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.     

Co-Authoring “We-ness” and Stories of Intimacy

Drawing from narrative ideas and practices, we consider how individuals, couples, and couples with therapists co-author and co-edit stories of “we-ness,” a kind of relational consciousness, and intimacy in the context of research interviews. Adapting the “small story” narrative approach of Michael Bamberg, and recognizing researcher reflexivity, we present details from two separate studies into: (1) how cohabitating couples co-authored stories of “we-ness” in and beyond a research interview; and (2) how young married couples co-authored stories of “we-ness” by describing how they made significant decisions together through difficult yet successful conversations. Inviting such stories of “we-ness” can talk this intimacy into being. We relate the processes and outcomes of these studies to using a narrative approach to help individuals and couples with concerns about intimacy within the context of therapy.     

Randomized Controlled Trial of Imago Relationship Therapy: Exploring Statistical and Clinical Significance

For decades, couples around the world have used Imago relationship therapy (IRT) to improve their relationships. While anecdotal success stories abound, no randomized controlled trial of IRT's impact has been accomplished until now. The authors review the results of a randomized controlled trial of distressed, treatment-seeking couples who completed 12 sessions of IRT and the impact their involvement had on their marital satisfaction. Results showed that (a) individuals in the treatment condition experienced statistically significant increases in marital satisfaction, while couples in the control group did not; (b) levels of marital satisfaction did decrease significantly from posttreatment to follow-up but remained significantly higher than at pretreatment; (c) though statistically significant, the improvements experienced by the treatment group were not clinically significant improvements; and (d) while approximately one-third of participants achieved recovery during treatment, at the dyad level, only one couple achieved recovery. Further analysis and recommendations for future research are discussed.     

Treatment‐as‐Usual for Couples: Trajectories Before and After Beginning Couple Therapy

Couple therapy has been shown to be a meaningful way to improve couples’ relationships. However, less information is known about couples’ functioning prior to entering treatment in community settings, as well as how their relationship functioning changes from initiating therapy onward. This study examined 87 couples who began community‐based couple therapy during a longitudinal study of couples in the military. The couples were assessed six times over the course of 3 years, including time points before and after starting couple therapy. Using an interrupted‐time series design, we examined trajectories across the start of couple therapy in relationship satisfaction, divorce proneness, and negative communication. The results demonstrated that couples’ relationship satisfaction was declining and both divorce proneness and negative communication were increasing prior to entering couple therapy. After starting couple therapy, couples’ functioning on all three variables leveled off but did not show further change, but previous experience in relationship education moderated these effects. Specifically, those who were assigned to the relationship education program (vs. control) demonstrated greater reductions in divorce proneness and greater increases marital satisfaction after starting therapy; however, they also started more distressed.     

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.     

Optimizing the alliance in couple therapy

The complexity of the relation between alliance and outcome in couple therapy was investigated in a study of 47 couples in brief therapy. Self-rated alliance was measured after the first and third sessions using the couple version of the Working Alliance Inventory. The results indicated that the correlation between alliance and outcome was significantly stronger when the partners agreed about the strength of the alliance, when the male partner's alliance was stronger than the female's, and when the strength of both partners' alliance increased as therapy progressed. The authors suggest that a unique feature of couple therapy is that the partners have both a preexisting relationship with each other (allegiance) and an alliance with the therapist to balance.     

Initial relationship goal and couple therapy outcomes at post and six-month follow-up

The purpose of this study was to investigate the relationship between client initial goal for couple therapy (i.e., improve the relationship or clarify the viability of the relationship) and the outcomes (including their relationship status, i.e., separated or together) at posttreatment as well as at 6-month follow-up. Two hundred forty-nine couples (N = 498 individuals) seeking treatment for relationship distress in a naturalistic setting were treated by 20 therapists. Client initial relationship goal was attained by intake paperwork protocol, which included client initial goal for couple therapy and client perception of partner goal. Clients who reported that their goal was to improve the relationship reported better outcomes at post. Couples who reported their goal was to improve the relationship were less likely to break up at a 6-month follow-up. Of the 115 couples stating they wanted to improve the relationship, only nine (7.8%) couples were separated at 6 months. In contrast, of the 16 couples in which both partners wanted to clarify the relationship prior to therapy, nine (56%) were separated at follow-up. Therapist awareness of each individual's relationship goal prior to couple therapy could enhance outcomes, and treatment tailored according to initial goals could set the stage for positive outcomes however defined.     

Therapeutic alliance and progress in couple therapy: multiple perspectives

Therapeutic alliance research in couple therapy using multiple perspectives and longitudinal data has been sparse. This study used structural equation modelling to explore relationships between changes in alliance and in progress from clients' and therapists' perspective in a fairly large sample of couples (N=195) during the initial stage of therapy at an on‐campus training clinic. Self‐rated alliance was measured after sessions 2 through 4 with the Working Alliance Inventory. There was very little change in alliance over the early sessions of therapy, and changes in alliance did not always account for changes in relationship satisfaction. Husbands' perceptions of satisfaction and alliance seem to play an important role in the dynamics of the therapeutic process. Findings suggest a reciprocal relationship between perceptions of alliance and progress in therapy when combining perceptions of therapists and couple clients. Clinical implications and future research are discussed.     

The Impact of a Digital Recorder Intervention in Pragmatic/Experiential Therapy for Couples: A Pilot Study to Assess Emotional Flooding

The present study explored the effectiveness of a unique intervention for couple therapy, the Canned Attitude Method (a technique developed by Brent Atkinson), which utilized a digital recorder in and between therapy sessions. Participant dyads were randomly assigned to the intervention group utilizing the digital recorders or the control group, in which Pragmatic/Experiential Therapy for Couples (Atkinson in J Syst Ther 17:18–35, 1998) was conducted without the use of digital recorders. Both the intervention and the control groups were composed of five couples each for a total of 20 participants. This study hypothesized that the use of the Canned Attitude Method in couple therapy would produce a significant change in marital satisfaction, emotional flooding, and positive psychological tendencies associated with intimate relationships. Findings approached significance, demonstrating decreases in the experience of emotional flooding, gains in relationship satisfaction, and a shift towards positive attributes within the couples’ relationships.     

Structural couple therapy in the treatment of inhibited sexual drive

Abstract

This paper presents a study of a structural couple therapy approach to the treatment of inhibited sexual desire (ISD). ISD is first conceptualized as a relational phenomenon that may be most effectively treated in a couple context. Structural couple therapy is advanced and applied to the treatment of a clinical sample of couples presenting with ISD. Results of the study suggest that a structural couple therapy approach to ISD is effective in reducing symptoms of the sexual disorder and in increasing couple satisfaction.     

Therapeutic Assessment with couples

Therapeutic Assessment can be helpful to many types of couples, including (1) those who are considering marriage and wish to know each other more deeply, (2) long-term couples who are in distress and considering separating, and (3) couples who have decided to separate but wish to better understand why they were unable to stay together. This article comprises the first complete case study of Therapeutic Assessment (TA) with couples. I describe how those steps common to all forms of TA (initial sessions, extended inquiries, assessment intervention sessions, and summary/discussion sessions) differ when applied to couples. I also discuss the use of the Consensus Rorschach as an assessment intervention with long-term distressed couples engaged in problematic projective identification. The case example involves a young heterosexual couple married for 12 years who were at an impasse in couples therapy. The assessment helped the partners explore mutual conflicts around the expression of anger and dependency needs, and to resolve a power imbalance within the couple. Long-term follow-up showed that the Therapeutic Assessment helped the couple have more compassion for each other and move beyond the destructive role-lock they had fallen into. Also, the referring therapist reported that the TA helped resolve the impasse in the couples’ therapy.     

Effect of marital satisfaction on self-regulation efforts in couples: Value of heart rate variability measurements

This study explored self-regulatory efforts during the viewing of couple interactions and their association with relationship satisfaction. High-frequency heart rate variability (HF-HRV) was measured for each participant during a video recall of a recent couple interaction to quantify the self-regulatory processes governed by parasympathetic activity. Among 30 couples, HF-HRV was measured continuously during three specific periods to explore its change over time using a video-recall procedure: (1) resting state; (2) viewing of couple interactions (expressing daily life situations and conflictual interactions); and (3) recovery. Results of multilevel models revealed a u-shaped pattern of HF-HRV responses for men and women across the three periods with a nadir at the midway through the process. This pattern of physiological change (vagal suppression) reflects a flexible response to a stressful situation. Nevertheless, the pattern of physiological responses varied according to the level of relationship satisfaction. Men who were more satisfied in their couple relationship presented greater vagal suppression than dissatisfied men. In contrast, no significant HF-HRV changes were found in women over the different periods of the video-recall procedure and no moderating effect of relationship satisfaction. We discuss the different patterns of physiological responses observed both for men and women in terms of interindividual variability according to the level of their relationship satisfaction. The present study highlights the important role of relationship satisfaction in regulatory processes.     

Couple therapy for military veterans: overall effectiveness and predictors of response

Despite the numerous challenges facing U.S. veterans and their relationships, there have been no examinations of the effectiveness of couple therapy for relationship distress provided to veterans. In the present study, 177 couples presenting for couple therapy at two Veteran Administration Medical Centers completed assessments of relationship satisfaction prior to therapy and weekly during therapy. Results revealed that the average couple showed significant gains in relationship satisfaction during treatment (d=0.44 for men; d=0.47 for women); gains were larger for couples beginning therapy in the distressed range (d=0.61 for men; d=0.58 for women) than for couples in the nondistressed range (d=0.19 for men; d=0.22 for women). Rates of premature termination were high, with 19% of couples completing fewer than three sessions and 62% rated as not completing a "full course" of therapy. Benchmarking analyses demonstrated that the average gains were larger than would be expected from natural remission and similar to previous effectiveness trials; however, average gains were smaller than those observed in couple therapy efficacy trials. Relationship, psychological, and demographic characteristics were generally unrelated to the amount of change in therapy after controlling for initial satisfaction. However, African American couples showed significantly larger gains than Caucasian, non-Hispanic couples. Thus, though yielding smaller effects than those shown in efficacy trials, the impact of couple therapy for veterans' relationship problems appears to generalize across various demographic, psychological, and relationship characteristics.     

Marriage Counseling: A Christian Approach to Counseling Couples

An approach to marriage counseling aimed at Christian couples is described. The theoretical bases of the approach are cognitive behavioral therapy and structural and strategic marital therapies. Techniques are drawn from various schools of marriage therapy. Shared Christian values between counselor and clients are used to promote increased marital commitment, marital satisfaction, and personal spiritual growth. Marital satisfaction might be increased through helping the couple increase their intimacy, enhance their communication, improve their conflict management, and forgive each other for past and present hurts.     

The Effectiveness of Attachment Injury Resolution Model (AIRM) on Increasing Trust among the Injured Women with Marital Infidelity: A Case Study Approach

Abstract

Objective: The present study aimed at determining the effectiveness of emotionally-focused couple therapy, based on attachment injury resolution model (AIRM) on increasing trust among the injured women with marital infidelity. Method: The present study was a single case experiment of the multiple baseline design type. The population included all injured women with marital infidelity, referring to Bushehr family therapy clinics, among whom three women were selected and participated in the intervention through purposive sampling method, based on the desired recall, By considering the inclusion and exclusion criteria and answering the trust scale. Data analysis was conducted by visual analysis, clinically meaningful (reliable change index and normative comparison) and percentage improvement formula. Results: The percentage obtained from the overall increase of trust among the injured women during the therapy was 38.76 and follow-up was 48.58. In addition, the reliable change index during the therapy and a follow-up was 2.77 and 3.49 in the first couple, 3.10 and 3.62 in the second couple, 2.66 and 3.67 in the third couple indicating that these values were significant and higher than z?=?1.96 during the therapy and follow-up (p?=?0.05). Conclusion: Based on the research results, the emotionally-focused couple therapy based on attachment injury resolution model can be used as an effective intervention in reducing the injuries by marital infidelity.     

Feminist Issues in Couple Therapy

Abstract

The authors reviewed the feminist couple therapy literature from 1995 to 2006. They summarized this large body of work into several key themes. The first revealed that feminist couples therapists are continuing to discuss and deconstruct gender issues in couple therapy. The second showed that feminists believe that therapists should be educated both academically and personally about culture and diversity so as to support couples in their therapy around their own issues of diversity as well as learning to deal with issues of social justice as a couple. In the third theme, the authors introduced readers to feminists' emphasis on connection and empathy within couple and sex therapy. And, in the fourth, the authors explored feminists' work with power in couple therapy as they applied to couple therapy in general as well as around the specific topics of: balancing family and work and therapy for familial violence.     

Association between attachment insecurity and couple adjustment: Moderation by couple memory networks

This study investigated whether couple‐related memories and their organization in memory networks could act as cognitive resources to protect against the negative impact of insecure attachment on couple adjustment. In two studies (n1 = 153, n2 = 567), participants in a romantic relationship described a significant couple‐related memory and provided networked memories associated with their couple‐related memory, to assess its organization in the memory system, and rated each memory for its level of need satisfaction. Findings across the two studies revealed significant moderations of need satisfaction in couple‐related memory networks, such that a higher level of satisfaction need within couple‐related memory networks was associated with a reduced negative association of attachment anxiety and avoidance with couple adjustment. When examined separately, it was shown that need‐satisfying networked memories, but not main couple‐related memories, moderated the negative association of insecure attachment with couple adjustment.     

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.     

Identity,Couple and Intergroup Dynamics in Intercultural Families: Implications on Life Satisfaction of Partners

The current study analyzed how identity, couple, and intergroup dynamics are related to life satisfaction among 210 intercultural partners living in Italy. Three levels of analysis were considered: a micro level, taking into account the identity aspect of each partner in terms of self- or hetero-ethnic identification; a meso level, examining the passion, commitment, and intimacy of the couple sphere of the partners; a macro level investigating the discrimination that partners can perceive by the community as an effect of the relationship between dominant and minority groups. The results show that for both partners, foreign and Italian, the variables that have a predictive value on life satisfaction bring into play the couple and the intergroup dynamics, leaving out the identitary one. Specifically, increased perceived discrimination as a member of a mixed couple leads to decreased life satisfaction by partners. In turn, we can see that a strong intimacy between partners enhances their life satisfaction. These results introduce a reflection on the role of the differences about the ethnic identity, considered erroneously the main cause of dissatisfaction in the mixed couple. The implications of the study are described and suggestions for future research discussed.     

Attachment Change in Emotionally Focused Couple Therapy and Sexual Satisfaction Outcomes in a Two-year Follow-up Study

Emotionally focused couple therapy (EFT) is an empirically validated attachment based approach to couple therapy. From an EFT perspective, sexual functioning is viewed within the context of an attachment bond, but sexual satisfaction in EFT has not been empirically tested. We examined self-reported sexual satisfaction across 24?months in a sample of 32 couples who received an average of 21 EFT sessions. We found that sexual satisfaction increased across six time points from pre to post therapy and across follow-up (6, 12, 18, and 24?months), and that decreases in attachment avoidance from pre to post therapy predicted increases in sexual satisfaction across time. These findings provide evidence that EFT may help couples improve their sexual satisfaction by reducing attachment avoidance in therapy.