From Research to Practice: Scoreboard for Couples Therapies

Which are the Winners in the Latest Research?

Jay Lebow

Couples therapy is on a roll. Whereas a mere 20 years ago, surveys showed that consumers didn't think much of it, today it's become increasingly accepted by the general public. Indeed, to end a marriage without benefit of some sort of marital therapy or counseling is now widely viewed as somehow irresponsible--as if the couple were remiss for not making that last-ditch effort to put themselves back together again. And whereas, two decades ago, the most prominent models of therapy focused almost exclusively on individual work, today as many as 70 percent of therapists here and abroad treat couples as part of their practices, according to a study conducted by prominent psychotherapy researcher David Orlinsky of the University of Chicago and his colleagues around the world.

Yet the research about couples therapy, as well as research about couples themselves--why some marriages succeed and others don't--hasn't kept pace with the growth of couples therapy. The slow pace of research on couples is partly due to the fact that relational distress isn't considered a "mental disorder" by DSM-IV, and thus doesn't usually qualify for government funding. In addition, researchers and clinicians have only recently recognized how important couples therapy can be in the treatment of such individual mental health problems as depression and anxiety. Even now, those researching the behavior of couples and couples therapy treatments have been limited to a small group of investigators dedicated enough to continue their work despite sporadic funding.

In spite of these handicaps, a considerable body of information has emerged that tells us a great deal about what works and doesn't work, both in couples' relationships and in couples therapy. The two strands of research inform each other: learning the specific differences between the ways couples interact in satisfying and unsatisfying relationships serves to pinpoint helpful behavioral, cognitive, and affective skills that therapists can encourage in their clinical work.

Research on Interactive Processes

What do we know from research about interactions between spouses that either promote or undermine good marital relationships? One fact that's been established is the not entirely surprising finding that satisfied couples manifest in their exchanges much higher rates of positive behaviors than of negative ones. Researcher John Gottman, now of the Gottman Institute in Seattle, Washington, one of the leading authorities on couples' behavior, who's meticulously documented the interactions of couples for more than 30 years, has been famously quoted saying that the ratio of positive to negative behaviors is at least 5 to 1 in satisfied couples. The types of behavior to which he's referring vary--remarks to each other, body language, helpful vs. challenging acts, and so forth. But this finding from his research with Julian Cook and several other colleagues in 1995 has been widely replicated in studies since then by him and others.

Gottman reports that if this ratio falls below the 5-to-1 level, couples are likely to be dissatisfied with their marriages. In those likely to divorce, the ratio hovers around 0.8 positive acts for every negative one. Gottman adds that really happy couples typically have ratios of positive to negative behaviors even higher than the 5-to-1 level.

This research has made therapists more aware of the importance of helping couples understand the long-term impact of their everyday, moment-to-moment interactions. They can then be taught to monitor their own remarks and behaviors and find ways of increasing the ratio of positive to negative exchanges with their mates. In fact, teaching this skill has become an essential ingredient of a variety of couples therapies, such as Douglas Snyder's Affective Reconstruction Treatment and Mona Fishbane's dialogical approach.

Satisfied couples communicate well and approach problems in a spirit of collaboration rather than antagonism; unhappy couples just continue being angry about the same old problems, while new ones accumulate. Numerous studies have pointed to the relationship advantages of direct communication and developing successful methods of problem-solving. Most couples therapies therefore build in a didactic-experiential set of interventions to help couples learn or regain their abilities to communicate and tackle problems. For example, couples are taught to clearly state their desires and complaints, to listen even when emotionally aroused, to brainstorm potential solutions that bridge differences, and to be sure to follow through on decisions.


Gottman reminds us, however, that even in satisfied couples, many problems are never actually "solved" throughout the duration of the marriage. Arguments often arise over the same issues throughout the course of a 40-year marriage. Spouses may never share the same interests, political perspectives, or social proclivities, and may repeatedly revisit differences over such issues as neatness and promptness. Nonetheless, the couple can learn how to "agree to disagree"--accept each other and certain differences, show respect, friendship, and love, and work around their problems without undue conflict, even if the issues in question never are finally resolved.

Another hallmark of satisfied couples is that they argue successfully and have ways of resolving differences. Gottman's research is especially relevant here since the general public often believes that happy couples simply don't argue. Not at all! In fact, being able to argue effectively--express differences in a way that doesn't sidetrack the discussion into old grudges and conflicts, or devolve into personal attacks--seems to be an essential skill of satisfied couples. Those lacking this skill fall prey to the accrual of unresolved issues and resentments, leading to patterns of defensiveness and contempt that undermine connection.

This research into the importance of knowing how to argue has generated treatment interventions that teach fair fighting and authentic repair--how to make up with each other. One means of making arguments fairer and less toxic to a relationship is the process of "softening," highlighted by couples therapy researcher Susan Johnson, psychology professor at Ottawa University. Teaching couples to achieve a moment by moment opening up and lowering of defenses in the face of conflict, which Johnson believes is critical for putting antagonistic relationships back on track, is a key component of her Emotionally Focused Couple Therapy.

Not ambushing the other person also makes fighting more productive. Gottman's couples therapy helps partners find alternatives to the overly rapid start-up of disagreements, in which one partner, more or less without preamble, blasts the other with his or her grievance, which generates emotional flooding and overwhelming states of arousal in the other.


Another feature of satisfied couples is that they accept each other and display what Gottman calls "positive sentiment override," referring to the overall positive regard they have for each other. This well of positive feeling shapes the way they approach potentially difficult marital issues and tends to immunize them against automatic patterns of blame and counterblame. Following the implications of this notion, several recent approaches, such as Integrative Behavioral Couple Therapy, developed by the late Neil Jacobson and Andrew Christensen, now emphasize mutual acceptance more than behavior change. In this model, couples are taught to distinguish between problems that can be changed and those that can't, or aren't worth the effort. Partners are helped to find ways to live with the unchangeable issues by engaging in self-talk that emphasizes the other's positive intent and the feeling of love that overrides the annoyance of the problem--that he or she can never learn to be less messy, for example.

Satisfied couples have secure attachments with each other that still allow room for the other to be him- or herself. Research indicates that those with secure attachments earlier in life are more likely to be able to create such attachments in marriage. Susan Johnson has found in more than 20 years of couples research and therapy that good marriages are based on deep, mutually dependable, responsive, accessible connections between partners--reflecting the secure attachment bonds of a mother and infant. Such bonds, she argues, give couples (and very young children, for that matter) a safe emotional base from which they can freely and without anxiety explore their own individual personalities and pursuits.

Satisfied couples share expectations, but only to a "good enough" extent. What matters for marital happiness is that the two partners share some overlap in their expectations of what a successful marriage "should" be and of what each owes to the other. But beyond that basic agreement, happy couples can be close or relatively distant from each other--passionately involved in each other's lives or living almost separately. Individual partners may be high powered and success oriented or low key and laid back--oriented to material rewards or spiritually inclined.

By contrast, the most distressed couples display high levels of defensiveness, criticism, contempt, belligerence, and stonewalling with each other. In the longitudinal research of Gottman and his colleague Robert Levinson, these characteristics during interactions between spouses, often displayed nonverbally in expressions and gestures of one partner toward the other--rolling eyes, disdainful sneer, arms folded across the chest, sarcastic tone, tight lips, narrowed eyes, etc.--emerged as the best predictors of divorce and of intractable marital distress.


Research Assessing Couples Therapy

The research on couples' relationships has helped identify the key focal points in marriages that should be the targets of therapeutic interventions. In parallel, a second set of investigators has begun to develop a significant body of work assessing whether couples therapy works and, if so, which interventions work best. The findings from these studies show that couples therapy is generally effective in reducing distress in relationships. The metanalysis produced by William Shadish and Scott Baldwin, for example, finds effect sizes for couples treatments to be in the same range as those for individual therapy--typically helping three out of four couples.

Couples therapy, both alone or in combination with other interventions, also has been demonstrated to be effective for treating several individual disorders. such as depression, anxiety disorders, and substance abuse. Two quite different factors appear to account for this result. First, partners can play a useful role in encouraging and supporting treatment in a partner. For example, Barbara McCrady of Rutgers University and the team of William Fals-Stewart from the Research Institute on Addictions in Buffalo, N.Y., and Timothy O'Farrell from Harvard Medical School have shown that one partner can help the other more fully engage in treatment, and encourage him or her to behave in ways that reduce the likelihood of substance abuse. The second factor stems from the remarkably high rates at which marital distress occurs along with individual disorders. In a recent national study of comorbidity, Mark Whisman of the University of Colorado found that 28 percent of individuals in distressed marriages also suffered from anxiety disorders, 15 percent met criteria for a diagnosis of depression, and 14 percent for

substance-use disorder. Thus, for a subset of individuals with these disorders, it's an open question whether the more pivotal problem is the individual disorder or the marital distress.

Following this logic, two different research groups--Steven Beach and Daniel O'Leary, then of the State University of New York, Stony Brook, and Neil Jacobson and colleagues--each found that a behavioral form of marital therapy was an effective treatment for individual depression affecting partners in distressed marriages. And whereas individual treatment in these studies also was shown to have an effect on individual depression, only the marital therapy had any effect on the marital distress. Marital therapy thus emerged as the treatment of choice for those with both depression and distressed marriages.


Research has shown that vastly different forms of marital therapy have a positive impact, and each has an overall level of impact similar to the other treatments. As in every form of treatment research, there have been demonstrations of the effectiveness of cognitive-behavioral approaches, but there also have been numerous studies demonstrating the impact of Susan Johnson's Emotionally Focused Couple Therapy. Additionally, two of the best studies in this field have focused on the psychoanalytic-intergenerational treatment called Insight-Oriented Marital Therapy, developed by Douglas Snyder, and a treatment focused on acceptance of one's partner, Andrew Christensen and Neil Jacobson's Integrative Behavioral Couple Therapy.

The cognitive-behavioral therapies accentuate learning and engaging in more skillful marital behaviors, such as communication and problem-solving. Emotionally Focused Couple Therapy centers on building secure attachment between partners through uncovering and nurturing the soft feelings of vulnerability and connection that lie beneath conflict. Insight-Oriented Marital Therapy helps couples understand partners' experiences in their families of origin, and how their family background affects or promotes difficulties in their relationships. This mode of therapy ultimately challenges engrained patterns of interaction. Integrative Behavioral Couple Therapy accentuates developing skills for living with one's partner and accepting the aspects of the other's behavior that can't be changed. Each method shows success in approximately 75 percent of couples. As Alan Gurman of the University of Wisconsin has suggested, it seems clear that there are many routes to the goal of changing the experience of being a couple.

Another finding is that aspects of treatment related to the process of therapy, such as the generation of a positive therapeutic alliance, play a crucial role in the treatment's success. Couples therapy is notoriously difficult. Clients often seek help only after problems have become nearly intolerable. By the time a clinician sees them, one of the partners may have pretty much written off the entire marriage, which undercuts his or her motivation to establish a strong, working relationship with the therapist. Thus, alliances between clients and the therapist are fragile early in treatment.

Studies by Lynne Knobloch-Fedders and William Pinsof of the Family Institute at Northwestern, like other investigations, demonstrate that early alliance predicts treatment outcome. Their findings suggest that therapists must be especially sensitive to what Pinsof calls the split alliance, in which one person feels allied with the therapist and the other doesn't.

In general, research data--even from a small body of studies--make a powerful case for the effectiveness of couples therapy. Yet the same data provide clear indications of its shortcomings.


Most studies show that the impact of these therapies on couples can be limited. When the treatment is successful, couples frequently don't reach a level of genuine marital well-being characteristic of genuinely happy unions, even though they're less dissatisfied, and their marriages work somewhat better. Then treatment isn't always successful, so the relationships of a significant percentage of couples in most studies simply don't improve at all. It appears that with enough bad feeling and erosion of John Gottman's "positive sentiment override," couples have a hard time making real progress in therapy. In addition, even when couples experience a positive outcome, the effects may not last. The few studies that have conducted follow-ups of clients over several years frequently find regression in levels of marital satisfaction over time. This has been the case particularly with Behavioral Couples Therapy, the approach with the most follow-up studies. These findings suggest that long-term marital distress has many of the properties of a chronic condition, and may be similarly resistant to treatment.

Yet some approaches show promise of generating positive outcomes that do last. The study by Snyder and Wills of Insight-Oriented Marital Therapy showed remarkable stability in the positive effects over a five-year period. This suggests that spouses who develop insight into their problems may have better results over the long haul.

Others approaches appear to be effective even with couples who have a long history of unhappiness in their marriages. The study of Integrative Behavioral Couple Therapy by Christensen, Jacobson, and colleagues showed a clinically significant impact on an extremely distressed sample of couples. Couples included in this study displayed a high degree of marital distress in a three-step screening process and had experienced marital discord for many years. Surprisingly, 71 percent of these couples improved following treatment, moving into the range of couples in nondistressed marriages on the Dyadic Adjustment Scale, the most widely used measure of marital satisfaction.

Despite these findings of effectiveness, surveys sometimes have shown a low regard for couples therapy. In a 1995 survey conducted by Martin Seligman, Consumer Reports asked readers who'd undergone therapy, either individual or marital, for their opinion of its impact on their lives. The results demonstrated that individual psychotherapy clients were almost universally satisfied, while clients of marital counselors had the highest rates of dissatisfaction--approaching 50 percent of the sample.


It may be that this finding reflects the results for clients who'd simply entered marital therapy too late and/or under duress, for whom treatment probably would have been short-lived and unsuccessful. It also may be that what respondents described as marital counseling may have little connection with what we now think of as marital therapy. However, to the extent that such negative attitudes are still held today, the field needs to find ways to make even those couples whose marriages aren't helped feel that seeing a marital therapist is worthwhile on some level--if only because they learn something about themselves individually or about why their marriages failed.

In sum, there are now four empirically supported methods of practice for which positive outcomes have been demonstrated: Behavioral Couples Therapy, Emotionally Focused Couple Therapy, Integrative Behavioral Couple Therapy, and Insight-Oriented Marital Therapy. We also should highlight, as Al Gurman has for many years, that there are many forms of couples therapy, such as Bowenian and narrative therapy, which may be effective but haven't been studied yet.

The totality of this body of research offers us the security of knowing that what we do as couples therapists truly does make a difference. However, there's a great deal that we still don't know about what can help couples improve their relationships most effectively and about how to foster changes that last.

Resources

Gurman, Alan S., and Neil S. Jacobson (eds.). Clinical Handbook of Couple Therapy. 3rd edition. New York: Guilford Press, 2002.

Jacobson, Neil S., and Andrew Christensen. Acceptance and Change in Couple Therapy: A Therapist's Guide to Transforming Relationships. New York: Norton, 1998.

Johnson, Susan M. The Practice of Emotionally Focused Couple Therapy: Creating Connection. 2nd edition. New York: Brunner-Routledge, 2004.

Snyder, Douglas K., A. M. Castellani, and Mark A. Whisman. "Current Status and Future Directions in Couple Therapy." Annual Review of Clinical Psychology 57 (2006): 317-44.

Whisman, Mark A. "Marital Dissatis-faction and Psychiatric Disorders: Results from the National Comorbidity Survey." Journal of Abnormal Psychology 108, no. 4 (November 1999): 701-06.

Topic: Couples

Tags: behavioral couples therapy | behavioral therapies | couple therapy | couples research | couples therapist | couples therapists | couples therapy research | DSM | emotion | gottman institute | Jay Lebow | John Gottman | marital counseling | marital therapy | martin seligman | psychotherapy research | research on couples | resistant to treatment | secure attachment

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