Systemic family therapy is an effective intervention for children and adolescents but further well-designed outcome studies are needed using clearly specified, manualised forms of treatment and conceptually relevant outcome measures.
SummaryBackgroundSelf-harm in adolescents is common and repetition occurs in a high proportion of these cases. Scarce evidence exists for effectiveness of interventions to reduce self-harm.MethodsThis pragmatic, multicentre, randomised, controlled trial of family therapy versus treatment as usual was done at 40 UK Child and Adolescent Mental Health Services (CAMHS) centres. We recruited young people aged 11–17 years who had self-harmed at least twice and presented to CAMHS after self-harm. Participants were randomly assigned (1:1) to receive manualised family therapy delivered by trained and supervised family therapists or treatment as usual by local CAMHS. Participants and therapists were aware of treatment allocation; researchers were masked. The primary outcome was hospital attendance for repetition of self-harm in the 18 months after group assignment. Primary and safety analyses were done in the intention-to-treat population. The trial is registered at the ISRCTN registry, number ISRCTN59793150.FindingsBetween Nov 23, 2009, and Dec 31, 2013, 3554 young people were screened and 832 eligible young people consented to participation and were randomly assigned to receive family therapy (n=415) or treatment as usual (n=417). Primary outcome data were available for 795 (96%) participants. Numbers of hospital attendances for repeat self-harm events were not significantly different between the groups (118 [28%] in the family therapy group vs 103 [25%] in the treatment as usual group; hazard ratio 1·14 [95% CI 0·87–1·49] p=0·33). Similar numbers of adverse events occurred in both groups (787 in the family therapy group vs 847 in the treatment as usual group).InterpretationFor adolescents referred to CAMHS after self-harm, having self-harmed at least once before, our family therapy intervention conferred no benefits over treatment as usual in reducing subsequent hospital attendance for self-harm. Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents.FundingNational Institute for Health Research Health Technology Assessment programme.
Determining the efficacy of therapeutic interventions is becoming an increasing political and ethical necessity. Comparative therapeutic outcome trials are most powerful when there is a precise specification, or manualization, of the forms that therapies took. Manuals have begun to be developed for structural/behavioural family therapy and couple therapy. The development of these manuals is often reliant on experts' self‐report, rather than a systematic analysis of the therapeutic process as it happens. This can limit their validity and applicability to standard clinical practice. In addition, no manuals exist which reflect less structured forms of family therapy aimed at incorporating systemic, postmodern and narrative frameworks. The feasibility of producing a workable manual that reflects the fluidity of such practices has been questioned. A research project to systematically create and test such a manual is reported. Multiple data sources and research methods, primarily qualitative, were applied to generate a rich specification of the therapy. In reporting these results the contents of various aspects of the final manual are indicated. Procedures to ensure that the prescribed practice is consistent with a widely used approach to systemic family therapy are also described. The manual will be an important tool for outcome research and therapeutic practice. The account of the research process should be helpful to researchers engaged in constructing a manual for other models of family therapy based on a rigorous analysis of actual practice. The manual itself is available for use by outcome researchers who wish to evaluate this widely used form of systemic family therapy.
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in ; Vol. 22, No. 12. See the NIHR Journals Library website for further project information.
The characteristics of a series of 274 families who were referred to a sexual abuse treatment programme were analysed. Information was obtained on 411 abused children and 362 non-abused children. Different forms ofsexual abuse were noted, with 77% of girls and 23% of boys affected. Boys tended to be abused at a younger age, more severely, and for longer periods than girls. There was a predominance of lower social class groups among the parents, and a wide variety of family structures, with reasonable stability over time. Ninety six per cent ofperpetrators were men, and biological and step-parents predominated. Contributing factors in both the family history and the current perpetrators and their wives included sexual abuse, violence, chaotic families, marital problems, sexual difficulties, alcoholism, and subnormality.Follow up of 120 families, 180 victims, and 226 siblings showed that prosecution occurred in 60% ofcases, with a high percentage of perpetrators being imprisoned. Treatment was offered to 87% of families, but because the treatment programme was in the early stages of development a variable number of children and parents were offered family treatment or treatment in groups for parents and children separately. There was an improvement in the victim's circumstances in 61% of cases, and a noticeable
BackgroundSelf-harm is common in the community with a lifetime prevalence of 13 %. It is associated with an elevated risk of overall mortality and suicide. People who harm themselves are high users of public services. Estimates of the 1-year risk of repetition vary between 5 and 15 % per year. Currently, limited evidence exists on the effectiveness of clinical interventions for young people who engage in self-harm. Recent reviews have failed to demonstrate any effect on reducing repetition of self-harm among adolescents receiving a range of treatment approaches. Family factors are particularly important risk factors associated with fatal and non-fatal self-harm among children and adolescents. Family therapy focuses on the relationships, roles and communication patterns between family members, but there have been relatively few studies of specifically family-focused interventions with this population. The Self-Harm Intervention: Family Therapy (SHIFT) Trial was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (grant no. 07/33/01) following a commissioned call for this research.Methods/DesignSHIFT is a pragmatic, phase III, multicentre, individually randomised, controlled trial comparing Family Therapy (FT) with treatment as usual (TAU) for adolescents aged 11 to 17 who have engaged in at least two episodes of self-harm. Both therapeutic interventions were delivered within the National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) in England. Participants and therapists were, of necessity, aware of treatment allocation, but the researchers were blind to the allocations to allow unbiased collection of follow-up data. Primary outcome data (repetition of self-harm leading to hospital attendance 18 months post-randomisation) were collected from the Health and Social Care Information Centre (HSCIC), augmented by directed searches of medical records at Acute Trusts. Secondary outcome data (including suicidal intent, depression, hopelessness and health economics) were collected at 12 and 18 months post-randomisation via researcher-participant interviews and by post at 3 and 6 months.DiscussionSHIFT will provide a well-powered evaluation of the clinical and cost effectiveness of Family Therapy for young people who have self-harmed on more than one occasion. The study will be reported in 2016, and the results will inform clinical practice thereafter.Trial registrationISRCTN59793150. 26 January 2009.
Post-modernism is a term that is omnipresent in the media, academic circles and contemporary culture. It is also a term that has caused substantial consternation among systemic family therapists. Systemic family therapy traces its origins from the 1950s, and there are currently several different models contained within the systemic paradigm. A unifying feature of systemic therapy is the importance placed on understanding psychological difficulties in the context of social relationships. Another point of agreement among systemic therapists is the significance of drawing distinctions and marking ‘difference’ as an aspect of creating change. A third common feature is the practice of working in teams, where one therapist conducts the interview, while a small number of others comment on their observations. The degree to which these models and practices have been influenced by postmodernism varies.
aThis short article presents a teaching session on the topic of positioning theory and narratives within the organizational context. The theory is made more accessible to students through playful group experiential learning in which the university assessment process is considered from different discourses and positions. Students could see how, in role, they were positioned and positioned others. Organizational narratives were brought to life.Practitioner points • Novelty and playfulness are important in the teaching of theory • Using the 'organization created around learning' offers a refreshing new arena in which to apply theory • Positioning theory is best understood through experiential learning. By using the role play, the student is exposed simultaneously to at least three positions; their own personal perspective, that of the character in the role play and the experience of listening to others Keywords: positioning theory; organizational study; teaching. Context and settingThis teaching took place in the second year of the University of Leeds MSc in Family Therapy. The group of 22 students included psychiatrists, clinical psychologists, nurses and counsellors. Most students were senior practitioners in the National Health Service and a few were from voluntary sector or academic settings. The MSc course included a series of sessions on the application of systemic thinking to organizations. These sessions involved topics such as the similarities and differences between clinical use of systemic ideas and consultation with organizations, the use of the coordinated
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