth and low control). These four typologies have proved to be surprisingly robust and have been repeatedly associated with child outcomes. Children and adolescents of authoritative parents are consistently found to be more prosocial, academically and socially competent, and less symptomatic. Children whose parents are described as authoritarian, permissive or disengaged show significantly worse outcomes, with children of authoritarian parents showing typically the most disturbed adjustment of the four parenting types. As discussed below, these associations may be in part brought about by child characteristics shaping parental responses, but nonetheless there are likely to be substantial parent to child effects. Although some parenting programs may make parents more authoritative, they have not been conceptualized in these terms – it would be interesting to see the effectiveness of a new program developed on these principles. PARENTING PROGRAMS 1047 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1047

Evidence Linking Parenting to Child Psychopathology Aggression, Conduct Disorder and Delinquency The finding that parent–child relationship quality is associated with aggressive behavior, conduct disorder and delinquency is one of the most widely reported findings in the literature, repeatedly found in: 1 Large-scale epidemiological investigations, such as the Cambridge and Isle of Wight studies in the UK, and the Dunedin and Christchurch studies in New Zealand; 2 Intensive clinical investigations, such as the work of Patterson and colleagues; and 3 Numerous naturalistic studies of diverse samples using a mixture of methods (Denham, Workman, Cole et al., 2000; Dodge, Pettit, Bates et al., 1995; Dunn, Deater-Deckard, Pickering et al., 1998; Gardner, Sonuga-Barke, & Sayal, 1999; Hetherington, Henderson, & Reiss, 1999; Kilgore, Snyder, & Lentz, 2000; Lyons-Ruth, 1996; Steinberg, Lamborn, Darling et al., 1994). The sort of parenting behaviors associated with these outcomes are high criticism and hostility, harsh punishment, inconsistent discipline, low warmth, low involvement, low encouragement and poor supervision. More recent research has begun to disentangle different aspects of parenting that may be associated with antisocial behavior; for example, after controlling for the effects of conflict in the relationship, the amount of warmth or type of control predict additional variance in externalizing problems (Fletcher, Steinberg, & Williams-Wheeler, 2004; Kerr & Stattin, 2000). The main take-home message is that several aspects of the parent–child relationship are important. An implication for parenting programs is that they should not be simplistic and focus only on one dimension of parenting. The connection between parent–child relationships and disruptive behavior holds for variation within the normal range as well as for clinical disturbance. That is so both for parenting (e.g., harsh parenting versus documented maltreatment) and child outcome (e.g., moderate aggression to conviction for minor and serious offenses; Lansford, Dodge, Pettit et al., 2002; Patterson & Bank, 1989). An implication for parenting programs is that the same principles (albeit differently applied) are important for preventive work and less severe populations, and for “hardend” cases. Depression, Anxiety and Other Emotional Problems Evidence supporting a link between quality of parent–child relationships and depression, anxiety and other emotional problems (e.g., somatic complaints, social withdrawal) is clear although weaker than that found for disruptive outcomes. Here again, the association is obtained from large-scale epidemiological investigations as well as clinical and normative developmental studies, and is evident in a range of samples and according to diverse methods (Dadds, Barrett, Rapee, & Ryan, 1996; Garber, Little, Hilsman, & Weaver, 1998; Wood, McLeod, Sigman, Hwang, & Chu, 2003). Just as it is the case for disruptive behavior, there is mounting evidence that individual variation in emotional symptoms is not specifically associated with a single dimension of the parent–child relationship. Low warmth and conflict are both reliably linked with depression and anxiety; however, the influence of control strategies is generally much weaker. Additionally, emotional symptoms in children are linked with overprotectiveness (Dadds, Barrett, Rapee et al., 1996). Therefore, parenting programs for emotional symptoms, of which there are few, should probably address overinvolvement and autonomy granting. Social Competence and Peer Relationships Family–Peer Links Evidence supporting a link between quality of relationships in the family and social competence – most commonly studied within peer relationships – is substantial and supported by both attachment and social learning approaches. Several studies from an attachment perspective demonstrate that the quality of child–parent attachment in infancy and early childhood predicts relationship quality with peers concurrently, although longitudinal associations are weak (Cassidy, Kirs, Scolton, & Parke, 1996; Moss, Rousseau, Parent, St-Laurant, & Saintonge, 1998; Sroufe, Egeland, & Carlson, 1999). In general, these studies show that, compared with children who were judged to have an insecure attachment relationship with parents, children with a secure attachment relationship are more likely to be rated as popular and accepted by their peers, and to be rated as having more prosocial skills which promote positive peer interactions (Greenberg, Siegel, & Leitch, 1983; Lieberman, Doyle, & Markiewicz, 1999). In the social learning model, the connection between parenting and peer relationships is believed to be mediated by social cognitions and behavioral strategies (e.g., concerning the effectiveness of aggressive behavior) learned from interacting with parents. Social learning researchers and those adopting the parenting typology approach have also emphasized the importance of parental monitoring and control in preventing the child from developing affiliations with deviant peers and poor role models (Brown, Mounts, Lamborn, & Steinberg, 1993). Empirical research using the social learning approach has established linkages between parenting and peer relationships (Dishion, 1990; Petit, Dodge, & Brown, 1988; Vuchinich, Bank, & Patterson, 1992). A related approach proposes that social-cognitive capacities important for positive peer relationships, such as emotional understanding, perspective-taking and emotional regulation, are developed in the context of the early parent–child relationship and are carried forward or generalized to later social relationships, including those with peers (Carson & Parke, 1996; Dunn, 1992; Parke, MacDonald, Burks et al., 1989). There is some uncertainty as to which theoretical position is strongest or which dimensions of the parent–child relationship are most relevant. As with the areas noted above, existing models of parent–child relationships converge in expecting that optimal parent–child relationships would be strongly linked with social competence and positive peer relationships, and that multiple components of the relationship, including warmth, conflict, and control and monitoring, have an important role. CHAPTER 64 1048 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1048

Again, parenting programs may be more likely to be successful if they attend to all these dimensions. Impact of Abusive Parenting on Physiological Functioning Rutter (1981) in his book Maternal deprivation reassessed concluded that it was not separation per se that necessarily was very harmful; rather, more important for child well-being was the quality of parenting that had preceded the separation, and in particular the quality of parenting and other experiences that then followed it. Research on animal models has illuminated some of the physiological concomitants of the stress that can arise from particular types of separation and poor parenting. For example, the work of Meaney and colleagues (Kaffman & Meaney, 2007) showed that after infant rats were separated from their mothers for short periods (less than 15 min) in the first 2 weeks of their lives, they showed much more marked rises in stress hormones (on the hypothalamic– pituitary–adrenal axis [HPA]), leading to sharp rises in cortisol in response to aversive stimuli, but that this overreactivity went back to normal after a few days. However, longer separations (3 h per day) during this period led to large and lasting overreactivity to stress, physiologically with six-fold increases in adrenocorticotropic hormone (ACTH) and cortisol production a year later in response to a mildly aversive stress (a puff of air in the eye), and behaviorally with far greater fearfulness, emotional arousal and poorer sociability with other rats. The core component is likely not to be the separation, but the treatment of the infant rat on reunion by the mother, who largely ignores it, seldom licking or grooming it, and sometimes trampling over it. Moreover, differences in physiological and behavioral responses to stress are not confined to cases of relatively extreme abuse. Amongst mother rats who have undisturbed access to their infants, there are marked differences in the prevalence of licking and grooming (L/G). Infants exposed to higher L/G grow up to have lower physiological reactivity, less fearful behavior and more prosocial behavior (Francis, Caldji, Champagne, Plotsky, & Meaney, 1999). This also affects brain growth, with offspring of high L/G mothers showing increased neural growth factors, specific receptors and cholinergic innervation of the hippocampus, which correlates with improved spatial learning and memory (Liu, Diorio, Day, Francis, & Meaney, 2000; Zhang, Chretien, Meaney, & Gratton, 2005); in contrast, pups of low L/G mothers show increased hippocampal cell death (apostosis). The mechanism is environmental because cross-fostering studies show that infants of low L/G mothers develop normally when reared by high L/G mothers (Caldji, Diorio, & Meaney, 2000). Various interventions can mitigate the effects of poor early rearing, including gentle handling by humans, provision of a more stimulating environment and even antidepressants. Each of these interventions was reasonably successful in both physiological and behavioral terms (Bredy, Humpartzoomian, Cain, & Meaney, 2003). Broadly similar findings apply to primates, who have more similar developmental trajectories to humans; they provide good models for examining how much is a result of genetic susceptibility and how much is due to rearing, and for examining gene–environment interactions in the development of psychopathology (Barr, Newman, Becker et al., 2003). These findings are likely to obtain for humans too. Thus, Nemeroff and colleagues found that, compared with controls, women who had a history of child maltreatment showed a six-fold increase in HPA axis reactivity to laboratory-induced stress (Heim, Newport, Bonsall, Miller, & Nemeroff, 2001). The child and adolescent literature is emerging (see chapter 28), but as yet there have been few studies. These studies have implications for parenting programs. First, children who have experienced repeated deprivation and abuse are likely to be biologically affected. The emotional overreactivity seen in some is not likely to be caused solely by learned habits in a background of typical physiology. Rather, some abused children may have been “set” to have far stronger reactions to stressors. This has implications for how they are seen, whether they are blamed for their reactions and may account for possible slowness to change behavior and “treatment resistance” compared with more appropriately raised children. Treatment implications are, compared with most children who had adequate parenting: 1 They need to be managed with understanding – reacting explosively in response to difficulties or frustrating situations may be far harder for them to control; 2 They should be managed in as calm and non-stressful a way as possible, to avoid setting off over-arousal with its concomitant outbursts of destructive aggression; and 3 They may take more learning trials to achieve goals, and may achieve less. Second, the biological data suggest that prevention and early intervention may be even more important than previously appreciated, in that children are not, as it were “only” psychologically affected by poor early experiences that can then be “corrected” by psychological therapy, but rather their experience may have lasting physiological and brain effects (Heim, Newport, Bonsall et al., 2001). Further research is now needed to determine the type, severity and duration of harmful experiences, how these interact with individual susceptibility and, crucially, how far early and later benign experiences and therapeutic interventions can modify not only behavioral responses, but also physiological responses. Helpful interventions worth investigating include biological and pharmaceutical ones in addition to psychosocial interventions. Limitations of Parenting Effects on Child Outcomes and Psychopathology Although there is increasing interest in the public and in government in promoting parent-based initiatives to improve the well-being of children, this is based on the assumption that improving parenting will lead to improvements in children’s well-being. However, the link is not a straightforward unidirectional one of simple cause and effect. If this is not understood, then parenting programs will be expected to deliver more than is possible, and disappointment will follow. Concerns PARENTING PROGRAMS 1049 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1049

about these limitations have been expressed in no uncertain terms in some quarters. Thus, Scarr (1992) asserted that for most children, parenting had little influence on their outcomes. By this she meant that apart from abusive parenting, the new behavioral genetic research alluded to below was showing that most of the variability in children’s outcomes was brought about by genetic factors, implying that so long as parenting was reasonable and “good enough,” differences in children’s developmental trajectories would be brought about by inherent factors. That parenting is not irrelevant is shown by the evidence of solid links provided in preceding sections, but it is nonetheless important to consider the limits of parenting effects. Genetic Influences on Parenting Genetically informed designs such as adoption studies can help tease out direction of effect. Parenting itself is not a purely socially determined activity. Results from several samples and methods show genetic mediation (Kendler & Baker, 2007; Neiderhiser, Reiss, Pedersen et al., 2004). Parents who are monozygotic (MZ) twins report engaging in more similar patterns of child-rearing with their children than do parents who are dizygotic (DZ) twins; this is also true for directly observed, dynamic, moment to moment, close interchanges in the parent–child relationship (Plomin, Reiss, Hetherington, & Howe, 1994). This has implications for those interventionists who believe parenting behavior is entirely socially determined. One consistent exception to the pattern of moderate to large genetic mediation of parent–child relationship quality is attachment. Studies of attachment in twins find similar rates of attachment security in MZ and DZ twins, suggesting only a small part is played by genetic factors in child attachment security (Bokhorst, Bakermans-Kranenburg, Fearon et al., 2003; O’Connor & Croft, 2001). Why genetic factors in attachment security exert considerably less effect than for other aspects of parent–child relationship quality is not readily apparent, but it is a replicated finding. Genetic designs can also help show environmental effects. In a unique “cross-fostering” study, in which adoptive parents of high and low socioeconomic status (SES) adopted children who were born into high and low SES families, Duyme, Dumaret, and Tomkiewicz (1999) found that low SES children adopted into high SES families exhibited a higher IQ than children who were adopted into low SES families, a difference of approximately 8 IQ points. By using a behavioral genetic “tool,” these researchers have provided some of the strongest evidence that an improved home environment can indeed have a causal link with children’s intellectual ability. Broader Social Influences There is a substantial covariation of risk factors in the child’s environment, such as marital discord, lack of money and poor schools; the same may be so for protective factors. Studies that fail to account for these environmental risks may overestimate the importance of the link between parenting and child outcomes. Further, the same parenting practice may have different effects in different contexts. For example, Pettit, Bates, Dodge, and Meece (1999) reported that parental monitoring of a child (e.g., knowing who he or she is with and what he or she is doing) played a particularly important part in preventing delinquency in adolescents living in violent and highrisk neighborhoods. The effect of similar levels of monitoring in low-risk environments was less. Thus, the larger social context moderates the patterns of associations and likely causal processes that operate more proximally to the parent–child relationship. A second example of research on contextualizing parenting focused on the child’s temperament. Kochanska (1997) reported that, for temperamentally fearful children, gentle parental control was associated with optimal behavioral/emotional regulation whereas temperamentally more aggressive (“fearless”) children required more firm control to achieve the same positive results. Other studies have similarly shown that children with difficult/irritable temperament may be less likely to develop behavioral problems under conditions of firm compared with lax or less restrictive control (Bates, Pettit, Dodge, & Ridge, 1998). Belsky (1997) has taken this view further in suggesting that children differ from one another in how susceptible they are to rearing influence. In his model, those children who are more irritable may be more susceptible to rearing influence. The implication for parenting programs is that they should not follow a “one size fits all children” rigid manualized approach, but rather should vary their recommendations according to child characteristics and the wider social context. Influence of Child Characteristics on Parenting The notion that there are “child effects” on parenting behavior is hardly new. Indeed, Bell and Harper’s (1977) book summarized numerous studies of several types showing the myriad ways in which child characteristics shape the parenting they receive. Key child characteristics included gender, age, temperament and presence of physical or intellectual or behavioral disability. In one classic study, Anderson, Lytton, and Romney (1986) crossed parent–child dyads in which the child was antisocial with parent–child dyads in which the child was not antisocial. Observations of parent–child interactions across the mixed pairings demonstrated that parents of nonantisocial children exhibited increased negativity toward the antisocial child, but parents of the antisocial children did not exhibit elevated conflict toward the non-antisocial child. In other words, it appeared to be the child’s behavior that was driving the interaction and not the parent’s. Another study used a longitudinal follow-up of a sample of adopted children (Croft, O’Connor, Keaveney et al., 2001). When the parent–child interactions were observed at age 4, the researchers found that child developmental status, indexed by lower cognitive ability, was associated with lower levels of parental positive interactions and higher levels of parental negative behavior. Two years later, many of the children had shown a significant improvement in cognitive ability. However, this developmental catch-up was not predicted by earlier parenting; CHAPTER 64 1050 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1050

instead, gains in the children’s cognitive ability predicted positive changes in the parents’ behavior between assessments. Intervention strategies with children with disorders can illuminate child effects on parenting. Compared with other mothers, mothers of children with attention deficit/hyperactivity disorder (ADHD) exhibit more negative control and less warmth. However, giving children medication for ADHD leads to positive changes in their parents’ behavior (Barkley, 1988). Thus, improvements in parenting behavior can be made without targeting the parent but merely improving children’s behavior. As well as making the theoretical point that child characteristics affect parenting behavior, this process has practical implications. In families where a child is overwhelming their parents’ parenting capacity, in addition to targeting parenting skills, changing child characteristics directly may also enable parenting to be better. In summary, recent research suggests that parenting styles are to some extent genetically influenced; parenting effects will vary in their impact on the child according to the context in which they live; and children with different temperaments will elicit different parenting styles and will have different parenting needs. All these considerations have implications for parenting programs, including the need for a careful assessment prior to commencing treatment, which should then be tailored accordingly. Programs for Infants Based on Attachment Theory In the last decade or so, many new parenting programs have sprung up that directly use attachment theory. Some use it in a very focused way, whereas others use it more loosely and incorporate other concepts. The core notion is that parents should increase sensitive responding to provide a secure base. For a review of the effects of disrupted early attachments, see Dozier and Rutter (in press). Content of Typical Programs Focused interventions typically last 5–20 sessions and videotape mother–infant interactions and then replay them. During replay the idea of recognizing the infant’s signals is brought out – in early stages, even if a mother is usually ignoring her infant, the therapist will try to find one bit of videotape where nonetheless she does respond. Perhaps the infant will smile and she will smile back, leading the infant to gurgle with pleasure. The therapist might say “Look, when he smiled you smiled back so warmly that he showed he loved it by gurgling!” In later sessions, when the mother’s confidence has been gained (over 95% of participants are mothers, but the principle is the same for fathers or other carers), a less satisfactory piece of interaction may be examined. When a mother is not responding, the therapist can point this out, and ask “What was going through your mind at that moment?” This may elicit many interesting responses, from preoccupation with the mother’s own needs or hassles (“I was wondering how to pay off my debt”) to misperception of cues (“I thought he was trying to wind me up” said of a messy eater), to strong negative emotions arising from her past experience (“When he does that I think he’s just like his father, who ruined my life”). The great strength of this approach is that: 1 It gives parents an accurate picture of what is actually happening (rather than just talking about their perception of their relationship with their infant, as in traditional parent– infant psychotherapies); 2 It enables them to see for themselves that when they change their behavior, this impacts on their infant; 3 It allows simultaneous exploration of the mother’s mental state, so that mental blocks to more sensitive responding can be explored and often overcome. Examples of focused programs include that by the Leiden group (Velderman, Bakermans-Kranenburg, Juffer et al., 2006). Broader attachment-based therapies have been developed for infants and children who have been abused and who may have been transferred to foster families. This provides an interesting context in which to apply attachment theory because by definition these children have experienced disruption of attachment figures, and almost always suffered abuse or neglect at their hands. These include the program devised by Dozier, Lindheim, and Acierman (2005), which is used with both birth and foster-parents. It lasts 10 sessions and is based on the following (empirically based) notions. 1 Like parents in intact families, foster-carers may have their own insecure (unresolved or dismissing) attachment representations which will predispose them to be insensitive to their foster-children, who will have elevated need in terms of disorganized attachment patterns. Dozier concludes that because of their states of mind, some carers may find that providing nurturance does not come naturally. Thus, the first goal of the intervention is to help foster-carers provide care even if it does not come naturally to them. 2 Infants in foster care often fail to elicit nurturance. Dozier’s group showed that fostered children fail to elicit nurturance from carers who would normally provide it. For example, after falling from a chair, such an infant may turn away; even an autonomous mother might say “Oh, I’m glad you’re OK” and tidy up the toys without picking the infant up and comforting him, as she would have had he shown distress. The intervention therefore aims to train foster-mothers to act in nurturing ways even in the absence of cues from the infant. 3 Abused infants are often poorly regulated at physiological, emotional and behavioral levels. This means they sleep poorly, often eat sporadically, show disruptive behavior and abnormal arousal patterns. The response by Dozier’s group is to teach parents to follow the child’s lead. Others might counsel that parents should stay especially calm so as not to over-arouse the child, be more patient and turn away from conflicts, but be quick to soothe the child and look assiduously for ways to do this. 4 Abused infants often have experienced threatening situations. This may lead them to cut off or dissociate or have other maladaptive interactions. Foster-parents are therefore trained to avoid being threatening, either emotionally through being PARENTING PROGRAMS 1051 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1051

angry, or by threatening the security of the relationship (e.g., saying they will return the child to social services). Other attachment-based programs include the Circle of Security program developed by Cooper, Hoffman, Powell, and Marvin (2005) for at-risk children in birth families. All three programs mentioned so far use video-feedback. Other interventions that do not use video-feedback include that developed by Zeanah and Smyke (2005) for children who were severely deprived in institutions such as Romanian orphanages, and more lengthy and intensive psychodynamic ones such as that of Slade, Sadler, and Mayes (2005). Olds (2006), in contrast, developed a home visiting program delivered by nurses (Nurse–Family Partnership) that is not based on attachment theory but on systematic evaluation of and evidence-based interventions for risk factors from pregnancy onwards. Thus, parents are encouraged to reduce cigarette and alcohol consumption in pregnancy through understanding the effects on their babies; once the baby is born, parent–child interaction is coached, including how to stimulate the baby appropriately, and wider issues such as partner violence and further general education for the mother are addressed. Effectiveness There have been several trials for attachment-based approaches. The meta-analysis by Bakermans-Kranenburg, van Ijzendoorn, & Juffer (2003) found 81 studies with a total of over 7000 parent–infant pairs assessed. Overall, they improved parental sensitivity by 0.33 standard deviations (SD) and attachment security by 0.20 SD. However, there were large variations between approaches used. Perhaps surprisingly, the most effective interventions were relatively short (under 26 sessions) and started later (after the infant was 6 months). Both of these finding go against cherished notions that early intervention must be better, and that more effort should lead to more change (in fact, the mean effect size for long interventions was –0.03). However, were the findings true for disorganized attachment patterns, which carry a worse prognosis? A separate metaanalysis of this group again found the more focused interventions still worked better (Bakermans-Kranenburg, van Ijzendoorn, & Juffer, 2005). Was it the case that short interventions were not effective for multi-problem families? Again, this was not the case, the short interventions still worked better than long ones (effect size 0.48). Possible reasons for these findings are that the short interventions focus more specifically on sensitive responding and mostly use video-feedback in a pragmatic behavioral way, rather than taking a more counseling or traditionally psychotherapeutic approach. Is it then the case that the longer interventions have a broader impact on a wider range of outcomes? There is rather limited information on this issue, but again the data do not appear to support this (van IJzendoorn, Bakermans-Kranenburg, & Juffer, 2005). What about parenting programs that do not rely heavily on attachment theory? Some use a general notion that if the parents are supported, then they in turn will relate better to their infants. For example, in a trial of the home visiting program Homestart, which involved a mean of 97 h of face-to-face contact with mothers, none of the many mother or child variables measured changed (McAuley, Knapp, Beecham, McCurry, & Sleed, 2004); a similar lack of effectiveness was found for the Oxfordshire Home Visiting project (Barlow, Parsons, & Stewart-Brown, 2005). In contrast, interventions that focus precisely on specified risk factors, even when these are many, seem to fare much better. Thus, the Nurse–Family Partnership (NFP) approach has been evaluated in three randomized controlled trials involving over 1000 mother–infant pairs. This has shown benefits for the children in terms of improved cognitive and emotional development and fewer accidents and injuries, and for the mothers in terms of fewer harmful health behaviors (e.g., smoking) and higher take-up of further education, less use of public handouts and a longer interval until subsequent pregnancy (Olds, 2006). Interestingly, in the third NFP trial (in Denver), mothers were randomized to receive the program from volunteer paraprofessionals or nurses. Both were given the same amount of training in the program, but overall the paraprofessionals failed to change the child or parent outcomes, whereas the nurses did. The problems of making early parenting interventions work under field conditions rather than in university trials was underlined by Spieker, Nelson, Deklyen, and Staerkel (2005), who embedded a trial of videofeedback with high-risk mothers in a Head Start preventive program in the USA, but there were no changes in parenting or child attachment status. Current Status of Attachment-based Interventions A number of conclusions seem warranted. First, interventions that only offer “support” for parents do not appear to improve quality of parenting or child attachment status, even though they are appreciated by parents. Second, the more specifically focused interventions that target particular parental behaviors such as sensitive responding lead to greater effect sizes on parenting and child attachment status. Third, the same is true of interventions that target broader risk factors such as maternal alcohol intake and further education; those with specific goals that make use of previously tested methods are more effective than less focused interventions. Fourth, it seems likely that using more skilled staff leads to larger effects. There are a number of unanswered questions that future studies could address. How important is increasing child attachment security, in itself? If the interventions only improve attachment security but not other outcomes, that will be of limited interest. Generally, long-term follow-up studies suggest that infants brought up in favorable circumstances who have insecure attachment patterns nonetheless do well in terms of later relationship quality and attainment, whereas those brought up with harsh parenting and disadvantaged circumstances do relatively poorly irrespective of attachment status (see summaries of the major longitudinal studies in Grossman, Grossman, & Waters, 2005). This is not to say that attachment patterns are not important, but rather to say that the research needs to broaden out to embrace other aspects of parent and child functioning. CHAPTER 64 1052 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1052

Programs for Children Based on Social Learning Theory Programs based on social learning theory have evolved over 40 years and there is a large evidence base. The vast majority are aimed at antisocial behavior as their proximal target outcome. The content and delivery of a typical program are shown in Table 64.1. Most basic programs take 8–12 sessions lasting 1.5–2 h each. Full accounts of programs are given by the developers (e.g., Triple P, Markie-Dadds & Sanders, 2006; Helping the Noncompliant Child, McMahon & Forehand, 2003; Parent–Child Interaction Therapy, Brinkmeyer & Eyberg, 2003; Defiant Children, Mash & Barkley, 2006; and The Incredible Years, Webster-Stratton & Reid, 2003). Format of a Typical Social Learning Program A typical individual program might run as follows. Part 1. Techniques for Promoting a Child-Centered Approach The first session covers play. This is seen as a fundamental aspect of improving the relationship with the child. Parents are asked to follow the child’s lead rather than impose their own ideas. Instead of giving directions, teaching and asking questions during play, parents are instructed simply to describe what the child is doing, to give a running commentary on their child’s actions. The target is to give at least four of these “descriptive comments” per minute. If the parent has difficulty in getting going, the practitioner suggests precisely what they should do, for example by saying “I’d like you to say to Johnny ‘You’ve put the car in the garage’.” As soon as the parent complies, the practitioner gives feedback, “That was a good descriptive comment.” After 10–15 min, this directly supervised play ends and the parent is “debriefed” for half an hour or more alone with the clinician. How the parent felt during the session is explored, and reservations and difficulties that arose are addressed. Usually, the effect of their behavior on the child during the training session is soon observed by the parent. Experiencing this close non-judgmental attention is surprisingly powerful for children, who at best feel they are “the apple of their parent’s eye.” For cases where virtually all communication with the child has become nagging and complaining, play is an important first step in mending the relationship. It often helps the parent to have fun with the child and begin to have some positive feelings towards them. Parents are asked to practice these techniques for 10 min every day. The second session involves elaboration of play skills. For the first 20 min, the previous week’s “homework” of playing at home is gone over with the parent in considerable detail. Often there are practical reasons for not doing it (“I have to look after the other children” or “I’ve got no help”) and parents are then encouraged to solve the problem and find ways around the difficulty. Solutions arrived at might include doing the play after the younger sibling has gone to bed or getting the oldest child to look after the baby while the parent plays with the toddler. For some parents there may be emotional blocks (“It feels wrong – no one ever played with me as a child”) which need to be overcome before they feel able to practice the homework. After this discussion, live practice with the child is carried out. This time the parent is encouraged to go beyond describing PARENTING PROGRAMS 1053 Content Structured sequence of topics, introduced in set order over 10–12 weeks Curriculum includes play, praise, rewards, setting limits and discipline Parenting seen as a set of skills to be deployed in the relationship Emphasis on promoting sociable self-reliant child behavior and calm parenting Constant reference to parent’s own experience and predicament Theoretical basis informed by extensive empirical research and made explicit Plentiful practice, either live or role-played during sessions Homework set to promote generalization Accurate but encouraging feedback given to parent at each stage Self-reliance prompted (e.g., through giving parents tip sheets or book) Emphasis on parent’s own thoughts and feelings varies from little to considerable Detailed manual available to enable replicability Delivery Strong efforts made to engage parents (e.g., home visits if necessary) Collaborative approach, typically acknowledging parents’ feelings and beliefs Difficulties normalized, humor and fun encouraged Parents supported to practice new approaches during session and through homework Parent and child can be seen together, or parents only seen in some group programs Crèche, good-quality refreshments and transport provided if necessary Therapists supervise regularly to ensure adherence and to develop skills Table 64.1 Features of effective social learning theory-based parenting programs. 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1053

the child’s behavior and to make comments describing the child’s likely mood state (e.g., “You’re really trying hard making that tower” or “That puzzle is making you really fed up”). This process has benefits for both the parent and the child. The parent gets better at observing the fine details of the child’s behavior, which makes them more sensitive to the child’s mood. The child gradually gets better at understanding and labeling their own emotional states, a crucial step in gaining selfcontrol in frustrating situations. Subsequent sessions follow the same pattern: 1 Reviewing the previous week’s homework; 2 Direct training of interaction with the child; and 3 Discussion afterwards of how it went. The speed at which the content is covered depends on progress. Later sessions cover the following ground. Part 2. Increasing Acceptable Child Behavior Praise and rewards are covered here. The parent is required to praise their child for lots of simple everyday behaviors such as playing quietly on their own, eating nicely, getting dressed the first time they are asked, and so on. In this way the frequency of desired behavior increases. However, many parents find this difficult. They may say “But he should be doing these things anyway, without being praised for it – there’s really no need.” When their child has misbehaved earlier in the day they are still cross, and this prevents them praising good behavior when it occurs. Some parents find that even when they want to praise their child, the whole process feels alien to them. Often, they never experienced praise themselves as a child. Usually, with directly coached practice, it becomes easier. Later sessions go through the use of reward charts. Part 3. Setting Clear Expectations Clear commands are covered next. A hallmark of ineffective parenting is a continuing stream of ineffectual nagging demands for the child to do something. In the program, parents are taught to reduce the number but make them much more authoritative. This is achieved through altering both the manner in which they are given, and what is said. The manner should be forceful (not sitting down, timidly requesting from the other end of the room; instead, standing over the child, fixing him in the eye and in a clear firm voice giving the instruction). The emotional tone should be calm, without shouting and criticism. The content should be phrased directly (“I want you to . . .”) and not indirectly or as a question (“Wouldn’t you like to . . .”). It should be specific, labeling the desired behavior which the child can understand, so it is clear to him when he has complied (“Keep the sand in the box”) rather than vague (“Do be tidy”). It should be simple (one action at a time, not a chain of orders), and performable immediately. Commands should be phrased as what the parent does want the child to do, not as what he should stop doing (“Please speak quietly” rather than “Stop shouting”). If a child is in the middle of an activity, rather than abruptly ordering a stop, a warning should be given (“In two minutes you’ll have to go to bed”). Rather than threatening the child with vague, dire consequences (“You’re going to be sorry you did that”), when–then commands should be given (“When you’ve laid the table, then you can watch TV”). Part 4. Reducing Unacceptable Child Behavior Consequences for disobedience are covered next. They should be applied as soon as possible. They must always be followed through – children quickly learn to calculate the probability they will be applied, and if a sanction is only given on every third occasion, a child is being taught he can misbehave the rest of the time. Simple logical consequences should be devised and enforced for everyday situations. If water is splashed out of the bath, the bath will end; if a child refuses to eat dinner, there will be no pudding. The consequences should “fit the crime,” should not be punitive and should not be long-term (e.g., no bike riding for a month), as this will lead to a sense of hopelessness in the child, who may see no point in behaving well if it seems there is nothing to gain. Consistency of enforcement is central. Ignoring is an important additional technique. This sounds easy but is a hard skill to teach parents. Whining, arguing, swearing and tantrums are not dangerous to children and other people and can usually safely be ignored. The technique is very effective. Children soon realize they are getting no pay-off for the behaviors and soon stop. Vice versa, if acting this way gets attention and shows them they can annoy and wind-up their parents, they will continue to hone their skills in so doing. Ignoring means avoiding discussion, avoiding eye-contact, turning away, but staying in the room to monitor. As soon as the child begins to behave appropriately, it is essential to attend and give praise. This is central to shaping up desirable behavior. Many parents find this difficult as they are often still angry with the child. Time out from positive reinforcement remains the final “big one” as a sanction for unacceptable behavior. The point here is to put the child in some boring place away from a reasonably pleasant context. This will not be the case if the home is generally negative, when being sent to a room alone will be a relief and not a punishment. Equally, if the room has lots of interesting toys it will also not be a punishment. Time out should be for a previously agreed reason (hitting, breaking things – not minor infringements) for a short time (say 1 min for each year of age). However, the child must be quiet for the last minute – if he is still screaming, he stays in for as long as it takes until he’s been quiet for a minute. Parents must resist responding to taunts and cries from the child during time out, as this will reinforce the child by giving attention. Time out provides a break for the adult to calm down too. Part 5. Strategies for Avoiding Trouble These include planning ahead to avoid troublesome times of day and situations, negotiating with the child how to accommodate their wishes while fitting in with the family goals, and developing a problem-solving approach with the child to promote independence, along the lines of problem-solving approaches taught directly by professionals to children (Kazdin, 2005). CHAPTER 64 1054 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1054

Effectiveness of Social Learning Programs Outcomes Research has predominantly looked at children with antisocial behavior. This is a reasonable target because it indexes a wide range of poor outcomes, and because parenting is implicated as a major contributory factor (see review above, and chapter 35). A decade or so ago there was still a question as to whether parenting programs improved child antisocial behavior. Since then systematic reviews and meta-analyses of scores of studies usually with no-treatment controls have confirmed that they do indeed generally work well for children aged 3–10 (Lundahl, Nimer, & Parsons, 2006; Maughan, Denita, Christiansen et al., 2005; McCart, Priester, Davies, & Azen, 2006; for a narrative review including comparison of individual versus group based studies see Scott, 2002). Mean effect sizes across studies vary from around 0.4 to 1.0 according to outcome, showing reasonably good effectiveness. The field has moved on to consider further questions, including comparison with active controls such as non-behavioral programs, investigation of predictors of treatment response and mechanisms of change. Comparison with Non-behavioral Programs There have been a number of head-to-head comparisons of non-behavioral humanistic approaches with behavioral programs, although most trials have been on relatively wellfunctioning volunteer samples. Humanistic approaches are usually based on the notion that supporting the parent in a non-judgmental accepting way will make them feel better and parent more effectively. Pinsker and Geoffrey (1981) compared a behavioral group with a humanistic approach, Parent Effectiveness Training (PET). On parent report, the behavioral group showed a significant reduction in child problem behavior whereas PET and controls did not; on direct observation, both treatment groups did better than controls. Bernal, Kinnert, and Schultz (1980) compared a client-centered group with behavioral management and waitlist controls, and found on parent report the behavioral group did better than the other two, but on direct observation no group changed. With a clinical sample, Nichol, Smith, Kay et al. (1988) studied families referred by local social services for active physical abuse and allocated them to individual play therapy for the child plus support from social worker for the mother, or home-based work that offered parent training plus parent support through casework. Parent training led to a greater reduction in parental coerciveness and aversive behavior towards their children, measured using direct observation. In summary, behaviorally based programs appear to improve child outcomes more reliably. What Makes Parenting Programs Work? Predictors and Moderators of Outcome In a controlled trial, if a characteristic of the participants such as child age or severity of symptoms predicts outcome in both the intervention and control groups, then it is a predictor. However, if after allowing for this there is additionally an interaction with treatment, so that one subgroup (say, younger children) do better than another (older children) in the intervention group only, then the characteristic is operating as a moderator. Until recently, analyses have mainly been at the level of predictors only, with one or two exceptions. A number of predictors have been identified. Child Age and Gender Clinicians often gain the impression that boys and older children, especially adolescents, do worse. Indeed, adolescents are generally found to do less well in parenting programs for antisocial behavior. Bank, Marlowe, Reid, Patterson, and Weinrott (1991) found a far smaller effect size when using parent training with adolescents than with younger children at the same institution. More generally, the meta-analyses of interventions for antisocial behavior and juvenile delinquency (see chapter 68) find that their effectiveness was considerably smaller than parent-training studies on younger children. However, studies on adolescents generally have the most severe, persistent cases. When cases of similar severity are compared directly, there is no age effect; Ruma, Burke, and Thompson (1996) compared response to treatment using the parent Child Behavior Checklist (CBCL) score for groups in early childhood (2–5 years), middle childhood (6–11 years) and adolescence (12–16 years). The adolescent group did slightly less well, but the difference disappeared on multiple regression analysis, which showed that greater initial severity was the only significant predictor of poorer response. Within the prepubertal age group, Dishion and Patterson (1992) had expected to find parent training more effective for younger (2.5–6.5 years) than older children (6.5– 12.5 years) assessed by direct observation. However, they found it was of similar effectiveness for both age groups, a finding replicated by Beauchaine, Webster-Stratton, and Reid (2005). The meta-analysis by Serekitch and Dumas (1996) found that across 36 studies (not within them), effectiveness was greater in older children, within the range 3–10 years. In summary, it appears that age is not a clear determinant of outcome. Naturally, in adolescence different approaches are needed, with more emphasis on negotiation, and close supervision when the young person is out of the house, but the belief that adolescents are inevitably very difficult to change is not supported by the evidence. Likewise, boys are as likely to improve as girls (Beauchaine, Webster-Stratton, & Reid, 2005; Scott, 2005). There is therefore room for some optimism when treating adolescents, so long as evidence-based approaches are skillfully applied. Child Psychopathology The meta-analysis by Reyno and McGrath (2006) found that more severe initial antisocial behavior predicted less change, but this was a bivariate association with no controlling for related factors such as family adversity. In contrast, taking such factors into account, Scott, 2005) found the opposite: those with higher initial levels improved more. Further studies that address this issue using multivariate statistics are needed. Child ADHD generally predicts a less good response (MTA PARENTING PROGRAMS 1055 9781405145497_4_064.qxd 29/03/2008 02:58 PM Page 1055

Cooperative Group, 1999; Scott, 2005), although some investigators find it is no bar to improvement (Beauchaine, WebsterStratton, & Reid, 2005). The MTA study is informative about possible mechanisms, because direct observations of the parents in the psychological treatment-only arm showed that they had changed their behavior, whereas using the same measure, child ADHD symptoms did not (Wells, Chi, Hinshaw et al., 2006). This would suggest that it is the characteristics of the child with ADHD that make them less sensitive to change, rather than alternative mechanisms such as, say, the parents themselves having ADHD so not implementing more effective parenting practices. In contrast, when studied, comorbid anxiety appears to predict better treatment response (Beauchaine, Webster-Stratton, & Reid, 2005). Family Factors Demographic indicators such as single parenthood, lower maternal education, lower family income and larger family size have all been found to have a small but negative effect on outcomes (Reyno & McGrath, 2006). Most studies find that parental psychopathology, especially maternal depression, predicts worse outcomes, as do life events and harsher initial parenting practices (Reyno & McGrath, 2006). Doolan (2006) found that for mothers with the most negative beliefs about their children (especially when they felt persecuted by them), their children’s behavior did not change at all. The implications of how programs may be modified to take into account these findings are discussed below. For a review of how parenting programs have been developed to address difficulties that prevent change in parenting, such as discordant partner relationships, depression and substance abuse, see Scott (2002). Mediators of Change In recent years, researchers have begun to investigate what mediates outcome, as recommended by Rutter (2005). To mediate treatment outcome: 1 The treatment has to change outcome; 2 Treatment has to change the mediator; 3 The mediator has to correlate with outcome; and 4 The effect of treatment on outcome has to reduce or disappear after controlling for the mediator (Baron & Kenny, 1986; Kraemer, Wilson, Fairburn, & Agras, 2002). In other words, the treatment does not work unless it changes the mediator. It would seem likely that for parenting programs to change child behavior, some aspect of parenting would first have to change. This is worth testing as it might not be the case – for example, the parenting program could make a couple realize that they should, say, stop arguing in front of their child, but still spend the same amount of time in play and joint activities and use the same disciplinary strategies; or the parenting might stay the same but as a result of the program, the parents may have changed the child’s school. These wider aspects of a child’s world are typically not measured in parenting intervention studies. Beauchaine, Webster-Stratton, & Reid (2005) found that changes in critical, harsh and ineffective parenting both predicted and mediated child change in antisocial behavior. Similarly, Tein, Irwin, MacKinnon, and Wolchik (2004) found that parental discipline and mother–child relationship quality mediated reduction in antisocial behavior in post-divorce children, whereas Gardner, Burton, and Klimes (2006) found that positive parenting also mediated change. In adolescents, there have been two high-quality studies. Eddy and Chamberlain (2000) investigated mediators of change in seriously antisocial adolescents (average 13 police contacts at age 15) looked after by specially trained foster-parents. They found that all three measured parenting constructs mediated change, namely effectiveness of discipline (fairness, punitiveness, use of positive reinforcement); quality of supervision (youth reports of supervision and of doing things the foster-parent did not know about, difference between fosterer’s and youth’s accounts of problem behavior, percentage of time spent by youth in the presence of an adult); and an overall positive adult–youth relationship (how much they liked each other). Additionally, the amount of time spent with deviant peers including the degree of their influence also mediated outcome. Taken together, these four factors accounted for 32% of variance in subsequent antisocial behavior – a substantial amount. Similarly, Huey, Henggeler, Brondino, and Pickrel (2000) in a trial of multisystemic therapy for delinquency showed that a positive relationship and firm discipline mediated outcome, and good supervision mediated deviant peer association, which in turn mediated subsequent antisocial behavior. Recent studies are beginning to investigate the extent to which parental beliefs, rather than just behavior, need to change – Doolan (2006) found that improvement in the positive view of the child mediated reduction in antisocial behavior. These studies have moved the field on, because they indicate not just which dimensions are associated with antisocial behavior in longitudinal studies, nor baldly whether treatment works, but rather show which variables need to change for a good outcome, thus helping to understand how treatment works (Rutter, 2005). This is turn has led to changes in programs. Thus, there is now a much stronger emphasis on preventing deviant peer association – for example, the Oregon Social Learning Center (OSLC) foster program penalizes youth for every minute they cannot verifiably account for their where-abouts. Future program modifications may include specifically cognitive elements to address negative cognitions that appear to stop change occurring (Sanders, Pidgeon, Gravestock et al., 2004). Future studies will need to take measures of mediators at several time points, to determine the sequence of changes – to answer, for example, whether parenting must change before child behavior can change; whether all aspects of the parenting relationship need to change to get most child improvement, or just those that are poorly practiced; how much parenting change is necessary for child change to occur; and what systematic interactions are there between parenting styles and child psychopathology that could inform how best to improve outcomes. 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run by highly motivated originators of programs, who supervise carefully chosen therapists intensively in demonstration projects. In the meta-analysis of child psychotherapy trials by Weisz, Donenberg, and Han (1995) those conducted in university clinics had a large mean effect size of 0.7 SD. In stark contrast, all the clinic-based studies reviewed since 1950 did not have any significant effects. This has enormous implications for service delivery, as it is of little use if interventions do not work under “real-life” conditions. Reasons postulated include: 1 Children with comorbid conditions are typically excluded from trials; 2 Therapists in trials deliver evidence-based programs for the condition under study only, whereas in real life therapists see many diverse conditions and do not deliver evidence-based programs – they have to be “jacks of all trades” (and so perhaps “masters of none”); 3 Even where therapists in everyday clinics do deliver evidencebased approaches, they do not receive good quality ongoing supervision. Therefore, for a therapeutic approach to be considered useful, findings need to be replicated in ordinary clinical settings by therapists who are part of the routine service and independent of the program originator. Weisz noted that fewer than 1% of published child psychotherapy trials met all three of the following criteria: 1 Carried out by teams independent of the program developer; 2 Delivered by clinicians employed in regular clinical practice; and 3 Used clinically referred children as participants. To address these concerns Scott, Spender, Doolan, Jacobs, and Aspland (2001) carried out a trial of Webster-Stratton’s Incredible Years program on regular clinical referrals for severe conduct problems (98th percentile), most of whom had comorbid ADHD (mean hyperactivity percentile 90th). Therapists were local clinicians given additional training. Despite these constraints, the effect size was large (over 1 SD) and maintained 1 year after the end of treatment (Scott, 2005). The authors suggested that the effectiveness was related to having skilled staff who, despite having regular clinical jobs, made time to come to supervision each week, when videotapes of practice were examined and alternative therapeutic approaches rehearsed. This approach to supervision is in contrast to traditional supervision, where therapists recount what they think went on, and are given advice. Therapist Variables Therapist performance can be divided into the following: 1 The alliance, which could be defined as how well, both personally and collaboratively, client and therapist get on together; 2 Fidelity or adherence to specific components of a model, which concerns the extent to which the therapist follows the actions prescribed in the manual; 3 The skill or competence with which the therapist carries out the tasks (i.e., how well the therapist performs the actions). A meta-analysis of youth studies of the alliance found it contributed on average an effect size of 0.21 SD to outcome; this held across treatment types, and across youth, parent and family approaches (Shirk & Carver, 2003). Kazdin, Whitley, and Marciano (2006) found about 7% of the variance in outcome of treatment for antisocial children was related to the alliance, although findings varied by informant. Given the importance of these qualities that are therapy type independent, does it matter what the warm and genuine therapist who makes a strong alliance does during the sessions? One might expect fidelity would be central, because if the “wrong” therapy is given, it should be less effective. However, studies are somewhat equivocal, thus Henggeler, Melton, Brondino, Scherer, and Hanley (1997) compared a total of 15 parent, therapist and youth-rated fidelity scales with seven youth outcomes in a trial of multisystemic therapy, and found statistically significant effects for only 11 out of 105 associations. The same group (Huey, Henggeler, Brondino et al., 2000) found that when they used a latent variable approach, therapist-rated fidelity improved family functioning and parent monitoring, both of which in turn reduced youth delinquency, but that parent- and youth-rated fidelity had no effect. This last finding could be because it requires a therapist to appreciate the complexity of fidelity, and also because therapists working across cases will be more consistent in their ratings than parents and youths, who may differ widely in their rating of the same phenomena. These somewhat modest findings for the role of adherence or fidelity raise the question whether applying the treatment according to the manual is necessary or sufficient to bring about change. Often adherence and fidelity ratings concern the extent to which certain actions specific to the therapy were carried out, such as following sequences as laid down in the manual during sessions, using certain questioning techniques, issuing homework, and so on. It is possible that a more important and relevant influence on effectiveness is the skill or competence with which these tasks are carried out. Thus, for example, two therapists running a parenting group might to the same extent discuss punishment, explore parents’ beliefs, teach time out as an alternative to spanking, rehearse it and issue homework. However, the more skilled one might do this in a more sensitive way with greater complexity, and so characterize the client’s mental state more accurately and be more proficient in overcoming barriers to rehearsal and homework, thus leading to more change. Supporting this notion, Forgatch, Patterson, and DeGarmo (2005) developed an observer-based instrument to assess therapist variables which included skill in a parenting program for recently divorced parents. They measured knowledge, structure, teaching skill, clinical skill and overall effectiveness. The outcome assessed was the proximal one of observed parenting practices, rather than child behavior; greater therapist skill led to more change in parenting. Likewise, in their trial under regular clinical conditions described above, Scott, Carby, & Rendu (2006a) found that therapist skill had a large effect on child outcomes; the worst therapist made outcomes slightly worse. 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CHAPTER 64 1058 implications for service delivery, because they suggest that at least for multiproblem clinical cases, a high level of therapist skill is required; staff training will need to reflect this. Conclusions Parenting programs have developed considerably in recent years. The best now incorporate modern empirical findings from developmental studies and use these to alter dimensions of parenting shown to improve specified child outcomes. Future developments may include better assessments of parenting so that programs can be tailored to specific needs rather than “one size fits all.” Studies are needed of the mechanisms that mediate changes in parenting behavior; for example, whether is it necessary for parental beliefs about the child to change, or whether it is sufficient for parents to learn better habits. Then how changes in parenting mediate child change and interact with different types of child temperament and behavior problems needs clarifying. 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1062 Family therapy, like other psychotherapies, has evolved over several decades and today includes a broad range of ideas that are often described as representing discrete theoretical models or schools (e.g., structural, strategic, Milan systemic, narrative; Carr, 2006). Different approaches to family therapy tend to focus on one particular aspect of change (e.g., the structural model on the need for change in relationships, or the Milan approach on the need to change beliefs) and are usually associated with particular groups or centers. In practice, the conceptual ideas as well as the techniques associated with each of them tend to be adopted quite widely and most family therapists integrate ideas from different approaches in their work, as single theoretical models often do not provide sufficient conceptual breadth or choice of treatment techniques to address the wide range of difficulties presented to clinicians. The boundary lines between family therapy and other therapeutic approaches are also indistinct and there are many overlaps. The distinctions are often more about historical developments and professional and philosophical allegiances than clearly defined conceptual differences. This is reinforced by research on common factors in psychotherapy, which suggests that they may account for as much as 90% of outcome variance (Asay & Lambert, 2000; Wampold, 2001), although the actual role of common factors is subject to much debate (Sexton & Ridley, 2004; Sexton, Ridley, & Kleiner, 2004; Simon, 2006; Sprenkle & Blow, 2004, 2007). Alongside this, the growing body of research on evidence-based practice identifies a number of clearly defined family treatments as effective (Lundahl, Risser, & Lovejoy, 2006; Shaddish & Baldwin, 2003; Stanton & Shaddish, 1997; Woolfenden, Williams, & Peat, 2007). Taken together they suggest that while there may be common factors across all psychotherapeutic approaches, particular problems may respond well to very specific treatment components which may be incorporated in a number of different treatment models, albeit sometimes conceptualized in different ways. At the same time, the research also indicates that successful treatments are united at another level by factors such as empathy or warmth of the therapist or the level of motivation of the client (Beutler, Malik, Alimohamed et al., 2004; Clarkin & Levy, 2004; but see chapter 18 for a somewhat different conclusion). Part of the effectiveness of family therapy will be the skill of the therapist to use the most appropriate approach and interventions and to maintain the engagement and motivation of family members. Theoretical and Empirical Developments The Family as a System Family Systems Theory, the conceptual framework for much of the thinking about working with families, has evolved considerably over the years. The original notion of the family as a system (Ackerman, 1938; Burgess, 1926), strongly influenced by cybernetic concepts (von Bertalanffy, 1968), described a number of features such as the recursive nature of relationships, the multilevel nature of communication (Bateson, 1972; Bateson & Ruesch, 1951), the development of recognizable patterns of interaction, the role of relationships and beliefs, and the allocation of family roles (Bateson, Jackson, Haley, & Weakland, 1956; Palazzoli, Boscolo, Cecchin, & Prata, 1978). More recent theoretical developments in family therapy theory have come from social constructionism (Berger & Luckman, 1966) and in particular narrative therapy (White & Epston, 1989). This emphasizes that what we consider as objective everyday reality is derived from and maintained by social experiences and that through social interactions we develop narratives to make sense of our own lived experience. Later in the chapter we discuss the impact that the incorporation of social constructionist ideas has had on the field. The second main strand in family therapy theory is the Family Life Cycle model (Carter & McGoldrick, 1999), which provides a “developmental lens” for understanding the way the family as a system evolves over time. Families need to provide stability and predictability but they also have to be able to change in order to adapt to new circumstances and the developmental demands of individual family members (Byng-Hall, 1991; Eisler, 1993). For instance, the child’s need for dependence and attachment requires a degree of stability and constancy in the family but, as the child develops, the family must find ways of meeting his or her needs for independence and separation too. As the family evolves through the predictable stages of the family life cycle, it needs to be able to adapt and change its habitual style of functioning. These expected stages of the family life cycle can be complicated by unexpected events such as illness, death, family separation or migration and the comFamily Interviewing and Family Therapy Ivan Eisler and Judith Lask 65 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1062 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

bined stress can contribute to the development of problems. There is evidence that at these transitional times there is an increased vulnerability and increased psychological morbidity (Gorell Barnes, Thompson, Daniel, & Burchardt, 1998; Hetherington, 1989; Kendler & Prescott, 1999; Ritsner & Ponizovsky, 1999; Sartorius, 1996; Varnik, Kolves, & Wasserman, 2005). The way the family responds to an emerging problem is a crucial factor in determining the extent of individual vulnerability to such pressures (Walsh, 1997). Role of the Family in the Development and Maintenance of Psychological Difficulties Early theorizing assumed that particular types of family organization or patterns of family interaction would be connected with specific presenting problems. Explanatory models such as the “double-bind” theory of schizophrenia (Bateson, Jackson, Haley et al., 1956) or the “psychosomatic family” model of anorexia nervosa (Minuchin, Rosman, & Baker, 1978) were highly influential and led to important clinical innovations. Paradoxically, while many of the treatments developed in this way seem to be efficacious, the theoretical models themselves have generally proved to be flawed (Eisler, 1995; Kog, Vandereycken, & Vertommen, 1985; Olson, 1972). This has resulted in a somewhat unfortunate legacy. On the one hand, there are those who still see family therapy in its original guise (i.e., a treatment that aims to correct family dysfunction which was thought to lie at the heart of individual problems). Although few family therapists would today subscribe to this notion, outside of the field the view is still held quite widely. On the other hand, many within the field of family therapy, partly as a reaction to concerns about families being blamed by the early theoretical models, argue that the impact of family factors on child development is part of such a complex matrix of influences that any explanation that focuses on them is bound to be misleading. While we have some sympathy with the latter view, it clearly does not take into account the large body of research that now exists on the role of family factors in the development of the child. These include a range of adversities from prenatal factors such as being an unwanted child (David, Dytrych, & Matejcek, 2003; Kubicka, Roth, Dytrych, & Matejcek, 2002) or maternal stress (Huizink, Robles De Medina, Mulder, Visser, & Buitelaar, 2002), the consequences of growing up in an environment characterized by negative emotion, harsh parenting, high levels of discord or hostility (Fergusson & Lynskey, 1996; Fergusson, Horwood, & Lynskey, 1992; Moffitt, Caspi, Harrington, & Milne, 2002; Riggins-Casper, Cadoret, Knutson, & Langbehn, 2003) or the impact of neglect (Rutter & O’Connor, 2004). Equally, there are factors in the family that may have a protective role or promote resilience (Rutter, 1999, 2006). There are three reasons why one has to be cautious about how these findings are interpreted in relation to clinical practice. First is the often-made point that there is a complex interaction over time between the effect of the family environment, personality and temperamental characteristics of the child, the impact of the developing disorder on the family, and resilience factors as well as mediating genetic factors (Fergusson & Lynskey, 1996; Rutter, 1999). This is highlighted by behavior genetic research showing the differential impact of the family environment on children within the same family (Dunn & Plomin, 1990; Reiss, Hetherington, & Plomin, 1995; Rutter, Silberg, O’Connor, & Simonoff, 1999). The second is the reciprocity of influences between parents and children, which is well documented empirically (Crockenberg & Leerkes, 2003; Crockenberg, Leerkes, & Lekka, 2007; Deater-Deckard, Atzaba-Poria, & Pike, 2004; Scaramella & Leve, 2004). The third and probably most important is the variability of the findings showing that the impact of even the most powerful factors is anything but uniform (O’Connor, Rutter, Beckett et al., 2000). There are many examples but perhaps the best way of illustrating our point is to use a specific example of how research findings of this kind do not easily translate into practice. There are a number of clinical and research accounts of the possible adverse effects of maternal eating disorder on the infant or young child (Lacey & Smith, 1987; Park, Senior, & Stein, 2003a; Russell, Treasure, & Eisler, 1998) showing obstetric complications, low birth weight, poorer physical development and in some cases the development of an eating disorder in the offspring when they reach adolescence. A series of observational studies by Stein and colleagues (Park, Lee, Woolley, Murray, & Stein, 2003b; Stein, Woolley, Cooper et al., 1994; Stein, Woolley, Cooper et al., 2006) has shown that mothers with a history of an eating disorder tended to be more intrusive and express more negative emotion with their infants during mealtimes and the children themselves had a more negative emotional tone and their mealtimes were more conflictual compared with controls. The children tended to be lighter than controls and their weight was related to the amount of conflict during mealtimes and the extent of the mother’s concern about her own body shape. The problematic interaction around mealtimes persisted at 5 years and when followed-up at 10 years the index children showed increased levels of shape and weight concerns and greater dietary restraint compared with controls (although at a considerably lower level than would be found in children with early-onset anorexia nervosa). A further study in the form of a randomized controlled trial (Stein, Woolley, Cooper et al., 2006) showed that a videofeedback intervention was effective in improving mother– infant interaction at mealtimes. Thus, we have research that identifies not only risk factors, but also some likely mechanisms through which these might operate and a possible effective preventive intervention derived from this. In spite of this, the clinical implications are much less straightforward than may seem at first sight. First, although the group effects in comparison with controls are strong, the findings apply only to a minority of the children in the index group. For instance, 27% of the index group was below the 25th centile for weight. This is much higher than the 4% in the control group but is still only a quarter of the sample. At age 10 there were no differences in the children’s weights. Similarly, there is considerable variability in the findings of FAMILY INTERVIEWING AND FAMILY THERAPY 1063 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1063

mother–child interaction within the index group, both in the initial study and at follow-up, and at 10 years there was no difference in levels of criticism or intrusive behaviors on the part of the mothers compared with controls. Second, while there is an association between the degree of a mother’s psychopathology and the disturbed interactional pattern, it is not clear what mechanism underpins this. Thus, it is unclear to what extent it is a direct consequence of the mother’s eating disorder (e.g., fearing that her infant might put on too much weight) or if the problems arise out of her lack of confidence in her parenting, resulting in being unnecessarily controlling with the child. The point we want to emphasize, however, is the complexity of the process through which adversity operates over time in individual cases. While it is clear that although as a group the children were at increased risk of developing disturbed eating attitudes, most in fact did not. Consider now the opposite scenario when as a clinician we see an adolescent with an eating disorder whose mother also had an eating disorder. Stein’s work would indicate that the two might be linked but actually tells us very little about how this potential link may have operated for these individuals and even less about what the target of our intervention would need to be. Knowing what factors may have a negative impact on a child’s development is of course useful, but without knowing if these are still operating and if so how they operate, our clinical interventions remain blunt instruments. The current emphasis by most family therapy approaches on family strengths and resilience (Walsh, 1997), and on trying to optimize the family’s own resources, may be no better in terms of the science that informs it but it has the merit of engaging families in positive ways instead of adding to their sense of failure and self-blame. Impact of Individual Problems on Family Life When one member of a family begins to develop a problem it affects other members and also the relationships within that system (Rolland, 1999). Some of the effects may be readily apparent such as bullying or aggression from a young person with attention deficit/hyperactivity disorder (ADHD), at other times the impact may be less obvious and not immediately apparent (e.g., “well” siblings receiving less attention from parents). The stress of dealing with difficulties may put a strain on the parents’ relationship or the relationships with wider family. For the clinician, the crucial issue is to understand the gradual process of reorganization of the family in response to the problem to the point where it becomes the “central organizing principle” in the family’s life (Eisler, 2005; Steinglass, 1998). The process will often start through the activation of protective and supportive processes in the family but can in time become part of what reinforces or maintains the problem. For example, what may start as supportive reassurance of an anxious and perhaps somewhat perfectionist child may with hindsight turn out to be the start of a process of parents being drawn into the emerging rituals of a developing obsessivecompulsive disorder (OCD; Amir, Freshman, & Foa, 2000; Calvocoressi, Mazure, & Kasl, 1999). Useful models for understanding the process through which the family accommodates to the child’s problem can be found in the studies of the impact on the family of serious and enduring physical illness and disability (Rolland, 1987, 1994; Steinglass, 1998) and anorexia nervosa (Eisler, 2005; Neilsen & Bara-Carril, 2003). Understanding how families respond to emerging problems is an area demanding further research. The way families respond to this invasion into their lives will vary, but there is a tendency for the problem to magnify certain aspects of the family’s dynamics and narrow the range of their adaptive behaviors (Whitney & Eisler, 2005). As the symptomatic behavior increasingly takes a central role in family life what may be normal variations in family functioning may become more pronounced and take on new meanings. Concern may begin to feel like overprotection and intrusiveness, while attempts to promote independence may feel like lack of care. For the clinician, the important thing to be aware of is that much of what is observed in families is, at least in part, an outcome of the process of family accommodation to the problem and should not be too readily labeled as dysfunctional. Family Interviewing and Family Therapy Interviewing Families as Part of the Assessment Process The family interview is an important component in a comprehensive assessment. It provides the clinician with an opportunity to observe the family in direct interaction, to assess patterns of relationships, the emotional climate of the family and a chance to see how the family is organized around the symptoms presented by the child. Interviewing the family for purposes of assessment is a good starting point for making an effective treatment alliance with the family. Hearing the concerns of family members and their hopes for the future is as important as gathering information and making an assessment of the problem and can determine the most effective ways of helping the family to promote change. Observing Patterns of Interaction From the first contact with the family the clinician has opportunities to observe patterns of interaction, both immediately and over time (Byng Hall, 1995; Minuchin, 1974), which provide information about family structure and the nature of relationships in the family. Who presents the problem, how others respond, who finds it easy or difficult to have their say and how disagreements are handled will all provide initial impressions about the family’s preferred style. Careful observation of the interaction process will provide information that may confirm or contradict the content of what is being said. For instance, a mother may describe her relationship with her teenage daughter as difficult or conflictual. This may be supported by observing regular clashes or irritable responses between the two but at the same time one may notice that there are also many warm and supportive interactions taking place. CHAPTER 65 1064 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1064

When making observations it is important not to draw conclusions too readily as to what the observed patterns might “mean” or how they might be related to the presenting problem. While certain interactions may be clearly unhelpful (e.g., a parent, perhaps unwittingly, reinforcing the challenging behavior of a 6-year-old or frequent changes of topic preventing the discussion of difficult emotional issues), there may be a range of different (often overlapping) explanations for the observed behaviors. It is important to explore the family members’ own perceptions of such patterns and how they are connected to the beliefs and expectations of the family and how much flexibility or rigidity there is around them. Some patterns may reflect family beliefs, often strongly influenced by cultural or specific family traditions about the nature of family life, gender roles and parenting tasks, and may include patterns of which the family members themselves may not be aware. Family Beliefs and Meanings Attached to Behaviors These can be useful in making sense of behavior and relationships but also aid the process of engagement so that a family feels more understood. Beliefs relating to the presenting problem are particularly important. Future therapy may focus on exploring those beliefs and questioning them so that new meanings can develop. It may be possible to identify strong individual and family narratives that cloud the possibility of other options for change (Parry & Doan, 1994). One of the central aims of interviewing families is to explore alternative perceptions and meanings. This will include giving space to family members whose voices are not readily heard but also looking for different ways of framing the family narrative in a way that may provide a more constructive way forward. For instance, when a family is invited to a clinical meeting only one parent (e.g., mother) might attend the session. A variety of explanations may be given (dad is too busy; mum normally deals with doctors’ appointments; he doesn’t really understand). Implicit in such explanations is often a suggestion that the father is somewhat detached or does not really care. Often the most effective way of getting the father to attend the next session is to explore possible alternative reasons for his non-attendance (“Is he not here because he doesn’t care or is it because he does not believe he can help?” “If he believed that coming here would make a difference to you, would he come?” “If he thought that coming here would help him understand better, would he want to be here?”). The value of such questioning is that it creates a new frame of reference for familiar behaviors and may allow new conversations to develop. Social and Cultural Contexts One of the criticisms of some of the earlier models of family therapy is that they were based on a normative western model of the family and did not take sufficient account of the diversity of family life across cultures and the considerable change that families have undergone in most societies. The notion of what family life means in terms of the nature of relationships within the family, the expectations of the way in which families change over the life cycle or the roles of different family members varies hugely. Children may grow up in foster and adoptive families or a succession of different families or may be part of more than one family constellation following marriage break-up. Single-parent families, same-sex parent partnerships and friendship networks provide different forms of family life. While much of this may seem self-evident, it is crucial to be open to the different experiences and expectations that families bring with them. We also have to be aware that as professionals our own personal and cultural contexts will inevitably color our observations and assessments. Exploring the family’s social and cultural contexts will help to give meaning to specific behaviors, beliefs and relationships, but it may also provide information on stresses (e.g., specific social expectations in the community) and resources such as sources of networking and support (Falicov, 1995). An evaluation of the role of professionals in the referral process and the history and relationship of the family with other helping systems is important, particularly where there has been multiagency involvement, which may itself have become disabling for the family (Asen, 2002). Exploration of the Presenting Problem in the Context of Individual and Family Development An understanding of current life cycle and developmental demands and how the family is meeting these can be very helpful (Carter & McGoldrick, 1999). Sometimes, outside pressures such as illness or bereavement or internal changes such as separation and divorce add extra demands for change in addition to and sometimes contradictory to developmental demands. For instance, when an adolescent develops psychosis the normal developmental need for greater autonomy may be countered by the need for greater care and supervision. Accommodating to the needs of the illness is an understandable (and generally positive) response, although over time it may itself become unhelpful and limit the possibilities for change. Enquiring about the impact of the problem on family life is a good way of understanding the way the family is functioning and can often also reveal areas of strength and resilience that are not at first evident. Assessing the Family’s Style of Dealing with Problems and Identifying Strengths and Weaknesses This should help to address the important question about how best to work with a family, identify transferable skills and also aid the engagement process. The therapist will draw from the evidence relating to positive parenting and resilience factors to identify areas of strength which can be developed. For example, the capacity for reflection and empathy can be developed through sensitive and skillful questioning. The ability to make sense of past experiences can also be developed through the therapeutic process. Completing a family genogram (Bloch, Hafner, Harari, & Szmukler, 1994; McGoldrick & Gerson, 1985) is a useful way of learning about the way in which the family has dealt with other problems, family traditions and beliefs about family coping with adversity. FAMILY INTERVIEWING AND FAMILY THERAPY 1065 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1065

Family Interview Techniques It is beyond the scope of this chapter to cover in depth the variety of techniques that have been developed for interviewing families (Dallos & Draper, 2005; Palazzoli, Boscolo, Cecchin, & Prata, 1980; Tomm, 1988). Much of this literature is concerned with the way in which different types of question can shape the therapeutic relationship and the importance of questioning (as opposed to information giving) in general, in maintaining a position of curiosity which aims to keep the therapist and the family open to new information and new meanings. The following is a brief outline of some of the different styles of questioning that have proved useful in family interviews. Tomm (1988) suggests the following classification. Lineal Questions All interviews will include some questions of this type (e.g., “What is the problem that you have come with?” “How long has it been going on for?”). The disadvantage of lineal questions is that they tend to elicit a rather well-rehearsed way of presenting the problem which may be quite fixed, and not only expresses the family’s belief about the nature of the problem but also often connects with feelings of helplessness, guilt, blame and resentment. Circular Questions These differ from lineal questions not only in form but also in their underlying assumption. They draw on the assumption that individual problems are connected or embedded in patterns of relationships, and the aim of these questions is to illuminate or make visible what these patterns are. So, instead of simply asking “What is the problem?” one might ask “How would different people in the family describe your problem?” “Who worries about it?” “When people get worried about how unhappy you are, does it make you more or less depressed?” Other questions might require family members to describe what they make of behaviors that they observe, or speculate about thoughts and feelings of other family members. For instance, instead of asking just about the duration of the problem, the therapist might ask “When did your family first notice that you had a problem?” or “What effect did it have on you when your parents started talking about the problem?” Additional questions might be asked about the way different people in the family responded to the problem and what interactions this might lead to “When your mother shows her worry, what does your father do?” Asking circular questions starts to provide a basis for describing the problem in a more contextual way and also allows for alternative descriptions to be heard. For instance, the family might explain that “Mum worries a lot whereas father does not show his feelings much,” implying that mother is too anxious and father too detached. Useful questions to develop alternative aspects of this might be “How do you know when your husband is getting worried?” and “When your dad tries to reassure your mum, what effect does it have on her worry?” This may lead to a discussion of the differences between experiencing and showing feelings, and the interplay within the family between behaviors and emotion of different family members. It may also be an opportunity to talk about individual and gender differences and perhaps the different expectations that each parent brings with them from their own family of origin. One way of organizing the use of circular questions is to connect them to a systemic hypothesis. The therapist links information about the family to form a hypothesis about the family and their relationship to the presenting problem. This hypothesis is then tested through circular questions and continually revised in the light of feedback until an idea is arrived at that fits well enough with the family to provide some useful new information for them. For example, a systemic hypothesis might suggest that when a child feels sad his mother becomes anxious that she is not a good mother and hands over the care to her husband, who worries about his wife and criticizes his son, who finds that self-harming is a way of bringing his parents back into a caring contact with him. This hypothesis could be tested with reflexive questions such as “What would happen if your father was not at home?” or to the mother “If you felt more confident in yourself as a mother what might you do differently?” Strategic Questions These are questions that are used with the primary aim of influencing the family in a particular way rather than obtaining information and are analogous to giving instructions but because they are formulated as questions this may not always be immediately apparent. “Why do you let your mother speak for you?” is as much a statement that implies that it would be better for the adolescent to speak for him or herself as a question asking for an explanation. Challenging interventions of this kind can be useful at times but should be used sparingly, as they can induce feelings of guilt and they may also undermine the therapeutic relationship with the family (Tomm, 1988). Reflexive Questions These are questions that are also intended to influence the family but are less directive, instead requiring family members to reflect on how things might be different under changed circumstances, or if they took a different course of action: “What would happen if you were able to hide your worry when your daughter got depressed?” “If your mother didn’t try to help next time you have a row with your father, which one of you would be more likely to find a way of ending the argument; who would be the one to suggest a compromise solution?” Reflexive questions will typically introduce an alternative way of framing a particular behavior, opening up new possibilities and challenging the assumptions that may underlie a particular pattern of behavior. They may address an emotion or an aspect of behavior that is not being expressed overtly and may only be guessed at. They may include an implicit assumption: “What will you argue about with your mother when you are no longer bulimic?” – implying both that there will be change and that arguments between adolescents and parents are normal. Reflexive questions, like circular questions, assume that behaviors and the meanings that we attach to them are CHAPTER 65 1066 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1066

part of the relational context of the family and that there may be more than one meaning that might be attached to a particular behavior. The aim is for the family to reflect on this context and to explore the way in which thoughts, feelings and behaviors of different family members connect and how they might change. Relative Influence Questions These are specifically linked with the technique of externalizing the problem and explore the influence the problem has had on the person(s) and, more importantly, the influence the person has had on the problem. Through the process (e.g., of exploring how the family has helped a young child with fears or anxiety) it may be possible to establish exceptions or unique outcomes when there has been some control over the problem and how these can be developed further. It is important for the clinician to be able to use a range of interview styles with families and to have a repertoire of different types of question. Circular questions can be extremely useful in illuminating patterns of relationships in the family and this in itself may be an important and powerful part of the therapeutic process. However, such questions are most usefully applied when the interviewer has developed a clear hypothesis about the nature of the family relationships and the part played by the symptomatic behavior in the family organization (Burnham, 1986). When the interviewer has a clear focus, one question will naturally lead to the next one, helping to confirm or disconfirm the particular hypothesis. However, if such questions are used without a clear focus they are more likely to create confusion and a sense of alienation (Reimers, 1999; Strickland-Clark, Campbell, & Dallos, 2000). Intervening in the Family Interaction Process Careful and sensitive observation of the processes within the family allows the therapist to assess the nature of the relationships, provides opportunities for joining the family but is also the basis for introducing change in more active ways. There are numerous techniques (Minuchin & Fishman, 1981) for this, including blocking repetitive patterns (e.g., when one person in the family regularly acts as a peacemaker), reinforcing behaviors such as positive parenting, setting rules to prevent repetitive escalation of arguments or encouraging a family member whose voice tends to get lost to make sure they are heard. Interventions may range from fairly unobtrusive non-verbal ones (fixing the gaze of the person who is speaking, making it more difficult for others to interrupt) to much more overt, even dramatic gestures (“Why don’t you go and sit next to your dad and try to work out a compromise with him without getting mum to help you?”) and may include specific suggestions or homework tasks. Alternatively, the therapist may ask a question or make a comment in a way that draws attention to what is happening. When commenting on family process it is always important to recognize that the same phenomenon can be described in a number of ways ranging from neutral, through ascribing agency to one or other participant in the interaction, to overtly critical. Even quite neutral comments from the therapist may appear critical to family members. The clinician therefore has to be careful in choosing an appropriate style of comment or question. Andersen (1987) recommends that reflections of this kind are best carried out in a tentative way rather than being pronouncements or authoritative interpretations which are likely to come across as being judgmental. Involving Children and Adolescents in Family Interviews Even very young children can be effectively included in family interviews, provided they are engaged in an age-appropriate way. All too often, however, such interviews end up simply as an adult conversation in the presence of the child. It is helpful to provide appropriate toys and drawing materials, and use creative and play techniques in a similar way that they would be used in individual interviews with a child. Engaging a child effectively is often reassuring for parents, who may be concerned whether bringing the child to a psychiatric setting is the right thing to do. The choice of language in talking to parents about their child’s problems is also important with young children present as it may be difficult for the child to understand what is being said. Often it is better to ask the parents to explain things to the child, rather than the clinician doing this directly as this may be less threatening for the child, and reinforces the sense that the parents are the experts for their own child. With very lively active children the first task is to create a working environment in which what family members have to say can be attended to. This is best achieved by actively collaborating with the parents. Asking the parents for advice on how best to occupy young children will reinforce the parents’ sense that they are being respected and also may make it easier for the child to listen and join in spontaneously at some point during the interview. Children may not be too keen to take part in discussions at first. Making it clear at the start of the session that everyone in the room will have an opportunity to have their say, while stressing that it is also OK to sit and listen, is important for some children, to avoid making them feel that they are being put on the spot. When the pressure on them to join in is removed, children will often join in spontaneously. Joining with a child in creative play or talking about a drawing he or she has made can also provide an opportunity for the child to have a voice in the session (see also Dare & Lindsey, 1979; Larner, 1996; Wilson, 1998). A similar situation can sometimes arise with adolescents who may be reluctant to talk, while the parents may have an expectation that the “experts” will succeed where they have failed. Sometimes, such an adolescent may be more willing to talk when seen individually, but this is by no means always the case. The advantage of a family interview is that even a reluctant or unwilling participant can be included in an interview through indirect means. Making it clear that the therapist respects the adolescent’s right not to speak can help avoid an unhelpful battle. This can be done in a way that respects the adolescent’s autonomy while at the same time making sure that he or she is not simply being ignored. One might encourage FAMILY INTERVIEWING AND FAMILY THERAPY 1067 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1067

the adolescent to listen but also to correct other family members if he or she thinks they have misunderstood or got things wrong. The therapist can check this out from time to time. Who to See and When Although it is always useful to see the whole family interacting together, conjoint interviews also have their limitations in both the assessment and treatment phases. During assessment there may be indications that some individuals do not have an effective voice in the family group or the presence of the whole family may seriously inhibit some aspect of discussion. For example, an adolescent may not want his or her parents to know about drug use or there may be concern that a child has been abused and may not want to talk about this in front of their parents. Similarly, there may be issues that parents may not wish to discuss with the child present (e.g., to do with marital issues or perhaps when parents of a child with disability may not be able to share negative feelings in front of the child). For these reasons it is generally useful to make at least some separate sessions a routine part of practice even when family therapy is indicated as the main mode of treatment. There are several other considerations that should be taken into account when deciding on individual or conjoint sessions. For instance, we might decide that it is age-appropriate to see an adolescent on their own, particularly if they express a wish for this. We should consider (and enquire about) to what extent this is determined by a wish to avoid talking about a painful or upsetting issue, which may not necessarily be a helpful thing to do. Some topics may seem difficult to address in a conjoint meeting although the discomfort may be largely to do with the clinician’s own uncertainty about how or whether to raise the issue. Asking questions about what is acceptable or usual in the particular family will tell the clinician what can or cannot be easily talked about and may open up the topic for discussion. Questions such as “If your parents thought you were smoking dope, what would they do?” or “Some teenagers are very up-front about what they get up to, others keep things closer to their chest – what is your son like?” may quickly lead to frank and open conversations. More importantly, this kind of discussion will clarify what the actual boundaries in the family are rather than being assumed by the therapist. In families where there is much hostility, criticism or open conflict, conjoint meetings may not always be helpful particularly if the hostility or conflict simply escalates in sessions. There is evidence that families with high parental scores on criticism are more likely to drop out of treatment (Szmukler, Eisler, Russell, & Dare, 1985). In a study comparing conjoint therapy with separated therapy (i.e., separate meetings with parents and the adolescent) for adolescent anorexia nervosa, critical families did better in separated therapy (Eisler, Dare, Hodes et al., 2000). It is sometimes assumed that family dysfunction should be the main indication for family therapy. In fact, the opposite is the case. Several studies have shown (Barrett, Healey-Farrell, & March, 2004; Eisler, Dare, Hodes et al., 2000; Hampson & Beavers, 1996a) that the quality of family functioning moderates the effect of family therapy, with poorly functioning families gaining less benefit. This should not be interpreted as simply showing that more dysfunction leads to poor outcome, as there is evidence that these effects might be specific to particular types of family intervention. For instance, collaborative approaches to treatment (which are often favored by therapists) are less effective with disorganized families (Hampson & Beavers, 1996b), who tend to respond better to a more directive and less open style whereas the opposite is true of more balanced type families. Our own study of separated and conjoint therapy was interesting in this context in showing a three-way interaction between level of criticism at the beginning of treatment, type of treatment and long-term outcome, but somewhat surprisingly this effect disappeared when end of treatment level of criticism was considered (Eisler, Simic, Russell, & Dare, 2007). This suggests that it may be an effect that is operating at the level of treatment engagement rather then a persistent effect of criticism itself. In general, it is often useful to try to separate the question of how and when to involve the family in treatment to help deal with the child’s problem from the question of how to address possible problems in the family. This is partly to avoid reinforcing disabling feelings of guilt and blame and partly that, as we discussed earlier, much of what may appear dysfunctional is part of the way the family has accommodated to the problem. Most importantly, it is seldom going to be the case that resolving a family difficulty is itself going to resolve the child’s problem. The Family Therapist in the Multidisciplinary Team Most clinicians working with children and adolescents will to a greater or lesser degree include families in their work. This is sometimes referred to as “family work” to distinguish it from “family therapy” although the divide between the two is somewhat artificial. Family therapists by virtue of their training will have developed specialist skills in working with families and may therefore take on more complex work but where there is an indication for family interventions the same principles should apply whether the work is carried out by the specialist family therapist or the non-specialist. The role of the family therapist within the multidisciplinary team is of course much wider than just seeing families. They will have to be able to identify when a family approach is likely to be helpful and the different styles of work that might be best suited for the specific problem or a particular family. The family therapist can provide support and supervision for other team members working with families which may involve using a oneway screen or video link. This can have a number of purposes. It allows for “live supervision” for less experienced therapists and provides a training environment in which other team members can learn new skills. It can provide a rich team experience in which professionals pool their ideas and thinking in order to understand the family and move forward with the therapy. As in all clinical work, there is a need to attend carefully to ethical issues. These can be more complicated when a number of people are being worked with at the same time and members of the team are observing through one-way screens. CHAPTER 65 1068 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1068

Frameworks for Intervention This section sets out a framework for grouping treatment approaches for working therapeutically with families under several conceptual headings and describes some basic interventions that arise from them. We believe that this is more useful than to focus on models of family therapy which provide a somewhat artificial categorization and do not reflect day-to-day practice particularly well. This also provides a way of grouping the empirical evidence for effectiveness of family interventions for different types of disorder. Maintenance Frameworks Much of the early theoretical work informing family therapy was concerned with the idea of the family as a self-regulating social system (Jackson, 1957) and the way in which family interactions and family structures maintain problems. Two influential strands of family therapy (structural and behavioral) have drawn heavily on these notions. As a number of authors have argued (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001; Schmidt & Treasure, 2006; Stice, 2002), a focus on maintenance mechanisms provides one of the strongest way of gaining an understanding of what makes treatments work and, perhaps not surprisingly, the strongest body of empirical evidence for the effectiveness of family therapy is found in this area. Structural Family Therapy Structural family therapy, developed by Minuchin and colleagues (Minuchin, 1974), originally derived from work with deprived families of delinquent boys (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967) and was later applied to work with psychosomatic problems, particularly anorexia nervosa (Minuchin, Rosman, & Baker, 1978). The model assumes that well-functioning families have a number of specific features such as clear and flexible boundaries between individuals and subsystems and well-defined roles within the family, and that they provide an appropriate balance between closeness and independence. Individual problems were seen to be embedded in self-perpetuating dysfunctional family structures. The model, because of its emphasis on family relationship and interaction, relies to a great extent on interventions into transactional patterns in the “here and now” – that is, within the therapeutic session. Interventions include strengthening the “parental subsystem”, where the therapist encourages the parents to work together to find a way of jointly managing the difficulty. This includes actively intervening in the process of discussion with encouraging language, highlighting success and framing the role of the parents as responsible and “in charge” of the children. During enactments, families are encouraged to demonstrate their usual family processes and interactions within the therapeutic session to provide an opportunity for the therapist to help the family to “do it differently” and to assess the impact of following a different pattern. In boundary making the therapist enquires about rules (or boundaries) defining the roles of different family members and the degree of flexibility with which they are maintained. The family are helped to redefine boundaries, increase flexibility by encouragement to “talk more” or “make clearer rules” within the safe environment of the session. Sometimes, the intervention is to “de-triangulate” a particular family member (e.g., when an adolescent becomes involved in helping parents to stop arguing). Behavioral Family Therapy Behavioral family therapy approaches draw on similar ideas as structural family therapy. They focus on the behavioral sequences that occur in family life (Patterson, 1971, 1982) and interventions are aimed at interrupting unhelpful patterns and strengthening positive ones. As in structural therapy, the therapist tends to work with observed processes within the therapy session, often focusing on specific areas such as communication skills, problem-solving or interrupting escalating patterns of symmetrical communication. Behavioral approaches include interventions aimed primarily at parents in the form of Parent Management Training (PMT), by far the best researched of all family interventions (for a full account see chapter 64). Evidence for Effectiveness Structural and behavioral approaches have been the most widely researched of all family interventions. The largest body of evidence is for behavioral family therapy and in particular parenting interventions for child and adolescent behavior problems (Brosnan & Carr, 2000; Kazdin, 2004) with PMT alone being evaluated in over 60 high-quality randomized controlled trials (Lundahl, Risser, & Lovejoy et al., 2006). There is also persuasive evidence for structural and behavioral approaches in the treatment of anorexia nervosa (but see chapter 41 for some reservations). A series of randomized controlled trials at the Maudsley Hospital, London, compared family therapy with individual supportive therapy following hospitalization for anorexia nervosa (Russell, Szmukler, Dare, & Eisler, 1987) and also compared two forms of out-patient family therapy (Eisler, Dare, Hodes et al., 2000; Le Grange, Eisler, Dare, & Hodes, 1992), demonstrating the efficacy of family therapy with continued improvement post-treatment for up to 5 years (Eisler, Dare, Russell et al., 1997; Eisler, Simic, Russell et al., 2007). The research has led to a gradual refinement of the treatment approach (Dare, Eisler, Colahan et al., 1995; Eisler, 2005; Rhodes, Gosbee, Madden, & Brown, 2005) from the original structural model described by Minuchin, Rosman, & Baker, (1978) but has retained as a central feature the empowerment of parents in helping their child tackle his or her eating problems. Similar results were obtained in the USA by Robin, Siegal, Koepke, Moye, and Trice (1994) using behavioral systems therapy and Lock, Agras, Bryson et al. (2005), Lock, Couturier, & Agras (2006), who adapted the Maudsley approach (Lock, Le Grange, Agras, & Dare, 2001). Several studies (Barrett, 1998; Barrett, Dadds, & Rapee, 1996; Barrett, Healey-Farrell, & March, 2004; King, Tonge, Heyne et al., 1998; Mendlowitz, Manassis, Bradley et al., 1999; Silverman, Kurtines, Ginsburg et al., 1998) have shown that behaviorally based family therapy was effective in treating children with OCD and anxiety disorders. An interesting addition to these findings comes FAMILY INTERVIEWING AND FAMILY THERAPY 1069 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1069

from Cobham, Dadds, and Spence’s (1998) study comparing cognitive–behavioral therapy (CBT) and CBT combined with PMT for children with anxiety problems. For children of nonanxious parents, both CBT and CBT + PMT resulted in good outcome in about 80% of cases. However, for children with anxious parents, individual CBT resulted in good outcome in approximately 40% of cases compared with 80% good outcome for CBT + PMT. Influencing Frameworks All psychotherapies are concerned with bringing about change but what characterizes the family therapy approaches that we discuss under this heading is that they have focused primarily on how change is brought about while being agnostic to the question of how the problems might have arisen. The two groups of therapies that are most clearly defined by an influencing framework are Strategic therapies (Haley, 1963, 1976) and Brief therapies (Watzlawick, Weakland, & Fisch et al., 1974) developed by the group at the Mental Research Institute (MRI) in Palo Alto, the latter eventually developing into what is now known as Solution-focused therapy (de Shazer, 1985). Similarly to the originators of the approaches described in the previous section, the Palo Alto group were interested in the way in which symptoms became part of the family regulatory system but also introduced the idea that repeated ineffective attempts at solutions could themselves maintain the problem. Their focus was on the interactive process that interfered with change, rather than the processes that maintained problems. They assumed that the process that blocked change would be specific to each individual or each family and, unlike structural therapy for example, did not assume that the family organization or family structure needed to be changed in a specific predetermined way. While there is obvious overlap with the structural and behavioral approaches described earlier, the main interest in the strategic approaches has been in how change happens rather than the kind of change that should be achieved. Brief solutionfocused therapy (de Shazer, 1985) has some overlaps with Motivational interviewing approaches (Miller & Rollnick, 2002) in developing differential strategies depending on the level of motivation of family members, who are classified as “clients” (ready for change), “visitors” (do not see themselves as having a problem) or “complainants” (have a problem but not sure they want to do anything to change). The following example may serve as an illustration of a strategic intervention. In an early family session with an adolescent with anorexia nervosa the therapist asks the following question: “Have you reached the stage when you feel that people trying to encourage you to eat are on your side and helping you fight anorexia or do you still always feel that they are against you?” The girl thought for a bit before responding: “Sometimes, but not very often at the moment.” The therapist nodded and added: “It is important that you go on noticing these instances. As they become more frequent it will make it easier for you to deal with the times when you feel that everyone is against you.” One can see several ideas underlying this intervention. The therapist had noted that the young woman and her parents were regularly locked in repetitive battles at mealtimes which resulted in the daughter partly giving in and the parents backing off. The daughter acknowledged that she had a problem and wanted to get better but after every meal felt resentful and angry with her parents. Asking the above question had a number of goals: 1 To establish an exception to the disabling family belief that every mealtime is inevitably a battle of wills; 2 To imply that when an exception happens, it is an indication of the start of a process of recovery; and 3 To imply that the exceptions will increase in frequency. The therapist was also using his position as an expert who had been through a similar process with many other families. While the discussion was with the daughter, it was important that it was witnessed by the parents, who were perhaps as much paralyzed by seeing their daughter’s despair as they were by their own sense of helplessness. Strategic ideas were also the basis of the early work of the Milan group. The Milan associates developed a stylized form of interviewing the family in which a co-therapist pair was supported by a team behind a one-way screen. The central assumption that guided the therapy was that the symptomatic behavior was part of a paradoxical bind that prevented the family system from changing and the aim of the therapeutic team was to devise an intervention that would counter the paradox of the symptom (Palazzoli, Boscolo, Cecchin et al., 1978). The therapeutic team developed hypotheses that were explored with the family through the use a “circular interview” (Bertrando, 2006). The observation of the family’s response to these questions was used during a mid-session discussion of the team to gain other perspectives and the therapist (especially in the earlier versions of the approach) would deliver a message aimed at “perturbing” what were thought to be stuck patterns of interaction and fixed beliefs (Palazzoli, Boscolo, Cecchin et al., 1980). Evidence for Effectiveness The therapies that we have grouped under this heading are relatively poorly researched. The strongest evidence has come from the work of Szapocznik and Kurtines (1989), who have systematically and over many years evaluated Brief strategic therapy for substance misusing adolescents. In addition to demonstrating the effectiveness of their treatment approach in a number of randomized controlled trials (Szapocznik & Williams, 2000), they have also shown the specific value of strategic techniques in engaging difficult-to-reach families (Coatsworth, Santisteban, McBridge, & Szapocznik, 2001; Santisteban, Suarez-Morales, Robbins, & Szapocznik, 2004). Many of the treatment components developed by Szapocznik and colleagues have been incorporated into the well-researched multidimensional treatments described later. Meaning Creating Frameworks An important idea that underpins all family therapy approaches is that all problems are embedded and shaped by CHAPTER 65 1070 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1070

their social context and to a lesser extent help to shape the context. If we try to understand the interpersonal nature of problems it is almost inevitable that we become concerned with language, beliefs, cognitions and narratives because these are central to understanding the process of social interaction. In the early developments of the family therapy field, these ideas were focused primarily on the exploration of interpersonal communication and in particular the way in which the overt content of communication was given different meanings by communication at another (meta) level (e.g., tone of voice, non-verbal cues). The ideas about the importance of beliefs in shaping behavior have been developed by a number of authors in the field. Following their split from the original Milan team in the early 1980s, Boscolo and Cecchin started developing a style of work that abandoned much of the early strategic components and focused on the process of the interview and the way it could bring forward new perceptions, unexplored stories and hidden meanings (Bertrando, 2006; Boscolo, Cecchin, Hoffman, & Penn, 1987). This was accompanied by a change in the understanding of the therapist’s role in bringing about change and a shift in emphasis away from behaviors to beliefs and narratives. The Therapist as Participant Observer Up until the early 1980s the therapist was invariably seen as an outside observer of the family process who could use his or her “metaposition” to gain an understanding of the family dynamic and intervene in a purposeful way to bring about change. This was challenged first by von Foerster (1979), who argued that the act of observation (and the describing of the observation) make the observer part of the system. The implication for the clinician was the need to recognize not only that any observations being made are influenced by the subjectivity of the observer’s perceptions, but also that they become part of a recursive pattern of mutual influences between clinician and family. This shift has had a major impact on the practice of family therapy. The first was a change in the conceptualization of family therapy from a treatment of families (with the implication that the family was problematic or dysfunctional) to a treatment with families, where the meetings with families provide the context for change rather than the target of change. Secondly, thinking about the therapist as being part of the system also led to the re-examination of issues of power and control (Hoffman, 1985) and to a more collaborative and less “expert” role for the therapist. Where a team was used, its role also changed and became a more open and transparent vehicle for bringing alternative perspectives on the work, for instance by making sure that families meet the team rather than always keeping the team invisible behind a oneway screen. Other developments leading to greater respectfulness and collaboration with families was the practice of inviting families to observe the team reflecting on the session in front of them (Andersen, 1987) or therapists developing their hypotheses jointly with families (Bertrando & Arcelloni, 2006). Language and Narratives The interest in meaning systems and their influences on shaping family interactions have always had their place in the family therapy field (Ferreira, 1963; Palazzoli, Boscolo, Cecchin et al., 1978; Watzlawick, Beavin, & Jackson, 1967). However, the more recent developments have placed language and narratives center stage for several influential therapy approaches, in particular narrative therapies (Parry & Doane, 1994; White & Epston, 1989) and the collaborative language approaches (Anderson & Goolishan, 1988; Goolishan & Anderson, 1987). These approaches have been the most overtly embedded in a social constructionist understanding which emphasizes the relativity of observed reality and which sees language and narratives as the vehicle through which people acquire their definitions of self. Individual problems are understood to be, at least in part, the result of the filtering of experiences through narratives that people have about themselves. These individual narratives are seen as being embedded in wider systems narratives such as cultural, political or educational narratives (Paré, 1995; White, 2005). Although the narrative and language approaches are theoretically distinct, there is a clear overlap with cognitive therapies both at a conceptual level (i.e., in seeing beliefs and meanings attached to problems as central targets of treatment) and borrowing each others’ intervention techniques (e.g., the use of behavioral scaling techniques by narrative therapists or the use of externalization of the problem in some CBT approaches). Evidence for Effectiveness The evidence for the value of approaches that have been described in this section is limited. There are a small number of studies that have directly evaluated treatments such as narrative therapy. Seymour and Epston (1989) followed up 45 cases of childhood stealing where the family intervention used a narrative approach and found that over 80% of cases were treated successfully. Carr (1991) reviewed 10 studies using a Milan systemic approach and concluded that they provided evidence for the effectiveness of the treatments. However, only four of the studies were randomized controlled trials and the samples were mostly small with a mixture of problems. More recently, there have been several studies evaluating family therapy for depression (Campbell, Bianco, Dowling et al., 2003; Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002; Trowell, Joffe, Campbell et al., 2007), in which the family approach had as a main focus addressing cognitions, beliefs and narratives that showed evidence for the efficacy of these approaches. The most recent of these studies (Trowell, Joffe, Campbell et al., 2007), which compared family therapy with brief psychodynamic psychotherapy, was notable in two respects. Both treatments achieved around 75% remission by the end of treatment (with an average of 11 sessions of family therapy or 25 sessions of individual psychotherapy) and both treatments showed a continuing improvement at 6-month follow-up. Multidimensional and Integrative Frameworks In recent years there has been a growing move towards integrating different approaches, both from within the family therapy field and outside it (Norcross & Goldfield, 2005). In FAMILY INTERVIEWING AND FAMILY THERAPY 1071 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1071

clinical practice it is not uncommon to find clinicians drawing on a number of conceptual models and using intervention techniques developed within a different approach than the one they see as their primary treatment approach. As Fraenkel and Pinsof (2001) point out, this happens in one of two ways. Clinicians include techniques or ideas from other approaches and incorporate them into their own conceptual framework, which Fraenkel and Pinsof describe as “technical eclecticism” (or “assimilative integration” following Messer, 1992). This can be contrasted with integration at a theoretical level or “theoretical eclecticism” (Fraenkel & Pinsof, 2001), in which different conceptualizations of the therapy process are drawn on and applied depending on the nature of the problem, stage of treatment or difficulties encountered in treatment. In this section we briefly describe four treatment models (Functional Family Therapy, Multisystemic Therapy, Multidimensional Family Therapy and Multidimensional Treatment Foster Care) that have integrated several family therapy approaches and have been well researched, and a model that has integrated systemic, cognitive–behavioral and psychodynamic approaches (Integrative Problem-Centered Therapy). Finally, we describe recent developments in using multi-family approaches with child and adolescent problems which also draw on a number of different conceptual frameworks. Functional Family Therapy This is an approach developed by Alexander and Parsons (1982) and Alexander and Sexton (2002) combining aspects of behavioral and structural approaches with strategic family therapy. Functional family therapy starts from the assumption that problem behaviors and symptoms (whatever their origin) take on a functional role in the way that relationships and family hierarchies are maintained and aim to replace problem behaviors with more appropriate behaviors that can serve the same function but in a positive way in the family organization. For example, in a family with a child with OCD the child may have a very close and intense relationship with mother centered on assurance seeking/receiving behaviors, and a more distant relationship with father, who tends to respond dismissively to requests for reassurance. The family might be encouraged to find alternative activities that would meet the need for closeness and assurance but not of symptom-related behaviors and would also seek to involve the father in spending time with the child in such activities. Multisystemic Therapy and Multidimensional Family Therapy Multisystemic Therapy (MST; Henggeler, 1999; Henggeler & Borduin, 1990) and Multidimensional Family Therapy (MDFT; Liddle, 1992; Liddle & Hogue, 2001) are two well-researched treatments that have been designed to include interventions at several different levels, drawing on conceptualizations from strategic, structural and behavioral family therapy. Both have been designed with a fairly specific target population in mind (delinquent and substance misusing adolescents). The integration of conceptual ideas from other approaches is based on an analysis of the target problem which both MST and MDFT see as needing to be addressed at individual and family as well as social levels. Interventions are targeted at several levels which aim to address individual and contextual issues around the problem behavior but also motivational and engagement issues, recognizing that the adolescent with the problem may be the least motivated person in the system. For both MST and MDFT, the analysis of the nature of the problems (delinquency and substance misuse) is central and provides the framework within which the integration of conceptual ideas from different treatment approaches takes place (which differentiates them, for instance, from Functional Family Therapy). A further treatment program could be added to this group, Multidimensional Treatment Foster Care (MTFC; Chamberlain, 2003). Although distinct in some ways (not least in the fact that the youth offenders enrolled in the program are placed in foster families) there are many overlaps with MST and MDFT in the structure and intensity of the treatment interventions as well as in many of the conceptual ideas that inform it. Multiple Family Approaches Multiple family approaches have also developed with a focus on particular problems and draw on multiple theoretical frameworks. They have a history in adult psychiatry, particularly in the treatment of schizophrenia (Lacquer, La Burt, & Morong, 1964; McFarlane, 2005; Strelnick, 1977), but in more recent years have increasingly been utilized with child and adolescent mental health problems (Asen, 2002; Asen & Schuff, 2006; Eisler, 2005; Saayman, Saayman, & Weins, 2006). The initial impetus for working with several families at the same time was partly pragmatic (i.e., to maximize the use of limited resources and to address the social isolation that patients and their families were experiencing). Theoretically, they drew on a mixture of systemic, group and psychodynamic ideas, and most multi-family groups also include a significant psychoeducational component. The practical experience of bringing together several families very quickly brought forward new ideas about the nature of the therapeutic relationship, the importance of maximizing family resources in dealing with individual problems and ways in which clinicians can facilitate change through providing a structured setting in which families can interact and learn from each other. Seeing several families together is not simply a matter of pragmatic or economic convenience. The multi-family group format affords many opportunities for helping families to learn from each others’ strengths, to reduce the sense of isolation and stigma and to use the group as a resource for problem-solving (Asen, 2002; Eisler, 2005). The most common form of multi-family work has 5–7 families meeting weekly or fortnightly for 1.5–2 h. Groups of this kind have now been developed for a growing range of problems including mood disorders (Fristad, Goldberg-Arnold, & Gavazzi, 2002; Goldberg-Arnold, Fristad, & Gavazzi, 1999), eating disorders (Geist, Heinmaa, Stephens, Davis, & Gavazzi, 2000), behavior problems (McKay, Harrison, Gonzales, Kim, & Quintana, 2002), schizophrenia (Asen & Shuff, 2006; Schepp, O’Connor, Kennedy, & Tsai, 2003), learning diffiCHAPTER 65 1072 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1072

culties (Russell, John, Lakshmanan, Russell, & Lakshmidevi, 2004) and school problems (Kratochwill, McDonald, Levin, Bear-Tibbetts, & Demaray, 2004). In the UK a more intensive format of multi-family treatment has been developed by Asen, Dawson, and McHugh (2001) in which families take part in a brief multi-family day program. Originally developed for work with multi-problem “multi-agency” families (Cooklin, Miller, & McHugh, 1983), it has been modified for treatment of anorexia nervosa (Eisler, 2005; Scholz, Rix, Scholz, Gantchev, & Thomke, 2005) and for school problems (Dawson & McHugh, 1994, 2006). Integrative Family Therapy Approaches A different approach to integration of treatment approaches is found in the work of authors who start from an analysis of the conceptual overlaps between different psychotherapeutic models (Breunlin, Schwartz, & MacKune-Karrer, 1997; Fraenkel & Pinsof, 2001; Lebow, 1987; Pinsof, 1994, 2005). Pinsof’s (2005) Integrative Problem-Centered Therapy (IPCT) provides a good example. IPCT integrates six different therapeutic orientations (behavioral, biobehavioral, experiential, family of origin, psychodynamic, self-psychology) and three treatment contexts or modalities (family/community, couple, individual). The underlying assumption of IPCT is that individual problems are maintained by a set of constraints (social/ organizational, biological, meaning, transgenerational, object relations, self) which roughly correspond to the therapeutic orientations. IPCT starts from a premise that individuals and families can usually resolve problems with minimal interventions aimed at reinforcing and building upon existing individual and family strengths. A brief problem-focused behavioral family intervention is recommended as an appropriate starting point for most child and adolescent problems and only when these have failed would the therapist need to start exploring potential deficits and constraints at other levels. The strength of IPCT (like that of other integrative approaches) is that it attempts to find common conceptual ground between different therapies and to maximize their potential by targeting different levels of difficulties by appropriate interventions. The disadvantage is that it assumes that the framework can be fitted to any kind of problem and that the way that treatments are tailored to individual needs comes purely from an analysis of the different levels of constraints that particular individuals and their families are faced with. This is theoretically attractive but difficult to evaluate empirically. It is notable that approaches such as MST, MDFT and MTFC have generated considerable outcome research whereas integrative approaches such as IPCT have not. Evidence for Effectiveness The strongest evidence for treatment approaches described in this section come from studies of multidimensional approaches used for treatment of youth offenders (Curtis, Ronan, & Borduin, 2004; Littell, Popo, & Forsythe, 2007; Woolfenden, Williams, & Peat, 2007) and substance misuse (Stanton & Shaddish, 1997). The meta-analyses in the above studies included mainly treatments using a multidimensional approach and these were also the studies producing the clearest results (although none of the meta-analyses compared multidimensional with other family therapy approaches). The evidence for the efficacy of multifamily therapy with child and adolescent problems is sparse so far. There have been few randomized studies and while they provide positive support (Barrett, Healey-Farrell, & March, 2004; Kratochwill, McDonald, Levin et al., 2004), the current overall conclusion has to be “promising but unproven” (McDonell & Dyck, 2004). Overview and Conclusions Family therapy, in our account, covers a broad range of approaches. Many of the things that apparently differentiate treatments are a matter of what is emphasized and inevitably there will be large overlaps with other approaches. We have suggested a way of conceptualizing different frameworks of treatments as a way of understanding some of the differences and similarities both within the family therapy field and outside of it. The empirical evidence in support of family therapy in the broadest sense is considerable. There have been more than 20 meta-analyses of family interventions, approximately half of which either included or were solely concerned with child and adolescent problems (for a review see Shadish & Baldwin, 2003). The findings are consistent in showing family therapy to be effective when compared to no treatment or waitlist controls (with an average effect size of 0.65) and to do at least as well as, or better than, alternative treatments, although the differences here are generally small. However, the quality of the evidence is variable depending on the type of problem being considered. In some areas (such as the treatment of substance misuse, anorexia nervosa, delinquency and behavior problems) the evidence for the effectiveness of family therapy of one kind or another makes it currently the treatment of choice. In other areas (depression, anxiety disorders, OCD) there is more limited evidence but nevertheless it points to family-based treatments being effective. When one takes a look across the field as a whole, perhaps the most striking thing is that taking a broad definition of family therapy (as any family-based or family-oriented treatment) then for most if not all child and adolescent problems it is shown to be effective. However, what is also clear is that for different kinds of problem often quite different types of family intervention have been shown to be useful. To what extent this is really a result of the specificity of treatment needs generated by particular problems or simply a reflection of the particular interests of researchers who have investigated these problems is unclear, as very little research exists at present comparing different family therapy approaches and what comparisons do exist are quite general and do not focus on specific components that might be needed when dealing with specific types of problem. In the treatment of conduct disorder, juvenile delinquency and substance misuse there is considerable conceptual as well as technical overlap between the best-researched treatments FAMILY INTERVIEWING AND FAMILY THERAPY 1073 9781405145497_4_065.qxd 29/03/2008 02:58 PM Page 1073

(MST, MDFT, MTFC and, to a lesser degree, Functional Family Therapy) although the proponents of these approaches do not always acknowledge the similarities. One of the negative consequences of the current emphasis on developing evidencebased practice is that it encourages treatments to be viewed as complete and competing packages, which tends to obscure the common ground between treatment models. The family therapy field has been particularly prone to this malaise and is awash with differently labeled (similar) treatments with little attempt to compare them at either a theoretical or an empirical level. The other downside of the focus on evaluating treatment models has been the dearth of research on factors that might act as mediators and moderators of treatment. At present, the evidence is thin on the ground but nevertheless indicates that these are clinically crucial areas to investigate. We discussed earlier the moderating effect of disorganization in the family (Hampson & Beavers, 1996b) and high levels of criticism (Eisler, Simic, Russell et al., 2007) which has implications for the style of family therapy best suited for these types of family. Such findings are rare at present yet they have important implications for clinical practice. Even less is known about family factors that might act as mediators of treatment (i.e., those that might be amenable to treatment and might need to change in order for treatment to be effective). This may well include variables that have been well researched from a developmental or etiological perspective such as attachment but that need to be looked at from a different angle. For instance, our clinical experience suggests that parent(s) with insecure attachment patterns can sometimes be difficult to engage in treatment and may feel they are being covertly blamed when asked to take quite an active role in their child’s treatment. Of course, this may be because of the particular way in which we work with families and it is possible that for such families an attachment-oriented family therapy (Byng-Hall, 1991; Diamond, Reis, Diamond et al., 2002) may be able to engage them more effectively in treatment regardless of whether attachment is shown to have a role in the development of the particular problem their child has. In order for these issues to be addressed by empirical study two major shifts are needed in the conceptual ideas informing family therapy research and indeed psychotherapy research in general. The first is the recognition that much more work is needed to find the common ground between treatments in order to highlight the specific aspects that differentiate them. This will allow outcome research to target much more focused questions about core ingredients of treatments and how these might interact with other factors. 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What is Psychodynamic Psychotherapy? The term “dynamic” first began to be used in the late 19th century by Leibniz, Herbart, Fechner and Hughlings-Jackson to highlight the distinction between a psychological and a fixed organic neurological impairment model of mental disorder. Dynamic approaches offer an alternative perspective to descriptive phenomenological psychiatry with the latter’s focus on accurate categorization of mental disorders; in contrast, dynamic approaches emphasize the way mental processes interact to generate problems of subjective experience and behavior. Such interactions can occur consciously as well as unconsciously, but the psychodynamic model has historically been understood as a model of the mind that emphasizes wishes and ideas that have been defensively excluded from conscious experience. In our view this is a narrow and somewhat misleading definition of psychodynamic concepts. The psychodynamic approach is better understood as a comprehensive account of human subjectivity that aims to understand all aspects of an individual’s relationship with their environment, external and internal. Freud’s great discovery was the power of the conscious mind to alter its position radically with respect to aspects of its own functions. In our view, psychodynamic should refer to this potential for dynamic self-alteration. All psychodynamic therapies aim to strengthen patients’ capacity to understand the motivations and meanings of their own and others’ subjective experiences, behavior and relationships. In this sense there is overlap with cognitive therapy, which of course also has psychodynamic origins, but at least classically focuses more narrowly on particular aspects of subjectivity (e.g., particular types of cognitive distortion) and is more targeted at specific behaviors or problems. By contrast, psychodynamic therapists strive to understand the organization of the child’s mind in its full complexity, the social influences on the child’s emotional experience and the ways in which the child’s subjectivity has adapted to internal and external pressures. The therapist aims to expand the child’s and parents’ conscious awareness of these mechanisms and influences, so that they are better able to use their increased emotional awareness to manage continuing pressures. It assumes that once the mechanisms are made conscious, the individual will be able to change their inner world or their behavior to improve matters. Psychodynamic psychotherapy can take a variety of forms; correspondingly, this chapter covers a number of therapeutic modalities. These include child psychoanalysis, individual and group psychotherapy, together with (using the above definition) certain family-based approaches, interpersonal approaches and psychodrama. Techniques differ in the extent to which they make use of play, supportive versus expressive techniques, or structured directive (group) work. Many current cognitive– behavioral therapies share with traditional psychodynamic approaches concerns such as the developmental and relational origin of particular ways of thinking, and use the relationship with the therapist as an example of broader patterns of relating (Beck, Davis, & Freeman, 2004). The following eight assumptions may be considered core to modern psychodynamic therapy. While some are shared by other approaches, as a set other orientations would be unlikely to embrace them wholeheartedly: Common Assumptions Notion of Psychological Causation The child’s problems are understood in terms of their thoughts and feelings. The emphasis is more on the child’s interpretation of events and the world than on its external reality. It is assumed that mental disorders can be adequately comprehended as specific organizations of a child’s conscious or unconscious beliefs, thoughts and feelings, whatever the root cause of such maladaptive organizations might be. The individual’s motivations (wishes and anxieties, including expectations of others) are assumed to underlie experience, mental functioning and behavior. Alternative explanations such as genetic predispositions or chance are not prominent. Limitations of Consciousness and the Influence of Non-conscious Mental States Psychodynamic clinicians generally assume that to understand conscious experiences we need to refer to other mental states of which the individual is unaware. Psychodynamic models assume that non-conscious narrative-like experiences, analogous to conscious fantasies, profoundly influence children’s behavior, capacity to manage their emotions and their social interactions. For example, attachment theory assumes that a mental representation of distress soothed by the parent is internalized as an unconscious expectation of future caregiving, 1079 Psychodynamic Treatments 66 Peter Fonagy and Mary Target 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1079 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

and becomes the foundation for a sense of the self as having understandable feelings that are deserving of care. This unconscious expectation guides the infant to seek soothing. Through the repetition of such experiences the capacity to self-soothe emerges without undue recourse to denial or amplification of distress. There is substantial empirical support for Freud’s suggestion that human consciousness cannot account for its maladaptive actions (Westen & Gabbard, 2002), but this should not be taken to imply a diminution of the emphasis placed on consciousness. Helping the child and caregivers to become aware of the unconscious expectations underlying the child’s behavior can help them to gain control of previously unmanageable emotions and behavior. For example, when working with young people who apparently deliberately mismanage their diabetes, helping them elaborate their subjective experiences of peers and parents turns out to help them bring their diabetes under control (Moran, Fonagy, Kurtz et al., 1991). It was helpful, for example, when the therapist could help a girl to understand that throwing away her insulin could be seen as an attempt to escape the intrusiveness of her overconcerned father, who used to listen outside her bedroom door in case she had a hypoglycemic attack. Once this was understood, more space could be created within the relationship without the need for her self-destructive protest. Assumption of Internal Representations of Interpersonal Relationships Psychodynamic clinicians consider interpersonal relationships, particularly attachment relationships, to be central to the organization of personality, and that representations of these intense relationship experiences are aggregated across time to form schematic mental structures, perhaps metaphorically represented as neural networks. These structures are seen as shaping interpersonal expectations and self-representations. Within many models self–other relationship representations are also viewed as organizers of emotion: certain feelings come to characterize particular patterns of interpersonal relating (e.g., sadness and disappointment at the anticipated loss of a person). Ubiquity of Psychological Conflict Psychodynamic approaches assume that wishes, affects and ideas will sometimes be in conflict. These conflicts are seen as key causes of distress, undermining a sense of safety and leading to maladaptive attempts to overcome this. Experientially insurmountable conflicts are commonly associated with adverse environmental conditions. For example, neglect or abuse is likely to aggravate an arguably natural ambivalence of the child towards the (in this case maltreating or neglectful) caregiver, who is nevertheless perceived as vital to the child’s continuing existence. Psychodynamic techniques often aim to identify and elaborate perceived inconsistencies, conscious or unconscious, in feelings, beliefs and wishes in order to reduce the individual’s distress when conflicts have become entrenched. Not only are conflicts thought to cause distress, they are also considered potentially to undermine the normal development of key psychological capacities that in turn reduce the child’s ability to resolve incompatible ideas. At times psychodynamic models attempt to contrast conflict and development-focused approaches, but the reality of developmental trajectories means that the two are most often seen together in the same individual. Assumption of Psychic Defenses Historically, the psychodynamic approach has been particularly concerned with defenses: mental operations that distort conscious mental states to reduce their potential to generate anxiety. The term may risk reification and anthropomorphism (who is defending whom against what?) yet it is generally accepted that self-serving distortions of mental states relative to an external or internal reality take place. Classifications of defenses have been frequently attempted, often in order to categorize individuals or mental disorders (Kaye & Shea, 2000), but few of these approaches have achieved general acceptance. Nevertheless, most might agree that mental operations such as projection (attribution of a self-state to the other), denial (refusal to acknowledge self-states) or splitting (simultaneously holding self-states with opposite valence but experiencing them only sequentially) are characteristic of an early phase of development and are more commonly found in individuals with more severe mental disorder diagnoses. By contrast, intellectualization (elaborating a self-serving but inaccurate rationale for one’s actions) or sublimation (diverting mental energy from drive-oriented to more constructive activity) are relatively mature and, when not used to excess, non-pathological forms. Aside from such broad categorizations, the cognitive and sociocognitive strategies associated with reducing anxiety or displeasure and enhancing safety are perhaps better thought of not as independent classes of mental activity or psychological entities, but as a pervasive dynamic aspect of complex cognition interfacing with emotional experience. Assumption of Complex Meanings Psychodynamic approaches assume that behavior can be understood in terms of mental states that are not explicit in action or within the awareness of the person concerned. Symptoms of mental disorder are classically considered as condensations of wishes in conflict with one another, alongside the defense against recognition of that wish. It is striking that different psychodynamic orientations find different types of meanings “concealed” behind the same symptomatic behaviors. Some clinicians focus on unexpressed aggression or sexual impulses, others on a fear of not being validated, yet others on anxieties about abandonment and isolation. Within a contemporary context it is the effort of seeking further personal meaning that would be considered most significant therapeutically. Elaborating and clarifying implicit meaning structures rather than giving the patient insight in the terms of any particular meaning structure may turn out to be the essence of psychodynamic psychotherapy (Allen & Fonagy, 2006). Emphasis on the Therapeutic Relationship There is consensus that it is helpful to establish an attachment CHAPTER 66 1080 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1080

relationship with a clinician. Different therapeutic schools explain this differently, but converging theorization and research data suggest that engagement with an understanding adult will trigger a basic set of human capacities for relatedness that appears therapeutic, apparently almost regardless of content (PDM Task Force, 2006). Controlled trials have repeatedly demonstrated that therapeutic alliance without theoretical content is insufficient (Dew & Bickman, 2005); however, the importance of the therapeutic alliance has been found across a wide range of therapeutic approaches, including counseling and cognitive therapies (Beutler, Malik, Alimohamed et al., 2004). Therapeutic technique varies in the degree of emphasis placed on: (i) the “transference” relationship, in which nonconscious relationship expectations, repudiated wishes, etc. are assumed to be played out and can be better understood through the shared experience of their enactment in a new context; and (ii) the “real” relationship, which captures the generic factor referred to above, of the therapeutic impact of having a relationship with an understanding adult, which may be a new experience for some young people. Therapists then vary in focusing mainly on interpretation of the “transference,” or on gaining a broader understanding of the child’s relationships and difficulties. A Developmental Perspective In common with many child therapists, psychodynamic psychotherapists are invariably oriented to the developmental aspects of their patients’ problems (when and how they started, how they relate to an idealized “normal” developmental sequence), and work at least in part to optimize developmental processes. Varying assumptions are made concerning normal and abnormal child and adolescent development. Importantly, the outcome of interventions is often evaluated in developmental terms, less in terms of reduction of problem behaviors associated with a disorder and more in terms of what emotional, social and behavioral characteristics may be expected of a particular child at a particular age. There are developmentally sensitive measures of social adjustment that have operationalized Anna Freud’s ideas concerning lines of emotional and social development (Fonagy & Target, 1994); how these map on to mainstream measures of social and emotional functioning needs to be researched. Outdated Assumptions Some features of the original psychodynamic model are no longer shared by all contemporary psychodynamic approaches. A good example concerns insight. Classically, psychotherapists regarded the patient’s insight into their repressed unconscious as central to the process of change. It is now clear that improvements commonly occur in the absence of insight into non-conscious processes (Gabbard & Westen, 2003). Insight does not guarantee improvement even if the two sometimes occur together. Modern psychodynamic psychotherapy focuses on (mixed) feelings, confusing interpersonal expectations, the complexity of relationship experiences and much less on identifying derivatives of unconscious drives. Whereas some therapists remain committed to the insight-oriented interpretive approach, most feel that uncovering repressed unconscious content is less important than engaging with children and helping them to think about their experience in a psychological way. Similarly, not all psychodynamic psychotherapists see a focus on transference as a key component of therapeutic work. However, it is commonly accepted that the relationship that the child creates in the therapeutic setting, either with the therapist or with other children in a group, can serve as a window on the child’s inner world. Modern, especially relational, psychodynamic psychotherapists often rely on their subjective reactions to help them understand the parts the child implicitly asks them to play. By this indirect route they hope to gain an understanding of the child’s internal struggles and the child’s representations of themselves and others. This is very different from the use of such understanding as part of an interpretive process. It may also be misleading to think of psychodynamic therapies as being invariably about “the unconscious.” Uncovering neurotic motivations that have been dynamically defended against is no longer the defining feature of the psychodynamic approach. Psychodynamic therapies are often about increasing mental coherence, and randomized controlled trials of the treatment of borderline personality-disordered adults show that improvement in psychodynamic psychotherapy is specifically associated with increased coherence of attachment narratives (Levy, Meehan, Kelly et al., 2006). It is postulated that having one’s attention drawn to an aspect of one’s experience that one is unaware of may increase this coherence. For example, if a child is continually failing at school to his parents’ distress, drawing his attention to his ambivalent feelings may help him recognize a secret wish to upset his parents. This may enable him to find ways to stand up to his parents without damaging his own prospects. However, under certain circumstances, such insight may undermine coherence, increasing the child’s confusion with iatrogenic consequences. For example, interpreting the masochistic wishes of a child who has been abused within the family may only add self-loathing and self-blame to his distress, making it harder for him to recover. Risks of Psychodynamic Psychotherapy Whereas pharmacological studies routinely test for the possibility of adverse reaction, psychological therapists mostly assume that their treatment is at worst inert. There are few systematic studies of adverse reactions. There may be particular disorders where psychotherapy represents significant risk to a patient. Irrespective of the assumed mechanism of change, most psychotherapists assume that the client is capable of considering their experience of their own mental states alongside the psychotherapist’s representation of these. We have recently drawn attention to the fact that this may be an unrealistic expectation in cases where the client’s capacity to represent their own mental states with any degree of coherence is very limited (Fonagy & Bateman, 2006). Such individuals may react to a therapist’s attempts to teach them about the “true” contents PSYCHODYNAMIC TREATMENTS 1081 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1081

of their mind by either breaking off the therapy or playing along without real understanding. It is possible that the difficulties psychodynamic therapists have in the past reported in relation to conduct problems may be associated with limitations in the ability of young people with severe behavioral problems to represent their own mental states (mentalize). Adolescents’ resistance to psychodynamic therapy could also be explained by age-specific limitations in social cognition (Blakemore & Choudhury, 2006). In general, it seems to us that modifications to classic psychodynamic technique along the lines described above may be necessary for these techniques to be appropriately used with young people whose mental disorder is associated with limitations in their mentalizing capacity. Also, psychodynamic therapists who continue to give their therapy alone when it is ineffective while failing to recognize and refer on conditions for which there is a solid evidence base (e.g., attention deficit/hyperactivity disorder [ADHD] or obsessivecompulsive disorder [OCD]) are allowing unnecessary harm to befall their patients. Theoretical Frameworks in Psychodynamic Therapy Developmental Considerations in Psychodynamic Thinking The theoretical bases for psychodynamic psychotherapy are rooted in Freud’s establishment of his developmental approach to the understanding of psychopathology. In Freud’s view, personality types and neurotic symptoms could be best understood in terms of fixations at and regressions to specific points of development; this has not been supported by any empirical evidence. Psychoanalysts following Freud have continued the developmental motif while taking radically different perspectives on both child development and psychopathology. Recent psychoanalytic models, such as relational theories (Mitchell, 2000) or psychoanalytic schema theories (Stern, 1993) focus their explanations on psychosocial development and the parent–child relationship. Despite this unequivocally developmental perspective, most psychoanalytic theorists have done little directly to explore the nature of early development through research or to incorporate empirically tested modern findings into their approaches, preferring instead to speculate about infancy on the basis of largely adult clinical experience. Historical and Current Traditions The field of psychodynamic child psychotherapy was historically established by Melanie Klein (1932) and Anna Freud (1946). Klein assumed that play in the consulting room was motivated by unconscious fantasy, activated by the child’s relationship to the analyst (the transference). This generated deep anxiety which required verbalization if it was to be addressed. The child’s relationship with external figures (e.g., parents, teachers) was considered far less relevant. By understanding the child’s perception of him or herself as a person, the clinician could gain an understanding of children’s experience of themselves. A highly influential psychoanalyst working in this tradition, Bion (1959) described how such projections could be evocative: they could impact upon the “container.” The capacity of the container of the projection to understand and accept these is seen by Kleinian analysts as critical to successful therapy as well as normal development. A highly influential psychodynamic therapist emerging from the Kleinian tradition was the pediatrician Donald Winnicott. Winnicott (1971) introduced drawing techniques into child psychotherapy, highlighting his interest in what was beyond verbal experience. The idea of an intermediate space between the subjective and the interpersonal has become a central notion in the work of relational therapists. Winnicott elaborated a developmental model within which the caregiver is committed to the infant but imperfectly, so that the child has gradually to sacrifice infantile omnipotence. This gave rise to a therapeutic attitude where the therapist’s constancy and tolerance create a sense of being understood and accepted that provides the patient with an important figure for internalization and identification. At the other end of the spectrum, Anna Freud introduced only minor modifications to Freud’s classic theories but dramatically reorganized the clinical situation of child psychotherapy, focusing on the child’s developmental struggle with the social as well as the internal environment (Edgcumbe, 2000). She viewed pathology as a disturbance of normal developmental processes and therapy with children as aimed at returning to normal developmental lines. Not in content but in structure, Anna Freud’s approach shares some ideas with modern developmental psychopathology. The aims of the developmental psychodynamic approach have some similarities with cognitive therapy; however, the means by which these improvements are considered to be most readily achieved are often quite different. For example, a psychodynamic psychotherapist working to enhance affect regulation may feel that working with the child’s feelings about his or her therapist is the best way to assist the child in acquiring the capacity to regulate emotion in the context of intense attachment relationships. Similarly, clarifying the child’s thoughts and feelings in relation to the therapist has the effect of strengthening mentalizing or reflective function. Modern Psychodynamic Therapy: Relational and Attachment Theory Approaches More recently, the Kleinian, Winnicottian and Anna Freudian traditions have all to some degree been superseded, especially in the USA, by an interpersonal relational perspective (Altman, Briggs, Frankel, Gensler, & Pantone, 2002). In a relational approach, conflict is no longer seen as within the individual but as produced by conflictual and contradictory signals and values in the environment. The relational therapist, like the therapist offering developmental help, does not work to impart understanding. The relational therapist’s style is more active and participatory and aims to explore and correct maladaptive patterns of relating. CHAPTER 66 1082 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1082

Importantly, the intersubjective relational approach does not privilege early developmental periods at the risk of overlooking current relationship needs (Greenberg, 1991). Interpersonal therapists therefore tend to be active, to work with current relationships of the client, rather than focusing on a deeper layer of reality beyond the surface. Relational ideas form the basis of the psychodynamic model underpinning interpersonal therapy (IPT), which has a strong evidence base in the adult literature on depression and a somewhat more meager one for its adolescent adaptation (Mufson, Dorta, Wickramaratne et al., 2004; Young, Mufson, & Davies, 2006). In some people’s eyes, IPT might have moved too far from its origins to be genuinely considered a psychodynamic approach, yet the clearly psychoanalytic adaptations of the interpersonal psychodynamic tradition retain the focus on the relationship-seeking aspect of human character and a pragmatic focus to the child’s life and the therapeutic relationship in the context of this. Attachment theory (Bowlby, 1980) overlaps with both the relational tradition and Winnicottian object relations theories. Attachment theory implements selected aspects of psychoanalytic theory, using a general systems model and an ethological approach, with the additional virtue of openness to empirical scrutiny. Bowlby’s work on separation and loss focused developmentalists’ attention on the importance of the security (safety and predictability) of the earliest relationships. It is postulated that safety and predictability give the child the capacity for relatively problem-free later interpersonal relationships. Bowlby assumed that representational systems (internal working models) evolve based on a template created by the earliest relationship of the infant to the caregiver. If the expectation that need and distress will be met by comforting is encoded into these models, the child will be able to approach relationships in a relatively non-defensive way. If this is not the case, if the child’s caregivers lacked sensitivity, the child’s representational system will be defensively distorted to either minimize or heighten experiences of arousal, and dismiss or become entangled in the response of others. Longitudinal work confirmed Bowlby’s emphasis on the formative nature of early relationships and the pathological significance of the disorganization of the attachment system (Lyons-Ruth, 2003; Sroufe, Egeland, Carlson, & Collins, 2005), although the child’s subsequent experience is also important in determining outcome (Rutter, 1987). Further, recent work has also demonstrated the relative independence of the attachment system from genetic influence (Fearon, van IJzendoorn, Fonagy et al., 2006; O’Connor & Croft, 2001). However, clinical approaches rooted in attachment theory are only beginning to emerge. Recently, a group of workers have focused on an application of attachment theory that goes beyond Bowlby’s original rationale framed in the context of the quality of the infant– caregiver relationship. It is suggested that the attachment relationship has a key role in the development of social intelligence and meaning-making. The key evolutionary role of attachment in human development is in the opportunity that it confers for the development of social cognition (Fonagy, 2003). The relationship to the attachment figure has a long-term developmental impact through facilitating the emergence of complex psychological processes. In interaction with the infant, the caregiver tends to “reflect” the infant’s emotional states back to him, instinctively “mirroring” his feelings in a way that helps the child to feel that they are contained and not out of control. Such interactions enable the child to learn how to represent his own thoughts and feelings. The capacity for mentalization builds upon affect regulation as well as attentional control. For example, the capacity for pretend play has been found to be associated longitudinally with the mother’s ability to mirror the infant’s affects (Koos & Gergely, 2001). Weak affect regulation, attentional control and mentalization leave infants vulnerable to the impact of trauma (maltreatment), which undermines mentalizing capacities (Cicchetti, Rogosch, Maughan, Toth, & Bruce, 2003). The therapeutic approach to emanate from this developmental model may be particularly appropriate for more severe conditions, such as emerging personality disorder and multiple comorbidities that include an emotional disorder diagnosis. The therapeutic focus is no longer on enhancing insight but rather on strengthening social-cognitive capacities, particularly mentalization. Brief Psychotherapy, Group, Dyadic and Family Psychodynamic Therapy In the child literature, brief therapy has not been systematically studied even though this may be the form of individual dynamic therapy that is most commonly delivered in community settings (Kennedy, 2004). The one exception to this is interpersonal psychotherapy for adolescent depression (Young & Mufson, 2004), which is based on identifying maladaptive interpersonal patterns, making these patterns explicit and helping the patient to disrupt these patterns during the course of the treatment. These generally fall into one of five categories: grief, interpersonal disputes, role transitions, interpersonal deficits or single-parent families (Young & Mufson, 2004). There are some open trials and randomized controlled trials (Mufson, Dorta, Wickramaratne et al., 2004; Young, Mufson, & Davies, 2006) showing the effectiveness of the technique. Group therapy is frequently employed for children and adolescents, particularly in school and residential settings. Group therapy offers several advantages beyond economy. For children and adolescents the group format reflects the developmental priority of finding and integrating into a peer group. Process research in group therapy (Schechtman, 2001) suggests that children benefit from cathartic experiences and sharing. In adolescence, the group process may help with separation– individuation and identity formation. A range of processes that take place in group therapy facilitate developmental goals: identification through recognizing commonalities, a refinement and calibration of social perceptions, a benefit from social support, a counteracting of social isolation and improved feedback to enhance self-esteem. There is some evidence that group therapy with medically ill children is beneficial (see systematic review by Plante, Lobato, & Engel, 2001). Many other factors may assist change: the instillment of hope; altruism through assisting others; corrective recapitulation of the primary family group; PSYCHODYNAMIC TREATMENTS 1083 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1083

the development of social skills; group cohesiveness; and interpersonal learning through developing positive relationships with another. The improvements seen can also be accounted for within other theoretical frameworks such as cognitive–behavioral or social learning models. Although psychodynamic psychotherapy groups are quite heterogeneous in character, in most group work it is assumed that conflicts and concerns within the group in some ways mirror those in the children’s lives outside of the group. Further, group members are frequently exposed to discussions that may foster new ways of dealing with personal or interpersonal issues and they are afforded an opportunity to exercise empathy capacity and perspective taking. Psychodrama offers a frame for group treatments and a method for creating a structured awareness-producing milieu. It has been used with a range of problems including middle school girls coping with trauma (Carbonelli & Partelno-Bareehmi, 1999), adolescents with developmental problems (Oezbay, Goeka, Oeztuerk, & Guengoer, 1993) and as an adjunct to family therapy (Blatner, 1994). The efficacy of these forms of group therapy needs to be evaluated through properly conducted randomized controlled trials. Increasing recognition of the formative character of aspects of early childhood has led to increasing concern with child mental health issues. Epidemiological and prevention studies have highlighted the prevalence of early maltreatment and other trauma that may impact on subsequent mental health (Pynoos, Steinberg, & Piacentini, 1999). The now generally accepted transactional model of early childhood development (Sameroff & Fiese, 2000), highlighting the complexity of the early caregiving environment, has offered a focus for therapeutic interventions in the child–caregiver relationship. Therapeutic interventions are directed not at the child who is presented as bringing a problem but at the child–caregiver relationship and its entire cultural, social, family, marital and parent context. Child–parent psychotherapy (CPP; Lieberman, 2004) is based on the premise that the attachment system is the main organizer of children’s responses to danger and safety in the first years of life and a therapeutic relationship can be mutative. Weekly joint child–parent sessions over 1 year are interspersed with individual sessions for the mother, with the aim of changing maladaptive parenting behaviors and supporting developmentally appropriate interactions while guiding the child–parent couple to create a joint narrative of traumatic events working towards their resolution. Two randomized controlled trials have demonstrated the effectiveness of this method (Lieberman, Weston, & Pawl, 1991; Lieberman, Van Horn, & Ippen, 2005). When compared with case management, including community referral for individual treatment, child– parent psychotherapy was associated with significantly more improvement in parent-rated measures of child symptomatology (Effect Size = 0.840). This runs counter to the finding of van IJzendoorn, Juffer, and Duyvesteyn (1995) in their review of attachment-oriented interventions with relatively low-risk samples without major psychiatric symptomatology. This review suggested that brief treatment was more effective than long-term treatment in increasing attachment security, but psychiatric symptomatology was not assessed. A dyadic narrativeoriented therapeutic approach similar to Lieberman et al.s’ has been demonstrated to be effective for toddlers of depressed mothers (Cicchetti, Rogosch, & Toth, 2000) and neglected and maltreated preschoolers (Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002). Psychodynamic psychotherapy now normally includes some “family work” or help for the parents. This is of course not the same as formal family therapy, which has a theoretical frame that is often antagonistic to or at least divergent from psychodynamic approaches. However, there are psychodynamically oriented implementations of family therapy that combine systemic approaches with psychodynamic ideas (Johnson & Lee, 2000). There is a move from both sides towards an integration between family and psychodynamic therapy. Thus, many more recent variants of structural family therapy recognize the relevance of aspects of the psychodynamic approach (e.g., attachment theory) as a core component of systemic family interventions. There is a spectrum, from more clearly psychodynamic approaches such as attachment-based family therapy (Diamond, Diamond, & Siqueland, unpublished data), to those that have taken only particular aspects of a psychodynamic perspective, such as multidimensional family therapy (Liddle, Dakof, Parker et al., 2001) and the biobehavioral family model (Wood, Klebba, & Miller, 2000). From the other direction, there are examples of traditional psychodynamic therapy taking on a family dimension. In the psychodynamic implementation of family therapy, intrapersonal problems are considered alongside characteristic family dynamics. The family is viewed as a system whose process determines adolescent development. Psychodynamic family therapy focuses on communication and negotiation, challenges problematic coalitions and supports the appropriate roles of parents and children in a family hierarchy. It also concerns itself with family narratives, helping families to understand the way they deal with the child’s problems at both conscious and unconscious levels (Lock, 2004). Treatment focuses on increasing parental self-efficacy but also on diminishing parental guilt. This is postulated to help parents to become more authoritative and able to manage problems while still being both warm and understanding. The therapist acts as a consultant, there to empower family members to solve their own problems. In narrative family therapy, the therapist relies on the creativity and playfulness of children with words and other activities. The therapist can facilitate the creation of coherent and lasting alternative stories by, for example, eliciting and developing a counterplot to a problem-saturated story. In emotion-focused family therapy (Johnson & Lee, 2000) techniques such as the family puppet interview, mutual storytelling and different forms of art therapy are used to set up a safe environment in which attachment needs can be identified and expressed. There is evidence for the effectiveness of emotion-focused family therapy, principally from couples research (Dunn & Schwebel, 1995). There is also empirical support for the efficacy of explicitly psychodynamic family therapy from studies with anorexia nervosa (see p. 1086). CHAPTER 66 1084 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1084

Empirical Basis of Psychodynamic Child Psychotherapy Randomized Controlled Trials Comprehensive reviews of outcome studies of psychodynamic approaches to child and adolescent mental health difficulties are few. Surveys focus on the treatment of children with mental health problems in general (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Kazdin, 2004; Target & Fonagy, 2005) or psychosocial interventions limited to “evidence-based treatments” (Hibbs, 2004; Weisz, 2004). The most comprehensive survey of outcome studies specifically concerned with psychoanalytic approaches was that undertaken by Kennedy 2004. The conclusions are more optimistic than the current state of empirical evidence justifies, which is reviewed below. There are no really good randomized controlled trials of psychodynamic psychotherapy with children. The few controlled trials are underpowered and suffer from other methodological limitations (Robin, Siegel, Moye et al., 1999; Sinha & Kapur, 1999; Smyrnios & Kirkby, 1993; Szapocznik, Rio, Murray et al., 1989; Trowell, Kolvin, Weeramanthri et al., 2002; Trowell, Joffe, Campbell 2007). All but one of these trials contrasted individual child psychotherapy with another treatment. In no case did child psychotherapy emerge as superior to the contrast treatment. These trials are all considered further below. Several studies employed quasi-randomized methods of assignment such as postcode (Moran, Fonagy, Kurtz et al., 1991) or therapist vacancy (Muratori, Picchi, Casella et al., 2001, Muratori, Picchi, Bruni et al., 2003). Six studies reported on findings with matched comparison groups (Fonagy & Target, 1994; Heinicke & Ramsey-Klee, 1986; Reid, Alvarez, & Lee, 2001; Target & Fonagy, 1994a,b). Three studies used experimental single-case methodology (Fonagy & Moran, 1990; Lush, Boston, Morgam, & Kolvin, 1998; Moran & Fonagy, 1987). On the basis of these studies, the evidence base for child psychotherapy is quite poor. Indications of Differential Effectiveness of Psychodynamic Approaches for Specific Clinical Problems Anxiety disorders There is only very preliminary evidence that psychodynamic psychotherapy may be effective in the treatment of anxiety disorders (Target & Fonagy, 1994). In this chart review study, children with anxiety disorders (with or without comorbidity) showed greater improvements than those with other conditions, and greater improvements than would have been expected on the basis of studies of untreated outcome. Muratori, Picchi, Casella et al. (2001) examined the efficacy among 58 children with depression and anxiety, of 11 sessions of psychodynamic therapy based on the Parent–Child Model involving work with the parents for 6 of the 11 sessions. This was contrasted with treatment as usual in the community (poorly described in the report). Allocation was based on therapist vacancy at referral. At 2-year follow-up only 34% of the treated group were in the clinical range on the Child Behavior Checklist (CBCL), compared with 65% of the controls. Unusually for trials of psychotherapy, treatment effects increased during the 2-year follow-up period (the so-called “sleeper effect”): the average child with emotional problems moved from the clinical to the non-clinical range in the psychodynamically treated group only (Muratori, Picchi, Bruni et al., 2003). In the control group, the average child remained at the same level of severity through the follow-up period. The conclusions from this trial are limited because of the small sample size and the lack of random allocation. However, it is encouraging that psychodynamic psychotherapy patients sought mental health services at a significantly lower rate than those in the treatment as usual comparison condition over the 2-year follow-up period. A very small randomized controlled trial (n = 30) of adolescents showed a surprisingly strong statistically significant benefit from 10 sessions of psychodynamic psychotherapy in a school setting in India. The vast majority of young people improved in psychodynamic psychotherapy (over 90%, reported effect size 1.8; Sinha & Kapur, 1999). Notably, young people with disruptive behavior were specifically excluded from this sample. Therapy outcome was independently, but not blindly, assessed by teachers. Childhood Depression A multicenter European trial compared family therapy with brief individual psychodynamic psychotherapy (Trowell, Joffe, Campbell et al., 2007). At 7-month follow-up none of the moderately to severely depressed young people who received psychotherapy met diagnostic criteria, whereas 29% in the family therapy group did. This trial did not have an untreated control group, so it is uncertain how far these results are superior to no treatment, although the results with individual treatment are comparable to children treated with a combination of fluoxetine and cognitive–behavior therapy (Goodyer, Dubicka, Wilkinson et al., 2007). Smyrnios and Kirkby (1993) investigated the therapeutic effects of a therapy combining psychodynamic and systemic principles with 30 school-age children. The children were randomly divided into three groups of 10: 1 One group received “time-unlimited” psychoanalytic therapy using a Kleinian model (on average 28 sessions, with a range of 3–62 sessions); 2 Another group received short-term therapy (on average 10.5 sessions, with a range of 5–12 sessions); and 3 A third group was offered a three-session consultation. All three groups showed significant improvements from pre-test to post-test on a number of individual and family ratings, but the effect size was greatest for the time-unlimited treatment. Effect sizes for target complaints at post-treatment, relative to consultation: 0.76 (95% confidence interval [CI], 0.28–1.3) for time-limited; 1.23 (95% CI, 0.84–1.6) for time-unlimited. At 4-year follow-up, the effect sizes for target complaints were no longer significantly different from the control group, who are likely to have had other treatments. In line with this, the consultation group caught up with the treated groups and reported significant improvement relative to post-treatment on PSYCHODYNAMIC TREATMENTS 1085 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1085

follow-up, severity of target problems and measure of family functioning. However, a high proportion (up to 50%) of the very small numbers in the original groups was lost to follow-up. Disruptive Disorders In the Anna Freud Centre retrospective study (Fonagy & Target, 1994), whereas children and young people treated for major depression were likely to improve even if they remained in the dysfunctional range after treatment, diagnoses related to conduct problems appeared particularly resistant to psychodynamic therapy (CD and ODD). Family Involvement In a comparison of family therapy and individual psychodynamic psychotherapy with a mixed behaviorally and emotionally disordered sample of Hispanic children, both treatments were found to be effective in reducing behavioral and emotional problems, relative to a no-treatment control group (Szapocznik, Rio, Murray et al., 1989). The symptomatic improvements were maintained at 1-year follow-up, but the control group caught up with these improvements over the follow-up period. It should be noted that there was considerable attrition in the control group and the analysis was not on the basis of intent-to-treat. A total of 16% of families dropped out of family therapy compared with 4% who abandoned individual psychodynamic therapy, but family functioning improved following family therapy and deteriorated following individual psychodynamic psychotherapy (i.e., between end of treatment and follow-up). Individual child psychotherapy is now rarely carried out without family work. In the Anna Freud Centre retrospective study, concurrent work with parents was a predictor of good outcome (Target & Fonagy, 1994). With younger children, particularly preschool age, a mother–child dyadic therapy where the parent and child are jointly seen appears to be an effective psychodynamic intervention. For example, in Lieberman, Van Horn, & Ippen (2005) study, 75 children who had been exposed to marital violence were treated in child–parent psychotherapy weekly for 1 year and this was contrasted with individual treatment and case management. The dyadic work yielded superior outcomes in terms of behavioral problems, traumatic stress symptoms and diagnostic status and post-traumatic stress disorder (PTSD) symptoms and general distress for the mother. Pervasive Developmental Problems Non-directive play is often used to try to promote communication skills in children with autism (Cogher, 1999). Although such interventions have common components they are not specifically psychodynamic. The Tavistock Clinic has developed a specialized psychodynamic approach to the treatment of individuals with autism (Reid, Alvarez, & Lee, 2001), but this has not been evaluated in a controlled trial. Eating Disorders A further specific diagnostic group for which some trial data are available is anorexia nervosa. Randomized controlled trials of behavioral family systems therapy aimed to contrast this therapy with an “inert” treatment and they chose ego-oriented individual therapy, a specially designed treatment with a clear psychodynamic basis (Robin, Siegel, & Moye, 1995; Robin, Siegel, Moye et al., 1999). Each patient received 10–16 months of therapy and was assessed at post-therapy, and followed up at 1, 2.5 and 4 years. Improvements were equivalent in both treatments; two-thirds of the girls reached their target weights by the end of treatment, and at 1-year follow-up 80% of those receiving family therapy and 69% of those treated individually had reached their target weights (a difference that was not statistically significant). As is often found, the nonpsychodynamic approach produced changes faster but in this instance carried the cost of a somewhat higher rate of hospitalization. Both therapies produced equally large improvements in attitudes to eating, depressed affect and family functioning (Robin, Siegel, & Moye, 1995). Robin et al. concluded that parental involvement was essential to the success of their interventions for younger adolescents with anorexia nervosa. The comparability of the effectiveness of family and individual approaches in the above studies is somewhat in contrast to the long-term superiority of family therapy for a group of young adult anorexics using a similar psychodynamic approach (Dare, Eisler, Russell, Treasure, & Dodge, 2001; Eisler, Dare, Russell et al., 1997; Eisler, Dare, Hodes et al., 2000; Russell, Szmukler, Dare, & Eisler, 1987). In these studies at the Maudsley Hospital, individuals who were relatively older generally benefitted more from individual treatment while younger individuals benefitted more from family-based approaches (for further details of these studies see chapter 41). Chronic Physical Illness There is a tradition of psychodynamic work with individuals with chronic physical conditions such as asthma and diabetes (Shaw & Palmer, 2004) but trial data are hard to come by. In a series of experimental single-case studies, individual psychodynamic therapy was found to improve several growth parameters probably associated with improvement of diabetic control (Fonagy & Moran, 1990). Trauma Goenjian, Karayan, Pynoos et al. (1997) reported a naturalistic study on the outcome of psychotherapeutically treated and untreated earthquake victims at 1.5 years (pre-treatment) and 3 years (post-treatment) after the earthquake. While the severity of PTSD symptoms significantly decreased among recipients of trauma/grief-focused brief psychotherapy, symptoms significantly worsened among untreated subjects. Layne, Pynoos, and Cardenas (2001) have developed a program for adolescents who experienced or witnessed violence. The UCLA School-Based Trauma/Grief Intervention Program for children and adolescents includes a systematic method for screening students, a manualized 16–20 week group psychotherapy protocol which addresses current stresses and conflicts not limited to the CHAPTER 66 1086 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1086

trauma exposure, and adjunctive individual and family therapy. As a package, the protocol is a skills-based cognitive–behavioral therapy program and is very far from a prototypical unfocused insight-oriented group psychotherapy, but the attention to developmental considerations and the model of traumatic stress within which the treatment is rooted (Pynoos, Steinberg, & Wraith, 1995) make the intervention deserving of consideration under a general psychodynamic heading. Controlled trials are now needed. More directly relevant is a multicenter randomized trial of the treatment of sexually abused girls treated in individual psychotherapy and psychoeducational group therapy (Trowell, Kolvin, Weeramanthri et al., 2002). A total of 71 sexually abused girls were randomized to either 30 sessions of individual psychoanalytic psychotherapy or 18 sessions of group psychotherapy with psychoeducational components. These young people presented with a range of psychiatric problems, most commonly PTSD and depression. Psychodynamic treatment was no different from psychoeducation in terms of overall levels of psychopathology measures and psychosocial functioning measures. In relation to PTSD, however, there were greater gains in the individual psychotherapy group; the between-treatments effect size ranged from 0.6–0.79 for specific symptoms. Trials are now needed comparing dynamic psychotherapy with other proven treatments such as cognitive– behavioral therapy and exposure. Summary The empirical status of all psychodynamic approaches remains controversial. The body of rigorous research supporting psychodynamic therapies for both adults and children for most disorders remains limited, particularly relative to research supporting pharmaceutical treatments and even other psychosocial approaches such as cognitive–behavioral therapy (Roth & Fonagy, 2005). There are both practical and theoretical difficulties in mounting trials of dynamic therapies, which go some way to explaining the lack of evidence. These include, for example, the bias against research by many practitioners of psychodynamic therapies, their epistemological problems with accepting the canons of modern scientific studies, the reluctance of funding bodies to invest in research on clinical problems considered “solved” by a combination of drug and cognitive– behavioral treatments, the expense of mounting trials sufficiently powered to yield information on what treatments are appropriate for which disorder and the failure to manualize psychodynamic treatments. Currently, there is some modest evidence to support the use of psychodynamic psychotherapy for children whose problems are either emotional or mixed. There is also evidence that the support and inclusion of parents are important aspects of this treatment, that effects tend to increase following the end of treatment and that behavioral problems are more resistant – at least to a classic insightoriented psychodynamic approach. Those who argue (correctly in our view) for continued investment in this approach point to the limitations of the evidence base in childhood supporting cognitive–behavioral therapy (Westen, Novotny, & Thompson-Brenner, 2004) or pharmacological approaches (Whittington, Kendall, Fonagy et al., 2004). Notwith-standing the general weakness of the evidence base of mental health treatments for children, this weakness is particularly strong for psychodynamic treatments and the shortage of research studies needs to be addressed urgently. In the light of the limitations of cognitive–behavioral therapy with severe disorders in comparison with medication (Goodyer, Dubicka, Wilkinson et al., 2007; March, Silva, Petrycki et al., 2004; Swanson, Arnold, Vitiello et al., 2002), it behoves us to investigate the effectiveness of alternative treatment approaches. Integration of Psychodynamic Psychotherapy into Child and Adolescent Mental Health Services This section addresses the place of psychodynamic child psychotherapy within child and adolescent mental health services (CAMHS). This will be described from the UK perspective, in which child psychotherapy is delivered mainly within the National Health Service (NHS), but many of the principles probably also apply elsewhere. In the UK, psychoanalytic psychotherapy for children and young people is usually delivered within a multidisciplinary CAMHS. A considerable part of child psychotherapists’ work is consultation with and supervision of other CAMHS professionals and paraprofessional staff, as well as contributing to thinking within the team and the network about the situations and emotional development of children referred. Working long-term and/or intensively with individual children has been shown to occupy only about one-third of the employed time of these specialized staff. Their perspective should complement rather than compete with systemic, biological, cognitive– behavioral or other frameworks. The range of contexts for child psychotherapy work has also very much extended, particularly the proportion of work focused on children who are being looked after by local authorities (child protective services); other areas to which child psychotherapists contribute include education, forensic services, pediatric liaison, perinatal services and parent–infant community settings. The perspective of psychoanalytic psychotherapy appears to be used in several distinct ways; the following approximate proportions of time are based on consistent data from three large-scale surveys (Rance, 2003): 1 To treat individual children (usually once weekly; 36%); 2 To provide training, supervision (8%), assessment (14%) and consultation (14%) using a psychoanalytic framework (e.g., to support treatment carried out by other professionals in a team or their trainees); 3 Working using a variety of techniques other than individual psychotherapy (e.g., family therapy, work on parenting, group therapy with young people, parent–infant therapy); this is often joint work with colleagues in other disciplines (18%); and PSYCHODYNAMIC TREATMENTS 1087 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1087