Mentalizing Family Violence Part 2: Techniques and Interventions.

This is the second of two companion papers that provide an overview of mentalization-based concepts and techniques when working with the seeming "mindlessness" of intra-family violence. The focus of this paper is on general mentalization-oriented approaches and specific interventions that aim to (1) disrupt the non-mentalizing cycles that can generate intra-family violence and (2) encourage the emergence of patterns of family interactions that provide the foundation for non-violent alternatives. Various playful exercises and activities are described, including the taking of "mental state snapshots" and "selfies" in sessions and staging inverted role-plays, as well as using theatrical masks and creating body-mind maps and scans. These can make "chronic" relationship issues come alive in session and permit "here and now" experiences that generate a safe context for mentalizing to take place. At the core of the work is the continuous focus on integrating experience and reflection. Without acute awareness of the thoughts and feelings occurring in the sessions, mere reflection is not likely to enable change. By increasing mentalizing in the family system, family members' trusting attitudes grow, both within and outside the family.

Mentalizing Family Violence Part 1: Conceptual Framework.

This is the first of two companion papers describing concepts and techniques of a mentalization-based approach to understanding and managing family violence. We review evidence that attachment difficulties, sudden high levels of arousal, and poor affect control contribute to a loss of mentalizing capacity, which, in turn, undermines social learning and can favor the transgenerational transmission of violent interaction patterns. It is suggested that physically violent acts are only possible if mentalizing is temporarily inhibited or decoupled. However, being mentalized in the context of attachment relationships in the family generates epistemic trust within the family unit and reduces the likelihood of family violence. The implications of this framework for therapeutic work with families are discussed.

A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa.

BACKGROUND: Considerable progress has been made in recent years in developing effective treatments for child and adolescent anorexia nervosa, with a general consensus in the field that eating disorders focussed family therapy (often referred to as Maudsley Family Therapy or Family Based Treatment) currently offers the most promising outcomes. Nevertheless, a significant number do not respond well and additional treatment developments are needed to improve outcomes. Multifamily therapy is a promising treatment that has attracted considerable interest and we report the results of the first randomised controlled trial of multifamily therapy for adolescent anorexia nervosa. METHODS: The study was a pragmatic multicentre randomised controlled superiority trial comparing two outpatient eating disorder focussed family interventions - multifamily therapy (MFT-AN) and single family therapy (FT-AN). A total of 169 adolescents with a DSM-IV diagnosis of anorexia nervosa or eating disorder not otherwise specified (restricting type) were randomised to the two treatments using computer generated blocks of random sizes to ensure balanced numbers in the trial arms. Independent assessors, blind to the allocation, completed evaluations at baseline, 3 months, 12 months (end of treatment) and 18 months. RESULTS: Both treatment groups showed clinically significant improvements with just under 60% achieving a good or intermediate outcome (on the Morgan-Russell scales) at the end of treatment in the FT-AN group and more than 75% in the MFT-AN group - a statistically significant benefit in favour of the multifamily intervention (OR = 2.55 95%; CI 1.17, 5.52; p = 0.019). At follow-up (18 months post baseline) there was relatively little change compared to end of treatment although the difference in primary outcome between the treatments was no longer statistically significant. Clinically significant gains in weight were accompanied by improvements in mood and eating disorder psychopathology. Approximately half the patients in FT-AN and nearly 60% of those in MFT-AN had started menstruating. CONCLUSIONS: This study confirms previous research findings demonstrating the effectiveness of eating disorder focused family therapy and highlights the additional benefits of bringing together groups of families that maximises the use of family resources and mutual support leading to improved outcomes. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11275465 ; Registered 29 January 2007 (retrospectively registered).

Innovations in Practice: Adolescent Mentalization-Based Integrative Therapy (AMBIT) - a new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs.

BACKGROUND: 'Hard to reach' young people are associated by virtue of their serious, multiple, and complex needs, the difficulty of delivering effective help to them, and their poor long-term outcomes. There is a lack of published evidence relating to the effectiveness of interventions directed at this group. METHOD: We review these concerns and the options available to service commissioners and clinicians seeking, if not an evidence-based approach then at least an evidence-oriented one. A mentalization-based multimodal intervention (AMBIT) is briefly described, proposing a new kind of specialist practitioner and taking a radically different approach to treatment manualization. RESULTS: A brief description is given of the different settings in which AMBIT is currently being developed, deployed, and evaluated, and of lessons learned. CONCLUSIONS: AMBIT offers promise as an evolving 'open source' framework supporting development of evidence-based local practice in chaotic complex settings.

Psychiatry beyond the current paradigm.

A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially 'applied neuroscience'. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

[Multi-family therapy in day care settings]. / Multi-Familientherapie in unterschiedlichen Kontexten.

This article describes the practice of multi-family therapy in day care settings. Between six to eight families attend together for whole days and weeks and the principles and the methods of this approach are described and illustrated with examples of systemic work with children with severe behavioural and learning disorders, as well as with adolescents presenting with anorexia nervosa.

[A family day clinic in child psychiatry. The Dresden model--concepts and first experiences]. / Familientagesklinik in der Kinderpsychiatrie - Das Dresdner Modell - Konzept und erste Erfahrungen -

AIMS: To present a systemic family therapy approach for children with psychiatric disorders, based on multiple family therapy principles and employing video-feedback and peer review techniques. Children and their parents together attend a family day clinic for periods of between 3 and 14 weeks. METHOD: We report on conceptual and clinical work, with case examples and discussion of a pilot study. RESULTS: At 6 months follow-up there are symptomatic and behavioural improvements in 75 % of the children and 90 % of the parents. CONCLUSIONS: Active involvement of parents in the therapy of their children appears to lead to better and longer lasting treatment results. Extensive interdisciplinary work between adult and child psychiatric services is needed, particularly with the more severe spectrum of parental psychiatric disorders.