running head: couples counseling through ebpp 1 … mp... · 2014. 12. 20. · effective therapy...

Running head: COUPLES COUNSELING THROUGH EBPP 1

Overcoming the Model Wars and Increasing Success in Couples Counseling Through

the Use of Evidence Based Practices in Psychology

A Research Paper

Presented to

The Faculty of Adler Graduate School

____________________

In Partial Fulfillment of the Requirements for

The Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

_____________________

By:

Stefanie Hofman

November 2014

COUPLES COUNSELING THROUGH EBPP 2

Abstract

Extensive research exists on couples counseling; none has surfaced to prove that one method is

superior. Yet, debate continues in professional and public forums over which represent the most

effective techniques. The “model wars” are the forum for debate. It is rife with advocacy and

misunderstanding yet it strives to support best possible outcomes in couples counseling. The

original goal of this research was to find what works best or, in lieu of an answer, supply the

growing debate with another model. However this author discovered that debates are

unnecessary. Research has led the author to the conclusion that the debate can stop because both

sides are right. Research into this topic has offered a unique body of knowledge about what does

and does not work in couples counseling; findings from this research may better equip therapists

to perform the distinctive task of helping couples in distress.


Table of Contents

Abstract ........................................................................................................................................... 2

History of the War .......................................................................................................................... 6

Consumer Satisfaction .................................................................................................................. 11

Marriage Therapy Works (For a While?) ..................................................................................... 12

Red Flags On the Battle Field: Marital Therapy ........................................................................... 15

Where Couples Therapy Fails Most Often ................................................................................... 17

Failure: Crisis Intervention Preparedness ................................................................................. 17

Failure: Assuming Individual Therapy Practices are Applicable ............................................. 19

Failure: The Therapist Gives Up............................................................................................... 20

The Therapist Variable ............................................................................................................. 22

Alliance ................................................................................................................................. 22

Pick-a-model mentality ......................................................................................................... 23

Conceptualization ................................................................................................................. 24

Allegiance ............................................................................................................................. 25

Indisputable Ingredients: Behavior, Insight and Emotion ............................................................ 26

Behavior .................................................................................................................................... 27

Insight ....................................................................................................................................... 28

Emotion ..................................................................................................................................... 28

Adlerian Marital Therapy ............................................................................................................. 29

Adlerian Concepts Supported ................................................................................................... 32

Adlerian Argument for a Common Factors Approach ............................................................. 33

The Model Wars: A Truce ............................................................................................................ 35

Evidence-Based Practices in Psychology (EBPP) ........................................................................ 36

Deeper Understanding of EBPP................................................................................................ 37

Best available research .......................................................................................................... 38

Clinical expertise .................................................................................................................. 38

Client context and preference ............................................................................................... 39

EBPPs: Implications for Working with Couples .......................................................................... 40

Get Over the War. Move On. .................................................................................................... 41

Use Clinical Expertise and Research to Treat Clients .............................................................. 42


Allegiance ............................................................................................................................. 42

Agreement ............................................................................................................................. 43

Client expectations ................................................................................................................ 44

Feedback ............................................................................................................................... 44

Long term maintenance......................................................................................................... 45

Learn the Letters ....................................................................................................................... 46

In Conclusion, Recommendations and How Do We Market? ...................................................... 47

Appendix ....................................................................................................................................... 51


Overcoming the Model Wars and Increasing Success in Couples Counseling Through the Use of

Evidence Based Practices in Psychology

In the model wars, couples therapy is a specialty under fire. Perhaps more than any time

before, payers, consumers and legislators are putting what therapists do under close scrutiny.

Within the field itself, among different theoretical schools, quarrels and contentious claims of

efficacy abound. Various divisions promote their model and techniques as superior to the rest.

Couples therapy research has had little impact on the day-to-day functioning of Couples

therapists due in part to the over-emphasis on treatment packages and models. Joining

methodically organized and systemized therapies and protocol-driven interventions, so-called

“experimentally established couples therapies” represent the latest campaign for an approved

standard of care. Unproven theories battle for acceptance. Therapy is being industrialized, as are

virtually all who practice it, do to the trends of medicalizing ( in part for insurance coverage) and

standardizing techniques for scientific methodologies. Researchers and clinicians are sometimes

perceived as having little in common, arguing between science and practical application. The

industry is ingrained in a history of emphasizing differences that once may have been necessary

in order to differentiate itself from mainstream psychotherapy (Sprenkle, Blow, & Dickey,

1999).

At the root of the controversy surrounding couples therapy is the ever-important question

of “what works?” The ongoing competition within couples therapy among different schools of

thought reflects the forceful personalities of their founders and the field’s general indifference to

research (Sprenkle, Blow, & Dickey, 1999.). Yet, few argue that this question is the common

goal that serves as a battle-field. The war is fought between two sides with common concern for

clients. This body of research seeks to discover if there is common ground on which a truce may


be built, that the field of couples counseling may be less polarized in assertions and more

cooperative in acquiring new and better ways to serve couples in distress.

Long held is the argument of whether efficacy is won on the particular therapeutic powers

of specialized techniques or if other non-empirical variables account for change. Each of the

sides has their advocates. Advocates of the medical model prefer specific therapies for specific

problems which are empirically supported and can be applied via therapeutic actions out of a

manual. Advocates on the other side, often referred to as the contextual model, prefer to trust the

process of therapy and understand clients’ individual needs and desires to grow, conceptualizing

the therapist as a facilitator of change rather than an administrator of a standardized treatment

(Wampold et al., 2001). A common factors approach, or the non-medical/ non-model approach

had taken a back seat to model developers who continue to create techniques which sell

programs, books, and fill seats at seminars (Sprenkle, Blow, & Dickey, 1999). Some fear that

the abandonment of the medical model would prevent the discovery of interactions between

treatment and personal characteristics. Fears abound about abandoning research which may

inform practitioners of best therapy methods for racial and ethnic minorities and other

underrepresented groups (Wampold et al., 2001). Recently however, the model-wars argument

has begun to include peace talks surrounding the idea of common factors - the ingredients of

effective therapy shared by all orientations, as more and more evidence fails to support one

model over another and reveals that the person of the therapist and other ubiquitous elements are

change factors.

History of the War

Marital therapy started out as a practical effort to help individuals in difficult marriages.

Early practice was done without much theoretical basis on which to conceptualize relationship


processes other than to acknowledge that couples therapy was a systems process. In the first

three decades of the marriage and family therapy (MFT) specialty, distinctiveness was preferred

over commonality. What began as a maverick discipline with feisty and confident founders

began to morph into preferred methods created by those early pioneers. Therapeutic models

began popping up in the 1960s through the 1980s along with professional organizations such as

the American Psychological Association. As formal models of couples treatment began to

develop with specific techniques, couples counseling moved into a recognizable form of practice

of its own.

Early models emphasized behavior and behavioral treatment became the first and only

research-validated treatment of couple distress. As behavior research grew, questions regarding

affect emerged. Attachment-theory research provided the backbone for therapies with an

emotional focus (Johnson & Bradley, 2011). However, without as much empirical evidence on

emotion-focused therapy, behavior-centered models continued to dominate popular practice

principles.

In the 1980s, drugs like Prozac and the arrival of managed care mandated therapists to

validate their methods with better research. The medical model contains five key components

which include: the client’s presenting disorder, a psychological explanation for the disorder, a

theoretical conceptualization sufficient to posit a mechanism of change, therapist administration

of mechanism of change, followed by the belief that the benefits of the psychotherapy were due

in most part to the specific ingredients in the technique (Wampold et al., 2001). Techniques

increasingly became standardized, straightforwardly described in manuals meant to quickly help

people with specific problems such as phobias, panic attacks, and depression. These manualized

techniques included therapies such as cognitive therapy or exposure therapy, which increasingly


became supported by evidence-based research. Available psychiatric drugs were marketed with

huge profits and success. A perception grew in many areas of the health delivery system that

psychological treatments for particular disorders were either ineffective or inferior to

pharmacological treatment (American Psychological Association, 2006). Research into

psychotherapy relied on clinical trials which are well suited to testing drugs, but, as opponents

argue, impose artificial limits on real-life psychotherapy (Carey, 2004). However, the medical

model prevailed and evidence-based approaches became the practice standard in managed care.

Bruce Wampold (University of Wisconsin, Madison) and associates comment on the medical

model as metaphor in the following quote:

Because several historical roots of psychotherapy are deeply imbedded in a medical model

of psychotherapy, because the medical model appears more scientific than various

alternatives, and because the economics of practice are imbedded in a health care delivery

system, the natural tendency has been to adopt medical model language. In spite of

numerous admonishments that counseling psychology distinguishes itself from other

psychological specialties because it focuses on health rather than pathology, the medical

model is too seductive and often we succumb to its allure, unaware of our implicit approval

of a model that cannot, in the long run, advance our specialty (2001, p. 268).

Managed care companies began to limit the number of sessions authorized for particular

diagnoses based on research findings. Documentation of therapeutic progress became the norm.

Increasingly, the therapist became accountable for outcomes (Carey, 2004). As this new norm

grew, therapists argued that the healing that was occurring within their offices every day was too

complex to be captured in standardized studies and that tracking progress for insurers was a

breach of confidentiality (Carey, 2004).


Many scientists who study treatment models are still entrenched in cognitive-behavioral

models while many day-to-day clinicians practice other approaches which have continued to

evolve through clinical practice. Scientists and practitioners have a long history of operating in

different realms; researchers within the confines of grant review committees focused on rigorous

research methodology; and practitioners within therapy offices with clients with complex

problems requiring clinical expertise. The tentative relationship between the practice and science

of therapy has for decades been at the heart of the model wars (Lebow, 2006). While science has

sought a medical model to apply to specific disorders, clinicians contend that innovations and

creativity produce effects that are most important to clinical, real-life settings.

In 1995 a task force from the American Psychological Association that included many

prominent researchers identified and established the scientific foundations of clinical practice

(Lebow, 2006). The task force issued a list of empirically supported treatments (ESTs) and

consecrated them as approved psychotherapies for specific conditions. These approved therapies

recognized clear, objective criteria determined under scientifically proven conditions, which

included two different and independent research studies, each run by a strict treatment manual,

and under conditions to control for which specific treatment group a particular approach is

effective (Lebow, 2006). The 1995 task force created the criteria which are still the standard for

assessing treatments for empirical efficacy.

Critics of this EST approach argued that ESTs ignore the role of the therapist in treatment,

limit creativity within clinical application, and favor therapies which are easy to. Furthermore,

critics contend that ESTs narrow the field of reimbursable treatments and limit therapist choice

in treatment planning (Lebow, 2006). Critics put forth an alternative to the medical model: the

conceptual model. The conceptual model emphasis is on the common factors as well as the


context in which psychotherapy takes place, and happens to be quite Adlerian. It contains four

key components: (1) an emotionally charged, trusting, confiding and safe relationship with a

therapist, (2) a therapy process within a healing context, (3) a rational, conceptual scheme that

provides an explanation for the client’s complaint which fits into the client’s worldview and (4) a

procedure which is consistent with the rationale of the treatment (Wampold et al., 2001). On the

surface it appears as though the medical model proponents are labeled as clinical scientists

whereas the contextual model advocates are labeled humanists and appear to be unscientific,

soft, and “touchy-feely” (Wampold et al., pp. 269, 2001).

In 2004 the debate publically continued at an American Psychological Association (APA)

meeting after another task force was formed to address the controversy and to find common

ground on which to build future practice. The controversy had divisive results within the

psychological community, splitting the field with an intense acrimony (Carey, 2004). National

attention began to be paid to the disagreement with articles appearing in public forums exposing

the dispute over the debate on whether psychotherapy is an intuitive process or a matter of

therapists following specific procedures. The gap between research and practice became an

irresolvable matter of discourse (American Psychological Association, 2006). Unfortunately,

“There are no winners in the ‘model wars’ of our field” (Gurman, 2011, p. 39).

Consumers became aware of the quarrels as debate boiled over into public forums such as

the New York Times and television shows like Phil Donohue and Oprah. A profession that was

already viewed through the lens of skepticism was exposing its internal disagreements. Other

disagreements arose within the psychological community at a time when media coverage quickly

exposed dissent and decreased consumer trust. As awareness and sensitivity to efficacy increased

and became scrutinized, therapists turned to results as reported by consumers, often as


researched within the realm of clinical trials. Some found marriage therapy especially lacking in

effectiveness while other forms of therapy held substantial merit as being effective, whether

conducted under a medical or contextual model.

Consumers were particularly warned to be weary of marriage counseling. Popular

periodicals picked up the war with polarizing articles such as “6 Reasons Marriage Counseling is

BS” (Laura Doyle, Huffington Post); “Does Couples Therapy Work?” (Elizabeth Weil, NY

Times); “Why Marital Therapy Often Fails” (Gary Neuman, Fox Times Magazine). In addition

to the internal model wars, consumers were influenced by a “Buyer Beware” caveat.

Consumer Satisfaction

Oddly, the satisfaction rate for marriage therapy is higher than the literature would

suggest. Consumer data suggests that 55% of couples improve after treatment (Gottman, 1999).

However, most data surveys use short term follow-up results where as long term results tend to

show a relapse effect. The relapse rate tends to be 30-50% after two years, with the highest

separation and divorce rate occurring within one year of therapy (Gottman, 1999). To

summarize, Gottman’s findings estimate that, “ …35% of couples marital therapy is effective in

terms of clinically significant, immediate changes, but that after a year about 30-50% of the

lucky couples who made the initial gains relapse” (Gottman, 1999, p. 5). In Gottman’s extensive

reviews of the body of literature available, he concludes that the results of most marital therapies

are mediocre (1999).

In the longest follow-up study done to date, 163 couples were checked five years post-

therapy. This study suggested that over half of the couples were unchanged or had deteriorated

two or more years after treatment ended with nearly 40% divorced (Christensen et al., 2010).

This long term study is known among researchers as the Cookerly study: Gottman references it


in his research as well. This study highlighted the failings of long term effects of marital

therapy.

Again, consumers often report higher levels of satisfaction than Gottman’s results would

predict. However, it is believed that the consumer ratings are based on the consumer’s over-all

feelings of satisfaction with the therapist or therapy process and do not reflect the status of

marital happiness (Gottman, 1999; Christensen, et al., 2010). Often, consumers wish to express

thanks to the therapist, despite the ineffectiveness of the intervention (Gottman, 1999;

Christensen, et al., 2010). The American Association for Marriage and Family Therapy

(AAMFT) reports on its web page that 752,370 couples seek marital therapy per year. Of all

marriage and family therapy consumers (which may also include individual and family therapy)

97.4% say they are generally satisfied with the service they received and 97.1% said they got the

type of help they desired (aamft.org). The good news is that clients seem to like their therapists,

if the consumer ratings are any indication.

Marriage Therapy Works (For a While?)

The overall efficacy of couples therapy is firmly established and it has been successfully

applied to many different types of couple distress (Gurman, 2011). In a clinical trial that

compared different types of marital therapy, Shadish and Baldwin (2005) and Snyder, Castellani,

and Whisman (2006) found that in a large number of randomized clinical trials, couples therapy

led to substantial improvements in relationship quality. Studies show that these improvements

tend to last over the short term, six months to a year after treatment ends (Christensen, et al.,

2010). However, as noted earlier, longer term effectiveness shows vast room for improvement,

perhaps because treatment effects gradually diminished over time. This may be, as posited by


Lebow et al.,( 2012) due to consumers’ attitudes that once they’ve had couples therapy, they

should not ever need it again, thereby viewing couple therapy as a once in a lifetime event.

Over time, trial, and development, therapy techniques have improved. Lacking

additional long-term data that has incorporated the gained wisdom in the practice of marital

therapy, current investigations lead to studies regarding the modalities of therapy and the

efficacy rates. The results of long-term effectiveness will no doubt be studied as time

progresses. In the meantime, researchers have shown increased interest in the elements of

therapeutic efficacy. As noted in Snyder and Halford (2012), several approaches to couples

therapy can produce significant improvement in relationships. Research over the past 30 years

supports the efficacy of a variety of treatment approaches for couples (Snyder & Halford, 2012).

Therapists may benefit from a compilation of techniques and practices that have been studied for

their effectiveness and from the traits or practices of therapists who hold a degree of expertise in

Couples therapy (a common factors approach). While studies indicate that a number of distinct

treatments produce greater change in marital satisfaction than no treatment (Atkins, et al., 2005),

little information exists that holds sound methodological value and consistent findings (Atkins, et

al., 2005). Furthermore, there are very few predictors of marital therapy outcomes (Atkins, et al.,

2005). This is problematic because predictors of change in treatment planning can inform

prognosis and dictate treatment decisions (Atkins, et al., 2005). However, it is important to

recall that the majority of couples are helped by whatever treatment they receive (Christensen, et

al., 2010). That better research has not been completed should not deter a marriage therapist

from gathering the best information currently available. The ethical therapist is responsible for

being as well prepared as possible. If multiple modalities of marital therapy are effective and

available to therapists (Reese, R. J., Toland, M. D., Sloane, N.C., & Norsworthy, L. A., 2010),


then finding the best parts of several modalities may be the therapist’s best approach to the

unique task.

Couples therapy has become one of the most widely practiced forms of therapy and has

emerged as the expected course to follow for treating marital distress. Research has established

that assorted therapeutic approaches produce significant results in Couples therapy (Snyder &

Halford, 2012), and that couples therapy positively impacts 70% of couples receiving treatment

(Lebow et al., 2012). However, the current literature shows no concrete or definitive answer to

the problem of couples counseling, because no one method seems to reign fully superior to

another. Some researchers (as reviewed by Beutler et al., 2012) have suggested that this failure to

identify one or more superior treatment approaches indicates that there must exist common

factors across treatments which provide a more essential element of effectiveness than the actual

method.

A review of current literature reveals that marital therapy is best served by attending to

emotion, insight, and behavior, as well as other clinical priorities (Chambers, 2012). Marital

therapy is a newer discipline, having been recognized as a separate or unique modality in 1970

(Martin, 1994) and therefore while much literature has been written on the subject, little reflects

standardized and empirical values. However, a careful hunt for empirically tested ideas and

reflections on best practices shows some important themes that can be universally applied,

despite the enormous variety of approaches and theories available. Chambers (2012) reports that

in the field of Couples therapy some priorities occur across varying practices. Since it has been

indicated that there is an inability to identify one or more superior models then this illustrates

that there are indeed common factors across treatments (Beutler et al., 2012). This is good news


for the therapist who must confront the battlefield, replete with a dearth of method offerings

available.

Red Flags on the Battle Field: Marital Therapy

William Doherty, Family Social Science professor and director of the Marriage and

Family Therapy program at the University of Minnesota, has been raising the red flag of concern

over marriage therapy for several years. As according to Doherty (2002), “A dirty little secret in

the therapy field is that couples therapy may be the hardest form of therapy, and most therapists

are not good at it” (p. 26). Some experienced therapists will admit to feeling stressed out by

couples therapy and some try to avoid the practice outright; inexperienced therapists may not

realize how little they know or how unprepared they are to deal with couples conflict and may be

taken by surprise (Weil, 2012). Some who find themselves providing couples counseling do not

take a single course in Couples therapy (Doherty, 2002). Not all programs adequately prepare

therapists for this unique challenge, warns Doherty. He and other outspoken pro-relationship

therapists, such as John Gottman, point out that while 80% of therapists say they do couples

counseling, only 12% have had any training specifically in couples work (Doherty, 2002).

Despite any number of excellent couples therapists, consumers are warned of a profession that is

ill-prepared to meet the needs of couples during a time when divorce rates are high and often

divorces are unnecessary (Doherty, 2001).

Couple distress is a difficult problem to treat. Engagement and retention in couples

therapy is often a problem. Many who seek therapy do not stay long enough for the process to be

effective (Lebow et al., 2012), others simply do not respond to treatment (Gottman, 1999). The

“buyer beware” view stems from the iconic portrayal of simple fixes of untested theories as seen

on Oprah, where marriage problems seem to correct themselves in about an hour. In a consumer


driven society, the buyer expects quick results and without which, may prematurely abandon the

process.

A nearly 50% divorce rate opens up a large opportunity for marriage therapy to continue

to grow and flourish without the limitations of war and dissent. While ESTs offer therapists a

wealth of tested treatment ideas to those who know how to incorporate them into their current

practices, ESTs do not win any superiority awards. Research has acknowledged that no one

model of intervention is a complete treatment by itself; no extensive treatment can make a sole

claim of efficacy or be considered sufficient for couples (Christensen et al., 2005).

Complex couples require more than one kind of treatment approach. Marital therapists

come from many disciplines but even those originating from the same discipline have marked

differences in treatment approaches (Martin, 1994). Peter A. Martin, in his book, A Marital

Therapy Manual, observed that the fields of individual, family and marital therapy have blurred

margins, often running one into the other simply by the systemic nature of relationships (1994).

Therefore, some therapists may unwittingly find themselves dealing with couples while others

specifically tailor their practice to work with couples. While practicing one type of therapy,

chances are one will be called to ebb and flow with the process determined by the needs of the

client. The needs of the client shift from one setting to another, from individual to couples, and

the needs of the couple in session may especially challenge the therapist. If a therapist is not

prepared to meet the different challenges associated with relationship work, they may not meet

Couples needs with confidence (Weil, 2012). The truth is, at this time, research is unable to fully

answer the question of how effective couple therapies work. Not enough information exists to

significantly inform much of everyday practice or training programs.


Couples therapy is the most challenging, with high stakes and immediate volatility.

Couples typically wait until the relationship has reached an intolerable level of conflict before

seeking help. By the time the couple has arrived for therapy, the problems may have become

very difficult to fix. The average couple waits six years before seeking help (Gottman &

Gottman, 1999). The couple seeking therapy for the first time, after waiting for the relationship

to deteriorate, is typically at odds, combative, and convinced that other person is the one who

needs to be fixed. Oddly, Gottman points out that the best predictor of divorce is having gone

through marriage therapy (1999), therefore creating an impression that marriage therapy can be

risky to marriage survival.

Where Couples Therapy Fails Most Often

Knowing what contributes to failed couples counseling can inform therapists about how

to approach couples most effectively. Dr. William Doherty, in his article published in

Psychotherapy Networker, November/December, 2002, 26-33, (Bad Couples Therapy: How to

Avoid Doing It), offers his ideas on what is missing in preparedness for couples counselors.

Others have offered ideas as well.

Failure: Crisis Intervention Preparedness

Doherty suggests that couples counseling is like a wrestling match; it can be over in a

matter of seconds. Compare that to the “baseball” game of individual therapy, which is paced

and deliberate. In couples work, the emotional intensity creates a need for structure. Doherty

suggests that the first mistake therapists can make in couples therapy is not being prepared for

the crisis intervention type of approach often needed. He claims that many therapists are not

well enough equipped with techniques of Couples therapy and clients will often sense this. In

his book, Take Back Your Marriage (2001), Doherty warns consumers about marriage therapists,


urging them to avoid unprepared therapists who may do more harm than good to the marriage.

He warns that there are two dangers that married therapy seekers face: The individually trained

therapist who is incompetent in couples work and the potential value system that says marriages

are disposable (Doherty, 2002). He suggests that the laid back style of an individual therapist is

not what a troubled marriage needs, but rather he posits that a marriage therapist should have grit

and not permit interruptions, speaking for the other, talking over each other, or engaging in

bickering. A marriage therapist must be able to handle the in-session conflict rather than be

overwhelmed by it. He states that many therapists are not aware of their own inability to handle

conflict and jump to thinking that individual work must be done before couple work can begin,

leaving the marriage hanging in the balance (Doherty, 2001). Doherty speaks of courage in a

marriage therapist, which includes taking a structured and strong stand so that the session does

not deteriorate into the chaos that happens at home, -the chaos that led them to seek help. Of

course, Doherty may suggest that couples seek out pro-relationship therapists who are aware of

their own cultural biases when it comes to commitment.

John Gottman agrees. In his book, The Marriage Clinic: A Scientifically Based Marital

Therapy (1999), Gottman states that it is an enormous leap to assume that the traits most often

associated with individual therapy, such as empathy, warmth, and genuineness, would apply to a

therapy model in relationship work. An individual therapist may be well within his or her rights

to be empathic with a client who is complaining about a third party but in relationship therapy

this complaining is likely about the third person sitting in the therapy room. Gottman contends

that working within the elevated emotional state is important and effective, whereas in individual

therapy, the therapist is often working to help the client regulate emotion so he or she can get to

the work of gaining insight.


Many couples wait until their relationship has reached a crisis point to seek therapy (as

Doherty also pointed out). Again, a couple in crisis will be combative, argumentative, and

resistant. A couples therapist should be prepared to take control of the session lest allow it to

disintegrate along with the relationship. This skill calls for a strong leader with an action-

oriented manner.

Failure: Assuming Individual Therapy Practices are Applicable

Couples therapists may be proficient with the individual model of therapy which relies on

insight leading to change over a period of time with a therapist who is receptive and supportive.

Clients may also enter therapy with an expectation for a couples therapist who exemplifies traits

of warmth, genuineness, nurturance, and empathy (Tambling & Johnson, 2010). A couple in

crisis needs a plan for immediate behavior change in the day to day relationship dynamic

(Doherty, 2002) and the behaviors which show up in the therapy room may require more

aggressive attention. The characteristics that often make a good individual therapist, such as

empathy, sensitivity, calmness, and openness are characteristics that do not always work with

couples who are combative, volatile, and self-righteous (Weil, 2012).

Couples need to be taught how to interact differently; they do not need to be shepherded

toward individual insight when it comes to repairing the relationship nor do they need a place to

replicate the bickering and belittling that happens at home (Gottman, 1999). At least not in the

beginning. Doherty suggests that, “all empirically supported forms of couples therapy require

active interventions aimed at teaching couples new ways to interact,” (Doherty, 2002). This

means immediate modification, usually in the form of homework given within the first session.

John Gottman reassures the therapy community with his belief that it would be

impossible to be adequately systematic and organized because what a therapist does first to


modify behavior depends a great deal on the behaviors initially presented. Gottman (1999)

suggests that rather than a methodical approach to marriage therapy, a prepared therapist will

own a tool-box of interventions that can be used based on each individual case. Gottman (1999)

suggests to create initial, rapid, and dramatic change in behavior, followed later by more

structured interventions.

Failure: The Therapist Gives Up

A failing of the therapist as posited by William Doherty is that of “giving up”. He sees

therapists give up on the couple, sometimes referring them for individual work or agreeing with

the couple that the relationship is too far gone to be saved. Therapist’s characteristics play a

role; there is no set checklist in use that informs a therapist when a relationship is beyond repair.

Perhaps the therapist is overwhelmed or under a managed-care limitation; perhaps the therapist’s

own values and beliefs influence him or her. No matter the cause, a therapist’s giving up

communicates a strong message to the clients. The American Association for Marriage and

Family Therapy code of ethics prohibits the therapist from telling a couple what to do, whether

to stay together or to break up but this often gets conveyed in advice to take care of one’s own

needs. A 1999 quantitative analysis showed that experienced therapists tended to be more active,

receptive and flexible, and better at handling Couples negativity (Friedlander, et al., 2011). If

couples often seek therapy as a last-ditch effort, perhaps the “bad” counselor is influenced by a

surrender attitude and defaults into individualistic thinking, seeking to put the individual

happiness of each member ahead of the interest of the marriage.

Cultural context may play a role. The American Psychological Association states that

approximately 40-50% of marriages end in divorce, thereby creating a divorce culture; all too

often divorce is accepted as a means to fix the unhappiness within a dysfunctional marriage. If a


therapist leans toward the cultural remedy of divorce as one potential remedy to marital

difficulty, the couple may be influenced by the therapist’s attitude. If the therapist is willing to

give up, the couple may follow suit.

Earlier it was noted that John Gottman (1999) reports significant correlations between

going for marriage counseling and getting a divorce. While this is not posited as a cause and

effect model, it may point to the cultural acceptance or expectation of divorce as a solution to

marital discord.

The Confines of Research

The nature of research is outcomes, in which researchers examine the impact of

interventions over time. It is costly, involving the selection, training, and supervising of

therapists and participants. Couples therapy (and its research outcomes) suffers from a lack of

beneficial medications that are otherwise applicable to individual research outcomes involving

medically-minded problems such as depression or alcoholism and which hold the promise of a

return on the investment (Christensen et al., 2005). No matter the funding outcomes, treatment

methods are studied in the “medical model” culture of research (Blow et al., 2007). Certainly

funds are more easily justified in the “medical model” context where results are obtained in

tightly controlled environments. The testers are specifically picked and trained to conduct

research by the creator(s) of the model so as to assure the best possible outcomes (Blow et al.,

2007). Laska et al. (2013) noted that the scientific exploration of treatment models has

discouraged the potential therapist variables which may affect outcomes and has labeled those

factors as “unscientific”. In efficacy research (the research that receives funding), the focus has

been on maximizing the treatment outcomes (Beutler et al., 2004). In other words, research

focuses on what is done, rather than how it is done. Therefore, little attention is paid to therapist


variables as contributors to therapy outcomes. Research offers little information to any

therapeutic role and often makes assumptions about therapist homogeneity (Blow et al., 2007).

Arguably, too much credit for therapeutic change has been given to model-based techniques

(Sprenkle et al., 2007). This is the foundation for the “war” between models. Not only do

researchers or model-makers vie for superiority, practitioners who deal in day-to-day reality of

clinical settings believe that scientific models leave out the personal elements that individual

therapists and clients bring to the table.

The Therapist Variable

Research points to significant gaps in the role of the therapist in therapeutic change in

marital therapy which means little is known about the variables and characteristics that embody

an effective couples therapist (Blow et al., 2007). Research is focused on methods rather than the

skills and traits of an effective couples therapist. Research studies are conducted under

controlled environments, usually with the originator of the method which may affect research

outcomes. Blow et al. have reviewed literature and surmise that many authors lament about the

lack of research on therapist variables as linked to outcomes and that these variables are not only

neglected points of potential outcome contributors, but also poorly understood (Blow et al.,

2007). There are many variables associated with the person of the therapist in couples therapy

that are not present in individual therapy. Several have been identified in the little research that

does exist.

Alliance. Alliance creates a challenge unique to couples therapy. Multiple interacting

alliances may develop and can be heavily influenced by preexisting dynamics (Friedlander et al.,

2011). Alliance is a critical factor for change but can also stop progress in its tracks if a

problematic alliance is formed (Friedlander et al., 2011). In his 2002 article in the


Psychotherapy Networker, William Doherty, University of Minnesota professor of Family Social

Science, warns of the ever present hazard of winning one spouse’s alliance at the expense of the

other. As previously mentioned, the techniques taught to therapists-in-training that focus on

individuals do not work for couples. A therapist must share a sense of purpose with the couple

and establish over-arching systemic goals rather than individualistic goals. Neutrality is central

and expected in couples counseling and supports a systemic approach to the therapy (Weeks et

al., 2005). Creating a safe environment for shared goals to be established can be difficult and a

therapist who allies too strongly with one partner may damage the alliance with the other. It is a

delicate balance because each member’s alliance matters and exerts effects on the course of

therapy (Friedlander et al., 2011). Further, while each couple member expects the therapist to

treat him or her with respect, how he or she wants the partner to be treated is another matter;

often one partner wishes for the therapist to take sides (Weeks et al., 2005).

The therapeutic relationship has long been understood to be a contribution to the

effectiveness of therapy and serves as a significant factor in change. The ability of the therapist

to establish a positive relationship with clients continues to receive the most consistent support as

an outcome indicator in marriage therapy (Blow et al., 2007). The modality of therapy will not

matter if the alliances are not productively created.

Over the last several decades, four meta-analytic summaries have found moderate but

robust correlations between alliance and outcomes. The quality of the alliance matters

ubiquitously (Fluckiger et al., 2011). Alliance has become an accepted assumption for

successful therapy.

Pick-a-model mentality. There are many theories and approaches to couples counseling.

Many MFT training programs coach students to choose a model, communicating that a student


should carefully choose one model from which to do the work to the best of their ability (Blow et

al., 2007). There has been a collective effort to influence clinicians’ beliefs and practices based

on comparative or controlled treatment studies (Gurman, 2011). In this structure, a disorder is

matched with a treatment model. Training programs consistently allege to have the answer to

marriage therapy, claiming that the method they have developed will solve marital discord.

Many method developers advocate for the exclusive use of their methods. Trainees are caught in

a tug-o-war between finding a solid theory and sticking with it or stuffing themselves with the

buffet of therapeutic offerings. Most are overwhelmed with options, confused by the chatter

within the profession that purports one way to be superior to the next.

Indeed, some models claim to be “the one” that works. Research consistently supports

efficacy for tested models furthering the therapy culture of sticking to one “tried and true”

method. Therapists may subscribe to one, follow its methodology, master its techniques, and

become comfortable with that exclusive model. Clients in this scenario are forced to adapt to the

therapist, rather than the therapist adapting to the couple’s needs. This structure disavows the

idea that what works with one couple may not work with another; one really effective approach

may leave out key tenets of another approach. Overall, models are often manualized, and leave

out ubiquitous therapeutic factors. Advocacy is high for specific empirically supported

treatments with close adherence to carefully developed and tested manuals and guidelines

established during clinical trials. Advocacy stems from the medical model prevalent in today’s

treatment culture which states that specific disorders require specific treatment plans (Fluckiger

et al., 2012).

Conceptualization. Theoretically based frameworks provide support for integrative case

conceptualizations among the dearth of available methods. Learning to acquire, assess, and


make sense of information couples present (case conceptualization) is essential to the success of

a therapist (Ellis et al., 2013). Couples therapists receive little training in how to conceptualize

couples and have an inordinate amount of information to organize and understand given the

complexity of any case (Chambers, 2012). The ability to disseminate a multitude of theories

and disciplines may be of particular challenge to an early career therapist (Stanton & Welsh,

2011). Stanton and Welsh further argue that being able to conceptualize a couples case is a

separate skill from treatment (2011). The challenge of case conceptualization could be

particularly significant for a therapist who has not had extensive exposure to couples and who is

inundated with theory and model information, but influenced to choose only one.

Allegiance. Allegiance is a therapist’s belief in a treatment and in its ability to effect

change. It is an important aspect of an effective therapist because insufficient therapist allegiance

can negatively influence therapy outcomes (Blow et al., 2007). Allegiance is formed when the

therapist or researcher has a specific interest or enthusiasm for a specified treatment model.

Allegiance is shown to be effectively powerful in increases in therapeutic effectiveness (Shadish

& Baldwin, 2005). As clinical psychology has been divided into many factions with each

claiming some level of superiority over others, clinical scientists have spent millions of research

dollars on thousands of efficacy studies (Elkins, 2012), proving their own allegiance to a chosen

method. When model developers test their own models, as most often occurs in marriage and

family therapy research, the results often reflect better outcomes when conducted by the

originator of the program than when replicated by therapists in the experimental conditions

(Blow et al., 2007). It has been suggested that this is because “the model developer and close

colleagues typically implement the experimental treatment, have procured funding to test the

model, and generate enthusiasm for the model being tested,” (Blow et al., p. 301, 2007).


Currently it is estimated that there are more than 400 theories of counseling and psychotherapy,

each with its own set of procedures (Elkins, 2012). This may suggest that many different

therapists offer their allegiances to many different types of models; developing allegiance to a

method is more important to outcomes than the method itself.

Allegiance suggests that when a therapist has a positive attitude toward a select treatment,

the therapist will conduct that treatment with higher levels of effectiveness and skill (Blow et al.,

2007). For example the therapist may show higher levels of confidence, hopefulness, and

enthusiasm and those values may offer a strong determinant of outcomes in clinical trials, which

in turn suggests that those values themselves are actually more important to outcomes than the

type of treatment used (Blow et al., 2007). Again, while researchers and clinicians continue to

battle in the “model wars”, research shows that allegiance to a model is the factor of importance,

rather than the model itself. The therapist, not the model, is the important factor in the allegiance

equation.

Gurman (2011) suggests that therapists are attracted to different approaches for a wide

variety of reasons, whether rational or irrational. Each choice is personal and inherently based

on the necessity for a good fit between the therapist’s preferred method of therapy and the person

of the therapist, his or her worldview and lived values (Gurman, 2011).

Indisputable Ingredients: Behavior, Insight and Emotion

Couples therapy has been empirically supported from a variety of theoretical perspectives

and techniques. Despite the broad variety of approaches, the found common ingredients are the

(1) introduction of new behaviors, (2) insight and (3) emotions; all three are required to support

change (Lebow, 2006).


Behavior

Therapies supporting behavioral changes are the most researched. However, behavior

therapy by itself has been shown to have the lowest efficacy rate (Marmarosh, 2013). But,

behavior cannot be separated from the mix as it affects the interplay of insight and emotion.

Behavior therapies emphasize actions and skills as the mechanisms of change, assuming that

while insight is helpful, it must be supported with training, practice and implementation of new

skills (McAleavey & Castonguay, 2013). Behavior therapy assumes that changes in behavior can

lead to increased insight. A 2005 meta-analysis of behavioral marital therapy showed that it was

more effective than no treatment at all. Behavior may be targeted for greatest efficacy when

aimed at couples coping with conflict. Research by John Gottman has shown that teaching

couples not to fight is not therapeutically sound, but rather teaching them new behaviors in how

to fight has lasting benefits (Gottman, 1999.) Indeed, most studies define couple therapy

outcomes as improvement in relationship functioning (Owen et al., 2012; Baucom et al., 2011),

and a central tenant of behavior is the improvement in communication (Baucom et al., 2011).

Traditionally, behaviors targeted also include increasing positive behaviors, decreasing negative

behaviors, the use of “I” statements, active listening and problem solving. However, little

research supports the long-term efficacy of behavior therapy alone and post therapy assessments

are largely non-existent (Baucom et al., 2011). While behavior change is necessary for the

combative, negative-cycling of distressed marriages, long-term effectiveness of behavior therapy

has encouraged the development of alternative treatment methods that may produce longer-term

results (Christensen et al., 2006).


Insight

From both historical and theoretical perspectives, one important aspect of therapy has

been and remains the concept of insight. Insight is an understanding of the motivations behind

behavior and choices. Insight has been found to be a common factor of psychotherapy

(McAleavey & Castonguay, 2013). Insight-oriented therapies focus on identifying the origins of

relationship themes for each partner, seeking to understand rudimentary family of origin

information which has shaped and colored these themes. Insight therapies seek to assess a

couple’s beliefs and behaviors and to take into consideration the lifestyles of the partners and the

resulting interaction of the two lifestyles (Corey, 2009). This type of intervention requires the

therapist to offer feedback and interpretation as an avenue for promoting insight. With its base in

Adlerian theory, these interpretations are required to create new awareness for motivations and

the goals of each partner’s behavior. Insight is the catalyst on which real change is built. Without

insight, change may be temporary.

Emotion

Emotion is an innate adaptive system, connecting people to their most basic needs,

rapidly alerting them to situations important to well-being (Greenberg, 2011). At the heart of

emotion in marriage is attachment. Marriage is an emotional attachment bond between two

partners where each is perceived to be the primary source of belonging, security, safety and

affection (Greenburg et al., 1993). Therapy that includes emotion has been shown to be more

effective than behavioral therapies (Lebow et al., 2012). The movement toward emotion in

therapy grew out of the overemphasis on cognition and behavior (Greenberg, 2011), and has

continued to expand proving itself effective as a key element in change. Emotionally Focused

Therapy (EFT) which has evolved into a full-blown theory of practice, includes a depth of


emotional experience and the formulation of new couple experiences where the partners are able

to clearly express attachment fears and needs and be emotionally open to their partner’s needs

(Lebow et al., 2012).

While behavior therapies strive to change patterns of behavior and communication,

emotion-focused therapies strive to change behaviors through emotional experiences within

session. Emotionally-focused therapies strive for the expression of underlying feelings and

needs within session to lead couples to change negative interactional patterns, which in turn will

allow partners to be more open and responsive to one another (Greenburg et al., 1993). The use

of emotions in couples therapy promotes affect regulation and the creation of secure bonds that

cultivate resilience and safe attachment bonds (Lebow, et al., 2012), in order to help clients make

productive use of their emotions (Greenberg, 2011). Emotion influences thought and behavior

and people generally do what they feel like doing rather than what reason dictates. To achieve

change or to motivate new behaviors, emotions first must change (Greenberg, 2011). Emotion

governs the view of self and others and influences interactions between people, therefore real

change fundamentally depends on emotional change.

Adlerian Marital Therapy

Adlerian psychology is a “systems” psychology. Adler advocated a holistic, systemic

view of behavior (Ansbacher & Ansbacher, 1956). Personality is indivisible but within the social

context, behaviors of the individual serve the larger system in which they occur. Adlerian

psychology integrates both individual personality and relationship systems (Kern et al., 1989).

Marriage, in the Adlerian perspective, is a social system. In his book, The Science of Living,

Adler stated that “…the questions of love and marriage can be solved only by socially adjusted

persons. The mistakes in the majority of cases are due to a lack of social interest, and these


mistakes can be obviated only if the persons change,” (Adler, 1969, p. 122). He continues on to

posit that marriage is not for private purposes only but for the social good (Adler, 1969). The

marriage therapist who operates from an Adlerian perspective is able to move back and forth

between the individual and the relationship (Kern et al., 1989), thus possibly giving the Adlerian

couples therapist an advantage in dispelling any harmful effects which may otherwise result from

a therapist trained to heed the singular target of individual behavior in a more allopathic

approach.

One of Adler’s most enduring concepts is that of gemeinschaftsgefühl, or social interest,

which underscores the Adlerian view of marriage in its context as a social system and the focus

on individuals as equals, working on a horizontal plane toward socially useful tasks (Mosak &

Maniacci, 1999). In Cooperation Between the Sexes: Writings on Women, Love & Marriage,

Sexuality and its Disorders, Adler states that, “… love in its essential meaning, the relationship

of the sexes, is always connected with social feeling and cannot be separated from it,” (Adler,

1978, p. 109). Marriage is based upon equality-a mutually expressed greater interest in the other

than in the self, based on valuing the differences, rather than sameness, each partner offers (Kern

et al., 1989). Adler called marriage an “intimate devotion”, giving each partner the feeling of

being worthwhile, irreplaceable, needed and accountable (Ansbacher & Ansbacher, 1956).

Adlerian theory has become increasingly integrated into prevailing current clinical

practices. As therapy movements come in and out of fashion, each creates its own bit of

hullabaloo while enjoying a moment of fame and often times offering a unique contribution to

the ongoing discussion (Mozdzierz, 2011). The only constant in the practice of counseling and

psychotherapy is the constant churning of fads, some leaving indelible and useful impressions on

the profession. Adlerian theory is becoming baseline theory for the new systems quickly


emerging and evolving, though it is not always recognized as such (Mosak & Maniacci, 1999).

Mosak and Maniacci (1999) posit that all practitioners hold a theoretical base; that even those

claiming no one base can be said to have an eclectic approach. How well one understands his or

her theoretical base is important; one may then use it to build upon with other useful techniques

and theories. The Adlerian marital therapist holds an advantage in having a strong understanding

of Adlerian theory, better allowing the therapist to build a strong methodology for treatment

based on sound theory and a firm foundation. Adlerian therapists have the advantage of a

theoretical basis from which to grow and foster a multi-modal, personalized approach to couples

therapy. In a 2007 literature review on the role of the therapist in treatment outcomes, Blow and

associates, searching for common factors, found that therapists who studied only one theory but

were knowledgeable of several diverse models, were more effective with clients than those who

had had the smorgasbord theoretical education offered at multidisciplinary schools. Blow and

associates advocate for a shift from encouraging students to be passionate about theories to being

passionate about a theory. It is daunting to learn several theories and many models without one

theory serving as the base on which to compare and balance all other learning. Having a

coherent passion for one theory provides a therapist with confidence and orients the therapist to

process (Blow et al., 2007). Without a coherent focus, one may suffer from the over-whelming

offerings of proven and unproven theories. The problem is not a lack of theoretical ideology.

Training in diverse models, with a solid theoretical base, may contribute to better

conceptualization of dysfunction, provide stronger allegiance toward treatment, and offer

flexibility to address the multi-variants which affect therapy outcomes (Corey, 2009).

Building on an Adlerian base, the previously mentioned three ingredients of clinical

focus are naturally incorporated: insight, emotion, and behavior. The prepared therapist will


know with which ingredient to deal most hastily: emotion, insight or behavior. Addressing the

most distressed portion of a couple’s dysfunction immediately may lend to therapist credence,

build alliance, and promote retention (Friedlander et al., 2011).

Adlerian Concepts Supported

Recent changes in how researchers conceptualize couples therapy support Adlerian

concepts. For example, common-factors thinking assesses the couple holistically. That is, rather

than require the couple to fit the treatment, the couple is considered in light of its individual

members, its cultural context, and the multi-lateral influence of these traits (Chambers, 2012). In

other words, common factors tend to be more inclusive of the systemic, holistic attitude held by

Adlerian theorists. Adler stated that, “The problem of love relationships is part of the problem of

human life. Its understanding is possible only if we regard the coherence with all other problems

of life,” (Adler, 1978, p. 105). Once again, as therapy matures, we see a greater inclusion of the

Adlerian concepts which have appeared at the rudimentary level of so many other approaches.

In an article by Stanton and Welsh, authors define systemic thinking as a

“…comprehensive cognitive reorientation that includes the willingness and ability to challenge

existing mental models, the understanding and use of systemic paradigms for structuring one’s

knowledge and thought, the understanding of systemic concepts, and the inculcation of those

concepts into practical thinking about life issues, circumstances, and problems…” (Stanton &

Welsh, 2012, p. 14). The Adlerian model stresses insight and reorientation at its base, making

the “newer” systemic thinking Adlerian at its core. Adler’s theories on human behavior may be

viewed as the first systems-based approach in couples counseling (Kern, et al., 1989). Adler’s

choice to view problems within the interrelationship between the parts and whole supports the

“new” holistic style of current research trends. The marriage therapist working from an Adlerian


perspective is able to move between the parts of the system and change in one part of the system

will in turn result in change at all levels (Kern et al., 1989).

Adlerian marital therapy is based in functionalism, continuously focusing on the purpose

of behavior and its influence on the system. It conceptualizes the transactions between the people

rather than the characteristics of individuals as primary players and does so within the greater

social context (Kern et al., 1989). Rooted within the interactions is the essential need to belong

and experience attachment as well as the insight required for lasting reorientation. Adler

recognized marriage as one of the basic life tasks and suggested that each of us has a need to

develop a close, intimate relationship. It is doubtful that Adler would have advocated for

manualized, pre-determined therapeutic approaches when dealing with the creative development

of the lifestyles that interfere in complicated and unique ways in each marriage. For Adler,

therapy was holistic, systematic and phenomenologically based- a far cry from the manualized

approaches managed care requires of the therapist on their panels today.

Adlerian Argument for a Common Factors Approach

The argument for establishing a common factors approach begins with the simple truth

that not all therapists are the same; some therapists will achieve better results than others. If

therapy were a simple “plug and play” operation, the variables among therapists would not

matter. When consumers shop for a therapist, they look more toward personal factors of the

therapist than they do of theoretical orientation. Oddly, despite the significant role of the

therapist, research literature reflects that we know surprisingly little about the characteristics of

the therapist which support change and efficacy (Blow et al., 2007).

Stanton and Welsh (2011) point out that the current trend is to focus more on the dynamic

interaction between a selected treatment model and common factors, including therapist style.


They further posit that the specialty of couples therapy requires the therapist to obtain a wide

knowledge of specialty interventions (Stanton & Welsh, 2011).

Chambers reviews the common factors (CF) movement, pointing out that the field is

moving beyond its historical focus on models and is starting to recognize principles of couples

work that appear to be universal and reach across varying delivery methods (Chambers, 2012).

It is important to examine common factors. While substantial evidence from clinical trials

informs technique, common factors are frequently marginalized for being “unscientific” (Laska,

et al., 2013). Laska et al. (2013) posit that our ability to maximize effectiveness is limited by

little support for current legitimate psychotherapy practices.

Carl Rogers has taught us that the person of the therapist is an undeniable source of

therapeutic influence. Rogers stated that, “If I can provide a certain type of relationship, the other

person will discover within himself the capacity to use that relationship for growth, and change

and personal development will occur,” (Rogers, 1961, p. 33). Adlerians have adopted the

Rogerian view of the relationship between therapist and client. Therefore, the Adlerian couples

therapist would be inclined to consider the non-empirical values that influence couples

counseling outcomes, or in other words, those variables centered around the therapist, rather than

the method.

Research is beginning to reflect advocacy for lessening the science-practice gap for

practical clinical settings (Lebow et al., 2012) so that clinicians may better understand how their

own style can be made useful for effective couples counseling. This begins with understanding

the common factors of successful therapies and expands into examination of therapists’

processes. An emphasis on common factors underscores effective couples therapy and brings the

client-therapist relationship back as a determinant of psychotherapy outcome.


The Model Wars: A Truce

On one side of the war zone are the staunch researchers, armed with empirically valid

studies, statistics and manuals. On the other side, poised in deflection, are the common factors

practitioners armed with warmth, empathy and the conviction that the therapeutic relationship is

more important than the approach. As with most conflicts, both sides have a point. But unlike a

conflict for which consensus seems unlikely, the model wars of Marriage and Family Therapy

may have a cease fire option.

While decades of research show that marriage therapy works, how it works remains less

known. The common factors approach is criticized as being a list of variables one can elicit as

ubiquitous features among practitioners, however research consistently shows that these common

elements are more responsible for change than are the unique contributions of the specific model

(Fife et al., 2014). It has been suggested that the therapist’s competence may be the most critical

variable, whatever the variety of therapy (Laska et al., 2013).

The American Psychological Association (APA) advocates for an outcome-based

approach , highlighting the importance of clinical expertise and client characteristics (Laska et

al., 2013). Devaluing one type of treatment in favor of another is not consistent with the APA

guidelines which sets out to implement ESTs in a “best practices” modality which includes the

common factors approach. An American Psychological Association (APA) policy definition of

evidence-based practice in psychology (EBPP) states that practice based on evidence must

consider the best available research, use clinical expertise, and consider client contextual

variables (APA, 2006).Therefore, it is unnecessary to discard ESTs in favor of common factors

and vise versa. Good therapy may be a blend of client-therapist variables and ESTs; of a mixture

of intuition and science. In this view, models of manualized, standardized therapy techniques


become the vehicles through which the common factors brought together by therapist and client

are delivered (Fife et al., 2014). The model wars which pit one side against the other, fail to

recognize the potential relationships between all the moving parts.

Evidence-Based Practices in Psychology (EBPP)

To review, the APA defines Evidence-Based Practices in Psychology as the integration of

the best available research with clinical expertise in the context of patient characteristics, culture,

and preferences (APA, 2006, p. 273). This definition’s purpose is to promote effective

psychological practice and enhance public health by applying empirically supported principles of

psychological assessment, case formulation, therapeutic relationship, and intervention (APA,

2006, p. 273). In this definition, intervention includes all services rendered by mental health

practitioners, including assessment, diagnosis, prevention, treatment, psychotherapy, and

consultation (APA, 2006). It is noteworthy that the definition does not include ESTs or Common

Factors in its description, thereby implying room for both and more. If the APA serves as an

ethical governing body to the work of clinicians and researchers alike, then the debate over one

method versus another seems a moot point. In fact, the exclusion of valuable information is in

direct opposition to the spirit of the APA’s definition of EBPPs.

Perhaps the model war mentality is based more on a pervasive misunderstanding of this

terminology and others. Research indicates that many graduate students and clinicians have

confused much of the terminology (Wilson et al., 2009) that serves as propaganda for a needless

conflict. Researchers found participants on both sides (ESTs and CFs) to be largely unclear

about what the definitions were, including that of EBPPs, and were unsure how the APA’s

definition applied to them. Many believe that ESTs are the same thing as EBPPs. With that

belief, is it no wonder that even under the inclusive definition given by the APA the CF and EST


proponents continue to bicker. However, this same research discovered that once clarity of

terminology and meaning was achieved, attitudes toward EBPPs vastly improved (Wilson et al.,

2009).

To be clear, ESTs (empirically supported treatments) start with a treatment and ask if it

will work for a certain disorder or problem under specified circumstances (APA, 2006). ESTs

are specific psychological treatments that have been shown to be efficacious (successful in

producing a desired or intended result) in controlled clinical trials. Conversely, evidence-based

practices in psychology (EBPP) is a more comprehensive concept. EBPPs begin with the client

and ask which research evidence will best support the clinician in achieving the best outcomes.

Furthermore, EBPP includes a broad range of clinical activities such as assessments, case

formulation, and therapeutic relationships. EBPP communicates a decision-making process for

integrating multiple modalities (APA, 2006). In other words, it is inclusive, rather than

exclusive.

Evidence-based practices in psychology recognize that many strategies work with clients.

Many have been refined through trial and error, through study, clinical application, and through

the kind of testing that constitutes the most scientific aspect of clinical practice (APA, 2006).

Yet EBPPs also recognize that testing has its limits which in turn creates the need to integrate

clinical expertise, which goes to the “person of the therapist” argument. EBPP appreciate the

value of multiple modalities and viewpoints.

Deeper Understanding of EBPP

If EBPPs include best available research, clinical expertise and client context or client

preference, it is important to clarify those components.


Best available research. This refers to the research practitioners use to keep up to date

on current trends, findings and empirical evidence. This may include consulting journals,

attending seminars, attending consultations, and continued education (CE). The APA recognizes

many avenues to finding the best available research. For example, clinical observations,

qualitative research where the practitioner learns from another’s experience, case studies, single-

case studies, public health research, outcome studies, studies of interventions, or randomized

controlled trials (RCTs). The emphasis is a directive to stay current with what is happening in

this professional field.

Evidence-based practices require that practitioners recognize the strengths and limitations

of evidence obtained from different types of research (APA, 2006, p. 275). The APA has

determined the types of research evidence as to their contribution to efficacy conclusions and

they are, in ascending order: clinical opinion, observation, and consensus among experts;

systemized clinical observation; and sophisticated empirical methodologies. Comprehensive use

of available research will consider treatment method, therapist, alliance as a complex, relational

and technical undertaking (APA, 2006).

Clinical expertise. According to the APA (2006), clinical expertise includes

competencies such as assessment, diagnostic judgment, systemic case formulation, treatment

planning and implementation, monitoring progress, self-reflection, evaluation, and knowledge of

research. Clinical expertise includes past experiences with clients, training, supervision, and

consultation. Clinical expertise is required to match the treatment to the client, pace things

accordingly, and describe the rationale behind the treatment goal (Wilson et al., 2006).

“Understanding psychotherapists’ expertise has broad implications for training and

education, defining empirically supported treatments, service delivery models, and quality of


care standards,” (Owen, 2013, p. 496). Owen continues to describe expertise as the following:

process outcomes or clients’ immediate ability to gain insight or complete behavioral changes,

the effectiveness of less common practices that can be measured against standard practices, and

the degree to which the therapist is able to elicit deeper change in the client (2013).

Furthermore, clinical expertise is the ability to monitor one’s own ability and to know

one’s limits of knowledge and skill which will inform the clinician when to seek resources or

consultation (APA, 2006). While a clinical approach may be eclectic or integrative, a planned

approach to the treatment relies on expertise, which is essential for identifying and integrating

the best research evidence with a particular client.

Client context and preference. Meeting clients where they are requires the therapist to

tailor therapy to unique needs and readiness. This category of EBPPs takes into account the

“what works for whom” question and allows therapy to be most effective as it responds to

specific problems, strengths, lifestyles, contexts, and preferences. Client context and preference

takes into account the client’s values, religious beliefs, worldviews, goals, and preferences for

treatment (APA, 2006). This underscores the question of how to best approach treatment

planning with clients whose characteristics or circumstances do not match up with samples

studied in research. While presenting problems may be similar across clients (such as affairs,

constant bickering, or disengagement), the rudiments of the problems may not be similar, or they

may be part of multiple symptoms for which specific treatment plans were not created. Different

strategies and different relationships may prove better suited for different populations, according

to the APA. Making room for client context and preference allows for a collaborative process in

which clients and practitioners negotiate ways of working together for the best possible


outcomes. EBPP seeks to maximize client choice among effective alternative interventions

which require balancing practitioner expertise with client preference (APA, 2006).

EBPPs: Implications for Working with Couples

If Evidence-based practices in psychology are those that are research-informed, therapist-

reliant, and client-centric then work with couples need not be hindered by any model-war chatter.

Evidence tells us that no one model reigns superior but that the relationship between therapist

and client matters most. While there may remain disagreement as to how best prepare therapists

in creating the therapeutic relationship, it is largely undisputed, (but thoroughly supported) that

the working alliance is positively correlated to therapy outcomes. The importance of the alliance

should now be viewed as working together with empirically supported treatments (Fife et al.,

2014) and the APA supports the integrative use of research, therapist variables, and client

variables. It is a win-win situation. It is the truce. Now it is time to take the victory to the field

and do the work which we are meant to do.

The available body of research focused on why and how therapy works gave rise to the

battles for victory. But again and again through study after study we are informed that therapy

indeed works, despite our inability to agree on a vernacular as to how (Elkins, 2012). Perhaps we

focus too much on how it works, on the missing information, and we do not place enough faith in

the substantial body of empirical evidence supporting the simple fact that therapy works.

Thousands of research articles have ideas on what works. Under the premise of the

APA’s definition of EBPPs, the ethical therapist may seek to learn about findings by colleagues

which have been hard won through scientific processes beyond the scope of clinical settings.

The following portion of this paper will seek to provide an extensive, but by no means

exhaustive, list of factors which have proven effective to and for other couples therapists, and


which have been written about and examined in professional journals. Using the APA’s

guideline to integrate the best “available” research, this may imply that while one practitioner is

able to gain access to some research, others may be able to access different literature. It is within

the spirit of adding to clinical expertise that information is shared and disseminated. Therefore,

implications of working with couples from an evidence-based practices platform subsequently

follows.

Get Over the War. Move On.

A paper which has the purpose of overcoming a model wars mentality for the good of

couples counseling must first implore that it is time for practitioners and researchers to

collaborate on increasing practical knowledge, rather than argue efficacy and effectiveness.

External validity may not exist for many legitimate techniques (Lebow, 2006) but if clinicians

can report and share results and anecdotal information, this fits into the spirit of the APA’s

concept of clinical expertise. It should become more accepted that client samples often do not

typify the general population and that results may be difficult to replicate outside of controlled

environments provided through research programs (Blow et al., 2007), but that clinical

observation can add qualitative value to the growing body of research evidence (Fife et al., 2014)

in order to continually increase our understanding of what will best help clients reach goals.

Qualitative research is consumer friendly as it contains translations of relevant research into

intimate relational processes which can be applied to general practice (Gurman, 2011).

Forcing clinicians to use only well designed and replicated studies in order to be paid by

insurers would require many therapists to master unfamiliar methods which may not match with

their worldviews. Furthermore, “… since it is well known that what therapists code as their

therapy ‘procedures’ for insurance reimbursement and HMO authorizations have little to do with


the methods they actually use, couple therapy would become like Mexico where it is said,

‘everyone is Catholic, even the Protestants’ ” (Wampold & Coleman, 2001, p. 268).

Use Clinical Expertise and Research to Treat Clients

Using clinical expertise to conceptualize and treat clients includes using information

gathered by other professionals. In reviewing some of the research that is available, common

themes and common factors in treating couples emerge. Specifically, the concepts of allegiance,

agreement, early intervening, feedback, and content will be covered briefly.

Allegiance. In the spirit of the APA’s call for the use of clinical expertise and available

research, practitioners can focus on proficiency in techniques and increase their information in

modalities. Practitioners have the opportunity to find models which they especially like.

Research suggests that therapist allegiance for a technique or model offers a common factor

which has been shown to support a positive therapeutic outcome (Elkins, 2012).Allegiance is

that feeling that a method is significant and meaningful on a personal level as well as

professional and is a technical intervention that the therapist desires to refine and learn more

about over the course of his or her professional life (Zeddies, 1999). It is the method that gets

the therapist excited about doing therapy!

Researchers have proposed that the controversy between the common factors versus

models dilemma actually takes place within the self of the therapist (Blow, Sprenkle, & Davis,

2007). When the therapist adopts a model which is congruent to his or her worldview, the

congruency between worldview and model align, ending the war which allows the therapist to

reach his or her full potential as a therapist. The model’s intended change mechanisms are

activated by the authentically practiced work through the person of the therapist (Blow,


Sprenkle, & Davis, 2007). This synergistic partnership between worldview and therapist

maximizes efficiency and allegiance leading to the best possible treatment for the client.

The adoption of a model is an intervention itself, providing the couple with confidence in

the therapist as well as a sense of hope early on in therapy (Davis & Piercy, 2007). The therapist

intervenes in the couple’s chaos by using model-specific and common factors interventions

aimed at altering the affective, cognitive and behavioral elements of the interactional cycle.

Thus, allegiance becomes a therapeutic element.

EBPP would also caution couples counseling practices in similar ways as critics like Bill

Doherty. If a practitioner cannot conjure enthusiasm and excitement for the work of couples

counseling, he or she should use clinical expertise and pass on the practice altogether.

Allegiance is an indisputable element of successful therapy practices, therefore if a therapist is

unable to provide that, he or she would be ethical and within APA guidelines to refer out the

couple.

Agreement. A growing body of research shows that a couple’s ability to agree on their

presenting problem is an indicator of effective outcomes. Biesen and Doss, (2013) found that

agreement on presenting problems was significantly more strongly related to several measures of

treatment engagement and outcome. Agreement on presenting problems led to less attrition and

greater engagement. Knowledge that agreement can lead to retention should inform the therapist

of its importance in clinical practice. Furthermore, agreement on the problem can inform the

therapist as to the severity of the Couples problem (Biesen & Doss, 2012). A couple that cannot

agree on what is the presenting problem or the reason for seeking therapy is most likely farther

“gone” than one who can (Doss et al., 2004).


“Negotiating mutually agreed-upon goals is a cornerstone of the working alliance as it

fuels client engagement and informs decisions regarding the direction and methods of therapy”

(Owen et al., 2012, p. 179). Alliance, which has emerged as a basic element necessary for

therapeutic effectiveness, is supported by the argument for establishing agreement in couples

therapy. The Owen et al. findings suggest an importance of early assessment of client goals for

couple therapy so that the direction of therapy best fits the couple’s level of distress (2012).

Client expectations. Research shows that clients formulate expectations regarding

therapy and these expectations influence the decision to seek therapy and impact the therapeutic

relationship (Tambling & Johnson, 2010). The person of the therapist as experienced by clients

serves as a key alliance building block. Meta-analyses find that characteristics such as therapist

empathy, warmth, and genuineness are correlated with positive client outcomes (Fife et al.,

2014). Specifically, marital therapy clients held expectations that the therapist would be active,

directive and would offer suggestions, and that communication and problem-solving skills would

be included components of therapy (Tambling & Johnson, 2010). Tambling and Johnson

conducted a meta-review on client expectations of marital therapy and discovered that across

studies it was the “person of the therapist” elements which were most important to therapy

seeking couples. Given what earlier data in this paper suggest about how marital therapists must

assert themselves in order to differentiate from individual therapists, therapists may use this

information to prepare for couples work toward greater outcome success. Furthermore,

therapists who find out what their clients’ expectations are may be able to tailor therapy to fit a

couple’s specific needs (Tambling & Johnson, 2010).

Feedback. Continuous assessment is a way of tracking client progress across therapy that

allows the therapist to monitor the progression of treatment. The APA supports this as a means to


help clients achieve desired results in therapy (APA, 2006). Previous client-feedback studies

show encouraging results (Reese et al., 2010). Client feedback has been found to benefit at-risk

clients for terminating therapy prematurely. Part of the rationale for this may be that clients who

benefit from therapy demonstrate improvement sooner rather than later in treatment. Meaning, it

is important for clients to benefit early on in therapy and one way to monitor improvement is by

use of client feedback. Reese and associates studied the use of feedback specifically with couples

and found that couples who were in a feedback condition gained clinically significant results as

compared to couples not in a feedback condition. These findings also suggest that feedback

conditions produce better clinical gains whether the couple was progressing as expected or not

(Reese et al., 2010).

One further implication of these findings suggests that practitioners become comfortable

with using assessments within their therapy practices. Assessment requires only that clients or

the practitioner complete and score questionnaires which can take as little as a few minutes

(Lebow, 2006). It may be more beneficial to track client progress frequently during therapy to

give a better sense of how and under which circumstances couples change over time (Lebow,

2006).

Long term maintenance. Randomized clinical trials have convincingly demonstrated

that couples therapy leads to substantial improvements in relationship quality but that these

improvements tend to persist over the short term, as in six months to a year after treatment

termination. The previously mentioned “Cookerly study” found that over half of couples were

divorced at five years post-treatment (Christensen et al., 2010). This plays into Gottman’s quip

that being in marital therapy is a predictor of divorce. Is there a way around this? The lack in

literature regarding two-years or more post-therapy leaves room for further research. In the


meantime, perhaps this finding should be followed up by using factors such as psycho-education

and client-commitment. It is not difficult to imagine informing couples that results of therapy

may be temporary and that commitment to follow up in later years would best deter the

possibility of temporary effects. Clients could be encouraged to resume therapy at certain

intervals to maintain the gains they accrued during treatment.

Learn the Letters

One final implication for work with EBPPs is to know the letters. That is, therapists who

engage in rhetoric regarding procedures, manuals, trials, studies, findings, and theories should

know of which they speak. One particular research study discovered that clinicians and

researchers alike were more often unaware of the accurate definitions of many of the widely used

acronyms in the field of psychology. This misunderstanding led to misconceptions of opposing

sides of arguments but for which agreement was easily gained once clarity of terms was achieved

(Wilson et al., 2009). Understanding the distinction between efficacy and effectiveness, for

example, is important in formulating opinions which perpetuate the controversy surrounding

ESTs and common factors (Karam & Sprenkle, 2010).The Wilson study found that attitudes

toward EBPPs became more positive as the definition of such was expanded and clarified and

that most participants of the study were in agreement to implement the EBPP concepts that the

APA has put forward (Wilson et al., 2009). This suggests that researchers and practitioners alike

may need to take an open-minded look at the definitions of industry acronyms and terminology.

(See Appendix for a table of terminology.) Doing so will increase credibility and reduce the

polarizing effects of misunderstanding.

Furthermore, couples therapists recognize that relationship skills alone are not sufficient

for doing effective work and therapists continue to hone skills through continuing education,


viewing the therapy relationship as the vehicle for carrying out the craft of therapy (Sprenkle,

Blow, & Dickey, 1999).

In Conclusion, Recommendations and How Do We Market?

This body of research began as an attempt to answer the questions, “What works in

couples counseling?”, “Why does marital therapy often fail?”, and “How can we make it better?”

It set out to find a model that could be applied across the board or to create a new one. It set out

to hush the industry’s bickering between the pro-model approach team and the pro-common

factors team. It assumed that common factors would emerge as superior and discovered that the

common factors movement is controversial, misunderstood, and under-studied. As research

continued it became clear that although a vast body of research has been conducted on

manualized methods, evidence clearly shows that no one model is superior over another, that

different couples will need different types of interventions in response to various complicated

complaints. This research discovered that many disagreements exist among the tangle of

terminology and that research advocates and practicing clinicians are not as far from a cease fire

as it would appear. Furthermore, it became clear that the APA has understood this conundrum

and responded with an inclusive, open and integrative welcoming approach that honors both

research-backed results and clinician effectiveness but that this idea remains largely

misconstrued or under-disseminated. Therefore, it is time to ask, “How do we counter the

failings that we can identify with an inclusive, open, and integrative spirit?”

First, we can honor the body of knowledge that shows that allegiance is of indisputable

importance in clinical practice. With allegiance, we earn the trust and respect of our clients, we

apply appropriate treatments convincingly and we increase therapy retention. Allegiance builds


alliance which is perhaps the only un-measurable aspect of couples therapy that is not disputed

as a core requirement for successful work.

Secondly, we can creatively use interventions that match the couple, rather than apply

models like medical drugs hoping to cure an identified symptom. We can use models which

match our own worldview, and common factors, and address three indisputable areas of

treatment of behavior, emotion and insight. Clients respond better in long term goals to treatment

which addresses all three and it takes the intuition and skill of the therapist to understand which

of the three most urgently needs to be addressed (Sprenkle, Blow & Dickey, 1999). Clients

expect and prefer their couples counselor to be directive, structured and to offer homework

(Gottman, 1999; Swan & Heesacker, 2013; Lebow, 2006). Paying attention to client preferences

increases outcomes and ethically meets the challenge set forth by the APA.

Thirdly, clinicians can be ready to meet the unique needs of couples and to know how to

structure sessions differently than in individual therapy sessions, which is where the majority of

graduate school training is focused. Being able to intervene when a combative and hostile

couple is in crisis mode is a very different way of working than when the therapist is faced with

individual clients. Couples differ in that they may need a therapist to take immediate control.

Also, couples counseling, to be effective, requires commitment to a minimum number of

sessions as deemed appropriate by the therapist. Furthermore, support has been shown to

encourage clients to maintain therapeutic effects with follow up sessions, dispelling the myth that

marital therapy is a once in a lifetime event.

In short, the couples therapist has the opportunity to learn from a large body of available

research how to be when facing couples, which is very different than when facing individuals.

The majority of research articles used for this body of evidence called for expanded graduate and


post-graduate training in marital therapy, person of the therapist, and other common factors

which are often under-valued in favor of “scientific” or historical elements of marriage and

couples therapy. Finding readable research and remaining current with qualitative evidence may

only serve to enhance the practice of couples counseling. There is value in being self-aware as a

couples therapist, to connect to a therapy which matches one’s worldview and sparks excitement

and inspiration.

From a marketing aspect, the” buyer beware” haze surrounding couples therapy offers a

unique opportunity for those seeking to commit to and perform excellent counseling services.

Therapists can create public awareness of the pitfalls of seeking help for relationship problems

from a therapist who lacks specific training. A therapist who is committed to, and has an

allegiance to, conducting couples counseling will undoubtedly offer a better service than one

who “also happens to” do couples counseling. It is a specialty and should be treated as such and

thus marketed as one.

Another opportunity to market well is to encourage potential clients to ask therapists to

state their value positions in regards to relationship commitment. Even if the value systems

between therapist and potential client do not fit, this practice may lend an air of professionalism

and expertise to the practice.

Couples therapists should be open about the background and training they have. Those

with MFT licensure can stand out against those without required coursework in marriage and

family therapy. Furthermore, a therapist may market the frequency with which he or she does

marital therapy and suggest that his or her practice actively seeks to help couples, rather than

occasionally stumbles across them.


Finally, whether in marketing materials or daily practice, a good couples counselor will

be the one who is excited to be doing this work, who has an optimistic and enthusiastic

allegiance to methods and practices, and who is there to serve the relationship in the best

possible way.


Appendix

Terminology to clear up confusion

EST Empirically supported treatment Backed by medical evidence or research to

show they work

CF Common factors Common components of therapy which are not

part of a scientifically proven study but are

ubiquitous to all methods, such as therapist,

personality, and client variables

RCT Randomized Controlled Trials

(most associated with efficacy)

The gold standard in clinical trials; used to test

efficacy or effectiveness; subjects are

randomly allocated to receiving one or the

other treatments under study

Efficacy Expected results occur under certain/ideal

circumstances (such as are produced in a

clinical trial); internal validity

Effectiveness Results occur under usual circumstances when

applied according to method; transportable

mental health services research


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