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for
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See accompanying of genogram.
narrative description

issue.

= history of
professional
journal or
organization

or
= consulted
worked with

= team

section of this

Training, Scholarship
and Service

e n t s
t r e at m

in biographies

Neil Jacobson

Doug Sprenkle
Programs)
(COAMFTE

today as described

Internal Family
Systems, Illinois

Ken Hardy

Project

Multiculturalism
New York

Olga Silverstein

Nancy BoydFranklin

Multiculturalism
New Jersey

Integrative
Couples Therapy.
Washington

n i s t
r u c t i o
c o n s t
d
l i d at e
o d e r n
l ly va
p o s t m
p i r i c a
r e / e m
e d c a
m a n a g

r a l

Peggy Papp

American Family
Therapy Association
founded 1977

Susan Johnson

Peggy Penn

Collaborative
Questions,
New York

and
Journal of Marital
Family Therapy

Monica
McGoldrick

Multiculturalismal,
Intergeneration
New Jersey

Multifaceted
Collaboration,
Massachussets

Lynn Hoffman

and
Journal of Marital
Family Counseling

on Accreditation
Commission
and Family
for Marraige
Therapy Education

for Marriage
American Association
Therapy, 1978
and Family

-structu

d
Emotion-Focuse
Couples Therapy,
Canada

p o s t

i s t
r u c t i v
c o n s t

of Marriage
American Association
1970
Counselors,
and Family

MARRIAGE AND

2000

1990s

Richard Schwartz

1980s

1970s
t
r e a l i s

state to
California first
and
regulate marriage
family counselors
1963

i s t

(Jay Haley)

Theodore Lidz

John Bell

Christian Midelfort

Family
Psychoanalytic
Family Group Therapy. Connecticut
Therapy
Massachussetts

Association

herapy,
PsychoanalyticT
Wisconsin

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agy
Boszormenyi-N

Disordered
Communication, Maryland

-positiv

a l
l o g i c

n a l i s m

Therapy, Pennsylvania

/functio

Lyman Wynne

American
Counselors
of Marriage
founded 1945

1960s

1950s

t u r e
s t r u c

FOR

Immigration

1940s

T H E A M E R I C A N A S S O C I AT I O N

january|February 2008

LEGACIES
pO F

For

SEPTEMBER|OCTOBER 2008

Inside this issue: The Role of MFTs in the Custody Process

T H E

A M E R I C A N

A S S O C I AT I O N

F O R

M A R R I A G E

A N D

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the

impaired

figures in couples
influential
history
and family therapy
phd

Alternative
Therapies

T H E A M E R I C A N A S S O C I AT I O N

FA M I LY

in some form

Zealand

The Womens

Betty Carter

David Epston

New
Narrative , Australia,

Marianne
Walters

Michael White

ed,

Michelle
Weiner-Davis

Texas

Solution-Orient
Illinois

Insoo Kim Berg

Language Systems,

Fa m i ly

ed,

Collaborative

Harry Goolishian

Steve deShazer

d, Wisconsin
Solution-Focuse

marriage and

march | april 2010

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Reflecting Team,
Norway

For

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Nebraska

Guiliana Prata
Mara Selvini
Palazzoli

John Weakland

Tom Anderson

Luigi Boscolo

Experiential
California

Virginia Satir

Richard Fisch

(MRI),
Brief Strategic
California

Virginia Satir

Paul Watzlewick

Jay Haley

Gregory Bateson

Brief Therapy,
Arizona

Milton Erickson

Paul Sayre

Marriage Guidance
England

Council,

Sexual Compulsivity

Strategic,
DC
Washington,

Cloe Madones

Jay Haley

Multiculturalism
Pennsylvania

Harry Aponte

Italy

Strategic (Milan),

Gianfranco Cecchin

january | February 2010

Don Jackson

T h e a m e r i c a n a s s o c i aT i o n

Harlene Anderson

Therapy

Fa m i ly

Salvador Minuchin
Family
Process
Structural Family
founded Therapy, Pennsylvania
1961

James Framo

Experiential
Family Therapy,
Wisconsin

Family
Psychoanalytic York
Therapy, New

Nathan Ackerman

marriage and

Contextual Family

For

l,
Intergenerationa
Pennsylvania

Carl Whitaker

Murray Bowen

T h e a m e r i c a n a s s o c i aT i o n

National Council
on Family Relations

David Mace

May
June
2006

FamilyTherapy
T H E A M E R I C A N A S S O C I AT I O N

10 YEARS OF
Family Therapy Magazine

MFT Myths
dispelled by
clinical research
Eli A. Karam, PhD

research and the practice of marriage and family therapy

(MFT) have often been viewed as separate endeavors. Some practitioners contend
that experience is more valuable in the therapy room than anything that can be
derived from research or scientific inquiry. Research, however, not only validates
what we know is effective, but also can correct erroneous beliefs and clinical
assumptions. These incorrect therapeutic assumptions may be the product of a
selective understanding or misunderstanding of research findings. A powerful
way to emphasize the importance of staying informed about new research is to
demonstrate historically how it has helped to disconfirm previously held myths
about MFT. In rejecting these previously unsubstantiated beliefs based on folk
wisdom, empirical evidence has increased our professions stature and aided
research-informed clinicians to become more competent in both psychoeducating
clients and modifying their own therapeutic views (Karam & Sprenkle, 2010).

j a n u a r y

f e b r u a r y

2 0 12

27

Top 10 Highest Attended

Sessions at AAMFT Annual
Conferences
1997 L earning Edge: Live Supervision with Salvador
Minuchin
565 attendees
1997 H
 ealing After Infidelity Through the Therapeutic
Use of Forgiveness with Frederick DiBlasio
550 attendees
1995 T
 hree Strength-Based Therapies with Steven J.
Wolin, William M. OHanlon and Lynn Hoffman
501 attendees
2002 Inclusive Therapy: Dealing with Inner and Outer
Bigotry with William M. OHanlon
389 attendees
1996  Learning Edge Series with Karl M. Tomm
383 attendees
2006 T
 o Leave or to Stay: Working with Couples on
the Brink with William Doherty
377 attendees
1997 P
 assionate Marriage: Sex, Love, and Intimacy
in Emotionally Committed Relationships with
David Schnarch
358 attendees
1996 S
 hattered Vows: Healing the Trauma of Infidelity
with Shirley Glass and Tom Wright
349 attendees
2006 T
 raumatic Loss, Healing, and Resilience with
Froma Walsh
347 attendees
2001 P
 utting Marriage Back Into Marriage Therapy
with Michelle Weiner-Davis
323 attendees

28

f a m i l y

t h e r a p y

m a g a z i n e

Contending that what we do is both

a combination of art and science, the
following are 10 examples of how
research has reshaped traditional
clinical wisdom and informed the
practice of marriage and family
therapy.

10

Create emotional
enactments to treat
schizophrenic family members.

From the late 1940s to the

early 1970s, the concept of the
schizophrenogenic mother was
popular in the family therapy lexicon.
Although research later confirmed
that maternal communication could
not cause schizophrenia, such a
blaming, pathologizing concept
without a basis in scientific fact, may
have caused a great deal of harm
for families and the profession. In
fact, MFT techniques in working
with these types of families centered
on creating highly emotionally
charged enactments (Whitaker,
1958). Current, evidence-based
family psychoeducational models
(McFarlane, 2002) are diametrically
opposed to this position, creating
therapeutic strategies that seek to
reduce expressed emotion in the
family system in order to reduce
rehospitialization, symptoms, and
distress while improving family
members coping and functioning.

Only former addicts who use

high levels of confrontation
should treat substance abusing
clients in individual therapy.

Traditions harking back to the

intense, confessional 12 step groups
from the 1970s and 1980s have
held that partners be segregated,
that treatment be confrontational,
and that former addicts are the
best therapists. Behavioral Couples
Therapy (BCT), a partner-involved,
non-confrontational treatment
for substance abuse that teaches
skills to promote partner support
for abstinence and emphasizes

relationship skill building, has

been proven to be more effective
than individual therapy at shaping
abstinence skills and improving
couple relationships (Fals-Stewart et
al., 2000). This body of research has
also demonstrated that a personal
history of previous substance abuse
has no bearing on a therapists results.

Anger predicts relationship

satisfaction and success.

Many therapists used to believe that

the expression of anger undermines
relationships, therefore therapeutic
techniques should be designed to
block this intense emotion. The
research of John Gottman (1999),
however, challenged conventional
wisdom about what accounts for
relationship success and failure.
The amount of anger observed
in premarital interactions had no
predictive validity in the future
success of the marriage in his
longitudinal research, as happy
couples were as likely to express
anger in discussions as those who
decided to eventually divorce. The
extent to which couples reciprocated
anger in their interactions also did
not predict relationship success,
thus demonstrating that it is normal
for even happy couples to react
negatively when facing negativity.
Although anger does not correlate
with divorce, Gottman discovered
that contempt, defensiveness,
criticism, and stonewalling are
the most significant predictors of
relationship failure.

Couples therapy is considered

a failure if the marriage is
not saved because divorce always
results in negative outcomes
for children.

Even though approximately half

of all married couples divorce,
historically many MFTs would
consider the therapy unsuccessful
if they were unable to save a
relationship. Early research on
children of divorce had a negative
view of adjustment to post-divorce

life, citing depression, academic

difficulty, and other psychopathology
as frequent outcomes (Wallerstein,
1989). This research may have
inadvertently scared some parents
into remaining in destructive or
incompatible relationships because
of fear of the impact of divorce
on their children. As compared to
this research that was flawed, due
to lack of control group and other
threats to validity, the longitudinal
work of Mavis Hetherington (1990)
and Constance Ahrons (2007) is
more methodologically sound and
optimistic about children of divorce.
In fact, there is no specific evidence
that children who go through divorce
are any worse off than those who stay
in a family system with parents who
are openly conflictual and hostile
with one another. Now we know that
there is opportunity for meaningful
psychoeducation and therapeutic
work with divorcing and bi-nuclear
families, as MFTs can teach
ex-spouses how to work together in
the best interests of their children.
Although divorce involves a difficult
transition period for the entire family
system, many children whose parents
learn to co-parent effectively, go on
to do well and make the necessary
adjustments to have healthy adult
romantic relationships.

Partners with a history of

domestic violence should
never be seen conjointly.

Within the field of intimate partner

violence (IPV), there is a popular
belief about never treating couples
conjointly. Batterers and victims
are typically treated individually or
in gender segregated groups. While
intimate terrorists may never be
good candidates for any type of
therapy, partners who have endured
situational violence, on the other
hand, may be ideal candidates for
a couples intervention. Research
conducted by MFTs (Stith, Rosen,
& McCollum, 2003) demonstrates
that carefully conceptualized
couples treatment that is supportive

in nature appears to be at least as

effective as traditional treatment for
IPV. Couples therapy can provide a
controlled, regulated structure for
partners to discuss highly conflictual
and emotionally charged topics. As
relationship distress is a powerful
predictor of partner aggression
(OLeary, Heyman, & Neidig,
1999), improvements in a couples
functioning combined with the
acquisition of conflict resolution
skills may reduce the reoccurrence
of IPV.

Adding additional sessions will

equate to more therapeutic gains.

Women are from Venus and

men are from Mars.

If an initial round of therapy doesnt

spark a client to change, then adding
additional sessions must be necessary
to increase therapeutic gains, right?
Ken Howard developed the DosageResponse Model to respond to this
assumption by evaluating therapy as
related to its effectiveness at various
dosages (Kopta, Howard, Lowry, &
Beutler, 1994). Dosage in this model
is equated to number of sessions.
This research highlighted that most
clients experience significant change
early in treatment, with 50 percent of
clients showing clinically significant
improvement after 8 sessions. For
those who do not initially improve
with therapy, however, more and
more effort is required to achieve
results. Therefore, there is a law of
diminishing returns when adding
more sessions if a positive change
in the clients feeling state does not
occur in this early stage of therapy.
Sometimes a referral to a therapist
who may be a better fit for the client
may be a more prudent option than
the prospect of more therapy with
the current therapist. This research
demonstrates the importance of
monitoring outcome on an ongoing
basis to assess when our therapy is
not benefiting our clients.

Although this belief has dominated

pop culture for the past several
j a n u a r y

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29

decades, there is a dearth of research

evidence to support the claim that
the sexes are significantly different.
Research demonstrates that men and
women are more similar than they are
different in terms of communicating
in their committed relationships
(Canary & Emmers-Sommer, 1997).
Many of the purported differences in
the gender literature are related more
to flaws in the studies themselves,
such as errors in recollection in
self-report studies, or individuals
reports that are constrained by a
social desirability bias. Gottmans
(1999) research highlights that men
and women want remarkably similar
things in marriage, and that both
genders report that deep friendship
is the most vital component of an
enduring marriage. Lists of other
variables that actually predict marital

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f a m i l y

t h e r a p y

m a g a z i n e

satisfaction show that there are only

slight differences in how the men and
women rate what is really important
to them in an intimate relationship.

Successful couples therapies

should focus on problem
solving strategies.

In the 1970s and 80s, traditional

behavioral couples therapy
(TBCT) was lauded by clinicians
and researchers alike for both its
practical problem solving and
behavior exchange strategies, as well
as impressive outcome evidence
(Jacobson & Margolin, 1979).
Despite this considerable support
for TBCT in the literature, model
innovator and researcher Neil
Jacobson was interested in studying
the substantial numbers of couples
for whom TBCT did not seem a
benefit. Estimates indicated that
although TBCT was efficacious,
only about half of all couples who
participated in therapy experienced
clinically significant change, and
nearly one-third of these couples
experienced a pattern of relationship
deterioration over time (Jacobson,
Schmaling, & Holtzworth-Monroe,
1987). Using this research as a basis
to revise and improve the model,
Jacobson and Andrew Christensen
developed Integrative Behavioral
Couples Therapy (IBCT) to
address concerns about long-term
maintenance of gains and focus
on emotional acceptance and
tolerance techniques. Providing
further evidence that couples
therapy should expand beyond this
traditional narrow scope of teaching
problem solving skills, Gottman
(1999) estimated that 69 percent
of all problems couples encounter
are ultimately perpetual issues that
cant be solved. Ultimately, Gottman
concluded that its the quality of the
dialogue and the mutual validating
of each partners position, not
the solving of the problem itself,
which will predict the success of the
relationship.

My MFT model is superior

to yours.

Meta-analyses point to a large effect

size of around .8 for psychotherapy
as compared to no treatment at
all (Smith & Glass, 1977). While
there is no doubt MFT works,
meta-analyses show no differences
between bona fide treatments.
Shadish and colleagues (1995)
concluded: Despite some superficial
evidence apparently favoring
some orientations over others, no
orientation is yet demonstrably
superior to any other. This finding
parallels the psychotherapy literature
generally (p.348). So, while MFT
has demonstrated relative efficacy,
there is little evidence for differential
efficacy among different models.

Specific ingredients of models

are primarily responsible for
therapeutic change.

The Empirically Supported

Treatment (EST) movement,
analogous with the medical model,
contends that specific ingredients
in therapy models are responsible
for change. By overlying a single
methodology, the randomized
clinical trial (RCT), researchers
may oversimplify the complexity
of psychotherapy by excluding
important client (i.e., hope and
motivation level), therapist, and
alliance variables that are integral
to outcome. Common Factors
proponents use empirical evidence
to argue that these key non-specific
components in treatment outcome
have far more to do with therapeutic
success than with any specific
therapeutic technique or model,
no matter how clearly articulated
or manualized (Sprenkle, Davis &
Lebow, 2009). In fact, the work of
Michael Lambert (2001) suggests
that specific ingredients from
models may only account for around
15 percent of the improvements
clients make in therapy. In
another groundbreaking metaanalysis research, Bruce Wampold

(2001) presents strong evidence

that differences among therapists
contribute more to outcome variance
than the treatments they practice.
Although this will continue to
be a highly debated issue within
our profession for the foreseeable
future, Wampold argues the
evidence convincingly corroborates
a contextual model for therapy and
disconfirms the prevailing, specific
ingredient-centered medical model. n
Eli A. Karam,
PhD, LMFT, is
assistant professor
at the University
of Louisville,
Kent School of
Social WorkFamily Therapy Program,
and president elect of the Kentucky
Association for Marriage and Family
Therapy (KAMFT). Karam is an
AAMFT Clinical Fellow and Approved
Supervisor.
References
Ahrons, C. (2007). Family ties after divorce:
Long-term implications for children. Family
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(2009). Common factors in couple and family
therapy: The overlooked foundation for
effective practice. New York: Guilford Press.
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(2003). Effectiveness of couples treatment
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Whitaker, C. A. (1958). Psychotherapy of

chronic schizophrenic patients. Oxford, UK:
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