Systemic Therapy

Systemic therapy is a psychotherapeutic approach that seeks the cause of a symptom in the relationships surrounding the child. Problem behavior is viewed as an expression of current patterns of communication and relationships within a system—that is, within the family, circle of friends, and school.

The focus broadens from the child to the entire environment. A withdrawn child is seen as part of a pattern that has developed among several people. The approach was developed beginning in the 1950s by, among others, Gregory Bateson, Paul Watzlawick, Virginia Satir, and Salvador Minuchin; in Germany, it was developed by Horst-Eberhard Richter and Helm Stierlin.

The approach is resource-oriented. Therapists engage in a curious, respectful dialogue and look for strengths that are already present, rather than focusing solely on deficits.

Systemic therapy uses its own conversation techniques. Four are particularly well-known:

• Circular questions: A family member is asked about another member’s perspective. “How do you think your sister feels when you argue?” This makes assumptions about relationships visible and open to discussion.
• Reframing: A behavior is given a new context. Defiance, for example, can be understood as an attempt to set one’s own boundaries. The new context opens the door to different responses.
• Genogram: A kind of family map spanning several generations. It helps identify recurring roles, patterns, and sources of stress.
• Family Sculpture: Family members physically arrange themselves in the room to represent closeness and distance. This reveals relationships that are often difficult to put into words.

Children are not reached through language alone. Depending on their age, play and creative methods are also used. Parents—and often siblings—are present in the room because change happens in everyday life among people, not just in the therapy room.

The Institute for Quality and Efficiency in Health Care (IQWiG) has assessed the benefits for children and adolescents based on 42 randomized controlled trials. The results vary depending on the specific disorder.

Benefits were observed, among other things, in:

• anxiety and obsessive-compulsive disorders, combined with a guideline-based approach
• Eating disorders (family-based therapy (FBT) is relevant here)
• hyperkinetic disorders, i.e., in the ADHD spectrum, in combination with medication
• substance-related disorders

In the case of affective disorders, such as depression, however, the IQWiG identified a disadvantage compared to other approaches. In other words, systemic therapy is not a panacea. The appropriate approach depends on the specific disorder and the individual child.

For a long time, systemic therapy in Germany was not covered by statutory health insurance. This has changed in two stages.

For adults, the Joint Federal Committee (G-BA) recognized the approach as the fourth guideline-based therapy, alongside behavioral therapy as well as analytical and depth psychology-based psychotherapy. It has been covered by health insurance since early 2020.

For children and adolescents, the decision followed on January 18, 2024. Following the adjustment of reimbursement rates, the treatment became available as a covered service in the summer of 2024 and is now also accessible to this age group. It is provided by licensed psychotherapists with appropriate advanced training and health insurance accreditation.

For parents, this means specifically: If your child begins therapy covered by health insurance, you can now also reach out to practices that use a systemic approach. The fact that parents and siblings are involved does not mean that the family is to blame for the problem. This approach uses the people closest to the child as part of the solution.

Complementary components include parent training or, in cases of marital conflict, couples therapy. Other approaches, such as psychodynamic therapy or behavioral therapy, may be more appropriate depending on the diagnosis.

Rückenwind “Eltern” provides coaching, not psychotherapy. Janike is a social worker and parent coach currently training to become a child and adolescent psychotherapist; she is not licensed and does not make diagnoses. An assessment and the selection of the appropriate approach should be handled by a child and adolescent psychiatry (KJP) specialist or a medical or psychotherapeutic professional.