Just writing up some research conducted with a group of practitioners..here's a sneak peak!
The application of family therapy in developmental disabilities is limited. Harris (1984a) was arguably the first to publish case material, focusing on difficulties that might emerge when the intergenerational structure of the family is disrupted. Others have explored the significant difficulties families can experience negotiating lifecycle transitions (Birch, 1986, Goldberg et al. 1995), while emphasising the need to recognise familial strengths and narratives (Coles, 2001,Goddard et al, 2000, Gray, 2001). More recently,
(2003) has integrated the behavioural and systemic models, in order to expand
mediation analysis and intervention. Baum and Lynggaard (2006) also advocate
strongly for family therapy, providing evidence for the beginnings of wider
acceptance in the field. Rhodes
The aim of this study is to explore the effects of systemic consultation (Rhodes et al., 2011), a form of case review built on the principles of systemic family therapy. Systemic consultation was designed to introduce the family therapy to clinicians trained in Applied Behaviour Analysis. In particular, the goal was to support them to become more aware of the patterns of interactions and relationships across multiple settings that might restrain effective behavioural intervention. Consultations are informed by systemic family therapy, first developed by Selvini-Palazzoli et al.(1978). This model considers the referred behaviour as one step in a sequence of interactions that can become stuck or rigid in the face of stressors or lifecycle transitions. Patterns can escalate, with relationship become increasingly fraught over time. While this serves as the primary model, issues relating to family and organisational structure are considered (Munuchin et al.,1978) and an emphasis is also placed on the amplification of strengths (De Shazer, 1985).
In systemic consultation a clinician presents a case to between three and six members of a reflecting team over a 90-minute period (for a detailed description see Rhodes et al., 2011). The team is made up of peers trained in systemic theory and interviewing, including one experienced family therapist. The case is presented slowly, in a structured format that allows for careful thinking based on a gradual appraisal of information. The presentation is augmented by a sociogram drawn on a large board, with relevant facts being noted visually as the ‘story’ unfolds. The team asks questions throughout the presentation, rather than engaging in anecdotes, statements or advice-giving. After a 90 minute period the team discusses the case between themselves while the clinician sits in the same room listening in (Andersen, 1995).This gradual process of inquiry is designed to allow for the introduction of new perspectives arising through reciprocal conversation with the clinician, rather than didactic case presentations.
This study was part of a larger project aimed to develop and refine the process of systemic consultation using Participatory Action Research (PAR) (McIntyre, 2008). PAR involves the collaborative participation of stakeholders in the testing and development of practices. In the larger project both systemic consultation team members and visiting clinicians were interviewed about their experience of systemic consultation, with results being regularly fed back into practice. The aspect of the study being reported here explores the experience of systemic consultation by visiting clinicians.
Ten visiting clinicians were invited to participate using a purposive sampling approach (Cohen et al., 2000). Clinicians were primarily employed in behaviour intervention roles, from a variety of disciplines, including psychology, special education and rehabilitation. All participation was voluntary and access to the systemic consultation was not predicated on agreement to participate in the research. All cases presented were highly complex in nature, involving challenging behaviour, such as physical aggression and property destruction, and involving acute problems such as neglect, violence and abuse. The majority of cases consisted of adolescents or adults with developmental disabilities living in residential settings, with a minority residing in the family home.
Summary of Findings
Prior to systemic consultations all clinicians described relying heavily on Applied Behaviour Analysis, with some more experienced staff also thinking in more relational terms. Cases were chosen because they had reached an impasse, where these skills were not sufficient to bring about change. Consultations had a variety of effects, including a focus on relationally-informed conceptualisations of client’s needs, the development of a facilitative position when working with staff and some skill development informed by systemic interviewing. These descriptions suggest that staff had been able to re-evaluate their cases, with consultations opening up new ways of working. It is important to note, however, that novice clinicians described managerial barriers to change and were more likely to feel overwhelmed without ongoing support.
One of the primary effects of systemic consultations was a shift in emphasis, enabling clinicians to develop a greater empathy for the relational needs of clients. Consultations allowed clinicians to interpret the meaning of challenging behaviour in interpersonal terms, as representing a need for reassurance and connection, needs that might relate to insecurity resulting from childhood trauma, to lifecycle transitions, or as part of what was becoming a negative cycle of interactions with staff. Applied Behaviour Analysis also interprets the meaning of behaviour, but does so in communicative rather than exclusively relational terms. From this perspective behaviour can serve a variety of important needs: for tangible reinforcement, for self-stimulation or self-regulation, to escape from an unpleasant situation or for the gaining of attention (Carret al., 1994). Some distinct differences can be drawn, however, between the types of relational needs described by clinicians in this study and these more overt conditioned responses. In particular the somewhat static attention-maintaining category can to be contrasted with the more dynamic construct of attachment, an internal working model that has it’s roots in an individual’s interpersonal history (Bowlby, 1969).
Findings from this study also have implications for the nature of the relationship between clinicians and professional carers. Clinicians described a change in the way they related to staff, based on a review of their role, taking a step down from an expert to facilitator position. In family therapy terms this represents a shift from a position of solitary observer, external to the system observed (Hoffman, 1993), to one involving the social negotiation of meaning from within (Anderson & Goolishian, 1988). These findings are supported by the work of Smyly (2006), who is critical of the expert role of clinicians consulting to group homes, emphasising the need for reflective conversations, ones that help staff consider alternative ways of understanding challenging behaviour rather than being told directly of the results of functional analyses. These types of conversations between clinician and staff mirror what Tomm (1988) calls ‘interventive interviewing,’ a method for introducing new ideas while considering power in relationships. Expert or ‘top-down’ advice is seen to promote ‘stuckness’ or homeostasis , while a more facilitative role is more likely to create opportunities for change.
One of the limitations of systemic consultation seems to be the potential moderating effect of clinical experience. Novice therapists were found to feel more overwhelmed after consultations, given the implied need for greater engagement with a living system, as opposed to the relative predictability of Applied Behaviour Analysis. Knowledge management theorist Snowden (2000) proposes that complex systems can only be understood in retrospect. Decision-making in these instances can only be tentative, based on an engagement with patterns as they emerge rather than planned and operationalised in advance. Family therapists Sadler and Hulgus (1989) describe this phenomenon as follows:
We reserve "explanation" for the description of causal processes, for example, those of physiology or chemistry. We use "understanding" to describe human meanings and not causal processes.
Novice clinicians may require ongoing support if they are to learn to work in this way, in the form of follow-up sessions or through training in systemic theory or interventive interviewing.
Another limitation of systemic consultation is the potential organisational barriers to change when clinicians chose to work differently. This is understandable given the increasing demand for accountability within health and human services, where hierarchical managerialism and technological regulation are prevalent (Burton and van den Broek, 2009). At a minimum it might be useful to invite managers to participate in consultations, to foster greater understanding between them and their clinical staff. There will be situations, however, where these types of barriers cannot be negotiated through systemic consultation.
Despite some promising findings research into systemic consultation is in its infancy. Future studies may benefit from the inclusion of a comparison group, consisting of clinicians receiving standard supervision. Social network analysis may also provide a quantitative method for evaluating outcomes (Freeman, 2006). In addition, the heterogeneity of cases was limited in this study, with the majority to living in group home settings. Further research is required to explore the applicability of this method for clinicians working with children and adults living at home as well as those living is less supported forms of accommodation.