The Del Sol Family Referral Route

Case Study: The Del Sol Family Referral Route

Rosa Del Sol was referred by Christopher’s teacher to the North Beach Neighborhood Outreach Center. At the time of intake, Rosa’s presenting concerns were marital conflict and parenting concerns, especially how to manage her 9-year-old son, Christopher. Family Composition The Del Sol family consists of Rosa, aged 35, and Miguel, aged 37, as well as three children— Christopher, aged 9; Teresa, aged 3; and Tina, aged 18 months. Rosa and Miguel have been married for 4 years. Christopher is Rosa’s son from a previous common-law relationship. Christopher’s biological father, Jim, aged 36, has not been involved in his life since Christopher was 2 years old, and Rosa does not know Jim’s whereabouts. Rosa states that Jim was a heavy drinker and became physically abusive during the pregnancy, and they separated shortly before Christopher’s second birthday. Rosa is the only child of Maria and Juan Valdez, aged 55 and 60, respectively. Juan was verbally and physically abusive toward Maria, and they separated when Rosa was 12 years old. Rosa has had no contact with her biological father since that time. Maria continued to parent Rosa on her own and has not remarried. Miguel is the oldest son of Sophia and Thomas Del Sol, aged 62 and 66, respectively. Miguel’s younger brother, Juan, aged 34, is not married and, according to Miguel, has a “drinking prob- lem.” Miguel’s father “abandoned” the family when Miguel was 7 years old. Miguel remembers the loud arguing and fighting between his parents. His mother was remarried, when Miguel was 10 years old, to Ken Wheeler. The Family System Rosa was in tears for most of the initial session, claiming she “just can’t take it anymore.” Miguel is constantly putting her down, insulting her in front of other people (even in the gro- cery store), and yelling at the children. Rosa feels that no matter what she does, she cannot seem to do anything right according to Miguel. Rosa is beginning to realize that she is being verbally abused as her father abused her mother. She is also uncomfortable with her reactions because she has been yelling back at Miguel and feels like the “war is on.”

Rosa feels the situa-tion is “out of control.” Sometimes her own anger and Miguel’s intensity of anger have frightened her. Physical abuse has not occurred up to this point, according to Rosa. She states that Miguel knows that if he ever touches her that would end the relationship. She is determined not to raise her children in an “abusive home” like the home of her own childhood. Rosa says she cries frequently and has had little energy to deal with the conflicts. Christopher has been hav- ing difficulty at school as well as the daily “battles” with Miguel. Miguel feels the problems between Rosa and him can be “solved on their own.” Miguel admits that he yells a lot at Rosa and calls her names. However, he points out that he always tells Rosa he is sorry. Miguel is of average height and slim build; he appears agitated and tense. He admits to experiencing a number of physical symptoms of stress, including a pounding heart, frequent headaches, and constant feelings of edginess and restlessness. Miguel describes him- self as a loner with no close friends. Miguel agrees with Rosa that he is moody but says, “A guy can’t be in a good mood all of the time.” Miguel’s posture and manner appear defensive, and he indicates that he is only here because Rosa had threatened to leave him if they didn’t get help. His family is important to him, and he realizes now that despite not wanting to repeat the actions of his stepfather, he can see that he is doing the same to his children. Christopher attends North Beach Elementary and Middle School and is in third grade. He is in a regular class after having repeated first grade. Christopher was diagnosed with attention deficit disorder (ADD) 6 months ago. He is currently on a trial of Ritalin. In the past month, the school has complained to Rosa that Christopher has become increasingly aggressive with his peers. Christopher’s teacher reports that he has made no friends in his class and has become socially isolated, either withdrawing or acting out angrily. The teacher notes that Christopher has poor social skills but is quite good in sport activities such as soccer and football. Christopher’s favorite sport is soccer, and in the summer he loves to swim, play football, and ride his bike. Three-year-old Teresa is a talkative girl who is generally good-natured. Tina, 18 months, tends to be quiet and allows Teresa to do all the talking for her. Both girls have been achieving their respective developmental milestones. Rosa has no concerns in this area. However, Rosa has noticed in the past 3 weeks that both girls have not been sleeping through the night. They have been whining and crying a lot more than usual. Teresa complains of a stomachache frequently. Rosa became upset when she told about Miguel’s coming home from work and marching into the bedroom in silence and Teresa asking, “Is daddy mad again?” Family Background Information Rosa completed 12th grade and then worked in a bank as a teller until the birth of Teresa. Her mother helped her raise Christopher when he was an infant and openly stated her disapproval of Rosa’s relationship with Jim. Maria lives nearby and, despite what Rosa describes as a “conflictual” relationship, is a source of support for Rosa. Maria often babysits the girls, although Maria now refuses to look after Christopher because “he is too difficult—just like his father.” Rosa describes the relationship between her mother and Miguel as “unfriendly”; “they tolerate one another,” as each tends to put the other down. Rosa feels stuck in the middle of a “no-win” situation. Miguel never got along with his stepfather, Ken. Ken frequently became drunk on the week- ends with Sophia leaving the boys to fend for themselves. Ken was not physically abusive, but when he was drinking “you stayed out of his way so he wouldn’t yell at you.” Miguel says his mother Sophia is an alcoholic, and he has chosen not to have contact with her or his stepfather. Miguel quit school and left home at age 15. He worked at odd jobs to support himself. Miguel admits to “being in the wrong crowd” and being heavily involved with drugs and alcohol as a teenager. Miguel feels proud that he is no longer involved “in that scene,” having quit on his own “without anyone’s help.”

Family Strengths and Challenges Stress and Demand Factors Family System All family members appear to be suffering from symptoms of stress, both physically and emotionally, and have experienced a number of changes recently. The purchase of their own home and the resulting high payments have left little money to cover remaining bills and groceries. The lack of money and high debt load have become a daily stressor. Rosa and Miguel agree that financial issues regularly precipitate most of their arguments. Christopher’s recent diagnosis of ADD is confusing to Miguel and Rosa. They have little information on this disorder or how to best deal with Christopher in managing his behaviors appropriately. Medication is expensive, and they do not have health insurance. Marital/Parental Subsystem Miguel has a sixth-grade education, has always worked, and is employed full-time at a small auto-repair shop. He also works a second job in an auto-parts store in the evenings and weekends to make ends meet. Miguel complains about his coworkers, stating that he has nothing in common with them and doesn’t want to waste his time with them. Miguel feels that his boss is always pressuring him to do more, and they often have loud disagreements. Miguel aspires to be a manager of his own shop and not have people telling him what to do. Miguel and Rosa purchased their home 4 months ago. It is located about 45 minutes by car from their old neighborhood, where Rosa was well-connected to the church and a number of friends. The couple enjoy owning their own home, but the mortgage payments are high. This leaves little money for other expenses and has been a source of daily conflict. Rosa and Miguel had decided that Rosa would stay home to care for the girls while they were young. Lately, however, Rosa has been suggesting that she work part-time at a gardening shop to help out financially and to be out of the house.

Miguel then could cut down on his hours of work and spend time with the family. Miguel reacted angrily to this issue and stated that he was “sick and tired of everyone hassling him about working and can’t a guy just make a living.” Miguel works hard at his two jobs and is very committed to doing the best for his family. However, all his energies have been devoted to making a living, with little time for any outside interests. Rosa disagrees with Miguel about the importance of money and prefers that Miguel spend time with her and the children as a family. Miguel admits he is getting physically tired and irritable and finds he is less able to handle life’s minor annoyances. He would like to be able to spend time with the children and get back into playing recreational soccer. Parent/Child Subsystem Information is incomplete. Sibling Subsystems Information is incomplete. Resource Factors Rosa describes herself as an outgoing, social person with a sense of humor, but lately she has been feeling alone and “down.” The family has one car that Miguel uses to travel to work, and Rosa feels isolated and “stuck in the house.” The family has few outside supports. Rosa, due to the move and transportation limitations, is isolated from her previous support network, which included neighborhood friends and the church community. Miguel has few friends and relies on Rosa to motivate and encourage him. Rosa has said it feels at times that she has four children, not three. The girls don’t have friends in the new neighborhood because the children living nearby are much older. The girls are becoming quite bored and cranky with Rosa, adding to the tension in the home. Christopher has made a couple of new friends; however, his poor social skills and short attention span have made this a challenge for him. Competence and Coping Factors Rosa grew up in an abusive home and is determined to not raise her children in that environment. She is very motivated to make changes in her life and has attempted over the last year to involve Miguel in activities to strengthen their family; he has re- fused to attend any couple enrichment weekends or courses that were available at no cost through the church. Rosa attended the sessions on her own, including a weekend retreat for families. Rosa has a wonderful sense of humor that has helped her cope with a number of adverse conditions. Rosa feels she has no support from Miguel in raising the children due to his drive to make money and his discomfort in being with the children. Rosa is a good mother to her chil-dren and is determined to continue to learn about positive parenting approaches. Miguel is a hard worker, and he feels he must do the very best in any job he takes on. High expectations create added pressure and stress. Miguel has been reluctant to tackle areas in which he feels incompetent. These include parenting, so he tends to avoid it when he can, often choosing work over time with the family. Miguel grew up in an abusive, alcoholic family and exhibits some of the symptoms com- mon to this environment such as poor self-image, a need for constant approval, and anger. He believes strongly that the husband’s role is to provide for his family. Miguel has difficulty recognizing that his family has needs other than just money from a husband and father.

This pattern was established in his family of origin. His strong desire to raise his children differently and to keep his family together will help him in achieving his goals. Intervention Planning Miguel and Rosa have decided on the following goals:

1. To develop appropriate strategies for managing anger.

2. To learn effective, respectful communication.

3. To learn more appropriate parent/child discipline strategies.

4. To expand the current support network of their family.

5. To increase their understanding of ADD and parenting techniques.

Family Therapy Model Chapter

individual assessment in couple and Family therapy A systemic perspective includes an awareness of individual issues that interact with cou- ple and family dynamics (Stanton & Welsh, 2012). Nurse and Sperry (2012) note the applicability of several individual, standardized assessments for couple and family evalu- ation (such as the MMPI-2, MCMI-III, Rorschach Inkblot Test, and the Kinetic Family Drawing Test), combining them with interviews, observation, clinical records, and col- lateral information to provide input to couples and families (p. 83).

Stanton and Nurse (2009; Nurse & Stanton, 2008) describe a model of personality-guided couple therapy that uses the MCMI-III to assess personality factors that interact reciprocally in couple relationships. The MCMI (Millon & Bloom, 2008) is a 175-item inventory for people who present for therapy; it provides 14 personality categories and 10 clinical dimensions. For couples therapy, there are identified couple personality interaction patterns that may help both individuals understand, empathize, and manage the personality-driven behav- iors in the relationship. LO 6 Family therapy Process and Outcome research What constitutes therapeutic change? What are the conditions within therapy that facilitate or impede such changes? How are those changes best measured? How effective is family ther- apy in general, and are some treatments or therapeutic models more efficacious than others for dealing with specific clinical problems or clients from a specific community or culture?

Do certain therapist or family characteristics influence outcomes? Is family therapy the most cost-effective way to proceed in a specific case, especially in comparison with alternate inter- ventions such as individual therapy or drug therapy? Or would a combined set of therapeutic undertakings be most effective in a specific case? How do race, ethnicity, gender, age, and sex- ual orientation factor into potential results? These are some of the questions that researchers in family therapy continue to grapple with in an effort to understand and improve the com- plex psychotherapeutic process. Psychotherapy research investigates the therapeutic process (the mechanisms of client change) to develop more effective methods of psychotherapy. There is considerable research evidence that couple and family therapy is effective for virtually every type of disorder and for various relational problems in children, adolescents, and adults (Sexton, Datchi, Evans, LaFollette, & Wright, 2013; von Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013). Now, researchers have turned their attention to comparative outcome studies in which the relative advantages and disadvantages of alternate treatment strategies for clients with different sets of problems are being probed. The research lens has broadened to examine the application of couple and family therapy to specific clinical problems in specific settings, as well as research on process variables that examines specific change mechanisms (Sexton & Datchi, 2014), so that differential outcomes from various therapeutic techniques can be linked to the presence or absence of specific therapeutic processes. Such investigations may iden- tify specific interventions that result in more effective treatment (Hogue, Liddle, Singer, & Leckrone, 2005).

Process Research

How do couples or families change as a result of going through a successful therapeutic expe- rience? What actually occurs, within and outside the family therapy sessions, that leads to a desired therapeutic outcome? Is there evidence for a set of constructs common to all effective therapies? Do specific therapies make use of these concepts in different ways that are effective? The emphasis today has shifted from broad outcome research to focus on treatment specific- ity, the particular change mechanisms in couple and family therapy. Clinicians appreciate this research because it aligns with their experience of therapy, making research relevant to practice (Sexton & Datchi, 2014). Process research identifies and operationally describes what actually takes place during the course of therapy. These variables impact “how the intervention works differently in different contexts with different parameters” (Sexton et al., 2013, p. 590).

What are the day-to-day fea- tures of the therapist–client relationship, the actual events or interactions that transpire during sessions that together make up the successful therapeutic experience? Can these be catalogued and measured? What specific clinical interventions lead to therapeutic breakthroughs? How can these best be broken down into smaller units that can be implemented by others in a manner consistent with the evidence-based method and thus taught to trainees learning to become fam- ily therapists? Are there specific ways of intervening with families with specific types of prob- lems that are more effective than other ways? What role does therapist gender play in therapy? What about therapeutic style (proactive or reactive, interpretive or collaborative, and so on)? What factors determine who remains in treatment and who drops out early on? How do cul- tural variables influence the therapeutic process? In a review of family interventions, Sexton and colleagues (2013) identified the therapeutic alliance (the nature of the relationship between ther- apist and clients); model-specific fidelity and adherence (faithful implementation of the model as designed); and client factors (symptom severity, socioeconomic status, etc.) as major moder- ators and mediators in the interventions.

From a practical economic viewpoint, family therapy research must demonstrate to insurance companies, managed-care organizations, government agencies, and mental health policy makers that its product is an effective treatment that should be included in any package of mental health services and benefits (Pinsof & Hambright, 2002). Process research does not simply concern itself with what transpires within the session but also with out-of-session events occurring during the course of family therapy. Finally, the experiences, thoughts, and feelings of the participants are given as much credence as their ob- servable actions. Thus, certain of the self-report methods we described earlier in this chapter may provide valuable input in the process analysis. Process research attempts to reveal how therapy works and what factors (in therapist be- haviors, patient behaviors, and their interactive behaviors) are associated with improvement or deterioration. For example, a researcher might investigate a specific process variable concerning family interaction—who speaks first, who talks to whom, who interrupts whom, and so forth. Or perhaps, attending to therapist–family interaction, the researcher might ask if joining an an- orectic family in an active and directive way results in a stronger therapeutic alliance than joining the family in a different way, such as being more passive or more reflective. Or perhaps the pro- cess researcher wants to find out what special ways of treating families with alcoholic members elicit willing family participation as opposed to those that lead to resistance or dropouts from treatment. Are there certain intervention techniques that work best at an early treatment stage and others that are more effective during either the middle stage or terminating stage of family therapy? See Box 16.4 for examples of therapeutic mechanisms that may initiate change.

Immediate client feedback on the therapeutic process is an important form of clinically relevant research. Many family therapists informally invite feedback from clients, but the pro- cess may be enhanced by the use of more formal means of monitoring progress, like the Sys- temic Inventory of Change (STIC: Pinsof & Chambers, 2009) and the System for Observing Family Therapy Alliances (Friedlander et al., 2006). Both provide focused questions regarding the therapeutic alliance and treatment progress. For example, the STIC asks clients to rate the statement, “Some of the other members of my family and I do not feel safe with each other in this therapy” (Pinsof & Chambers, 2009, p. 443). Family therapists may conduct research on their own interventions by using computerized feedback systems to inform the process and progress of treatment (Sexton & Datchi, 2014).

Some models evidence what Heatherington, Friedlander, and Greenberg (2005) refer to as well-articulated theories about systemic change processes. Emotionally focused couple therapy (see Chapter 9) is based on considerable research on the role of emotion in therapy, integrates such re- search with attachment theory, and offers a step-by-step manualized therapeutic plan to help cli- ents access and process their emotional experiences. Functional family therapy (Chapter 12) applies behavioral and systems theories to treat at-risk adolescents. Techniques for building therapeutic alliances and reframing the meaning of problematic behavior have been integrated into successful process studies, especially related to retention in therapy (Sheehan & Friedlander, 2015).

Empirically supported process studies thus far have been carried out primarily in the be- havioral and cognitive-behavioral approaches. These brief, manualized treatment methods, with specific goals, are not necessarily the most effective but are easier to test using traditional research methodology than other treatment methods. Least well defined, for research pur- poses, are the social constructionist therapies. By and large, they have not yet developed test- able propositions (e.g., how does the miracle question in solution-focused therapy affect client outcomes beyond a shift in “language games”?; Heatherington, Friedlander, & Greenberg, 2005). See Chapters 14 and 15 for recent attempts at addressing some of these concerns. Sim- ilarly, while narrative therapists purport to “re-author” people’s lives, how precisely can that be measured, and how do we know when re-authoring has been successful? For most models dis- cussed in this text, greater evidence for the specifications of change mechanisms is still needed to meet the research criteria for how best to tap into the therapeutic change process. Outcome Research Ultimately, all forms of psychotherapy must respond to this question: Is this procedure more efficient, more cost effective, less dangerous, with more long-lasting results than other ther- apeutic procedures (or no treatment at all)? To be meaningful, such research must do more than investigate general therapeutic efficacy; it must also determine the conditions under which family therapy is effective—the types of families, their ethnic or socioeconomic back- grounds, the category of problems or situations, the level of family functioning, the therapeu- tic techniques, the treatment objectives or goals, and so on.

Effective research needs to provide evidence for what models work best for what specific problems, and under what conditions (Sexton et al., 2013). This is termed family intervention research (Liddle, Bray, Levant, & Santisteban, 2002) and may be defined as “a systematic approach to understanding the prac- tices, their outcomes, and the varying moderating and mediating variables that may affect the success or failure of different clinical interventions” (Sexton, Kinser, & Hanes, 2008, p. 165). By linking process issues with outcome results, the family therapist would be proceeding using an empirically validated map. The Society for Family Psychology of the American Psy- chological Association convened a task force to develop a classification of evidence-based treat- ments; they describe levels of evidence from evidence-informed (limited research support) to evidence-informed with promising preliminary evidence (one rigorous research analysis or sev- eral limited studies) to evidence-based treatment (well-formulated models with two or more rigorous studies) in order to categorize family interventions with a commitment to clinically relevant outcomes (Sexton, Gordon, Gurman, Lebow, Holtzworth-Munroe, & Johnson, 2011). This model is illustrated in Figure 16.5. It has been used by Darwiche and deRoten (2015) to identify multidimensional family therapy (Liddle, 2009), functional family therapy (Alexander et al., 2013; Sexton, 2011), brief strategic family therapy (Szapocznik et al., 2012), and family- focused grief therapy (Kissane & Lichtenthal, 2008) as Level III: Evidence-Based Treatments. Major reviews of couple and family therapy interventions establish the efficacy and ef- fectiveness of these treatments for a variety of treatment issues and client populations (Sexton et al., 2013; Sprenkle, 2012; von Sydow et al., 2013). Sexton and colleagues (2013, pp. 589– 590), consistent with the strength-of-evidence model above, suggest that seven factors must be considered in rating couple and family therapies: (1) intervention type, from broad approaches to detailed and structured methods, perhaps in a manual; (2) clinical outcomes, “the effectiveness of a CFT intervention for general and specific client concerns” (p. 590); (3) strength of research re- flects the rigor of the research and the strength of the outcome measures; (4) client characteristics, including demographic and diversity factors that impact generalizability of the findings; (5) com- mon therapeutic processes employed that moderate outcomes; (6) the context reflects the setting in which the treatment was provided; and (7) quality is a measure of confidence in the findings.

Sprenkle (2012) notes the importance of randomized clinical trials (RCTs) in assessing cou- ple and family therapy interventions but stresses that RCTs can include qualitative depth dimen- sions and common factors. He also notes the more challenging issue that most RCT research is conducted by the originators of the specific models under investigation, creating what he terms “allegiance” issues that warrant caution in the interpretation of the results. The flip side of this concern is his finding that the strongest current CFT research, based on methodology ratings, comes from research teams that have been together for more than 10 years, focused on specific models like multisystemic therapy, functional family therapy, or brief strategic ther- apy. Additional aspects impacting the strength of research included use of behavioral outcomes in addition to self-report, use of concrete outcomes not readily distorted, a focus on fidelity to treatment design, inclusion of minority participants, comorbid participants who reflect the prevalence or co-existing problems in real life treatment, use of multiple sites with longitudinal follow-up, inclusion of cost effectiveness, consideration of specific change mechanisms, inde- pendence of the research (conducted by others than model developers), and research in real-life practice settings and not just in a funded research context (Sprenkle, 2012). Evidence supporting family-level interventions is strong for child and adolescent con- duct or behavioral problems; many combine family therapy with parenting programs (Sexton et al., 2013).

A review of systemic therapy for child and adolescent externalizing disorders ex- amined 47 RCTs and found systemic therapy is equally or more efficacious; no adverse effects; superior engagement and retention rates, although minority participants had lower rates than majority participants; enduring positive effects; and positive outcomes across several aspects of functioning (von Sydow et al., 2013, p. 608). Family-based treatments for substance-abusing adolescents, adolescent bipolar disorder, and youth depression have received empirical sup- port (Sexton et al., 2013). Sprenkle (2012) provides a summary list of couple and family therapies that have several RCTs that demonstrate evidence that they achieve valuable results; see Table 16.2.

TABlE 16.2 Evidence-based practice: problems/issues with strong couple and family therapy effects • Adolescent conduct disorder/delinquency • Getting adolescent and adult substance abusers into treatment • Adolescent and adult substance abuse • Childhood and adolescent anxiety disorders • Childhood oppositional defiant disorder • Adolescent anorexia nervosa • Family management of adult schizophrenia • Coping for family members of alcoholics unwilling to seek help • Getting adult alcoholics into treatment • Adult alcoholism • Moderate and severe couple discord • Adult depression when combined with couple discord • Couple violence associated with alcoholism and drug abuse • Situational (not characterological) couple violence • Type I diabetes for adolescents and children Source: Adapted from Sprenkle (2012), p. 25

Evidence-Based Family Therapy: Some Closing Comments The demand for accountability can be seen in medicine and education as well as in psychol- ogy, where professionals are being pressured to base their practices on evidence whenever fea- sible. For psychotherapy, there is increasing momentum to establish an empirically validated basis for delivering healthcare services (Goodheart, Kazdin, & Sternberg, 2006; Kazdin & Weisz, 2010; Nathan & Gorman, 2007), 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 trials for specific diagnostic cate- gories are of limited use with the varied populations and types of problems they see in their practice (Goodheart, 2006).

Many 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. 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 formu- lation, 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 op- erate 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 treat- ing clients who seek their help. This choice is based on a general conviction that no one approach adequately addresses every clinical situation that arises. Westen, Novotny, and Thompson-Brenner (2004) suggest that researchers might do better by focusing on what works in real-world practice than on developing new treatments or manuals from the labo- ratory. 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 (Sprenkle, Davis, & Lebow, 2009). Nevertheless, there is a growing acceptance of the place of evidence-based studies in clin- ical practice, and practitioners may experience increased pressure from third-party payors and government agencies to base their interventions on established evidence-based treat- ments. Clinicians in the future will be held increasingly accountable for providing outcome assessments for their clinical interventions.


Research in family therapy preceded the develop- ment of therapeutic intervention techniques, but pri- orities 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 method- ologies more appealing and germane than the more formal, traditional experimental methodologies based on quantitative methods. Various models to classify and assess families ex- ist, employing either a self-report or an observational format. Most noteworthy are the Circumplex Model of family functioning based on the family properties of flexibility and cohesion and the Family Environ- ment Scale. Observational measures, with which family therapists observe behaviors, have been de- signed by Beavers to depict degrees of family compe- tence and by the McMaster Model to classify family coping skills. Measures of couple adjustment and in- dividual factors that influence family dynamics are also used in research and practice. Both the process and outcome of family ther- apy interventions have been studied with increased interest in recent years. The former, identifying what mechanisms in the therapist–client(s) en- counter produce client changes, helps ensure greater therapeutic effectiveness. Outcome re- search, 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 interven- tions work most effectively with what client popu- lations. Of particular interest today is the search for the relative advantages and disadvantages of alter- native therapeutic approaches for individuals and families with different sets of relational difficulties. Evidence-based family therapy is likely to become increasingly important due to efforts to make ther- apy more effective and cost efficient.

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