21st Century, the Term Marriage

¶ … 21st century, the term marriage and family therapy (MFT) seems as if it was long available as a principle means of treatment. In the timeline of psychotherapy, however, it is relatively young. During its brief tenure, the field has undergone a number of changes that continue to this day. In fact, several experiential family therapy modalities are resulting in significant results in outcome studies. One of these newer couples therapies, developed by Susan Johnson and Leslie Greenberg, is called emotionally focused therapy (EFT). It is based on an attachment model of adult intimacy and addresses essential emotional responses and interactions to enhance relationships. In contrast to the traditional "emotion contrast therapy," EFT regards many unpleasant emotions as sources of useful information. Furthermore, EFT is being recognized for its integrative approach. It adds to cognitive therapy with a focus on the constructive aspects of specific emotions; to the psychoanalytic therapies through an emphasis on the present day rather than the past as well as on how problems are produced in addition to why; and to interpersonal psychotherapy with a stress on the self and the importance of past interpersonal relations. Lastly, EFT is gaining in support by both clinicians and patients due to its emphasis on productive means of training and supervision. It is in the process of developing a supervision model, which, unlike those developed by other MFT therapies in the past will be based on efficacy of supervision in addition to the degree of instruction on the specific therapy.

Marriage and family therapy (MFT) arose after the establishment of two separate schools of thought: Sigmund Freud's psychoanalysis and Carl Rogers' client-centered therapy, which were both predicated on the basis that psychological problems arise from unhealthy interactions with other individuals and could thus be resolved with private relationships between patient and therapist.

Broderick and Schrader's (1981, 1991) classic tracing of the history of marital counseling identified four distinct phases; Phase I (1929-1932), the "Pioneer" stage, dominated by a small handful of forward-lookng practitioners; Phase II (1934-1945), the "Establishment" stage, signaled by the formation of the American Association of Marriage Counselors (AAMC); Phase III (1946-1963), the "Consolidation" stage, leading to the first legal recognition of the marriage counseling profession (in California, in 1963); and Phase IV (1964-1978), the "Formative" stage, marked by the building of a professional literature, an occasional effort at scientific study, and what L'Abate and McHenry (1983, p. 3) called "intense growth and clarification of standards and competencies" for training and practice.

Despite appearing interested in the emotional welfare of partners, early marriage counselors infrequently met in what is now considered the usually preferred format of conjoint interview. In 1963, 30 years after the supposed beginning of the profession, Michaelson estimated from the case records of the three major marriage and family clinics in the United States that, in the 1940s, only 5% of marriage counselors' cases met conjointly, rising to 9% during the 1950s and to only 15% in 1960. By the mid-1960s, clinicians who primarily identified themselves as marital therapists normally used the conjoint format in couple cases, while those who practiced marital therapy in other mental health disciplines still were divided between conjoint and individual approaches (Alexander, 1968). It was not until the end of the '60s that Olson (1970), in the field's first comprehensive analytical review, identified the "predominant use of the technique of conjoint therapy" (p. 503).

Although MFT had agreed on the conjoint approach of therapy, the field was "seriously lacking in empirically tested principles, and it is without a theoretically derived foundation on which to operate clinically" (Olson, p. 503). Likewise, Broderick and Schrader (1981) found a "lack of clear commitment to any particular clinical philosophy" (p. 12). And Manus (1966) clearly stated that marriage counseling was a mere "technique in search of a theory" (p. 449).

From the 1960s, MFT evolved from a psycholanalytic into a clinical perspective. The list of these early therapists included Jay Haley, Salvador Minuchen, Virginia Satir, Carl Whitaker, Murray Bowen, Nathan Ackerman, Ivan Boszormenyi-Nagy and James Framo. Training institutes and academic programs through established marital organizations and universities also began developing at this time. Changes in the field continued throughout the 1980s and 1990s (Locke, 184).

One of the major pioneers in MFT, who had particular impact on the development of the emotionally focused therapy was Murray Bowen. Similar to other founders of family and marital therapy, Bowen was a psyschiatrist who specialized in schizophrenia. More so, however, he emphasized theory in his practice that made a major impact on the philosophy of MFT. Bowen's major interest was mother-child symbiosis, which led to his concept of "differentiation of self." This was the act of being autonomous from others and independence of thought from feeling. If parents rear emotionally healthy children, those children will develop a strong differentiation of self. This concept is defined as the ability to balance emotional and intellectual influences in cognitive functioning, as well as intimacy and autonomy in relationships (Bowen, 1978). A related concept is that people will tend to select a partner with a level of differentiation of self similar to one's own. It follows that if the relationship is to change, both partners will need help in achieving an increase in their level of differentiation. He expanded the mother-child symbiosis to include fathers, leading to the idea of "triangulation" or diverting conflict between two people by involving a third (Nichols 42).

At first, Bowen provided individual therapists for each family member, but found that this approach divided families (1976). He thus began treating families together and thus came about family therapy. Bowen was struck by the family members' intense emotional reactivity, where feelings completely overwhelmed indiviudals over objective thought. It was Bowen who introduced the therapist's own genogram as part of the training as a need to reflect on the person of the therapist in interaction with the client. For psychotherapy.

Bowen's basic concepts of theory were organized into eight interconnected variables: the emotional system with its variation in the counterbalance between togetherness and individuality; levels of differentiation of self; mechanisms of reactivity in the nuclear family; triangles; multigenerational transmission process; sibling position; anxiety, chronic and acute; and emotional cut off. No one concept could be explained by another. No one concept could be eliminated or isolated from the theory. Clinical families, Bowen's own family system, and all of human society were studied within the framework of theory.

Partners therapy in general and emotionally-focused therapy in specific also is based on the work developed 50 years ago by John Bowlby. As a psychiatrist, Bowlby worked with the World Health Organization to study the psychological adjustment of babies and children orphans for World War II. Based on studies from worldwide cultures, Bowlby concluded that humans have an innate desire for attachment or personal trust and security. Children have needs for attachment with at least one parent, and adults have these needs with a romantic partner. When children do not have the ability to get attachment figures to respond to them and their needs, they will do whatever possible to get that response. Children who do not feel their parents care, for instance, will become rebellious or withdrawn and depressed.

Related to the attachment theory were the relationships between adults that developed in the 1970s with bereavement studies (Bowlby and Parkses, 1970) and marital separation (Weiss, 1973 and 1977) (see Goldberg 71). This grew into a larger idea of marital relationships (Weiss, 1982 and 1991).

Johnson has found that attachment distress in couples might arise when one partner is unsupportive or emotionally unavailable, causing the other to experience insecurity. In emotionally focused therapy, any attachment ruptures between "distressed" partners are called "attachment injuries," If one partner withdraws after the other gets fired from a lucrative position and cannot help support the family, it can lead to attachment injury and a break in trust that could damage the marriage relationship.

Up to this point, this paper has dealt with the development of therapy modalities for the patients. Hand-in-hand with these models came frameworks for the training and supervision of the MFT professionals. It was recognized early on that the therapists had to understand and be immersed in the particular form of therapy. According to Liddle, early in the history of family therapy, training was fairly homogeneous (1988, 3). It was not characterized by clearly articulated curricula and objectives. In the 1970s to 1980s, training and supervision grew, with each approach having its own educational specifics, conferences, books, and so forth.

There was a tremendous heterogeneity of goals and objectives due to who was being trained, in what context and the specific modality being studied. The characteristics of the individuals conducting the training and those being trained also impact the type of family therapy training. Presently, the concept of training is all the more complex because of the increased complexity of the Western society and the role that potential marriage disillusionment occurs.

When Liddle's book was written in 1988, he noted, "Today the training and supervision sybsystem has become vital to the family therapy field because it transfits the field's values, body of knowledge, professional roles and skills to the new clinicians" (5). Further, "Just as the models of family therapy are, unsurprisingly, isomorphically represented in their corresponding training models and methods, so the development of the clinical reality of family therapy can serve as a methaphor for the training and supervision area."

However, in 1988 MFT was truly in its earliest states and not much time had gone by since supervision and training was mostly something that was done and not giving forethought on the "how's." Training and supervision were taken for granted; supervisors and clinicians were placed in positions without much prior preparation; and assessment for clinicians, let alone their supervisors, was almost nil.

Yet why was there a need for such training? Liddle compared the beginning of therapy with that of training. Each had to start off on the right foot. Although supervision can easily be defined in a narrow sense -- as the process of teaching a clinician how to conduct therapy -- it has much broader ramifications. Effective supervision prepares trainees for their career as well as upgrades the profession and promotes the field. It can help therapists launch their professional lives toward the highest possible point of self-esteem in terms of maturity, training and experience (154).

Conversely, trainees who consistently have ineffective instructors are at considerable risk of providing inadequate service to their clients and tarnishing their own and profession's standing. Importantly, "supervision thus involves significantly more than the mere transmission of technical information or clinical skills: it challenges participants both personally and intellectually in a context in which the best and worst of a supervisor's or therapist's individual style can emerge" (154).

Even in 1988, despite Liddle's optimism for such supervisory techniques as live and video and individuals behind the mirror there was still "an uncertainty, a lack of standards and guidelines, and a lack of consensus on how best to train and supervise (5)."

Most of the MFT training and supervision in the 1980s was "top down." The supervisor would bestow his/her so far gained knowledge to the trainees. There would be little if any dialogue and two-way give-and-take.

According to Liddle, Bowen approached this inadequacy as he did his therapy. "One cannot attempt to convey the essence of the training regimen without first addressing the basic ideas themselves" (62). With Bowen's approach, noted Liddle, "training is seen essentially as a person-to-person effort, with the instructor having as much to learn as the learner. In a sense the training process becomes a dialogue between engaged minds..." (71). The instructor must be close enough to the student to have an impact, but separate enough not to interfere. "In short, the instructor, along with the learner, continually works on differentiation of self."

In recent years, the thrust for supervision and training has expanded on Bowen's underlying premise. Several studies in the '90s for example, (Bernard & Goodyear, 1992; Holloway, 1995; Holloway & Neufeldt, 1995) noted it is better to understand how supervisors can be trained to do supervision effectively rather than focusing only on how supervision is done and "in a review of the efficacy of supervision, (they) concluded that the effects of specific supervisory interventions to therapist and client change in behavior remained largely unknown."

Likewise, it may be more important to see what factors can limit the effectiveness of training than being concerned about the actual therapy approach. Goodyear et. al (1998) wrote that there are "three especially important barriers to drawing solid inferences from supervision research about the effectiveness of particular approaches: considering 'supervision' and 'training' as interchangeable interventions, an absence of efficacy research in supervision, and a reliance on satisfaction measures for outcomes."

The first challenge to comprehending the effectiveness of a specific supervision approach is that researchers often confuse supervision with training. In numerous reviews of the literature, authors have lumped supervision with training of this type as if they were the same. The second barrier is to determine the supervision approach that promotes more positive results than another necessitates comparative studies of supervisory models. However, supervision studies of this type have not been conducted.

Many psychotherapy researchers consider the 'gold standard' to be the randomized, control group experiment that is used in efficacy and effectiveness studies. Efficacy studies compare a particular treatment to a control group to answer the question 'Does this specific treatment work better than no treatment at all?' Effectiveness studies compare a treatment to one or more others and to answer the question 'How do the outcomes of this treatment compare to those in this other treatment?' (Goodyear 1998).

Goodyear continued that "There appears to be three reasons why supervision research does not have the tradition of efficacy and effectiveness studies. First, there is little theory-driven research in supervision. Second, supervision researchers do not have supervision manuals or protocols to follow to ensure that a reasonably accurate version of a model is being followed. Third, it is difficult to design research that protects clients." It would be unethical and even dangerous to assign some trainees to a supervision intervention and others to a control group where they see clients but receive no supervision.

A third barrier to determining supervision's effectiveness is the widespread dependence on satisfaction measures to assess supervision outcomes. Goodyear presented the following analogy:

imagine asking a number of people leaving a donut shop whether they were satisfied with their donuts and would be willing to return to this particular shop. Most would probably give affirming answers to both of these questions. Their answers, though, are of no use at all to someone interested in ascertaining the nutritional value of those donuts. Similarly, to ask trainees about whether they were satisfied with supervision or their supervisor gives minimal information about the "nutritional" value of their experience.

As a result, Goodyear made suggestions on how research should be conducted to determine effectiveness of training and supervision.

Differentiate Training and Supervision: Counselor educators would be well-served to more clearly differentiate the function of training from that of supervision. One reason for doing this is that the optimal conditions for training might be somewhat different than those for supervision.

Develop Profiles of Students: Sufficient information about particular trainee characteristics for counselor education programs need to be encouraged to develop profiles of students at the onset and throughout graduate training. It will not be possible to know more about training or supervision until better understanding how students' personal characteristics affect these interventions.

Conduct Effectiveness Studies: Because of the proliferation of supervision models in the past 20 years, the researcher can choose models that are distinct enough to warrant investigation.

Liddle (1988) offered some examples that could be found in research, which are seen to decrease the efficiency of training. For example, (183), due to wanting to please their supervisors, trainees will often become robots and follow the instructor's every command. This greatly limits creativity and finding new ways of helping the clients with their needs. The same result occurs if the supervisor intimidates the trainee. The latter becomes afraid of being assertive and discovering his/her own approach. In addition, sometimes the trainee has to adopt a model of MFT that is alien to his/her previous training. The emphasis is not on efficiency, here, but rather on the model itself.

Another tendency commonly involved with negative supervision deals with the isomorphic nature of the liver supervision context: interactive patterns at one level of training that tend to mirror or duplicate those at the other levels. In other words, the relationship between supervisor and trainee may resemble that between trainee and family members or those among family members themselves (Liddle & Saba, 1983 and 1985). Instructors not familiar with this tendency can become involved with escalating situations. If, however, the supervisor recognizes the isomorphic process, he/she will be able to readily notice and alter the negative situation.

The bottom line, say some present-day MFT professionals who are studying the concepts of supervision and training, it may perhaps be most productive to determine the means for the most effective training scenarios across all therapy modalities. Regardless of approach, the goal is to provide the trainees with the most positive and relevant educational experience. The stress in training should first be placed on these productive means of instruction and then secondly on teaching the specifics of the modality itself. There are sure to be principles if followed that trainees will agree offer them the best possible means for constructive therapy with their patients. These include:

Supervision works best when the mentors, supervisors, and therapists have access to and make use of a treatment manual (Corrigan & McCracken, 1997; Milne & James, 2000).

Supervision is more effective if the techniques and procedures to be used are modeled for the therapist (Bryant & Fox, 1995; Isaacs, Embry, & Baer, 1982; Kramer & Reitz, 1980; Street & Foot, 1984; West, Bubenzer, (Pinsoneault, & Holeman, 1993).

Supervision is more effective if the trainee has the opportunity to practice a procedure or technique prior to performing that behavior (Isaacs et al., 1982).

Therapist performance improves more rapidly when the therapist is observed performing therapy directly (Breunlin, Karrer, McGuire, & Cimmarusti, 1983; Liddle, 1991b; Milne, Pilkington, Gracie, & James, 2003; Street & Foot, 1984).

Case review in supervision is primarily useful for understanding the therapist's intentions and case conceptualizations (Liddle & Schwartz, 1983; McCollum & Wetchler, 1995). Sixth, supervisory feedback is most effective if the feedback is based on direct observation, is clear and specific about the therapist's learning task, task goal achievement, and limits negative statements especially if related to the person of the therapist (Kluger & DeNisi, 1996).

All supervision principles need to be carried on within a context of a strong therapist-supervisor alliance (Bordin, 1983; Efstation, Patton, & Kardash, 1990; Gill, 2001; Heatherington & Friedlander, 1990; Horvath, 2001; Ladany & Friedlander, 1995; Pinsof, 1994; Pinsof & Catherall, 1986; Solomon, 1977; White & Queener, 2003).

Supervisors need to be responsive to the person of the therapist in terms of their personal and professional histories (Mead, 1990; Wampold, 2001) where personal histories include ethnic, gender, racial, socioeconomic, and family-of-origin factors (Storm, McDowell, & Long, 2003), whereas professional histories include the therapist's knowledge of and experience using therapy theories and techniques (Mead, 1990).