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EcoSystemic Structural Family Therapy

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Melanie Tepel

on 1 December 2013

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Transcript of EcoSystemic Structural Family Therapy

EcoSystemic Structural Family Therapy
The ESFT model targets treatment for children and adolescents with moderate to severe emotional and/or behavioral problems and their families.


Key Components
ESFT is an evidenced-based family therapy approach designed to intervene with families of children who are experiencing behavioral health problems and are at the risk of out-of-home placement
History & Overview
Theoretical Constructs
All behavior is a form of communication within a defined cultural context.
Symptoms occur within the context of social interactions.
Families are evolving multibodied symptoms that continually regulate their internal structure, rules and roles, in response to developmental and environmental changes
Family members relate to each other in patterned ways that are observable and predictable.
Families are hierarchically organized, with unwritten rules for interactions between and within the subsystems.
Inadequate hierarchical structure and boundaries maintain symptomatic behavior.
Family patterns are replicated in the surrounding ecosystems.
Five interrelated constructs guide ESFT therapists in their understanding of clinical problems: family structure; family and individual emotional regulation; individual differences,affective proximity, and family development
History

Ecosystemic structural family therapy (ESFT) is a systemic, strength-based, and trauma-informed family therapy model that has evolved from structural family therapy

Population
Empirical Data
Clinical Qualifications
• Demonstrate proficiency of required knowledge in couple and family therapy field,
• Engage in competent relational family therapy practice with individuals, couples, and families having diverse backgrounds.
• Practice within legal and ethical guidelines
• Demonstrate cultural competence with clinical practice (age, gender, sexual orientation, religion, spirituality, health / ability, ethnicity, culture, national origin, race, and socioeconomic status.

A master’s, doctoral, or medical degree in a field appropriate to clinical work with families and/or couples is required.

Implementation Strategy
Training Needed
Qualifications
The process to be an AAMFT approved supervisor for ESFT is a two year process and requires that you attend a supervisor training course that we conveniently offer. We offer a 30 hour, 4 day course on marriage and family therapy supervision. The material covered meet the nine learning objectives set forth by the AAMFT Committee on Supervision.
Data Tracking
Clinical staff will be required to complete clinical logs to document and track the progress of your clients. I understand that this is already being done, so this will just be a continuation of your current policies.
Performance Improvement
Performance improvement or quality assurance
Vignette
IP- Eric seven years old, Referred by school counselor because of frequent, intense and tantrums, which could last for hours. During these tantrums, he would yell, curse, hit, break objects and sometimes urinate on the possessions of whoever was the target of his anger. These eruptions would often be accompanied by hopeless and disparging self-statements, such a "I shouldn't be alive"; "I'm so stupid and bad". This behavior occurs at home, around the neighborhood, and at school
References
This evidence based model was developed by Lindblad-Goldberg in the late 1970s with continuous improvements promulgated to date at the Philadelphia Child and Family Training Center
ESFT is based on the fundamental assumption that child, parental, and marital functioning are inextricably linked to their relational environment.
Family Structure
ESFT directs clinicians to focus on the way that family members accommodate to one another ?
the mutual expectations of family members around daily routines ,
how close or distant the family members are ?
how families organize and regulate themselves?
hierachy - power differentials among members and generations
Family and Individual Emotional Regulation
"Emotion and its regulation form the core of internal and interpersonal processes shaping the organization of self
This process of maintaining emotional organization"

in the family is a powerful organizer in regards to emotional closeness and distance in families. For ESFT therapists, helping relationship systems remain organized, emotionally connected, and emotionally balanced is paramount.

Individual Differences
Account for individual family member needs and promoting positive growth and development.
Clinicians comprehend and appreciate the tension between the intrapersonal and interpersonal domains.
"ESFT therapists are encouraged to investigate as much about who are the players as about how they dance together"
Affective Proximity

Proximity can be looked at as involvement:the balance between dependency and autonomy
The concept of emotional proximity has been introduced to account for the role attachment plays throughout the life course.
Close and securely attached relationships are promulgated when family members feel they can count on each other during times of stress or perceived threat.
Family Development
"Viewing the family from a life cycle perspective allows ESFT clinicians to take a more macro viewpoint acknowledging that current challenges may have originated from outside of the family, as well as from within".


Stage One: Constructing a Therapeutic System

identifying those people and extra-familial systems that need to become part of the therapeutic system and inviting them to participate in the treatment process.
beginning the process of building a therapeutic alliance with each member of the therapeutic system
The clinician partners with each family member to develop collaborative alliances with the goal of clarifying concerns and treatment expectations, fostering a shared understanding of assessment issues, and ultimately co-creating a treatment plan.

Stage Two: Establishing a Meaningful Therapeutic Focus
In addition to identification of the presenting problem(s), resources, family strengths and vulnerabilities, and supports are also identified and integrated into boarder family themes that resonate with the treatment system.

1. strengthen the therapeutic alliance and sense of partnership with the family.
2. identify sources of motivation for change within the family;
3. contextualize the presenting problem(s) by providing a developmental, relational,
contextual, trauma-informed re frame of the problem;
4. develop a clearly articulated circular hypothesis regarding the core negative
interaction pattern maintaining the problem; and
5. propose then seek agreement to problem solving loops around a presenting complaint/
symptoms resulting in a treatment plan

Stage Three: Creating Key Growth-Promoting Experiences
create interactional experiences to promote growth or change rather than a repetition of recurrent maladaptive patterns
strengthen parental executive skills;
promote co-caregiver alliances;
increase tolerance for frustration
create age expected parent–child connection/attachment
Specific goals are developed collaboratively with the members of the therapeutic system upon co-creation of the problems to be resolved.
resolution of the presenting problem and elimination of the negative familial interaction cycles;
a shifting of the developmental trajectories of children, such that they are moving toward greater capacity for self-regulation and social- emotional competence;
enabling families to organize and emotionally connect in such a way that they become more growth promoting in their interactions with one another
enabling relevant community systems to organize in such a way that a family’s efforts toward creating a growth-promoting context are supported
Stage Four: Solidifying Change and Termination
the goal is to help families integrate different themes generated in therapy as well as assist families in developing a clear conceptual under- standing of how their behaviors produce their desired outcomes how they can continue to do so.
Here the responsibility for evoking change shifts from the clinician to the family members and the focus is on how families will deal with the problems, both ones dealt with in therapy and new ones that emerge.
As with other SFT-based interventions, the changes created during the therapeutic process must generalize outside the therapy context.

Clinical Implications
Who Will Train?
What do training Materials Consist of?
What is the training process and time frame?
Questions for Exam
7. What is the usual maximum length of time that ESF therapists work with a family?

A. 32 weeks
B. 12 weeks
C. A year
D. This is no time limit
Answer: A

8. The therapeutic alliance is based upon which of the following?

A. Agreement on the goals and tasks for therapy
B. The family's view of a maintained partnership with the clinician
C. A heirarchial therapeutic relationship based upon mutual respect and collaboration
D. A&B
Answer: D

1. Who developed ESFT?
a. Salvador Minuchin
b. Carl Whitaker
c. Lindblad-Goldberg
d. Virgina Satir
2. What population does ESFT target?
a. Suicidal Adolescence
b. Couples
c. young adults
d. children and adolescents with moderate to severe emotional and/or behavioral problems and their families.
3. What is the first stage when using ESFT in session?

A. Constructing a Therapeutic System
B. Establishing a meaningful therapeutic Focus
C. Creating Key Growth-Promoting Experience
D. Solidifying Change and Termination


4. This first stage is similar to what Structural Family Therapy practice?

A. Hierarchy
B. Joining
C. Challenge
D. Boundries
5. Which of the following is NOT an assessment tool in the ESFT model?
A. Identify sources of motivation for change within the family
B. Strengthen sense of partnership within the family
C. Contextualize presenting problems
D. Formulate linear hypotheses regarding the core negative interactional patterns

6. Which is NOT one of the theoretical assumptions of the ESFT model?
A. Symptoms occur within the contexts of social interactions
B. All behavior is a form of communication
C. Families are not heirarchially organized
D. Families are their best own resources for change.
Answer: C
ESFT training sessions are held for family-based clinicians and their supervisors, directors, and clinicians
Training includes:
Didactic presentations
Clinical Skill development
Role Playing
Supervisors and clinicians receives two days of training per for a total of 17 days per year over a three-year cycle
New clinicians and supervisors attend two days of start-up training
A total of 53 days of training is provided within three-year period
Supervision of Clinical Staff
We ensure that ESF therapists properly monitored through weekly supervisions for three hours. In order to ensure that the practicing therapists are providing top notch service and that your clients are provided with the exceptional care, we adhere to the AAMFT guidelines that state that approved supervisors must undergo what we call “refresher courses” every 5 years. During this course, we discuss current supervision literature, ethical and legal issues, supervision contracts and contextual issues. The laws, rules and regulations are constantly changing and we would not be doing our due diligence if we were not staying educated on these matters.
In order to make sure that therapists do not become overburdened, each team does not exceed 8 cases.

Family- middle class living in an urban neighborhood. Parents have advanced degrees with father, Allen, 40, working long hours during this week. His family time is confided mostly to weekends. Mother, Sue,39, works part-time devoting most of his time to taking care of his children. Parents have been married for 15 years. Both of Allen's parents are deceased as well as Sue's father. Sue's mother lives nearby in a retirement home
Siblings- Older sister, Amy,14, is in ninth grade; Described as well-adjusted, liked by peers, and earns good grades in school. Amy is often out of the house or alone in room talking on the phone with friends.
Conclusion
Goals of Therapy
Reduce the occurrence of out of home care for the families
Enhance the family's ability to cope with the child's emotional disturbances
Enhance the coping skills of the individual family members
Youth with SED in Pennsylvania
CASSP provided PA with a chance to examine the needs of children and their families from a mental health standpoint
They found that there was a need to help both families and the children rather than a one or the other
From this, FBMHS became the first statewide service to implement the CASSP values
ESFT become the primary model used in FBMHS because the goals of the model matched those of the family based services.
ESFT Assessment
Multi-year evaluation, focused on the outcomes of a variety of contexts, outcome measures, and program evaluations.
4,000 families served with data collected and analyzed on almost half those families from 39 different sites (N=1,968)
Study included families with an eldest child from 11-12 years of age exhibiting "psychiatric problems"
IPs were assessed at intake for problem solving, role allocation, behavior control, general functioning, communication, affective involvement, and affective responsiveness
Goals of Study
1. A Reduction in psychiatric hospitalizations and other out-of-the-home placements for children.
2. An enhancement of the families' ability to cope with a child or adolescent with SED.
3. Enhancement of the psychosocial functioning of all family members, including the child with SED.
Study Outcomes of ESFT Effectiveness
Post treatment data strongly support the effectiveness of ESFT.
The most dramatic change was observed in the reduction of out-of-home placements for children and other family members
-Pre-treatment % of IPs that experienced psychiatric hospitalization-
80
%
Post-treatment % reduced to
28
% for any family member;,
20
% for IPs, and
13
% of family members utilized emergency room care.
Outcomes & Effectiveness Cont.
Two-Thirds of the families remained in treatment between 4-9 months.
ESFT reflects the changing trends in the behavioral health field, moving organizations away from the linear perspective requiring clinicians to create an individually-oriented treatment plans
Relational treatment plans meet both MCO's and the ESFT clinician's needs
Study / Treatment Setting
ESFT supports services delivered in the “least restrictive” setting, like the family’s home, to promote safety and comfort, rather than in an inpatient service or residential treatment facility.
The benefits of in-home and in-community delivered services have resulted in the State of Pennsylvania’s decision to create a new statewide in-home/community service to offer ESFT
Goldberg, M.L., & Northey, W. F., (2003) EcoSystemic Structural Family Therapy: Theoretical and Clinical Foundations. Contemporary Family Therapy, 1-12. doi: 10.1007/s10591-012-9224-4

Dore, M., Goldberg, M.L., & Jones, W., (2004) Effective Family- Based Mental Health Service for Youth with Serious Emotional Disturbance in Pennsylvania [The Ecosystemic Structural Family Therapy Model]. 2-16

Philadelphia Child and Family Therapy training center, inc (2013). Retrieved from http://philafamily.com/wp-content/uploads/2013/06/Brochure.pdf
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