Marriage and Family Therapy was born from a powerful idea: that people cannot be understood in isolation. We are shaped by relationships, systems, culture, and context. Healing, therefore, must also be relational.
And yet—somewhere along the way—the field drifted.
Many clients enter therapy hopeful and leave feeling confused, unseen, or subtly overridden by expertise that doesn’t quite fit their lived reality. Not because therapy is inherently harmful, but because too often, the systems that guide training, research, and practice prioritize professional authority over client wisdom.
This isn’t a personal failure. It’s a systemic one.
When Expertise Becomes a Barrier
Traditional therapy models frequently rely on top-down frameworks: the therapist as expert, the client as recipient. Even well-intentioned approaches can unintentionally recreate the very power dynamics clients are trying to heal from—especially for those whose voices have historically been marginalized within healthcare systems.
Research consistently shows that clients themselves are the strongest drivers of meaningful change in therapy. When people are engaged as collaborators—rather than subjects—outcomes improve. Therapeutic alliances deepen. Cultural responsiveness strengthens. Repair becomes possible in real time.
Yet, across the field of Marriage and Family Therapy, client involvement often remains limited to feedback forms, outcome measures, or post-hoc evaluations. Helpful, yes—but incomplete.
Listening is not the same as partnering.
From Feedback to Partnership
Service user involvement invites a deeper shift: one that asks us to reimagine how power moves through therapy.
Rather than viewing clients as sources of data, this approach recognizes lived experience as a form of expertise—one that belongs alongside clinical training, not beneath it. It asks therapists, educators, and researchers to practice cultural humility not as a concept, but as a structure.
In practice, this can look like:
- Clients actively shaping the direction and pacing of therapy
- Feedback used reflexively, not defensively
- Supervision models that attend to power, identity, and relational impact
- Training programs that include lived experience as part of how therapists are formed—not just evaluated
This is not about abandoning skill or structure. It’s about integration.
Third-Order Change: Shifting the System Itself
In systems theory, meaningful transformation doesn’t happen by tweaking techniques alone. It happens when the rules of the system change.
Centering lived experience represents a form of third-order change—a reorganization of how authority, accountability, and knowledge are distributed across therapy’s many layers. Education, research, supervision, and practice all become sites of shared responsibility rather than unilateral control.
When this happens, therapy becomes more than a service. It becomes a relationship grounded in consent, collaboration, and mutual influence.
Why This Matters—Especially Now
At its core, therapy is an ethical practice. And ethics are not static—they evolve as we listen more closely to those we serve.
Re-centering lived experience helps close long-standing gaps between intention and impact. It invites therapists back into the relational roots of the work. It restores integrity to a field that was never meant to function through distance or dominance.
This is not about fixing clients. It’s about trusting them.
At Cultivating Capacity, this philosophy is not theoretical—it’s embodied. Therapy here is a partnership. Your voice matters. Your experience shapes the work. And your capacity for insight is never in question.
There is space for all of you here. And there is a way forward that feels like yours.
References
This reflection was adapted from an synthesis and comparative analysis paper I submitted as part of my doctoral journey; copies available upon request.
American Association for Marriage and Family Therapy. (2015, January 1). Code of ethics. AAMFT. https://www.aamft.org/AAMFT/Legal_Ethics/Code_of_Ethics.aspx
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693–704. https://doi.org/10.1037/a0016062
Aoki, Y., Yaju, Y., Utsumi, T., Sanyaolu, L., Storm, M., Takaesu, Y., Watanabe, K., Watanabe, N., Duncan, E., & Edwards, A. G. (2022). Shared decision-making interventions for people with mental health conditions. The Cochrane Database of Systematic Reviews, 11(11), CD007297. https://doi.org/10.1002/14651858.CD007297.pub3
Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 83–111). American Psychological Association. https://doi.org/10.1037/12075-003
Dixon, K. M., Kivlighan, D. M., Hill, C. E., & Gelso, C. J. (2022). Cultural humility, working alliance, and Outcome Rating Scale in psychodynamic psychotherapy: Between-therapist, within-therapist, and within-client effects. Journal of counseling psychology, 69(3), 276–286. https://doi.org/10.1037/cou0000590
Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS): Revisiting the client's frame of reference. Psychotherapy, 52(4), 391–401. https://doi.org/10.1037/pst0000026
Duncan, B. L., & Reese, R. J. (2024). The evolution of feedback: Toward a multicultural orientation. Psychotherapy, 61(2), 101–109. https://doi.org/10.1037/pst0000524
Duncan, B., & Sparks. J. (2012). The partners for change outcome management system (PCOMS): The heart and soul of change project. Canadian Psychology, 53, 93–104. doi:10.1037/a0027762.
Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., & Utsey, S. O. (2016). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60(3), 353–366. https://doi.org/10.1037/a0032595
Jonášová, K., Čevelíček, M., Doležal, P., & Řiháček, T. (2025). Psychotherapists' experience with in-session use of routine outcome monitoring: A qualitative meta-analysis. Administration and Policy in Mental health, 52(1), 106–122. https://doi.org/10.1007/s10488-024-01348-4
Katafiasz, H., & Patton, R. (2021). Closing the loop: Addressing diversity in a COAMFTE-accredited MFT education program. Contemporary Family Therapy, 43, 100–111. https://doi.org/10.1007/s10591-020-09558-2
King’s College London (KCL). (n.d.). Service user research enterprise (SURE). KCL. https://www.kcl.ac.uk/research/sure
Kuehl, B. (2008, September/October). A tribute. Family Therapy Magazine, 7(5), 12-22.
Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48(1), 72–79. https://doi.org/10.1037/a0022238
McComb, J. L., Diamond, R. M., Breunlin, D. C., Chambers, A. L. and Murray, K. S. F. (2019), Introducing client feedback into marriage and family therapy supervision: A qualitative study examining the transition to empirically informed supervision. Journal of Family Therapy, 41, 214-231. https://doi.org/10.1111/1467-6427.12222
McDowell, T., Knudson-Martin, C., & Bermudez, J. M. (2019). Third-order thinking in family therapy: Addressing social justice across family therapy practice. Family process, 58(1), 9–22. https://doi.org/10.1111/famp.12383
Reese, R. J., Toland, M. D., Slone, N. C., & Norsworthy, L. A. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy: Theory, Research, Practice, Training, 47(4), 616–630. https://doi.org/10.1037/a0021182
Shearer, K. D. and Lister, Z. D. (2025), Relational teaching in mental health education: A 20-year narrative review. Journal of Marital and Family Therapy, 51, e70010. https://doi.org/10.1111/jmft.70010
Sparks, J. A., Kisler, T. S., Adams, J. F. and Blumen, D. G. (2011), Teaching accountability: using client feedback to train effective family therapists. Journal of Marital and Family Therapy, 37, 452-467. https://doi.org/10.1111/j.1752-0606.2011.00224.x
Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi.org/10.1353/hpu.2010.0233
Turnbull, A. P., Friesen, B. J., & Ramirez, C. (1998). Participatory action research as a model for conducting family research. Journal of the Association for Persons with Severe Handicaps, 23(3), 178-188. https://doi.org/10.2511/rpsd.23.3.17