Abstract
Background
Systemic therapy (ST) was approved as a further psychotherapy approach in line with the German Psychotherapy Directive’s requirements in 2020 for adults and in 2024 for children and adolescents, and is thus covered by statutory health insurance.
Methods
Selective literature review on the theoretical foundations and clinical practice of ST, including recent meta-analyses of its efficacy.
Results
The theoretical foundations of ST include systems and communication theory, moderate constructivism, the multigenerational perspective, and, in some manuals, the attachment perspective. Structural-strategic family therapy and the solution-focused therapy approach are key elements of its clinical practice. ST is mostly provided in individual or multi-person settings. Important interventions include solution-focused and circular questions, positive reframing, genograms, sculptures, tasks, and prescriptions. Several disorder-specific ST manuals have been developed. The efficacy of ST has been evaluated in 7 recent meta-analyses: ST has been found effective against various disorders, both in adults (affective disorders, anxiety/obsessive-compulsive disorders, substance use disorders, eating disorders, schizophrenia/psychotic disorders) and in children and adolescents (anxiety/obsessive-compulsive disorders, hyperkinetic disorders, substance use disorders, eating disorders, and mixed disorders). For example, in the treatment of depression in adults, ST was shown to be superior to no add-on treatment (Hedges g: 1.09, 95% confidence interval [0.78; 1.40]).
Conclusion
ST broadens the scope of treatment options for mental disorders, with a specific focus on their social context.
Systemic therapy (ST) is a psychotherapeutic method focusing on the social context of mental disorders. It was scientifically recognized in 2008 for all age groups (adults, children, and adolescents) by the German Scientific Advisory Board for Psychotherapy (Wissenschaftlicher Beirat Psychotherapie, WBP) (1, 2). In 2020, after a further review by the German Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), ST was also recognized by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) under German social law and included in the list of services covered by statutory health insurance as a directive-based procedure for adult psychotherapy (3). In 2024, systemic therapy was also accepted as a directive-based procedure for child and adolescent psychotherapy (4).
Definition.
Systemic therapy (ST) is a psychotherapeutic method focusing on the social context of mental disorders. It was scientifically recognized in 2008 for all age groups (adults, children, and adolescents) by the German Scientific Advisory Board for Psychotherapy.
Learning objectives
In this article, we provide an overview of systemic psychotherapy that should enable the reader to give well-founded answers to the following questions:
What are the theoretical foundations of ST?
What are the features of ST in clinical practice?
What characterizes the clinical practice of of ST?
Systemic therapy as a directive-based procedure.
Systemic therapy (ST) was approved as a further psychotherapy approach in line with the German Psychotherapy Directive’s requirements in 2020 for adults and in 2024 for children and adolescent.
Systemic therapy developed from family and couple therapy starting in the 1950s. It is foused on the interactions between mental symptoms and the biopsychosocial context (Box 1). Mental disturbances have effects on other family members; conversely, interpersonal relationships (e.g., relationship conflicts) affect the individual’s mental well-being. Relationships can strengthen the individual but can also be a source of stress, most often unintentionally. ST is thus mainly addressed to the social context of mental health problems and deals not only with the problems themselves, but also with resources (1).
Box 1. Definition.
Systemic therapy has been defined as a psychotherapeutic method focusing on the social context of mental disorders (1, 7). Systemic therapy is centered on reciprocal interactions on the intrapsychic, biological-somatic, and interpersonal levels. The main goal of treatment is to change symptom-promoting interactions (particularly at the familial and social levels), narratives, and intrapsychic patterns to promote a more functional self-organization of the patient and the treatment-relevant social systems, making use of the patient‘s own competencies (3).
Couple and family therapy (CFT) is a scientifically recognized psychotherapeutic approach in North America. Although its approach is integrative, i.e., not narrowly based on any single psychotherapy approach, its general orientation is always systemic. In contrast, European regulatory structures concerning psychotherapy, including the German Psychotherapists Act, tend to address the theoretical principles of treatment procedures rather than the setting in which treatment takes place. ST has been a recognized technique in many European countries for many years and is attracting increased attention outside Europe as well (5). Couple/family therapy and ST have a great deal in common. ST, however, can be implemented not just in multi-person settings (MPS, i.e., with families, couples, non-family caregivers, and other professional carers), but also as individual, group, or multi-family group therapy (6).
Theoretical foundations
The theoretical foundations of ST are systems and communication theory, moderate constructivism, the multigenerational perspective, and often also attachment theory and transtheoretical concepts such as the biopsychosocial model (8). ST requires consideration of family structures and interaction patterns, as well as resources and solutions and “the good in the bad.” The basic perspectives and main founders of ST are presented in Table 1, and its key concepts are explained briefly in what follows (1, 9, 10).
Table 1. Basic perspectives and major proponents of systemic psychotherapy.
| Perspectives and basic ideas | Major proponents |
| The structural-strategic perspective | |
|
• Clinical problems are seen as an expression of dysfunctional family structures that are no longer suited to development. • Families are regarded as rule-governed systems whose structure can be sufficiently objectively recognized from the outside and influenced in a targeted manner through therapy. • Focus on reciprocal causality (“vicious circles”). |
Minuchin, Haley, Madanes, Selvini-Palazolli |
| The multigenerational, attachment, and mentalization perspective | |
|
• Combines psychodynamic, attachment-theoretical, psychotraumatologic, and systemic concepts. • Focuses on attachment patterns, mentalization, and differentiation and their transgenerational transmission. • Attention to familial delegations, legacies, loyalties and familial “debit and credit accounts.“ |
Bowlby, Bowen, Boszormenyi-Nagy, Stierlin, Asen & Fonagy, Schnarch |
| Experiential (experience-actvating) family therapy | |
|
• Combines humanistic and systemic concepts. • Focuses on the exchange of emotions in couple relationships/families and on self-esteem regulation and proximity-distance preferences. |
Satir, Johnson |
| The solution-oriented approach | |
| • Focuses on resources/solutions rather than on problems/symptoms. Interventions are adapted to the patients‘ motivation for seeking treatment. | de Shazer, Berg |
| The self-organization perspective | |
| • Focuses on self-management and self-organization. Avoids normative ideas about families and health. | Cecchin |
| The narrative perspective | |
| • Focuses on how reality and identity are co-constructed through narratives. | White, Seikkula, Anderson |
Theoretical foundations.
The theoretical foundations of ST are systems and communication theory, moderate constructivism, the multigenerational perspective, and often also attachment theory and transtheoretical concepts such as the biopsychosocial model.
With an orientation toward moderate constructivism, ST differentiates between objectively measurable data (e.g., genetic paternity) and subjective perspectives (e.g. “perceived paternity”; subjective health) (11). Varying perspectives can lead to disagreement about the accuracy of a given description, but such differences can also be used therapeutically.
A constitutive element of ST is the consideration of networks and cycles of mutual influence, a circular approach characterized by reciprocal interactions, inspired by (family) systems theory and by cybernetics, i.e., the theory of system control and regulation (12, 13). Important aspects include boundaries (agreements, usually implicit, about who belongs to the social system in question), verbal and non-verbal communication, explicit and implicit rules (recurring patterns in mental and social systems), and subsystems (e.g. biological, mental, social, and societal).
Human systems have a greater range of variation (more degrees of freedom) than non-human systems; they are, therefore less predictable and can be influenced only to a limited extent and with less certainty of achieving any desired aim (13). The concepts of the self-organization and autopoietic properties” of living systems imply that any intervention will have a chance of effecting a desired change only if it is well aligned with the characteristics of the person under treatment and his or her family. Certain positions (“attractors”) narrow the scope for development and may severely limit individual perceptions; for example, the conviction that “With my depression genes, I will always feel bad.”
The ST approach centers on the interactions between symptoms and context, self-reinforcing patterns of interaction (vicious circles), structural families characteristics such as closeness/distance and hierarchies, power differences. and the greater cultural context (1).
Clinical practice
Diagnostic evaluation
Clinical diagnostic and classification systems such as the ICD-10 and ICD-11 focus on the individual patient and his or her deficits, while ST takes a greater interest in social contexts and resources and has a more fluid concept of mental illness. Symptom-oriented diagnostic instruments and clinical diagnoses are used in research, teaching, and the clinical practice of ST as working hypotheses with limited applicability and are supplemented by resource and system diagnosis.
Diagnosis.
ST takes a greater interest in social contexts and resources and has a more fluid concept of mental illness. Symptom-oriented diagnostic instruments and clinical diagnoses are used as working hypotheses with limited applicability and are supplemented by resource and system diagnosis.
Important information sources for relational diagnosis are initial interviews in the individual or multi-person setting, the observation and analysis of verbal and nonverbal interactions, genograms (family trees), standardized system-diagnostic procedures such as questionnaires and sculpting methods (14–16). The participants’ statements and observed patterns of interaction (e.g., whenever the mother says something, the father and son look at each other and smile quietly) enable the formulation of initial hypotheses about family boundaries and coalitions, or specific patterns such as parentification, in which a child feels responsible for comforting or protecting a distressed parent (17).
Therapeutic practice
The basic therapeutic approach uses questions (Box 2) and is intended to ensure respect for, and a positive approach toward, all relevant persons (including absent ones), neutrality, and beneficial cooperation with all involved parties (significant others both within and outside the family). Inflexible attitudes are to be avoided, and a “language of change” is used to open up new possibilities. The goals of treatment are jointly developed on the basis of the patients’ concerns and those of the persons around them. The perspectives of patients and their relatives are taken into account along with the therapist’s assessments, clinical experience, and evidence-based knowledge of suitable treatment strategies for specific symptoms. “Ambivalence about change” is commonly encountered and is openly explored and discussed (1).
Box 2. Systemic questions.
-
On the context of the referral:
What does your family doctor think is the matter?
-
On the relationship context:
How would your mother/wife/daughter/grandchild describe the problem?
-
On the goals of treatment:
If a miracle happened while you were sleeping tonight and your problem disappeared by the time you woke up tomorrow morning, how would you know? (the “miracle question”)
If necessary, sessions also take place in varying settings (e.g., both individual and multi-person settings; or group therapy combined with multi-family therapies, designated as “group therapy in MPS”). Flexibility of this type necessitates clarity and transparency about what is being done as well as clear rules about confidentiality. The approach varies depending on the context (setting, age of the patient, type of disturbance, cultural aspects, etc.). If the patient is a child or adolescent, both parents should always be involved if possible; adolescent patients can also be treated in a split setting (adolescent alone; parents alone). The individual setting is more common for adult patients (18, 19).
Ten to 25 treatment sessions are often sufficient, but there may be many more. In Germany, the maximum reimbursable amount of systemic therapy is currently set at 48 so-called therapy units, each consisting of 50 minutes in an individual or multiperson setting or 100 minutes in group therapy. Sessions are held at intervals from one to six weeks. Teamwork, note-taking, video recordings, and video feedback are helpful, as are breaks in therapy sessions for reflection, self-awareness, and supervision/peer consultation (6, 17).
Therapeutic practice.
The basic therapeutic approach uses questions (Box 2) and is intended to ensure respect for, and a positive approach toward, all relevant persons, neutrality, and beneficial cooperation with all involved parties. Inflexible attitudes are to be avoided, and a “language of change” is used to open up new possibilities.
The goals of systemic psychotherapy are….
jointly developed on the basis of the patients’ concerns and those of the persons around them. Their perspectives are taken into account along with the therapist’s assessments, clinical experience, and knowledge of treatment strategies for specific symptoms. “Ambivalence about change” is common and is openly explored and discussed.
Central interventions
ST is described in multiple textbooks (e.g., Ref. 6; eSupplement, Appendix 1 [eSupplement available in German only]). Key interventions include systemic solution-oriented questions, positive reframing, genograms, and sculpting work (3, 6, 20, 21).
Reframing is a common type of intervention; it emphasizes “the good in the [seemingly] bad” and thereby heightens self-esteem. Cooperative relationships are fostered by describing behavior, for example, not as “compulsive,” but as “exceedingly careful”; not as “hysterical,” but as “stimulatingly lively” (6).
A genogram (family tree) is a symbolic-pictorial representation of a family that aids in the exploration of the historical-cultural context (16, 22). It contains information on all family members over at least three generations (dates of birth/death, marriages, occupations, illnesses, and so on).
Family sculpting enables symbolic-metaphoric representation of family relationships, either as a “living sculpture” (with the persons participating in MPS) or as a figure-placement procedure. The current situation at the start of therapy and the desired situation at the end of therapy are relevant for the diagnostic evaluation and the planning of treatment. Important dimensions are closeness/distance and hierarchy (who is depicted as being “on top,” and who “on the bottom”?) (16).
Systemic-structural interventions are intended to visualize family structures and interaction patterns so that they can be beneficially changed (1, 6, 12). This is done, for example, by carefully and respectfully addressing recurring verbal and nonverbal patterns with questions: for example, “Mrs. X, it seems to me that, whenever you say something, your husband and son smile to themselves. Am I right about that?” If the answer is yes, the therapist can further explore Mrs. X’s thoughts and their significance, the thoughts of Mr. X and their son, and the feelings that are engendered in all three.
Family tree.
A genogram (family tree) is a symbolic-pictorial representation of a family and that aids in the exploration of the historical-cultural context. It contains information on all family members over at least three generations (dates of birth/death, marriages, occupations, illnesses).
Overview of systemic manuals
There are multiple systemic, mostly disorder-specific manuals, which have been described elsewhere in greater detail (6). Most of them were developed on the basis of structural family therapy (12), the solution-oriented approach (21), and basic research (eSupplement, Appendix A2).
Methods
We selectively searched the literature for recent meta-analyses (years of publication, 2014–2024) on the global effectiveness of ST for mental disorders in adults and in children and adolescents. Relevant publications were retrieved from the Medline, ProQuest, and Google Scholar databases, from existing reviews (1, 5, 23–26) (eSupplement, Appendix A4), and the reference sections of other retrieved publications. Further information on the search strategy and inclusion and exclusion criteria can be found in the eSupplement, Appendix A3.
Results
Meta-analyses on the effectiveness of ST
Seven meta-analyses were found (Table 2) concerning the effectiveness of ST in adults (27–29) or in children and adolescents (30–33) (Table 3). The most comprehensive studies of the effectiveness of ST are those of the IQWiG on adult and child/adolescent psychotherapy (28, 31). We describe the IQWiG analyses and other recent meta-analyses and summarize the findings on selected aspects in two tables. An overview of further meta-analyses and Cochrane reviews is provided in the eSupplement, Appendix A4.
Table 2. Identified meta-analyses on the efficacy of systemic therapy (ST).
| Authors | Age group | Intervention(s) studied | Disorders/preblems mainly addressed | Included RCTs | |
| Year of publication | Number | ||||
| Pinquart et al., 2014 (27) | adults | ST | mental disorders | 1975–2014 | 37 |
| IQWiG, 2017 (28) | adults | ST | mental disorders (and somatic diseases) | 1987–2016 | 33 |
| Vossler et al., 2024 (29) | adults | ST | depression | 1975–2022 | 30 |
| Riedinger et al., 2017 (30) | children/adolescents | ST | mental disorders | 1973–2012 | 56 |
| IQWiG, 2023 (31) | children/adolescents | ST | mental disorders | 1998–2020 | 42 |
| Huang et al., 2024 (32) | children/adolescents | ST | depression | 1997–2021 | 9 |
| Seidel et al., 2024 (33) | children/adolescents | ST vs.CBT | mental disorders | 1997–2020 | 15 |
CBT, cognitive behavioral therapy; RCT, randomized controlled trial; ST, systemic therapy; vs., versus
Table 3. Evidence table for ST in adults: selected findings of recent meta-analyses (24, 25).
| Authors, year (reference) |
Diagnosis (outcome measure) |
Intervention vs. control | Period of observation | Number of studies |
Results:
Hedges’ g [95% CII] and interpretation |
| Vossler et al., 2024 (29) | depression(depression score) | ST vs. no treatment | post-test | 20 | g: 1.09 [0.78; 1.40] + |
| follow-up | 9 | g: 1.23 [0.80; 1.68] + | |||
| ST vs. other PT | post-test | 15 | g: 0.25 [−0.06; 0.56] 0 | ||
| follow-up | 13 | g: 0.09 [−0.15; 0.33] 0 | |||
| IQWiG, 2017 (28) | anxiety disorder (complete remission) | ST vs. other PT | 1 year | 1 (with 3 study arms: Knekt, 2004 [e19]; n = 158) | OR: 0.95 [0.47; 1.94] 0 |
| IQWiG, 2017 (28) | obsessive-compulsive disorder (global symptom improvement) | ST + pharmacotherapy vs. pharmacotherapy alone | 2–3 months | 2 | OR: 3.48 [1.34; 9.03] + |
| IQWiG, 2017 (28) | eating disorders(partial remission) | ST vs. counseling and patient education | 12 months | 1 (Dare, 2001 [e20], n = 84) | OR: 10.29 [1.15; 92.19] + |
| IQWiG. 2017 (28) | mixed disorders(symptom improvement) | ST vs. PT | 5 and 12 months | 1 (Lau, 2007 [e21], n = 151) | OR: 0.36 [0.14; 0.88] + |
| IQWiG, 2017 (28) | somatic symptoms(fatigue, CIE in inflammatory bowel disease) | ST vs. no additional treatment | 3 months | 1 (Vogelaar, 2014 [e22], n = 97) | g: −0.56 [−0.84; −0.27] + |
| IQWiG, 2017 (28) | schizophrenia(global symptoms) | ST + pharmacotherapy vs. pharmacotherapy alone | 2 and 2.5 years | 2 | g: −1.26 [−1.55; −0.98] + |
| IQWiG, 2017 (28) | substance use disorder (heroin dependence)(partial remission) | ST + methadone reduction program vs. counseling, patient education, + methadone reduction program | 6 months | 1 (with 3 study arms: Yandoli, 2002 [e23], n = 119) | OR: 3.23 [1.38; 7.57] + |
CI, confidence interval; CIS, Checklist Individual Strength—fatigue score; n, number of patients in study; OR, odds ratio; PT, psychotherapy; ST, systemic therapy, vs., versus
Interpretation: +: ST superior to the comparison group; 0: no significant difference between ST and comparison group; -: ST inferior to the comparison group.
Hedges’ g: 0.2 weak, 0.5 moderate, 0.8 strong effect
IQWiG (2017): the efficacy of ST in adults
Systematic literature searches identified 42 randomized controlled trials (RCTs) of ST (as individual, couple, family, group, or multifamily group therapy) in adults with established ICD or DSM diagnoses; 33 RCTs provided usable data. Three different types of comparison were examined for each of eight disorder groups: ST compared to guideline-based therapies, to other types of psychotherapy, to counseling and patient education, or to no (additional) treatment. The analyses of the endpoints that were examined in these studies led to the calculation of hundreds of effect sizes. These highly detailed results are reported in what follows below only in summarized fashion, qualitatively and by effect size (Table 3). The degree of reliability of the conclusions was categorized by the IQWiG into four classes: “proof,” “indication,” or “hint” of greater benefit of the experimental intervention, or “no hint of a benefit” (28).
Family sculpture.
Family sculpting enables symbolic-metaphoric representation of family relationships, either as a “living sculpture” (in MPS) or as a figure-placement procedure. The current situation at the start of therapy and the desired situation at the end of therapy are relevant for the diagnostic evaluation and the planning of treatment.
Evidence was found for a benefit of ST in the treatment of depression, eating disorders, mixed disorders (compared to guideline therapy), and substance use disorders (compared to counseling and patient education), as well as anxiety and obsessive-compulsive disorders, schizophrenia, and bipolar disorders (compared to no additional therapy, or ST plus medication versus medication alone). In the treatment of personality disorders, no difference in efficacy was found between ST and other types of guideline-based psychotherapy. Nine studies yielded evidence of a positive effect of ST on somatic and/or mental health when used as add-on treatment for various somatic illnesses (e.g., chronic inflammatory bowel disease, coronary heart disease, musculoskeletal symptoms) (28).
Selected IQWiG findings are shown in (Table 3 (28): among other findings, the efficacy of ST in the treatment of anxiety disorders does not differ significantly from that of other types of psychotherapy, while ST plus pharmacotherapy is superior to pharmacotherapy alone in the treatment of obsessive-compulsive disorder and schizophrenia. When used in heroin addicts participating in a methadone program, systemic family therapy had a more beneficial effect on heroin abstinence than counseling and patient education.
The G-BA has recognized the efficacy of ST in the following types of mental disorder in adults, on the basis of the IQWiG analyses:
affective disorders, anxiety/obsessive-compulsive disorders, eating disorders, substance use disorders, schizophrenia/psychotic disorders
IQWiG (2023): the efficacy of ST in children and adolescents
The IQWiG (31) identified a further 50 RCTs on the efficacy of ST against mental disorders in childhood and adolescence. 42 RCTs provided usable data. The efficacy of ST was examined in eight categories of disorder in comparison to guideline-based psychotherapy, non-guideline-based psychotherapy, other treatments, and no treatment, with further comparisons of ST plus medication versus medication alone. The results were determined for each disorder, comparison and outcome; here, too, the highly detailed results are reported in what follows in summarized form, qualitatively and only in part quantitatively (Table 4). The degree of reliability of the conclusions was categorized here as well, with Anhaltspunkt (“hint” of a benefit) representing the lowest degree.
Table 4. Evidence table for ST in children and adolescents: selected findings of recent meta-analyses (27–29).
| Authors. year (reference) |
Diagnosis
(outcome measure) |
Intervention vs. control | Period of observation | Number of studies |
Results: Hedges’ g [95% CII] and interpretation |
| Huang et al.. 2024 (32) | depression (depression score) |
ST vs. no treatment | post-test | 2 (n = 117) | SMD: −1.75 [−2.96; −0.54] + |
| ST vs. TAU | post-test | 3 (n = 146) | SMD: −0.45 [−1.14; 0.24] 0 | ||
| ST vs. other PT | post-test | 3 (n = 263) | SMD: −0.04 [−0.28; 0.20] 0 | ||
| Seidel 2024 (33) | depression (BDI < 9) | ST vs. CBT | 12–16 weeks | 1 (n = 64) | OR: 0.35 [0.13; 0.97] − |
| Seidel 2024 (33) | anxiety disorder(PARS) | ST vs. CBT | 12 weeks | 1 (n = 97) | MD: −1.10 [−2.82; 0.62]; 0 |
| Seidel 2024 (33) | obsessive-compulsive disorder (CY-BOCS < 14) | ST & CBT vs. CBT | 14 weeks | 1 (n = 61) | OR: 3.81 [1.29; 11.2] + |
| Seidel 2024 (33) | eating disorder, bulimia (persons without binge attacks) | ST vs. CBT | 6 months | 1 (n = 109) | RD: 0.197, p = 0.04 + |
| Seidel 2024 (33) | eating disorder, anorexia (BMI) | ST vs. CBT | 18 months | 1 (n = 74) | MD: 0.28 [−0.51; 1.06] 0 |
| Seidel 2024 (33) | hyperkinetic disorder (BRIEF) | ST vs. CBT | 2.1 months | 1 (n = 146) | g: 0.25 [−0.08; 0.57] 0 |
| Seidel 2024 (33) | substance (cannabis) use disorder (ADI-Light for cannabis) |
ST vs. CBT | 12 months | 1 (n = 450) | OR: 1.68 [1.15; 2.44] + |
| IQWIG 2023 (31) | mixed disoders (RCBC) | ST vs. PT | 6 months | 1 (n = 52) | g: −0.63 [−1.19; −0.07] + |
ADI-Light for Cannabis, Adolescent Diagnostic Interview-Light for remission, abuse, dependence; BDI, Beck Depression Inventory; BMI, body mass index; BRIEF, Behavior Rating Inventory of Executive Function—Total Score; CBT, cognitive behavioral therapy; CI, confidence interval; CY-BOCS, Children”s Yale-Brown Obsessive Compulsive Scale; g, Hedges’ g; MD, mean differences; n, number of patients in study or studies; OR, odds ratio; PARS, Pediatric Anxiety Rating Scale; PT, other psychotherapeutic methods; RCBC, Revised Child Behavior Checklist; RD, risk difference; TAU, treatment as usual.
Interpretation: +: ST superior to the comparison group; 0: no significant difference between ST and comparison group; -: ST inferior to the comparison group. Hedges’ g: 0.2 weak, 0.5 moderate, 0.8 strong effect
In five of the eight disorder groups, the IQWiG found evidence for a benefit of ST: for anxiety/obsessive-compulsive disorders, compared to guideline-based therapy and no treatment; for eating disorders, compared to other types of psychotherapy or other treatment; for hyperkinetic disorders. as an add-on to medication compared to medication alone (there was no significant difference in efficacy compared to CBT either); and for substance use disorders, as well as for mixed disorders, compared to guideline-based treatment. The findings for affective disorders were mixed: ST was inferior to the comparison therapies in some studies, but superior to no treatment in others, and the IQWiG summarized these findings as suggesting a existing, but lower benefit of ST. The analyses of the IQWiG, unlike those of older meta-analyses, revealed no benefit of ST for disruptive behavior disorders or autism spectrum disorders (eSupplement, Appendix A4).
The G-BA has recognized the efficacy of ST in the following types of mental disorder in children and adolescents, on the basis of the IQWiG analyses:
anxiety/obsessive-compulsive disorders, behavioral/emotional disorders with onset in childhood/adolescence (hyperkinetic disorders), eating disorders, substance use disorders, mixed disorders
Other recent meta-analyses
Key findings of the meta-analyses on the efficacy of ST for adults (Table 3) and children and adolescents (Table 4), are presented in the tables; further findings from meta-analyses can be found in the eSupplement, Appendix A4.
Vossler et al. (2024) (29) identified 30 RCTs comparing the efficacy of ST with that of alternative or no treatment for depression in adults. ST yielded greater improvement in depressive symptoms than no treatment, both in the post-test and on later follow-up. ST and alternative types of psychotherapy did not differ significantly in efficacy (Table 3). Moderator analyses suggest that the benefit of ST is less than that of CBT (2 RCTs) and marginally greater than that of psychodynamic therapy (2 RCTs).
Huang et al. (32) included nine RCTs in their meta-analysis of the efficacy of ST for depression in children and adolescents (Tables 2 and 4). ST relieved depressive symptoms with greater efficacy than placement on a waiting list and with the same efficacy as supportive psychotherapy and treatment as usual (TAU). A few studies suggest that ST may be superior to psychodynamic psychotherapy (SMD -0.66 [-1.13; –0.18]) and inferior to CBT (SMD 0.58 [0.11; 1.05]) (eSupplement, Appendix A4.4). (eSupplement, Appendix A4.4).
The efficacy of systemic therapy against depression in adults.
In an meta-analysis, systemic therapy had greater efficacy against depressive symptoms than no treatment and similar efficacy to other types of psychotherapy.
A meta-analysis by Seidel et al. (33) compared the efficacy of ST with that of CBT in children and adolescents with mental disorders on the basis of a subsample of the studies identified by IQWiG (2024): 15 RCTs were assigned to 5 disorder groups (Table 2, eSupplement Appendix A4.3). In some cases, meta-analyses could not be performed, because there were too few homogeneous primary studies. For depression, CBT was apparently superior to ST; for eating disorders, ST was superior, but only in part; for anxiety disorders and hyperkinetic disorders, it could not be concluded that ST was either superior or inferior to CBT. A statistically significant and clinically relevant superiority of ST over CBT was found in the treatment of substance use disorders, while, in the treatment of obsessive-compulsive disorder, ST added to CBT was found to be more effective than CBT alone (Table 4).
The efficacy of systemic therapy against depression in children and adolescents.
In an meta-analysis, systemic therapy had greater efficacy against depressive symptoms than placement on a waiting list and similar efficacy to supportive psychotherapy or other types of psychotherapy.
Side effects
In the published research on ST, like research on psychotherapy in general, there is a scarcity of findings on possible adverse effects and malpractice (24, 27). At any rate, the findings in adult patients do not suggest that ST leads, on average, to a worsening of symptoms or psychosocial well-being (28). Beyond the general potential side effects of psychotherapy (e.g., worsening of symptoms), the potential modality-specific side effects of ST might include traumatic insights gained during interventions in a multigenerational perspective, negative effects on the family, adverse consequences of uncovered family secrets, and adverse consequences of the therapist taking sides in interpersonal conflicts (34).
Side effects.
In the published research on ST, like research on psychotherapy in general, there is a scarcity of findings on possible adverse effects and malpractice. The findings in adult patients do not suggest that ST leads, on average, to a worsening of symptoms or psychosocial well-being
Indications, contraindications, and guidelines
Indications, contraindications, and guidelines.
The German Joint Federal Committee (G-BA) recognized ST in 2018 as a method of adult psychotherapy under German social law with documented efficacy in five areas: affective disorders, anxiety/obsessive-compulsive disorders, substance use disorders, eating disorders, and schizophrenia/psychotic disorders.
In consideration of the findings of the IQWiG meta-analyses (28, 31), the German Joint Federal Committee (G-BA) recognized ST in 2018 as a method of adult psychotherapy under German social law with documented efficacy in five areas: affective disorders, anxiety/obsessive-compulsive disorders, substance use disorders, eating disorders, and schizophrenia/psychotic disorders (3). It also decided on January 18, 2024 to recognize ST as a procedure for children and adolescents under social law. Here, too, five areas of application were recognized: anxiety/obsessive-compulsive disorders; behavioral/emotional disorders with onset in childhood and adolescence (hyperkinetic disorders); eating disorders; substance use disorders; and mixed disorders. For other indications, the G-BA saw no evidence that ST was either ineffective or harmful, but it viewed the likelihood of bias in many studies and the frequent lack of comparison with other guideline-based forms of psycho- or pharmacotherapy as an impediment to recognition. As the regulatory framework of the G-BA now acknowledges that ST has met the threshold criterion of demonstrated efficacy, both in adult psychotherapy and in child and adolescent psychotherapy, and ST has accordingly been approved under German social law, it may now be used for all mental disorders in accordance with the psychotherapy guidelines (3, 4). ST can also improve the mental well-being (and, to some extent, the physical well-being) of the somatically ill (28).
There is an indication for ST especially in those areas where the G-BA has recognized it. Family therapy/ST is more frequently recommended in international guidelines, but this is only slowly changing in the German treatment guidelines (5, 35). ST is considered in a few guidelines for child/adolescent and adult psychotherapy (eSupplement, Appendix A6).
Systemic therapy (ST) in a multi-person setting (MPS) is indicated if the disorder affects more than one person, if the patient or their significant others request it, if the patient is heavily dependent on others (and, in particular, if the patient is a child or adolescent), if family interactions clearly affect the course of the illness and vice versa, or if family resources need to be activated. In the case of minors, the involvement of parents is essential for the success of the therapy, but joint physical presence in the therapy room is not mandatory. MPS is contraindicated if couples/family therapy sessions are rejected by the patient or his/her family, or if there is a risk of violent escalation, verbal abuse, or re-traumatization (1, 18, 36).
As for the potential contraindications of ST, there is currently no evidence of ineffectiveness or harm in relation to the areas of application of the psychotherapy directive, although there remains a need for further research in this area. For some disorders, the evidence for ST remains weak or non-existent (e.g., post-traumatic stress disorders and personality disorders).
Contraindications to systemic therapy.
As for the potential contraindications of ST, there is currently no evidence of ineffectiveness or harm in relation to the areas of application of the psychotherapy directive, although there remains a need for further research in this area.
Conclusion
In a number of common mental disorders, ST can markedly alleviate symptoms and improve the disorder. Because of its documented efficacy, ST has been scientifically and legally recognized in Germany as a psychotherapeutic method for all age groups. It is also considered in other countries to be one of the basic approaches to psychotherapy (5, 37). Efficacy studies and basic research have shown that the focus of ST on social relationships is crucial for mental and physical health (38). Research gaps still remain, including comparisons of ST with guideline therapies (Tables 3 and 4) and research on ST for disorders in young children, on MPS, and on the adverse effects and risks of ST. There are also implementation deficits of ST at German university clinics (39, 40) (eSupplement, Appendix A1) and in outpatient psychotherapeutic and specialist care.
Conclusion.
In a number of common mental disorders, ST can markedly alleviate symptoms and improve the disorder. Because of its documented efficacy, ST has been scientifically and legally recognized in Germany as a psychotherapeutic method for all age groups.
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Questions on this article.
Participation is possible at cme.aerzteblatt.de.
The submission deadline is 14 November 2025.
Only one answer is possible per question. Please select the answer that is most appropriate
Question 1
For which age groups is systemic therapy a scientifically recognized psychotherapeutic method?
adults
children and adolescents
all age groups
no age group
This is currently being studied, and there is no definitive answer yet.
Question 2
Is systemic therapy a guideline-based procedure recognized by social law in Germany?
No.
This is being examined with regard to all age groups, and a decision is still pending.
Yes, for the treatment of adults; it is being examined with regard to children and adolescents, and a decision is still pending.
Yes, for the treatment of children and adolescents; with regard to adults, it is being reviewed and a decision is still pending.
Yes, for all age groups.
Question 3
When is systemic therapy in a multi-person setting indicated?
when the person undergoing therapy is too shy
when the patient’s significant others reject it
when family members are estranged and out of contact
when family interactions are presumed to affect the illness, and vice versa
when family resources are to be deactivated
Question 4
Which of the following is an important element in the diagnostic evaluation of relationships, in the context of systemic therapy?
the interpretation of unconscious conflicts
the creation of family trees
assertiveness training
intelligence tests
body-oriented exercises in the initial exploratory sessions
Question 5
For which groups of disorders has the G-BA recognized ST as effective?
anxiety disorders, eating disorders, mixed disorders, substance use disorders
affective disorders, anxiety/obsessive-compulsive disorders, substance use disorders, eating disorders, psychotic disorders
depression, eating disorders, mixed disorders, substance-related disorders
anxiety disorders, obsessive-compulsive disorders, personality disorders, eating disorders
depression, anxiety disorders, obsessive-compulsive disorders, personality disorders
Question 6
What is meant by a “living sculpture” in systemic therapy?
a symbolic-metaphorical representation of family relationships in which people are placed in a room in a multi-person setting
a sculpture made of clay or other malleable material
a figurative representation created in a multi-person setting
an object used in the family with special symbolic meaning
a network of relationships involving the parents and the patient
Question 7
Which method is most likely to be used in systemic therapy to make family structures and interaction patterns visible?
hypnosis
eye movement desensitization and reprocessing
systemic-structural interventions
analysis of structural functioning level
social skills training
Question 8
Which of the following is a contraindication to systemic psychotherapy in a multi-person setting?
schizophrenia
relapsing depression
bipolar disorders
personality disorders
a high risk of violent escalation, verbal abuse, or re-traumatization
Question 9
Which of the following sentences is an example of positive reframing?
Ms. M is highly intelligent.
Ms. M has a good social environment.
Ms. M is a successful lawyer.
Ms. M senses possible rejection very quickly—she has very fine antennae that miss nothing.
Ms. M seems to be a loving mother to her two children.
Question 10
In 2023, the IQWiG studied the efficacy of systemic therapy in children and adolescents. For which group of disorders could no evidence of benefit be found?
obsessive-compulsive disorders
eating disorders
disruptive/conduct disorders
anxiety disorders
mixed disorders
Acknowledgments
Translated from the original German by Ethan Taub, M.D.
Footnotes
Conflict of interest statement
Prof. von Sydow receives royalties for books published by Beltz-Verlag and Hogrefe-Verlag. The other authors state that they have no conflict of interest.
References
- 1.von Sydow K, Beher S, Retzlaff R, Schweitzer-Rothers J. Göttingen: Hogrefe; 2007. Die Wirksamkeit Systemischer Therapie/Familientherapie. [Google Scholar]
- 2.Wissenschaftlicher Beirat Psychotherapie (WBP) Gutachten zur wissenschaftlichen Anerkennung der Systemischen Therapie. Dtsch Arztebl. 2009;106:208–211. [Google Scholar]
- 3.Gemeinsamer Bundesausschuss (G-BA) (2009/2024) Psychotherapie-Richtlinie in der Fassung vom 19.02.2009, veröffentlicht im Bundesanzeiger Nr. 58 (S. 1 399) vom 17.04.2009, in Kraft getreten am 18.04.2009. Zuletzt geändert am 21.03.2024, veröffentlicht im Bundesanzeiger (BAnz AT 18.06.2024 B3), in Kraft getreten am 19.06.2024. www.g-ba.de/richtlinien/20/ (last accessed on 14 October 2024) [Google Scholar]
- 4.Gemeinsamen Bundesausschuss (G-BA) Beschluss des Gemeinsamen Bundesausschusses über eine Änderung der Richtlinie über die Durchführung der Psychotherapie (Psychotherapie-Richtlinie): Systemische Therapie bei Kindern und Jugendlichen. www.g-ba.de/beschluesse/6420/ (last accessed on 14 October 2024) 2024 [Google Scholar]
- 5.Friedlander ML, Heatherington L, Diamond GM. Systemic and conjoint couple and family therapies: recent advances and future promise. In: Barkham M, Lutz W, Castonguay LG, editors. Bergin and Garfield‘s handbook of psychotherapy and behavior change. 50th anniversary edition. John Wiley & Sons, Inc; 2021. pp. 539–581. [Google Scholar]
- 6.von Sydow K, Borst U. Weinheim: Beltz; 2018. Systemische Therapie in der Praxis. [Google Scholar]
- 7.Pinsof WM, Wynne LC. The effectiveness and efficacy of marital and family therapy: an empirical overview, conclusions, and recommendations. J Marital Fam Ther. 1995;21:585–613. [Google Scholar]
- 8.McDaniel SH, Hepworth J, Doherty WJ. Heidelberg: Carl-Auer-Systeme Verlag; 1997. Familientherapie in der Medizin. [Google Scholar]
- 9.von Sydow K. Was ist Systemische Therapie? (Theoretische Grundlagen). Kap. 1. In: von Sydow K, Borst U, editors. Systemische Therapie in der Praxis. Weinheim: Beltz; 2018. pp. 47–69. [Google Scholar]
- 10.von Sydow K. Systemische Psychotherapie. Kap. 4. In: Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K, editors. Klinische Psychologie und Psychotherapie: Ein verfahrensübergreifendes Lehr- und Lernbuch. Göttingen: Hogrefe; 2024. [Google Scholar]
- 11.Watzlawick P. München: Piper; 1976. Wie wirklich ist die Wirklichkeit—Wahn, Täuschung, Verstehen. [Google Scholar]
- 12.Minuchin S. Freiburg: Lambertus; 1997. Familie und Familientherapie: Theorie und Praxis struktureller Familientherapie. [Google Scholar]
- 13.Bateson G. Frankfurt/Main: Suhrkamp; 1972/1983. Ökologie des Geistes (Steps to an ecology of mind: collected essays in anthropology, psychiatry, evolution, and epistemology. Chandler.) [Google Scholar]
- 14.Richter D, Brähler E, Ernst J. Göttingen: Hogrefe; 2015. Diagnostische Verfahren für Beratung und Therapie von Paaren und Familien. [Google Scholar]
- 15.von Sydow K. Standardisierte interpersonelle Diagnostik. Kap. 11. In: Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K, editors. Klinische Psychologie und Psychotherapie: Ein verfahrensübergreifendes Lehr- und Lernbuch. Göttingen: Hogrefe; 2024. [Google Scholar]
- 16.von Sydow K, Taubner S. Symbolisch-metaphorische und projektive Verfahren. Kap. 12. In: Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K, editors. Klinische Psychologie und Psychotherapie: Ein verfahrensübergreifendes Lehr- und Lernbuch. Göttingen: Hogrefe; 2024. [Google Scholar]
- 17.von Sydow K. München: Ernst Reinhardt Verlag; 2015. Systemische Therapie (aus der Reihe: Wege der Psychotherapie) [Google Scholar]
- 18.von Sydow K. Settingvariationen/-wechsel und der Einbezug von Bezugspersonen. Kap. 38. In: Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K, editors. Klinische Psychologie und Psychotherapie: ein verfahrensübergreifendes Lehr- und Lernbuch. Göttingen: Hogrefe; 2024. [Google Scholar]
- 19.Retzlaff R. Mehrpersonensetting und Multifamilientherapie. Kap. 39. In: Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K, editors. Klinische Psychologie und Psychotherapie: Ein verfahrensübergreifendes Lehr- und Lernbuch. Göttingen: Hogrefe; 2024. [Google Scholar]
- 20.von Sydow K. Systemische Interventionen. Kap. 20. In: Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K, editors. Klinische Psychologie und Psychotherapie: Ein verfahrensübergreifendes Lehr und Lernbuch. Göttingen: Hogrefe; 2024. [Google Scholar]
- 21.de Shazer S. Heidelberg: Carl Auer; 2018. Der Dreh: überraschende Wendungen und Lösungen in der Kurzzeittherapie. [Google Scholar]
- 22.McGoldrick M, Gerson R, Petry S. Göttingen: Hogrefe; 2022. Genogramme in der Familienberatung. [Google Scholar]
- 23.Carr A. Couple therapy, family therapy and systemic interventions for adult-focused problems: the current evidence base. J Fam Ther. 2019;41:492–536. [Google Scholar]
- 24.Carr A. Family therapy and systemic interventions for child-focused problems: the current evidence base. J Fam Ther. 2019;41:153–213. [Google Scholar]
- 25.von Sydow K. Forschungsstand, wissenschaftliche und sozialrechtliche Anerkennung der Systemischen Therapie. Kap. 89. In: von Sydow K, Borst U, editors. Systemische Therapie in der Praxis. Weinheim: Beltz; 2018. pp. 929–43. [Google Scholar]
- 26.von Sydow K, Beher S, Schweitzer J, Retzlaff R. The efficacy of systemic therapy with adult patients: a meta-content analysis of 38 randomized controlled trials. Family Process. 2010;49:457–485. doi: 10.1111/j.1545-5300.2010.01334.x. [DOI] [PubMed] [Google Scholar]
- 27.Pinquart M, Oslejsek B, Teubert D. Efficacy of systemic therapy on adults with mental disorders: a meta-analysis. Psychother Res. 2016;26:241–257. doi: 10.1080/10503307.2014.935830. [DOI] [PubMed] [Google Scholar]
- 28.IQWIG (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen) Systemische Therapie als Psychotherapieverfahren bei Erwachsenen Abschlussbericht. Auftrag N14-2. Version 1.0 veröffentlicht am 24.05.2017. www.iqwig.de/download/N14-02_Abschlussbericht_Systemische-Therapie-bei-Erwachsenen_V1-0.pdf. (last accessed on 28 August 2017) 2017 [Google Scholar]
- 29.Vossler A, Pinquart M, Forbat L, Stratton P. Efficacy of systemic therapy on adults with depressive disorders: a meta-analysis. Psychother Res. 2024;22:1–17. doi: 10.1080/10503307.2024.2352741. [DOI] [PubMed] [Google Scholar]
- 30.Riedinger V, Pinquart M, Teubert D. Effects of systemic therapy on mental health of children and adolescents: a meta-analysis. J Clin Child Adolesc Psychol. 2017;46:880–894. doi: 10.1080/15374416.2015.1063427. [DOI] [PubMed] [Google Scholar]
- 31.IQWiG. Systemische Therapie als Psychotherapieverfahren bei Kindern und Jugendlichen Abschlussbericht. Auftrag N21-03. Version 1.0 veröffentlicht am 24.02.2023. www.iqwig.de/download/n21-03_systemische-therapie-bei-kindern-und-jugendlichen_abschlussbericht_v1-0.pdf (last accessed on 28 February 2023) 2023 [Google Scholar]
- 32.Huang Y, Li Y, Haun MW, et al. Systemic therapy for children and adolescents with depression: a systematic review and meta-analysis. Curr Psychol. 2024;43:3355–3367. [Google Scholar]
- 33.Seidel DH, Markes M, Grouven U, et al. Systemic therapy in children and adolescents with mental disorders: a systematic review and meta-analysis. BMC Psychiatry. 2024;24:125. doi: 10.1186/s12888-024-05556-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Strauß B. Risiken und Nebenwirkungen. In: von Sydow K, Borst U, editors. Systemische Therapie in der Praxis. Weinheim: Beltz Verlag; 2018. pp. 912–919. [Google Scholar]
- 35.Ochs M, Nordholt S. Systemische Therapie sowie familienorientierte Interventionen in den Behandlungsleitlinien. Geht das? Darf das? Muss das?—Eine aktuelle Übersicht. Kontext. 2022;2:182–200. [Google Scholar]
- 36.Scheib P, Wirsching M. Stuttgart & New York: Schattauer; 2004. Paar- und Familientherapie: Leitlinie und Quellentext (Unter Mitarbeit von Balck F, Geigges W, Kersting A, Kröger F, Schweitzer J, Wälte D, von Wieterseheim J) [Google Scholar]
- 37.Castonguay L.G, Eubanks CF, Iwakabe S, et al. Epilogue: prevalent themes, predictions, and recommendations. In: Barkham M, Lutz W, Castonguay LC, editors. Bergin and Garfield’s handbook of psychotherapy and behavior change. New York: Wiley; 2021. [Google Scholar]
- 38.Waldinger R, Schulz M. Erkenntnisse aus der weltweit längsten Studie über ein erfülltes Leben (The good life. Lessons from the world’s longest scientific study of happiness. New York: Simon & Schuster) München: Kösel; 2023. The good life … und wie es gelingen kann. [Google Scholar]
- 39.von Sydow K, Borst U, Geyerhofer S. Aus- und Weiterbildung in Systemischer Therapie an Hochschulen und privaten Instituten. Kap. 90. In: von Sydow K, Borst U, editors. Systemische Therapie in der Praxis. Weinheim: Beltz; 2018. pp. 944–962. [Google Scholar]
- 40.Teismann T, Thoma P, Taubner S, Wannemüller A, von Sydow K. Göttingen: Hogrefe; 2024. Klinische Psychologie und Psychotherapie: Ein verfahrensübergreifendes Lehr- und Lernbuch. [Google Scholar]