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
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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
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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
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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
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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.
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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
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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.
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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.
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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.
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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.
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