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Improving the wellbeing of families with complex problems using novel attachment-based therapies.

1. Summary of the impact

The Attachment Narrative Therapy (ANT) programme of research incorporating Systemic Autism-related Family Enabling (SAFE) has improved the lives of families with complex problems. These innovative therapies have led to improved wellbeing, training and service provision in the UK nationally, and in several European countries and Asia. More than 2,000 professionals trained in these therapies have worked therapeutically with over 120,000 families in the last seven years. As well as impacting on professional practice and wellbeing of families, the research has enhanced existing health-related services and training programmes since 2013, resulting in economic impacts with revenue of over £500,000 for the two main family-therapy training organisations alone.

2. Underpinning research

The impacts described result from unique research into novel attachment-based systemic interventions led by Professor Dallos and the research team (including McKenzie, since 2009, together with Doctoral student, parent representative, and latterly Research Assistant, Vassallo from 2013) since 2004, with significant academic outputs including 8 books and more than 90 journal papers.

Attachment can be described as a supportive bond between a child and caregiver creating a sense of safety through meeting the physical and emotional needs of the child. Ideally, a secure attachment is formed, giving a child a safe base from which to explore the world and return to for comfort. Through working with families with complex problems, the research has identified intergenerational, severe and multi-faceted attachment problems resulting in high levels of emotional arousal and distress. In these families, talking and cognitive therapies have limited success where family members are too aroused to engage in reflective thinking and problem-solving.
As a therapeutic approach for working with families with complex problems, Professor Dallos and his team developed a conceptual framework for the interventions - Attachment Narrative Therapy (ANT) [3.1]. This novel approach works on the principle that therapists provide a secure base and empower families to explore understandings and effect change [3.2]. The methodology employs activities rather than predominantly reliant on ‘talking’, facilitating families to explore problems and solutions for themselves using mapping, sculpting, drawing and role-play.
Initially, ANT research involved trialling techniques with families in collaboration with local services throughout the South West. Formulating family problems with an attachment lens and using systemic ANT principles in therapy were found to be helpful for families including those where a child had a diagnosis of autism [3.3]. In 2012, McKenzie, Dallos and Vassallo began a research project exploring the use of ANT principles in supporting families of children with autism [5.4], resulting in the development of SAFE (Systemic Autism-related Family Enabling).
In 2016 a pilot study for SAFE indicated reduced family distress and led to the development of a SAFE practice manual by Dallos and McKenzie. The impact of SAFE was supported by funding from NIHR (2017-2019) for a Randomised Controlled Feasibility Trial (N = 146 family members) and an extended parallel qualitative study of family experience of the intervention funded by Autistica. The research team were invited to be a centre for Autistica’s Discover Research Network in 2017. The SAFE research studies included collaboration with three NHS hospital trusts, charitable bodies and national family therapy organisations. The findings of the NIHR trial revealed positive changes for families receiving SAFE, compared to those receiving standard care, in mental health and problem-solving strategies, including coping with challenging behaviour. Similarly the Autistica study showed that families found SAFE helpful in alleviating family distress and building on strengths [3.5].
In 2017, SAFE research was extended to provide an intervention that could support families and teachers of children with autism to work in partnership [3.6]. Promising initial results with 32 family and teacher pairs led to a whole-school pilot study in a primary school serving 425 children. Findings of the pilot study indicated that SAFE-for-Schools had enhanced school practice, and led to better home-school communication and improved learning engagement by the children. The approach was subsequently shared across the associated Multi-Academy Trust.

3. References to the research

Journal articles R2-R6 can be found by clicking here (R1 is a book)
1. Dallos, R., & Vetere, A. (2009). Systemic therapy and attachment narratives: Applications in a range of clinical settings. Routledge.
1. Vetere, A., & Dallos, R. (2008). Systemic therapy and attachment narratives. Journal of Family Therapy, 30(4), 374-385.
  1. Hudson, M., Dallos, R., & McKenzie, R. (2017) Systemic Formulation for families of children with autism. Advances in Autism, 3(3), 142-153.

  2. McKenzie, R., & Dallos, R. (2017). Autism and attachment difficulties: Overlap of symptoms, implications and innovative solutions. Clinical child psychology and psychiatry, 22(4), 632-648.

  3. McKenzie, R., Dallos, R., Stedmon, J., Hancocks, H., Vickery, P. J., Barton, A., Vassallo, T., Myhill, C., Chynoweth, J. and Ewings, P. (2020). SAFE, a new therapeutic intervention for families of children with autism: a feasibility trial. BMJ Open, 10(12), 1-11 .

  4. Vassallo, T., Dallos, R., McKenzie, R. (2020). Parent and teacher understandings of the needs of autistic children and the processes of communication between the home and school contexts. Autism-Open Access, 10(4), 1-10 .

Key research grants (See S5 and S6 for final reports)

A study to establish the feasibility of a definitive randomised controlled trial evaluating SAFE, an intervention for families of children with autism - PB-PG-0815-20058. Funding body: NIHR, Lead researcher: Rebecca McKenzie, £255,844.00, 1st June 2017 – 31 May 2019

SAFE: an early intervention for families of children with autism and Asperger syndrome - ID: 7239 Funding body: Autistica, Lead researcher: Rebecca McKenzie, £85,547.16, 1st June 2017- 31 May 2019.

4. Details of the impact

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ANT, incorporating SAFE, has enhanced training and service provision nationally and internationally leading to improved wellbeing of families with complex problems.

Impacts on practitioners

During the last decade, training based on the research has improved the skills of practitioners in delivering therapeutic intervention through services using ANT and SAFE approaches, leading to improved mental health and problem-solving skills among families [S5, S6, S8, S9, S10].

Between August 2013 and 2020, more than 300 professionals have received training on these interventions annually which are cascaded through services (>2000 professionals over the 7 year period from August 2013) [5.1, 5.2].

“This is ground breaking work which is leading the field and much needed to help practitioners who are dealing with these highly stressed families and is becoming a key part of our training at IFT. Feedback from students at all levels is that this is highly relevant to their work, accessible in its articulation of theory and helpful for them to make significant changes to their practice and increase their therapeutic connection with families facing tremendous challenges”. (Director of CPD and Innovation - Institute of Family Therapy, 5.2)

The impact of research-informed training is far-reaching, with ANT and SAFE workshops providing training for more than 50 international professionals annually through, for example, The Family Therapy Association, Romania (2015); Counselling Centre, University of Warsaw (2016), the Society of Family Therapy, Czech Republic (2017) [5.3] and the Williams Road Family Therapy Centre, Australia (2020).

Training examples in the UK include courses for clinicians at the Maudsley Hospital in London and for the All Wales Neurodevelopmental Clinical Excellence Network, and annual courses for the Bowlby Centre, which promotes attachment orientated expertise for professionals in the UK and abroad [S1]. Dallos also provides annual courses for systemic practitioners at the Institute of Family Therapy (IFT) [5.2]. The training courses are well attended in the context of scarce funds for clinical training, which is testament to the reputation of ANT and SAFE approaches as delivering real benefits to clinicians and their clients. Since 2013, more than 150 attendees have gone on to receive further in-depth supervision from Dallos, for over two months at a time, in developing services based on ANT and SAFE principles. The research has had an impact on these training providers by extending their knowledge, contributing to training portfolios and bringing in substantial revenue. For IFT and the Bowlby Centre combined, this annual revenue is in the region of £80,000 (> £500,000 over the 7 year period from August 2013). The Bowlby Centre and IFT evaluate all training sessions based on feedback from participants. This is overwhelmingly positive in terms of professional development and the ultimate impact on services and families [5.1, 5.2].

“The feedback from participants regarding the training has been extremely positive and demand for the training continues to be high. It has led to significant impact on the work of the participants and a significant number have continued to receive clinical supervision from Prof Dallos that shapes their delivery of services” (Chair of Executive Committee – Bowlby Centre, 5.1)

Impacts on the health and wellbeing of families

A conservative estimate would be that the training and supervision described above results in improved service provision and healthcare outcomes for 18,000 families in the UK with complex problems each year (> 120,000 families over the 7 year period from August 2013). Service providers report that these innovative interventions improve mental health and coping among family members by facilitating understanding of need and providing strategies to deal with problems including wider support networks. In addition, these approaches have provided an innovative tool [5.4] to distinguish autism from attachment-related difficulties in the diagnostic process, an ongoing area of difficulty for clinicians which can result in distress for families due to misdiagnosis and inappropriate treatment for children as documented in 3.4.

“It [ANT] has also informed differential diagnosis in cases where it has been challenging to separate autism spectrum difficulties, from developmental problems arising from trauma/attachment-related issues. One of the greatest impacts however, has been in supporting parents to attune to their child’s developmental needs, and considering the impact of the child’s disability on parents’ lives. The systemic nature of the approach foregrounds parents’ need to support one another, and it provides tools not only for working with parents, but also for enhancing the support system around the family” (Dr Mark Hudson, Child and Adolescent Mental Health Services, 5.4)

Embedded image The National Institute of Health and Care Excellence (NICE) guidelines identify a gap in the care recommended for families of children with autism with complex problems. The multi-site randomised controlled feasibility trial (RCT) of the SAFE intervention funded by the National Institute of Health Research [5.5] and the parallel qualitative study funded by Autistica [5.6], led by McKenzie, shed light on how the intervention benefits families and can address this gap in care. The NIHR research findings indicate that families receiving SAFE show marked differences, on the primary outcome measure, after 24 weeks compared to a control group in three areas associated with improved mental wellbeing: 1. Building on family strengths. 2. Coping with difficulties such as challenging behaviour. 3. Enhancing communication between family members.

Figure 1. Change in building strengths, coping with difficulties and family communication over 24 weeks: Differences between families receiving SAFE and control group.

A reduction in scores indicates positive change.

(McKenzie et al., 2020 [3.5])

The research showed that the intervention can be confidently delivered by existing NHS therapists [5.5]. The trial also led to ongoing relationships with local NHS services leading to positive changes in care for families of children with autism. For example, Dallos, McKenzie and co-applicant Julian Archer MD initiated enhanced provision for families at the main recruitment centre (Plymouth NHS Child Development Centre). This involved cessation of unsuccessful behavioural strategies and recruitment of three Clinical Psychologists trained in ANT and systemic practice by Dallos [5.7].

The Autistica study showed that the intervention was helpful for all participating family members and SAFE elicited positive change in mental health of family members including increased understanding and closeness, improved communication, problem solving, and confidence, and less sense of isolation:

“I have already found these sessions so helpful they have helped me understand what I can do differently to help J (child with autism), myself and the family and given me confidence to make decisions and changes for the better” (Primary Caregiver in Autistica study, 5.6)

Impacts on education and child and family services

Families in the RCT highlighted difficult relationships between themselves and school, including informal exclusions and the need for further training for school staff. Such experiences are well documented nationally by organisations such as the National Autistic Society and the Autism Education Trust. This finding led to the development of SAFE for Schools (SfS), an adapted version of SAFE, which was subject to a whole school pilot study, in 2019-2020. The research included design and delivery of training materials in SfS principles for staff and parents. SfS focuses on building partnership, understanding and collaborative problem-solving among the key individuals around the child, in order to facilitate wellbeing and positive educational outcomes. Findings indicate substantial impact on educational planning, practice and methods beyond the pilot school via the associated Discovery Multi Academy Trust which provides for 1260 children. SfS has improved home/school relationships, facilitated better educational engagement, leading to enhanced coping strategies and calmer home lives for the children [5.8].

“Safe for Schools has been a revelation and the impact it has had on the pupils and staff at our school is immeasurable” (SENCo, Beechwood Primary Academy, 5.8)

Impacts on the delivery of professional services

Training and supervision have facilitated the development of improved policy, practice and health care in a range of services. For example, Dallos trained more than 100 key staff across all children’s services in Cornwall from 2013-2015 as part of the ‘Reclaiming Social Work’ initiative stemming from the Monroe Report in 2011. This training impacted on social work policy, practice and client wellbeing across the whole county. Dallos provided a systemic ANT-informed model for statutory child and family social work supporting the development of a network of new roles across Cornwall Child & Family Social Work Services. For example, policy was changed to establish Principal Social Workers in every team. These are advanced practitioners with responsibility for improving provision and care through supervision, mentoring and support to other social workers with heavy case-loads. This training also contributed to Cornwall being the first authority to invest in applying a systemic model to an adult social care context, as a creative response to ensure the best care despite the pressures facing these services.

Dallos has collaborated with Professor Vetere (University of Surrey) to develop ANT-informed community projects including ‘Safer Families’ serving families with highly complex problems including violence, in Reading, Oxford and London 5.10] and has consulted with community services which grew from Safer Families in Ireland, Finland, Malta and Norway [S10]. Dallos also collaborated with senior clinicians to improve patient outcomes by establishing new clinics focusing on working systemically with complex problems, based on evidence–based ANT and SAFE techniques. Since August 2013, new clinics and enhanced services based on ANT and SAFE were established within Child and Adolescent Mental Health Services (CAMHS) in Nottingham, Torbay, Sheffield and Liverpool [S4, S9]. In these NHS and community clinics, evidence on outcomes is routinely collected from multiple sources including family feedback, medical records and therapists practice logs. Service providers report substantial benefits for child, adolescent, adult and family care in these innovative clinics, including addressing an absence of targeted support for families with complex problems [5.4, 5.9, 5.10].

“ANT principles with their understanding of arousal and arousal regulation, relational dangers, unprocessed trauma responding, the need for safety and comforting, and the ability to self-reflect and to heal and repair relationships is central to good practice….Feedback from multiple sources leaves me in no doubt that the ANT model addresses the relationship between content and process in systemic psychotherapy, and benefits individuals, families, couples and team working.” (Director of Safer Families, 5.10).

5. Sources to corroborate the impact

  1. The Bowlby Centre training testimonial written by Chair of the Executive Committee

  2. The Institute of Family Therapy training testimonial written by Director of Innovation and Continuing Professional Development

  3. Faculty of Medicine, Charles University, Testimonial, Czech Republic

  4. Trent testimonial-Clinical Doctoral Training and CAMHS (Nottingham and Sheffield)

  5. Final report for Randomised Controlled Feasibility Trial - PB-PG-0815-20058 funded by The National Institute of Health Research

  6. Final Report for research study - 7239 funded by Autistica

  7. The Child Development Centre, testimonial, University Hospitals Plymouth NHS Trust

  8. Beechwood Primary Academy, testimonial about SAFE for Schools written by SENCo

  9. Child and Adolescent Mental Health Services testimonial (Torbay and NW England)

  10. SAFER Families Intervention Service testimonial by Director

Additional contextual information

Grant funding

Grant number Value of grant
PB-PG-0815-20058 £208,575