Multisystemic
Approaches
Dr Sarah Parry
Clinical Psychologist
Aims & Objectives
– Introduce systemic and multisystemic ideas
– Consider the role of multisystemic assessments
– Explore some ways to undertake multisystemic
assessments and formulation
– To develop further understanding of how systems
work together
Definitions
Systemic assessment can:
– Be a therapeutic activity
– Enhance awareness and ownership of, or freedom from, systemic dynamics
– Make a therapeutic difference
Multisystemic assessment is:
– A way of considering the wider context surrounding the ‘system’
– A framework for exploring influences upon the individual within the ‘onion’
Ecological
Systems Theory -
Bronfenbrenner
Ecological (environmental)
system interventions
– Mostly microsystem & mesosystem
– Schools unlikely to be major cause of significant gaps (Strand,
2014b)
– Exosystem
– Work environments, opportunities, extended family narratives
– Neighbourhoods, communities
– Macrosystem
– Political policies & agendas
– Cultural belief systems, access to resources
– Chronosystem
Intervention example
– Multisystemic therapy
Systems and Systemic
Practices
History of Systemic Approaches
– Roots in family therapy
– Systemic family therapy as it later came to be known
– Systemic therapy traces its roots to the Milan school of Mara
Selvini Palazzoli
– Also derives from the work of Salvador Minuchin, Murray
Bowen, Ivan Boszormenyi-Nagy, as well as Virginia Satir and
Jay Haley
– Early schools of family therapy represented therapeutic
adaptations of the larger interdisciplinary field of systems
Systemic Approaches
– Looks at circular or reciprocal influence rather than linear
influence.
– Rules of Relationships: Every family or system has explicit or
subtle rules to guide behavior.
– Rules apply to:
Power structure: Who has the power?
History: What are the family legends, myths and history that
have been inherited from previous generations?
Systemic principles
– The family is a system
– An ‘open’ system, open to the influence of social / cultural
contexts
– There is communication between its members
– There will be shared ideas/ beliefs about the family and the
world
– Structure (rules, routines, hierarchies, roles etc.) will exist in
the family and influence its functioning
– Causality is circular (Imagine if A makes B happen, in circular
causality, B is also a cause itself, and can modulate or
perpetuate A. So you get a circle, with A causing B causing A
causing B), not linear (A-B)
– A family changes over time and difficulty in adapting to these
changes may result in a problem
Systemic Concepts
Coalitions: Who is aligned with whom?
Hierarchy: Power, authority, decision making, limit setting
Roles: Care, decisions, tasks, communication, gendered/age-defined?
Boundaries: Are the boundaries loose or rigid? Close or distant? Clear
or unclear?
Culture: What is the cultural identity of the family? (religion,
socioeconomic status, ethnicity, class, lgbtq+).
Communication: What are the communication patterns and meta-
communication?
Life Cycle: What is the developmental stage of the family? (New
couple, launching children, empty nest, married without children, etc.)
Systemic Principles (Smyly
2006)
– It is the underlying beliefs about a situation that inform our
point of view and our actions
– Uncovering or deconstructing these beliefs in conversation
with a system is seen as a central focus of the work
– Moving away from the problem saturated story
– The generation of alternative stories or construction of new
meanings which make sense to the system
Engaging the system
(Jenkins & Parry, 2006)
Practitioners need to:
– Bring more of the system into the room and help it
have a voice
– Notice what is and isn’t in our awareness
– Notice what is dynamically happening to us, the
system will find ways of getting us to experience the
dynamics and until we do we can be of very little
help
– Accept that being stuck is inevitable and valuable.
Then describe the experience to the system as an
What is Systemic Practice
interested in?
Looking for patterns & processes (circularity not linear processes)
Interactions/communication between people (not within)
Symptoms are issues of the interpersonal (not pathology)
Context
Key skill - genograms
Systemic therapists use them:
– To set the family-oriented tone for the work
– As a tool for alliance-building and engagement
– For information-gathering
– As a format for intervention – considering patterns and the intergenerational
carryover of patterns
– Doing own genogram as part of development as a therapist (family of origin)
– Consider the genogram as an interview process, not just a diagram (content and process)
– The difference between ‘taking a history’ and listening to the family’s life stories
McGolddrick et al. (2008)
The genogram interview
1. Map the family structure
• Start with the household, who’s who, gradually casting the net wider.
• Cultural and religious history, occupations
• Notice themes and patterns (e.g. ‘a family of all boys’ / only children).
2. The current situation
• Recent changes in the family (births, deaths, separations, moves…)
• Who knows about the problem, their involvement/responses to it.
3. Family relationships and roles
• The impact of the problem on family relationships (and vice versa).
• Double lines= close; zigzags=conflict; dashed line=distant.
4. Adding contextual factors
• Whatever is important to the family – including support systems
Elements of a Genogram
Tips, Applications & Considerations
Consider:
– Look again at the genogram
– Have you missed anyone out? Why?
– Look at the genogram from the following perspectives:
– Gender
– Culture
– Religion
– Alliances
– Patterns
– Beware – what is the potential impact of doing this with
the child/ family?
– Does it have an impact on you?
Elements of a Genogram
Tips, Applications & Considerations
Tips:
– Focus on one person
– Draw the genogram from their perspective
– You may need to draw more than 1 genogram for a complicated
family.
Applications:
– For own reference
– Quick communication with colleagues
– Supervision
– With clients (children often like it)…
– Comprehensive record keeping
Cultural Genogram
On your paper, decide on a key of symbols to represent how you will
develop your personal cultural genogram. You may like to consider some
of these areas, as well as anything else that seems relevant to you:
• Family relationships
• Friendships
• Other important relationships in your life (past and present)
• Beliefs
• Religion
• Class
• Education
• Special connections
• Personal characteristics
• Hobbies and interests
• Careers
