• By Dartington SRU
  • Posted on Tuesday 23rd November, 2010

The road to better family therapy

When Thomas Sexton, the head of Functional Family Therapy Associates, first started in the field of family therapy he hadn’t been taught what to do. He had to learn things the hard way, which meant getting things wrong a lot of the time. From his experiences he has learned humility: the impact a therapist can have on a young person is limited. Sexton argues that we cannot change people. The only thing we can change is the probability that the next time the young person comes across a decision they will choose differently. A therapist cannot fix families’ problems, but they can help give them the ability to fix their problems themselves.Sexton, who was speaking at The Association for Child and Adolescent Mental Health conference in Cardiff this month, has also learned the value of accountability. It is the therapist’s job to lead the progress in family therapy, not simply to follow. Ultimately, the responsibility for the outcome of family therapy rests on the therapist’s shoulders. And what is the trick to being able to influence families to create better outcomes? A good map and plenty of creativity. The family therapist needs to navigate among extremely complex family relationships. It is not good enough to try different approaches at random, or base on intuition the hope that the destination will be better than the departure point. Therapists may succeed sometimes this way by chance, but they may also end up making matters worse. All this serves to underline the importance of functional family therapy It provides a map to help the therapist guide the family through individual phases, each with specific goals. The first goal is to reduce the accumulated negative emotions within the family. The final goal is to help the family apply the lessons learned inside the therapy room to the outside world. The progress through these goals is constantly assessed by the family, the therapist and the supervisor, and then used to inform the practice of functional family therapy. This feedback mechanism makes this therapy as much evidence-based within practice as it is as a program. But it is creativity which makes it possible to make a structured program like functional family therapy work for individual families. Being creative means adapting and “translating” the program so it matches the unique demands of each family. The goals remain the same; how they are reached, however, will change. Creativity is, though, only possible if the map is known well enough. Otherwise, it’s impossible to know the desired destination. To this effect, the map of the therapy is more like a Global Positioning devise or GPS system rather than a traditional static map. To take an alternative route, the therapist doesn’t just make a random guess. Instead, like a GPS, to recalculate the route, they need to use the best information available about the most efficient alternative route: the data from the continuous assessment.So we know that the therapist is the mediator between the program and the outcome. How can we make sure they can successfully deliver the program to families and help them reach their destination? That was the focus of Astrid Van Dam, the clinical director of Functional Family Therapy Associates, and another speaker at the conference.Van Dam feels strongly about ensuring the quality of functional family therapy. It takes a lot of effort to get a family into the therapy room and the drop-out rate from services is high. When the family is there, the therapist needs to make an impact.However, as programs are introduced in new areas, and their method of operation is disseminated, quality can be overtaken by quantity. Families who have come a long way to access the services are failed. There are two key ways to try and prevent this. First, systematic ongoing training and supervision for therapists and, second, creating a culture that supports the best possible practice in each organization that delivers the service. Continuing training and supervision is the key. To actually make a difference, “the creative therapist” needs to know the model well enough, and needs to learn through practice. The use of one-way mirrors, taping sessions to review progress and weekly supervision are the normal ways to disseminate the therapy. Quality monitoring includes regularly collecting data from the family, the therapist and the supervisor. It is not unknown for the supervisor to come knocking on the therapist’s door to give them advice in the middle of a therapy session if something is not going well. According to Van Dam, while it takes a while for the therapists to get used to this amount of supervision and feedback, the families like it. All they want is good-quality help and, when it is explained that the purpose of the supervisor’s role is to improve the service, they are happy with it. But no matter how good a family therapist is, there is a limit to what they alone can do if they are working against competing interests in a workplace. To truly integrate evidence-based practice requires the organization which the therapist works in to be supportive of them. This is why functional family therapy does not train individual therapists but whole working groups. Furthermore, before training anyone, Van Dam does an assessment on the organization and any possible barriers to implementation of therapy. The model is then matched to the characteristics of the agency which will be implementing it, so that it will become “practice as usual” within the agency. If implemented successfully, the aim is to create change - not just in individual families or practitioners, but to change the nature of practices and the larger systems they exist in. In common with Sexton, who emphasizes the accountability of the therapist in the outcome of functional family therapy, Van Dam extends the responsibility to the trainer. The secret of effective therapy and implementation is to be humble about what you can achieve but to also be accountable for the outcomes. “We are open to changing our training practices when we see something is not working,” Van Dam explains.Thus, just as the therapist is accountable for the outcome of a family, the trainer is responsible for the outcomes of family therapy itself. Reference:Lionel Hersov International Speaker Fellowship Conference, 2010 “Functional Family Therapy and Related Family-Based Approaches to Youths with Mental Health Problems…theories, developments, strategies, techniques”, The Association for Child and Adolescent Mental Health Cardiff, Wales (10//)

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