Journal of Marital and Family Therapy doi: 10.1111/j.1752-0606.2009.00171.x April 2010, Vol. 36, No. 2, 185–196 CREATING SYNERGY IN PRACTICE: PROMOTING COMPLEMENTARITY BETWEEN EVIDENCE-BASED AND POSTMODERN APPROACHES Stephanie Jacobs, Karni Kissil, Dalesa Scott, and Maureen Davey Drexel University Postmodern and evidence-based practice (EBP) are compared and contrasted with the primary aim of adapting evidence-based practice with a more flexible epistemological lens. We begin by reviewing the epistemological underpinnings of postmodern and EBP within the field of marriage and family therapy (MFT). We next discuss how these contrasting philosophies inform therapists’ traits and practice in the context of translational research and practice-based evidence. Finally, we point toward some promising directions for a flexible adaptation of evidence-based practice in which both modern and postmodern clinicians can practice, and ways to incorporate some of these more flexible principles into the clinical training of MFT students. Modern and postmodern philosophies of science continue to influence theory, practice, and research in the field of marriage and family therapy (MFT). Generally, whether a clinician utilizes an empirically supported treatment like Emotionally Focused Therapy (Johnson & Greenberg, 1988) or a postmodern practice like Narrative Therapy (White & Epston, 1990) is usually determined by his or her modern or postmodern epistemological stance. In the field of MFT, the debate about the relevance of evidence-based practices (EBPs) has highlighted tension between modern and postmodern epistemologies which scholars have noted (e.g., De Simone, 2006; Larner, 2004; Laugharne & Laugharne, 2002). Larner (2004), for example, described this tension between modern clinicians and scholars who tend to value and privilege randomized controlled trials and postmodern scholars and clinicians who additionally value evidence coming from everyday clinical practice, in particular directly from clients’ narratives. Similarly, Laugharne and Laugharne (2002) suggested that mental health care researchers, clinicians, and clients often have conflicting viewpoints—perspectives that mirror either a modern or postmodern philosophy of science—and that understanding these competing viewpoints is crucial for effective mental health service. The tension between these viewpoints can prevent a fuller integration of all types of evidence, whether it is from a postmodern perspective or a more modern and evidence-based one. Such an integration would reflect a philosophy of science that Larner (2004) referred to as ‘‘paramodern’’ (p. 17). A paramodern perspective recognizes the art and the science of therapy and is able to ‘‘hold both modern and postmodern approaches in tension’’ (Larner, 2004, p. 17). Such an integration of art and science or empiricism and practice allows for ‘‘a therapeutic stance that is pragmatic, creative, intuitive and curious’’ (Larner, 2004, p. 32). To that end, a ‘‘paramodern’’ perspective is one that we believe can more effectively move the field of MFT forward. The premise of this article is timely in the context of the current dialogue in the field about core competencies and common factors. Similar to the core competencies established by the American Association for Marriage and Family Therapy (AAMFT), our focus is on flexibility The first two authors contributed equally to the development of this manuscript. Stephanie Jacobs, MS, Ed.S., Doctoral Student in Programs in Couple and Family Therapy, Drexel University; Karni Kissil, MA, MEd, LMFT, Doctoral Student in Programs in Couple and Family Therapy, Drexel University; Dalesa Scott, MFT, Doctoral Student in Programs in Couple and Family Therapy, Drexel University; Maureen P. Davey, PhD, LMFT, Programs in Couple and Family Therapy, Drexel University. Address correspondence to Maureen Davey, Programs in Couple and Family Therapy, Drexel University, Mail Stop 905, 1505 Race Street, Suite 403, Philadelphia, Pennsylvania 19102; E-mail: mpd29@drexel.edu April 2010 JOURNAL OF MARITAL AND FAMILY THERAPY 185 in practice and research so that integrative treatments can be supported by facilitating a more flexible adaptation of evidence-based practice, regardless of a therapist’s epistemological stance (e.g., modern or postmodern; AAMFT, 2003; Nelson et al., 2007). This further provides a viable way to promote treatment that takes into account multiple variables, such as clients’ feedback, evidence-based treatments, contextual variables, myriad therapeutic styles, and measurable outcomes, which is in accordance with the core competencies (AAMFT, 2003). More recently, the common factors debate (Blow & Sprenkle, 2001; Blow, Sprenkle, & Davis, 2007) has pushed the field of MFT to clarify the essential elements of effective treatment. Blow and Sprenkle (2001) suggested that MFTs should move away from model-specific theories and focus more on common factors that work through the various integrative approaches. The role and characteristics of the therapist, however, are a common factor and are considered more important than the model in explaining therapeutic change (Blow et al., 2007). In other words, models work through therapists and depend on how therapists apply the models, which we believe is directly related to therapists’ beliefs in the treatment and how closely those treatments are aligned with their epistemological stances. Congruent with the common factors approach, our article focuses on the importance of considering the therapist’s role, in particular the epistemology of the therapist. In this article, we also encourage the mastery of several integrative models and the ability to flexibly tailor treatment approaches that best facilitate change in clients. This article is not intended to comprehensively review the modern and postmodern theoretical, empirical, or methodological literatures. Rather, our aim is threefold: (a) to revisit some of the core principles of postmodernism and modernism that have informed the development of the field of MFT, (b) to consider the unique opportunities these principles provide in the age of evidence-based practice, and (c) to negotiate the tension between practicing as a postmodern therapist and adapting evidence-based practice with a more flexible epistemological lens that integrates both the art and the science (Larner, 2004) of MFT. MODERNISM AND EVIDENCE-BASED PRACTICE Based on the Enlightenment ideals of rationalism, materialism, and reductionism, modernism assumes that something cannot be valid if it cannot be measured or proven, and tends to promote universal theories that attempt to explain all experience (Laugharne, 2004; Laugharne & Laugharne, 2002). In fact, the philosopher of science and positivist Karl Popper viewed ‘‘normal’’ science as the practice of dogmatically and genuinely testing a theory in an attempt to falsify or refute it; the ‘‘normal’’ scientist, then, is someone trained in critical thinking and tends to ask ‘‘why?’’ (Worrall, 2003). Investigating how and why something works for certain populations and problems has found a new voice in the current trend toward EBPs in both the clinical and medical fields (e.g., Kazdin, 2008). EBPs tend to provide more precision and tailored treatment by encouraging clinicians to use the most current and best available scientific evidence, and their own clinical expertise—in addition to clients’ needs, values, and preferences—to make decisions about the care of their clients (Ford, Schofield, & Hope, 2003; Kazdin, 2008; Roberts, 2000). Although first introduced by the medical community, EBPs have found firm ground in the MFT field. Evidence-based treatment approaches such as Multisystemic Therapy for adolescents with serious externalizing problems like conduct disorders and substance abuse (MST; e.g., Henggeler, Pickrel, & Brondino, 1999), Multidimensional Family Therapy for adolescent drug abuse and delinquency (MDFT; e.g., Liddle, 1999), Functional Family Therapy for externalizing disorders in adolescence (FFT; e.g., Alexander, Robbins, & Sexton, 2000), and Emotionally Focused Therapy for marital distress (EFT; e.g., Johnson & Lebow, 2000) have provided empirically and data-driven treatments. Extensive outcome and process research on the part of EBP proponents have identified key change mechanisms that have advanced clinical knowledge and practice. Robbins, Alexander, and Turner (2000), for example, noted that reframing reduces defensive family behaviors in FFT with families of behavior-problem youth. Johnson and Talitman (1997) connected the therapeutic alliance to successful treatment of satisfied couples after 12 weeks of EFT. These 186 JOURNAL OF MARITAL AND FAMILY THERAPY April 2010 examples of EBP research add to the clinical knowledge and practice in the MFT profession. Moreover, in an age of increased accountability due to managed care’s oversight of client care, EBPs provide credibility for the field. Indeed Sexton, Ridley, and Kleiner (2004) argued that EBPs like these are required to advance and to develop the MFT profession and to increase its credibility through research efforts that integrate theory and practice, and ultimately help clinicians to understand clients and change processes. Although the current evidence-based movement is a modernist or positivistic approach that privileges objective evidence to advance the understanding of client care and treatment (Faulkner & Thomas, 2002), postmodern practitioners have expressed concern that EBPs tend to promote an empirical search for universal client truth that may not recognize other sources of knowledge as equally valid. In other words, the EBP approaches can create a hierarchy that privileges one source of information (scientific data) over the clients’ narratives, not fully taking into account individual variation. To that end, postmodernists have raised the question: Are EBPs the only source of knowledge about how to treat clients (e.g., Bracken, 2003; Laugharne, 2004; Pocock, 1995)? POSTMODERNISM Positivistic researchers typically use empirical tools and methods to discover ‘‘objective’’ truth with less personal bias, while postmodern scholars tend not to look for the creation of universal laws, but choose instead to focus on interpreting and understanding the meaning of experience more specific to the individual (Murray, 1997). Post-positivistic researchers hold an interpretive belief that context and personal meanings do influence one’s concept of ‘‘truth’’ and seek to understand that which is being observed. Critical postmodern scholars, therefore, primarily aim to liberate those oppressed by social groups and tend to critique positivistic views of objective truth as something imposed by those who control the power to shape knowledge (White & Klein, 2008). Thomas Kuhn (1962) defined ‘‘normal’’ science as the routine puzzle-solving performed by scientists to maintain a paradigm until it is overthrown. Kuhn exposed the power struggle inherent in scientific communities by punctuating the belief that those who control knowledge also control the discourse about it. This belief is embedded in postmodernism, which questions modernity’s attempt to ‘‘trump’’ other forms of experience and encourages the need for many more inclusive views of reality to coexist in order to fully understand and to ultimately embrace different ways of knowing (Laugharne, 2004). As opposed to discovering truth, postmodernists tend to view truth as a function of language and thus privilege the less tyrannical stories of individuals or local communities. Postmodern clinicians, therefore, tend to avoid asserting themselves as technical experts, and instead support clients’ own efforts to heal. This approach is most evident in postmodern approaches like Narrative Family Therapy, Collaborative Language Systems, and SolutionFocused Family Therapy that focus more on coping as opposed to curing (Anderson, 1997; Lipchik, 2002; White & Epston, 1990). Not viewed as static, postmodernists perceive human stories as dynamic, moving, and changing in time; the truth of experience, then, is cocreated between the client and clinician to produce a meaningful and coherent life story. In contrast to evidence-based practices, postmodern approaches have been strongly criticized for a lack of emphasis on conducting research to demonstrate their effectiveness (e.g., Liddle, 1991). Although modernists and postmodernists continue to struggle to determine ultimate claims to ‘‘truth,’’ we believe that more midrange ideas anchored in therapists’ epistemologies can ease the current tension between modernists and postmodernists in the field of MFT. HOW EPISTEMOLOGY INFORMS THERAPISTS’ CHARACTERISTICS A growing body of research and theory has investigated the relationship between therapists’ practices and their philosophical stances, suggesting that different epistemological beliefs inform therapists’ choice of theoretical orientation and therapy style (e.g., Saferstein, 2007). Epistemological beliefs or epistemic styles refer to clinicians’ ‘‘ways of knowing,’’ or approaches April 2010 JOURNAL OF MARITAL AND FAMILY THERAPY 187 to reality, which involve unique psychological processes and corresponding unique understandings of reality (Royce, 1964). Lyddon (1989) suggested that therapists maintaining differing philosophical commitments hold different perspectives regarding the processes and methods of human change which, in turn, inform their style and practice of therapy. Royce and his colleagues (Royce & Moss, 1980; Royce & Powell, 1983) have attempted to identify individual psycho-epistemologies (Strano, 1990) and developed a conceptual model that specifies three epistemic styles: (a) empiricism; (b) rationalism; and (c) metaphorism. These three styles are not mutually exclusive, but hierarchically arranged with the individual typically exhibiting a dominant epistemic style (Royce & Powell, 1983). Empiricism emphasizes sensory experience as the main way of knowing, where individuals know to the extent that they perceive accurately. The empirical view of knowledge, therefore, is primarily inductive and determined by the reliability and validity of that individual’s observation. Empiricism is embedded within Biosocial Theory (Troost & Filsinger, 1993), which assumes that there is a connection between the biological and social domains and views psychopathology as learned and measurable dysfunctional behavior that can be changed through contracting or conditioning. Empiricism, for example, is the epistemological worldview that informs behavioral therapy (Schacht & Black, 1985). Rationalism maintains the dominant assertion that thought has superiority over the senses with regard to obtaining knowledge. Rationalism is embedded within the Rational Choice social framework (Homans, 1961), which assumes that individuals are capable of making rational decisions and can weigh the costs and benefits to determine a preferred course of action. Those with a rational epistemic style are devoted to testing their views of reality in terms of logical consistency. Rationalists view a single, stable, external reality and believe that individuals passively perceive an independently existing reality (Mahoney, 1991). Rationalists view psychopathology as stemming from irrational emotions or behaviors that can be controlled by rational thought (Royce & Powell, 1983). The therapist’s role, therefore, is to instruct the client to think more rationally, increasing the correspondence between the individual’s perceptions and the reality of the events that the client is confronted with (Mahoney, 1991). Rationalism, for example, is the epistemological worldview that informs cognitive therapy (Lyddon, 1989). Both empiricism and rationalism are part of the modern approaches to therapy and the long tradition of realism in the mental health field in which a well-adjusted or a mentally healthy individual is the one who accurately sees what is actually there (Neimeyer, 1993). This implies the existence of one truth, with the validity of one’s belief system being determined by the degree of its match with the real world. Therapists working from a rationalist-empiricist epistemology tend to view their role as corrective as opposed to a creative role, aiming to close the gap between the client’s perceptions and reality. A rationalist-empiricist therapist tends to also take an active and directive position with the client and is more problem focused (Granvold, 1996). The rationalist-empiricist therapist is typically persuasive, analytical, technically instructive, and can be highly psychoeducational (Neimeyer, 1993). Bowen Family Systems Therapy (Bowen, 1978), Structural Family Therapy (Minuchin, 1974), and Cognitive-Behavioral Family Therapy (Epstein, Schlesinger, & Dryden, 1988) are among the family therapy models that are informed by the rationalist–empiricist epistemology, which assumes that adjustment and functionality are related to the degree that a person’s beliefs and behaviors are consistent with rational thinking and an objective reality. Metaphorism is a perspective in which knowledge is more flexible and is nested within individually and socially constructed symbolic processes. Metaphorism is embedded within the social theory of Symbolic Interactionism (Blumer, 1969), which assumes that reality is ever changing through the creation of shared meanings in interactions between individuals and groups. Reality is perceived as personal and mutable rather than fixed. Individuals construct their bases of knowledge from their personal learning histories, external experiences, and their own personally constructive processes (Vincent & LeBow, 1995). Individuals are viewed as proactive in their personal constructions of their realities (Mahoney, 1991). Metaphorists view psychopathology as an unsuccessful effort to change or develop, or an inability to adequately adjust to a situation or circumstance. The emphasis is placed on 188 JOURNAL OF MARITAL AND FAMILY THERAPY April 2010 adjustment and the novel construction of new ways of knowing within an ongoing process of developmental change, rather than the correction of dysfunction (Vincent & LeBow, 1995). Metaphorism is the epistemological worldview that underlies constructivist therapy (Lyddon, 1989; Neimeyer, Prichard, Lyddon, & Sherrard, 1993; Schacht & Black, 1985). This epistemic style is congruent with the postmodern approach to therapy in which ‘‘reality’’ is not viewed as a given, but rather as socially constituted and therefore constantly changing depending on the culture, time, circumstance, and participant. ‘‘Reality’’ is comprised of meaning-making processes where the individual is in charge of organizing his or her experiences (Mahoney, 1991). Therapists working from a metaphoric ⁄ constructivist epistemology view their role as creative rather than corrective in facilitating the broader development of the client’s constructions. Constructivist therapists tend to be less directive, provide more information to clients, are less problem focused, and engage in a more exploratory interaction in their behavior with clients (Granvold, 1996). They are also described as more reflective, collaborative, and ‘‘intensely personal’’ in their therapeutic style (Neimeyer, 1993, p. 225). Narrative Therapy (White & Epston, 1990), Solution-Focused Therapy (Lipchik, 2002), and Collaborative Language Systems (Anderson, 1997) are among the family therapy models informed by the metaphorist epistemology, assuming an ever-changing socially and individually constructed reality. Prior theoretical literature has suggested a strong link between therapists’ epistemology and different features in therapy, such as characteristic style of therapy, therapist’s choice of interventions, and the nature of the therapeutic relationship (e.g., Lyddon, 1990; Saferstein, 2007). Research investigating this link has been primarily conducted in the field of clinical psychology, and specifically focused on comparing cognitive therapies with other approaches, for example psychoanalytic psychotherapy. Research studies have supported an association between personal epistemology and counseling preferences (Neimeyer & Morton, 1997; Neimeyer et al., 1993), therapist’s personal style (Saferstein, 2007), theoretical orientation (Arthur, 2000, 2006; Neimeyer et al., 1993), and specific therapeutic interventions (Granvold, 1996; Saferstein, 2007). In the family therapy field, Bateson has been credited with the introduction of the term ‘‘epistemology’’ (e.g., Keeney, 1982). Bateson described epistemology as a personal theory regarding the nature of reality (Bateson, 1951). He was an early advocate of the adoption of a ‘‘cybernetic’’ epistemology based on pattern and communication over the more conventional ‘‘lineal’’ epistemology of the physical sciences (Bateson, 1971). In the late 1970s and early 1980s, several writers emphasized the relevance of epistemological issues to the developing field of family therapy (e.g., Keeney, 1979; Rabkin, 1977). These earlier publications began a debate in the field addressing the utility of an ‘‘aesthetic’’ (metaphoric) emphasis in balancing the overly pragmatic (rational ⁄ empirical) emphasis in family therapy (Strano, 1990). In the last two decades, the debate in the field has been focused on modern (empiricistrationalist) versus postmodern (metaphorist) approaches, and the dominant stance has been ‘‘either ⁄ or’’ in searching for the ‘‘right’’ epistemology. In the next part of this article we describe a possible integration of these two competing philosophies in order to promote a complementary paramodern position (Larner, 2004). INTEGRATION OF TWO PHILOSOPHIES The characteristics of evidence-based therapists (rational-empiricists) and postmodern therapists (metaphorists) are different because of the epistemology informing their practice. EBP therapists tend to implement empirical treatments as the answer to cure clients’ problems. Prior treatment research ‘‘proves’’ the assumption. Although other sources of information may be considered, the EBP clinician tends to privilege the empirically validated practice of choice. The EBP, therefore, may ‘‘trump’’ other sources of relevant client information. The postmodern therapist, in contrast, considers all relevant sources of client information as equally valid. To that end, clients’ perceptions of their problems—often narrated as stories—hold as much weight as any research study. The question then is: ‘‘Can a postmodern therapist engage in evidence-based practice?’’ We believe that a postmodern therapist can utilize an evidence-based practice, but not to the exclusion or minimization of client input. It is the stance of the postmodern therapist that allows for such inclusion, integration, and adaptability. April 2010 JOURNAL OF MARITAL AND FAMILY THERAPY 189 Ideas should be judged not by the scientific method alone but by their perceived usefulness in dealing with life and with the constraints that block growth and development (Pocock, 1995). A postmodern therapist, therefore, will view feedback from clients themselves as key evidence and use client stories to serve the therapeutic process. Thus, this stance allows for shared decision making between client and clinician which is congruent with a postmodern clinician’s epistemology and way of intervening in clients’ lives. Clients value clinician expertise, but want to participate more in the decision-making process of their care (Laugharne, 2004). Consequently, postmodern therapists will practice from a ‘‘democratic framework’’ and include a degree of self-governance on the part of clients that emphasizes the importance of the therapist–client relationship (Laugharne & Laugharne, 2002). Postmodern therapists, therefore, who implement an EBP must know the assumptions and values of the treatment(s) offered, must include clients in the decision-making process, must temper the use of diagnostic categories in favor of treatments emphasizing individual uniqueness, and must account for client choice and demands (Laugharne & Laugharne, 2002). An example of a postmodern framework that illustrates this trend toward more client choice is the current evidence-based, client-choice medical model that includes evidence outside of science (Ford et al., 2003). Ford et al. (2003) suggested several key components for successful evidence-based, client-choice practice; these ideas have been adapted for the field of MFT: (a) Clinicians should have access to quality, accurate empirical evidence and appropriately ‘‘fit’’ the evidence to the client; (b) Clinicians should have the ability to interpret complex information to clients and consult others when they are lacking in knowledge; (c) Clinicians should explore client preferences for information and involvement; (d) Clinicians should disclose the possible benefit and harm of the chosen EBP; (e) The client-clinician relationship should be characterized by mutual trust, honesty, and respect; and (f) Both client and clinician should agree on the EBP utilized. From a research perspective, a shared decision-making model should also engage clients in research agendas; for example, the public—who often funds the research—should have a voice in its practice (Faulkner & Thomas, 2002). It would be appropriate for the postmodern therapist to ask, ‘‘To what extent, if any, do the progenitors of the EBP treatment that I am choosing to implement allow clients to influence the research process?’’ According to Faulkner and Thomas (2002), such user involvement will help to ensure that research agendas are relevant to clients, and encourage them to influence which forms of mental health care to investigate and which treatment outcomes matter. This will shift research methodologies from mere symptom relief to more consideration of the daily aspects of clients’ lives that impact successful treatment. Action-oriented research methods like Participatory Action Research, for example, could help to make this shift possible (Small, 1995; Susman & Evered, 1978). Faulkner and Thomas (2002) also suggest that user-led research provides for alternative explanatory frameworks by attending to what marginalized groups say about their experience. This can help to balance the power differential where professional researchers might advance their careers at the expense of the subjects who are often not compensated for their participation. In contrast, by focusing on the research process aimed at including the participants, clients are informed about the research results and subsequent actions taken. Such a model reflects the liberating and emancipating attitude of the postmodern therapist (metaphorist). The future postmodern clinician, therefore, will be mature, experienced, and able to integrate a postmodern epistemology (metaphorist) with evidence-based practices (rational-empiricist), and possess an awareness of the pros and cons of both approaches to make sound clinical judgments (Roberts, 2000). Translational Research and Practice-Based Evidence In negotiating the tension between being a postmodern, modern, or integrative communitybased therapist and adapting evidence-based practice with a more flexible epistemological lens, there are additional helpful applications of these ideas: practice-based evidence (PBE) and translational research. PBE (Horn & Gassaway, 2007) refers to a bottom-up approach of gathering data that relies on the input from practicing clinicians to inform treatment. PBE represents a cyclical approach where clinical care is evaluated regularly and integrated into what 190 JOURNAL OF MARITAL AND FAMILY THERAPY April 2010 clinicians do with their clients. ‘‘Research would have to expand to include a broader conception of acceptable methodologies, and the practitioner would be encouraged to function as a local scientist’’ (Stricker, 1992, p. 543). According to Kazdin (2008), ‘‘there is evidence for specific interventions in the highly controlled contexts in which they are studied but not yet much empirical support for evidence-based practice in the clinical contexts where decisions are made by individual clinicians’’ (p. 147). We believe these differences can be bridged by using PBE and by conducting more translational research. Translational research—currently a major funding priority of the National Institute of Health (NIH)—has been defined by NIH as research that seeks to translate advances from the bench into clinical applications, in particular the dissemination of new ideas from research into clinical applications (e.g., Ginexi & Hilton, 2006). Translational research evolved as a result of the realization that ‘‘clients were more likely to get better when treated in a research study than when they were in the community setting where they are most likely to be seen’’ (McCollum & Stith, 2002, p. 5). Thus, the main goal of translational research is to take the new knowledge developed in academic and research labs and find viable ways to incorporate them into everyday clinical practice, with the ultimate objective of improving the quality of life for our clients (e.g., Bakken & Jones, 2006). On the other side, community-based clinicians, including MFTs, are often reluctant to adopt EBPs for their everyday practice because they feel that the models developed in the lab are not directly applicable to their community settings with diverse client populations and are not always congruent with their therapeutic styles (e.g., Kazdin, 2008; Patterson, Miller, Carnes, & Wilson, 2004). Thus, research often gets dismissed as irrelevant, incomprehensible, or both (Sprenkle, 2003). Clinicians have also reported feeling overburdened, being constrained by time and heavy caseloads, having few incentives or opportunities to learn evidence-based practices, and not having an organizational structure or reimbursement system in place to practice new treatments in their practice settings (Liddle et al., 2006; Sandberg, Johnson, Robila, & Miller, 2002). Without stake holders from the insurance companies, higher administration, clinicians, and clients, it is very difficult to implement a new practice unless these structural barriers are overcome. ‘‘From the provider perspective, contextual factors such as the political atmosphere, public awareness, and financing concerns can each pose barriers to implementing innovative evidence-based practices’’ (Ginexi & Hilton, 2006, p. 335). A viable way to bridge the gap between evidence-based practice and PBE would be to conduct more translational research, with the epistemological stance of the community-based therapists accounted for in transporting EBPs, in more diverse community settings. This can be accomplished by partnering with community agencies and building collaborations between professionals who identify themselves as clinical researchers and those who identify themselves as clinicians (Kazdin, 2008). Gathering feedback from clinicians and being flexible in adapting EBPs so they better fit a particular context and therapeutic style is a viable way to facilitate change in both clinical researchers and EBPs and clinicians from various epistemological styles (e.g., postmodern, modern, integrative). A feasible way to adapt models for community settings, therefore, is to clarify the clinicians’ and clinical researchers’ epistemological stances up front. Liddle et al. (2006), for example, provided an illustrative example of adapting an evidencebased model (Multidimensional Family Therapy) so it could be transported to an adolescent day drug treatment setting. ‘‘The transportation process was isomorphic with the implementation of therapy itself, both involving flexibility of the model to fit the particulars of the case and setting, and a collaborative team approach . . . reading feedback about staff members’ ability to implement the new interventions was critical and trainers adapted training and supervision according to staff feedback’’ (Liddle et al., 2006, p. 104). In this way, PBE and translational research could augment the current practice delivered in community settings, so they are adapted from more academic, lab-trained clinicians to community-based therapists working in non-university settings with a diverse client population. This would encourage more flexibility in transporting EBPs which tend to be developed for modern clinicians, so community-based therapists, both modern and postmodern, can feel comfortable with the implementation of EBPs and their epistemological stance as clinicians. April 2010 JOURNAL OF MARITAL AND FAMILY THERAPY 191 DISCUSSION AND CONCLUSION Pragmatically, a modernist (rational-empiricist) views the clinician as an expert who possesses empirically sourced ‘‘truth’’ or knowledge needed to cure clients. In contrast, a postmodernist (metaphorist) critically questions the motives of those with claims of objective truth, and views the client as the expert, whose personal narrative is an equally valid source of information. Instead of highlighting the tension between modernism and postmodernism, however, others hold a more complementary perspective of the two philosophies, for example, the paramodern approach noted above (Larner, 2004). Bracken (2003) similarly views the evolution of postmodernism not as a rejection of modernism, but as a contributing continuation of the original meaning of Enlightenment. Postmodernism is not a rejection of Enlightenment values and ideals but seeks instead to understand the era’s limitations and recognizes its ‘‘down side.’’ Regarding practice, then, postmodern mental health tends to shift away from the isolation and distinction of professional disciplines toward practices that embrace multiple perspectives and cut across traditional, professional boundaries (Bracken, 2003). Similarly, Pocock (1995) suggested that modern and postmodern positions on reality and knowledge ought not to create a theoretical division but can be harnessed to have a restraining effect on each other. Postmodernism can curb the modern mistake of believing in (unbiased) objective knowledge and attempting to discover (unbiased) absolute truth; modernism can restrain the postmodern oversight of addressing only surface appearances and abolishing external reality as a constraint on stories. Roberts (2000) posited that both evidence-based approaches grounded in modern science and narrative-based approaches grounded in postmodernism are necessary and complementary companions, not competitors. A paramodern stance additionally helps, because it represents a complementary solution where both modern and postmodern approaches are situated together as a necessary and complimentary tension (Larner, 2004). ‘‘This art of balancing clinical experience, relational know-how and science or research helps to prevent evidence-based practice from becoming a strait jacket for the field’’ (Larner, 2004, p. 33). Translational research and PBE, with the epistemological stance of the community-based therapists accounted for in transporting EBPs, could augment the current practice delivered in community settings. In this way, EBPs could be adapted from more academic, lab-trained clinicians to community-based therapists working in non-university settings, with a diverse client population. This would encourage more flexibility in transporting EBPs which tend to be developed for modern clinicians, so postmodern clinicians and community-based therapists can feel comfortable with the implementation of EBPs and their epistemological stance as clinicians. Postmodern therapists and community-based clinicians, therefore, can be encouraged to regard scientific discovery as a discourse among the scientific community and to consider evidence-based practices and client experiences both as critical and equally valid sources of knowledge (Laugharne, 2004; Laugharne & Laugharne, 2002). In this way, we believe postmodern therapists and community-based therapists can practice evidence-based therapy that is based on modern scientific assumptions. Finally, it is also important to harness these ideas in training the next generation of MFT clinicians, supervisors, academics, and researchers. Recommendations for Clinical Training of MFTs Training in family therapy programs can be adapted to affect a more complementary approach between modern and postmodern philosophies. A possible method for integrating modern and postmodern perspectives and evidence-based practices is offered by Simon (2006), who proposed that ‘‘a therapist becomes maximally effective when he or she uses a model of proven efficacy whose underlying worldview closely matches his or her own’’ (p. 343). Placing the self of the therapist at the center of the modern-postmodern divide indicates that the therapist’s stance—a philosophical and therapeutic position and attitude most comfortable and ‘‘fit’’ to the therapist—is what permits a postmodern clinician to effectively implement an evidence-based practice. 192 JOURNAL OF MARITAL AND FAMILY THERAPY April 2010 To achieve this goal, MFT trainees would need to develop a broad knowledge base of the major models of family therapy, modern, postmodern, and evidence-based practices, which should include the epistemological underpinnings of each approach as well as define their own epistemological stances. Training programs should promote a shift away from encouraging a ‘‘one-model clinician’’ where therapists are trained to become ‘‘experts’’ in a particular model that is usually the one mastered by their supervisors. Instead, MFT programs should strive to produce clinicians who are comfortable evaluating relevant evidence pertaining to their cases, and choosing the most appropriate interventions with consideration of client factors as well as their own preference, style, and epistemology. The question is how can this process become a regular part of clinical work? While most MFT programs have a solid foundation of clinical training, these programs do not often produce scientist-practitioners (Sprenkle, 2003). Studies show that simply teaching research skills in MFT programs does not affect the extent to which therapists use research in their clinical decision making (Johnson, Sandberg, & Miller, 1999; Williams, Patterson, & Miller, 2006), likely because therapists do not perceive these two domains as necessarily intertwined. In order to create a change in this approach to clinical work, MFT programs should emphasize that therapy is both art and science (Hodgson, Johnson, Ketring, Wampler, & Lamson, 2005), and that research is an integral part of good therapy. This can be done by incorporating research into the clinical work, instead of teaching it as a stand-alone subject. Additionally, MFT trainees would benefit most from supervision and coursework starting from the beginning of their training, integrating evidence-based research and PBE in a cyclical feedback loop (Barkham & Mellor-Clark, 2003), thus assisting them in becoming local scientists in their community agencies. Several useful models for the integration of EBP and practice in MFT programs have been offered (e.g., Gouze & Wendel, 2008; Patterson et al., 2004; Williams et al., 2006). For example, Gouze and Wendel (2008) proposed nine clinically relevant modules for assessment and intervention and a process for evaluating best evidence literature in choosing and integrating interventions that comprehensively address the family presentation. They further suggested an ongoing process of reevaluation of change processes and adaptation of the chosen interventions accordingly. In this way, clinicians develop a ‘‘working mental health treatment manual’’ (p. 269) that is not model specific, but rather an integrative evidence-based process. Similarly, Patterson et al. (2004) and Williams et al. (2006) proposed a model to help clinicians become better consumers of research. Current models of EBP integration, however, do not emphasize therapists’ variables in choosing interventions (such as style and epistemology), which we believe is essential for successful integration. Clinical supervision has an important role in promoting the integration of EBPs and clinical practice and, therefore, could be reworked to accomplish this goal. Supervision, then, entails incorporating a cyclical process of evaluation and adaptation. Specifically, interns could review their cases in supervision, conceptualize each case from several different models, including modern and postmodern approaches, and come up with specific areas for intervention. The next step is to conduct a literature search, where the model proposed by Patterson et al. (2004) and Williams et al. (2006) can be useful. The authors proposed several steps in conducting the search, including ways to select and access articles, how to evaluate the quality of the studies found, and methods for synthesizing the information gathered in an applicable way. (For a practical tool to help clinicians ask relevant questions about studies and their applicability to their clients, see table 1 ‘‘Critical Review Form for Therapy’’ in Patterson et al., 2004, p. 186.) After searching for relevant EBP literature, the trainees can then decide which interventions are clinically appropriate based on their epistemological styles, preferences, research evidence, and salient client and contextual variables. The interns will then evaluate the implementation of the chosen model in their community practice setting and provide feedback on the effectiveness of the model to the specific circumstances of the case, and the way it will need to be modified to fit the specific client. After modifying the intervention, the interns can then implement the modified intervention in the next session and again bring feedback to their supervisors. This process will repeat itself weekly, until the end of therapy with the specific client. April 2010 JOURNAL OF MARITAL AND FAMILY THERAPY 193 This ongoing cyclical process of evaluation, implementation, feedback, and modification will enable therapists to obtain information about client change processes during therapy and get feedback on the effectiveness of their interventions during therapy (proximal outcomes) rather than just final outcomes at the end of treatment (Sprenkle, 2003). In this way, top-down and bottom-up processes of evaluation and implementation can be integrated in creating a ‘‘bilingual’’ clinician who has the ability to go back and forth between these two domains (evidence-based research and PBE) and tailor an intervention that is empirically supported while at the same time takes into account the specific circumstances and context of each client, as well as the therapist’s epistemology and style. Supervisors in MFT training programs have a major role in creating the shift in the field by training the next generation of clinicians. Many supervisors are trained in the one-modelexpert approach, which is usually not an evidence-based model (Sprenkle, 2003). As the best role models for new therapists are those who practice what they teach, supervisors will have to become well versed in EBP practices and postmodern approaches and comfortable with the process of integration and tailoring. MFT programs can additionally support supervisors by providing EBP and postmodern trainings and workshops and by providing supervision-ofsupervision in the implementation of the new supervisory model. To facilitate flexibility in thinking, it can be useful to team two supervisors with different epistemological stances and practice preferences for the same supervision group to allow for a broader view of therapy and a focus on integration of seemingly contradicting philosophies. Considering that teaming two supervisors is not always feasible and can be costly, we see this as a temporary solution until supervisors get the training they need to become well versed in most modern, postmodern, and evidence-based approaches. Conducting supervision in such a way will teach future therapists that there is more than one ‘‘right’’ way to conduct therapy by utilizing different approaches, models, and interventions to tailor the most effective treatments. REFERENCES Alexander, J. J., Robbins, M. S., & Sexton, T. L. (2000). Family-based interventions with older, at-risk youth: From promise to proof to practice. Journal of Primary Prevention, 42, 185–205. American Association for Marriage and Family Therapy, Clinical Competencies Task Force. (2003). Proposed competencies. Washington, DC: Author. Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy. New York: Basic Books. Arthur, A. R. (2000). The personality and cognitive–epistemological traits of cognitive-behavioral and psychoanalytic psychotherapies. British Journal of Medical Psychology, 73, 243–257. Arthur, A. R. (2006). Who do you think you are? A study of how psychotherapists’ styles affect orientation choice and practice. In D. Loewenthal & D. Winter (Eds.), What is psychotherapeutic research? (pp. 295– 313). London: Karnac Books. Bakken, S., & Jones, D. A. (2006). Editorial: Contributions to translational research for quality health outcomes. Nursing Research, 55, S1–S2. Barkham, M., & Mellor-Clark, J. (2003). Bridging evidence-based practice and practice-based evidence: Developing a rigorous and relevant knowledge for psychological therapies. Clinical Psychology and Psychotherapy, 10, 319–327. Bateson, G. (1951). Psychiatric thinking: An epistemological approach. In J. Ruesch & G. Bateson (Eds.), Communication: The social matrix of psychiatry (pp. 228–256). New York: Wiley. Bateson, G. (1971). The cybernetics of ‘‘self’’: A theory of alcoholism. Psychiatry: Journal for the Study of Interpersonal Processes, 34, 1–18. Blow, A. J., & Sprenkle, D. H. (2001). Common factors across theories of marriage and family therapy: A modified Delphi study. Journal of Marital and Family Therapy, 27, 385–401. Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298–317. Blumer, H. (1969). Symbolic interactionism: Perspective and method. Englewood Cliffs, NJ: Prentice Hall. Bowen, M. (1978). Family therapy in clinical practice. New York: Aronson. Bracken, P. (2003). Postmodernism and psychiatry. Current Opinion in Psychiatry, 16, 673–677. De Simone, J. (2006). Reductionist inference-based medicine, i.e. EBM. Journal of Evaluation in Clinical Practice, 12, 445–449. 194 JOURNAL OF MARITAL AND FAMILY THERAPY April 2010 Epstein, N., Schlesinger, S. E., & Dryden, W. (Eds.). (1988). Cognitive-behavioral therapy with families. New York: Brunner ⁄ Mazel. Faulkner, A., & Thomas, P. (2002). User-led research and evidence-based medicine. British Journal of Psychiatry, 180, 1–3. Ford, S., Schofield, T., & Hope, T. (2003). What are the ingredients for successful evidence-based client choice consultation? A qualitative study. Social Science & Medicine, 56, 589–602. Ginexi, E. M., & Hilton, T. F. (2006). What’s next for translational research? Evaluation and the Health Professions, 29, 334–337. Gouze, K. R., & Wendel, R. (2008). Integrative model-based family therapy: Applications and training. Journal of Marital and Family Therapy, 34, 269–286. Granvold, D. K. (1996). Constructivist psychotherapy. Families in Society: The Journal of Contemporary Human Services, 77, 345–359. Henggeler, S. W., Pickrel, S. G., & Brondino, M. J. (1999). Multisystemic treatment of substance abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability. Mental Health Services Research, 1, 171–184. Hodgson, J. L., Johnson, L. N., Ketring, S. A., Wampler, R. S., & Lamson, A. L. (2005). Integrating research and clinical training in marriage and family therapy training programs. Journal of Marital and Family Therapy, 31, 75–88. Homans, G. C. (1961). Social behavior: Its elementary form. New York: Harcourt, Brace & World. Horn, S., & Gassaway, J. (2007). Practice-based evidence study design for comparative effectiveness research. Medical Care, 45, 50–57. Johnson, L. N., Sandberg, J. G., & Miller, R. B. (1999). Research practices of marriage and family therapists. The American Journal of Family Therapy, 27, 239–249. Johnson, S., & Greenberg, L. (1988). Emotionally focused therapy for couples. New York: Guilford Press. Johnson, S. M., & Lebow, J. (2000). The ‘‘coming of age’’ of couple therapy: A decade review. Journal of Marital and Family Therapy, 23, 175–183. Johnson, S., & Talitman, E. (1997). Predictors of success in emotionally-focused marital therapy. Journal of Marital and Family Therapy, 23, 135–152. Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve client care. American Psychologist, 62, 146–159. Keeney, B. (1979). Ecosystemic epistemology: An alternative paradigm for diagnosis. Family Process, 18, 117– 129. Keeney, B. P. (1982). What is an epistemology of family therapy? Family Process, 21, 153–168. Kuhn, T. (1962). The structure of scientific revolutions. Chicago: University of Chicago Press. Larner, G. (2004). Family therapy and the politics of evidence. Journal of Family Therapy, 26, 17–39. Laugharne, R. (2004). Psychiatry in the future. Psychiatric Bulletin, 28, 317–318. Laugharne, R., & Laugharne, J. (2002). Psychiatry, postmodernism and post normal science. Journal of the Royal Society of Medicine, 95, 207–210. Liddle, H. A. (1991). Empirical values and the culture of family therapy. Journal of Marital and Family Therapy, 17, 327–348. Liddle, H. A. (1999). Theory development in a family-based therapy for adolescent drug abuse. Journal of Clinical Child Psychology, 28, 521–532. Liddle, H. A., Rowe, C. L., Gonzalez, A., Henderson, C. E., Dakof, G. A., & Greenbaum, P. E. (2006). An empirically supported and culturally specific engagement and intervention strategy for African American adolescent males. American Journal of Orthopsychiatry, 75, 215–225. Lipchik, E. (2002). Beyond technique in solution-focused therapy. New York: Guilford Press. Lyddon, W. J. (1989). Personal epistemology and preference for counseling. Journal of Counseling Psychology, 36, 423–429. Lyddon, W. J. (1990). First- and second-order change: Implications for rationalist and constructivist cognitive therapies. Journal of Counseling and Development, 69, 122–127. Mahoney, M. J. (1991). Human change processes. New York: Basic Books. McCollum, E. E., & Stith, S. M. (2002). Leaving the ivory tower: An introduction to the special section on doing marriage and family therapy research in community agencies. Journal of Marital and Family Therapy, 28, 5–7. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Murray, M. (1997). A narrative approach to health psychology. Journal of Health Psychology, 2, 9–20. Neimeyer, R. A. (1993). Constructivism and the cognitive psychotherapies: Some conceptual and strategic contrasts. Journal of Cognitive Psychotherapy, 7, 159–171. Neimeyer, R. A., & Morton, R. J. (1997). Personal epistemologies and preferences for rationalist versus constructivist psychotherapies. Journal of Constructivist Psychology, 10(2), 109–123. April 2010 JOURNAL OF MARITAL AND FAMILY THERAPY 195 Neimeyer, R. A., Prichard, S., Lyddon, W. J., & Sherrard, P. A. D. (1993). The role of epistemic style in counseling preference and orientation. Journal of Counseling and Development, 71, 515–523. Nelson, T. S., Chenail, R. J., Alexander, J. F., Crane, D. R., Johnson, S. M., & Schwallie, L. (2007). The development of core competencies for the practice of marriage and family therapy. Journal of Marital and Family Therapy, 33, 417–438. Patterson, J. E., Miller, R. B., Carnes, S., & Wilson, S. (2004). Evidenced-based practice for marriage and family therapists. Journal of Marital and Family Therapy, 30, 183–195. Pocock, D. (1995). Searching for a better story: Harnessing modern and postmodern positions in family therapy. Journal of Family Therapy, 17, 149–173. Rabkin, R. (1977). Strategic psychotherapy. New York: Basic Books. Robbins, M., Alexander, J., & Turner, C. (2000). Disrupting defensive family interactions in family therapy with delinquent adolescents. Journal of Family Psychology, 14, 688–701. Roberts, G. (2000). Narrative and severe mental illness: What place do stories have in an evidence-based world? Advances in Psychiatric Treatment, 6, 432–441. Royce, J. R. (1964). The encapsulated man: An interdisciplinary essay on the search for meaning. Princeton, NJ: Van Nostrand. Royce, J. R., & Moss, L. P. (1980). Psycho-epistemological profile manual. Edmonton, Canada: University of Alberta Press. Royce, J. R., & Powell, A. (1983). Theory of personality and personal differences: Factors, systems, processes. Englewood Cliffs, NJ: Prentice Hall. Saferstein, J. A. (2007). The relationship between therapists’ epistemology and their therapy style, working alliance, and the use of specific interventions. Dissertation Abstracts International: Section B: The Sciences and Engineering, 68(1-B), 634–707. Sandberg, J. G., Johnson, L. N., Robila, M., & Miller, R. B. (2002). Clinician identified barriers to clinical research. Journal of Marital and Family Therapy, 28, 61–67. Schacht, T. E., & Black, D. A. (1985). Epistemological commitments of behavioral and psychoanalytic therapists. Professional Psychology: Research and Practice, 16, 316–323. Sexton, T., Ridley, C., & Kleiner, A. (2004). Beyond common factors: Multilevel-process models of therapeutic change in marriage and family therapy. Journal of Marital and Family Therapy, 30, 131–149. Simon, G. (2006). The heart of the matter: A proposal for placing the self of the therapist at the center of family therapy research and training. Family Process, 45, 331–344. Small, S. (1995). Action-oriented research: Models and methods. Journal of Marriage and the Family, 57, 941– 955. Sprenkle, D. H. (2003). Effectiveness research in marriage and family therapy: Introduction. Journal of Marital and Family Therapy, 29, 85–96. Strano, J. D. (1990). Epistemic style and therapist theoretical orientation and background: A national survey of family therapy professionals. Dissertation Abstracts International, 50(11-B), 5015. Stricker, G. (1992). The relationship of research to clinical practice. American Psychologist, 47, 543–549. Susman, G., & Evered, R. (1978). An assessment of the scientific merits of action research. Administrative Science Quarterly, 23, 582–603. Troost, K. M., & Filsinger, E. (1993). Emerging biosocial perspectives on the family. In P. G. Boss, W. J. Doherty, R. LaRossa, W. R. Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family theories and methods (pp. 677–710). New York: Plenum Press. Vincent, N., & LeBow, M. (1995). Treatment preferences and acceptability: Epistemology and locus of control. Journal of Constructivist Psychology, 8, 81–96. White, J., & Klein, D. (2008). Family theories (3rd ed.). Thousand Oaks, CA: Sage. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. Williams, L. M., Patterson, J. E., & Miller, R. B. (2006). Panning for gold: A clinician’s guide to using research. Journal of Marital and Family Therapy, 32, 17–32. Worrall, J. (2003). Normal science and dogmatism, paradigms and progress: Kuhn ‘versus’ Popper and Lakatos. In T. Nichols (Ed.), Thomas Kuhn. (pp. 65–100). Cambridge: Cambridge University Press. 196 JOURNAL OF MARITAL AND FAMILY THERAPY April 2010