The Relationship Between Marriage and Family Therapists and Complementary and Alternative Medicine Approaches: a Qualitative Study
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By Becvar, Dorothy S; Caldwell, Karen L; Winek, Jon L
In this article, we delineate the qualitative phase of a mixed- method research study focused on understanding the relationship between Clinical Members of the American Association for Marriage and Family Therapy (MFT) and complementary alternative medicine (CAM). Based on an analysis of the data derived from telephone interviews with 54 respondents, we describe four themes: definitional issues, depth of awareness of CAM, fit with MFT, and ethical considerations. Our discussion focuses on the findings of this phase, considerations from the quantitative phase, and reflections on the research study as a whole. While acknowledging the limitations of the study, we conclude that the growing awareness of and involvement with CAM approaches and practitioners among MFTs suggest a need for further education for both professionals and clients. We also note the importance of additional research support for the use of CAM practices.
INTRODUCTION
Complementary and alternative medicine (CAM) has been defined as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine" (National Center for Complementary and Alternative Medicine, 2002, p. 1). The idea for researching the relationship between marriage and family therapists (MFTs) and CAM emerged out of curiosity. All three of the researchers are MFTs working in academic settings, DB in a school of social work, and KC and JW in a department offering master's degree programs in counseling and MFT. Two of us (DB, KC) had been making recourse personally to a variety of CAM approaches for many years and have taught courses focused on increased understanding in this area. DB also previously had looked into the relationship between MFT and CAM at a theoretical level. In terms of our working relationships, DB and KC already had collaborated on another research project, as had KC and JW. And all three of us wanted to know more about what other MFTs might be thinking or doing with regard to CAM. We had a strong suspicion that increased awareness and usage of CAM by the general public was having an impact on their practices. We were interested in learning about the extent of their knowledge and/or exploration in this area. We wondered to what degree, if any, personal use might have influenced professional behavior. We felt that it was an appropriate time for further exploration.
As we thought about our research design, we opted for the added benefits to be derived from "integrating quantitative and qualitative methods in a single research study" (Sells, Smith, & Sprenkle, 1995, p. 199). We thus utilized a "mixed-method" approach or "the inclusion of a quantitative phase and a qualitative phase in an overall research study" [italics in original] (Johnson & Onwuegbuzie, 2004, p. 20). And our purpose was to gain an in-depth understanding of and depict the ways in which MFTs understand CAM as well as make sense of and describe their participation in this realm.
In the first phase of our research study we conducted a national survey of Clinical Members of the American Association for Marriage and Family Therapy (AAMFT). We then described and discussed the results of our quantitative analysis of the 424 responses to a paper- and-pencil questionnaire (Caldwell, Winek, & Becvar, this issue). The second phase of the survey, which was begun before the completion of the first phase, involved follow-up conversations with 54 of the respondents to the questionnaire who indicated their willingness to participate in a telephone interview. Our story about what we learned, based on both a qualitative analysis of the transcribed interviews and a consideration of these findings relative to the results of the quantitative study, is reported here. To better situate this study and our findings in the larger context, we begin with a review of the literature.
LITERATURE REVIEW
Consistent with the increasing use of CAM practices in the US since the early 1990s (Astin, 1998; Barnes, Powell-Griner, McFann, & Nahin, 2004; Eisenberg et al., 1993, 1998; Paramore, 1997; Rafferty, McGee, Miller, & Reyes, 2002), various health and mental health professionals have conducted surveys aimed at understanding the role that CAM practices play for practitioners in their respective fields. Among nurses in Canada as well as in the US, widespread, although not total, acceptance of CAM practices in general have been reported. Also recognized by this group is the need for both better professional preparation and more extensive efficacy research to support the inclusion and utilization of CAM practices (Brolinson, Price, Ditmyer, & Reis, 2001; Hessig, Arcand, & Frost, 2004; Joudrey & Gough, 2003; Joudrey, McKay, & Gough, 2004; Tracy et al., 2003). Similar themes emerged in surveys conducted with physicians and medical students (Barnard, Lewith, & Kemp, 1997; Boucher & Lenz, 1998; Chez, Jonas, & Crawford, 2001; Greiner, Murray, & Kallail, 2000; Levine, Weber-Levine, & Mayberry, 2003; Rooney, Fiocco, Hughes, & Halter, 2001; Sikand & Laken, 1998), as well as with pharmacists (Koh, Teo, & Ng, 2003), and with dieticians (Cashman, Burns, Otieno, & Fung, 2003; Lee, Georgiou, & Raab, 2000).
It appears from our review of the literature that much less attention has been given to the role of CAM and its use in the mental health arena. We found no evidence of surveys of counselors, MFTs, or social workers, although there were a few theoretical and/ or clinical articles related to the general topic of CAM in each field (cf., Becvar, Cook, & Pontius, 1998; Cook, Becvar, & Pontius, 2000; Meyerstein, 2000; Stone, 2002). Only in psychology did our search reveal a study similar to the one we conducted. Bassman and Uellendahl (2003) surveyed 1000 members of the American Psychological Association (APA). They received responses from 202 psychologists. Despite the fact that the sample size was so small that the findings could not be generalized, the demographic characteristics of this subgroup were determined to be similar to, and thus representative of, the APA membership as a whole. The data did suggest a wide variation in knowledge of CAM, with very few psychologists reporting direct use of specific practices. Rather than referring, most respondents reported that they recommend CAM; about 50% desired more knowledge about CAM; and many expressed concern or confusion about the ethics and legality of incorporating alternative modalities. These findings are similar in many ways to those in our study.
Before proceeding to a discussion of our methodology, we would like to reiterate that ours was a discovery-oriented process. We all perceived a logical fit between the assumptions of CAM and MFT. Certainly we were aware of the importance of sensitivity to the larger context and the impact of other systems on the process of change. Both clinically and personally we also had experienced the utility of incorporating CAM practices. However, we had found little in the literature to indicate the extent of knowledge and use of CAM among others in our field.
METHOD
Given our overall goal to gain an in-depth understanding of and depict the ways in which MFTs understand CAM as well as make sense of and describe their participation in this realm, the qualitative methodology utilized for the second phase of the research was representative of what Merriam (2002) defines as a basic interpretive study. It also might be termed a generic qualitative study (Caelli, Ray, & Mill, 2003), one that aims for credibility by addressing our theoretical positioning as researchers, demonstrates congruence between methodology and methods, describes our strategies to establish rigor, and delineates the analytic lens through which we examined the data. Using the continuum of qualitative research outlined by Sandelowski and Barroso (2003), we would locate this study and its findings between thematic surveys, which "convey an underlying or more latent pattern or repetition discerned in the data" (p. 912), and conceptual/thematic descriptions, with "findings rendered in the form of one or more concepts or themes either developed in situ from the data or imported from existing theories of literature outside the study" (p. 913).
The processes of designing, implementing, reflecting on the data, and describing our findings were informed throughout by postmodern ideas and sensitivities as well as systems thinking at the level of second-order cybernetics (Becvar & Becvar, 2006). That is, we subscribe to the notion that there are many valid ways of knowing, none of which necessarily describes the way things really are. Thus we were able to assume a both/and stance relative to the design of our study. We see subjectivity as inevitable and believe that we all participate in the creation of the reality we experience as a function of our beliefs and perspectives. Accordingly, we were aware that the interview processes in which each of us engaged would be influenced by both the unique characteristics of the interviewe\r and each unique interviewer-interviewee configuration. And we recognized that ultimately all we could offer might be a story about what we had learned, as well as some reflections about how further explorations might enhance this story.
Before undertaking this study, the Institutional Review Board of Appalachian State University approved all research procedures and instrumentation. A cover letter included with the original mailed survey explained the purpose of the study and requested return of the questionnaires. Consent was implied with return of the completed survey. In addition, a subset of respondents to the mail survey indicated their willingness to participate in telephone interviews with the researchers by also returning a stamped, self-addressed postcard providing their phone number and times when they would be available. One hundred postcards, about one-fourth of the participants in the mail survey (n = 424), were returned. Successful contact was made with 54 of these respondents over a period of 11 months. The list was divided among the three researchers, all of whom conducted telephone interviews based on a semistructured interview guide, which also included a brief introduction and request for verbal consent to participate (see Appendix). Each researcher recorded responses on a computer as the conversations were occurring. The transcripts were then combined and imported into the QSR NUD*IST (1997) computer program to facilitate management of the data.
Ours was a generic qualitative approach (Patton, 2002), with analysis of the data conducted in a variety of ways. Each phase of the process was recorded in a project journal by one of the researchers (KC). This journal, an important part of our audit trail, represented the means by which we were able to track ideas in a manner that was easily accessible for everyone's review. Initially, each researcher received the complete transcript of all interviews formatted according to the 10 questions of the interview guide. The next step in the process involved a reading of these transcripts by each researcher in preparation for our first in- person meeting as an entire group. Indeed, it seems important to mention at this point that the geographic location of the researchers was a factor throughout the process, given that DB resides in Missouri and KC and JW reside in North Carolina. Although we were well aware that we all shared the same general theoretical orientation, we felt a need to gain a greater understanding of each person's knowledge about CAM before engaging in any discussion of themes, reactions to, or reflections on the transcribed interviews. Therefore, at our first face-to-face meeting, we began by interviewing each other using the same semistructured interview guide employed with the participants. This enabled us to become better acquainted regarding our individual styles of interviewing, describe our personal experiences with CAM, and sensitize ourselves further to our own interpretive biases. Over the next 2 days, we then proceeded by reading together, case-by-case, each of the 54 transcripts, and telling our respective "stories" about the interview process and our experiences with the various participants. We then concluded this step by jointly creating our first coding scheme based on the identification of two main themes, definitional differences regarding CAM, and depth of awareness of CAM.
Our next step involved each researcher working with the transcripts separately. Two of the researchers (KC, JW) chose to proceed with the data analysis using the QSR NUD*IST (1997) program, and one (DB) chose to analyze the data manually. We met jointly for the second time several months later while attending a conference. At this meeting, DB shared her findings based on an analysis of each question across all respondents, which we labeled a horizontal analysis. KC provided information regarding the adequacy and limits of an initial coding system that she had created. After this meeting we proceeded by again working individually, with each researcher expanding on the work previously completed. This included searching for negative instances that challenged our hypotheses. Finally, the data analysis and the delineation of the findings were completed during a face-to-face meeting between DB and KC, during which the thoughts of all three researchers were integrated and illustrated.
Our horizontal analysis, based on our review of each question across all cases, was grouped into the 10 categories that made up our interview guide. From our vertical analysis, which was based on a review of each case as a whole as well as of the aggregated data, we created two additional categories. By considering all 12 categories thus created, we were able to group what we found into five major areas. The first of these areas focuses on a description of the sample, which we provide in the section that follows. We then proceed to a consideration of our findings, "the interpretations themselves" (Sandelowski & Barroso, 2002, p. 215). These we have designated as definitional issues, depth of awareness of CAM, fit with MFT, and ethical considerations.
Throughout the course of this study we were aware of the need to meet the criteria developed by Lincoln and Guba (1985) for evaluating the trustworthiness of qualitative research. Accordingly, we attempted to satisfy the requirements for credibility through the collection of sufficient data, triangulation of our three perspectives, and a search for negative instances that challenged our emerging hypotheses and pushed us to reformulation. The provision of a detailed, rich description that offers sufficient information for readers to judge the applicability of our findings to other settings was designed and is intended to fulfill the requirements for transferability. Our audit trail, which comprised the research journal as well as copies of all e-mails sent and received, along with the illustrations for each of the themes we describe, aim to establish the dependability of our results. To achieve confirmability, we used the process of interviewing one another to identify and gain further understanding of our assumptions, worldviews, biases, theoretical orientations, values, and epistemological stances. The major dilemmas that we encountered and resolved were the different ways in which each of us approached the processes of interviewing and data analysis, as well as the logistics involved with a long-distance collaboration. Finally, relative to authenticity, we affirm that the information provided here represents the most fitting story we could create together at this time, for this sample, and given our current perspectives. We also acknowledge that we have represented as best we could a range of different realities.
DESCRIPTION OF PARTICIPANTS
We found the respondents (n = 54) to be a very heterogeneous group representing a wide variety of settings, with much diversity in approaches and a broad range of clients and problems with which they dealt. The therapy contexts included agencies, outpatient clinics, private practice, schools, the juvenile justice system, health maintenance organizations, divisions of family service, adult protective services, psychiatric practices, medical practices, employee assistance programs, and child guidance clinics. The roles and licensures represented included pastoral counseling, counseling, MFT, social work, family nurse practitioners, mental health workers, teachers, pastors, and consultants. Typical problems encountered and/ or orientations included alcohol and drug abuse, eating disorders, chronic mental illness, career counseling, family therapy, individual therapy, and couples therapy. The respondents ranged in age from 34 to 83 with a sample bias indicating that most were 50 to 70 years old and had been practicing for many years. They were drawn from 27 different states, and the continuum of employment ranged from full-time to part-time to semiretired to retired, with all continuing to be Clinical Members of AAMFT.
Responses to a question asking how the respondents became acquainted with CAM seemed to indicate that there are many pathways to knowledge in this area, with the most frequently mentioned being some form of workshops, seminars, or training, as well as through graduate school or work. Nearly as frequently mentioned were experiences within the families of the respondents and personal use. Colleagues and friends were a third avenue, whereas clients were mentioned least frequently as a source of information. Because of differences in interviewing style, only 12 respondents were asked if they had an interest in knowing more about CAM. For the respondents who answered this question, most (n = 9) were interested in learning more, two expressed mild interest, and one did not want to know more.
FINDINGS
To be meaningful, the findings of a qualitative study must provide new information, offering insights about or different ways of understanding the target population (Caelli et al., 2003). Generally designated as themes or recurring topics (Sandelowski & Barroso, 2002), they represent the researchers' interpretations of the data. As noted above, we identified/created four such topics.
Definitional Issues
Definitional issues emerged as a theme early on as we became aware of the very different ways in which respondents described their perceptions of CAM. For the purposes of this study, we proposed, consistent with the stance of the National Center for Complementary and Alternative Medicine (2002), that CAM practices are those therapies available to the public but are not widely integrated into the conventional medicine community. We therefore included in this realm such modalities as lifestyle change, diet and nutrition considerations, and chiropractic, which several participants clearly excluded in their discussions of CAM practices. For example, one r\espondent noted, "Lifestyle change is always a part of therapy," and another stated, "I go to a chiropractor once a week and I don't consider that alternative." Some participants were unsure about what to include, taking their cues from the research questions, and some had unique definitions, as the following quotes illustrate:
To me complementary and alternative medicine practices fly into about three major categories. There are those that are faith based and prayer, but then there are those that are being explored and have some phenomenological validity, we don't know why this works. And then there are some that are on the fricking end of the universe.
To me the faith and meditation and laying on of hands, you can call that alternative. The one that stands out in the middle category would be laughter. We know that humor reduces stress, humor is the best medicine, it generates endorphins. . . . And then [in the third category] you've got the coffee enema guys. That goes to copper bracelets to talismans under your tongue.
One participant took exception to the whole notion of grouping some practices into an "alternative" category: "I don't like the term alternative because of the connotations: Clients refer to acupuncture as 'new agey' even though it's been around for thousands of years." And another respondent, who had had a bad experience with a CAM practitioner said, "I don't do any complementary medicine," even though she acknowledged that she would refer to a massage therapist and often worked with clients regarding lifestyle changes and nutrition.
Depth of Awareness of CAM
Along with differences around definitions came immediate recognition of a clear distinction between those who had a broad awareness of CAM as a whole, with its various categories as well as the approaches subsumed by each, and those who had knowledge, either superficial or in-depth, of a few approaches. For purposes of discussion and description we metaphorically termed the former group as having knowledge of the forest in contrast to the latter group, who could be said to have knowledge of one or more trees. An example of a "forest" person is illustrated with the following quote:
I have an interest [in CAM], but not a narrow interest. There's a broad array of options. It's like in religion. You really need to be sensitive to the person you're working with and be aware that there may be some complementary medicines that wouldn't work for you but would work with them especially if they bring it in, like an herbalist or hypnosis.
In contrast, when asked about how he became acquainted with CAM, one "tree" person responded by saying, "I've had a client off and on through the years, she has these things in her home. Herbs, vitamins, and minerals. As far as knowing anything about it, no I don't."
The specific practices, or "trees," mentioned most often were the manual healing/touch therapies, particularly massage, with mind- body practices next. Diet, nutrition, and lifestyle choices were the third most frequently mentioned, followed by alternative systems of medical practice. Herbal medicine was an area familiar to some, whereas biological and pharmacological treatments and bioelectromagnetic applications were each mentioned only one time.
Fit with MFT
Although a few respondents did not see a fit between CAM and MFT, most spoke of there being one, either pragmatically, as an important expansion of their therapeutic repertoire, or theoretically, as a fit with the systemic/holistic paradigm according to which they work. Twenty of the respondents spoke of the pragmatic consideration of finding "what works" for clients, and there were many references (n = 22) to the importance of fitting treatment to client beliefs. For example, one respondent replied, "If it works, use it." Another stated
I always think there's room for new things in therapy. If a family comes in and says, "I'm interested in this," then it's disrespectful of me not to encourage them in it. If the client brings it in, I'll talk with them about it. I don't practice alternative medicines myself.
There also seemed to be a perception among many respondents that the use of CAM fosters a sense of personal empowerment for clients: "I think it is a hand and glove interface. It lets them know they have control over their lives, it puts them in charge."
Relative to theoretical fit, there was frequent (n = 20) mention of the holistic orientation of both marriage and family therapy and CAM. For example, a typical response in this category was, "CAM should be an integral part of it [family therapy]. Family therapy looks at whole systems. I look at the whole human. Systems, the whole body and such." This same idea is illustrated more fully as follows:
Family therapy is a natural holistic approach. There's an interaction between body-mind and soul. Someone may have a spiritual or emotional wound and it shows up physically. Trauma victims often have visceral stored memories and they need to work with that.
One respondent offered an equally interesting perspective: "There is a comfortable fit. The difference from other therapists is that MFTs look at systems, not just at the individual, and all alternative modalities are part of the system itself."
Given this perception of fit, it is not surprising that for the most part respondents who indicated personal involvement in CAM felt that it enhanced their ability to be effective, both in terms of being a role model for clients and in how they practiced therapy. Accordingly, one respondent stated, "I think CAM influences my practice in the sense that I model a healthy life style. I serve as a role model." Another noted, "CAM is a considerable influence on who I am and what I believe. The mind is only part of our health." And a third stated, "It makes me a better therapist if I stay healthy. Then I can tap into my own inner wisdom. When I strive for peace my work goes better. I see that as a priority in my life. Then I do a better job."
Despite this perception of the positive impact of personal use, respondents indicated cautious integration of CAM practices into their therapy, with much awareness of limits. Most stated that they recommend, encourage, refer, and support CAM use by clients as appropriate. Thus a typical response to the question regarding the extent to which they incorporated CAM practices into therapy was, "Similar to how I encourage people to pray. I do not impose. If they have a faith life I might encourage a scripture to reflect on." Another respondent stated
I do not try to push it. I mention it and if people are interested, I will give referrals. People come to these [practices] by different paths and at different speeds. They are not appropriate for people who do not think in this way. I mention them as an alternative.
The primary exception to this stance came from those with training in a particular modality (e.g., relaxation techniques, guided imagery, yoga), who said they may incorporate this activity themselves if the setting in which they practice allows. Indeed, context often seemed to have an impact on practice approach.
Consistent with the attitude of openness coupled with caution expressed by a majority of the sample, most of those interviewed indicated that they do make referrals to CAM practitioners and that they often have a wide variety of resources in mind. Referrals for 32 different kinds of practices or professionals were mentioned, with the most frequent being chiropractic, acupuncture, massage and bodywork, as well as various kinds of CAM practitioners (e.g., holistic dentist, homeopathic doctor, naturopath, holistic physician). However, such referrals tend to be made in response to cues from the clients as illustrated by such statements as, "Sometimes [I refer]. It depends on where the clients are and what they are looking for. I look for what I feel will be a good fit." According to another interviewee, "[I refer] only if asked. I do not suggest because it's not in my mandate. It frequently comes up because that is the world we live in today."
Only one-fourth of the sample (n = 13) were asked the question, "Has your awareness of CAM affected your therapy's effectiveness?" Of those responding, all but two felt that their practice was enhanced, some to a very high degree and very enthusiastically. They noted an expanded sense of self for both clients and therapists as well as an increased repertoire of interventions for themselves. Relative to the impact on clients, one respondent stated, "CAM serves to give people hope. Often with traditional [allopathic] medicine it is over and out. There are many ways to help oneself. CAM helps someone to be proactive rather than reactive as with traditional medicine." In a similar response, another respondent noted that such awareness "makes it [therapy] more broad based and effective. People have more control over their healing process. It [CAM] empowers people around their work." The following two quotes provide representative illustrations of the perceived impact on therapists: "It has augmented the kinds of things I am able to do to bring people some relief," and "I think so. By expanding my idea of how things are created, how stress is created and how that affects one's mind and body."
Ethical Considerations
In addition to the specific question, "What are the ethical issues you have considered related to the use of CAM in family therapy?" issues around ethics emerged throughout the conversations with the respondents. The overriding concern articulated was the need to stay within the scope and limits of therapist competence. For example, a frequently repeated theme was, "First, the whole issue of being really unlicensed as a physician and understanding the law. I couch instruction with understanding. We need to recognize the limits of our training." From another respondent we hear the same ideas articulated a little more fully:
I \try very hard not to overstep my boundaries. I'm not a physician. I know a lot about complementary medicine, but I'm careful to not press this on my clients. I'm careful how I word things. I might say, "This has been useful for other people with your situation. You might want to find out about this. You might want to go talk to this person about this practice."
A related concern was the need to take great care when referring to or warning about CAM practitioners. As one respondent noted, "Anytime you recommend to something alternative you take some risk. I think the client's well-being is imperative. You have to be careful when you recommend." Or, in three other representative quotes:
MFTs can't prescribe but they can suggest. I would not send someone in a direction I did not check out myself. Just because it worked for me does not mean it will work for them. There are two sides to that. Knowing who the practitioners are and how well trained they are. And clients need to be aware. If they go in too accepting, they can get burned.
I think it's very dangerous to refer anybody to something you don't know much about. . . . I can't imagine referring to something I've not tried. I'd have to get more familiar with it or if I knew people and trusted people who knew about experiences of others that had been helped by a treatment.
There's a fine line about respecting what clients try and warning them. There's a lot of new age stuff that's bogus and frankly a waste of time. It's tricky to warn a client without maligning someone else who's practicing. There's some dangerous stuff out there. There are definitely some practitioners that I try to steer clients away from.
Issues such as these are related to another frequently mentioned concern regarding the need for research support for various approaches as well as awareness of the presence of charlatans:
My judgment as well as my observations are that, not unlike any other field, there are plenty of charlatans out there who are preying on individuals and groups who are suffering and looking for relief. So my concerns are that the average citizen and general public are not informed and educated enough to discern legitimate forms of complementary medicine and what are considered to be alternative modalities. . . . It is important to be critical of any new treatment modality until there has been rigorous scientific study of efficacy.
DISCUSSION
When asked for suggestions they might offer to other therapists regarding their practice of MFT and CAM, respondents were nearly unanimous in their recommendations. They noted the importance of being open to other possibilities and answers, getting appropriate training, being cautious, doing personal research and experiencing for themselves the various approaches, taking their cues from clients, getting supervision, and helping clients to explore wisely. Most of these sentiments are captured very well by one of the respondents. Indeed, the following may be considered an exemplary quote, one that illustrates a central tendency found within the data (Chenail, 1995):
There are some new therapies that sound off the wall, for helping people psychologically, but be open to examining what the potential is. . . . Ethically, we have a real responsibility to protect our clients. We have to help clients process when they're getting out of bounds. We have to be very careful to know what the hazards are. We guide people to the edge of what they need to deal with and be careful not to push them over the edge. We carry a powerful ethical responsibility not to hurt people. . . . We need to have minimum risk and maximum benefit. The ethical issue is that we have to know what we're offering in alternatives. We have to know the potential benefit and potential danger to all of them. So many of the alternative medicines aren't well researched. . . . The issue is that we must learn to learn and be open to learning and all the presuppositions we carry within us, we must open them up to be examined.
As illustrated in this quote, a common thread that is woven throughout the responses to the various questions is a basic concern for the well-being of clients. This is expressed in a general willingness to consider expanding beliefs and practices that might prove useful to clients that is tempered by a recognition of the limits of competence and the need for caution as is the case whenever exploring any new field.
As we reflect on the various themes and trends that emerged for us from the data from both phases of our study, we would suggest that there certainly appears to be growing interest in CAM among many MFTs consistent with the increased awareness and utilization of such practices in the larger society. This certainly also is consistent with the findings relative to various other professional groups as indicated in our review of the literature. Although validation of growing interest matched the perception we shared at the outset and was confirmed by the quantitative analysis, what surprised us as a function of the qualitative analysis was the tremendous variation in both definitions and depth of awareness of CAM described by the self-selected subset of respondents whom we interviewed. Particularly interesting in this regard was the fact that some equated the inclusion of CAM approaches with the need to be a physician.
Although not addressed in the quantitative phase, as noted previously (Becvar et al., 1998) and consistent with the perceptions of many of the respondents participating in the qualitative phase, there is frequent agreement regarding the logical fit between the assumptions underlying family therapy and those on which complementary alternative medicine is premised. It therefore is not surprising that many MFTs seem to have established a comfortable working relationship with a variety of CAM approaches and thus are open to and desirous of learning more.
Although we inferred from the first phase of the study a need for further education in this area for professionals as well as for clients, in the second phase we gained more specific information. To ensure the safety and well-being of everyone involved, there is a consistent call for more clarity regarding ethical and legal issues as well as more scientific research to support anecdotal evidence regarding the efficacy of various CAM modalities. In addition, although insurance companies have begun to provide coverage for some CAM services, there continues to be a concern about their cost and availability to all segments of the population.
Having reflected a bit more on our findings, it now seems appropriate to consider the processes utilized in the research program as a whole, the limitations of this phase of our study, and suggestions for future research. As noted previously, we chose a mixed-methods approach (Johnson & Onwuegbuzie, 2004), one that privileged equally both quantitative and qualitative methodologies. Rather than seeing one as preparatory for the other, and/or combining them in one study, the two phases occurred in separate, but overlapping, fashion rather than sequentially, with the results of the former fed back into the consideration of the findings of the latter. It is our belief that much was gained from such an approach, consistent with our intent to gain an in-depth understanding of and depict the ways in which MFTs understand CAM as well as make sense of and describe their participation in this realm. Not only did we have two different lenses through which to look, but we also had more extended contact with the respondents.
As was noted in the quantitative report, the limitations of that study included lack of information regarding those who chose not to participate, and a sample drawn only from Clinical Members of AAMFT rather than from among all MFTs practicing in the US. Not only do those limitations remain for the current study, they are of greater significance given the fact that the respondents whom we interviewed selected themselves. We thus would infer increased interest in or concern with CAM as a bias of this sample. Another limitation is that each of the researchers had her or his own style of interviewing, and not all participants were asked all questions. However, this limitation was offset to some degree by the richness of perspectives derived from having a three-person team as well as the use of both computer-assisted and manual approaches to data analysis.
Although we believe that this research study has helped to address a gap in our knowledge by tapping into the wisdom of clinicians, there appears to be much room for future research. Indeed, we would suggest conducting a similar study with a sample of MFTs derived from different sources, such as the American Family Therapy Academy (AFTA), the International Family Therapy Association (IFTA), and/or those licensed as MFTs in various states and provinces. Another area to target might be students and faculty in MFT training programs. Research aimed at describing appropriate teaching/learning contexts for enhancing practitioner knowledge about CAM also might be useful. An additional study might address the efficacy of therapy when CAM practices are or are not included. Certainly this seems to be an area ripe for further exploration, and we look forward to future study and discussions regarding the relationships between MFTs and CAM.
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Dorothy S. Becvar
Saint Louis University
Karen L. Caldwell and Jon L. Winek
Appalachian State University
Dorothy S. Becvar, PhD, School of Social Work, Saint Louis University; Karen L. Caldwell, PhD, and Jon L. Winek, PhD, Department of Human Development and Psychological Counseling, Reich College of Education, Appalachian State University.
Funding for this project provided by the University Research Council of the Cratis Williams Graduate School, Appalachian State University.
Correspondence may be directed to Dorothy S. Becvar, PhD, School of Social Work, Saint Louis University, 3550 Lindell Boulevard, St. Louis, Missouri, 63103; E-mail: becvards@slu.edu
APPENDIX
TELEPHONE INTERVIEW GUIDE
1. How did you get acquainted with Complementary and Alternative Medicine (CAM)? With which CAM practices are you most familiar?
Ask about knowledge of (a) Diet, nutrition, lifestyle changes
(b) Mind/body practices
(c) Alternative systems of medical practice
(d) Manual healing/touch therapies
(e) Pharmacological and biological treatments
(f) Bioelectromagnetic applications
(g) Herbal medicine
2. Do you have an interest in knowing more?
3. What type of practice do you have?
Ask for a description of (a) Primary professional identity/ licensure
(b) Secondary professional identity/licensure
(c) The setting
(d) Types of clients
(e) Full/part time
(f) Most prevalent diagnoses
(g) Acceptability/availability of CAM in community
4. To what extent does your personal use of CAM affect your therapy practice?
5. To what extent do you incorporate CAM practices into your therapy?
6. Do you ever refer clients to a CAM practitioner? If "Yes," for what services?
7. Has your awareness of CAM affected your therapy's effectiveness?
8. How do you see the fit between family therapy and CAM?
9. What are the ethical issues you have considered related to the use of CAM in Family Therapy?
10. What suggestions do you have for other therapists regarding their practice of MFT and CAM?
Copyright American Association for Marriage and Family Therapy Jan 2006
