The Development and Evolution of Family Therapy Research: Its Impact on Practice, Current Status, and Future Directions THOMAS L. SEXTON* CORINNE DATCHI†

Science has always been a central part of family therapy. Research by early pioneers focused on studying the efficacy of both couple and family interventions from a systemic perspective. Today we know more now than ever before about the processes of diverse families and the therapeutic outcomes of family therapy practices. Despite the acknowledged importance of family therapy research, there are still questions about its impact on “real life” practice. Despite all the flaws of each, research and practice are critical interacting elements of a dialectic relationship: High-quality practice combines reliable scientific knowledge with individual clinical judgment made by family therapists in the context of their dynamic transactions with a family or couple. Future research can help uncover the mechanisms we have yet to know and test the ones we have identified while the dynamic interaction of research and practice that can lead to further innovations and developments central to the future of family therapy. Keywords: Research; Clinical Practice; Evidence-Based Treatments Fam Proc 53:415–433, 2014

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amily therapy research has built a substantial body of evidence for the effectiveness of systemic treatments, and our current knowledge of family processes and therapeutic change has become increasingly complex and sophisticated. Research reviews and metaanalyses have established that couple and family therapies as stand-alone interventions or part of a multimodal treatment program produce positive outcomes for a variety of clinical problems (Carr, 2009a,b; Gurman, 1971, 1973; Gurman & Kniskern, 1981a,b; Gurman, Kniskern, & Pinsof, 1986; Retzlaff, von Sydow, Beher, Haun, & Schweitzer, 2013; Sexton, Alexander, & Mease, 2004; Sexton, Datchi, Evans, LaFollette, & Wrigth, 2013; Sexton, Robbins, Hollimon, Mease, & Mayorga, 2003; Sprenkle, 2002, 2012; von Sydow, Beher, Schweitzer, & Retzlaff, 2010; von Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013). Pinsof and Wynne (1995) found that some family-based interventions were more effective than individual or standard treatments for specific disorders. Most recently, Alan Carr (2014a,b) gathered further evidence from meta-analyses and qualitative reports that systemic intervention programs were successful in reducing a wide range of child and adult problems. In sum, current reviews continue to provide strong support for family and *Center for Adolescent and Family Studies, Indiana University, Bloomington, IN. † Professional Psychology Family Therapy, Seton Hall University, South Orange, NJ.

Correspondence concerning this article should be addressed to Thomas L. Sexton, Ph.D., A.B.P.P., Center for Adolescent and Family Studies, Indiana University, 1900 East Tenth Street, Bloomington, IN 47406-7512. E-mail: [email protected] 415

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couple therapy as either a broad treatment modality or specific intervention programs with systematic principles, goals, and activities. Scientific advances regarding the processes and outcomes of family therapy are the result of new developments in family therapy research, in particular the shift from broad outcome studies to investigations of specific change mechanisms. This shift and emphasis on specificity have made research increasingly relevant to clinical practice. We are now studying specific clinical change models (e.g., Multisystemic Therapy, Functional Family Therapy, Multidimensional Family Therapy) rather than the broad modality of family therapy or broad theoretical approaches (e.g., structural or strategic family therapy). We now have research and statistical methods that allow us to describe the trajectories of therapeutic change and understand the degree to which therapist activities, the timing of interventions, the alliance and other specific processes influence these trajectories. We are also able to capture multidimensional relational processes from multiple perspectives and thus explain the complexity of family therapy. In the past 40 years, family therapy research has fostered the development and fine-tuning of a number of specific and systematic evidence-based models with a high probability of producing positive clinical outcomes when practiced as prescribed. Treatment specificity has made it possible to develop systematic research programs of treatment models and of core therapeutic change mechanisms. For example, Multisystemic Therapy (MST) has been tested for more than 30 years in 23 randomized trials, 17 independent evaluations, and many other studies of severe conduct problems, substance abuse, emotional disorders, sexual offenses, family maltreatment, and chronic health problems (Multisystemic Therapy, 2014). Similarly, Multidimensional Family Therapy (MDFT; Liddle, 2009) and Functional Family Therapy (FFT; Sexton, 2011) are specific change models with an extensive record of outcome and process studies that show the utility of systematic research programs to clinical practice. These change models have been implemented in various community-based settings where program development was combined with systematic research to investigate change mechanisms as well as other issues relevant to successful treatment dissemination. The work of Pinsof, Knobloch-Fedders, and Mann (2007) and Friedlander, Escudero, Heatherington, and Diamond (2011) on the therapeutic alliance has advanced our understanding of the alliance in family therapy and its relation to outcomes; it also has informed the development of change models and treatment interventions. Family therapy research programs are essential to the production of clinically useful knowledge because they make it possible to ask increasingly complex research questions that are necessary to the development and improvement of treatment models. These research programs also illustrate how much effort and time is required to develop, study, and refine the clinical interventions we need to address the challenges of today’s world. Despite the acknowledged importance of family therapy research, there are still questions about its impact on “real life” practice. It is well-known that family therapy research is difficult and there is much we don’t know. Yet, many practitioners remain cautious about the applicability of research findings to complex and unique client situations, and they have been slow in adopting research-based programs, which they often perceive as cookie-cutter interventions. Many worry that as we become more evidence based, the creativity and dynamism of the early days of family therapy will be gone. Some of the gap is due to differences between the clinical and scientific communities. Practitioners have, by nature, a more idiographic approach to knowledge while researchers, quite naturally, search for trends and probabilities. The lack of a shared language is certainly a barrier in the translation of research into practice; so is the formulation of research questions based on academic concerns rather than clinical considerations.

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We suggest that despite all the flaws of each, research and practice are critical interacting elements of a dialectic relationship: High-quality practice combines reliable scientific knowledge with individual clinical judgment made by family therapists in the context of their dynamic transactions with a family or couple. The question is not whether research goes into practice, but how it informs and is informed by practice. Practice fosters insight and provides clues about what is relevant to clinical work; it can guide our investigations of therapeutic change. Done correctly, research can help uncover the mechanisms we have yet to know and test the ones we have identified. In sum, it is the dynamic interaction of research and practice that can lead to further innovations and improvements in family therapy. How we support this dialectic relationship between research and practice is a critical question. This will require trust and foresight on the part of clinicians: trust in the validity and the strength of different treatment approaches and the ability to see how the dialectic between research and practice can enhance clinical decision-making. The current paper has three primary goals. First, we consider the dynamic nature of family therapy research and its evolution over time. Second, we use the findings of the most current reviews and meta-analyses to answer some of the primary questions raised by clinicians in real-life practice settings: Has family therapy research advanced practice? Does family therapy work across settings and clients? What do we know about common factors and model-specific change mechanisms of family therapy? Finally, we propose new directions for family therapy research and specifically discuss ways that science can become part of the daily activities of family therapists.

EVOLUTION OF FAMILY THERAPY RESEARCH Science has always been a central part of family therapy. Research by early pioneers focused on the efficacy of both couple and family interventions from a systemic perspective (Pinsof & Wynne, 1995). This early work established family therapy as an effective and clinically useful approach to treatment. In the ensuing decades, the research agenda broadened from answering initial questions of outcome (i.e., establishing whether it works in general) to assessing more specific applications of family therapy with specific clinical problems in specific settings. The result of these decades of research is a strong, scientific evidence base for the effectiveness of family therapies (Sexton et al., 2004; Sexton et al., 2013; Sprenkle, 2002, 2012; von Sydow et al., 2010, 2013). Outcome research for couple and family therapy has drawn from meta-analyses that combine results across large client groups and individual outcome studies conducted in local communities with diverse clients in realistic clinical settings. In addition to these outcome research efforts, process research studies have identified the change mechanisms that underlie positive clinical outcomes that are both common across methods and specific to certain approaches. The research in family therapy has evolved to the point that some now identify it as family intervention research (Liddle, Bray, Levant, & Santisteban, 2002), a type of family research that focuses on the change process, attempting to find what therapeutic interventions and/or treatment programs are most effective in helping families change. Sexton, Kinser, and Hanes (2008) defined intervention research as “a systematic approach to understanding the practices, their outcomes, and the varying moderating and mediating variables that may affect the success or failure of different clinical interventions” (p. 165). Intervention science research is particularly useful for clinical practice because it focuses on the “fundamental” questions of practice: (1) Does this intervention/technique/practice work? (2) Where, with what, and for whom does it work? In which setting? With what “problems”? And with what type of client? And (3) What about it works? (What are the clinical mechanisms that produce the change?) The hope is to have psychological

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treatments that, when practiced competently with appropriate clients, can have a high likelihood of producing the changes sought by those who seek services. Family therapy science has also become diverse in its current methodology allowing for the study of more complex and detailed outcome and process questions. For example, researchers now collect data from multiple participants (e.g., parental figures and children) and combine them strategically to answer process questions such as: Does the discrepancy in individual alliance scores for parents and children predict drop out in family therapy (Heatherington, Friedlander, & Greenberg, 2005)? Does therapist model-specific adherence impact the outcome of treatment (Sexton & Turner, 2010)? Family therapy researchers also use mixed methods to study contextual influences and the role of meanings in shaping family interactions (Weisner & Fiese, 2011). This methodological diversity is in response to the complexity of studying family interactions and change processes. Because of its nature, each study must consider multiple perspectives over multiple time points in regard to multiple constructs. Driven by necessity the diversity of approaches also improves the potential to generate clinically useful findings. Sexton et al. (2008) illustrated the range of family intervention research approaches. Figure 1 is an adaptation of that work illustrating the interaction between intervention specificity, research evidence, and the classification of interventions and intervention programs that currently reflect the family therapy research landscape (see Figure 1). Family intervention research is firmly rooted in basic descriptive research on families that describes relational patterns and the role of family structure, among other issues. As studies become more specific, they are able to address more types of efficacy/effectiveness (absolute, relative, contextual), study increasingly specific interventions, and focus on a growing number of relevant moderators and mediators. Change mechanisms research is among the most specific research, in that it is theory driven and specific to a treatment model. Systematic case studies provide an ideographic view of the clinical process. These studies are particularly useful in identifying the individual experiences in the change process that might lead to a better understanding of clinical mechanisms or outcomes. Transportability studies consider various issues related to the transportation of MFT interventions/treatments to the community settings where they might be practiced. Such studies might consider the contextual variables (e.g., therapist variables, client variables, organizational service delivery systems) that may either enhance or limit successful community implementation. Qualitative and meta-analytic research reviews help contribute to understanding and identifying common elements, new treatment mechanisms or differential results across studies. Family therapy research is also a dynamic process. What we know and the methods we use to build knowledge evolve over time. In fact, this is one of the major difficulties in bridging the research-practice gap. Some look at the evidence and say, “it always changes.” In fact it does and it should. The aim of research is to expand and refine our understanding of the complex phenomena we study. As empirical knowledge accrues over time, it takes new shapes and meanings. New research methods including techniques for data analysis have made it possible to investigate areas we could not study and to model family processes in relation to mental health outcomes. New findings shed new light on what we believed to be true two decades ago and compel us to look at family relationships, psychopathology, and therapeutic change more complexly.

HAS FAMILY THERAPY RESEARCH ADVANCED CLINICAL PRACTICE? The raison d’^ etre of psychological and psychotherapy research—and the reason why it matters to clinical practice—is to produce empirical knowledge that will establish the www.FamilyProcess.org

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High Mechanisms of change, phases, goals & techniques, ways to

Evidence Based Treatments (systematic intervention programs)

Evidence Diverse, methodological sound, comprehensive, mechanisms & outcomes

Evidence Informed Approaches Intervention Specificity

(common mechanisms, programs with secondary evidence)

Specificity of Evidence

Common Factors Broad Modalities

Low Non-specific, static

Evidence Weak methods, limited, non-specific

FIGURE 1. Evidence and Intervention Specificity

utility of mental health services as well as improve treatment and client outcomes in a socio-economic context that emphasizes cost-effectiveness, accountability, and beneficence. Family therapy research has provided a wealth of information with regard to the effectiveness of family therapy as a treatment modality and helped to establish family therapy as a legitimate intervention in managed care settings (Carr, 2009a,b; Sexton et al., 2004; Sexton et al., 2013). Family therapy is now recognized as a treatment of choice for the prevention and reduction of youth violence and problem sexual behaviors, youth and adult drug use, adolescent depression, mania and anxiety, and the management of schizophrenia. Family therapy research has produced scientific evidence necessary for the inclusion of family-based treatments in the National Registry of Evidence-Based Programs and Practices, the Model Program Guide of the Office of Justice Programs, and the Blueprints Programs of the Center for the Study and Prevention of Violence at the University of Colorado Boulder. These public archives hold records that inform policymaking and funding decisions at the local and national level, and their inclusion of family-based treatments increases the visibility of family therapy and its role in addressing significant social and clinical problems. Family therapy research has provided substantial evidence about the clinical value of family therapy. Meta-analyses and individual studies of family-based interventions have shown that the effects of family therapy are superior to no treatment and similar to if not better than alternative programs such as individual or group psychotherapy in situations where family processes represent risk factors for the development and maintenance of psychopathology (Sexton et al., 2013, 2004; Shadish & Baldwin, 2003; also see the special issue of the Journal of Marriage and Family Therapy, vol. 38, n. 1, published in January 2012). Compared to individual therapy, family therapy is also associated with lower health care costs and greater reductions in posttreatment health care use in managed care settings (Crane & Christenson, 2012). Conclusions about the effectiveness and cost-effectiveness of family therapy, however, may only be applicable to those interventions that have been empirically tested rather than the broad theoretical approaches that lack research. Sexton et al. (2013) used the “levels of evidence” approach defined by the Task Force for Evidence-Based Treatments in Couple and Family Psychology to evaluate the results of 205 family therapy studies published since 2003. Their findings echo the conclusions of prior research reviews, and highlight a few remarkable trends in contemporary family Fam. Proc., Vol. 53, September, 2014

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therapy science: The majority of family therapy studies (82%) looked at the effects of a few systematic family-based intervention programs (i.e., multisystemic therapy, functional family therapy, cognitive behavioral family therapy, and multidimensional family therapy). Family therapy as a general treatment method received less attention (18%). Family therapy reviews have identified a growing emphasis on specificity in intervention science, which is necessary to investigate the processes and outcomes of what works and to enhance the development of existing models of practice. Once it has been established that a specific treatment works, it becomes possible to answer more complex questions about the ingredients of change, the types of outcomes, the client, the therapist, and the context of service delivery. Both Sprenkle (2012) and Sexton et al. (2013) note significant advances as relates to some of these questions; they also comment on the narrow focus of contemporary family therapy research: Family therapy studies have supported the effectiveness of a few systematic family intervention programs (e.g., MST, FFT) for youth externalizing behaviors, drug abuse, schizophrenia, bipolar disorders, in a variety of clinical settings, including residential and outpatient facilities; it has identified the specific distal outcomes of these systematic interventions on comorbid populations, using multiple dependent variables and perspectives to measure the impact of treatment on various areas of individual and relational functioning; it has established the link between therapists’ model adherence and treatment outcomes, yet produced limited knowledge about the change mechanisms of successful intervention programs. The narrow focus of contemporary family therapy research contrasts with the movement toward theoretical integration and technical eclecticism in real-world clinical practice. Similarly, the lack of scientific attention to clinical activities or processes contrasts with the emphasis on skills and techniques in training programs that prepare family therapists to serve diverse populations with a wide range of problems. It may seem that integrative approaches allow for more flexibility and increase therapists’ ability to match treatment to individual cases, and that they are more responsive to the shifting demands of clinical practice and therefore a better choice (Lebow, 2014). This is not to say that empirically supported systematic intervention models restrict clinicians’ flexibility and responsiveness; in fact, some of these models draw from a broad theoretical and empirical base and emphasize the process of matching interventions to the client as a core principle of practice. Given its narrow focus, family therapy research may not do justice to the variety of potential applications of specific family therapy models. Another concern is the dearth of relative effectiveness, cost-effectiveness, and processoutcome studies in family therapy research, which makes it difficult to compare how different family therapies work, to identify model-specific pathways to change, and to answer questions about the differential effectiveness of successful family-based intervention programs for particular disorders, levels of problem severity, and client characteristics, among others (Datchi & Sexton, in press; Sexton et al., 2013). In the absence of evidence regarding the superiority of any treatment approach, some have concluded that successful family-based programs were equivalent and have questioned the contribution of modelspecific ingredients relative to common factors (Shadish & Baldwin, 2003). The underlying assumption—one that conflicts with a systemic view of change—is that it is possible to separate common factors from the unique processes of specific treatment programs. We propose to move beyond this artificial division and the view that successful intervention programs are effective structures for activating common factors, and suggest that common factors and model-specific change mechanisms are interdependent processes and their interaction with one another produces unique intermediary outcomes that are essential to progress in treatment. Current family therapy research on change mechanisms supports this argument. Treatment differences in the relation between the family therapy alliance and outcomes suggest www.FamilyProcess.org

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that the type of family-based intervention matters (Friedlander et al., 2011). For example, Friedlander et al. (2011) found that treatment completion in family therapy for teenage anorexia was linked to individual parental alliances but not individual adolescent alliances, while client retention in family therapy for youth externalizing problems was contingent on a balanced alliance, which indicates that the processes of the therapeutic alliance—the form it takes and how it works—are treatment-dependent. It is noteworthy that the process-outcome research published in the past 10 years, which represents 15% of all family therapy research, has focused on a few empirically supported treatments, namely FFT, MDFT, MST, and Brief Strategic Family Therapy (BSFT; Datchi & Sexton, in press; Sexton et al., 2013). These are programs with a well-established record of effectiveness that provide a suitable—and desirable—context for the study of mediating and moderating variables, including common factors of family therapy. Process-outcome research has begun to highlight the complexity and interconnectedness of family therapy processes; it has produced critical knowledge about the timing and delivery of specific therapist behaviors which can be used to guide clinical practice and inform training, supervision, and the dissemination of effective family-based programs. Although much needed, it remains an underdeveloped domain of family therapy science.

WHAT EVIDENCE DO WE HAVE ABOUT THE SUCCESS OF FAMILY THERAPY ACROSS SETTINGS AND POPULATIONS? Using research in clinical practice requires confidence in the validity of the findings, in particular their generalizability to a diversity of clients and contexts. Building confidence has been one of the challenges in the dissemination of evidence-based practices. It is a common belief and concern among practitioners that research is suspect because it did not occur in real-life clinical settings where therapy actually happens. For most research conducted in laboratories and other controlled environments, this is a reasonable fear. However, an increasing number of family therapy studies are now taking place in the real world of clinical practice. In the past 10 years, about 77% of the research occurred in community-based settings, both outpatient and inpatient, and produced evidence that family-focused intervention programs could be implemented with relative success outside of university laboratories and training clinics (Sexton et al., 2013). This research also highlighted the variables that moderated the outcomes of effective interventions. For example, treatment adherence is a therapist variable with substantial influence on treatment outcomes in the community. Varying levels of adherence help predict changes in youth behavior problems and internalizing symptoms: High levels are associated with reduced delinquency, drug use, and other externalizing symptoms in FFT, MDFT, MST, and BSFT, while intermediate levels are linked to improvements in youth internalizing disorders in MDFT (Chapman & Schoenwald, 2011; Hogue et al., 2008; Robbins et al., 2011; Sexton & Turner, 2010). Questions about the effectiveness of family therapy with diverse populations, however, continue to be a minor focus of family therapy research (Sexton et al., 2013). For the most part, study samples are racially White and non-Hispanic with the exception of family therapy research on conduct disorder, youth drug abuse, psychoeducation for major mental illness, and child/adolescent internalizing problems (Sprenkle, 2012). This limitation may speak to the difficulty of identifying communities that would provide access to diverse—and sometimes—vulnerable populations; it may also indicate a need for greater collaborative relationships between researchers, practitioners, and other communities of interest. Strong programmatic research in psychotherapy requires teamwork at multiple levels: between researchers; between researchers and practitioners; between researchers and implementation sites or community-based mental health Fam. Proc., Vol. 53, September, 2014

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organizations; and between researchers and local communities. Reciprocity is an essential characteristic of collaborative research-practice partnerships where data is collected, analyzed, and fed back to the communities of interest in ways that guide routine clinical activities and generate further discussion on relevant research questions. The dissemination of MST and FFT offer examples of such partnerships and their role in establishing the community-based effectiveness of evidence-based treatments with diverse populations. Both MST and FFT have been tested in ethnically and culturally diverse communities in the United States and Europe (Flicker, Waldron, Turner, Brody, & Hops, 2008; Harpell & Andrews, 2006). The most current research suggests that MST enhanced youth behavioral outcomes compared to alternative treatments for racially diverse adolescents in the United Kingdom, that juvenile offenders with severe mental health problems were on average less likely to re-offend when they had participated in MST in Washington State, and that the positive effects of MST on behavior problems persisted over time in a non-English speaking Norwegian community (Butler, Baruch, Hickey, & Fonagy, 2011; Mayfield, 2011). Likewise, when implemented with high levels of model adherence, FFT was found to reduce recidivism among juvenile offenders in community-based settings in the United States and Ireland (Barnoski, 2002; Graham, Carr, Rooney, Sexton, & Satterfield, 2014; Sexton & Turner, 2010). The successful implementation of family therapy programs in the community may depend on the development of model-specific conceptual frameworks for dissemination. These frameworks should define the stages of implementation, the goals and tasks of each stage, and the role of key players including administrators, supervisors, therapists, and training consultants. An example can be found in Schoenwald, McHugh, and Barlow’s (2012) discussion of the transport of MST to diverse communities in the United States and abroad. MST Network Partners, a group of national and international mental health organizations with a record of effectiveness in implementing MST, are full collaborators in the dissemination and evaluation of the model (see Multisystemic Therapy website). They participate in discussions that influence research on treatment effectiveness and transportability. Family therapy research on community-based implementation is still in its infancy. Most studies are transportability trials that report the outcomes of specific interventions in the community (Schoenwald et al., 2012). With the rise in use of specific evidence-based models of family therapy, interest is turning to the issue of model integrity and fidelity. Unlike general nonspecific practice, specific models provide a “yard stick” with which to measure whether the treatment delivered is the one that was intended. Evidence suggests that therapist adherence and alliance building are both significant predictors of therapeutic outcomes in the MDFT model (Hogue et al., 2008). For example, studies of adherence in family-based intervention programs have demonstrated that for efficacious programs to achieve success in community settings, the programs must be consistently delivered in a manner that adheres to the models’ specifications (Barnoski, 2002; Sexton & Turner, 2010). Moreover, therapist adherence to a clinical intervention model is related to distal outcomes such as adolescent re-offense rate and incarceration (Barnoski, 2002; Henggeler & Rowland, 1997; Schoenwald, Henggeler, Brondino, & Rowland, 2000). Follow-up studies have also demonstrated that therapist adherence predicts improvements in family relations and reductions in youth recidivism rates (Schoenwald et al., 2000). Despite the importance of model fidelity, little is known about those processes or variables that influence therapist adherence. In the years to come, it is vital that dissemination science investigate the factors that influence the implementation and sustainability of effective treatment programs in various social and organizational settings, in order to increase the availability of evidence-based interventions and thus reduce health disparities in diverse communities. www.FamilyProcess.org

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WHAT DO WE KNOW ABOUT THE COMMON AND MODEL-SPECIFIC FACTORS OF EFFECTIVE FAMILY THERAPY? We know much less about the change mechanisms of effective family therapy than we do about the outcomes of broad and specific intervention programs. While there is considerable interest in identifying the ingredients of change, process research is complex and usually embedded in the study of specific treatment interventions situated in specific contexts of service delivery. The multiple variables in and outside of the treatment program that influence client outcomes are hard to isolate and test in relational and most often conjoint interactions between therapist and family. It is often challenging to separate discrete interventions from relationship factors in order to determine their respective effects on the outcomes of family therapy. Change mechanisms are part of a complex set of purposeful interventions in therapy, and understanding them outside the context in which they occur may neither be practical nor sensible. Change mechanism research, however, determines the utility of family therapy research in clinical practice because it describes the therapist activities that produce positive client outcomes and specify which factors to activate when in the course of treatment. To date, this research has focused on a few mechanisms of change (i.e., therapeutic alliance and therapist adherence) and a few evidence-based interventions for youth delinquency and substance use. Several reviews have documented extant findings regarding what we can confidently say about what goes into effective treatment (Greenberg & Pinsof, 1986; Sexton et al., 2003, 2013). Much of the process research that has been conducted falls within three domains: (1) establishing a therapeutic alliance with family members; (2) managing conflicted family interactions; and (3) changing family interactions. While not an exhaustive list, it is intended to illustrate the major findings of this work.

Therapeutic Alliance As early as 1978, Gurman and Kniskern (1978) concluded that “the ability of the therapist to establish a positive relationship . . . receives the most consistent support as an important outcome-related therapist factor in marital and family therapy” (p. 875). As it is studied today, the alliance is “a multilevel and systemic construct that describes the interactions of individual and group processes and their influence on the development of the therapeutic relationship in family therapy” (Datchi & Sexton, in press). Process research has investigated the link between the alliance and client outcomes in family therapy and identified several family and treatment variables that moderate the strength of the relation. For example, in the treatment of teenage anorexia, it is the quality of the parental alliance that helps predict retention, whereas in the treatment of youth externalizing problems, it is a balanced alliance that is associated with treatment completion (Friedlander et al., 2011). Timing and ethnicity are also factors that moderate the relation between the alliance and client outcomes: Unbalanced alliances in the first session of family therapy help predict dropout for Hispanic but not Anglo families (Flicker et al., 2008).

Managing Family Interactions A comprehensive review of the process of family therapy concluded that, in general, negativity may be predictive of premature termination (Friedlander, Wildman, Heatherington, & Skowron, 1994). Yet, research findings also suggest that conflict/ negativity is malleable in treatment. For example, Melidonis and Bry (1995) demonstrated that therapists could reduce family members’ blaming statements and increase their positive statements by asking questions about exceptions and by selectively attending to positive Fam. Proc., Vol. 53, September, 2014

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statements. Similarly, reframing interventions has been shown to reduce the likelihood of family members’ defensive communications in family therapy (Robbins, Alexander, Newell, & Turner, 1996; Robbins, Alexander, & Turner, 2000). Diamond and Liddle (1996) demonstrated that in successful resolutions of therapy impasses, therapists were able to create an emotional treaty among family members by blocking and working through negative affect and by amplifying thoughts and feelings that promoted constructive dialogue.

Changing Family Interactions Process studies have begun to demonstrate a link between changes in family interactions and treatment outcomes. For example, Schmidt, Liddle, and Dakof (1996) demonstrated significant decreases in negative parenting practices and significant increases in positive parenting features over the course of family therapy, and they linked these improvements in parenting to improvements in adolescent drug use and behavior problems. Likewise research on family psychoeducation has established the value of increasing families’ understanding of the mental illness and giving family members problem solving tools to manage the symptoms of severe mood and psychotic disorders (Lucksted, McFarlane, Downing, Dixon, & Adams, 2012). These ingredients of change are key to reducing family expressed emotion or extreme worrying and/or statements of criticism and hostility toward the index patient, which are a well-established risk factor for the onset and relapse of serious mental illness such as bipolar disorder and schizophrenia (McFarlane, 2006). Finally, the work of Shpigel, Diamond, and Diamond (2012) has established a link between maternal psychological control and autonomy granting, levels of adolescent attachment security, and youth mental health outcomes in attachment-based family therapy for adolescent depression (Shpigel et al., 2012). Greenman and Johnson’s (2013) review of emotionally focused therapy studies also highlights the mechanisms that produce positive change in couples: Specific emotionally focused therapy interventions (e.g., reframing, heightening) help disrupt blaming interactions, and deep emotional experiencing, self-disclosure, and intimate sharing are critical therapeutic events associated with relationship satisfaction and the resolution of attachment injuries. This research specifies how relational processes and individual variables mediate treatment outcomes; it also provides support for attachment-based systemic theories of change and illustrates the clinical relevance of process studies.

THE FUTURE ROLE OF FAMILY THERAPY RESEARCH The emerging consensus is that effective family therapy requires the activation of both core common factors such as the therapeutic relationship and treatment-specific interventions such as those prescribed by evidence-based change models (Sexton, 2011; Sexton & Coop Gordon, 2009). The best family-focused treatments are those that are both scientifically sound and clinically relevant. Yet, in real-world practice settings, research seems out of reach and family therapists continue to rely on their clinical experience rather than scientific findings. The research-practice gap continues to be and is not a new challenge. It is important to note that considerable work has gone into thinking about how research and practice can come together. For example, training programs espouse a scientist-practitioner model, meta-analyses, and qualitative review attempt to synthesize research findings into trends, and national organizations are creating treatment guidelines and “lists” of best practices in the field of family therapy. Yet, there seems to be moderate improvement at best. We have yet to find the best way to translate research findings into information that is clinically useful; we also have to think about family therapy in a way that www.FamilyProcess.org

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embraces the less than perfect but valuable contributions of research as relates to practice. The utility of family therapy science depends on its ability to inform mental health practice, public policy making, and training. To do so, research must provide evidence that family-based treatments are effective in natural settings under real-world conditions. It is clear that to meet this goal, family therapy research can only lead if it utilizes diverse research methods. Randomized clinical trials help answer the broad question of which treatment or interventions to use for which type of problems. Unfortunately they do not address the many ideographic questions practitioners must consider in the course of treatment. Consequently, family therapy research will only impact practice if it uses diverse methods that investigate different levels of evidence. The research should focus not only on outcomes (what works) but also on processes (how it works), and identify the change mechanisms of good interventions. To be useful process and outcome research needs to meet high methodological standards and include the study of diverse outcomes (e.g., individual and relational, severity of symptom and level of functioning) from multiple perspectives (e.g., parents, children, partners, teachers). Translating the findings of family therapy research into clinical decisions is complex because of the dynamic nature of the findings. The relevant questions change as interventions become more specific and research evidence evolves and accumulates. Randomized comparison trials are well suited to the study of family therapy efficacy. They provide initial evidence for interventions or programs; yet, in a lot of cases the evidence is not specific to particular clients, problems, or contexts. When a series of studies have established that an intervention program works, research should focus on the effectiveness of treatment in diverse clinical settings with a wide range of clients and problems. It should also look at the change mechanisms associated with good treatment outcomes. By following this sequence of scientific inquiry, researchers will produce different levels of evidence, and thus increase the breadth of family therapy science and establish family therapy interventions as possibly useful. As the evidence grows in support of a particular intervention at different levels (outcome, process, process to outcome), so may the trust of clinicians and the perception that research is clinically relevant. In other words, multi-level evidence has the potential to be more convincing and to guide clinicians in how they select interventions based on client characteristics, the nature of the symptoms, the level of symptom severity, and the context in which they provide services. Despite near universal agreement about the importance of research we still know little about how to better integrate scientific knowledge into practice. We have done much to present information in a way that is more accessible than ever for practitioners. However, reducing the research-practice gap will take more than providing digestible research summaries. The next steps must involve making research an integral part of practice. As such, we focus on three recent developments that support this goal: core competencies, treatment guidelines, and measurement feedback systems. Core competencies refer to agreedupon standards of proficiency and provide a framework for training clinicians. They also define the educational outcomes of training programs. Both in the United States and the United Kingdom, core competencies in marriage and family therapy emphasize researchinformed clinical practice and constitute a viable avenue for research dissemination and utilization. Treatment guidelines provide actionable information on the options available for various clinical problems. They increase our confidence in the validity of empirical findings and translate these findings into concrete procedures for choosing and implementing treatment. Last, measurement feedback systems make research a central activity of each family therapy session through ongoing data gathering and clinical feedback; as such, they support the role of the therapist as a local clinical scientist.

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Core Competencies The identification and definition of core clinical skills and abilities is one of the ways in which research findings can be integrated into practice. The competency approach (Bieschke, Fouad, Collins, & Halonen, 2004; Kaslow et al., 2004; Sexton et al., 2008) is built on the idea that if therapist core abilities and related behaviors are identified we can better chart the appropriate course of professional development and create benchmarks to evaluate the knowledge and activities of clinicians. In the United States, the American Association for Marriage and Family Therapy (AAMFT, 2004) has proposed a set of 128 core competencies for MFT training and practice that involve knowledge, skills, attitudes, and policies necessary to improve the quality of services delivered by family therapists. For family therapists, the core competencies constitute minimum standards for independent practice. For training programs, accreditation bodies, and licensing groups, the core competencies specify the goals and outcomes of MFT graduate education and clinical training, and thus provide a yardstick for measuring MFT supervisees’ aptitude and readiness for independent practice. Not only do core competencies play a critical role in the training and evaluation of family therapists, they can also provide evidence-based principles for clinical decision-making. For example, Stratton, Reibstein, Lask, Singh, and Asen (2011) described how a group of experts in the United Kingdom used research on effective systemic therapies to specify evidence-based core competencies for marriage and family therapy. They reviewed treatment manuals written for randomized control trials that had produced evidence of superior clinical outcomes, and identified clinical activities and skills that emerged as necessary ingredients of effective family therapy. These research-based activities and skills were organized into five domains of competence and integrated into National Occupational Standards (NOS) for family therapy practice. The NOS are designed to serve as a performance measure; they also provide a mechanism for disseminating empirical findings and bringing together research and practice in a systematic way. Core competencies and process and outcome research are a necessary match. If core competencies are to the standard for clinical training and community-based practice we need to ensure that those competencies have a foundation that goes beyond judgment, tradition, and face validity (i.e., “it just seems right.”). Instead, core competencies will only have lasting impact if they have a research foundation. Without such a foundation we are not sure that these are indeed “core” competencies. Competencies should also integrate the systematic review and analysis process that are central to the treatment guidelines process described below. It is likely that the study of core competencies will be done through broad based community research of common practices rather than through clinical trials. Thus, the measurement feedback approach, described below, is a useful mechanism to study competencies and their relationship with client change.

Treatment Guidelines To successfully transport research into practice, we first need to consider two features: the strength of the cumulative evidence and the domains that are evaluated including (1) the specificity of the intervention; (2) the methodological quality of the evidence; (3) the levels of the cumulative evidence for practice over time; and (4) the context, the clients, and the problems with which it works. When these components are in place, it becomes possible to translate research findings into actionable items that can inform decisions regarding which treatment to choose, how long to implement it with what kind of client and clinical problem. It also becomes possible to formulate helpful guidelines that help practitioners know what degree of confidence to have in an intervention program and that

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help researchers find gaps in knowledge and identify pathways for successful model development (Sexton & Coop Gordon, 2009). Until the development of treatment guidelines we did not have a method that clinicians could trust for identifying what scientific evidence may offer useful clinical guidance and for delivering this evidence to practice settings. In most cases, qualitative research reviews and meta-analyses do not specify how the findings can be used in practice. In addition, the difficulty is to determine how much and what type of evidence is needed to recommend an intervention. Treatment guidelines help overcome many of the barriers in making research findings relevant. Based on a rigorous systematic review of all the existing evidence, coded and analyzed at the highest methodological levels, they offer specific recommendations for choosing and implementing interventions that fit specific mental health problems. Treatment guidelines use three criteria to make recommendations: the reliability or trustworthiness of the evidence (to what degree is the evidence for this intervention/program trustworthy?), the generalizability of the evidence (for whom does this work, in what contexts is it effective, what are the critical change mechanisms?), and the actionable nature of the evidence. Treatment guidelines identify the most effective and clinically useful programs—those that are evidence based, that demonstrate effectiveness compared to alternative treatments, and that activate specific change mechanisms with diverse clients in various contexts. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE, 2009) has implemented a process for disseminating empirical findings to healthcare professionals through published treatment guidelines. After a comprehensive review of the evidence, NICE guidelines are delivered in both full-size (i.e., inclusive of methodological and analysis procedures) and compact varieties (i.e., just the guidelines for use by a broader public). NICE has published quality standards on 15 areas of treatment and preventative care, ranging from substance use to glaucoma (NICE, 2012). In the United States, the Institute of Medicine (IOM, 2011) developed standards for “finding what works in healthcare” and for conducting a comprehensive review of the evidence: establishing a team with the expertise necessary to conduct a systematic review; remaining cognizant of the potential for bias and managing conflicts of interest among all relevant parties; protecting the integrity of the team by insuring the ability to make independent decisions about guidelines; standardizing the topic under systematic review; developing a systematic review protocol; and finally, submitting the protocol for peer review (IOM, 2011). These standards serve to increase the confidence that clinicians can have in reports produced by the IOM (2011) and other like-minded organizations that have standardized their review process.

Participant Research through Measurement Feedback Systems Despite all the significant innovation, improvements, and comprehensive findings of family intervention research, the future of family research may not lie in further development of more complex traditional research methods but in the transportability of research from the laboratory to clinical practice settings. Stricker and Trierweiler (1995) coined the term “local clinical scientist” to describe the attitudes shared by clinicians and researchers. Their idea was that to rely on findings alone would put the clinical practitioner in the position of hopelessly following outdated information (Stricker, 2006). Instead, clinicians that have a scientifically minded approach are likely to better integrate science into practice. Stricker’s (2006) notion is similar to the calls for increased participant based research. Unfortunately, practitioners rarely engage in many of the core elements of these movements, particularly in regard to gathering systematic information about their daily Fam. Proc., Vol. 53, September, 2014

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activities. In fact, at times, clinicians even seem averse to systematically gathering data as a normal part of practice (Bickman, 2008; Kelley & Bickman, 2009). What is often lost is the idea that useful, relevant, and valuable clinical evidence can be gathered outside traditional scientific studies to inform client-specific and agency-level decision-making (Chorpita, Viesselman, & Hamilton, 2005). What have been missing are the advances in the methods by which clinicians can become local scientists. If they are to embrace continuous measurement of clinical processes and outcomes, adopt a scientificmindedness to practice, and develop an interest in data-based practice and practice-based data, they must be empowered with methods of gathering data that are valued, useful, and accessible in the busy life of clinical practice. Only then can family interventions become a valuable participant in the systematic inquiry of family research (Sexton et al., 2008). Recent advances in technology provide the missing tool for family practitioners to become local scientists and add to the collective knowledge base about what works with families. Evidence on clinical processes, outcomes, and decision-making can be collected systematically and easily on every case through computerized measurement feedback systems (MFSs; Bickman, 2008). These data form the backbone of a potentially flexible and real-time information system that can inform individual treatment as well as contribute to building contextual efficacy evidence in a more efficient and timely manner. The use of MFS information has been termed “evidence farming” and provides an ideal methodology to weigh outcome-based evidence with locally relevant information to promote scientifically valid and clinically useful knowledge. The aggregation of such data across clients, practitioners, and settings could serve to revolutionize the way that evidence is accumulated and used to inform intervention. MFSs are systematic measurement tools that provide real-time feedback relevant to clinical decision-making. They integrate reliable and valid measurement of client factors, clinical process, and client improvement with useful “feedback” that can easily be adopted into short and long-term clinical decisionmaking. They are a mechanism to conduct practice-based research by systematically monitoring client progress and health status and by identifying patients not benefiting from treatment (Lambert, 2001). Practice-based research can also provide critical “data” to the clinician for many of the within-treatment decisions that go into good clinical decisionmaking. In fact, with relevant and reliable client information, the clinician can address changes in therapeutic progress and be flexible in their provision of treatment, while being able to use client-based information and clinical judgment to adjust and adapt treatment to better fit the client and improve outcomes. Measurement feedback systems offer clinically relevant information through ongoing measurement of both treatment progress and process. This enhances clinical decisionmaking through the integration of two essential elements: systematic and theory-based measurement and specific and clinically useful feedback to clinicians, supervisors, and organizations who provide mental health services (Sexton, Patterson, & Datchi, 2012). More than a technical tool, MFSs represent a dynamic part of providing comprehensive treatment to clients by not only gathering information but also providing a mechanism for translating client and psychotherapy data into clinical feedback using real-time technology. This allows clinicians to focus on interpreting the information delivered by the MFS, examine the effect of treatment session by session, and make decisions about the course of psychotherapy. In addition, this new technology makes it possible to visualize change at both the individual and systemic levels, to assess how each family member or partner is responding to treatment, and to compare their experiences of the family and couple relationships. This feedback provides information about what does and does not seem to be working so that clinicians can be more responsive to the needs of their clients by continuing, discontinuing, or altering treatment plans. There are two illustrative examples of www.FamilyProcess.org

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these approaches in the family therapy area. Pinsof, Breunlin, Russell, and Lebow (2011) have provided detailed information about the use of a measurement feedback system in the context of psychotherapy, and illustrated how family therapists can facilitate therapeutic change by activating processes that are both client-centered and informed by empirical data. Sexton & Fisher (in press) describe the application of a measurement feedback system to an evidence-based family treatment (Functional Family Therapy/Clinical Feedback System).

FUTURE INNOVATIONS IN FAMILY THERAPY Research about the critical elements of the family therapy process and its outcomes with diverse clients and contexts will be a critical part of what helps usher in the next generation of family therapy. It is in these studies that the field identifies unique areas of practice that are useful in various situations, common practices that promote good outcomes, and treatment programs that have, when done with fidelity, resulted in positive client outcomes with some of the most difficult clinical problems in our culture. It is from the cumulated research that new theories and ways of conceptualizing change emerge. Thought of in this way, research is one of the central vehicles to innovation in family therapy. It is innovation that pushes any system, family therapy included, to remain exciting and viable in the difficult world of practice. It is innovation from research and clinical practice that will engender the excitement and advancement of family therapy practice. We suggest that research, albeit more broadly conceptualized, will be essential to innovations in practice that will move family therapy forward. Research has the ability to synthesize the outcomes and process of one or many families in a single practice with a single practitioner or in a multisite clinical trial. It is in the interpretation of these data that we will find one source of understanding what we do, how well it works, what to do differently, and how to better study the phenomenon of change and the therapeutic process that results in that change. As such, we suggest that integrating science and practice in family therapy requires a conceptual shift away from viewing science and practice as distinct domains and toward one that considers these seemingly different domains of the work of family therapists and psychologists as activities that occur together and exist in a dialectic relationship to one another. We suggest that science and practice are, in fact, different sides of the same coin: sides that bring unique perspectives to understanding the same process of client change. Thus, both the accumulated knowledge of methodologically sound and systemic science and expertly conducted clinical practice are necessary and neither is sufficient to bring the best available treatments to the clients who seek the services (Sexton et al., 2008). Considered in this way, science and practice in family therapy not only go hand in hand but are critical for the success of one another and have the potential to help overcome the continuing gap between the domains of research and practice. Last but not least, we must not forget the role of family therapy training in bridging the gap between research and practice. It is during their graduate education that family therapists build their foundations for competent practice and must learn the value of research as well as the methods for integrating empirical knowledge into clinical decisions. Although family therapy students recognize their ethical duty to promote welfare and provide treatment that fits the needs and worldview of their clients, some if not most adopt, study, and integrate therapeutic approaches they find attractive. These approaches may or may not be systemic interventions with a scientific record of effectiveness. In fact, when asked about their theoretical approach to treatment, it is not uncommon for students to answer they chose what they liked, what spoke to them, and what matched their values. They emphasize the self of the therapist, rather than the science of family therapy, in ways that could be ethically problematic. Research on training strategies that promote the Fam. Proc., Vol. 53, September, 2014

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integration of research and practice is almost nonexistent. We located one published qualitative study that looked at the experience of Master’s level trainees in a student-led research practice team and described the role of sharing and mentoring in promoting a research-informed attitude toward clinical practice (Owenz & Hall, 2011). Investigating how family therapy education can promote the development of family therapists as local clinical scientists is also one of the next steps toward a greater integration of research and practice. REFERENCES American Association for Marriage and Family Therapy. (2004). Marriage and family therapy core competencies. AAMFT. Retrieved from www.aamft.org Barnoski, R. (2002). Washington State’s implementation of functional family therapy for juvenile offenders: Preliminary findings. Washington State Institute for Public Policy. Retrieved from http://www.wsipp.wa.gov/ReportFile/803/Wsipp_Washington-States-Implementation-of-Functional-Family-Therapy-for-Juvenile-Offenders-Preliminary-Findings_Full-Report.pdf Bickman, L. (2008). A measurement feedback system (MFS) is necessary to improve mental health outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 47(10), 1114–1119. Bieschke, K. J., Fouad, N. A., Collins, F. L. Jr, & Halonen, J. S. (2004). The scientifically-minded psychologist: Science as a core competency. Journal of Clinical Psychology, 60(7), 713–723. doi:10.1002/jclp.20012. Butler, S., Baruch, G., Hickey, N., & Fonagy, P. (2011). A randomized controlled trial of multisystemic therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 50(12), 1220–1235. Carr, A. (2009a). The effectiveness of family therapy and systemic interventions for adult-focused problems. Journal of Family Therapy, 31, 46–74. Carr, A. (2009b). The effectiveness of family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 31, 3–45. Carr, A. (2014a). The evidence base for family therapy and systemic interventions for child-focused problems. Journal of Family Therapy, 36(2), 107–157. Carr, A. (2014b). The evidence base for couple therapy, family therapy and systemic interventions for adultfocused problems. Journal of Family Therapy, 36(2), 158–194. Chapman, J. E., & Schoenwald, S. K. (2011). Ethnic similarity, therapist adherence, and long-term multisystemic therapy outcomes. Journal of Emotional and Behavioral Disorders, 19(1), 3–16. Chorpita, B. F., Viesselman, J. O., & Hamilton, J. (2005). Staying in the clinical ballpark while running the evidence bases. Journal of the American Academy of Child & Adolescent Psychiatry, 44(11), 1193–1197. Committee on Standards for Systematic Reviews of Comparative Effectiveness Research; Institute of Medicine (IOM). (2011). Finding what works in health care. Washington, DC: U.S. National Academies Press. Crane, D. R., & Christenson, J. D. (2012). A summary report of the cost effectiveness of the profession and practice of marriage and family therapy. Contemporary Family Therapy, 34, 204–216. doi:10.1007/ s10591-012-9187-5. Datchi, C., & Sexton, T. L. (in press). Integrating research and practice through intervention science: New developments in family therapy research. In T. L. Sexton & J. Lebow (Eds.), Handbook of family therapy (2nd ed.). New York: Brunner-Routledge. Diamond, G., & Liddle, H. A. (1996). Resolving a therapeutic impasse between parents and adolescents in multidimensional family therapy. Journal of Consulting and Clinical Psychology, 64(3), 481–488. Flicker, S. M., Waldron, H. B., Turner, C. W., Brody, J. L., & Hops, H. (2008). Ethnic matching and treatment outcome with Hispanic and Anglo substance abusing adolescent in family therapy. Journal of Family Psychology, 22(3), 439–447. Friedlander, M. L., Escudero, V., Heatherington, L., & Diamond, G. M. (2011). Alliance in couple and family therapy. Psychotherapy, 48(1), 25–33. Friedlander, M. L., Wildman, J., Heatherington, L., & Skowron, E. A. (1994). What we do and don’t know about the process of family therapy. Journal of Family Psychology, 8(4), 390–416. Graham, C., Carr, A., Rooney, B., Sexton, T., & Satterfield, L. (2014). Evaluation of functional family therapy in an Irish context. Journal of Family Therapy, 36(1), 20–38. Greenberg, L. S., & Pinsof, W. M. (1986). Process research: Current trends and future perspectives. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook. Guilford clinic psychology & psychotherapy series (pp. 3–20). New York: Guilford. Greenman, P. S., & Johnson, S. M. (2013). Process research on emotionally focused therapy (EFT) for couples: Linking theory to practice. Family Process, 52, 46–61. doi:10.1111/famp.12015.

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