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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 1 Technical University Braunschweig, Germany 2 University of North Carolina, Chapel Hill, NC, USA 3 Klaus Grawe Institute for Psychological Therapy, Zurich, Switzerland 4 Texas A&M University, College Station, TX, USA Abstract 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 Abstract 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 Abstract 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 Abstract 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 Abstract 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 1 University of Bielefeld, Germany 2 University of Braunschweig, Germany Abstract 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 1 University of Queensland, St. Lucia, Australia 2 Griffith University, Mt. Gravatt, Australia Abstract 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 1 University of Denver, CO, USA 2 NorthWest Media, Inc., Eugene, OR, USA Abstract 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. Prolog 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 Abstract 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 Abstract 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 Abstract 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 Abstract 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 possible. 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 1 University of Miami, Coral Gables, FL, USA 2 Texas A&M University, College Station, TX, USA Abstract 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 Abstract 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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