Introduction to Marriage and Family Counseling.

THE PROFESSION OF COUPLE, MARITAL, AND FAMILY THERAPY (CMFT): DEFINING OURSELVES AND MOVING

FORWARD

Karen S. Wampler and Adrian J. Blow Michigan State University

Lenore M. McWey Florida State University

Richard B. Miller Brigham Young University

Richard S. Wampler Michigan State University

The field of Couple, Marital, and Family Therapy (CMFT) has evolved and strengthened, but we still have work to do when it comes to identity, comprehensive scholarly resources, empirical support, and name brand recognition. We explore the reasons for these challenges and propose ways to address them: embracing the interdisciplinary nature of the field, consis- tently organizing treatment effectiveness by problem rather than by intervention model, con- tinuing innovation in theory development, and utilizing more diverse and meaningful research methods. This approach provides a more accurate representation of the scope of practice of CMFTs, the range of mental and physical health problems we address, and the depth and extent of the existing research on the effectiveness of relational therapies.

Those of us who identify with the profession of Couple, Marital, and Family Therapy (CMFT) know who we are and the value of what we do, but beyond terms such as “family systems therapy,” “relational therapy,” or “problems in context,” it is difficult to describe exactly where we fit as a profession in an integrated health care system. Most frustrating, many outside the CMFT field assume that we are defined by who is in the therapy room with us (modality) instead of by who we are thinking about when we are in the therapy room (conceptualization). For example, we continually have to assert, “We see individuals too.” The purpose of this article is to suggest ways to address challenges in defining our profession and practice, as well as to describe steps we can take to more comprehensively and accurately describe the theoretical, research, and clinical knowl- edge base of our field. Our ultimate goal is to suggest a framework that can be used to describe more effectively the role of CMFTs in an integrated health care system, the value of the practice of CMFT for a broad range of relational, mental health, and physical health problems, and suggest directions for practice, theory, research, and policy.

Individual and family as a focus of treatment is not an “either-or,” but a “both-and.” CMFT, as a profession and practice, exists in the context of a health care system that is based on the indi- vidual as the unit for diagnosis, treatment, and reimbursement of services. For many health

Karen S. Wampler, PhD, Human Development and Family Studies, Michigan State University, East Lansing,

MI; Adrian J. Blow, PhD, Human Development and Family Studies, Michigan State University, East Lansing, MI;

Lenore M. McWey, PhD, Family and Child Sciences, Florida State University, Tallahassee, FL; Richard B. Miller,

PhD, Sociology, Brigham Young University, Provo, UT; Richard S. Wampler, PhD, Human Development and

Family Studies, Michigan State University, East Lansing, MI.

Address correspondence to Karen S. Wampler, Department of Human Development and Family Studies,

522 W. Circle Dr., 7 Human Ecology Building, Michigan State University, East Lansing, Michigan 48824; E-mail:

[email protected]

January 2019 JOURNAL OF MARITAL AND FAMILY THERAPY 5

Journal of Marital and Family Therapy 45(1): 5–18 doi: 10.1111/jmft.12294 © 2017 American Association for Marriage and Family Therapy

providers, the level of the individual is in the foreground when thinking about physical and mental health. In contrast, the level of the family, while understood as fundamental to human functioning in general, is often left in the background when assessing problems and determining treatment. Yet, family leaps to the foreground in the photograph of an injured toddler sitting alone in an ambulance in war-torn Syria, seeing people desperately searching for family members after the tsu- nami in Japan, or taking in the courtroom scenes of anguish for both the family of the victim and the family of the person being tried. Family is readily used as a metaphor for understanding all kinds of human systems: A military unit as a “band of brothers,” “She is a like a sister to me,” or “Our team is like a family.”

The disconnect between the focus of CMFTs on relationships and a health care system that uses the individual as the unit of treatment poses two challenges. First, we have to continue to forge our identity and unique brand to demonstrate that we are specially trained professionals available to help. Second, we have to fight for recognition as leaders in collaborative care, able to conceptualize problems in context, and develop related interventions that work effectively in a complex health treatment system. It is our responsibility to articulate through theory and research when a family-level intervention is primary, when it is secondary, and when it is not likely to be helpful.

IDENTITY

Modality versus Conceptualization CMFT attracted attention early on because therapists were seeing family members together,

unique in mental health treatment at the time. The most common name for the field, “marriage and family therapy,” implies modality—that we see family members together. Although there were debates, such as whether Bowen Theory could be considered systemic because clients were often seen as individuals, or whether all family members had to attend a session for it to be considered family therapy as asserted by Whitaker, CMFT has consistently defined itself in terms of its con- ceptualization and not in terms of modality. Unfortunately, the misconception that CMFT is defined by who is in the therapy room still persists in both lay and professional audiences. For example, the following inaccurate definition of the field of CMFT appears in a recent family psy- chology textbook:

Both family psychology and family therapy adhere to a systems paradigm, but the empha- sis of family therapy tends to be on population [modality] rather than epistemology [con- ceptualization]. That is, marriage and family therapy exists to treat couples and families, while family psychology treats any constellation of the family, including individuals, from a systems paradigm (Thoburn & Sexton, 2016, pp. 9–10).

Reducing CMFT from a conceptualization to a modality has led to other anomalies in recog- nizing the scope of CMFT as a field. For example, many do not think of parenting interventions as part of CMFT because the parent is frequently seen without the child, even though the goal of treatment is improving the relationship between the parent and child in order to improve the well- being of the child. Severely disrupted or missing family relationships are associated with the most challenging mental and physical health issues (e.g., dementia, PTSD, substance abuse) and life situ- ations (e.g., homeless persons, refugees, mass trauma victims). Building or rebuilding a primary relationship system is an essential aspect of intervention for these types of cases, even though ther- apy might begin with seeing the individual alone or in groups of unrelated individuals. In the case of the most serious relationship issues, such as family violence, child maltreatment, and serious relationship distress, seeing family members together is frequently, and appropriately, contraindi- cated, at least initially. Even though the client is seen alone, a CMFT would still use a relational conceptualization with a goal of rebuilding and/or creating new primary relationships.

Modality itself (individual vs. couple vs. family) is not the defining characteristic of CMFT. But, if not modality, how do we define ourselves? We suspect that those identified with CMFT could readily generate defining characteristics including flexibility in who attends each session plus knowledge and experience to work effectively with a wide range of problems. Our profession has always struggled with the identity issue. We do not have answers, but suggest that the history of

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the field of family medicine provides many parallels to the issues CMFT has faced. The “family” in family medicine implies modality, but, the term is clearly understood as meaning a scope of prac- tice and specialized training, not who is seen in the examining room. Learning more about the evo- lution of titles, definitions of the scope of practice, and identification as primary care providers in family medicine could prove instructive as we think about the continuing evolution of CMFT in defining its identity as a profession.

Clarify When a Problem is Primarily Relational and When It is Not CMFT has a systemic focus that views mental health and relational difficulties as bidirectional

and multidetermined. However, CMFT was originally based on theories that used a unidirectional, reductionist analysis emphasizing the role of family relationships in mental health problems. The use of the term “identified patient” in early conceptualizations of systemic therapy is an example of such reductionism, implying that individual difficulties were “really” difficulties in the family. Other fields also currently struggle with the issue of reductionism; for example, the current heavy focus on neuroscience in the field of psychology to the exclusion of other areas (c.f., Schwartz, Lilienfeld, Meca, & Sauvign�e, 2016).

As a profession, CMFT has long since moved to a view of human health that uses a biopsy- chosocial perspective recognizing the influence of multiple factors in mental and physical health outcomes. These include an intrapersonal conceptualization (what is going on inside an individual, e.g., thoughts, feelings, behaviors, genetic predispositions, biological); the interpersonal (what is going on between an individual and significant relationships, e.g., relationship distress, conflict, disconnection); and a social-contextual conceptualization (what is going on in the broader cultural context in which the individual resides, e.g., racism, kinship structure, neighborhood violence). The interpersonal level, specifically primary relationships like those in the family, has been the cen- tral focus of the profession and the practice of CMFT, but not at the cost of ignoring intrapersonal (e.g., depression) and social-contextual information (e.g., poverty).

It has been extremely difficult for CMFT to maintain clarity on this point, yet clarity is essen- tial as we continue to assert our role in a collaborative health care system, and continue to effec- tively develop the research and theoretical base of CMFT. The confusion arises from two sources. First, we are always thinking systems. It is part of our DNA to see everything as related in a web of inter-connections in which primary relationships, such as families, play a crucial role in every prob- lem. This is a strength of CMFT, but is also an example of reductionism, reducing everything to level of the family. Such a stance works against us as a field and creates polarizing comparisons with other mental health providers. Being recognized and accepted as an essential part of a collab- orative health care system requires us to make a clear case for when relational therapy is primary, secondary, supplementary, or not necessary. It also requires us to undertake more sophisticated theory development and research that incorporates individual, interpersonal, and social-cultural context.

The second source of difficulty in maintaining clarity on where CMFT fits in a collaborative health care system is that, in Western cultures, both mental and physical health are considered solely qualities of the individual. Diagnostic systems like the DSM and ICD are prime examples of the dominance of the individual level in the conceptualization of health, and the rationale for treat- ment that guides what type of health care provider is considered appropriate (and eligible for reim- bursement). Ironically, the DSM provides a more nuanced approach to the role of family-level interventions than is often found in the CMFT literature. For example, the following description of the role of relationships can be found in the introductory chapter to the section on “Other con- ditions” (i.e., “V” codes, defined as those not considered mental disorders) in the DSM-V (Ameri- can Psychiatric Association, 2013).

Key relationships, especially intimate adult partner relationships and parent/caregiver- child relationships, have a significant impact on the health of individuals in these relation- ships. These relationships can be health promoting and protective, neutral, or detrimental to health outcomes. In the extreme, these close relationships can be associated with mal- treatment or neglect, which has significant medical and psychological consequences for the affected individual. A relational problem may come to clinical attention either as the

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reason that the individual seeks health care or as a problem that affects the course, prog- nosis, or treatment of the individual’s mental or other medical disorder. (p. 715).

Descriptions like the above that make an explicit connection between different levels of analy- sis are essential; however, for the field of CMFT, the DSM description does not go far enough. The relational component in the description is limited to the dyadic, parent-child or couple, and does not include the health of other subsystems such as siblings, the family as a whole, or the multi- generational family. The analysis is also unidirectional, seeing relationships as impacting an indi- vidual and leaving out the impact of the individual on the family, which CMFTs would see as recursive, bidirectional, and systemic.

The work of the Relational Processes Working Group (Foran, Beach, Smith Slep, Heyman, & Wamboldt, 2013) is an excellent example of the type of sustained work needed to define and orga- nize the research evidence for the role of the family-level factors in human health. This group of scholars has focused on making a case for including reliable assessments and diagnoses of four kinds of relational issues in the upcoming revision of the ICD: partner maltreatment, partner rela- tional problems, child maltreatment, and caregiver–child relational problems (Foran et al., 2013). The chapter by Reiss (2013) provides an especially clear example of how to conceptualize the role of relational interventions in health outcomes. He provides a framework and language for thinking about the complex issues involved and identifies four mechanisms to understand the possible con- nections between the relational and individual levels of treatment: common causal influences, mutual exacerbation, clinical course moderator, and absence of causal connection. This body of work is focused on diagnosis and assessment, but it also provides a methodology for how CMFTs might approach conceptualizing and organizing the existing research literature on family-level interventions in a way that is useful for practitioners, policymakers, researchers, and health care providers.

Be Clear That We Use Broad Definitions of “Marriage” and “Family” Another continuing challenge to establishing the identity and scope of the profession is to

clearly convey that CMFT is not limited to narrow, legal definitions of “marriage” and “family.” Increasingly, CMFTs have included “couple” as well as, or instead of, “marital” or “marriage” in titles to be clear that we work with all kinds of intimate couple relationships. The use of the term “family” also presents challenges because the meaning of the term varies widely by culture. We believe that the term “primary relationships” is a more accurate way to characterize the relation- ships that are the focus of CMFT. Sociologists contrast “primary” with “secondary” relationships and define “primary” as those:

Made up of close, personal, and intimate relationships that endure over the longterm, and in some cases through a person’s entire life. They consist of regular face-to-face or verbal interactions, and are composed of people who have a shared culture and who frequently engage in activities together. The ties that bind the relationships of primary groups together are made up of love, care, concern, loyalty, and support, and also sometimes ani- mosity and anger. That is to say, the relationships between people within primary groups are deeply personal and loaded with emotion. People that are part of the primary groups in our lives include our family, close friends, members of religious groups or church com- munities, and romantic partners (Crossman, 2016, pp. 1–2).

CMFTs utilize their understanding of these primary networks to conceptualize problems pre- sented by an individual, couple, or family and draw on the resources in these relationships to bring about change. Being clear about the broad range of relationships that CMFTs conceptualize as “family” is crucial in establishing our identity across global cultures and in navigating political controversies over definitions of couple, marriage, and family. It is also important in defining our scope of practice.

Need for Comprehensive Scholarly Resources That Reflect Our Identity Lack of CMFT comprehensive scholarly resources. Research evidence on the effectiveness of

relational interventions for specific problems is essential to the credibility and viability of the

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practice and the profession of CMFT. There is a great deal of published clinical research done by scholars identified with the profession; however, with the exception of the series of influential and highly cited reviews of family therapy research initiated and developed by Sprenkle (Pinsof & Wynne, 1995; Sprenkle, 2002; Sprenkle, 2012), the most comprehensive scholarly resources on family therapy are from the more narrow perspective of couple and family psychology (c.f., Lebow, 2016). Even in the Sprenkle reviews, a majority of authors for the 2012 and 2002 reviews and all of the authors for the 1995 reviews are identified with couple and family psychology (2012, p. 4). Consistent with the goal of the series to represent the strongest models, Sprenkle appropri- ately used the stringent standard of at least two randomized clinical trials (ECTs) by two indepen- dent teams of researchers as criteria for the topic to be included in the 2012 reviews. For many reasons, a research tradition of programmatic, funded RCTs is more common in psychology than in CMFT.

In addition to reviews of the research literature, published handbooks are a core means of defining the scope of a profession’s research, theory, and practice. Couple and family psycholo- gists, beginning with the classic handbook by Gurman and Kniskern (1981) to the more recent (Bray & Stanton, 2013; Sexton & Lebow, 2016), have undertaken the task of organizing and edit- ing these handbooks. A clinical psychologist is the prime developer and first author of by far the most popular textbook for the field, now in its 11

th edition (Nichols & Davis, 2017). When couple

and family therapy is included in comprehensive psychotherapy handbooks, the topic is placed as one chapter in a last section on specializations (c.f., Barlow, 2011). Equally telling, research on therapy with children and adolescents is included in a separate chapter in this type of resource illus- trating again how these topics are not considered as part of couple and family psychology, although we consider them a core part of CMFT. Encyclopedias of family therapy (c.f., Lebow, Chambers, & Breunlin, 2018) are another resource for a field, but they cover varied topics in brief entries. While valuable, encyclopedias do not provide comprehensive syntheses and analyses of the broader topics that define a field and its current status.

Consequences of lack of CMFT resources. Unfortunately, using the model of couple and fam- ily psychology to organize the CMFT research literature has resulted in a narrow and incomplete view of the existing research on the effectiveness of systemic, relational interventions. Couple and family psychology is one of 56 divisions (interest or topic groups) within the American Psychologi- cal Association (APA website). Topics of high interest to the broader field of CMFT such as pedi- atrics, physical health, close relationships, adulthood and aging, and psychotherapy with children and adolescents are the focus of other APA divisions.

To be comprehensive, reviews of CMFT research must include the strong research evidence on relational therapy for young children (Berlin, Zeanah, & Lieberman, 2016; Powell, 2006) and the extensive research on parenting interventions. The strong research literature on family inter- ventions and health (Hodgson, Lamson, Mendenhall, & Crane, 2014; Knafl, Leeman, Havill, Crandell, & Sandelowski, 2015) should also be included in comprehensive reviews of the CMFT literature. Though not as extensive, research on the impact of systemic therapy on relational out- comes for individuals, as opposed to individual mental health outcomes, should be included in CMFT reviews. Ecologically Based Family Therapy (EBFT; Slesnick, Erdem, Bartle-Haring, & Brigham, 2013), designated as one of two evidence-based approaches for runaway or homeless youth in a major review of 49 family interventions (Urban Institute, 2016), is an excellent example of this type of research. Research on aging is another particularly important focus (Holland & Gal- lagher-Thompson, 2011) for reviews of CMFT research.

We cannot emphasize enough that we believe that scholarly resources from couple and family psychology, although limited in scope, are extremely valuable and have been and continue to be an essential base for the development of the profession of CMFT. These resources are appropriate and complete from the perspective of the specialty of couple and family psychology. They are nec- essary, but not sufficient, for the broader field of CMFT. We cannot ignore the failure of the broader field of CMFT to clearly establish a framework for identifying, compiling, and evaluating the research base of family-level interventions in a much more comprehensive way that is consis- tent with the identity of the practice and the profession of CMFT.

Include a multidisciplinary approach in CMFT resources. The identity of CMFT will also be strengthened by an understanding of the role of family from the perspective of disciplines like

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biology, sociology, anthropology, law, social psychology, and history. These disciplines provide fundamental ways to inform family-level interventions. It is important to find ways to summarize basic concepts, frameworks, and research from these other fields in a way that is accessible to CMFTs. Understanding a physiological perspective is one important way for CMFTs to under- stand the fundamental importance of the family when dealing with illness, aging, divorce, etc., issues. For example, the third edition of the Handbook of Attachment (Cassidy & Shaver, 2016) includes eight chapters on biological perspectives underlying primary human relationships. Over- views of this type of material should be included in textbooks and other resources. Taking an anthropological perspective would help in understanding family dynamics, not only of interna- tional families, but also those from important subcultures within the dominant culture.

Ironically, extensive data are widely published and available on the connection of family-level variables to physical, mental, and societal health outcomes, but the field of CMFT has largely ignored this information. These data provide compelling evidence for family-level interventions and strong guidance for future directions in theory, research, and innovations in practice. This is one major cost to the field of being disconnected from its multidisciplinary roots in medicine, soci- ology, psychology, etc. Sources of information include several well-known and widely respected longitudinal studies that document the role of relationships, especially intimate family relation- ships, as the major predictor of physical and mental health outcomes. The Adverse Childhood Experiences study (ACE; Dong et al., 2004) is just one example. Among the 17,000 children fol- lowed in the ACE study, adverse childhood experiences were associated in adulthood with social, emotional, and cognitive impairment, adoption of risky health behaviors, disease and disability, and early death. CMFTs are very familiar with the list of the most serious adverse childhood expe- riences: child maltreatment (emotional, physical, sexual), neglect (emotional, physical), and family environment (domestic violence, substance abuse, mental illness, parental discord, crime). All of these adverse experiences are ultimately relational, and CMFTs need to be cognizant of the need for prevention, intervention, and treatment for children and adults having such experiences.

It is also important to think globally and use an international perspective in establishing the scholarly base for CMFT. The top five mental, neurological, and substance-use disorders world- wide identified by the World Health Organization (WHO) have potentially important relational aspects. WHO lists these in terms of estimates of the “health lost” due to disease or injury: unipolar depressive disorders, alcohol-use disorders, schizophrenia, bipolar affective disorder, and Alzhei- mer’s/other dementias (Collins, Patel, & Joestl, 2011). While these conditions are defined as resid- ing in the individual, CMFTs could readily identify family-intervention research addressing the systemic/family effects of each of these problems and identify ways systemic interventions could be useful for a number of key outcomes. Research on relational interventions for these problems exists, but has not been organized in a way that is easily accessible to CMFTs.

MOVING FORWARD

Need for Innovation in Theory One of the challenges that we face as a field is that we are largely still beholden to the founding

theorists who were instrumental in our field’s development (e.g., Minuchin, Bowen, Satir). There has not been enough innovation in terms of new theory development or research-based validation of foundational theories in the last 50 years. That is not to say that these theories are wrong or use- less, but some (e.g., Whitaker, Bowen, Satir) have not undergone the scrutiny of rigorous interven- tion research. A serious problem in evaluating such theories is the reliance on the therapist’s description of single case therapy experiences. While not invalid, these single case studies cannot be a substitute for studies with multiple cases and rigorous collection of qualitative and quantita- tive data.

In cases where research on theory has been conducted (e.g., structural, strategic), model devel- opers have tended to claim these models as their own, made them inaccessible to regular clinicians through high costs, or have made them overly complicated in their conceptualization and imple- mentation. Theories developed from structural and strategic approaches, such as Brief Strategic Family Therapy and Functional Family Therapy, have undergone multiple clinical trials funded by Federal agencies (e.g., SAMSHA, NIH). In spite of this research success, they have not been

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widely taught in training programs and are likely to be adopted only by agencies that can afford the high training costs.

In addition, while the postmodern wave of the 90s was innovative, it moved the field away from core systemic ideas such as family hierarchy, structure, and history. While these approaches provided a new metaphor for the field in terms of using stories to move therapy forward, they also served to shift the core brand identity of our work. Several couple therapy models (e.g., Emotion- ally Focused Couple Therapy, Integrative Behavioral Couple Therapy) have been well researched, but primarily for generic couple problems, with some small studies focused on other problems such as depression or trauma. Much more research is needed when it comes to their application to speci- fic couple and family issues and mental and physical health problems.

In the decades to come, a new wave of innovation in the development and evaluation of CMFT theories must occur. We believe that our field needs to hold onto its core systemic princi- ples of problem conceptualization and interventions based upon this conceptualization. A new wave of development of theories of change will require more funding and there must be CMFT researchers who have the skills to acquire these funds.

Research and Assessment Multiple sources of CMFT evidence. Randomized clinical trials (RCTs), a research methodol-

ogy that includes random assignment to treatment and comparison groups and close compliance with a treatment protocol, have consistently found systemic-based treatments to be effective in improving adolescents’ and adults’ mental health (Lebow, 2016; Sprenkle, 2012). The validation of CMFT treatments using RCTs has been crucial in the establishment of CMFT as an effective approach for treating individual and relationship disorders. This evidence has allowed CMFT to qualify for a seat at the table in the integrated health care system. Indeed, RCTs have long been considered the “gold standard” methodology for determining the efficacy and effectiveness of clini- cal interventions for physical, mental, and relational disorders, with other methods being viewed as inferior and inadequate.

However, some scholars have argued that the exclusive reliance on RCTs to provide evidence of clinical effectiveness is too narrow, leading researchers and clinicians to, in essence, ignore other valuable sources of evidence. For example, APA’s Presidential Task Force on Evidence-Based Practice concluded that evidence-based practice “requires an appreciation of the value of multiple sources of scientific evidence” (American Psychological Association, 2006, p. 280). The argument for the inclusion of multiple sources of evidence has been bolstered by studies showing the validity of a broader range of research methodologies. For example, an important review of 136 studies in The New England Journal of Medicine demonstrated that studies using observational and nonran- domized designs yielded results that were statistically equivalent to those from RCTs (Benson & Hartz, 2000). In addition, a major criticism of evidence-based practice that relies solely on RCTs is that the process of dissemination of scientific knowledge is based on a top-down approach, where researchers, based on evidence from carefully controlled clinical trials, dictate treatment guidelines to therapists in natural clinical settings (Castonguay, Barkham, Lutz, & McAleavey, 2013). For clinicians, such guidelines may be inappropriate or ineffective in less controlled settings.

With the recognition for the need for a more inclusive range of research methodologies that can inform evidence-based practice, Khagram and Thomas (2010) have suggested a “platinum standard” for evidence. The platinum standard recognizes the importance of RCTs in establishing efficacy and effectiveness, but the standard is broadened to include other forms of evidence, includ- ing rigorous case studies and qualitative approaches. The authors argue that these other methods provide important information about the mechanisms of change, for example, which strengthen validity of the theoretical basis of the treatment model. An example of this type of research is included in the special issue of the Journal of Marital and Family Therapy (Sprenkle, 2012) focused on the research evidence for CMFT. Chenail et al. (2012) reported a meta-synthesis of 49 qualita- tive studies that led to a grounded theory of clients’ experiences and evaluation of CMFT. Using a platinum standard perspective, this synthesis of qualitative studies provides evidence for the effec- tiveness of CMFT that cannot be gleaned from RCTs.

Practice-based evidence. Howard and associates (Howard, Moras, Brill, Martinovich, & Lutz, 1996) argued that there are three questions that should be asked about any therapy treatment

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modality. First, is it “efficacious,” meaning has it been validated in carefully controlled experimen- tal conditions? Second, is it “effective,” has it been tested in naturalistic clinical conditions, usually using experimental or quasi-experimental methods? And, third, is it working for this specific client? The third question has been explored the least, but it is of most interest to clinicians.

In response to the need for therapists to monitor each client’s treatment progress, client-based research has been developed to establish empirical evidence about therapy effectiveness by taking a down-up approach, called practice-based evidence. This type of research is valuable in determining effectiveness on a case-by-case basis within common treatment settings, such as private practices and mental health agencies. Practice-based evidence privileges the important role of therapists in the research enterprise and allows therapists to assess treatment effectiveness for specific cases. Rather than an either-or dichotomy, evidence-based practice and practice-based evidence are best viewed as representing different research paradigms that are complementary (Castonguay et al., 2013).

“Benchmarking” is a way to assess clinical effectiveness in client-based research and refers to the method of using the magnitude of improvement, or effect size, from pretest to posttest across clients as compared to the effect sizes reported in existing RCTs and meta-analyses (Lueger & Barkham, 2010). Benchmarking is becoming increasingly common in psychotherapy effectiveness research (Castonguay et al., 2013). In Great Britain, for example, benchmark statistics for various disorders and populations have been published, providing a standard of comparison for research- ers to use to determine the effectiveness of clinical practices (Barkham, Mellor-Clark, & Stiles, 2015). This allows researchers to establish the effectiveness of treatments in natural clinical settings based on client change and does not require a control or comparison group.

Assessment. Assessment plays a critical role in client-based research, with the focus being on the timing and delivery of assessments, rather than the specific measures used in the assessment process (Howard et al., 1996). Instead of the traditional practice of administering assessments only at pretest and posttest, client-based researchers assess client progress throughout the course of therapy. In this way, therapists monitor clients’ progress and can make changes in treatment strategies when the assessment data indicate that the clients are failing to make progress. This is important for two reasons. First, although CMFT treatments have been found, overall, to be effec- tive, not all clients experience significant improvement. Second, research has found therapists to have dramatically inaccurate perceptions of client progress or deterioration, in most cases being too optimistic (Hatfield, McCullough, Frantz, & Krieger, 2010; Lambert, 2013). Thus, it is impor- tant for the therapist and for client welfare to regularly assess progress during the course of therapy.

There is substantial evidence that regularly monitoring client progress and providing feedback to the therapist significantly improve treatment outcome. Although much of this evidence comes from individual therapy (Shimokawa, Lambert, & Smart, 2010), there is also evidence that system- atic clinical feedback dramatically improves CMFT outcomes (Anker, Duncan, & Sparks, 2009) and can be a core component of systemic therapy (Halford et al., 2012).

Practice research networks. A significant feature of practice-based research is the use of a Practice Research Network (PRN; Barkham, 2014), where a group of clinicians and researchers collaborate using common assessments and protocols to address clinical questions by pooling data from a large number of clinical settings. A key feature of PRNs is the sense of shared ownership among members of the network, including both clinicians and researchers (McAleavey, Lockard, Castonguay, Hayes, & Locke, 2014). PRNs began in the medical field among family practitioners, but they now exist in many mental health professions. For example, since 1993, the American Psy- chiatric Association has sponsored a PRN (West et al., 2015), and a network of over 240 university and college counseling centers have partnered to form the Center for Collegiate Mental Health (McAleavey et al., 2014).

One avenue for widening CMFT research on therapy outcomes is using a PRN. CMFT researchers at Brigham Young University have been leading the development of such a PRN tai- lored for systemic therapists (Johnson, Miller, Bradford, & Anderson, 2017). The strategy is to involve a number of CMFT sites around the country and to combine data from all of the sites to create large, de-identified datasets to be made available for CMFT researchers to use. In this PRN, an internet-based system is used in which clients complete assessments on electronic tablets (e.g.,

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iPads) before each session. A unique identifier is used for each client to maintain anonymity in the PRN database. The results are immediately scored and displayed as line graphs, allowing the ther- apist to quickly examine each client’s assessment scores on the PRN’s secure website before going out to greet the client(s). A menu of validated, widely used measures for individual adult, individ- ual child (ages 5–18), couple, and family functioning is available for clinics to build the specific set of assessments they wish to use at their site.

PRNs benefit both clinicians and researchers. Consistent with the values of practice-based research, PRNs provide an assessment system that can be used by therapists to monitor client pro- gress over sessions, which improves treatment outcomes. As therapists work together at different sites to collect clinical data, large clinical datasets can be accrued, allowing for the use of sophisti- cated statistical analyses and the study of marginalized or underrepresented populations. The PRN is theory-neutral, focusing on changes over time in therapy and therapy outcomes; however, it would be possible in future PRN modifications to ask the therapist to define a theoretical approach and allow that approach to vary across sessions.

Systemic clinical research. A hallmark of systemic clinical research is the focus on the research question, rather than the treatment modality being tested. That is, a systemic perspective guides the questions being asked in the study, regardless of the treatment being used. For example, Law and Crane (2000) studied the relationship between CMFT treatment and subsequent health care utilization, accessing a very large insurance company database. They found that couple ther- apy was predictive of a 21% decline in health care utilization. In addition, family members who were the focus of family therapy experienced a 9.5% decrease in health care utilization. Law and Crane also asked a systemic question: did other family members participating in family therapy also experience a reduction in health care utilization? They found an overall decrease of 30.5% in health care use after therapy for other family members participating in treatment with the focus patient.

The inclusion of mediating variables in clinical research also can facilitate the systemic focus of studies. Too much research has focused on the effect of a specific treatment modality on specific outcome variables without regard for the mechanisms of change that led to improvement (Kazdin, 2007). By including systemic mediating variables in the research design, it could be possible to test, for example, whether specific aspects of Bowenian therapy are mechanisms of change by using sta- tistical analyses to examine whether triangulation in the family-of-origin significantly mediated the relationship between independent and dependent variables of interest, regardless of who actually attended therapy.

Role of the Therapist A promising area of research is related to the person of the therapist. There is a growing body

of literature suggesting that the therapist accounts for a large part of the change in therapy (Blow, Sprenkle, & Davis, 2007). CMFTs are well trained in working across a variety of client constella- tions (e.g., individuals, parent-child, family, couple) in comparison to other fields (Crane & Chris- tenson, 2014), and work with challenging cases and patterns of family problems (Blow & Karam, 2017). However, more research is needed regarding what skills and traits make a couple, marital, and family therapist effective (Blow et al., 2007).

Research on therapists also challenges us to consider how as a field we go about training our practitioners. What are the core skills sets we envision in licensed practitioners? Increasingly, train- ing programs are challenged to move away from emphasizing the learning of theory to new and innovative ways to improve the effectiveness of their trainees. This has been helped a great deal by technology in which therapists now have ways to watch their work more often and think about it more reflexively. A recent paper suggests that training programs monitor the outcomes of their trainees, providing additional training to under-performing therapists (see Blow, 2017). This pro- cess allows therapists to be considered uniquely and have remedial training to support their partic- ular needs and developmental trajectory.

The body of research on therapist effectiveness also challenges us to carefully consider who is enrolled into the field, and how we must act as gatekeepers when therapists are not performing as they should (see Blow & Karam, 2017; and Blow, 2017 for a full discussion). Not only do effective family therapists require specific skills and talent, but they also must have the ability to

January 2019 JOURNAL OF MARITAL AND FAMILY THERAPY 13

conceptualize cases systemically, and to then to effectively intervene in a system that is usually experiencing a great deal of tension and conflict. In addition, therapists need to be able to respond to wide ranges of diversity that present in therapy. These realizations should impact both who are enrolled into our programs and how we go about training these individuals. It is important that those who train our next generation of practitioners help develop an understanding of their shared identity as CMFTs.

In recent years, we have been impressed by calls from leaders in the field of CMFT for con- sumers to seek out therapists with expertise in specific relationship problems. These calls are simi- lar to the medical world urging individuals to see specialists for their life-threatening medical problems. While we concur with these calls, they are considerably weakened by the absence of a body of evidence suggesting that individuals are indeed better off seeing a CMFT. We believe that prioritizing research in the area of therapist effectiveness with complex cases (outcome) and what therapist qualities are effective in working with these cases (process) is important to establishing our place in the field of mental health.

Children and Adolescents It is estimated that as many as 15 million children in the United States meet diagnostic criteria

for a mental health diagnosis (Kazak et al., 2010). This number is significantly higher for children from low-income families and those involved with the child welfare and criminal justice systems. There is a tremendous need for effective family-based services. Interventions to improve outcomes for children and adolescents have been a primary focus of the profession and practice of CMFT from the beginning; yet, we can do much more to include children in CMFT research.

Family-based interventions are effective with a host of child and adolescent presenting prob- lems including, but not limited to, anxiety, attention deficit, conduct, developmental, eating, mood, and substance-related disorders (Kaslow, Broth, Smith, & Collins, 2012; Ollendick & Shirk, 2011). As systems thinkers, however, we tend to deemphasize diagnoses in favor of understanding the context in which symptoms occur. Nevertheless, diagnosis is the language common to the larger mental health provider culture in which we exist. If we aim to be providers of choice, we must do a better job of communicating within the larger mental health community.

Research suggests child outcomes are most positive when parents are a part of the intervention (Kaslow et al., 2012). There have been significant advances in parent intervention research, and specific parenting programs have been shown to reduce emotional and behavioral concerns among younger children and adolescents alike (Kaslow et al., 2012; Webster-Stratton & Reid, 2010); how- ever, the extensive literature on parenting interventions is not always included CMFT literature because often the child is not directly involved in the intervention. Although some view parent training approaches as being nonsystemic in modality, they are systemic in conceptualization. The premise of these programs is to improve child outcomes by equipping parents with tools effective in promoting healthy child social and emotional development. Over the course of the intervention, as parents use their training to alter their behavior, the resulting changes in their child’s behavior reinforce the parents’ use of new techniques; and this recursive process continues. Importantly, there is a great need for parenting interventions. In fact, for families “at-risk” for child maltreat- ment, parent education is one of the most widely prescribed case plan requirements (Barth, 2009). CMFTs should be leaders in this work.

Although we know family interventions are effective, all too often young children are left out of the therapeutic process. Of course, there are instances when including children is contraindi- cated (e.g., intimate partner violence, infidelity), but even when the inclusion of children is appro- priate, our therapeutic approaches tend to function at a developmental level best suited for adolescents and adults. Perhaps one reason for this is that many of our classic theories tend to rely heavily on verbal means of expression. This is unfortunate because several tools associated with CMFT translate well for interventions involving younger children. For instance, we are skilled observers of behaviors and systems, we are accustomed to assessing and tracking nonverbal com- munication, and many of us apply experiential approaches, utilizing metaphor and symbolism to foster the safe expression of emotions and thoughts. We, as CMFTs, can use these strengths to join, assess, and intervene with children and families seeking help.

14 JOURNAL OF MARITAL AND FAMILY THERAPY January 2019

Moreover, there are a number of ways to increase our use of research on systemic interven- tions for children and families. One way would be to require more child-focused courses in CMFT training programs. Courses can be modified to include foundational readings from child theorists such as Bowlby, Piaget and Bandura, centering discussions on systemic extensions of these individ- ual or dyadic theories. Training also can include in-depth exposure to basic research on relational mechanisms of change for child outcomes. Identifying relational mechanisms of change is impor- tant because it highlights areas that can be targeted in interventions. For instance, research has identified the parent–child relationship as a significant pathway in the known link between parent and adolescent (c.f., McWey, Claridge, Wojciak, & Lettenberger-Klein, 2015) and parent and young child mental health concerns (Dong et al., 2004). These basic research findings have direct implications for CMFTs. Specifically, these results suggest that improving the parent–child rela- tionship can be a means to significantly improve the mental health of parents and children alike. Broadening the literature base to include contemporary child development, child psychiatry, and communication research also would be useful. Finally, including an applied component in child- focused therapeutic training may aid in therapists feeling more comfortable with young children in the room.

To be leaders, we must be informed. As such, it would be valuable to incorporate more train- ing on systemic evidence-based models into our curriculum. There are a number of barriers, how- ever, to doing so. Training costs tied to some of these models pose a significant obstacle. In academic contexts in which shrinking budgets are a reality, we, as a discipline, must determine which training costs are priorities. Further, some clinicians balk at the notion of manualized evi- dence-based practice (EBP), suggesting that EBP interferes with the “art” of therapy. It is simply inaccurate, however, to assume that therapists are restricted to solely following scripts in the deliv- ery of these interventions. Of course, there are content areas that must be addressed in order to deliver evidence-based models with fidelity, but there absolutely is room for therapist flexibility and expertise in EBP. Indeed, it is acceptable to adapt evidence-based interventions and exciting research is underway, led by CMFTs, which aims to systematically engage in adaptations to better meet the unique needs of specific populations and treatment contexts (c.f., McWey, Pazdera, Ven- num, & Stevenson-Wojciak, 2013; Parra-Cardona et al., 2017).

In sum, children are central in family systems and we, as CMFTs, need to do more to include children and adolescents in our work. Ways to promote this work include: better integrating basic science, child development, and mental health knowledge into our courses, research, and practice; communicating the value of a systemic approach to the larger mental health community; expand- ing the training in our graduate programs to include more child-focused interventions and EBP models; and conducting research that establishes CMFT as an important part of the treatment of child and family concerns.

CONCLUSION

Numerous books, handbooks, articles in scholarly journals, encyclopedias, and textbooks exist on family-based practice, theory, and research. Unfortunately, this literature is largely orga- nized around a set of classic and modern theories of CMFT and an approach of summarizing the evidence base of the field adopted from a psychology subspecialty focused on work with couples and families. The field has yet to develop an appropriate, widely accepted and comprehensive framework for articulating the identity of CMFT and the extensive scholarship that underlies both the practice and profession. Accomplishing this task requires an interdisciplinary, family- level, truly systemic analysis. It requires a commitment to this identity and an operationalization in training our newest therapists and in the continuing education of our more seasoned practi- tioners. This task also serves as an essential basis for identifying the priorities for new and enhanced directions in theory, research, training, and policy. We have outlined some steps toward this goal.

Several factors have pulled against the ability of the field to maintain recognition of the importance of this task and to devote significant intellectual, organizational, and financial resources to accomplish it. CMFT is embedded in Western culture that is heavily based on the individual. Health care systems are based on the individual and, with few exceptions, require a

January 2019 JOURNAL OF MARITAL AND FAMILY THERAPY 15

diagnosis of an individual’s mental and/or physical health status for reimbursement of services. CMFT achieved legal recognition more recently than other mental health professions. Like all family-based research and practice, CMFT has been under siege to demonstrate that systemic family-level interventions are valuable. Under these conditions, it is difficult to take an authorita- tive, balanced, and open stance about the scholarly base of the field, about what is known and what is not yet known about family-level interventions. Yet, to be credible, CMFT must avoid a defensive stance in its efforts to make a case for the role and value of family-level interventions. This is essential in defining its unique, overlapping, and complementary roles with other health care professions.

The role families play in all human societies, the extensive data on the connection of family functioning to mental and physical health outcomes across family systems and subsystems, the importance of the health of the whole family to the health of individuals across the lifespan, the health of the community and broader society, and the extensive evidence of the effectiveness of relational interventions, all make a strong case for the importance of this mission. We look for- ward to updated textbooks, literature reviews, articles, books, and other resources that better define the identity of CMFT and provide a basis for rapidly moving both the profession and prac- tice forward.

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