Effects of Behavioral Marital Therapy: A Meta-Analysis of Randomized Controlled Trials

Associations between dimensions of the social environment and cardiometabolic health outcomes: a systematic review and meta-analysis

OBJECTIVES

The social environment (SE), that is, the social relationships and social context in which groups of people live and interact, is an understudied element of the broader living environment which impacts health. We aim to summarise the available evidence on the associations between SE and cardiometabolic disease (CMD) outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus and Web of Science Core Collection were searched from inception to 28 February 2024.

ELIGIBILITY CRITERIA

We included studies for which determinants were SE factors such as area-level deprivation and social network characteristics and outcomes were type 2 diabetes mellitus and cardiovascular diseases incidence and prevalence.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts and full text were screened in duplicate. Data appraisal and extraction were based on the study protocol published in PROSPERO. Methodological quality was assessed with the Newcastle-Ottawa Scale. We synthesised the data through vote counting and meta-analyses.

RESULTS

From 10 143 records screened, 281 studies reporting 1108 relevant associations are included in this review. Of the 384 associations included in vote counting, 271 (71%) suggested that a worse SE is associated with a higher risk of CMD. 14 meta-analyses based on 180 associations indicated that worse SE was associated with increased odds of CMD outcomes, with 4 of them being statistically significant. For example, more economic and social disadvantage was associated with higher heart failure risk (OR 1.58, 95% CI 1.08 to 1.61; n=18; I2=95%). With the exception of two meta-analyses for men, meta-analysed sex-specific associations consistently showed results in the same direction as the overall meta-analyses.

CONCLUSION

Worse SE seems to be associated with increased odds of CMD outcomes, although certain SE dimensions are underexplored in relation to CMD.

PROSPERO REGISTRATION NUMBER

CRD42021223035.

Subjective emotion trajectories in couple therapy and associations with improvement in relationship satisfaction

Existing couple therapies are generally effective for reducing romantic relationship distress and divorce, but therapy outcomes remain poor for many. Outcomes can be improved through greater understanding of session-by-session therapeutic processes, particularly in real-world treatment settings. Modern couple therapy models commonly emphasize the importance of emotional experiences as key change processes, yet few empirical studies have tested the merits of this focus. The present study addresses this limitation by examining trajectories of subjective emotions and their association with change in a key relationship outcome, relationship satisfaction, among military veterans and their partners at a VA Medical Center. Partners rated their relationship satisfaction prior to couple therapy sessions and subjective emotions immediately after sessions. Consistent with hypotheses, both hard (e.g., anger) and soft (e.g., sadness) negative emotions decreased significantly over the course of therapy. Those couples with greater decreases in hard negative, but not soft negative, emotions showed significantly more improvement in relationship satisfaction. Positive emotions did not significantly change across couples in general, but those couples whose positive emotions did increase also showed more improvement in relationship satisfaction. These results suggest change in subjective emotions may be one process underlying improvement in couple therapy and lend empirical support to the emphasis on emotion-based change processes underlying acceptance-based and emotion-focused couple therapies.

Meta-analysis of couple therapy in non-randomized clinical trial studies: Individual and couple level outcomes

Couple therapy has outperformed control conditions in randomized clinical trials (RCTs). However, there have been some questions whether couple treatment in naturalistic settings is as effective as those with more rigorous controls. The current meta-analysis examined 48 studies of couple therapy in non-randomized clinical trials. The pre-post effect size was Hedge's g = 0.522 for relational outcomes and Hedge's g = 0.587 for individual outcomes. However, there was significant heterogeneity in the results. Several moderators explained some of the variance in these estimates. For relationship outcomes, studies who had older couples and longer length of relationship had better outcomes. Studies with a higher percentage of racial/ethnic minority (REM) couples and studies in Veteran Affairs Medical Centers (VAMC) had lower relational outcomes. For individual outcomes, studies that had more sessions, older couples, and VAMC had better outcomes. Studies with a higher percentage of REM couples also had worse individual outcomes. Trainee status was not consistently related to relational or individual outcomes. Implications for research and practice are provided.

Heterogeneity estimation in meta-analysis of standardized mean differences when the distribution of random effects departs from normal: A Monte Carlo simulation study

BACKGROUND

Advantages of meta-analysis depend on the assumptions underlying the statistical procedures used being met. One of the main assumptions that is usually taken for granted is the normality underlying the population of true effects in a random-effects model, even though the available evidence suggests that this assumption is often not met. This paper examines how 21 frequentist and 24 Bayesian methods, including several novel procedures, for computing a point estimate of the heterogeneity parameter ([Formula: see text]) perform when the distribution of random effects departs from normality compared to normal scenarios in meta-analysis of standardized mean differences.

METHODS

A Monte Carlo simulation was carried out using the R software, generating data for meta-analyses using the standardized mean difference. The simulation factors were the number and average sample size of primary studies, the amount of heterogeneity, as well as the shape of the random-effects distribution. The point estimators were compared in terms of absolute bias and variance, although results regarding mean squared error were also discussed.

RESULTS

Although not all the estimators were affected to the same extent, there was a general tendency to obtain lower and more variable [Formula: see text] estimates as the random-effects distribution departed from normality. However, the estimators ranking in terms of their absolute bias and variance did not change: Those estimators that obtained lower bias also showed greater variance. Finally, a large number and sample size of primary studies acted as a bias-protective factor against a lack of normality for several procedures, whereas only a high number of studies was a variance-protective factor for most of the estimators analyzed.

CONCLUSIONS

Although the estimation and inference of the combined effect have proven to be sufficiently robust, our work highlights the role that the deviation from normality may be playing in the meta-analytic conclusions from the simulation results and the numerical examples included in this work. With the aim to exercise caution in the interpretation of the results obtained from random-effects models, the tau2() R function is made available for obtaining the range of [Formula: see text] values computed from the 45 estimators analyzed in this work, as well as to assess how the pooled effect, its confidence and prediction intervals vary according to the estimator chosen.

Couple therapy in the 2020s: Current status and emerging developments

This paper provides a critical analysis and synthesis of the current status and emerging developments in contemporary couple therapy. Its narrative centers on the evolution of couple therapy into a prominent intervention modality and coherent body of practice. The review begins with the consideration of the field's strong empirical underpinnings derived from research on couple therapy and basic relational science. Couple therapy comprises the widely accepted method for reducing relationship distress and enhancing relationship quality. Moreover, both as a stand-alone intervention and in conjunction with other treatment formats, couple-based interventions have garnered considerable empirical support for their effectiveness in addressing a broad spectrum of specific relational dysfunctions as well as individual emotional and physical health problems. We highlight the convergence of methods through common factors, shared strategies, and remarkably similar arrangements across approaches. Our review also points to key differences among approaches, the importance of recognizing respective strengths and limitations linked to these differences, and building on differences across models when selecting and tailoring interventions for a given couple. The discussion concludes with a consideration of recent trends in the field including the impact of telehealth and related digital technologies, the expansion of specific treatments for specific problems and diverse populations, the interface of couple therapy with relationship education, and enduring challenges as well as new opportunities addressing broader systemic and global dynamics.

Treated together-changed together: The application of dyadic analyses to understand the reciprocal nature of alliances and couple satisfaction over time

In a Norwegian study of 73 couples attending a residential couple therapy program lasting between 6 and 12 weeks, weekly self-report data on therapy alliance and couple satisfaction were collected using routine outcome monitoring (ROM). The aim was to show how dyadic analyses could be applied to examine the predictive association between alliances and couple satisfaction. Results showed that improved alliance between dyad members and their couple therapist predicted their spouses' couple satisfaction. Furthermore, improved couple satisfaction predicted improvement in spouse's alliance. The clinical implication of these findings should heighten awareness to the importance of establishing and maintaining the alliance of male partners in couple therapy, something that predicts their spouses' couple satisfaction. These findings help nuance the already existing literature on the working alliance. Furthermore, we propose that dyadic analyses should be widely used in any psychotherapeutic research that aims to understand the reciprocal effects of dyads.

A Summary of Current Findings on Quality of Life Domains and a Proposal for Their Inclusion in Clinical Interventions

Whilst the assessment of quality of life (QoL) and well-being has burgeoned in the past 50 years, there still remains relatively little research into its treatment in psychology, in spite of the launching of such approaches as positive psychology to widen the ambit of interventions to promote well-being. We posit that there are a number of outstanding QoL areas that could be integrated into standard therapeutic procedures, and that this would this result in an increase in well-being as a therapeutic outcome. To investigate this an exploratory search of the literature was undertaken of associations between improvements in a life domain and increased well-being or QoL. Ten domains (relationships, work, money, health, and leisure, mindfulness, self-esteem, resolution of past life events, mental style and life management skills) were identified. In view of the substantial evidence of the cumulative impact of these domains upon well-being, it is proposed that conducting a unidimensional clinical intervention that focuses only on the presenting issue is not sufficient. Implications and possible therapeutic pathways are discussed and it is recommended that practitioners include such QoL domains in their assessment, case formulation, and intervention planning.

The Alliance-Outcome Association in Couple Therapy: A Common Fate Model

The working alliance has been shown to be a robust predictor of couple therapy outcomes. However, there are still questions regarding the best way to conceptualize and analyze the association between the alliance and outcomes in the couple therapy context. This study presents results from a relatively novel analytic approach for evaluating the alliance and therapy outcomes via the shared influence model (i.e., common fate statistical methodology) with 93 couples who had at least three sessions. Examining the alliance in couple therapy this way allows for nuance in conceptualizing the process of the alliance among partners and the therapist in couple therapy. Empirically, the question that remains is whether the shared experience of the alliance between partners is a stronger predictor of therapy outcome as compared to the unique individual experiences of the alliance. This approach has not yet been utilized to model the couple alliance-outcome association. Results revealed that the shared influence model demonstrated a significant association between the alliance and therapy outcome. Specifically, the couple-level alliance construct was adequately represented from the partners' alliance ratings with the therapist, and couples that report higher shared alliance experiences were also likely to have better therapy outcomes. These findings suggest that conceptualizing and analyzing the alliance at the couple level may be strongly advantageous. Implications for research and practice are provided.

Evaluation des webbasierten PaarBalance®-Partnerschaftsprograms bei beratungsbegleitendem Einsatz

<b><i>Hintergrund:</i></b> Beziehungsprobleme gehen mit psychischen und physischen Problemen einher. Auch wenn effektive Behandlungsmöglichkeiten existieren, suchen viele Paare spät oder keine professionelle Hilfe. Die Kombination eines Online-Programms mit einer Paarberatung kann helfen, Barrieren wie hohe Kosten, lange Anfahrtswege oder Wartezeiten zu reduzieren und den Zugang zu effektiver Beratung zu erleichtern. <b><i>Methoden:</i></b> Die Studie prüfte die Wirksamkeit des PaarBalance®-Online-Programms zur Verbesserung der Beziehungszufriedenheit in Kombination mit einer niederfrequenten Face-to-Face-Paarberatung in einem unkontrollierten Prä-post-Design. In diesem naturalistischen, an die Routinepraxis der Beratenden (<i>n</i> = 8) angelehnten Design erhielten die 92 Teilnehmenden, welche über die Beratungsstellen oder über Zeitungsartikel rekrutiert wurden, während eines 15-wöchigen Interventionszeitraums neben wenigen Beratungsterminen einen Zugang zum Online-Programm. Gemessen wurde die Auswirkung des kombinierten Unterstützungsangebots auf Beziehungszufriedenheit, Depressivität und Angst zu drei Messzeitpunkten (Prä, Post nach 15 Wochen und Follow-up nach 12 Wochen). Die Daten wurden mit hierarchisch linearen Modellen analysiert. <b><i>Ergebnisse:</i></b> Die Beziehungszufriedenheit verbesserte sich signifikant während der Interventionsphase (Cohens <i>d</i> = 0,29) und blieb während der Follow-up-Phase stabil. Für Depression und Angst zeigten sich keine signifikanten Veränderungen. <b><i>Schlussfolgerungen:</i></b> Die Ergebnisse weisen darauf hin, dass das PaarBalance®-Programm in Kombination mit einer niederfrequenten Paarberatung ein effektives Mittel zur Verbesserung der Beziehungszufriedenheit darstellen könnte. Zukünftige kontrollierte Studien sind nötig, um die Wirksamkeit dieses Modells abschließend zu klären.

Client Perceptions of the Most and Least Helpful Aspects of Couple Therapy

Couples have a unique perspective to share about the therapy they receive. The current study uses a mixed-methods design to examine what couples report about most and least helpful elements of two behaviorally-based treatments tested in a large clinical trial of couple therapy. Results indicate that responses are highly variable and fall into five main themes, which are then compared between treatment conditions, genders, and outcome groups. One interesting finding is that all groups reported wanting more discussion of sexual issues. Findings are discussed in the context of common factors research, recent developments toward unified principles of change in couple therapy, and model-specific differences.

Cognitive-Behavioral Therapy for Relationship Distress: Meta-analysis of RCTs with Social Work Implications

PURPOSE

The purpose of the present meta-analysis is twofold: 1) determine the aggregated statistical effect of cognitive-behavioral couples therapy (CBCT) for relationship distress in randomized controlled trials and 2) use the findings to inform clinical social work practice and research.

METHODS

A systematic review was conducted using electronic databases and the reference lists of included studies. The random effects model meta-analysis used a hedges' g effect size.

RESULTS

After the removal of an outlier, a homogeneous (Q = 16.66, df = 12, p = .16, I ² = 27.96), significant, moderate effect favoring CBCT (Hedges' g summary effect = .421, Z = 4.51, p < .0001, 95% confidence interval: 0.238 to 0.604, standard error = .093, variance = .009, k =  13) was obtained.

DISCUSSION

It is anticipated that cognitive-behavioral/evidence-based social work clinicians and researchers will use the findings to support their clinical practice and advance their clinical research, respectively.

Efficacy of the web-based PaarBalance program on relationship satisfaction, depression and anxiety - A randomized controlled trial

OBJECTIVE

Although relationship distress is strongly associated with mental health problems, poorer social functioning and lower quality of life, only a minority of distressed couples engage in effective couples therapy. Common barriers are the financial burden, fear of being stigmatized, long waitlists and logistical concerns, such as the difficulty in scheduling appointments. Therefore, more accessible help for relationship distress is needed, such as internet-based interventions.

METHOD

This study evaluates the efficacy of the German web-based PaarBalance program, an 18-sessions online program for couples and individuals in an intimate relationship. Participants with relationship distress recruited via the internet had access to the unguided self-help program for twelve weeks. A total of 117 individuals (N = 60 participated as couples, N = 57 participated without a partner) were randomly assigned to begin the intervention immediately or to a 12-week waitlist control group. The primary outcome was relationship satisfaction. Secondary outcomes included symptoms of depression and anxiety.

RESULTS

The intervention group showed significant improvement in relationship satisfaction (Cohen's d =0.77) compared with the waitlist control group. Small to medium effect sizes in favor of the intervention group, but no statistically significant differences were found regarding depression (d = 0.43) and anxiety (d = 0.45).

CONCLUSION

PaarBalance seems to be an effective self-guided intervention to improve relationship satisfaction in people with relationship problems.

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.

Trajectories of Sexual Satisfaction and Frequency During and After Couple Therapy for Relationship Distress

Using a sample of 134 distressed, different-sex couples, this study investigated the effects of Integrative Behavioral Couple Therapy and Traditional Behavioral Couple Therapy on sexual dissatisfaction and sexual frequency both during treatment and in the five years following treatment. Therapy effects depended on treatment type, gender, and whether sexual distress was identified as a presenting problem; while couple therapy may initially improve some aspects of the sexual relationship, impacts tend to fade over follow-up. Couple therapy may benefit from incorporating a greater emphasis on sex and inclusion of techniques from sex therapy.

Cognitive-behavioral and emotion-focused couple therapy: Similarities and differences

Background

Couples and families often seek therapy to deal with relational distress, which is a result of external or internal factors of the relationship. Two approaches are acknowledged to be most effective in dealing with relationship distress or psychological disorders in couples: (a) cognitive behavioral couple therapy with new directions (CBCT) and (b) emotion-focused couple therapy (EFCT). In this article we investigate how much CBCT and EFCT really differ with regard to working with emotions, which is claimed to be a major focus of EFCT, and whether there exist significant differences in efficacy between these two approaches.

Method

This article critically reviews the theoretical background, process, techniques and outcomes associated with CBCT and EFCT in an effort to challenge the assumptions noted above.

Results

There is no evidence that EFCT is more emotion-focused than CBCT. Both approaches were repeatedly examined with RCT studies with follow-ups. In sum, no significant differences in effect size were found between CBCT and EFCT.

Conclusion

CBCT and EFCT are both effective in reducing couples’ distress.

CBCT and EFCT are both effective in helping couples deal with relationship distress.

Both are similarly effective in helping couples to better understand and cope with their presenting concerns.

Both approaches address the importance of personal schema, triggering relevant cognitions and emotions.

Both approaches help couples wherein one partner has been diagnosed with a clinical disorder.

Interventions for Couples

Because relationship discord and dissolution are common and costly, interventions are needed to treat distressed couples and to prevent distress among vulnerable couples. We review meta-analytic evidence showing that 60-80% of distressed couples benefit from behavioral and emotion-focused approaches to couple therapy, but we also note that treatment effects are weaker in actual clinical practice than in controlled studies, dissipate following treatment for about half of all couples, and may be explained by factors that are common across models. Meta-analyses of prevention programs reveal reliable but smaller effects, reflecting a need to know more about whether and how communication mediates effects, about how risk and diversity moderate effects, and about how technology-enabled interventions can reduce attrition in vulnerable populations. Interventions for couples are improving and expanding, but critical questions remain about how and for whom they work.

Mechanisms of change in a brief, online relationship intervention

[Correction Notice: An Erratum for this article was reported online in Journal of Family Psychology on Nov 14 2019 (see record 2019-69050-001). In the article, the effect sizes listed in the "Mech. slope the effect sizes listed in the "Mech. slope →CSI slope" and "Indirect effect of treatment" columns of Table 2 were calculated incorrectly and mistakenly reported as Cohen's d values. These errors do not change any of the conclusions of the study. However, the correct values, column heads, and associated footnote CSI slope" and "Indirect effect of treatment" columns of Table 2 were calculated incorrectly and mistakenly reported as Cohen's d values. These errors do not change any of the conclusions of the study. However, the correct values, column heads, and associated footnote are presented in the erratum.] Internet delivery of couple interventions is becoming increasingly popular; however, little is known about mechanisms of change during these interventions. One online, self-help relationship intervention-the OurRelationship program-has been shown to improve relationship satisfaction (Doss et al., 2016) during the intervention and to maintain gains through 12-months follow-up (Doss, Roddy, Nowlan, Rothman, & Christensen, 2019). This study seeks to understand mechanisms during and following this program using the same sample of 300 couples (600 individuals) randomly assigned to the program or a waitlist control group. Results from the bivariate growth curves revealed that greater increases in relationship satisfaction during the intervention were explained by improvements in negative communication, emotional intimacy, as well as target problem confidence and severity. However, changes in acceptance of targeted relationship problems, positive communication, and self-protective orientation were not related to changes in satisfaction during the intervention. Additionally, in a multivariate model, relationship target problem severity alone remained significant in the presence of other mechanisms. Improvements in positive and negative communication during the intervention and level of negative communication at the end of the intervention predicted maintenance of gains in satisfaction over 12-month follow-up. Results replicate previous findings that communication (Doss, Thum, Sevier, Atkins, & Christensen, 2005) and emotional intimacy (Doss et al., 2005; Hawrilenko, Gray, & Córdova, 2016) are key components in initial decreases in relationship distress. Furthermore, results suggest that improvements in communication may help couples more effectively navigate problems following the intervention-above and beyond its associations with prepost improvements in satisfaction. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Efficacy of Emotionally Focused Couples Therapy and Behavioral Couples Therapy: A Meta-Analysis

Behavioral couple therapy (BCT) and emotionally focused couples therapy (EFCT) are well-established treatments to reduce couple distress. This meta-analysis summarizes the current state of knowledge on the efficacy of these two therapy methods by focusing on randomized controlled trials only. A literature search revealed 33 suitable primary studies (2,730 participants in total), all of them measuring relationship satisfaction. Robust-variance random-effects meta-analysis revealed medium effect sizes at post-test (overall: g = 0.60; BCT: g = 0.53; EFCT: g = 0.73) and small effect sizes of 6 months after treatment (overall: g = 0.44; BCT: g = 0.35; EFCT: g = 0.66), but these gains were not maintained after 12 months (BCT only: g = 0.06). Between the two therapy methods, no significant effect size differences could be found. Results have to be interpreted with caution due to potential publication bias.

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.

A methodological review of meta-analyses of the effectiveness of clinical psychology treatments

This article presents a methodological review of 54 meta-analyses of the effectiveness of clinical psychological treatments, using standardized mean differences as the effect size index. We statistically analyzed the distribution of the number of studies of the meta-analyses, the distribution of the sample sizes in the studies of each meta-analysis, the distribution of the effect sizes in each of the meta-analyses, the distribution of the between-studies variance values, and the Pearson correlations between effect size and sample size in each meta-analysis. The results are presented as a function of the type of standardized mean difference: posttest standardized mean difference, standardized mean change from pretest to posttest, and standardized mean change difference between groups. These findings will help researchers design future Monte Carlo and theoretical studies on the performance of meta-analytic procedures, based on the manipulation of realistic model assumptions and parameters of the meta-analyses. Furthermore, the analysis of the distribution of the mean effect sizes through the meta-analyses provides a specific guide for the interpretation of the clinical significance of the different types of standardized mean differences within the field of the evaluation of clinical psychological interventions.

Maintenance of Gains in Relationship and Individual Functioning Following the Online OurRelationship Program

In the United States, more than 40% of marriages end in divorce and more than one third of intact marriages are distressed. Unfortunately, only a minority of couples seek couple therapy to improve their relationships. Online interventions, with their increased reach and reduced costs, offer the potential to improve relationships nationwide. The online OurRelationship program has been shown in previous nationwide studies to improve relationship and individual functioning. The present study examined whether initial gains in the OurRelationship program were maintained in the following year and whether the extent of maintenance varied across important demographic and individual factors. In this study, 151 distressed heterosexual couples (302 individuals) who were randomized to the OurRelationship program were assessed 3 and 12 months following the intervention. Initial gains in relationship satisfaction, relationship confidence, and negative relationship quality were maintained through 12 months; positive relationship quality significantly improved over follow-up. Furthermore, couples maintained their initial gains in depressive symptoms, perceived health, work functioning, and quality of life; anxious symptoms continued to significantly decrease over follow-up. Finally, there was no evidence that historically underserved groups-racial/ethnic minorities, lower income couples, or rural couples-experienced greater deterioration. In fact, Hispanic couples reported continued improvement in relationship confidence and negative relationship quality in the 12 months following the program. The ability of the OurRelationship program-an 8-hour, primarily self-help program-to create long-lasting improvements in distressed relationships indicates it may have the potential to improve the lives of distressed couples on a broad scale.

Partner criticism during acute-phase cognitive therapy for recurrent major depressive disorder

Many patients with major depressive disorder (MDD) are married or in marriage-like relationships that could influence treatment process and outcomes. We clarified relations of patient-reported criticism from partners (perceived criticism) and criticism of partners with psychosocial functioning and changes in cognitive therapy (CT) for depression. Partnered outpatients (N = 219) received a 12-week CT protocol and completed measures repeatedly. As hypothesized, perceived criticism and criticism of partners correlated with personality (e.g., perceived criticism: trait mistrust, self-harm; criticism of partners: negative temperament, aggression), social-interpersonal problems (perceived criticism: cold and overly nurturant behavior; criticism of partners: vindictive and domineering behavior; both measures: poor adjustment in partnered and family relationships), cognitive content (both measures: negative failure attributions, dysfunctional attitudes), and depressive symptom intensity (both measures), although effect sizes were small-moderate. Both criticism measures decreased little during CT and remained elevated compared to community norms, despite the fact that relations between the criticism measures and depressive symptoms included both stable trait and more transient state components. From these findings, we speculate that some patients with MDD elicit or amplify criticism in ways that harm their relationships and psychosocial functioning and may benefit from additional or strategic treatment.

Sexual Assault and Dyadic Relationship Satisfaction: Indirect Associations Through Intimacy and Mental Health

Rates of child and adult sexual assault (SA) among women are staggering and place women at risk for intra- and interpersonal difficulties. However, the independent contributions of child and adult SA or the mechanisms of this risk are unknown. This study's goal was to examine the indirect effects of child and adult SA on women's own and partner's relationship functioning through their impact on women's mental health, emotional intimacy, and sexual intimacy. Results revealed that the association of women's child SA with both her own and her partner's relationship satisfaction operated through emotional intimacy. Considerations for the study of women with a history of SA in the context of couple functioning are discussed.

Conceptual and statistical issues in couples observational research: Rationale and methods for design decisions

Observational behavioral coding methods are widely used for the study of relational phenomena. There are numerous guidelines for the development and implementation of these methods that include principles for creating new and adapting existing coding systems as well as principles for creating coding teams. While these principles have been successfully implemented in research on relational phenomena, the ever expanding array of phenomena being investigated with observational methods calls for a similar expansion of these principles. Specifically, guidelines are needed for decisions that arise in current areas of emphasis in couple research including observational investigation of related outcomes (e.g., relationship distress and psychological symptoms), the study of change in behavior over time, and the study of group similarities and differences in the enactment and perception of behavior. This article describes conceptual and statistical considerations involved in these 3 areas of research and presents principle- and empirically based rationale for design decisions related to these issues. A unifying principle underlying these guidelines is the need for careful consideration of fit between theory, research questions, selection of coding systems, and creation of coding teams. Implications of (mis)fit for the advancement of theory are discussed. (PsycINFO Database Record

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.

Long-Term Effectiveness of Treatment-as-Usual Couple Therapy for Military Veterans

Despite the fact that veterans face increased psychological and relationship distress as a result of their service-related experiences, no study to date has explored the long-term effectiveness of couple therapy for veterans. In the present investigation, 238 individuals (113 couples and 12 additional individuals) completed assessments 18 months after termination of treatment-as-usual couple therapy at two Veteran Administration Medical Centers. From pretreatment to 18-month follow-up, couples experienced significant increases in relationship satisfaction (d = 0.59) and significant decreases in both psychological distress (d = -0.31) and presence of intimate partner violence (d = -0.47). Overall, pretreatment demographic, psychological, and relationship characteristics did not significantly moderate maintenance of gains across 18 months. However, African American individuals (d = -0.58) and individuals not reporting intimate partner violence at pretreatment (d = -0.46) experienced smaller improvements in relationship satisfaction through 18-month follow-up. Further, older participants showed smaller reductions in psychological symptoms 18 months after treatment (d = 0.16). Thus, for many veterans and their spouses, treatment-as-usual couple therapy is effective at intervening in psychological and relationship distress long-term. Moreover, the long-term effectiveness of couple therapy with veterans appears to generalize across many demographic, intrapersonal, and interpersonal factors.

Revised scoring and improved reliability for the Communication Patterns Questionnaire

The Communication Patterns Questionnaire (CPQ; Christensen, 1987) is a widely used self-report measure of couple communication behavior and is well validated for assessing the demand/withdraw interaction pattern, which is a robust predictor of poor relationship and individual outcomes (Schrodt, Witt, & Shimkowski, 2014). However, no studies have examined the CPQ's factor structure using analytic techniques sufficient by modern standards, nor have any studies replicated the factor structure using additional samples. Further, the current scoring system uses fewer than half of the total items for its 4 subscales, despite the existence of unused items that have content conceptually consistent with those subscales. These characteristics of the CPQ have likely contributed to findings that subscale scores are often troubled by suboptimal psychometric properties such as low internal reliability (e.g., Christensen, Eldridge, Catta-Preta, Lim, & Santagata, 2006). The present study uses exploratory and confirmatory factor analyses on 4 samples to reexamine the factor structure of the CPQ to improve scale score reliability and to determine if including more items in the subscales is warranted. Results indicate that a 3-factor solution (constructive communication and 2 demand/withdraw scales) provides the best fit for the data. That factor structure was confirmed in the replication samples. Compared with the original scales, the revised scales include additional items that expand the conceptual range of the constructs, substantially improve reliability of scale scores, and demonstrate stronger associations with relationship satisfaction and sensitivity to change in therapy. Implications for research and treatment are discussed. (PsycINFO Database Record

Checking up on Couples-A Meta-Analysis of the Effect of Assessment and Feedback on Marital Functioning and Individual Mental Health in Couples

The primary aim of the current meta-analysis was to investigate the overall effect of a relationship checkup (RC), a couple-oriented assessment, and feedback intervention. Systematic literature searches revealed 12 eligible randomized trials published between 1995 and 2015. Results showed significant overall pre-post effect of an RC on marital functioning (Hedge's g = 0.20) and individual mental health (g = 0.44). The between-group controlled effect size was significant at postassessment (g = 0.23) and up to six-month follow-up (g = 0.23). Characteristics of the RC format, therapist-guided versus self-directed, or the study samples, distressed versus healthy, did not moderate the overall effect of the RC. Thus, our results suggest an RC to improve couples' marital functioning up to six-month follow-up, while the effect on individual mental health and repeated delivery of a RC awaits further research.

Cognitive-Behavioral Couple Therapies: Review of the Evidence for the Treatment of Relationship Distress, Psychopathology, and Chronic Health Conditions

Cognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that has strong empirical support for alleviating relationship distress. This paper provides a review of the empirical status of CBCT along with behavioral couple therapy (BCT), as well as the evidence for recent applications of CBCT principles to couple-based interventions for individual psychopathology and medical conditions. Several meta-analyses and major reviews have confirmed the efficacy of BCT and CBCT across trials in the United States, Europe, and Australia, and there is little evidence to support differential effectiveness of various forms of couple therapy derived from behavioral principles. A much smaller number of effectiveness studies have shown that successful implementation in community settings is possible, although effect sizes tend to be somewhat lower than those evidenced in randomized controlled trials. Adapted for individual problems, cognitive-behavioral couple-based interventions appear to be at least as effective as individual cognitive behavioral therapy (CBT) across a variety of psychological disorders, and often more effective, especially when partners are substantially involved in treatment. In addition, couple-based interventions tend to have the unique added benefit of improving relationship functioning. Findings on couple-based interventions for medical conditions are more varied and more complex to interpret given the greater range of target outcomes (psychological, relational, and medical variables).

Integrative Behavioral Couple Therapy: Theoretical Background, Empirical Research, and Dissemination

Integrative Behavioral Couple Therapy (IBCT), developed by Drs. Andrew Christensen and Neil Jacobson, builds off the tradition of behavioral couple therapy by including acceptance strategies as key components of treatment. Results from a large randomized clinical trial of IBCT indicate that it yields large and significant gains in relationship satisfaction. Furthermore, these benefits have been shown to persist for at least 5 years after treatment for the average couple. Not only does IBCT positively impact relationship constructs such as satisfaction and communication, but the benefits of therapy extend to individual, co-parenting, and child functioning. Moreover, IBCT has been shown to operate through the putative mechanisms of improvements in emotional acceptance, behavior change, and communication. IBCT was chosen for nationwide training and dissemination through the Veteran Affairs Medical Centers. Furthermore, the principles of IBCT have been translated into a web-based intervention for distressed couples, OurRelationship.com. IBCT is continuing to evolve and grow as research and technologies allow for continued evaluation and dissemination of this well-supported theoretical model.

It Takes Two? An Exploration of Processes and Outcomes in a Two-Session Couple Intervention

Although relationship distress is common, couples often forego professional help due to concerns such as time constraints, financial costs, and stigma. The two-session relationship checkup is an alternative format of couple intervention developed to address these concerns. In this qualitative study, we interviewed 20 coupled participants and six clinicians to examine the checkup's processes and outcomes. The phenomenological themes that emerged revealed sequential processes by which this format works. Couple themes included client motivation, the therapeutic relationship, and therapeutic change in terms of perceptions and behaviors-particularly with regard to communication. Clinician data largely mirrored these themes. The results suggest the intervention addressed barriers to help-seeking and may be a viable selective option for at-risk couples.

Behavioral Couples Treatment for Substance Use Disorder: Secondary Effects on the Reduction of Risk for Child Abuse

Risk for child abuse was examined prior to and after behavioral couples treatment (BCT) among 61 couples in which one or both parents were diagnosed with substance use disorder (SUD). All couples were residing with one or more school-age children. Mothers and fathers completed pretreatment, post-intervention, and 6-month post-intervention follow-up assessments. Results of piecewise latent growth models tested whether the number of BCT sessions attended and number of days abstinent from drugs and alcohol influenced relationship satisfaction and its growth over time, and in turn if relationship satisfaction and change in relationship satisfaction influenced risk for child abuse. For both mothers and fathers, attending more BCT sessions lead to a direct increase in relationship satisfaction, which in turn led to stronger reductions in risk for child abuse. This effect was maintained from the post-intervention through the 6-month post-intervention follow-up. For fathers, number of days abstinent significantly influenced reduction in child abuse potential at post-intervention via relationship satisfaction. This indirect effect was not present for mothers. The overall benefits of BCT on mothers' and fathers' risk for child abuse suggest that BCT may have promise in reducing risk for child abuse among couples in which one or both parents have SUD.

A randomized controlled trial of the web-based OurRelationship program: Effects on relationship and individual functioning

OBJECTIVE

Within the United States, one third of married couples are distressed and almost half of first marriages (and more than half of unmarried cohabiting relationships) end in divorce/separation. Additionally, relationship distress has been linked to mental and physical health problems in partners and their children. Although couple therapy is effective in reducing relationship distress, it is utilized by less than one third of divorcing couples. Therefore, more accessible interventions for relationship distress are needed.

METHOD

This study tests the efficacy of the OurRelationship program, an 8-hr online program adapted from an empirically based, in-person couple therapy. In the program, couples complete online activities and have 4 15-min calls with project staff. Nationwide, 300 heterosexual couples (N = 600 participants) participated; couples were generally representative of the US in terms of race, ethnicity, and education. Couples were randomly assigned to begin the program immediately or to a 2-month waitlist control group.

RESULTS

Compared to the waitlist group, intervention couples reported significant improvements in relationship satisfaction (Cohen's d = 0.69), relationship confidence (d = 0.47), and negative relationship quality (d = 0.57). Additionally, couples reported significant improvements in multiple domains of individual functioning, especially when individuals began the program with difficulties in that domain: depressive (d = 0.71) and anxious symptoms (d = 0.94), perceived health (d = 0.51), work functioning (d = 0.57), and quality of life (d = 0.44).

CONCLUSIONS

In a nationally representative sample of couples, the OurRelationship program was effective in significantly improving both relationship and individual functioning, suggesting it can substantially increase the reach of current interventions through its low-cost, Web-based format.

The Norway Couple Project: Lessons Learned

Couple therapists in routine practice may find it difficult to apply findings from an increasingly expanding and complex body of couple therapy research. Meanwhile, concerns have been raised that competency in evidence-based treatments is insufficient to inform many practice decisions or ensure positive treatment outcomes (American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist, 2006, 271). This article aims to narrow the research/practice gap in couple therapy. Results from a large, randomized naturalistic couple trial (Anker, Duncan, & Sparks, Journal of Consulting and Clinical Psychology, 2009, 693) and four companion studies are translated into specific guidelines for routine, eclectic practice. Client feedback, the therapeutic alliance, couple goals assessment, and therapist experience in couple therapy provide a research-informed template for improving couple therapy outcomes.

Prediction of treatment response at 5-year follow-up in a randomized clinical trial of behaviorally based couple therapies

OBJECTIVE

Building on earlier work examining predictors of short- and moderate-term treatment response, demographic, intrapersonal, communication, and interpersonal variables were examined as predictors of clinically significant outcomes 5 years after couples completed 1 of 2 behaviorally based couple therapies.

METHOD

One hundred and thirty-four couples were randomly assigned to Integrative Behavioral Couple Therapy (IBCT; Jacobson & Christensen, 1998) or Traditional Behavioral Couple Therapy (TBCT; Jacobson & Margolin, 1979) and followed for 5 years after treatment. Outcomes include clinically significant change categories of relationship satisfaction and marital status at 5-year follow-up. Optimal subsets of predictors were selected using an automated, bootstrapped selection procedure based on Bayesian information criterion.

RESULTS

Higher levels of commitment and being married for a longer period of time were associated with decreased likelihood of divorce or separation (odds ratio [OR] = 1.39, p = .004; OR = 0.91, p = .015). Being married for a longer period of time was also associated with increased likelihood of positive, clinically significant change (OR = 1.12, p = .029). Finally, higher levels of wife-desired closeness were associated with increased odds of positive, clinically significant change and decreased odds of divorce for moderately distressed, IBCT couples (OR = 1.16, p = .002; OR = 0.85, p = .007, respectively), whereas the opposite was true for moderately distressed, TBCT couples (OR = 0.77, p < .001; OR = 1.17, p = .002, respectively).

CONCLUSIONS

Commitment-related variables are associated with clinically significant outcomes at 5-year follow-up as well as at termination and moderate-term follow-up.

25 years of systemic therapies research: progress and promise

OBJECTIVE

In this article we describe and assess the state of the science on systemic psychotherapies. In the quarter century since the first issue of Psychotherapy Research was published, considerable progress has been made. There is an increasingly solid evidence base for systemic treatments, which includes a wide range of approaches to working conjointly with couples and families. Moreover, there are exciting new developments that hold promise for explicating the dynamic processes of therapeutic change in couple and family systems.

METHOD

We begin by explaining how we view "systemic therapies" as different from individual approaches and then summarize what we have learned in the past 25 years about this set of treatments, how we have learned it, and what we have yet to learn.

RESULTS AND CONCLUSIONS

We consider current trends in research on outcomes and change process mechanisms, and end with speculations about what lies ahead in the interrelated domains of systemic research and practice.

Quality of life and marital adjustment after cognitive behavioural therapy and behavioural marital therapy in couples with anxiety disorders

BACKGROUND

Anxiety disorders may affect nearly one in four persons and may cause significant impairment of interpersonal relationships including marital relationships. The effect of the disorder on the spouse and the impact of including the spouse in therapy are not well studied.

AIM

To determine if Cognitive Behavioural Therapy (CBT) improves the quality of life of participants with anxiety disorders and if marital adjustment of couples with anxiety disorders can be improved with Behavioural Marital Therapy (BMT), relative to standard care of pharmacotherapy and psychoeducation.

METHODS

An open label randomised controlled trial. Participants were randomly assigned to CBT+BMT or standard of care. Final assessments were carried out at 3.5 months after baseline. Quality of life was assessed using the WHOQOL-Bref instrument and Marital adjustment was measured using a marital quality scale. Chi-square test, student's t-test and Analysis of Variance (ANOVA) and Effect sizes with Cohen's d were used to compare differences between groups.

RESULTS

Clinically meaningful effect sizes for the CBT+ BMT intervention were evident for the marital adjustment scores among participants (d=0.63) and their spouses (d=1.29), and for the psychological (d=0.84), social (d=0.72) and environmental (d=0.52) domains of the WHOQOL of participants and psychological (d=0.86), social (d=0.32) and environmental domains (d=1.01) of the WHOQOL of spouses of participants.

CONCLUSION

CBT for the partner with anxiety disorder and BMT for couples with anxiety disorders and marital discord and involvement of the spouse in the therapy will be a useful addition to the management of a couple where one partner has an anxiety disorder.

The Marriage Checkup: a randomized controlled trial of annual relationship health checkups

OBJECTIVE

This study assessed the efficacy of the Marriage Checkup (MC) for improving relationship health and intimacy.

METHOD

Cohabiting married couples (N = 215, Mage women = 44.5 years, men = 47 years, 93.1% Caucasian) recruited from a northeastern U.S. metropolitan area through print and electronic media were randomly assigned to MC treatment or wait-list control. Treatment but not control couples participated in assessment and feedback visits, at the beginning of the study and again 1 year later. All couples completed 9 sets of questionnaires over 2 years. Outcome measures included the Quality of Marriage Index, the Global Distress subscale of the Marital Satisfaction Inventory-Revised, the Intimate Safety Questionnaire, and the Relational Acceptance Questionnaire.

RESULTS

A latent growth curve model indicated significant between-group differences in intimacy at every measurement point after baseline (d ranged from .20 to .55, Md = .37), significant between-group differences in women's felt acceptance for every measurement point after baseline (d ranged from .17 to .47, Md = .34), significant between-group differences in men's felt acceptance through the 1-year 2-week follow-up (d across follow-up ranged from .11 to .40, Md = .25), and significant between-group differences in relationship distress through 1-year 6-month follow-up (d across follow-up ranged from .11 to .39, Md = .23).

CONCLUSIONS

Longitudinal analysis of the MC supports the hypothesis that the MC significantly improves intimacy, acceptance, and satisfaction. Implications for dissemination are discussed.

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."

Could intranasal oxytocin be used to enhance relationships? Research imperatives, clinical policy, and ethical considerations

PURPOSE OF REVIEW

Well-functioning romantic relationships are important for long-term health and well being, but they are often difficult to sustain. This difficulty arises (in part) because of an underlying tension between our psychobiological natures, culture/environment, and modern love and relationship goals. One possible solution to this predicament is to intervene at the level of psychobiology, enhancing partners' interpersonal connection through neurochemical modulation. This article focuses on a single, promising biobehavioral sub-system for such intervention: the attachment system, based largely upon the expression of the neuropeptide oxytocin. Could the exogenous administration of oxytocin - under the right conditions - be used to facilitate relational or marital well being?

RECENT FINDINGS

If so, it would require considerable forethought. Recent research complicates the popular image of oxytocin as a universal social enhancer or 'love hormone' and shows that it may exert a variety of different effects, at different dosages, on different people, under different circumstances. Accordingly, we discuss what is known about oxytocin, including its 'good' and 'bad' effects on human behavior and on higher-order functional processes.

SUMMARY

Building upon animal-model, human preclinical, and clinical findings, we outline a proposal for the use of oxytocin in the therapeutic neuroenhancement of contemporary romantic relationships. Highlighting key targets for future research along the way, we then conclude by discussing some of the clinical and ethical considerations that would pertain to the implementation of this knowledge in applied settings.

The state of psychotherapy supervision: recommendations for future training

This paper reviews the current state of psychotherapy supervision in psychiatric training programmes. A focused literature search was carried out that examined three questions concerning the content, process and outcome of psychotherapy supervision. Results indicate that although requirements for training have broadened somewhat, methods of instruction in supervision have remained the same for many decades. In addition, there is a lack of discussion on what supervision outcomes should be assessed. This paper explores these areas and provides some suggestions for the future of psychotherapy supervision that are evidence-based and generalizable to an international audience. It is time to arrive at an international consensus about guidelines for psychotherapy supervision in psychiatry training programmes. This paper attempts to provide a starting place for psychotherapy supervisors and educators so that we can advance the field forward.

Web-Based Couple Interventions: Do They Have a Future?

To examine the current and potential future impact of formal and informal resources to enhance romantic relationships, 1,160 individuals were surveyed. When asked about resources previously utilized, participants reported that numerous forms of relationship help, including talking to a friend/coworker/family member, an individual therapist, and reading self-help materials had a larger impact than attending couple therapy. When asked about potential resources they would be likely to use in the future for relationship problems, participants indicated a strong preference for online self-help resources that included detailed feedback paired with a comprehensive, structured program. Implications for future development and dissemination are discussed.

Behavioral couple therapy: building a secure base for therapeutic integration

Behavioral couple therapy (BCT), one of the two most empirically supported approaches to the treatment of couple discord, has undergone enormous changes in its four decades-long clinical and conceptual history. The evolution of thought about what maintains couple disaffection and distress and what can be done about it from a behavioral perspective is reviewed. These changes are considered in the larger context of the field of behavior therapy, noting shifts within BCT that parallel the three "waves" of development within that field. Integrative behavioral couple therapy (IBCT), the most visible and influential of the several BCT approaches, is examined, with particular attention to its functional-contextual base and the nature and role of functional analysis in clinical case conceptualization. It is argued that continuing enhancement and refinement of IBCT as an integrative therapeutic method will require greater flexibility in the techniques that are used and increased attention to the self of the IBCT therapist.