USE OF STANDARDIZED ASSESSMENT INSTRUMENTS IN COUPLE THERAPY: THE ROLE OF ATTITUDES AND PROFESSIONAL FACTORS
Lavee, Yoav
The study examined therapeutic approach, professional affiliation, training, seniority, and work setting as predictors of attitudes toward standardized instruments and their use in couple therapy. Data were gathered from 163 certified marriage and family therapists in Israel. Results showed that 27.6% of marital therapists used standardized instruments for assessment. More positive attitudes toward standardized instruments were associated with the extent of training in their use and with a structural-strategic approach. Logistic regression analysis indicated that positive attitudes, training, and work setting best predict the application of standardized assessment instruments. Reasons for the relative lack of use of standardized assessment instruments are discussed. It is recommended that more training in assessment instruments be included in marriage and family therapy training.
During the last two decades increasing importance has been attached to valid and reliable assessment in family and couple therapy. In parallel, there has been significant growth in the development of assessment tools for this purpose. A large body of literature has been devoted to reviewing the quantitative and qualitative assessment tools used in couple and family therapy (Fredman & Sherman, 1987; Grotevant & Carlson, 1989; Jacob & Tennenbaum, 1988; Jordan & Franklin, 2003; Sperry, 2004; Touliatos, Perlmutter, & Straus, 1990) and their effectiveness in clinical practice (Bagarozzi, 1989; Bradbury, 1995; Duffy & Chenail, 2004; Floyd, Weinand, & Cimmarusti, 1989). Despite evidence of the utility of such instruments in therapy, clinicians tend to rely on their impressions, intuitions, and data they collect in interviews, rather than on tools whose validity and reliability has been proven by research (Boughner, Hayes, Bubenzer, & West, 1994; Bray, 1995; Fraenkel, 1997; Reichertz & Frankel, 1993).
This study focuses on standardized quantitative assessment instruments. It extends previous research on the use of standardized assessment tools in clinical practice by examining (a) the use of such instruments for couple assessment in therapy, (b) therapist attitudes toward using such measures, and (c) factors that predict therapist attitudes toward standardized measures in couple assessment and their use of it.
COUPLE ASSESSMENT IN COUPLE THERAPY
Clinical assessment is an essential part of any treatment, both physical and mental. In couple therapy, the assessment provides information about the couple’s problems and strengths, enables an evaluation of the individual, interpersonal, and environmental factors that may exacerbate problems or hinder the couple’s recuperation, and helps to identify internal and external forces that may affect intervention outcomes (Floyd, Haynes, & Kelly, 1997). The assessment enables the therapist to establish therapeutic goals and to plan modes of intervention.
Skills in clinical assessment and diagnosis are considered to be among the core competencies of marriage and family therapists (MFTs; American Association for Marriage and Family Therapy, 2004). The assessment skills refer to the comprehension of individual, couple, and family assessment instruments, including their strengths and limitations, their reliability and validity, and their relevance to therapeutic decision making, as well as the ability to administer the instruments and interpret their results.
Several assessment methods are used in couple and family therapy, including interviews, qualitative assessment methods, behavioral observations, clinical rating scales, and self-report instruments. The various methods may differ in the types of data they use and in the ways in which the data are collected. They may also be characterized by the extent to which the data collected are subjective (based on the therapist’s or the clients’ perception of the relationship) or objective (based on observable data), and the degree to which it represents an internal or external view of the relationship (Cromwell, Olson, & Fournier, 1976; Deacon & Piercy, 2001; Olson & Cromwell, 1975). No single method provides a complete picture; a more comprehensive assessment of the relationship may be obtained by a multidimensional assessment that involves each partner’s perception together with the therapist’s view (Bray, 1995; Cromwell et al., 1976; Cromwell & Peterson, 1983; Olson, 2000).
Standardized assessment instruments are believed to provide efficient, valid, and reliable measures of various aspects of the couple relationship, which can serve as an adjunct to the therapist’s subjective judgment. Existing instruments include personality assessment tools developed for the assessment of individuals but also used in relationship assessment, instruments that were developed specifically for couple assessment, and family assessment instruments used for couple assessment or adapted for this purpose.
Personality Assessment Instruments
Personality assessment instruments were not used in couple therapy until the late 1980s, when therapeutic and assessment approaches integrating intrapersonal and interpersonal-systemic components were introduced under the assumption that personality assessment tools may be useful for understanding couple processes. Use of these instruments still encounters some objection in the field of family therapy (Bagarozzi, 1989; Nurse, 1999), but research on family therapists’ use of standardized assessment instruments (Boughner et al., 1994) has shown that clinicians are more likely to use personality measures than instruments developed specifically to assess the marital system.
Couple Assessment Tools
Couple assessment tools have been developed predominantly as research instruments to assess: areas of consensus and conflict; the level of relationship satisfaction, emotional expression, and communication; marriage attitudes and beliefs; sexuality; parenting issues; commitment; trust; and other facets of the relationship (Floyd et al., 1997; Jacob & Tennenbaum, 1988; Sabatelli, 1988). Such instruments, primarily self-report questionnaires, may be used in clinical practice to obtain the clients’ subjective perceptions of the relationship. They can provide the therapist, within a relatively short time, with information about similarities and differences in the partners’ attitudes, beliefs, and perceptions regarding various aspects of the relationship, allowing the therapist to evaluate the severity of relationship problems, to set therapeutic goals, and to assess improvement in couple functioning achieved in therapy. Self-report instruments may also allow the partners to express their feelings and perceptions more freely in situations where one or both partners are uncomfortable disclosing their perceptions to their spouse.
Several instruments originally developed to assess family relations were later adapted to assess couple relationships as well. Such instruments include, for example, the Circumplex Model of Family Systems (Olson, Russel, & Sprenkle, 1989; Olson, Sprenkle, & Russel, 1979) and its related self-report questionnaire and clinical rating scale (Olson, 2000; Olson & Killorin, 1985), and the McMaster Model of Family Functioning (Epstein, Bishop, & Baldwin, 1982), whose clinical rating scale has been found useful in assessing couple relationships (Thomas & Lewis, 1999).
RESEARCH ON THE USE OF STANDARDIZED ASSESSMENT INSTRUMENTS IN CLINICAL PRACTICE
The development of assessment instruments and their applications in clinical practice have received considerable attention in the scientific literature, but relatively little research has been conducted on MFTs’ attitudes and practices regarding the use of standardized instruments in practice. Several researchers (Bagarozzi, 1989; Bradbury, 1995; Floyd et al., 1989) have noted the scarcity of clinicians using such instruments. In a survey of family therapists, Boughener et al. (1994) found that only 33% reported using any standardized instrument for assessment purposes, and that no single test was used by more than 8% of therapists. Seventy percent of therapists believed that the use of standardized instruments was not important for their clinical work.
The relative indifference to standardized instruments by coouple therapists has been attributed to several factors: lack of theoretical agreement among different therapeutic approaches as to what aspects of the relationship need to be assessed (Bray, 1995; Grotevant & Carlson, 1989); discrepancies between research and clinical practice in assessment goals (Bray, 1995; Floyd et al., 1989; Pinsof & Wynne, 2000; Wilkinson, 1998); and difficulties in evaluating and applying research-based instruments for clinical purposes (Deacon & Piercy, 2001). In particular, instruments that were developed for research purposes often lack scoring instructions and guidelines for their clinical application. As a result, therapists may not know how to score them and how to interpret scores in relation to established norms.
The aims of this study were to examine the extent to which couple therapists use standardized instruments in assessing their clients’ marriages, to investigate therapists’ attitudes toward using such measures, and to identify the professional factors that predict their attitudes toward standardized measures in clinical practice and their use of these measures. We hypothesized that the application of standardized measures in couple assessment would be positively related to therapists’ attitudes toward the use of such instruments and to their training in their use. We also hypothesized that differences in the extent to which such instruments were used would be related to the therapists’ academic background, clinical orientation, and experience in family and couple therapy. More specifically, we hypothesized that couple therapists whose primary professional background is in clinical psychology would use standardized assessment tools more often than others (e.g., social workers and school counselors) because the use of diagnostic instruments is a central part of their professional training (Bagarozzi, 1989). In addition, we hypothesized that therapists whose clinical and theoretical orientation leads them to focus on observable behaviors (e.g., cognitive-behavioral, structural-strategic) would employ standardized instruments more often than those who focus on intrapersonal processes in the relationship (e.g., psychodynamic, object relations) because structured assessment is embedded in the former approaches (Christensen, Jacobson, & Babcock, 1995; Floyd et al., 1989), whereas the latter approaches advise against the use of measurements that result in a diagnosis. Finally, we hypothesized that younger, less experienced therapists would use standardized assessment measures more often than those who are more experienced because newly trained therapists tend to have a stronger need to rely on structured assessment and intervention techniques (Greenberg, 1983).
METHOD
Participants
Data were collected from 163 certified family therapists who were members of the Israeli Association of Marriage and Family Therapy (IAMFT). Family therapists certified by IAMFT must hold a master’s or doctoral degree in a helping profession (e.g., psychology, social work, school counseling) or a doctoral degree in an adequate medical specialty (e.g., psychiatry, family practice).1 In addition to their respective professional training, they must have graduate or postgraduate training in MFT and 3 years of practice under supervision (Lavee, 2003).
Initially, questionnaires were mailed to all 806 certified family therapists who were registered members of IAMFT in 2002. Of these, 20% returned completed questionnaires. As Table 1 shows, 84% of respondents were women, and the average age of the therapists was 52.6, with a mean of nearly 16 years of clinical experience. More than one-half the respondents were social workers, about 28% were psychologists, and the rest had a primary academic education in school counseling, family therapy, or other professional fields (e.g., psychiatry, art therapy, special education). More than one-half the respondents reported that their primary approach in couple therapy was psychodynamic, almost one-quarter reported it to be structural-strategic, and 10% reported it to be cognitive-behavioral. Other approaches listed, totaling a little more than 15%, included narrative, Adlerian, intergenerational, object relations, imago, gestalt, and existential couple therapy. Sixty percent reported that they worked in private practice or private family therapy clinics, and the rest were employed in public family therapy clinics or other public service agencies.
Instruments
The questionnaire included five measures designed to examine: (a) aspects of the couple relationship considered to be important in assessing couples in therapy; (b) the methods used in the assessment; (c) specific standardized instruments being used, if any; (d) the attitudes toward the use of standardized assessment tools; and (e) the extent of training in standardized instruments.
Relationship aspects in the assessment. Based on the literature and on existing assessment instruments (Bradbury, 1995; Floyd et al., 1997; Sabatelli, 1988), a list of 21 aspects of the relationship (e.g., communication, commitment, conflict areas, power relations, couple strengths) was developed. Respondents were asked to rate the importance of assessing each aspect on a scale ranging from 1 (not important at all) to 5 (very important). Space was provided for the respondents to list and rate additional relationship components not included in the list that they deemed important to assess.
Assessment methods in couple therapy. Respondents were given a list of assessment methods used in couple therapy (Bray, 1995; Grotevant & Carlson, 1989; Schumm, 1990; Touliatos et al., 1990), such as interviewing both partners jointly or separately, outside observation, clinical rating scales, and self-report questionnaires. They were then asked to check the methods they were using for assessing couples.
Use of standardized instruments. Respondents were given a list of commonly used instruments and were asked to specify the extent to which they used each one in assessing couples in therapy (frequently, infrequently, or not at all). The list of instruments was based on previous research (Boughner et al., 1994) and on a review of instruments used in couple therapy (Floyd et al., 1997). All instruments have been used in both research and clinical practice in Israel. Respondents were also asked to add to the list any other instruments they were using in clinical practice, including nonstandardized measures.
Attitudes toward the use of standardized instruments. Attitudes toward the use of standardized instruments in clinical assessment were measured by a 10-item scale developed for this study. The scale consists of items that represent positive attitudes (e.g., “Standardized instruments contribute to success in couple therapy;” “Standardized measures may help in testing clinical hypotheses”), and negative attitudes (e.g., “The use of standardized measures may hamper therapist-client interactions”). Items were constructed to reflect the debates in the professional literature concerning the pros and cons of the clinical use of standardized assessment (Bray, 1995; Bradbury, 1995; Floyd et al., 1989). Respondents were asked to check the degree of their agreement with each item on a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). A factor analysis showed that all items loaded on a single factor, with a Cronbach alpha reliability of .78.
Standardized assessment training. The extent of training in standardized assessment instruments received as part of the training in MFT was measured by a single item with scores ranging from 1 (not at all) to 5 (a great deal).
RESULTS
Attitudes Toward Using Standardized Assessment Instruments
Table 2 presents the frequencies of respondents who agreed and those who disagreed with each statement included in the attitudes scale. The data in Table 2 indicate that the majority of respondents have unfavorable attitudes toward the use of standardized tools in clinical assessment, with only 10% maintaining that assessment should be based on standardized measures. The majority (62.3%) of respondents considered the use of standardized assessment instruments to be appropriate only for evaluating specific components of the relationship. Nearly one-half reported that they would have used an instrument capable of measuring a meaningful component of the couple relationship had such an instrument been available. However, the respondents did not agree that standardized instruments are not an adequate method for couple assessment, and only 35% relegated such instruments to measuring trivial relationship components.
To explore factors that explain therapists’ attitudes toward the use of standardized instruments, we examined the role of training, primary professional affiliation, therapeutic approach, primary work setting, and years of experience in MFT. A small but statistically significant positive correlation was found between the extent of training in standardized assessment tools and positive attitudes (r = .15, p
Therapeutic approach was also found to explain attitudes toward using standardized assessment tools. An analysis of variance showed a statistically significant difference (F = 5.33, p
Assessment Methods and the Use of Standardized Instruments
To examine the use of standardized instruments, respondents were asked what they assess, how they assess it, and to what extent standardized instruments are used in assessment. Table 3 describes the relationship aspects that respondents rated as important or very important for assessment in couple therapy. As shown in the table, communication style was ranked highest, with more than 96% of respondents listing it as an essential relationship component, followed by commitment, trust, and relationship satisfaction. Other aspects considered to be important for assessment included conflict management and resolution, conflict areas, couple strengths, and emotional expression.
Regarding the methods used by therapists for assessing couple relationships, the findings indicate that 96% of respondents favored conjoint couple interviewing and that three out of four therapists also conducted separate interviews with each partner. Other methods used in the assessment process included observation, meeting other family members, assessment by therapy teams, and use of qualitative methods, such as drawings, sculpting, and cards.
Regarding the extent to which therapists use instrument in assessing couples, 27.6% of respondents reported using standardized assessment instruments. Sixteen percent reported using other assessment tools, such as intake forms and other nonstandardized instruments, and 56.4% did not use any assessment instruments at all.
Table 4 shows the standardized instruments most frequently used by respondents. As the data in Table 4 indicate, the most frequently used instrument by couple therapists in Israel is Enriching Relationship Issues, Communication and Happiness (ENRICH; Olson, Fournier, & Druckman, 1985). A little less than 10% use the Minnesota Multiphasic Personality Inventory (MMPI-2; Butcher, Graham, Williams, & Ben-Porath, 1990) and the Marital Satisfaction Inventory (MSI; Snyder, 1979), and 7% use the Family Adaptability and Cohesion Evaluation Scale (FACES-III; Olson, Portner, & Lavee, 1985). All other standardized instruments are used in clinical practice by a smaller number of therapists.
Predictors of Using Standardized Assessment
To examine the factors that predict the use of standardized instruments in clinical practice, we assessed the role of attitudes and professional variables, including primary professional affiliation, work setting, therapeutic approach, and seniority on frequency of use.
Attitudes were found to be a significant predictor of actual use of standardized assessment instruments. A univariate analysis of variance with a post hoc test revealed a significant difference (F = 18.54, p
The effects of professional variables on the use of standardized assessment tools were examined by comparing the frequencies of use among clinicians in different work settings and with different professional affiliations, therapeutic approaches, and levels of seniority (Table 5). The data show that school counselors tend to use standardized instruments more frequently than do social workers and psychologists. This finding is contrary to our expectation that psychologists would use standardized instruments more often, given that the use of diagnostic instruments is a central part of their professional training.
The data in Table 5 also show that 34% of therapists in private practice use standardized assessment instruments, significantly more often than those in public services (19.4%; χ^sup 2^ = 4.00, p
In the final analysis, a stepwise logistic regression was conducted to examine the factors that best predict the use of standardized assessment tools in couple therapy. In this multivariate analysis, we entered attitudes, training, professional affiliation, therapeutic approach, work setting, and seniority as possible predictors of the dependent variable: using or not using standardized instruments. The findings (Table 6) indicate that three variables predict therapists’ use of standardized assessment instruments: attitudes, training, and work setting. Therapists who hold positive attitudes towards standardized assessment are six times more likely to use them in clinical practice than are those who hold negative attitudes; therapists who were trained in standardized assessment are nearly five times more likely to use them than those who received no training; and therapists working in private practice are three times more likely to use standardized assessment tools than those working in public services.
DISCUSSION
This study extends the body of knowledge about the use of standardized assessment instruments in couple therapy and provides some explanations for the previously identified gap (Boughner et al., 1994) between the development of assessment instruments and their application in clinical practice. The findings confirm that such a discrepancy does indeed exist, with only about one in every four therapists making use of standardized instruments as part of the assessment process. An additional 16% of therapists reported using nonstandardized assessment methods, such as intake forms, self-report questionnaires, and rating scales, which were not validated in research. Given the return rate of 20% of the marital therapists who were contacted and assuming that those who do use standardized instruments were more likely than others to respond, we estimate that the extent of clinical use of standardized assessment instruments is actually lower than that found in this study.
Although the study was conducted among Israeli couple therapists only, we suggest that the findings and conclusions may also apply to those practicing in other Western countries. The similarities between our findings and those in a previous survey of family therapists in the US (Boughner et al., 1994) strengthen our confidence in the validity of the current study and its relevance to the practice of couple therapy elsewhere.
Our findings show that the majority of marital therapists do not use any kind of structured assessment method and depend primarily on clinical interviews. This finding corroborates previous findings that clinical interviews are the most frequent method used for assessment in couple therapy (Fraenkel, 1997; Miller et al., 1994; Wilkinson, 1998) and that clinicians tend to rely on their own judgment of couple relationships (Bray, 1995; Floyd et al., 1989; Fraenkel, 1997). As expected, we found that therapists working within cognitive-behavioral models are more likely to use standardized assessment tools, whereas psychodynamically oriented marital therapists are least likely to use such methods in couple assessment. In contrast to our expectation, psychologists use standardized instruments less frequently than those whose primary professional backgrounds are in educational counseling or social work. This finding may be explained by the large number (> 55%) of clinical psychologists in our sample who were trained in the psychodynamic approach to couple therapy. In addition, more than 90% of psychologists had not received any training in the use of standardized instruments in couple assessment.
Are Research-based Instruments Inadequate for Clinical Practice?
It might be argued that therapists tend not to use standardized tools because such measures do not answer the needs of therapists in clinical practice. Our findings suggest that the relative lack of use of standardized instruments is not a reflection of unavailability of adequate instruments for assessing the couple relationship. Indeed, various instruments are available for the assessment of major relationship components. For example, when asked about the relationship aspects that are most important in assessing couples in therapy, more than 96% of respondents cited the couple’s communication. Evidently, communication may be assessed by several relationship assessment tools, such as the Dyadic Adjustment Scale (Spanier, 1976), ENRICH (Oison et al., 1985), the MSI (Snyder, 1979), as well as by more specific tools, such as the Communication Skills Test (Floyd & Markman, 1984).
Likewise, other relationship aspects that were ranked high on the list of importance for couple assessment, such as commitment, trust, relationship satisfaction, and conflict management, can be assessed by existing standardized instruments, such as the Commitment Inventory (Stanley & Markman, 1992), the Trust Scale (Remple, Holmes, & Zenna, 1985), the MSI (Snyder, 1979), and the Inventory of Marital Conflicts (Olson & Ryder, 1970). Given that no single instrument provides a complete picture of the couple relationship, therapists may need to utilize several assessment tools in order to capture the complexity of couple functioning.
Negative Attitudes Predict Underutilization of Standardized Assessment Instruments
Another explanation for the relative lack of use of standardized assessment instruments lies with the negative attitudes of therapists toward this assessment modality. Consistent with previous studies (Boughner et al., 1994; Floyd et al., 1989), we found that nearly two-thirds of respondents did not believe that assessment in couple therapy should be based on standardized measures or that standardized assessment instruments can contribute to therapeutic outcomes. Indeed, attitudes had the largest effect on the likelihood that therapists would use standardized instruments.
Training Makes a Difference
The findings further suggest that both the attitudes toward assessment instruments and their utilization are affected by the extent to which therapists are familiar with such instruments. In this study, 80% of respondents received little or no related training in their preparation as MFTs. This finding supports those of Bray (1995) and Young and Long (1998), who reported on the lack of academic training in the use of standardized assessment tools and about the fact that assessment classes are the least popular in MFT programs. Adequate training in couple assessment methods enhances the appreciation of the usefulness and effectiveness of standardized assessment and increases the likelihood that such instruments are used in couple therapy. Such training is likely to expand marital therapists’ understanding of couple assessment instruments, develop the skills needed to administer and interpret their results, and eventually improve the quality of couple assessment and therapy.
NOTE
1 In addition, graduates of AAMFT-certified marriage and family therapy programs in the US may be certified by the IAMFT. There are no separate MFT graduate programs in Israel.
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Yoav Lavee
University of Haifa, Israel
Yitzhak Avisar
Family Therapy Clinic, Netanyia, Israel
Yoav Lavee, PhD, School of Social Work, University of Haifa; and Yitzhak Avisar, MA, Family Therapy Clinic, Netanyia, Isreal.
Correspondence concerning this article may be addressed to Yoav Lavee, PhD, School of Social Work, University of Haifa, Haifa 31905, Israel; E-mail: lavee@research.haifa.ac.il
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