Marriage and family therapists

• TYPE OF PSYCHOLOGY: Clinical; Counseling; Consulting; Developmental; Family; Psychotherapy; Social

Marriage and family therapy is a specific profession in the mental health field that focuses on understanding problems based on a relational and systemic worldview. Marriage and family therapists are licensed professionals who do clinical psychotherapy with individuals, couples, and families. They help to mediate family conflicts and address mental health issues.

What is a Marriage and Family Therapist?

Most people are familiar with the applied psychology and social work professions, but marriage and family therapy is not as well-known. Marriage and family therapy (MFT) is unique in its focus on working with clients within the context of their relationships. This means that MFTs often see more than one person at a time for therapy, either a couple or an entire family. The MFT profession holds the belief that no one operates alone. Everyone is affected by their relationship with others, and it is not possible to assist people in addressing their problems without considering these relationships. MFT takes a systemic approach that explores the interactions, feedback loops, and circular impact of problems.

History

The family therapy movement began in the 1950s when psychologists started to gain insight into the impact of family dynamics on psychological disorders and struggles. Before this, all therapy and mental health focused solely on the individual. It was believed that an individual may have a personal defect or internal flaws specific to them until child psychologists began to recognize the profound impact parents, families, and other relationships have on an individual's mental health. Following World War II, researchers found evidence that families were greatly influenced by those coming home from the war. The "schizophrenogenic mother" was a debunked theory developed at the beginning of the creation of marriage and family therapy; this described how a mother was thought to create confused and inadequate children, leading to schizophrenia through her passive and cold interactions. Although this was later discredited, it began the thought process of family impact on mental health conditions. Family therapy progressed by looking deeper into relational dynamics, feedback loops, and exploring how to create healing in people's lives. Among others, key figures connected to family and relational theory include Gregory Bateson (double binds), Murray Bowen (intergenerational), Jay Haley and Don Jackson (furthered research on schizophrenia), John Bowlby (attachment), Nathan Ackerman, Carl Whitaker, Virginia Satir (experiential), and Salvador Minuchin (structural family therapy).

Over time, MFT expanded to assist in a variety of relational issues and familial conflicts. The American Association for Marriage and Family Therapy outlines several categories of focus that are most commonly addressed in MFT, including substance abuse and addiction, adolescent and childhood behavioral challenges, couples challenges, emotional concerns, family issues, gender identity and LGBTQ+ populations, and medical issues. While all these issues may be addressed in individual counseling sessions, it is often helpful to also address some topics in group therapy with a partner or spouse, family, or other loved one. For example, families of an individual with a substance use disorder may benefit from family therapy to address the relational problems stemming from the addiction; spouses of individuals with Parkinson's disease, Alzheimer's disease, or terminal illnesses may benefit from individual and group support.

Underlying Philosophy

The overall philosophy of the marriage and family therapy field revolves around the emphasis put on people as relational beings. All humans are influenced by the relationships in their lives or even the absence of relationships. Marriage and family therapy views problems as a systemic collection of experiences that have influenced a person's way of functioning. This worldview is different from other mental health professions, as problems and people are often viewed through a more individualistic and possibly deficit-based perspective. Clients may notice the difference in the questions, focus, and interventions that marriage and family therapists will use to create goals, process information, and help create change.

Marriage and family therapists often utilize different theories than other helping professions, which have all been created in reaction to the original family systems theory. Family systems theory was expanded into intergenerational family therapy, created by psychiatrist Murray Bowen in the 1960s while working with patients with schizophrenia and their families. He changed his approach from focusing on internalized issues of the patient to exploring the relational impact of their families. Bowen focused his theory on understanding the family of origin impact on people in which the goal of therapy was to increase awareness of patterns to help clients increase functioning. Following the family systems theory, many other theories have emerged either expanding this belief or introducing a new perspective. These theories include the following: structural family therapy, strategic family therapy, humanistic (experiential/Gestalt therapy), object relations theory and attachment theory, narrative therapy, emotionally focused therapy, and solution-focused brief therapy. All of these theories originate from a systemic approach. They vary in how they understand how change happens. For example, structural family therapy focuses on the relationships and patterns in the family and believes that change happens through altering the structure of the family. Narrative therapy focuses on how meaning is developed through experiences in our lives, creating a problem storyline and believes that change happens through insight into the meanings and working to find alternative and preferred meanings in one's life.

Cognitive behavioral therapy and psychodynamic theory are also used by MFTs; however, they were not originally developed as systemic theories. MFTs also incorporate approaches that reflect evidence-based approaches to therapy such as eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive behavioral therapy.

Education and Training

Marriage and family therapy is a specific form of psychotherapy involving viewing clients and their problems through a relational perspective. MFTs begin with entering a master's-level program, generally two to three years in length. Many programs also seek accreditation from the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), which sets standards for MFT training. To be accepted into a graduate program, the individual must already have a bachelor's degree. This degree may be in psychology, nursing, social work, education, or other counseling-related fields. If the applicant does not have a bachelor's degree in a helping profession, they may be required to complete additional coursework before being considered. They may attend marriage and family therapy doctorate programs or choose clinical psychology or counseling doctorate programs. However, unlike some other mental health professions, having a master's degree in MFT will allow for licensure, owning a private practice, and the ability to supervise others. Marriage and family therapy has been recognized as a core mental health profession. Other mental health professions in this category include psychiatry, psychology, social work, and psychiatric nursing.

After completing a MFT graduate program, students begin an intern or trainee phase of their learning. This is regulated on a state-by-state basis. During the intern phase, the professional must work in the field seeing clients and keeping track of their own clinical hours, supervision hours, client advocacy hours, and other professional development hours. All fifty states, the District of Columbia, and several US territories recognize the MFT profession and administer licensure according to their own jurisdictional regulations. For example, in California, Associate Marriage and Family Therapists must have three thousand clinically supervised hours with specific requirements for different types of experience. The supervisor is a licensed professional (at least two years) who has completed the approved supervisor requirements and is responsible for overseeing the cases and signing documentation. The American Association of Marriage and Family Therapy provides standards of the profession that all state licensure aims to meet. COAMFTE accredits programs that meet the standards of the profession. Often, it takes two to four years after the degree to complete the requirements to sit for the licensing exam. Many jurisdictions use the National Marital and Family Therapy Examination developed by AMFTRB as part of licensure.

All states require interns to complete relational hours which are distinctive to this specialty. Interns must see a large number of couples and families to get their hours. Due to the emphasis on the relational and systemic approach of MFT, these hours are very important. Working relationally can be a challenge for mental health professionals since the American Psychiatric Association's 2022 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), which is the main guide for diagnosing mental disorders, focuses mainly on diagnosing individuals, even though clinicians are also expected to consider context. Marriage and family therapists see problems as less within the individual client or patient and more as resulting from the system of relationships that has become dysfunctional, causing stress and conflict. Since this is not the norm in how American culture explains and understands personal issues, learning to think systemically requires a learning curve for MFTs.

Supervision

Perhaps more than other clinical specialties, the MFT profession focuses on supervision. Supervisors are expected to fill a combination of roles that include supportive, didactic, and therapeutic, as well as serving as the gatekeepers of the profession. Although supervisors cannot act as the trainee's actual therapist, there is often a therapeutic-like relationship of support and learning. Supervisors have a large impact on the philosophy and the practice of their interns. They must share their supervision philosophy to provide transparency in their approach. Supervision may be provided for the interns at their place of employment or in some cases, interns are responsible for seeking out and paying for their own supervision. The intern must be under supervision the entire time they are counting hours toward their licensure. The supervisor oversees all clinical cases and ensures clients receive the appropriate care. Supervisors are also seen as the gatekeepers for the profession, as it is their responsibility to ensure that the interns follow the ethical standard of doing no harm. They provide feedback to the intern on their abilities, successes, and areas for improvement. It is also possible for a supervisor to provide feedback that an intern may not be appropriate for the profession.

Live supervision is also common to the MFT profession and is highly prized. A supervisor watches the intern's therapy sessions on video, through a one-way mirror, or by actually sitting in on the sessions. Although this can be a stressful experience for interns, it also yields much feedback. Supervision in other fields such as social work or psychology often is done through case consultations. The professional reports to the supervisor about what happened in the session and what they feel worked and did not. Case consultations are also used by MFT supervisors; however, live supervision provides all the details of the session that can be left out or overlooked. For example, if a supervisor is watching a session, they can pick up on nonverbal cues such as eye contact, body language, and tone. Since nonverbal communication represents a considerable portion of expression, these elements are essential in understanding clients. Therefore, the added value of live supervision is that it provides much more information for the supervisor than simply being told about the therapeutic process.

Law and Ethics

The practice of marriage and family therapy is governed by state laws and the ethics code of the profession. There is an ethical code written by the American Association of Marriage and Family Therapy, which includes all the expectations of how therapists should behave and how to ensure that they do no harm to their clients. The code of ethics is not only taught in training programs but is also highly tested on the licensing exams and is also required to be part of a continuing education post-licensure. The laws of marriage and family therapy vary slightly from state to state. These laws include information on mandated reporting, where clinicians are required to break confidentiality to report suspected abuse, suicidality, and homicidal ideation. Licensed professionals must remain up-to-date on changing legal and ethical codes.

Practice

Marriage and family therapists can practice in many settings, including private practice, hospitals, community clinics, substance abuse treatment centers, residential facilities, or nursing homes. Telehealth became increasingly prevalent in MFT in the 2020s, expanding treatment access to individuals with limited mobility and those living in remote areas. Telehealth practice is also governed by licensure and telehealth rules, including rules tied to the location of the client. Many agencies that hire mental health professionals also hire MFTs, depending on the role and state requirements. Marriage and family therapists with a doctoral degree may also qualify for university academic positions. On a rare occasion, even MFTs with only a master's degree may be able to do some adjunct teaching at most universities. Marriage and family therapists at a master's level can also own a private practice.

Choosing a Professional

When choosing a mental health professional, there are a few things to remember to help make an educated decision. Psychologists, marriage and family therapists, and social workers provide therapy and counseling. Psychologists are often the professionals who do psychological testing, and all have doctoral degrees. This means that they can offer expertise in the testing profession and may also be more expensive to see in private practice. Social workers often work in mental health care agencies, focusing more on case management and obtaining resources. Social workers can also advance their degrees to get a doctorate or become licensed clinical social workers, which you will also find in working in private practice. Marriage and family therapists will most likely be master's level clinicians, and their training and education experience focus on therapy; therefore, they often have more experience in seeing clients right out of school. Whereas psychologists and social workers can focus on other avenues of mental health in their training, such as case management or testing, MFTs focus primarily on therapy. Again, this varies based on the individual as some psychologists will focus their training mostly on doing therapy. There will be a difference in the theoretical approach these professionals take based on their education, training, and personality. Regardless of the type of helping professional, each individual must find a professional who fits their needs. If one therapist is not a good fit, it is important to seek another professional who may be a better fit.

Bibliography

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