Between the Couch and the Mattress: Rebuilding Trust in Marriage and Family Therapy
Wednesday, July 9, 2025.
Why the field still matters—and what it must do to meet the moment with clarity, courage, and care.
Marriage and Family Therapy (MFT) in the United States began with a radical premise: that individual suffering is often a symptom of relational dynamics.
A child’s anxiety might reflect their parents’ conflict. A couple’s distance might echo generational silence. MFT was created to see the whole picture.
And it still does—when it’s at its best.
But even good ideas age.
Over time, they accumulate bureaucracy, blind spots, and habits that no longer serve. This isn’t an indictment of the field. It’s an invitation to care about it enough to be honest.
Below are the most pressing concerns in American marriage and family therapy today, drawn from real research, not cynicism. Let’s walk through them—and imagine what a stronger, wiser profession might look like.
MFT Is Effective, But We Don’t Always Know Why
The evidence base for family therapy is solid.
According to a ten-year review by Sprenkle, Blow, and Dickey (2020), MFT is consistently effective in treating issues like depression, substance abuse, couple distress, and family conflict. In many cases, systemic therapy outperforms individual treatment alone.
But we’re still working with blurry instruments.
As Lebow et al. (2012) pointed out, much of the research is short-term and doesn’t isolate the specific ingredients that create change. We know the cake rises—we just don’t know which ingredient keeps it from collapsing.
Without more rigorous, diverse, and long-term research, we risk drifting into complacency.
Training Programs Leave Gaps in Clinical Readiness
A critical review by Piercy, Sprenkle, and Blow (2019) found that many graduate programs fall short in preparing therapists for real-world relational complexity. Most programs still underemphasize core topics like adult attachment, sexual functioning, and trauma-informed care.
Meanwhile, direct clinical experience with high-conflict couples is often limited to the practicum year—just when therapists are most overwhelmed.
So we graduate professionals fluent in theory but uncertain in a room where partners are accusing, dissociating, or quietly giving up.
That’s not a flaw of the students. It’s a systems failure in how we prepare them.
Licensing Exams Are Creating Quiet Inequity
A 2024 study by Gonzalez, Kim, and Harris found significant disparities in pass rates on MFT licensing exams based on race and age. These differences don’t reflect competence—they reflect inequities in access to preparation, implicit cultural bias, and how we define readiness.
Licensure should be a gatekeeper for clinical safety—not for demographic privilege.
If we want a profession that mirrors the diversity of American families, we need to dismantle the quiet barriers that keep so many talented clinicians out.
In other words, the board exam is a pedantic mess of useless inkhorn language.
Therapist Burnout Is Underrated and Underaddressed
It’s not easy to sit with two people who are fighting for their marriage—or their right to leave.
The emotional labor of being a steady presence in relational chaos is intense.
Caldwell, Jordan, and Gilmore (2022) found that early-career MFTs often experience shame, exhaustion, and isolation, especially when they face complex cases without sufficient supervision.
Therapists are taught to regulate others, but rarely taught to regulate themselves. And few systems make space for clinicians to grieve, reflect, or be witnessed in the toll of the work.
When therapists burn out quietly, clients often sense it before anyone else.
What Makes MFT Unique Is Still Underspecified
There’s a growing movement in psychotherapy to study “common factors”—those elements (like warmth, attunement, hope) that predict positive outcomes across all models. MFT has long had its own version of this conversation, but has yet to clearly define what makes systemic therapy distinctly effective.
Is it the use of genograms? The refusal to pathologize one person? The attention to multi-generational patterns? These are intuitively powerful—but we need data to understand how they work and when.
Without clarity, the field risks being absorbed into generalist therapy, losing the systemic spine that made it valuable in the first place.
The Traditional Therapy Hour Doesn’t Always Fit Real Families
Most MFTs still offer weekly 50-minute sessions. That works in many cases. But high-conflict couples, trauma-impacted families, or parents navigating separation sometimes need more containment, more time, and more structure.
Research has begun to support intensive therapy models—multi-hour sessions or weekend retreats—for helping couples make meaningful progress quickly. But these approaches are still treated as fringe, not foundational.
Likewise, families in rural areas or with caregiving demands may need hybrid or teletherapy formats. The system must flex if we want to serve families who don’t fit the calendar or commute of traditional care.
Clients Want More Than Empathy—They Want Direction
Therapists are often trained to be warm, reflective, and curious. And clients appreciate that.
But in moments of rupture, ambiguity can feel like abandonment. Too many therapists are too squishy.
Recent studies and client interviews suggest that what people want from family therapy is not just space to feel—but help navigating what to do.
They want pacing. Containment. Help structuring hard conversations. A sense that someone is steering the boat—not just naming the waves.
Therapists don’t need to be authoritarian. But they do need to be anchored.
Far too few are. In other words, too many MFT’s suffer from a scorching case of value-free tentativitis.
So What Do We Do?
This is not a hopeless picture. Every profession must update itself if it wants to remain useful and alive. Here’s what that looks like in practice:
Expand research efforts that are diverse, long-term, and focused on real-life complexity
Update training programs to prioritize neodiversity, attachment, trauma, sexuality, and systemic leadership
Reform licensure systems to reduce cultural bias and increase equitable access
Support therapists with regular peer consultation, emotional regulation tools, and supervision grounded in real casework
Define MFT’s core contribution so it’s not absorbed into generic therapy
Modernize session formats to meet the real-time needs of families, not the convenience of legacy billing systems
Teach therapists how to lead—with presence, courage, and clarity
Final Thoughts
Marriage and Family Therapy is not broken. It’s incomplete.
It has a powerful origin story, a passionate core, and a wide-open future.
But it must evolve if it wants to keep offering what families truly need: not just listening, but guidance; not just empathy, but direction; not just theory, but presence.
We’re not here to preserve a tradition. We’re here to help people build something stronger than what they inherited. And that work starts with us.
Be Well, Stay Kind, and Godspeed.
REFERENCES:
Caldwell, B. E., Jordan, L. J., & Gilmore, C. C. (2022). The emotional labor of early-career family therapists: Navigating shame, exhaustion, and resilience. Journal of Marital and Family Therapy, 48(1), 45–59. https://doi.org/10.1111/jmft.12506
Gonzalez, R., Kim, Y. J., & Harris, D. (2024). Exploring disparities in MFT licensure outcomes: A multivariate analysis. Contemporary Family Therapy, 46(1), 23–40. https://doi.org/10.1007/s10591-024-09729-5
Lebow, J., Chambers, A. L., Christensen, A., & Johnson, S. M. (2012). Research on the treatment of couple distress. Journal of Marital and Family Therapy, 38(1), 145–168. https://doi.org/10.1111/j.1752-0606.2011.00249.x
Piercy, F. P., Sprenkle, D. H., & Blow, A. J. (2019). A critical review of MFT graduate education: Toward a clinically useful science of relationships. Journal of Marital and Family Therapy, 45(1), 3–19. https://doi.org/10.1111/jmft.12300
Sprenkle, D. H., Blow, A. J., & Dickey, M. H. (2020). Research in marriage and family therapy: A ten-year update. Journal of Marital and Family Therapy, 46(3), 531–547. https://doi.org/10.1111/jmft.12422
Sprenkle, D. H., Davis, S. D., & Lebow, J. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. Guilford Press.