Family Therapy. Roskilde September 2015

Transcription

1 Family Therapy Roskilde September 2015

2 Family Interventions n Family conjointly with identified patient n Parents only/marital/couple n Parents + children + other over treatment trajectory n Family + wider network + identified patient n Wide range of aims and outcomes

3 Treatments for Eating Disorders Terms used Abbrevia.on Terms used Abbrevia.on Adolescent Focused Therapy Behavioral Family Therapy Cogni7ve Analy7c Therapy Cogni7ve Behaviour Therapy Cogni7ve Behaviour Therapy - Enhanced Cogni7ve Remedia7on Therapy AFT Individual Suppor7ve Psychotherapy ISP BFT Interpersonal Psychotherapy IPT CAT Maudsley Model for Treatment of Adult with AN MANTRA CBT Media Literacy ML CBT- E Mentalisa7on Based Therapy MBT CRT Mo7va7onal Enhancement Therapy MET Cue Exposure CE Mul7- Family Group Day Treatment MFGDT Day Hospitaliza7on Programs Dialec7cal Behavior Therapy DHP Mul7- Family Group Therapy MFGT DBT Systemic Family Therapy SFT Family Based Treatment FBT Systemic Family Therapy for AN SFT- AN Family Day Workshops FDW Suppor7ve Psychotherapy SPT Family Therapy FT Specialist Suppor7ve Clinical Management SSCM Group Parent- Training Guided Self Help GPT GSH

4 Aims of Family Therapy 40" 35" 30" 25" 20" 15" 10" 5" 0" Youth"Behaviour" General"Mental"Health" Paren9ng" Family"rela9onships" Schizophrenia" %"

5 Family Therapy - Types

6 Family Therapy meta-analyses

7 Family Therapy - moderators n n n Therapeutic Alliance Ø split or unbalanced alliances Ø the importance of ensuring safety Ø foster a strong within-family sense of purpose about the purpose, goals, and value of conjoint treatment Fidelity and Adherence Client Factors and poor outcomes Ø Severity of symptoms of identified client Ø Low family income Ø Low socioeconomic status (SES) Ø Single parent status Ø Young parent age Ø Unstable housing Ø Reliance on government subsidies

8 Adherence and outcomes The Effec.veness of Func.onal Family Therapy for Youth With Behavioral Problems in a Community Prac.ce SeAng. Sexton, Thomas; Turner, Charles Journal of Family Psychology. 24(3): , June Comparison of Felony Recidivism Rates for the High and Low Adherent Therapists within the High and Low Rela7onship Peer and Family Risk factors.

9 Youth Behaviour

10 Multisystemic Therapy (MST) n n n The primary purpose of assessment is to understand the fit between the identified problems and their broader systemic context. Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change. Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members. n n Interventions should be present-focused and action-oriented, targeting specific and well-defined problems. Interventions should target sequences of behavior within or between multiple systems that maintain identified problems.

11 Multisystemic Therapy (MST) n Interventions should be developmentally appropriate and fit the developmental needs of the youth. n Interventions should be designed to require daily or weekly effort by family members. n Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes. n Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members' needs across multiple systemic contexts

12 MST: Incarceration/conviction Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 01 incarceration/conviction Study MST Control RR (random) Weight RR (random) or sub-category n/n n/n 95% CI % 95% CI 01 end of treatment Henggeler /43 28/ [0.17, 0.57] Henggeler /82 13/ [0.16, 1.03] Leschied /210 53/ [0.68, 1.31] Subtotal (95% CI) [0.23, 1.16] Total events: 67 (MST), 94 (Control) Test for heterogeneity: Chi² = 11.36, df = 2 (P = 0.003), I² = 82.4% Test for overall effect: Z = 1.60 (P = 0.11) 02 follow up (1.7 year) Henggeler /82 37/ [0.52, 1.07] Subtotal (95% CI) [0.52, 1.07] Total events: 31 (MST), 37 (Control) Test for heterogeneity: not applicable Test for overall effect: Z = 1.60 (P = 0.11) Favours MST Favours control

13 MST: Re-arrests Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 02 rearrested Study MST Control RR (random) Weight RR (random) or sub-category n/n n/n 95% CI % 95% CI 01 short term follow up (12-18 month follow up) Borduin /92 60/ [0.25, 0.53] Henggeler /43 25/ [0.45, 1.05] Leschied /210 84/ [0.92, 1.42] Timmons-Mitchell /48 39/ [0.61, 0.97] Subtotal (95% CI) [0.45, 1.09] Total events: 174 (MST), 208 (Control) Test for heterogeneity: Chi² = 28.49, df = 3 (P < ), I² = 89.5% Test for overall effect: Z = 1.57 (P = 0.12) 04 long term follow up (8-14 year follow up) Borduin /92 68/ [0.48, 0.75] Borduin /24 10/ [0.09, 0.96] Subtotal (95% CI) [0.31, 0.90] Total events: 49 (MST), 78 (Control) Test for heterogeneity: Chi² = 1.40, df = 1 (P = 0.24), I² = 28.7% Test for overall effect: Z = 2.37 (P = 0.02) Favours MST Favours control

14 MST: Days of incarceration Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 03 incarceration (days/weeks) Study MST Control SMD (random) Weight SMD (random) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI Henggeler (62.80) (103.50) [-0.76, -0.12] Henggeler (13.90) (19.10) [-1.18, -0.09] Leschied (117.98) (91.68) [-0.17, 0.22] Total (95% CI) [-0.71, 0.11] Test for heterogeneity: Chi² = 9.23, df = 2 (P = 0.010), I² = 78.3% Test for overall effect: Z = 1.44 (P = 0.15) Favours MST Favours control

15 MST: Number of arrests Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 04 number of arrests Study MST Control SMD (random) Weight SMD (random) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI 01 short term follow up Borduin (1.04) (3.62) [-1.86, -1.06] Henggeler (1.34) (1.55) [-0.99, 0.09] Henggeler (1.39) (3.11) [-0.45, 0.19] Henggeler (0.61) (0.67) [-0.56, 0.16] Henggeler (1.52) (1.15) [-0.15, 0.74] Rowland (0.19) (0.41) [-0.80, 0.31] Timmons-Mitchell (1.50) (1.50) [-0.98, -0.15] Subtotal (95% CI) [-0.81, 0.02] Test for heterogeneity: Chi² = 41.89, df = 6 (P < ), I² = 85.7% Test for overall effect: Z = 1.86 (P = 0.06) 02 4 year follow up Henggeler (0.43) (1.80) [-0.77, 0.11] Subtotal (95% CI) [-0.77, 0.11] Test for heterogeneity: not applicable Test for overall effect: Z = 1.46 (P = 0.14) Favours MST Favours control

16 MST: Self-reported delinquency Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 05 Self reported delinquency Study MST Control SMD (random) Weight SMD (random) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI 01 end of treatment Henggeler (5.10) (16.50) [-1.04, 0.04] Henggeler (0.57) (0.62) [-0.60, 0.03] Henggeler (39.00) (36.00) [-0.33, 0.39] Henggeler (4.70) (11.00) [-0.90, 0.12] Rowland (11.57) (2.17) [-0.29, 0.81] Subtotal (95% CI) [-0.42, 0.07] Test for heterogeneity: Chi² = 6.15, df = 4 (P = 0.19), I² = 35.0% Test for overall effect: Z = 1.43 (P = 0.15) 02 6 month follow up Henggeler (38.00) (36.00) [-0.31, 0.41] Subtotal (95% CI) [-0.31, 0.41] Test for heterogeneity: not applicable Test for overall effect: Z = 0.29 (P = 0.77) 04 2 year follow up Ogden (54.06) (56.44) [-0.75, 0.23] Subtotal (95% CI) [-0.75, 0.23] Test for heterogeneity: not applicable Test for overall effect: Z = 1.03 (P = 0.30) 05 4 year follow up Henggeler (0.43) (1.80) [-0.77, 0.11] Subtotal (95% CI) [-0.77, 0.11] Test for heterogeneity: not applicable Test for overall effect: Z = 1.46 (P = 0.14) Favours MST Favours control

17 MST: Peer bonding Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 09 MPRI: peer bonding Study MST Control SMD (random) Weight SMD (random) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI Borduin (1.81) (1.88) [-1.47, -0.71] Henggeler (3.90) (5.30) [-0.66, 0.40] Henggeler (3.36) (3.49) [-0.23, 0.41] Total (95% CI) [-1.16, 0.40] Test for heterogeneity: Chi² = 22.93, df = 2 (P < ), I² = 91.3% Test for overall effect: Z = 0.95 (P = 0.34) Favours MST Favours control

18 MST: Maturity Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 10 MPRI: maturity Study MST Control SMD (fixed) Weight SMD (fixed) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI Borduin (1.81) (1.88) [-0.39, 0.31] Henggeler (4.30) (4.80) [-0.62, 0.45] Henggeler (2.48) (2.72) [-0.18, 0.45] Total (95% CI) [-0.18, 0.25] Test for heterogeneity: Chi² = 0.78, df = 2 (P = 0.68), I² = 0% Test for overall effect: Z = 0.32 (P = 0.75) Favours MST Favours control

19 MST: CBCL: Parent report (2 years post assessment) Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 12 CBCL: Parent reports (2-years after pre-assessment) Study Parent training Control SMD (fixed) Weight SMD (fixed) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI 01 CBCL 89-Item Problem Scale (2-years after pre-assessment) Ogden (18.32) (23.69) [-1.01, -0.02] Subtotal (95% CI) [-1.01, -0.02] Test for heterogeneity: not applicable Test for overall effect: Z = 2.03 (P = 0.04) 02 CBCL Externalising (2-years after pre-assessment) Ogden (8.24) (9.62) [-0.66, 0.32] Subtotal (95% CI) [-0.66, 0.32] Test for heterogeneity: not applicable Test for overall effect: Z = 0.68 (P = 0.49) 03 CBCL Internalising (2-years after pre-assessment) Ogden (6.04) (10.97) [-1.19, -0.19] Subtotal (95% CI) [-1.19, -0.19] Test for heterogeneity: not applicable Test for overall effect: Z = 2.69 (P = 0.007) Favours treatment Favours control

20 MST: CBCL: Teacher s report Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 13 CBCL: Teacher reports (2-years after pre-assessment) Study Treatment Control SMD (fixed) Weight SMD (fixed) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI 01 TRF 89-Item Problem Scale (2-years after pre-assessment) Ogden (12.50) (17.67) [-1.62, -0.58] Subtotal (95% CI) [-1.62, -0.58] Test for heterogeneity: not applicable Test for overall effect: Z = 4.12 (P < ) 02 TRF Externalising (2-years after pre-assessment) Ogden (6.69) (10.31) [-1.61, -0.57] Subtotal (95% CI) [-1.61, -0.57] Test for heterogeneity: not applicable Test for overall effect: Z = 4.09 (P < ) 03 TRF Internalising (2-years after pre-assessment) Ogden (5.65) (6.13) [-1.67, -0.62] Subtotal (95% CI) [-1.67, -0.62] Test for heterogeneity: not applicable Test for overall effect: Z = 4.26 (P < ) Favours treatment Favours control

21 MST: Revised behavior problems checklist Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 20 Revised Behavior Problem Checklist (RBPC) Study MST Standard care SMD (random) Weight SMD (random) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI Borduin (0.81) (0.85) [-1.81, -1.02] Henggeler (30.80) (33.90) [-0.45, 0.61] Henggeler (30.20) (30.30) [-0.47, 0.19] Total (95% CI) [-1.42, 0.42] Test for heterogeneity: Chi² = 29.87, df = 2 (P < ), I² = 93.3% Test for overall effect: Z = 1.07 (P = 0.29) Favours MST Favours control

22 MST: General psychiatric symptoms Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 22 General Psychiatric symptoms (SCL/BSCL) Study MST Control SMD (random) Weight SMD (random) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI Borduin (0.79) (1.03) [-0.44, 0.26] Henggeler (0.11) (0.10) [-0.26, 0.81] Henggeler (0.34) (0.66) [-0.82, -0.18] Total (95% CI) [-0.56, 0.27] Test for heterogeneity: Chi² = 6.85, df = 2 (P = 0.03), I² = 70.8% Test for overall effect: Z = 0.67 (P = 0.50) Favours MST Favours control

23 MST: Psychiatric symptoms (4-year follow-up) Review: Comparison: Outcome: ASPD: MST 01 Multisystemic therapy vs Standard care 23 Psychiatric symptoms: YAS (4-year follow-up) Study Treatment Control SMD (fixed) Weight SMD (fixed) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI 01 Externalizing scale Henggeler (8.11) (6.85) [-0.28, 0.60] Subtotal (95% CI) [-0.28, 0.60] Test for heterogeneity: not applicable Test for overall effect: Z = 0.72 (P = 0.47) 02 Internalizing scale Henggeler (9.36) (6.60) [-0.33, 0.55] Subtotal (95% CI) [-0.33, 0.55] Test for heterogeneity: not applicable Test for overall effect: Z = 0.51 (P = 0.61) Favours treatment Favours control

24 Eating Disorders

25 Clinical Intervention - Maudsley n Family seen as route to change rather than a cause of problem. n Clinical stages Ø Gain family co-operation Ø Meal Ø Identify family dynamics Ø Create change

26 Behavioural Family Systems Therapy n Family seen as route to change rather than a cause of problem n Clinical intervention Ø Family join as a team to address the problem Ø Focus on weight with parents in charge Ø Identify cognitive distortions in family members Ø Pass responsibility back to adolescent

27 Conjoint Family Therapy vs. Separated Family Therapy for anorexia nervosa (N=40) Eisler, Simic, Russell et al. J child Pyschol Psychiatry 2007

28 Conjoint Family Therapy vs. Separated Family Therapy for anorexia nervosa (N=40) Eisler, Simic, Russell et al. J child Pyschol Psychiatry 2007

29 Psychotherapy including family therapy vs. dietary advice for Anorexia Nervosa (N=30) Hall, Crisp, Br J Psychiatry 1987

30 Comparison of 2 Family Therapies for Adolescent Anorexia Nervosa: A Randomized Parallel Trial" Agras et al JAMA Psychiatry. 2014;71(11): doi: /jamapsychiatry " Participant Recruitment and Randomization in a Trial Comparing 2 Family Therapies for the Treatment of Adolescent Anorexia Nervosa FBT indicates family-based therapy; SyFT, systemic family therapy." a Participants withdrawn during the treatment period were included in the analysis." "

31 Comparison of 2 Family Therapies for Adolescent Anorexia Nervosa:" A Randomized Parallel Trial" Agras et al JAMA Psychiatry. 2014;71(11): doi: /jamapsychiatry " Change in the Primary Outcome Change in the percentage of ideal body weight was measured from baseline to the 1-year followup. FBT indicates family-based therapy; SyFT, systemic family therapy." "

32 Comparison of 2 Family Therapies for Adolescent Anorexia Nervosa: A Randomized Parallel Trial" Agras et al JAMA Psychiatry. 2014;71(11): doi: /jamapsychiatry " Moderator Effect Showing Weight Change From Baseline to End of Treatment High and low scores on the Children s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) indicated. FBT indicates family-based therapy; SyFT, systemic family therapy." "

33 Comparison of 2 Family Therapies for Adolescent Anorexia Nervosa: A Randomized Parallel Trial n n n n No significant between treatment groups for the primary outcome, for eating disorder symptoms or comorbid psychiatric disorders at the EOT or follow-up. Remission rates included FBT, 33.1% at the EOT and 40.7% at follow-up and SyFT, 25.3%and 39.0%, respectively. Family-based therapy led to significantly faster weight gain early in treatment, significantly fewer days in the hospital, and lower treatment costs per patient in remission at the EOT (FBT, $8963; SyFT, $18 005). An exploratory moderator analysis found that SyFT led to greater weight gain than did FBT for participants with more severe obsessivecompulsive symptoms.

34 Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa" Lock et al Arch Gen Psychiatry. 2010;67(10): doi: /archgenpsychiatry " Consolidated Standards of Reporting Trials diagram. AFT indicates adolescent-focused individual therapy; FBT, family-based treatment. *Full remission requires both Eating Disorder Examination score and body mass index while partial remission only requires body mass index; thus, sample sizes differ because a few participants did not provide Eating Disorder Examination score." "

35 Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa" Lock et al Arch Gen Psychiatry. 2010;67(10): doi: /archgenpsychiatry " Observed partial and full remission rates by treatment assignment (end of treatment [EOT]: adolescent-focused individual therapy [AFT], n = 49; family-based treatment [FBT], n = 50; 6-month follow-up: AFT, n = 47; FBT, n = 44; and 12-month follow-up: AFT, n = 49; FBT, n = 45)." "

36 Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa n No differences in full remission between treatments at EOT n At both the 6- and 12- month follow-up, FBT was significantly superior to AFT on full remission.

37 A Randomized Controlled Trial of Family Therapy and Cognitive Behavior Therapy Guided Self- Care for Adolescents With Bulimia Nervosa and Related Disorders Schmidt et al 2007 American Journal of Psychiatry 164, American Journal of Psychiatry Flowchart of Study Participants, Random Assignment, and Dropouts in a Trial of Family Therapy and Cognitive Behavior Therapy Guided Self-Care for Adolescents With Bulimia Nervosa and Eating Disorder Not Otherwise Specified

38 From: A Randomized Controlled Trial of Family Therapy and Cognitive Behavior Therapy Guided Self-Care for Adolescents With Bulimia Nervosa and Related Disorders Schmidt et al 2007 American Journal of Psychiatry 164, Longitudinal Assessment of Binge-Eating and Vomiting From Baseline to Month 10 in a Trial of Family Therapy and Cognitive Behavior Therapy Guided Self-Care for Adolescents With Bulimia Nervosa and Eating Disorder Not Otherwise Specified

39 Family Therapy (Maudsley Model) vs. CBT Guided Self-Care for Bulimia Nervosa n n n n At 6 months, bingeing had undergone a significantly greater reduction in the guided self-care group than in the family therapy group BUT difference disappeared at 12 months. There were no other differences between groups in behavioral or attitudinal eating disorder symptoms Direct cost of treatment was lower for guided self-care than for family therapy. Overall evidence for FT for bulimia nervosa

40 Family Based Treatment vs. Supportive Psychotherapy for Adolescent Bulimia Nervosa: Remission and partial remission (N=80) FBT superior to supportive psychotherapy Le Grange, Crosby, Rathouz et al. Arch Gen Psychiatry 2007

41 Bipolar disorder and Schizophrenia

42 Individual Family Psychoeducation vs. Waiting-List Control for child Bipolar Disorder (N=20): Mood Severity Index and Expressed Emotion Adjective Checklist Fristad, Development and Psychopathology 2006

43 Individual Family Psychoeducation vs. Waiting- List Control for child Bipolar Disorder (N=20) Fristad, Development and Psychopathology 2006

44 Behavioral Family Management vs. Case Management for Schizophrenia (N=40) Telles, Karno, Mintz et al. Br J Psychiatry 1995

45 Relative intervention + carer TAU vs. carer TAU for psychosis (N=106) Leavey, Gulamhussein, Papadopoulos et al. Psychol Med 2004

46 Multiple-family group treatment for schizophrenia (n=59) Bradley, Couchman, Perlesz et al 2006

47 Psychoeducation vs. routine care for patients with schizophrenia and their families (n=236) Bauml, Frobose, Kraemer et al., 2006 Rehospitalization rates after 1 year and 2 years (*p <.05)

48 Psychoeducation vs. routine care for patients with schizophrenia and their families (n=236) Bauml, Frobose, Kraemer et al., 2006 Days in hospital after 1 year and 2 years (p <.05)

49 Core features of MBT- F 1. The Therapist Stance 2. Basic Good Practice 3. The MBTF Loop 4. Formulating and Planning