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Journal of Marital and Family Therapy

doi: 10.1111/j.1752-0606.2011.00271.x
January 2012, Vol. 38, No. 1, 329

INTERVENTION RESEARCH IN COUPLE AND FAMILY


THERAPY: A METHODOLOGICAL AND SUBSTANTIVE
REVIEW AND AN INTRODUCTION TO THE SPECIAL
ISSUE
Douglas H. Sprenkle
Purdue University

This article serves as an introduction to this third version of research reviews of couple and
family therapy (CFT) that have appeared in this journal beginning in 1995. It also presents
a methodological and substantive overview of research in couple and family therapy from
about 2001 2002 to 2010 2011 (the period covered in this issue), while also making connections with previous research. The article introduces quantitative research reviews of family-based intervention research that appear in this issue on 10 substantive areas including
conduct disorder delinquency, drug abuse, childhood and adolescent disorders (not including the aforementioned), family psycho-education for major mental illness, alcoholism, couple distress, relationship education, aective disorders, interpersonal violence, and chronic
illness. The paper also introduces the rst qualitative research paper in this series, as well
as a paper that highlights current methodologies in meta-analysis. The rst part of this article rates the 10 content areas on 12 dimensions of methodological strength for quantitative
research and makes generalizations about the state of quantitative methodology in CFT.
The latter part of the papers summarizes and makes comments on the substantive ndings
in the 12 papers in this issue, as well as on the eld as a whole.
This issue is the third of three research reviews of couple and family therapy (CFT) that
have appeared in JMFT, spanning about 17 years. I have had the good fortune of being associated with all three of the reviews. I was Editor of the Journal when we published the rst in
1995 (which covered CFT research through about 1993 1994), guest edited by Pinsof & Wynne
(1995). I was the guest editor of the second review that rst appeared in book form in 2002
(Sprenkle, 2002a), but was also serialized, three articles at a time, in this Journal throughout
2003. For this reason, sometimes authors cite articles from the second review as either 2002
or 2003 depending upon whether they are referring to the book or the journal versions. I will
use 2002 to refer to the second review. Nonetheless, the articles were identical in both formats. Karen Wampler was Editor of JMFT at the time of the second volume, which covered
research from about 1993 1994 to 2000 2001. I also am guest editing this volume and have
worked with Editor Ron Chenail throughout the process from start to nish. It covers CFT
research from about 2001 2002 to 2010 2011.
The changes from the rst to the second versions were evolutionary, not revolutionary,
and the same trend characterizes the differences between the second and the current special
issue. Relationship enhancement (called relationship education in the current version) was
added to the quantitative substantive areas in issue two, as was couple violence (called interpersonal violence or IPV in the current version). There were no new quantitative substantive areas
added in this third special issue. Authors wrote review papers on 10 quantitative substantive
areas: conduct disorder delinquency, adolescent and adult drug abuse, childhood and adolescent disorders (not including conduct disorders drug abuse), family psycho-education (FPE) for
major mental illness, alcoholism, couple distress, relationship education, affective disorders,
IPV, and chronic illness. There were also two additional papers described later.
Douglas H. Sprenkle, PhD, Department of Human Development and Family Studies, Purdue University.
Correspondence concerning this article should be addressed to Douglas H. Sprenkle, Department of Human
Development and Family Studies, Fowler House, 1200 W. State Street, Purdue University, West Lafayette, IN
47907. E-mail: sprenkled@purdue.edu

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We made three important changes in this third edition. First, we included the rst
qualitative paper among the three special issues: Clients Relational Conceptions of Conjoint
Couple and Family Therapy Quality: A Grounded Formal Theory (Chenail et al., 2012, this
issue). Although the major emphasis of these research reviews is likely to remain quantitative, I
have long believed that qualitative and quantitative paradigms are complementary (Moon,
Dillon, & Sprenkle, 1990) and that qualitative analysis can add richness and depth and is
especially valuable for reporting on the subjective experiences of clients in therapy, the focus of
Chenail et al.s paper. Recent quantitative empirical analysis (Anker, Duncan, & Sparks, 2009)
oers compelling evidence for the role of client feedback in enhancing couple therapists performance, and I believe there is a strong rationale for the synergy of the two paradigms in both
advancing knowledge and improving practice.
Second, each chapter concludes with a several-page mini-paper called A Clinician
Responds. Sometimes, these clinician responses were written by the papers authors, if they
were active clinicians and chose to write the response themselves; in other instances, responses
were authored by invited clinician authors. In either case, these papers are interesting reections
on the clinical implications of the research described for practicing professionals in the trenches.
Non-researchers may nd it protable to read these responses before tackling the research
reviews themselves. In any event, our intension was to make an overt attempt to bridge the
often noted chasm (Karam & Sprenkle, 2010; Sprenkle, 2002b) between research and practice.
Third, the chapter on meta-analysis in the current volume is not (as was the case in the
previous two volumes) a general meta-analysis of the CFT literature, but rather a paper that
focuses on current methodological advances in meta-analysis as applied to several specic content areasThe Effects of Family Therapies for Adolescent Delinquency and Substance
Abuse: A Meta-analysis (Baldwin et al., 2012, this issue). Because of its cutting-edge analysis,
it is an important methodological piece for people interested in meta-analysis that goes beyond
the content area analyzed.
Fourth, another evolutionary development in the current special issue is that persons
trained primarily in marriage and family therapy were the lead authors on four of the papers,
including this one. There were no CFT lead authors in the rst edition, and three in the second.
Elsewhere, I have noted (Sprenkle, 2002b) that most of the leading research papers in CFT
have been written by psychologists and psychiatrists and not by those primarily trained in
CFT. Therefore, having four of the papers rst authored by CFTs is an evolutionary change in
the direction of no longer farming out the best CFT research to scholars from the senior disciplines. Clearly, however, scholars primarily trained in CFT still have a way to go before
assuming even a majority of the authorships.

METHODOLOGICAL REVIEW OF QUANTITATIVE RESEARCH IN TEN AREAS


This section focuses on the quantitative methodology reported in the 10 substantive areas.
In these special issues, the authors of the papers have placed a major focus on randomized clinical trials (RCTs) because this methodology allows reasonable inferences to be made about the
efcacy of interventions in these areas.
I am well aware that no research methodology is perfect. In fact, although I greatly respect
RCTs, I have written elsewhere (Sprenkle, 2002b) regarding their limitations. Among other
things, there is no guarantee that the most wonderfully crafted RCT will have strong external
validity nor necessarily make any impact on the real world of clinical practicean issue to
which we will return under the topic of transportability later. Nonetheless, the fact remains
that RCTs are likely to remain the gold standard for intervention methodology research for
the foreseeable future. Frankly, if CFTs want to have their discipline taken seriously by the
external world (including other disciplines, governments, insurance companies, and other thirdparty payers), they will have to continue producing high-quality RCTs.
The good news is that RCTs have the potential to be externally valid, can include qualitative components to add richness and relevance, and can be used to study even alternate ways
of looking at what brings about change in therapy, like common factors. Many of the problems with RCTs are not inherent in the paradigm itself but rather how they are used and
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misinterpretedoften over-interpreted to make claims that are too far reaching (Sprenkle,
Davis, & Lebow, 2009). As will be made clear in this article, most of the RCTs in this volume
were performed by the developers of the intervention models, who are highly invested in the
models they have created. Because of these allegiance issues, and the lack of testing of the
models in most cases by those not professionally related to the developers, and the relatively
few instances in which models are tested in real-life community settings that approximate actual
practice, it is prudent to be cautious regarding whether these approaches would be as eective
with typical therapists in real-world settings. It is also easy to over-interpret results, especially
to jump to faulty conclusion regarding the reasons for which interventions produce signicant
results (why do they work?)an issue to which we will return below.
In the rst of the three research reviews, Pinsof and Wynne (1995) highlighted the distinction between ecacy and eectiveness research. Ecacy refers to the eects of interventions
that are studied in controlled clinical trials under specied conditions, usually in a university or
hospital or university or researcher-controlled clinic setting. Eectiveness refers the impact of
real world, in-the-eld clinic therapy, more like the normal circumstances under with
most interventions are provided. Pinsof and Wynn note that Most of the research provided in
this selective overview pertains to ecacy (1995, p. 586). Unfortunately, the same can still be
said of most of the research in this current special issue, even though there is more eectiveness
research today than in 1995. While we somewhat loosely call research of the type described in
this issue eectiveness research, technically most of it remains ecacy research. A much
more challenging test of an approach is whether clinicians other than the developers or their
students can use the model advantageously in less controlled real-world conditions.
With these important caveats, I ask the reader to turn his or her attention to Table 1 that
shows ratings of the research in the 10 quantitative substantive areas by 12 dimensions of methodological strengtha + was given when the dimension was a strength of the area, and a
) was assigned when it was a growth area. One point was given for each strength, and therefore, a research area could have a maximum of 12 points. The ratings were based mostly on
the reports of the authors of this special issue who were asked to comment on the methodological strengths and limitations in their area. They are among the worlds leading experts on these
bodies of research that therefore I believe their ratings are trustworthy. In those instances
where they did not comment on a specic dimension, I made the rating myself based on my
extensive knowledge of this literature from serving as an editor of the three CFT research
reviews. In the one instance where I disagreed with an author, I noted this in a footnote in the
table. While I make no claim that the areas rated within a point or two of each other are meaningfully dierent, I believe that most knowledgeable scholars, if they had the time to study
these bodies of research in their entirely, would place the content areas in the same total gross
methodological quality groupings even if there might be some disagreement on specic ratings.1
For several dimensions, it is probably more accurate to say the strengths were relative
strengths in comparison with the research being carried out in the other content areas. First,
none of the content area had many examples of replications by researchers who were not professionally related to the developers of the intervention (independent studies in Table 1).
Second, nor did many of the areas have large numbers of eectiveness studies whereby interventions were successfully transported to real-world clinical settings (even though some areas
were relatively speaking stronger than the others). The same concern can be voiced about cost
studies and mechanisms of change. For these low incident strengths no methodological
dimension was considered a (relative) strength unless there were a minimum of two published
papers that demonstrated the strength, at least one of which had to be written by a dierent
investigator or research team. I considered putting use of non-Euro-American samples in the
same subgrouping of dimensions, but some of the content areas were strong on this dimension
in an absolute sense, like adolescent substance abuse.
General Results by Substantive Areas
I gave all of the content areas one point for having a sufcient number of manualized
RCTs (methodological strength dimension one) and believe it is likely that most external
(non-CFT) audiences would conclude there is reasonable evidence for the efcacy of some
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)
)

+
)

)
+

)
)

+
+

+
+

10

+
+
)

+
+
+

+
+
+

+
+
+

+
+
+

+
+
+

10

+
+

+
+3

+
+
+

+
+
+

)
)

+
+

+
+
+

+
+
+

)
)
6

+
+

)
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+
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)

)
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+
)
+

+
+
+

+
+
+

)
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)
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+
+
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+
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+

)
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)
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)
+
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+
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+

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)
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+
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+
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2

)
)

)
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+
+
)

+
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+
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+
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+

4
3

3
5

10
9
6

12
11
11

Should be considered a relative strength as none of the research areas had many examples. A minimal standard was set of at least two randomized
clinical trials (RCTs) by two independent investigators or investigator teams. 2A strength in the adolescent drug treatment literature but not the adult
literature. 3The paper authors listed this as a weakness, but I think there are a number of examples where non-reactive dependent variables were used in
the child and adolescent (other) literature like weight gain, hospitalizations, relapses, and so forth.

Conduct disorders
Drug abuse
Psycho-education
for major mental
illness
Couple distress
Alcoholism
Relationship
education
Depression
Childhood and
adolescent
disorders (other)
Chronic illness
Interpersonal
violence
Totals

Non
FollowEuroNon-Reactive
Numbers Programmatic
Treatment American Co-Morbid ups > Cost
Research
Behavioral Dependent
of
Mechanisms Independent Transport to
1 year Studies1 of Change1 Studies1
Samples Samples
Fidelity
> 10 yrs.
Measures Variable
RCTs
Real World1 Totals

Table 1
Methodological Strengths by Substantive Research Areas

intervention models approaches in each of the 10 areas. This is no small accomplishment


because manualized RCTs are difcult to do and each area has many of them. In terms of
methodological strengths, the substantive content areas with the highest overall ratings among
the 10 areas included conduct disorder delinquency (12)the only content area with no negative ratings, drug abuse (11), FPE for major mental illness (11), couple distress (10), and
alcoholism (9). Although I did not do these ratings in the second research review, I would
have rated all of these just mentioned areas, except couple distress, as the strongest areas
methodologically in the 2002 issue. Couple distress moved up to the rst tier in strength ratings in this issue in large measure because of the excellent research published mostly since
2001 by Christensen, Atkins, Baucom, & Yi (2010) on integrative behavioral couples therapy
(IBCT), as well as the ongoing program of research on emotion-focused therapy (EFT;
Johnson & Zuccarini, 2010). Unfortunately, however, as will be noted later in the substantive
review, a number of couple therapy models have no research support, so the research record
regarding couple therapy is based on a small minority of the couple therapy models actually
practiced in the world.
I rated relationship education in an intermediate tier (six points). As I will note later, relationship education is also a bifurcated area in that there were both very strong research by
scholars like Howard Markman Scott Stanley and colleagues at the University of Denver on
PREP and related programs (Markman & Rhodes, 2012, this issue), by W. Kim Halford of
Grifth University in Australia on Couple Care (Halford, 2010); while at the same time, there
were a multitude of relationship education programs with no research record whatsoever, or
weak research.
I consider the areas of depression, IPV, childhood and adolescent disorders (not including conduct disorders and drug abuse), and chronic illness to be (taken as a whole) developing areas of research with more limitations than strengths. I use the phrase taken as a
whole intentionally, because there were strong researchers and individual studies within
each area. Furthermore, all of these areas made some methodological progress since the previous reviews.
Science Is a Team Sport and the Game is played out in Decades and Careers
It was striking, but not surprising to me, that the content areas with the highest methodological ratings were also research areas dominated by teams of researchers that have worked
together on their intervention programs more than a decade (methodological criteria two). In
fact, I set the standard for programmatic team research higha decade together was the
minimum. I think that it is important to recognize that family social science addresses problems
that are so complex that it is rare for individuals to make substantial progress alone. Strong
research is also typically an accretive process whereby one study builds on previous works. For
example, in the highest rated area, conduct disorder delinquency was dominated by research
teams related to multisystemic therapy (MST), functional family therapy (FFT), multidimensional treatment foster care (MTFC), and brief strategic therapy (BSFT), all of which represented teams together longer than a decade. In fact, FFT efcacy RCTs dated back over three
decades, and MST trials began over a quarter century ago (Henggeler and Sheidow, 2012, this
issue).
It is also notable that four of the ve top areas (couple distress being the exception) tended
to be dominated by teams afliated with medical schools. Most of these teams were comprised
of full-time researchers who live from grant to grant and who in many instances have
devoted signicant portions of their careers to these lines of research. (Prominent examples
would include Scott Henggeler with MST (Henggeler & Sheidow, 2012, this issue) and Howard
Liddle with multidimensional family therapy, (MDFT; Liddle, Dakof, Turner, Henderson, &
Greenbaum, 2008). Although there are some exceptions (for example, Howard Markman and
Scott Stanley, PREP [Markman & Rhodes, 2012, this issue] and Andrew Christiansen at UCLA
[IBCT, Christensen et al., 2010]), it was relatively rare for academicians who also have major
teaching, advisory, and supervisory responsibilities to be as productive or produce research of
such consistently high quality. The time involved in pursuing high-quality programmatic
research cannot be underestimated. Certainly, good work can be carried out in other contexts,
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and non-programmatic research can also be valuable, but it appeared to be hard to keep up
with the full-time researchers in medical-related contexts when it came to high outputstrong
methodology research. The exceptions have built strong teams.
Continuing the theme of teams, it was also interesting that the approach in the middle of
the methodological pack, relationship education, was very strong when teams worked together
for a decade or longer (most notably Markman Stanley and colleagues on PREP and Kim
Halford and colleagues on Couple Care) and relatively weak when long-term teams were absent
or no longer active. The four areas considered developing methodologically had fewer
examples of long-term teams when compared with the content areas rated higher.
Other Areas of Strengths and Weaknesses
The third dimension of methodological strength in Table 1 was whether or not investigators used behavioral as well as self-report dependent variables. That is, did the investigators
code behavioral outcome measures like communication or problem-solving as opposed to
simply using self-report measures like indices of relationship satisfaction. This is potentially
important because self-report and behavioral measures are not necessarily strongly correlated
and self-report measures are more vulnerable to distortions like social desirability. As Table 1
showed, six of the research areas frequently used behavioral measures, and those tended to be
the programs with the highest overall ratings.
The fourth dimension was whether investigators used non-reactive dependent variables.
This refers to variables that cannot easily be faked or distorted and whose meaning is typically
obvious and non-controversial. Examples include outcomes like divorce, hospitalization,
incarceration, failed drug test, and so forth. I was pleased to nd sufcient examples of
non-reactive dependent variables in each of the content areas, so this was a strength in couple
and family therapy research generally.
The fth dimension was whether researchers gave sufcient attention to treatment delity
and its impact on outcome. For example, investigators in the area of conduct disorder delinquency offered strong evidence that the effectiveness of programs like MST and functional family therapy (FFT) was diminished considerably when treatment delity was lacking (Henggerler
and Sheidow, 2012, this issue). Also, emphasizing treatment delity provided evidence that
interventionists were doing what the programs said they were doing and offered evidence for
therapist consistency. This was a strength in eight areas. This general strength may have been
because of the fact that there is now federal-funded research in most of these areas and it
requires attention to treatment delity.
The sixth dimension was whether minority (non-Euro American) samples were widely
included in the research. This was a particular strength in the area of adolescent drug abuse
research (and to a lesser extent in adult drug abuse), and it was also a relative strength for conduct disorder, and FPE for major mental illness (which produced a great deal of international
research [Lucksted et al., 2012, this issue]), relationship education, and childhood adolescent
disorders (not including conduct disorders or drug abuse). For the other half of the areas, this
dimension was a weakness. As a whole, researchers have performed a good job of including
more women than previously and have made signicant but uneven improvement across areas
regarding ethnic racial diversity, but there were only isolated examples throughout the literature of studies that included samples of minorities like gays and lesbians.
The seventh dimension was a rating of whether researchers frequently used samples that
were comorbid. A criticism of RCTs is that to specify populations about which one is trying to
make conclusions (a strength at one level of analysis), say couples who are highly distressed on
a measure of marital adjustment, subjects are eliminated who have other diagnoses, like major
depressive disorder. However, such comorbid subjects are very prevalent in typical treatment
samples. Presumably, if intervention programs are effective with comorbid subjects, they are
more robust and more transportable to real-life clinical settings. Again, slightly more than half
the areas (conduct disorders delinquency, drug abuse, psycho-education for major mental illness, couple distress, IPV, and chronic illness) showed strength regarding comorbid subjects.
Here, a few of the developing areas were rated positively. There were a number of studies of
IPV, for example, where the subjects were also substance abusers. There were also many studies
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in the area of chronic illness where subjects had diagnoses for mental disorders like major
depression (Shields et al., 2012, this issue).
The eighth dimension was whether the body of literature included multiple studies with follow-ups of more than one year. This standard was set fairly high because there is considerable
attenuation of impact of CFT interventions over time. For example, Christensen et al. (2010),
whose excellent long-term research showed that IBCT produced results superior to traditional
behavioral couples therapy (TBCT) at 2 years, discovered that dierences washed out at a
5-year follow-up. On this criterion, ve areas showed strength, and once again, they were the
highest rated methods.
The ninth dimension was whether cost-benet or cost-effectiveness studies were completed.
This is potentially a crucial line of research for CFT because some relational interventions have
expensive up-front costs, for example, MST (Henggeler and Sheidow, 2012, this issue). This
fairly expensive program has been widely adopted, I am certain, because it has proved to save
money on even more expensive alternatives like incarceration. Only four (and all top rated
areas) provided evidence of cost research. Sadly, in the rst JMFT review, Pinsof and Wynn
called for more attention to this kind of research (1995, p. 609), and I must repeat that call
now. It is hard to over-emphasize the value of cost research for CFT in a cost conscious
culture.
The tenth dimension rated whether investigators studied the mechanisms of change behind
their intervention models. The specic components of interventions are based at least on theory
or basic science research about the phenomenon being studied. Better yet, research should eventually conrm the added value of each component. Ironically, however, although models as a
whole have been empirically validated, it was relatively rare to nd empirical evidence regarding
what were the active ingredients versus inert llers in the treatment models. This is an extremely
important issue because without such evidence, the reasons the model developers believe are
responsible for therapeutic change could be mistaken. Perhaps, the success of models is less
because of unique specic mechanisms of change and more because of common factors that
are shared with other successful models (Sprenkle et al., 2009).
Ideally, all empirically validated models would have research not only on the mechanism
(mediators) of change but also on the conditions circumstances under which these models work
well or not (moderators of change). Only three of the areas offered sufcient research on mediators to rate that dimension as a relative strength. Research on moderators was so infrequent
that I did not even code it, although there were some examples in the literature like Johnson
and Talitman (1997), which delineated some of the circumstances under which EFT was more
and less likely to be successful.
The eleventh dimension was whether there were independent studies of the interventions in
the area by investigators who were not the model developers or their students or other professional relatives of the developers. As noted previously, a positive rating on this dimension
(only four areas in Table 1) is only a relative strength because there are not many examples
in any research area. This is a signicant issue because there is empirical evidence that the
allegiance of researchers is fairly strongly associated with outcome (Wampold, 2001). Not
surprisingly, the developers of models are highly invested in their approaches and are rewarded
professionally if their models do well. So, even though researchers are only very rarely intentionally deceptive, certain biases may crepe into research about models favored by the investigators. Biases include using alternatives (control groups) to the experimental treatment that are
less well organized, which have less invested therapists or have other characteristics which suggest they are less valued by the researchers.
If You Build It, They May Not Come
The twelfth and nal dimension deserves special attention. It concerns whether the
intervention models in the content area have been transported to the real world of clinical
practice. Although six of the areas (all top rated areas overall) met a minimum criteria of two
real-world (at least located) studies from a minimum of two research groups, the areas
receiving strength ratings are only strong relative to the other content area. As noted
previously, the vast majority of the research in CFT remains efcacy research.
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In the absence of extensive, truly real-world transported research, it is by no means clear


whether even the most impressive programs, whose research support appears in the leading
journals, (a) will work as well in practice settings, and or (b) will be considered practical feasible enough by clinicians or clinical organizations to implement them, and or (c) will be considered interesting or engaging enough by clinicians so that they will use the models if they are
not receiving funding or forced by external incentives to do so. As I reviewed the literature,
a number of empirically supported treatments seemed to be gathering dust on researchers
shelves rather than having much impact on common practice. Even if you build a very effective
program, clinicians may not come ocking to it. Even authors of some content areas that
did include enough minimal evidence of transportability to get a strength rating, for example,
alcoholism (OFarrell & Clements, 2012, this issue) and FPE for major mental illness (Lucksted
et al., 2012, this issue), noted that only a small percentage of providers in their content areas
use their empirically validated programs.
I also thought it was not clear what constitutes transported research. First, is successful
transportation based on doing research simply located in a community clinical setting (as
opposed to, say, a university clinic), or whether the program will be used in the community setting after the special funding or unique perks for the research are gone? By the former denition (which I used for the ratings), there is a lot more transported research than by the latter
criterion.
Second, is successful transportation based on the effectiveness of the intervention with
intentionally limited experimental controls to approximate real life, or is successful transportation bringing the same kind of research control found in efcacy studies to community
research settings? The following quote from the Henggeler and Sheidows (2012, this issue)
paper seems to suggest the latter understanding from a group that is proud of its record of
transport.
Moreover, as detailed by Fixsen, Naoom, Blase, Friedman, and Wallace (2005), the
eective transport (i.e. transport that achieves client outcomes similar to those
obtained in clinical trials) of evidence-based treatments to real world settings faces
many substantive barriers. For example, on the treatment intervention side, all aspects
of the intervention (treatment, supervision, administration) must be well specied,
eective training materials and resources must be developed, a cadre of training
experts must be organized and funded, and a quality assurance system must be validated (showing that the training actually promotes delity of treatment implementation). On the provider side, compatible therapists (e.g. bright hard working clinicians
who are comfortable with families and are amenable to intensive training and oversight of their work), supervisors, and administrative support must be hired; sta must
commit to extensive training and ongoing quality assurance; and the administrative
structures must often be modied (e.g. facilitating the use of cars for home based services, cell phones, comp time, and school visits). At the community level, a steady ow
of appropriate referrals (i.e. clients similar to those served in the successful clinical trials), sucient funding (e.g. some aspects of most evidence-based family therapies do
not t with extant funding structures), and stakeholder support and political will (e.g.
judges, school ocials, mental health, juvenile justice, and social welfare authorities
are essential to program success. These are only a subset of the many chal-lenges of
transporting evidence based programs to community settings.
Nevertheless, likely due to their ability to attenuate very challenging and costly clinical
problems, the evidence supported family-based treatments discussed subsequently are
among the most widely transported evidence-based treatments in the eld. As noted
subsequently, the development and use of purveyor organizations has been critical to the
success these treatment models have achieved in overcoming barriers their large scale
transport (italics added), p.
It is clear from this quote that for these authors, successful transport means bringing
experimental-like controls to a real-world setting. However, others might argue that these

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controls would introduce enough special elements into the real-world setting to make the
research less real world. That is, if these kinds of controls are necessary, have the investigators really demonstrated that the intervention can work in typical settings? I have no answer to
this question, but believe the eld needs to wrestle with it.
This quote raises several other issues related to transportation research. One is the dicey
question of the extent to which investigators should form, as advocated in this quote, purveyor organizations (which are typically for prot groups that include founding researchers)
to train, supervise, and monitor the intervention research. For more on the controversy regarding purveyor organizations, I will refer the reader to the comments by Roy Bean in his Clinician Responds paper (Bean, 2012, this issue) that follows the meta-analysis paper (Baldwin
et al., 2012, this issue). Sufce it to say here, the advocates of purveyor organizations, like
those just quoted, argue these organizations make transportation research possible. Detractors,
among other things, question whether research groups that received public funding to develop
programs should be allowed to restrict access to them, especially for prot.
Another issue raised by this quote is the many challenging barriers to transporting CFT
models to community settings. These authors argue that transport is especially challenging
when investigators are testing complex ecological models that include home, school, and community interventions.
The quote also drives home the fact that transportation research is often a political process where learning to work with judges, school, and welfare ofcials is probably equal if not
more important than what one learned in graduate school about research methods. The authors
of the FPE for major mental illness article (Lucksted et al., this issue), for example, also talked
about how transportation research in their area was successful in some states but not in others
depending on the extent to which researchers obtained buy-in from key leadersa political
process.
Finally, the quote raises issues about the training of CFTs and the degree to which the process must be restricted by the research enterprise or can remain open to most interested
professionals including private practitioners and graduate students. The models with research
programs that have developed purveyor organizations tend to restrict any formal training in
these models. Typically, only individuals who are employees of agencies that have contracts
with the purveyor organizations can get training, supervision, and follow-up. Contrast this with
an approach like EFT which uses an open model. Its developers have (a) made training manuals, workbooks, and other training materials very accessible, (b) offer frequent geographically
dispersed workshops that most clinicians can qualify to attend, and (c) provide an online support community and many opportunities for continuing education. EFT also has an admirable
record of transported research in real-world settings. So, it is by no means clear that successful transport necessarily requires a restricted model of training.
I am certain that advocates of ecological models that tackle pressing social problems like
conduct disorder and adolescent substance abuse would argue that these approaches are not
designed for private practice and require specialized training that must be more controlled
and limited. Nonetheless, it seems somewhat ironic, even if necessary, that transportation of
a model depends on limiting access to those who might want to learn it and that students
cannot readily learn some of our most impressive empirically validated approaches. My purpose here is not to solve these dilemmas, but make them more explicit for future conversations.
Summary
This section of the paper has focused on the methodological strengths and limitations of
the quantitative research in 10 content areas of CFT. Overall, the strongest areas methodologically were conduct disorders delinquency, drug abuse, psycho-education for major mental illness, couple distress, and alcoholism. In my judgment, the methodology of the research in these
areas contains many examples that are as strong as the research in any of intervention sciences.
The developing areas were chronic illness, childhood adolescent disorders (not including conduct disorders delinquency and drug abuse), IPV, and depression. Relationship education was
in the middle of the pack.
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Looking at the eld of quantitative research on CFT as a whole, it is strong in that each
of the areas contains a large number of manualized RCTs and non-reactive dependent variables
are used in all areas. There is a fairly strong emphasis on treatment delity, and seven of the
10 areas include research teams that have worked together a decade or longer.
On the other hand, there is a great need for more cost research, for more replications by
research groups not professionally related to the founders of the models, for more research on
the mechanisms of change, and for more investigations that approximate real-world clinical
practice to enhance ecological validity. Although there have been signicant improvements on
the use of more diverse samples, researchers in most areas have a long way to go here also.

SUBSTANTIVE OVERVIEW OF THE STATE OF KNOWLEDGE OF TWELVE


AREAS IN CFT RESEARCH
In this section of the paper, I will give an overview of each of the 12 papers in this issue,
highlighting key developments in substantive ndings especially since the previous special issue
(Sprenkle, 2002a). While methodology will be emphasized less than that in the previous section,
methodological comments will be made primarily about specic programs within the areas.
Conduct Disorder Delinquency
Henggeler and Sheidow (2012, this issue) demonstrate the great advantages that accrue
when a team develops an intervention and then employs an accretive program of research to
test and rene the model over decades. Henggeler and his team began efcacy trials of MST in
1986 (over a quarter of a century ago). By the time of the current paper, there were an impressive 18 randomized trials of this model and several long-term follow-ups including two of nine
and 14 years. Furthermore, real-world effectiveness trials began in 1992, and now there are
independent replications of the program in two countries in Scandinavia as well as in the
United States. Perhaps most impressively, MST reaches about 17,000 youth and families each
yeara strong indication of the impact that MST is having on society. Data presented here
showed that the program had an impressive record of reducing re-arrests and incarcerations
among conduct disordered youth and recidivism among young sex offenders.
The extent to which local agencies adopt MST is all the more impressive given that there
are many up-front costs associated with utilizing the program. The training is relatively expensive. Most agencies employ 24 masters-level MST therapists and a half time doctoral-level or
advanced masters-level supervisor. Each therapist has a small caseload of 46 families, and oncall services are made available 24 7. Treatments typically last 35 months. MST is a model
that uses structural, strategic, social learning, and cognitive behavior principles to intervene not
only at the family level but also at the levels of peer community interaction and the schools.
Why are agencies and the funding organizations willing to support such a labor-intensive
and expensive program? A major reason is that Henggeler and associates did research to show
that MST was cost-effective and that it actually saved money when compared with the costs
associated with arrests, incarcerations, residential treatment centers, and other ways of dealing
with delinquency (Aos, Phipps, Barnoski, & Lieb, 2001).
Several of the programs described in this article (including functional family therapy, FFT,
and multidimensional treatment foster care [MTFC], as well as MST) were among the few in
this volume that have completed formal cost-effectiveness research (Aos et al., 2001). In addition to cost-eectiveness research, MST research showed the rare combination of methodological virtues including seeking out dicult clients including comorbid subjects, using diverse
samples, employing non-reactive independent variables, researching the mechanisms of change,
replicating the model with independent investigators, and oering a relatively strong record of
transporting research to real-world clinical settings.
Functional family therapy (Sexton & Turner, 2010) is another program designed to combat
antisocial behavior that focuses more on in-the-room family therapy that lasts an average of 12
sessions over three to 4 months. The methodology in the research on FFT was also strong,
although there was no compelling evidence for real-world eectiveness research by independent
researchers and there was less research with diverse samples than with MST. Nonetheless, FFT
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has the advantage of smaller up-front costs, and therapists carry larger caseloads of 1215. Like
MST, FFT is having a large impact with 270 programs around the world and with 12,000
youths and their families treated annually.
Multidimensional treatment foster care (Chamberlain, Saldana, Brown, & Leve, 2010)
oers a program of foster care as an alternative to incarceration or placements in treatments
centers. Foster placements typically last six to nine months, although family therapy, individual
therapy, and skills training sometimes continue for three months after reunication. The program exists at 50 sites with teams that have caseloads of no more than 10 youths. Interventions
are oered in the foster home, the family home, the school, and the community. Again, the
research methodology for this approach, which included two published RCT and two quasiexperimental designs, was good. However, because there were many fewer investigations, studies by independent researchers and transportability studies are still ongoing, and because the
published studies have been mostly with Caucasians, the methodology was not as strong as for
MST.
The last program described in this article was BSFT (Szapocznik, Hervis, & Schwartz,
2003), which the authors considered a promising model. Developed in the 70s in Miami to deal
with the issues of Hispanic youth, it is perhaps better known for its work with drug abuse and
is covered in that article in this special issue as well. It oers weekly family therapy sessions in
the clinic or the home, and treatment typically lasts about 4 months with 1216 sessions most
typical. There were two RCTs with conduct disorders, with current evidence for its short-term
eectiveness. A multi-site independent evaluation is now in progress. The program was clearly
making an impact as it existed at 100 sites and treated 2500 families.
Drug Abuse
Rowe (2012, this issue) presents a generally optimistic overview of the progress on the family treatment of drug abuse. Regarding adolescent drug abuse, about 17 years ago, in the rst
JMFT review, Liddle and Dakof (1995) called family treatment promising but not denitive.
By the second JMFT review, Rowe and Liddle (2002) could state more denitively that the
family approach to adolescent drug abuse was the most eective approach. The research
reviewed for the current volume supports the superiority of family intervention, probably
because there is now good evidence for a reciprocal interaction between family dynamics and
drug use. Furthermore, the adolescent approaches that take an ecological approach (and seek
to impact the individual, family, peers, and school) generally seem to obtain the best results.
In this paper, Rowe documents that in several recent clinical trials, MDFT obtained better
results than individual CBT and group CBT for minority adolescent substance abusers at 12month follow-ups (Liddle et al., 2008). MST, which is best known for its potency with delinquency, also showed impressive outcomes when integrated into a juvenile court program and
reduced drug use, compared with standards services, among 127 youth sexual oenders
(Letourneau et al., 2009). In another program focused on broader systems, Slesnik and
Prestopnik (2009) ecologically based family therapy (EBFT), which included in home family
therapy, showed strong results in comparison with services as usual and oce-based FT. This
program treated the dicult population of runaway and homeless teens, which were thought to
be too severe a population to be amenable to family therapy.
In general, it appears to be advantageous to use approaches that intervene directly with
multiple systems like the home, school, courts, and social services. Perhaps as a result, an
added benet of the treatments that have been developed for adolescent substance abuse is that
they have proved effective with a variety of comorbid problems like delinquency, internalizing
problems like suicide attempts, other mental health issues, and poor school performance.
However, research on brief strategic family therapy (BSFT) showed that a program based
on within family structuralstrategic interventions, which does not focus on multiple systems
interventions, can also produce impressive outcomes. A clinical trial with 126 Hispanic adolescents showed that BSFT was superior to group therapy in reducing marijuana use (Santisteban
et al., 2003). As a sign of the respect for BSFT, it is currently being tested in the National Institute for Drug Abuse (NIDA) clinical trials network in eight sites with over 400 adolescents and
their families.
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Perhaps, there has been even greater progress since the last review (Rowe & Liddle, 2002)
in the treatment of adult substance abuse. Three areas of research have been especially notable.
First, there was work with family members to engage the adult substance abuser into treatment.
Signicant examples include the Engaging Moms Program (EMP), which achieved a strong
record of engaging black mothers of substance-exposed infants into treatment (Dakof et al.,
2010) as well as producing positive individual and family outcomes over 18 months. There was
also new research on the successful engagement program Community Reinforcement and Family Training (CRAFT). While most often used with families of alcoholics, there is now evidence
that CRAFT is more potent than AlAnon Facilitation in getting adult drug abusers into treatment (Meyers, Miller, Smith, & Tonigan, 2002), although there was no evidence that CRAFT
was more helpful with the personal functioning of the concerned signicant others of the drug
abusers.
A second notable area of research since the last review was the expansion of behavioral
couples therapy (BCT) as a treatment for adult substance abuse. It was shown to reduce drug
use, enhance relationship satisfaction, reduce drug-related arrests, diminish partner violence,
produce fewer hospitalizations, and reduce costs (Fals-Stewart, Lam, & Kelley, 2009b). A third
notable area of research was research on working with drug abusing parents not only to diminish drug use but also to improve parenting and child functioning.
The adolescent treatment literature is the best in family therapy regarding the inclusion of
minority samples. Hogue and Liddle reported (2009) that nine of 14 rigorously controlled outcome studies of family intervention used at least half minority populations. EMP is a treatment
for adults that demonstrated an extensive research record with minorities (Dakof et al., 2010).
There were also good examples of long-term follow-up in this literature. There was also
more than average attention in the adolescent literature (but little in the adult studies) to mechanisms of change. Altering negative parenting practices and bolstering parenting skills seems to
be a central tenant and goal of virtually all of the family-based approaches for adolescent drug
abuse and is potentially a . . . common factor that may predicts outcomes (Rowe, 2012, this
issue). Unfortunately, however, there was little research on the mechanisms of change in the
adult research.
Both MDFT and MST also provided evidence that drug treatment programs for youth can
be successfully disseminated into practice settings. However, as previously mentioned, successful
dissemination is as much a political as a scientic process that requires buy-in at all levels
and proper training and supervision. Therefore, it is not surprising that the majority of drug
treatment around the country continues to be practiced routinely with little use of evidencebased models.
Childhood and Adolescent Disorders (not including Conduct Disorders Delinquency and Drug
Abuse
Since the material on conduct disorders delinquency and drug abuse is dealt with in other
articles, Kaslow, Broth, Smith, and Collins (2012, this issue) focus mostly on the internalizing
disorders of children and youth. It is notable how generally less developed this research is in
comparison with the externalizing disorders. As readers of the conduct disorder delinquency
and drug chapters will note, teams have worked together for decades to build impressive programs of well-funded research in which studies built upon one another. Here, long-standing
research teams are less common except in a few sub-areas. Presumably, there is less money
available for research on internalizing problems because they are generally less disruptive to
society than the externalizing disorders. Another difference is that the interventions used for
the externalizing disorders were mostly classic family therapy. Conversely, in this article, the
interventions tended to be family based (family members were typically involved in a psychoeducational program). There were only a few instances (noted below) were researchers studied
traditional family therapy interventions.
Only one RCT was completed on a family-based program for childhood depression since
the preview review in 2002 (Northey, Wells, Silverman, & Bailey, 2002), and the Stress Busters
program produced fewer depressive symptoms than a wait-list control (Asarnow, Scott, &
Mintz, 2002). There was initial support for ve programs for adolescent depression that were
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tested in RCTs, but all need to be replicated by other groups and compared with each other.
At least one of these programs (attachment-based family therapy, ABFT) was a systemic family
therapy intervention (Diamond, Siqueland, & Diamond, 2003).
The 2002 review did not address bipolar disorder (BD). Miklowitz et al. (2009) (FamilyFocused Treatment) and Fristad, Verducci, Walters, and Young (2009). Multiple Family
Psycho-Educational Groups, MFPG) did RTCs reported in this paper demonstrating that family-based intervention for youth with BD was benecial. Here again, however, the research is
just beginning, and there is no basis for comparison among the methods.
The research on family-based treatment for anxiety disorders was probably the most developed in this article. Both the 2002 review and the current article supported the efcacy of Family Cognitive Behavioral Therapy (FCBT), a nding that was strengthened by the evidence
from several independent research groups in the current paper (Kendall, Hudson, Gosch,
Flannery-Schroeder, & Suveg, 2008). There was also evidence that CBT can be combined with
attachment-based family therapy to reduce symptoms of anxiety (Siqueland, Rynn, &
Diamond, 2005).
There were three evidence-based parent programs for attention-decit disorder (ADD)
described in the 2002 review, and these same programs have conducted RTCs in the current
decade: Parent-Child Interaction Therapy (PCIT; Matos, Bauermeister, & Bernal, 2009), Triple
P-Positive Parenting Program (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009), and The
Incredible Years (IY; Jones, Daley, Hutchings, Bywater, & Eames, 2007). Their emphasis is on
young children and those in elementary and middle schools. More attention needs to be given
to adolescents and to programs that combine family and pharmacological treatments.
These same three programs were also used to effectively reduce obsessive compulsive disorder (ODD). As with the treatment of ADD, they targeted younger children, and there is a need
for family-based programs that are appropriate for teenagers.
While the 2002 review did not include treatment of autism spectrum disorders (ASD), the
current review described several RCTs that focused on parent education management for this
challenging population. This area of research is in its infancy, but is promising especially given
the high cost of experts providing individual therapy to ASD youth.
Eating disorders were also not addressed in the previous review. A number of RCTs have
supported the Maudsley approach to the treatment of adolescent anorexia nervosa (Eisler,
Simic, Russell, & Dare, 2007). This is a family therapy modality combining structural and
strategic components with FPE about eating. This is one of the few adolescent disorders that
have been replicated by independent investigators. It was also one of the few research programs
with long-term follow-up (5 years). Unfortunately, only one RCT was conducted since 2002 on
family approaches to bulimia nervosa (BN). It led to reduced binging and purging but gains
dissipated at 6-month follow-up (Le Grange, Crosby, & Lock, 2008). Clearly, more research is
necessary on BN.
Taken as a whole, the methodologies of the studies described in this article are not as
advanced as those described in the delinquency and adolescent drug review issues, as was noted
in the methodological review earlier.
Family Psycho-education for Major Mental Illness
Lucksted, McFarlane, Downing, and Dixon (2012, this issue) describe the somewhat heterogeneous group of programs that fall under the rubric of FPE for major mental illness. Central
to all of these programs is the assumption that the way relatives behave toward and with a person with mental illness has an important impact on the persons well-being and the outcomes
he or she will experience with treatment. They also all assume that family members need information, assistance, and support to cope with the challenges of caring for a person with severe
mental illness. Interventions include teaching, consultation, cognitive restructuring, and behavioral interventions like problem solving. The mentally ill person (the consumer) is included in
most but not all of these programs, and some are designed for one family, while others are
based on multiple family groups (MFG-FPE). All programs focus on helping families to gain
the knowledge and skill to promote the recovery of the consumer while avoiding the outmoded
and injurious assumption that the family is the cause of the illness.
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Since the 2002 review paper, regarding FPE with adults with schizophrenia (MacFarlane,
Dixon, Lukens, & Lucksted, 2002), there were a variety of new RCTs. There was a signicant
study in Washington State involving 97 consumers and their family members that replicated
previous work showing that, compared with standard care, MFG-FPE reduced relapse,
symptomatology, and hospitalization with no net increase in outpatient services over 3 years
(McDonell et al., 2007).
Investigators completed a great deal of international research. There were six randomized
trials of FPE in China, which demonstrated that relative to standard care, FPE was superior
regarding various metrics of relapse and consumer and family functioning. There were additional international investigations in Australia, Italy (two), Pakistan, and India (Lucksted et al.,
2012, this issue). These studies all conrmed the core ndings of the previous FPE studies
suggesting that the interventions were very robust in diverse settings, although there are still
not enough studies to discern global patterns. FPE can be considered a solid evidence-based
practice for reducing relapse and hospitalization and for improvement in client symptoms
especially in conjunction with psychiatric medication (Lucksted et al., 2012, this issue).
Overall in the United States and elsewhere, ndings suggested that impact of FPE on family burden, however, was mixedperhaps because FPE includes heightening family awareness
of the potential of consumer suicide, which may actually heighten the sense of burden in the
family (Lucksted et al., 2012, this issue).
There was recent attention given to early intervention for schizophrenia. Several Scandinavian studies have incorporated FPE into their designs, and an RCT in Denmark showed that
young people in the experimental group showed lower suicide rates, fewer negative symptoms,
lower drug abuse, and reduced family burden than controls after 2 years (Jeppesen et al., 2005).
A model developed by William MacFarlane in Portland, Maine, is now being tested in six US
cities using a diverse representative population. This clinical trial is called the Early Detection
and Intervention for the Prevention of Psychosis (McFarlane et al., 2010).
Lucksted et al. (2012, this issue) also report on cost-effectiveness research in the United
States, Japan, and Australia, which demonstrated that the extra staff time to organize and
implement FPE was either cost neutral or resulted in actual savings.
There were also signicant strides in the PFE treatment of adults with bipolar disorder with
three RCTs completed since the 2002 research review. Two studies were performed by David
Miklowitz and colleagues. Miklowitz, George, Richards, Simoneau, and Suddath (2003) completed a 2-year follow-up of 101 consumers that showed, relative to a crisis management plus pharmacotherapy condition, 9 months of FPE led to improvement on relapse, mood disorders
symptoms, and medication adherence. In a study with 293 consumers (Miklowitz et al., 2007),
Family-Focused Therapy, a version of FPE, was one of three-9-month weekly or by-weekly
intensive psychotherapies that was compared with a collaborative care control including
three education sessions over 6 weeks. Although the intensive modalities produced superior
results, there were, however, no dierences among the FPE Family Focused Therapy and other
intensive methods including CBT and Interpersonal Therapy (IPT). A smaller RCT by Rea, Miklowitz, Tompson, and Goldstein (2003) found fewer hospitalizations and relapses across 2 years
with FPE versus individual treatment. While there has been much less research on the application
of FPE to bipolar disorder than to schizophrenia, and it is less denitive, it is still promising.
The authors also reported on applications of FPE to other adult problems like eating
disorders, obsessive personality disorders, dual disorders, and posttraumatic stress disorders.
However, published work on these issues is not yet sufciently developed or methodologically
sophisticated enough to draw rm conclusions.
Especially given the consistent and cross-culturally favorable results of FPE with schizophrenia, it is unfortunate that the last part of this article focused on the very limited extent to
which FPE has been adopted in real-world clinical settings. Even 17 years after the rst review
article in JMFT, the majority of families with schizophrenic members have no access to any
evidence-based version of FPE. Where dissemination has been successful, programs have been
adopted to local needs, and there has been a strong emphasis on buy-in from administrators,
therapists, families, consumers, and those who reimburse. What works appears to require
political and persuasive talents not often taught in graduate school methods courses.
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Alcoholism
OFarrell and Clements (2012, this issue) detail the progress that has been made in the
study of the systemic approach to the treatment of alcoholism. The gains were most dramatic
from the rst JMFT review by Edwards and Steinglass (1995), in which there was only evidence
that couple treatment was marginally more eective than individual treatment for the problem
drinker willing to seek help, to the previous review (OFarrell & Fals-Stewart, 2002). In that
paper, OFarrell and Fals-Stewart (2002) oered impressive and more denitive evidence for
the superiority of BCT to individual treatment in terms of reduced drinking as well as increased
relationship satisfaction.
The current article shows how BCT has expanded its reach to a broader group of patients
including women. Three randomized trials by three different research groups using somewhat
different protocols showed that BCT is a fairly robust method of reducing drinking and
increasing relationship outcomes among women and their partners (Fals-Stewart, Birchler, &
Kelly, 2006). Another RCT produced better relationship outcomes and reduced drinking among
a sample of gay and lesbian problem drinkers (Fals-Stewart, OFarrell, & Lam, 2009c).
OFarrell also reported that he successfully transported BCT to a community clinic in Calgary,
Alberta, Canada (OFarrell, Murphy, Alter, & Fals-Stewart, 2008). Finally, Fals-Stewart,
Klostermann, Yates, OFarrell, and Birchler (2005) developed a brief version of BCT that was
as eective (and more cost-eective) than the longer 12 session version.
Research since 2002 on relational approaches for the alcoholic who has sought help has been
almost all from a behavioral perspective. There were no new studies of family systems therapy
(FST) since 2002. Those studies described in the 2002 paper (OFarrell & Fals-Stewart, 2002), and
in a few papers appearing since based on the old data, suggest that for whatever reason, FST has
not produced nearly as strong and consistent a record of improvement as has BCT.
In terms of programs for family members when the alcoholic is unwilling to seek help,
OFarrell and Clements (2012, this issue) described three manualized programs for family members: Rychtariks coping skills therapy (Rychtarik & McGillicuddy, 2005), Al-Anon facilitation
and referral to Al-Anon, and a ve-step coping skills intervention developed in the UK
(Copello et al., 2009). All three resulted in reduced emotional stress for the concerned others of
the treatment-resistant alcoholic compared to a baseline or to a wait-list control group.
In terms of a CFT program designed to initiate change in an alcoholic unwilling to seek
help, there has been one new study since 2002 of the Community Reinforcement and Family
Training (CRAFT) approach. In the 2002 paper (OFarrell & Fals-Stewart, 2002), CRAFT had
been shown to be more eective than confrontational approaches (like the well-known Johnson
Institute intervention) or detachment approaches like Al-Anon in well-controlled ecacy
studies. In the current paper, OFarrell and Clements described the Santa Fe country project
that tested whether CRAFT could be transferred to a community treatment agency. It produced engagement rates of 5565%, which were comparable to the ecacy studies (Dutcher
et al., 2009).
One of the most disappointing aspects of this research is that none of these empirically validated approaches have been widely adapted. More investigations are needed to test their transportability to clinical practice settings. Although the caliber of the methodology of the research
(especially BCT) was generally quite strong, little quality research has been carried out on the
mechanisms of change. Furthermore, although considerable progress was made using female
patients, and there was one study on gay and lesbian clients, few studies used a high proportion
of minority clients. There was also little research with couples both of whom are alcoholics.
There was little research with clients with substantial psychiatric comorbidity. Finally, OFarrell
and Clements suggested that there should be more research with clients who are problems
drinkers and not just those who are alcoholics.
Couple Distress
Lebow, Chambers, Christensen, and Johnson (2012, this issue) offer both bad news and
good news about couple therapy research since the 2002 review (Johnson, 2002). The bad news
includes the reality that there is no longer government funding for marital therapy that is not
tied to Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses. There was
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also little research on any widely recognized models of couple therapy since 2002 other than
IBCT and EFT, and many widely used approaches have no research base. Furthermore, an
astonishing 70 percent of psychotherapists do at least some couples therapy, suggesting that
much this work is carried out by untrained professionals; this may account for the generally
poor ratings given couples therapy in consumer satisfaction surveys (Lebow et al., 2012, this
issue).
The good news is that a great deal of research demonstrated that couples distress is inextricably linked with a panoply of both psychological and physical disorders, in a circular way.
Therefore, researchers will be likely to nest couple research in investigations of diagnosable disorders. For example, the greater the couple distress, the more likely one or both members will
become depressed or depression will be exacerbated, and the greater the depression, the more
likely one or both partners will become relationally distressed (Beach and Whisman, 2012, this
issue). These circular patterns were strongest for bipolar disorder, alcohol use disorder, and
generalized anxiety disorder but also existed for a broad range of mood, anxiety, and substance
abuse disorders. There was also growing evidence for the relationship between relationship distress and physiological factors. For example, researchers documented higher levels of stress hormones in dissatised and divorcing couples as opposed to couples that are happily married (see
also the article on chronic illness.(Shields et al., 2012, this issue).
Another piece of good news is that the methodology of recent couple therapy research,
especially IBCT, was quite strong. A 5-year longitudinal study by Christensen et al. (2010)
employed a large, diverse sample of dicult cases and state-of-the-art methods and analysis. It
showed that about 50% of even highly distressed treated couples remained non-distressed
5 years after treatment with no booster sessions. Interestingly, in comparison with TBCT,
which emphasizes behavioral change, IBCT, which emphasizes emotional acceptance as well as
behavioral change, showed a dierent trajectory of improvement with couples improving gradually and consistently throughout treatment versus TBCT couples improving quickly and then
tapering o. IBCT also had higher rates of couple satisfaction at 2 years posttreatment, but
these dierences disappeared at 5 years. This nding led Christensen to develop a common factors explanation of change in couples therapy that is outlined in this paper.
Research on EFT since 2002 also offered good news. While it mostly employed small samples, this was appropriate for exploratory research using methods like task analysis. Research
focused on the key ingredients in changenow thought to be the depth of emotional experience
in key sessions and the development of new patterns whereby couples were able to clearly
express attachment needs and fears to each other and become generally more responsive to
each others needs. EFT also was used with new populations. EFT branched out to deal with
more distressed clients including survivors of traumas like major betrayal, severe chronic sexual
abuse, and maritally distressed patients with breast cancer (Johnson & Zuccarini, 2010). Overall, in the past decade, EFT strengthened its link to attachment research by emphasizing EFTs
capacity to generate strong attachment bonds and diminish perceptions of threat and to create
a safe haven and secure base. EFT is also an example par excellence of an empirically validated
model that has a large impact on day-to-day oce practice.
The authors also described important research on couple therapy for specic difculties
such as Snyder, Baucom, Gordon, and Pelusos (2007) work on indelity, as well as topics that
are given special attention in other articles in this volume like couples and substance abuse, violence, and depression. The burgeoning literature on the therapeutic alliance was also reviewed.
Taken as a whole, as noted previously, limitations in this area include the number of inuential couple therapy models such a Bowen therapy, narrative therapy, and psychodynamic
models that remain largely untested even though they have been around for generations. Other
than TBCT, IBCT, and EFT, little work has been carried out on mechanisms of change. With
a few exceptions, the authors also note that research subjects remain largely a bastion of white
heterosexual Europeans and North Americans.
Relationship Education
Markman and Rhoades dene relationship education as programs that provide education,
skills, and principles that help individuals . . . and couples . . . increase their chances of having
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healthy and stable relationships. (Markman and Rhoades, 2012, this issue, p.). They prefer
this term to less inclusive nomenclature like marriage education, couples marriage enrichment,
couple marriage enhancement, couples communication, and prevention of marital distress and
divorce. They describe how relationship education overlaps with, but is also distinctive from
couples therapy.
These authors found 30 relationship education studies since 2002 that evaluated 21 programs. They reported separate recent meta-analyses of this literature (Blanchard, Hawkins,
Baldwin, & Fawcett, 2009; Hawkins, Blanchard, Baldwin, & Fawcett, 2008) that showed there
were somewhat smaller eect sizes than for treatment studies (for example, an eect size of .44
for communication measures at both posttest and follow-up). Markman and Rhoades, however,
believe that these eect sizes are impressive given that the majority of relationship education
studies are preventive interventions.
Strengths of the recent literature included expansion to heretofore underserved groups like
low-income couples, racially diverse samples, unmarried couples who may or may not be planning to marry, individuals not currently in relationships, cohabiting couples, couples in which
one partner has a medical problem, adoptive and foster parents, and couples facing issues such
as children by previous partners, co-parenting, and issues related to child support. Some scholars also tested innovative delivery systems like relationship education through the telephone
and Internet (Braithwaite & Fincham, 2009).
The conceptual basis of recent research has also moved beyond the previous emphasis on
behavioral exchange and social learning theories that emphasized communication and conict
management to now include protective factors in relationships as well as transformative processes
such as commitment, sacrice, and forgiveness. The conceptual basis of new programs also
includes the link between marital quality and a variety of individual functioning dimensions like
mental health, and how parenting and child functioning interrelate with relationship quality.
Another strength is growing evidence that relationship education programs can be transported to
real-world community settings (especially PREP and the Family Expectations Program).
A signicant development in the past decade was the emergence of two large-scale relationship education projects. The rst was a study on the effectiveness of the Prevention and Relationship Enhancement Program, PREP (Markman, Rhoades, Stanley, Ragan, & Whitton,
2010). It was able to demonstrate a marked reduction in the incidence of divorce for participants one year after the intervention.
The second was the federally funded Building Strong Families study (Wood, McConnell,
Moore, Clarkwest, & Hsuech, 2010). This huge (N = 5,102) eight-site RCT program provided
relationship education to unmarried couples having a child together. While results were generally disappointing, the Oklahoma site, called Family Expectations, when analyzed independently, showed that participating couples had higher levels of happiness, aection, support,
delity, and parenting skills and were more likely to stay together vis-a`-vis the control group.
This program integrated PREP with a program called Becoming Parents.
Markman and Rhoades believe that signicant factors in the success of the Oklahoma site
were the use of greater incentives to get participants to complete the program, an excellent set
of postworkshop services, and a strong organizational structure. Perhaps, when it comes to
doing successful large-scale research, strong organization and infrastructure are as important or
more important than the academic aspects of research design and the quality of a program on
paper.
Weaknesses of the current research included, despite the aforementioned progress regarding
diversity, there being few programs for underserved populations like older couples, gay, lesbian,
or transgendered couples, and those already divorced or separated. Many of the 30 new studies
were evaluated by the same researchers who developed and sometime delivered the interventions. Closely related, only a few of the programs (not related to PREP) were part of a programmatic body of research. Few of the studies used observational measures and relied
exclusively on self-report. Also, few of the studies had long-term follow-upsa concern as relationships education effects tend to attenuate with time and require booster sessions. There was
also little attention paid to the mediators (apart from improved communication) and moderators of change.
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I am also personally concerned that there are a large number of relationship education
programs, widely advertised and brazenly promoted at conferences as effective that have no
research support whatsoever. Furthermore, I am concerned that several relationship education
programs that used to have a strong record of published research, like the Couple Communication Program (CC) and the Relationship Enhancement Program (RE; Guerney & Maxson,
1990), do not appear in this review. What happened to these excellent programmatic research
eorts? On the positive side, I believe that scholars at the University of Denver (Howard
Markman, Scott Stanley and colleagues) who have been responsible for the impressive programmatic research on PREP (Markman and Rhoades, 2012, this issue) and W. Kim Halford
(Halford, 2010) of Grith University, Australia, have set high standards for other relationship
education researchers to follow.
Depression
In their article, Affective Disorders, Beach and Whisman (2012, this issue) stress that
one of the major advancements during the past decade has been research demonstrating there
are reciprocal, bidirectional connections between marital difculties and depression. Furthermore, depressed patients also report considerable distress in their parenting relationships including lax, detached, inconsistent, and ineffective parenting, which also appears to be part of a
bidirectional vicious cycle. It now seems clear that marriage and family variables are often
important parts of the stress generation (Hammen, 1991) circular pattern of causation between
stressful life events and depression. Especially when there is family discord, treatments that
avoid these variables often set the stage for relapse and recurrence. The authors argue that individual (including empirically supported treatments) and pharmacological interventions for
depression are often incomplete without attention to family issues.
Research before the special issue in 2002 (Beach, 2002) included three well-designed outcome studies from the 1990s that compared behavioral marital therapy to individual treatment
for depression. These studies demonstrated that these couple modalities were equivalent in
reducing depressive symptoms but that marital therapy was better than individual therapy at
improving relationship functioning. There was also a study in 2003 that oered tentative evidence that EFT may be eective in the treatment of unipolar depression (Dessaulles, Johnson,
& Denton, 2003). A major meta-analysis (Barbato & DAvanzo, 2008) of the literature on marital therapy and depression also armed that (a) there was equivalence between couple and
individual therapy for depression when depression was measured with continuous or dichotomous outcome measures, (b) couple therapy was signicantly more potent than individual therapy at improving relationship distress when it was present, and (c) there were currently
insucient data to compare marital therapy and medication.
Unfortunately, there were only two outcome studies since 2002 that evaluated couple therapy for depression. (As one of these studies was carried out in Germany, I was surprised by
this dearth of recent investigationsespecially because depression is a DSM disorder and presumably research of this type would be fundable). However, both current studies employed
strong methodology and shed light on some additional issues not addressed by the previous
research.
The German study by Bodenmann et al. (2008) tested Coping Oriented Couples Therapy
(COCT) that taught members of dyads to self-disclose about stressors, to provide useful support to each other, and to rene that support based on couple feedback. The program was relatively brieften two-hr sessions. The method also used key elements from standard BMT.
Sixty dyads were randomly assigned to COCT or to interpersonal psychotherapy (IPT), a psychodynamic modality, or cognitive therapy. Similar to previous ndings, all methods reduced
depression signicantly but not relative to each other. Unlike previous studies, there were no
dierences among the groups on self-reported relationship satisfaction or dyadic coping. Where
COCT was markedly superior, however, was on the observer rater measure of expressed emotion (EE), an indicator of dyadic criticism that has been shown to predict exacerbations of
mental disorders. Non-maritally distressed couples were included in the sample, and the study
showed the potential of COCT to reduce both depression and EE in non-distressed dyads. The
study also argued for the inclusion of observer ratings in future research.
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Cohen, OLeary, and Foran (2010) also developed a program for depressed individuals
(mostly with major depression) who were in relationships that were mildly or non-distressed. It
was a ve-session, two-hour highly structured program that compared a new brief couple therapy for depression (BCT) with a wait-list control group. Changes on depression were highly signicant in comparison with the wait-list controls. Beach and Whisman believe this study
introduced a compact and potentially cost-eective treatment that, like the Bodenmann program, can be used with mildly or non-distressed couples.
Another development since 2002 was the ability to distinguish a natural break point
between a taxon of discordant versus non-discordant couples using large representative
national samples (Beach and Whisman, 2012, this issue). There are now interview as well as
self-report screening scales that can be used to distinguish to which group a couple belongs.
Future research could test the merits of assigning non-discordant couples that contain a
depressed partner to a brief program like Cohens or Bodenmanns.
Beach and Whisman also reported on ve studies since 2002 that investigated the impact
of parent training as a treatment for depression. All of the studies showed that program participation led to both reduced depressive symptoms and enhanced parenting skills.
Beach and Whisman noted there is little attention in this literature to comorbid conditions
(quite typical with depression). Other than Bodenmanns use of an observational measure for
EE, there has been little use of observational measures to assess important variables like EE.
Although Beach et al. (2008) did a study of a parenting intervention with 163 African American mothers, there was also little research in this area that used minority couples or couples
who were socially or economically disadvantaged.
Interpersonal Violence
Stith, McCollum, and Amanon-Boadu (2012, this issue) start their paper with the growing
evidence for the active involvement of women in IPV, and the somewhat modest track record
of same sex pro-feminist-based interventions for male offenders and female victims. While the
stereotype of the male only offender remains accurate in many cases, as community samples
began to be gathered, it became clear that about half of cases were reciprocally violent and that
when violence was unilateral, women were the perpetuators in as many as 70% of the cases.
This does not gainsay the fact that male perpetuators are often more powerful and dangerous.
The authors point out that standard clinical practice continues to be separate gender
groups based on pro-feminist and cognitive behavior approaches and that these approaches
were institutionalized in state standards in 45 states, 95% of which mandated traditional treatment for IPV. In fact, 68% of state standards specically prohibited conjoint couples treatment
during the primary phase of intervention. Yet, as this article makes clear, there is growing evidence that for some clients, systemic interventions can often be more effective for IPV (Stith
et al., 2012 this issue).
A key to both the safety and effectiveness of interpersonal treatment was client selection
limited to those parties whose violence occurred only in the relationship (called situational
couples violence) and was generally limited to a particular issue or issues. If the violence was
characterological, was a form of intimate terrorism, or there was a history of violence outside
the family, then gender-specic group treatments, or legal recourse, remained probably the best
options.
Systemic treatment of IPV is what I would call a developing area of research, because there
are few instances of programmatic research and a number of methodological limitations. The
work by Fals-Stewart, Klosterman, and Clinton-Sherrod (2009a) was the closest thing we have
to a program of research in this area, but these investigators interest in IPV was secondary to
their work on reducing alcohol and drug abuse in couples in which one partner had an addiction. Nonetheless, they consistently found signicantly greater reductions in partner violence in
couples whom they treated with BCT than those who received individual treatment only (see
the papers by OFarrell and Clements [2012, this issue] and by Rowe [2012, this issue]). Stith
et al. (2012, this issue) also carried out several studies on IPV starting at Virginia Tech, Falls
Church, in 1997. They describe their Domestic Violence-Focused Couples Treatment (DVFCT),
an 18-week program that includes two formatseither a multi couple (MC) group or a single
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couple (SC) version. Both formats led to signicant reductions in physical violence toward
partners as measured by partner reports. Furthermore, especially for men, the MC format
engendered a number of other benets, like reduced anger. However, no new studies using this
method were reported.
The rest of the completed projects reported in this article were single studies, one of which,
however (Mills, 2008), was supported by the National Science Foundation. Compared to traditional treatment, the Circles of Peace (CP) interventionthat included conferences between victims and oenders of violence and incorporated roles for family members and friends as
supportsshowed signicantly fewer arrests in the 24 months following treatment. Stith et al.
(2012, this issue) also report on several large-scale federally funded projects that are in progress,
demonstrating that the case for systemic treatment has clearly obtained the attention of major
funding agencies.
Clients Views of Couple and Family Therapy
Chenail, St. George, Wulff, Duffy, Scott, and Tomm (2012, this issue) offer a qualitative
meta-synthesis of how clients in couple and family therapy view and evaluate their experiences.
A meta-synthesis is the qualitative counterpart of a quantitative meta-analysis and attempts to
draw conclusions based on an integration of many studies. In this case, data from 49 refereed
journal articles from 1990 to 2010 were used to develop an inductive grounded formal theory
of CFT client experience evaluation preferences.
I am not alone in thinking that therapists who believe that their work is evidence based
need to attend to client perceptions. Their importance was underscored by the APA Presidential
Task Force on Evidence-Based Practice, EBPP (APA 2006):
Psychotherapy is a collaborative enterprise in which patients and clinicians negotiate
ways of working together that are mutually agreeable and likely to lead to positive
outcomes. Thus, patient values and preferences (e.g. goals, beliefs, preferred modes of
treatment) are a central component of EBPP. (p. 280).
Furthermore, the same Task Force stressed that there are many types of research evidence
and that qualitative research can be used to describe the subjective, lived experiences of people, including participants in psychotherapy (APA, 2006, p. 274). I believe these statements
are just as applicable to evidence-based couple and family therapy and to using qualitative
methods, like meta-synthesis as important sources of data about therapy. This article does for
CFT exactly what the Task Force was calling for in psychology.
About the rst 40% of this article is a careful description of meta-synthesis and the sevenstep process that the authors employed to draw their conclusions and to formulate an inductive
formal grounded theory. Among other things, their inclusion criteria included analyzing only
studies about which they had reasonable condence in the trustworthiness of the data. This
entailed an assessment of the original articles methodologiesusing a rating rubric. For example, studies were typically excluded where there was a failure to report quality control methods
such as audit trails, peer debrieng, member checking, or triangulation. As a result of the appraisal process, the authors dropped 36 of the 89 articles originally in their data pool. However, the
authors noted considerable redundancy in their ndings and thought that they could have
reached theoretical saturation with a much smaller sampleperhaps as few as 1215 studies.
Although the 49 studies represented a wide variety of couple and family therapy models,
the authors did not nd signicant differences related to theoretical orientation. The authors
interpreted their results as afrming many of the characteristics that the common factors in
CFT literature (Sprenkle et al., 2009) has suggested are related to therapeutic success like clients wanting to be actively involved, the importance of clients own motivation and inner
strength, the importance of the therapist cultivating hope, setting goals collaboratively, being
empathic, warm and non-judgmental, the clients appreciation of their alliance with their therapiststhat includes emotional bonds, and agreement about the tasks and goals of therapy, seeing positive connections between in-therapy actions and out-of-therapy change, and clients
seeing change in both their viewing of problems and the doing of their own behavior. The
authors also thought that (although these clients did not use this more technical language) their
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words appeared to support Sprenkle et al.s (2009) identication of four couple and family
therapy-specic common factors: (a) the importance of viewing problems in relational terms,
(b) the value of interrupting problematic relational patterns, (c) expanding the direct treatment
system to include more than individuals, and (d) expanding the therapeutic alliance to include
the various systems and sub-systems involved in treatment.
The authors said the clients placed special emphases on the importance of therapists
being balanced and fair, and also sensitive to the alliances that the family members have with
each other. In fact, the very success of therapy often rested on the development of an intrafamily alliance in which members began to see and act upon a common understanding of
their problems and a new level of caring that came from that understanding. In the sense of
second-order cybernetics, therapists needed to be aware of clients awareness of this intrafamily alliance.
Another area of special emphasis was the authors conclusion that family members want to
be dynamic participants in their therapy and provide critical information and feedback
throughout the process, another nding consistent with common factors (Anker et al., 2009).
Therapists should regularly ask clients for feedback regarding what is helpful and what is on
and o track.
As with any analysis of original documents, this meta-synthesis was impacted by the limitations of the primary studies. It was not possible, for example, to draw conclusions about race,
culture, gender, sexual orientation, or socioeconomic variables because these variables were not
sufciently addressed in the original investigations. Important contextual information about the
interviews was also often missing. I also thought that although the role of emotion in change
was implied in many of the quotes from clients, it was not explicitly mentioned in the commentary and may have been underemphasized. Nonetheless, there is much that is rich and edifying
in this document, and therapists would be well advised to read the results and discussion sections, as part of being research informed clinicians.
Chronic Illness
Shields, Finley, Chawla, and Meadors (2012, this issue) describe the developing area of
family interventions for managing chronic illnesses including traumatic brain injury (TBI),
stroke, spinal cord injury, cardiovascular disease, cancer, and diabetes.
Few of the family interventions for managing these illnesses could be labeled psychotherapy. Instead, most were psycho-educational programs and were often administered by bachelors- or masters-level professionals from a variety of disciples. The programs also varied greatly
in terms of content, duration, and method of service delivery.
In the sub-area of treatment for type 1 diabetes for youth, however, several family therapy
models were adapted for diabetes and, among all the interventions described in this article,
were also the most grounded in theory and thoroughly researched. MST, which has also
appeared in the articles in this volume on conduct disorder delinquency and drug abuse,
improved adherence to glucose testing and reduced the number of emergency room visits. These
studies also included a high proportion of minorities (Ellis et al., 2008). Behavioral Family Systems Therapy (BFST-D) included communication training, problem-solving training, cognitive
restructuring, and functional family therapy. Families randomly assigned to BFST-D, in comparison with education support and standard care conditions, also had signicant increases in
glycemic control and declines in diabetes-specic conict (Wysocki et al., 2006).
Shields et al. (2012, this issue) noted that these successful interventions were focused on
children with poor glycemic control who were clearly at risk. Many less successful family intervention programs for chronic illnesses targeted subjects whether they were at risk or not,
thereby making signicant results less likely.
In general, the results for type 1 diabetes were the most conclusive. Family interventions
for patients and caregivers with stroke and cardiovascular disease were inconclusive. Results
were more promising for traumatic brain injury, spinal cord injury, and cancer, but results for
these three areas should be considered preliminary.
In addition to focusing more on patients who need the interventions, the authors called
for more attention to studying and targeting the mediators of change as well as the
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circumstances conditions (moderators) under which change is most likely and using statistical
procedures appropriate for these analyses. Finally, they suggested working more with healthcare providers to develop interventions that will actually be used as opposed to gathering dust
on researchers shelves.
Meta-analysis
Baldwin, Christian, Berkeljon, and Shadish (2012, this issues) provide a meta-analysis that
is less a substantive review of content, but is rather more a paper that focuses on advanced
methods of meta-analysis.
The content, however, does afrm that Brief Strategic Family Therapy (BSFT), Functional
Family Therapy (FFT), MDFT, and MST all produced statistically signicant results at the
end of treatment when compared to treatment as usual and to alternative treatments (although
the effects sizes were modest). Furthermore, there was insufcient evidence to determine
whether these models were signicantly different from each otherafrming at least for now
the common factors hypothesis that there is no compelling evidence that any empirically validated MFT modality is superior to another (Sprenkle et al., 2009).
The rst methodological advancement in the current study was inuence analysis, which is
designed to determine whether a given study carries a disproportionate amount of weight in the
aggregate effect size, and what the results would have been if this study were not included. In
fact, there were three studies that were outliers and which, whether they were included or not
included, had a major bearing on outcomes. The second advancement was the assessment of
publication bias, which assumes that unpublished studies have weaker results. The authors
described ways of estimating this bias even if the unpublished studies cannot be located and
analyzed separately. There was no clear evidence of publication bias in this meta-analysis. The
third advancement was multivariate meta-analysis that enables meta-analysts to compare effect
sizes for primary outcomes (delinquency substance abuse) with secondary outcomes (like family
change variables) to see whether the interventions were most powerful for the variables they
were designed to treat. The effect sizes were larger for the former, but, probably due to insufcient power, they were not statistically signicant. Low power also prevented the investigators
from nding signicant differences in a number of moderator variables they examined like
mean age, the proportion of the sample that was minority, and so forth.
As the literature grows and power is enhanced, these methods will enable meta-analysts to
address again the question of the relative efcacy of treatments, on which outcomes the treatments had differential effects, and what variables moderate outcomes. Aside from limited
power, another shortcoming of this investigation was that it only examined posttreatment and
not follow-up outcomes. On the plus side, it was probably the most sophisticated meta-analysis
to appear in the family therapy literature and will be of great value to future researchers.

SUMMARY AND CONCLUSIONS


Reading the 12 papers in this issue should leave little doubt that CFT has established itself
as a scientic discipline. Couple and family therapy began with a belief in the Big
Ideanamely, that relationships matter. During the early decades of the discipline, this
belief was more akin to religious dogma than to an assertion rooted in evidence that could pass
muster with skeptical outsiders. During the past three decades, the number of CFT evidencebased investigations with good methodology has grown exponentially. We can now assert with
considerable condence that many CFT interventions frequently add value and that relationships do indeed matter when it comes to many interventions.
Table 2 is a list of problems issues discussed in this special issue for which there is strong
evidence for a modality eect, namely that using relationally oriented couple and family methods achieves results that clearly add value to traditional, non-CFT methods of addressing these
issues. All of these problems issues were addressed through multiple RCTs, often over decades,
and in many cases by multiple research groups using a variety of systemic methods.
Table 2 would have been much longer if I had included many promising interventions
discussed in this issue that have not yet been suciently replicated to reach the same level of
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Table 2:
Problems Issues Addressed in this Issue for which there is a Strong Couple and Family
Therapy (CFT) Modality Eect
CFT > TAU
Adolescent Conduct disorder delinquency
Getting adolescent substance abusers into treatment
Adolescent substance abuse
Getting adult substance abusers into treatment
Adult substance abuse
Childhood and adolescent anxiety disorders
Childhood oppositional deant disorder
Adolescent anorexia nervosa
Family management of adult schizophrenia
Coping for family members of alcoholics unwilling to seek help
Getting adult alcoholics into treatment
Adult alcoholism
Moderate and severe couple discord
Adult depression when combined with couple discord
Couple violence associated with alcoholism and drug abuse
Situational (not characterological) couple violence
Type 1 diabetes for adolescents and children

condencelike management of early onset schizophrenia, youth with bipolar disorder, adults
with bipolar disorder, adolescents with depressive disorder, to mention a few.
I will not repeat the methodological recommendations made at the end of the rst part of
this paper. Sufce it to say that methodology and substantive content come together in many
ways. Let me conclude by addressing several points of intersectionrst, the need for more
attention to the mechanisms of change. Its link to substantive content is that while we can say
with great condence that CFT works, we can still say very little about why most specic
approaches work. Few scholars have uncovered the active ingredients versus inert llers in the
often very impressive interventions described in these pages. Why remains shrouded in mystery. When or under what circumstances is just as great an unknown and an additional
important research challenge for the future.
Closely related, most of what we know is still about absolute efcacyhow our treatments compare with no treatment control groups, or now more commonly with treatments as
usual (that often may not be equally valued). We still have little evidence about relative efcacy, how our CFT evidence-based treatments compare with other CFT evidence-based treatments (under conditions in which they are equally valued). The link to content is that without
this research on relative efcacy, we can say nothing about the superiority of one CFT treatment versus another treatment, even in the same research areas.
Taken together (little knowledge regarding specic mechanisms of change, and little
research on relative efcacy), these gaps reinforce the judgment that there is little current evidence to refute the common factors hypothesesnamely that CFT works because of common
mechanisms of change that are not unique to specic models but are common to all successful
approaches to CFT, at least within the same research area (Sprenkle et al., 2009). That is, while
we may be able to speak with some condence about a modality eect (systemic treatment is
often better than non-systemic treatment), we cannot have the same condence about the
advantages of specic systemic interventions models. It will be interesting to see whether this
conclusion is challenged by credible evidence in the decades to come.
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NOTE
1

I had originally hoped to use the standard rating procedure of using multiple coders to
achieve inter-rater reliability for this table. However, it became apparent that persons other
than experts in the content areas (like the paper authors in their own areas) did not feel
qualied to do the ratings and could not be readily trained to do so. This was not only
true of graduate students but also peersas doing the ratings required a breadth and depth
of knowledge of the research across all the areas. So, I settled on combining my own
knowledge with that of the authors. Hence, although I believe the ratings are credible, it
was not feasible to use standard inter-rater reliability validity procedures.

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