Family Therapy Review Preparing for Comprehensive and
Licensing Examinations, 1st Edition
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FAMILY THERAPY REVIEW
Preparing for Comprehensive and
Licensing Examinations
Edited by
Robert H. Coombs
UCLA School of Medicine
LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS
2005 Mahwah, New Jersey London
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Copyright © 2005 by Lawrence Erlbaum Associates, Inc.
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Library of Congress Cataloging-in-Publication Data
Family therapy : review preparing for comprehensive and licensing examinations / edited by
Robert H. Coombs.
p. cm.
Includes bibliographical references and index.
ISBN 0-8058-4312-4 (case : alk. paper)—ISBN 0-8058-5175-5 (pbk : alk. paper)
1. Family psychotherapy—Examinations, questions, etc. I. Coombs, Robert H.
RC488.5.F349 2005
616.89' 156'076—dc22
2004010402
Books published by Lawrence Erlbaum Associates are printed on
acid-free paper, and their bindings are chosen for strength and durability.
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
for
David, Jeremy, and Kim
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Contents
Preface xi
Acknowledgments xxvii
BASIC CLINICAL KNOWLEDGE AND SKILLS
PART I: INDIVIDUALS AND THE FAMILY
1 Family Health and Dysfunction 3
John DeFrain, Richard Cook, and Gloria Gonzalez-Kruger
2 Human Lifespan Development 21
JoanM. Lucariello and Jacqueline V Lerner
3 Human Diversity 41
Barbara F. Okun
4 Psychopathology 67
Len Sperry, Maureen P. Duffy, Richard M. Tureen, and Scott E. Gillig
5 Psychopharmacology 87
Roy Resnikoff
PART II: THERAPEUTIC SKILLS AND TOOLS
6 Theories of Family Therapy (Part I) 117
Kim Snow, Hugh C. Crethar, Patricia Robey, and Jon Carlson
vii
viii CONTENTS
7 Theories of Family Therapy (Part II) 143
Hugh C. Crethar, Kim Snow, and Jon Carlson
8 Assessment, Diagnoses, and Treatment Planning 169
Jo Ellen Patterson, Todd M. Edwards, and Stefanie L. Carnes
9 Case Management 191
Patricia C. Dowds and David G. Byrom
10 Managing Behavioral Emergencies 213
Phillip M. Kleespies, Barbara L. Niles, Catherine J. Kutter,
and Allison N. Ponce
COMMON CLIENT PROBLEMS
PART III: DISTRESSED COUPLES
11 Conflict and Disenchantment 235
Edward F. Kouneski and David H. Olson
12 Separation, Divorce, and Remarriage 257
Craig A. Everett, Steve E. Livingston, and Lee Duke Bowen
13 Sexual Problems 277
Joan D. Atwood
14 Intimate Partner Violence 301
Sandra M. Stith and Karen H. Rosen
PART IV: CHILD AND ADOLESCENT ISSUES
15 Developmental Disabilities 325
Robert M. Hodapp, Jaclyn N. Sagun, and Elisabeth M. Dykens
16 Behavioral and Relationship Problems 349
Thomas L. Sexton, Alice E. Sydnor, Marcy K. Rowland, and
James F Alexander
17 Substance Abuse 371
Aaron Hogue, Sarah Dauber, Leyla Faw, and Howard A. Liddle
18 Child Abuse and Neglect 393
Carrie C. Capstick and Peter Fraenkel
PART V: DIMINISHED HEALTH AND WELL-BEING
19 Care Giving and Grief 415
Dorothy S. Becvar
CONTENTS ix
20 Alcohol and Other Drug Dependencies 435
Edward L. Hendrickson and Eric E. McCollum
21 Nonpharmacological Addictions 459
William G. McCown
22 Depression and Anxiety 483
Frank M. Dattilio
23 HIV/AIDS 509
Julianne M. Serovich and Shonda M. Craft
CAREER ISSUES
PART VI: PROFESSIONAL DEVELOPMENT
24 Ethical and Legal Issues in Family Therapy 531
Samuel T. Gladding
25 Preparing for Licensing Examinations 549
Kinfy Sturkie
26 Continuing Professional Development 569
William C. Nichols
About the Authors 589
Appendix: Answer Key 601
Author Index 619
Subject Index 633
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Preface
Family therapy, an important component in today's healthcare system, offers affordable mental
health care in the context of family circumstances. Family dynamics influence the physical
health and emotional wellness of its members, present and future. Family therapists consider
family circumstances an integral part of diagnosis and treatment, even when working with a sin-
gle client. Individual problems are assessed within the context of family structure, boundaries,
beliefs, roles, sentiments, activities, and interactions.
More than a collection of individuals, the family is a living system, an organic whole wherein
a change in one member brings changes in the entire family system. Hospital psychiatrists noted
in the 1950s that when certain patients improved another family member often got worse. Sub-
sequent therapists learned that the most effective way to change the individual—the identified
patient—is to alter the family dynamics (Nichols & Schwartz, 2001, p. 57). "The goal of fam-
ily treatment," Glick and colleagues noted, "is the improved functioning of the family as an
interlocking system and network of individuals" (Glick, Berman, Clarkin, & Rait, 2000, p. 21).
Like other schools of psychotherapy, family therapy includes the following elements (Glick
et al., 2000):
1. An effective patient-therapist relationship
2. Release of emotional tension or development of emotional expression
3. Cognitive learning
4. Insight into the genesis of one's problems
5. Operant reconditioning of the client toward more adaptive behavior patterns using
techniques such as behavioral desensitization
6. Suggestion and persuasion
7. Identification with the therapist
8. Repeated reality testing or practicing of new adaptive techniques in the context of
implicit or explicit emotional therapeutic support
9. Construction of a more positive narrative about oneself and the world
10. Instillation of hope
xi
xii PREFACE
Family therapy accomplishes each of these but "does so in the context of the whole fam-
ily, with the goal of improving the entire group's overall functioning" (Click et al., 2000,
p. 240).
Research consistently shows that the more a client's family becomes appropriately involved
hi therapy, the greater the likelihood of treatment success. An edited book by Sprenkle (2002)
analyzed hundreds of family therapy outcome studies—conduct disorder and delinquency,
substance abuse, childhood behavioral and emotional disorders, alcohol abuse, marital prob-
lems, relationship enhancement, domestic violence, severe mental illness, affective disorders,
physical disorders—revealing that family therapy is at least as effective as other therapies, and
in many cases more so. With regard to family-based interventions for drug abuse problems,
for example, Rowe and Liddle (2002, p. 76) note, "There is certainly cause for great excite-
ment There is little doubt, given the existing empirical base, that the family-based treatment
field is at the cutting edge of drug abuse intervention science."
Summarizing the outcome of more than five hundred family therapy evaluation studies,
Glick and his colleagues (2000, p. 634) report:
1. Family treatment is more effective than no treatment at all. Studies that contrasted
family and marital treatment with no-treatment control groups found statistically significant
differences: roughly 67% of marital cases and 70% of family cases improved. These outcome
results improved slightly when the identified patient was a child or an adolescent rather than
an adult. No one method of therapy is clearly better than another.
2. The deterioration rate (i.e., the percentage of patients who become worse or experience
negative effects of therapy) is about 10% lower than for individual therapy.
3. Family treatment is the preferred intervention strategy for several types of problems.
Since 1970, outcome data suggest that couples therapy is superior to individual therapy for
marital conflict situations, especially for increasing marital satisfaction and reducing couple
conflict. However, both family therapy and individual therapy were tied for other problems,
often in situations where the identified patient had a serious Axis I problem (i.e., any clinical
disorder—except for mental retardation and personality disorders—as well as other conditions
that may be at the center of clinical attention).
Family therapy clients represent a wide variety of problems including couples in crises,
young children or adolescents with their parents, children and families in the foster care system,
sexual abuse victims and perpetrators, individuals addicted to alcohol or other drugs and their
families, other addicted people—compulsive gamblers, sex addicts, workaholics, compulsive
buyers and eating extremists—and their families, juvenile offenders and others in the criminal
justice system, families dealing with severe mental illnesses and emotional disorders, such as
anxiety, depression, and grieving loved ones who have lost a family member.
Family therapists work in a wide variety of settings—private practice, schools and Head
Start centers, businesses and consulting companies, employee assistance programs, social
service agencies, government agencies, courts and prisons, county mental health departments,
hospitals, community mental health centers and residential treatment facilities, universities
and research centers (Marriage and Family Therapists).
Family therapists typically practice short-term therapy—twelve sessions on average—about
one-half are one-on-one sessions with the other half divided between couple/family therapy,
or a combination of treatments (Marriage and Family Therapists). Not only is family therapy
usually relatively brief, it is also solution-focused, specific, with attainable therapeutic goals,
and designed with the "end in mind." (FAQs on MFTs).
PREFACE xiii
"Since the early 1970s," Guttman (in Click et al., p. xxxiii) noted, "family therapy has
developed exponentially, both as a philosophy and as a treatment modality." Since that time,
the MFT profession has experienced a fifty-fold increase. At any given time, family therapists
are currently treating over 1.8 million people.
The membership of the American Association for Marriage and Family Therapy (AAMFT),
the professional association that serves family therapists, grew quickly, from 237 members in
1960, to 9,000 in 1982, and to more than 23,000 in 2002 (A Career as an MFT). And this
number doubles when adding in members of the California Association of Marriage and Family
Therapy (CAMFT)—more than 25,000 Californians, with few who hold joint memberships.
The first state to license family therapists (in 1963), California has an extensive infrastructure of
seventy-seven schools and universities that offer family therapy programs. Each year about one
thousand California students take the family therapy examination. With twenty-nine regional
chapters, CAMFT sponsors an annual conference, publishes the California Therapist, and has
a strong voice in the state legislature. (Contact CAMFT at 7901 Raytheon Road, San Diego,
CA 92111; telephone 619-292-2638; Web site: www.camft.org.)
Not surprisingly, states recognizing and regulating family therapists have grown steadily—
from eleven in 1986 to forty-six in 2003. And other state legislatures are considering regulatory
bills (Directory of MFT Licensing Boards). Of the states that license the family therapist, only
four (10%) originated before 1980, and twenty-four of the forty (60%) were initiated after 1990.
Compared with psychiatry, clinical psychology, and social work, family therapy is clearly a
newcomer. "Family therapy was born in the 1950s, grew up in the 1960s and came of age in the
1970s," noted Nichols and Schwartz (2001, p. 7). From "a radical new experiment" (p. 307),
family therapy grew to be an established force in the 1960s and 70s, complete with its own
association (the AAMFT) replete with state affiliates, a professional journal, and an annual
national conference. Unlike other therapeutic movements organized around one major theory
or innovator (e.g., psychoanalysis, behaviorism) or by professional degree (e.g., psychology,
psychiatry, social work), family therapy uses a variety of theories and draws followers from
many professional backgrounds (p. 307).
By the mid-1990s, the profession compared with other mental health professions in the
following ways, as noted by a report of the U.S. Public Health Service's Center for Mental
Health Services (Manderscheid & Sonnenchein, 1996):
• Family therapists comprised 11% of the clinically trained mental health personnel in
the U.S. Counseling and psychology were at comparable rates (14% and 16%, respectively).
Social work and psychosocial rehabilitation comprised the highest rates at 22% each, while
the lowest rates were shared among psychiatry (8%), school psychology (5%) and psychiatry
nursing (2%).
• Most people in the mental health disciplines were trained in social work or counseling with
more than 30,000 trainees each. Psychology trainees followed with 18,000 trainees, with family
therapy and psychiatry having between 6,000 and 7,000 trainees each. Psychiatric nursing had
2,000 trainees.
• The distribution of family therapists varied considerably across the states, ranging from
fewer than 3 per 100,000 resident population in West Virginia, Delaware, Ohio, North Dakota,
Louisiana, and Arkansas, to more than 20 per 100,000 in Oklahoma, Indiana, Texas, and
Nevada, to more than 73 per 100,000 population in California. Generally, more states in the
West and the Northeast had more than 10 family therapists per 100,000 than did states in the
South and Central United States. The national average was 17.6 marriage and family therapists
per 100,000 population.
xiv PREFACE
• The gender distribution varied greatly by discipline. Family therapists and psychologists
were the most balanced with 53% of family therapists female and 47% male. In psychology,
44% were female, 56% male. Psychiatrists were primarily male (75%), while psychiatric nurses
(95%), social workers (77%) and counselors (78%) were mostly female.
• Psychiatrists and counselors were at opposite ends of the age/experience spectrum. Psy-
chiatrists were primarily older males, 60% of whom had been in practice for over 20 years.
• Social workers, family therapists, and counselors were the primary clinical staff of mental
health and other health clinics. Roughly 50,000 clinically trained professionals were employed
in clinics, either as their primary or secondary work setting.
• Psychologists and family therapists predominated the approximately 140,000 clinically
trained mental health personnel who worked in private practice, either as their primary or sec-
ondary work setting, followed by social workers and counselors. Psychiatrists and psychiatric
nurses represented the lowest percentage of clinically trained mental health personnel who
worked in private practice settings.
• Among the various work activities—patient care/direct service, research, teaching and
administration—the primary work activities of mental health professionals usually involved
direct patient care, ranging from 67% for school psychologists to 96% for psychosocial re-
habilitation professionals. Almost nine of ten family therapists (88%) were involved in direct
patient care.
• The disciplines involved in research were psychiatric nursing (25.1%), psychology
(19.7%), psychiatry (17.4%), and MFT (16.5%). Counseling, social work, and school psy-
chology have the lowest rates (0.1%, 1.3%, and 4.0%, respectively).
• Teaching was a very common activity among psychiatric nurses (59%), psychiatrists
(49%), family therapists (47%), and psychologists (31%). Only 11% of social workers and 9%
of counselors are involved in teaching activities.
• The majority of family therapists (56%), psychiatrists (52%), and psychiatric nurses (52%)
were involved in administrative activities, followed by social workers (35%) and psychologists
(27%).
AAMFT was originally called the American Association of Marriage Counselors (AAMC).
Directed by David Mace, who later became my colleague at the Wake Forest University School
of Medicine, AAMC was organized in 1942 as a professional organization to set standards for
marriage counselors. In 1970 the AAMC changed its name to the AAMFT, emphasizing family
therapy, yet retained a focus on couple relationships, and became the major credentialing body
for the field. Through its requirements for membership, national family therapy standards have
been set and are used by various states to regulate the profession. (Contact AAMFT at 1133
15th Street N. W., Suite 300 Washington DC 20005-2710, telephone: 202-452-0109.)
AAMFT's code of ethics addresses proper behavior with regard to the following: responsi-
bility to clients; confidentiality, professional competence and integrity; responsibility to stu-
dents, employees, supervisees, and research subjects; financial arrangements; and advertising.
It also lobbies state and federal governments for the interests of family therapists, such as
uniform state licensing. Because of its large membership, enough income is generated to make
the AAMFT a powerful player in mental health politics and has aided recognition of fam-
ily therapy as a distinct field by the government and the public alike (Nichols & Schwartz,
2001).
Though not as influential as AAMFT, other organizations provide conferences, publications,
and networking opportunities. The American Family Therapy Academy (AFTA), for example,
an organization not readily open to the rank-and-file family therapist, was organized in 1977
PREFACE xv
as a group whose membership presumably confers high status. Five categories of members are
admitted: charter, clinical-teacher, research, distinguished, and international. To be considered
for APTA membership, applicants usually must obtain three enthusiastic support letters from
existing members. Despite efforts to remain small, AFTAs membership doubled between
1983 and 2003—from 500 to over 1,000 (Nichols & Schwartz, 2001). AFTA holds an annual
conference, a bi-annual clinical research conference, and publishes a newsletter three times a
year for its members. (Contact AFTA at 1608 20th Street, NW, 4th Floor, Washington, DC 2009,
telephone: 202-333-3690, fax: 202-333-3692, e-mail: [email protected]; Web site: www.afta.org.)
A world-wide family therapy organization, the International Family Therapy Association
(IFTA), was organized in 1986 as a way for family therapists in different countries to interact.
IFTA sponsors the World Family Therapy Congress in a different country each year, with
past hosts including Finland, Greece, Holland, Ireland, Israel, Hungary, Mexico, Poland, and
Turkey. In addition, IFTA publishes a biannual journal, the Journal of Family Psychotherapy,
and a newsletter, The International Connection. (Contact IFTA at the Family Studies Center,
Purdue University Calumet, Hammond, Indiana 46323-2094, telephone: 219-989-2027, fax:
219-989-2772, e-mail: [email protected], Web site: www.ift-familytherapy.org.)
National standards for the accreditation of family therapy training programs are set by a
subsidiary organization of the AAMFT—the Commission on Accreditation for Marriage and
Family Therapy Education (COAMFTE)—which accredits family therapy training programs at
the master's, doctoral, and postgraduate levels. Recognized since 1978 by the U.S. Department
of Education as the national accrediting body for family therapy, the COAMFTE works coop-
eratively with its parent organization (the AAMFT), state licensing and certification boards,
and the Association of Marriage and Family Therapist Regulatory Boards (AMFTRB).
The COAMFTE accredits three types of programs:
• Master's degree programs designed to prepare individuals for beginning a career in MFT
by providing basic didactic and clinical information, as well as professional development and
socialization.
• Doctoral degree programs prepare students for academic careers, research, advanced
clinical practice, and supervision. The doctoral curriculum includes advanced instruction in
marriage and family therapy research, theory construction, and supervision.
• Postgraduate degree clinical training programs provide clinical education in family ther-
apy to trainees with a master's or doctoral degree in family therapy, or in a closely related field.
A program may allow for specialized training in a particular modality or treatment population
(About COAMFTE).
The COAMFTE's accreditation process benefits the public, training programs, students, and
the profession by:
• Providing assurance to the public and consumers that the accredited program has under-
gone extensive external evaluation and meets standards established by the profession.
• Providing a stimulus for self-evaluation and a cost-effective review mechanism that
strengthens the reputation and credibility of a program because of the public regard for
accreditation. Accredited programs become eligible for funding under several federal grant
programs.
• Assuring students that the appropriate knowledge and skill areas necessary for entry into
a chosen field are included in the course of study and that the training program is financially
stable.
xvi PREFACE
• Assuring prospective employers that the educational training of a job applicant with a
degree from an accredited program indicates adequate professional preparation.
• Contributing to the family therapy professions' unity and creditability. The profession
benefits by bringing together practitioners, teachers, and students in the vital activity of setting
educational standards of entry level professionals, and of continually improving professional
education, research, scholarship, and clinical skills.
What topics are mandated in family therapy training programs? According to national
(COAMFTE) standards, students must complete 12 standard didactic units (SDUs) in the
following areas (Commission on Accreditation):
• Theoretical Foundations (2 SDUs). The historical development, theoretical foundations,
and contemporary conceptual directions of the field of family therapy. Students learn to con-
ceptualize and distinguish the critical epistemological issues in marriage and family therapy.
All teaching materials will be related to clinical concerns.
• Clinical Practice (4 SDUs). A comprehensive survey of the major models of fam-
ily therapy, including methods and major mental health assessment methods and instru-
ments.
• Individual Development and Family Relations (2 SDUs). Individual development, family
development, family relationships, and issues of sexuality (including sexual dysfunctions and
difficulties) as they relate to family therapy theory and practice. Courses also include significant
material on issues of gender and sexual orientation as they relate to marriage and family theory
and practice; issues of ethnicity, race, socioeconomic status and culture; and issues relevant to
populations in the vicinity of the program.
• Professional Identity and Ethics (1 SDU). Professional identity, including professional
socialization, professional organizations, licensure and certification. Content will also focus
on ethical issues related to the practice and profession of family. The object is to inform
students about legal responsibilities and liabilities of clinical practice and research, family law,
confidentiality issues and the AAMFT Code of Ethics. Additionally, students learn about the
interface between therapist responsibility and the professional, social and political context of
treatment.
• Research (1 SDU). Research methodology, data analysis and the evaluation of research
to include quantitative and qualitative research.
• Additional Learning (1 SDU). Students may choose the learning experience, or the pro-
gram may mandate a course or other experience appropriate to students' specialized interest
and background in family therapy.
All family therapists need certain basic skills, according to an AAMFT sponsored Core
Competency Task Force that convened in September 2003. Within each of six domains—
admission to treatment; clinical assessment and diagnosis; treatment planning and case man-
agement; therapeutic interventions; legal issues, ethics, and standards; and research and pro-
gram evaluation—family therapists must master five sets of skills: conceptual skills (un-
derstand therapeutic principles), perceptual skills (be able to interpret relevant data through
paradigmatic and conceptual lenses), executive skills (demonstrate appropriate behaviors, ac-
tions, and interventions in the therapy process), evaluative skills (be able to assess and appraise
relevant aspects of therapeutic activities), and professional skills (be able to conduct therapy
effectively) (personal correspondence from AAMFT, November 2003). These skills are elab-
orated as follows:
PREFACE xvii
Admission to Treatment
Conceptual Skills
• Understand systems concepts, theories, and techniques that are foundational to the practice
of marriage and family therapy
• Understand theories and techniques of individual, marital, family, and group psychother-
apy
• Understand the mental health care delivery system
• Understand the risks and benefits of individual, couple, family, and group psychotherapy
Perceptual Skills
• Recognize contextual and systemic issues (e.g., gender, age, socioeconomic status, cul-
ture/race/ethnicity, sexual orientation, spirituality, larger systems, social context)
• Consider health status, mental status, other therapy, and systems involved in the clients'
lives (e.g., courts, social services)
• Recognize issues that might suggest referral for evaluation, assessment, or specialized
care beyond clinical competence
Executive Skills
• Gather and review intake information
• Determine who should attend therapy and in what configuration (i.e., individual, couple,
family)
• Decide if, when, and how other professionals and significant others are needed to con-
tribute to the clients' care
• Facilitate involvement of all necessary participants in treatment
• Explain practice setting rules, fees, rights and responsibilities of each party, including
privacy and confidentiality policies and duty to care
• Establish and maintain appropriate and productive therapeutic alliances with the clients
• Solicit and use client feedback throughout the therapeutic process
• Develop and maintain collaborative working relationships with clients, referral resources,
and payers
• Manage session dynamics with multiple persons
• Develop a workable therapeutic contract
Evaluative Skills
• Evaluate case for appropriateness for treatment within professional competence
• Evaluate intake policies and procedures for completeness and contextual relevance
Professional Skills
• Understand the legal requirements and limitations for working with minors and vulnerable
populations
• Collaborate effectively with clients and allied professionals
• Complete case documentation in a timely manner and in accordance with relevant laws
and policies
