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

FORWARD

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

Lenore M. McWey Florida State University

Richard B. Miller Brigham Young University

Richard S. Wampler Michigan State University

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

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

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

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

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

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

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

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

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

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

[email protected]

January 2019 JOURNAL OF MARITAL AND FAMILY THERAPY 5

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

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

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

IDENTITY

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

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

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

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

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

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

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

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

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

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

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

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

January 2019 JOURNAL OF MARITAL AND FAMILY THERAPY 7

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

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

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

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

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

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

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

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

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

8 JOURNAL OF MARITAL AND FAMILY THERAPY January 2019

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

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

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

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

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

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

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

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

January 2019 JOURNAL OF MARITAL AND FAMILY THERAPY 9

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

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

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

MOVING FORWARD

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

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

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

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

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

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

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

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

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

With the recognition for the need for a more inclusive range of research methodologies that can inform evidence-based practice, Khagram and

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