Journal of Marital and Family Therapy doi: 10.1111/jmft.12096 April 2015, Vol. 41, No. 2, 136–149

STRENGTHENING THE SYSTEMIC TIES THAT BIND: INTEGRATING COMMON FACTORS INTO MARRIAGE AND FAMILY THERAPY CURRICULA Eli A. Karam University of Louisville

Adrian J. Blow Michigan State University

Douglas H. Sprenkle Purdue University

Sean D. Davis Alliant International University

Specific models guide the training of marriage and family therapists (MFTs) as they offer both structure and organization for both therapists and clients. Learning models may also benefit therapists-in-training by instilling confidence and preventing atheoretical eclecticism. The moderate common factors perspective argues that models are essential, but should not be taught as “the absolute truth,” given there is no evidence for relative efficacy of one empirically validated model versus another, and no single model works in all instances. The following article provides a blueprint for infusing a common factors perspective into MFT programs by reviewing innovations in course design, outlining specific teaching strategies, and highlighting potential implementation challenges.

OVERVIEW In this article, we encourage those who train marital, couple, and family therapists (MFTs) to integrate established common factors and empirically supported principles of change into established curricula. Common factors refer to all techniques and therapeutic change mechanisms that transcend various models and are related to successful outcomes. First we will examine both the history and benefits of teaching-specific models in MFT education, before arguing for a more inclusive and integrative, moderate common factors approach. While we do not propose throwing out the classic MFT theories that have historically guided the field (i.e., Structural, Strategic, Bowenian) or the more recent empirically supported “next-generations” models (i.e., Emotion-Focused Therapy, Integrative Behavioral Couples Therapy, Multisystemic Therapy, Functional Family Therapy), we do believe that a core focus on single approaches does not reflect the reality of the “real-world” practice of MFT. We believe learning about common factors is an excellent way to bring about a theoretical as well as empirical integration, not otherwise possible when the focus is on competing models.

Eli A. Karam, PhD, Marriage and Family Therapy Program, The Kent School of Social Work at the University of Louisville; Adrian J. Blow, PhD, Couple and Family Therapy Program, Department of Human Development and Family Studies, Michigan State University; Douglas H. Sprenkle, PhD, Marriage and Family Therapy Program, Department of Child Development and Family Studies, Purdue University; Sean D. Davis, PhD, Marital and Family Therapy Program, Alliant International University—Sacramento Campus. Address correspondence to Eli A. Karam, Family Therapy Program, Kent School of Social Work, Louisville, Kentucky 40292; E-mail: [email protected]

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The History of Teaching-specific Models

Marriage and family therapists as profession originated in the late 1950s and 1960s with a series of rebellious pioneers who rejected the dominant individual-based behavior and psychoanalytic models of the time in favor of something new. These prominent early figures, many from disparate disciplines, banded together as systemic soldiers against the linear mental health establishment to find a common ground, focusing on similar themes such as centrality of the family system, the interconnection between people and things, and changing problematic communication. In tracing the evolution of our profession, Jay Lebow points out how this harmony was short-lived, stating that “family therapy had an exciting beginning in which a shared vision was emphasized, followed by a period of conflict between models.” (Lebow, 2013, pp. 15). In something akin to a civil-warlike period in our MFT history, the 1970s centered on promoting distinction and brand differentiation among models. This emphasis on “difference” was influenced by the personas of charismatic model developers, each trying to brand what they did as a unique and pure form of family therapy. These psychotherapeutic “rock stars” toured the country, looking for new fans from the worlds of social work, psychiatry, and other related mental health disciplines that would be recruited to become the first generation of MFT students. At this time, empirical evidence was not necessary in the sales pitch, as model popularity primarily relied on word of mouth, emotional appeal, and the powerful live demonstrations of family therapy techniques. Leaders trained their fervent followers, not on college campuses, but at free-standing institutes throughout the United States in single school, pure model approaches. If you were in the market for a family therapy education, you might have felt both excited and confused, as there were many establishments to choose from, each purporting to teach “the absolute truth,” including the Philadelphia Guild Guidance Clinic, the Bowen Center for the Study of the Family in Washington, D.C., the MRI Brief Therapy Center in Palo Alto, the Ackerman Institute of New York, and Haley & Madanes’ Family Therapy Institute of Washington, DC, just to name a few of the early meccas of family therapy training. As a student at any of these centers, however, you were only taught one model, the proprietary approach of the model developer. For example, a family therapy trainee at the Philadelphia Guild Guidance Clinic would be trained entirely in Structural Family Therapy, without having any exposure to popular alternatives at the time, like the experiential models of Satir and Whitaker or the transgenerational theories of Bowen or Nagy. As the profession and practice of family therapy became more mature, training programs were soon situated primarily in university settings when in 1978, the United States Department of Education (USDE) recognized the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) as the national accrediting body for MFT. The standards of the COAMFTE focus on grounding clinicians in a systems/relational perspective as a basis for their treating of problems. From this time forward in MFT educational history, students were introduced to series of different classic models and approaches throughout the curriculum. Even though the exposure to a myriad of models was now available, MFT training still tended to focus on highlighting differences, rather than similarities between the models (Sprenkle, Davis, & Lebow, 2009). Rather than presenting an integrative framework, many training programs encouraged a “choose your favorite model” approach, resulting in a depth over breadth mentality to clinical training. The Benefits of Teaching-Specific Models As opposed to a potential radical stance on common factors which would completely diminish the value of models, advocates for a moderate stance see merit in learning-specific MFT theories and approaches, and as many of these as possible (Blow, Sprenkle, & Davis, 2007; Sprenkle & Blow, 2004a). After all, common factors are not “islands,” but rather they work through models (Sprenkle & Blow, 2004b). Models provide the beginning family therapy student structure, organization, and coherence—a therapeutic blueprint to guide work with client systems. Only when we learn several models really well can we see the similarities that exist between them. Additionally, learning models may have some merit as it can create confidence and avoid atheoretical eclecticism, a type of haphazard selection of April 2015

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techniques and interventions that often resembles what the third author calls “seat of the pants” therapy (Sprenkle et al., 2009). Over the past two decades, the MFT profession has worked diligently to compete with the other major mental health disciplines by advancing the science behind the art of what we do. Given that many of our classic MFT models have no data to support their claims, we need to acknowledge and pay careful attention to the next generation of MFT models that have excellent empirical support as to their effectiveness with specific populations (Sprenkle, 2012; Sprenkle & Blow, 2004a). In teaching these current models to the next generation of research-informed MFTs, Karam and Sprenkle (2010) urge educators to link the old to the new. For example, those students learning Emotion-Focused Therapy (EFT) should be able to see the commonalities between this approach and in the work of its experiential predecessors such as Satir and Whitaker. The existence of these empirically supported models, however, does not nullify the importance of common factors. To the contrary, we believe that there are significant areas of overlap among even the evidence-based models within family therapy. For example, both EFT and Functional Family Therapy (FFT) place considerable emphasis on building a strong alliance with client systems. Several evidence-based treatments have been shown to be effective with similar problems and similar populations, for example, the evidence-supported treatments for troubled adolescents: FFT (Alexander, Pugh, & Parsons, 1998), Multisystemic Therapy (MST) (Henggeler, 1998), and Multidimensional Family Therapy (MDFT) (Liddle, 1999). We are confident that these models have many similar change mechanisms.

MAKING A CASE FOR TEACHING COMMON FACTORS ALONGSIDE SPECIFIC MODELS Believing that it is better to be passionate about theory than a theory, we argue that the traditional “choose your favorite model” approach is not an appropriate fit for the evolution of MFT training programs. This learning style suggests that if you master one model, you are by definition choosing not to master another. Instead, we offer the following reasons to include stressing the importance of common factors alongside the teaching of specific models. The Empirical Argument: Meta-Analysis Specific models and techniques used alone have little influence on the outcome of treatment (Shadish, Ragsdale, Glaser, & Montgomery, 1995). In the largest meta-analysis in the MFT field to date, Shadish and colleagues make the following conclusions: (a) marital and family therapy works; (b) the majority of those who participate in marital and/or family therapy are better off than those who do not; (c) the odds are two of three that a randomly chosen client who received MFT is better off than a randomly chosen control client at posttest; and (d) no orientation of MFT was shown to be demonstrably superior to any other MFT orientation (Shadish & Baldwin, 2003; Shadish et al., 1995). Although clinical experience and this meta-analytic research evidence would suggest that there is no single model or theory capable of fitting all clients or family systems, many model developers and their followers continue to perpetuate this myth (Sprenkle et al., 2009). This myth could confuse novice therapists, as they may feel pressured early on in their training to pick the “right” model, or they may pick an approach without being fully informed about all of its complexities. While there is clear evidence for the effectiveness of certain MFT approaches, there is not yet strong evidence for the relative effectiveness of the various models as compared to one another. Karam and Sprenkle (2010) explain how learning this information helps students realize they do not prematurely have to pledge allegiance to the superiority of any one model, even though there may be value in choosing a model that is a good fit for their own worldview (Simon, 2006). Believing in a model (i.e., allegiance) is itself a common factor associated with positive outcome (Wampold, 2001). The Practical Argument: The Integrative Reality of Many Practicing MFTs Although it is natural that some models will resonate with students more than others, it is unrealistic to believe that the therapists will stay with one pure model throughout the duration of 138

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their careers, especially as they work with a wide range of clientele and presenting problems. Jay Lebow (1997) has labeled this movement away from relying one model in favor of adapting a more integrative style as the “quiet revolution” in couple and family therapy. The majority of seasoned therapists do not utilize only one or two approaches in their work, a notion supported by comprehensive studies which conclude that MFTs generally do not professionally practice this way (Northey, 2002; Orlinsky & Rønnestad, 2005). Therapists-in-training, especially, must experiment with ideas and techniques on their own so that they can discover for themselves what works and makes sense, given their own particular personality and caseload. The Professional Argument, Part 1: Alignment With AAMFT Core Competencies Whereas MFT training was once known for input-oriented education (i.e., the accumulation of 500 clinical hours as graduation requirement), in recent years, the focus of skill development for therapists-in-training has shifted to output-oriented education by articulating profession-specific core competencies aimed at a wide variety of common assessment and intervention techniques, as well other conceptual, executive, and professional skills. Core competencies refer to the basic or minimum skillset that each practitioner should possess to provide safe and effective care before graduating from a COAMFTE program (Nelson et al., 2007). Most MFT educators and supervisors can relate to the experience of watching students struggle in session when trying to apply a pure model to a specific problem or population. Students may also often encounter frustration or diminished self-confidence as they try to implement complex interventions that do not fit with the client system. These AAMFT Core Competencies are not model-specific, but instead are designed to help students think critically about both the strengths and limitations of what they are implementing in session, and to match the technique to the client’s needs, goal, and values (Nelson et al., 2007). If you are only proficient in one model however, even if you know it extremely well, it is unlikely that you will be able to excel in all of these core areas. The common factors approach reinforces the fact that some of the skills students typically already feel good about (like their ability to “engage each family member” in order to establish the therapeutic alliance) are both strong evidence-based contributors to change and recognized as important core competencies for beginners to master. Nelson and colleagues (2007) credit MFT common factors research for laying the foundation for the core competencies project by giving a better understanding about what really works in therapy. The Professional Argument, Part 2: Acknowledging the Evidence-Based Relationship Therapy Movement in Clinical Psychology While training students in evidence-based practices (EBP) has become an increasingly valued component in MFT graduate programs over the past decade, evidence-based training should not be limited to teaching only models. We advocate for programs to include other empirically supported change principles and common factors, what it means to be an evidence-based therapist, self-of-the-therapist, the therapeutic alliance, feedback from clients, and ways to understand and use client characteristics and extratherapeutic factors to maximize change. Focusing exclusively on EBP within a training program may constrain the theoretical flexibility and critical thinking skills of therapists-in-training and may not be conducive to the development of a personalized integrative approach. In addition, research on therapist competency does not support the notion that merely learning evidence-based practice leads to better outcomes. Rather, these approaches are only as effective as the skills and competencies of the therapists delivering the treatment (see Blow et al., 2007 for a review). The American Psychological Association (APA) has already legitimized the integration of common factors into training by commissioning the Task Force on Evidence-Based Therapy Relationships. This task force identified six elements of the therapy relationship that have been found to be “Demonstrably Effective.” These elements include the alliance in individual psychotherapy, alliance in youth psychotherapy, alliance in family therapy, cohesion in group therapy, empathy, and collecting client feedback. Elements of the therapy relationship found to be “Probably Effective” include goal consensus, collaboration, and positive regard. Relationship elements found to be “Promising but Insufficient Research to Judge” include congruence/genuineness, repairing alliance ruptures, and managing countertransference (Norcross & Wampold, 2011). April 2015

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The Availability Argument: Open Access of Common Factors Versus Restricted Access of Some Evidence-Based Models Recently, Dattilio, Piercy, and Davis (2014) have urged MFTs to take a broader, more clinically palatable view of evidence-based treatment to bridge the researcher–clinician divide. Unfortunately, proprietary restrictions block the ability for many curious MFTs to learn about cuttingedge, evidence-based treatments. For example, unless you are a therapist working at an agency that has a contract with an existing “gold standard” treatment program such as MST or FFT, it may be difficult to obtain training and exposure to these models (Sprenkle, 2012). A moderate common factors approach, on the other hand, may serve to counteract the restrictive nature of access to some of these newer models. Therefore, we strongly believe that MFT educators should prepare their students for what common factors integration may look like in their first postgraduate job setting. For example, Integrative Family and Systems Treatment (I-FAST) is an emerging approach that exemplifies best practices for working with difficult youth and family client systems without the aforementioned proprietary barriers. This home-based treatment model, developed and implemented within the community mental health system, consists of three major common factors derived from the evidence-based literature on family treatment with at-risk children, youth, and families. These common factors are as follows: (a) develop and maintain a positive therapeutic alliance with the family members; (b) intervene to bring about second-order change in problematic patterns by having the parents be the ones to solve the presenting problem; and (c) work collaboratively with the various systems involved with the family so they collaborate in supporting the parents as the ones solving the presenting problem (Fraser, Solovey, Grove, Lee, & Greene, 2012). As a “both/and” approach, I-FAST uses agency and clients’ strengths and resources alongside broader and more flexible evidence-informed techniques in social services delivery to realistically fit the demands of community mental health (Fraser & Solovey, 2007). To be more open and less restrictive about access to this moderated common factors approach, I-FAST developers have recently published a user-friendly manual to aid in wide dissemination (Fraser, Grove, Lee, Greene, & Solovey, 2014).

COMMON FACTORS THAT SHOULD BE EMPHASIZED ALONGSIDE THE TEACHING OF SPECIFIC APPROACHES In addition to teaching-specific models, what common factors should MFT educators strive to highlight and infuse into the coursework and supervision? Almost all that has been documented in individual therapy common factors research could also hold true for systemic therapies. Michael Lambert (1992) originally proposed the following clusters, which were later modified by Hubble, Duncan, and Miller (1999) and then by Wampold (2001) as pertaining to the field of individual psychotherapy (Although the space parameters of a journal article like this do not permit an indepth review, please see Sprenkle and colleagues’ publication (2009) for a detailed historical research and clinical perspective on common factors.). Common Factors Inherent All Psychotherapy Modalities Client factors. These are ingredients in the life and environment of the client that contribute to change largely separate from the therapeutic process. Examples of these are family support, chance events such as winning the lottery, meeting a new person, or a religious experience. They also include personality or inherent trait characteristics of clients that allow them to gain far more from the process of therapy than other clients. We have all had the privilege and experience of working with clients who are psychologically minded, who take the process of therapy seriously, and who actively work at their goals outside of the therapy room. For these clients, what they bring to the therapy experience is highly instrumental in their change. Another important change factors to consider related to the client is the natural process of change and the stage in which the client is in related to change (Levesque, Prochaska, & Prochaska, 1999). Therapist factors. In general, specific models deemphasize therapist factors even in the face of the accretive empirical and anecdotal evidence that some therapists are more effective than others and that some therapists are certainly more effective with certain client characteristics and with 140

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certain presenting problems. Wampold (2001) in an excellent review suggests that therapist effects are larger than treatment effects and that in many cases, the therapist does precious little, but what she or he does is very precious. Change is greatest when the therapist is skillful and provides trust, acceptance, acknowledgement, collaboration, and respect for the client in an environment that supports risk and maximizes safety. The therapeutic alliance. The client–therapist working alliance has been conceptualized in a variety of ways. Bordin (1979) suggested the alliance is composed of three elements: bonds (the affective quality of the client–therapist relationship that includes dimensions like trust, caring, and involvement); tasks (the extent to which the client and therapists are both comfortable with the major activities in therapy and the client finds them credible); and goals (the extent to which the client and therapist are working toward compatible goals). Hope and expectancy. Clients come to therapy because they have lost hope or have a depleted morale. Hope, or helping clients to think differently about their self and family system, can help open the space necessary for change to occur. Howard, Moras, Brill, Martinovich, and Lutz (1996) stressed the importance of moving a client from demoralization to remoralization by tapping into hope and positive expectations early in treatment. Interventions (behavioral, cognitive, affective) that cut across all models. Behavioral interventions essentially consist of changing the “doing.” They occur when therapists facilitate clients’ changing interactional patterns or dysfunctional sequences, modifying boundaries and changing family structures, learning new skills, becoming more supportive of each other, and learning to empower self and others. Cognitive interventions change the ways in which clients view problems and their life situations. They occur when therapists facilitate clients gaining new perspectives (new meanings) about interactional processes within themselves and the family, between the family and other systems, and across generations. Affective interventions impact emotional experiencing and regulation. In MFT, they occur when therapists facilitate clients regulating or experiencing emotions and making emotional connections with themselves, the therapist, and (most importantly) each other. Allegiance of the therapist or researcher. As long as it does not hinder the therapist from being flexible and responsive to the needs of the client system, allegiance to an approach may bring hope and confidence to the clinical work. You must fully believe in or “buy” what you are doing before you can credibly “sell” it to a client. In his meta-analytic research, Wampold (2001) presents compelling empirical proof that allegiance effects account for significantly more of the outcome variance in psychotherapy than the choice of the actual treatment model. Feedback. In addition to the above list, it has been recently argued that providing organized feedback to clients is yet another common element associated with successful psychotherapy (Halford et al., 2012). Multiple studies have documented significant improvements in both retention in and outcome from treatment when therapists have access to formal, real-time feedback from clients regarding the process and outcome of therapy (Anker, Duncan, & Sparks, 2009; Harmon et al., 2007). Michael Lambert’s research (2010a,b) also has demonstrated that utilizing systematic feedback, potentiating common factors such as the therapeutic alliance and other client variables, consistently improves therapy outcomes and can greatly improve treatment effectiveness for clients at risk of treatment failure. Given the importance of these findings both on initial engagement and overall therapeutic outcome, it makes sense to teach MFTs early in their careers to become proficient in receiving and processing feedback with clients around these important common factors to strengthen the therapeutic alliance and keep therapy focused. Common Factors Unique to MFT While an understanding of these seven common factors is inclusive enough to be applied to all modalities and types of psychotherapy approaches, there are certain common factors only associated with MFT. Specifically, we believe it is important throughout the curriculum to emphasize the following four common factors unique to MFT: (a) conceptualizing difficulties in relational terms, (b) disrupting dysfunctional relational patterns, (c) expanding the direct treatment system, and (d) expanding the therapeutic alliance (Sprenkle & Blow, 2004a,b; Sprenkle, Blow, & Dickey, 1999; Sprenkle et al., 2009). April 2015

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Conceptualizing difficulties in relational terms. While not denying the role of biology or intrapsychic causation, most MFTs would conceptualize a client problem within a complex web of reciprocal influences. Essentially, the translation of human difficulties into relational problems involves seeing problems through systemic lens, a core foundation of the field. Disrupting dysfunctional relational patterns. The flip side of seeing a conflict in relational terms is subsequently intervening to disrupt the cycle while in session. Davis and Piercy (2007a,b) concluded that therapists help clients to both disrupt and later process their respective parts in negative interactional sequences using a combination of behavioral, cognitive, and affective interventions. Expanding the direct treatment system. Many family therapists tend to push to involve more people than the immediate client/s directly in treatment (Pinsof, 1995). These include persons not physically present in treatment, but who affect the problem in important ways. For example, after doing family-of-origin work with an adult son, the client is ready to work on his relationship with his aging mother. The therapist expands the system to conduct this dyadic session, as the mother moves from the indirect into the direct client system. Expanding the therapeutic alliance. The expanded therapeutic alliance accounts for the complexity of the different interpersonal subsystems relevant to the therapy. For example in the case of family therapy with two parents and two teen siblings, the therapist forms an alliance not only with each member of the family individually, but also with certain subsystems (i.e., co-parents, children), and with the family as a whole (Pinsof, 1995).

EXAMPLES OF COMMON FACTORS INSPIRED CURRICULA Each of the authors of this article considers himself to be a common factors scientist–practitioner, balancing his time between clinical research, practice, and the training future MFTs at both the master’s- and doctoral-level. The following are brief descriptions of common factors-oriented courses from MFT training programs. While each unique in its own way, all are designed with the same goal in common—to facilitate student integration of common factors into their professional development through direct feedback, critical thinking exercises, self-reflective questioning, and clinically relevant, applied assignments. Common Factors Supervision (University of Louisville) Common factors supervision is based on the belief that no one theory is always effective when working with a client system. Rather than focusing on mastering a specific model in first-year supervision, the common factors framework is used primarily to get students comfortable with hypothesizing and conceptualizing about the various client, therapist, and relationship factors at play in a particular case (Karam, 2011). For instance, each student prepares by reflecting on the following common factors inspired questions listed below in Table 1 before presenting a new case to the supervisor and other peers. Students receive ongoing feedback and supervision on how to activate common factors such as building/repairing the therapeutic alliance, nurturing hope, and facilitating client motivation. They also receive peer and supervisor input on “way of being,” paying close attention to moments when they are attuned to clients and being their authentic selves, as opposed to times in a therapy session when they are disconnected or out-of-sync with the client’s experience (Fife, Whiting, Bradford, & Davis, 2014). Special attention is given to conceptualizing client difficulties in relational terms, and hypothesizing about dysfunctional relational patterns and cycles by focusing on the following supervisory questions listed below in Table 2 that tap into common factors unique to MFT. In second year or advanced supervision, there is an increased emphasis on studying your interventions through a common factors lens. By examining data from actual sessions, students explore behavioral, cognitive, and affective components of their interventions that help clients to slowdown their cycle, observe their own process, and take personal accountability for their part in the systemic problem (Davis & Piercy, 2007b).

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Describe your client’s a sense of hope about this therapy? Describe your own sense of hope about this therapy?

How did you convey a sense of hope during the session? What are the client system’s expectations about situation and the therapy?

What are the goals for this therapy?

Please explain how the tasks or structure of the therapy a good fit for the client system

Did you find yourself liking the client system or were they difficult to tolerate?

Do you feel the client system felt comforted in your presence and safe enough to disclose important information?

What personal What are the client system characteristic do you strengths (self-identified vs. bring into this therapy other identified) in this that you think will therapy? benefit your client system? How do you know What has been helpful in the whether your past for your client system in conceptualization of dealing with the issue(s) that the problem matches has brought them to therapy? that of the understanding of your client system? How did you decide What stage of change is each how active versus how member of the system in passive to be in the (Precontemplation, session? Contemplation, Preparation, Action, or Maintenance) at the onset of therapy? How did you adapt to What resources exist to benefit the client system the client in both the direct during the session? and indirect systems? What caused your shift?

Hope/ Expectancy

Therapeutic Alliance

Client

Therapist

Table 1 Supervision Questions: Broad Common Factors

Is your approach coherent and organized enough to give you confidence that you know what you are doing with this client system? Why do you believe your approach will work with this client system?

Allegiance

How did you use What modifications, if any, assessment will you need to make to instrument/ your approach in order to tracking work with this client instrument to system? provide feedback? What other sources How did you present your of information approach to instill will you need to confidence in the client gather feedback system? from the indirect system?

What feedback did you share with client system?

What feedback did the client system give you?

Feedback

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•

•

What is this client system’s problem cycle? How do you see each member in the system contributing to the problem cycle?

Conceptualizing Difficulties in Relational Terms

•

What techniques and interventions have you used to disrupt the client system’s dysfunctional relational patterns?

Disrupting Dysfunctional Relational Patterns

•

•

•

Expanding the Therapeutic Alliance

Who are the Describe the alliance you feel you have with: important players in the indirect cli• Each individual member of the system. ent system? • All family members directly involved in How do you the therapy (direct system) believe these peo• Client system’s support network not directly involved in therapy (i.e., the ple will impact indirect system) the therapy? Who else should • Your therapeutic support network be involved assisting you with this case (i.e., superdirectly in the visors, supervision members, co-theratherapy? Why pist, etc.) now?

Expanding the Direct Treatment System

Table 2 Supervision Questions: Common Factors Unique to Marriage and Family Therapists

MFT Theory and Practice Integration Capstone (University of Louisville) It is not unusual for a beginning therapist-in-training to haphazardly pick techniques to use in session without any overall theoretical rationale. This is known as syncretism, wherein the student searches for anything that seems to work, often making no attempt to determine whether the therapeutic procedures are either appropriate or effective (Lazarus, 1996). While we believe this syncretistic confusion is completely developmentally normal for young therapists, it is our goal by the end of this capstone integration course in a master’s program for students to have developed a more purposeful way of working by developing a personalized approach to common factors integration. Before adopting ideas from various therapeutic models, students are taught to evaluate critically these ideas to discern between what is model-specific versus what is more generic and inherent to all good therapies. Specific projects in this course include the following: (a) an assignment that requires students to practice expanding the direct system when clinically necessary, (b) a common factors integrative treatment plan and case study, and (c) the “Tower of Babel” assignment that requires students to highlight how different models have used their own proprietary language to describe similar, generic, therapeutic interventions and processes. As the culminating project prior to graduation, students are required to develop an integrative theory of change paper and videotaped representation of their work, using the common factors as a template in which to think about their preferred theoretical orientation. This capstone assignment is designed to be a critical evaluation of how the common factors have influenced the student’s clinical development (Karam, 2011). Common Factors Feedback (The Family Institute at Northwestern University) Marriage and family therapists researchers/educators at the Family Institute at Northwestern University developed two linked, common factor-based systems for measuring client change, providing feedback of that change to the therapist, and identifying therapist, client, and relationship level common factors. The systemic therapy inventory of change (STIC) tracks clinical change through the use of online self-report questionnaires in multiple systemic domains—individual adult, couple, family/household, and child functioning. Lastly, STIC addresses another universal common factor by monitoring the client’s experience of the therapeutic alliance. Designed as a companion instrument to the STIC, the Integrative Therapy Session Report (ITSR) is a therapist self-report instrument that provides a clinically meaningful and statistically reliable picture of what occurred in a recently completed session and could provide students and clinical supervisors with data about both therapist common factors and interventions that cut across models (Pinsof et al., 2009). The Internet-based system through which therapists access their clients’ STIC & ITSR data and receive real-time feedback is currently being used by more than 75 MFT students being trained at The Family Institute at Northwestern, as well as a number of faculty and other therapists in surrounding community mental health agencies. The feedback technology provides bar graphs with clients’ absolute initial scores and change profiles on clinically relevant scales and subscales over the course of therapy. Students may access STIC & ITSR data about their clients at any point during therapy to use either in session or in supervision (Pinsof, Goldsmith, & Latta, 2012). The Research-Informed Clinician (Purdue University) Although many MFT practitioners will not go on to create original research of their own, students should be critical consumers of research findings and respect empirical evidence that can contribute to clinical effectiveness. The research-informed clinician curriculum (Karam & Sprenkle, 2010) was designed to address the gap between clinical research and practice in MFT training programs. A “research-informed” perspective as opposed to the scientist–practitioner framework focuses on concrete ways for MFT master’s students to integrate research findings into their clinical practice. Along with learning about other forms of evidence-based practice, this practical MFT research course is designed to give students an understanding of the empirical underpinnings related to change. For example, the science behind the common factors is emphasized throughout the curriculum, including exploring evidence from important meta-analytic studies that demonstrates in psychotherapy who offers the treatment is typically more potent than the treatment itself April 2015

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(Blow et al., 2007; Wampold, 2001). In addition to understanding the importance of these therapist factors, students are exposed to alliance and client motivation research. Students are also given the opportunity to experiment with progress research/feedback instruments to track client change over time (See Karam & Sprenkle, 2010 for a complete description of the course). Doctoral Sequence on Common Factors and Change Mechanisms (Michigan State University) At the doctoral program in Couple and Family Therapy at Michigan State University, students take two semester long classes focused on change. One focused on common factors and change mechanisms/principles, and the other focused on evidence-based therapies. The common factors course includes an overview of all of the common factors literature in both psychotherapy and MFT-specific areas. A signature assignment in this class is for students to incorporate varying feedback instruments into their clinical work and to write an in-depth analysis related to how this feedback enhanced their work with clients. Therapists are required to implement feedback mechanisms with individual clients as well as couples and families. In the second course, students deconstruct evidence-based therapies through a common factors lens by looking at factors such as researcher allegiance and model organization/coherence. Another assignment invites critical analysis of similarities/differences between leading empirically supported MFT models. Common Factors in Couple and Family Therapy Doctoral Course (Alliant International University ~ Sacramento Campus) The common factors class at Alliant International University’s Sacramento campus begins by familiarizing students with the current state of the common factors (Sprenkle et al., 2009) and principles of change (Christensen, Doss, & Atkins, 2005) literature. The remainder of the course focuses on having students develop critical thinking skills in this area by writing a paper about what they believe are principles of change evident across models and in their own work. Students also write a paper outlining what they believe are common relational processes addressed by various models. Students also find video clips from their own practices that demonstrate these common processes. Students leave the class with the ability to identify common factors and principles of change across various models, and know how to work across models to the benefit of diverse clients.

CHALLENGES TO COMMON FACTORS INTEGRATION INTO MFT CURRICULA Although it is difficult to argue the potential benefits that exist when common factors are taught alongside specific models, still we expect some hesitation and potential criticism from existing structures and stakeholders in the MFT field. Below we respond to what we believe will be some of the greatest challenges to this form of common factors integration. Faculty Buy-In Modifying a curriculum that has been previously identified by a model-specific culture cannot be achieved by one faculty member alone, but must be a shared effort. Therefore, faculty buy-in and engagement in creating a common factors inspired curriculum are essential. Without this support, it may send a confusing or inconsistent message to students. Faculty meetings would be an appropriate venue to discuss integrating a common factors perspective into the curriculum. Framing this endeavor as a curriculum modification rather than a wholesale curriculum change initiative may enhance buy-in. In garnering this faculty support, it also may be helpful to ask faculty where they can incorporate common factors into their existing course structure. Identifying intersections with other courses and substantive MFT content areas adds synergy to the curriculum and also helps overcome the resistance to “adding one more thing” to an already-crowded syllabus. In general, faculty members are more likely to implement changes that are seen as enriching or strengthening their courses and supporting COAMFTE core competencies rather than replacing or competing with what they have traditionally taught. From attending to their suggestions, we learn more about a faculty member’s own teaching passions and build collaborative, rather than adversarial, collegial environment. 146

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Model-Specific Nature of Professional MFT Licensure Exam Another factor that may constrain educators’ ability to support this common factor curriculum integration is the manner which potential practitioners are evaluated to enter the profession of marriage and family therapy. Because professional licensure exams still give weight to knowledge of the classical models and their progenitors, the moderate common factors approach aims to guide the therapist-in-training in a “both/and” approach to integrative learning about the theory and practice of MFT. The student should learn about the specific techniques associated with classic MFT schools and models, but also appreciate unifying ties that bind all effective relational therapies. Adaptation of Feedback Instruments Some changes can be simple such as adding the use of feedback measures to training. As increasing support for formalized feedback grows, it is a disservice to not offer this aspect in all clinical work. Although we have argued about the inclusion of outcome informed, real-time feedback instruments as a part of a common factors curriculum, they are several challenges that should be addressed before adding this component. Despite a growing research base suggesting that collecting client feedback improves therapy outcome (Duncan, 2010; Duncan, 2004), a majority of clinicians do not routinely utilize outcome measures in clinical practice (Hatfield & Ogles, 2004), especially after leaving their graduate or training program. In fact, a survey conducted by Hatfield and Ogles (2004) found that only 37% of surveyed clinicians routinely used some form of outcome measurement. Multiple reasons have been reported for why this is the case, including some seeing the task as too time-consuming, adding too much paperwork, or adding additional burden to the client (Hatfield & Ogles, 2004). Most of these critiques are quickly overcome when therapists begin to use these measures. Other clinicians have acknowledged that outcome measurement is not implemented as they do not see it as relevant or helpful in clinical practice (Hatfield & Ogles, 2004). Again, the growing body of research evidence seems to contradict this claim. To promote engagement and counter the argument that these feedback studies are long and take up valuable therapy time to complete, it has been found that therapists may be more likely to use feedback instruments if they take no more than 5 min to complete, score, and interpret (Duncan, 2004). Karam and Sprenkle (2010) contend that students could be energized by this technology if they see faculty members and supervisors use feedback measures in clinically relevant and practical ways with their own cases and course examples. It may also help if faculty used similar feedback mechanisms as they engage with students in supervision and in course work. Ongoing Debate Within the Field of Mental Health Students will be entering a professional world where scientific inquiry still gives preference to specific ingredients and pure models. Although we see a moderate common factors view as an inclusive and useful framework for all MFT training programs, we believe students should understand both the history and controversies within the field (Karam & Sprenkle, 2010). For instance, Sexton, Ridley, and Kleiner (2004) believe that common factors are too general and that therapists should use manualized approaches or pure models of change for guidance and direction. In another example, the contextual model that is in alignment with a common factors perspective is contrasted with the medical model more typically associated with RCT research (Wampold, 2001). Students can engage critical thinking skills when they are exposed to opposing views and debates within the field around common factors versus specific ingredients. Faculty should help individuals form their own opinions around this issue and challenge students to weigh the pros and cons of the common factors debate in both class assignments and interactive discussions.

CONCLUSION What do our beginning trainees need to know in order to grow into effective therapists, remain clinically relevant in the marketplace, and think critically about what really works in therapy? In an attempt to respond to this question, we have presented a rationale and given specific examples of how common factors could be infused throughout MFT training programs. What we have provided here are some of our suggestions, but we do not want to sound as if we have all of the April 2015

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answers precisely figured out. Rather, our aim was to continue the dialogue within the field as to what is important in training the next generation of MFTs. We acknowledge that competent integration only comes about after years of clinical work, practical application of multiple theories with different clients, supervision, self-of-the-therapist work, and other countless formative experiences. For this reason, we argue at the beginning of training for using the “both/and” approach of teaching common factors alongside specific models for MFT students. If instilled early in training process, this approach can lay a strong foundation for personal integration and critical thinking that will deepen as the therapist matures, keeping both the individual and profession responsive to change and vital for years to come.

REFERENCES Alexander, J., Pugh, C., & Parsons, B. (1998). Blueprints for violence prevention: Book 3. Functional family therapy. Denver, CO: C&M Press. Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693–704. Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298–317. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252–260. Christensen, A., Doss, B. D., & Atkins, D. C. (2005). A science of couple therapy: For what should we seek empirical support? In W. M. Pinsof & J. Lebow (Eds.), Family psychology: The art of the science (pp. 43–64). Oxford/New York: Oxford University Press. Dattilio, F. M., Piercy, F. P., & Davis, S. D. (2014). The divide between “evidenced-based” approaches and practitioners of traditional theories of family therapy. Journal of Marital and Family Therapy, 40, 5–16. Davis, S. D., & Piercy, F. P. (2007a). What clients of couple therapy model developers and their former students say about change, part I: Model-dependent common factors across three models. Journal of Marital and Family Therapy, 33(3), 318–343. Davis, S. D., & Piercy, F. P. (2007b). What clients of couple therapy model developers and their former students say about change, part II: Model-independent common factors and an integrative framework. Journal of Marital and Family Therapy, 33, 344–363. Duncan, B. L. (2010). Getting in the zone: Accelerating your development. In B. L. Duncan (Ed.), On becoming a better therapist (pp. 95–122). Washington, DC: American Psychological Association. Duncan, B. L., Miller, S. D., & Sparks, J. (2004). The heroic client: Principles of client directed, outcome -informed therapy (revised). San Francisco: Jossey-Bass. Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40, 20–33. Fraser, J. S., Grove, D., Lee, M. Y., Greene, G. J., & Solovey, A. (2014). Integrative families and systems treatment (I-FAST): A strengths-based common factors approach. New York: Oxford University Press. Fraser, J. S., & Solovey, A. D. (2007). Second-order change in psychotherapy: The golden thread that unifies effective therapies. Washington, DC, APA Books. Fraser, J. S., Solovey, A., Grove, D., Lee, M. Y., & Greene, G. (2012). Integrative families and systems treatment: A middle path towards integrating common and specific factors in evidence based family therapy. Journal of Marital and Family Therapy, 38(3), 515–528. Halford, K., Hayes, S., Christensen, A., Lambert, M., Baucom, D., & Atkins, D. (2012). Toward making progress feedback an effective common factor in couple therapy. Behavior Therapy, 43, 49–60. Harmon, S., Lambert, M., Smart, D., Hawkins, E., Nielsen, S., Slade, K., et al. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17, 379–392. Hatfield, D. R., & Ogles, B. M. (2004). The use of outcome measures by psychologists in clinical practice. Professional Psychology: Research and Practice, 35, 485–491. Henggeler, S. (1998). Blueprints for the prevention of violence: Book 6. Multisystemic therapy. Denver, CO: C&M Press. Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of psychotherapy: Efficacy, effectiveness, and patient progress. American Psychologist, 51(10), 1059–1064. Hubble, M. A., Duncan, B. L., & Miller, S. (1999). Directing attention to what works. In M. A. Hubble, B. L. Duncan & S. Miller (Eds.), The heart and soul of change: What works in therapy. Washington, DC: The American Psychological Association.

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Karam, E. A. (2011). Integrating common factors into a MFT curriculum. Family Therapy Magazine, 10(5), 32–34. Karam, E. A., & Sprenkle, D. H. (2010). The research informed clinician: A guide to training the next generation MFT. Journal of Marital and Family Therapy, 36, 307–319. Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of Psychotherapy Integration (pp. 94–129). New York: Basic. Lambert, M. J. (2010a). Prevention of treatment failure: The use of measuring, monitoring, and feedback in clinical practice. Washington, DC: American Psychological Association. Lambert, M. J. (2010b). Yes, it is time for clinicians to routinely monitor treatment outcome. In B. Duncan, S. Miller, B. Wampold & M. Hubble (Eds.), The heart and soul of change: Delivering what works in treatment (pp. 239– 266). Washington, DC: APA Press. Lazarus, A. A. (1996). The utility and futility of combining treatments in psychotherapy. Clinical Psychology: Science and Practice, 3(1), 59–68. Lebow, J. (1997). The integrative revolution in couple and family therapy. Family Process, 36(1), 1–17. Lebow, J. L. (2013). Couple and family therapy: An integrative map of the territory. Washington, DC: American Psychological Association. Levesque, D. A., Prochaska, J. M., & Prochaska, J. O. (1999). Stages of change and integrated service delivery. Consulting Psychology Journal: Practice and Research, 51(4), 226–241. Liddle, H. A. (1999). Theory development in a family-based therapy for adolescent drug abuse. Journal of Clinical Child Psychology, 28(4), 521–532. Nelson, T. S., Chenail, R. J., Alexander, J. F., Crane, D. R., Johnson, S. M., & Schwallie, L. (2007). The development of core competencies for the practice of marriage and family therapy. Journal of Marital and Family Therapy, 33 (4), 417–438. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48, 98–102. Northey, W. F. (2002). Characteristics and clinical practices of marriage and family therapists: A national survey. Journal of Marital and Family Therapy, 28, 487–494. Orlinsky, D. E., & Rønnestad, M. H. (2005). How psychotherapists develop: A study of therapeutic work and professional growth. Washington, DC: American Psychological Association. Pinsof, W. M. (1995). Integrative problem-centered therapy: A synthesis of family, individual, and biological therapies. New York: Basic Books. Pinsof, W. M., Goldsmith, J. Z., & Latta, T. A. (2012). Information technology and feedback research can bridge the scientist–practitioner gap: A couple therapy example. Couple and Family Psychology: Research and Practice, 1 (4), 253–273. Pinsof, W. M., Zinbarg, R. E., Lebow, J. L., Knobloch-Fedders, L. M., Durbin, E., Chambers, A., et al. (2009). Laying the foundation for progress research in family, couple, and individual therapy: The development and psychometric features of the initial systemic therapy inventory of change. Psychotherapy Research, 19(2), 143–156. Sexton, T. L., Ridley, C. R., & Kleiner, A. J. (2004). Beyond common factors: Multilevel-process models of therapeutic change in marriage and family therapy. Journal of Marital and Family Therapy, 30, 131–150. Shadish, W. R., & Baldwin, S. A. (2003). Meta-analysis of MFT interventions. Journal of Marital and Family Therapy, 29, 547–570. Shadish, W. R., Ragsdale, K., Glaser, R. R., & Montgomery, L. M. (1995). The efficacy and effectiveness of marital and family therapy: A perspective from meta-analysis. Journal of Marital and Family Therapy, 21, 345–360. Simon, G. M. (2006). The heart of the matter: A proposal for placing the self of the therapist at the center of family therapy research and training. Family Process, 45, 331–344. Sprenkle, D. H. (2012). Intervention research in couple and family therapy: A methodological and substantive review and an introduction to the special issue. Journal of Marital and Family Therapy, 38(1), 3–29. Sprenkle, D. H., & Blow, A. J. (2004a). Common factors and our sacred models. Journal of Marital and Family Therapy, 30, 113–129. Sprenkle, D. H., & Blow, A. J. (2004b). Common factors are not islands – they work through models: A response to Sexton, Ridley, and Kleiner. Journal of Marital and Family Therapy, 30, 151–158. Sprenkle, D. H., Blow, A. J., & Dickey, M. (1999). Common factors and other nontechnique variables in marriage and family therapy. In M. A. Hubble, B. L. Duncan & S. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 329–360). Washington, DC: The American Psychological Association. Sprenkle, D. H., Davis, S., & Lebow, J. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.

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