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									     Strengthening Couples and Families
      Dissemination of Interventions for the
   Treatment and Prevention of Couple Distress

      Kurt Hahlweg,1 Donald H. Baucom,2 Mariann Grawe-Gerber,3
                       and Douglas K. Snyder4
                            Technical University Braunschweig, Germany
                        University of North Carolina, Chapel Hill, NC, USA
               Klaus Grawe Institute for Psychological Therapy, Zurich, Switzerland
                          Texas A&M University, College Station, TX, USA


The quality of family life is fundamental to the well-being of the community. The stability of the
family has a pervasive influence on the psychological, physical, social, economic, and cultural well-
being of children and parents. Strengthening couple, parenting, and family skills has the potential
to improve the quality of life and health status of children, our future generation. Over the past
30 years, approximately 100 clinical trials have demonstrated the efficacy and effectiveness of
couple therapy and interventions to prevent relationship distress and divorce. However, the
impact of these programs on a public health level is highly questionable. Few therapists and
counselors actually use evidence-based interventions; likewise, few couples actually use counseling
or treatment services whenever they experience a deteriorating relationship. Therefore, the most
important question for the next 10 years is: Are we ready to disseminate our effective
interventions to the public? This chapter describes the steps necessary to disseminate a public
health model of couple therapy and prevention. For example, do we have sufficient knowledge of
risk and protective factors? Are there ‘‘ready-to-use’’ resources (e.g., treatment manuals and
psychoeducational materials)? Are there effective training and supervision programs available? Do
strategies exist that help to build sustainability? And: Do we have continuous quality control
measures to monitor the ongoing implementation of the interventions?
The field of couple therapy and prevention has made great strides over the past decades, and
innovations continue to evolve as theoreticians, researchers, trainers, and clinicians employ recent
findings to benefit couples and families. In order for the field to benefit maximally from these
ongoing findings and recommendations, it is important that coordinated efforts be made, such as
those in the recommendations discussed in this chapter.
  A Unified Protocol for Couple Therapy
                                   Andrew Christensen

                          University of California, Los Angeles, CA, USA


Drawing from the ‘‘unified protocol for emotional disorders’’ by David Barlow, Laura Allen, and
colleagues (Allen, McHugh, & Barlow, 2008; Barlow, Allen, & Choate, 2004) and drawing from
several evidence-based treatments for couple problems, this chapter proposes a unified protocol
for couple therapy. The protocol is based on five central principles: (1) provide a contextualized,
dyadic, objective conceptualization of problems, (2) modify emotion-driven dysfunctional and
destructive interactional behavior, (3) elicit avoided emotion-based private behavior, (4) foster
productive communication, and (5) emphasize strengths and encourage positive behavior. These
principles are implemented based on a functional analysis of behavior. The clinical and research
implications of this unified protocol for couple therapy are discussed.

The verdict from clinical trials is in – couple therapy works. It improves relationship qual-
ity and reduces the likelihood of separation and divorce. Not surprising to most in the field
but good news nonetheless. A number of literature reviews (Snyder, Castellani, &
Whisman, 2006) and meta-analyses (Shadish & Baldwin, 2003) attest to the efficacy of
specific types of couple therapy, such as traditional behavioral couple therapy (TBCT;
Jacobson & Margolin, 1979) and emotion-focused couple therapy (EFT; Johnson &
Denton, 2002). The effect sizes for couple therapy are as large as or larger than those
obtained for individual therapy or medical interventions (Shadish & Baldwin, 2003).
Recently Caldwell, Woolley, and Caldwell (2007) estimated the cost-effectiveness of
two evidence-based couple therapies, TBCT and EFT, and concluded that both were
cost-effective ‘‘when paid for by government to reduce public costs of divorce or when
paid for by insurers to offset the increased health care expenses associated with divorce’’
(p. 1).
    The existing research provides evidence for the efficacy of several different types of
couple therapies such as TBCT (Jacobson & Margolin, 1979), EFT (Johnson & Denton,
2002), cognitive-behavioral couple therapy (CBCT; Baucom, Epstein, & LaTillade,
2002), insight-oriented couple therapy (IOCT; Snyder & Wills, 1989), and integrative
                     Integrative Approaches
                       to Couple Therapy
                Implications for Clinical Practice,
                     Training, and Research

                   Douglas K. Snyder and Molly F. Gasbarrini

                         Texas A&M University, College Station, TX, USA


Although meta-analyses affirm that various treatments for couple distress produce statistically and
clinically significant outcomes, research findings also indicate that a large percentage of couples
fail to benefit or subsequently deteriorate following current therapies. Based on these findings, we
advocate potential advantages of integrative approaches to couple therapy. We distinguish among
assimilative, transtheoretical, and pluralistic approaches to integration and describe exemplars of
each. Integrative approaches to couple therapy are compared to distillatory or common-factors
approaches emphasizing common elements of treatment components, therapist characteristics,
and client or relationship attributes. We argue that clinical practice of integrative approaches to
couple therapy requires conceptual and clinical decision-making skills transcending those of any
one theoretical modality and emphasizing the selection, sequencing, and pacing of diverse
interventions in a coherent manner. We conclude with implications of integrative couple-based
treatments for future research.

Meta-analyses of couple therapy affirm that various approaches to treating couple distress
produce statistically and clinically significant improvement for a substantial proportion of
couples, with the average couple receiving therapy being better off at termination than
80% of couples not receiving treatment (Shadish & Baldwin, 2003). However, tempering
enthusiasm from this overall conclusion are additional findings that in only 50% of treated
couples do both partners show significant improvement in relationship satisfaction, and
that 30–60% of treated couples show significant deterioration at 2 years or longer after
 Would a Comprehensive Psychological
    Model for Working with Couples
  Improve Dissemination of Evidence-
 Based Treatments of Couple Problems?
           A Clinician and Trainer’s Point of View

                                Mariann Grawe-Gerber

              Klaus Grawe Institute for Psychological Therapy, Zurich, Switzerland


There is an increased interest in evidence-based couple therapy (EBCT) to look for common change
factors that make the different treatments work rather than doing more comparative research.
We suggest to take the field even a step further by making use of the findings of scientific
psychology, psychotherapy research, and the neurosciences, such as Grawe’s general change
mechanisms and his consistency theory for developing case formulations and treatment plans.
Such a comprehensive research-based theory could serve as a model for integrating different
empirically based treatment procedures. We also argue that it is not patient oriented to mainly
train clinicians in only one treatment modality. Training in research-informed psychotherapy
would imply that more future clinicians would also become more familiar with EBCT and would
then also be able to treat patients with individual and relationship problems in a more systematic
and theory-based way.

Couple therapy, individual therapy, family therapy, and child therapy are at first glance
basically nothing but treatment modalities. The terms only tell you who will be present
during the therapy session. Different schools of psychotherapy have developed their
own belief systems, theories, models, and corresponding procedures and interventions
to work within these treatment modalities.
         Couple-Based Interventions
    to Assist Partners with Psychological
            and Medical Problems
        Donald H. Baucom, Jennifer S. Kirby, and Jasmine T. Kelly

                        University of North Carolina, Chapel Hill, NC, USA


A great deal of couple-based treatment research has been conducted in multiple countries since
the early 1970s. Most of these investigations have focused on altering couple functioning in order
to benefit the couple’s relationship per se, whether attempting to alleviate relationship distress,
prevent the development of relationship discord, or enhance already healthy relationships. In
addition, the couple’s relationship can be a valuable resource in helping the partners work
together as a team when one person experiences a significant individual problem, whether it
involves individual psychopathology or a health problem. This chapter describes how therapists
can employ what they know about relationship functioning to assist couples who are experiencing
one of these individual difficulties. The following three types of couple-based interventions are
described. Partner-assisted interventions do not focus on the couple’s relationship per se but rather
employ the partner as a coach or surrogate therapist to help the other individual make important
changes focal to the psychological or health concern. Disorder-specific interventions emphasize
changing the couple’s relationship but only in those domains that are focal to the health or
psychological concern. Finally, couple therapy can be employed if the couple is experiencing
relationship distress that becomes a broad source of stress on the vulnerable individual. Examples
regarding how to employ these couple-based interventions for specific types of psychopathology
and health concerns are provided. Broadening the use of couple principles to these populations
can greatly expand the range of services provided by therapists to couples in need over the
lifespan of their relationship.

In the 1960s and 1970s, psychologists and other mental health professionals began devel-
oping a new approach to working with couples based on social learning or behavioral
principles. The explicit goal of these cognitive-behavioral interventions was to improve
or optimize the couple’s relationship. In this chapter, we will focus on ways in which
                What Makes Couples-Based
                  Interventions Work?
A Centuries’ Debate with Few Answers to Offer

                    Nina Heinrichs1 and Tanja Zimmermann2
                                 University of Bielefeld, Germany
                               University of Braunschweig, Germany


Despite a large amount of research in the area of couple therapy and the knowledge that there are
several couples-based interventions which work, there has been only little application of evidence-
based interventions for couples in therapeutic practice. Many therapists are trained primarily in
individual therapy. Although it is well known that partners are also impaired by mental and
physical disorders of their significant others, partners or children are only rarely included in
treatment. There are differences in each of these therapy modalities (individual vs. couple or child
vs. adult) but little is known about the mechanisms of change that help understand how they work.
Thus, we analyzed the extent to which the four principles of change (mastery, clarification, problem
actuation, and resource activation) identified by Grawe were used in two different couples-based
interventions where the woman was faced with gynecological cancer. Side by Side is a couples’
intervention program which is compared to a partner-assisted brief educational program for ill
woman. Side by Side is expecting to make better use of clarification of feelings, resource activation,
and motivational clarification, whereas the educational interventions should work through the
therapeutic alliance and acquisition of skills. The results showed that Side by Side is working better
than the educational intervention in supporting women in coping with cancer. All common factors
were significantly more distinct in Side by Side. The common factors mediated relationship
outcome. It seems beneficial to compare mechanisms of change across treatment modalities in
order to move forward from the ‘‘splintering perspective’’ to a ‘‘family perspective’’ including the
individual, the partner, and the child.
                     Taking It to the People
       Using Technology to Enhance the Impact
           of Couple Relationship Education

                      W. Kim Halford1 and Leanne M. Casey2
                           University of Queensland, St. Lucia, Australia
                              Griffith University, Mt. Gravatt, Australia


There is established efficacy of couple relationship education (CRE) in assisting at least some couples
to maintain a mutually satisfying relationship (Halford, in press). However, the impact of CRE on the
prevalence of couple relationship problems is modest at best, primarily because of the low reach of
evidence-based programs. The low reach is partly due to difficulties in getting evidence-based
programs adopted into delivery systems, and partly because of the modest uptake of CRE in the
target population of couples. Information technologies provide new options for enhancing couples’
access to evidence-based CRE. Such technologies can provide an evidence-based approach to CRE
that can be easily adopted to enhance accessibility for couples. In this chapter we analyze the
challenges to extending reach, particularly reach to couples most likely to benefit from CRE, and
describe an exemplar program in which information technology is designed to enhance the reach
and impact of CRE by combining web-based assessment and flexible delivery of skills-based training.

The Concept of Impact and Couple Relationship Education
In public health terms, the impact of an intervention can be defined as its effect on the prev-
alence of a particular problem within a given population (Society for Prevention Research,
2004). Specifically with reference to couple relationships, we base this chapter on the
assumption that the collective aim of couple relationship education (CRE) providers is to
increase the rates of couples with high relationship satisfaction and to reduce the prevalence
of couple relationship problems, violence, and separations. These outcomes are valuable in
their own right, as well as in their potential for improving individual well-being, reducing
social costs of relationship problems, and enhancing economic productivity.
Extending the Reach of Research-Based
        Couples Interventions
             The Role of Relationship Education

      Howard J. Markman,1 Galena K. Rhoades,1 Richard Delaney,2
                  Lee White,2 and Caesar Pacifici2
                                     University of Denver, CO, USA
                                NorthWest Media, Inc., Eugene, OR, USA


In this chapter we explore ways of extending the reach of research-based approaches to couples
intervention to partners, service providers, and policy makers. We focus specifically on prevention
and relationship education efforts over the past 30 years and summarize lessons learned from
these efforts that can influence practice and social policy. We show how today these services are
becoming the main way that empirically based couples interventions are reaching couples in
general and underserved, high risk partners and individuals in particular. We conclude with a
discussion of two new studies that illustrate some of the lessons learned and that highlight some
of the key issues that our field faces as we move forward.

Washington, DC, October 1963
  The man dressed in a dark suit, who is destined to die less than a month later, reaches
  for the quill pen and signs his name for the last time to a piece of legislation. He smiles
  and may be thinking of his family background and the role that mental health problems
  had in shaping his future. He is determined to change forever how his country deals
  with community mental health and unbeknownst to him at the time, he has opened
  the door to increasing Federal involvement in the personal lives of children, adults,
  couples and families in the U.S. He leaves the room, perhaps thinking that a nightmare
           New Themes in Couple Therapy
 The Role of Stress, Coping, and Social Support

                                     Guy Bodenmann

                                University of Zurich, Switzerland


Stress and coping in couples are themes that have received increased attention in theory building
and research in the last decades. Many findings show that everyday stress has a negative impact
on relationship satisfaction and the likelihood of divorce. On the other hand, studies reveal that
individual and, even more specifically, dyadic coping (the way couples deal with stress together)
are powerful predictors of relationship functioning and the developmental course of close
relationships. These findings suggest that it might be worthy to address stress issues in couple
therapy and to focus on the improvement of dyadic coping (in addition to communication training
and problem-solving training). One key target of coping-oriented couple therapy is improvement
of dyadic coping.

Theoretical Background
Presently, different approaches and techniques are offered for the treatment of couples’
problems and marital distress. These different methods are regularly presented and sum-
marized in handbooks of couple therapy (e.g., Halford & Markman, 1997; Harway,
2005; Jacobson & Gurman, 2002; Wetchler, 2007) or in the context of prevention (Berger
& Hannah, 1999). In the last few years, there have been several publications about the use
of couple therapy as a promising psychological intervention for the improvement of mar-
ital distress among couples (Christensen & Heavey, 1999). According to these overviews,
there are currently six different empirically supported treatments for couples in distress:
       Translating Basic Science Research
           on Premarital Cohabitation
              into Clinical Practice
    Galena K. Rhoades, Scott M. Stanley, and Howard J. Markman

                                  University of Denver, CO, USA


Cohabitation is increasingly common in the US, with the majority of couples now living together
before marriage. This chapter briefly reviews research on cohabitation, its association with marital
distress and divorce for those who marry (the cohabitation effect), gender differences, and
theories underlying this association. Suggestions are made for future areas of exploration in this
field and the implications of the existing research for relationship education efforts and clinical
intervention with couples are discussed. The accumulating evidence favors discussing the
cohabitation effect in relationship education settings and helping individuals explore their own
expectations about cohabitation as well as how cohabitation may or may not change their
relationships and influence future relationship goals. With regard to cohabiting couples presenting
for therapy, it may be important for clinicians to help them consider their pathways into
cohabitation, their commitment levels, plans for the future, and power dynamics. For married
couples in therapy, it may be useful for some to look at the process by which they married and to
recommit to decisions they made together.

In recent decades, living together before marriage has become increasingly common in the
US. At least 50–70% of couples married during the 1990s cohabited premaritally
(Bumpass & Lu, 2000; Stanley, Whitton, & Markman, 2004). Historically, cohabitation
has been studied mainly by researchers in sociology and demography, professions typi-
cally not occupied with intervention. Perhaps because of this, little of the empirical knowl-
edge about the risks of cohabitation for some couples has made it into the hands of
practitioners of either couple therapy or couples’ education. The purposes of this chapter
are to briefly review what is known about premarital heterosexual cohabitation and to
translate these major findings into tangible ideas for clinical practice. We limit our review
                         Power and Arousal
           New Methods for Assessing Couples

                                      Brian Baucom

                         University of California, Los Angeles, CA, USA


Power and emotional arousal are well-documented correlates of relationship quality. Existing work
on power has used one of two assessment techniques, either self-report questionnaires or time-
consuming behavioral coding; likewise, existing work on emotional arousal has generally been
based on either invasive physiological measures or self-report questionnaires. Though these
methods of capturing power and arousal have led to a rich line of discovery, each is subject to
limitations that restrict when and how each can be used. This chapter describes new methods for
assessing power processes and encoded arousal during interaction that circumvent the restrictions
of traditional methods. Example applications of these methodologies in studies of the demand/
withdraw interaction pattern and response to couple therapy are presented. Results of the
example applications are briefly discussed, and future directions for the study of romantic
relationships using these approaches to measure power and emotional arousal are offered.

   ‘‘The fundamental concept in social science is Power, in the same sense in which
   Energy is the fundamental concept in physics.’’ – Bertram Russell

    As epitomized by Russell’s observation, couple researchers and therapists have long
considered power to be a central aspect of romantic relationships. Results of empirical
studies have supported this assumption, documenting many significant correlations
between aspects of power and relationship functioning. The interactional use of power,
or power processes (Cromwell & Olson, 1975), has been found to have particularly impor-
tant consequences for relationship quality. Though much significant progress has been
           Couple/Family-Based Assessment
              Strategies for Individuals
             with Psychological Problems
                                   Steffany J. Fredman

     National Center for Posttraumatic Stress Disorder, Women’s Health Sciences Division,
                     and Boston University School of Medicine, MA, USA


A taxonomy for categorizing couple/family-based interventions for individual psychopathology
has been in existence for more than a decade, but to date, no framework has been developed to
classify assessment strategies within the field of couple/family psychopathology. To address this
gap, this chapter offers a heuristic for conceptualizing differences among assessment strategies by
distinguishing between those that are broadly applicable across psychological problems (non-
disorder-specific strategies) and those that are focal to a particular form of psychopathology
(disorder-specific strategies). As reviewed in this chapter, the bulk of family psychopathology
research has been conducted using non-disorder-specific instruments that characterize the overall
emotional climate of patients’ family environments. Less work has been done using disorder-
specific measures that assess family processes focal to a particular form of psychopathology.
Nonetheless, as suggested subsequently, it is important to include such approaches in the array of
available assessment strategies to facilitate the implementation of couple/family-based
treatments for individual psychopathology that are as targeted and, therefore, as potent as

It is well known among clinicians that one’s interpersonal environment can have a pro-
found impact on that person’s functioning and well-being. This is especially true for indi-
viduals suffering from psychopathology, where relationships can serve as a resource by
helping them address and manage the difficulties associated with their condition, or the
relationship can serve as an impediment to recovery by creating high levels of stress or
by interfering with behavioral changes that the individual needs to make. Numerous
research studies support the idea that the family environments of individuals with psycho-
logical disorders do indeed matter and have important implications for treatment outcome,
Serving Rather Than Recruiting Couples
            Thoughts on the Delivery of Current
              and Future Couple Interventions

              Brian D. Doss,1 Kathryn Carhart,2 Annie C. Hsueh,2
                             and Kristen P. Rahbar2
                               University of Miami, Coral Gables, FL, USA
                             Texas A&M University, College Station, TX, USA


Despite the proven efficacy of empirically based couple interventions, only approximately 31% of
couples seek premarital education and only 37% of couples seek marital therapy before filing for
divorce. We suggest that a primary reason for this low rate of help seeking is that couple
interventions are not designed or delivered in a way that makes them attractive to couples. In this
chapter we review the existing literature on the reasons couples seek relationship-focused
interventions, the steps and manner in which they seek these interventions, and which types of
couples are especially likely and unlikely to seek couple interventions. From this literature, we
conclude that these interventions would reach more couples if: (a) they were advertised in
different ways, (b) resources were provided during the help-seeking process, (c) barriers to these
interventions were reduced, and (d) special efforts were made to encourage high-risk couples to
participate. Based on these conclusions, we present three approaches to further the reach of these
interventions. Specifically, we review examples and advantages and disadvantages of three
potential approaches: (a) dissemination of empirically based interventions to ‘‘real-world’’ settings,
(b) modify empirically based interventions so they can be delivered by nonprofessionals in novel
settings, and (c) adapt empirically based interventions into self-help formats.

Because of the impact of close romantic relationships on physical, mental, and child func-
tioning, reviewed in the first section of this book, the potential effect of marital and family
interventions delivered on a broad scale is enormous. However, couple interventions have
an important limitation – most couples do not use them.
              Couples and the Silicon Chip
               Applying Information Technology
                to Couple Relationship Services

                      Leanne M. Casey and W. Kim Halford

                            Griffith University, Mt. Gravatt, Australia


Information technology (IT) is developing at a phenomenal rate and has the potential to play an
important role in dissemination and enhancement of couple services. IT applications have the
capacity to substantially increase availability of couple services and can be adapted to facilitate
both two-way (professional and client) or multiple (group) communication. We review existing
applications of IT in the couple relationship services literature and propose a number of ways in
which IT could be used to enhance the quality and accessibility of couple services. Drawing our
experience in developing IT applications, we discuss the challenges in designing such applications
and suggest a number of issues that should be considered in order to maximize the potential of
this new development in couple services.

A couple discuss the bitter divorces that they each witnessed between their parents when
they were children, decide they want to manage their conflict more effectively, and search
the Internet. They complete an online inventory that identifies that their current conflict
management style is a risk for their relationship. The couple download audiovisual train-
ing materials and work through some exercises together, and have two telephone-based
reviews with a psychologist on their progress. A woman, reeling from the discovery of
her partner’s infidelity, accesses the web in a desperate search for answers. She locates
an online support group, finds the support she needs, and links to an e-book that provides
her with useful information to help her understand and manage her distress. A couple
struggle to cope with the husband’s chronic illness. Unable to attend a clinic because of
his restricted mobility, they locate an online therapist and use weekly webcam sessions
to learn knowledge and skills that help them to cope.

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