Paediatrics: Family therapy

Family therapy

This term covers a wide range of treatments with a similar diversity of theoretical underpinnings. They share the idea that problems are affected by the communication between family members and such communication can serve to maintain or to ameliorate their difficulties.

One of the points of difference concerns understanding of the prob-lem. Family therapy based on systems theory might identify recurring dys-functional patterns of interaction and typically might hypothesize that the presenting problem in one family member is a manifestation of this. Such a view, of pathology being located between, rather than within people, may be at odds with the Western focus on the individual. An example of such an approach is the school-refusing child who is being kept home to act as a buffer between parents who are in conflict. The child’s presence may prevent dangerous escalation, but may also interfere with the parents’ ability to resolve their differences. Therapy in this case might focus on helping the parents to address their difficulties without involvement of the child, and for the child to trust his/her parents to do this and to get on with being a child, e.g. going to school.

An alternative is to help the family members to be aware that they are feeling overwhelmed by the problem, have lost confidence, and are not seeing that they do have the resources to deal with it. They might be helped to think of occasions when they have overcome difficulties without the help of their child; or to see how they do this and more often. The child may be helped to see that he/she does, at times, overcome his/her fear and gets on with being a child, and can do more of this.

Finally, we can consider family therapy for multifactorial illnesses, such as autism. This is not a product of any particular family pattern or dysfunc-tion. However, this does not mean that the family cannot be helped to manage this better. Such an approach is likely to focus on support, on psycho-education, and on helping the family to address the developmental (independence) issues, which are there for any family, but so much more difficult when there is a child with chronic illness or disability.

Outcome

The heterogeneity of family therapy, the wide variety of problems it is used to address, and sometimes an overemphasis on complex theory that can seem a long way from clinical practice have contributed to a dearth of outcome research. There is evidence though for effectiveness in a range of conditions including anorexia nervosa (AN).

Contraindications

Non-clinicians often see family therapy as a potential panacea for all fam-ily based problems. Unfortunately this is not the case and family therapy is not always the correct way to address such difficulties. Family therapy is not possible if the family cannot, or will not, attend. It is contraindicat-ed in families where one member is being severely scapegoated. Unless there is reason to believe that such a family is open to the idea of doing things differently once this pattern is identified, family therapy should be discontinued.