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.     

Couples Therapy: Unravelling the Strands

Work with couples is one of the more widely practised forms of counselling or psychotherapy, yet seems to have found it difficult to establish its own identity and theoretical base. A theoretical tradition specific to work with the couple relationship has, however, developed over the past 40 years. Recently, this tradition has become more clearly demarcated and has begun to show signs of vigorous growth. It is important for therapists whose primary identification is with individual or family therapy, but who work with couples, to be familiar with this theoretical tradition, and with its practice implications. This paper selects six aspects of theory relating to couples therapy that the author has found useful in practice, and seeks to show how, separately and together, they can illuminate the nature and dynamics of the couple relationship.     

Five Useful Questions in Couples Therapy

This article describes an approach to couples counseling in which the use of questioning is the major therapeutic intervention. It describes my journey from using questions to gather information to employing questions as clinical interventions in their own right. It notes that small questions can change the tone, mood and direction of the session, while bigger questions open up the social and moral context of couple life. Five examples of these ‘bigger’ questions are described. I conclude that successful questions open up new areas for discussion, avoid a narrow ‘problem’ focus, and stimulate yet more questions.     

Group Therapy with Couples in Conflict

This article describes a psychoanalytically based time limited model of couples group therapy, using live clinical material to illustrate the process and flow of therapy. Because of the pre-therapy clear agreement regarding number of sessions, it is important that the contract be adhered to by all parties, underscoring issues of reliability regarding commitment and fostering completion. Critical themes such as dependence and independence rapidly become focal issues in treatment. Mirroring, reflecting, confronting, supporting and interpreting are among the treatment techniques utilized. A heterosexual co-therapy team is recommended as the optimal therapeutic pair for group leadership.     

The experience of learning Emotionally Focused Couples Therapy

This study examined the process of learning Emotionally Focused Couples Therapy (EFT) as reported by 122 EFT therapists and therapists-in-training. Participants completed an online questionnaire assessing their experiences of learning EFT, with particular emphasis on EFT theory, alliance, interventions, perceived impact on clients, and impact on self. Findings suggest that therapists are drawn to the attachment-based model of EFT, appreciate the EFT framework and structure, that clients endorse the usefulness of the model and that learning the model has contributed to personal healing and improved relationships for the trainees. Results also show that the transition to EFT from another model can be taxing and requires time, support, and additional supervision/training to increase comfort level and competency with EFT. Nevertheless, results also highlight that learning EFT can be a rewarding and worthwhile endeavor.     

The Critical Component of Cognitive Restructuring in Couples Therapy: A Case Study

This case study is offered as an example of how cognitive‐behavioral strategies, namely, cognitive restructuring of couples' schemas and the use of specific homework assignments, may be integrated into the course of couple therapy. The article suggests that all therapeutic modalities, regardless of their theoretical orientation, embrace some form of cognitive restructuring and behavioural instruction as a primary agent of change. Cognitive restructuring is highlighted in particular as a critical component of treatment. Michelle Webster, who practices Emotionally Focused Therapy, responds to Frank Dattilio, and he then replies.     

Disrupting Power and Privilege in Couples Therapy

Power disparities underlie many of the issues that couples bring for therapy. People in relationships are not equal; often one partner is systematically conferred unearned advantage and dominance. This article synthesizes results from three qualitative research studies to propose a social justice approach for clinical practice with couples. Interventions are suggested to keep issues of power and privilege a central focus while addressing the ordinary issues partners present for therapy.

The Impact of Behavioral Couple Therapy on Attachment in Distressed Couples

Emotion‐focused therapy (EFT; Greenberg & Johnson, 1988 Emotionally focused therapy for couples. New York: Guilford Press) is anchored in attachment theory (Johnson, 2003 Attachment processes in couples and families. New York: Guilford) and considers change in attachment schemas essential in the process of improving satisfaction in relationships (Johnson, 1999, Research and couples therapy: Where do we go from here? American Family Therapy Academy Newsletter). However, there are little data on how measures of attachment change over the course of EFT or any other couple therapy. The current study examines whether increases in attachment security predict improvements in marital satisfaction during behavioral couple therapy, which would suggest that change in attachment style is a key process variable even for a non‐attachment‐focused treatment. Multilevel models of data from 134 couples participating in a randomized clinical trial of integrative behavioral couple therapy and traditional behavioral couple therapy (Christensen et al. Journal of Consulting and Clinical Psychology, 72, 2004, 176) indicate that although there is a trend for early change in attachment‐related anxiety and avoidance to predict later change in marital satisfaction, early change in marital satisfaction strongly predicts change in attachment‐related anxiety through the end of treatment and 2‐year follow‐up. These findings suggest that changes in satisfaction may lead to changes in attachment rather than the reverse and that change in attachment may not be the mechanism of change in all efficacious couple therapy.     

Gay,Lesbian, and Heterosexual Couples About to Begin Couples Therapy: An Online Relationship Assessment of 40,681 Couples

We currently have little idea of precisely who goes for couples therapy. This is a report of the results of a validated online assessment of relationship and individual functioning based on 39,251 heterosexual, 1,022 lesbian, and 438 gay couples about to begin couples therapy. Using validated and reliable questionnaires of relationship and individual functioning, this report presents and compares, for each sexual-orientation, the percentage of couples, pre-therapy, who are coping with a variety of relationship problems. To test for the replicability of results, the sample was divided randomly into two subsamples and statistical tests were performed on each sample. Couples initiating therapy suffer from greater distress and many more co-morbidities than has been presumed in previous literature, and same-sex couples present a particular set of both strengths and challenges compared to heterosexual couples. Gay-male and lesbian couples were very different on trust and monogamy, as were heterosexual and lesbian couples. Based on this epidemiologically sized sample, the challenge to our field may be to create interventions with much larger effect sizes than we currently have.     

Attachment Repair in Couples Therapy: A Prototype for Treatment of Intimate Relationships

This paper describes a prototype for the treatment of intimate relationships that takes into account how to evaluate attachment styles in the couple relationship and in psychotherapy, and how to integrate this understanding into clinical practice. It is important for the couple’s therapist to understand attachment, its neurobiological underpinnings, and its origins in early development. Secure attachment in an adult relationship may be challenged if one or both partners have experienced disruption of a primary attachment relationship. The goal of successful treatment is to restore the normative growth of intimacy, empathy, understanding, healthy dependency, and connection.

Forgiveness and Reconciliation in Emotionally Focused Therapy for Couples: The Client Change Process and Therapist Interventions

This article presents psychotherapy process research findings related to the forgiveness and reconciliation model, known as the Attachment Injury Resolution Model (AIRM), within the context of emotionally focused therapy for couples (EFT). Outcomes for EFT as an intervention for general relationship distress and AIRM have been successfully tested. Audiotapes of nine resolved and nine nonresolved EFT couple cases were used to study the client change process, the validity of AIRM, and EFT interventions used at each stage of the model. Study findings suggest resolved couple clients engaged deeply with their internal experience were more deliberate and controlled in their processing and more affiliative in their interpersonal responses in comparison with nonresolved couples. Resolved versus nonresolved client in‐session performances were discriminated on the basis of four model components. These were associated with significant shifts from secondary reactive emotions to primary attachment–related emotional processing of the injurious incident and with interactions that focus on shaping emotional responsiveness. Key EFT interventions employed in successful attachment injury resolution are also identified.     

The Impact of Blamer‐softening on Romantic Attachment in Emotionally Focused Couples Therapy

Emotionally Focused Couples Therapy (EFT; Johnson, 2004 ) treats relationship distress by targeting couples' relationship‐specific attachment insecurity. In this study, we used hierarchical linear modeling (Singer & Willett, 2003 ) to examine intercept and slope discontinuities in softened couples' trajectories of change in relationship satisfaction and relationship‐specific attachment over the course of therapy from a total sample of 32 couples. Softened couples (n = 16) reported a significant increase in relationship satisfaction and a significant decrease in attachment avoidance at the softening session. Although softened couples displayed an initial increase in relationship‐specific attachment anxiety at the softening session, their scores significantly decreased across post‐softening sessions. Results demonstrated the importance of the blamer‐softening change event in facilitating change in EFT.     

Cotrainers as Models of Relationships: Effects of the Outcome of Couples Therapy

This study investigated the generally neglected effects of the cotrainer relationship in studies of the outcome of couples communication training. Male-female cotrainer pairs modeled verbal dominance patterns similar or dissimilar to those of client couples. As hypothesized, changes in couples' speaking patterns after a two-hour workshop mirrored their trainers' models. Female-dominated couples exhibited greater modeling of dominance patterns, and male-dominated couples exposed to a dominant female trainer reported relatively negative impressions of both trainers. The need for cotrainers to be aware of the relationship models they present and clients' responses to these models is discussed.     

Assessing Competencies in Couples and Family Therapy/Counseling: A Call to the Profession

Psychometrically sound measures of family therapy competencies are necessary to assess the effectiveness of training on student performance. This article critiques the self-report and observer rating measures developed to date to assess the clinical skills of trainees in the individual and in the family therapy fields. Suggestions are made to foster future instrument development specifically designed for the field of couples and family therapy/counseling.     

Vulnerable Emotional Expression In Emotion Focused Couples Therapy: Relating Interactional Processes To Outcome

This study examined whether interactions characterized by high expression of emotional vulnerability in one partner followed by a highly supportive response style by the other partner predicted greater improvement on domains of forgiveness, unfinished business, trust, and relationship satisfaction in a sample of 32 couples presenting for Emotion Focused Couples Therapy with unresolved emotional injuries. For each outcome measure, two separate hierarchical regression models were tested (injured partner vulnerability and offending partner supportiveness; offending partner vulnerability and injured partner supportiveness). Both models significantly predicted improvement on the majority of outcome measures. Practice suggestions for working with emotionally injured couples are provided in light of the findings.     

Relational Ethics,Depressive Symptoms,and Relationship Satisfaction in Couples in Therapy

The purpose of this study was to examine depressive symptoms and relationship satisfaction as problems related to relational ethics in one's family of origin and current partner relationships in a sample of 68 other‐sex couples seeking therapy at a large university clinic. We used the Actor Partner Interdependence Model to analyze dyadic data collected prior to beginning therapy. Specifically, we found significant actor effects between relational ethics in one's family of origin and depressive symptoms, as well as between depressive symptoms and low relationship satisfaction for both male and female partners. We also found significant partner effects for relational ethics in current partner relationship, depressive symptoms, and low relationship satisfaction. Clinical application of contextual therapy theory is discussed.     

Couples Therapy for Intimate Partner Violence: A Systematic Review and Meta‐Analysis

Intimate partner violence is a serious public health problem accompanied by substantial morbidity and mortality. Despite its documented impact on health, there is no widely recognized treatment of choice. Some studies indicate that couples suffering from situational violence may benefit from couples therapy, but professionals are cautious to risk the possibility of violent retaliation between partners. After a comprehensive literature search of 1,733 citations, this systematic review and meta‐analysis compiles the results of six studies to investigate the effectiveness of couples therapy as a treatment for violence. Preliminary data suggest that couples therapy is a viable treatment in select situations.