Relationship education and counselling

Recent research findings
CFCA Paper No. 33 – July 2015

Relationship counselling

The remainder of the paper focuses on the more interventionist end of the relationship-related services spectrum, exploring the evidence for the effectiveness of relationship counselling in treating relationship distress. Compared with the relationship education research, there has been relatively little research focusing on relationship counselling in the past decade. Reviews and meta-analyses of the research, along with relevant primary studies, have been examined and the findings that are pertinent to practitioners and policy-makers are presented.

What is relationship counselling?

Relationship counselling5 usually refers to interventions that involve a couple attending multiple sessions with one counsellor, generally together but individual sessions for one or both partners may also be included (Markman & Rhoades, 2012). Most couples who attend relationship counselling differ from those who attend relationship education (see Box 4) and tend to be experiencing high levels of distress within their relationship. Couples come to counselling with the intention of decreasing distress and increasing the health of their relationship (Markman & Rhoades, 2012). Schofield and colleagues suggest that relationship counselling approaches “typically aim to improve communication skills and commitment, and ameliorate conflict, relationship distress and dissatisfaction in couples who recognise that they are experiencing relationship difficulties” (In press, p. 4).

Box 4: Characteristics of Australian relationship education and counselling participants

There are significant differences between couples presenting for relationship education and relationship counselling. A recent Australian study by Schofield and colleagues (in press) compared the demographic, relationship, health and wellbeing characteristics of 368 participants attending counselling, compared to 92 participants attending relationship education.

Some differences between the two participant groups in Schofield and colleagues study included couples counselling participants being more likely to be married (65%) than relationship education participants (46%), and much less likely to be university educated. Relationship counselling participants were significantly younger when they started their relationship, had been in the relationship for a significantly longer period and had more children than relationship education participants (Schofield et al., in press). Relationship education participants in the study had a higher socio-economic background than the general Australian public, and found it easier to manage their finances than relationship counselling clients (Schofield et al., in press). They were also more likely to be in better health, with lower levels of depression, and were significantly less likely to nominate “serious reasons” as their motivation for attending (Schofield et al., in press). Relationship education participants found communication significantly more important as a reason for attending than couples counselling participants (Schofield et al., in press).

Practitioners working with couples and families may find that couples presenting for couples counselling have higher levels of relationship discord and reduced health (Schofield et al., in press). In fact, relationship counselling clients in Australia reported four times the rate of very high psychological distress, compared to the rate found in the general Australian population (Petch, Murray, Bickerdike, & Lewis, 2014).

The reasons given for attending relationship counselling can be wide ranging with relationship counsellors tending to focus on the specific issues that the couple present with. As noted by Snyder and Balderrama-Durbin, “couple therapists confront a tremendous diversity of presenting issues, marital and family structures, individual dynamics and psychopathology, and psychosocial stressors characterising couples in distress” (2012, p. 14). Carson and Casado-Kehoe (2012) further suggested that presenting issues in counselling are highly varied and can include problems such as infidelity, domestic violence and addiction as well as common concerns such as communication difficulties, conflicts over beliefs, values and roles, financial disagreements, problems with child rearing or as a step towards separating. Due to the complex nature of the issues and high levels of distress couples may present with, relationship counselling often involves multiple sessions over an extended period of time (Halford & Snyder, 2012).

Negative effects associated with relationship distress and conflict

Relationship distress and conflict have been found to be associated with a range of negative factors affecting the individual, couple and family. For example, in a US population-based survey of married individuals, Whisman (2007) found that marital distress was associated with an increased risk of a range of psychological disorders. The strongest associations were between marital distress and bipolar disorder, alcohol-use disorders and generalised anxiety disorder. Further to this, in a review of the research on the treatment of couple distress, Lebow and colleagues (2012) reported that the relationship between couple distress and psychopathology (such as depression) is cyclical with both negatively affecting each other. Relationship distress is also related to “social role impairment with family and friends, impaired work functioning, general distress, poorer health, and increased likelihood of suicidal ideation” (Lebow, Chambers, Christensen, & Johnson et al., 2012, p. 3). Relationship distress has also been associated with poor physical health, including depressed immune functioning (Bambling, 2007).

The negative effects of relationship distress are not limited to the couple. Researchers have found links extending the effects to children with it being associated with mental health issues such as childhood depression, substance abuse and behavioural problems (Bambling, 2007). Further to this, interparental conflict has been found to be negatively associated with parenting behaviours; meta-analytic findings suggest that conflict between parents is related to impaired parenting practices with the strongest effects found between interparental conflict and higher levels of harsh parental discipline and lower levels of parental acceptance (e.g., expressed love, support and sensitivity; Krishnakumar & Buehler, 2000).

It is the serious and wide-ranging nature of the negative effects of relationship distress on the individuals experiencing it and their children that highlight the importance and need for effective relationship counselling.

Few distressed couples seek professional help

Despite the negative effects of relationship distress, the limited research available suggests that only a small number of those experiencing it actually seek professional assistance. For example, a Relationships Australia (2011) study reported that of the 1,204 adults they interviewed, only 22% sought professional help when experiencing relationship issues. The majority had discussed their concerns with friends (35%), partners (20%) or family (16%). Further to this, a US study (n = 2,323) found that among respondents who had divorced, 37% had received counselling prior (with 34% seeking assistance from a therapist, 42% from a religious leader, and the remaining 24% from both; Johnson et al., 2002). Of those interviewed who were currently married, 19% had sought counselling for their marriage (Johnson et al., 2002). It appears that a minority of couples seek assistance when experiencing relationship difficulties.

Key messages

  • Relationship distress and conflict are associated with a range of negative factors affecting the individual, couple and family.
  • The connection between relationship distress and mental health problems (such as depression) is cyclical with both negatively affecting each other. As the two are interlinked, practitioners working in mental health should assess for relationship difficulties and those working with couples should assess for individual mental health issues.
  • The majority of those experiencing relationship difficulties do not seek professional assistance.

What does the research tell us about the effectiveness of relationship counselling?

This section provides an overview of the research available on the effectiveness of relationship counselling, focusing largely on meta-analyses and including some of the issues that have been raised with the research.

Although relationship counselling is widely practiced (e.g., one international study found that 70% of psychotherapists reported working with couples; Orlinksy & Ronnestad, 2005 reported in Lebow et al., 2012) and has been for many years, there has been relatively little growth in research in to its efficacy. Reports on the research in the 2000s had very similar findings to a review of the research in the 1990s, suggesting that little has changed. For example, in 2000, Johnson and Lebow reported:

The main models of couple therapy at the end of the 1990s are very similar to those identified in Sprenkle’s (1990) review of the field a decade ago, namely cognitive-behavioral, narrative, solution-focused and emotionally-focused. Other models such as feminist, Bowenian, psychodynamic, and integrative, have also flourished. However, it is still the case that only a few methods of intervention have been subject to research validation. (p. 25)

The most recent reviews of research on relationship counselling continue to report that there are a small number of models of therapy that have been evaluated but a large number that continue to be practiced with little or no research validation of their effectiveness:

The challenge continues for the numerous forms of couple therapy other than [the limited number that have had some form of evaluation] to demonstrate their efficacy. The last decade has seen no additional broad approaches to couple therapy moving toward becoming empirically tested. (Lebow et al., 2012, p. 14)

Overall effectiveness of relationship counselling

There are several meta-analyses and studies that provide evidence for the efficacy of a small number of models of relationship counselling. Several models have been evaluated using multiple randomised control trials (RCTs) while others have had at least one randomised control trial.6 For example, Shadish and Baldwin (2003) reviewed 20 published and unpublished meta-analyses of marriage and family interventions (MFT; of which 11 included marital therapy). The findings from the meta-analysis suggested that both marriage and family interventions were effective compared to no treatment. The authors reported that MFT interventions were at least as effective as other types of treatment such as individual therapy and showed clinically significant results in 40-50% of those treated. In summarising their findings for clinicians, the authors noted that there did not appear to be significant differences in findings for different types of MFT interventions, that there had been little research done on the clinical representativeness of the interventions (i.e., how closely the conditions under which the studies were done compared to how treatment would generally be carried out in “real world” clinical settings), and there is little known regarding which factors may moderate the effects of MFT interventions, although how the research was done appeared to have as strong an effect on outcomes as the model of intervention used (Shadish & Baldwin, 2003). For example, the setting in which the research takes place - university or non-university, measurement reactivity, measurement specificity, measurement manipulability and number of subjects have all been found to moderate the effects of types of therapy.

The same authors performed a meta-analysis of 30 randomised experiments of distressed couples that compared Behavioural Marital Therapy (BMT) consisting of communication training, behaviour exchange, cognitive restructuring and emotional expressiveness training with no-treatment controls (Shadish & Baldwin, 2005). The studies, dated from 1973 to the early 1990s, included unpublished dissertations and published studies, and were limited to studies aimed at reducing marital or psychological distress. The authors reported that, overall, BMT was significantly more effective in reducing marital or psychological distress than no treatment, although less effective than reported in previous meta-analyses. The authors suggested that the inclusion of unpublished dissertations with small sample sizes and small or negative effect sizes led to the lower effect size that they reported and that previously reported higher effect sizes might have been inflated. They also noted that communication training/problem-solving training was the only component of BMT that predicted greater effectiveness, and cognitive restructuring actually predicted lower effect sizes. Further to this, Shadish and Baldwin found no significant association between effect size and clinical representativeness or effect size and number and length of sessions.

Finally, in a review of research on treating couple distress, Lebow and colleagues (2012) reported on a range of studies that supported the efficacy of relationship counselling with the authors concluding “studies continue to show that most couple therapy has an impact, with about 70% of cases showing positive change. These build on the already two decades of existent findings suggesting couple therapy is an effective mode of treatment” (p. 148).

Differences in effectiveness between theoretical approaches to relationship counselling

While there is evidence to support the efficacy of relationship counselling compared to no treatment, as noted by Shadish and Baldwin (2003), there is limited available research identifying why relationship counselling is effective or why there are few differences in efficacy found between theoretical models of relationship interventions. One longitudinal study of 134 highly distressed couples compared traditional behavioural couple therapy (TBCT) and integrative behavioural couple therapy (IBCT; Christensen, Baucom, Atkins, & Yi, 2010) and found few differences in effectiveness at follow-up. The researchers found that although couples who received IBCT reported higher marital satisfaction than those who received TBCT in the earlier stages of follow-up, by the 5-year follow-up the effects of each treatment were no longer significantly different. Both treatments reported similar significant improvements in marital satisfaction. Approximately a quarter of couples in each treatment group were separated or divorced at the 5-year follow-up, with the authors noting that the couples who divorced or separated were more likely to have started treatment somewhat more distressed, to have improved little and to have shown significant deterioration following the completion of therapy.

Further to this, a meta-analysis of 23 studies (20 published and 3 unpublished dissertations) by Wood, Crane, Schaalje, and Law (2005) investigated whether particular relationship counselling approaches were more effective in treating different levels of relationship distress. The study identified 41 treatment groups of which seven were rated mildly distressed, 33 moderately distressed and one severely distressed. Treatments were coded into previously established treatment models— behavioural marital therapy (BMT), emotionally focused therapy (EFT), mixed (if the treatment involved components of different treatment models), BMT components (if the treatment was limited to only one component of BMT) and others. The majority of studies involved BMT. Although the authors noted that the small number of studies found limited the meta-analysis and that there was a need for more replication studies focusing on different models of treatment, they reported that differences in treatment approaches were found once differences in levels of distress were identified. The authors concluded that: couples experiencing different levels of distress should not be viewed as one homogenous group; that any intervention for mildly distressed couples would be better than no treatment as there were no significant differences found between treatment models; and that moderately distressed couples should receive a full treatment model rather than isolated components. The authors suggested that further research is required to tease out potential differences in the effectiveness of various approaches to relationship counselling in treating couples experiencing disparate levels of relationship distress.

See Table 1 for a brief summary of selected approaches to relationship counselling that have reported positive outcomes in treating relationship distress.

Table 1: Brief descriptions of selected relationship counselling approaches that have undergone outcome evaluationsa
Approach Description
Notes: a The table is not intended as an exhaustive list of all approaches to relationship counselling but rather an overview of models with some empirical support for their effectiveness. b These three therapies have demonstrated positive outcomes in treating couple distress in one trial only (IOCT: Snyder & Wills (1989); ISCT: Goldman & Greenberg (1992); IBCT: Jacobson & Christensen (1996) and Christensen et al. (2004) cited in Snyder et al., 2006). c Snyder & Mitchell, 2008.
Behavioural couple therapy (BCT)/ Behavioural marital therapy (BMT; including couple cognitive behavioural therapy [CBT]) The most well-researched approaches used to treat distressed couple relationships (Bambling, 2007), BCT and BMT work on increasing positive behaviours and decreasing negative behaviours to improve relationship satisfaction (Halford & Snyder, 2012; Baucom, Sevier, Eldridge, Doss, & Christensen, 2011). These approaches include several treatment components: communication training, problem-solving training, contingency contracting, behaviour exchange, desensitisation, cognitive restructuring and emotional expressiveness training (Snyder, Castellani, & Whisman, 2006; Shadish & Baldwin, 2005). Cognitive behavioural therapy (CBT) techniques, often added to BCT, assume that how couples interpret their partner’s behaviour is as important as the actual behaviour in influencing distress or satisfaction (Bambling, 2007). CBT helps couples identify problematic thoughts, feelings and reactions, and to identify unrealistic expectations (Bambling, 2007).
Emotion focused couple therapy (EFCT) Influenced by attachment theory, EFCT works on the assumption that relationship distress disrupts attachment to create strong problematic reactions in the couple due to their fears of abandonment (Bambling, 2007). Relationship behaviours that are problematic are considered to be secondary responses to this abandonment fear (Bambling, 2007). This therapy works to reduce hostile emotions and angry behaviours, and increase the expression of emotional vulnerability and attachment needs (Halford & Snyder, 2012; Bambling, 2007).
Integrative behavioural couple therapy b (IBCT) Recent research has begun to explore IBCT, which combines traditional BCT techniques with strategies focusing on fostering emotional acceptance amongst couples (Snyder et al., 2006). Therapists using this therapy explore partners’ emotional reactions to one another’s messages, with the assumption that this will help develop more effective and sensitive communication for couples (Baucom et al., 2011).
Insight oriented couple therapy b (IOCT; also known as Affective-Reconstructive Couple Therapy c) IOCT interprets maladaptive relationship patterns from a developmental perspective, working to develop better ways for partners to interact through helping them to understand and change any enduring dysfunctional patterns (Snyder, 2009). This therapy considers unmet needs and unresolved anxieties, stemming from prior relationships, as linked to patterns of emotional and behavioural responses in their current relationship (Snyder, 2009).
Integrated systemic couple therapy b (ISCT) Attempting to disrupt any negative repetitive, self-perpetuating, cycles of interaction in the couple’s relationship, ISCT works by changing the meaning the couple attributes to these interactions (Snyder et al., 2006). The process followed by therapists to achieve this includes: restructuring interactions, reframing problems through the use of positive connotations, prescribing the symptom, urging the couple to go slow, and then prescribing a reenactment of the negative interactions (Snyder, 2009).

Key messages

  • Several approaches to relationship counselling have been found to be moderately effective in reducing relationship distress or increasing relationship satisfaction compared to no treatment, although there has been limited new research in the past decade.
  • Few differences in effectiveness have been found between different theoretical approaches to relationship counselling.
  • Initial levels of distress may be an important factor in the success or failure of counselling and it may be of value for practitioners to assess for this. Initial research suggests that moderately distressed couples should receive a full treatment model and that highly distressed couples may be less likely to experience positive outcomes from counselling.

Mechanisms of change in relationship counselling

Although there is evidence for its effectiveness, there is limited understanding of the mechanisms of change (i.e., how or why it works) in relationship counselling. There is debate regarding whether treatment effectiveness is related to the specific theoretical model used or variables common to all relationship counselling (Davis, Lebow & Sprenkle, 2012; Sprenkle, 2012). There is also discussion on whether integrated approaches that encompass elements from multiple models of relationship counselling could lead to increases in the effectiveness of treatment (Christensen et al., 2010; Snyder & Balderrama-Durbin, 2012). The debate is particularly relevant to those teaching relationship counselling. For example, should students be taught one particular theoretical model of therapy, several models of therapy or should there be more focus on common factors, such as therapeutic alliance, if these are actually responsible for a large proportion of the change seen in therapy? There is currently limited research available to conclusively support one or other of these theories and it may be that it is a combination of both; for example, as posited by Davis and colleagues (2012), well-evidenced theoretical approaches may provide the structure and organisation through which common factors operate. What is known is that:

  • several theoretical approaches to relationship counselling have been found to be moderately effective in improving a range of couple functioning outcomes;
  • at least one integrated approach has evidence of its efficacy although little evidence of greater effectiveness than other single theory approaches over the longterm (integrative behavioural couple therapy; Christensen et al., 2010); and
  • there is evidence to support the positive impact of certain common factors in therapy (e.g., Bambling, 2007; Halford et al., 2012; Lebow et al., 2012; Shimokawa, Lambert, & Smart, 2010; See Box 5 for further details of common factors).

Box 5: Common factors in relationship counselling

The research on common factors that may be effective across theoretical approaches, particularly in the field of relationship counselling (compared to research on individual therapy), is limited and needs expansion but there are several common factors that have evidence for their importance in affecting therapy outcomes.

  • Working or therapeutic alliance: The quality and strength of the relationship between each client and the therapist has been found to be strongly related to, and necessary for, positive counselling outcomes (Davis et al., 2012; Sprenkle, Davis, & Lebow, 2009). Research suggests that the alliance needs to be formed early in therapy to ensure that couples do not drop out of therapy. Clients’ gender and views of the alliance have also been found to affect treatment outcomes (Bambling, 2007; Lebow et al., 2012). Couples who share a similar view of the strength of the alliance with each other and the counsellor are more likely to experience positive therapy outcomes (Bambling, 2007). Finally, it has been reported that the most highly distressed couples are more likely to form poorer alliances (Lebow et al., 2012).
  • Client expectancy and hope: Couples’ beliefs that the counselling is credible and likely to help them as well as having hope of a positive outcome are linked to more positive outcomes in therapy (Bambling, 2007; Davis et al., 2012). The therapist’s ability to present treatment that is consistent with clients’ expectations has also been linked to favourable outcomes in relationship counselling (Bambling, 2007).
  • Feedback: Research (largely exploring individual psychotherapy) has suggested that providing progressive formal feedback (either from the clients, themselves, or a clinical supervisor) on the progress of therapy throughout counselling may help cut drop-out rates and improve outcomes, particularly for those who are considered unlikely to benefit from therapy (Anker, Duncan, & Sparks, 2009; Shimokawa et al., 2010; Snyder & Halford, 2012).
  • Client and therapist characteristics: Similarly to the findings on the effectiveness of relationship education, although the evidence is limited, other variables such as client characteristics (e.g., relationship commitment, individual mental health issues, initial levels of relationship distress, motivation and engagement in therapy; Davis et al., 2012) and therapist characteristics (e.g., sensitive to unique client needs including culturally sensitive, friendly and positive towards client) have also been found to affect relationship counselling outcomes.

In a review of relationship counselling, Snyder and colleagues (2006) suggested that the evidence available supports the benefits of training relationship counsellors in both common factors and the ability to practice integratively across theoretical approaches while also suggesting that further research is needed to identify and overcome the barriers to transferring relationship counselling research in to practice.

Key messages

  • There is continued debate, although currently limited evidence, regarding exactly why relationship counselling is effective, with research focusing on explanations of change based on specific theoretical models or factors common to all approaches.
  • Several common factors, although requiring further investigation, have been found to affect outcomes in relationship counselling: the therapeutic alliance; expectancy and hope; the provision of feedback during counselling, and client and therapist characteristics.

Limitations of relationship counselling

Although randomised control trials and meta-analyses provide support for the efficacy of relationship counselling there have been a number of limitations raised regarding its effectiveness, some of which have been noted in previous sections of the paper and have been raised in multiple reviews of the research.7

  • Many couples experiencing relationship distress do not seek professional assistance. As noted above, only a small proportion of those couples experiencing distress seek relationship counselling.
  • The effects of relationship counselling tend to deteriorate over time. For example, it has been reported that 30-60% of couples show a significant reduction in the effects of relationship counselling at 2-year or longer follow-ups (Snyder et al., 2006).
  • Relationship counselling is not effective for all couples. Regardless of approach, there appears to be approximately 25-30% of couples for whom relationship counselling does not work, that is, they show little improvement in relationship distress or relationship satisfaction after treatment (Christensen et al., 2010; Halford & Snyder, 2012). Also, within couples there are often differences in the effects of treatment and when these are taken into consideration the effectiveness of relationship counselling is further reduced (Bambling, 2007).
  • Couples having the most relationship difficulties tend to benefit less from relationship counselling. Research suggests initial levels of relationship distress are highly related to treatment outcomes, with those experiencing greatest distress showing least improvement in distress levels (Snyder et al., 2006). As noted by Christensen and colleagues (2010) in their longitudinal study of IBCT and TBCT, those couples that went on to separate or divorce were more likely to have reported high levels of relationship distress and lower marital satisfaction prior to treatment than those who did not go on to separate or divorce, although all couples in the study had been chosen because they were experiencing chronically high levels of distress.

Concerns regarding limitations of the research itself have also been raised and these are outlined briefly in Box 6.

Box 6: Limitations of relationship counselling research

There are a number of limitations of the research on relationship counselling that may limit the findings and their generalisability. These are the most commonly reported limitations.

  • There are a large number of approaches to relationship counselling that have not been rigorously evaluated. As noted previously, although several approaches to relationship counselling have been investigated for their effectiveness, there are a large number still widely practised that have not been the subject of rigorous testing (Johnson & Lebow, 2000; Sprenkle, 2012). This is not to say that these therapies are necessarily ineffective but that they have not undergone rigorous evaluation of their effectiveness. Considering that some of these therapies have been around for decades this should not be the case (Lebow et al., 2012).
  • There is not a lot of “transportation” of research studies to the “real world” of therapy. As noted by Sprenkle (2012), most of the research on relationship counselling relates to “efficacy” (i.e., “the effects of interventions that are studied in controlled clinical trials under specified conditions, usually in a university or hospital or university or researcher-controlled clinic setting” [p. 5]) rather than “effectiveness” (i.e., the “normal” therapeutic circumstances under which most therapy takes place). It is, therefore, worth interpreting the research findings and their applicability to the “real world” of therapy with caution. For example, in an examination of 50 published clinical trials of couple therapy outcome studies, Wright, Sabourin, Mondor, McDuff, and Mamodhoussen (2006) reported the clinical representativeness 8 of relationship counselling as only “fair” based on scores overall being lower than the midpoint of their clinical representativeness scale. They did find that although clinical representativeness of patient problems was high with patients generally presenting with clinical levels of couple distress and a broad range of problems, it was lower on other dimensions (e.g., advertisements for free relationship counselling were often used to recruit couples; graduate students who were given intensive training and close supervision were often used to conduct the therapy; and the number of sessions was often set and the treatment highly structured) suggesting that while overall the trials were rated as fair, there were many areas that were not clinically representative.
  • Research continues to be largely on married, middle-class, heterosexual white couples (Bambling, 2007; Sprenkle, 2012). There is little research on the effectiveness of relationship counselling for other groups such as low-income couples, lesbian and gay couples or those from minority ethnic backgrounds, thus limiting the generalisability of the findings.
  • The majority of research has been done by a small number of researchers who are highly invested in the models of relationship counselling they are testing. As noted by Sprenkle (2012), the developers of the intervention models also generally run the randomised control trials, which may lead to an allegiance effect (i.e., if the researcher or therapist has a bias towards a particular approach this may positively influence the results of that approach). This, along with the limited testing of therapy in the “real world”, Sprenkle suggests, raises questions regarding how effective the treatments may be when performed by “typical therapists in real-world settings” (p. 5).
  • There is limited understanding of why or how different approaches to relationship counselling are effective. As dicussed in the previous section, research has found little difference in the effectiveness of different approaches to relationship counselling and although it is a growing area of research, there is still little understanding of the mechanisms of change in therapy (Bambling, 2007; Lebow et al., 2012). Some researchers have suggested that factors common to all approaches to relationship counselling may be responsible (the “common factors” approach) while others have suggested it is the unique elements and mechanisms of particular approaches that are responsible for their effectiveness (the “model-driven change paradigm”, p. 37; Davis et al., 2012).

 

Key messages

  • Research to date suggests that relationship counselling does not work for approximately 25-30% of those who attend, regardless of approach. Couples facing the most relationship difficulties and highest levels of distress tend to have worse outcomes in counselling.
  • There are a number of widely practised approaches to relationship counselling that still remain largely untested.

Implications and conclusions

The research findings from both areas have implications for policy, practice and future research. For example, while relationship education research has expanded since the mid 2000s to study a wider range of couples, such as those with lower incomes, unmarried couples who have children together, couples where one partner has an illness or couples who have fostered or adopted a child, this still may not be reflective of the diversity of couples in the wider community (Markman & Rhoades, 2012; Halford & Bodenmann, 2013). There is potential to expand this wider application of relationship education to the many groups who still remain under-served, such as older couples, gay, lesbian or transgendered couples, separated and divorced people, cohabiting couples, individuals looking for a relationship (Markman & Rhoades, 2012), couples with ageing parents, couples forming stepfamilies and couples transitioning to retirement (Halford & Bodenmann, 2013). Couples in these diverse groups are still “not well understood or represented in relationship education programs” (Bradbury & Lavner, 2012, p. 115). These findings can be extended to relationship counselling research where there has also been limited research focusing on these groups (Lebow et al., 2012). It is important, however, that any programs or interventions catering for diverse couples are evidence-based and that this evidence is generated from studies that sample a diverse range of couples (Johnson, 2012) so that it is clear from the evidence that these couples will benefit from the relationship education or counselling offered to them.

5 The term “relationship counselling” is used throughout and is used interchangeably with other common terms in the literature such as “couples counselling”, “couple therapy”, “relationship therapy” and “marital therapy”. Where differences are apparent the appropriate term has been specified.

6 Although considered the most rigorous method of evaluating effectiveness, research has highlighted potential concerns with the practicality and ethicality of running RCTs in social services (e.g., Child Family Community Australia, 2013; Dixon et al., 2014; Fairhurst & Dowrick, 1996; Sibbald & Roland, 1998).

7 For reviews of the research including its limitations see Halford & Snyder, 2012; Lebow et al., 2012: Snyder et al., 2006; Snyder & Halford, 2012; Sprenkle, 2012.

8 Clinical representativeness refers to how closely the conditions under which studies are performed compares to how treatment is generally carried out in “real world” clinical settings.