Supporting Families Affected by Adversity: An Open Feasibility Trial of Family Life Skills Triple P

This pilot feasibility study examined the effects of a new trauma-informed parenting program, Family Life Skills Triple P (FLSTP), in an open uncontrolled trial conducted in a regular service delivery context via video conferencing. FLSTP was trialed as a group-delivered 10-session intervention. Program modules target positive parenting skills (4 sessions) and adult life skills including coping with emotions, taking care of relationships, self-care, dealing with the past, healthy living, and planning for the future. Participants were 50 parents with multiple vulnerabilities, due to social disadvantage or adverse childhood experiences, who had children aged 3-9 with early onset behavior problems. Outcomes were assessed across four data collection points: baseline, mid-intervention (after Session 4), post-intervention, and 3-month follow up. Findings show moderate to large intra-group effect sizes for changes in child behavior problems, parenting practices and risk of child maltreatment, and medium effect sizes for parental distress, emotion regulation and self-compassion. Parents and practitioners reported high levels of consumer satisfaction with the program. Parents with lower levels of parental self-efficacy, lower personal agency and higher baseline scores on a measure of child abuse potential were at greater risk of not completing the program. The strength of these preliminary findings indicates that a more rigorous evaluation using a randomized clinical trial is warranted.

Family-Based Treatment for Anxiety, Depression, and ADHD for a Parent and Child

Children with mental illness commonly live with caregivers who suffer from mental illness. Integrated mental-health-treatment approaches can provide more convenient and comprehensive care for families. This case report describes family-based treatment (FBT) for one parent/child dyad. The parent was a 37-year-old female with a history of anxiety and major depressive disorder and concern for symptoms of attention-deficit/hyperactivity disorder (ADHD). The child was an 8-year-old female with generalized anxiety disorder and concern for ADHD and behavioral problems. The parent received individual cognitive behavioral therapy (CBT) and parent management training. The child received CBT. Both also received medication management. The FBT team met regularly for coordinated treatment planning. Self-reported assessments via the Child Behavior Checklist showed meaningful improvement; anxiety decreased to nonclinical range week 12 and depression decreased to nonclinical range week 8. Clinician assessments showed improvement for both patients. Though more time intensive, FBT can yield significant improvement, particularly for children. Pragmatic approaches to treatment planning are important to minimize barriers to FBT.

Sensitivity to change of the Systemic Therapy Inventory of Change (STIC) intersession scales

Objective: The Systemic Therapy Inventory of Change (STIC) is a systemic measurement feedback system that provides therapists with feedback regarding the multidimensional clinical change in individual, couple, and family therapy. The STIC Intersession scales include Individual Problems and Strengths (IPS), Relationship with Partner (RWP), Family/Household (FH), and Child Problems and Strengths (CPS). They are administered to clients before each therapy session. The purpose of the current study is to investigate the STIC Intersession scales' sensitivity to change, the ability to detect reliable and valid changes that occur after an intervention. Method: Participants (N = 583) who voluntarily received individual, couple, or family therapy services in a randomized clinical trial attended the study. Results: By comparing the changes in pre-therapy and post-therapy scores of the STIC Intersession scales with those of the corresponding reference measures, the external sensitivity to change of the STIC Intersession scales was supported. The IPS Intersession scale showed greater change than the Beck Anxiety Inventory. However, no evidence supported the discriminant validity of CPS's change scores. Conclusion: Thus, the STIC Intersession IPS, RWP, and FH can be validly used to assess multi-systemic changes in both research and clinical work.

Multidimensional Family Therapy for Justice-Involved Young Adults with Substance Use Disorders

The present study explored the acceptability, feasibility, fidelity, and outcomes of a young adult adaptation of multidimensional family therapy (MDFT), an evidence-based family treatment originally developed for adolescents. Participants included 22 individuals between the ages of 19 to 25 who were enrolled in a criminal drug court program. MDFT was found to be feasible and was delivered with strong fidelity to young adults and their families. Participants reported high satisfaction with MDFT, and 95% completed treatment. Analyses revealed statistically significant decreases in substance use on all indicators from baseline to the 6-month follow-up. Significant improvements were also noted in vocational functioning, including a 73% increase in full-time employment from baseline to 6-month follow-up. Criminal justice outcomes included a significant decrease in legal risk, and 86% of study participants had no rearrests from baseline through the 18-month follow-up period. The article concludes with recommendations for implementing family-based interventions with young adults, as well as future research directions in this important area.

Families tackling adolescent anorexia nervosa: family wellbeing in family-based treatment or other interventions. A scoping review

PURPOSE

Family-based treatment (FBT) has contributed significantly to the treatment of anorexia nervosa (AN) in young people (YP). However, parents are concerned that FBT and the active role of parents in the task of refeeding may have a negative impact on family relations. The aim of the review is to assess whether families engaged in FBT for AN are more or less impacted in their family wellbeing and caregiver burden, compared to families with a YP diagnosed with AN, who are not undergoing treatment with FBT.

METHOD

Computerized searches across six databases complemented by a manual search resulted in 30 papers being included in the scoping review.

RESULTS

The review identified 19 longitudinal studies on change in family wellbeing in families in FBT-like treatments, and 11 longitudinal studies on change in family wellbeing in treatment where parents are not in charge of refeeding. Only three randomized controlled studies directly compare FBT to treatment without parent-led refeeding.

CONCLUSION

The available research suggests no difference between intervention types regarding impact on family wellbeing. Approximately half of the studies find improvements in family wellbeing in both treatment with and without parent-led refeeding, while the same proportion find neither improvement nor deterioration. As parents play a pivotal role in FBT, there is a need for good quality studies to elucidate the impact of FBT on family wellbeing. Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Expressed emotion and early treatment response in family-based treatment for adolescent anorexia nervosa

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.

Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: Common adaptations and considerations for treatment engagement

OBJECTIVE

Family-Based Treatment (FBT) is the leading manualized treatment for adolescent eating disorders; however, there is limited research on the adaptation of FBT for diverse families (i.e., families belonging to identity groups subject to systemic barriers and prejudices). The purpose of this qualitative study was to address: (1) adaptations made to the FBT model (if any) by clinicians working with diverse youth and families; (2) the barriers/facilitators of maintaining adherence (fidelity) to the model for these families; and, (3) the barriers/facilitators to access and engagement in FBT for diverse families.

METHOD

Forty-one FBT clinicians were recruited globally using purposive and snowball sampling, and listservs from eating disorder networks. Clinicians participated in individual interviews or focus groups, discussing their experiences delivering and adapting FBT for diverse families. Qualitative data was transcribed verbatim and analyzed using directed content analysis.

RESULTS

Some participants reported making adaptations to every phase of the FBT model, while others did not, when working with diverse families. In Phase 1, participants cited adapting the family meal, length/number of sessions provided, and addressed systemic barriers. In Phase 2, participants adapted the length of the phase and rate/level of independence given back to the adolescent. In Phase 3, participants increased or decreased the number of sessions, or eliminated this phase to address barriers to engagement in FBT.

DISCUSSION

This is the first study to qualitatively examine clinicians' experiences of implementing FBT with diverse families. Results may inform future FBT planning, clinician training, clinical decision-making tools, and opportunities for modifications to the foundational model.

PUBLIC SIGNIFICANCE

This qualitative study examined clinicians' perceptions and experiences implementing FBT with diverse families, specifically what adaptations (if any) were made to the foundational model, and the barriers and facilitators to adhering to and engaging in the model. Results show that some participants reported making adaptations to every phase of FBT, while others did not, with diverse families. Findings may inform future treatment planning, clinician training, clinical decision-making tools, and potential modifications to FBT.

Service evaluation of multi-family therapy for anorexia groups between 2013-2021 in a specialist child and adolescent eating disorders service

The aims of the service evaluation were to examine the effectiveness of multi-family therapy for anorexia nervosa (MFT-AN) on family relationships, as well as to understand families' experiences of MFT in a specialist child and adolescent eating disorders service between 2013-2021. Mixed-methods were used (t-tests and reflexive thematic analysis). Delivery was in-person in 2013-2019, and moved online from 2020 due to COVID-19. Responses from a total of 57 families and 190 people were analysed. MFT improved family functioning from pre-to post MFT as measured by the Systemic Clinical Observation in Routine Evaluation (SCORE-15). Sub-group analysis by family roles showed that at four-month follow-up, the effects were no longer significant among parents. On the contrary, preliminary analysis showed that although young people did not report any improvement at post-intervention, family functioning was reported to increase at follow-up. Four themes were constructed: being together as a family and as a group; individuality: everyone's recovery is different; MFT as an emotion 'hotpot', and in-person versus virtual groups: not a one-size-fits-all. More robust follow-up data are needed to ascertain the effects of online MFT-AN.

Attachment-Based Family Therapy for Adolescents and Young Adults With Suicide Ideation and Depression

Background: Suicide ideation among adolescents is difficult to treat. Attachment-based family therapy (ABFT) is a promising evidence-based family intervention developed to decrease depressive symptoms and suicide ideation among adolescents. Aims: This open trial assessed the feasibility of ABFT for adolescents (12-23 years) with suicide ideation and depression in an outpatient community mental health center in the Netherlands, by monitoring treatment compliance and satisfaction, treatment dose, and symptom reduction. Methods: Eligible patients were referred by the multidisciplinary treatment team at the facility. Treatment dose was monitored by the therapist. Depression (CDI-2), family functioning (SRFF), and strengths and difficulties (SDQ) were assessed online before the intervention and at 3, 6, and 9 months after baseline. Suicide ideation (SIQ-JR) was assessed at each therapy session, and a satisfaction questionnaire was administered postintervention. A total of 25 families signed informed consent, received ABFT treatment, and were included in the analyses. The therapists were at beginners' level of ABFT, working under supervision during the trial. Results: The treatment dose was acceptable, though impacted by COVID-related lockdowns, and treatment compliance was 89%. Patients received on average 22 ABFT sessions, and about half of the patients received additional psychotherapy. On average, patients were satisfied with ABFT. There was a significant decrease in suicide ideation postintervention (d = 0.69) and significant effects on the CDI-2, SRFF, and SDQ at follow-up with medium-to-large effect sizes (d = 0.53-0.94). Limitations: These results should be interpreted with considerable caution, as there was no control group to establish the effectiveness of ABFT, and the sample was small. Conclusion: ABFT appears to be a feasible therapy for youth with depression and suicide ideation in an outpatient community mental health setting.

The Attachment Mapping Protocol (AMP): An Assessment and Treatment Tool for General Psychotherapy, Systemic Family Therapy and Multifaith Spiritual Care

This paper introduces the Attachment Mapping Protocol (AMP), which is an assessment and treatment tool for use in individual psychotherapy, systemic family therapy and multifaith spiritual care, using a bio-psycho-social-spiritual model of care. Attachment theory has a long and significant history in psychology, with an evolving relationship within the above clinical domains. A central aim of this paper will be to recognize and affirm the extension of attachment theory beyond the traditional parameters of nascent parental, guardianship bonds and individual, developmental psychology, to reveal a much broader spectrum of valid attachment considerations for mental health and spiritual well-being. A case study will be applied to the interviewing instrument to demonstrate its utility for broadening assessment beyond attachment figures to include surrogate attachments of other persons, places and things. A model of spiritual discernment derived from the Spiritual Exercises of Ignatius of Loyola will undergird this larger worldview of attachment considerations.

Attachment-based family therapy versus nondirective supportive therapy for lesbian, gay, bisexual and questioning adolescents with depression, and suicidal ideation: An exploratory study

INTRODUCTION

Lesbian, gay, bisexual, and questioning (LGBQ) adolescents are particularly at risk for suicidal ideation; however, little clinical research is focused on treating this population. Attachment-based family therapy (ABFT) is among the few empirically supported youth suicide treatments adapted for LGBQ adolescents. The purpose of this exploratory study is to determine the differential treatment effects and rates of change for LGBQ and heterosexual adolescents with depression and suicidal ideation receiving either ABFT or family enhanced nondirective supportive therapy (FE-NST).

METHOD

The sample included 129 adolescents (31% LGBQ), ages 12-18 randomized to the two treatment groups. Multilevel modeling was used to examine individual changes in depression and suicidal ideation over the 16-week treatment.

RESULTS

Results revealed that LGBQ adolescents in the ABFT condition showed a greater rate of reduction in depressive symptoms over treatment, slope = -0.94, p < 0.001, than did LGBQ adolescents in the NST condition, slope = -0.41, p = 0.12. Heterosexual adolescents showed symptom reduction in both treatment conditions (ABFT slope = -0.47, p < 0.001; NST slope = -0.79, t (113) = -7.48, p < 0.001). Changes in suicidal ideation were found across time, but not across conditions.

CONCLUSION

LGBQ adolescents in the ABFT condition had a sharper decrease in depressive symptoms and better outcomes at week 16.

Development and implementation of a relationship-focused outpatient multifamily program for adolescent anorexia nervosa

Multifamily therapy (MFT) for adolescent eating disorders (ED) is anchored in systemic theory and family therapy, but two conceptual and practical paths have emerged from this common framework. The first one, called ED-focused MFT, is centered on behavioral change and weight gain in the early stages of treatment, while the second, known as relationship-focused MFT, is less directly focused on symptom improvement and more on family changes. Compared to ED-focused MFT, validation of more relationship-focused MFT models has been lagging behind although they are frequently implemented and practiced in Europe. The purpose of this article is to give more visibility to existing relationship-focused MFT models by presenting an integrative, yet predominantly family-oriented MFT program developed for adolescent anorexia nervosa (AN) (12 to 18 years) on the ED unit of a large pediatric hospital in France. After presenting the history and development of this relationship-focused MFT program, including the challenges it encountered and its evaluation, we describe its rationale and objectives, then outline its course and content, giving illustrations of techniques and activities for each of the five phases of the program. Finally, we review the current status of this model, its advantages and limitations, and provide a critical appraisal of existing evidence and recommended future research directions.

Researching what we practice-The paradigm of systemic family research: Part 1

This is part 1 of two articles that focus on the ideological and philosophical preference regarding how to relate to and conduct research in the field of systemic couple and family therapy. Thus, this article outlines the theoretical groundwork for part 2 of "Researching what we practice" in the same journal. Research in certain areas of systemic couple and family therapy (CFT), such as that influenced by social constructionism and postmodernism, has a different epistemological tradition than in the natural sciences. Thus, only research from a narrow, selected spectrum of epistemologies has been incorporated as a key source in the knowledge base of systemic CFT. The consequence is that the field of postmodern systemic CFT risks promoting only a limited range of research designs and knowledge while excluding other designs and knowledge types, reasoning that these are less useful in clinical practice. The rationale behind this perspective is derived from ideology and philosophy rather than scientific criteria. Accordingly, in our field of study, different epistemological perspectives are easily viewed as dichotomous, thus causing professional gaps in our field. This tendency constrains the mutual exchange and development that are needed. We present a possible way out of this dichotomized deadlock, first and foremost by acknowledging - and encouraging the use of - the great variety and breadth of existing research and knowledge. Referring to the guiding principles of evidence-based practice, we argue that this would endow the systemic CFT therapist and researcher with a greater knowledge base and range of research methodologies. This could help improve the quality of treatment provided to our clients and enhance the legitimacy of postmodern systemic CFT as a branch of psychotherapy.

Effectiveness and feasibility of structured emotionally focused family therapy for parents and adolescents: Protocol of a within-subjects pilot study

Mental health issues are widespread among children and adolescents worldwide. Although mental health difficulties may manifest themselves in many different diagnoses, there is growing support for a limited number of underlying transdiagnostic processes. Attachment encompasses a key transdiagnostic mechanism, namely emotional regulation. This study protocol aims to evaluate the feasibility and potential effectiveness of structured emotionally focused family therapy (EFFT), the goal of which is to develop secure attachment between parents and their children to reduce children's vulnerability to mental health problems. A within-subjects design with three waves, a waiting period, treatment, and follow-up, will be conducted. Families will serve as their own controls. Approximately 15 to 20 families with adolescents (aged 12-18 years) as the 'identified patients' will be included. They will participate in 16-21 sessions of EFFT. The study will use a multi-method approach. Self-report questionnaires will be administered repeatedly (i.e., pre-waiting period, pre-treatment, halfway treatment, post-treatment, and follow-up), measuring parent-adolescent attachment, partner-partner attachment, negative interactions, and adolescent psychological complaints. Multi-level analyses will be conducted. Semi-structured interviews will be administered at follow-up to evaluate feasibility and acceptability of EFFT. Treatment integrity will be assessed. The present study is the first to evaluate feasibility of structured EFFT and obtain a first impression of its effectiveness. This information will help us to improve EFFT. Limitations are discussed. Trial registration: Recruitment commenced in June 2022. The approximate trial duration is 36 months. The trial was registered at ClinicalTrials.gov (NCT05657067) on December 9, 2022, and Open Science Framework (https://osf.io/39dt2/) on June 14, 2022.

Family-Based Behavioral Treatment for Childhood Obesity Implemented in Pediatric Primary Care: A Randomized Clinical Trial

Importance

Intensive behavioral interventions for childhood overweight and obesity are recommended by national guidelines, but are currently offered primarily in specialty clinics. Evidence is lacking on their effectiveness in pediatric primary care settings.

Objective

To evaluate the effects of family-based treatment for overweight or obesity implemented in pediatric primary care on children and their parents and siblings.

Design, Setting, and Participants

This randomized clinical trial in 4 US settings enrolled 452 children aged 6 to 12 years with overweight or obesity, their parents, and 106 siblings. Participants were assigned to undergo family-based treatment or usual care and were followed up for 24 months. The trial was conducted from November 2017 through August 2021.

Interventions

Family-based treatment used a variety of behavioral techniques to develop healthy eating, physical activity, and parenting behaviors within families. The treatment goal was 26 sessions over a 24-month period with a coach trained in behavior change methods; the number of sessions was individualized based on family progress.

Main Outcomes and Measures

The primary outcome was the child's change from baseline to 24 months in the percentage above the median body mass index (BMI) in the general US population normalized for age and sex. Secondary outcomes were the changes in this measure for siblings and in BMI for parents.

Results

Among 452 enrolled child-parent dyads, 226 were randomized to undergo family-based treatment and 226 to undergo usual care (child mean [SD] age, 9.8 [1.9] years; 53% female; mean percentage above median BMI, 59.4% [n = 27.0]; 153 [27.2%] were Black and 258 [57.1%] were White); 106 siblings were included. At 24 months, children receiving family-based treatment had better weight outcomes than those receiving usual care based on the difference in change in percentage above median BMI (-6.21% [95% CI, -10.14% to -2.29%]). Longitudinal growth models found that children, parents, and siblings undergoing family-based treatment all had outcomes superior to usual care that were evident at 6 months and maintained through 24 months (0- to 24-month changes in percentage above median BMI for family-based treatment and usual care were 0.00% [95% CI, -2.20% to 2.20%] vs 6.48% [95% CI, 4.35%-8.61%] for children; -1.05% [95% CI, -3.79% to 1.69%] vs 2.92% [95% CI, 0.58%-5.26%] for parents; and 0.03% [95% CI, -3.03% to 3.10%] vs 5.35% [95% CI, 2.70%-8.00%] for siblings).

Conclusions and Relevance

Family-based treatment for childhood overweight and obesity was successfully implemented in pediatric primary care settings and led to improved weight outcomes over 24 months for children and parents. Siblings who were not directly treated also had improved weight outcomes, suggesting that this treatment may offer a novel approach for families with multiple children.

Trial Registration

ClinicalTrials.gov Identifier: NCT02873715.

Multidisciplinary implementation of family-based treatment delivered by videoconferencing (FBT-V) for adolescent anorexia nervosa during the COVID-19 pandemic

Family-Based Treatment (FBT)-the most widely supported treatment for pediatric eating disorders-transitioned to virtual delivery in many programs due to COVID-19. Using a blended implementation approach, we systematically examined therapist adherence to key components of FBT and fidelity to FBT by videoconferencing (FBT-V), preliminary patient outcomes, and team experiences with our FBT-V implementation approach as well as familial perceptions of FBT-V effectiveness. We examined our implementation approach across four pediatric eating disorder programs in Ontario, Canada, using mixed methods. Participants included therapists (n = 8), medical practitioners (n = 4), administrators (n = 6), and families (n = 5; 21 family members in total). We developed implementation teams at each site, provided FBT-V training, and offered clinical and implementation consultation. Therapists submitted video recordings of their first four FBT-V sessions for fidelity rating, and patient outcomes. Therapists self-reported readiness, attitudes, confidence, and adherence to FBT-V. Focus groups were conducted with each team and family after the first four sessions of FBT-V. Quantitative data were analyzed using repeated measures ANOVA. Qualitative data were analyzed using directed and summative content analysis. Therapists adhered to key FBT components and maintained FBT-V fidelity. Changes in therapists' readiness, attitudes, and confidence in FBT-V over time were not significant. All patients gained weight. Focus groups revealed implementation facilitators/barriers, positives/negatives surrounding FBT-V training and consultation, suggestions for improvement, and effectiveness attributed to FBT-V. Our implementation approach appeared to be feasible and acceptable. Future research with a larger sample is required, furthering our understanding of this approach and exploring how organizational factors influence treatment fidelity.

Early Family Intervention for Youth at Risk for Bipolar Disorder: Psychosocial and Neural Mediators of Outcome

BACKGROUND

The impairing neurodevelopmental course of bipolar disorder (BD) suggests the importance of early intervention for youth in the beginning phases of the illness.

OBJECTIVE

We report the results of a 3-site randomized trial of family-focused therapy for youth at high-risk (FFT-HR) for BD, and explore psychosocial and neuroimaging variables as mediators of treatment effects.

METHODS

High-risk youth (<18 years) with major depressive disorder or other specified BD, active mood symptoms, and a family history of BD were randomly assigned to 4 months of FFT-HR (psychoeducation, communication and problem-solving skills training) or 4 months of enhanced care psychoeducation. Adjunctive pharmacotherapy was provided by study psychiatrists. Neuroimaging scans were conducted before and after psychosocial treatments in eligible participants. Independent evaluators interviewed participants every 4-6 months over 1-4 years regarding symptomatic outcomes.

RESULTS

Among 127 youth (mean 13.2 ± 2.6 years) over a median of 98 weeks, FFT-HR was associated with longer intervals prior to new mood episodes and lower levels of suicidal ideation than enhanced care. Reductions in perceived family conflict mediated the effects of psychosocial interventions on the course of mood symptoms. Among 34 participants with pre-/post-treatment fMRI scans, youth in FFT-HR had (a) stronger resting state connectivity between ventrolateral PFC and anterior default mode network, and (b) increased activity of dorsolateral and medial PFC in emotion processing and problem-solving tasks, compared to youth in enhanced care.

CONCLUSION

FFT-HR may delay new mood episodes in symptomatic youth with familial liability to BD. Putative treatment mechanisms include neural adaptations suggestive of improved emotion regulation.

Implementation and outcomes of home-based treatments for adolescents with anorexia nervosa: Study protocol for a pilot effectiveness-implementation trial

OBJECTIVE

Although family-based treatment (FBT) is considered a first-line treatment for adolescent anorexia nervosa (AN), it is underutilized in community settings and is unavailable to many families for a multitude of practical reasons (e.g., costs of treatment, transportation constraints). Adapting FBT interventions for delivery in home-based and community-based settings may reduce pragmatic barriers to treatment uptake and engagement.

METHODS

This pilot effectiveness-implementation trial will assess outcomes, implementation, and mechanisms of FBT adapted for the home setting (FBT-HB), delivered in the context of community-based behavioral health agencies. Adolescents with AN-spectrum disorders (n = 50) and their caregivers will be randomly assigned to either FBT-HB or home-based treatment as usual (TAU; integrated family therapy approach). Caregivers and adolescents will provide data on weight, eating, and putative treatment mechanisms, including caregiver self-efficacy and adolescent eating-related and weight-related distress. Implementation constructs of feasibility, acceptability, and appropriateness will be measured among providers and participating families.

HYPOTHESES

We expect that FBT-HB will be feasible, acceptable, and appropriate, and will outperform TAU in terms of improvements in adolescent weight and eating-related psychopathology. We further expect that caregiver self-efficacy and adolescent eating-related and weight-related distress, but not general distress, will show greater improvements in FBT-HB relative to TAU and will be associated with better adolescent weight and eating outcomes in FBT-HB.

POTENTIAL IMPLICATIONS

The proposed study has clear potential to advance scientific and clinical understanding of the real-world effectiveness of FBT for AN, including whether adapting it for the home setting improves its accessibility and effects on treatment outcome.

Parent and clinician perspectives on virtual guided self-help family-based treatment (GSH-FBT) for adolescents with anorexia nervosa

PURPOSE

Guided self-help (GSH) treatments have the capacity to expand access to care, decrease costs, and increase dissemination compared to traditional therapist-directed treatment approaches. However, little is known about parent and clinician perspectives about the acceptability of GSH for adolescents with eating disorders.

METHODS

This study utilized a mixed methods approach to obtain qualitative and quantitative data regarding clinician and participants' experiences with GSH. Parent participants were enrolled in a randomized trial comparing GSH family-based treatment (GSH-FBT) to family-based treatment delivered via videoconferencing (FBT-V) for adolescents (12-18 years old) with a DSM-5 diagnosis of anorexia nervosa (AN). Parent participants provided qualitative feedback using the Helping Alliances Questionnaire about their experience of treatment. Clinician participants were six master's or PhD-level therapists. These clinicians were trained in and provided both treatments (GSH-FBT and FBT-V). They provided responses to questionnaires and participated in a 1-h focus group about their experience as treatment providers.

RESULTS

Regardless of treatment condition, parents listed more improvement than worsening of symptoms in their child with AN. Clinicians reported lower scores on competency and comfort metrics with GSH-FBT compared to FBT-V. Qualitatively, clinicians reported both advantages and disadvantages of delivering GSH-FBT.

CONCLUSION

Further studies are needed to better understand how GSH interventions can be disseminated to patients and families, particularly those with limited access to specialized eating disorder treatment centers. Level of evidence Level I, data collected as part of a randomized controlled trial.

Authority in therapeutic interaction: A conversation analytic study

A paradigmatic shift toward postmodern, collaborative practice in family therapy raises questions about how therapists can use professional authority to facilitate change and how clients can assert their knowledge and agency. We used conversation analysis to investigate how the authority to know and to determine here-and-now action (i.e., who does what, and how, in therapy) was negotiated and accomplished in 10 sessions of emotion-focused therapy involving chair work. Therapists were observed to rely on a particular interactional sequence structure: stepwise entry into a directive, in which directives were preceded by a question-answer sequence. We show how instances where clients' views were elicited prior to the delivery of a directive resulted in different interactional consequences from instances where therapists straightforwardly directed clients to perform some action. The study offers evidence concerning how therapists can facilitate chair work collaboratively and responsively.

Comparing individually based and family-based treatments for internalizing, externalizing, and family symptoms in Latino youth

Rigorous randomized trials that test promising culturally centered treatments for Latino youth and families are needed. This study adds to the knowledge base by comparing the efficacy of Culturally Informed and Flexible Family Treatment for Adolescents (CIFFTA) to an Individually Oriented Treatment-As-Usual (ITAU) in its ability to retain Latino youth and families in treatment, reduce internalizing and externalizing child symptoms, and improve family functioning. CIFFTA uses an adaptive/flexible approach to deliver individual therapy, family therapy, and psycho-educational modules tailored to each family's unique clinical and cultural characteristics. Two hundred Latino adolescents 11-14 years of age completed a baseline assessment, were randomly assigned to CIFFTA or ITAU, then were assessed again after 16 weeks of intervention. Results show that CIFFTA had significantly higher retention (83%) than ITAU (71%), OR = 2.05, p = .036. Youth in both conditions showed significant reductions in youth and parent reported externalizing and internalizing behaviors, and there were no differences in change between conditions. Parents in CIFFTA reported significantly greater reductions in family conflict, d = 0.38, p = .025 than in ITAU. In CIFFTA, children of less acculturated Latino parents showed more improvement than the children of more acculturated parents. In ITAU, the reverse was true, children of more acculturated parents reported more improvement. This evidence of CIFFTA's impact on retention, family conflict, and differential effect depending on cultural values and behaviors, has important implications for the field of Latino psychology and family treatment.

Processes and outcomes of an emotion-focused family therapy two-chair intervention for transforming problematic parenting patterns

Emotion-focused family therapy (EFFT) is a therapy model which includes a two-chair intervention aimed at facilitating awareness and an interruption of problematic patterns of parenting as well as a reconnection to healthy caregiving instincts. The present study employed a task analysis to examine the process of this intervention with parents in a therapeutic setting and report on preliminary outcomes. Four trained EFFT therapists conducted chair work interventions with four parents (total of 16) and parents completed questionnaires directly following the intervention. Results indicated that most parents experienced significant emotional resolution of their love-based fears and an increase in confidence in supporting their children struggling with mental health issues. Use of the intervention in clinical settings is an effective and efficient way to support parents in responding to their children's mental health challenges.

Recruiting and training multilingual family therapists: A content analysis of COAMFTE-accredited marriage and family therapy program websites

Among U. S. Limited English Proficiency (LEP) communities, language needs and preferences create significant barriers to accessing quality healthcare and contribute to growing physical and mental health disparities. To mitigate these barriers, it is critical to recruit and train a new generation of linguistically diverse providers, including marriage and family therapists (MFTs). This study examined how Marriage and Family Therapy (MFT) program website content promotes a commitment to recruiting and training multilingual MFTs. The study sample consisted of all currently accredited programs (N = 122) and included coding for the presence or absence of (a) an explicit commitment to multiculturally and linguistically informed training, (b) specialized multilingual training and supports, and (c) multilingual faculty involved in training multilingual students or engaged in related scholarship. Results indicate that a majority of MFT programs are communicating a commitment to multiculturally informed training, but the same is not true of linguistically responsive training.

Multisystemic therapy for child abuse and neglect: Parental stress and parental mental health as predictors of change in child neglect

BACKGROUND

Despite high prevalence, child neglect has long been passed over in research. Serious long-term consequences call for effective intervention programs. However, as a result of the lack of research, there is a lack of effective interventions. In order to develop such intervention programs and to maximize the effectiveness of existing programs, it is necessary to examine what factors are related to the reduction of neglect and, subsequently, what change mechanisms their effectiveness is based on.

OBJECTIVE

In this intervention study we investigated whether changes in parental mental health and parental stress after Multisystemic Therapy for Child Abuse and Neglect (MST-CAN), an effective evidence-based intervention program for child neglect, are related to changes in child neglect.

PARTICIPANTS AND SETTING

Study participants were 144 parent-child dyads participating in the MST-CAN program.

METHODS

We analyzed changes from pre- to post-treatment in child neglect, parental mental health, and parental stress, and conducted a multiple regression analysis to examine whether changes in parental mental health and parental stress predict changes in child neglect.

RESULT

Our results showed that child neglect, as well as parental stress, significantly decreased and parental mental health significantly improved during the program. While improvements in parental mental health were not related to the reduction of child neglect, a decrease in parental stress significantly predicted the reduction of child neglect.

CONCLUSION

These findings suggest that parental stress might be a promising target for evidence-based intervention programs to reduce the occurrence of child neglect. Implications and suggestions for further research are discussed.

"You helped me out of that darkness" Children as dialogical partners in the collaborative post-family therapy research interview

Applying Dialogical Methods for Investigations of Happening of Change (DIHC), this study investigated how children who had been diagnosed with an oppositional defiant or conduct disorder participated in a collaborative post-therapy research interview and talked about their experiences of family therapy. The results showed that the children participated as dialogical partners talking in genuine, emotional, and reflective ways. Encountered as full-membership partners, the children also co-constructed meanings for their sensitive experiences. However, their verbal initiatives and responses appeared in very brief moments and could easily have been missed. The collaborative post-therapy interview offered a safe forum for co-reflection by participants on what they had found useful or difficult in the family therapy process. In this interview setting, the family first listens to reflection by the therapists on the therapy process and their thoughts on some of the family's related sensitive issues. The results indicate that when therapists present themselves as not-knowing, receptive and accountable, therapists may facilitate reflection for all family members, including children.

Treatment efficacy of multiple family therapy in helping Chinese children of depressed parents in Hong Kong, China

This article reports results of a study that assessed the efficacy of multiple family therapy (MFT) for helping children of depressed parent(s), using a quasi-randomized controlled trial design. In total, 76 children participated in the study, with 51 children were assigned to the experimental group (EG) and 25 to the comparison group (CG). The EG children and their parents completed the three-month MFT program, while the CG children and their parents attended two psychoeducational talks scheduled at the same time as the MFT. A group × Time repeated measure ANCOVA did not discern the intervention types having any effect on children's lives in the post-treatment phase or at the three-month follow-up. However, the MFT brought some promising positive changes in the EG children's perceived social support, both overall and that from the father and other family members at three-month follow-up; compared to the CG children, the EG children also attached more importance to the support from their mothers in the post-treatment phase and that from other family members at the three-month follow-up. The results implied the potential efficacy of the MFT in facilitating an increase in the overall social support of children of depressed parents and their positive interactions with both the healthy and the depressed parent and other family members. Owing to multiple statistical limitations, caution is required while interpreting the results. A larger sample and a more sophisticated research design were suggested for future studies examining the efficacy and therapeutic mechanism of the MFT.

Integrative Systemic Supervision: Promoting Supervisees' Theoretical Integration in Systemic Therapy

Integrative systemic therapy (IST) is a meta-theoretical perspective, grounded in systemic theory and integration, that transcends therapy models in individual, couple, and family therapy. To foster supervisees' theoretical integration and systemic thinking, two of IST's primary tools-the essence diagram and blueprint-are described and applied to inform an integrative, systemic meta-perspective for supervision. Recommendations, specific guiding questions, and examples are provided to operationalize these tools in the multi-level supervision system (i.e., supervisor-supervisee-client system). IST supervisors and other supervisors who are interested in integrative, systemic training can use these tools to guide the process of supervision and strengthen supervisees' ability to hypothesize, plan, converse, and read clients' feedback in relation to the various tasks of therapy. The essence diagram and blueprint are applied to facilitate case consultation and cultivate the development of supervisees' clinical competencies. Particularly, the problem-solving focus of IST has been adapted to include a competency-based and professional growth-oriented dimension for supervision to better promote supervisees' development. Lastly, the advantages and challenges of IST-influenced supervision are discussed.

Disturbed families or families disturbed: a reconsideration

BACKGROUND

The relationship between anorexia nervosa (AN) and family disturbance has been a subject of debate since its first description. What began as a clear view of the pathologically disturbed family causing AN has become ever more complex over the decades.

OBJECTIVE

The aim of this review is to explore the literature to examine the changes and evolution of clinical opinion around family dysfunction and AN over the last 20 years.

METHODS

A narrative review of heterogeneous studies in peer-reviewed publications sourced from the major databases, including PubMed and ScienceDirect, to illuminate the topic of family distress and AN by highlighting the conflicting and complementary ways it has been studied.

RESULTS

This review has highlighted the complexity of the relationship between anorectic sufferers and their families. It has explored the literature about parental burden, emotions and cognitive mechanisms together with parental attitudes about weight and shape. It is clear that there is no consistent psycho-social pathology in families which has been shown to be causative. However, over the last twenty years, research has highlighted the distress and family dysfunction caused by having to look after an anoretic child with poor mentalisation skills, insecure attachment and emotion dysregulation.

CONCLUSION

The area has become clearer over the last 20 years; research suggests a bi-directional relationship between AN and family dysfunction, with difficult dynamics becoming entrenched within the family. This is best addressed, the consensus suggests, by specialist family therapy and carer skills interventions. Longitudinal research is needed to definitively answer the question with rigorous scientific certainty.

EMB RATING

Level V.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies. Level II: Evidence obtained from well-designed controlled trials without randomization. Level III: Evidence obtained from well-designed cohort or case-control analytic studies. Level IV: Evidence obtained from with multiple time series analysis such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Association of a Family Integrated Care Model With Paternal Mental Health Outcomes During Neonatal Hospitalization

IMPORTANCE

During newborn hospitalization in the neonatal unit, fathers often feel anxious and excluded from their child's caregiving and decision-making. Few studies and interventions have focused on fathers' mental health and their participation in neonatal care.

OBJECTIVE

To study the association of a family integrated care (FICare) model (in single family rooms with complete couplet-care for the mother-newborn dyad) vs standard neonatal care (SNC) in open bay units with separate maternity care with mental health outcomes in fathers at hospital discharge of their preterm newborn and to study whether parent participation was a mediator of the association of the FICare model on outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multicenter cohort study was conducted from May 2017 to January 2020 as part of the fAMily Integrated Care in the Neonatal Ward Study, at level-2 neonatal units in the Netherlands (1 using the FICare model and 2 control sites using SNC). Participants included fathers of preterm newborns admitted to participating units. Data analysis was performed from January to April 2021.

EXPOSURE

FICare model in single family rooms with complete couplet-care for the mother-newborn dyad during maternity and/or neonatal care.

MAIN OUTCOMES AND MEASURES

Paternal mental health was measured using the Parental Stress Scale: NICU, Hospital Anxiety and Depression Scale, Post-partum Bonding Questionnaire, Perceived (Maternal) Parenting Self-efficacy Scale, and satisfaction with care (EMpowerment of PArents in THe Intensive Care-Neonatology). Parent participation (CO-PARTNER tool) was assessed as a potential mediator of the association of the FICare model with outcomes with mediation analyses (prespecified).

RESULTS

Of 309 families included in the fAMily Integrated Care in the Neonatal Ward Study, 263 fathers (85%) agreed to participate; 126 fathers were enrolled in FICare and 137 were enrolled in SNC. In FICare, 89 fathers (71%; mean [SD] age, 35.1 [4.8] years) responded to questionnaires and were analyzed. In SNC, 93 fathers (68%; mean [SD] age, 36.4 [5.5] years) responded to questionnaires and were analyzed. Fathers in FICare experienced less stress (adjusted β, -10.02; 95% CI, -15.91 to -4.13; P = .001) and had higher participation scores (adjusted odds ratio, 3.424; 95% CI, 0.860 to 5.988; P = .009) compared with those in SNC. Participation mediated the beneficial association of the FICare model with fathers' depressive symptoms (indirect effect, -0.051; 95% CI, -0.133 to -0.003) and bonding with their newborns (indirect effect, -0.082; 95% CI, -0.177 to -0.015).

CONCLUSIONS AND RELEVANCE

These findings suggest that the FICare model is associated with decreased paternal stress at discharge and enables fathers to be present and participate more than SNC, thus improving paternal mental health. Supporting fathers to actively participate in all aspects of newborn care should be encouraged regardless of architectural design of the neonatal unit.

Family-Based Obesity Prevention Interventions among Hispanic Children and Families: A Scoping Review

This scoping review examined intervention and sample characteristics of family-based obesity prevention interventions among Hispanic youth. This review also examined the degree to which existing interventions were culturally-adapted, acknowledged social determinants of health (SDoH), and collaborated with community stakeholders. A comprehensive search across Medline Ovid, Embase, Scopus, PsycInfo, and Pubmed was used to identify 13 studies primarily based in the U.S. (92.3%). Data was extracted by two independent reviewers. Most used a randomized control trial design (69.2%), a behavior change theory (84.6%), and reported moderate to high (≥70%) retention (69.2%). Studies targeted improvements in physical activity (69.2%) and fruit and vegetable intake (92.3%) through nutrition education, cooking demonstrations, and tastings. Younger children from low socioeconomic backgrounds (61.5%) were well represented. Most interventions were culturally-adapted (69.2%), all studies reported collaboration with stakeholders, yet only half used strategies that acknowledged SDoH (46.2%). To increase our understanding of the underlying mechanisms by which family-based approaches can reach and engage Hispanic youth and families, future studies should rigorously evaluate theoretical constructs, family processes, and SDoH that influence program participation and health behaviors. This information will guide the design and development of future interventions aimed at reducing obesity disparities among Hispanic youth.

General and Eating Disorder Psychopathology in Relation to Short- and Long-Term Weight Change in Treatment-Seeking Children: A Latent Profile Analysis

BACKGROUND

Concurrent general psychopathology (GP) and eating disorder psychopathology (EDP) are commonly reported among youth with overweight/obesity and may impact weight change.

PURPOSE

We identified patterns of GP and EDP in children with overweight/obesity and examined the impact on weight change following family-based behavioral obesity treatment (FBT) and maintenance interventions.

METHODS

Children (N = 172) participated in 4 month FBT and subsequent 8 month weight maintenance interventions. GP and EDP were assessed prior to FBT (baseline). Child percentage overweight was assessed at baseline, post-FBT (4 months), and post-maintenance (12 months). Latent profile analysis identified patterns of baseline GP and EDP. Linear mixed-effects models examined if profiles predicted 4- and 12-month change in percentage overweight and if there were two-way and three-way interactions among these variables, adjusting for relevant covariates.

RESULTS

Results indicated a three-profile structure: lower GP and EDP (LOWER); subclinically elevated GP and EDP without loss of control (LOC; HIGHER); and subclinically elevated GP and EDP with LOC (HIGHER + LOC). Across profiles, children on average achieved clinically meaningful weight loss (i.e., ≥9 unit change in percentage overweight) from baseline to 4 month FBT and sustained these improvements at 12 month maintenance. There was no evidence that latent profiles were related to percentage overweight change from baseline to FBT (p > .05) or baseline to maintenance (p > .05). There was no evidence for two-way or three-way interactions (p > .05).

CONCLUSION

Concurrent GP and EDP do not portend differential short- or long-term weight change following FBT and maintenance. Future research is warranted on the durability of weight change among youth with GP and EDP.

TRIAL REGISTRATION

NCT00759746.

Crisis Intervention Psychotherapy in the Age of COVID-19

Crisis intervention psychotherapy (CIP) is an underutilized form of therapy that can be offered as a treatment during psychiatric disasters and emergencies, and it may be especially useful during the age of Coronavirus Disease 2019 (COVID-19). CIP is a problem-solving, solution-focused, trauma-informed treatment, utilizing an individual or systemic/family-centered approach. CIP is a brief form of psychotherapy delivered as a companion or follow-up to psychological first aid. Crisis psychotherapy is designed to resolve a crisis and restore daily functioning. CIP can be adapted as a single session for a COVID-19 mental health emergency or for a hotline or as 2 to 20 sessions of treatment with COVID-19 patients and families offered virtually on a psychiatric inpatient unit, through a consultation-liaison service, or in outpatient settings. This article reviews the history of critical incident stress management and the use of its replacement, psychological first aid. The history and core principles of crisis psychotherapy and 8 core elements of treatment are described. The use of digital and virtual technology has enabled the delivery of crisis psychotherapy during the COVID-19 pandemic. A case study of a family impacted by COVID-19 is reported as an illustration. The use of a 6-week timeline, an ecological map, and a problem-solving wheel-and-spoke treatment plan are demonstrated.

"It's splendid once you grow into it:" Client experiences of relational teletherapy in the era of COVID-19

The novel Coronavirus pandemic (COVID-19) and subsequent social distancing practices have altered the way we move through the world and access physical and mental healthcare. While researchers and clinicians have begun to explore the impact of telehealth delivery on psychotherapy and treatment outcomes, the purpose of this study was to explore the lived experiences of individuals in teletherapy, specifically those engaging in teletherapy with a romantic partner or family member. Using a thematic analysis of open-ended online survey questions, we explored the experiences of 25 individuals who engaged in couple or family teletherapy after social distancing began. The resulting themes included "making do," safe therapeutic space, convenience, logistical challenges, and therapist accommodation. We discuss the clinical implications of these themes to support effective couple and family teletherapy and offer suggestions and considerations for remote clinical interventions and practices. [Correction added on 22 March 2021, after first online publication: The term '19' has been changed to '(COVID-19)' in the first line of the Abstract section, in this version.].

Family Talk versus usual services in improving child and family psychosocial functioning in families with parental mental illness (PRIMERA-Promoting Research and Innovation in Mental hEalth seRvices for fAmilies and children): study protocol for a randomised controlled trial

BACKGROUND

Parental mental illness is common and can lead to dependent children incurring a high risk of developing mental disorders, physical illness, and impaired educational and occupational outcomes. Family Talk is one of the better known interventions designed to prevent the intergenerational transmission of mental illness. However, its evidence base is small, with few robust independent randomised controlled trials, and no associated process or cost evaluations. The PRIMERA (Promoting Research and Innovation in Mental hEalth seRvices for fAmilies and children) research programme involves a mixed method evaluation of Family Talk which is being delivered in mental health settings in Ireland to improve child and family psychosocial functioning in families with parental mental illness.

METHODS

The study comprises a multi-centre, randomised controlled trial (RCT), with nested economic and process evaluations, to assess the clinical and cost-effectiveness and implementation mechanisms of Family Talk compared to usual services. The study is being conducted in 15 adult and child mental health settings in Ireland. Families with a parent with mental illness, and children aged 5-18 years (n = 144 families) will be randomised to either the 7-session Family Talk programme (n = 96) or to standard care (n = 48) using a 2:1 allocation ratio. The primary outcomes are child psychosocial functioning and family functioning. Secondary outcomes are as follows: understanding and experience of parental mental illness, parental mental health, child and parental resilience, partner wellbeing and service utilisation. Blind assessments will take place at pre-intervention and at 6- and 12-month follow-up.

DISCUSSION

Given the prevalence and burden of intergenerational mental illness, it is imperative that prevention through evidence-based interventions becomes a public health priority. The current study will provide an important contribution to the international evidence base for Family Talk whilst also helping to identify key implementation lessons in the scaling up of Family Talk, and other similar interventions, within routine mental health settings.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN13365858 . Registered 5th February 2019.

Attachment-based family therapy in the age of telehealth and COVID-19

The COVID-19 pandemic has transformed so many aspects of our lives. For psychotherapists, telehealth is likely a permanent part of the future mental health landscape. For family therapists using a manualized treatment, this brings unique challenges and creative opportunities. In this article, we describe the adaptation of attachment-based family therapy (ABFT) in the context of telehealth and COVID-19. ABFT is an empirically supported treatment model designed for adolescents and young adults struggling with depression, anxiety, trauma, and suicide. ABFT is a semi-structured, process-oriented, and trauma-informed family therapy model which presents its own unique challenges and benefits in telehealth environments. We present our adaptations based on years of telehealth clinical experience and address how this model supports the impact of COVID-19 on families.

Comparative Costs of a Parent-Only and Parent and Child Treatment for Children with Overweight or Obesity

OBJECTIVE

Models such as family-based treatment (FBT), delivered to both the parent and child, are considered the most efficacious intervention for children with obesity. However, recent research suggests that parent-based treatment (PBT; or parent-only treatment) is noninferior to FBT. The aim of this study was to evaluate the comparative costs of the FBT and PBT models.

METHODS

A total of 150 children with overweight and obesity and their parents were randomized to one of two 6-month treatment programs (FBT or PBT). Data was collected at baseline, during treatment, and following treatment, and and trial-based analyses of the costs were conducted from a health care sector perspective and a limited societal perspective.

RESULTS

Results suggest that PBT, compared with FBT, had lower costs per parent-child dyad from the health care sector perspective (PBT = $2,886; FBT = $3,899) and from a limited societal perspective (PBT = $3,231; FBT = $4,279).

CONCLUSIONS

These findings suggest that a PBT intervention has lower costs and is noninferior to an FBT intervention for both child and parent weight loss.

Way of being and the therapeutic pyramid: Expanding the application of a common factors meta-model

Common factors proponents have suggested the need for principle-based meta-models to explain how various factors interact with each other to produce change. The therapeutic pyramid is a common factors meta-model that outlines how therapeutic skills and techniques, the therapeutic alliance, and a therapist's way of being interactive to produce therapeutic change. Skills and techniques occupy the smallest top portion of the pyramid, with the therapeutic alliance in the middle and a therapist's way of being forming the foundation of the pyramid. The success of any layer rests on the quality of the immediately underlying layer. This study illustrates the broad applicability of common factors meta-models by applying the therapeutic pyramid to couples therapy, family therapy, training and supervision, and professional ethics.

Resolving Coparenting Dissatisfaction In Couples: A Preliminary Task Analysis Study

This study explored the change that unfolded when parents resolved their coparenting dissatisfaction during an Integrative Brief Systemic Intervention (IBSI) for parent couples. We conducted a task analysis (Greenberg, 2007) to build a model of resolving coparenting dissatisfaction. We compared a postulated model of change (rational model) based on theoretical and clinical assumptions to the observations of the actual change process that couples experienced in an IBSI (empirical analysis). The empirical analysis was conducted on six IBSI therapy cases (three exhibiting positive development and three exhibiting no development). We defined positive development in IBSI as moving from coparenting dissatisfaction to coparenting satisfaction. The final rational-empirical model included six steps that facilitated the resolution of coparenting dissatisfaction. This study contributes to deepening the knowledge of how coparenting may change during marital therapy.

[Intensive home treatment (IHT): indication criteria for children and adolescents]

BACKGROUND

Intensive home treatment (IHT) is an intervention that provides intensive psychiatric (crisis) care in the home environment.

AIM

To formulate indication criteria for IHT in children and adolescents, to improve assessment and to reduce the time needed for triage.

METHOD

The Delphi method was used to assess the opinion of experts on the indication for IHT in children and adolescents. In round 1, 18 employees of the IHT team of Levvel (Academic Centre for Child and Adolescent Psychiatry) list the indication criteria that they thought should be used to determine whether a patient belonged to the IHT target group. Open coding was used to analyze the responses and to derive statements that, in the following three rounds, were rated by the participants on their importance.

RESULTS

33 statements were deemed important enough (> 80% consensus) to include in the final list. These statements concerned the aim, target group, treatment services, the role and responsibilities of the referrer and logistical issues.

CONCLUSION

The list with assessment indicators is a promising tool to help IHT teams working with children and adolescents improve and standardize their triage.

Eliciting Stance and Mitigating Therapist Authority in Open Dialogue Meetings

Open Dialogue is a collaborative systemic approach to working with families in crisis. A core feature is the creation of dialogue through the elicitation of a multiplicity of voices. Using conversation analysis, we studied 14 hr of Open Dialogue sessions. We found that therapists recurrently produced utterances containing "I'm wondering." These utterances topicalized particular issues and invited stance positions from other participants while also allowing the therapist to mitigate their deontic authority and present potentially disaligning stances. Therapists thus exercised authority in eliciting stances, but provided recipients with multiple avenues for responding. These findings illustrate that therapist authority is not necessarily antithetical to dialogue and, in well-crafted forms, may even be necessary for the creation of polyphony through the elicitation of multiple stances.

Treating systemic issues in families affected by cystic fibrosis: A solution-focused approach

Cystic fibrosis (CF) presents with various symptoms that impair day-to-day functioning and require lifelong treatment. Due to the chronic and severe nature of this disease, families are often impacted by the stress associated with treatment, complications of the disease, and the understanding that their loved one will one day die from CF. This article seeks to address a perceived gap in the literature for providing a model-specific approach to address psychosocial stress in families affected by CF. We provide a rationale for using solution-focused brief therapy (SFBT) to work with this population based on its empirically supported effectiveness, versatility, and capacity to be brief in nature. We describe how SFBT interventions can be used by practitioners working with this population, present a fictitious case illustration depicting the clinical use of specific SFBT interventions, and offer suggestions for future research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Parenting after Weight Loss Surgery: A Conceptual Model and Two Case Reports

The ways families approach eating, shape, and weight can result in stress for individual family members and challenge the overall functioning of the family. This is further complicated among families with a parent who has history of obesity or undergone weight loss surgery (WLS). Although WLS can positively impact other family members, it can also exacerbate conflicts regarding feeding and weight. Such conflicts can involve uncertainty regarding the extent to which the entire family should make the dietary changes recommended for the post-WLS parent. Conflict might also center on the appropriate level of concern regarding the children's risk of developing (or maintaining) obesity. This paper uses two case examples to describe the application of a specialized, time-limited intervention: Parent-Based Prevention following Bariatric Surgery (PBP-B). The program was developed to address the unique challenges and concerns that arise after, or are exacerbated by, WLS. Each detailed case example illustrates a common child-feeding challenge and the employment of key PBP-B strategies throughout the course of treatment. In the first case, the parent who had undergone WLS believed the family's current eating behaviors were the same as those that had led to her own overeating, obesity, and co-occurring psychiatric symptoms, while her husband disagreed. In the second case, both parents were concerned about their son's weight, yet due to their prior eating histories, they felt unable to construct boundaries around the feeding experience. Both cases follow families through the entire intervention and illustrate key points and challenges. These cases underscore the need for novel treatment modalities to support families following parental WLS.

From "4Rs and 2Ss" to "Amaka Amasanyufu" (Happy Families): Adapting a U.S.-based Evidence-Based Intervention to the Uganda Context

In Uganda, one in five children presents mental health challenges, including disruptive behavior disorders (DBDs). DBDs can persist through adulthood and result in negative outcomes. Effective interventions for DBDs have been developed and tested in high-poverty communities in developed countries. Yet, most African countries, such as Uganda, lack such interventions. This paper describes the adaptation process of an evidence-based intervention of U.S. origin to optimize fit to context with intervention fidelity, as part of a randomized trial conducted with youth that exhibit behavioral challenges and their caregivers in 30 schools in Uganda. The process involved: initial meetings with headteachers and teachers to introduce the study and the main concepts of the intervention; initial manual review focusing on 4Rs and 2Ss content by the Uganda team; engagement of community stakeholders for additional feedback on content and cultural relevance; final revision of the manual; and collection of children's drawings for the illustration of the manual. This paper describes both similarities and differences between the original and adapted intervention content and methods of delivery. The findings also highlight the importance of involving community stakeholders in the adaptation process.

Barriers and Facilitators to Implementing Attachment-based Family Therapy into a Child Welfare Setting: A Qualitative Process Evaluation

Child welfare systems (CWSs) worldwide show increased interest in adopting empirically informed clinical strategies to increase treatment effectiveness. Many empirically supported treatments (ESTs) exist, but little is known about EST implementation barriers and facilitators in CWS. This study explored CWS providers' experiences of implementing attachment-based family therapy (ABFT) in home-based services of the Flemish CWS (in Belgium). Sixteen CWS providers (twelve counselors and four supervisors) involved in three home-based services were interviewed. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection, coding, and analysis of interview data. Findings revealed that implementation success was related to ABFT's fit with the CWS's mission, philosophy, and existing practices. CWS providers' belief in the compatibility between ABFT and CWS increased investment in implementation efforts and persistence to overcome challenges and setbacks. Some barriers pertained to the learning of ABFT and some barriers pertained to systems level challenges such as lack of leadership and support, poor coordination with referral sources and other youth care partners, and lack of policy support. For successful expansion of ESTs into CWS settings, various barriers at multiple systemic levels need to be addressed.

Can We Uncouple Neighborhood Disadvantage and Delinquent Behaviors? An Experimental Test of Family Resilience Guided by the Social Disorganization Theory of Delinquent Behaviors

Although the influence of neighborhood disadvantage on youth development of delinquent behavior is well established, findings from this research have yet to inform the development of family-centered prevention programming to protect youth from these erosive effects. The current paper examines the role of family integration in buffering the impact of social disadvantage in a sample of N = 298 families randomly assigned either to a control condition or to a family-based prevention program previously shown to enhance marriage and parenting. We first confirmed that neighborhood concentrated disadvantage predicted change in delinquent behaviors across the course of the study. Additionally, replicating prior work, parents participating in the Protecting Strong African American Families (ProSAAF) program, relative to those randomly assigned to the control group, significantly improved their use of effective communication strategies with each other and reduced ineffective conflict in front of youth. This resulted in a significant indirect effect of ProSAAF on change in youth delinquent behaviors. Furthermore, using mediated moderation analysis, the study tested the buffering effect of greater family integration, showing that experimentally produced change in interparental communication skills and the resulting reduction in youth exposure to parental conflict buffered the effect of neighborhood disadvantage on change in youth delinquent behaviors, supporting a mediated moderation model in which family environments buffer neighborhood effects.

Sitting In: The Experience of Learning and Practicing Family Therapy through Being a Co-Therapist in Hong Kong

This article explores family therapy trainees' subjective experiences of working as cotherapists with a supervisory-level therapist in a Chinese context, regarding their perceptions of and positioning in it and also their opinions on the benefits and/or pitfalls of cotherapy. Individual interviews with a total of six cotherapists revealed three themes: (1) Cotherapy was perceived as an experiential learning journey that evolved from anxiety and excitement to empowerment and nurturing; (2) a collaborative master-apprentice relationship of openness, trust, and mutual respect was developed with both sides' interactive effort, which included common commitment and concern for the client, the supervisor's awareness and explicit address of the role hierarchy, principle setting prior to the cooperation, and honest pre- and-postsession sharing and discussion; (3) the dual-purpose supervisor-trainee cotherapy brought direct benefits for all involved parties and for others. The findings have useful implications for integrating treatment and training for optimal training/learning outcomes and for advancing knowledge transfer from senior to junior and from academia to the field, with reference to local cultural characteristics.

Interventions to Empower Adults with Eating Disorders and Their Partners around the Transition to Parenthood

The transition to parenthood is perceived as a stressful life event, when parents experience an immense change of their psychological focus and a reorientation of roles and responsibilities in the family system. This process may be even more challenging in the presence of a parental eating disorder history. This paper reviews the impact of parental eating disorders on the parents, the couple relationship, and their child during the perinatal period. A parental eating disorder is associated with more negative expectations of parental efficacy as well as specific difficulties in couple communication over the child's feeding, shape, and weight. Providers who better understand the effects of an eating disorder on parental functioning can more effectively intervene early on. We also present couple- or parent-based, empirically supported interventions for adults with eating disorders and their partners in the prenatal and postnatal periods: Uniting Couples in the treatment of Anorexia Nervosa (UCAN) and Uniting couples In the Treatment of Eating disorders (UNITE) both enhance recovery from the eating disorder through a couple-based intervention; the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) incorporates the support of partners, when appropriate; Parent-Based Prevention (PBP) focuses on improving parental functioning and reducing risk of negative parental and child outcomes. Finally, we discuss the clinical implications of addressing parental eating disorders and encourage more research on these families.

Family Dynamics and Pediatric Weight Management: Putting the Family into Family-Based Treatment

PURPOSE OF REVIEW

The treatment of pediatric obesity entails working with entire families. However, aside from parenting and family health behaviors, family dynamics and relationships are not often incorporated in clinical treatment of obesity.

RECENT FINDINGS

Evidence across several studies suggest a relationship between family dynamics and child weight, with impaired family dynamics associated with higher weight status in children. Evidence is mixed if child age and family function are associated. Unfortunately, there is little evidence that addressing family dynamics (i.e., relationships and overall family system) will improve weight in children with obesity. Notably, few studies target family dynamics specifically. There are several validated measures of family dynamics available for researchers to explore the family system as it relates to child health and behaviors. A deeper understanding of family dynamics and relationships may provide new avenues to address issues of weight in children; accounting for the family, and their underlying functioning, may benefit the clinician and child engaged in weight management.

Exploring Exceptions and Discovering Solutions: A Case Presentation of Autism and the Family

As the prevalence of autism spectrum disorder (ASD) continues to rise, there is a rapidly increasing need for treatment services among individuals diagnosed with ASD and families. Currently, the majority of the evidence-based treatments, such as Applied Behavior Analysis, overlook the notable systemic effects of ASD and maintain a problem-focused lens. There is a growing body of research calling for strength-based, relational interventions that build on existing resources to enhance coping, efficacy, and well-being among families affected by ASD. Solution-Focused Brief Therapy (SFBT) is a widely practiced clinical approach that is increasingly being used among clinicians to address the systemic effects of developmental disabilities in the family. However, particular modifications to specific interventions may better accommodate autism-associated deficits in executive functioning (e.g., goal development and impulsivity), perspective taking, or restricted interests when using an SFBT approach. This article offers recommendations for adapting a solution-focused approach by modifying commonly used SFBT interventions to address family-driven treatment goals using a collaborative stance with families of children with ASD. A case presentation is included to demonstrate SFBT as informed by the unique challenges and inherent resources of families affected by ASD that have been identified in the extant literature.

Implementing family based treatment in a child and youth eating disorder program: impact on admissions

OBJECTIVES

Anorexia Nervosa (AN) treatment is frequently associated with high costs often due to the use of hospitalization. In Family Based Treatment (FBT) a main goal is to manage recovery of AN in the home environment rather than relying on lengthy hospital admissions. This study examined whether the use of hospitalization altered following the introduction of FBT to a youth eating disorders program in 2009.

METHOD

This study compared retrospective data of 71 female adolescent patients diagnosed with AN: 10 who received treatment as usual prior to the implementation of FBT; 10 who were treated immediately after FBT implementation; and a further 51 adolescents who received FBT since 2009.

RESULTS

Results indicate that since the implementation of FBT there was a significant reduction in admissions to the medical ward and a significant reduction in cumulative length of stay on both the psychiatric and medical wards in adolescents presenting with AN.