Couples with Intimate Partner Violence Seeking Relationship Help: Associations and Implications for Self‐Help and Online Interventions

In‐person conjoint treatments for relationship distress are effective at increasing relationship satisfaction, and newly developed online programs are showing promising results. However, couples reporting even low levels intimate partner violence (IPV) are traditionally excluded from these interventions. To improve the availability of couple‐based treatment for couples with IPV, the present study sought to determine whether associations with IPV found in community samples generalized to couples seeking help for their relationship and whether web‐based interventions for relationship distressed worked equally well for couples with IPV. In the first aim, in a sample of 2,797 individuals who were seeking online help for their relationship, the levels and correlates of both low‐intensity and clinically significant IPV largely matched what is found in community samples. In the second aim, in a sample of 300 couples who were randomly assigned to a web‐based intervention or a waitlist control group, low‐impact IPV did not moderate the effects of the intervention for relationship distress. Therefore, web‐based interventions may be an effective (and easily accessible) intervention for relationship distress for couples with low‐intensity IPV.     

Using Acceptance and Commitment Therapy to Treat Distressed Couples: A Case Study With Two Couples

Although the field of couple therapy has made significant strides in recent years, there continues to be a need for theoretically sound and empirically supported treatments. The current case study examines whether Acceptance and Commitment Therapy (ACT), an experiential acceptance-based behavior therapy, can be effective in treating distressed couples. Although ACT has demonstrated effectiveness in treating a variety of disorders in individuals, it has not been systemically applied to the treatment of couple distress, and the current study is the first empirical examination of ACT for the treatment of couples. Two married couples participated in the study. A number of core ACT interventions were modified to treat couples in a conjoint format. Cognitive defusion exercises were used to help couples reduce their fusion with and the believability of negative thoughts and feelings related to the relationship. Mindfulness and acceptance techniques were used to help couples increase awareness of their reactions to negative relationship cycles. Finally, value-directed action was used to help partners act in ways consistent with relationship values even in the presence of unwanted thoughts and feelings. The results of this preliminary case study suggest that ACT may be effective in increasing marital adjustment and satisfaction, and in reducing interpersonal and psychological distress in couples. Future studies with larger samples and more controlled designs are needed to build on the results from this single-case study.     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

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.     

Low-level relationship aggression and couple therapy outcomes.

Increasing evidence supports the efficacy of conjoint therapies that focus on intimate partner violence for couples who engage in mild to moderate physical aggression but want to preserve the relationship and end the aggression. However, there has been no examination of how this population responds to couple therapy that does not have a specific focus on aggression. This lacuna in the research literature is of concern because couples with a history of low-level aggression often seek couple therapy, but couple therapy without a focus on violence is thought to potentially exacerbate aggression. In the current study, the authors examined the efficacy of non-aggression-focused behavioral couple therapy for couples with and without a history of mild physical aggression. One hundred thirty-four couples, 45% of whom had experienced low-level aggression in the year prior to therapy, completed up to 26 sessions of couple therapy and 2 years of follow-up assessments. Results demonstrated no significant differences in relationship and individual outcomes by history of aggression. In addition, couples maintained very low levels of physical aggression during and after treatment and showed reductions in psychological aggression when relationship and individual functioning improved.     

A randomized clinical trial of a brief, problem-focused couple therapy for depression

The aim of this study was to evaluate a brief couple therapy for depression targeted for mildly discordant or nondiscordant couples struggling with the negative impact of depression. Subjects included women with major depression or dysthymia who had husbands without clinical depression. Thirty-five couples were randomly assigned to the 5-week intervention (n = 18) or a waitlist control group (n = 17), and followed up 1 and 3 months later. Results showed a significant effect of treatment in reducing women's depressive symptoms, with 67% of women improved and 40% to 47% recovered at follow-up, compared to only 17% improved and 8% recovered among women in the control group. Treatment was also effective in secondarily improving women's marital satisfaction, reducing husbands' levels of psychological distress and depression-specific burden, and improving both partners' understanding and acceptance of depression. The treatment was implemented in five 2-hour sessions, representing an efficient, cost-effective approach. Findings support the growing utility of brief, problem-focused couple interventions that simultaneously target depression, relational functioning, and psychological distress experienced by the loved ones of depressed persons.     

The formation of the therapeutic alliance in couple therapy

This study examines the predictive validity of several clinical variables--including marital distress, individual symptomatology, and family-of-origin experiences--on the formation of the alliance in couple therapy. Eighty people who were treated with a naturalistic course of integrative conjoint psychotherapy at a large midwestern outpatient clinic were assessed on the clinical variables before session 1. They also completed ratings of the therapeutic alliance after sessions 1 and 8. Individual symptomatology did not predict alliance formation at either treatment stage. Higher levels of marital distress predicted poorer alliances to treatment between partners at session 1. Marital distress also predicted therapeutic alliance quality for men and women at session 8. Family-of-origin distress predicted alliance quality for men at session 1, and for women at session 8. Family-of-origin distress for men and women predicted split alliances early in treatment, and marital distress predicted split alliances for women at session 8. Clinical implications for the assessment and treatment of couples are discussed.     

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.     

Potential Bone-Marrow Donors and Their Spouses: The Effects of Volunteerism on Distress Levels1

The current study sought to provide a better understanding of the reactions of bone-marrow volunteers to the possibility of donating by examining these volunteers in the context of their closest relationships. Using Tesser's (1988) self-evaluation maintenance (SEM) model as a guide, we examined the influence of spouses who are also volunteers on each member of the couple's distress levels and on the marrow volunteer's ambivalence about donating. We also examined the independent effects of known risk factors for donation-related distress and the combined effects of spouse volunteer status and these risk factors on distress levels. Questionnaire data were collected from 278 couples selected from 39 bone-marrow donor centers. Results demonstrated that when spouses of potential donors were engaged in any type of volunteer activity, members of the couple felt greater anxiety than when spouses were not volunteers. Additionally, other variables were found to have a conjoint effect with spouse volunteer status on volunteer and spouse anxiety levels.     

Couple‐based Intervention for Depression: An Effectiveness Study in the National Health Service in England

This study represents an effectiveness study and service evaluation of a cognitive behavioral, couple‐based treatment for depression (BCT‐D) provided in London services that are part of the “Improving Access to Psychological Therapies” (IAPT) program in England. Twenty‐three therapists in community clinics were trained in BCT‐D during a 5‐day workshop, followed by monthly group supervision for 1 year. The BCT‐D treatment outcome findings are based on 63 couples in which at least one partner was depressed and elected to receive BCT‐D. Eighty‐five percent of couples also demonstrated relationship distress, and 49% of the nonclient partners also met caseness for depression or anxiety. Findings demonstrated a recovery rate of 57% with BCT‐D, compared to 41% for all IAPT treatments for depression in London. Nonclient partners who met caseness demonstrated a 48% recovery rate with BCT‐D, although they were not the focus of treatment. BCT‐D was equally effective for clients regardless of the clinical status of the nonclient partner, suggesting its effectiveness in assisting both members of the couple simultaneously. Likewise, treatment was equally effective whether or not both partners reported relationship distress. The findings are promising regarding the successful application of BCT‐D in routine clinical settings.     

From Application to Approach: A Systematic Review of 50 Years of Psychoanalytic Couple Therapy

ABSTRACT

This systematic review of contributions to peer-reviewed journals in the area of couple interventions aims to provide a comprehensive and intensive overview of this evolving field, within psychoanalysis. Using a pan theoretical systematic review methodology, 113 peer-reviewed journal articles were reviewed, dated between 1963 and 2014, addressing the topic of couple therapy and psychoanalysis. This article addresses a number of specific questions including, where authors have published their work, what methodologies they have used, with which couples psychoanalysts have been working, how writers from within different theoretical orientations talk about their work with couples, and how the field has changed over time. It also explores emerging themes of the relationship between couple and individual therapy, sex, and co-therapy. This review of writing over the past 50 years suggests that although Classical contributions have waned over time, couple psychoanalysts from within Object Relations, Self Psychology, Intersubjectivity, and Relational orientations have evolved in their discourse about couple distress, from an application of psychoanalytic concepts to full-bodied, well-articulated, clear, and concise approaches to diagnosis and treatment. The first 50 years of writing in the field of couple psychoanalysis has brought us distinct treatment models, which have opened the door for greater communication and sharing within and between orientations.     

Depression, Marital Satisfaction and Communication in Couples: Investigating Gender Differences

The correlation between depression and dysfunctional marital interaction is well documented, but only a few studies have examined gender-related differences in marital interaction patterns of couples with a depressed partner. In this paper we examined differences in observed marital communication in a sample of 62 Swiss couples presenting for treatment of depression. There were 16 maritally distressed couples with a depressed wife, 21 maritally nondistressed couples with a depressed wife, 18 maritally distressed couples with a depressed husband, and 7 maritally nondistressed couples with a depressed husband. Marital interaction behavior was found to depend on gender, depression, marital distress, as well as gender of the depressed partner. Our results suggest the need for a gender-sensitive model of the link between marital interaction and depression.     

Taking stock of the longitudinal study of romantic couple relationships: The last 20 years

Longitudinal dyadic research provides significant benefits for our understanding of romantic couple relationships. In this systematic review, we begin by providing a broad overview of topical trends and approaches in longitudinal couple relationships research from 2002 through 2021. Then, we narrow our review to dyadic relationship quality articles, highlighting key themes as well as noting important gaps in the research. Using an intersectional perspective that acknowledges multiple ways that disadvantage, power, and oppression may be seen in both research and in couples' lived experience, we note prominent paradigms used in examining couple relationships, what types of questions have been most valued, and what groups and approaches are underrepresented in the literature. Most longitudinal couple relationships research is quantitative, relies on self-report approaches from American couples in the early-to-middle years of their relationships, concentrates more on negative aspects of relationships than positives, and takes a communication-satisfaction paradigm in studying couples. We see a clear need to increase the use of methodologies beyond self-report measures, conduct more studies with within-group minority, older adult, culturally-diverse, and context-specific samples to explore the diversity of relationships, and fully consider both strengths and positive processes in relationships as well as the challenges couples experience.     

Couple Therapy in the Presence of Mental Disorders

Abstract

Mental disorders and relationship discord commonly occur together and couples where one or both parties suffer from a mental disorder are commonly seen in couple therapy. Symptoms of mental disorders can usefully be conceptualized cybernetically and viewed as part of negative feedback loops that couples become trapped in without denying the potential contribution of biological or other types of knowledge. Most of the existing research focuses on couples and depression and couple therapy has been found to have efficaciousness as a treatment of depression especially when depression occurs along with relationship discord. There is less research on couple therapy and other mental disorders but general guidelines are offered that couple therapists can use with any of the mental disorders.     

The therapeutic alliance in couples therapy: clinical considerations

This article presents clinical considerations about the therapeutic alliance in couples therapy, stimulated by pertinent new research findings reported in this issue. A loyalty dimension of the couple's relationship is described, as well as its influence on the therapeutic alliance in couples therapy. The therapist's establishment of a "meta-alliance" with the couple around their loyalty conflicts, avoidance of splits and disruptions, and prioritization of marital distress (versus individual symptoms) as the primary focus of treatment all serve to solidify the therapeutic alliance. In addition, identifying the partners' early family-of-origin distress can help predict and respond to strains in the therapeutic alliance that may occur later in therapy. Finally, the therapist helping the couple to balance their relational power differences in therapy and to address their concerns about the impact of the therapist's gender also strengthens their therapeutic alliance. A clinical case and vignettes are included to illustrate these issues.     

Assessing Family Coordination in Divorced Families

Posttraumatic stress disorder (PTSD) and partner relationship difficulties commonly co-occur among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF). This study reports upon results for six male OEF-OIF Veterans with PTSD and their female relationship partners who completed cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD), which is a treatment that targets reductions in PTSD and couple distress. Case- and group-level data supported reductions in Veterans' PTSD symptoms and female partners' relationship distress. These findings suggest that CBCT for PTSD may be a promising intervention for OEF-OIF Veterans' PTSD and their partners.     

An Infertility Primer for Family Therapists: II. Working with Couples Who Struggle with Infertility

The distress of infertility and its medical treatments are profound, and the effects reverberate in each partner, the couple dyad, and the couple's relationships with family, friends, and medical systems. Yet family therapists, like others in our society, are often uninformed or misinformed about the experience of infertility. While the legacies of infertility may be painful and enduring, they often remain unspoken, and hence may be overlooked in standard interviews. This article describes the experiences of couples struggling with infertility, most of whom have sought medical intervention, and it provides treatment interventions for guiding couples through this difficult and often uncharted terrain. Case vignettes derived from 2 years of this clinical research study are included.     

Time and Rhythm in Couples

In this article, a theory is offered on the role of time in couple functioning and distress. The theory argues that no single set of temporal patterns is associated with couple distress or satisfaction. Rather, it advocates attention to the individual differences between couples in their understanding of the meaning of the temporal patterns in their relationship. The couple's narrative about the evolution and maintenance of these temporal patterns can be understood as revealing much about partners' experiences of the relationship in terms of the concepts of closeness and power. Interventions on the temporal dimension may be useful when the couple presents with an explicit problem in temporal patterns; when a particular temporal pattern prevents the couple from addressing other issues; and when the therapist wishes to reframe a problem in a manner that lowers conflict intensity. Along with the theory, a preliminary taxonomy of time problems in couples is presented as a guide to assessment. This is followed by clinical vignettes to illustrate how the theory can be used in couple therapy.     

A Randomized Controlled Trial of Coach Contact During a Brief Online Intervention for Distressed Couples

The negative impacts of relationship distress on the couple, the family, and the individual are well‐known. However, couples are often unable to access effective treatments to combat these effects—including many couples who might be at highest risk for relationship distress. Online self‐help interventions decrease the barriers to treatment and provide couples with high quality, research‐based programs they can do on their own. Using a combined multiple baseline and randomized design, the present study investigated the effectiveness of the Brief OurRelationship.com (Brief‐OR) program with and without staff support in improving relationship distress and individual functioning. Results indicated the program produced significant gains in several areas of relationship functioning; however, these gains were smaller in magnitude than those observed in Full‐OR. Furthermore, effects of Brief‐OR were not sustained over follow‐up. Comparisons between couples randomized to Brief‐OR with and without contact with a staff coach indicated that coach contact significantly reduced program noncompletion and improved program effects. Limitations and future directions are discussed.