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The evidence base of Family Therapy

The Evidence Base of Family
The Evidence Base of Family
Therapy and Systemic Practice
Therapy and Systemic Practice
Peter Stratton
Peter Stratton
Emeritus Professor of Family Therapy, University of Leeds, UK
Emeritus Professor of Family Therapy, University of Leeds, UK
© The Association for Family Therapy and Systemic Practice UK
© The Association for Family Therapy and Systemic Practice UK

The Evidence Base of Family Therapy and Systemic Practice 1
Peter Stratton, Emeritus Professor of Family Therapy, University of Leeds, UK. 1 Overview
Family Therapy and Systemic Practice (FTSP) has evolved into a variety of forms to meet the needs of the people who come for therapy. Our clients bring the full range of psychological and relationship difficulties while living their lives in a variety of family structures and relationships. They also occupy the full life span and the great range of ethnic and other cultural variation that communities now contain. This review starts with an account of the basis of systemic therapy and explains why it offers a particular kind of resource.
This report draws on a substantial number of recent meta-analyses and systematic reviews that consistently point to a strong positive conclusion about the general effectiveness of the approach. We draw on the detail of all the research surveyed to identify the extensive range of conditions, for children and adults, for which FTSP can be evaluated. These reviews demonstrate successful application in the conditions for which significant amounts of comparative research data have been published. 72 conditions (as defined by the research) found family therapy to meet established criteria. FTSP is shown to have benefits beyond diagnosable conditions providing a useful adjunct therapy or alternative approach when an initial approach has not worked.
Six major programmes for well-developed and documented forms of family therapy are reported. They demonstrate high levels of effectiveness and cost-effectiveness. Many involve therapies for adolescent substance abuse and conduct disorder. Funding, and thereby evidence, follows political priorities and neglects other areas of need in the population. People whose suffering has been neglected by research funding risk being deprived of the services they need.
The research review demonstrates that systemic therapies are effective, acceptable to clients, and cost effective for a sufficient range of conditions to give confidence that the wide application in current practice is justified and could usefully be extended.
1 Please reference as: Stratton, P (2016). The Evidence Base of Family Therapy and Systemic Practice. Association for Family Therapy, UK.
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Contents
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OVERVIEW……………………………………………………………………………………………………………………………..1
BACKGROUND OF THE REPORT …………………………………………………………………………………………………3
2.1 SCALE OF THE PROBLEM………………………………………………………………………………………………………………. 3
2.2 SYSTEMIC THERAPY BREAKS THE MOULD …………………………………………………………………………………………… 4
REVIEW OF THE RESEARCH EVIDENCE ………………………………………………………………………………………..6
3.1 WHAT IS SYSTEMIC THERAPY?……………………………………………………………………………………………………….. 6
3.1.1 The Systemic Family Therapy Perspective…………………………………………………………………………….. 6
3.1.2 How Systemic Family Therapy Works ………………………………………………………………………………….. 8
3.2 OVERVIEWS AND META-ANALYSES OF EFFICACY AND EFFECTIVENESS. ………………………………………………………… 11
3.2.1 Meta-Analyses and systematic studies combining findings on general efficacy. ……………………… 13
3.2.2 Some alternative approaches focused on core issues for therapists. ……………………………………… 20
3.3 ESTABLISHED FORMS OF SFCT THAT HAVE BEEN EXAMINED IN EXTENSIVE RCTS AND OTHER RESEARCH ………………… 23
3.3.1 Multi-Dimensional Family Therapy (MDFT) ………………………………………………………………………… 23
3.3.2 Multisystemic therapy (MST) ……………………………………………………………………………………………. 26
3.3.3 Functional family therapy (FFT) ………………………………………………………………………………………… 28
3.3.4 Brief strategic family therapy (BSFT) …………………………………………………………………………………. 29
3.3.5 Emotion Focussed Therapy (EFT) ………………………………………………………………………………………. 29
3.3.6 Systemic couples therapy…………………………………………………………………………………………………. 30
3.4 REVIEWS OF THE EFFECTIVENESS OF FAMILY THERAPY FOR SPECIFIED CONDITIONS…………………………………………. 31
3.4.1 Family and couple therapy with children and adolescents ……………………………………………………. 32
3.4.2 Family and couple therapy with adults ………………………………………………………………………………. 33
3.4.3 A Final alphabetical Listing of all conditions with evidence for efficacy or effectiveness. ………….. 34
3.5 CONSIDERATIONS BEYOND SIMPLE EFFECTIVENESS ……………………………………………………………………………… 38
3.5.1 User acceptability and dropout…………………………………………………………………………………………. 38
3.5.2 Cost-effectiveness …………………………………………………………………………………………………………… 40
3.5.3 What do Systemic Family and Couples Therapists do? …………………………………………………………. 42
CONCLUSIONS ………………………………………………………………………………………………………………………44
4.1 FUTURE RESEARCH NEEDS ………………………………………………………………………………………………………….. 44
4.2 WHY FAMILY THERAPY IS AN ESSENTIAL PROVISION…………………………………………………………………………….. 47
REFERENCES …………………………………………………………………………………………………………………………49
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The Evidence Base of Family Therapy and Systemic Practice
2 Background of the Report 2.1 Scale of the problem
“One in four adults experiences at least one diagnosable mental health problem in any given year. People in all walks of life can be affected and at any point in their lives, including new mothers, children, teenagers, adults and older people. Mental health problems represent the largest single cause of disability in the UK. The cost to the economy is estimated at £105 billion a year – roughly the cost of the entire NHS.” (Mental Health Taskforce to the NHS in England, 2016, p. 4).
These estimates are based on the person diagnosed as ill. But when one person has a mental illness all members of their family are impacted, so even these figures are a likely to be seriously underestimated. There is a reciprocal tendency in that the person’s relationships are at least a potential source of support but the tragedy is that the current mental health system makes too little provision for helping families work effectively to help a member who is suffering. As evidenced in this report, many cases of psychological difficulty benefit from being treated in collaboration with the person in the context of their supportive relationships.
But “despite the existence of cost-effective treatments, it receives only 13% of NHS health expenditure. The under-treatment of people with crippling mental illnesses is the most glaring case of health inequality in our country.” ( LSE, 2012, p. 2).
A particular concern in the UK is the underfunding of mental health services for children which receives only a small proportion of this 13% mental health budget:
“Half of all mental health problems have been established by the age of 14, rising to 75 per cent by age 24. One in ten children aged 5 – 16 has a diagnosable problem such as conduct disorder (6 per cent), anxiety disorder (3 per cent), attention deficit hyperactivity disorder (ADHD) (2 per cent) or depression (2 per cent). Children from low income families are at highest risk, three times that of those from the highest. Those with conduct disorder – persistent, disobedient, disruptive and aggressive behaviour – are twice as likely to leave school without any qualifications, three times more likely to become a teenage parent, four times more likely to become dependent on drugs and 20 times more likely to end up in prison. Yet most children and young people get no support.” (Mental Health Taskforce to the NHS in England, 2016, p.5).
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There is good evidence, reviewed in this report, that FTSP has a number of benefits beyond its effectiveness with referred conditions, including greater acceptability to clients and families, continued improvement after discharge, cost-effectiveness, and reduced use of health and social services resources.
2.2 Systemic therapy breaks the mould
Therapies designed to treat individual people have a remarkable record of achievement. Estimates of the number of people helped by individual therapies such as cognitive behaviour therapy (CBT) range from 23% (Elkin, 1994; Dreissen, 2013) through 50% (LSE, 2012) up to 75% in some smaller studies.
“A half of all patients with anxiety conditions will recover, mostly permanently, after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse.” (P.1 LSE 2012)
However, with at least 25% of people in need not being helped and large numbers either not accessing treatment or dropping out before treatment it is completed, we have no reason for complacency. Rather, we should build on the current moves to foster a variety of approaches and support practitioners to incorporate an ever increasing range of possibilities into their practice. Systemic family and couples therapy offers something unique. It was not developed by taking people out of the central context within which they live their lives, treating a ‘mental illness’ or some other dysfunction inside them and then returning them to that context. Instead the therapy takes place within their system of close relationships: The family context that both challenges and supports each one of us.
The advantages of working with the couple or family are becoming recognised and individualist therapies, particularly the cognitive, the behavioural and the psychoanalytic have recently started working with couples and even whole families. But they are extending a model of ‘cure’ that was developed for treating individuals. Even when they are drawing on techniques that have been developed within systemic therapy, this is not the same as a coherent approach that was developed specifically to work through relationships. We can therefore expect that it is research using recognised systemic forms of therapy that is most relevant to this review.
As this review demonstrates, Systemic Family and Couples Therapies (SFCT) provide effective help for people with an extraordinarily wide range of difficulties. In section 3.4.3 we list 72 conditions for which there is evidence of the value of SFCT. The range covers childhood conditions such as conduct and mood disorders, eating disorders, and substance misuse; and in adults, couple difficulties and severe psychiatric conditions such as schizophrenia. Throughout the life span, it is shown to be
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effective in the treatment and management of depression and chronic physical illness, and the problems that can arise as families change their constitution or their way of life.
While the range is remarkable, the effectiveness of FTSP is perhaps not so extraordinary. After all, the great majority of families cope adequately with a range of difficulties. Families that include a child with serious mental health difficulties, for example, have been shown to come to therapy with substantial strengths and resilience (Allison et al., 2003). So we should expect that a determined effort by people trained and experienced in mobilising the resources of families that have reached an impasse would be effective.
This review of the existing evidence base finds substantial evidence for the efficacy and the effectiveness of family interventions2. Where economic analyses have been carried out, family therapy is found to be no more costly, and sometimes significantly cheaper, than alternative treatments with equivalent efficacy.
In the light of such a strong evidence base for the effectiveness of Family Therapy, we conclude that trained family therapists need to be employed not just to provide Family Therapy services but also:
 to support training of future family therapists through education and supervision;
 to provide training and support for professionals applying specific family interventions such as
Systemic Practitioners.
 to provide supervision and, where appropriate, training of other professionals working with families;
 to develop the research base of their practice by participating in research, perhaps most usefully through practitioner research networks.
2 Efficacy studies investigate the outcomes of well defined therapies for clear diagnostic conditions using standardised measure under controlled conditions. For example a randomised clinical trial, with clients randomly allocated between two kinds of treatment. They allow comparison of therapies when applied under optimal conditions and are oriented to statistical significance.
Effectiveness studies are more naturalistic outcome studies, reflecting everyday practice. They cannot usually follow rigorous procedures but are likely to be especially informative about how well a therapy will work under normal clinic conditions. They are oriented to whether changes are clinically significant.
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3 Review of The Research Evidence 3.1 What is systemic therapy?
When reviewing research we encounter many different criteria of what to include as systemic therapy or family therapy. The implications of findings about the effectiveness of therapy, from specific studies or reviews that combine the results of selected studies, depends on the definition of therapy that is being applied. So an essential preliminary is to attempt a description of the fundamental assumptions and ways of working in the many formats of family therapy and systemic practice.
Some answers to this question are available on the website of the Association for Family Therapy, UK (www.aft.org.uk ). A very useful resource is their leaflet What is Family Therapy at http://bit.ly/2cw1l1D . Alternative sources are current handbooks (Carr, 2012; Sexton and Lebow, 2015) that provide detailed coverage of different forms and aspects of FTSP.
Systemic family therapy is an approach to helping people with psychological difficulties which is radically different from other therapies. It sees its work as being to help people to mobilise the strengths of their relationships so as to make disturbing symptoms unnecessary or less problematic.
3.1.1 The Systemic Family Therapy Perspective
We live our lives through our relationships. Research into what matters most to people consistently finds that close relationships, especially family relationships, rank higher than anything else (Layard, 2005).
Our sense of who we are and our sense of wellbeing are intimately associated with our relationships – both to other people and to the contexts in which we live. When relationships do not give us what we need, we lose our sense of comfort and confidence about the person that we are.
When relationships go seriously wrong, powerful psychological process come to operate. Often not in full awareness, and while they may offer some protection they often bring unwanted consequences.
Much psychological distress is a result of these processes. Conditions that get given labels such as depression, anxiety, and conduct disorder, are very often effects of relationship problems. Conversely, when systemic family therapists see someone in psychological distress they look first for ways that existing relationships could adapted to better help that person. Even when conditions have a clear biological basis, psychological and relationship problems have a real impact on the levels of distress and likelihood of relapse.
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Relationship problems are usually best treated by meeting with those in the relationships. Often that means working with the couple / all members of the family or the household together. The advantages are many:
 Problems are being treated in the context in which they arose
 The other people in the family or group with close relationships are a powerful (and nearly always
willing) resource for change.
 Therapeutic gains that have been achieved in collaboration with the family and other relational systems are most likely to continue as the person moves forward in their context of everyday living.
In fact, we find that therapy carried out within relational systems is so effective that it is often not necessary to understand where a problem such as depression came from. More often we need to understand what is preventing the problem from being resolved, and to find out what resources the relational system has to bring to bear. But, resolving it within the web of relationships is particularly effective. The research described in this review supports a claim that working in this way has been shown to have benefits for all family members both at the time and for how they handle future difficulties.
We also find that systemic family therapy is effective with chronic and intractable conditions where it does not make sense to talk of a cure. Here we are about establishing a quality of life through the system of relationships and in a way that recognises and incorporates the condition.
Systemic therapists will often prefer to work with as many as practicable of the people in the close network of relationships, whether a couple, the family members living together or a wider network, for example to include grandparents. Several practical advantages have been demonstrated: Gurman & Burton (2014) offer reasons why conjoint couples therapy is likely to avoid problems that arise when seeing individuals: “structural constraints on change; therapist side-taking and the therapeutic alliance; inaccurate assessments based on individual client reports; therapeutic focus; and ethical issues relevant to both attending and nonattending partners” (p.470). Similarly Baucom et al (2014) state: “Several investigations indicate that relationship distress and psychopathology are associated and reciprocally influence each other, such that the existence of relationship distress predicts the development of subsequent psychopathology and vice versa. Furthermore, findings indicate that for several disorders, individual psychotherapy is less effective if the client is in a distressed relationship. Finally, even within happy relationships, partners often inadvertently behave in ways that maintain or exacerbate symptoms for the other individual. Thus, within both satisfied and distressed relationships, including the partner in a couple-based intervention provides an opportunity to use the partner and the
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relationship as a resource rather than a stressor for an individual experiencing some form of psychological distress.” (p.445).
3.1.2 How Systemic Family Therapy Works
60 years ago an inspired group realised that in some cases, apparently irrational behaviour of an individual made complete sense when seen in the context of that person’s close relationships. From that point they started to work directly on relationships with a particular attention to patterns of (mis)- communication. For a brilliant example of the understanding of problems arising from the forms that communication takes in family relationships, see Watzlawick et al, (1967)
Systemic family therapy has developed over some 60 years to the point at which we have a varied repertoire of highly effective methods that a family therapist can call on to meet the needs of specific clients and families. These include:
o An awareness of how family processes operate and ability to make these apparent to the family.
o An ability to work with children in relation to their parents and vice-versa.
o Working with families to understand and productively use the influence of their family history and traditions.
o Through both conversation and action, helping family members to recognise options they have not been making use of.
o Collaborative exploration of strengths and resources of family members that they can bring to bear to support each other.
As an effective overview of what this review is trying to achieve, Carr (2016) brings together his substantial body of literature reviews to answer four questions:
Question 1 – Does systemic therapy work?
Question 2 – What sort of systemic therapy works for specific problems? Question 3 – What processes occur in effective systemic therapy? Question 4 – Is systemic therapy cost-effective?
A systemic therapist will create a highly adapted and flexible combination of for each unique client. From this perspective, we should ask ‘what are the conditions that optimise the tailoring of therapy – what therapeutic situation opens up the best opportunities for effective work? There will be cases in which having several of the people who are important in the relationships present creates opportunities that are very difficult to achieve working with an individual. The work often proceeds by bringing difference in assumptions and beliefs into the open for discussion and accommodation.
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The systemic perspective is to always take account of the full range of systems that can be seen as nesting inside each other. It is this orientation that has led the field to place a high priority on working with all aspects of diversity and to be concerned with issues of power and difference such as the impact of migration, economic hardship, and racism. Systemic practice may be with an individual, a couple, a family, a group of families, professional systems and other wider contexts. It is most often offered to couples or families but always with the larger and smaller systems in mind, and with an awareness that change at any level of the systems is likely to impact on the other systems. A counterbalance is provided by an increasing willingness in systemic therapy to incorporate understandings of internal processes as they have been understood by psychodynamic and cognitive therapies.
A typical family therapy clinic helps families deal with a great variety of physical and psychological difficulties. The families will vary widely in terms of family structure, ethnicity and culture. Even so, treatment very often consists of about seven sessions. Carr (2016) suggests that on the basis of the evidence “We can say (to clients), ‘Family therapy helps about two out of three families with problems like yours. You will know after about six to 10 sessions if family therapy is likely to help you. You may wish to give therapy a trial for six to 10 sessions and review progress at that stage.’.” (p. 39).
Within the broad orientation described here, systemic therapy has developed many different approaches, methods and techniques (Burnham, 1992). So FTSP is not one single approach and although there is a commonality in the focus on the relational system and wider context as resource and constraint, and an understanding of the connections between behaviour, beliefs, relationship and emotions, different approaches may focus on different aspects of interaction. This is in large part a clinical judgement about what area requires intervention. For example the focus may be on interrupting repetitive and unhelpful patterns of behaviour in families or it may focus on helping a couple to view their relationship in a different way. At other times it will be to overcome or to deal better with symptoms, illnesses and their consequences. Systemic therapies also help people to change redundant patterns and restrictive narratives which limit their lives, in such a way as to overcome suffering and symptomatology.
A summary description for the public from the AFT website:
“Family Therapy helps people in close relationship help each other. It enables family members, couples and others who care about each other to express and explore thoughts and emotions safely, to understand each other’s experiences and views, appreciate each other’s needs, build on strengths and make useful changes in their relationships and their lives. Individuals also can find Family Therapy helpful, as an opportunity to reflect and strengthen important relationships.
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Family and systemic psychotherapists also work with the ‘systems’ or teams of people based in the caring professions and in a variety of settings such as in social care, schools, hospitals, hospices, substance misuse services, older adults services, youth offending projects, community outreach projects, and also in a wide range of organisational consultancies.”
Finally, a concise statement of systemic therapist orientation comes from a qualitative metasynthesis by Chenail et al (2012) of 49 studies of clients’ experiences of their conjoint couple and family therapy: “Regardless of the clinical orientation, the investigators did not find significant differences in family members’ experiences across the 49 studies examined. These common factors across couple and family therapy suggest that irrespective of their models, couple and family therapists embrace curiosity for, and attention to, what family members find helpful and unhelpful in therapy.” ( P.258- 259)
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3.2 Overviews and meta-analyses of efficacy and effectiveness.
This report has been compiled to answer the (deceptively) simple question ‘does systemic family and couple therapy work?’. After reviewing the published evidence from this broad orientation, it will be possible to unpack different issues that refine the question (see section 3.5). We are fortunate to have several careful reviews available which combine specific studies to draw general conclusions. While some individual research studies are included for specific reasons, this report primarily draws on these reviews.
There is a form of therapy outcome research that is widely assumed to be the most compelling, the Randomised Control Trial (RCT). Two examples of specific RCTs are described in order to be familiar with their methodology and to clarify the kinds of implications that can be drawn from them. Then we will be in a position to evaluate the studies that have combined collections of RCTs in meta- analyses and systematic reviews. These two are also useful studies in their own right with a broad definition of the problem, as is common in meta-analyses, and are indicative of the significant number of outcome studies that are too recent to have been included in current meta-analyses or systematic reviews.
Dakof et al (2015) compared multidimensional family therapy (MDFT, Liddle, in press) with a standard group-based treatment of adolescent group therapy. A sample of 112 youth who were referred by a US juvenile court for offending and substance use. They were randomly assigned to one of the two treatments and extensively tested at baseline and at 6 monthly intervals up to 24 months. During treatment itself both groups achieved similar reductions in delinquency, externalizing symptoms, rearrests, and substance use. But at follow-up, extending to 24 months, only the MDFT treatment group maintained their gains in externalizing symptoms (d _ 0.39), commission of serious crimes (d _ .38), and felony arrests (d _ .96). There were no differences in substance use or arrests for minor misdemeanours, but the authors point out that it is reduction in criminal behaviour that is the major objective of the courts. Strengths of this study are the comparison of a well-defined model of systemic therapy with a realistic standard treatment, measurement of the real life effects that matter to the youths, their families, and the justice system.
Perrino et al (2016) compared treatments for youth identified through delinquency but their main focus was the internalising which relates to later major depression (Wesselhoeft, 2013) and risk of conduct disorder and delinquent behaviour. 242 youths were randomised into either standard community practice or ‘Familias Unidas’ which is an intervention of multiparent group sessions drawing on Ecodevelopmental Theory. The intervention was developed for reducing sexual and other risk taking e.g. an RCT study of reducing HIV risk (Prado et al, 2012) but was tested here because it works to strengthen parenting and family factors relevant to internalizing symptoms. The main
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finding was of superiority of the Familias Unidas group with a medium effect size of d=0.48. They also examined the relationship of this improvement to aspects of parent-adolescent communication and found that those who started off with the poorest communication benefitted most from the Familias Unidas intervention. Here we have an RCT which reports not on a diagnosable symptom but on important aspects of family life with well-established future risks. The team analysed not just the comparison of the two treatments but also for whom and how the intervention works. Another impressive aspect is that they achieved 95% participation at the 12 month follow-up as a result of substantial efforts which included keeping assessors blind to the form of intervention.
These two examples may already indicate that trying to draw reliable conclusions by combining a significant number of such studies is a complex task. One route is to identify all of the RCTs that meet rigorous standards and use statistical methods to combine the data. Each RCT is given a weighting according to criteria such as the size of the sample and overall statistical conclusions are drawn. This is a meta-analysis and can give a much more reliable indication of the efficacy of a therapeutic approach than any individual RCT. But it does depend on there being a sufficient number of good quality RCTs and they have to fit the model of a well-defined therapy applied to clients with a clear diagnosis. For a variety of reasons discussed in this report, there may not be enough of such studies in FTSP to be a basis for a meta-analysis. The option then is to conduct a rigorous systematic review and such reviews are included with meta-analyses in the next section. Clear criteria for the quality of evidence-based treatments in couple and family have been proposed by Sexton et al (2011). This paper is a useful guide to understanding why certain aspects of RCTs are necessary. They should use treatment manuals, apply measures of adherence to the treatment, clearly identify client problems, describe service delivery contexts, and use valid measures of clinical outcome. Sexton & Datchi (2014) offers a useful overview of the outcome evidence up to 2013:
“Science has always been a central part of family therapy. Research by early pioneers focused on the efficacy of both couple and family interventions from a systemic perspective (Pinsof & Wynne, 1995). This early work established family therapy as an effective and clinically useful approach to treatment. In the ensuing decades, the research agenda broadened from answering initial questions of outcome (i.e., establishing whether it works in general) to assessing more specific applications of family therapy with specific clinical problems in specific settings. The result of these decades of research is a strong, scientific evidence base for the effectiveness of family therapies (Sexton et al., 2004; Sexton et al., 2013; Sprenkle, 2002, 2012; von Sydow et al., 2010, 2013). Outcome research for couple and family therapy has drawn from meta-analyses that combine results across large client groups and individual outcome studies conducted in local communities with diverse clients in realistic clinical settings. In addition to these outcome research efforts, process research studies have identified
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the change mechanisms that underlie positive clinical outcomes that are both common across methods and specific to certain approaches”. (p.417).
Four major approaches to treatment have been widely applied and researched in a variety of contexts and have become called the “big four”: Brief strategic family therapy (BSFT/SET); Multisystemic therapy systemic family therapy (MSFT); MultiDimensional Family Therapy (MDFT) and Functional Family Therapy (FFT). All four meet the requirements for evidence-based treatments as specified by the Sexton et al (2011) guidelines. They are considered specifically in Section 3.3.
In this compilation, and in the overview of support for CFT for specific conditions in Section 3.4 there is inevitable overlap in the material used for different reviews. Each meta-analysis and systematic review