The emergence of managed care has radically altered the delivery of mental health services. Increasingly, those who pay for treatment are demanding proof of efficacy. This demand for efficacy has extended to those professionals practicing family therapy (F. W. Kaslow, 2000). In this section, I review what is known about the efficacy of family therapy.
Historically, empirical research has not been a strong component of family therapy (Gladding, 2006). Lebow and Gurman (1995) noted,
[A]t one time, most research on couples and families was conducted with little or no connection to the outstanding clinical developments in the field. Alternative modes of investigation such as inductive reasoning, clinical observation, and deconstruction have dominated in the development of methods and treatment models. Some couple and family therapists have even been reluctant to acknowledge that empirical research has an important role. (p. 29)
Fortunately, this reluctance was overcome, and solid research evidence for the efficacy of family therapy for a dizzying array of issues now exists (Carr, 2009a, 2009b; Sanderson et al., 2009) – evidence that professionals practicing family therapy can use to defend their work in the world of managed care.
Based on the findings of Pinsof and Wynne (2000) and their strong recommendation regarding the inclusion of relevant and appropriate family members in effective treatment, it would seem obvious that counselors and therapists would rapidly adapt to this process. The truth, however, is that professional counselors and therapists have been slow to adopt this practice in their work. In fact, the latest study of the practice patterns of family therapists revealed that approximately half of their client load was individuals (Doherty & Simmons, 1996).
Research on treatment outcome predictors is useful to family therapy practitioners. Unfortunately, little credible research has been conducted in the area. Two notable exceptions are studies by Hampson and Beavers (1996) and Szapocznik and his research team (Briones, Robbins, & Szapocznik, 2008; Robbins et al., 2008).
Hampson and Beavers (1996) studied family and therapist characteristics in relation to treatment success. Their subjects were 434 families treated at an actual family therapy clinic in Dallas, Texas. Hampson and Beavers reported the following predictors of successful treatment: number of family therapy sessions attended, third-party ratings of family competence, self-ratings of family competence, and therapists' ratings of working alliance. Hampson and Beavers's measure of family competence included items on family affect, parental coalitions, problem-solving abilities, autonomy and individuality, optimistic versus pessimistic views, and acceptance of family members. They reported that the six-session mark was the breakpoint in increasing the probability of good results. However, a sizable subset of families did well with fewer than six sessions. What distinguished this subset of families were their strong self-ratings of competence. Hampson and Beavers were careful to note that family size, family income, family structure (e.g., blended), family ethnicity, and counselor or therapist gender did not predict outcome.
In a related vein, Szapocznik and his research team saw initial treatment engagement as critical to good outcomes in family therapy. They stated,
The first step in BSFT then is to establish a therapeutic alliance with each family member and with the family as a whole. Challenging how the family functions prematurely, particularly challenging a powerful member in the family, can damage the therapeutic relationship with negative consequences such as one member's or the whole family's dropout, resistance to change, challenge to therapist's leadership, and lack of involvement in the therapeutic process. Indeed, research has shown that failure to maintain a balanced alliance with all family members can lead to early treatment dropout. (Briones et al., 2008, p. 91)
Szapocznik and his colleagues backed up their assertions about the importance of engagement with interesting research findings. In one study, they found that "93% of families that received the BSFT engagement were successfully engaged into treatment compared to
42% of families that received Engagement as Usual" (Briones et alv 2008, p. 87). They also reported that BSFT engagement led to dramatically better treatment retention (i.e., 77% vs. 25%, respectively).