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Finally, marital and couple discord shows evidence of abatement as a result of therapy (Baucom et al., 1998). Dunn and Schwebel (1995) examined 15 methodologically rigorous, published outcome studies and found that behavioral, cognitivebehavioral, and insight-oriented marital therapy were all more effective than no treatment in bringing about changes in spouses’ behavior and in the general assessment of the marital relationship. Psychoeducational work with couples, such as the Prevention and Relationship Enhancement Program (PREP), described in Chapter 16, have been shown to be effective in increasing relationship satisfaction (Markman, Renick, Floyd, Stanley, & Clements, 1993) and to remain so in fourto five-year followups. Similarly, emotionally focused couple therapy (Johnson & Greenberg, 1995) aimed at restructuring a couple’s negative interactional patterns, has been supported by research results. A significant proportion of couples do not respond to couples therapy, however, and among those that do respond a significant portion’s relationship will deteriorate upon later follow-up (Christensen, Baucom, Vu, & Stanton, 2005).
EVIDENCE-BASED FAMILY THERAPY: SOME CLOSING COMMENTS
The recent rush to achieve accountability can be seen in medicine and education as well as in psychology, where professionals are being pressured to base their practices on evidence whenever feasible. Within the psychotherapy realm, there is increasing momentum to establish an empirically validated basis for delivering healthcare services (Goodheart, Kazdin, & Sternberg, 2006; Kazdin & Weisz, 2003; Nathan & Gorman, 2002), based on the assumption that clinical interventions backed up by research will make the effort more efficient, thereby improving the quality of healthcare and reducing healthcare costs (Reed & Eisman, 2006).
Both researchers and practitioners are interested in making therapy more effective. Academically based clinical researchers have been especially supportive of this idea, and have attempted to apply the methodology of scientific research to the therapeutic endeavor, often developing efficacy treatment programs under rigorous and controlled conditions that they believe generalize to real-world problems dealt with by practitioners. Practicing clinicians, who also would like to base their interventions on evidence, nevertheless complain that these narrow treatments based on randomized controlled clinical trials4 for specific diagnostic categories are of limited use with the varied populations and types of problems they see in their practice (Goodheart, 2006). Many also contend that while the efforts to improve the quality and cost-effectiveness of psychotherapy, as well as enhancing accountability, are clearly laudable, to date evidence that empirically validated techniques improve healthcare services or reduce costs in everyday practice is still limited.
The widely accepted definition of evidence-based practice (APA, 2005) is as follows:
Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and patient values.
4Randomized controlled trials (RCTs) are considered by proponents to be the “gold standard” in drawing causal inferences about the effects of an intervention. Much as in the investigation of the effectiveness of a new drug in medical research, clients are matched and randomly assigned to a treatment group or to a placebo group or perhaps to a no-treatment group. Differences in results are attributed to the treatment, thus providing evidence for its effectiveness with that population.
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B O X 1 7 . 5 R E S E A R C H R E P O R T
ASSUMPTIONS UNDERLYING EVIDENCE-BASED THERAPY RESEARCH
A homogeneous client population is studied. Clients are randomly assigned to treatment or no
treatment.
Therapists are carefully selected, trained, and monitored.
Specific interventions are prescribed. Treatment is designed for a specific disorder or
diagnosis.
Treatment is brief and of a fixed duration. Treatment manuals are employed to ensure all
receive same interventions.
Process change mechanisms are articulated. Clear goals are delineated.
Multiple outcome measures are specified. Follow-up procedures over extended periods are
employed.
The definition affirms the contributions of:
•research evidence (quantitative and qualitative methodologies, clinical observations, single-case studies, process and outcome research)
•clinical expertise (therapist skill, judgment and experience in assessment, case formulation, treatment planning, techniques of intervention)
•patient characteristics (personality, specific problem, cultural background, gender, sexual orientation, social and environmental context, race)
One difficulty in reconciling the views of practitioners and researchers is that they operate in different worlds—the former focused on service to clients, the latter on expanding understanding of a clinical phenomenon or testing the effects of new procedures (Weisz & Addis, 2006). Experienced clinicians are apt to be integrationists, taking what’s most appropriate from a variety of theories or techniques to help their specific client or family, and are not likely to be content to follow fixed rules from manualized guidelines in treating clients who seek their help. Westen, Novotny, and Thompson-Brenner (2004) suggest that researchers might do better by focusing on what works in real-world practice than spend their efforts on developing new treatments or manuals from the laboratory. There also continues to be debate on what constitutes research evidence, and on the extent to which psychotherapy is a human encounter in which common factors (attention from a caring therapist, the expectation of improvement, catharsis, hope, feedback, safety in a confidential relationship) help produce successful outcomes, regardless of therapeutic model.
Nevertheless, there is a growing acceptance of the place of evidence-based studies in clinical practice, and practitioners may experience increased pressure from third-party payors to base their interventions on established evidence-based treatments. In some cases, managed care and insurance companies have begun to provide reimbursements only to practitioners using evidence-based treatments. Some local, state, and federally funded programs already are based on evidencevalidated programs, and this trend is likely to continue. Clinicians in the future will be held increasingly accountable for providing outcome assessments for their clinical interventions.
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SUMMARY
Research in family therapy preceded the development of therapeutic intervention techniques, but beginning in the 1960s priorities changed, and the proliferation of techniques outdistanced research. That situation has now begun to even out, and a renewed family research-therapy connection is beginning to be reestablished. Some practitioners, likely in the past to dismiss research findings as not relevant to their everyday needs and experiences, have found qualitative research methodologies more appealing and germane than the more formal, traditional experimental methodologies based on quantitative methods.
Various research attempts to classify and assess families exist, employing either a self-report or an observational format. Most noteworthy among the former are the attempts by Olson and his associates to construct their Circumplex Model of family functioning based on the family properties of flexibility and cohesion, and work by Moos to construct his Family Environment Scale. Observational measures, usually in the form of rating scales by outside observers, have been designed by Beavers
to depict degrees of family competence and by Epstein, Bishop, and Baldwin to classify family coping skills according to the McMaster Model.
Both the process and outcome of family therapy interventions have been studied with increased interest in recent years. The former, involved with what mechanisms in the therapist-client(s) encounter produce client changes, requires the higher priority because identifying the processes that facilitate change helps ensure greater therapeutic effectiveness. Outcome research, including both efficacy and effectiveness studies, having established that marital and family therapy are beneficial, has turned its attention to evidence-based practices—what specific interventions work most effectively with what client populations. Of particular interest today is the search for the relative advantages and disadvantages of alternative therapeutic approaches for individuals and families with different sets of relational difficulties. Evidence-based family therapy is likely to become increasingly prevalent as efforts are underway to make healthcare delivery more effective and cost-efficient.
RECOMMENDED READINGS
Goodheart, C. D., Kazdin, A. E., & Sternberg, R. J. (Eds.) (2006). Evidence-based psychotherapy: Where practice and research meet. Washington, DC: American Psychological Association.
Liddle, H. A., Santisteban, D. A., Levant, R. F., & Bray, J. H. (Eds.). (2001). Family psychology: Science-based interventions. Washington, DC: American Psychological Association.
Nathan, P. E., & Gorman, J. M. (2002). A guide to treatment that works. London: Oxford University Press.
Sprenkle, D. H., & Piercy, F. P. (2005). Research methods in family therapy (2nd ed.). New York: Guilford Press.
Touliatos, J., Perlmutter, B. F., Strauss, M. A., & Holden, G. W. (2001). Handbook of family measurement techniques. Newbury Park, CA: Sage.
C H A P T E R 18
A COMPARATIVE VIEW OF FAMILY
THEORIES AND THERAPIES
In this, the final chapter, we present an overview of the various models we have considered, reviewing some of the similarities and differences that exist. It is important to note at the outset that originators of theories by necessity focus on a relatively narrow set of concepts, staking out positions that attempt to make their contribution unique. Little effort is directed toward seeking similarities with other theories; indeed, the opposite is usually the case. However, on closer examination, we find that overlaps in theory and technique, as well as notable differences, exist. It is those differences that bring adherents to a particular model.
Purists in theory are easy to come by; purists in practice, less so. Ideally, it is important to know a variety of theories, fitting specific techniques, regardless of theoretical origin, to appropriate client populations. A well-trained family therapist needs to understand various theories and the populations with which each works best. Most family therapists start out following one theoretical framework and its corresponding set of clinical procedures, but soon learn to supplement and adapt where the theory— inevitably with some shortcomings—is inadequate for certain clients. In practice, then, most therapists become eclectic, ultimately adopting (and adapting) techniques that their experience tells them work best with specific sets of problems.
Many therapists believe that it is harder to stick with a single theory or set of techniques in working with families than when treating individuals. Systems are complex, and each family member has specific needs that may conflict with those of fellow family members. By definition, members of a family are at different stages of life cycle development and may require different intervention procedures. The therapist needs to evaluate and respond to each member, to the entire family system, and further, the larger system of which all are a part—extended families, the community, cultural, racial, social class, and ethnic inputs and considerations. Social constructionists as well as advocates of gender-sensitive family therapy have been especially influential in drawing attention to the social and political climate in which today’s families function.
In the end, skilled clinicians are more alike in what they do with families than their different theories would suggest. Intangibles—personal experience, involvement, focused interest, energy, sensitivity, empathy, warmth, humor, and so forth—as well as theoretical knowledge and therapeutic know-how may be the key variables
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