JOURNAL OF MARITAL AND FAMILY THERAPY 357
INTEGRATIVE MODULE–BASED FAMILY THERAPY:
A MODEL FOR TRAINING AND TREATMENT IN A
MENTAL HEALTH SETTING
Richard Wendel, Karen R. Gouze, and MaryBeth Lake
Children’s Memorial Hospital
Thirty years ago, leaders in psychiatry expressed hope for more interdisciplinary collaboration
with family therapy. Since then marriage and family therapy (MFT) has entered the mainstream
of clinical practice in psychiatry and psychology. It is mandated for training in psychiatry and
psychology. We propose a model for collaboration, training, and treatment in interdisciplinary
mental health settings that strives to integrate empirical bodies of knowledge in MFT, psychiatry,
and psychology and to provide a usable and testable clinical approach to treatment. It can be taught
to trainees with various or limited training in MFT. This model delineates nine critical domains that
guide treatment. Flexibility is central to this model, focusing on techniques and clinical methods
based on empirically supported treatments, when available, and best-practice standards.
THE PROBLEM AND NEED
Current Challenge and Opportunity for Family Therapy
In 1974, McDermott and Char wrote “The Undeclared War between Child and Family Therapy.” In
this article they decried the lack of mutual respect and cooperation between psychiatry and family therapy
and stated that “many child psychiatry training programs have ignored training in family therapy” (p.
423). They noted that there were then “pathetically few” (p. 422) articles in psychiatric journals directly
related to family functioning and that psychiatry had “fumbled the ball” (p. 424). At the same time, family
therapy had contributed to the polarization by being “anti-medical” (p. 425) and “antidiagnostic” (p. 425).
McDermott and Char concluded by calling for child psychiatrists to “catch up with a rapidly changing field
from which they have become separated” and encouraging family therapists to overcome “internal disputes
between schools of thought” (p. 435) and join the mainstream of clinical practice.
In the 1980s and 1990s, two related trends emerged in marriage and family therapy (MFT). The first
dealt with the establishment of family therapy as an independent profession. Marriage and family therapy
was no longer only an activity that occurred within the professions of psychiatry, psychology, and social
work. Rather, it became a specialized profession with its own body of knowledge and licensing standards.
However, as MFT became more established, some viewed it as increasingly isolated from practice in the
other mental health professions. In 1994, Shields, Wynne, McDaniel, and Gawinski stated that MFT had
become marginalized and family problems had been “trivialized” (p. 126) within the discourse of mental
Richard Wendel, DMin, Assistant Professor of Clinical Psychiatry and Behavioral Sciences, Northwestern University,
Feinberg School of Medicine, Adjunct Faculty of the Family Institute at Northwestern University, and Allied Health
Professional at Children’s Memorial Hospital; Karen R. Gouze, PhD, Assistant Professor of Psychiatry and Behavioral
Sciences, Northwestern University, Feinberg School of Medicine, and Director of Training in Psychology at Children’s
Memorial Hospital; and MaryBeth Lake, MD, Associate Professor of Psychiatry and Behavioral Sciences, Northwestern
University, Feinberg School of Medicine, and Director of Education and Child and Adolescent Psychiatry Residency Training
at Children’s Memorial Hospital, Chicago, Illinois.
Address correspondence to Richard Wendel, 2502 N. Clark Street, Chicago, Illinois, 60614; E-mail:
Journal of Marital and Family Therapy
October 2005, Vol. 31, No. 4, 357–370
JOURNAL OF MARITAL AND FAMILY THERAPY October 2005
health practice. Shields et al. called for the “promotion of MFT” as an “interdisciplinary field” (p. 135) and
for more collaboration in clinical work, training, and research.
Thirty years after the challenge of McDermott and Char (1974), mental health practice has continued
to lack fully integrated approaches to family treatment and training in many multidisciplinary mental
health settings. In 2004 McDermott described the current era in Child and Adolescent Psychiatry as
“atheoretical” (p. 657), yet he reminded us that “you can’t practice without some kind of theory.” He
further noted that the biopsychosocial model of Engel, first proposed in the 1970s, has not advanced or
been developed in psychiatry. In the end we are still left with “no integration of the three levels” (p. 657).
McDermott stated that psychiatry needs more active theory building that takes the multiple levels of human
functioning seriously. Within MFT discourse, Carol Anderson (2003) has described this specialization and
isolation as an ever-widening gap between researchers and clinicians.
In addition, the practice of psychotherapy has significantly changed in the last decade. Kazdin (2005)
has noted that theory-based models “have been largely abandoned” (pp. 13–14). He identifies four critical
developments that require reconceptualizing therapy. First, clinical interventions need to be focal and
therapies testable. Second, current research now recognizes “multiple influences” and this necessitates
changes in therapeutic practice. Third, there is too much variance within specific approaches to say “it
works.” Finally, treatment outcome research focuses on “specific techniques” not “approaches.” Clearly,
we need to develop practice models that include a wider variety of established research and best practice
techniques and empirical domains.
It is in this light that we offer the model, Integrative Module-Based Family Therapy (IMBFT) . There
are challenges and opportunities before us to construct models of treatment with our interdisciplinary
peers that are theoretically sound, clinically focused, and empirically based. Such models need to balance
clinical judgment with testable hypotheses and be able to be modified as new clinical and research findings
emerge. This is a challenging task. Psychiatry, psychology, and the many family therapies have differing
linguistic traditions and theories of etiology. But the potential is enormous—first for troubled children,
adults, and their families, and second, for the professions involved in cooperative efforts.
This work emerged in the context of a residency training program in child and adolescent psychiatry
and a psychology internship in a large, university-based children’s hospital that offers comprehensive
mental health services and multiple levels of care for children, adolescents, and their families. Our
psychiatry department encounters the full range of diagnostic categories and treatment needs. The child
and adolescent psychiatry residents and psychology interns have extensive opportunity for interdisciplinary
learning with students and faculty from social work, family therapy, education, recreation therapy, speech
pathology, neurology, and pediatrics. The setting provides a unique opportunity to meet the challenge
presented by McDermott and Char (1974) and Shields et al. (1994) to provide treatment and training that
integrates psychiatric, psychological, and MFT models.
Problems with Existing Models in the Context of Current Training Demands and Requirements
Marriage and family therapy came on the scene as an exciting, promising, and admittedly maverick
practice. The early years were typified by charismatic figures imparting never-before-seen insights and
interventions. Training in MFT became possible as the classic models were codified. Over time, as theory-
based therapies were practiced, it became clear that no one model was sufficient for all problems. Each
theory answered some questions but not others. If eras can be typified, the 1980s were a time in MFT when
the vast majority of human problems were seen as stemming from external social forces and relational
processes. In the 1990s, developments in biological psychiatry demonstrated the multifactorial and bidirec-
tionality of psychosocial and biological forces in human behavior (McDaniel, Hepworth, & Doherty,
1995; Wood, 1995). Advances in efficacy research have added to the dissolution of the models. The rapid
growth in empirical findings has made MFT models more tangential and clinical training more difficult
(Dannifer, Hundert, & Henson, 2003). In 1997, Lebow wrote a significant article noting a movement away
from theoretical models toward integrative practice in MFT. According to Lebow, a new paradigm was
emerging in which theoretical and interventional boundaries blurred, and the practice of pure theoretical
models was becoming rare. Lebow compared the impact of this integrative revolution with the “Falling
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of the Berlin Wall” (p. 2): “inevitable” and happening “quickly.” Lebow insisted that integrative practice
provides for a broader range of treatment options and greater flexibility. Integrative models are also more
readily based on postmodern epistemological foundations. In turn, this revolutionary practice in family
therapy is hastening the acceptance of MFT within the broader mental health field. For Lebow, the
“umbrella of systems theory” (p. 2) affords a greater appreciation for multiple levels and variables. Implicit
in such paradigms is an appreciation for diversity of practice. This shift signifies the maturation of MFT
and the increasing influence of research on clinical care. According to Lebow, what makes this possible is
the “historical association between family therapy and the treatment of the most difficult disorders” (p. 3).
By the late 1990s some called clinicians to “set aside the model” in family therapy (Hoffman, 1998, p. 152).
Lastly, the evidence-based medicine (EBM) and empirically supported treatment (EST) movements within
psychiatry and psychology, respectively, are beginning to have an impact on the field of MFT. Clearly,
increased attention is being paid to integrative practice.
There are many integrative models in MFT today, yet one could argue that none is sufficiently tailored
to the treatment and training needs of a child and adolescent psychiatry department with a multidisci-
plinary mental health approach. For example, the Metaframeworks model of Breunlin, Schwartz, and
Mac Kune-Karrer (1992) has been highly influential and paved the way for more integrative practice.
However, it is still too closely aligned with less empirically supported traditional family MFT concepts
and practice and does not sufficiently include psychiatric Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) based assessment.
The Integrative Problem-Centered Therapy of Pinsof (1995) exemplifies a significant step in the growth
of integrative practice in MFT. It is biobehavioral and multimodal embracing individual, couple, and family
therapy. Nevertheless, this model has limitations. For example, IPCT requires more theoretical immersion
than is reasonable for a 1-year interdisciplinary training setting. Terms, such as the “problem-maintenance
structure,” and many of the conceptual relationships (see Pinsof, 1995, pp. 54, 78, 214) may require more
advanced training. Furthermore, IPCT is not child-focused enough for training in a comprehensive child
mental health setting. Some of the metaframeworks within IPCT are insufficiently empirically supported
(e.g., Object Relations and Self Psychology), whereas certain areas that are empirically supported and
pertinent to child treatment are underemphasized. Lastly, the “presumptions of least pathology” (p.
92) carries the risk of unnecessarily lengthened treatments, extending suffering, and increasing family
instability, especially for patients with major mental illness. A more comprehensive diagnostic assessment
is needed when children present with the full range of mental health problems.
One of the major challenges faced by MFT throughout its history is multivariable complexity. That
is, the more people, developmental layers, and processes involved, the greater the complexity. It is possible
that no single model will ever answer the clinical needs of all families. For example, Cunningham and
Henggeler (1999), Snyder and Whisman (2004), and Sexton, Ridley, and Kleiner (2004) discuss the
intricacies of theory building and practice when treatment variables increase. Models may need to be
tailored to specific treatment and training needs within an overall empirical zeitgeist. Related to this
concern is the lack of diagnostic consensus in the field. The American Psychiatric Association (APA) has
struggled to form valid and useable diagnostic categories. Marriage and family therapy has historically
been less focused on psychiatric diagnostics and research. There have been attempts to develop more
family-based diagnostics (Kaslow, 1996). However, this concept has failed to gain wide acceptance. Shared
commitments and language to identify problems for clinical focus give more hope for interdisciplinary
progress. Mental health multidisciplinary settings bring together practitioners who have an appreciation
for psychiatric diagnostics, psychological development, and family dynamics so that discourse can focus
on accuracy of comprehensive assessment and tailored clinical intervention.
Training Guidelines and Challenges in Psychiatry and Psychology
Despite the opportunity presented in multidisciplinary settings, training guidelines for child and
adolescent psychiatry and psychology remain vague in the area of family therapy. For child and adolescent
psychiatry training, the Accreditation Council for Graduate Medical Education (ACGME) guidelines are
nonspecific, stating that a program needs to provide “opportunities for the development of both conceptual
JOURNAL OF MARITAL AND FAMILY THERAPY October 2005
understanding of and clinical skills in the major treatment modalities with children and adolescents,” which
includes family therapy among others. This allows for programs to be creative and resourceful. However,
without specified guidelines there is a risk that residents may lack competence in such a crucial area of
training. From one program to another there is wide variation in clinical and supervisory experiences, not
to mention types of family therapy models used.
Similarly, in psychology, The Accreditation Guidelines of the APA state broadly that internship
training should be consistent with the current science and practice in the field, but also gives programs
considerable latitude in determining what this means and how it should be operationalized in the training
model for a particular program. The APA shies away from requirements to teach a particular approach
to therapy or a specified set of intervention skills; yet it is difficult to imagine a program in clinical
child/adolescent therapy that would not consider family therapy training to be within its purview. In fact,
the APA’s Archival Description of Professional Training in Clinical Child Psychology (http://www.apa.
org/crsppp/childclinic.html) notes the importance of “knowledge of normal family processes as they relate
to children’s development including the impact of family dynamics, normal family functioning, and child
rearing practices on normal child development and on the development of children’s problems.”
Marriage and family therapy is generally regulated by state licensing boards based on standards
developed by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)
of the American Association for Marriage and Family Therapy. Fundamental to these requirements is
that MFT is based on a relational view of life and is not a modality of treatment or of diagnosis. Rather,
MFT considers a wide variety of potential problem areas, including individual, couple, family, group, and
community problems. Training is focused on developing competency in individual and family human
development across the lifespan. These guidelines emphasize collaboration with other professionals and
recognize the importance of treatments outside of MFT (e.g., psychopharmacology). Marriage and family
therapy also sets strict requirements for the training and certification of supervisors.
The current training challenge for mental health clinicians and educators is to integrate large bodies
of theoretical and experimental literature in MFT, family studies, adult, child, and adolescent psychiatry,
and developmental psychology and psychopathology. It needs to be accessible to students who are
confronted with extremely challenging multiproblem families that contain identified patients with multiple
comorbidities and, frequently, other family members with serious psychiatric illnesses.
High quality training in MFT is of particular concern, because early training experiences appear
to be an important predictor of future attitudes toward use of MFT by practitioners. Guttman, Feldman,
Engelsmann, Spector, and Buonvino (1999) examined the relationship between MFT training experiences
of psychiatrists and their subsequent practice profile. The following positive correlations were identified
from this study: training and future practice in MFT; training and future involvement as supervisors,
faculty, administrators of training programs, and researchers in MFT; training and Continuing Medical
Education (CME) in MFT; and training and positive attitudes toward MFT in future practice. Of possible
influences evaluated in the study, the most negative was disappointing early MFT clinical experiences
during residency. According to these findings, helping trainees to cope with clinical disappointments and
treatment failures is crucial in effective MFT education and later practice.
Need to Present a More Current and Integrative Approach to MFT
In a multidisciplinary hospital setting, teaching and practicing within the boundaries of the classic
models are insufficient for both training and treatment. Attempting to develop a clinical sense without a
theoretical superstructure does not provide psychiatric residents and psychology interns with adequate
cognitive organization to learn or a solid enough foundation from which to derive effective treatment
strategies. Within the climate of an interdisciplinary mental health setting, a clinical dimensional
perspective, such as Metaframeworks (Breunlin et al., 1992) has potential. Dimensional models allow for
faculty to build on the previous training of residents and interns in EBM/EST while adapting their skills
to family treatment. Integrative Model-Based Family Therapy attempts to build on earlier dimensional
The recent “Common Factors Debate” in the April 2004 issue of the Journal of Marital and Family
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Therapy (Sexton & Ridley, 2004; Sexton, Ridley, & Kleiner, 2004; Sprenkle & Blow, 2004a, 2004b)
demonstrates the need for new theory building and practice development that embrace the heuristic clinical
wisdom of family therapy and the burgeoning empirical literature. The proposed practice and training
model reflects some of the critical dimensions (e.g., family structure, cognitive mastery, affect experi-
encing, and behavioral regulation) identified by Sprenkle and Blow (2004a), and the theoretical framework
exemplifies some of the criteria (e.g., comprehensive, empirical, heuristic, metatheoretical, systematic,
practical and clear) noted by Sexton et al. (2004). The model also strives to incorporate available literature
on empirically supported treatments and to provide a framework for future empirical testing of treatment
The current empirical literature in psychiatry and psychology related to MFT has suffered from
restrictions of a psychiatric nosology that minimizes familial, relational, and social variables and
processes. For example, “family-based” treatment for a particular DSM-IV diagnosis may not actually
represent “family therapy.” Studies to date have primarily used skill building, cognitive-behavioral
therapy, psychoeducational, and behavioral parent training models of treatment. Some of the more complex
community-based and/or multisystemic treatments are intensive, costly, and not easily generalizable.
It seems clear that including the family in treatment improves outcomes for most psychiatric illnesses,
particularly for externalizing disorders (Alexander & Parsons, 1973; Barton, Alexander, Waldron, Turner,
& Warburton, 1985; Henggeler et al., 1986; Henggeler, Melton, & Smith, 1992; Henggeler, Melton, Smith,
Schoenwald, & Hanley, 1993) and when working with parents with their own emotional problems (Baucom,
Shoham, Mueser, Daiuto, & Stickle, 1998), but the data are insufficient overall. It is quite possible that
some family interventions may be better suited for some families and for some disorders. The interaction
between culture and family therapy is difficult to define. Obstacles to gaining evidence include the lack
of family-based diagnoses, measures of optimal home environments, and clinically validated scales. The
distinctions between individual psychopathology and behaviors exhibited in the context of family life are
often not captured in our current evaluation and treatment procedures. When youth are viewed as members
of family systems, a deeper understanding of the system often elucidates the individual problem. For MFT
to gain a more systematized and consistent focus in clinical care and in training programs, a model that
could lend itself to empirical validation and generalizability is ideal.
PRESENTATION OF THE MODEL
Introduction to the Model
Integrative Module-Based Family Therapy identifies nine clinically relevant dimensions for assessment
and intervention. Although all have yet to be empirically tested, they are derived from a large body of
empirical literature in psychiatry, clinical psychology and developmental psychology, family studies, and
MFT documenting their relevance to individual and family functioning. Because of the current lack of
empirically supported treatments in MFT, the dimensions were also chosen based on current best-practice
approaches. During treatment, the selection and application of modules is based on a comprehensive
evaluation that includes DSM-IV assessment of individual psychopathology, including relevant biological
factors, pertinent medical conditions, as well as a family and relationally based assessment that includes
psychosocial domains relevant to the presenting problem. Based on this evaluation and shared treatment
plan, the therapist focuses on a critical dimension (defined by one of the modules) hypothesized to be the
most effective in reaching the therapeutic goal(s). When available, such decisions should be made on the
basis of empirical support. For example, in a family with a schizophrenic member and high expressed
emotion, the affect regulation module is critical as research supports the relationship between dampening
expressed emotion and symptom reduction, including decreased number of hospitalizations and relapses
(Anderson, Reiss, & Hogarty, 1986). In instances in which little empirical support is available, the determi-
nation of particular modules for intervention is based on a “best-practice” approach. Initial assessment
requires the clinician to identify the most salient and/or treatable module through clinical interview and,
where appropriate, the use of standardized measures. The clinician formulates a treatment plan based on
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this assessment. During the course of treatment other modules may be “inserted” as they become more
relevant or as the initial presenting problems improve and the family’s concerns/goals change. The model
is purposefully designed to allow for maximum flexibility on the part of the clinician while still providing
a structured approach to assessment and treatment.
For example, a family may present with a 9-year-old boy exhibiting, through familial report,
uncontrolled outbursts of anger and aggression. Psychiatric assessment may consider a wide variety of
potential disorders (e.g., developmental disorders, bipolar and depressive disorders, attention-deficit/
hyperactivity disorder, oppositional defiant disorder, and/or conduct disorder). When there is empirical
support, pharmacotherapy is considered within the comprehensive treatment plan and compliments
family evaluation and intervention. Using clinical interview techniques and standardized measures,
such as the Child Symptom Inventory, the family therapist assesses within the nine domains (see below)
before intervention. Intervention is then guided by this assessment using therapeutic modalities (e.g.,
individual, couple, family) and techniques consistent with empirically supported treatments within the
specified problematic module(s) when available (e.g., empirical support for parent training in reducing
symptoms of oppositional defiant disorder) or “best-practice” approaches. The nine modules, described
below, are: Psychiatric and Related Medical Conditions, Developmental, Narrative/Cognitive, Affect
Regulation, Behavior Regulation, Relationship/Attachment, Community, Mastery/Self-Efficacy, and
Psychiatric and Related Medical Conditions Module
Integrative Module-Based Family Therapy is founded upon a comprehensive psychiatric, DSM-
IV five-axis assessment using traditional psychiatric tools and psychological testing as needed. Our
focus is primarily psychiatric, psychological, and familial conditions. However, medical concerns are
included within axis III. McDaniel, Hepworth, and Doherty (1992, 1995) and Wood (1995) have shown
the significance and advantages of including medical conditions within a biopsychosocial approach for
MFT. For some families, addressing the medical condition of one or more family members may be an
important first step in facilitating more adaptive individual and family functioning (Campbell & Patterson,
1995; McDaniel, Campbell, Hepworth, & Lorenz, 2004; Patterson, 1988; Rolland, 1994; Seaburn, Gunn,
Mauksch, Gawinski, & Lorenz, 1996). A common example of psychological factors affecting medical
illness is depression or anxiety contributing to medication nonadherence, and this would also fall within
the purview of this module.
The developmental module is designed to address problems related to the developmental stages within
the family, interactions among these stages, and issues associated with the family life cycle. Consistent
with Breunlin et al.’s (1992) development metaframework, this module recognizes five levels: “biological,
individual, subsystemic (relational), familial, and societal” (p. 159). Work within this module draws on
Breunlin et al.’s concept of developmental oscillations, those periods of turbulence normally accompanying
the transitions that characterize developmental growth. These are periods of particular vulnerability for
families and frequently precipitate referral to child and adolescent mental health facilities. Families in
need of intervention within the developmental module might best benefit from a combination of family
treatment, treatment of select subsystems, and/or individual treatment. Family-of-origin work also falls
within the purview of the developmental module. Frequently, the responses of older family members to the
challenges of individual or family transitions are mediated by experiences within their own family of origin
at times of developmental transition. Family therapists have long recognized the impact of one’s original
family on the structure, functioning, and narratives that develop in the family one forms as an adult.
Narrative/Cognitive Module (Focus on Cognitive Structures)
The cognitive or narrative module focuses on maladaptive cognitive constructions that the family as a
whole or individual members have related to the presenting problem. The range of therapeutic interventions
spans classic cognitive–behavioral therapy (CBT) and moves outward to family psychoeducation and
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helping individuals and families reauthor their lives (Freedman & Combs, 1996; White, 1995a, 1995b;
White & Epston, 1990). In keeping with work such as Freeman, Epston, and Lobovits (1997) children are
often open to storytelling and story reformation. This is a clinical area that has strong empirical support
in individual treatment, especially CBT for many disorders (Kazdin & Weisz, 2003; Lewinsohn, Clarke,
Rohde, Hops, & Seeley, 1996; March, Mulle, & Herbel, 1994; Roth & Fonagy, 1996; Spence, Donovan, &
Brechman-Toussaint, 2000). Extending this domain to the family includes addressing problem-saturated
family stories, family myths, and the maladaptive cognitive styles of individual family members, and the
family as a whole. Standard texts (Reinecke & Clark, 2004; Reinecke, Dattilio, & Freeman, 1996) in CBT
now demonstrate considerable flexibility and breadth in techniques and interventions, which include family
assessment and treatment. Although empirical research in the areas of family and relationship-based
cognitive therapy is limited, the strong empirical support for the effectiveness of individual CBT treatment
and emerging evidence in family and group CBT suggests that this is a promising direction for family
therapy that should be further explored.
Affect Regulation Module
The affect regulation module captures the emotional life of the family. Difficulties with affect
regulation—the inability to control anger, anxiety, and depression—are among the most common
referral problems for children and adolescents. Furthermore, children and adolescents presenting with
these problems frequently live in families with poor affect regulation (Beardslee, Versage, & Gladstone,
1998; Burt, Krueger, McGue, & Iacono, 2003; Hammen, Shih, Altman, & Brennan, 2003; Luoma et al.,
2001; Manassis & Hood, 1998) and high levels of expressed emotion (Bolton et al., 2003; Peris & Baker,
2000). Reducing expressed emotion in families with a member suffering from schizophrenia has been
demonstrated to diminish the number of hospitalizations and the frequency/intensity of psychotic breaks
(Anderson, Reiss, & Hogarty, 1986) and it has been hypothesized to improve functioning in children with
bipolar disorder (Fristad, 2001). This module is thus based on the assumption that reducing expressed
emotion in families and improving parental modeling of self-regulation skills will lead to improved family
and individual functioning.
Behavior Regulation Module
As family therapy moves toward empirically supported treatments, it is important that our models
be flexible enough to incorporate effective interventions. The modular approach proposed allows for
such flexibility in treatment. Unlike many of the other modules, which are supported only indirectly by
empirical research, the behavior regulation module is based on a large empirical literature supporting the
effectiveness of behavioral interventions for individuals, couples, and families. Children and adolescents
with poor behavioral regulation frequently come from homes characterized by poor parental monitoring
(Sagrestano, Paikoff, Holmbeck, & Fendrich, 2003; Vance, Bowen, Fernandez, & Thompson, 2002), child
maltreatment (Cicchetti & Toth, 2000), harsh discipline (Buehler & Gerard, 2002), and poor parenting
skills (Campbell, 1990). The behavior regulation module incorporates the development of positive
parenting skills, an effective intervention for children with behavior regulation difficulties (Eyberg &
Boggs, 1998; Forehand & McMahon, 1981; Kazdin, 2005; Webster-Stratton, 1990). It is also geared toward
helping the family to develop a structure that reinforces appropriate roles, expectations, and family rules.
Collaborative problem-solving (Greene, 2004) is an example of an effective, family-based intervention that
shows great promise for treating youth with behavior problems and would naturally fall within the behavior
regulation module. Other empirically supported treatments that incorporate behavioral intervention include
Patterson’s (1982) work on coercive cycles and Henggeler et al.’s (1986, 1992, 1993) work on multisystemic
Traditional models of MFT were founded in the 1950s and 1960s on the assumption that individual
pathology is best treated within the context of family relationships. During the same period, developmental
psychologists were embracing the work of John Bowlby, who postulated that caregiver–child attachment
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was the foundation for all healthy human development. The relationship or attachment module draws on
the work emanating from these early efforts. Theoretically, this module assumes that primary attachments
establish a template for all current and future relationships. Over time, the experiences one has form the
basis for future expectations of how he or she will be treated. It is within the attachment context that
children learn to understand the nuances of social interactions, develop expectations of the world as a
safe and predictable place, and begin to perceive themselves as lovable and capable. Faulty attachments
are associated with poor affect regulation (Cole & Kaslow, 1988; Sloman, Atkinson, Mulligen, & Liotti,
2002; Sroufe, 1996), poor behavior regulation (DeVito & Hopkins, 2001; Greenberg, Speltz, DeKlynen, &
Endriga, 1992; Matas, Arend, & Sroufe, 1978), and poor cognitive mastery (Edwards, 2002; Matas et al.,
1978). Working within the attachment or relationship module requires the therapist to focus on developing
more positive relationships between children and caregivers and between other members of the family
(e.g., the marital dyad). Exploring family-of-origin issues that interfere with healthy attachment as well as
individual psychiatric issues (e.g., parental depression, child learning disabilities) that make relationship
formation difficult also falls within the purview of this module.
Community Module (Social Context, Gender, Culture, Sexual Orientation, Religion)
Historically, MFT has paid attention to the social world beyond individuals, couples, and families and
identified risk and protective factors (Walsh, 1998, 2003). Building on the contributions within MFT and
psychology literature, this module entails sensitivity to the patient’s and family’s place in their community,
cultural influences, gender issues, sexual-orientation concerns, and religious dimensions. Attending to this
module enables clinicians to integrate findings from the basic research in our field and respond to trends
within several social domains (see Amato, Johnson, Booth, & Rogers, 2003; Pinsof, 2002).
Recently there have been considerable advancements which help clinicians address culture (Bean,
Perry, & Bedell, 2001, 2002; Keiley et al., 2002; Kim, Bean, & Harper, 2004; Silk, Sessa, Morris, Steinberg,
& Avenevoli, 2004), race (Mandara & Murray, 2002), gender (Haddock, Zimmerman, & MacPhee, 2000;
Laird, 2000), sexual orientation (Bepko & Johnson, 2000; Bernstein, 2000; Kurdek, 2004; Sanders &
Kroll, 2000; Solomon, Rothblum, & Balsam, 2004), and religion (Snider, Clements, & Vazsonyi, 2004) in
our work. Many clinicians and clinical educators have developed guidelines or perspectives for working
with these dimensions in therapy (Ariel & McPherson, 2000; Doherty, 2003; Long & Serovich, 2003;
McDowell, Fang, Brownlee, Young, & Khanna, 2002; Wendel, 2003). However, much more needs to be
done in these important areas (Constantine, Juby, & Liang, 2001; Inman, Meza, Brown, & Hargrove, 2004;
Nelson, Brendel, Mize, Lad, Hancock, & Pinjala, 2001; Parke, 2001). Nevertheless, this module recognizes
these important dimensions and their need to be included in our work.
Mastery/ Self-Efficacy Module
Functional impairment and adequacy, along with specific symptoms, have frequently been used in
the fields of psychology and psychiatry as markers of poor mental health (Bird et al., 1990; Bird, 1999).
Often, it is parents’ concerns about their child’s competence and daily functioning that bring families into
treatment. Failures to attain age-appropriate skills, whether in tasks of daily living or in the domains of
emotional, behavioral, cognitive, and social development, constitute the presenting problem. Although
families generally ascribe individual responsibility for these deficits or delays, they are best treated within
the family since these norms are contextually determined. Marriage and family therapy can support
developmentally appropriate levels of independence through psychoeducation and can provide parent
training that supports appropriate behavioral and emotional goals. Working in this module also allows
the therapist to reduce parent negativity and increase parental support and praise for child and adolescent
valued activities and performance. Moving between this module and the narrative module, the therapist can
assist the family in “externalizing the problem” (White & Epston, 1990) leading to the child’s increased
control over and mastery of the problem. Furthermore, MFT can help families “rewrite” their narratives to
support a greater sense of accomplishment, both at the family and the individual level.
Family Structure Module
One of the oldest and most widely accepted areas of assessment and intervention in MFT is family
JOURNAL OF MARITAL AND FAMILY THERAPY 365
structure. This module uses classic formulations for assessment and intervention focusing on family
hierarchy (leadership), family boundaries, and family roles (expectations). (For empirical reviews involving
this dimension see Amato, 2001; Beardslee et al., 1998; Buehler & Gerard, 2002; Burt, Krueger, McGue,
& Iacono, 2003; Kelly, 2000; Kline et al., 2004; Lansford, Ceballo, Abbey, & Stewart, 2001; Leon, 2003;
Martinez, & Forgatch, 2002; Wamboldt & Wamboldt, 2000; Yoko, Wickramaratne, Warner, Mufson, &
Weissman, 2002). Studies have consistently shown that family disruptions and instability are associated
with a variety of risk factors (Cuffe, McKeown, Addy, & Garrison, 2005).
SUMMARY AND STRENGTHS OF THE MODEL
Clearly, mainstream clinical treatment must involve person-specific, diagnostically related care that
is sensitive to familial, social, and contextual variables and processes. Marriage and family therapy risks
marginalization until it develops disorder-specific, empirically supported treatments consistent with its
professional climate and values (Shields et al., 1994). Until then, a practice model that draws on empirical
research in related fields and “best-practice” standards is a reasonable bridge between MFT, clinical and
developmental psychology, and adult, child, and adolescent psychiatry. Within a tertiary care academic
setting, we have found the proposed treatment and training model is teachable and clinically useful.
Psychiatry and psychology trainees tend to be familiar with at least some of the literature within each of the
modules. This allows faculty to build on previous knowledge, to assist the trainees in integrating what they
know, and to broaden their assessment and intervention skills. This approach circumvents one of the major
drawbacks of traditional model-focused MFT in which assessment is usually done using the constructs of a
particular theory. For example, within Bowen theory the clinicians assess the degree of self-differentiation.
In contrast, this model allows assessment and intervention typical of our historical models without being
bound to them and also draws our attention to other critical data. As Shields et al. (1994) state, a “source
of strength in family therapy has been the broad based interdisciplinary contributions” (p. 120). Currently,
MFT provides an ideal diagnostic and therapeutic context within which to consider a biopsychosocial
approach (Dannifer et al., 2003; McDermott, 2004). Critical to this effort, however, is the development of
a model that both draws on the empirical literature and has the potential to provide a format for empirical
testing of therapeutic outcomes.
Guttman et al. (1999) have shown that early interdisciplinary training for psychiatrists in family
therapy is an important predictor of future use of and regard for MFT. The proposed dimensional model
invites trainees to learn and use lessons from a wide range of approaches to clinical care that integrate the
theoretically, clinically, and empirically based approaches of different mental health disciplines.
The proposed model is particularly useful because the identified domains comprising the modules
are both theoretically sound and clinically relevant. Over time, they also hold promise for providing a
framework for empirical validation of outcomes in MFT. As stated earlier, MFT has lagged behind some of
the other forms of child and adolescent mental health treatment in pursuing empirical support for outcomes.
Recent reviews of effectiveness in MFT (Pinsof & Wynne, 2000; Sprenkle, 2002, 2003) catalog numerous
individual effectiveness studies with little in common that would allow for more cogent metanalysis of
effectiveness based either on the MFT treatment approach used or the psychiatric presentation of the
identified patient. Work, such as James Alexander’s on Functional Family Therapy for externalizing
behavior (see e.g., Alexander & Parsons, 1982) and Scott Henggeler’s multisystemic treatment (Henggeler
et al., 1986) are examples of assessment/treatment models that allow for empirical validation of a coherent
theoretical model with testable outcomes. Further work is needed to establish empirically supported
MFT treatments for a range of individual and family presenting problems. The proposed model is based
on a large body of MFT practice and available empirical literature in developmental and clinical child
psychology and child and adolescent psychiatry.
In the last 30 years previous clinical partners have in some ways become professional strangers.
Psychiatry, psychology, and MFT have paid a price for development and specialization. We are less aware
of what each other is doing and what can be brought to bear on our collective work. We hope that the
proposed model is an advancement in theory development, interdisciplinary practice, and potential for
JOURNAL OF MARITAL AND FAMILY THERAPY October 2005
empirical validation for MFT practice. Use of this model will draw clinicians and supervisors toward
critical therapeutic domains with focused or best-practice interventions. It is hoped that researchers and
clinicians will benefit from both the model and the unanswered questions it poses. Even more, it decreases
professional isolation and invites colleagues to learn from each other and share the challenges of our
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