Evidence and couple and family therapy

This issue of Family Process includes several papers related to evidence and the practice of couple and family therapy. In this editorial, I call attention to two papers by Lorås et al. (2023); Whittaker et al. (2023), and a special section in this issue focused on expanding the representativeness of research about couple therapy (Mitchell & Gordon, 2023). In their two-part article, Loras and colleagues convincingly articulate how essential empirical evidence is to the practice of couple and family therapy and the value of evidence-based practice. However, they also point to barriers that sometimes limit the use of evidence by some couple and family therapists. They speak to the wide array of practitioners who incorporate a family systems perspective (often living in towers of Babel using the word “systemic” in different ways) and how differences in point of view can transmute into not only distorted ways of seeing each other's methods but also in some broadly rejecting evidence-based practice. Specifically, they highlight how some with a poststructural viewpoint reject quantitative research—the kind of information which is most essential within the scientific method. Reviving conversations that had seemed to run their course in the 1980s (Gurman, 1983), these critics of quantitative research create a caricature of the research enterprise, in which investigators are viewed as overselling findings without considering threats to validity or context and are inattentive to the aspects of conversing and relating that are most in focus in poststructural therapies. In the spiral that evolves from such a position, research can come to be seen as responsible for such problematic developments as the industrialization of mental health practice and even the tendency for choices in the mental health system to veer toward individual therapy and psychopharmacology rather than toward relational therapies [this, even in the wake of the considerable empirical evidence that couple and family therapy is at least as effective as these other forms of intervention (Friedlander et al., 2021), making the case for relational therapies]. Surely, some quantitative researchers and advocates for specific empirically supported therapies have contributed to the problem; over-selling the meanings of their findings. However, although certainly there do remain some who conduct quantitative research and hold a narrow, simplistic, oversold view of the meanings of research (Westen et al., 2005), there are few investigators in the field of couple and family therapy who bring the narrow view of research in this stereotype. Most couple and family therapy researchers and, more broadly, psychotherapy researchers are more than aware of potential threats to validity, the possible influence of the researcher on findings, the multiple meanings that can be extracted from findings, and the preponderance of findings that suggest most all bona fide therapies are effective (Wampold & Imel, 2015). As Loras and colleagues accentuate, evidence-based practice has evolved well beyond the early arguments about creating lists of treatments to incorporating a broad array of evidence that can inform the practice of therapy. Loras and colleagues also highlight that a new variation has arisen for minimizing the impact of research by some, in which only qualitative research and other research that does not involve scales, numbers, or ratings (such as discourse analysis) are viewed as meaningful. Family Process has a foundation in the value of multiple pathways for examining the most important questions in our field. This includes publishing articles about theory, summaries of methods of clinical practice, case studies, quantitative studies, qualitative studies, and other forms of investigation, such as conversation analysis. We publish a great deal of both quantitative and qualitative research and each of these research methods has its unique value. The strengths of quantitative research lie in increasing objectivity, including larger samples, and with that the possibility of increasing the generalizability of results, and readily allowing for comparisons between different groups. The strengths of qualitative research lie in suggesting nuances often obscured by quantitative indices and providing depth of information about individual and collective experiences. One method cannot substitute for the other. Therefore, it is a great concern when critics suggest that only one set of methods is worthy of consideration. Ultimately, this must lead to a limited point of view; one which does not allow for traditional quantitative designs is especially vulnerable to distorted findings. There are ironies involved. One is that most clinicians do not consider research to be an important input to their practice; in surveys quantitative research unfortunately remains a less important input into the practice of clinicians, far from the powerful force pictured by those who fear the power of these studies in shaping how clinicians will practice (Orlinsky & Ronnestad, 2005). A second irony is that those anchored in postmodern epistemologies often have embraced research methods, such as qualitative research, that are most subject to precisely the type of investigator bias about which they are concerned when criticizing quantitative research (arguing that the importance of these effects in qualitative research can be mitigated by investigators stating their positions and points of view—a good idea but not one likely to reduce bias). As I have written elsewhere (Lebow, 2016, 2018), concerns like those raised by Loras and colleagues are particularly important at this moment in history, when the foundations of what is known about the world through science have regularly come to be questioned by some who look to impose their truths on others. It does make a difference that there are documented objective findings that LGBTQ families function as well as others, that racism has pervasive effects, and that vaccines help eradicate and limit the impact of diseases, even though some choose to ignore such information. Broadly, the policies of Donald Trump and others like him around the world exemplify what can happen when scientific investigation is rendered secondary to one's subjective sense of the world and kinds of evidence are selectively incorporated. Additionally, some research designs are more objective and provide more information than others for answering specific questions (Shadish et al., 2002). What is known can only be evaluated in relation to the quality of a research design to address specific questions. This segues to our section in this issue focused on ways of increasing the representativeness of samples in couple therapy and couple relationship education. Couple therapy and couple relationship education have the good fortune to have a fairly substantial base of evidence for their impact and factors that enhance that impact (Doss et al., 2022; Markman et al., 2022). Unfortunately, this research has been typically conducted in highly unrepresentative samples, primarily in the United States and Canada. It is likely that some of the source for this problem lies in couple therapy and relationship education historically being seen as sources of help for middle-class White opposite-sex couples. Additionally, how research has evolved about couple therapy has contributed to the problem. Couple therapy owes an enormous debt to a few key figures who have spear-headed most of the research. With one or two exceptions, these research efforts have occurred outside the context of large grants that could enable broader proactive recruitment, and sometimes this research has occurred in locations with little diversity. Whatever the source, the problem of unrepresentativeness in the research is clear as well as the failure until recently to acknowledge this problem. As Tseng and colleagues have shown in two reviews, one in this special section (Tseng et al., 2021, 2023), much couple therapy and couple relationship education research is centered on white, American, middle-class clients. Lacking representative samples, we do not know how therapies impact different groups, the factors that might enhance engagement and outcomes for specific groups, or how to best create and test cultural adaptations of treatments that have proven so valuable in other contexts (Bernal & Domenech Rodríguez, 2012; Parra-Cardona et al., 2018, 2021; Perez-Brena et al., 2022). And the problem is more complex than just wanting samples to be diverse. How, in fact, does one get to more inclusiveness in research (and more broadly in couple therapy itself)? Our special section features several papers that help imagine how inclusiveness can be expanded—some from examining efforts in the context of research (Mitchell et al., 2023; Whitton et al., 2023) and others from reimagining how to present couple intervention (Daire et al., 2023; Williamson et al., 2023). Certainly, it is an essential task to ask how to enable better recruitment and participation by a wider range of people in couple therapy research. Mitchell and Gordon in their section provide clues to how such research might move forward and offer in their introductory article (Mitchell & Gordon, 2023), a clear set of actionable recommendations, which can help reduce the questions about inclusiveness and representativeness raised about this research. In sum, it is a time for better and more expansive research about couple and family therapies. It is also a time when it is within reach for there to be a clear consensus in which couple and family research and research on couple and family therapy are viewed as important inputs into couple and family therapy. In the best version of this, research is viewed as one essential input for practice, but not the only input and the results of the research are presented in ways that reflect but do not oversell the findings (by, e.g., suggesting clinicians should only be doing one kind of therapy—not a finding consistent with the literature). Each finding is best seen as part of an evolving body of work. Multiple methods of research are employed and respected; each considered in the context of its particular value. And we should monitor research to be sure it is up to our best standards, in terms of validity and design but also in terms of the inclusiveness and representativeness of samples and the choice of questions to address that have most meaning for our field. It is a gift in the couple and family therapy field that part of it has been a thoughtful and deep discourse about epistemology. This journal has been and continues to be one of the most important places where that discourse thrives (Barbetta & Telfener, 2021). But perhaps, we can leave the extremes of this discourse that vitiates empiricism behind. We have seen several recent investigations that feature research focused on or originating from some of the most prominent practitioners of poststructural therapies, who, even though they raise thoughtful questions about epistemology, have found significant ways to incorporate research to inform their methods (Seikkula et al., 2018; Sparks & Duncan, 2018; Tomm, 2014; Tseliou et al., 2021a, 2021b). Hopefully, this sense of broadening acceptance of research will continue.

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