Family and Systemic Therapies 359Evaluation of family therapy
Criticisms
Some family therapists have little knowledge of specific syndromes in child
and adolescent psychiatry. Rather, all problems are seen as arising from
abnormal patterns of relationships. They fail to recognise the contribution
of partly or entirely constitutional disorders such as Asperger syndrome or
ADHD. Even with a condition such as a disruptive behavioural disorder,
where psychosocial factors are highly relevant, a family therapy approach
might not pick up the specific reading disorder present in up to a third of
cases, and so fail to address the causal contribution this may be making.
Some family therapists seldom see children or adolescents on their own.
Yet an individual interview is often essential to reveal depression, bullying,
or abuse. For fear or shame or other reasons, children and adolescents may
not say what they mean in front of other family members.
Families come for help because they feel that their child’s symptoms
need addressing directly. However, they may be put off by what they per-
ceive as irrelevant intrusion into their private relationships. Some forms,
notably Milan systemic, may use a second team to observe the therapist,
which is expensive. In Milan therapy, it is hard for a therapist to be
neutral if they have statutory obligations to protect the child or adolescent
from abusive practices. The lack of explanation of why the questioning
is following this line, and the confusing nature of the intervention, can
alienate some families who vote with their feet and don’t come back.
Rejoinders
Many, if not all, of these concerns can be overcome through flexible
working. For example, in a multidisciplinary team, it is often possible to
have an initial general assessment before proceeding to family therapy,
although in practice most family therapists do not work this way. Engaging
the family is the art of the therapist, and a skilled one will not lose families
by becoming too probing too soon, but will be sensitive to what the family
can tolerate. One of the main advantages of having a background in family
therapy is to be able to recognise and address intrafamilial influences on
behaviour, which a linear ‘diagnostic’ approach fails to do.
Outcome studies
There have been several randomised controlled trials in the past decade for
a restricted range of conditions, showing that: family therapy as practised
at the Maudsley Hospital is an effective therapy for anorexia nervosa;
Multisystemic Therapy (which, as its name suggests, includes several
components, so that generalisation in the community is maximised) is
helpful for juvenile delinquency, drug misuse and child abuse; Functional
Family Therapy (a more classical approach but with a behavioural slant)
is helpful for juvenile delinquency; and Brief Strategic Family Therapy is
helpful for drug misuse. These are all notoriously hard conditions to treat,