What, why, and for whom: couples interventions: a deconstruction approach

This paper provides a commentary on the special series on universal processes and common factors in couple therapy (Halford & Snyder, this issue). The authors in this section share their insights, from varying perspectives, about what it is in couples therapy and relationship education programs that work, why they work, and for whom they work best. In so doing, these articles address specific elements of couples interventions--in effect, taking a couples approach apart in order to understand it better. However, as a collection, this section takes this approach to understanding one step further. It puts the elements back together again, making the process of couples therapy/relationship education more accessible and easier to customize based upon the couple, the presenting complaints, the therapist, and the context. The term "deconstruction" is used to describe how the specific elements of couples interventions are understood and reassembled in new, theoretical, and empirically validated ways. It is argued here that once it is understood that a couples intervention works, why it works, and for whom it works, we are able to individualize our approach to specific couples in an effort to make couples therapy better at improving relationships and keeping them improved.     

Sudden gains in treatment-as-usual couple therapy for military veterans

Previous studies of couple therapy have conceptualized change as a gradual process. However, there is growing evidence that, for many clients, the majority of gains in other treatment modalities are often achieved between just 2 sessions. Isolating the frequency, nature, and predictors of these sudden gains (SGs) in couple therapy can add to a growing understanding of how and why couple therapy works. In a sample of 67 couples receiving treatment-as-usual couple therapy in two Veterans Affairs hospitals, 25% of individuals experienced a SG in relationship satisfaction. The magnitude of these SGs were large (d = 1.62) and fully explained the total pre-post change for individuals who experienced them. Individuals with SGs showed significantly greater satisfaction gains during therapy; however SGs were not related to relationship satisfaction or relationship status at 18-month follow-up. SGs were predicted by the content of the previous session, putative change mechanisms of communication, intimacy, and behavior, as well as the partner's SGs during the same period. Results suggest that SGs are an important component of change during couple therapy for some individuals, challenging the assumption of continuous change in previous studies. In addition, predictors of SGs were generally consistent with theoretical and empirical examinations of mechanisms of change in couple therapy.     

Integrative approaches to couple therapy: implications for clinical practice and research

Although meta-analyses affirm that various treatments for couple distress produce statistically and clinically significant outcomes, research findings also indicate that a large percentage of couples fail to benefit or subsequently deteriorate following current therapies. Based on these findings, we advocate potential advantages of integrative approaches to couple therapy. We distinguish among assimilative, transtheoretical, and pluralistic approaches to integration and describe exemplars of each. Integrative approaches to couple therapy are compared to distillatory or common factors approaches emphasizing common elements of treatment components, therapist characteristics, and client or relationship attributes. We argue that clinical practice of integrative approaches to couple therapy requires conceptual and clinical decision-making skills transcending those of any one theoretical modality and emphasizing the selection, sequencing, and pacing of diverse interventions in a coherent manner. We conclude with implications of integrative couple-based treatments for future research.     

The Added Value of Studying Embodied Responses in Couple Therapy Research: A Case Study

This article reports on the added value of embodied responses identified through sympathetic nervous system (SNS) activity in couple therapy research. It focuses on moments of change and the timing of therapeutic interventions or therapeutic moves in a couple therapy session. The data for this single‐case study comprise couple therapy process videotapes recorded in a multi‐camera setting, and measurements of participants’ SNS activity. The voluntary participants were a marital couple in their late thirties and two middle‐aged male psychotherapists. The division into topic segments showed how the key issue of seeking help, which was found to comprise three separate components, was repeatedly dealt with in the session. SNS activity showed different degrees of synchronization between the couple, between the therapists, and between the couple and therapists during the dialogue pertaining to these three components. The issue of timing emerged as a complex, even ambivalent, phenomenon. Arousal in the therapists was in line with their therapeutic activity, whereas in the clients it was more anticipatory. The approach used here rendered visible some of the intensity that therapeutic dialogue can generate when dealing with issues of relationship change in the couple context and showed how this intensity can be dialogically regulated in the therapeutic system.     

Family therapy and the politics of evidence

This article situates family therapy in the politics of evidence-based practice. While there is a wealth of outcome research showing that family therapy works, it remains on the margin of mainstream therapy and mental health practice. Until recently it has been difficult to satisfy 'gold standards' of randomized control research which require manualization and controlled replication by independent investigators. This is because systemic family therapy is language-based, client-directed and focused on relational process rather than step-by-step operational techniques.
As a consequence family therapy is an empirically supported treatment unable to join the evidence-based club. The politics here concerns what is 'evidence', who defines it and the limitations of a scientist-practitioner model. Therapy is art and science and its research needs to be grounded in real-life clinical practice. Common factors such as personal hope and resourcefulness and the therapeutic relationship contribute more to change than technique or model.
While arguing for a wider definition of science and evidence it is politic to seek evidence-based status for family therapy. Family therapy is a best practice approach for all therapists where systemic wisdom helps to decide what to do with whom when . A systemic-practitioner model is informed by quantitative and qualitative research and holds modern and postmodern perspectives in tension, a stance I call paramodern . Family therapy is both scientific and systemic; it is a science of context, narrative and relationship.     

Treating the Doll's House Marriage

The Doll's House, a common pitfall for family therapists, is an extremely unequal relationship in which one spouse's incompetence is required or encouraged by the other. This pattern of marriage is common in a sick population and is chosen by people with clear individual pathology. It may be stable and satisfying, but it is crisis prone. Doll's Houses are likely to be disrupted by the arrival of children, financial reverses, and, most important, the intrusion of another person upon whom the Doll is dependent and who sets out to equalize the marital relationship. A well-intentioned therapist with an intolerance for pathology can destroy the marriage. Therapy seems more successful when the therapist respects the basically unequal framework the couple has chosen and works toward greater understanding and respect for unique individual needs within that framework.     

Groundhog day: The individual,the couple,the group and the space between

Abstract

The film Groundhog Day first came out in 1993. Five years later, it is still cited in a variety of contexts. The author proposes that this is because the film is a cultural artefact which both elucidates and frustrates the ideal of romantic love in the couple as the agent of internal change.

The author also proposes a re-viewing of the meaning of the concept of couple. The convergence of object relations theories with group analysis suggests that the mind works by repeating and externalizing internal group structures in social relationships. The couple, then, becomes an intermediary structure between the individual and the group where intimacy facilitates a re-working of group internal structures. It is the collapsing and the opening of the ‘space between’ which is the agent of change. This process creates strength, power and a feeling of wholeness. But it also implies the expression of anger, pain and disappointment. The author illustrates these points with an interpretation of the Groundhog Day film and with a clinical case study of a couple in therapy.     

Cognitive-Behavior Family Therapy: Contemporary Myths and Misconceptions

The field of couple and family therapy has grown in the direction of expanding its horizons by looking toward innovative ideas and whatever works to facilitate change. Despite its demonstrated track record with a broad range of behavioral and emotional disorders, the cognitive-behavior therapies (CBT) may have been underutilized by couples and family therapists unlike some of the more traditional and postmodern approaches. This article explores some of the basic tenets of the cognitive-behavioral approach with families and proposes it as both a useful intervention tool as well as a theoretically compatible model to systemic approaches. In addition, a number of contemporary myths and misconceptions are discussed that may be precluding CBT's utilization by therapists in the field.     

Common factors in the enhancement of dyadic coping

Stress and coping are important constructs in understanding the dynamics of close relationships. Couple therapy and marital distress prevention approaches have become increasingly focused on these variables to gain knowledge of how stress and coping may impact the quality and stability of close relationships. In this paper, we outline couple's coping enhancement training (CCET) and the coping-oriented couple's therapy (COCT); both, couple interventions derived from stress and coping research. We address specific features of each approach and report data on their efficacy and effectiveness. We also examine both the common and specific factors that may play a role in the effectiveness of these approaches.     

Couple therapy in a therapeutic community setting†

An account is given of couple therapy offered as part of a comprehensive treatment programme in a unit run as a therapeutic community. The additional therapeutic force provided by couple or family therapy is important in dealing with adult patients who may not be highly motivated for change or who may not initially present their difficulties as springing from marital or family relationships. A combined approach with these kinds of patients may succeed where either group therapy or couple therapy alone is likely to fail.     

Love in Action: An Integrative Approach to Last Chance Couple Therapy

This article presents an integrative approach to the special challenges of therapy with couples on the brink of dissolution or divorce—who often describe this therapy as their “last chance.” In some, one partner is considering ending the relationship, and in others, both partners are considering ending it. Often, these couples have had prior dissatisfying experiences in couple therapy. Four types of last chance couples are described: high‐conflict couples; couples in which partners have differing goals for their lives or different timelines for reaching shared goals; couples in which one or both partners have acted in a manner that violates the values, expectations, emotional comfort, or safety of the other; and couples in which there has been a gradual loss of intimacy. The Therapeutic Palette, a multiperspectival, theoretically eclectic integrative approach, is enlisted as a general framework for selecting and sequencing use of particular theories and their associated practices, based on the three “primary colors” of couple therapy: time frame/focus, level of directiveness, and change entry point. An additional complementary framework, the creative relational movement approach, is proposed to provide an integrative frame encompassing both language‐based and action‐based practices, suggesting that meaning is held and expressed as much through interaction or “relational motion” as it is through language. Principles of change are described. Due to the couple's level of crisis and desire for immediate evidence of possible improvement, priority is given to action‐based interventions in early stages of therapy, by engaging couples in “experiments in possibility.” Typical action approaches are described. An extended vignette follows.     

Factorial and construct validity of the revised short form integrative psychotherapy alliance scales for family, couple, and individual therapy

The Integrative Psychotherapy Alliance model brought an interpersonal and systemic perspective to bear on theory, research, and practice on the psychotherapeutic alliance. Questions have been raised about the independence of the theoretical factors in the model and their operationalization in the Individual, Couple, and Family Therapy Alliance Scales. This paper presents results of a confirmatory factor analysis of the scales that delineated at least three distinct interpersonal factors as well as shorter versions of the three scales to facilitate their use in research and practice. The paper also presents the results of a study testing each factor's association with client retention and progress over the first eight sessions in individual and couple therapy. At least two of the interpersonal factors were uniquely associated with progress in individual and couple functioning. Implications of the results for theory, research, practice, and training in individual, couple, and family therapy are elaborated.     

What Does it Mean to be a Common Factors Informed Family Therapist?

The common factors paradigm in couple and family therapy has gained popularity over the past several decades, leading many therapists to refer to themselves as common factors family therapists. Despite this, no consensus exists on what it means to be a common factors family therapist, or if such a designation even makes sense given that the common factors paradigm is not a model. Synthesizing the existing common factors literature, a case is made for the designation “common factors informed family therapist,” and the following six core principles are outlined that characterize this designation: (1) sees overlap among theories; (2) passionate about theory, not a theory; (3) client centered; (4) monitors hope and the therapeutic alliance; (5) views clients as people rather than objects; and (6) prioritizes healing over therapy. Each of the concepts is discussed in depth, and clinical implications are provided.     

Benchmarking Community-Based Couple Therapy: Considering Measurement Reactivity

Couple therapy has been shown to be effective in randomized clinical trials; however, results from naturalistic couple therapy have been less consistent. This study utilized a benchmarking approach to compare the effectiveness of couple therapy in a community-based setting with findings from efficacy treatments, such as treatment within randomized clinical trials. The current study is the largest couple therapy sample published to date (N = 3,347 couples). Clients in couple therapy were asked to provide initial and weekly ratings of symptomology on the Outcome Questionnaire (OQ-45.2). We found that treatment effect sizes found at community clinics were smaller than efficacy studies (i.e., the benchmark). However, when taking into account measurement reactivity, the effect sizes were comparable. This is the first benchmarking study for community-based couple therapy, allowing for meaningful comparisons and understanding of outcomes in real-world couple therapy. Implications for the field are offered in terms of evaluating community-based psychotherapy studies with benchmarking for couple therapy. Results of this study provide clinicians and researchers a way to meaningfully compare couple therapy outcomes, accounting for differences in community-based practices and randomized clinical trials. This benchmark also underscores the impact of measurement sensitivity, an issue commonly overlooked in psychotherapy research and practice.     

Unraveling Change in Therapy: Three Different Process Research Methodologies

In response to repeated calls for process research on couple and family therapy, three different process research methodologies - grounded theory, change events analysis, and experimental manipulation - are presented and evaluated. A process research conceptual framework outlining some of the important issues in process research is presented. To illustrate each methodology, three completed process studies are briefly described, and a sample of results is provided. The strengths and weaknesses of each methodology are discussed, along with their role in generating and testing clinically relevant change theories. It is argued that each of these methodologies can provide researchers with important tools for unraveling the processes of change in couple and family therapy and should be used more frequently.     

Effectiveness of Couple Therapy in Practice Settings and Identification of Potential Predictors for Different Outcomes

Even though couple therapy is efficacious, there is no improvement in up to 50% of the couples. Also effect sizes found in effectiveness studies in real-world settings are considerably lower than those found in efficacy studies. There is a need to understand more about couple therapy effectiveness in practice settings and the factors responsible for different outcomes. A German nationwide study on the effectiveness of couple counseling including 554 couples applied the same methodology as two earlier studies in the same field. A remarkable consistency was found over the three independent studies in the burden with individual and relationship distress as well as in the rates of improvement. This supports the insight that the improvements reached through couple therapy in practice settings are only about half of the effect sizes reached in efficacy trials. Additionally this study investigated 64 factors, which were found to be influential for relationship quality and stability in earlier studies, for their impact on outcome. Factors present at initiation and termination of therapy were found, which correlate significantly with outcome and with separation of the couple in the follow-up. These factors could be included in prediction models for improvement and separation of the couple. The implications for the practice of couple therapy and for future research are discussed.     

Affective Arousal During Blaming in Couple Therapy: Combining Analyses of Verbal Discourse and Physiological Responses in Two Case Studies

Blaming one’s partner is common in couple therapy and such moral comment often evokes affective arousal. How people attune to each other as whole embodied beings is a current focus of interest in psychotherapy research. This study contributes to the literature by looking at attunement during critical moments in therapy interaction. Responses to blaming in verbal dialogue and at the level of the autonomic nervous system (ANS) were investigated in two couple therapy cases with a client couple and two therapists. Video-recorded couple therapy sessions were analyzed using discursive psychology and a narrative approach. The use of positioning, a discourse analytic tool, was also studied. ANS responses of the participants, including the therapists, were measured as electrodermal activity. The findings demonstrate how identity blaming, i.e. positioning the other person in ways counter to their preferred identity narrative, was accompanied by increased electrodermal activity in most participants. In the two cases studied, blaming centered on the themes of loyalty, trust and parenting. It is argued that identity blaming in these thematic domains increases the arousal level of the partners, since disloyalty, unfaithfulness and irresponsible parenting threaten the stability of the relationship.     

The Contribution of Emotionally Focused Couples Therapy

This article describes emotionally focused couple therapy and the contribution of this model to the field of couple therapy. A focus on emotional processing in the present moment, on process factors and on a genuine empathic connection with both clients is at the heart of this model. The creation of new patterns of emotional responses results in the creation of key new interactional responses. EFT is empirically validated on several levels: on the level of treatment outcome, and on the levels of the relational theory in which it is based and key moments and factors in the change process.     

Engaging men in family therapy: does the gender of the therapist make a difference?

The results of this exploratory Delphi study provide a beginning formulation of a gender-sensitive approach to working with men in the specialized field of couple and family therapy. The research specifically investigated what a panel of thirty-six 'expert' family therapists believed would be appropriate and effective techniques to engage men in therapy and in the process of family change. This report focuses on findings highlighting differences between what female and male therapists preferred as techniques to work with men in family therapy.