Classic Models of Marriage and Family Therapy (MFT)
Please prepare a response to each of the items below. In this interaction you will discuss
concepts regarding competency and theory in MFT, research and ethical foundations of MFT
theories, and the philosophical foundations of MFT theories (Gehart, 2014).
Gehart, D. R. (2014) Mastering Competencies in Family Therapy
To help lay the foundation for your study of Classic Models of MFT, prepare to discuss the
following using Gehart, 2014 Chapters 1, 2 and 3.
• Competency and
Theory in MFT: How does one get from trainee to seasoned
MFT? What is so important about theory? What does it mean to be competent as a
MFT?
• Research and ethical foundations of MFT theories: What do we learn from the “common
factors” research? Why is evidence-based practice important? What makes ethical
principles more than just rules?
• Philosophical foundations of MFT theories: What are the systemic principles that provide
the foundation for the MFT field? What is “social constructionism”? Consult with
your professor about selection of a personal model of MFT.
• Additionally, find one concept that you do not fully understand and discuss this concept
with your professor in order to gain an understanding of it.
Chapter1
Competency and Theory in Family Therapy
The Secret to Competent Therapy
There is a secret to providing competent family therapy. Fortunately, it is an open secret,
and the goal of this chapter is to sketch a map showing where and, more importantly, how
to look for it. You are probably familiar with the basic landscape. You may recognize
therapy’s more promising pathways and some of the dead-end routes. But like everyone
setting out on a journey, your choice between the high road and the low road would be
easier if you knew what was in store for you beforehand.
Since I know you will race ahead if I make you wait too much longer, let’s lay out our
map on the table right now and get a better sense of this secret on the first page. Mapping
a successful therapeutic journey involves five steps.
Mapping a Successful Therapeutic Journey
These five steps follow a classic method used by all explorers in uncharted territory. And
that’s what each new therapeutic relationship is: uncharted territory, an unknown region,
a terra incognita. Although it may seem that clients can be easily lumped into groups—
depressed clients, distressed couples, children with attention deficit and hyperactivity
disorder ADHD, for example—any experienced therapist can tell you that each client’s
journey is unique. The excitement—and secret—to competent therapy is mapping the
distinctive terrain of each client’s life and charting a one-of-a-kind journey through it.
The first step is to delineate as much of the terrain as possible: to get the big picture.
What are the contours of the relationships? Where are the comfort zones? Where is the
page marked “Here Be Dragons?” As with all maps, the bigger and more detailed the
record, the easier it is to move through the territory. In family therapy, our maps are our
case conceptualizations, assessments of the client using family therapy theories. Once you
have a map of the big picture, you identify the landmarks, the oases and obstacles. You
notice where the rest stops are and identify what dangers lie ahead. In therapy, you can
recognize the oases as client resources: anything that can be used to strengthen and sup-
port the client. The obstacles appear as those potential or existing hindrances to creating
change in the client’s life: Are there really dragons there, or is the region just unfamiliar?
Like a cartographer surveying the landscape, therapists assess potential hindrances
carefully, ruling out possible medical issues in consultation with physicians, identifying
psychiatric issues by conducting a mental status exam, and considering basic life needs,
such as financial or social resources, through case management. When actual or probable
impediments are addressed early in the therapeutic process through clinical assessment,
the therapeutic journey is likely to proceed more easily and smoothly.
Once you have your map with oases and obstacles clearly identified, you can
confidently select a realistic path toward the client’s chosen destination or goal. If you have
done a good job mapping, you will be able to choose from among several different
paths, depending on what works best for those on the journey: namely, you and the
client. This translates to being able to choose a therapeutic theory and style that suit
all involved. Seasoned clinicians distinguish themselves from newer therapists in their
ability to identify and successfully navigate through numerous terrains: forests, seas,
deserts, plains, paradises, and wastelands. The greater a therapist’s repertoire of skills,
the more able the therapist is to move through each terrain. Once a preferred path is
chosen, the therapist generates a treatment plan, a general set of directions for how
to address client concerns. Like any set of travel plans, treatment plans are subject to
change due to weather, natural disaster, human error, and other unforeseeable events,
otherwise known as “real life.” Therapists can rest assured that unexpected detours,
delays, and short cuts (yes, unexpected good stuff happens also) will be part of any
therapeutic journey.
Once you select a course of action, you need to check frequently to make sure that
(a) the plan is working and (b) you are sticking with it. In therapy, this translates to
assessing client progress along the way. If the client is not making progress, the therapist
needs to go back and reassess (a) the accuracy of the map and (b) the wisdom of the plan.
Almost always, it is easy to make improvements in both areas that will get things back on
course. The key is assessing client progress often enough to notice when you are off course
as soon as possible.
Finally, you need to leave a trail to track where you have been. Leaving a trail always
helps you and your way back if you get lost: others (as well as yourself) can see why and
how you proceeded. Therapists leave a trace of their path by generating thorough clinical
documentation, which helps in two highly prized aspects of therapy: getting paid by thirdparty payers (i.e., insurance) and avoiding lawsuits (i.e., the state lets you practice). By
making it clear where you are going, you can help everyone concerned better understand
your specific route of treatment. So, competent therapy is that simple: five basic steps that
this book will walk you through, step-by-step.
From Trainee to Seasoned Therapist
The difference between trainees and seasoned therapists can be found in the quality of the
map, the effectiveness of the path of treatment, and the speed with which it takes to move
through the steps. A seasoned therapist may move through the five steps of competent
therapy in the first few minutes of a session, whereas a trainee may take more time, collecting information and trying various options. How long it takes is less important than
the quality of the journey. This book is designed to help you move through these steps
more effectively, whether you are just starting out or have been doing therapy for years.
Competency and Theory: Why Theory Matters
Although much has changed in the past decade in mental health—better research to guide
us, new knowledge about the brain, more details about mental health disorders, increased
use of psychotropic medication—the primary tool that therapists use to help people,
theory, has not. Therapeutic theories provide a means for quickly sifting through the
tremendous amount of information clients bring; then targeting specific thoughts, behaviors, or emotional processes for change; and finally helping clients effectively make these
changes to resolve their initial concerns. Even with fancy fMRIs, (functional magnetic
resonance imaging) neurofeedback machines, and hundreds of available medications,
no other technology has taken the place of theory. However, the changing landscape of
mental health care has altered how therapy theories are understood and used. Specifically,
theory and how it is being used and understood has been recontextualized by two major
movements in recent years: a) the competency movement, which includes multicultural
competency; and b) research or evidence-based movement, which is discussed in detail in
the next chapter. These movements have not ended the need for theory, but have instead
changed how we conceptualize, adapt, and apply theory.
Why All the Talk About Competency?
All health professions, including mental health, have been abuzz in recent years with talk
of competencies, detailed lists of the knowledge and skill professionals need to effectively
do their job. The main source of this movement has been external to the field, and has
come from stakeholders who believe that professionals should not only be taught a consistent set of skills but their learning should be measured on real-world tasks (for a detailed
discussion see Gehart, 2011). Thus, this movement is asking educators to shift their focus
from conveying content to ensuring students know how to meaningfully apply the knowledge and skills of their given profession.
Each major mental health profession—including counseling, marriage and family therapy, psychology, psychiatry, psychiatric nursing, and chemical dependency counseling—
has developed a unique set of competencies. Thankfully, there are many, many similarities
across them. Appendix A and B include two of the more commonly used sets of competencies in family therapy: the Marriage and Family Therapy Core Competencies developed by
a task force commissioned by the American Association for Marriage and Family Therapy
(Appendix A; Nelson, Chenail, Alexander, Crane, Johnson, & Schwallie, 2007) and the
Marriage, Couple, Family, and Child Counseling standards (Appendix B) developed by
the Commission for the Accreditation of Counseling and Related Educational Programs.
On nights when you have insomnia, you may find it helpful and interesting to read through
what will be expected of you as a family therapist or counselor, regardless of the title on
your license.
These competencies are being used to more clearly define what family therapists must know
and do in order to be competent. If you are new to the field, this is actually will make the task
of learning to be a family therapist far easier: the goals are now clearly defined. This book is
designed to help you develop these competencies as quickly and directly as possible.
Competency and (Not) You
Although at first it may seem insensitive, the vernacular expression commonly used by my
teen clients sums up the mind-set of competency best: “It’s not about you.” It’s not about
your theoretical preference, what worked for you in your personal therapy, what you are
good at, what you find interesting, or even what you believe will be most helpful. Competent therapy requires that you get outside of your comfort zone, stretch, and learn how to
interact with clients in a way that works for them. In short, you need to be competent in
a wide range of theories and techniques to be helpful to all of the clients with whom you
work. If you allow me to go on, you might even begin to see how this makes some sense
and might even be in your best interest.
Perhaps it is best to explain with an example: you will likely either have a natural propensity for generating a broad-view case conceptualization using therapy theories or have
a disposition that favors a detail-focused mental health assessment and diagnosis; humans
tend to be good with either the big picture or the details. However, to be competent,
a therapist needs to get good at both even if one is easier, preferred, and philosophically
favored. Similarly, you may prefer theories that promote insight and personal rejeection;
after all, that may be what works for you in your life. However, that may not work for
your client, and/or research may indicate that such an approach is not the most effective
approach for your client’s situation or cultural background. Thus, you will need to master
theories of therapy that may not particularly interest you or even fit with your theory of
therapy. Even though you may not like this idea at first, I think that by the time you are
done with the book, you might just warm up to it.
I first learned this competency lesson when working with families in which the parents had difficulty managing the behaviors of their young children. I was never a huge
fan of behaviorism, but it did not take too many hysterically screaming, clawing, and
biting two-year-olds before I was preaching the value of reinforcement schedules and
consistency. Given my strong—admittedly zealous—attachment to my postmodern approach at the time, I have every faith that you will be driven either by principle (ideally) or
desperation (more likely) to move beyond your comfort zone to become a well-rounded,
competent therapist.
Common Threads of Competencies
Whether you are training to be a counselor, family therapist, psychologist, or social
worker, you will notice that are common themes across the various sets of competencies.
You will want to take particular note of these:
• Diversity and Multicultural Competence: The use of therapeutic theory is always
contextualized by diversity issues, which means that the application and applicability
vary—sometimes dramatically—based on diversity issues, such as age, ethnicity, sexual
orientation, ability, socioeconomic status, immigration status, etc.
• Research and the Evidence Base: To be competent, therapists must be aware of the
research and the evidence-base related to their theory, client populations, and presenting problem.
• Ethics: Perhaps the most obvious commonality across sets of competencies is law and
ethics; without a firm grasp of the laws and ethical standards that relate to professional
mental health practice… well, let’s just say you won’t be practicing very long. A solid
understanding of ethical principles, such as confidentiality, is a prerequisite for applying theory well.
•
Person-of-the-Therapist: Finally, unlike most other professions, specific personal quali-
ties are identified as competencies for mental health professionals, which will be discussed in more depth below.
Diversity and Competency
Over the past couple of decades, therapists have begun to take seriously the role of diversity in the therapy process, including factors such as age, gender, ethnicity, race, socioeconomic status, immigration, sexual orientation, ability, language, and religion. These
factors inform the selection of theory, development of the therapy relationship, assessment
and diagnosis process, and choice of interventions (Monk, Winslade, & Sinclair, 2008). In
short, everything you think, do, or say as a professional is contextualized and should be
informed by diversity issues. If you think effectively responding to diversity is easy or can
be easily learned or that perhaps your instructors, supervisors, or some famous author has
magic answers to make it easy, you are going to be in for an unpleasant surprise. Rather
than a black-and-white still life, dealing with diversity issues is more like finger painting:
there are few lines to follow, it is messy for everyone involved, and it requires enthusiasm
and openheartedness to make it fun.
I have often heard new and experienced therapists alike claim that because they are
from a diverse or marginalized group, they don’t need to worry about diversity issues.
Conversely, I have heard therapists from majority groups say things such as, “I don’t
have any culture.” Both parties have much to learn on the diversity front. First of all, we
are all part of numerous sociological groups that exert cultural norms on us, with the
more common and powerful ones stemming from gender, ethnicity, socioeconomic class,
religion, and age. Many, if not most, people belong to some groups that align more with
dominant culture and to some that are marginalized. However, it is important to realize
that some groups experience far more traumatic and painful forms of marginalization
than others, and to further complicate matters, each individual responds to these pressures differently.
To illustrate, some people experienced the process of coming out as gay as highly traumatic and want therapists to address these issues gingerly; others find it insulting when
therapists assume they feel oppressed due to sexual orientation, because they live in communities that are largely supportive. Furthermore, many Americans seem unaware that
there is a very strong and distinct “American culture” of which they are a part; in fact,
the various regions of America have very unique characteristics of which therapists need
to be aware. As another example, midwestern men typically express their emotions far
differently than men in California; therapists who expect the two types of men to handle
emotions in a similar way are going to unfairly pathologize one or the other.
Suffice it to say, competently handling diversity issues requires great attention to the
unique needs of each person, and it is a career-long struggle and journey that adds great
depth and humanity to the person-of-the-therapist. In this book, you will begin this journey by examining diversity issues related to each of the theories covered and start integrating these issues into case conceptualization, assessment, and treatment planning. Diversity
is so central to using theory that you will find discussions of diversity throughout each
chapter, in addition to an extended section at the end of each chapter covering various
forms of ethnic, gender, and sexual identity diversity related to the implementation of the
specific theory.
Research and Competency
Another common thread found in mental health competencies is understanding and,
more importantly, using research to inform treatment and to measure one’s effectiveness and client progress. In recent years, there has been a powerful movement within
the field to become more evidence-based in mental health. This involves two key
practices: a) using existing research to inform clinical decisions and treatment
planning; and b) learning to use evidence-based treatments, which are specific and
structured approaches for working with distinct populations and issues (Sprenkle, 2002).
These movements are discussed in detail in Chapter 2 (in perhaps too much detail for
some); issues related to the evidence base for each therapeutic theory are also discussed
at the end of each theory chapter, with the related evidence-based treatment highlighted.
In addition, Chapters 11 and 12 cover leading evidence-based treatments in the field of
couple and family therapy. If you were hoping to escape a discussion of research in your
theory text, you will initially be disappointed; however, I hope by the end you find the
integration an invigorating addition.
Law, Ethics, and Competency
I often quip with students entering the field that if they think therapists can cut corners with
legal or ethical issues, they should transfer to a business program so that they can make
some money without worrying about such details and avoid a felony prison sentence after
working as an unpaid intern for four plus years. That might be a bit of an exaggeration,
but not much. Therapists who fail to develop competence in legal and ethical issues will
not last long. Although this book does not directly cover these issues, they are so central
to the profession that even before you begin reading about theories and treatment planning, you need a brief introduction so you don’t run off and start applying the concepts
in this book to identify the underlying causes of problems in your clients, friends, family,
neighbors, pets, and yourself. All mental health professional organization—the American
Association for Marriage and Family Therapy, the American Counseling Association, the
American Psychological Association, and the National Association of Social Workers—
have codes of ethics that their members must follow. Thankfully, there is significant agreement between the various organizations resulting in general agreement on most key issues;
federal and state laws also generally agree on the key principles. These issues are covered
in depth in Chapter 2.
Person-of-the-Therapist and Competency
Finally, being a competent therapist requires particular personal characteristics that are
often difficult to define. Some qualities are basically assumed to be prerequisites for a
professional—integrity, honesty, and diligence—and take the form of following through
on instructions the first time asked, raising concerns before they spiral into problems, staying true to one’s word, etc. It is hard to establish competency in anything without these
basic life skills.
The more subtle issues of the person-of-the-therapist come out in building relationships with clients. To begin with, the research is clear that clients need to feel heard,
understood, and accepted by therapists, which often takes the form of offering empathy
and avoiding advice giving (Miller, Duncan, & Hubble, 1997). Furthermore, therapists
need to identify and work through their personal issues to avoid bias and inappropriately pathologize a client—what psychodynamic therapists call countertransference
(see Chapter 6). Although more difficult to quantify, these issues often become quickly
apparent by strong emotions or unusual interactions in relationships with clients, supervisors, instructors, and peers. Managing these well is part of being a competent
therapist.
Finally, a more difficult aspect to define is therapeutic presence, a quality of self
considered to have intrapersonal, interpersonal, and transpersonal elements, including
elements of empathy, compassion, charisma, spirituality, transpersonal communication,
patient responsiveness, optimism, and expectancies—making it elusive and difficult to
operationalize (McDonough-Means, Kreitzer, & Bell, 2004). Clients—rather than a
professional—are the best judges this subtle quality because in the end, it comes down to
how the client experiences the therapist as a human being in the room. Although these
competencies are more difficult to measure, they are nonetheless some of the more important to develop.
How This Book Is Different and What It Means to You
Mastering Competencies in Family Therapy is a different kind of textbook. Based on a new
pedagogical model, learning-centered teaching (Killen, 2004; Weimer, 2002), this book
is designed to help you actively learn the content and develop real-world competencies
rather than simply deliver the content and hope that you will memorize it. Thus, learning
activities are a central part of the text so that you have opportunities to apply and use the
information in ways that facilitate learning. The specific learning activities in this book are
a) case conceptualization, b) clinical assessment, c) treatment planning, and d) progress
notes; these translate the theory learned in the chapter to practical client situations. This
book teaches real-world skills that you can immediately use to better serve your clients.
This book is different in another way: it is organized by key concepts rather than general headings with long narratives sections. This organization—which evolved from my
personal study notes for my doctoral and licensing exams back before I had e-mail (and, no,
dinosaurs were not roaming the planet then)—facilitates the retention of vocabulary and
terms because of the visual layout. Each year I receive numerous e-mails from enthusiastic
newly licensed therapists thanking me for helping them to pass their licensing exams—they
all say that the organization of the book made the difference. So, spending some time with
this text should better prepare you for the big exams in your future (and if you have already
passed these, you should be all the more impressed with yourself for doing it the hard way).
In a Nutshell: The Least You Need to Know: The chapters begin with a brief summary
of the key features of the theory. Although it may not be the absolute least you need to
know to get an A in a theory class or help a client, it is the basic information you should
have memorized and are able to quickly articulate at any moment to help you keep your
theories straight.
The Juice: Significant Contributions to the Field: In the next section, I use the principle of primacy (first information introduced) to help you remember one of the most
significant contributions of the theory to the field of family therapy. In most cases,
well-trained clinicians who generally use another approach to therapy are likely to be
skilled and use this particular concept because it has shaped standard practice in the
field. This section is your red flag to remember a seminal concept or practice for the
theory. Feedback from students indicates this is often one of their favorite sections.
(I only hope that isn’t because they skim the rest of the chapter; but, of course, you
would never think of such a thing.)
Rumor Has It: The People and Their Stories: In this section, you can read about the developers of the theory and how their personal stories shaped the evolution of the ideas. And,
yes, some of the rumors are juicier than others. As the focus of this text is how therapy
theories are actually used in contemporary settings, I have deemphasized the history and
development of the theory, but you will find brief summaries of such history here.
The Big Picture: Overview of the Therapy Process: The big picture provides an overview
of the flow of the therapy process: what happens in the beginning, middle, and end, and
how change is facilitated across these phases.
Making Connections: The Therapy Relationship: All approaches start by establishing a
working relationship with clients, but each approach does it differently. In this section,
you will read about the unique ways that therapists of various schools build relationships
that provide the foundation for change.
The Viewing: Case Conceptualization: The case conceptualization section will identify the
signature theory concepts that therapists from each school use to identify and assess clients
and their problems. This really is the heart of the theory and where the real differences
emerge. I encourage you to pay particularly close attention to these. You can also read
more about case conceptualization in Chapter 13.
Targeting Change: Goal Setting: Based on the areas assessed in the case conceptualization
and the overall therapy process, each approach has a unique strategy for identifying client
goals that become the foundation for the treatment plan.
The Doing: Interventions: Probably the most exciting part for most new therapists, the
doing section outlines the common techniques and interventions for each theory. In some
cases, a section for techniques used with special populations is included if these are notably
different than those in standard practice.
Putting It All Together: Case Conceptualization and Treatment Plan Templates: After
graduation, you will probably thank me most for this section, which provides templates
for theory-specific case conceptualization and treatment plans that can be used for addressing depression, anxiety, or trauma with individual clients and confict with couples and
families. These plans tie everything in the chapter together (just imagine a little bow on top).
Tapestry Weaving: Working with Diverse Populations: This section reviews specific approaches for working with diverse populations using the theories covered in the chapter.
Each chapter includes sections on ethnic and sexual identity diversity issues.
Research and Evidence Base: Finally, the chapters end with a brief review of the research
and evidence base for each theory to offer a general sense of empirical foundations for the
theory. In some cases, influential evidence-based treatments (see Chapter 2 for a definition)
are highlighted.
Online Resources: A list of web pages and web documents are included for those who
want to pursue specialized training or conduct further research on the theory.
Reference List: Many students pass right over reference lists and forget all about them.
But if you have to do an academic papers or literature review on any of these theories,
this should be your first stop. In this case, I had several hundred books and articles go
through my 12' 3 12' office while writing the editions of this book. Thus, you can certainly shorten the time it takes to locate key resources by pursuing these before you hit the
library yourself. (Oh, I forgot, no one steps foot in these places anymore; I meant “surf”
the library’s web page while still in your bunny slippers.)
Case Example: Finally, each chapter ends with a case vignette, case conceptualization, clinical
assessment, treatment plan, and progress note to give you of sense of how the theory looks
in action and how to put down on paper. The details for how to complete these forms are
in Chapters 13–17.
Voice and Tone
Finally, I should mention that the voice and tone of this textbook is a bit different than
your average college read. Hopefully, you have noticed by now that I am talking right
at ya. I also like to add some humor and have some fun while I write. Why? Well, first,
I have more fun writing this way. But, more importantly, I want to engage you as if you
were one of my students or supervisees learning how to apply these ideas for the first time.
Family therapies are relationship-based practices, one in which the parties co-construct
knowledge together. So, it’s hard for me to write about these ideas as a detached, faceless
author, thereby perpetuating the myth of objectivity in knowledge construction (you’ll
better understand why I’m worried about this after reading about the philosophical foundations of family therapy in Chapter 3). So, as I write, I’m imagining you as a real person,
eager to learn about how to use these ideas to help others. I am going to try to reach out
to you, answer questions I imagine you have, and periodically tap you on the shoulder to
make sure you are still awake.
Suggested Uses for This Text
Suggestions for Thinking About Family Therapy Theories
As you read the chapters in this book, you are going to be tempted to identify which ones
you like the best and deemphasize the ones that you are less attracted to. This may seem
like a great idea at first, but here are some points to consider:
Favorite vs. Useful: The theories that the average therapist finds personally useful are
probably not the same ones that the average client of a new therapist is likely to find useful.
Many therapists are psychologically minded, meaning that they enjoy thinking about the
inner world and how it works. However, most new therapists begin working in lower-fee
clinics that serve diverse, multiproblem clients and families, many (but not all) of whom
are not psychologically minded because they are often struggling with issues of survival
and/or come from cultural traditions that place less value on analysis and understanding
of the inner world. So, the theory you find most useful to you personally may not be a
good fit for your first client.
Appreciative: The theories in this book are not casually chosen. They have become
part of the standard cannon of theories because generations of therapists have found
them helpful. Each has wisdom worthy of study. The one lesson I have learned over the
years is that the more theories therapists understand, the better able they are to serve
their clients because their understanding of the human condition and its concomitant
problems is broader. Thus, I recommend approaching each theory with an attitude of
searching for its most wide and useful parts. I facilitate this for you in the “Juice” section of each chapter, which identifies the one concept I believe has near universal utility
from the particular theory.
Common Threads: Family therapy theories are ironic: in one sense they are very different and inform distinct and mutually exclusive behaviors and attitudes. However, the
better you understand one, the better you understand them all. In fact, some therapists,
the common factors proponents, argue that theories are generally equally effective because they are simply different modes for delivering the same factors (Miller, Duncan, &
Hubble, 1997; you will read more in Chapter 2). So, it is quite possible that commonalities
across theories are more important than their differences.
Suggestions for Using This Book to Learn Theories
First, I recommend that you set aside an hour or two to read about a single theory from
beginning to end (from the “In a Nutshell” to “Putting It All Together”) to help get the
full sense of the theory. Some chapters have a couple theories in one, so for these, it is fine
to read the chapter in chunks. Additionally, some learners may find it helpful to scan the
treatment plan (either the template or example at the end of the chapter) or some other
section first to provide a practical overview; that said, I have tried to organize the ideas
in the way most people seem to prefer. But I encourage you to discover what works best
for you, as different learners have different strategies that work best for them. When you
are done with a chapter, you might want to try completing a case conceptualization and
treatment plan for yourself (you may have to make up a problem if you are nearly perfect)
or someone else to get a sense of how this would work.
Finally, I strongly recommend that either after reading the chapter or after going to
class you take good ol’ fashioned notes. Yes, I mean it. I recommend that you type up
(or if you prefer, handwrite) a complete outline of the key concepts in your own words.
Why do I advocate such painful torture? When we read long, dense books such as this
one, we all fade in and out of alert attentiveness to what we are reading—often lapsing
into more interesting fantasies or less interesting to-do lists—and—gasp!—sometimes
even skim large sections of the text (no, I am not surprised or offended). The only way
to make sure that you really understand the concepts you read about is to put them in
your own words and organize them in a way that makes sense to you. If you need to take
culminating exams or plan to pursue licensure, you will have to log the concepts in this
book into your long-term memory, which requires more than cramming for a final exam.
If you are new to graduate and professional school, I am sorry to be the bearer of the
sad news: this is not like undergraduate study, where forgetting everything you learned
the week after finals was generally not a problem. Being a mental health professional
requires that you master and build upon what you learn. You will be expected to know
what is in this book for the entire time you are active in the profession (seriously—and
if you think that is bad, just wait until you get to a class on diagnosis—you’ll have to
memorize an even longer book). So, if your former study habits included all-night cram-
ming, gallons of espresso (or other favorite caffeine-delivery system), and little recall
after the exam, you might want to try my note-taking tip or some other strategy as you
move forward.
Suggestions for Using This Book to Write Treatment Plans
I want to emphasize that the treatment plan format, templates, and examples in this book
are just that: formats, templates, and examples. They do not represent the only approach
or the only right approach. They are simply a solid approach based on the common standards and expectations. You most likely will work at a counseling agency or institution
that uses another format, but the same general rules (those in Chapter 15) will still apply.
That is why understanding the principles of how to write good goals and interventions is
more important than memorizing the format.
Furthermore, don’t use the templates and examples too rigidly. Feel free to modify the
goal statements and techniques to fit the unique needs of your client. I have provided some
relatively specific goals as an example of what might work and encourage you to radically
tailor these for each client’s unique needs. You will notice that treatment plans in the case
study do not rigidly follow the templates; I encourage you to do the same.
Suggestions for Use in Internships and Clinical Practice
When working as an intern or licensed mental health professional, this book can be useful for teaching yourself theories and techniques in addition to learning how to complete
clinical documentation. You will likely find that when you work with new populations
and problems, you may be interested in considering how other therapy models might
approach these situations. This book is designed to be a prime resource that can be
quickly scanned to identify other possibilities. Alternatively, you might have a colleague
or supervisor who uses a theory with which you are not familiar. You can use this book
to quickly review that theory and keep from looking uneducated. In addition, this book
is written to help you appreciate and find common ground across theories, which can be
of particular benefit when working in a “mixed theory” context. However, to actually
learn to practice any of these theories well, I strongly urge you to take advanced training
from experts in that approach.
Suggestions for Studying for Licensing Exams
Licensing exams are not designed to be unnecessarily tricky or scary, they simply ensure
that you have the necessary knowledge to practice therapy without supervision and not
harm anybody. And they are a vocabulary test. If you have honestly engaged in your
classes, done your homework, avoided cramming for tests and papers, and made it a
priority to get decent supervision, you should have a strong foundation for taking your
licensing exam. You should already have in your possession books (such as this) that cover
all of the content to be studied for the exam. If your exam is to be taken upon finishing
a lengthy post-master’s internship, you should use the entire two- to four-year period to
read as many books as possible on the theories and materials covered by the exam (that
means no novels for a few years).
I do not recommend that all of my students take long, expensive “review courses”
because such courses are not necessary for those who are proactive in mastering the material on the exam long before they sign up to take it. If you start studying only after you are
approved to take the test, you are starting about two to four years too late—and then, yes,
you will need to take a crash course. My basic suggestion for studying for a mental health
licensing exam is this: read an original text on each major theory during your postdegree
internship, use the DSM, and keep up with laws and ethics; and then buy the practice
exams (without the study guides) and take them until you consistently get 5% above the
required passing score (e.g., 75% if the passing score is 70%). If you
nd that you are weak
in a particular area, such as theory or DSM, use a text such as this, which is designed for
the license review in mind. Once you consistently get 75%, you are ready—with the most
learning and the least expense—to take the test.
Suggestions for Faculty to Measure Competencies and Student Learning
This book is specifically designed to help faculty and supervisors simplify and streamline
the onerous task of measuring student competencies as required by the various accreditation bodies. The forms and scoring rubrics for assessing student learning using counseling,
psychology, social work, and family therapy competencies are available on the book’s web
page for instructors (see login.cengage.com). On this website, instructors will also find free
online lectures, PowerPoint slides, sample syllabi, and a test bank. This text may be used
as the primary or secondary text in a family therapy theories class or as a primary text in
a prepracticum or practicum/fieldwork class. Because of its combination of solid theory
and practical skills, it can easily be used across more than one class to develop students’
abilities to conceptualize theory and complete clinical documentation, skills that are not
likely to be mastered in a single class.
When designing a class to measure competencies and student learning using these
treatment plans and case conceptualizations, I recommend initially going over the scoring rubrics with students so that they understand how these are used to clearly define
what needs to be done and the expectations for the final product. I have found that is
most helpful to provide two to three opportunities to practice case conceptualization
and treatment planning over a semester to provide feedback and enable students to
improve and build upon these skills in an systematic fashion. Specifically, I have a small
group present a case conceptualization and treatment plan with each theory studied
based on a video the class watches on the theory; that way they have enough information to actually conceptualize the client dynamics and treatment. Then the entire class
can see an example and discuss the thought process of developing the plan. A later or
final assignment for the class can be to independently develop a treatment plan for a
case (either one assigned by the instructor, from a popular movie, personal life, or actual client). By the end of a semester, with these activities, students will have developed
not only competence but also confidence in their case conceptualization and treatment
planning abilities.
ONLINE RESOURCES FOR STUDENTS
Students will find numerous useful resources for the text on the Cengage website (www
.cengagebrain.com) and the author’s websites (www.dianegehart.com; www.mastering
competencies.com).
These include:
• Online lectures: MP4 recordings of yours truly discussing content of select chapters
• Digital forms for all assignments: case conceptualization, clinical assessment, treatment
plan, and progress note
• Scoring rubrics for each assignment
• Links to related websites and readings
• Glossary of key terms
ONLINE RESOURCES FOR INSTRUCTORS
Instructors will find numerous resources for the book on the Cengage website (login
.cengage.com) and the author’s websites (www.masteringcompetencies.com; www
.dianegehart.com). These include:
• Online lectures by the author
• Sample syllabi for how to use this book in a theory class, prepracticum skills class, or
practicum class
• PowerPoint slides for all chapters
• Digital forms for all assignments: case conceptualization, clinical assessment, treatment plan, and progress note
• Scoring rubrics for each assignment correlated to each profession’s competencies:
counseling, family therapy, psychology, and social work
• Test bank
• Web quizzes
Chapter 2
Research and Ethical Foundations of Family Therapy Theories
Lay of the Land
This chapter covers two key foundational elements of competent family therapy practice:
the evidence base and ethics. The evidence-base section is divided into four major sections:
1. evidence-based practice
2. common factors research
3. evidence-based treatments
4. review of the marriage and family therapy (MFT) evidence base
The ethics section covers legal and ethical issues that are particularly salient when
working with couples and families. I have invited a colleague, Ben Caldwell, to write this
section. He quotes legal and ethical codes by memory, with numbers, and in far more
detail than most listeners would prefer. I should also warn you that he rarely offers the
black-and-white answers we all hope for. Even so, I am sure even seasoned therapists will
learn a thing or two from this section.
Research and the Evidence Base
In the 21st century, all therapists are expected to be well versed in the evidence base
for the treatments they use and the problems they treat, in much the same way that we
expect our medical doctors to only use procedures and drugs that have been well researched for our particular medical condition. This may or may not come as a surprise
to you, but in many ways, mental health therapists have not been well versed in the
evidence base for their field, especially when compared to other medical professions.
(FYI: we are considered by most as medical professionals.) For many years, it has been
as if researchers and clinicians spoke two different languages, with little communication between parties. In some cases, the research has been too specific or too vague to
be useful to the average practitioner. In other cases, therapists work from philosophical
positions that do not value research, instead focusing on the individual needs of a particular client. The good news is that translation efforts over the past two decades have
made becoming an evidence-based practitioner easier than you might imagine. This
chapter covers three strands of research that inform daily practice of family therapy in
contemporary practice— evidence-based practice, common factors, and evidence-based
treatments—and also introduces you to an excellent resource for quick and easy review
of the MFT evidence base.
The Minimum Standard of Practice:
Evidence-Based Practice
More commonly used in the medical field, evidence-based practice uses research findings
to inform clinical decisions for the care of individual clients. In a nutshell, evidence-based
practice refers to knowing the evidence base related to a specific client’s problem and
contextual issues and using that information to make treatment decisions. For example,
the research literature is very clear that systemic-structural family therapy approaches
are the treatment of choice for adolescents with conduct and substance abuse disorders.
Even if you are not formally trained in one of these approaches (see Chapters 4, 5, and 11
to start your training), because the evidence base is so strong ethically, you should use
this knowledge to inform your treatment decisions. Think of it this way: If you were this
child’s parent, would you want to take your child to a therapist who has his or her own
way of doing things based on theory and experience, or to one who uses research on
best practices to decide how best to help your child? You’d need a really strong referral
to choose the first option.
Every therapist should strive to be an evidence-based practitioner. Many would consider it an ethical obligation, because the evidence base is quickly redefining standard
practice (see the section below on ethics). Patterson, Miller, Carnes, and Wilson (2004)
describe five steps of evidence-based practice for family therapists:
Step 1: Develop an answerable question to focus the search for information: What
treatments are most effective for teens who cut to relieve emotional pain?
Step 2: Search the literature for the best empirical evidence to answer the question:
search digital databases such as PsychInfo and scholar.google.com using the keywords adolescents, self-harm, and treatment.
Step 3: Evaluate the validity, impact, and applicability of the research to determine its
usefulness in this case: Is the study randomized? Were there comparison groups?
What was the treatment effect size? Were the findings clinically relevant?
Step 4: Determine whether the research findings are applicable to the current client’s
situation: What are the potential benefits and risks of applying these findings with
this client? Do I need to consider any diversity factors, such as age, ethnicity, class,
or family system?
Step 5: After implementing the EBP, evaluate the effectiveness in this client’s individual
case: How did the client respond? Were there signs of improvement, no change, or
worsening?
Becoming a evidence-based practitioner requires a willingness to continually learn and
adapt one’s practice to integrate the latest findings in the field. It also requires that therapists are responsive to their client’s individual needs—even if researchers indicate that a
particular approach works for most clients with a specific condition, you need to evaluate
whether it works for yours; if it doesn’t, you need to adjust your approach. Essentially, it
comes to down to making a more informed decisions so that you are optimally efficient.
As research becomes more clinician friendly and relevant, I anticipate that therapists will
have a far closer relationship to their evidence base.
Heart of the Matter: Common Factors Research
Over the past decade, professional literature has been abuzz over the “common factors debate” (Blow, Sprenkle, & Davis, 2007; Sprenkle & Blow, 2004; Sprenkle, Davis, & Lebow,
2009). Common factors proponents contend that the effectiveness of therapy has more to
do with the key elements found in all theories than with the unique components of a specific
theory. To simplify the argument even further: the similarities matter more than the differences. This position is supported by meta-analyses (research on several research studies) of
outcome studies in the field: when research studies control for confounding variables (such
as therapist loyalty, comparison group, or measures of outcome), there is little evidence to
support the superiority of one theory over another, both in psychotherapy (Lambert, 1992;
Wampold, 2001) and in family therapy, specifically (Shadish & Baldwin, 2002).
Within the common factors community, some (Miller, Duncan, & Hubble, 1997) emphasize the common factors while minimizing the role of theory, whereas others take a
more moderate approach (Sprenkle & Blow, 2004), maintaining that theories are still important because they are the vehicles through which therapists deliver the common factors,
and because specific models may have an added benefit in certain contexts. Sprenkle and
Blow (2004) point out that the common factors approach does not require therapists to
relinquish therapeutic models but instead to understand their purpose differently. Rather
than providing the “answer” to the client’s problems, common factor proponents propose
that using a structured treatment inspires confidence from clients in the therapeutic process, allowing therapists to coherently actualize common factors. From this perspective,
a therapeutic model is better understood as a tool that increases therapist effectiveness
rather than the “one and only true path” that resolves the client’s problem.
Lambert’s Common Factors Model
The most frequently cited common factors model is grounded in the work of Michael
Lambert (1992). After reviewing outcome studies in psychotherapy, Lambert estimated
that outcome variance (the degree to which change is attributed to a specific variable)
could be attributed to four factors:
Lambert’s Common Factors model
• Client Factors: An estimated 40%; includes client motivation and resources
• Therapeutic Relationship: An estimated 30%; the quality of the therapeutic relationship as the client
evaluates it
• Therapeutic Model:
techniques used
n estimated 15%; the therapist’s specific model for treatment and the
• Hope and the Placebo Effect:
help
n estimated 15%; the client’s level of hope and belief that therapy will
Often these percentages are cited as facts, but although they are well-informed estimates
based on a careful analysis of existing research, the numbers were not generated through an
actual research study. They should be considered general trends in the research that inspires
therapists to critically reconsider how they can help clients rather than exact percentages.
Wampold’s Common Factors Model
Wampold (2001) conducted a meta-analysis similar to Lambert’s, but compared only studies
that included two or more actual therapy models (rather than comparing a model to the generic
“treatment as usual” or a no-treatment control group). He presents evidence for the following:
Wampold’s Common FaCtor model
• Therapeutic Model: 8%; the unique contributions of a specific theory
(compare with 15% in Lambert’s model)
• General Factors: 70%; therapeutic alliance, expectancy, hope
• Unknown Factors: 22%; variance that is not related to known variables
Wampold’s research further underscores that common elements across theories contribute more to positive therapeutic outcomes than the unique elements of a specific
theory. Thus, research across theories continually indicates that general or common factors have the greatest impact on outcome; although this result may be due to the limits
of research (Sprenkle & Blow, 2004) or other factors, it is the best information to date
on the subject.
Client Factors
Lambert’s (1992) research, which has been made most accessible to clinicians in the work
of Miller, Duncan, and Hubble (1997), emphasizes the importance of activating client resources, such as by encouraging clients to create and use support networks and increasing
client motivation and engagement in the therapeutic process. Tallman and Bohart (1999)
propose that most theories work equally well because of the client’s ability to adapt and
utilize whatever techniques and insights the therapist may offer; the therapeutic process
effectively becomes a Rorschach (ink blot test) that the client uses to create change.
Miller, Duncan, and Hubble (1997) describe two general categories of client factors:
1. Client characteristics include the client’s motivation to change, attitude about therapy
and change, commitment to change, personal strengths and resources (cognitive, emotional, social, financial, spiritual), and duration of complaints.
2. Extratherapeutic factors include social support, community involvement, and fortuitous life events.
Therapeutic Relationship
In both Lambert’s and Wampold’s research, the quality of the therapeutic relationship
appears to be more important than the specific model in predicting outcome, a finding
that is consistent with much of the traditional wisdom in the field. In an effective relationship, the therapist accommodates to the client’s level of motivation, works toward
the client’s goals, and demonstrates a genuine, nonjudgmental attitude. A particularly
interesting—and humbling—finding is that the client’s evaluation of the relationship is
more strongly correlated with positive outcome than the therapist’s evaluation (Miller,
Duncan, & Hubble, 1997).
Despite the clear and consistent evidence for the importance of the therapeutic relationship, most outcome studies, especially those on evidence-based therapies, try to
control for and factor out the impact of the therapist on treatment, thereby obscuring the
role of the therapist in effective treatment (Blow, Sprenkle, & Davis, 2007). Perhaps this
is done because it is hard to fully operationalize and measure the therapeutic relationship, or perhaps because researchers want a more scientific-sounding explanation (the
treatment did it, not the relationship). Whatever the reason, the evidence-based treatment literature seems to undervalue and underestimate the importance of the therapeutic
relationship. However, common factors research redirects therapists’ attention to this
important component. Therapists wanting to closely attend to relationship variables can
use measures such as the Session Rating Scale (see Chapter 16) to monitor the relationship on a weekly basis.
Therapeutic Model: Theory-Specific Factors
Theory-specific factors are what the therapist says and does to facilitate change while following his/her therapeutic model. These factors are what therapists and third-party payers
consider important. However, as Lambert’s research and estimations indicate, technique
may not be as important as is typically assumed, actually being only half as important as
the therapeutic relationship. However, it is still an influential factor over which therapists
have significant control.
Hope and the Placebo Effect: Expectancy
Hope and expectancy, or the placebo effect, refer to clients’ belief that therapy will help
them resolve their problem. Lambert’s (1992) emphasis on this factor heightens therapists’
awareness of an often-neglected aspect of the therapeutic process, at least in the research
literature (Blow, Sprenkle, & Davis, 2007). With this awareness, therapists can more consciously work to instill hope, which is particularly critical in the initial sessions.
Diversity and the Common Factors
Common factors can be particularly useful when working with diverse clients—whether
culturally, sexually, linguistically, or in ability—because diversity always implies unique
client resources and challenges, particularly for the therapeutic relationship, choice of approach, and strategies for instilling hope. For example, although gay, lesbian, bisexual,
and transgendered clients are often ostracized in the general community, many have extensive informal and formal social support networks; the same is true of many ethnic groups
and disabled or chronically ill people. Thus the societal challenge is partially offset by
unique resources. Therapists can help clients leverage these resources to better manage the
often daunting challenges of being different from the majority.
Similarly, with diverse clients, the task of creating a therapeutic relationship in which
the client feels accepted rather than judged requires more mindfulness and thoughtfulness
because the therapist may not be aware of all the dynamics and traditions of these groups.
Education on local diverse communities is of course necessary, but humility and admitting
that you do not know the answer is often more important because it cultivates respect and
openness (Anderson, 1997). When therapists proceed with curiosity and a willingness to
learn, they often discover distinct and effective means for instilling hope from within the
client’s culture and primary community, further strengthening the therapeutic relationship.
Do We Still Need Theory?
The natural question that follows from the common factors debate is: Do we still need
theory? As noted by Sprenkle and Blow (2004), some therapists lean toward the “dodo
bird verdict,” suggesting that theory matters very little. The more moderate stance of
Sprenkle and Blow (2004) emphasizes that “the models are important because they are the
vehicles through which the common factors do their work” (p. 126).
Following this moderate position, theory still plays a critical role for new and seasoned clinicians, but not the role one might initially expect it to play. Rather than providing a system to
help clients alleviate their symptoms and resolve their problems, a theory is a tool that helps the
therapist to help the client. Thus, theory may be most relevant for the therapist—not the client.
Theory gives therapists a system for interpreting the information they get about clients
so that they can say and do things that will be useful. It also helps therapists know how best
to relate and respond to clients. Without theory, it is easy to get lost in a sea of information,
emotion, and challenging behaviors. Theory gives therapists a systematic way of dealing
with the wide range of difficulties clients bring. Thus, choosing a theory involves identifying a theory that makes sense to the therapist and is useful to the therapist in navigating the
“wild ride” that is psychotherapy. That said, future research may identify specific circumstances in which certain models work better for certain clients (Sprenkle & Blow, 2004).
Show Me Proof: Evidence-Based Therapies
Just in case you thought the debate was over, there is yet another thread in the theory debate
that is pulling therapists in the apparently opposite direction from the common factors research: empirically supported treatments, often referred to as “evidenced-based therapies.”
These therapeutic models, which were developed through research and randomized trials
(Sprenkle, 2002), should not be confused with evidence-based practice (EBP; see above),
although evidence-based treatments are sometimes referred to as evidence-based practices
to keep us all thoroughly confused (this is one instance where the plural refers to something
quite different than the singular).
When therapists, licensing boards, or funding institutions refer to therapy models as
“evidence-based,” they are generally referring to a set of standards that a 1993 task force
of the American Psychological Association (APA) established for what was initially called
empirically validated treatments (EVTs) and later called empirically supported treatments
(ESTs), the change underscoring that a treatment is always in the process of being further
studied and refined (American Psychological Association, 1993; Chambless et al., 1996).
The APA established several categories for describing empirically supported therapies, and
others have developed similar categories.
Empirically Supported Treatments (ESTs) and Their Kin
Empirically Supported Treatment Criteria
Empirically supported treatments (ESTs) meet the following criteria (Chambless &
Hollon, 1998; Sprenkle, 2002):
• Subjects are randomly assigned to treatment groups.
• In addition to the group that receives the treatment being studied, there must also be
one of the following:
■ A no-treatment control (usually subjects are on a waiting list)
■ An alternative treatment (for comparison; may be an unspecified approach: “treatment as usual”)
■ A placebo treatment
• Treatment is significantly better than the no-treatment control and at least equally as
effective as an established alternative.
• Treatment is based on a written treatment manual with specific criteria for including
or excluding clients.
• A specific population with a specific problem is identified.
• Researchers use reliable and valid outcome measures with appropriate statistical measures.
Criteria for Additional Forms of Evidence-Based Treatments
In addition to the criteria for empirically supported treatments, criteria have been set for
other evidence-based treatments:
• Efficacious Treatments: Meeting more stringent criteria, these treatments must
meet the requirements for EBTs and must also undergo two independent investigations (studies conducted by someone who is not closely involved in the development of the treatment or invested in its outcome) (Chambless & Hollon, 1998;
Sprenkle, 2002).
• Efficacious and Specific Treatments: Meeting the highest standards, these treatments
must meet the criteria for efficacious treatments and must also be superior to alternative treatments in at least two independent studies (Chambless & Hollon, 1998;
Sprenkle, 2002).
EST Pros and Cons
The advantages of ESTs are the following:
1. They have greater scientific support.
2. They have written manuals to guide treatment and are highly structured.
3. They target a specific population with a specific problem.
The disadvantages of ESTs are these:
1. They have limited applicability because they target a specific and therefore limited
population.
2. They are expensive: therapists need highly specific training in the model and also need
to be trained in a number of models to function effectively in most work environments.
Meta-Analytically Supported Treatments (MASTs)
A meta-analysis is a quantitative research method that combines results from multiple
studies, generally by examining the effect size or the outcome variance attributed to the
treatment. Using meta-analytic studies, Shadish and Baldwin (2002) developed the following criteria for MASTs to broaden the type of research that can be used to establish efficacy
while maintaining rigorous scientific standards:
• Effect sizes from more than one study of the treatment must be combined
meta-analytically.
• All studies must be randomized comparisons of the treatment to a no-treatment control
group.
• Meta-analysis must indicate a statistically significant effect size and a significant test.
• Meta-analysis must use sound methods (e.g., aggregating effect sizes).
Real-World Applications of ESTs and MASTs
In 2002, Shadish and Baldwin identified 24 family therapy theories that fit the criteria
for a MAST, whereas only 5 met the criteria for an EST. This difference existed primarily
because ESTs require (a) a written treatment manual and (b) a narrowly defined population with a specific problem, whereas MASTs allow for other forms of training and more
general populations to demonstrate efficacy. The findings of the APA’s 2005 follow-up report on ESTs highlight the necessity for more broadly defined standards for evidence-based
treatments such as MASTs (Woody, Weisz, & McLean, 2005). This survey indicated that
although a higher percentage of ESTs were taught in the classroom, clinical training in
ESTs dropped significantly from 1993 to 2003. When asked to identify the reasons, supervisors cited “uncertainty about how to conceptualize training in ESTs, lack of time, shortage of trained supervisors, inappropriateness of established ESTs for a given population,
and philosophical opposition” (p. 9). Arguably, all but perhaps the last of these obstacles
are clearly linked to the exact things that make ESTs unique: written treatment manuals
and a narrowly defined population. Thus, although promising, ESTs have some practical
limitations at this time, especially for the general practitioner.
Research in Perspective
Therapists need to keep the evidence-based therapy movement in perspective. Almost all
research indicates that any therapy is better than no treatment at all: that is one of the
major ideas behind the common factors movement (Miller, Duncan, & Hubble, 1997;
Sprenkle & Blow, 2004). The evidence-based therapy approach refines what we know
and aims to develop better and more specific therapies; however, this does not mean that
nothing in the field has ever been researched or studied before. A more fair and realistic
assessment is that family therapy and mental health therapies have an established history
of meaningful research, and our ability to do research more precisely continually increases.
Research courses have been part of family therapy curricula from the beginning and are
increasingly valued and expanded. A research orientation is not new; however, our ability
to conduct more meticulous and useful studies is improving.
Perhaps it is useful to reflect on the broader picture. More than in many other mental health disciplines, family therapy theories were developed through observational
research (Moon, Dillon, & Sprenkle, 1990). Teams of therapists observed sessions
through one-way mirrors, developed hypotheses about what might work, tested these
hypotheses, and then refined them as they went along. Rather than trying to prove a
theory, these therapist-researchers were using outcomes to inform the development of a
new frontier in mental health: working with couples and families. This type of research
is rigorous in a different dimension than ESTs; namely, it can be usefully applied in
everyday work settings by persons with standard training. According to Shadish and
Baldwin (2002), many family therapy approaches that draw from this tradition fit the
criteria for MASTs: these treatments worked for decades and have been refined and
designed to target specific populations in evidence-based treatments, many of which are
highlighted in this book.
Review of the MFT Evidence Base
Finally, I want to let you know about an academic gold mine that makes grad students and
their faculty particularly giddy when they finally discover it: the January 2012 edition and
the 38th volume of the Journal of Marital and Family Therapy (known to MFT nerds as
JMFT; Sprenkle, 2012). You may not have had the best relationships with journal articles
up to this point in your education—that is common. But I think this one is going to change
all that. In a nutshell, this edition of JMFT includes 12 articles in which experts in the field
summarize the entire evidence base for you. It is an academic’s fantasy come true. This
is the third of such reviews of the MFT evidence base, making it the only mental health
discipline I know of to have such a concise and easily accessible review of the associated
research (and trust me, I have looked). This single resource can make evidence-based practice with couples, families, and children a breeze.
The areas of research reviewed include:
• Conduct disorder and delinquency with adolescents (Baldwin, Christian, Berkeljon, &
Shadish, 2012; Henggeler & Sheidow, 2012)
• Child and adolescent disorders (Kaslow, Broth, Smith, & Collins, 2012)
• Affective disorders (e.g., mood disorders; Beach & Whisman, 2012)
• Treatment of couple distress (Lebow, Chambers, Christensen, & Johnson, 2012)
• Treatment of couples experiencing interpersonal violence (Stith, McCollum,
Amanor-Boadu, & Smith, 2012)
• Relationship education for nondistressed couples (Markman & Rhoades, 2012)
• Family psychoeducation for severe mental illness (Lucksted, McFarlane, Downing, &
Dixon, 2012)
• Family therapy for drug abuse (Rowe, 2012)
• Couple and family interventions for health problems (Shields, Finley, Chawla, &
Meadors, 2012)
• Client perceptions of MFT (Chenail, St. George, Wulff, Duffy, Scott, & Tomm, 2012)
Legal and Ethical Issues in Couple and Family Therapy
Benjamin E. Caldwell, Psy.D.
I teach law and ethics for the couple and family therapy program at Alliant International
University in Los Angeles. I know, for many of you, that when you hear the phrase “I teach
law and ethics,” you brace yourself for cautionary tales of what you had better not do, or
else the licensure police will come beating down your door.
This section is not like that. I promise. I will start with a brief overview of professional practice standards
for psychotherapists (you may already be familiar with those; if not, there are a handful of excellent
texts fully devoted to those standards). Then I will review some of the specific areas of difference for
therapists working with couples and families. Finally, I will discuss technology and a therapist’s refusal to
treat certain clients—two controversial issues that are reshaping professional standards in family
therapy today.
Lay of the Land: More than Just Rules
Here is my one (and only, I promise) paragraph of fear-mongering. People
can sue you, or file a complaint against you to your licensing board, any
time, for any reason. They can sue you for looking at them funny. They
can complain about you for breathing too loudly (or too quietly). They can
sue you for not suing them first. If you base your entire practice on trying
to never get sued or never have a complaint lodged against you, you are
trying to control something that is beyond your control. Now, whether
someone will win that lawsuit, or whether a board will do anything about
that complaint—that is another story. You can and should take reasonable
steps to protect yourself, including knowing your state’s laws, maintaining
professional liability insurance, and consulting with colleagues, supervisors, and attorneys
whenever necessary. But doing all of those things does not make you ethical. They are like
a football player’s shoulder pads: they are great for protection from injury, but they do
not make you a great football player.
The fact is, being an ethical professional is about much more than simply knowing and
following the rules. It is true that rules-based (and, as is often the case, fear-based) teaching
about law and ethics does help you to know what the rules are—at least, until the rules change.
But being an ethical professional is about knowing what to do when the legal and ethical rules
governing our field do not tell you specifically what to do. There are times when those rules are
not clear, or when they appear to contradict themselves. In those situations, simply knowing
the rules will only leave a therapist confused and anxious, hoping that he or she does not do
the wrong thing. It is in those instances when your character as a professional is most revealed.
Being an ethical professional means engaging in a thoughtful and careful decision-making process that results in the best outcomes for your clients, within the accepted standards of the field.
Those accepted standards are largely consistent across mental health professions. This
section is not meant to be a replacement for a full law and ethics course or textbook, and
is not meant to cover the full scope of the legal and ethical issues in psychotherapy. (For
a complete textbook focused on the legal and ethical issues in couple and family work,
I recommend Wilcoxon, Remley, and Gladding’s Ethical, Legal and Professional Issues
in the Practice of Marriage and Family Therapy.) Instead, this section is meant to offer
particular guidance on those issues most relevant to—or most different in—couple and
family therapy. Working with more than one person on a therapeutic issue raises unique
concerns, and it is these concerns I will emphasize. A brief, broader overview is necessary
to set the stage, but if you are already familiar with general professional ethics in psychotherapy, you can safely skip this part and pick up at “Specific legal and ethical concerns
in couple and family work.”
The Big Picture: Standards of Professional Practice
Practicing any form of therapy in a professional manner means understanding three levels
of rules that govern professional behavior:
• Laws
• Ethics
• Standard of Care
Laws
First, there are laws. Laws are either set by the local, state, or federal government, in the form
of legislation, or by judges, whose rulings in some cases establish specific responsibilities for
professionals. Tarasoff v. California Board of Regents, which established a therapist’s responsibility to intervene when a client poses an immediate danger to an identifiable victim, is an
example of case law impacting psychotherapists. Laws are often about what you must do (like
pass a licensing exam in order to practice independently) and must not do (like insurance fraud
or sleeping with clients). They do not have exceptions, except those also spelled out in law. For
example, you must maintain confidentiality except when a client is a threat to him- or herself
or others, and in other instances defined in state and federal law. Regulations are a subset of
laws. Instead of being set by a state legislature, regulations are often set by licensing boards
through state administrative processes. They do, however, hold the power of law.
A key point to remember: laws trump everything else. If a law conflicts with an element
of an ethical code, the therapist must abide by the law, but should do so in whatever manner allows for the most adherence to the ethical code.
Ethics
The second level of standards that govern professional behavior is ethics. Each of the major professional associations in mental health publishes a code of ethics that serves to guide
responsible professional behavior. Counselors, social workers, and psychologists have
ethics codes published by the American Counseling Association (www.counseling.org),
National Association of Social Workers (www.nasw.org), and the American Psychological
Association (www.apa.org), respectively. In family therapy, the American Association for
Marriage and Family Therapy (www.aamft.org) and California Association of Marriage
and Family Therapists (www.camft.org) each publishes its own ethics code. These codes
go beyond the rules of the law, and define in more detail the expectations of family therapists. However, no ethical code can be expected to offer specific guidance on every possible
scenario that a therapist will encounter. Being an ethical practitioner is about much more
than knowing the codes; it is about understanding ethical reasoning so that you can make
the best choice of what to do when the legal and ethical rules are not clear.
There are a handful of biomedical ethical principles (Beauchamp & Childress, 2009)
that may be used when weighing the ethics of decisions in mental health work:
• Fidelity refers to keeping promises and upholding loyalty. This can be challenging in
couple and family work, where family members may attempt to get the therapist to
take sides in their internal struggles.
• Justice refers to treating people fairly, bearing in mind that fairly does not always mean
equally.
• Autonomy refers to the right of clients to make their own decisions and act independently.
In family therapy, it is particularly important that a therapist respect a client’s right to make
his or her own decisions regarding romantic relationships, such as choosing to cohabit,
separate, divorce, or marry; and regarding child care, including custody and visitation.
• Bene
cience refers to the therapist’s obligation to actively work to benefit clients. If a
couple or family does not appear likely to benefit from ongoing treatment, the clients
should be referred to another therapist.
• Nonmaleficence refers to avoiding harm to clients or others.
When ethical guidelines for handling a particular situation are unclear or appear to
contradict, it is generally recommended that mental health professionals return to these
general principles to assess the risks and benefits of their options.
Standard of Care
Finally, the third level of standards governing professional behavior is called the standard of
care. California’s definition of “reasonable suspicion” of child abuse, which triggers a therapist’s mandated reporting responsibility, is one effort to define the standard of care in law:
For purposes of this article, “reasonable suspicion” means that it is objectively reasonable for a
person to entertain a suspicion, based upon facts that could cause a reasonable person in a like
position, drawing, when appropriate, on his or her training and experience, to suspect child abuse
or neglect. “Reasonable suspicion” does not require certainty that child abuse or neglect has
occurred nor does it require a specific medical indication of child abuse or neglect; any “reasonable suspicion” is sufficient. (California Penal Code 11166(a)(1))
In essence, the standard says, “If another therapist would suspect child abuse with the
information and training you have, you should suspect it too.” This is what it means to
have a standard of care: it is what most people at the same professional level are doing.
Case documentation (described in Chapters 13–17) works on a similar principle: While
legal and ethical standards do not tend to specify what should be in progress notes, therapists tend to follow standard formatting and include similar content, because that is what
their peers do. Even in elements of therapy for which there is no legal or ethical standard,
failing to live up to the standard of care is seen as inadequate professional behavior.
There is no single place to look for a standard of care in writing. However, if you are
unclear about the standard of care on any specific issue, the wise thing to do is consult with
the colleagues and supervisors you most respect. They can best inform you what others in
the profession are doing.
Specific Legal and Ethical Concerns in Couple and Family Work
There are several areas specific to couple and family work where the rules differ from
individual therapy. These include identifying the patient, documentation, confidentiality, communicating with other systems, working with minors, child abuse reporting, and
intimate partner violence.
Who Is Your Patient?
Perhaps the most difficult challenge in couple and family work is identifying who exactly
it is you are treating. In individual therapy, it is easy to identify your patient: look at the
person sitting in front of you. Couples and families, however, come to therapy with complex complaints. In some instances, they identify one member of the family as the problem
who has brought them to you. In other instances, they say that the entire relationship or
entire family is struggling. Who is the therapist treating?
The question is not just academic. How you answer it will have an impact on how
you organize your treatment plan, how you document the case, how you handle conflict
between family members, and even how payment takes place. Indeed, it is likely to reflect
your underlying philosophy when it comes to couple and family work.
Therapists who specialize in treating couples and families often view themselves as
treating the entire system as a unit. These therapists usually label themselves as “relational”
or “systemic” in their work. Accordingly, they will keep a single file for the entire family,
even if different combinations of family members are present in specific sessions. The treatment plan will be focused on systemic goals involving relationship or family functioning,
goals that usually are agreed upon by all members of the couple or family attending therapy. Relational therapists do not ignore individual functioning, but rather they consider it
in its interpersonal context.
Documentation
If the therapist is treating the family as a unit, he or she is likely to be keeping a single file
on the entire family. That would mean one treatment plan for the entire family, and one
progress note per session, no matter how many family members attended. That also means
that under most state laws, the consent of every family member in treatment would be
needed to release records to any individual family member requesting them.
If you are treating an individual, and other family members sometimes join in therapy
to support the individual’s progress toward his or her treatment goals, then it makes the
most sense to document the session as part of the individual client’s existing file, noting
the involvement of the others. In this case, only the individual receiving treatment needs
to consent to the release of their records.
Some work settings require therapists doing couple or family work to keep a separate
and distinct file for each participant in the therapy. While this does allow for detailed
recording of each person’s behavior—something that can get lost when a single progress
note is written for a session involving several family members—it also means that the
therapist will spend significant additional time documenting each session and needs to be
thoughtful about how he or she documents family interaction in an individual’s file. In this
instance, each individual could consent to the release of his or her own records, but the
person could not request the release of other family members’ files. (State laws on this may
vary, so it is of course important to be familiar with the laws of your state.)
Confidentiality
Confidentiality is both a legal and ethical requirement for psychotherapists, and most of
the time it is fairly straightforward: You cannot share what clients tell you. (My treatment
contract for many years has included the line, “The therapy office is like Las Vegas. What
you say here, stays here.”) There are exceptions to this spelled out in the law: therapists are
required to break confidentiality to report child abuse, and when necessary to stop clients
who pose an imminent danger to themselves or others. There are many other exceptions
to confidentiality spelled out in state and federal law, and it is important that your clients
be made aware of both the general rule of confidentiality and its specific exceptions.
Confidentiality becomes more complex when working with couples and families. Con-
sider a married couple where one partner is having an affair. If that partner tells you about
the affair during a phone call, and then tells you something like “I really want to make
my marriage work, but I am not ready to end the affair yet. Please don’t tell my spouse,”
what should you do? Revealing the secret could lead the couple to give up on treatment,
and possibly their marriage. Keeping the secret, however, would mean colluding with the
partner having the affair—and if the other partner found out later that you had known
about the affair and not told him or her, that person would likely feel betrayed.
If you are treating a couple or family, it is vital to have a policy addressing the holding
of secrets. The codes of ethics for family therapists do not say what a therapist’s policy
on secrets should be, but rather they require that the therapist have a policy on secrets,
inform clients in writing of what the policy is, and stick to it. Two schools of thought have
emerged about what the ideal secrets policy is:
1. A “no secrets” policy. This policy allows the therapist to communicate anything learned
from any individual in the family to any of the other individuals in the family at any
time. In short, it says that the therapist will not hold a secret for one family member.
There are clear advantages to this policy: Holding secrets creates power imbalances in
the therapy room, and could require that a therapist “play dumb” about such important issues as affairs or substance use. Refusing to hold secrets means that any such
information, if it comes to the therapist, can be dealt with in the therapy setting.
2. A limited-secrets policy. While family therapists typically do not advocate holding all
secrets, there are many who believe it is advantageous to hold some information in
individual confidence. Doing so allows for a more thorough and trustworthy assessment process. For example, a couple therapist may see each partner individually during
the assessment stage of therapy with plans to work with the couple together afterward.
By assessing individually, and being willing to hold secrets from that assessment, a
therapist can encourage clients to be more honest about relational issues they may
not feel comfortable discussing in front of their partner. Affairs, substance use, and
domestic violence are all examples of subjects that clients may be more honest about
individually than in front of their loved ones.
Whatever policy you choose, it is good to have it as part of your treatment contract
when working with couples and families. It is good to discuss the policy with your clients
to make sure they understand it. And, most importantly, once you have set your policy,
you must follow it.
Communicating with Other Systems
Family therapists often handle issues relating to divorce, custody, parenting, and family functioning, and as a result often have connections other systems, such as schools
and court systems. In some cases, it may be that outside system that hires and pays the
therapist, again raising the question of who, exactly, the “client” is. The therapist may be
required to submit regular progress reports to the court, for example, on treatment goals
that the clients had little to no say in.
All family members should be made aware as early as possible in therapy of the nature
of the relationship the therapist has with third parties involved in the treatment. All family members should be informed about what information will be shared, with whom, and
for what reason.
Working with Minors
Even if you are intending to do individual therapy, working with minors will make you
a family therapist. Family members typically must give consent for the minor to receive
treatment, they often want to be included in the therapy process, and they usually have a
right to access treatment records. (Each of these varies a bit from state to state, so be sure
you are familiar with your state’s laws.)
State laws differ as to when a minor can consent on their own for therapy. Generally
speaking, someone under the age of 18 cannot enter therapy without the consent of his
or her parents. However, some states make exceptions to this. In California, for example,
minors age 12 and older can independently consent for therapy if the therapist determines
that the minor is mature enough to participate intelligently in treatment.
Whether it is part of an individual or family process, any work you do with a minor on
his or her own should come with clear boundaries. Bear in mind here that family members
may have conflicting motivations. Parents who are fearful for their child’s well-being may
want you to tell them everything that happens in an individual meeting with the child.
The child, meanwhile, often will prefer a safe place to explore difficult emotional issues
without the sense that his or her parents are always peering in. Many therapists resolve
this conflict through a written agreement that defines what information will stay between
the therapist and the minor, and what information will be shared with the family. (As
you may have guessed, this would be common among therapists using a “limited secrets”
policy.) For example, if a minor is struggling to navigate peer relationships at school, the
minor may not want the therapist to share that information with their parents—and it can
be argued that the greater good is served by the therapist holding that information. (The
child gets a safe place to be honest about their struggles, and the parents are not harmed
by not having that information.) On the other hand, if a minor is engaging in drug or
alcohol use, or otherwise endangering his or her physical health, that information would
be shared with the parents. Again, whatever policy the therapist chooses to employ when
it comes to secrets, the policy should be clear, consistent with the laws of your state, in
writing… and followed.
Child Abuse Reporting
In working with children and families, a therapist often will develop the suspicion that
child abuse has taken place. Sometimes this will arise directly from what clients tell the
therapist; other times, the therapist makes this assessment based on physical or behavioral
evidence of abuse. While state laws vary, psychotherapists typically must report physical
abuse, sexual abuse, and neglect to local authorities so that the victim, as well as other potential victims, can be protected. It is vital to be aware of your state’s rules for what must
be reported, to whom, and how quickly once the therapist learns of the abuse.
Therapists who work with adolescents and their families should be particularly aware
of their state’s laws concerning the reporting of consensual sexual activity among minors.
States may differentiate between consensual sexual activity that qualifies as criminal and
activity that qualifies as abusive (e.g., in some states there are some instances of statutory
rape that would be considered criminal but not abusive). Since abuse must be reported,
but criminal activity that is not abuse typically cannot be reported, every therapist must
remain keenly aware of his or her state’s current laws. The age of your client, the age of
their partner, the nature of their relationship (e.g., whether an older partner appears to
be exploiting a younger one), and the specific activities they have engaged in all may be
relevant to the question of whether their relationship can be considered abusive.
Intimate Partner Violence (IPV)
Several researchers have suggested that couples therapists more thoroughly assess all couples entering therapy for current and past intimate partner violence (IPV). Without thorough assessment, such violence often goes unreported. Among couples seeking outpatient
counseling, in the past 12 months, 36% to 58% have experienced male-to-female violence
and 37% to 57% have experienced female-to-male violence (Jose & O’Leary, 2009). Recent or ongoing violence can be a major impediment to successful couple therapy, and is
considered a contraindication for emotionally focused therapy (Johnson, 2004), one of the
best-validated approaches to couple work.
Generally speaking, a therapist cannot break confidentiality to report IPV on its own.
If children have witnessed violence between their parents, however, the situation becomes
more complex, as does the therapist’s responsibility to protect the children involved. In
California, when children have witnessed domestic violence, a therapist can (but is not
required to) report this to law enforcement as emotional abuse. Be sure you know your
state’s laws on child abuse reporting before filing a report based on children witnessing
violence in the home.
The treatment of IPV for those convicted of a first or second offense raises specific ethical questions, particularly with regards to weighing potential risks against potential beneffects of treating couples together. At present, treatment is often through court-mandated,
gender-specific group therapy (Babcock, Green, & Robie, 2004). Such treatments appear
to have small but meaningful impacts on recidivism (Stith, McCollum, Amanor-Boadu, &
Smith, 2012). However, they also suffer from high dropout rates, and often draw recidivism
data from arrest reports. This makes their measure of recidivism subject to underreporting.
For therapists who treat couples, inevitably some of their clients will have a history of
IPV. Other couples enter therapy with active, ongoing violence. There has been debate in
the literature for years about how these couples should be treated. That debate follows
many of the issues noted above, particularly related to balancing the chance of benefit for
couples with the risk of harm. Some consider the risk of harm too great to engage in any
couple- or family-based treatment for at least several months after the last violent incident,
noting concerns that some aggressors may become more violent when treated for IPV in
a couple context. Others cite conflicting publications that support seeing couples together
when their violence history has been low level and mutual (e.g., Bograd & Mederos, 1999).
Depending on where you practice, there may be state, county, or agency rules governing
the treatment of domestic violence, particularly if one partner has been convicted of IPV.
Current Legal and Ethical Issues in Couple and Family Work
Professional standards change over time. Ideally, as a professional, you will take an active role in those changes. The AAMFT Code of Ethics (AAMFT, 2012) calls on family
therapists to take an active role in developing or changing laws and regulations regarding family therapy to ensure such rules are in the public interest (principle 6.7). Often
the changes in professional standards come about as a result of new forms of treatment
or changes in the larger populations we serve. There are two specific issues that are currently reshaping the professional standards for couple and family therapy: technology
and therapist values.
Technology
As videoconferencing and related technology have become more sophisticated, therapists
have begun to use technology to provide services to clients who otherwise may not be able
to come into the office. Clients who live in rural areas without adequate health care services can be particularly helped by phone or videoconference therapy, as can clients with
specific language needs that cannot be met by providers close to them.
Providing therapy services over the phone or through the Internet is a challenging undertaking with individuals; with couples and families, it becomes even more challenging.
Much of the information a therapist gathers in working with a couple and family has to
do with the interaction between clients in session. When the couple or family can only be
seen through a computer screen—or, if the therapy is taking place by phone, when the
couple or family cannot be seen at all—it becomes much more difficult for a therapist to
assess the dynamics being acted out in the room. It may be for this reason that research on
therapy that takes place by phone or videoconference has so far focused almost exclusively
on individual therapy (Barak, Hen, Boniel-Nissim, & Shapira, 2008).
For those therapists who do wish to attempt couple or family work through the phone
or the Internet, there are several things to be aware of. First, a therapist’s license only authorizes him or her to work in the state where he or she is licensed. A therapist licensed
in Texas, for example, could not do telephone therapy with a couple in New York; the
therapist would likely be seen as practicing in New York without a license. 1 Second, therapists providing phone- or Internet-based services must abide by additional ethical requirements, including (a) ensuring that electronic therapy is appropriate, considering the clients’
needs and abilities; (b) informing clients about the potential risks and benefits of electronic
therapy; (c) ensuring the security of the connection, to protect privacy and confidentiality;
and (d) ensuring that the therapist has appropriate training and experience in using the
technology. These requirements are present in both the AAMFT and ACA codes of ethics.
The ACA code goes further, requiring that therapists also plan with clients what to do if
the connection is lost or a crisis occurs. Finally, there are no well-established protocols for
couple and family therapy aided by technology.
Technology is also impacting couple and family work in a very different way: by changing how couples and families relate to one another. While electronic communication allows
families to maintain connection more easily over great distance, it also is frequently used to
facilitate affairs and risky sexual behavior. The negative impacts of online activities are an
increasingly common reason given by couples who seek therapy in my practice. However,
the negative impacts of online relationships on couples and families are only beginning to
be understood from a research perspective (Hertlein & Webster, 2008).
Therapist Values
At least three court cases have come about in the past several years concerning psychotherapists who said they were unwilling to treat gay and lesbian clients. These have led to
a broader discussion in the field about where therapists’ obligations to serve clients end
and their right to practice based on their own values begins.
It is generally accepted that family therapy cannot be value-free. Any therapist brings
his or her values into the therapy room. Indeed, a value for helping the larger community
through healthy relationships is often part of why someone becomes a family therapist. In
the interest of autonomy, therapists are usually taught to understand clients through the
lens of the clients’ values. The CAMFT Code of Ethics calls on therapists to be aware of
their own personal values and not impose those values upon their clients. Similar clauses
can be found in the ethics codes of the APA, ACA, and NASW.
In the court cases, however, therapists have asserted that their values relating to sexuality preclude them from treating gay and lesbian clients. Julea Ward, a counseling student at
Eastern Michigan University, refused to treat a lesbian client and worked with her supervisor
to ensure the client could be treated by another therapist at the same agency who did not
share her conflict. EMU felt that her refusal to treat the client was discriminatory, and told
Ward she must complete a remediation plan. She refused to do so, and was expelled from
the program as a result. She then sued the university. Jennifer Keeton, a student at Augusta
State University, filed a similar lawsuit after also being told she must complete a remediation
plan to ensure she would not impose her values regarding sexuality on her clients. She had
not refused to treat specific clients, but ha...
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