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Psychotherapy Research
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25 Years of systemic therapies research: Progress and
promise
Laurie Heatherington
a
, Myrna L. Friedlander
b
, Gary M. Diamond
c
, Valentín Escudero
d
&
William M. Pinsof
e
a
Department of Psychology, Williams College, Williamstown, MA, USA
b
Educational and Counseling Psychology, University at Albany/SUNY, Albany, NY, USA
c
Department of Psychology, Ben Gurion University of the Negev, Negev, Beer-Sheva, Israel
d
Department of Psychology, Universidad de la Coruña, La Coruna, Spain
e
The Family Institute at Northwestern University, Northwestern University, Chicago, IL, USA
Published online: 15 Dec 2014.
To cite this article: Laurie Heatherington, Myrna L. Friedlander, Gary M. Diamond, Valentín Escudero & William M. Pinsof
(2015) 25 Years of systemic therapies research: Progress and promise, Psychotherapy Research, 25:3, 348-364, DOI:
10.1080/10503307.2014.983208
To link to this article: http://dx.doi.org/10.1080/10503307.2014.983208
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METHOD PAPER
25 Years of systemic therapies research: Progress and promise
LAURIE HEATHERINGTON1
, MYRNA L. FRIEDLANDER2
, GARY M. DIAMOND3
,
VALENTÍN ESCUDERO4
, & WILLIAM M. PINSOF5
1
Department of Psychology, Williams College, Williamstown, MA, USA; 2
Educational and Counseling Psychology, University
at Albany/SUNY, Albany, NY, USA; 3
Department of Psychology, Ben Gurion University of the Negev, Negev, Beer-Sheva,
Israel; 4
Department of Psychology, Universidad de la Coruña, La Coruna, Spain & 5
The Family Institute at Northwestern
University, Northwestern University, Chicago, IL, USA
(Received 3 May 2014; revised 10 October 2014; accepted 20 October 2014)
Abstract
Objective: In this article we describe and assess the state of the science on systemic psychotherapies. In the quarter century
since the first issue of Psychotherapy Research was published, considerable progress has been made. There is an increasingly
solid evidence base for systemic treatments, which includes a wide range of approaches to working conjointly with couples
and families. Moreover, there are exciting new developments that hold promise for explicating the dynamic processes of
therapeutic change in couple and family systems. Method: We begin by explaining how we view “systemic therapies” as
different from individual approaches and then summarize what we have learned in the past 25 years about this set of
treatments, how we have learned it, and what we have yet to learn. Results and Conclusions: We consider current trends
in research on outcomes and change process mechanisms, and end with speculations about what lies ahead in the
interrelated domains of systemic research and practice.
Keywords: couple and family therapy; systemic therapy; mechanisms of change; family treatment
On this 25th anniversary of the launching of Psychotherapy
Research, we assess what we have learned
about systemic therapies since 1990, how we have
learned it, and what we have yet to learn. In this
article, we consider recent research on therapeutic
outcomes and change process mechanisms, and the
significance of the current state of the science for
what lies ahead in the interrelated domains of
systemic research and practice.
The moniker systemic therapy includes a diverse set
of therapeutic interventions that on the surface may
appear to be different species, and in fact, under some
methods of categorization, might well be. Consider
that among even just a few of the systemic therapies
(e.g., emotion focused couple therapy (EFT), narrative
family therapy, multisystemic family therapy,
attachment-based family therapy (ABFT), structuralstrategic
family therapy, psychoeducational family
therapy), the foci (emotion, behavior, cognition), the
philosophical roots (objectivist, constructivist), and
the intervention styles (client-centered, therapist-centric;
directive, collaborative; depth-oriented, didactic)
diverge substantially.
What then, in 2015, do these therapies have in
common, and what defines them as different from
other therapies? Briefly, the distinguishing features
are the same features that originally defined systemic
therapies as distinct: A primary concern with shifting
the interpersonal and interactional (vs. intrapersonal)
dynamics that shape and maintain psychological
problems, and case formulations that locate and
treat problematic feelings and behaviors in the
context of dyadic, family, or wider systems. Systemic
therapists eschew linear formulations (i.e., A causes
B), preferring to work from a “meta-perspective” that
focuses on circular causal explanations of the ways in
which problems both sustain and are sustained by
patterns of interacting with important others in their
Correspondence concerning this article should be addressed to Laurie Heatherington, Ph.D., Department of Psychology, Williams College,
18 Hoxsey Street, Williamstown, MA, USA. Email: lheather@williams.edu
Psychotherapy Research, 2015
Vol. 25, No. 3, 348–364, http://dx.doi.org/10.1080/10503307.2014.983208
© 2014 Society for Psychotherapy Research
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lives. As explained by Watzlawick, Beavin, and
Jackson (1967), “If a person exhibiting disturbed
behavior (psychopathology) is studied in isolation,
then the inquiry must be concerned with the nature
of the condition and, in a wider sense, with the
nature of the human mind. If the limits of the inquiry
are extended to include the effect of this behavior on
others, their reactions to it, and the context in which
all of this takes place, the focus shifts from the
artificially isolated monad to the relationship between
parts of the system” (p. 21). Rohrbaugh (2014, p. 2)
nicely summarized the essential features of a systemic
paradigm: Circularity, context, and pattern interruption
and suggested that these features imply that systemic
theories are more concerned with how problems are
maintained interpersonally, i.e., circular causality,
rather than how and why they originated. A full
discussion of the history and distinguishing features
of systemic therapies is beyond the scope of this
article, but is well explained elsewhere (cf., Friedlander
& Diamond, 2011; Gurman, 2008; Rohrbaugh,
2014; Sexton, Weeks, & Robbins, 2003).
Just as individual therapies have evolved from
“pure” or singular approaches to more integrative
ones, so have systemic therapies. Further, while early
systemic theories and couple and family therapies
(CFTs)––and the research that attended them––
focused on observable patterns of interaction, they
have evolved to include attention to cognition (e.g.,
attributions and the ways in which individuals and
families make meaning of events), emotion, and
culture. This shift has been especially salient in the
past 25 years, as progress in basic psychological
science, e.g., research on emotion, adult attachment,
parenting, family communication in relation to psychosis,
and marital interaction (e.g., Gottman, 1999)
has become incorporated into systemic theory,
research, and practice. Although there is some disagreement
about whether such variables are truly compatible
with a systemic perspective (Rohrbaugh,
2014), many contemporary CFTs show these kinds
of influences from other approaches.
Another major change has been the accelerated
development of several broad-based, manualized
family intervention programs, which have been widely
disseminated, internationally as well as nationally.
Yet a third notable development is the increasing
integration, both theoretical and technical, CFTs that
originated as separate “schools,” each with its own
proponents and adherents (Lebow, 2013). For
example, traditional behavioral couple therapy
(BCT; Jacobson & Margolin, 1979), which paid less
attention to recurring patterns of interpersonal behavior,
was further developed as integrative behavioral
couple therapy (IBCT; Christensen, Jacobson, &
Babcock, 1995; Jacobson & Christensen, 1996),
which has a more systemic focus (and also incorporates
acceptance-based ideas).
It is thus particularly challenging to draw clear
boundaries between “systemic” and “nonsystemic”
approaches. Systemic therapy is typically, but not
always, a conjoint approach for working with couples
and families, largely because a relational perspective
on symptoms and problems leads logically to an
interest in working with all actors simultaneously. On
the other hand, systemic practice can also involve
thinking systemically in formulating cases but
working––occasionally or even exclusively––with individuals
in order to accomplish systemic change, or
working with wider systems, including multiple family
groups. Further, systemic practice includes psychoeducational
approaches in which families are seen
together for the purpose of supporting one member’s
recovery from severe and persistent disorders, e.g.,
schizophrenia and bipolar disorder. These approaches
are systemic, even though they do not postulate that
the origin of the mental illness is in dysfunctional
family interactions, in that they include assessment of
and (if needed) modification of recurring patterns of
interpersonal behavior that present challenges to
recovery and increase the likelihood of relapse.
For this reason, and because this is the only article
in the Special Issue to focus on systemic or couple/
family therapy, we included in this review not only
approaches that are most readily identified as systemic,
but also couple and family treatments that
target specific individual problems (e.g., schizophrenia)
by including the family system in the patient’s
assessment and treatment. However, given space
limitations, we focus our discussion most closely on
CFTs that have an explicitly systemic focus, i.e., those
that explicitly target interpersonal change in a conjoint
treatment format. We begin with major sections
on treatment outcomes and change processes, followed
by a discussion of advances in methods and
measures, and conclude with some speculations
about the future of systemic therapy research.
Do Systemic Therapies Work?
The Simple Answer
Over the last two decades, psychotherapy research
and practice in general have been preoccupied with
questions about the evidence base for specific treatment
approaches, i.e., does it work? With regard to
systemic CFTs, it is clear that the simple answer to
this global question is a resounding “yes.” Many
reviews and meta-analyses of CFT since 1990 have
established that, compared to no-treatment or waitlist
controls, these treatments are efficacious for a
variety of problems, and indeed more efficacious
Psychotherapy Research 349
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than individual treatments for some client concerns
(Alexander, Holtzworth-Munroe, & Jameson, 1994;
Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998;
Carr, 2014a, 2014b; Friedlander & Diamond, 2011;
Friedlander & Tuason, 2000; Sexton, Alexander, &
Mease, 2004; Sexton, Datchi, Evans, LaFollette, &
Wright, 2013; Shadish & Baldwin, 2005; Shadish,
Ragsdale, Glaser, & Montgomery, 1995).
There are of course, different standards for assessing
the evidence base of a therapy approach and
within these standards, different labels to identify the
level of research support. With regard to the most
widely used, if controversial, standards (Chambless &
Hollon, 1998), CFT fares well. Numerous CFTs are
listed on the Division 12 (Clinical Psychology) and/or
Division 53 (Clinical Child and Adolescent Psychology)
websites of evidence-based treatments as having
“strong” research support (previously called “wellestablished”
treatments) or “modest” research support,
(previously called “probably efficacious”), with
fewer labeled as “controversial,” i.e., those with mixed
results or for which the claims about how it works are
at odds with the research evidence. Table 1 displays
this information. Interested readers will find
descriptions of the treatments and research citations at
the following sites: http://www.div12.org/PsychologicalTreatments/treatments.html
and http://effectivechil
dtherapy.com/content/ebp-options-specific-disorders.
Also many couple and family treatments are included
in SAMSHA’s National Registry of Evidence-Based
Programs and Practices (http://nrepp.samhsa.gov/
AboutNREPP.aspx). This online database indexes
evidence-based treatments and rates the quality and
breath of their research support.
The More Complete, Complex, Answer
As recently noted by Sexton et al. (2013) in Bergin
and Garfield’s Handbook of Psychotherapy and Behavior
Change, the more complex, accurate answer to
the question is “yes, but …” That is, the bulk of the
CFT outcome research has focused on a rather
narrow range of systemic interventions and a specific
set of problems. For example, Multisystemic Therapy,
Functional Family Therapy, and Multidimensional
Family Therapy were designed for and applied
to co-occurring sets of youth externalizing behaviors,
i.e., antisocial behavior at school and home and
problematic substance use and abuse. These are
mature, widely disseminated, comprehensive interventions
that target multiple, intersecting social
systems (family, peers, school). Effect sizes are
generally moderate to high (with some mixed results
that depend on moderating client characteristics).
The quality of this research evidence is also high,
although it drops off a bit in clinical effectiveness
studies in the community (Sexton et al., 2013).
Similarly, there is strong evidence for the efficacy of
family psychoeducational treatments for schizophrenia
and bipolar disorder (Lefley, 2009).
Other family therapy approaches, however (e.g.,
solution-focused therapy, constructivist therapy,
Bowen therapy, narrative therapy), are virtually untested
or have comparably weaker evidence of efficacy.
Interestingly, this same assessment of the state
Table I. Empirical support, systemic therapies.
“Strong” research support/“Well-established” treatmentsa
Behavioral Couples Therapy for Alcohol Use Disorders
BFST for Disruptive Behavior Problems and Substance Abuse
Emotion-focused Therapy for Couples
Family-Based Treatment for Anorexia Nervosa (Maudsley Hospital model)
Family Focused Therapy for Bioplar Disorder (depression only)
Family-focused Treatment for Adolescents with Bipolar Disorder
Family Psychoeducation for Schizophrenia
Functional Family Therapy for Disruptive Behavior Problems and Substance
Abuse
Multidimensional Family Therapy for Substance Abuse in Adolescents
Multisystemic Therapy for Disruptive Behavior Problems and Substance Abuse
“Modest” research support/“Probably efficacious”
treatments
Behavioral Couples Therapy for Depression
Behavioral Family Therapy for Substance Abuse
BFST
Family Psychoeducation and Skill Building for (youth) Bipolar Disorder
Family-based Treatment for Bulimia Nervosa (Maudsley Hospital model)
Family Focused Group Therapy for OCD
“Possibly efficacious” treatments Family Therapy for PTSD Transitional
Family Therapy for Substance Abuse
Strengths Oriented Family Therapy
a
Sources: Division 12 & Division 53 website lists of evidence-based treatments. The Division 12 list uses the categories “strong,” “modest,”
and “controversial research” support; the Division 53 corresponding categories are “well-established,” “probably efficacious,” and “possibly
efficacious”.
350 L. Heatherington et al.
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of the science has echoed in the literature throughout
the past 25 years (Friedlander, Heatherington, &
Escudero, in press; Heatherington, Friedlander, &
Greenberg, 2005). If anything, the divide between
well researched and under-researched interventions
has widened over time as more and more research
builds for a select group of models.
A somewhat similar situation exists in the couple
therapy arena. First, overall, there is less efficacy
research on couple therapy; Sexton et al.’s (2013)
review of the 13 meta-analyses and 249 studies from
2003 to 2010 found that only 18% of the research
focused on couple (vs. family) therapy, and that
most of the research on manualized couple therapies
was conducted in university rather than community
settings. Second, most of the research, and the
strongest research, focuses on two approaches,
Behavioral Couple Therapy and Integrative Behavioral
Couples Therapy. Both are successful in
improving couple satisfaction and general mental
health, with more mixed results for symptom reduction,
depending on the disorder; for example, results
tend to be better for substance use problems in one
spouse than for depression. EFT for couples (Greenberg
& Johnson, 1988) also has strong empirical
support (Lebow, Chambers, Christensen, & Johnson,
2012). Fewer studies (only 12) examined outcomes
of general couple therapy, with 2/3 of these
studies reporting significant positive outcomes (Sexton
et al., 2013). A few other models have been
tested in single randomized controlled trials (RCTs),
including insight-oriented couple therapy (Snyder &
Wills, 1989) and integrated systemic therapy (Goldman
& Greenberg, 1992), which showed similar
successful results to existing treatments but better
maintenance over time. The latter result is potentially
important given the well-established finding
that couple therapy results in clinically significant
reductions in relationship distress, but that the effect
dissipates over time (Shadish & Baldwin, 2005;
Snyder & Halford, 2012).
The Answer is Still Incomplete
Beyond the fact that some treatments are well-studied
and others are not, our answer to the more complex
question of whether systemic therapies work is still
incomplete for several additional reasons.
Some important presenting problems are less
well-studied. The criterion for determining whether
treatments are “empirically supported” has been
symptom reduction for individual DSM disorders
(American Psychiatric Association, 2013). Although
systemic therapies can and do address dysfunctional
interpersonal patterns that sustain individual
diagnoses (e.g., couple therapy for depression), they
also focus on relational conflict. Unfortunately, the
degree to which these approaches are “empirically
supported “in terms of addressing relational problems
is undocumented. Despite valiant efforts, attempts
over the past 25 years to include relational diagnoses
as bona fide disorders in the DSM have not been
successful (Kaslow & Patterson, 2006). Treatments
for some of the common presenting problems in
clinical practice (e.g., parent-adolescent conflict)
remain excluded from lists of empirically supported
treatments unless they are also identified with a DSM
diagnosis, e.g., adolescent substance abuse, conduct
disorder. For this reason, the standard RCT-diagnosis-based
framework for efficacy studies does not
always fit, particularly for couples and families seeking
help for relational conflict rather than for a problem
situated within one person (Friedlander, Lee, Shaffer,
& Cabrera, 2014). Moreover, the common practice
of using a generic systemic approach with multiproblem
families with complex, co-morbid diagnoses
(paternal alcoholism, maternal depression, and youth
substance abuse) is difficult to study within the
framework of RCT methodology, which is based on
individual diagnoses and the manualized intervention
protocols that attend them (Escudero, 2012).
To address this conundrum, Sexton et al. (2011)
proposed an alternate set of standards for CFT
outcome research, “Guidelines for Evidence-Based
Treatments in Couple and Family Therapy.” In this
scheme, both full treatments and specific interventions
(e.g., reframing) are considered. The guidelines
take into account not only the quality of the research
evidence, but also the clinical relevance/significance
of the demonstrated outcomes (individual functioning,
couple/family relationship functioning, and costbenefit
feasibility of implementation in community
settings), whether the research has demonstrated
change mechanisms consistent with theoretical predictions,
and evidence of effectiveness across different
research sites and with clients from different cultural
backgrounds.
Based on these considerations, Sexton et al. (2011)
derived a broader set of outcome-relevant labels:
(1) “Iatrogenic or harmful interventions/treatments,”
(2) “Pre-evidence informed” interventions or treatments/common
practices/non-specific theoretical
approaches, (3) Level I: “Evidence-informed” interventions/treatment,
(4) Level II: “Promising” interventions/treatments,
and (5) Level III: “Evidencebased”
treatments. The evidence-based treatments
are then further evaluated by (1) the strength of the
research evidence, (2) the strength of the evidence for
proposed change mechanisms, and (3) “contextual
efficacy,” i.e., the ecological validity (settings, clients,
etc.,) of the research evidence. Examples of Level I
Psychotherapy Research 351
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approaches are Snyder’s (2006) Affective Reconstructive
Marital Therapy and Structural Family Therapy
(Minuchin & Fishman, 1981). ABFT (Diamond,
Siqueland, & Diamond, 2003) and the specific intervention
of reframing are cited as examples of Level II
approaches, and Behavioral Marital Therapy (Jacobson
& Margolin, 1979) and Family Psychoeducation
for Schizophrenia (Goldstein & Miklowitz, 1995) as
Level III treatments. (Note: Since this 2011 article,
some of these treatments have been further developed
and might be classified differently now.) Sexton et al.
did not attempt to create a comprehensive classification
of evidence-based treatments for particular CFT
problems, or an “either/or” (empirically supported/not
empirically supported) list, arguing instead for the use
of a continuum of evidence, with careful attention to
the quality of the evidence in terms of external as well
as internal validity.
Also notable in this effort is the inclusion of
evidence-based “interventions” in addition to full
treatment programs. This inclusion reflects increasing
attention in the (individual as well as CFT)
psychotherapy literature on trying to articulate and
assess the evidence for transtheoretical, empirically
supported principles of change (Beutler & Castonguay,
2005; Rosen & Davison, 2003). For example,
Chorpita and colleagues (Chorpita & Daleiden,
2009; Weisz & Chorpita, 2012) argued for training
clinicians in interventions that are common across
evidence-based treatment protocols. These authors
contended that among the advantages of such a
modular approach is parsimony (i.e., one can learn
20 core practice elements rather than rely on multiple
manuals) and flexibility (i.e., one can choose to
eliminate or add a particular element in accordance
with the target problem) (Chorpita, Daleiden, &
Weisz, 2005).
Indeed, the empirical support for modular treatments
is increasing (Chorpita et al., 2013). In couple
therapy, it has been noted that effective treatments
differ but share certain core elements, leading to
predictions that “the next decade likely will find a
much more evidence-based approach to articulating
and testing such principles” (Lebow et al., 2012,
p. 160). For example, in family therapy, one principle
of change might be helping clients achieve a new, more
constructive perspective on their interpersonal conflicts,
with different approaches using various strategies
(reframing, narrative strategies, creating space for
partners to really listen and understand the other’s
primary, underlying emotion). Empirically supported
principles of change also might include, but are not
limited to, relationship factors (Norcross, 2011).
Recently, Lebow (2013) provided a thoughtful
integrative perspective, arguing that the era of separate
and competing “schools” of family therapy is over. He
and his colleagues (Breunlin, Pinsof, & Russell, 2011;
Russell & Lebow, 2011) attempted to cast a systemic
net over the entire field of psychotherapy, integrating
different modalities (biological, individual, couple,
and family) as well as different theoretical approaches
(CBT, EFT, IBCT, etc.,) within a comprehensive
problem-centered meta-framework. This shift has
obvious implications, and provides fertile ground for
future outcome research. Moreover, the shift ties
outcomes and change process research closely together
in more clinically meaningful ways.
Current practice and effectiveness data are
lacking. A second reason why our answers are still
incomplete is that we do not fully know how CFT is
currently practiced in community settings and what
characterizes outcomes in these settings. What treatments,
or combinations of treatments, are being
used? Northey’s (2002) survey found that 31% of
American Association for Marriage and Family
Therapy members claimed behavioral or cognitivebehavioral
marital therapy as their primary orientation,
but the others’ orientations are unspecified.
Further, when carefully specified or manualized
treatments are being used in the community, with
what fidelity is the treatment being applied? Research
suggests that even in carefully controlled clinical
trials for well specified treatments, e.g., Brief Strategic
Family Therapy (BSFT), obtaining fidelity can
be an elusive goal (Robbins et al., 2011). Moreover,
fidelity may be especially elusive in difficult cases,
where therapist responsiveness calls for deviation
from the “map.” For instance, in a multi-site trial
of BSFT the lowest fidelity was found in cases
involving especially high substance use and youth
externalizing behavior, including multiple arrests
(Lebensohn-Chialvoa, Haslerb, Rohrbaugh, & Shoham,
2010).
Further, there is a dearth of training opportunities
in couple and family therapy, as well as a number of
constraints on CFT practice in community settings
(Lebow, 2013). Given these facts and that most of
the CFT approaches with well-established efficacy
focus on a specific set of problems, it is likely that (as
in individual therapy) many couple and family
therapists are using some type of treatment––or
combinations of treatments––that have not been
fully tested.
There are two obvious immediate research needs.
The first is for more well-designed studies of treatment
effectiveness of CFT in community settings, and
across additional treatment approaches. Even beyond
those understudied approaches previously reviewed,
there are newer extended systemic formats in need of
testing. These formats are especially popular in Europe
and include network and community-based
352 L. Heatherington et al.
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interventions, multifamily group therapy, family day
treatment (Asen, 2007, Asen & Scholz, 2010), and
extended residential treatment (10–12 wks.) for whole
families with treatment resistant adults (Asen, Dawson,
& McHugh, 2001). In general, these extended
systemic treatments represent innovative approaches
that combine therapy modalities, e.g., individual
family, groups of families, groups of parents, and
groups of children, with an extraordinary sensitivity to
cultural and community diversity. Promising programs
of multifamily group intervention have been
used in the treatment of drug addiction (Schaefer,
2008), child abuse (Asen, George, Piper, & Stevens,
1989), eating disorders (Dare & Eisler, 2000; Scholz &
Asen, 2001) and adolescents with wide range of
difficulties (Wattie, 1994).
The second immediate need is for a better understanding
of the constraints on CFT practice outside
of research settings. How compatible are the guidelines
for carrying out a particular treatment in an
everyday practice setting (scheduling practices, number
of sessions allowed by the clinic or payers,
expectations of the typical clients in the setting,
readiness of therapists to adopt the treatment)?
How accessible, in terms of the cost and time
involved in training and implementation, are the
manualized, marketed treatment programs (e.g., as
MST and BSFT) to clinicians in community settings?
What percentage of practitioners actually use
these manualized approaches, and what are their
experiences or challenges in using them, including
impediments to practicing them with high fidelity?
An ongoing project headed by Goldfried (2011) to
solicit feedback from practitioners about their
experience using empirically-supported CBT treatments
in community settings is a good model for
discovering the effectiveness of systemic therapies.
Indeed in general, the quest for better outcomes and
more meaningful dissemination of couple and family
therapy requires bridging the rather wide gap (Dattilio,
Piercy, & Davis, 2014) between research and
practice in systemic therapy. The development of
sustainable practice-research collaborations and networks
(Borkovec, 2004; Castonguay et al., 2010) is a
wide open and potentially fruitful project.
Knowledge of moderators is sparse. To be
most clinically useful, CFT effectiveness researchers
need to pay more attention to moderators, including
client, therapist, and systems factors. Testing moderators
of effectiveness is the next most important
research step for the “mature” treatments, i.e., those
that are already well supported by the available
evidence and are being widely disseminated. A good
example is a recent study (Robinson, in press) which
found that above and beyond SES factors, the quality
of the neighborhood interacted with extent of parental
monitoring in multisystemic family therapy, such that
parental monitoring predicted decreases in youth
externalizing behavior only in relatively “better”
neighborhoods. This finding echoes the results from
basic research regarding family strengths in extremely
poor neighborhoods. For example, neighborhoods
below a certain level of poverty significantly diminished
and virtually nullified the effects of family
strengths on adolescent functioning/delinquency
(Gorman-Smith, Tolan, & Henry, 2000). These
findings underscore the importance of considering
wider social systems in the development of systemic
theories and the testing of family interventions.
Knowing more about the limits of CFT treatment
packages––or at least knowing more about how their
outcomes and processes should be qualified for
differing contexts––will enhance both their clinical
applications and our understanding of how they work.
As globalization increases, an especially important
moderator for the next quarter century of research is
client culture and the fit (or lack thereof) with the
assumptions and tasks of the treatment approach
being used. There is plenty of theory and opinion on
this topic but a dearth of programmatic research. It
may be more useful and practical for researchers to
ask more focused research questions involving populations
and needs in their own domains (e.g., “Is
group psychoeducational family therapy for schizophrenia
equally effective for Latino/a families in
community mental health settings in Los Angeles
as it is for Anglo families? And if not, how can it be
adapted?”) rather than very broad questions (“Does
culture matter?” “Does matching of therapist and
client culture matter?”).
Another highly salient demographic trend has to
do with family structure. In Europe as in many
developed countries, more people are remaining
single and many are marrying later, and the population
is aging. Gay unions, gay marriage, and more
liberal adoption laws in some places mean an
increase in diverse family forms and arrangements
with extended family “kin” (birth parents, coparents)
of different kinds. What, if any, are the
ways in which these variables influence the nature
and outcome of CFT?
Further, even among the most well-studied therapies,
we do not yet fully know what accounts for
change, particularly precisely how changing interpersonal
dynamics can reduce individual distress. The
question of how therapy works is of more than purely
theoretical or academic interest. Effectiveness and
mechanism of change questions are interrelated, since
a full understanding of the change mechanisms that
mediate good outcomes provides leads for selecting
important moderators of treatment outcomes. For
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example, in couple therapy, a significant minority of
clients, approximately 25–35%, do not improve
(Snyder & Halford, 2012). This is a stubbornly stable
finding, although newer developments in couple
therapy, e.g., IBCT, show moderately better outcomes
(Christensen, Atkins, Baucom, & Yi, 2010;
Snyder & Halford, 2012). But what are the characteristics
of the non-responding couples? Do these
characteristics interact with the specific tasks and
stages of systemic treatment or with the way in which
it is implemented, that explains their lack of response?
This knowledge has the potential to move our work
forward substantially in the next 25 years.
We turn now to a discussion of change mechanisms:
What we know, how we know it, and what we
have yet to discover.
How Do Systemic Therapies Work?
What We Know So Far
Within the past 25 years, change process research in
CFT has focused increasingly on common factors
(Sprenkle, Davis, & Lebow, 2009), particularly the
working alliance, as well as on specific factors within
empirically supported systemic therapies. The
research on specific factors has included study of
in-session micro-changes (e.g., Bradley & Furrow,
2004), change over the course of therapy (e.g.,
Shpigel, Diamond, & Diamond, 2012), and therapist
adherence to and competence delivering theoryspecific
interventions (e.g., Diamond, Diamond, &
Hogue, 2007; Hogue, Dauber, Samuolis, & Liddle,
2006; Huey, Henggeler, Brondino, & Pickrel, 2000;
Robbins et al., 2011), among others.
As a complete review of CFT change process
research is beyond the scope of this article, we will
focus in depth on change process research in three
arenas. These areas were chosen for their transtheoretical
applicability and because they illustrate
how change process research has direct relevance to
clinical practice. We begin by summarizing what is
known about in-session processes that maximize engagement
in CFT, followed by a review of research on
how the therapeutic relationship, particularly the working
alliance, can be a catalyst for systemic change. Finally,
we discuss how two powerful systemic interventions,
reframing and enactment, can effect interpersonal
change in couples and families, both within theoryspecific
models and within more general systemic
approaches.
Engagement in treatment. Engagement has
been studied in three ways: Encouraging family
members to participate in conjoint treatment, keeping
families in therapy, and facilitating clients’ active
participation in the session. In general, results
suggest that successful engagement in treatment
requires a planful strategy that pays attention to
shifting systemic forces within the family.
Research on engaging and retaining family members
has primarily been conducted within BSFT.
The earliest studies tested the effectiveness of a
specially designed engagement intervention for Hispanic
families with adolescent drug users (e.g.,
Santisteban et al., 1996). A recent, multi-site controlled
trial of BSFT with diverse families showed
that adherence to the treatment manual facilitated
engagement and retention (Robbins et al., 2011). A
small sample, comparative analysis of first sessions
from this controlled trial (Sheehan & Friedlander, in
press) indicated that keeping families in treatment
was more likely when the therapist created rapport,
paid attention to resistance, and facilitated parent
involvement, safety, and discussions about family
members’ shared contributions to the problem.
Studies on within-session engagement, or active
involvement in the therapy process, have focused
primarily, but not entirely, on adolescents, where the
key seems to be “rolling with resistance,” identifying
personally meaningful goals for the adolescent, and
becoming an ally (Diamond, Liddle, Hogue, &
Dakof, 1999; Higham, Friedlander, Escudero, &
Diamond, 2012). With adults as well as adolescents,
therapists who are successful at engagement tend to
be supportive (Foster et al., 2009), transparent
(James, Cushway, & Fadden, 2006), and lighthearted
(Escudero, Boogmans, Loots, & Friedlander,
2012; Heatherington, Escudero, & Friedlander
in press). Consistent with a problem-centered
approach (Pinsof, 1995), case studies suggest that
effective therapists work first with the problem in
which family members are most invested so that,
later on, they can leverage therapeutic work with
another problem or with a different subsystem in the
family (e.g., Escudero et al., 2012; Friedlander et al.,
2014; Heatherington et al., in press; Raymond,
Friedlander, Heatherington, Ellis, & Sargent, 1993).
Therapeutic relationships. Various investigations
of clients’ perceptions of successful CFT, most
of which are qualitative, point to qualities of the
therapeutic relationship, including empathy (Hammond
& Nichols, 2008), which was not considered a
particularly important element of systemic therapies in
the early days of their development (see Chenail et al.,
2012, for a comprehensive review of this literature).
Several investigations (Christensen, Russell, Miller, &
Peterson, 1998; James et al., 2006; Sells, Smith, &
Moon, 1996), for example, concluded that clients
have favorable views of CFT therapists who demonstrate
warmth, who are informal and authentic, and
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who help them feel safe and develop clear treatment
goals. It seems that clients tend to appreciate therapists
who are “caring and understanding” as well as
“able to generate relevant suggestions” (Kuehl, Newfield,
& Joanning, 1990, p. 318).
These therapeutic qualities reflect the basic components
of the working alliance (an emotional bond
and negotiation of goals and tasks) that are central to
individual psychotherapy (Bordin, 1979). A recent
meta-analysis showed that the strength of the alliance––as
rated by observers or as reported by
clients––is as robust a predictor of outcomes in CFT
as it is in individual therapy (Friedlander, Escudero,
Heatherington, & Diamond, 2011). Indeed, even in
disparate approaches to CFT, alliance is a key common
factor (Davis & Piercy, 2007).
There are, however, some unique aspects of alliance
in systemic therapies that have been carefully operationalized
and studied intensively in the last 25 years.
Two of these unique features are (1) the presence of
“split” or “unbalanced” alliances among family members,
and (2) within-system alliances (Pinsof, 1994),
or the degree to which family members collaborate
productively on the goals and tasks of conjoint
therapy.
Split and ruptured alliances. Family members’
disparate feelings about the therapist or about participating
in therapy are common occurrences in CFT
(e.g., Goldsmith, 2012; Heatherington & Friedlander,
1990; Knobloch-Fedders, Pinsof, & Mann,
2007; Robbins et al., 2006; Symonds & Horvath,
2004). Although these “split” or “unbalanced” alliances
do not invariably lead to dropout (e.g., Flicker,
Turner, Waldron, Brody, & Ozechowski, 2008;
Muñiz de la Peña, Friedlander, & Escudero, 2009),
severely split alliances tend characterize poor outcome
cases more so than good outcome cases (e.g.,
Beck, Friedlander, & Escudero, 2006; Friedlander,
Lambert, Escudero, & Cragun, 2008). On the other
hand, the association between discrepant alliances
and dropout depends on how the split is operationalized
and how termination is defined (BartleHaring,
Glebova, et al., 2012). It does seem that in
couple therapy with heterosexual partners, the male
partner’s alliance with the therapist tends to be
relatively more influential than the female partner’s
alliance (e.g., Bartle-Haring, Glebova, et al., 2012;
Symonds & Horvath, 2004), but this pattern may
differ depending on the therapist’s gender and on
which partner initiated the request for help.
Compared with the increased attention to alliance
ruptures in individual psychotherapy, relatively little
attention has been paid to the rupture repair process
in systemic therapies. Operationalizing ruptures as
clients’ negative alliance-related behavior, either as
challenges (e.g., questioning the therapist’s competence)
or as passive withdrawal (e.g., refusing to reply
or avoiding eye contact), evidence suggests that
parents as well as adolescents experience ruptures
(Escudero et al., 2012; Friedlander et al., 2014;
Heatherington et al., in press; Shelef, Diamond,
Diamond, & Liddle, 2005). Since ruptures can lead
to dropout, it is important to know how to repair
them successfully (Goldsmith, 2012). Evidence suggests
that by enhancing emotional connections,
therapists can successfully repair even severe alliance
ruptures (Escudero et al., 2012; Heatherington et al.,
in press). Moreover, it has been shown that in cases
where ruptures are repaired (i.e., returned to their
pre-rupture level) within one or two sessions, the
outcomes tend to be better than in cases with no
ruptures (Goldsmith, 2012).
Within-system alliances. Unbalanced alliances
are often accompanied by poor within-system alliances
(Pinsof, 1994), or that aspect of family
members’ relationships to each other that pertains
to their ability to collaborate and function as allies in
regard to their goals for the their therapy and their
agreement about the appropriateness of the tasks in
which they expect to engage in their therapy. Not
surprisingly, when clients differ in their feelings
about the therapist or about participating in treatment,
the result is poor family collaboration (e.g.,
Escudero et al., 2012; Friedlander, Heatherington,
Johnson, & Skowron, 1994; Friedlander, Lambert, &
de la Peña, 2008), and a weak within-system alliance
seems to be more problematic in couple therapy than
either partner’s alliance with the therapist considered
alone (Anderson & Johnson, 2010; Pinsof, Zinbarg,
& Knobloch-Fedders, 2008). Research suggests that
families may experience a poor within-system alliance
due to (i) differing views on the problems or
potential solutions, (ii) differing views on the value
of therapy for addressing problems and finding
solutions, or (iii) family members not feeling connected
in coping with their concerns, even when they
agree with one another about the nature of these
concerns (Lambert, Skinner, & Friedlander, 2012).
Also not surprisingly, a poor within-system alliance
is readily observable in session (e.g., Lambert et al.,
2012). Studies suggest that the within-system alliance
is predictive of parents’ reports of early improvement
after the third session (Friedlander, Lambert, & de la
Peña, 2008) and tends to strengthen over time
(Escudero, Friedlander, Varela, & Abascal, 2008;
Montesano, Feixas, Muñoz, & Compañ, 2014).
There is some evidence that in heterosexual couple
therapy, ae female partner’s personal distress may
decrease as the male partner’s perception of the withincouple
alliance increases, but her distress may increase
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as his personal alliance with the therapist increases,
underscoring the need to consider split alliances in
the context of the within-system alliance, (Anderson
& Johnson, 2010).
Systemic interventions and the process of
change. The conjoint nature of CFT allows interventions
that promote interpersonal change and
learning, both directly and indirectly. In reframing,
clients are encouraged to consider alternate constructions
of their problems, via direct encounters with the
therapist and/or each other, or indirectly, by witnessing
changes between others. In enactments, therapists
assess family interactions in vivo, and intervene to
promote therapeutic change. Below, again as illustrations
of some key change process research findings,
we discuss each of these in turn.
Reframing. Typically, families present for therapy
complaining about a specific family member
(i.e., the identified patient), and typically, these
complaints are formulated in intrapersonal terms
(e.g., “my son is disrespectful” or “my husband is
selfish”). One of the hallmarks of systems therapy is
reframing the presenting problem in relational or
interactional terms, rather than intrapersonal terms.
Reframing can be accomplished with a range of
interventions, including circular questioning (e.g.,
“Which person in the family most provokes your
son’s disrespect?”), initiating in vivo enactments of
interactional patterns, and focusing on the function
of the symptom or the impact of the problematic
behavior on family relationships (Nichols & Tafuri,
2013). Reframing is designed to reduce blame and
provide the rationale and motivation to identify and
transform interactional patterns that cause or maintain
distress.
A robust body of research focuses on reframing
problems (and/or solutions) in interpersonal terms in
family therapy and addresses associations between
reframing and problem construction, as well as the
immediate impact of reframes during the session. In
regard to the therapeutic effects of reframing and
problem constructions, parents participating in
ABFT for depressed adolescents tend to define their
problems in interpersonal terms after the therapist
has made a relational reframe intervention (Moran,
Diamond, & Diamond, 2005), such as. A statement
or question that is designed to shift the focus of the
conversation from the adolescent’s depression to the
rupture in the adolescent-parent relationship, e.g.,
"When your daughter is feeling depressed about not
succeeding in school, does she come to you for
support?" In constructivist family therapy, parents’
problem constructions may shied from intrapersonal
to interpersonal when each family member is
encouraged to express his or her individual perspective;
the affective responses of family members may
shift when the “new story” emerges and hope or the
possibility of change is acknowledged. In terms of
the immediate impact of reframing, delinquent
adolescents in Functional Family Therapy may
respond less negatively to a reframe intervention
than to other types of interventions (Robbins, Alexander,
Newell, & Turner, 1996). And in ABFT,
when a therapist makes relational reframe interventions,
attends to core relational themes, and highlights
vulnerable emotions (e.g., pain, loss)
associated with relational ruptures, parents tend to
be less negative, particularly when the parent-therapist
alliance is strong (Moran & Diamond, 2008).
Enactment. Perhaps the most unique feature of
systemic therapies is the use of enactments, which
are in-session family interactions, usually initiated by
the therapist, e.g., “can you and your partner talk
with your daughters about your rules regarding their
use of the Internet?” Enactments allow the therapist
to assess a couple’s or family’s relational patterns,
and provide opportunities to restructure these patterns
to facilitate change (Davis & Butler, 2004;
Woolley, Wampler, & Davis, 2012). Indeed, enactments
are a staple across a wide range of CFTs,
including Structural Family Therapy, EFT
and BCT.
Over the past 25 years, a number of process studies
have attempted to map out therapist interventions
and client performances associated with successful or
productive enactments. Results indicate, for example,
in helping family members remain engaged with one
another in the session, therapists who focus family
members on their thoughts and feelings about the
impasse, on the potential benefits of engagement, and
on their attributions for one another’s behavior may
be able to facilitate the family’s movement from
disengagement to sustained engagement (Friedlander
et al., 1994). Additionally, during adolescent-parent
enactments in MFT, adolescents may be more
disclosing and their parents more open and responsive
when therapists shift the focus of the conversation
from the adolescent’s problem behavior to feelings of
pain, loss and regret associated with the relational
rupture (Diamond & Liddle, 1996).
More recently, enactment has been examined in
the context of CFT models that focus primarily on
attachment and emotional processing, particularly
EFT (Greenberg & Johnson, 1988) and ABFT
(Diamond, Diamond, & Levy, 2014). These therapies
use enactments to resolve ruptures in family
members’ attachment relationships and to create
safer and stronger emotional connections. Consequently,
research on these models has explored the
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link between in-session enactments between family
members, changes in attachment and emotions, and,
in turn, changes in psychological relationship satisfaction,
attachment, forgiveness and psychological
symptoms. For example, studies examining the resolution
process in EFT among couples treated for
attachment injuries (e.g., infidelity, abandonment)
suggest that couples who successfully resolve their
attachment ruptures may become more affiliative with
one another, that is, more disclosing, expressing
needs, affirming and understanding. In addition,
resolvers may exhibit deeper levels of experiencing
(i.e., coming into contact with new feelings and new
meanings related to such feelings) and less blaming,
withdrawal and defensiveness behaviors (Makinen &
Johnson, 2006; Zuccarini, Johnson, Dalgleish, &
Makinen, 2013). Resolution is characterized by a
softening process, during which the injured individual
processes primary vulnerable emotions related to the
injury, expresses needs for care and support, and the
offending other responds in kind (e.g., expresses
commitment to the relationship, shame and sadness).
Specific strategies used by therapists to facilitate the
softening process include reflection of primary emotion,
evocative responding and heightening (Zuccarini
et al., 2013).
In other studies (Woldarsky Meneses & Greenberg,
2011, 2014) the process of forgiveness has been
examined in the context of EFT. Results suggest that
he forgiveness process may require the injurer to
contain and tolerate the partner’s anger; accept
responsibility for the injury, exhibit shame/regret/
remorse/empathy; and express a heartfelt apology.
With regard to the injured partner, forgiveness may
involve a shift in the view of the other (Woldarsky
Meneses & Green-berg, 2011). With regard to the
link between interpersonal forgiveness and outcome,
expression of shame, followed by acceptance and
then forgiveness may be key to increasing relationship
satisfaction in couples (Woldarsky Meneses &
Greenberg, 2014).
These few examples illustrate the fruits of the past
quarter century of research on the process of change
in systemic therapy. These and other findings were
made possible by parallel advances in the methodology
of studying CFT, to which we now turn.
How We Know What We Know
In recent decades new self-report measures, observer
rating systems, and statistical models have been
developed to study therapeutic change across time.
This is a major step forward, in that it facilitated a
growing number of small sample and evidence-based
case studies that demonstrated links between specific
in-session processes and client outcomes (e.g.,
Escudero et al., 2012; Friedlander et al., 2014; Gill,
Hyde, Shaw, Dishion, & Wilson, 2008; Montesano
et al., 2014). Moreover, a few investigations highlight
the value of systematically providing therapists with
feedback from family members about how they view
the treatment progressing (e.g., Anker, Duncan, &
Sparks, 2009; Reese, Toland, Slone, & Norsworthy,
2010). In this section, we briefly review a selection of
the measures, designs and analyses that have been
used to capture systemic dynamics.
Measures. A key task for family therapy researchers
is to adapt or devise new measures of important
constructs to fit the systemic context. Considerable
attention has been paid, for example, to the therapeutic
alliance in systemic therapy An early set of self-report
measures, the Couple Therapy Alliance Scale and the
Family Therapy Alliance Scale) (Pinsof & Catherall,
1986) have more recently been factor analyzed,
shortened and built into a comprehensive measure
of family progress, as described below (Pinsof et al.,
2009). Further, two observational measures of the
alliance in CFT have appeared in the literature. The
first, the VTAS-R (Diamond et al., 1999) is a revision
of the individual therapy-focused Vanderbilt Therapeutic
Alliance Scale. It contains 26 items concerning
client behaviors in relation to the therapist, rated by
trained judges. A factor analysis of ratings made from
videotapes identified six VTAS-R items that reliably
estimate “a positive working alliance” for parents and
adolescents across three therapy approaches (Robbins,
Turner, Alexander, & Perez, 2003): The client’s
acknowledgment of the problem, straightforward
relating, open exchange with the therapist, apparent
identification with the therapist’s approach, experience
of the therapist as understanding and supportive,
and collaboration to solve the adolescent’s or family’s
problems. The second observational measure,
developed empirically from a review of the CFT
literature, clinical experience, and an intensive analysis
of taped family sessions in which clients’ private
perceptions of the alliance were known, is the System
for Observing Family Therapy Alliances (SOFTA-o;
Friedlander, Escudero, & Heatherington, 2006;
Friedlander et al., 2006). Using the SOFTA-o,
trained judges can reliably rate clients’ behaviors on
four dimensions: Engagement in the Therapeutic
Process, Emotional Connection to the Therapist,
Safety within the Therapeutic System, and Shared
Sense of Purpose within the Family (similar to
Pinsof, 1994) within-system alliance. The latter two
dimensions reflect unique aspects of conjoint
CFT. An e-version (Escudero, Friedlander, &
Heatherington, 2011) allows coding of digitally
video-recorded therapy sessions, and qualitative comments
that are time-stamped, making it useful for
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training, supervision and practice (Carpenter, Escudero,
& Rivett, 2008; Escudero & Friedlander, in
press) as well as research.
Another set of systemic constructs, interpersonal
control, complementarity, and symmetry in communication
(Bateson, 1935) was operationalized by adapting a
system for coding dyadic relational discourse (Rogers
& Farace, 1975) to multi-person groups. This measure,
the Family Relational Communication Control
Coding System (FRCCCS; Friedlander & Heatherington,
1989), has been used in several studies of
conjoint family therapy (e.g., Beyebach & Carranza,
1997; Friedlander & Heatherington, 1989; Raymond
et al., 1993). Most recently, the FRCCCS was used in
conjunction with the SOFTA to identify patterns of
interaction that characterized better versus worse
alliances, as reported by observers (Muñiz de la
Peña, Friedlander, Escudero, & Heatherington,
2012). Results suggested that competitive symmetry,
reflecting a struggle for control, between therapist and
adolescent may be more frequent in problematic
alliance cases and may decrease in cases where the
alliance improves over time.
Finally, the measurement of progress and outcomes as
well as processes in CFT has seen advances. In systemic
therapies, assessing outcomes requires attention to
changes in both individual problems and relational
problems. Tracking how people change in psychotherapy,
along with the “feeding back” to clinicians of
data on how clients are doing during the course of
therapy––i.e., client focused “progress” or “feedback”
research (Howard, Moras, Brill, Martinovich, & Lutz,
1996; Kazdin, 2007), has emerged in the past two
decades as an important component of individual
therapy, with empirical evidence demonstrating that
tracking and regularly feeding back to clinicians client
change data improves outcomes (Bickman, Kelley,
Breda, de Andrade, & Riemer, 2011; Lambert &
Shimokawa, 2011; Shimokawa, Lambert, & Smart,
2010). Some adaptations of feedback systems for
individual therapy have been adapted for family
therapy (e.g., Partners for Change Outcome Research
System; Miller & Duncan, 2004; Clinical Outcomes
in Routine Evaluation; Stratton, Bland, Janes, &
Lask, 2010), and one progress feedback system has
been designed specifically for multi-systemic and
multi-dimensional feedback, the Systemic Therapy
Inventory of Change (STIC; Pinsof et al., 2008, 2009;
Pinsof, Goldsmith, & Latta, 2012). The STIC consists
of (i) an initial demographic questionnaire and
an integrated set of client-report questionnaires to
assess multiple client systems (e.g., individual, familyof-origin
couple, family and child) that clients complete
before the first session to identify clinical
problems and set pre-treatment levels for tracking
change; (ii) briefer versions of the six system scales
that clients complete after every session; and (iii)
three brief alliance scales, to track in the alliance in
individual, couple and family therapy over time
(Pinsof et al., 2008). A software system and website
(Psychotherapychange.org) collects STIC data, analyzes
them and feeds them instantly back to therapists
(and supervisors if desired), informing the therapist
about any statistically significant changes in client
functioning or alliance since the last session. This
(Pinsof et al., 2008, 2009, 2012) set of scales, which
has consistently demonstrated reliability and validity,
permits investigation of how much couple therapy
impacts adult, family and child functioning or how
much individual therapy affects couple, family and
child functioning, and can be used to test moderators
and mediators of change. User friendly and Internet
based feedback systems like the STIC, used collaboratively
with clients as an integral part of treatment,
begin to close the practice-research gap by giving
therapists useful data to inform and influence the
therapeutic process as it unfolds.
Designs and analyses. In recent years, group
designs of systemic CFT therapies have become
considerably more complex. The current process
literature contains multi-level models that test for
therapist effects (Anker, Sparks, Duncan, Owen, &
Stapnes, 2011) and actor-partner interdependence
(Anker, Owen, Duncan, & Sparks, 2010; Friedlander,
Kivlighan, & Shaffer, 2012), and reciprocity has been
studied in small samples using sequential analysis
(Friedlander, Lambert, Escudero, et al., 2008; Moran
& Diamond, 2008; Muñiz de la Peña et al., 2012;
Raymond et al., 1993).
Evidence-based case studies, as defined by Carlson,
Ross, and Stark (2012), include transcribed in-session
data and quantifiable assessments of clinically meaningful
changes across time (e.g., Escudero et al., 2012;
Friedlander et al., 2014; Gill, Hyde, Shaw, Dishion, &
Wilson, 2008; Heatherington et al., in press; Montesano
et al., 2014). Some small sample studies report
data on every session (e.g., Friedlander, Lambert,
Escudero, et al., 2008) or on sessions selected for
intensive analysis based on alliance (Moran & Diamond
2008; Higham et al., 2012; Lambert et al.,
2012; Muñiz de la Peña et al., 2012) or session
impact scores (Friedlander, Bernardi, & Lee, 2010).
The literature also contains qualitative analyses of a
single, representative session (Sutherland & Strong,
2011), of a few sessions (Beck et al., 2006; Lambert
et al., 2012; Moran et al., 2005), and of in-session
moments that clients identified as especially good or
poor (e.g., Bowman & Fine, 2000; Helmeke &
Sprenkle, 2000; Strickland-Clark, Campbell, & Dallos,
2000). Qualitative studies have used methods
based on grounded theory, conversation analysis
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(Diorinou & Tseliou, 2014; Sutherland & Strong,
2011), ethnography (Kuehl et al., 1990), and constant
comparison (Friedlander, Heatherington, & Marrs,
2000; Higham et al., 2012; Lambert et al., 2012).
To date, there have also been quite a few task
analyses of change events (Bradley & Furrow, 2004;
Coulehan, Friedlander, & Heatherington, 1998;
Friedlander et al., 1994; Furrow, Edwards, Choi, &
Bradley, 2012; Higham et al., 2012; Makinen &
Johnson, 2006; Nichols & Fellenberg, 2000; Woldarsky
Menses & Greenberg, 2014; Woolley, Wampler,
& Davis, 2012). Discovery-oriented task
analyses are particularly informative in that they
illuminate step-by-step changes, in session, that lead
to successful resolutions of specific issues. When
followed up by larger scale studies (e.g., Woldarsky
Menses & Greenberg, 2014), the specific change
strategies can be analyzed in relation to post-therapy
client outcomes. The findings of these kinds of
studies are particularly relevant to clinical practice as
well as for testing micro-theories of change processes.
Summary: Looking Ahead
This 25-year retrospective reveals considerable progress
in systemic/CFT therapies, not only in the
development of treatments, but also in the evidence
base for their effectiveness and in methodologies for
studying them. Needs and directions for future
research have been addressed throughout this article
with regard to specific topics, and point to some
general future trends. To close, and as a charge to
the next generation of systemic therapy researchers,
we list some recommendations for what the next 25
years should bring:
(1) Demonstrations of therapy efficacy and effectiveness
of CFTs across a broader range of
individual and relational problems. Ideally,
these demonstrations would also include
increased attention to cost-benefit considerations,
i.e., demonstrations that the costs of
training and implementation of systemic
treatments are offset by its benefits, such as
preventing family violence, school dropout,
and substance addiction.
(2) More fine-grained, nuanced research on
change processes and moderators and mediators
of treatment effectiveness. While we
know that systemic therapies work, it is the
answers to how, for whom, and under what
circumstances that will deliver the most clinically
important information to practitioners.
(3) More conceptual and empirical work on
empirically supported principles of change
in couple and family therapy.
(4) Broader study of the use of regular, systematic
feedback over the course of therapy to
therapists (and other stakeholders) about
clients’ functioning, to inform assessment,
plan treatment and monitor progress for
both clinical (mid-course corrections) and
research (understanding how clients change)
purposes. Researchers should assess the
promise of this technology for diminishing
the divide between researchers and clinicians
by making data immediately useful,
actionable, and relevant to practice.
(5) More collaboration between people engaged
primarily in clinical practice, those engaged
primarily in clinical research, and those
engaged primarily in basic research on systemic
processes in couples and families. The
development of practice-research networks
for CFT is recommended.
(6) The use of information technology, not only
to deliver progress feedback, but also as an
adjunct to treatment itself. The development,
use, and study of “apps” in couple
and family therapy is a wide-open arena for
research.
(7) Consideration of the ways in which systemic
thinking can be integrated into general
psychotherapeutic thinking and practice.
There is a considerable body of evidence
that attention (both theoretically and practically)
to interpersonal and contextual variables
is not something that should just
pertain to family and couple therapy. The
field of psychotherapy needs to transcend
the arbitrary family, couple and individual
therapy distinctions and move toward a
more inclusive, comprehensive and integrative
perspective that links the systemic and
individual (and perhaps biological) into an
optimally successful psychotherapy.
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