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Assignment: Apply Theory in Family-Level Intervention
Name
Professional Practice with Individuals and Families
For Professor of MSW-5002 v5
September , 2022

Week 5 – Assignment: Apply Theory in Family-Level Intervention
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This assignment will be submitted to Turnitin™.
Instructions

As should be well engrained by now, social work practice occurs at the micro-, mezzo-, and macro-levels. Practice with families is considered micro-level, but systems theory also tells us that what happens at one level influences what happens in the other levels. An understanding of the factors that impact on families at all levels is critical for you to develop a comprehensive assessment of the problems that families face. For you to integrate all possible perspectives and explanations of a family’s issues, you must explore a variety of perspectives

For this assignment, select a family issue such as alcohol abuse, working with a disabled member of the family, a marital affair, a child with severe emotional or behavioral problems at school, sexual orientation, or another issue you are interested in researching further.

Develop an educational pamphlet specifically for families who are facing this issue. The purpose of this pamphlet is education families about the issue they are struggling with and to begin engaging the family in the idea of social work treatment by normalizing their struggle. (Hint: while most of what we read about engagement focuses on in-person interactions with clients, there are things to be learned from this week’s readings about how to present information in a way that can jumpstart the process of engagement). This pamphlet should include:

A description of the issue, as it pertains to the family- not as an individual issue.
A discussion about how things that happen at the micro, mezzo, and macro (or individual, group, organization, and community- if that’s easier to conceptualize) levels influence the family’s experience with this issue.
A brief description of how a family’s experience of this issue might be assessed if they presented for social work intervention,
Brief descriptions of at least TWO different theoretically informed, evidence-based family interventions used in social work treatment for this particular issue.
Support your assignment with at least three scholarly resources. In addition to these specified resources, other approp Length: 2 to 3-page pamphlet, not including title and reference pages riate scholarly resources, including seminal articles, may be included
Your assignment should demonstrate thoughtful consideration of the ideas and concepts presented in the Course by providing new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards.
Interventions with Families
This week, you will explore social workers’ attitudes and philosophies about the role of professionals in dealing with families and the initial assessment. Attitudes about families can be thought of as a continuum per the National Federation of Families for Children’s Mental Health (2017):
Attitudes about families can be thought of as a continuum
per the National Federation of Families for Children’s Mental Health (2017):
Professionally Centered
On one end of the continuum is a professional stance that considers the professional to be the expert and views the family as a hostile, resistive force in the way of achieving professional goals. This is the least friendly to families, the least family-centered. The professional-parent relationship is viewed as adversarial, with the parent as the problem. At best, this attitude results in the view of parent as student, or patient, someone who can be taught or treated.
Family Allied
This professional philosophy is a step in the right direction, but it still views the professional as expert. The improvement is that this philosophy views families as helpers and allies to the professional, rather than as hostile obstacles. Still, the professional knows best, and the relationship to the parent is one of getting the parent to become a partner in helping the professional. The parent remains “one down” however, because the professional decides the rules and roles, and the parent is agent of the professional.
Family Focused
The next step on the continuum is the family-focused attitude, which views families as consumers of services, so the professional strives to attune the services to the needs and desires of the parent as consumer. The parent is seen as an equal colleague, one who has expertise, knowledge, and choice. The two work together as a team to address mutually agreed upon goals.
Family Centered
The final step on the continuum is one that is seldom reached. In fact, if the third level of Family Focused was consistently reached, most parents would report a dramatic improvement and probably be quite satisfied. Some parents and professionals, however, believe that the best and most appropriate philosophy is one in which professionals put themselves “one-down” to the parent in the relationship. In this view, parents know what is best for themselves and their children, and professionals exist to help parents, to be the agents of parents in achieving parent goals. In this view, the parent is seen as the employer and the professional as an employee. The professional asks, “How can I help you; how can I be of service to you
Access Directly
ttitudes about families can be thought of as a continuum
per the National Federation of Families for Children’s Mental Health (2017):
Professionally Centered
Family Allied
Family Focused
Family Centered

Reference:
National Federation of Families for Children’s Mental Health. (2017).
Ultimately, a family-centered attitude is the theoretical ideal. Exploring how you can become family-centered from the very beginning of your contact with the family is important. Beginnings with families start with your initial contact. You must decipher their expectations, anxieties, motivation, and why they are contacting you at this time. Initial information is critical in forming an effective working relationship.
Last week, we looked at a developmental approach to understanding and assessing families. We now focus on some skills for engaging and assessing a client family and moving into intervention. The next step would be to form an initial hypothesis. You are not looking for answers yet but finding questions. Decide what questions will provide more information that might prove helpful. Be careful not to jump to easy conclusions.
The following information contains guidelines to Help you:
Initial Interview
You must join with everyone. This is not a recipe for success, but rather an art form. Introduce and personally connect with everyone you meet. Remember to be culturally sensitive and respectful. Discover each person’s motivation, expectations, and personal goals.
Initial Assessment
• Rule out potential causes of harm
• Rule out possible substance abuse
• Rule out biological problems
• General family assessment is then completed
General Family Assessment – focus on relevancy
• Affect
• Behavior
• Cognition
• Meaning – narrative
• Spirituality
• Couple and family system
• Family Structure – alliances, sibling position, boundaries
• Life cycle issues
• Relationship with other systems they are involved with
Be sure to review this week’s resources carefully. You are expected to apply the information from these resources when you prepare your assignments.
Weekly Resources and Assignments
Review the resources from the Course Resources link, located in the top navigation bar, to prepare for this week’s assignments. The resources may include textbook reading assignments, journal articles, websites, links to tools or software, videos, handouts, rubrics, etc.

Conclusion

References

• Diagnostic and Statistical Manual of Mental Disorders
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). DSM-5.
Read Appendix B
Reference;
https://dsm.psychiatryonline.org/doi/epdf/10.1176/appi.books.9780890425596
• Wraparound Services: An Effective Intervention for Families Impacted by Severe Mental Illness
Reference
Kessler, M. L., & Ackerson, B. J. (2004). Wraparound services: An effective intervention for
Wraparound Services:
An Effective Intervention
for Families Impacted
by Severe Mental Illness
Michelle L. Kessler, MSW
Barry J. Ackerson, PhD, MSW
ABSTRACT. Children and families impacted by severe mental illness
(SMI) have multiple strains that effect family functioning, child safety,
and parental rights. Traditional services for children and families
struggling with severe mental illness have not achieved success in im-
proving family functioning and keeping families intact. Wraparound is
a philosophy and a system of care with a promising evidence base that
could enhance collaboration of child welfare, mental health, and com-
munity services to work more effectively with families impacted by
SMI. [Article copies available for a fee from The Haworth Document Delivery
Service: 1-800-HAWORTH. E-mail address: Website: © 2004 by The Haworth
Press, Inc. All rights reserved.]
KEYWORDS. Se
• Outdated Practitioner Views about Family Culpability and Severe Mental Disorders
Rubin A, Cardenas J, Warren K, Pike CK, & Wambach K. (1998). Outdated practitioner views about family culpability and severe mental disorders. Social Work, 43(5), 412–422.
References
Outdated practitioner views about family culpability and severe mental disorders.
Authors:
Rubin A; Cardenas J; Warren K; Pike CK; Wambach K
Affiliation:
1Professor, School of Social Work, University of Texas, Austin, TX 78712; e-mail: arubin@mail.utexas.edu
Source:
Social Work (SOC WORK), Sep98; 43(5): 412-422. (11p)
Publication Type:
Journal Article – research, tables/charts
Language:
English
Major Subjects:
Mental Disorders — Etiology
Family Role
Attitude of Health Personnel — Southwestern United States
Causal Attribution
Minor Subjects:
Southwestern United States; Biological Factors; Summated Rating Scaling; Reliability; Scales; Surveys; Factor Analysis; Questionnaires; Construct Validity; Analysis of Variance; Social Workers; Students, Social Work; Parental Role; Human
Abstract:
Current theories and research about the etiology and treatment of psychotic disorders increasingly point to the importance of biological factors. Accompanying this shift in the etiological literature has been an accumulation of evidence indicating the need to move away from treatment modalities that make families of people with psychotic disorders feel culpable in the causation or perpetuation of their relatives’ disorders. The current study reports the development of a reliable and valid scale to assess the extent to which practitioners have made this shift. It also reports two surveys, the findings of which imply grounds for concern about what many practitioners do when working with clients with severe and persistent mental illness and their families.
Journal Subset:
Allied Health; Peer Reviewed; USA
Instrumentation:
Practitioner Views about Parenting and Mental Illness
ISSN:
0037-8046
MEDLINE Info:
PMID: NLM9739630 NLM UID: 2984852R
Entry Date:
20050425
Revision Date:
20200708
DOI:
10.1093/sw/43.5.412
Accession Number:
107294473
Database:
CINAHL Complete
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Outdated Practitioner Views about Family Culpability and Severe Mental Disorders
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Contents
1. Instrument
2. Developmental Study of Students
3. Practitioner Survey
4. Results
5. Limitations
6. Conclusion
7. Table 1 Percentage of Responses to Each Response Category of Each Scale Item
8. References
Full Text
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Current theories and research about the etiology and treatment of psychotic disorders increasingly point to the importance of biological factors. Accompanying this shift in the etiological literature has been an accumulation of evidence indicating the need to move away from treatment modalities that make families of people with psychotic disorders feel culpable in the causation or perpetuation of their relatives’ disorders. The current study reports the development of a reliable and valid scale to assess the extent to which practitioners have made this shift. It also reports two surveys, the findings of which imply grounds for concern about what many practitioners do when working with clients with severe and persistent mental illness and their families.
Key words: attitudes; families; mental illness; practitioners
Current theories and research about the etiology and treatment of psychotic disorders increasingly point to the importance of biological factors. Only about two decades ago these disorders were attributed by mental health professionals and the public at large to flaws in parenting and family interactions, whereas the scientific literature now emphasizes such things as genetics, early (perhaps prenatal) physical illnesses and brain traumas, and other physiological forces that produce neurochemical abnormalities in the brain (Gottesman, 1991, 1996; Maziade & Raymond, 1995; McFarlane, 1996;Torrey, 1994).
Accompanying this shift in the etiological literature has been an accumulation of evidence indicating the need to move away from treatment modalities that cause families of people with psychotic disorders to feel culpable for the causation or perpetuation of their relatives’ disorders. Research has indicated that family systems therapies that tend to attribute psychotic disorders to parental or family dysfunction not only are ineffective in alleviating symptoms or preventing relapse but also may exacerbate both (Lefley, 1994; McFarlane, 1996). The latter can happen when the treatment intensifies the guilt and sense of blame felt by the family, which in turn increases family members’ anxiety and preoccupation with their relative’s problems. Increased anxiety and preoccupation are likely to intensify the level of expressed emotion in the family and the level of criticism and overinvolvement by family members who, feeling blamed for causing the disorder, are less able to be supportive and philosophical in the face of its long-term persistence (Kuipers & Bebbington, 1990). Research has indicated that people with psychotic disorders are more vulnerable to relapse at higher levels of expressed emotion, anxiety, overinvolvement, and criticism. They are less vulnerable when family members can be more supportive and not act on needs or misunderstandings that induce unrealistic hopes for a full and early recovery (Hogarty, Reiss, & Anderson, 1990; McFarlane, 1996).
In addition to illuminating the counter-therapeutic effects of standard therapies that induce a sense of blame, current research has supported the efficacy of newer treatment approaches. These approaches — generally termed family psychoeducation — provide families with support, educate them about the disorder in a way that identifies biological causation and alleviates their sense of guilt or shame, foster the development of their social support network, and train them in skills to help them cope with their relative’s unusual and perhaps provocative behavior (Falloon, 1990; Gingerich & Bellack, 1996; Hogarty et al., 1990; Hugen, 1993; Leff, 1995; McFarlane, 1996; Stern & Drummond, 1991). Quite unlike refuted family systems approaches with these families, psychoeducational interventions attempt to build an alliance between the practitioner and family members (Gingerich & Bellack, 1996). McFarlane (1996) noted that family psychoeducation assumes that “family members are not only blameless but in fact secondary victims of a biological illness” and regards them “as partners in treatment and rehabilitation — a group of lay collaborators with special knowledge of the patient” (p. 12).
Given all the literature that has appeared since the mid-1970s along the foregoing lines, it may seem reasonable to suppose that family members with a psychotic relative entering the mental health services delivery system today will no longer be made to feel culpable for generating or precipitating the disorder, will no longer receive debunked and ineffectual treatments, and instead will receive psychoeducational interventions consistent with current theory and research. We have encountered well-informed colleagues who scoff at the notion that mental health practitioners continue to perpetuate outdated beliefs and treatments that imply family blame for psychotic disorders. The idea that current theory and research about psychotic disorders has led to a dramatically widespread change in the practices of mental health practitioners can also be found in the professional literature (Coursey, 1994; McFarlane, 1996).
To date, however, no one has studied this issue empirically. Although the current literature provides obvious grounds for optimism about improved practitioner orientations and interventions, there is a basis for examining the extent to which menial health practitioners trained and experienced in traditional family and other therapies that tend to view most or all emotional problems as a function of family dynamics continue to be guided by this orientation even when dealing with psychotic disorders. As recently as 1989, for example, Bernheim concluded that the current literature had not yet been adequately incorporated in the curriculum of professional schools and that the “redress of the neglect and the harm” suffered by too many families of mentally ill individuals “at the hands of well-meaning but uninformed or misinformed mental health professionals is long overdue” (p. 563). Hogarty (1991) argued that social work has an ethical responsibility to teach content relevant to the needs of people with chronic mental illness, particularly by avoiding endorsement of family therapy theories and methods that fail to meet empirical criteria for effectiveness. Even so, we encounter colleagues working in mental health settings, even those licensed as advanced clinical practitioners, who occasionally make statements such as “Crazy kids come from crazy families.”
Another basis for concern has to do with the difficulties involved in assessing emerging psychotic disorders among adolescents. Because of the indeterminacy of the diagnosis for adolescents and because practitioners do not want to stigmatize the youths unnecessarily or to create unwarranted anguish for the family, they may be averse to allowing a psychosis hypothesis to guide their practice in dealing with adolescents and their families. With the noblest of intentions, therefore, the practitioner may prefer to view the problem as a transitory function of flawed family dynamics that can be resolved through some relatively short-term family or other therapy unless the problem really is the beginning of a severe and persistent brain disorder.
Despite their good intentions, practitioners may be unaware of the suffering they can cause when they apply a practice framework that is contraindicated for psychotic disorders. As we have noted earlier, doing so will be ineffectual and perhaps harmful to the individual with the disorder. In addition, there is the stress and burden that family members experience; for example, Lefley (1989) discussed the “Kafkaesque nightmare” experienced by parents who have been given the message not only by society but also by mental health professionals that they have been culpable in generating or precipitating a devastating illness in their beloved child. Many parents react to this nightmare by “trying to determine how, when, why, and under what conditions their behaviors could have led to such horrendous consequences,” and no matter how well they may answer these questions, “there is residual and often unjustified guilt” as they “berate themselves for angry responses to provocation, demands that may have been too stressful, expectations that may have been too high, and failure to distinguish between volitional and avolitional behavior in someone retrospectively perceived as ill” (p. 557).
In addition, family members may experience a double bind from well-meaning therapists applying the wrong framework. The therapist on the one hand may covertly blame family members while on the other hand claiming overtly to help them (McFarlane & Beels, 1983). As Lefley (1989) noted, a mother “suffering from the pain of her child’s illness, the stigmatisation of having ’caused’ it, and the burden of overseeing a treatment plan” must try “to balance conflicting advice from professionals” who may blame her whenever things go wrong. She may be deemed overprotective if she discourages her child from unnecessary risks, neglectful or rejecting if she encourages aspirations and independence, and a “saboteur” if she demurs from following professional advice (p. 558). And if the clinician conveys to her child that his or her symptoms serve a function in perpetuating a dysfunctional family system, this may exacerbate the hostility aimed at an already burdened parent and may lead to the severance of the parent-child relationship, which, in addition to causing the pain experienced by both parent and patient, can eliminate the patient’s support system.
The severity and possible timeliness of the foregoing concerns are reflected in studies showing that experienced mental health professionals serving family members who have a severe and persistent mental disorder express the same level of psychological burden as do lay family members (Lefley, 1989). More than 90 percent of the psychotherapists responding to one survey reported frequently overhearing their colleagues make negative or disparaging comments about family members of clients with severe and persistent mental disorders (Lefley, 1989).
In light of the foregoing observations, we initiated an investigation to assess the views of social work students and social work practitioners about the role of parenting and family dynamics in the etiology and treatment of severe and persistent mental illness. The study focused on social workers only because the authors are all social workers and have access to social work respondents. Although some studies have indicated that relatively few social workers prefer working with individuals with a severe and persistent mental illness (Drolen, 1993), our focus on social workers does not imply an effort to single them out as any better or worse than other mental health practitioners in respect to the phenomenon being studied.
Several phases and objectives made up our investigation. We began by developing a summative Likert-style scale that we called Practitioner Views about Parenting and Mental 1 Illness. Then we tested the scale’s reliability and validity on a developmental sample of social work students. The developmental study enabled us to refine the scale. It also provided some interesting descriptive information about the views of MSW and BSW students in one school of social work. The final 14-item version of the scale was then administered in a mailed survey to 261 social work practitioners licensed as advanced clinical practitioners. That survey provided additional data supporting the high reliability of the scale. More important, it yielded interesting findings on the views of practitioners in general and some surprising findings on correlates of practitioner views.
Instrument
In developing and refining the scale, we followed the scale development steps as recommended by authors such as Nunnally and Bernstein (1994), Devellis (1991), and Rubin and Babbie (1993). On the basis of our experience in the field and our familiarity with the literature, we identified two primary domains relating to practitioner attitudes: beliefs about the etiology of serious mental illness and practitioners’ characterizations of family members as either allies or barriers in the process of rehabilitation. After generating a pool of items based on these domains, we sought collegial feedback from a variety of sources who had experience in treating people with mental illness, including faculty, students, and practitioners in the fields of social work and psychology. On the basis of the responses of 12 colleagues, a set of 23 items remained after eliminating items judged unclear or ambiguous. Each scale item consisted of a statement followed by a six-point Likert scale of responses ranging from 1 = strongly agree to 6 = strongly disagree. We chose not to use a middle category for “uncertain” or “neutral” responses to avoid any tendencies respondents might have to avoid taking a position.
After the developmental study, nine items were eliminated from the scale, resulting in a 14-item instrument. With six response categories, scores on the instrument could range from 14 to 84, with lower scores indicating more agreement with biological etiology and psychoeducational intervention ideas. Higher scores indicate more agreement with etiological and treatment notions that view mental illness as a function of flawed parenting and family dynamics. The items in the final version of the instrument are displayed in Table 1. (Readers are encouraged to use this instrument in their own research or practice and do not need to request the authors’ permission. The authors will send copies of the instrument on request.)
Developmental Study of Students
In the developmental study, the scale was administered in spring 1995 to 167 students at a school of social work located in a large public state university in the southwestern United States. The sample included all the senior BSW students and all first- and second-year MSW students. The scale was administered at the end of sessions of classes in which all students were enrolled. Because these classes included one course required of all seniors and field seminars required of all first- and second-year students, no student was enrolled in more than one of the courses. Doctoral students Helping in the data collection briefly introduced the study (without revealing information bearing on the social desirability of possible responses), disseminated the instrument, and then left the room to ensure anonymity and voluntary participation. Completed instruments were inserted by participating students in a collection box that was retrieved after students left the room. Students completed 148 instruments, resulting in a response rate of 89 percent.
The data for the scale’s item analysis indicated nine items that had an inadequate dispersion of responses and low item-total correlations. These items were eliminated from the rest of the analysis and from the final version of the scale. The remaining 14 items had high internal consistency reliability (alpha = .87). As would be expected with an alpha that high, a factor analysis produced a scree plot indicating that the scale was essentially unidimensional, with one factor accounting for 38.2 percent of the common variance. In conducting the reliability analysis, as well as subsequent analyses, missing values for scale items were handled by calculating the individual respondent’s mean score on the completed items and then inserting that value for the missing item. It should be noted that missing data per respondent were rare occurrences; for example, in the subsequent practitioner survey, only 13 of 261 respondents had any missing data.
With an overall mean scale score of 41.1, the students’ responses to the 14 items indicated views that were on average in slight agreement (3 x 14 = 42) with current theory and research supporting a psychoeducational approach and slight disagreement with statements suggesting parental culpability in the generation or precipitation of their child’s disorder. The implications of this result depend on the reader’s outlook. If the reader agrees with current theory and research supporting a psychoeducational approach, the reader may view slight agreement as a glass that is slightly more than half full, which some might conclude is not bad, particularly in light of the fact that these were students and not experienced practitioners and that respondents to scales often avoid the most extreme response categories (Moser & Kalton, 1972; Rubin & Babbie, 1993). Moreover, these results are consistent with the notion that current research and theory may be included somewhere and, to some degree, in the curriculum. On the other hand, to the extent that the reader feels that students should express stronger agreement with current theory and research, he or she might wish the glass were closer to full.
After students completed the scale, they completed a questionnaire about their educational status and prior study or experience regarding mental illness, family systems therapy, and psychoeducational treatment. None of the background items, including those pertaining to year in program, were significantly associated with scale responses.
One questionnaire item was designed to assess the scale’s convergent construct validity. It asked, “Suppose you were assigned to work with the family of a 20-year-old client with schizophrenia. Which of the following approaches would come closest to portraying the practice approach you would like to use?” It then listed five response categories. At one extreme was the category: “Help family members change problematic family dynamics that have contributed to causing the illness” (an approach in opposition to current theory and research supporting a psychoeducational model). At the other end was a category indicative of the opposite approach, consistent with current theory and research: “Teach family members about the biological and nonfamilial causes of schizophrenia, teach them strategies for coping with their relative’s irrational behavior, and help them obtain social support and other resources to help alleviate their burden.” The categories were coded from one to five, with the lower codes in the direction of the psychoeducational end of the continuum. The correlation between responses to this item and summated scale scores was .62 (p<.001, r² = .38). With 38 percent of the variance in this criterion variable accounted for by scale scores, this indicated a strong relationship supporting the scale’s convergent construct validity. (Correlations at .50 and above, accounting for about 25 percent or more of variance, are generally considered strong; see Cohen, 1988; Rubin & Babbie, 1993.)
Practitioner Survey
In the practitioner survey, the scale was mailed in fall 1995 to all 507 MSW social workers licensed as advanced clinical practitioners and working in the medium-sized southwestern state capital city, where the study school of social work is located. The survey was restricted to that city primarily for reasons of feasibility. We had very limited funding for the study and had a list of all the local licensed practitioners and their addresses. Limiting the study to that city also seemed reasonable because of the presence of the school of social work, a state hospital, the state mental health department, and a well-established county mental health program for people with severe and persistent disorders. We reasoned that if current research and theory were not reflected adequately in the views expressed by practitioners in that city, then there would be grounds for concern and replication of our study by others elsewhere.
Our funding permitted two mailing waves: an initial mailing and a follow-up mailing. The ultimate response rate was 51 percent (n = 261). The reliability of the scale in the practitioner data exceeded the high reliability of the student data. Among practitioners, coefficient alpha was .91, and a factor analysis again indicated a unidimensional scale, with one factor accounting for 52.7 percent of the common variance.
Results
The mean scale score for all respondents was 46.6. One noteworthy finding is the degree of agreement by respondents with item 6, regarding the importance of biological factors in causing most psychoses (Table 1). Eighty-seven percent of respondents agreed with item 6, and 71 percent agreed moderately or strongly. The responses to the other 13 items, however, suggest that although practitioners recognize the importance of biological factors, they believe that parental and family culpability are also important causes. For example, 74 percent of respondents agreed to some extent with item 3, which stated that as a rule mentally healthy young adults had better parenting than young adults with severe mental disorders. And the large majority of those agreeing with that statement expressed moderate to strong agreement.
For item 2, 69 percent of the practitioners disagreed with the statement that emotionally unhealthy parenting is usually not a major cause when children grow up to have a serious mental illness. Again, the large majority expressed moderate to strong views that clash with current theory and research. In other words, more than three-fifths of the respondents expressed the view that if a serious mental illness emerges at some point in life, unhealthy parenting is probably a major cause.
Three-fifths of practitioners (61 percent) agreed to some extent with item 7, that a person with a severe mental illness probably has had an emotionally disturbed parent. Although very few of the respondents expressed strong agreement with this statement, the fact that so many agreed at all with it is remarkable in light of the extreme wording of the statement. That is, the statement goes beyond asserting parental culpability and actually labels the parent emotionally disturbed. Item 8 is somewhat similar to item 7, albeit less extreme in its wording, and the majority of respondents (57 percent) agreed that parental dysfunction is a primary cause of serious mental illness in children.
Also remarkable are the responses to item 11, to which 40 percent of respondents indicated agreement with the statement that adolescents with severe mental illness are usually accurate when they attribute their problems to unhealthy parenting. These responses (as well as those to be discussed next) lend credence to Lefley’s (1989, 1994) concern about clinicians often exacerbating the parent-child relationship and the family burden by conveying to the child that the child’s problems serve a function in perpetuating a dysfunctional family system.
A large proportion of responses clashed with current theory and research, not only in regard to what causes persistent and often life-long brain disorders but also in regard to what prolongs them. Whereas research suggests that even the best circumstances will usually just forestall relapse, and not prevent it (Hogarty et al., 1990), over two-thirds (68 percent) of the respondents expressed some degree of agreement with item 13, which stated that family resistance to change is usually an important obstacle prolonging the illness of clients with a serious mental illness. And with item 12, 46 percent of respondents believed that when interventions with youths with a severe mental illness are not effective, it is usually the result of the persistence of parental dysfunction. Responses to items 12 and 13 may be connected to responses to item 14, in which the majority of respondents agreed that the onset of a family member’s mental illness usually serves a function in preserving the family system.
But perhaps most troubling are the responses to items 4, 5, and 10, because those three items go beyond what practitioners think about etiological forces and refer to what they believe should actually be said to family members. In each of those items, a large proportion of practitioners, albeit not quite a majority, responded in a manner that clearly conflicts with empirically supported psychoeducational principles. Regarding item 4, for example, half of the clinical practitioners agreed that an aim of therapy should involve getting family members to understand how their family dynamics have helped cause their relative’s severe mental illness. Almost half of the respondents (48 percent) to item 5 disagreed with the statement that therapists should inform relatives that their own behaviors or family dynamics did not help cause their relative’s illness. And 41 percent of the respondents agreed with the statement in item 10 that an aim of therapy should involve getting parents to understand how their parenting has helped cause their young adult’s or child’s severe mental illness.
To better understand the meaning and potential clinical implications of our findings, we compared the scale scores of practitioners who currently provide direct services to clients with the scores of those who do not. An analysis of variance indicated a significant difference (p < .001 ) between the two groups, with the mean of those currently providing direct services (49.0) higher than the mean of those who do not (39.4). The same difference was found when comparing the views of the direct services practitioners with the views expressed in our earlier survey of students. The direct services practitioner mean of 49 was significantly higher than the student mean of 41.1 [t(323) = 5.32, p < .01]. These differences were not trivial in magnitude. Their effect sizes of .63 and .61 approximate the average effect sizes commonly found in meta-analyses of practice research (Rubin & Babbie, 1993).
The direction of this finding was surprising. It means that the views expressed by practitioners currently coming in direct contact with clients are less in line with current theory and research than the views of students or of practitioners not currently seeing clients. Moreover, the score of 49 means that on average direct services practitioners were in the middle — halfway between slightly agree and slightly disagree — regarding statements that the authors believe are either clearly in line or clearly out of line with recommended and empirically supported orientations and clinical practices for this target population.
In light of this finding, we wondered whether perhaps the practitioners currently providing direct services were less experienced than the others. We also wondered whether those whose caseloads contained the most clients with a severe and persistent mental illness were the ones whose views are most consistent with current theory and research. Similarly, perhaps the practitioners with the most problematic views were not working with this target population anyway, and therefore were unlikely to do much harm. However, subsequent analyses did not support these conjectures. No significant correlation was found between scale score and percentage of current caseload consisting of clients with a severe and persistent mental illness, number of such clients served during the entire career, years elapsed since receiving the MSW degree, or years elapsed since acquiring licensure status as an advanced clinical practitioner. When all of these variables were controlled in an analysis of covariance, practitioners currently providing direct services continued to have significantly higher scores than the others. (Readers are reminded that the entire sample consisted of people licensed as advanced clinical practitioners. State requirements stipulate a minimum of three years of post-MSW direct practice experience to qualify for this classification; therefore even those respondents not currently providing direct services are experienced and qualified as direct services providers.)
Limitations
Despite the striking and perhaps alarming degree of incongruence between the current literature about severe and persistent mental disorders and the practitioners’ responses to our scale, our conclusions must be tempered by the limitations of our sample. Our developmental study involved only one school of social work. In the practitioner sample, we surveyed clinicians in only one city and from only one segment of the profession. Finally, although a 51 percent response rate for a mailed survey is good, it nonetheless threatens the external validity of the results. More research is recommended to assess whether our findings can be generalized. Social workers and other mental health professionals should be surveyed in other geographical areas. In future surveys, data regarding the types of agencies in which respondents are employed (rather than simply asking global questions regarding experience in working with clients diagnosed with serious mental illness) would be useful in discerning the effect of agency setting on practitioner viewpoints.
Qualitative investigations are also needed to probe into the deeper meanings of their responses. Students in other schools of social work and other mental health disciplines should be surveyed to better gauge how adequately curricula are disseminating current theory and research and fostering practice orientations consistent with the current state of the art.
Should future studies replicate our findings, a key challenge will involve trying to understand why the practitioners who should have the most clinical expertise — that is, those providing direct services — are significantly less likely to hold views that are consistent with current theory and research about severe and persistent mental disorders than are practitioners who do not provide direct services. Perhaps the explanation is connected to the divergence between what people with severe mental illness and their families need and the roles and theories preferred by practitioners who are drawn to the practice of psychotherapy. Several earlier studies have suggested that this may be so (Rubin, 1978; Rubin & Johnson, 1982, 1984). If this indeed is the explanation, then continuing education and other knowledge dissemination strategies about current theory and research targeted at direct services practitioners who are likely to come in contact with families of individuals with severe mental disorders may not be the best way to remedy the problem. If the reason many practitioners’ views diverge from current knowledge about people with severe mental disorders and their families has less to do with their lack of exposure to that knowledge than with their preference for theories and interventions geared to alternative client populations, then simply attempting to reinform them about A practice model that they dislike and resist may not change their views or practices.
Thus, although it is tempting at this point to recommend continuing education and other knowledge dissemination strategies, we would like to learn more about this phenomenon before proposing remedies that could turn out to be costly and ineffectual. After more investigation into this problem, we will be better informed as to what to recommend to alleviate it. We hope that the study reported here will stimulate the additional research needed and that the scale we have developed will be of use to future investigators conducting such research.
Conclusion
Our findings raise doubts about the adequate dissemination of the profound scientific advances that have been made over the past two decades regarding the etiology and treatment of severe and persistent mental illness and about their integration into practice by clinical practitioners. Although most practitioners recognize that biological factors are important, many of them continue to believe that parental and family culpability also are important factors and that rather than alleviate parents and other family members of their sense of culpability, getting them to recognize their own culpability should be an aim of therapy. Thus, our findings imply grounds for concern about what many practitioners do when working with clients with severe and persistent mental illness and their families and about the harm they could be inflicting because of their misinformation or lack of information, no matter how noble their intentions may be.
Some practitioners might have a more optimistic reaction to our findings, perhaps citing the fact that in our student survey, the average response was in slight agreement with current theory and research and therefore arguing that this suggests that recent advances are being incorporated and disseminated in the professional curriculum.
If our findings could be explained as a cohort effect, with older practitioners’ views simply being a function of their outdated training, less experienced practitioners would be expected to express views more consistent with current theory and research. However, years of experience did not correlate with views expressed by practitioner respondents. Thus, although it may be true that recent advances are being incorporated in the social work curriculum, that would not obviate the implications of our practitioner findings. Moreover, the student views were not more in the direction of current theory and research than were the views of practitioners who do not provide direct services.
Some practitioners might also support a more optimistic interpretation by pointing to the fact that on most items nearly half or more of the practitioner respondents expressed views consistent with current theory and research, thus arguing that the glass is half full. But if a practitioner accepts that severe and persistent mental illnesses are primarily brain disorders with biological etiology, then a rosy interpretation of our findings can be countered with a medical analogy. Suppose roughly half of practicing physicians erroneously believed that flawed parenting or family dysfunction played an important role in the causation of indisputably physical illnesses, such as diabetes, and believed that part of the treatment plan should include getting family members to understand their culpability. When dealing with physical illnesses, we have high standards for practitioners. We would be outraged if approximately half of them were being guided by outdated, scientifically refuted, harmful views. We would also be outraged if graduating medical students on average only slightly disagreed with these incorrect and harmful views. Should our standards be any lower for mental health clinicians’ views about severe and persistent mental disorders, in light of the scientific advances that have been made regarding those disorders?
Unlike refuted family systems approaches, psychoeducational interventions attempt to build an alliance between the practitioner and family members.
Original manuscript received March 6, 1997
Final revision received July 30, 1997
Accepted September 18, 1997
Table 1 Percentage of Responses to Each Response Category of Each Scale Item
Legend for Chart:
A – Item
B – Strongly Agree (%)
C – Moderately Agree (%)
D – Slightly Agree (%)
E – Slightly Disagree (%)
F – Moderately Disagree (%)
G – Strongly Disagree (%)
A: 1. People who grow up in emotionally healthy families will not
develop schizophrenia.
B: 4
C: 9
D: 7
E: 9
F: 28
G: 43
A: 2. Emotionally unhealthy parenting is usually not a major cause when
children grow up to have a serious mental illness.
B: 10
C: 14
D: 8
E: 13
F: 30
G: 26
A: 3. As a rule, mentally healthy young adults had better parenting
than young adults with severe mental disorders.
B: 22
C: 34
D: 18
E: 7
F: 11
G: 7
A: 4. Getting families to understand how their family dynamics have
helped cause their relative’s severe mental illness should be an
aim of therapy.
B: 8
C: 19
D: 22
E: 12
F: 18
G: 21
A: 15. Therapists should inform relatives of clients with severe mental
illness that their own behaviors or family dynamics did not help
cause their relative’s illness.
B: 18
C: 20
D: 14
E: 22
F: 18
G: 8
A: 6. Biological factors play an important part in causing most
psychoses.
B: 35
C: 36
D: 16
E: 5
F: 5
G: 3
A: 7. A person with a severe mental illness probably has had an
emotionally disturbed parent.
B: 7
C: 23
D: 31
E: 15
F: 17
G: 7
A: 8. Parental dysfunction is a primary cause of serious mental illness
in children.
B: 13
C: 27
D: 17
E: 11
F: 19
G: 14
A: 9. Severe emotional disorders are caused primarily by biological or
environmental forces beyond parental control.
B: 12
C: 28
D: 16
E: 19
F: 19
G: 6
A: 10. Getting parents to understand how their parenting has helped
cause their young adult’s or child’s severe mental illness should
be an aim of therapy.
B: 7
C: 14
D: 20
E: 18
F: 21
G: 21
A: 11. Adolescents with severe mental illness are usually accurate when
they attribute their problems to unhealthy parenting.
B: 2
C: 14
D: 24
E: 19
F: 25
G: 15
A: 12. When interventions with youths with a severe mental illness are
not effective, it is usually because of the persistence of parental
dysfunction.
B: 2
C: 21
D: 22
E: 18
F: 22
G: 15
A: 13. Family resistance to change is usually an important obstacle
prolonging the illness of clients with a serious mental illness.
B: 12
C: 29
D: 27
E: 13
F: 13
G: 7
A: 14. The onset of a family member’s mental illness usually serves a
function in preserving the family system.
B: 8
C: 19
D: 29
E: 11
F: 19
G: 14
© 1998 National Association of Social Workers, Inc.
References
Bernheim, K. F. (1989). Psychologists and families of the severely mentally ill. American Psychologist, 44, 561-564.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.
Coursey, R. D. (1994). Serious mental illness: The paradigm shift involved in providing services and training students. In D. T. Marsh (Ed.), New directions in the psychological treatment of serious mental illness (pp. 123-140). Westport, CT: Praeger.
Devellis, R. F. (1991). Scale development: Theory and applications. Newbury Park, CA: Sage Publications.
Drolen, C. S. (1993). Effect of educational setting on student opinions of mental illness. Community Mental Health Journal 29, 223-234.
Falloon, I. R. H. (1990). Behavioral family therapy with schizophrenic disorders. In H. A. Nasrallah (Series Ed.), M. I. Herz, S. J. Keith, & J. P. Docherty (Vol. Eds.), Handbook of schizophrenia: Vol. 4. Psychosocial treatment of schizophrenia (pp. 135-151). New York: Elsevier.
Gingerich, S. L., & Bellack, A. S. (1996). Research-based family interventions for the treatment of schizophrenia. Research on Social Work Practice, 6, 122-126.
Gottesman, I. I. (1991). Schizophrenia genesis: The origins of madness. New York: W. H. Freeman.
Gottesman, I. I. (1996). Advances in the genetics of schizophrenia excite media and scientists. NAMI Advocate, 17, 14-16.
Hogarty, G. E. (1991). Social work practice research on severe mental illness. Research on Social Work Practice, 1, 5-31.
Hogarty, G. E., Reiss, D. I., & Anderson, C. M. (1990). Psychoeducational family management of schizophrenia. In H, A. Nasrallah (Series Ed.), M. I. Herz, S. I. Keith, & J. P. Docherty (Vol. Eds.), Handbook of schizophrenia: Vol. 4. Psychosocial treatment of schizophrenia (pp. 153-166). New York: Elsevier.
•
Kessler, M. L., & Ackerson, B. J. (2004). Wraparound services: An effective intervention for families impacted by severe mental illness. Journal of Family Social Work, 8(4), 29–45.
• Capacity-Building Family-Systems Intervention Practices
Dunst, C. J., & Trivette, C. M. (2009). Capacity-building family-systems intervention practices. Journal of Family Social Work, 12(2), 119-143.

Capacity-Building Family-Systems Intervention Practices.
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Dunst, CarlJ.1 (AUTHOR) cdunst@puckett.org
Trivette, CarolM.1 (AUTHOR)
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Journal of Family Social Work. 2009, Vol. 12 Issue 2, p119-143. 25p. 2 Diagrams, 3 Charts, 1 Graph.
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Subject Terms:
*Families
*Intervention (Social services)
*Family relations
Social support
Family social work
Systemic family therapy
Author-Supplied Keywords:
capacity-building
early childhood intervention
family support
family-systems
Abstract:
This article includes a description of a family-systems model for implementing early childhood and family support assessment and intervention practices. The model includes both conceptual and operational principles that link theory, research, and practice. Lessons learned from more than 20 years of research and practice have been used to revise and update the model, which now includes a major focus on family capacity building as a mediator of the benefits of intervention. Key components of the most recent version of the model are described, and findings from research syntheses showing the relationship between the different components of the family-systems model and parent, family, and child behavior and functioning are summarized. Future directions are described. [ABSTRACT FROM AUTHOR]

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1Orelena Hawks Puckett Institute, Asheville, North Carolina
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• Capacity-Building Family-Systems Intervention Practices
Dunst, C. J., & Trivette, C. M. (2009). Capacity-building family-systems intervention practices. Journal of Family Social Work, 12(2), 119-143.
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Capacity-Building Family-Systems Intervention Practices.
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Contents
1. ENABLING AND EMPOWERING FAMILIES
2. Conceptual Principles
3. Operational Principles
4. PROMOTING AND ENHANCING FAMILY CAPACITY
5. Definition of Early Childhood Intervention and Family Support
6. Systems Theory Framework
7. Capacity-Building Paradigm
8. Family-Systems Intervention Model
9. RESEARCH FOUNDATIONS
10. CONCLUSIONS
11. REFERENCES
12. Footnotes
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This article includes a description of a family-systems model for implementing early childhood and family support assessment and intervention practices. The model includes both conceptual and operational principles that link theory, research, and practice. Lessons learned from more than 20 years of research and practice have been used to revise and update the model, which now includes a major focus on family capacity building as a mediator of the benefits of intervention. Key components of the most recent version of the model are described, and findings from research syntheses showing the relationship between the different components of the family-systems model and parent, family, and child behavior and functioning are summarized. Future directions are described.
Keywords: early childhood intervention; family support; family-systems; capacity-building
Contemporary interest in early childhood intervention with young children with disabilities and children at risk for poor developmental outcomes can be traced to a number of experimental studies conducted between 1940 and 1970 (for a review of these studies, see Dunst, [29]). The main goal of these, as well as subsequent intervention studies, was to lessen the effects of a disability or to prevent negative effects associated with poor environmental conditions. This was accomplished in the largest majority of studies by professionals intervening directly with young children or by professionals instructing parents on how to provide their children supplemental experiences deemed important for improving child functioning.
Most early childhood initiatives during the 1960s and 1970s, and even those in the 1980s, were based on an assumption that the children, their parents, or the environment were in some way deficit and that remedial measures were indicated (Lambie, Bond, & Weikart, [81]). It was also generally assumed that the interventions afforded the children would alleviate or reduce the consequences of the (presumed) deficits. The assumptions that constituted the foundations of these child-focused, deficit-based approaches to early childhood intervention were challenged by a number of experts (e.g., Foster, Berger, & McLean, [68]; Zigler & Berman, [110]), which became the basis of a new way of conceptualizing early childhood intervention. Bronfenbrenner ([13]), for example, noted in his review of early childhood intervention programs, that the likelihood of these programs being successful is dependent, in part, on supporting parents who, in turn, would have the time and energy to promote their children’s development.
More than 25 years ago, we began a process of transforming a deficit-based, child-focused early intervention program (Cornwell, Lane, & Swanton, [21]) into a strengths-based, family-focused early childhood intervention and family support program (see, e.g., Dunst, [41]; Trivette, Deal, & Dunst, [53]). The program began in 1972, and its practices were heavily influenced by deficit-based thinking at that time. Children were assessed to identify what they were not capable of doing, and professionals taught parents to use different techniques to promote children’s behavior that were judged as lacking. In the early 1980s, as part of advances in family and systems theory (Bronfenbrenner, [14]), it became increasingly apparent that the family as well as the child needed to be the focus of intervention if the experiences afforded children and their families were likely to be optimally effective (Hobbs et al., [40]). The implications of the changes were a complete “rethinking” in how early childhood intervention and family support were conceptualized and implemented (Dunst, [41]).
The transformation we undertook was guided by key elements of social-systems (Bronfenbrenner, [14]), empowerment (Rappaport, [91]), family strengths (Stinnett & DeFrain, [100]), social support (Gottlieb, [71]), and help-giving (Brickman et al., [12]) theories. These different theories guided the conduct of research (e.g., Dunst, [28]; Dunst, Leet, & Trivette, [42]; Dunst & Trivette, [42]c; Dunst, Trivette, & Cross, [53]; Trivette & Dunst, [36]) as well as attempts to use key elements of the theories as part of interventions providing parents and other family members information, resources, advice, guidance, and other types of support to strengthen parenting and family functioning (e.g., Dunst, Cooper, & Bolick, [36]; Dunst & Trivette, [36]; Dunst & Trivette, [42]a; Dunst, Vance, & Cooper, [53]). One outcome of this research and practice was the publication of Enabling and Empowering Families: Principles and Guidelines for Practice (Dunst, Trivette, & Deal, [26]), which included methods and strategies for conceptualizing and implementing a family-systems approach to early childhood intervention and family support.
The purpose of this article is to describe a revised and updated version of the approach to early childhood intervention and family support described in Enabling and Empowering Families. The article is divided into three sections. The first includes an overview of the originally proposed model to provide a backdrop against which to understand the evolution and transformational features of the model. The second section includes a description of a revised and updated approach to supporting and strengthening families based on more than 20 years of lessons learned from both research and practice (e.g., Dunst, [34]; Dunst & Dempsey, [38]; Dunst, Hamby, & Brookfield, [38]; Trivette & Dunst, [39]a). The third section summarizes the results from meta-analyses of the relationships between the different components of the family-systems model and parent, family, and child behavior and functioning. The article concludes with thoughts about the future applicability of the model.
ENABLING AND EMPOWERING FAMILIES
Enabling and Empowering Families included sets of both conceptual and operational principles to structure an approach to working with families that used different kinds of enabling experiences and opportunities specifically intended to have empowering consequences and benefits (Rappaport, [91]). According to Brandtstädter ([10]), conceptual principles “yield general rules for producing some desired effect, [whereas operative principles] supply decision aids for the effective implementation of [the] rules in the concrete action context” (p. 15). The conceptual principles, taken together, were intended to provide a framework for rethinking how and in what manner family-systems intervention practices were implemented. The operational principles constituted a set of assessment and intervention practices proposed to be easily used by professionals from different disciplines and backgrounds while working with families involved in early childhood intervention and family support programs.
Conceptual Principles
The eight conceptual principles constituting the foundations of Enabling and Empowering Families are the following:
• 1. Adoption of both a social-systems perspective of families and a family-systems definition of intervention. Accordingly, a family was viewed as a social unit embedded within other informal and formal social units and networks, where events in those units and networks reverberated and influenced the behavior of the family unit and individual family members (Bronfenbrenner, [14]). Intervention was defined as the “provision of support … from members of a family’s informal and formal social network that either directly or indirectly influenced child, parent, and family functioning” (Dunst, Trivette, & Deal, [26], p. 5).
• 2. A focus on the family and not just a child as the unit of intervention. This principle was based on the fact that families who do not have the necessary supports and resources cannot adequately rear healthy, competent, and caring children (Hobbs et al., [77]). The provision of supports and resources to families was, in turn, expected to provide parents the time, energy, knowledge, and skills to provide their children development-enhancing learning opportunities (Bronfenbrenner, [14]).
• 3. Primary emphasis on family member empowerment as the goal of intervention. The premise of this principle is that a sense of control and mastery is an important mediator of behavior in many domains of functioning (Bandura, [ 6]). Empowerment was accomplished by creating opportunities for family members to acquire the knowledge and skills to better manage and negotiate daily living in ways positively affecting parent and family well-being and a sense of mastery and control (Rappaport, [91]).
• 4. Use of promotion rather than either treatment or prevention models for guiding intervention. This principle was based on the premise that the absence of problems was not the same as the presence of positive functioning (Bond, [ 8]). According to Carkhuff and Anthony ([16]), helping is the act of promoting and supporting family functioning in a way that enhances the acquisition of competencies that permit a greater degree of control over subsequent life events and activities.
• 5. A focus on family and not professionally identified needs as the targets of intervention. This practice was derived from environmental press theory (Garbarino, [70]) that postulated the conditions under which people are motivated to address their needs. Accordingly, a practitioner did not assume a need for Helpance until the family had set forth a need, where the request for Helpance came from the family or individual family members (Pilisuk & Parks, [88]). The family-identified needs, in turn, were addressed by helping families use their strengths and capabilities to obtain the necessary resources and supports to meet needs.
• 6. Identify and build on family strengths as a way of supporting family functioning. This principle was based on the belief that all families have existing strengths and the capacity to become more competent (Rappaport, [91]), and that strengths-based interventions were likely to be more productive compared to attempts to prevent or correct weaknesses (Garbarino, [70]).
• 7. Using a family’s informal social support network as a primary source of supports and resources for meeting family needs. This principle was based on a burgeoning body of evidence demonstrating the positive influences of support from family, friends, and neighbors on well-being and in other domains of functioning (e.g., Cohen & Syme, [19]; Sarason & Sarason, [93]). Therefore, to the extent possible and appropriate, informal supports were targeted as sources of information, guidance, Helpance, and so on, because the “foresighted professional knows that it is the parent who truly bears the responsibility for the child, and the parent cannot be replaced by episodic professional services” (Hobbs, [76], pp. 228–229).
• 8. Adoption of professional help-giving roles that place major emphasis on competency enhancement and the avoidance of dependencies. The premise of this principle was the contention that different kinds of helping beliefs and behaviors shaped and influenced interactions between professionals and families, and that certain help-giving practices were more likely to have competency enhancing effects (Brickman et al., [12]). As noted by Rappaport ([91]), empowering help-giving practices require a breakdown in the typical relationships between professionals and families.
The delineation of these eight conceptual principles constituted an attempt to integrate the thinking of many noted experts and apply that thinking to the development of a family-systems approach to early childhood intervention and family support. The conceptual principles, in turn, were used to operationalize the principles in ways that mirrored or reflected the principles in action.
Operational Principles
The eight conceptual principles were used to develop an operational framework for guiding the conduct of family-systems assessment and intervention practices, as originally presented in Enabling and Empowering Families (see Figure 1). As stated in our book,
“Family needs and aspirations, family strengths and capabilities (family functioning style), and social support and resources, are viewed as separate but interdependent parts of the assessment and intervention process. The help-giving behaviors used by professionals are the ways in which families are enabled and empowered to acquire and use competencies to procure supports and mobilize resources for meeting needs” (Dunst, Trivette, & Deal, [26], p. 10).
Graph: FIGURE 1 Family-systems assessment and intervention model constituting the focus of Enabling and Empowering Families (Dunst, Trivette, & Deal, [26]).
The implementation of the assessment and intervention model was accomplished first by identifying family member needs and aspirations, second by identifying supports and resources for meeting needs, third by identifying existing and new strengths for obtaining resources and supports, and fourth by employing help-giving behaviors that strengthen family capacity to carry out actions intended to obtain supports and resources to meet self-identified needs.
Operational principles and goals of the assessment and intervention model are related (see Table 1). As noted in Enabling and Empowering Families (Dunst, Trivette, & Deal, [26]), the assessment and intervention model is a “dynamic, fluid process” (p. 52) that involves different degrees of attention to each component of the model, depending on the emphasis of family member–help-giver exchanges. “The division of the assessment and intervention process into separate components was done primarily for heuristic purposes” (p. 52), because they are interdependent and require an integrated approach to assessment and intervention (Dunst, Trivette, & Deal, [26]).
TABLE 1 Relationship Between the Four Operational Principles and Assessment and Intervention Goals of Each Family-Systems Model Component
Operational principles Assessment and intervention goals
1. To promote positive child, parent, and family functioning, base interventions on family-identified needs, aspirations, personal projects, and priorities. Identify family aspirations and priorities using needs-based assessment procedures and strategies to determine the things the family considers important enough to devote time and energy.
2. To insure the availability and adequacy of resources for meeting needs, place major emphasis on strengthening the family’s personal social network as well as promoting utilization of untapped sources of information and Helpance. Identify family strengths and capabilities to (a) emphasize the things the family already does well and (b) determine the particular strengths that increase the likelihood of a family mobilizing resources to meet needs.
3. To enhance successful efforts toward meeting needs, use existing family functioning style (strengths and capabilities) as a basis for promoting the family’s ability to obtain and mobilize resources. “Map” the family’s personal social network to identify both existing sources of support and resources and untapped but potential sources of aid and Helpance.
4. To enhance a family’s ability to become more self-sustaining with respect to meeting its needs, employ helping behaviors that promote the family’s acquisition and use of competencies and skills necessary to mobilize and secure resources. Function in a number of different help-giving roles to enable and empower the family to become more competent in mobilizing resources to meet its needs and achieve desired goals.

Both interview and self-report assessment scales were used to identify family needs, family strengths, and sources of supports and resources for meeting needs. The purpose of the needs-assessment component of the model was to identify those family needs and aspirations that a family considered important enough to devote its time and energy. The purpose of the supports and resources component of the model was to identify the family, informal, and formal sources of supports and resources to meet needs. The purpose of the family strengths component of the model was to identify a family’s capabilities that were used to obtain supports and resources to meet needs.
Twelve help-giving principles guided the ways in which professionals interacted with families while using the assessment and intervention practices (Dunst & Trivette, [36]). The help-giving principles were identified from an extensive review of the help-giving literature, with an explicit focus on those practices that were associated with empowerment-type outcomes and benefits (see especially Dunst & Trivette, [42]b; see Table 2). The help-giving behaviors, taken together, were viewed as the kinds of enabling (in the good sense of the word) experiences and opportunities that would support and encourage parents’ use of their strengths to obtain and procure desired supports and resources.
TABLE 2 Twelve Principles of Effective Help-giving
Help-giving is more likely to be effective when:
1. It is both positive and proactive and conveys a sincere sense of help giver warmth, caring, and encouragement.
2. It is offered in response to an indicated need for Helpance.
3. Engages the help receiver in choice and decisions about the options best suited for obtaining desired supports and resources.
4. Is normative and typical of the help receivers’ culture and values and is similar to how others would obtain Helpance to meet similar needs.
5. It is congruent with how the help receiver views the appropriateness of the supports and resources for meeting needs.
6. The response–costs for seeking and accepting help do not outweigh the benefits.
7. Includes opportunities for reciprocating and the ability to limit indebtedness.
8. Bolsters the self-esteem of the help receiver by making resource and support procurement immediately successful.
9. Promotes, to the extent possible, the use of informal supports and resources for meeting needs.
10. Is provided in the context of help giver–help receiver collaboration.
11. It promotes the acquisition of effective behavior that decreases the need for the same type of help for the same kind of supports and resources.
12. It actively involves the help receiver in obtaining desired resource supports in ways bolstering his or her self-efficacy beliefs.
The assessment and intervention model was used in a variety of ways with families differing in needs, family structure, socioeconomic backgrounds, and other person and situational differences to evaluate its applicability and usefulness for supporting and strengthening family functioning. Lessons learned from the use of the family-systems model, as well as research investigating basic premises of the model, were in turn used to make changes and modifications in how the assessment and intervention model was conceptualized and implemented. The first set of changes are described in Supporting and Strengthening Families: Methods, Strategies and Practices (Dunst, Trivette, & Deal, [37]b).
PROMOTING AND ENHANCING FAMILY CAPACITY
The 20 years since the publication of Enabling and Empowering Families has provided us the opportunity to reflect on and refine its major tenets. Perhaps most surprising is the fact that nearly all the principles and practices have stood the test of time and still have value for guiding early childhood intervention and family support. Additional lessons learned from research and practice on the family-systems model have been used to further revise, refine, and update different elements of the model emphasizing those features that matter most in terms of having capacity-building characteristics and consequences. The emphasis on capacity building as both a process and benefit of family-systems assessment and intervention is based on research demonstrating that enabling experiences and opportunities positively influencing self-efficacy beliefs and other control appraisals mediate changes in many domains of life, including, but not limited to, parents’ own judgments and capabilities to provide their children development-enhancing learning opportunities (Bandura, [ 7]; Skinner, [99]).
The updated version of the family-systems assessment and intervention model includes an operational definition of early childhood intervention and family support; a social-systems perspective of child, parent, and family behavior and functioning; a set of five different but compatible models that, taken together, constitute a capacity-building paradigm; and an operational framework for structuring the implementation of family-systems assessment and intervention practices. The key features of each of these elements are described next to illustrate advances in understanding of one particular approach to early childhood intervention and family support.
Definition of Early Childhood Intervention and Family Support
Early childhood intervention and family support are defined as the provision or mobilization of supports and resources to families of young children from informal and formal social network members that either directly or indirectly influence and improve parent, family, and child behavior and functioning. The experiences, opportunities, advice, guidance, and so forth afforded families by social network members are conceptualized broadly as different types of interventions contributing to improved functioning. The sine qua non outcome of the supports and resources afforded or procured by families includes any number of capacity-building and empowering consequences.
Our definition of intervention differs from most other definitions by its inclusion of informal supports as a focus of intervention and capacity building as a main consequence of the provision or mobilization of supports and resources. The inclusion of informal supports is based on research showing the manner in which these types of supports are related to improved parent and family functioning (for a review, see Dunst, Trivette, & Jodry, [30]). The focus on capacity building as an outcome of intervention is based on research demonstrating the manner in which different kinds of experiences and opportunities that have empowering characteristics and consequences, in turn, influence other dimensions of parent, family, and child behavior and functioning (Bandura, [ 7]; Dunst, Trivette, & Hamby, [59], [34]; Skinner, [99]).
Our own research (e.g., Dunst, Trivette, Davis, & Cornwell, [42]; Dunst, Trivette, Starnes, Hamby, & Gordon, [65]), as well as that of others (e.g., Coyne & DeLongis, [24]; Galinsky & Schopler, [37]; Lincoln, [82]), has found that the manner in which support is provided, offered, or procured influences whether the support has positive, neutral or negative consequences. Affleck, Tennen, Rowe, Roscher, and Walker ([ 4]) found that the provision of professional social support in response to an indicated need for Helpance was associated with positive consequences, whereas the provision of social support in the absence of an indicated need for support had negative consequences. This is the basis, in part, for the identification of family concerns and priorities as the first step in our approach to family-systems assessment and intervention.
Systems Theory Framework
The provision or mobilization of supports and resources is accomplished in the context of a social systems framework, where a family is viewed as a social unit embedded within both informal and formal social support networks. According to Bronfenbrenner ([14]), the behavior of a developing child, his or her parents, other family members, and the family unit as a whole are influenced by events occurring in settings beyond the family, which nonetheless directly and indirectly affect parent, family, and child behavior and functioning. Operationally, the supports and resources afforded families by informal and formal social support network members are defined as the experiences, opportunities, advice, guidance, material Helpance, information, and so forth afforded or procured by family members that are intended to influence family member behaviors and functioning.
A basic premise of systems theory is that behavior is multiply determined and is a joint function of the characteristics of environmental experiences (supports and resources) and the person himself or herself (Bronfenbrenner, [15]). For example, research now indicates that the provision of help in response to an indicated need for support is likely to have positive consequences, whereas the provision of help in the absence of an indicated need for support is likely to have negative consequences (see especially Affleck, Tennen, Allen, & Gershman, [ 3]). Accordingly, the likelihood that an experience or opportunity afforded a person will have capacity-building influences is, in part, determined by an indicated need or desire for support and resources.
Capacity-Building Paradigm
Various attempts to operationalize and integrate different but compatible models of intervention led us to develop what we have come to call a capacity-building paradigm (see Table 3). These contrasting worldviews each have different implications for how interventions are conceptualized and implemented. The traditional worldview considers children and families as having deficits and weaknesses that need treatment by professionals to correct problems, whereas a capacity-building worldview considers children and families as having varied strengths and assets, where the focus of intervention is supporting and promoting competence and other positive aspects of family member functioning.
TABLE 3 Defining Features of Contrasting Approaches for Conceptualizing and Implementing Early Childhood Intervention and Family Support Practices
Capacity-building paradigm Traditional paradigm
Promotion models Treatment models
Focus on enhancement and optimization of competence and positive functioning Focus on remediation of a disorder, problem, or disease or its consequences
Empowerment models Expertise models
Create opportunities for people to exercise existing capabilities as well as develop new competencies Depend on professional expertise to solve problems for people
Strength-based models Deficit-based models
Recognize the assets and talents of people and help people use these competencies to strengthen functioning Focus on correcting peoples’ weaknesses or problems
Resource-based models Service-based models
Define practices in terms of a broad range of community opportunities and experiences Define practices primarily in terms of professional services
Family-centered models Professionally centered models
View professionals as agents of families who are responsive to family desires and concerns View professionals as experts who determine the needs of people from their own as opposed to other peoples’ perspectives
The models making up the capacity-building paradigm each include elements that place primary emphasis on the supports, resources, experiences, and opportunities afforded or provided children, parents, and families for strengthening existing, and promoting the acquisition of new competencies. Promotion models emphasize the enhancement of competence rather than the prevention or treatment of problems (Cowen, [23]; Dunst & Trivette, [52]; Dunst, Trivette, & Thompson, [66]). Empowerment models emphasize the kinds of experiences and opportunities that are contexts for competence expression (Dunst & Trivette, [29]; Zimmerman, [66]). Strengths-based models emphasize people’s competence and how the use of different abilities and interests strengthen family member functioning (Dunst, [34]). Resource-based models emphasize a broad range of supports and resources (rather than services) as the experiences and opportunities for strengthening functioning (Dunst, Trivette, & Deal, [37]a; Raab, Davis, & Trepanier, [65]). Family-centered models emphasize the pivotal and central roles family members play in decisions about supports and resources best suited for improving parent, family, and child behavior and functioning (Dunst, [33]). Taken together, the five models provide a way of structuring the development and implementation of child and family intervention practices. The different models have proven useful for disentangling and unpacking what matters most in terms of those practices having desired consequences (e.g., Dunst, [34]; Dunst, Trivette, & Hamby, [59]; Dunst, Trivette, Hamby, & Bruder, [59]).
Family-Systems Intervention Model
The updated version of the four operational components of our family-systems assessment and intervention model are the same as those described in Enabling and Empowering Families but have been further refined based on research and practice (see Figure 2). The model is implemented by using capacity-building help-giving practices to identify family concerns and priorities, the supports and resources that can be used to address concerns and priorities, and the use of family member abilities and interests as the skills to obtain supports and resources.
Graph: FIGURE 2 Major components of a capacity-building family-system assessment and intervention model.
The needs and aspirations component of the model has been changed to family concerns and priorities to reflect both families’ dislike for the term need(y) and advances in our understanding of those life conditions that motivate people to alter or change their circumstances (Dunst & Deal, [37]). Concerns are defined as the perception or indication of a discrepancy between what is and what is desired. Priorities are defined as a condition that is judged highly important and deserving of attention. Both concerns and priorities are viewed as determinants of how people spend time and energy seeking or obtaining resources and supports to achieve a desired goal or attain a particular end. While any number of terms have been used interchangeably to describe both concerns and priorities (Dunst & Deal, [37]), these particular terms cover the largest number of family situations that become the targets of intervention.
The supports and resources component of the model remains the same but has been redefined in terms of the kinds of Helpance that constitute the information, instrumental Helpance, experiences, opportunities, and so on, for addressing and responding to family concerns and priorities. The sources of support and resources still include both formal and informal social network members, with the caveat that family members are highly likely to seek out particular network members depending on which concerns and priorities are the focus of attention. The supports and resources deemed most appropriate are ones that actively involve family members in obtaining and procuring Helpance rather than the noncontingent provision of help (see especially Dunst & Trivette, [42]b). It may seem expedient to provide or give families supports and resources, but doing so deprives them of opportunities to use existing skills or develop new competencies that can perpetuate a need for help (Skinner, [98]). To the extent that social network members “supply a needed resource but leads a person to see the production of that resource as contingent on what [others] do rather than his or her own behavior” (Brickman et al., [11], p. 34), the support may have a negative or harmful consequence.
The family functioning style component has been changed to family member abilities and interests for two reasons. First, defining family strengths in terms of family qualities (Stinnett & DeFrain, [100]), family dynamic factors (Otto, [87]), and other qualitative family dimensions (Curran, [25]) has proven difficult to operationalize for many early childhood and family support practitioners. Second, our own research and practice (e.g., Dunst, [34]; Trivette & Dunst, [38]b), as well as that of others (e.g., Kretzmann & McKnight, [65]; Scales, Sesma, & Bolstrom, [94]), has found that defining family strengths in terms of specific abilities, interests, talents, and so on, makes the process of promoting family member identification and use of their strengths much more straightforward. We are still reminded of Stoneman’s ([28]) contention that “Every family has strengths and, if the emphasis [of intervention] is on supporting strengths rather than rectifying weaknesses, chances of making a difference in the lives of children are vastly increased” (p. 462).
The help-giving behavior component has been changed to capacity-building help-giving practices to reflect advances in our understanding of the particular kinds of help-giving practices that are most likely to have empowering characteristics and consequences. Research identifying the characteristics of effective help-giving practices has identified two clusters of help-giving that have capacity-building influences: relational help-giving and participatory help-giving (Trivette & Dunst, [105]). Relational help-giving includes practices typically associated with good clinical practice (e.g., active listening, compassion, empathy, respect) and help-giver positive beliefs about family member strengths and capabilities. Listening to a family’s concerns and asking for clarification or elaboration about what was said is an example of a relational help-giving practice. Participatory help-giving includes practices that are individualized, flexible, and responsive to family concerns and priorities, and which involve informed family choices and involvement in achieving desired goals and outcomes. Engaging a family member in a process of using information to make an informed decision about care for his or her child is an example of a participatory help-giving practice. Research syntheses of the relationships between both types of help-giving practices and parents’ personal control appraisals and parent, family, and child behavior and functioning indicates that both types of helping practices are related to most outcomes. The results also showed that the relationship between relational and participatory help-giving and parent, family, and child behavior and functioning are mediated by personal control appraisals (Dunst, Trivette, & Hamby, [38], [34]).
RESEARCH FOUNDATIONS
The extent to and manner in which the practices constituting the focus of each component of our family-systems assessment and intervention model are related to parent, family, and child behavior and functioning in a predicted manner has been the focus of a number of recently completed research syntheses (Dunst, Trivette, & Hamby, [34]; Dunst, Trivette, Hamby, & O’Herin, [34]; Hamby, Trivette, Dunst, & O’Herin, [34]; Trivette, Dunst, O’Herin, & Hamby, [34]). The analyses are briefly reported here and for the main effects between different measures of each of the four components of our family-systems model (help-giving, concerns, strengths, and supports) and the same or similar outcomes included in the different studies in the four meta-analyses.
Studies in the four syntheses were identified by searches of multiple electronic databases (Psychological Abstracts, ERIC, MEDLINE, Academic Search Elite, etc.), examination of seminal papers on each of the model components, and hand searches of key journals and all retrieved articles, chapters, and books. The average number of studies that were included in any one synthesis was 45 (range = 28–78). The average number of participants in the studies included in any one synthesis was 7,489 (range =3012–10055).
The independent measures in the studies included different scales measuring capacity-building help-giving practices (e.g., Trivette & Dunst, [104]), family concerns (e.g., Dunst & Leet, [28]), family supports (e.g., Dunst, Jenkins, & Trivette, [40]), and family strengths (e.g., Deal, Trivette, & Dunst, [26]). All the scales used to measure the independent variables, except those in the Dunst, Trivette, and Hamby ([34]) meta-analyses of family-centered help-giving practices, were instruments we developed or have used in studies we and our colleagues have conducted.
The help-giving practices scales included measures of help-giver active listening and empathy, help-receiver choice and decision making, help giver–help receiver collaboration, and help-receiver active involvement in obtaining desired supports and resources. The family concerns scales included measures of an indicated need for basic resources (e.g., food and shelter), employment and financial resources, health and dental care, child care, time for self and family, and dependable transportation. The family strengths scales included measures of family commitment, problem-solving strategies, patterns of interaction, coping strategies, and family values. The social support scales included measures of support from spouse or partner, family members and other kin, friends and neighbors, church members and coworkers, early childhood programs and practitioners, and parent and social groups.
The dependent measures in the studies were grouped into five categories: personal control and self-efficacy, parent well-being, parenting, family functioning, and child behavior. The personal control and self-efficacy belief measures included scales measuring control over general life events (e.g., Boyd & Dunst, [ 9]; Nowicki & Duke, [86]). The parent well-being measures included scales assessing stress, depression, and other adverse psychological states (e.g., Abidin, [ 1]; Radloff, [90]). The parenting scales measured different aspects of parent competence and confidence (e.g., Dunst & Masiello, [43]; Guidubaldi & Cleminshaw, [37]). The family functioning scales included measures of family cohesion, integration, and well-being (e.g., Hampson & Hulgus, [53]; McCubbin & Comeau, [36]). The child behavior scales measured different aspects of positive and negative child functioning (e.g., Achenbach, [ 2]; Conners, [20]). The particular dependent measures in the analyses presented here are ones that were included in at least three of the four meta-analyses so that comparisons of the relationships between the family-system model component measures and the same or similar outcomes could be made.
The correlations between the independent and dependent measures were used as the sizes of effects for the relationships between the family-systems components and the dependent measures (Rosenthal, [92]). The direction of the correlations between measures were coded so that a positive correlation between the independent and dependent measures represented more positive and less negative behavior functioning. Procedures described by Shadish and Haddock ([96]) were used to combine effect sizes, giving more weight to studies with larger sample sizes. The average weighted effect sizes were used as the best estimate of the strength of the relationship between measures. Data interpretation was aided by the 95% confidence intervals of the average weighted effect sizes. An interval not including zero indicates that the average size of effect is statistically different from zero at the.05 level (Hedges, [75]).
The average weighted effect sizes between the component measures and the outcomes were all significantly different from zero as evidenced by no confidence intervals including zero (see Figure 3). Stated differently, variations in the measures of each family-systems component were related to variations in the outcomes in ways that were expected. The more the study participants experienced capacity-building help-giving practices, the better the outcomes; the fewer concerns the study participants reported, the better the outcomes; the more family strengths the study participants reported, the better the outcomes; and the more social support that was available to the study participants and their families, the better the outcomes. The patterns of relationships and sizes of effects, however, were not the same as evidenced by the unevenness in the strength of the relationships between the independent and dependent measures, which are briefly described next.
Graph: FIGURE 3 Average weighted effect sizes and 95% confidence intervals for the relationships between the four family-systems model components (independent variables) and five categories of parent, family, and child outcomes (dependent measures). (Note: The numbers on the bars are the number of effect sizes included in the analyses).
The size of the effect between help-giving practices and self-efficacy beliefs was more than twice as large as the relationships between either family concerns or social supports and this same outcome. The fact that help-giving practices were more strongly related to self-efficacy beliefs was not unexpected, inasmuch as this has consistently been found as part of this line of research (see especially Dunst, Trivette, & Hamby, [59]; [38]; Dunst, Trivette, & Hamby, [34]).
Family strengths were more strongly related to family functioning compared to the other family-systems component measures, whereas help-giving practices were more strongly related to child behavior and functioning compared to the other family-systems components measures. Both family concerns and family strengths were more strongly related to parent well-being compared to the relationships between either help-giving practices or social supports and this same outcome. In contrast, all four family-systems component measures were more similarly related to the parenting outcome measures.
The fact that there were differential relationships between measures was not unexpected. This has been the rule rather than the exception in nearly every kind of analysis we have performed on measures of the family-systems model components. The differential relationships between measures indicate that the four family-systems practices components each exert different influences on parent, family, and child behavior and functioning. Despite the differential influences of each type of practice, the findings, taken together, show that measures of each component of the family-system model are related to parent, family, and child behavior and functioning in a manner consistent with predictions from the conceptual frameworks guiding both our research and practice (e.g., Dunst, [30]; Dunst et al., [66]; Trivette, Dunst, & Deal, [30]; Trivette, Dunst, & Hamby, [29]).
CONCLUSIONS
The family-systems model as well as specific components of the model have been evaluated as part of many different child, parent, and family intervention studies (e.g., Dunst, [35], [34]; Dunst et al., [35]; Dunst, Masiello, & Murillo, [34]; Dunst, Raab, et al., [38]; Dunst & Trivette, [35]; Dunst, Trivette, Gordon, & Pletcher, [58]). The main focus of these and other studies was the identification of the conditions under which needs-based, social support, strengths-based, and capacity-building help-giving interventions and practices were likely to be most effective. A lesson learned from these intervention studies was the fact that the more straightforward the interventions, the higher the probability that the interventions would be implemented as planned and intended, and have expected benefits. This was likely the case because “there is evidence that it is easier to achieve high fidelity of simple [rather] than complex interventions … because there are fewer ‘response barriers’ when the model is simple” (Carroll et al., [17]).
A few examples should help elucidate the contention that “less is more” when using family-systems assessment and intervention practices. In an intervention study of teenage mothers involved in a parenting support program, the participants were enrolled in a work-study program (infant and preschool classrooms) where they had the opportunity to observe and work with teachers who interacted with children in development-enhancing manners (Dunst, Vance, et al., [53]). Over the course of just 20 weeks, the teenage mothers increasingly used the same kinds of interactional styles observed in the classrooms with their own children. In an intervention study of parents from extremely low socioeconomic backgrounds, the parents’ strengths (abilities and interests) were used as sources of young children’s learning opportunities (Dunst, [34]). Results showed increases in the learning opportunities afforded the children, and both child and parent positive behavioral consequences. Similar kinds of straightforward interventions have also been found to also have positive effects (e.g., Bakermans-Kranenburg, van IJzendoorn, & Juffer, [ 5]).
Following the publication of Enabling and Empowering Families, and in the intervening 20 years, we became aware of numerous attempts by others to use the principles and practices we articulated in our book with families from many different cultural and ethnic backgrounds, with families in different countries, with children and families with varying life circumstances and conditions, and by practitioners in many different kinds of early childhood intervention, family support, health, and human services programs (e.g., Coutinho, [22]; DePanfilis, [27]; Hossain, [78]; Kalyanpur & Rao, [79]; McCarthy et al., [83]; Mitchell & Sloper, [85]; Sheridan, Warnes, Cowan, Schemm, & Clarke, [97]). At the time Enabling and Empowering Families was written, we strived to develop a model and a set of principles and practices that were flexible enough to be used in different settings and contexts with families having diverse backgrounds and life circumstances. The flexibility we had hoped to achieve is reflected, at least in part, by the broad-based use of the family-systems assessment and intervention model.
One focus of our current research on family-systems intervention is further Assessments of the relationships between the model components and the extent to which different elements of each component have either or both direct and indirect effects on parent, family, and child behavior and functioning. This is being accomplished by both structural equation modeling of data from studies we have conducted (see e.g., Dunst, [31]; Dunst, Hamby et al., [38]; Trivette et al., [29]) and meta-analytic structural equation modeling (Cheung & Chan, [18]; Shadish, [50]) of studies conducted by ourselves and others examining the relationships between two or more components of our model and child, parent, or family outcomes. The goal is a better understanding of how the family-systems components are related and the conditions under which optimal benefits are realized. The expected outcome of this next generation of research is the isolation of those component characteristics that matter most in terms of having predicted effects and both the disentangling and unpacking of how the different components are related to one another, and, in turn, influence parent, family, and child behavior and functioning. Findings from these efforts will be used to completely revise Enabling and Empowering Families with a focus on the key ingredient practices and how they can be implemented to best support and strengthen child, parent, and family functioning.
REFERENCES
1 Abidin, R. (1990). Parenting stress index: Manual), (3rd ed.. Charlottesville, VA: Pediatric Psychology Press.
2 Achenbach, T. M. (1993). Manual for the child behavior checklist. Burlington, VT: Author.
3 Affleck, G., Tennen, H., Allen, D. A., & Gershman, K. (1986). Perceived social support and maternal adaptation during the transition from hospital to home care of high-risk infants. Infant Mental Health Journal, 7, 6–18.
4 Affleck, G., Tennen, H., Rowe, J., Roscher, B., & Walker, L. (1989). Effects of formal support on mothers’ adaptation to the hospital-to-home transition of high-risk infants: The benefits and costs of helping. Child Development, 60, 488–501.
5 Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., & Juffer, F. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195–215.
6 Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.
7 Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.
8 Bond, L. A. (1982). From prevention to promotion: Optimizing infant development. In G. W.Albee & J. M.Joffe (Eds.), Primary prevention of psychopathology: Vol. VI. Facilitating infant and early childhood development (pp. 5–39). Hanover, NH: University Press of New England.
9 Boyd, K., & Dunst, C. J. (1996). Personal assessment of control scale. Asheville, NC: Winterberry Press.
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• Taking Brief Strategic Family Therapy from Bench to Trench: Evidence Generation Across Translational Phases
Horigian, V. E., Anderson, A. R., & Szapocznik, J. (2016). Taking brief strategic family therapy from bench to trench: Evidence generation across translational phases. Family Process, 55(3), 529–542
Reference
Family Process
Volume 55, Issue 3 p. 529-542
Original Article
Full Access
Taking Brief Strategic Family Therapy from Bench to Trench: Evidence Generation Across Translational Phases
Viviana E. Horigian, Austen R. Anderson, José Szapocznik
First published: 14 July 2016
https://doi.org/10.1111/famp.12233
Citations: 24
This work was supported by grant UG1DA013720 awarded by the National Institute on Drug Abuse, and UL1TR000460 awarded by the Clinical and Translational Science Institute. [Correction added on 20 July 2016, after first online publication: Funder information has been added.]
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• The Basic Research That Led to BSFT Development: Stage 0
• Development of the BSFT Intervention, Adaptations, and Refinement: Stage I
• Efficacy Testing: Determining the Value of BSFT the Intervention:Stage II
• Effectiveness Testing: Examining BSFT Under “Real-World” Conditions: Stage III/IV
• Effects of Therapist Adherence and Behaviors on Treatment Outcomes
• Implementation in Widespread Practice: Stage V
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Abstract
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In this article, we review the research evidence generated over 40 years on Brief Strategic Family Therapy illustrating the NIH stages of intervention development and highlighting the translational process. Basic research (Stage 0) led to the discovery of the characteristics of the population and the nature of the problems that needed to be addressed. This step informed the selection of an intervention model that addressed the problems presented by the population, but in a fashion that was congruent with the population’s culture, defined in terms of its value orientations. From this basic research, an intervention that integrated structural and strategic elements was selected and refined through testing (Stage I). The second stage of translation (Stage II) included efficacy trials of a specialized engagement module that responded to challenges to the provision of services. It also included several other efficacy trials that documented the effects of the intervention, mostly in research settings or with research therapists. Stages III/IV in the translational process led to the testing of the effectiveness of the intervention in real-world settings with community therapists and some oversight from the developer. This work revealed that an implementation/organizational intervention was required to achieve fidelity and sustainability of the intervention in real-world settings. The work is currently in Stage V in which new model development led to an implementation intervention that can ensure fidelity and sustainability. Future research will evaluate the effectiveness of the current implementation model in increasing adoption, fidelity, and long-term sustainability in real-world settings.
Translational research focuses on understanding the scientific and operational principles underlying the process involved in turning observations in the laboratory, clinic, and community into interventions that improve the health of individuals and the public. However, translational research has taken different meanings for different researchers (Rubio et al., 2010; Woolf, 2008). In behavioral intervention research, several conceptualizations share the notions of steps, stages, or phases for intervention development and testing, but models differ in what stages they include and in the way they number and name their stages. While models typically agree that efficacy and effectiveness research vary along a continuum from maximizing internal validity to maximizing generalizability, they differ in the importance and the role of theory and basic research in intervention development and in the point at which they emphasize a focus on implementation. The NIH stage model was created to define and refine the activities involved in behavioral intervention development, and it stresses that “intervention development is not complete until an intervention reaches its maximum level of potency and is implementable with a maximum number of individuals in the population for which it was developed” (Onken, Carroll, Shoham, Cuthbert, & Riddle, 2014, p. 26). In particular, this model heightens the significance of testing interventions in the community prior to the full effectiveness testing, emphasizes the importance of considering the intervention’s ease of implementation as early as possible in the intervention development process, and underscores the value of examining mechanisms of behavior change in every stage of intervention development. Under this model, development of a behavioral intervention is composed of six stages: basic science (Stage 0), intervention generation, refinement, modification, and adaptation and pilot testing (Stage I); traditional efficacy testing (Stage II); efficacy testing with real-world providers (Stage III); effectiveness research (Stage IV); and dissemination and implementation research (Stage V). Some important considerations with respect to this model is that it is iterative, nonrecursive, multidirectional and is not prescriptive, that is, it does not require that research is done in a prespecified order, rather, what is required is that researchers adequately justify the logic of their proposed sequence.
Several family-based treatments for adolescent substance use and behavioral problems have proven to be effective (Hogue, Henderson, Ozechowski, & Robbins, 2014; Tanner-Smith, Wilson, & Lipsey, 2013), are far along the NIH stages of intervention development, and are being implemented broadly (Horigian, Anderson, & Szapocznik, in press). Brief Strategic Family Therapy (BSFT; Szapocznik, Hervis, & Schwartz, 2003) is a family treatment model developed and tested for nearly 40 years at the University of Miami’s Center for Family Studies for youth with behavior problems, such as drug and alcohol use, delinquency, association with antisocial peers and unsafe sexual behaviors. BSFT is an integrative model that combines structural and strategic family therapy techniques to address systemic/relational (primarily family) interactions that are associated with adolescent problem behaviors. The structural components of the BSFT treatment draw on the work of Salvador Minuchin (1974; Minuchin & Fishman, 1981), and the strategic aspects are based on work by Haley (1976) and Madanes (1981). With the use of structural and strategic techniques, the goal of the BSFT model is to change the patterns of family interactions (structural) that allow or encourage problematic adolescent behavior (strategic/problem focused). By working with families, BSFT not only decreases youth problems but also creates better functioning families (Santisteban et al., 2003). Because changes are brought about in family patterns of interactions, these changes in family functioning are more likely to endure after treatment completion because multiple family members have changed the way they behave with each other. In keeping with the integration of structural and strategic principles, BSFT is a present problem-focused, directive, and practical approach (i.e., strategic)—focusing on identifying and enacting the changes in patterns of interactions (i.e., structural) necessary to ameliorate the adolescent’s presenting problems. Other family issues, such as problems between the parent figures, are addressed only if they are directly related to the adolescent’s drug abuse, problem behavior, or risky sexual symptoms.
Three conceptual principles guide BSFT. The first principle is that the family is a system, where family members are interdependent and interrelated—what one family member says or does affects everyone else in the family. The second BSFT principle is that repetitive family patterns of interaction affect individual family members’ development and behavior. Patterns of interaction are defined as the sequential behaviors among family members that become habitual, repeat over time, and are idiosyncratic to a family system. A maladaptive family structure is characterized by repetitive family interactions that persist even when these interactions fail to meet the goals of the family or its individual members. As part of this principle, the BSFT model holds that improvements in family members’ experience and behavior require strengthening adaptive family interactions and transforming/restructuring maladaptive family interactions. The third principle reflects BSFT’s strategic nature in that therapy is planned, problem focused, and practical (i.e., intended to achieve certain goals).
Brief Strategic Family Therapy is a short-term program usually implemented in 12–16 (range 8–24) sessions typically delivered once a week for 1–1½ hours over a 4-month period. The actual number of sessions and length of service are determined by the therapist’s ability to achieve the necessary improvements in specific behavioral criteria and severity of family problems. BSFT employs four specific theoretically and empirically supported techniques delivered in phases to achieve specific goals at different times during treatment. Early sessions are characterized by joining interventions that aim to establish a therapeutic alliance with each family member and with the family as a whole. The therapist here demonstrates acceptance of and respect toward each individual family member as well as the way in which the family operates as a whole. Early sessions within treatment also include tracking and diagnostic enactment interventions designed to systematically identify family strengths and weaknesses and develop an overall treatment plan. A core feature of tracking and diagnostic enactment interventions includes strategies that encourage the family to behave as they would usually behave if the therapist were not present. Rather than directing comments to the therapist, family members are encouraged to speak with each other about the concerns that bring them to therapy. From these observations, the therapist is able to diagnose both family strengths and problematic relations. Reframing techniques are then used to reduce family conflict and create a motivational context (i.e., hope) for change. Throughout the entirety of treatment, therapists are expected to maintain an effective working relationship with family members (joining), facilitate within-family interactions (tracking and diagnostic enactment), and directly address negative affect/beliefs and family interactions. As treatment progresses, the focus of treatment shifts to implementing restructuring strategies to transform family relations from problematic to mutually supportive and effective. Restructuring interventions include (i) directing, redirecting, or blocking communication; (ii) shifting family alliances; (iii) helping families develop conflict resolution skills; (iv) developing effective behavior management skills; and (v) fostering parenting and parental leadership skills.
In this special report, we present the stages of intervention development for BSFT and the evidence developed at each state of the translational process. The NIH stage model as applied to BSFT is summarized in Table 1.
Table 1. NIH Intervention Development Stages as Applied to BSFT
Stages of BSFT development Published results
Stage 0 Characteristics of population • Cuban immigrants hold cultural values, such as family, hierarchy, and present orientation (Szapocznik et al., 1978).

Family process • Intergenerational acculturation conflict occurs within immigrant families (Szapocznik et al., 1978).

Stage I Intervention conceptual model • Family problems can be understood from a systems perspective that explores interdependency between members and repetitive patterns of interaction that form the family structure. Therapy would be most effective if it was planned, practical, and problem focused (Szapocznik et al., 1978).

Design of the intervention • Brief Strategic Family Therapy is made up of different components: joining, tracking and eliciting, diagnosing, reframing, and restructuring (Szapocznik & Kurtines, 1989; Szapocznik et al., 2003).

Model adaptations and refinement • A one-person family therapy adaptation was created to deal with the challenges of bringing whole families into treatment (Szapocznik et al., 1983).
• Family effectiveness training was developed to confront the challenges of acculturation and intergenerational differences in Hispanic immigrant families (Szapocznik, Santisteban et al., 1989).

Stage II Efficacy • Specialized techniques for engagement and retention were developed and tested (Coatsworth et al., 2001; Santisteban et al., 1996; Szapocznik et al., 1988).
• BSFT resulted in improved family functioning relative to psychodynamic therapy, thus preventing iatrogenic effects (Szapocznik, Rio et al. 1989).
• BSFT, relative to group therapy, reduced drug use and conduct problems while it improved family functioning—again, preventing iatrogenic effects (Santisteban et al., 2003).
• BSFT, relative to supportive listening, reduced bullying and state/trait anger while it improved mental health and social functioning in boys (Nickel, Muehlbacher et al., 2006).
• BSFT, relative to supportive listening, reduced substance use, bullying, and sexually risky behaviors while it improved mental health problems in girls (Nickel, Luley et al., 2006).

Stage III/IV Effectiveness • BSFT, relative to treatment as usual, reduced externalizing behaviors, arrests, and incarceration while it improved engagement, retention, and family functioning (Horigian, Feaster, Robbins et al., 2015; Robbins, Feaster, Horigian, Rohrbaugh et al., 2011).
• Adherence to manualized BSFT predicted all outcomes (Robbins, Feaster, Horigian, Puccinelli et al., 2011).

Stage V Implementation in real-world settings • The BSFT organization implementation intervention is necessary to achieve fidelity and sustainability of BSFT (Szapocznik et al., 2015).

The Basic Research That Led to BSFT Development: Stage 0
Several studies led to characterizing the population and the nature of the problem which informed the conceptualization of the model and the intervention techniques. Clinical observations of Cuban adolescent behavioral problems and family intergenerational/intercultural conflict in the early 1970s made evident the need to better understand the cultural factors contributing to severe intergenerational conflict and drug and behavioral problems of adolescents. The nature of the conflict between parents and their children had a distinct cultural flavor with youth advocating for independence and parents demanding obedience to the old ways. Early formative research conducted at the Center for Family Studies (Szapocznik, Scopetta, de los Angeles Aranalde, & Kurtines, 1978; Szapocznik, Scopetta, & King, 1978; Szapocznik, Scopetta, Kurtines, & Aranalde, 1978) indicated that Cuban families in Miami tended to value family connectedness over individual autonomy and that they tended to focus on the present rather than on the past. These findings provided the challenge of developing a treatment model that would align with these values. Additionally, this research led to understanding intergenerational differences in acculturation as a process that exacerbates family conflict. Studies have documented the value of the family as a central system in adolescents’ healthy development (Szapocznik & Coatsworth, 1999).
Development of the BSFT Intervention, Adaptations, and Refinement: Stage I
Consistent with the value placed on the family and the intergenerational/intercultural conflicts evidenced by these families, a structural (Minuchin, 1974; Minuchin & Fishman, 1981) approach was selected that addressed the family as a whole, transformed negative affect into bonding, and opened lines of communication and negotiation between the generations. Because the families presented to treatment with a sense of urgency, including a sense that existing problems needed quick resolution and because they tended to have a present orientation, a strategic (Haley, 1976; Madanes, 1981) application to structural family therapy was selected which was problem focused, practical, and planned. A planned focus on patterns of interactions permitted therapists not to get lost in the many contents concerning the family, but rather to focus on interactions that were maladaptive—that is, that were preventing the family from achieving their goals (Szapocznik et al., 1978).
BSFT Adaptations
As BSFT has been modified and improved across the phases of translation, variations of the treatment model were created in an effort to meet clinical gaps that the earlier model failed to meet. Two of these adaptations are helpful to review for the role that they played in the further development of BSFT and in the field as a whole.
One-person Family Therapy (OPFT)
Prior to developing the specialized BSFT Engagement interventions, other approaches were tested. These aimed at achieving whole-family changes in repetitive patterns of interactions while working with less than the whole-family unit. One of these approaches was One-Person Family Therapy (Foote, Szapocznik, Kurtines, Perez-Vidal, & Hervis, 1985; Szapocznik, Kurtines, Foote, Perez-Vidal, & Hervis, 1983, 1986). This intervention aimed to explore whether improvements in maladaptive repetitive patterns of family interactions could occur while working primarily with one powerful member of the family. Family systems approaches to therapy traditionally assumed that the identified patient’s psychopathology is a symptom of underlying maladaptive interactions in the family that acted to sustain the identified patient’s symptoms; and that to change these maladaptive patterns of interactions, work with the whole family was required. The goal of one-person family therapy was to determine if families indeed needed to be present for maladaptive patterns of interactions to change. In developing one-person family therapy, researchers capitalized on the systemic principle of complementarity, which suggests that if one member of a system alters her/his behavior, it will have effects on the other members of the system.
One-person family therapy was delivered by family therapists who were familiar with BSFT. OPFT had the same goals as BSFT, but the intention was to bring about the same changes as conjoint BSFT without having the whole-family present for all sessions. Like conjoint BSFT, OPFT was delivered about once a week, for a total of 12 sessions. At most, two of the sessions were allowed to include multiple members of the family. The other sessions included one member of the family with whom the therapist would work who was either a powerful member of the family or a member of the family that was central to family interactions. In contrast to the conjoint BSFT approach, OPFT did not assume that joining needed to occur with each family member. Through role playing and sketching out family relationships, the therapist was able to observe enactments of family patterns of interactions, discern the role the individual played in these interactions, and plan how the one person would change her/his behavior to interfere with the family’s repetitive patterns of interactions. Through various cognitive exercises such as role reversal and Gestalt-guided imagery techniques, the client’s internalized representations of their family relationships were altered. The therapist helped the client then identify modifications that they could make to their own behavior within the family. In response to the new behaviors, the family system typically reacted by attempting to keep the client from disrupting the family homeostasis, which often created a systemic crisis. At this time, the whole family was brought in for one of two conjoint sessions. In these conjoint sessions, with a family in crisis, the therapist had the opportunity to apply conjoint BSFT techniques to facilitate changes in the family’s repetitive patterns of interactions that were preventing the family from achieving their own goals. Theoretically, family interactional patterns could be changed by working primarily with one client; and motivation was elicited through crises in the whole family to come into a treatment session.
A randomized clinical trial compared OPFT with conjoint BSFT (Foote et al., 1985; Szapocznik et al., 1983, 1986). At 4- and 6-month follow-ups, both treatments were associated with reduced externalizing, internalizing, and drug use behaviors. There were also improvements in family functioning, measured by blind, independent raters, over time for both treatments. OPFT performed as well on adolescent and family outcomes compared to conjoint BSFT. This work demonstrated that it was possible to change family interactional patterns and achieved desired adolescent outcomes while working mostly with a key family member. This work, however, was discontinued because teaching OPFT was far more challenging than teaching conjoint BSFT. However, what was learned in working with one person was used to build the Engagement module of BSFT, which requires working with less than the whole family to bring the whole family into treatment.
Family Effectiveness Training (FET)
Family effectiveness training was developed from research on family-based risk factors that are shown to be predictive of adolescent substance use (Szapocznik, Santisteban et al., 1989). The risk factors were specifically identified for Hispanic immigrant families in which intergenerational conflict combined with generational differences in acculturation to undermine parental leadership, which in turn made possible the emergence and maintenance of adolescent problem behaviors. Younger persons, in this case adolescents, tended to acculturate more quickly than older persons, in this case their parents, which led to differences/conflicts across generations in values, attitudes, and behaviors that had a clear cultural flavor (Szapocznik et al., 1978).
According to family systems theory, a healthy family is flexible enough to accommodate to developmental and cultural challenges, while supporting the growth of each individual member. With this goal, the FET intervention attempted to achieve two general outcomes: The first was to provide the family with the knowledge and skills needed to manage potential developmental conflicts in the future through negotiation skills and by having family members better understand each other’s cultural perspective. Moreover, as families discussed cultural and intergenerational differences, maladaptive patterns of family interactions that emerged were treated with the BSFT intervention. Through 13 weekly sessions, a facilitator created a participatory process in which cultural and intergenerational areas of potential conflict were introduced and discussed by the family. The first component of treatment Helped the family in adapting to their child becoming an adolescent. The second component engaged the family in discussions and interactions around cultural content, while treating maladaptive patterns of family interaction using the BSFT interventions. These two components were aimed to prevent further intergenerational conflict as the child developed into adolescence.
A randomized trial of the efficacy of FET compared to a minimal contact wait-list control revealed significant relative gains in relevant outcomes. Seventy-nine Hispanic families with youth (aged 6–12) were recruited in the Miami area. The youth in the FET group were rated as significantly improved on behavioral problems, and the families in the FET group exhibited improved functioning and family environment. Thus, there is evidence that psychoeducation integrated with BSFT interventions are efficacious for the prevention of conflict around developmental and cultural challenges for Hispanic families and can help reduce behavioral problems in children aged 6–12.
Efficacy Testing: Determining the Value of BSFT the Intervention:Stage II
The 1960s and 1970s saw an explosion of adolescent drug use. Nationally, in the late 1970s and early 1980s, there was widespread belief among counselors that families needed to be involved in the treatment of adolescent problem behaviors, but repeatedly counselors complained about their inability to bring families into treatment. In the early model development work, engaging and retaining families of problem adolescents in BSFT treatment was also a challenge. In response, BSFT theory and practice was extended to incorporate the “presenting problem” of the family’s lack of engagement in treatment. Clinically, as family members were given the task of bringing whole families into BSFT treatment, this provided an opportunity for examining family structure. Interactional patterns that emerged were viewed as a challenge for the therapist to strategically overcome in order to bring whole families into treatment. The BSFT Engagement module was thus developed with the aim of engaging whole families into treatment. Once the approach was developed, it was tested in three separate studies that used BSFT specialized engagement techniques. In the first study (Szapocznik et al., 1988), Hispanic (mostly Cuban) families with drug abusing adolescents were randomly assigned to BSFT with Engagement as Usual (the control condition) or to BSFT + BSFT Engagement (the experimental condition). The Engagement as Usual condition was modeled after community-based adolescent outpatient programs’ approaches to engagement in the Miami area. The results of the study revealed that 93% of the families in the BSFT Engagement condition, compared with only 42% of the families in the Engagement as Usual condition, were engaged into treatment (defined as attending an admission session). Furthermore, 75% of families in the BSFT Engagement condition completed treatment (defined as the family and the therapist reaching a mutual decision that treatment could be terminated), compared with only 25% of families in the Treatment as Usual condition.
In a second study testing BSFT engagement (Santisteban et al., 1996), families were randomly assigned to a BSFT Engagement or Engagement Control (no specialized engagement) condition. In the BSFT Engagement condition, 81% of families were successfully engaged, compared to 60% of the families in the Engagement Control condition (defined as attending the admission session plus one family therapy session). A key finding of this study was that the effectiveness of BSFT Engagement procedures was moderated by Hispanic nationality. Among the non-Cuban Hispanics (composed primarily of Nicaraguan, Colombian, and Puerto Rican families) assigned to the BSFT Engagement condition, the rate of engagement was high (93%) compared to the much lower rate (64%) found in Cubans assigned to this same BSFT Engagement condition. All of these differences were significant. Most of the Cuban families had U.S.-born adolescents, whereas the majority of adolescents from other national backgrounds were foreign born. Evidence suggests that U.S.-born Hispanic adolescents tend to be more Americanized compared with adolescents born outside the United States (Schwartz, Pantin, Sullivan, Prado, & Szapocznik, 2006). There is also evidence that in Hispanic families, acculturation to American values and behaviors is associated with decreased orientation toward family (Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987). As a result, it is possible that the lower engagement rate found for Cubans was due to higher rates of Americanization in the Cuban families. It is possible that more Americanized families perceive less need for family involvement in adolescent drug abuse treatment. This finding resulted in the incorporation of specific family reconnection strategies, focusing on reorientation toward the importance of family, into the current version of BSFT Engagement.
A third study (Coatsworth, Santisteban, McBride, & Szapocznik, 2001) tested the ability of BSFT + BSFT Engagement to engage and retain adolescents and their families in comparison to a community control condition. An important aspect of this study was that the control condition was implemented by a community treatment agency and, as such, was less subject to the influence of the investigators. The Hispanic adolescents and families in this study were primarily Cuban or Nicaraguan. Findings in this study indicated that BSFT Engagement successfully engaged 81% of families into treatment—significantly higher than the 61% rate in the community control condition. Likewise, among families who were successfully engaged, 71% of BSFT cases, compared to 42% in the community control condition, were retained to treatment completion.
The efficacy of the BSFT model in reducing behavior problems and drug abuse has been tested in several randomized, controlled clinical trials. In the first trial, Szapocznik, Rio et al. (1989) randomized 6–11-year-old Cuban boys with behavior and emotional problems to one of three conditions: BSFT model, individual psychodynamic child therapy, or a recreational placebo control condition. The two treatment conditions, implemented by highly experienced therapists, were found to be equally efficacious, and more efficacious than the recreational control, in reducing children’s behavioral and emotional problems and in maintaining these reductions at 1-year follow-up. However, at 1-year follow-up, the BSFT condition was associated with a significant improvement in blind, independently rated family functioning, whereas individual psychodynamic child therapy was associated with a significant deterioration in family functioning.
In a second study, Santisteban et al. (2003) randomly assigned Hispanic (half Cuban and half from other Hispanic countries) behavior-problem and drug abusing adolescents to receive either the BSFT model or adolescent group counseling. The BSFT condition was significantly more efficacious than group counseling in reducing conduct problems, associations with antisocial peers, marijuana use, and in improving observer ratings of family functioning. In this study, baseline family functioning was found to be a moderator of treatment effects. For families entering the study with comparatively good family functioning, family functioning remained high in the BSFT condition, whereas it deteriorated in the families of adolescents in group therapy. For families entering the study with comparatively poor family functioning, the BSFT condition significantly improved family functioning, whereas family functioning did not improve in families assigned to adolescent group therapy. Additionally, adolescent group counseling was associated with clinically significant increases in marijuana use.
The efficacy of BSFT was further tested by Nickel, Luley, Krawczyk, and Loew (2006) and Nickel, Muehlbacher, Kaplan, and Cerstin (2006) in two separate studies on bullying behavior with boys and girls. The study on bullying behavior in boys found that when compared with supportive listening, BSFT was more efficacious than the control group in reducing bullying behavior, cortisol levels, and state/trait anger and in increasing mental health and social functioning. Likewise a trial involving girls who were bullying others demonstrated that BSFT was more efficacious than supportive listening in reducing bullying, substance use, risky sexual behaviors, anger, and interpersonal problems and in increasing mental health and social functioning.
Effectiveness Testing: Examining BSFT Under “Real-World” Conditions: Stage III/IV
While BSFT was tested in community settings in a few of the efficacy trials, these trials occurred with research therapists and with complete oversight of the researchers, in line with the intent to maximize internal validity of the intervention. With the intention of maximizing external validity and generalizability, an effectiveness trial (Robbins, Feaster, Horigian, Rohrbaugh et al., 2011) of BSFT was conducted within the National Institute on Drug Abuse’s National Drug Abuse Treatment Clinical Trials Network (CTN). The study compared BSFT and Treatment as Usual (whatever treatment the agency typically provided for drug using adolescents) by randomizing 480 families of adolescents (213 Hispanics, 148 White, and 110 Black; 377 male, 103 female) referred to drug abuse treatment at eight community treatment agencies located around the United States. Seventy-two percent of these adolescents were referred for treatment by the juvenile justice system, and most of the remaining cases were referred from residential treatment. Sixty-nine percent had diagnoses of drug abuse or dependence. Services in both conditions were delivered by therapists in community agencies, but under supervision of the master trainer and researchers. These therapists were randomized within agency to deliver either the BSFT or treatment as usual (TAU). In this intent to treat study design, and consistent with research in BSFT efficacy, BSFT was significantly more effective than TAU in engaging and retaining families in treatment. Families in TAU were 2.33 times (11.4% BSFT; 26.8% TAU) more likely to fail to engage (defined as not completing at least two sessions) compared with families in the BSFT condition. Families in TAU were 1.41 times (40.0% BSFT; 56.6% TAU) more likely to fail to retain (defined in this study as completing fewer than eight sessions) compared with families in BSFT. These differences were significant and were consistent across ethnic groups. It is important to note that therapy took much longer to administer than expected. The usual expectation is that BSFT therapy should last approximately 4 months, which is consistent with how BSFT is implemented in practice. However, the median length of treatment for those participants who were retained in treatment across both conditions was approximately 8 months. With respect to adolescent drug use outcomes, the effectiveness study showed no significant differences between conditions on the number of drug using days per 28-day periods across the 1-year postrandomization. However, nonparametric analyses showed that the median number of self-reported drug use days per month at the 12-month follow-up was significantly higher in the treatment as usual condition (3.5 days) than in the BSFT condition (2 days). It is important to note that the median number of drug-use days was low and restricted, with an interquartile range between 1 and 3 days of self-reported use per month. Such a restricted range made it difficult to detect statistically significant or clinically meaningful effects. As detailed above, an overwhelming majority of adolescents in the study were referred from juvenile justice or from residential treatment, both of which involved surveillance and limited opportunities to engage in drug use. These referral sources may have been responsible for the relatively low baseline rates of drug use, and in the case of the juvenile justice referrals, continued surveillance may have been responsible for the low levels of drug use over time.
Patterns of findings for family functioning differed between adolescent and parent reports. The BSFT condition produced significantly greater improvements in parent-reported family functioning (defined as positive parenting, parental monitoring, effectiveness of parental discipline, parental willingness to discipline adolescents when necessary, family cohesion, and absence of family conflict) compared with the treatment as usual (TAU) condition. Adolescents in both conditions reported significant improvements in family functioning, with no statistically significant differences by treatment condition.
Post hoc analyses of the BSFT effectiveness study evidenced that BSFT was more effective than TAU in reducing alcohol use in parents and that this effect was mediated by parental reports of family functioning. In addition, BSFT as compared with TAU had its strongest effect in reducing adolescent drug use among youth whose parents used drugs at baseline (Horigian, Feaster, Brincks et al., 2015). A long-term follow-up of the BSFT effectiveness study found that at a mean of 4.7 years (range 3–7) postrandomization, individuals who received BSFT reported fewer lifetime arrests (IRR = .68) and incarcerations (IRR = .63) as well as fewer last-year arrests (IRR = .54) and incarcerations (IRR = .70) (Horigian, Feaster, Robbins et al., 2015). They also self-reported lower externalizing behaviors while there were no statistically significant differences in drug use at the follow-up. Despite a lack of differences in substance use, there is evidence for the long-term effects of BSFT on important treatment outcomes.
Therapist Behaviors, Therapy Process, and Outcomes
Process research has demonstrated that negativity in family interactions in the first session leads to failure to retain families in treatment past the first session (Fernandez & Eyberg, 2009); that families are more likely to engage into treatment if negativity is reduced (Robbins, Alexander, & Turner, 2000); and that reframing is the technique that is least likely to damage therapists’ rapport (alliance, bond) with family members (Robbins et al., 2006). Process research has also evidenced that early engagement requires therapists to maintain a balanced bond with the parent (often the father figure) and the problem youth. If, in the first session, the strength of the bond the therapist develops with the parent and the youth is not balanced, this unbalance leads to early dropout from treatment (Robbins et al., 2000). These findings have been incorporated into BSFT treatment as conducted today.
Effects of Therapist Adherence and Behaviors on Treatment Outcomes
Using data from the BSFT effectiveness trial, Robbins, Feaster, Horigian, Puccinelli et al. (2011) examined the extent to which BSFT therapists adhered to the BSFT model. To do this, adherence items were assessed along four theoretically and clinically relevant prescribed therapist behaviors: joining, tracking and eliciting enactments, reframing, and restructuring. The scales for the four domains of adherence used in the study were confirmed through factorial analyses. These items were assessed by trained independent raters who watched randomly selected videos of therapy sessions.
Results of these analyses revealed that higher levels of restructuring and reframing (reducing negativity and creating a motivational context for change) significantly increased the likelihood of families being engaged into treatment. Furthermore, higher levels of each of the four BSFT technique domains, therapist joining, tracking and enactment, reframing, and restructuring, predicted significantly higher rates of retention, defined as a family attending at least eight sessions. As would be expected, joining decreased across time while restructuring increased. Findings revealed that smaller declines in joining and larger increases in restructuring predicted significantly less adolescent drug use at the 12-month follow-up. That is, therapists who were high in joining in early sessions and remained so throughout treatment were associated with “better” adolescent drug use outcomes. Therapists whose attempts to restructure maladaptive family interactions increased most during the course of treatment were also associated with “better” adolescent drug use outcomes. Thus, therapists who failed to maintain high levels of joining and/or implement sufficient numbers of restructuring interventions were less able to affect the youths’ drug use.
These results demonstrated that the specific therapist behaviors prescribed by the BSFT approach are needed to engage families into treatment, retain them, improve family functioning, and reduce adolescent drug use. When therapists did not engage sufficiently in these behaviors, adolescent outcomes tended to suffer. The authors’ experience during the trial led them to conclude that adherence levels were affected by a number of within-agency systemic factors, including overburdened therapists and therapists’ lack of embeddedness within dedicated BSFT units. These conclusions have been confirmed in subsequent experience in implementation of BSFT in real-world settings.
Implementation in Widespread Practice: Stage V
The lessons learned from the BSFT effectiveness multi-site trial led to the recognition that providing training to therapists was insufficient to achieve fidelity and sustainability. It was essential to obtain the support of all levels of the organization. Therefore, BSFT theory and practice was extended to the agency as a system in which the presenting problem was to obtain organizational support for BSFT adoption, fidelity, and sustainability. BSFT, as currently implemented, intentionally executes strategic interventions at the organizational level to ensure successful implementation of BSFT, which translates to increased therapist fidelity and improved adolescent outcomes and long-term sustainability. In the current BSFT implementation model, the agency is viewed as a system, of which the therapist is one member. Because the vast majority of agencies implementing the BSFT program are adopting an evidence-based program for the first time, changes in their standard practices are required to successfully implement the BSFT model. Strategic interventions at the level of the organization can engage the leadership in ways that will overcome barriers to adoption (funding by case rather than by hour), fidelity (allowing adequate time for therapist supervision and training and placing leadership in charge of ensuring fidelity), and sustainability (basing funding on outcomes rather than client hours; Szapocznik, Muir, Duff, Schwartz, & Brown, 2015). Once the leadership accepts their crucial role in implementation, the BSFT model managers and the agency collaborate on therapist selection and the agency establishes a dedicated BSFT unit. Agency leaders regularly receive information on fidelity, and it is their responsibility to ensure that therapists achieve and maintain fidelity. The BSFT Institute team supports the agency leadership with extensive training, supervision of therapists and fidelity feedback to therapists, middle management, and upper management. To support sustainability, one of the BSFT therapists in training is identified conjointly by the agency and the BSFT Institute to become the BSFT on-site supervisor. The role of this person is to advocate for BSFT within the agency and to ensure long-term fidelity among the other BSFT therapists. Critical to the sustainability of the model is licensing the agency’s BSFT unit. A decade earlier, the model called for certifying therapists. However, this led to therapists shopping around for other jobs using their new credentials, and they often quickly left the agency for better paying positions, thereby threatening the sustainability of the model at the target agency. Agencies, rather than therapists, are now granted a license to practice the BSFT model once staff have been trained to a predesignated level of competency and once the agency possesses the necessary resources to implement the model. Part of the work of sustainability is ensuring that therapists trained in the BSFT model receive adequate compensation, commensurate with their new competencies. Current implementation of BSFT has achieved sustainability in a number of sites for over 6 years. In addition, agency data suggest improved engagement and retention of families, and improved outcomes in a range of populations, including delinquent adolescents and families in the welfare system in which the outcome is retention of the youth within the home without additional incidents.
Conclusions and Future Directions
Brief Strategic Family Therapy as implemented today is the result of 40 years of the interplay between theory, clinical practice, and research. This special article describes how clinical observation informed subsequent steps of research and how research has shed light on how to design effective translation. Originally developed to address conflicted parent and adolescent relationships in Hispanic immigrant families, the model has evolved and been tested in response to specific clinical needs: Specialized engagement techniques were added to bring reluctant families into treatment; reframing became increasingly prominent as a way to reduce negativity, increase motivational context for change, and increase engagement and retention; and an implementation program, supported by the creation of the BSFT Institute, was established. The model has now been tested with a broad range of racial/ethnic populations and target problems. The experience of BSFT implementation with the insights provided by the effectiveness trial made clear that an organizational-level systemic approach is critical in ensuring successful adoption, fidelity, and sustainability of BSFT. This approach is used in BSFT implementation today. Future research in BSFT will assess the full model as implemented today, including specialized engagement folded within BSFT, and an organizational implementation intervention that views the agency as a system in which problem-focused interventions are conducted to achieve the support of agency leadership in ensuring successful adoption, therapist fidelity, and sustainability of the model over time. Future research can also aid in rigorously documenting the cost-effectiveness of BSFT implementation.
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• Coatsworth, J. D., Santisteban, D. A., McBride, C. K., & Szapocznik, J. (2001). Brief strategic family therapy versus community control: Engagement, retention, and an exploration of the moderating role of adolescent symptom severity. Family Process, 40, 313– 332.
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