Beyond a single standard: levels of evidence approach for evaluating marriage and family therapy research and practice

Randomized clinical trial (RCT) research has come to dominate the research landscape of marriage and family therapy (MFT). Despite becoming the ‘gold standard’ for evaluating clinical research and clinical practices, there is a growing debate regarding the reliance on RCTs as the primary basis for evaluating clinical intervention in MFT. Given the natural diversity of clients, settings and clinical problems faced by practitioners and the relational and recursive interactional process of MFT, one of the major challenges for the field of MFT will be to come to grips with the research–practice gap by moving beyond a single methodological standard through adopting a ‘levels of evidence’ approach as a framework that promotes diverse research methods, different methodological criteria (depending on the method), and evaluation based on the accumulated type of evidence needed to answer a specific policy, clinical practice choice, or within a model clinical decision.     

Effectiveness Research in the Context of School-Based Mental Health

There are many challenges to transporting evidence-based treatments from laboratories into real-world settings. However, if we hope to make our evidence-based treatments accessible and available to children and usable by community professionals, effectiveness research is imperative. We argue that schools represent an ideal real world setting in which to conduct such research. The goals of this paper are to present the advantages of conducting effectiveness research in the school setting and to encourage clinical researchers to engage in effectiveness research in this location, as there are benefits to children, pre-service professionals, communities, and researchers. We attempt to further advance the literature by discussing the challenges associated with this work and by providing a case example (The Youth Experiencing Success in School [Y.E.S.S.] Program) that demonstrates real world application of our recommendations.     

Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations

Pragmatic trials testing the effectiveness of interventions under “real world” conditions help bridge the research-to-practice gap. Such trial designs are optimal for studying the impact of implementation efforts, such as the effectiveness of integrated behavioral health clinicians in primary care settings. Formal pragmatic trials conducted in integrated primary care settings are uncommon, making it difficult for researchers to anticipate the potential pitfalls associated with balancing scientific rigor with the demands of routine clinical practice. This paper is based on our experience conducting the first phase of a large, multisite, pragmatic clinical trial evaluating the implementation and effectiveness of behavioral health consultants treating patients with chronic pain using a manualized intervention, brief cognitive behavioral therapy for chronic pain (BCBT-CP). The paper highlights key choice points using the PRagmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool. We discuss the dilemmas of pragmatic research that we faced and offer recommendations for aspiring integrated primary care pragmatic trialists.

     

Gender Biases and Therapists’ Conceptualization of Couple Difficulties

In spite of the fact that gender issues have played an important role in many family therapy training programs, little research has been developed to explore the effects of gender and gender biases in therapists’ conceptualizations of client problems. This study explores beginning and advanced marriage and family therapy (MFT) student’s inclusion of gender in the conceptualization of a clinical case. To examine clinician’s thinking, 32 therapists (18 beginning MFT students and 14 advanced MFT students) were asked to 1) view the first 20 minutes of an intake interview conducted by a sex therapist, and 2) identify the couple’s central issues. Qualitative and quantitative analyses were used to explore constructs associated with therapists considerations and inclusion of gender and cultural issues in their conceptualizations of marital difficulties. Results revealed that trained MFT students who considered gender may have analyzed gender issues more extensively than untrained MFT students. In addition, results of qualitative analysis of participant critiques revealed subtle forms of gender and cultural biases. Discussion focuses on how these biases, some of which are linked to clinical theory, can lead to differential expectations and inequality in the treatment of men and women in couple therapy. Implications for clinical training, curriculum development, and future research are also discussed.     

A Cognitive-Behavioural Approach to the Secondary Prophylaxis of Work-Related Back Pain

Abstract

A clear call has been made for the prevention of the development of chronic back pain. Indeed, chronic back pain is quite prevalent, causes great suffering, and is extremely costly. Although several attempts have been made in clinical settings to prevent the development of chronic pain, there are few reports on the techniques involved. Consequently, this paper aims to summarize some current initiatives in secondary prevention which are relevant for health care professionals. After reviewing some background principles, a guide to prevention is provided. This is based on a four-stage approach that includes screening, assessment, preventive intervention, and recycling of the program. Although research to date suggests that these methods are promising, there is a real need to conduct further research to determine the effectiveness of such programs as well as to develop the techniques further.     

Systematic review of the effectiveness of interpersonal coach education interventions on athlete outcomes

ObjectivesTo systematically review and evaluate the literature on the effectiveness of coach education interventions. Specifically, we aimed to: (a) describe the non-formal coach education interventions aimed at coaches' interpersonal knowledge base, (b) highlight underpinning theoretical models, (c) assess the methodological quality of articles evaluating these interventions, (d) identify participant characteristics, and (e) establish the effect of these interventions on athletes' cognitive, affective, and behavioural outcomes.DesignSystematic review of published empirical research.MethodPublished English language articles were identified using electronic databases and manual searches of reference lists. The quality of the identified articles was assessed using the Effective Public Health Practice Project (EPHPP) tool.ResultsFour interventions fulfilled the inclusion criteria and were thus systematically reviewed. Overall, education interventions based on coach effectiveness training and achievement goal theory produced mixed effects on a variety of athlete outcomes, such as anxiety, self-esteem, fear of failure, and motivational orientation.ConclusionsDue to the diversity in athlete outcomes and intervention design, it is difficult to draw firm conclusions around the effectiveness of coach education interventions. The small number of identified interventions highlights the current paucity of empirical data on coach education intervention effectiveness. More research is needed to further our understanding of intervention effectiveness to allow for growth and improvement in coach education. Furthermore, theory-based, rather than “theory inspired” coach education interventions are required.     

An Addendum to the 1997 Outcome Research Chart

In 1997, an article in the American Journal of Family Therapy was published that summarized the outcome research regarding the efficacy of specific approaches of Marriage and Family Therapy in treating certain disorders (Sandberg et al ., 1997). The article updated the original matrix of findings reported by Gurman, Kniskern, and Pinsof (1986) by reviewing the relevant research through 1995, and provided a summary of findings in an updated version of the original 1986 chart. Since the publication of that article (Sandberg et al ., 1997), feedback has been received from a number of MFT researchers who pointed out some omissions and oversights in the updated chart. After responding to their feedback, it has been concluded that a number of changes must be made to the 1997 summary chart to present a more complete summary of MFT outcome research up through 1995.     

In What Circumstances Does Job Performance Vary With Ages?

Abstract

This paper examines what is known about employee age and the effectiveness of job behaviour, concentrating on studies carried out in work settings and linking these with laboratory investigations. Rated job performance is shown to be generally unrelated to age; overall, absenteeism tends to be greater among younger employees; accidents are more common at lower ages; and staff turnover declines with age. A framework is proposed in terms of three main components of job behaviour: (1) physical ability; (2) adaptability; and (3) general work effectiveness. The major practical need is seen to be the implementation of procedures that enhance adaptability among older employees. An outline model is suggested, with the objective of identifying those jobs in which greater age is either a benefit or a limitation. This model indicates that, in research as well as in practice, the key issues now concern the nature and enhancement of adaptability.     

What Do Medical Providers Need to Successfully Intervene with Intimate Partner Violence?

ABSTRACT

Increasingly, medical providers (physicians and mid-level providers) rely on research evidence to inform their medical practice. In order for medical providers to accept their role in diagnosing and intervening with IPV, they need clinical tools and institutional support. This paper explores the tools (prevalence rates, screening questions, intervention strategies) and support (educational, institutional, professional, research) needed to assist medical providers in successfully intervening with IPV. It also looks at the importance of guidelines and expert consensus panel statements to help establish best clinical practices when direct research evidence is lacking or conflicting.     

The Lived Experience of Marriage and Family Therapy Doctoral Graduates: A Phenomenological Study

Abstract

This qualitative study was conducted with nine individuals who have successfully completed a Marriage and Family Therapy (MFT) doctoral program. A hermeneutic phenomenological approach was employed to explore the experiences of these MFT doctoral graduates and the contributing factors to their success. The four overarching themes that emerged from the data included: (1) Necessity of and dependence on connections and support systems, (2) Becoming adept at overcoming challenges through limited resources, (3) Ability to translate skills and integrate processes, (4) Gratitude and appreciation for the journey. Implications for this field of study are discussed. Future research and implications are explored.     

Learning Multiple Family Therapy Through Simulated Workshops

Multiple Family Therapy (MFT) can be learned more rapidly through simulated workshops. A chronological approach to a simulated workshop is outlined describing mechanics and techniques. The hardest parts of simulated and real MFT are taking off and landing. Specific exercises are detailed to facilitate the early phases when professionals tend to simulate excessive psychopathology. However, recovery is usually rapid and dramatic in simulations; thus, the workshop leaders appear impressive. How to end "healthily" is the final challenge. Group input for assessment of simulated and real MFT is essential. From this feedback, subassertives and schizophrenics may be at the highest risk for deleterious effects from real MFT.     

The Practice of Suicide Assessment and Management by Marriage and Family Therapists

Abstract

Over 90% of mental health providers encounter suicidal clients. However, the majority of marriage and family therapists (MFTs) are not exposed to suicide-specific trainings within their clinical coursework. Due to the lack of consistent training protocols for suicide assessment and management among MFTs, this qualitative study identified common MFT responses to suicidal clients, including assessment of risk severity and intervention modalities. Responses were then compared to best practices for suicidal clients. Participants inconsistently adhered to best practices identified in the larger field of mental health, revealing the need for increased MFT training on suicide to ensure appropriate and effective care.     

The EMDR integrative group treatment protocol: EMDR group treatment for early intervention following critical incidents

IntroductionThis paper presents an overview of the Eye Movement Desensitization and Reprocessing – Integrative Group Treatment Protocol (EMDR-IGTP) that has been used since 1998 with both children and adults in its original format or with adaptations to meet the circumstances in numerous settings around the world for thousands of survivors of natural or man-made disasters and during ongoing geopolitical crisis.MethodThe author's intention is to highlight and enlightened the reader of the existence of this protocol that combines the eight standard EMDR treatment phases with a group therapy model and an art therapy format and use the Butterfly Hug as a form of a self-administered bilateral stimulation, thus providing more extensive reach than the individual EMDR application.ConclusionRandomize Controlled Trial Research is suggested to establish the efficacy of this intervention.     

Psychoanalyst's Values and Countertransference

On the subject of countertransference we attempt to establish a line of continuity between Freud's own expression "blind spot" and Fromm's idea of "counterattitude". It is pointed out that both expressed the idea of the analyst's unconscious as an "instrument" for understanding the patient's unconscious. It follows that the decision to openly use or not to use countertransference in analysis also depends on the concept we have of it and on its extent. The psychoanalyst's real and illusory values and his convictions with regard to human nature influence the countertransference and the analytic relationship. Analytic listening itself may be distorted by it. We must be highly aware of this to avoid enclosing what the patient says in a theoretic scheme. What is needed, therefore, is an open theoretic scheme, more oriented towards understanding than interpretation. Aspects of analytic communication and of the relationship between language, thought and insight are examined. A humanistic point of view is assumed in distinguishing between the transferral and the real plane, and the reasons behind the legitimacy of such a distinction are expounded.     

Structural Family Therapy and Autism Spectrum Disorder: Bridging the Disciplinary Divide

ABSTRACT

Applied Behavior Analysis (ABA) is an evidence-based practice approach for the treatment of individuals with autism. The systemic effects of autism suggest that family therapy would considerably enhance the treatment of individuals with autism. Marriage and family therapy (MFT) training does not routinely include exposure to autism beyond the associated diagnostic criteria. Structural Family Therapy (SFT) is a systemic model that is familiar to those trained in family therapy and appropriate for the needs of families affected by autism. Therefore, the authors have used SFT as a foundation for supervising MFT trainees working in an autism treatment setting.     

Termination: Legal and Ethical Considerations for Marriage and Family Therapists

Every Marriage and Family Therapist (MFT) must carefully plan how to initiate, convene, and terminate therapy. Determining how to ethically terminate therapy in a variety of therapeutic contexts can be challenging. Though termination is a common aspect of all therapeutic relationships, a lack of empirically based information on how to terminate therapy leaves practitioners alone in determining how best to end the treatment relationship. Furthermore, the subject of termination is discussed so scarcely in MFT literature that few authors have attempted to establish a standard for ethical termination. In the current climate of evidence-based services, predetermined session limits, and increased litigation for malpractice, MFTs must examine their termination procedures. This paper identifies the current available literature on termination and discusses the ethical and legal considerations for practicing MFTs as outlined by the AAMFT Code of Ethics (2004) American Psychological Association. 2004. Code of ethics., Washington, DC: Author.  [Google Scholar]. Directions and suggested methods for future research are set forth.     

Gendered Training: Men and Men's Issues in Marriage and Family Therapy Programs

Few studies examine men's experiences in becoming a therapist. Only a modicum of attention appears to be paid to men's professional training needs in MFT training programs as expressed in the family therapy literature. Five recommendations, based on the author's experiences and male student voices, are provided for how to best meet the needs of male students in MFT training programs. These recommendations are (1) be aware of men's experiences and don't assume silence means disinterest, (2) develop depth in clinical training on men's issues, (3) incorporate theories of masculinity into curriculum, (4) engage male students in the training process, and (5) provide support to male students through mentorship and support groups.     

Qualifying Confidentiality Obligations

Objectives : To test the range of beliefs regarding the ethics of testing, in resource poor settings, new therapies that are less efficacious but more affordable and feasible than the best current therapeutic standard.

Design : Using a web-based survey, we presented a hypothetical scenario proposing to test a therapy for HIV disease ("therapeutic inoculation") known to be less efficacious than highly active antiretroviral therapy (HAART). Respondents evaluated various trial designs as ethical or unethical.

Participants : 604 subscribers to two listservs for individuals interested in international health research ethics.

Main outcome measures : Proportion of respondents endorsing trials testing this "substandard" therapy, and proportion endorsing placebo-controlled trials.

Results : There were 215 respondents from 47 countries. Forty-five percent of respondents were from low or middle income countries; 96% devoted at least some time to research activities; and 75% had "some" or "considerable" research experience in developing countries. Of respondents, 97% (95% CI 94.7 to 99.4) endorsed testing therapeutic inoculation, without HAART, in patients with HIV disease; 86% (95% CI 81.4% to 90.7%) endorsed testing against placebo. Sixty-eight percent explicitly endorsed principles where the standard of care for subjects in clinical trials is determined by local, not universal, standards. There were no differences in responses based on respondent education-level or the income-level of their country of citizenship.

Conclusion : There was broad agreement that a therapy of potential local benefit may be tested, even when that therapy is known to be inferior to the standard of care in wealthy countries. Most agreed that a placebo control may be used in some circumstances.