The Efficacy of Behavioral Couples Therapy and Emotionally Focused Therapy for Couple Distress

Twenty treatment outcome studies, 13 of which evaluated behavioral couples therapy (BCT) and seven of which evaluated emotionally focused therapy (EFT) were reviewed, leading to the following conclusions. BCT leads to short and long-term gains for moderate to severe couple distress. In the long term BCT probably leads to no better outcomes than its constituent components—behavioral exchange training and communication and problem solving skills training. Addition of a cognitive therapy component to BCT or the use of a variety of treatment formats does not improve the efficacy of BCT. Integrative couples therapy and insight-oriented marital therapy may be more effective than BCT, but studies supporting this conclusion require replication. EFT leads to short and long-term gains for mild to moderate couple distress. Addition of a cognitive therapy component to EFT does not enhance its efficacy. EFT may be more effective than problem solving therapy and less effective than integrated systemic therapy, but the two studies supporting this conclusion require replication.Michael Byrne, PhD, is a Clinical Psychologist, Midland Health Board, Ireland; Alan Carr, PhD, is Director of the Clinical Psychology Training Programme, Department of Psychology, Arts Building, University College Dublin, Belfield, Dublin 4, Ireland (alan.carr@ucd.ie). Marie Clark, PhD, is Lecturer, Department of Psychology, University of Surrey, United Kingdom.     

An Ounce of Prevention: A Model for Working with Couples At-Risk for Battering

Literature on preventing spousal battering before it starts is virtually non-existent. This article describes a prevention of abuse program that targets couples at-risk for battering. At-risk couples and the process of engaging them in couples counseling are described. The prevention model is based on a Bowenian approach that focuses on partner differentiation and reducing emotionality and promoting rational thinking. It is assumed that increasing differentiation decreases the risk of spousal battering. The various techniques used to facilitate differentiation are presented as well as a case example illustrating a successful prevention of abuse experience.     

Adaptation of CBT for Traumatized Egyptians: Examples from Culturally Adapted CBT (CA-CBT)

In this article we illustrate how CBT can be adapted to a traumatized Egyptian population with Islamic beliefs, giving examples from our adaptation of Culturally Adapted–CBT (CA-CBT) for this cultural group. We discuss a culturally sensitive assessment measure of local somatic complaints and cultural syndromes that was devised based on clinical experience with traumatized Egyptians. We also demonstrate how to normalize symptoms, create positive expectancy about the treatment, and educate about trauma. We give examples of how mindfulness can be adapted for an Egyptian Islamic population, and we describe local religious strategies, such as dhikr (religious chanting), salah (ritualistic prayer), and dua (supplication), that may be used to promote attentional shift from rumination topics and to teach attentional control. We describe how “loving kindness” can be adapted for this group. We outline how to modify culturally generated catastrophic cognitions and how to conduct interoceptive exposure and to create positive re-associations in a culturally sensitive manner. We describe how worry themes are explored and addressed based on a heuristic panic attack–PTSD model; how to teach anger management in a culturally sensitive way; and how to address sleep-related problems in this population. We suggest using cultural transitional “rituals” at the end of the treatment to give patients a sense of closure and a positive feeling of transformation. A case example is presented to illustrate cultural challenges associated with delivering CA-CBT to an Egyptian population. We introduce certain concepts such as cultural grounding and explanatory model bridging, both therapeutic techniques that increase adherence, positive expectancy, and cultural consonance.     

The Role of Theory and Research in the Practice of Cognitive-Behavioral Couple Therapy: If You Build It,They Will Come

Cognitive-behavioral couple therapy (CBCT), while empirically validated and highly efficacious, does not always have positive results for couples. One factor that may limit the efficacy of this intervention is the way in which therapists are trained to provide this type of therapy. More specifically, there is a need for therapists to gain a solid foundation in CBCT theory in order to maximize treatment results. This paper presents an argument for why an understanding of theory is necessary for therapists in treating couples. Then, this paper presents our training model and how we integrate theory into our training of both graduate student therapists and more experienced clinicians. We take the stance that “if you build it, they will come.”     

Providing Relationship Interventions to Same-Sex Couples: Clinical Considerations,Program Adaptations,and Continuing Education

Despite remarkable similarities to different-sex couples in terms of core relationship processes and outcomes, same-sex couples differ from different-sex couples in important ways, including relational strengths (e.g., more egalitarian) and challenges associated with their sexual minority identity (e.g., discrimination). Given that most cognitive-behavioral relationship interventions have been designed for and tested on different-sex couples, clinicians wishing to serve same-sex couples will need to make appropriate adaptations to these interventions in order to remove heterosexist bias and sensitively meet the unique needs of same-sex couples. Further, clinicians should strive to be culturally competent in serving this population by developing knowledge of same-sex couple dynamics and issues, and by building a sense of comfort working with these families, which may involve addressing personal biases. The current paper seeks to provide an introduction to same-sex couple relational processes, and offers clinical recommendations and intervention adaptations to better serve this population. Some examples will refer to the development of the Strengthening Same-Sex Relationships programs, culturally sensitive relationship education programs specifically designed for and successfully piloted with male and female same-sex couples.     

Adaptation of CBT for Traumatized South African Indigenous Groups: Examples from Multiplex CBT for PTSD

This article describes how Culturally Adapted Multiplex CBT, a treatment that emphasizes somatic processing and emotion regulation, was adapted for a traumatized South African indigenous group, the Sepedi. A model of psychopathology is presented, the Multiplex Model of Trauma-Related Disorder, which depicts the processes that generate multiple comorbidities and prominent somatization in minority, refugee, and other non-Western populations. The nine dimensions of Culturally Adapted Multiplex CBT are discussed, and so too the “cultural adaptation diamond.” Concepts such as “explanatory model bridging” are presented. A culturally sensitive assessment measure of local somatic complaints and cultural syndromes (the Sepedi Symptom and Syndrome Addendum, or Sepedi SSA) is detailed, as well as how CBT techniques were implemented with this group—for example, modification of culturally specific catastrophic cognitions, doing exposure (e.g., interoceptive exposure), teaching attentional control and mindfulness techniques, and teaching “loving kindness.” Case examples with clinical outcomes are provided to further illustrate how Multiplex CBT was adapted for the South African indigenous group.     

A Pilot Study of the Effects of Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder on Parenting

Parental posttraumatic stress disorder (PTSD) is associated with parenting difficulties. Cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD) improves PTSD symptoms, relationship adjustment, and partners’ mental health functioning. However, the impact of CBCT for PTSD on parenting competency is unknown. In this pilot study, the effects of CBCT for PTSD on parenting competency were investigated in 14 individuals (6 patients with PTSD and 8 partners) who had children under age 18. Results suggested that most participants perceived themselves as competent in their parenting prior to treatment, and some enhancements in competency occurred following CBCT for PTSD. Moreover, changes in parenting competency were associated with improvements in patient-rated PTSD. Adjunctive interventions targeting parenting and goals for future research are discussed.     

Relationship Education for Military Couples: A Pilot Randomized Controlled Trial of the Effects of Couple CARE in Uniform

Military life can place excess strain on couple relationships. The Couple CARE relationship education program was tailored to address the challenges of military couples. Thirty-two Australian military couples participated in a pilot feasibility study assessing the Couple CARE in Uniform adaptation against an active control. Relationship satisfaction and communication improved in both conditions, with no significant difference between the conditions. Couples' high relationship satisfaction on presentation, paired with modest statistical power, might have contributed to the null results. However, Couple CARE in Uniform had significantly higher consumer satisfaction than the comparison condition, suggesting it is a program worthy of further evaluation.     

A Controlled Study of Eye Movement Desensitization and Reprocessing (EMDR) for Boys with Conduct Problem

Summary

We suggest that trauma contributes to the development and persistence of conduct problems, and should be addressed. Eye movement desensitization and reprocessing (EMDR) was selected as a promising trauma treatment. Twenty-nine boys with conduct problems in residential or day treatment were randomized into standard care or standard care plus 3 trauma-focused EMDR sessions. The EMDR group showed large and significant reduction of memory-related distress, as well as trends towards reduction of post-traumatic symptoms. The EMDR group also showed large and significant reduction ofproblem behaviors by 2-month follow-up, whereas the control group showed only slight improvement. These findings provide support for EMDR's use as a trauma treatment for boys ages 10-16, as well as support for the hypothesis that effective trauma treatment can lead to reduced conduct problems in this population.     

A Controlled Pilot-Outcome Study of Sensory Integration (SI) in the Treatment of Complex Adaptation to Traumatic Stress

This study tested whether sensory integration (SI) treatment combined with psychotherapy would improve symptom outcome over psychotherapy alone in the treatment of complex posttraumatic stress, as measured by the Disorders of Extreme Stress Not Otherwise Specified (DESNOS) clinical construct in a group of 10 adult patients with histories of childhood abuse. DESNOS symptoms were assessed at three time periods (T1, baseline; T2, after experimental group SI treatment; and T3, after wait-list control group SI treatment) using the Structured Interview for Disorders of Extreme Stress (SIDES). The Sensory Learning Program? (SLP), developed by the Sensory Learning Institute of Boulder, Colorado, was used as the SI treatment modality. Results indicated significant differential improvement for the group treated with SLP in SIDES Total Score (T1/T2 and T2/T3), Self Perception (T1/T2 and T2/T3), Affect Regulation (T2/T3), and Alterations in Meaning (T1/T2).     

The Application of Family Systems Theory to Organizational Consultation: A Content Analysis

A content analysis was performed on 43 articles published between 1970 and 1998 discerned as relating family systems theory (FST) frameworks and constructs to organizational consultation. Frameworks and constructs were coded and then investigated in relation to four independent variables: type of organization, decade of article publication, gender, and educational training of author. Results indicate that the use of FST frameworks and constructs vary depending upon the characteristics of the organization, time period, and consultant. Results highlight specific FST frameworks and constructs most common in organizational consultation.     

Clinical Guidelines for Working With Stepfamilies: What Family,Couple, Individual,and Child Therapists Need to Know

This article draws on four decades of research and clinical practice to delineate guidelines for evidence‐informed, clinically sound work with stepfamilies for couple, family, individual adult, and child therapists. Few clinicians receive adequate training in working with the intense and often complex dynamics created by stepfamily structure and history. This is despite the fact that stepfamilies are a fundamentally different family form that occurs world‐wide. As a result many clinicians rely on their training in first‐time family models. This is not only often unhelpful, but all too often inadvertently destructive. The article integrates a large body of increasingly sophisticated research about stepfamilies with the author's four decades of clinical practice with stepfamily relationships. It describes the ways in which stepfamilies are different from first‐time families. It delineates the dynamics of five major challenges stepfamily structure creates: (1) Insider/outsider positions are intense and they are fixed. (2) Children struggle with losses, loyalty binds, and change. (3) Issues of parenting, stepparenting, and discipline often divide the couple. (4) Stepcouples must build a new family culture while navigating previously established family cultures. (5) Ex‐spouses (other parents outside the household) are part of the family. Some available data are shared on the impact of cultural and legal differences on these challenges. A three‐level model of clinical intervention is presented: Psychoeducational, Interpersonal, and Intrapsychic/Intergenerational Family‐of‐Origin. The article describes some “easy wrong turns” for well‐meaning therapists and lists some general clinical guidelines for working with stepfamily relationships.     

Developing the couple perspective in parenting support: evaluation of a service initiative for vulnerable families

The importance of the relationship between parents is frequently underestimated by those designing and developing services to support parents in bringing up their children. Instead, the primary focus of recent family support initiatives in the United Kingdom has been on improving parenting skills. This article describes the outcomes of a project designed to maximize the effectiveness of parenting support to vulnerable families through sensitizing the workforce of a community‐based adult mental health agency to take account of the parental couple in providing postnatal support groups, parenting workshops and relationship counselling. Evaluating outcomes from these services suggests that a couple orientation adds significant value to the effectiveness of parenting support.     

Posttraumatic Stress in Survivors of Childhood Cancer and Mothers: Development and Validation of the Impact of Traumatic Stressors Interview Schedule (ITSIS)

This study presents initial data validating the use of a new instrument, the Impact of Traumatic Stressors Interview Schedule (ITSIS), to assess the occurrence of cancer-related posttraumatic stress in childhood cancer survivors and their mothers. Sixty-six child/adolescent cancer survivors and 64 of their mothers, as well as 130 young adult survivors, completed the ITSIS and other measures of posttraumatic stress and general distress. Five ITSIS factors were identified for the mothers and for the young adult survivors, and three ITSIS factors were identified for the child/adolescent survivors. Factors in all three samples reflected symptoms of posttraumatic distress, concern over medical late effects, communication, and changes in self due to cancer. Only young adult survivors had a factor reflecting a positive engagement with the cancer history. Factors correlated with validation measures in predicted ways. The findings further the conceptualization of posttraumatic stress in pediatric cancer by describing the traumatic experience for survivors and mothers. Comparing factors across samples allows an examination of different influences of cancer within families and over the course of development.     

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.     

Assessing Psychological Inflexibility Pertaining to Self in Patients With Posttraumatic Stress Disorder Using an Indirect Measure of (Nonassociative) Propositions

Relational frame theory (RFT) is a modern behavioral account of human language and cognition, which focuses on relations or propositions, rather than associations, as core explanatory constructs. In an attempt to measure such propositions, RFT researchers have developed the implicit relational assessment procedure (IRAP). It has been argued that the size of an IRAP effect may provide a metric for psychological inflexibility. The current study aimed to determine whether psychological inflexibility, as measured by the self-focused Natural Language-IRAP (NL-IRAP), would be higher in a clinical sample of individuals with a diagnosis of PTSD (N = 29) when compared to a nonclinical sample. Subsequently, the study investigated whether the self-focused NL-IRAP could be used to predict the presence of a clinical diagnosis, using a ROC analysis. As predicted, higher levels of psychological inflexibility were observed for the clinical group. The self-focused NL-IRAP also correctly classified the presence of PTSD (AUC = 76%) with a sensitivity level of 79.3% and a specificity level of 59.2%. Overall, the use of the IRAP as a nonassociative clinical measure appears promising.     

Resolving the Curious Paradox of the (A)Sexual Lesbian

SUMMARY

Lesbians' erotic lives have been bracketed by opposing sexual narratives. According to a variety of experts, sex between two women is an unnatural and unlikely event. Data from a number of other sources suggest that lesbian sex is both frequent and ecstatic. For many long term partners, these polarized narratives serve as filters, screening out a myriad of middle ground practices and scenarios. Because more subtle possibilities are invisible or discounted, couple's only alternative-after the passionate courtship phase of the relationship has ended-is lesbian bed death. In such cases, renewed erotic contact depends on the restoration of the erased sexual middle-ground. This paper focuses on the strategies clinicians can use to neutralize the hegemonic either/or lesbian sexual narratives and expand their client's erotic repertoires.     

Durability of Cognitive Behavioral Therapy Effects for Youth and Adolescents With Anxiety,Depression, or Traumatic Stress:A Meta-Analysis on Long-Term Follow-Ups

Cognitive behavioral therapies (CBT) for youth with anxiety, traumatic stress, and depression have demonstrated strong effects in individual studies and meta-analyses. Relatively more attention has been given to posttreatment effects, though, and assessment of follow-up effects has been limited at the meta-analytic level. The current meta-analysis aimed to (a) examine the effects of youth CBT at posttreatment, 1-month, 3-month, 6-month, 1-year, and long-term (2 + years) follow-up as well as (b) identify research-related variables (e.g., measure respondent type) that relate to effects. Using a random effects model across 110 child and adolescent CBT groups, within-group effect sizes were large at posttreatment (g = 1.24) and from 1-month through long-term follow-up (g = 1.23–1.82), and effect sizes did not significantly differ by treatment target (i.e., anxiety, traumatic stress, depression). However, availability of outcome data for effect sizes diminished across later follow-up assessments. Moreover, effect sizes were significantly associated with outcome respondent type across assessment timing, with outcome measures from caregiver and youth respondents associated with smaller effect sizes (B = -0.97, p < 0.001) relative to outcome measures that were evaluator-reported. Results provide initial support for the durability of treatment effects for youth CBTs and highlight the importance of some confounding variables. Implications for improving treatment research standards and prioritizing assessment of long-term follow-up assessment are discussed.