The Gap Between Couple Therapy Research Efficacy and Practice Effectiveness

Meta‐analyses of randomized controlled trials of couple therapy find large improvements in couple adjustment, but published evaluations of the effectiveness of couple therapy in routine practice find only small‐to‐moderate effects. The current study analyzes possible explanations for the research‐efficacy to practice‐effectiveness gap and offers suggestions for enhancing couple therapy effectiveness. Major recommendations are that therapists should clarify whether couples’ therapy goal is to clarify commitment to the relationship or to improve the relationship; use standardized assessment of the individual partners and the relationship; and use systematic monitoring of therapy progress and the therapeutic alliance. It is also possible that the greater use of evidence‐based therapies when treating couple relationship distress could enhance couple therapy outcome.     

Relationship Education and Therapy for Same‐Sex Couples

The gay and lesbian community suffers higher rates of discrimination, mental health problems, and relationship break‐up than their heterosexual counterparts. In this paper we analyse the challenges confronting same‐sex couples, and the implications for couple education and therapy with same‐sex couples. We describe some similarities in the challenges confronting heterosexual and same‐sex couples (e.g., negotiation of shared realistic relationship expectations, effective communication). These similarities suggest existing evidence‐based approaches to couple therapy and relationship education are likely to assist same sex couple relationships. We also describe distinctive challenges for same‐sex couples (e.g., homophobic discrimination, internalised homophobia, and low support from many families for same sex relationships). These distinctive challenges suggest some adaptation of existing approaches to couple education and therapy could enhance their relevance and effectiveness to same sex couples.     

Money management and control in the Indian joint family across generations

Studies of money management and control will have more cross‐cultural relevance if the family context of money across generations is taken into account. The study of money management and control in middle‐income nuclear and joint family households in urban India illustrates the importance of examining money flows within the wider family context because there is a two‐way flow of money beyond the married couple – between parents and adult children, siblings and other members of the extended family. In the three or four generational joint family, control and management at the household level is not necessarily duplicated for the constituent couples. We draw on open‐ended interviews of 40 persons from 27 urban middle‐income households in North India, between November 2007 and January 2008, to show that the male control of money is the dominant pattern. This pattern is linked to the ideology of male dominance that is found among the middle, lower middle and struggling households, particularly in non‐metropolitan households. The upper‐middle‐class households predominantly in metropolitan households show a pattern of joint or independent control. The focus is on the couple's money decisions within the context of the wider family.     

Attachment Change in the Beginning Stages of Therapy: Examining Change Trajectories for Avoidance and Anxiety

The purpose of this study was to investigate the nature of self‐reported attachment change (avoidance and anxiety) in the context of six sessions of couple therapy designed to emphasize both therapist‐centered and couple‐centered (i.e., enactment‐based) clinical process during the beginning stages of therapy. A total of 48 couples with at least one partner who reported clinically significant relationship dissatisfaction participated in this study. Findings confirmed that some couples experience positive attachment‐related change (anxiety or avoidance), while also identifying a subset of individuals who may not experience optimal levels of attachment‐related change. In addition, findings point toward both differences and similarities between change trajectories for avoidance and anxiety. Finally, there was evidence that socio‐demographic factors may be associated with attachment change.     

Discursive Methodologies for Couple and Family Therapy Research: Editorial to Special Section

In this article, we aim to introduce the special JMFT section on discursive research methodologies for couple and family therapy research. These are qualitative research methodologies which resonate with the systemic emphasis on the semantics and the pragmatics of therapy discourse. First, we provide a brief overview of such methodologies and their use in the family therapy field. We then introduce the context and the content of the special section, where four approaches, including conversation analysis, discursive psychology type of discourse analysis, poststructurally informed discourse analysis (subject positioning analysis), and semantic analysis, are introduced by means of analyzed extracts from a Tom Andersen consultation session with a couple in distress and their therapist. We conclude with implications for the field. For Tom and Michael     

Incorporating Internet‐based Interventions into Couple Therapy: Available Resources and Recommended Uses

Although there are a number of highly efficacious in‐person treatments designed to ameliorate relationship distress, only a small proportion of distressed couples seek out in‐person treatment. Recently developed internet‐based interventions based on these in‐person treatments are a promising way to circumvent common barriers to in‐person treatment and give more distressed couples access to these efficacious interventions. The overarching aims of this review are to provide couple and family therapists with a broad overview of the available internet‐based interventions and provide suggestions about how these interventions might be utilized before, during, or after in‐person treatment. The majority of the review centres on internet‐based interventions for distressed couples and covers four distinct types of resources: relationship advice websites; assessment/feedback interventions; enrichment interventions for satisfied couples; and interventions targeting at‐risk or distressed couples. Included is a case study of one couple's journey through a newly developed intervention targeting at‐risk couples, OurRelationship.com . Internet‐based interventions targeting individual psychopathology (e.g. anxiety and depression) are also reviewed. These interventions would be particularly useful as an adjunctive resource for in‐person couple or family therapy when referrals for a concurrent in‐person individual therapist are not feasible (because of time, financial, or geographic constraints). We close with three appendices: two appendices with information on currently available internet‐based interventions; and one appendix with recommendations on how to incorporate these resources into in‐person therapy.     

THE QUESTION CUBE: A MODEL FOR DEVELOPING QUESTION REPERTOIRE IN TRAINING COUPLE AND FAMILY THERAPISTS

This paper presents a three-dimensional model for teaching questioning to those wishing to develop skills in couple and family therapy. The model breaks questions into their component parts of format (the style of the question: open, closed, forced choice, rating, or ranking); orientation (the person who is being inquired about: self or other), and subject (the content of the question: behavior, feelings, beliefs, meaning, or relationship). The model is presented in the context of our post-Milan version of couple and family therapy training. The model is useful in that it allows students gradually to increase their repertoire of questions in a way that offers step-wise learning and integrates with their existing skills.     

Family Diversity and Child Health: Where Do Same‐Sex Couple Families Fit?

Increasing family diversity during the past half century has focused national attention on how children are faring in nontraditional family structures. Much of the limited evidence on children in same‐sex couple families suffers from several shortcomings, including a lack of representative data. We use the National Health Interview Survey (2004–2012) and the National Survey of Children's Health (2011–2012) to identify children in different‐sex married and cohabiting families, never and previously married single‐parent families, and same‐sex couple families. Considering important characteristics such as the child's race or ethnicity and adoption status, household socioeconomic standing, family stability, and parent health, we examine the relationship between family type and parent‐rated overall child health. The results suggest that poorer health among children in same‐sex couple as well as different‐sex cohabiting couple and single‐parent families appears to be largely the product of demographic and socioeconomic differences rather than exposure to nontraditional family forms.     

Establishing the Validity of the Affirmative Training Inventory: Assessing the Relationship between Lesbian,Gay, and Bisexual Affirmative Training and Students’ Clinical Competence

This study established the validity and factor structure of the Affirmative Training Inventory (ATI; T. S. Carlson, C. R. McGeorge & M. Rock, unpublished) as a measure of lesbian, gay, and bisexual (LGB) affirmative clinical training. Additionally, this study examined the latent associations among the subscales of the ATI and the Sexual Orientation Counselor Competency Scale ( Bidell, 2005 ) utilizing a sample of 248 master’s and doctoral couple and family therapy students. The findings from this study provide empirical support for the relationship between specific classroom‐related content associated with LGB affirmative therapy and students’ perceptions of their own ability to work competently with LGB clients. This study also found a positive association between the degree to which couple and family therapy programs adopt a LGB‐affirmative stance and students’ beliefs, knowledge, and skills associated with competent therapy with LGB clients.     

Why do couples seek relationship help online? Description and comparison to in‐person interventions

Couples are increasingly utilizing newly developed online adaptations of couple therapy; however, different presenting problems could drive couples to seek either online or in‐person services. This study compared the presenting problems of 151 couples seeking an online couple intervention for relationship distress (OurRelationship) with responses from 147 couples seeking in‐person couple therapy. Presenting problems were generally consistent across gender and whether or not the respondent was the initial help‐seeker. Online and in‐person samples frequently endorsed difficulties with communication and emotional intimacy; however, they differentially endorsed trust, time together, and child/parenting difficulties. Therefore, while basing online interventions on existing couple therapies is generally supported, efforts should be made to tailor online services to meet the unique needs of this population.     

Therapist effects on dropout in couple therapy

Marriage and family therapy scholars have argued that therapists play a crucial role in successful couple therapy, yet little research has empirically documented that the therapist in couple therapy has a significant impact on outcomes. Known as the study of therapist effects, this study sought to assess the amount of variance attributed to the therapist in couple therapy outcomes. Using dropout as the outcome variable, this study analyzed data from 1,192 couples treated by 90 masters and doctoral student therapists at a university‐based training clinic. Results from multilevel analysis indicated that therapists in the sample accounted for 9.4% of the variance in couple dropout while controlling for initial couple impairment. Therapist gender and therapist experience did not significantly predict variability in therapist effects. These findings give promise to future research on therapist effects in couple therapy and encourage exploration into which therapist characteristics and behaviors contribute to successful clinical outcome.     

Couples relationship standards and satisfaction in Pakistani couples

Relationship standards are beliefs about what is important in a satisfying couple relationship, which vary considerably between cultures, and might mean that what couples seek from couple therapy differs across cultures. We assessed the standards of n = 49 Pakistani couples and whether those standards predicted couple satisfaction. To provide referents for the Pakistani standards, we also assessed selfreported relationship standards in n = 33 Western couples and n = 30 Chinese couples. Pakistani couples endorsed couple bond standards (e.g., expressions of love) as similarly important, and family responsibility (e.g., extended family relations) standards as more important, than Western or Chinese couples. In Pakistani couples, Couple Bond predicted couples' relationship satisfaction, but family responsibility and Religion predicted only wives' satisfaction. Modest sample sizes necessitate caution in interpreting results but suggest existing couple therapies might need modification to address the distinctive relationship standards of Pakistani couples.     

Adapting enactments to couple reactivity: five developmental stages

Interest in change interventions that are common to different models of relationship therapy has spurred investigation of enactments as one such candidate. In change-focused enactments, therapists structure and coach couple/family interaction, as opposed to channeling interaction through the therapist. Still, varying levels of couple/family distress, volatility, and reactivity mean that readiness for enactment intervention varies along a broad continuum and changes over the course of therapy. This suggests the need for differentiated enactments. Currently, however, no model exists for adapting enactments to changing relationship conditions. We propose a five-stage developmental model of clinical operations in couple therapy that adapts the process and structure of enactments to changing levels of relationship distress, interactional volatility, and emotional reactivity. The model increases the possibility for therapists to use enactments successfully over the entire course of couple therapy. Issues to be considered in using the couple enactments model as a template for the development of enactment models for other relationship systems are noted.     

Engaging Fathers in Family Therapy with Violent Adolescents

Violent behavior in adolescents can often signal profound distress or pain arising from family conflicts, hostile marital separations, sudden losses and other family turmoil. By circumventing blame the therapist engages the family in a constructive process that allows adolescents to change and grow and parents to share pain and sorrow about their own issues and responsibilities for their children. This re‐establishes healthy generational boundaries, produces a clearer co‐parenting alliance (e.g. after divorce) and creates sibling support. This paper describes an experiential approach, for working with violent adolescents in family therapy influenced by the pioneer work of Satir and Whitaker. It integrates systemic and developmental theories linking the presenting problem to relevant family events. The therapist: (1) explores adolescent development in the family and social context; (2) establishes a therapeutic alliance through understanding the interpersonal context for violent behavior, and (3) re‐directs negative actions into positive connections with family members. Segments of family therapy sessions with two adolescent boys and their families from different cultural backgrounds illustrate the impact of paternal absence for adolescent well‐being and the need to actively engage fathers in family therapy. Mario, the father's ‘tumor’, and Juan with his despairing violence are two problematic adolescents brought to therapy because of their aggressive behavior at home and/or in the school. The paper describes how to give them a different voice and build a therapeutic alliance with the family.     

Fundamentals of Theory and Practice Revisited: Sex Therapy: Historical Evolution,Current Practice. Part 2

This is the second of a two‐part series on the treatment of sexual difficulties. It presents a systemic approach to sex therapy and uses illustrative case histories to explore: the interrelationship between the presenting person or couple; the ‘sexual’ as part of the relationship; the symptom; the medical considerations; the cultural context; and the framework and thinking of the therapist.     

Integrative Systemic Therapy: Lessons on Collaboration and Training for the 21st Century

The field of couple, marital, and family therapy (CMFT) is at an important juncture of identity development and synthesis. Integrative Systemic Therapy (IST) is a problem‐centered metaframeworks approach that meets the growing needs of family therapists working with diverse and complex family systems and restores the field to its original focus on collaboration. This paper describes the process by which IST developed featuring anecdotes from live interviews with the founders. We briefly outline IST's theoretical pillars and the essential way IST practitioners deliver treatment including a blueprint for therapy. Finally, we propose that IST is a comprehensive, systemic guide uniquely beneficial to CMFT training and discuss our approach to integrating IST into our training of students in a COAMFTE accredited program.     

Lost in Translation? Embracing the Challenges of Working With Families From a Refugee Background

This article describes the difficulties a mainstream family therapy service experienced in working with families from a refugee background. The experience of six therapists and five bicultural workers, who are also the referring agents, was captured in focus groups, and the reflections that emerged shaped a four‐part approach for working with families from a refugee background. Live consultation, either by the family therapist or bicultural worker, is suggested as a way to marry the expertise of family therapists who are not cultural ‘insiders’ with the ‘lived experience’ and cultural expertise of bicultural support workers. The process of reflecting on therapeutic failure resulted in several principles for working therapeu‐tically with families with a history of refugee trauma, unmet resettlement needs and family relationship challenges. These include maintaining a flexible approach to therapy, ascertaining a clear understanding of the referral context, defining an explicit therapeutic contract from the first session, being mindful of the important role that language plays and terminating therapy if it is contra‐indicated.     

Confronting Anxiety in Couple and Family Therapy Supervision: A Developmental Supervisory Model Based on Attachment Theory

Referencing relevant supervisory literature and attachment theory, this article presents a developmental couple and family therapy supervisory model that emphasises the efficacy of the supervisory relationship. Issues concerning anxiety, cognition and learning theory are addressed and phases in the supervisory process are identified and described. Cognitive, emotional and social development are linked to attachment theory and discussed in the supervisory context.     

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.