OUTCOME LITERATURE A series of recent reviews continue to find that couples therapy is modestly effective, although concerns remain regarding both the proportion of couples who make progress and the duration of changes . A number of specific treatment modalities have enough replicated support to be designated as EVTs/ESTs. Behavioral marital therapy and emotionally focused therapy have the strongest current research base, and have been accepted as empirically validated . A newer therapy that is gaining empirical support is integrative behavioral couples therapy . Also called just integrative couples therapy , IBCT goals are both emotional acceptance and behavior change. The first is brought about via the revelation of vulnerable feelings, which enhances empathy. The second is accomplished by identifying problems as externalized situations couples get into with each other versus blaming each other for the bad things you do to me . This allows the couple to more objectively identify the specific triggers for their cycles of negative interaction and to then intervene. The scientifically based marital therapy developed by John Gottman and colleagues deserves inclusion on any list of effective couples therapies. Based on his sound marital house theory and well-executed in-house clinical research over the past decade, Gottman’s work has garnered substantial support. Reviewers list IBCT along with cognitive-behavioral marital therapy , strategic therapy, and insight-oriented marital therapy as being better than no treatment for couple distress, although these four therapies do not have the degree of empirical support that BMT and EFT do. Epstein offers additional support for cognitive-behavioral approaches. Marital and premarital enrichment/enhancement programs, including couple communication , relationship enhancement , the prevention and relationship enhancement program , and PAIRS continue to enjoy empirical support as well . Couples participating in these programs, especially those with a strong skills base, report satisfaction with relationship education as well as gains in communication, quality of relationship, and changes in the way they handle conflict over time. As with couples’ therapy per se, effects of these interventions past the 6to 12-month mark are less well-documented, with the strongest support for PREP . A recent metaanalysis , provides support for premarital enhancement programs as well. Overall effect sizes were moderately large , indicating that couples who participated in What the Research Tells Us 443 444 SPECIAL ISSUES FACED BY COUPLES such programs were better off than 79% of those who do not. Premarital enrichment leads to immediate and short-term gains in relationship quality and interpersonal skills. Two recent additions to the prevention/enhancement ranks were found. One, called the Marriage Checkup gives couples a two-session motivational interview consisting of assessment and feedback . Even two years after participation, MC resulted in moderate changes for the better in couples’ relationships, and increased levels of therapy-seeking by wives. The second, Couples’ Coping Enhancement Training , takes a cognitive-behavioral and couples’ coping skills approach. Couples who completed the 18-hour course maintained gains in marital adjustment at one-year follow-up. Couples therapy has been shown to be helpful in the treatment of a host of mental health disorders and difficulties . For example, in the treatment of depression, Kung notes that couples therapies that attend to four dimensionsmarital stress, support, role expectations, and interactional dynamicsare likely to be the most effective. In particular, Kung recommends Teichman and Teichman’s cognitive marital therapy . Mead finds the strongest empirical support for BMT in the treatment of co-occurring marital distress and depression. Denton, Golden, and Walsh note that although couples and individual therapies seem equally effective in treating depression, couples therapy is typically superior in enhancing relational adjustment. In special sections of the Journal of Marital and Family Therapy devoted to MFT effectiveness, support is noted for the treatment of schizophrenia , substance abuse , alcohol abuse , and affective disorders , with mixed results in studies of couple counseling for adult chronic illnesses . In a related vein, Cloutier, Manion, Walker, and Johnson found EFT to be effective over the course of two years in helping couples cope with the marital distress generated by caring for chronically ill children. In a multicase qualitative study, Trute, Docking, and Hiebert-Murphy found brief conjoint therapy helpful for couples in which the female partners were both recovering addicts and survivors of childhood sexual abuse. A review by Sexton and colleagues supports the effectiveness of couples therapy in the treatment of depression, substance abuse , and to a modest degree for sexual disorders. Johnson adds agoraphobia and obsessive-compulsive disorders to the list. Lantz and Gregoire report that traumatized Vietnam veteran couples responded well to existential couples therapy, with treatment gains maintained at one-year follow-up. From a cultural perspective, Santisteban and colleagues emphasize that it is important to match relationship patterns to treatments. Couples who embrace cultural patterns of symmetrical and egalitarian relationships are likely to do well in therapies that emphasize direct negotiation. In contrast, couples who organize their relationships along complementary lines may do better with more indirect interventions such as those promoted in strategic models or in therapies that focus on acceptance. PROCESS LITERATURE Couples therapy process research looks at what happens inside therapy sessions that makes a difference to outcome. Frielander, Wildman, Heatherington, and Skowron conducted a seminal review of this literature in 1994. These authors concluded that important processes in couples work should include an active therapist; client changes in cognition, behavior, and especially affective states; the therapeutic bond as experienced by the client; and client’s level of engagement in therapy. At the turn of the millennium, Lebow concluded that the therapeutic alliance was the primary empirically supported change process in couples therapy. More recently, authors such as Diamond and Diamond have suggested that from a transtheoretical approach, common key tasks in the process of couples therapy would include building alliances, reattribution/reframing, reattachment, and for those couples with children, attention to parenting practices. However, Sexton and colleagues caution: In its present state, the trends and specific findings of couples therapy process research provide no more than provocative possibilities . They do identify three empirically supported change mechanisms, including the reduction of negative communication/blame, the therapeutic alliance, and a therapy structure in which the couple is allowed substantial responsibility in guiding their sessions. Factors such as clients’ level of distress or psychopathology and therapist experience may moderate the effects of couples therapy. Getting more specific, Heyman , in his impressive review of approximately 200 studies on couples’ observation research, concludes that critical interventions are based on teaching couples how to monitor and then exit their poor communication cycles. Core processes that need to be assessed in therapy include: How does the conversation start? Does the level of anger escalate? What happens when it does? Do they enter repetitive negative loops? Do they indicate afterward that what occurred during the conversation is typical? Is their behavior stable between . . . discussions? Do their behaviors differ when it is her topic rather than his? Do they label the other person or the communication process as the problem? Using concepts derived from the sound marital house theory, Gottman and colleagues note that building positive affect is a crucial task in the process of therapy. Telling partners to just be nice to each other doesn’t work; Gottman and colleagues recommend rebuilding the couple’s friendship in three ways. The first is through deeply knowing one’s partner . The second is expressing fondness and admiration for one’s partner. The third is to turn toward one’s partner in everyday interactions, rather than ignoring or discounting. It is important that these processes be carried out in nonconflictual contexts. Additionally, couples must be helped to exit negative cycles of interaction. This can be accomplished in four ways: softened startup, accepting influence, repair and deescalation, and compromise . If couples become gridlocked in negative sentiment override and eventual emotional detachment, Gottman recommends techniques such as creating shared symbolic meaning and honoring life dreams to reconnect the partners. Such reengagement is accomplished through exploring each person’s experience history with the basic emotions . . . the meaning of everyday rituals, as well as the meaning of fundamental roles in their family of origin and their own marriage and family . Johnson , from the perspective of EFT, has identified a number of key therapy processes related to successful outcomes. Clients in EFT report that crucial sessions involve deep experiencing and positive self-focused statements, which tend to allow their partners to come closer and to respond with reciprocal self-disclosure. Johnson refers to such moments as softening, which refers to a previously hostile and blaming spouse’s asking for an affiliative response from the other in a vulnerable and congruent fashion. The other spouse, previously withdrawn, is then able to be accessible and responsive, thus creating emotional engagement . A recent qualitative study by Helmeke and Sprenkle examined pivotal change moments in couples therapy. They found that these moments were characterized by being highly individualized, personal, and private, [r]ather than being emotionally charged moments that were shared by or at least evident to all the participants . Pivotal moments in early sessions often gave hope, clarified, or reframed couple problems. Additionally, therapists often needed to revisit core emotional themes across a number of sessions before pivotal moments occurred later in therapy. This study is noteworthy for its focus on couples’ immediate postsession reports of important changes experienced from their own perspectives. SUMMARY/SYNTHESIS It should be clear at this point that many forms of couples therapy are effective modes of intervention. In keeping with the idea that affective processes are key in couple relationships, attention to both interrupting cycles of negative emotion and to rebuilding emotional connections in therapy seem pivotal in all effective therapies. Evidence for this can clearly be seen in EFT, and in the recent modifications of BMT to include more focus on emotion , and in Gottman’s approach. However, it should be noted that certain types of couples do better in therapy; those who are younger and who don’t have children, those who start therapy with less negative affect, those who are less gender-traditional, those with less individual psychopathology, those who are not yet seriously disengaged from each other, and those who are economically advantaged . Another indicator of overall effectiveness is that couples therapy has been shown to reduce the utilization of other health care services . However, although couples therapy has now clearly demonstrated a basic level of success, some cautionary notes are in order. As Johnson and Lebow note, most client couples are White and middle class; thus, so is most of the research on couples therapy. Although diversity issues are beginning to be addressed in the basic literature regarding couples’ adjustment, relational satisfaction, and relational stability, the field of couples therapy research has lagged behind. Some studies have started to address the particular personal/therapist qualities and skills needed to deliver effective couples therapy to specific populations, such as rural couples , ethnically diverse couples , and gay, lesbian, or bisexual couples . Additionally, more research linking process and outcome would be helpful. Newer, complex models and statistical techniques are allowing for more sophisticated work to emerge in this area. Likewise, creating sustained changes in couples therapy remains a challenge.
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