I think of family therapy models as being on a continuum from “theory based” to “research based.” Of course, most models fall somewhere in between, rather than at the extremes, but the distinction is not that different than that seen in individual therapy, with psychodynamic falling more toward the theory based end, and cognitive behavioral falling more toward the research end.
10 factors in Family Therapy Research
While it may be easy to look first to the “proven” results of family therapy’s effectiveness, there are quite a few issues that make outcome research in family therapy difficult. Several are noted below:
- Treatment Focus
- What is the problem? An acting out teen? An over-controlling and hyper-functional parent? Or his/her depressed and withdrawn co-parent? If you target and change one but not the others, is that a success? Family therapy holds they are all inter-linked, so how can you say one is more important to treat or more important to track for research outcomes?
- Even if you define a specific individual problem – like bulimia – some therapies can define the problem as a couple dynamic and work to change the couples’ pattern of interacting to stop the bulimia. Other therapies can focus on the individual dynamics of a person choosing to binge and purge, drawing on the same research as any individual therapist would, and incorporate the significant other as a “co-therapist” rather than a part of the problem. Both are typically still seen as “couple therapy” however.
- Some therapies focus on more narrowly defined problems – like teen marijuana use – while others focus on more widely defined problems – like “intimacy” which can mean time together, time apart, sexual satisfaction, planning for the future… All can still be called family or couples therapy.
- Definition of Success
- If a miserably married couple divorces after couples therapy, is that a therapeutic failure? Some theories say “Yes” – such as strategic therapy which views this as the therapist’s failure to find the right strategy – while others say “No” – such as structural therapy which views this as resulting from a defect in the family’s structure.
- What if you ask people instead of theories? What if one parent says “Yes,” while the other parent says “No”? What if both parents answer “No,” but their children answer “Yes”?
- Treatment Model – many different schools of family therapy use the same techniques (e.g., reframing, focused improvement in communication skills, decreased expressed conflict, better boundaries between subsystems….). So, how do you include these overlapping techniques in one therapy model (which you think will prove superior), and remove them from a compared model without hamstringing it? Finding your method is significantly more effective compared to another method when the second method is purposely weakened means little.
- Retention and Relapse
- Family therapists traditionally have been more concerned than individual therapists with issues of retention during treatment, and relapse prevention after treatment. This means that showing a large effect size for some kind of family therapy at the end of treatment with the families that stay in treatment means little. What about the ones that dropped out? How long does the treatment effect last? Does it transfer to new settings and conflicts so the “successfully treated family” doesn’t have to come back?
- Family and couples therapy is often much more flexible. Some therapists stick with the one-hour-once-a-week model. Gottman, for example, does not, and will initially see couples for more than an hour, and by the end of therapy will space sessions out to perhaps one a month as a way to reduce relapse. This means that variables as simple as “number of sessions” or “average weekly minutes of therapeutic contact” are no longer simple – they vary over the course of therapy.
- True Improvement versus Halted Decline
- Liddle et al. (2002) report that the transition from generally distressed to generally non-distressed after treatment occurs for 35% (Jacobson et al., 1984) to 41% (Shaddish et al., 1993) of couples, although Johnson & Greenberg (1994) found that 70% of couples fall in the non-distressed range when distress regarding a specific problem is assessed.
- The issue is that when married couples in treatment are compared to married couples on a wait-list, the couples on the wait-list decline into the very distressed range. Thus, the treatment really has only to halt the decline in order to yield significant results. Thus, a statistically significant result may not mean much (see Gollan and Jacobson’s chapter in Liddle et al. 2002).
- Methods – Methods in family therapy are varied, and range from self-report questionnaires, observational techniques, and physiological readings, to therapist rating scales.
- Self-report questionnaires are easy to use and score, but limited in what they reveal. Further, what does it mean if two family members disagree significantly in their responses? Do you average the discrepant scores? Always pick the spouse whose first name comes first in an alphabetical list?
- Observational techniques are very time consuming and require great inter-rater reliability, but reveal a lot. However, the task used to observe the family shapes the results; conflict-management-tasks pull for negative emotions and conflict, while game-playing-tasks pull for problem-solving and easy communication. Further, the observational method must be studied and proven.
- Physiological readings are generally left out of individual therapy research. However, Gottman and others have tied them to general conflict resolution, dysfunctional communication patterns, and types of domestic violence with success. They also advocate using these in therapy sessions as a way to improve the process. Including physiological responses often requires an additional kind of expertise that most psychologists do not have.
- Therapist rating scales are a sub-type of observational techniques, which can be the best of both worlds in some ways. However, all rating scales and questionnaires share a common weakness – are they equally valid across different kinds of families? This asks whether there is bias in the measure that leads to bias in the therapist’s views. (see Bray’s chapter in Liddle et al. 2002)
- Non-linear events do not lend themselves to linear statistics very well. Thus, using events at Time A to prevent events at Time B may be easy to do in individual therapy. However, in family therapy, events at Time B shape the interpretation given to events at Time A, and thus impact all future data collection (Time C).
- For example, Family #1 sees open conflict at Time A as a bad sign, because at Time B they still had not resolved the problem, and arguing “obviously made matters worse.” Family #2 sees open conflict at Time A as a good sign, since at Time B they had resolved the problem, and arguing “obviously” allowed them to “get it out in the open.” The next time an emotionally charged issue comes up (Time C), Family #1 (based on their negative experience) tries not to engage in open conflict, while Family #2 (based on their positive experience) allows it. So, what does open conflict predict about eventual problem resolution in families?
- Purpose of Therapy
- Some look at couple and family therapy as primarily problem-focused (or tertiary prevention), while others see it as prevention-focused (primary or secondary prevention). Thus, working with parents to help them work collaboratively to gain control of teen acting-out behavior is a problem-focused intervention for that teen. However, it is a prevention-focused intervention for his/her 10 year old sibling, as we hope the parents will not have the same problems with the sibling when s/he reaches adolescence.
- To divide these approaches even further, one therapist might work with a step-family after the teen has started to act out, and use a very problem-focused, clinical intervention. Another therapist may see the members of a step-family for brief therapy as they prepare to move into one household, and educate them about what to expect, consult with them on what their new family life should be like and how they could shape it before they are in the throes of its development, and prepare parents for commonly seen struggles in step-family formation. This therapist is using a much more primary prevention approach (or a kind of “inoculation therapy”).
- Beyond this, there are also specific couples programs to help couples remain happily partnered, family programs to prevent teen violence in high-risk neighborhoods, and parent programs to improve parenting during the pre-school years and prevent oppositional and aggressive behaviors (see Pinsof and Hambright’s chapter, as well as Tolan’s chapter, in Liddle et al, 2002)
- “Real” Treatment
- Family therapy is in many ways much closer to “real world” therapy than treatment models used in individual therapy studies, although some question this. This is sometimes called market relevance when you start talking to insurance companies about the success of family therapy in real world settings.
- A range of therapists with different background treat a range of families with complex combinations of stressors and problems, under real world constraints of time and resources. However, the more “real world” the treatment study is, the more removed from controlled laboratory conditions the study is likely to be as well. This makes strong and clear conclusions about the results difficult to obtain and interpret.
- You could go further and talk about family therapy as a more complex therapy than individual therapy. It’s one thing to sit in a quiet therapy room with an individual client and interpret for them some of the unreasonable and unkind expectations they have of others based on their internalized mother-object. It’s quite another thing to sit in family therapy and do this, and have the client’s external mother-object butt-in and contradict you, and declare she isn’t bringing anyone to therapy next week because you are the problem.
- It’s one thing to study “corrective emotional experiences” with the individual client and therapist, but in family therapy, the therapist is more of a transitional object. The corrective emotional experiences are more likely to come from other family members. So what if therapy leads to limited repair in the relationship between a teen son and his father, but significant repair in the relationship between the son and mother? How do you code this in your research? Success, failure, half success?
- Beyond this you can ask who is included in family therapy. Can a teen who is not acting-out skip therapy, while the parents and acting-out sibling attend? If a mom comes to you wanting family therapy to deal with the difficulties her daughter has accepting mom’s live-in boyfriend, does the boyfriend come to therapy? If a teen wants to talk in family therapy to both his divorced parents about a problem he is having in both parents’ homes, do his parents’ new spouses attend? If yes, what if one doesn’t want to?
So Does Family or Couples Therapy Work?
Liddle and colleagues (2002) answer by noting that the more “research based” models are sometimes called FBESTs, or Family Based Empirically Supported Treatments. They note that FBESTs have shown the following (see pages 24-27 and 81):
- dramatic (around 34% but at high as 56%) decreases in adolescent acting out behaviors, drug use, and re-arrest maintained at four and five year follow-ups
- preventative decreases in the acting out behaviors of siblings of problem teens maintained at three year follow-ups
- double the treatment retention rates for minority families
- treatment effects with Axis I and Axis II disorders
- treatment effects with families of various ethnicities, SES, and structures
However, Liddle et al. (2002) offer that based on meta-analysis, there is little data to support one family therapy as being better than another, even when applied to specific problems. This means there is little to dictate which treatment, for which problem, administered by whom, in what way, is best.
Pinsoff and Wynne (2000) answer that family and/or couples therapy is better than individual therapy for:
- depression in women in distressed marriages
- marital distress
- adult substance abuse
- adolescent conduct disorders and substance abuse
- anorexia in young females
- childhood autism
- aggression and non-compliance in ADHD children
- and cardiovascular risk factors
and is better than no treatment for all of the above in addition to
- child conduct disorder
- and chronic illness in childhood
Gurman and colleagues (in Garfield and Bergin) would add “medical” disorders (like eating disorders, diabetes, and asthma), anxiety, and phobias to the list of problems that benefit more from family or couples therapy than individual therapy. Gurman and colleagues offer that, generally, about two thirds of clients in any kind of family therapy get better, which is fairly similar to the numbers gained in individual therapy intervention research. They would add more specifically that:
- Better gains are found when both members of a couple work on marital problems.
- Better gains occur when the therapist is more active in the early phases of therapy.
- Basic mastery of the theory and techniques by the therapist seems enough to halt deterioration, but more skill by the therapist is required for positive growth in therapy.
- Therapy with two therapists is just as good as therapy with one therapist.
- And short term therapy (20 sessions and under) can produce positive results.
Summary: In summary, we can say this. The research regarding the effectiveness of family therapy is complicated. However, generally speaking, research supports that family therapy, when conducted by people who know the theories and techniques well, can be helpful for a wide range of problems, although not for all problems. It would seem that overall, the different models of family therapy are equally valid and effective.