Maureen Duffy and Ronald J. Chenail
L’ Abate’s critique of evaluation and, for that matter, the state of affairs in psy- chotherapy, because of weakness or absence of a connection to theory raises some important points and obscures others. His concern about the need for critical reflection on our practices of evaluation and intervention are concerns that we share and take seriously. The fairly recent and tragic case of the girl in Colorado who suffocated and died during a rebirthing/rebonding process purportedly based on attachment theory reminds us how real our theories and practices are. Theory development and attention to the relationship between theory and practice is not simply an academic pursuit; it is an ethical one, and we share L’ Abate’s position that we need to pay attention to theory and connect our practices of evaluation and therapy to it.
What is obscured is that L’ Abate is situating his comments within the positivist paradigm, which is just as much a metatheory as the systems theory he critiques. Rigorous and systematic practices of evaluation (or counterevalu- ation) and therapy conducted within other paradigms (e.g., social construc- tionist) are validated qualitatively in ways congruent with the paradigm.
Mixing paradigms is more problematic for us than mixing theories within a paradigm. The paradigm issue is not trivial because the views of reality and knowledge contained within it are fundamentally different.
We would argue with L’ Abate that “systems theory has not produced testable models” and point again (see chapter 3) to the outstanding work of the research teams from the University of Miami (Liddle & Dakoff, 1995;
Szapocznik & Coatsworth, 1999) who have been testing systemic approaches over long periods of time with the adolescent substance-abusing population and confirming meaningful positive treatment outcomes. Additionally, evi- denced-based research on systemic family therapy is able to be translated into manualized formats similar to manualized medical protocols. (Pote, Stratton, Cottrell, Shapiro, & Boston, 2003)
Rather than fretting about how to select a particular theory to which to adhere (a difficult task in family therapy), looking at what is common across multiple models of therapy seems more promising. The social sciences suffer this lack of mid-range theory and practitioners and clients suffer as a result.
The factors for which specific theories account may not in the end be curative.
What the client brings to the table in terms of resources, the therapeutic rela- tionship, and hope may have more to do with cure than practices derived from specific models (Hubble, Duncan, & Miller, 1999).
COUPLEAND FAMILY ASSESSMENT 263 Talk is messy. Writing is no less messy and we fail to see how changing from the medium of talk to writing will solve the problem of a poor connec- tion between evaluation and intervention. The anthropologist Alton Becker (1991) notes that writing is at once overstated and understated—it says too much and leaves too much out. Writing shares many of the same problems of signification as does talk. Qualitative approaches to assessment in family therapy avoid making a problem of any mode of communication (oral, writ- ten, gesticular, graphic, artistic, or performative) by embracing all modes as significations of the meanings of human experiences and as open to assess- ment from the expert and the collaborative standpoints.
L’Abate’s Reply
I am delighted to disagree strongly with Duffy and Chenail. They are doing their best to distract me and the readers with the issues I have raised in my final chapter. Their dialectical anti-empirical position is contradicted by the construction of an objective test. This construction implies a logical positiv- ism position—that is, performing operations (i.e., constructing and validating a paper-and-pencil test) not found in dialectical approaches. If they like those approaches, why not simply use the interview method with all its explicit dangers of subjective interpretation, and so forth? By producing and validat- ing an instrument, they have embraced a logical positivistic position.
Another distracting point that avoids the basic issue about writing is to equate it with talk in its qualities, shortcomings, and defects. The bottom line of writing is reproducibility and replicability—qualities that are expensive in reproducing talk, audio-, or video tapes. Talk is subject to distortions, generali- zations, or forgetting, which do not occur when writing is used as a medium of communication. If talk is so great, why did they construct a test based on writing? Progress in science, industry, law, government, medicine, and psy- chology is made on the basis of writing, not talk.
I wish Duffy and Chanail had stayed with the issues rather than going outside them. Nonetheless, I appreciate their looking at the larger picture and raising issues that, although tangential to my points, remain relevant to overall evaluation of couples as well as all our respondents—individuals and families.
Sylvia Fernandez and Sloane Veshinski
The identified need for tools to measure and assess, in a structured way, constructs deemed important in understanding the family- and system-spe- cific issues and values led to the development of an array of instruments. The choice of instruments discussed in the chapter dealing with custody and divorce assessment is based on issues and theories regarding healthy and appropriate family functioning, such as the family context, family
relationships, and family culture. The selected instruments have been or are in the process of being field tested and their psychometric properties being determined and/or reported (Nurse, 1999).
L’ Abate’s critique of inadequate links with theory or theoretical models with the selected instruments may not be disputed by many of the instrument developers. However, they may disagree with him regarding the appropriate- ness of the constructs measured and the functionality of the outcomes for determining interventions and making custody and visitation recommenda- tions. L’ Abate further observes inadequate links with results of assessment to the type of intervention. Anecdotal evidence suggests effectiveness of inter- ventions (Fischer & Corcoran, 1994).
Assessment instruments are a diagnostic or screening tool that may sub- stantiate already available data or provide a beginning point for treatment and interventions. The training and experience of the clinician is the moderating variable in how the assessment data are used in determining the appropriate treatment and intervention. The choice of instruments and interventions is a reflection of the clinician’s knowledge, skills, and counseling/therapy orienta- tion.
L’ Abate’s challenges regarding the adequacy of the links of the identified instruments to theory or theoretical models and that of the results of assess- ment to the type of intervention are on target and well taken. With the excep- tion of three, the selected instruments had been developed since 1990 and still have a long way to go to be satisfactorily validated; as L’ Abate acknowledged, this is a long and tedious process. Reviewers of the tests, discussed in chapter 9, cited in the Mental Measurements Yearbook (Plake, 2003) voiced similar concerns about the theoretical grounding and empirical reliability and validity of the tests and instruments. Thus, caution when using these tests and instru- ments is recommended.
L’ Abate challenges the sole use of talk as a means of assessments and suggests that relying on programmed writing may be the direction to go.
Solely relying on talk or writing potentially takes away the opportunity to seek clarification, to use multiple avenues for gathering information, and, possibly, to miss multicultural influences. L’ Abate offers his model, which is currently in development and at a point at which he charges other test devel- opers are: it is still empirically unsubstantiated. Qualitative and quantitative data provide the best range of data for making appropriate recommendations and interventions.
The assessment instruments discussed in chapter 9 are not recommended for use singly, but rather in combination to provide the best range of data to facilitate making a decision or recommendations, as illustrated in the case example. Using only one approach would be flawed and biased toward clini- cians’ knowledge, skills, and theoretical orientation. Interventions that depend solely on talk presuppose the verbal ability of the client and the cognitive level
COUPLEAND FAMILY ASSESSMENT 265 of functioning; those that depend solely on writing presuppose the client’s literacy, that is, his ability to read, comprehend, and write.
The task of the authors of chapter 9 was to identify that which is cur- rently available to meet the needs for child custody and divorce assessment strategies and inventories to assist clinicians in making appropriate recom- mendations. The authors’ task was neither to critique the reported reliability and validity nor to deconstruct the selected instruments.
L’Abate’s Reply
I agree with almost everything Fernandez and Vershinski say; however, I want to add a couple of references not contained in my original response, but rele- vant to the points made there. They may illustrate and reinforce my position:
linking evaluation with workbooks, workbooks with face-to-face (f2f) or distance interventions, and using workbooks in education and prevention, rather than only in therapy. Through workbooks, I am trying to bridge the considerable gaps between evaluation and therapy, prevention and therapy, and theory with practice. In the work that I have already cited in this chapter (L’ Abate, 2004b, 2005), I make workbooks instruments of model and theory testing, adding another dimension to their versatility.
Dennis Bagarozzi
Dr. L’ Abate’s remarks about chapter 7 deserve attention because they highlight important issues concerning marital/family assessment, that is, “insider–outsider”
perspectives and the role of expertise in assessment. Clearly, Bartholomew and his colleagues have used the Relationship Questionnaire in their research concerning attachment styles for over a decade. This short, forced-choice, paper-and-pencil instrument offers a valuable insider’s perspective. The AAI, on the other hand, offers an outsider’s/expert’s vantage point. In the best of all possible worlds, both perspectives would be considered. Dr. L’ Abate’s prefer- ence for paper-and-pencil self-report measures that do not rely upon face-to- face observations and therapist–patient interactions are consistent with his emphasis upon writing and distance approaches to intervention.
As a therapist, I am convinced that self-report measures, regardless of how they are obtained, only give a unidimensional insider’s perspective that is subject to experimenter effects. Nothing can replace the therapist’s critically trained eye as he observes the interactive dynamics of couples and family systems. I have reservations about any approach to behavior change that relies solely upon self-report. Knowing Dr. L’ Abate, I am sure he does not intend to
“throw the baby out with the bath water.” I invite his observations about my comments.
L’Abate’s Reply
I strongly, but amicably, disagree with Dennis on some of his responses to this chapter. One can get into respondents’ (i.e., couples’) perspectives as much as by what they write as what they talk. In 20 years of using writing in its various structures with couples and families, I received information through writing I would have never received through talk. Talk is deceptive (and so writing can be), uncontrollable, and subject to distortions, generalizations, and forgetting that explain why writing has been used for centuries as the basis for progress.
Skyscrapers are built on talk, not on blueprints, and I view this position that observers’ omnipotent but subjective observations are paramount with a jaun- diced eye.
Recently, our (L’ Abate, L’ Abate, & Maino, 2005) review of clinical records accumulated over 25 years of part-time private practice failed to confirm my biases about the cost effectiveness of workbooks. During the first 10 years of our practice, individual, couples, and families were seen without homework assignments (i.e., workbooks). During the next 15-year phase of our practice, treatment was in some ways made contingent on respondents’ completing written homework assignments. In all that I have written about workbooks, I claimed their cost effectiveness as their major advantage, but I was wrong. We found convincingly and statistically significantly that all our respondents (individuals, couples, and families) had a much greater number of f2f sessions than respondents without homework—so much for clinical judgment or, at least, my clinical judgment. Therapists have nothing to fear from administer- ing written homework assignments!
Furthermore, keep in mind that thousands of relationships, many of them intimate, are established online. Over the last few years, I have established collaborative relationships with colleagues around the world. Thus, it is bene- ficial to use the power of the Internet to reach and help the many people (i.e., couples) who need help and not necessarily talk.
Lynelle C. Yingling
In his commentary, Dr. L’ Abate makes some helpful comments. I agree that, in order to be valid, family assessment must have a connection with family systems theory and must have a clinical purpose based on family therapy technique models. Unfortunately, L’ Abate overlooks the contributions made by Dr. Lyman Wynne in the GARF DSM-IV taskforce to bring together pri- mary family assessment leaders to reach consensus on the overlapping vari- ables from clinical and theoretical orientations. If there is any hope for family assessment to be accepted as helpful and necessary by clinicians and consum- ers (including managed care companies), we should probably continue on that path of consensus building. If we could agree on the basics, we could stylistically expand the details to fit personalities of various clinicians and to
COUPLEAND FAMILY ASSESSMENT 267 be implemented through the various media tailored to fit the functioning level of the family. Written instruments are helpful in reframing the attention of the client family members. However, I have few clients in my practice who can make change based on written workbook materials alone; talk is still essential in order to calm reactivity and enable a client to think clearly and experience change through clinical coaching. Perhaps some day our society will see the benefit of preventive enrichment activities, but that is not the world I see in my office today.
As we try to make progress in family assessment, I am reminded of a met- aphor shared by a rancher husband of an attendee at a Groves Conference many years ago. At the banquet, I asked what he thought of the conference.
He replied that it reminded him of an island where horses existed. Over time the horses became so inbred that they finally self-destructed. Are we on an island?
L’Abate’s Reply
Of course I have heard about Wynne’s taskforce. However, instead of talk, as most task forces do, I prefer to offer writings that deal with the issue (L’ Abate, 2005, submitted for publication) or present relational models incorporating DSM-IV into a theory-derived, research-based framework. This framework allows integration of various psychiatric syndromes into one coherent, rela- tional theory (L’ Abate, 2005, submitted for publication; L’ Abate, Lambert, &
Schenk, (2001). In this theory, psychiatric categories are continuous and con- tiguous with each other, allowing a traditional categorical psychiatric list of syndromes to be integrated into a coherent whole. Perhaps, Dr. Yingling may want to read about what has been done in this area, rather than wait for future words from my friend from Rochester and his taskforce.
I fail to see how the rancher’s metaphor applies to what I have written.
Perhaps I do not share the same sense of humor as the rancher or Dr. Yingling.
As a past presenter to the Groves Conference, I found it to be a very enlightened group of sociologists with a sprinkling of psychologists. Perhaps Dr. Yingling may explain how that metaphor applies to what I have written? Finally, I do not share Dr. Yingling’s pessimism about the future of prevention.
Friedrich, Olafson, and Connelly
Luciano L’ Abate wrote his comments before reading our completed chapter 10 and the full reference list, so he may wish to amend them after he has had a chance to review the final draft. What follow are our interim responses to his preliminary responses.
L’ Abate notes that most of the book’s chapters, ours included, were dis- connected from theory. Evaluation, assessment, and treatment of childhood trauma and abuse are new, disparate, and rapidly changing fields. It would be
premature to impose a unifying theory upon them. Indeed, research findings from this dynamic area of inquiry have challenged and even undermined existing theoretical models, especially those in family systems theory, but also psychoanalytic theory and that school of biological psychiatry that seeks the genetic basis for mental disorders. The disconnection from theory has been one of the strengths of this new area of inquiry; it can allow researchers to see afresh what is in front of them, rather than shoehorning their data into rigid schemata. To give just one example: children who have been chronically abused and traumatized do not present with symptomatologies similar to the adult combat veterans upon whom the classical PTSD diagnosis was formu- lated; however, theory-bound psychometricians continue to develop instru- ments to assess children using these adult male criteria. Only in 2003 did a major committee in the federally funded Network of Child Traumatic Stress centers look afresh at the Complex Posttraumatic Stress Disorder diagnosis in severely, chronically abused children in order to reconstitute a theoretical base upon which more adequate instruments could be developed. This will be done by gathering data without preconceptions from the DSM IV—Aristotle trumps Plato.
L’ Abate’s second criticism, that inadequate links exist between evaluation and intervention, criticizes chapter writers for what they did not set out to achieve. This is not a book about treatment. Many psychological assessments, especially when family violence, childhood trauma, and child abuse are at issue, are conducted for forensic, not treatment, purposes. Child trauma treat- ment is a new and very promising field, and certain instruments in chapter 10, such as the DES, the CBCL, and the TSCC, can be administered at 3-month intervals to assess treatment process. A number of studies not included in our reference list (because that was not our mandate) have used these instruments to assess treatment process. Readers interested in a survey of instruments and available child trauma treatments are referred to Saunders, Berliner, and Hanson, 2002.
L’Abate’s Reply
I really do not have any reply to these authors. I think they have done a good defense job, even though the excuse of not writing for a treatment book is somewhat lame. Indeed, it proves the point that this book is concerned with evaluation but leaves the whole issue of relationships between evaluation and treatment completely unresolved. It also demonstrates my point that evalua- tion and treatment continue to be disconnected from each other. As long as this practice continues, the issue of relating treatment to evaluation will remain a murky one.
If evaluation is not linked to treatment, what is the good of evaluation?
Decisions are made on the basis of evaluation about treatment and what kind of treatment. We can no longer think of “just psychotherapy” or, with
COUPLEAND FAMILY ASSESSMENT 269 children, “just play therapy,” or, more to the point, “just couple therapy.” The days of one treatment fits all are gone. Have we reached the stage that we wanted years ago — “What kind of treatment for what couple at what cost and by whom?” Just look up the recent publication of the Handbook of Family Therapy edited by Sexton, Weeks, and Robbins (L’ Abate, 2003b) and see how many treatments are available. Yet, there is no way to define and know which treatment is good for which couple.
Why? Clinicians and couple therapists, as in the case of individual and family therapists, simply do not use objective tests. They are not required by third parties or by national professional organizations, nor is the use of objec- tive tests included in many codes of ethics. Then why evaluate? If treatment is not differentiated to the point of “different strokes for different folks,” the enterprise of evaluation is like a leaf in the wind—it goes nowhere until it falls to the ground. The only reason I see for evaluation is now taking place in what is called the stepped-up care movement. (Years ago, in 1990, I called this increasing hurdles.) Borrowing from the medical model (without any shame or doubt), one starts with the cheapest, most ubiquitous, and most expedient instrument—for example, the thermometer. Given the results, one institutes the cheapest treatment (“Take two aspirins and call me in the morning”). If that does not work, “Visit me” is the response. Each step is more expensive then the preceding one (e.g., more tests). Why all these tests? A diagnosis about the nature (type, severity, location, etc.) of the complaint needs to be reached. Why? A specific treatment matches the nature of the “disease.” This may be a hit-or-miss proposition, as in the prescription of many antidepres- sant or antipsychotic medications, but eventually a “goodness of fit” is found.
Is this process perfect? Of course not. However, evaluation is taking place to determine what specific treatment to apply.
I have argued, and will continue to argue, that as long as treatment is tak- ing place verbally, it will be nearly impossible to obtain the match necessary to link treatment with evaluation. That means that our treatments will not be replicable from one therapist to another or from one clinic to another and thus no progression because the final arbiter of what treatment to apply is going to be the word of the therapist. I have shown, as mentioned in my reply to Dennis, how incorrect clinical judgment can be, especially my own. As long as we rely on words to treat people, no progress will take place (L’ Abate, 2003a). To those who ask me to define progress, I answer, “When we do the most good for the most people with the least amount of expense.” Psychother- apy with couples, individuals, and families is and will continue to be a small drop of water in a large bucket. We need to come up with new ways to help all the hurting, stressed, and distressed couples, individuals, and families who are not reached, and do not want to be reached, by talk. Writing and distance writing may be one answer; TV will be another.