Couple relationship education and counselling: Research evidence and the implications for practice

Couple relationship education and counselling: Research evidence and the implications for practice

Jemima Petch and W. Kim Halford
30 July 2015

This webinar summarised research on the efficacy of couple therapy and relationship education, and discussed the implications for practice.

Relationship education and counselling

Audio transcript: Couple relationship education and counselling: Research evidence and the implications for practice

Audio transcript (edited)

Webinar facilitated & speakers introduced by Sharnee Moore

MOORE

Good morning everyone and welcome to this CFCA webinar, couple relationship education and counselling, research evidence and the implications for practice. My name is Shanee Moore and I'm a research fellow here at the Australian Institute of Family Studies. Today we will hear about research concerned with the efficacy of couple therapy and relationship education and discuss implications of practise. This webinar is part of a series of resources on the topic of relationship education and counselling, and we will send you links to these after today's presentation.

Before I introduce our speakers, I would like to acknowledge the traditional custodians of the lands on which we meet. In Melbourne, the traditional custodians are the Wurundjeri people of the Kulin Nation. I pay my respects to their elders past and present, and to the elders from other communities who may be participating today. It is now my pleasure to introduce today's speakers, Dr Jemima Petch and Professor Kim Halford.

Jemima is head of research at Relationships Australia Queensland, an adjunct researcher at the University of Queensland, and a clinical psychologist. Jemima has a particular interest in promoting healthy couple relationships through relationship education and therapy, measuring and enhancing treatment effectiveness, individual couples and family counselling, and leading organisational change to support the adoption of evidence-based practice and assessment.

Kim is professor of clinical psychology at the University of Queensland and a registered clinical psychologist. Kim has published a large number of books and articles, primarily focused on couple therapy and couple relationship education. He works with a wide range of couples facing different issues and transitions.

Now I need to alert you to some brief housekeeping details before I hand over to Jemima and Kim. One of our core functions of the CFCA information exchange is to share knowledge. So I would like to remind everyone that you can submit questions via the chat box at any time during the webinar. There will be a limited amount of time for questions at the end of today's presentation and we will try to respond to as many as possible. We also want you to continue the conversation we begin here today.

To facilitate this, we have set up a forum on the CFCA website where you can discuss the ideas and issues raised today and share your own experiences. We will share with you a link to the forum at the conclusion of today's presentation. Please remember that this webinar is being recorded and the audio transcript and presentation slides will be made available on the CFCA website and YouTube channel in due course. Accessible versions will also be available. So without further ado, please join me in giving our speakers a very warm virtual welcome.

PETCH

Thank you, Shanee. I'm Jemima Petch and I'll be speaking a little bit later on in the presentation. I'll hand over to Professor Kim Halford to introduce.

HALFORD

Well good morning everybody and thank you, Jemima. We're going to be talking about both relationship education and relationship counselling, and in that I'm going to focus particularly on relationship education. Then Jemima's going to talk about relationship counselling, and we'll finish with some implications for practice.

Let's start first of all with the distinction between couple education and couple counselling. As suggested on this slide, couple education is targeted on couples who currently see their relationship as satisfying and it has the broad goals of building commitment and further enhancing satisfaction. But a particular focus is trying to prevent the long-term development of relationship distress. Typical evidence-based approaches are brief, perhaps 8 to 12 hours of contact. Some examples of those programs are the couple care program that Jemima, myself and the team developed here in Australia, or the positive relationship education program developed by Howard Markman and his colleagues in the US.

In contrast, couple counselling is designed for people who think their relationship currently has significant difficulties – they're distressed. The goals are often to clarify the commitment about whether they want to stay together to reduce the distress and hopefully improve satisfaction. Typically the research based or evidence based approaches are more intensive than education, anything up to 30 hours of contact. Examples of evidence-based approaches are integrated behavioural couple therapy and emotion focus therapy.

While that is the sort of distinction there's also significant overlap between these two approaches. Some people who seek out couple education do have some distress, and education sometimes uses a brief intervention for distressed couples. And conversely there are some people who have very mild distress who might seek out counselling. So while they're somewhat distinctive, there's some overlap.

What we're planning to do today is first of all to talk a little bit about the changing context in which couple relationships exist and then to spell out some of the evidence on couple relationship education. Then we'll talk about couple counselling and finish with the implications for practise. Under both couple education and couple counselling we're going to talk a bit about the evidence or how effective it is, its reach or the extent to which it gets to the couples who might potentially benefit, and some new directions we see for each of those approaches.

So let's start with the changing context of couple relationships. This shows a slide that is almost certainly quite out of date now. It shows the percentage of married couples across a number of western countries who first met online via their age groups. Essentially what it's saying is that substantial proportions of people at the start of this decade were meeting online and this has been growing exponentially. It's quite likely now that more than half of all couples meet online. So a lot of the relationship action is online and that's going to be a theme that comes through some of the other points that we'll make today.

Another important shift in couple relationships over the last generation or so has been the important rise of cohabitation, either as a prelude or as an alternative to marriage. This shows the proportion of all couple households in the US, Canada and Australia that were cohabiting rather than married in 1970 in the dark blue and 2005 in the lighter blue. What you can see is there has been a dramatic increase in the proportion of all households that are cohabitating rather than married. Many of these couples are cohabiting and might then go on to marry.

About 80 per cent of couples who marry in Australia live together for some period of time before they marry. But others are choosing cohabitation as an alternative to marriage and that's increasingly common amongst older age groups interestingly. So we see a lot of people in the 50 plus age group who've been either widowed or divorced who choose to cohabit rather than marry a second partner. One implication of this for relationship education is around the issue of timing.

Traditionally in the 20th century the way in which relationships developed, where people met through face to face interactions, developed a more serious relationship, signalled their commitment through becoming engaged, then got married, and often moved in together and then they would parent subsequent to that. Relationship education as an early intervention really developed with a focus on engaged couples. Because that was seen at the classic point in which the committed couple relationship began.

However, when you look at the 21st century, you find that there's much more diversity in how people come into relationships. Many people are meeting online, as well as meeting through social networks. They date. The majority of people will cohabit before they decide whether or not they're to marry. About 30 per cent of couples who have a child together are cohabiting rather than married for their first child. So often people are parenting without getting married and they may or may not get married at some point along this way.

We also see increasing divorce rates. So many people are separating, many more than there were 40 or 50 years ago. There's a lot more people who are then re-partnering and forming step families. So you can see, there's a lot more diversity in the current situation than there was. One implication for relationship education is that we might target a variety of different points here across the different developmental trajectories towards a committed relationship where we might have relationship education.

For example, we might look at people who are planning to cohabit and offer them brief interventions to help them make an informed choice about whether or not they want to move in together. We might help people with the transition to parenthood. We might work with people who are separating to try and assist them to co-parent more effectively. Or we might look at people who are re-partnering and the unique challenges of stepfamilies.

So all of that's really saying that the trajectories into committed relationships are quite different. Relationship education focussed on engaged couples, now we're looking at a much more diverse array of windows of opportunity to offer relationship education to couples.

So let's look at relationship education and its effects. There have been now well over 100 trials of relationship education. This slide shows a meter analysis, which summaries the results across all of those studies. It shows, in standard deviations, the change in relationship satisfaction for people from pre- to post-relationship education and the maintenance of those effects across six months in a couple of hundred studies.

In essence, what it says is there's a small increase in relationship satisfaction on average for couples when they go through relationship education, and that's sustained fairly well for six months. Some people suggest this means relationship education is a fairly weak intervention because the effect sizes are small. But another way of interpreting this is that there may be some couples that benefit more than others.

In this slide we've summarised some different ways that you might target and offer relationship education. I'd like to walk you through it. We talk about the idea of universal selective and indicated relationship education. The idea of universal education is that we offer it to all couples, irrespective of their background or stage of life. We would expect that many of those couples would do quite well even without relationship education. Because there are lots of people who do have satisfying relationships without going to psychologists or relationship educators or social workers.

So we might expect there that the immediate effects if people come in and they're reasonably happy are fairly small on how satisfied they are. Again, because many people will do well, the relationship education effects overall that we detect might be quite small. On the other hand, we might try and be selective about who we offer relationship education to and try and pick out couples who we think are particularly likely to struggle to maintain relationship satisfaction. We call them high-risk couples. For example, people whose parents divorced are themselves more likely to divorce. People forming stepfamilies often struggle to maintain relationships long term to a greater extent than people in forming their first relationships.

So we can, at least to some extent, identify people who are more likely to struggle to maintain their relationships. And if we screen couples and selectively offer relationship education, even if they're satisfied at the start, we might expect to see some modest increase in the short term. But in the long term, we'd expect to see a larger effect for those high-risk couples than we would if we offered relationship education universally.

Finally, we might focus on what's called indicated interventions. This refers to the idea that people are already showing some signs of distress. So they tend to be a high representation of high-risk couples. Their initial satisfaction before education is a little bit lower and so there we might expect to see a larger immediate response to education and perhaps a positive long -term benefit.

The sort of thing that my colleague Guy Bodeman and I were suggesting in a paper that we wrote describing these, is that you might expect to see the major long term effects of relationship education for selective offerings of education and the major short term effects for indicated interventions. To illustrate what that means, this shows the trajectory of relationship satisfaction in couples having their first child together. Again, it's a meter analysis, summarising 37 different studies that followed people from around the time of the birth of the child to 12 months later. The downward slopes reflect that the men and women are both showing an average decline in relationship satisfaction across the first 12 months. This has been very well replicated that if you have a first child, that often puts a strain on the couple relationship. But it's not the same strain for all couples.

This shows a study that Jemima and I did together where we tracked 250 couples from three months before the birth of their first child to about two and a half years later. So it's about three years time all together, and we looked at couples and stratified them into high and low risk for future relationship problems. High risk meant they had more than three of the following risk indicators for relationship problems. Their parents in the family of origin had been divorced. They had low education. One partner had not completed Year 12. They had low income. There was some history of psychological distress, anxiety or depression in one or both partners. The pregnancy was unplanned or there was at least one incident of inter-partner violence.

If you had three or more of those, we would regard you as high risk. Two or less, you are of less risk. This shows the trajectory of relationship satisfaction for high risk in the red and low risk in the black, from before the birth to two and half years later. The dotted red line indicates the cut off on this measure for relationship distress, clinical levels of distress. Basically what it shows is there's a decline in satisfaction for both men and women, both high risk and low risk, but the extent of the decline is much greater for the high risk couples than for the low risk couples, and that's true for men and women.

One implication of that is, if you imagine now you did a relationship education trial, it would easier to show an effect with the high risk couples if you prevented their decline, because their underlying decline without intervention is much steeper than it is for the low risk couples.

So is it true that high risk couples seem to benefit most from relationship education? Here's a summary of a review that my colleague Guy Bodeman and I did of about 19 different studies that had been done on relationship education, where they'd followed up the effects for a minimum of 12 months after the education. Most of them had two or three years of follow up. It shows in dark blue the number of studies that showed a significant effect and light blue the studies that showed a small effect.

What you can see is the vast majority of studies have been selective. So they've looked for high-risk couples and most of them show an effect. There are relatively few studies that have applied a universal application of relationship education. Only two and one of those found an effect and one did not. There are only two studies that were working with somewhat distressed couples and indicated intervention, and both of them had positive effects. So the research basically is pretty consistent that there is an effect, a selective effect, but we're really not sure if there's a universal effect. There's not enough evidence to show that.

So now let me talk about Reach. One of the ideas that people have come up with is to take the existing education programs and try and make them more universally available. There were two really large-scale studies in the last few years in the United States: the building strong families and the strengthening healthy marriages studies. Both of them produced really disappointing results. There was no effect overall for the building strong families project and only very small effects for the strengthening healthy marriages.

Some people have interpreted this as suggesting that relationship education doesn't work very well, at least for the low income couples who were targeted here. However, a recent meter analysis by Alan Hawkins suggests that relationship education, if you look at it within those studies, was actually quite effective for the people who had reasonably low income but showed no positive effects for those who were really impoverished.

I would interpret the results as really suggesting if you're worried about whether you can keep a roof over your head, learning to communicate is not going to make a big difference. On the other hand, if you've got enough resources just to get by then relationship education might well be helpful. Another way of thinking about Reach is how do we get people to come to our programs. As a colleague of mine describes it, the challenge is getting couples in the room to take the sort of services we're already offering.

However, what a lot of other industries have done is change the way they offer services. Bankers, for example, no longer expect people to come to the bank but rather they take banking services through mobile phones, internet, mobile devices – take the banking services to the customers. We had been pursuing a similar strategy using online and other self-directed programs, which we call flexible delivery, to allow people to access relationship education at home.

For example, Jemima and I have worked on a program we call couple care, which consists of six units. In each unit, people look at a small video vignette, which models skills and introduces ideas. They do a series of structured exercised with their partner, which culminates in them developing a plan for how they'd like to enhance their relationship, which we call a self-change plan. Then they have a video or telephone based coaching session to help them apply these ideas in the relationship.

It takes between one and a half and two hours a week for a couple across about six weeks to complete, but you can do it at home. Does that produce any benefits? Well here's a study that we published earlier this year where we looked at the immediate benefits from couple care. We randomly assigned people to couple care or control, and the control was a guided reading program. We stratified the couples according to whether they were highly satisfied in their relationship at the time they presented or had mild relationship distress and indicated intervention. What the slide basically says is satisfaction jumped substantially for those with mild distress, and there's a moderate effect size increase. It made no immediate effect for the currently satisfied group.

Turning now to research on long-term effects. This shows two trials. One with couples in the early stage of their relationship on the left and one with couples who have just had their first child on the right. Because of time I won't go through this in great detail, but, in essence, what it shows is we've got low-risk and high-risk couples in the control group or receiving relationship education. And it shows the change in their satisfaction across four years for the left hand study and three years for the right hand study.

In essence, what the slides show is all of the effects were for the high-risk couples, and we dramatically improved the outcomes for high-risk couples but really make little difference to the low risk couples.

Let me now just talk briefly about new directions. I've talked about the idea that traditionally relationship education targeted engaged couples, which made sense in 1950 and 1960, but doesn't really make sense in 2015. I've talked about different times that you might intervene and I've given some examples of people in early stage relationships and parenting. I want to take the last example, when people have separated and possibly are considering re-partnering, and just briefly describe what we've been doing there.

We've been working with parents who are separated and who have a child but can't agree on how to co-parent and looking at how we might enhance their ability to form meaningful parenting arrangements. This slide here shows a randomised trial that we've just completed where we assigned people to family mediation as usual, MAU or a motivational interviewing enhanced mediation. This is where we taught the mediators to pay particular attention when parents were talking to them about when the parent said things about how they could change in positive ways to enhance their parenting, or how they might collaborate more effectively with their former partner and to get people to elaborate on that. This shows the number of parents who reached an agreement at the end of mediation.

Green means they have reached full agreement on all of the areas in dispute and it means they reached partial agreement. They could resolve some of the issues for which they sought mediation. Red means they got no agreements at all on the issues that were a source of dispute. What you can see is motivational interviewing basically doubles the percentage of families who get full agreement and halves the number of families who get no agreement. So we can substantially improve the extent to which parents in dispute can reach an agreement with appropriate educational interventions after separation.

That concludes the key points I wanted to get through on the research on relationship education. So now I'm going to hand over to Jemima to talk about relationship counselling.

PETCH

Thank you, Kim. Okay. So when we think about couple relationships, we know that most couples are happy. If studies look at couple relationship happiness cross sectionally, so a snapshot in time, we find that about 20 per cent of couples are unhappy.

We know that the first ten years of a couple's married life and that's obviously when most of the studies have been conducted at this point in time but the first ten years or a sort of committed cohabitating married couple's life are the times where relationship satisfaction seems to decline the most. And this often coincides with couples having children as well, which we have seen from Kim Halford's slides, are the times where couples might be experiencing some stress around the inclusion of parenting obligations.

You can then see that relationship functioning, relationship satisfaction sort of plateaus during those middle years of their relationship. There might be a slight decline towards 50 - 45, 50 years of marriage and this might coincide with the empty nest syndrome, particularly around the time of retirement when changes are again occurring in the relationship and the couple might be challenged by those changes. This seems to occur even if you control the things that might otherwise effect relationship functioning, things like income or education, number of children, the age of children.

So we know that there is this sort of average decline but that many people are happy irrespective of this, and we probably can see couples turning up to therapy or couples seeking separation around these key challenge times, in the first ten years or perhaps even a little bit later in their relationship.

At the moment, we see that about a third to 40 per cent of Australian marriages are likely to end in divorce. The good news about this though is that couple therapy does work. There's been over 30 randomised controlled trials of couple therapy efficacy. And what they tend to show is that a couple who attends couple therapy is better off than 80 per cent of couples who don't attend therapy. So that's the sort of large effect sized light blue column here that you see. (Indistinct) et al did a meter analysis of all existing randomised controlled trials of couple therapy.

So it's producing a strong effect. These are couple therapies that traditionally are of five different varieties. There's behavioural couples therapy, cognitive behavioural couples therapy, integrative behavioural couples therapy, insight oriented couples therapy and emotion-focussed couples therapy. Those are predominantly the couples therapies that have been investigated and have produced this large effect size.

Interestingly, when we then try to translate those couple therapies into routine practice or look at what's actually happening in community practices, couple therapy in routine care is not producing as high, as large an effect size. The three studies that you see here by Hallberg and Klan and Dos et al, they've all looked at couple therapy as practised in community settings. And we can see lower effect sizes occurring.

If we then look at clinical significant change, that's the percentage of couples who move from the distressed range of relationship functioning into the well range of relationship functioning and are therefore considered recovered, we can see a similar picture with the two randomised controlled trials studies. That's the Christians and et al one and the Snider and Wills study. They're efficacy trials. You can see that about 50 per cent of couples in these randomised control trials are reporting being recovered after couple therapy.

However, of the two effectiveness studies – the ones done in routine practice – we're seeing a smaller number of couples reporting clinically significant change. A smaller number are reporting that they're recovered and a larger number are reporting that they haven't made a significant change. So they're still in the distressed range.

We're not quite sure what is causing these differences between randomised control trials, which I'm calling efficacy studies, and routine care or effectiveness studies. There are very few effectiveness studies out there of couple therapy. In fact, there's only three, and these two that I've got here – Dos and Hallberg's two studies – they're the only ones that have so far reported clinically significant change.

In contrast, there's over 30 randomised controlled trials of couple therapy. So is it just a chance finding that we're seeing such a big difference when we're translating couple therapy into routine care? There are some other hypotheses about why this might be happening and I'm happy to touch upon those in our talking time later down the track. But some of the things that recent researchers have looked at are: do the couples differ on certain characteristics? Do the treatments differ? Do the practitioners differ in the way they practise or are there other differences, such as the way couples are assessed before, during and after the study that might explain some of these different findings?

But I guess the good news is: couple therapy works. The concerning question I guess I have is why does it seem to work less well in community practice? Researchers also looked at what predicts improvement from couple therapy. There are a few things that have been looked at here. There's the common factors. Previously there was not as much attention paid to common practice. We all knew that they made some difference, but we didn't know how much they might predict outcome. But it seems that the level of empathy, the matched expectations between the therapist and the couple and the congruence, they do seem to predict a better outcome for couples.

The feedback informed therapy or the FIT approach also seems to predict better outcomes. So couples who are offered outcome rating scales and session rating scales to complete during their course of couple therapy are also reporting better outcomes. It's particularly the male therapist alliance and having the same alliance – so if both female and male partner or both partners think that the alliance is strong – then that is what's predicting a better outcome.

Just briefly, some of the alliance measures that are out there are commonly used in community practice and in research are the Duncan and Miller scales here. This is the session rating scale that you can see looks at the bond or the relationship, goals and topics, approach and method. And you can track it each session to see how the client thinks that the alliance is going.

Looking at couples therapy specifically, there has been one study done recently that's looked at integrative behavioural couples therapy and what are predicted outcome for couples in that trial. What they saw was that couples who had been together longer and for couples where the female partner showed lower levels of arousal and less hard influencing tactics during problem solving, those couples reported better couple therapy outcomes. During couple therapy, the couples who showed an improvement in couple communication skills that had early change in the presenting problem and they also showed a greater acceptance of the problems in their relationship, those were the couples who reported better outcomes.

So we're starting to understand a little bit more about the mechanisms of change or the predictors of improvement for couple therapy, but there's still a long way to go. Only about a third of couples are coming to couple therapy. I think this speaks a little bit of the reach of couple therapy, the limitations of its reach. Some of the points that Kim Halford made about the way we're offering couple therapy is we're asking couples to find us rather than making couple therapy readily accessible in online formats or self-help formats.

This might explain why, if you look at the attendance of couples to couple therapy, it's still very low. In the first five years of marriage, which we know is a time where on average relationship satisfaction is starting to decline and would be a key time for couples to attend relationship educational couple therapy. There's one study here that very neatly looked at a large sample of American couples, and only 14 per cent of those had attended some couple therapy. But a much larger number are seeking some sort of relationship help from relationship orientated books or retreats and workshops.

So we know that couples are looking and interested in some sort of form of help, but they might not particularly want to come to therapy. And even more interesting I find, is that 60 per cent of this group here, the ones that came to couple therapy, had already tried books or retreats and workshops. So couple therapy was almost like their third next step.

Let's look a little bit in the direction of new discoveries and new things that researchers are looking at for couple therapy. I think we particularly need to start offering online couple therapy, self help therapies and therapies that has a couple relationship focus but just one partner can attend. One particular example I wanted to go through today is of a self help program that's being trialled in the US. It’s by Dos et al. an it’s called, "The our relationships program". It's a web-based program based on integrative behavioural couples therapy. So we know that what it's based on is a couples therapy shown to work well in randomised controlled trials. But it's all done on the web, and it is interactive and tailored to the people going through the program.

At the moment, it is just in the US but what you can see from the map here with the blue dots is that it has a very broad reach across the whole nation. The couples complete an assessment online and then they can go through the program in their own time. There is about four or five hours of material to go through and there are prompted couple discussions to have. There's very little professional contact during this program.

However, the preliminary analyses, which I've summarised here, show that if we're looking at the couples who are starting in the relationship distressed zone, their pre-, post-outcome measures are showing effect sizes similar to a full integrative behavioural couples therapy study. So they're showing an effect size of .8, which is as good as any face-to-face couple therapy. And you can still see a moderate effect size improvement for all participants. There are very promising results so far with this online program.

Another interesting way that couple therapy is being offered is changing couple therapy to address individual psychological problems or health problems in one of the partners. Because there's such a strong association between couple relationship distress and individual psychological distress and/or health and medical problems, it does make sense to help couples or provide couple therapy to treat these individual issues.

There are two types of adaptations. I won't go into them in much detail, but for the psychological disorders up the top, what has been investigated is disorder-specific couple interventions, where the intervention focuses on changing the couple interactions that influence the disorder or different components of the treatment. One such study looked at changing alcohol abuse treatment. So alcohol abuse disorder was the individual psychological problem of interest and changing that to include a couple focus. They found as you can perhaps see in this study that behavioural couples therapy compared to no treatment control produced a moderate effect size here of just over .5. Interestingly enough, if you've provided the couple therapy to modify to include some of the alcohol abuse disorder treatment components and you compared that to traditional individual cognitive behavioural therapy for alcohol abuse disorder, you actually can see that behavioural couples therapy still out performed individual cognitive behaviour therapy, which is very promising.

It seems that the behaviour couples therapy improves the relationship functioning first and then that later reduces drinking and drug use. But it also has some additional benefits, such as improving child outcome. It seems somewhat more cost effective and it reduced interpersonal violence as well.

Lastly, I wanted to touch upon implications for practice. Kim and I are going to do these slides together. We'll take it sort of in turns. I think what I've learnt from the research and from watching couple therapy done within private practice as well as in Relationships Australia or not for profit sector is that there seems to be a difference between the research and community practice in the use of evidence-based assessments.

A good assessment I think is crucial, and researchers often over assess, but we can take some tips here about what is a good assessment. So good brief clinical assessments that have high reliability and validity are crucial. We also want to have assessments that we know are sensitive to change. In the relationship area, there are a number of these sorts of assessments that we would be happy to recommend. I think what we also have learnt is that regular ongoing assessments or what we call progress tracking can really help both the couple and the practitioner know when therapy is either not assisting the couple or it is on track, and the couple can be reinforced and rewarded for the good work that they've done.

I think it's important to use that assessment to guide the recommended treatment approach. So the therapist and couple together can negotiate what sort of treatment. Is it education? Self-help? Is it therapy and how long does that treatment ideally go for? And then the couple and therapists need to agree on the goals and tasks of treatment. This is really something that I think researchers do very well when they recruit couples and feed back the assessment – they talk about this is what the therapy is going to cover. These are the goals that we've all got. These are the tasks that we're going to accomplish each week and the couple agrees to that. Otherwise they often don't stay in the study, I guess. But in breaching in practice, we do this to varying degrees, this agreement of goals and tasks and length. and I think that we could do that probably a little bit better.

HALFORD

So this slide shows a model of how we're starting to think about the way you might respond to couples' needs. We've identified people in terms of first of all the level of risk they have or current or future relationship problems, what their current relationship functioning is, and some different sorts of interventions that you might offer. In essence, what we're suggesting is if people are doing well, and we're looking at the bottom of the slide here, and they're at low risk for future relationship problems, you probably don't want as a system to invest a lot of resources in helping those people, very brief interventions.

So things like recommending books, maybe a website that gives information, perhaps a one-off public lecture that talks about what healthy relationships might look like might be enough to reassure people that they're doing okay and prompt them to continue to pay attention to their relationship. For those people who are at moderate risk and who are showing maybe mild relationship distress, then the research is suggesting that perhaps brief assessment and feedback can be a useful thing. So you can imagine people might do an online assessment, get some standardised feedback. We've done research on these sorts of systems saying these are the strengths in your relationship and here are some potential challenges. That might be supplemented with one telephone call or video conference to give a little guidance or just shake that up.

Or if people felt the need for a bit more they could go to a structured program, but again something that might be delivered either in a face-to-face format or online or in the couple care version where they do videos and exercises at home. But again trying to make the intervention available in a range of formats to give it good reach. And then we've got folks who have high risk for future or current problems who may be distressed at the moment. Then it's probably couple therapy that's going to be the most effective, and we've identified there a range of evidence-based approaches.

But again we'd emphasise that doesn't necessarily mean that all of that has to be face-to-face traditional therapy. We might use online systems either as the entire intervention – as in the my relationship, which Jemima described – or it might be a supplement to face-to-face therapy. Perhaps you can do some of the exercises and watch some videos at home to make couple therapy more cost effective.

PETCH

So far I guess the implications for practice when we're looking at treatment is after doing the assessment and trying to negotiate with the couple what sort of treatment approach seems suitable for their particular distress and risk. It seems so far evidence is suggesting using one of those five empirically supported couple treatments is likely to produce a better benefit than a different couple therapy style.

This is not to say that the other couple therapies don't work. I think we just haven't researched them and at the moment when we're looking at couple therapy as practised in an eclectic sort of way, it doesn't seem to be producing as strong an outcome as one of those five couple therapies. That's something that I think definitely needs a lot more research. Because we know that in routine practice, couples often have significant barriers to attend
15 to 20 or more couple sessions. Community organisations also have challenges in terms of providing that many treatment sessions in an intense way. So this is something that I think still needs a bit of work.

Tailoring couples therapy and couple relationship education to what the couple particularly is finding challenging is also important.

HALFORD

And the last slide is a couple of final points. It's clear that the therapeutic alliance is an important element, but particularly couple therapy. And as Jemima was describing, consistent monitoring of the progress of therapy and the quality of the therapeutic alliance, session by session, across the course of therapy, seems to be very important.

Therapists are not very good at identifying couples who are getting worse across the course of couple therapy, and this systematic assessment prompts conversations between the therapist and the client to make sure that they keep the therapy on track.

One final comment that I'd make is a theme across both education and therapy is, traditionally both couple education and therapy have been very couple interaction process focussed, looking at communication skills, conflict management, those sorts of things, but without attention to the particular life stage or challenges the couples are facing. The research that Jemima's described and some of the work that I've described is trying to introduce, as well, some more specific content about the challenges couples face. So if one partner's depressed, how can the couple manage that? If one partner has a major health problem, how do they manage that? If the couples are making the transition to parenthood or some recent work we've been doing on transition to retirement, what's some specific suggestions we can get the couple to consider about how to handle those life challenges? I think there'll be increasing emphasis on that sort of content.

WEBINAR CONCLUSION

IMPORTANT INFORMATION - PLEASE READ

The transcript is provided for information purposes only and is provided on the basis that all persons accessing the transcript undertake responsibility for assessing the relevance and accuracy of its content. Before using the material contained in the transcript, the permission of the relevant presenter should be obtained.

The Commonwealth of Australia, represented by the Australian Institute of Family Studies (AIFS), is not responsible for, and makes no representations in relation to, the accuracy of this transcript. AIFS does not accept any liability to any person for the content (or the use of such content) included in the transcript. The transcript may include or summarise views, standards or recommendations of third parties. The inclusion of such material is not an endorsement by AIFS of that material; nor does it indicate a commitment by AIFS to any particular course of action.

Slide outline: Couple relationship education and counselling: Research evidence and the implications for practice

Slide outline

  1. Relationship Education and Counselling
    • Professor W. Kim Halford University of Queensland & Dr Jemima Petch Relationships Australia - Queensland
    • Child Family Community Australia, Australian Institute of Family Studies, Australian Government.
    • The views expressed in this presentation are those of the presenters and may not reflect those of the Australian Insitute of Family Studies or the Australian Government.
  2. Couple Education & Counselling
    • Couple education
      • Satisfied couples
      • Goals
        • Build commitment
        • greater satisfaction, prevent distress
      • EB approaches
        • 10-12 hours
        • Couple CARE
        • PREP
    • Couple counselling
      • Distressed couples
      • Goals
        • Clarify commitment
        • less distress, greater satisfaction
      • EB approaches
        • 15-30 hours
        • IBCT
        • EFT
    • Halford & Snyder (2012)
  3. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  4. % Married Couples met Online by Age
    • Diagram:
      • Australia
        • 19-25: 34%, 26-35: 15%, 36-45: 7%
      • Spain
        • 19-25: 19%, 26-35: 9%, 36-45: 7%
      • UK
        • 19-25: 21%, 26-35: 9%, 36-45: 8%
      • US
        • 19-25: 16%, 26-35: 42%, 36-45: 25%
    • Dutton, Helsper, Whitty, Li, Buckwalter & Lee (2012)
  5. Rise of Cohabitation
    • Diagram: % of couple households:
      • US
        • 1907: 2%, 2005: 12%
      • Canada
        • 1970: 1%, 2005: 17%
      • Australia
        • 1970 1%, 2005 16%
  6. Changing Trajectories of Couple Relations
    • Relationship education
      • Classic 20th century
        • Introduced in social networks > Engaged > Marry & Cohabit > Parent
      • Common 21st century
        • Meet online, social networks > Date, Cohabit > Parent > Separate > Repartner
  7. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  8. Meta-Analysis of Couple Education Effects on Relationship Satisfaction
    • Diagram: summarises the results of a meta-analysis of all trials of couple relationship education up to 2007, and shows that on average education produces a small average increase in couple satisfaction that is maintained for at least 6 months.
  9. Types of CRE
    • CRE Risk profile Pre CRE satisfaction Immediate satisfaction Maintenance of satisfaction
      Universal Mixed Mainly high, some low Small to nil Small effect
      Selective High Mainly high, some low Small to nil Large effect
      Indicated High All low Moderate to large increase Large effect
    • Halford & Bodenmann (2013)
  10. Couple Satisfaction of new parents
    • Diagram: summarises a meta-analysis of 37 studies following the changes in relationship satisfaction for men and women across the transition to parenthood. It shows there is, on average, a moderate decline in satisfaction for both genders, with the decline being a little larger for women than men.
    • Mitnick, Heyman & Slep (2009); n = 37 studies
  11. Relationship Satisfaction in New Parents
    • Diagram: shows two graphs for the decline in relationship satisfaction of women, on the left graph and men on the right graph, across the transition to parenthood. Both men and women are classified into high and low risk groups on the basis of things like an unplanned pregnancy, psychological distress in either partner, or a history of parental divorce in the partner’s family of origin. As shown, high risk predicts a steeper decline in relationship satisfaction in new parents for both men and women.
    • Data from Petch, Halford, Creedy, & Gamble (2012): High risk = >=3 of parental divorce, low education, low income, psych. distress, unplanned pregnancy, IPV.
  12. Long term Effects of CRE
    • Diagram: Number of studies
      • Universal
        • No effect 1%, Effect 1%
      • Selective
        • No effect 3%, Effect 11%
      • Indicated
        • No effect 0%, Effect 2%
      • Halford & Bodenmann (2013)
  13. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  14. The Marital Moon Shots
    • Building Strong Families (Wood et al, 2010, 2012)
      • RCT of n = 6212 low income expectant or new parent unmarried couples
      • 20-40 hours of RE across 9 US locations
      • Poor attendance, no overall effects
    • Strengthening Healthy Marriages (Hsueh et al., 2012)
      • RCT of n = 6298 low income couples, 80% married
      • RE across 8 US sites
      • Small but reliable effect
  15. Meta-Analysis of Relationship Education for Low Income Couples
    • Diagram: shows a meta-analysis of the effect of relationship education on low income couples. It shows that there is a moderate increase in couple satisfaction after education in low income couples, but those in sever poverty show little increase in satisfaction.
    • Hawkins et al. (2014)
  16. Couple Relationship Education
    • "The challenge is getting couples in the room"
  17. Image: Black & white photo of bank from late 19th century "Bankers waiting for customer to come in the room"
  18. Images: Today's online and automatic self-service banking options.
  19. Flexible delivery = accessible
    • Images: Couples accessing service delivery online, by telephone and though printed and digital material.
  20. Couple CARE Structure
    • 6 units
    • Each Unit
      • Video (12 to 15 minutes)
      • Guidebook exercises (20 to 25 minutes)
      • Self-change plan (5 to 10 minutes)
      • Educator coaching (30 to 45 minutes)
    • 1.5 to 2 hours/week for couple across 6 to 8 weeks.
  21. Immediate Change Couple Satisfaction After Flexible Delivery CRE
    • Diagram: shows the change in couple satisfaction immediately after relationship education. It shows that couples with low satisfaction before education show a moderate effect size increases in satisfaction, but couples with high satisfaction before education show little change. In other words the immediate benefit form relationship education seems to be for couples somewhat low in satisfaction at presentation.
    • Halford, Pepping, Hilpert, Bodenmann, Wilson, Busby, Larson, & Holman (2015)
  22. Couple Satisfaction Change, Risk and Relationship Education (RE)
    • 4 year change in newlyweds diagram:
      • LR Cont
        • Unchanged: 80%, Deteriorated: 15%, Distressed: 5%
      • LR RE
        • Unchanged: 70%, Deteriorated: 20%, Distressed: 10%
      • HR Cont
        • Unchanged: 45%, Deteriorated: 45%, Distressed: 10%
      • HR RE
        • Unchanged: 70%, Deteriorated: 25%, Distressed: 5%
    • Halford, Sanders, & Behrens (2001)
    • 3 year change in new parents diagram:
      • LR Cont
        • Unchanged: 25%, Deteriorated: 55%, Distressed: 20%
      • LR RE
        • Unchanged: 30%, Deteriorated: 55%, Distressed: 15%
      • HR Cont
        • Unchanged: 20%, Deteriorated: 35%, Distressed: 45%
      • HR RE
        • Unchanged: 40%, Deteriorated: 40%, Distressed: 20%
    • Petch, Halford, Creedy & Gamble (2012)
  23. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  24. Changing Trajectories of Couple Relations
    • Relationship education
      • Classic 20th century
        • Introduced in social networks > Engaged > Marry & Cohabit > Parent
      • Common 21st century
        • Meet online, social networks > Date, Cohabit > Parent > Separate > Repartner
  25. Parenting Agreements from Flexible Delivery Family Mediation
    • MAU
      • None 35%, Partial 40%, Full 25%
    • MI
      • None 20%, Partial 35%, Full 45%
    • Morris, Halford & Petch (2015)
  26. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  27. Longitudinal Relationship Satisfaction
    • Diagram: shows the trajectory of relationship satisfaction across time in long term marriages. It suggests that satisfaction declines gradually across the first 15 years of marriage, and then stabilizes.
    • VanLaningham, Johnson & Amato (2001)
  28. Effect size d of pre-therapy to post-therapy changes in efficacy and effectiveness trials of couple therapy
    • Diagram: *Effectiveness trials, ** Meta-analysis of efficacy trial
    • *Halweg & Klann (1997): 0.37
    • *Klann et al. (2010): 0.51
    • *Doss et al. (2012) 0.45
    • **Baucom et al. (2003): 0.85
    • Halford, Pepping & Petch, 2014
  29. Comparison of variability and clinical significance of change immediately after couple therapy in efficacy and effectiveness trials
    • Diagram: *Effectiveness trials, ** efficacy trial
    • Doss et al. (2012)*
      • Recovered: 18%
      • Improved: 24%
      • Unimproved: 58%
    • Hahlweg & Klann (2007)*
      • Recovered: 24%
      • Improved: 10%
      • Unimproved; 66%
    • Christensen et al. (2004)**
      • Recovered: 48%
      • Improved: 14%
      • Unimproved: 38%
    • Snyder & Wills (1989)**
      • Recovered: 46%
      • Improved: 18%
      • Unimproved: 36%
    • Halford, Pepping & Petch, 2014
  30. What predicts improvement from couple therapy?
    • Common Factors (empathy, expectations, congruence)
    • FIT approach
    • ICBT:
      • Imp. comm. skills,
      • Behaviour change in PP,
      • Acceptance of problems
    • Anker, Duncan, & Sparks, 2009; Baucom, Atkins, Simpson & Christensen 2009; Symonds & Horvath, 2004;
  31. Example of Alliance Measure
    1. Diagram: Session Rating Scale shows an example of a form that people can complete after a therapy session to rate their relationship with the therapist. This can be given after each session and the average alliance graphed across session to show changes over time.
    2. (Duncan, Miller & Johnson, 2002)
  32. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  33. Reach of Couple Therapy Plan
    • Diagram: Percentage of couples seeking various types of help for relationship problems in the first 5 years of marriage
      • Books: 22%
      • Retreats/Workshops: 19%
      • Couple therapy: 14%
    • Doss, Rhodes, Stanley & Markman, 2009
  34. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  35. New Directions -
    • Expand reach through offering
      • Online therapies
      • Self-help
      • Therapies that just 1 partner can attend
  36. New directions: Expanding reach - US example
    • Diagram: Figure 1: Geographical representation of couples shows a graph of the US and where couples lived who signed up for the online OurRealtionship web site. Its shows that people all over the US took part.
    • Diagram: Effect size (d=) for pre-post OurRelationship.com compared to wait-list control couples showing changes in satisfaction across the course of the program, and that there was large effect size improvement in couple’s satisfaction for distressed couples
      • All participants: 0.55
      • Distressed participants: 0.88
    • (Doss, 2014; Doss, Benson, Georgina & Christensen, 2013)
  37. New Directions
    • Couple therapy for individual psychological problems
      • AUD (O'Farrell & Fals-Stewart, 2006)
      • OCD (Baucom, Whisman, Paprocki, 2012)
      • Eating Disorders (Baucom, Whisman, Paprocki, 2012)
      • Depression (Bodenmann et al., 2008; Cohen et al., 2010
    • And health/medical problems
      • Cancer, arthritis, cardiovascular disease, chronic pain, human immunodeficiency virus and Type 2 diabetes (Martire et al., 2010)
  38. Meta-analysis of Behavioral Couples Therapy versus Control or Individual CBT on Alcohol Use Disorder and Relationship Outcomes
    • Diagram:
      • BCT versus control: 0.52 Effect Size (g)Hedges
      • BCT versus Ind. CBT: 0.42 Effect Size (g)Hedges
    • Schumm, O'Farrell, Kahler, Murphy, & Muchowski 2014
  39. Plan
    • The Changing Context of Couple Relationships
    • Couple Relationship Education
      • Effects
      • Reach
      • New directions
    • Couple Counselling
      • Effects
      • Reach
      • New directions
    • Implications for practice
  40. Implications for Practice
    • Evidence-based assessments are crucial
    • Regular ongoing assessments (progress-tracking)
    • Use assessment to guide recommended treatment approach
    • Agree of goals and tasks and length or treatment
  41. Tiered Intervention Model: Example of recommended intervention based on risk (low to high) and relationship functioning.
    • Risk Relationship functioning Intervention
      High-Low +

      Moderate or high relationship distress - seeking improvement in relationship

      4. Couple therapy (BCT, EFCT, IBCT, CBCT, IOCT)

      Moderate or Low No or mild relationship distress

      3. Couple relationship education
      2. Assessment and feedback

      Low +

      No relationship distress

      1. Self-help

  42. Implications for Practice
    • Empirically supported treatments and booster sessions
    • Offer tailored CRE
  43. Implications for Practice
    • Attend to therapeutic alliance (FIT) and common factors.
  44. Questions?
    • Join the Conversation
    • You can continue the conversation started here today, and access a range of related resources, via the following link: www.aifs.gov.au/cfca/news-discussion

This webinar was held on 30 July 2015.

Across nearly all cultures, sharing a lifelong committed relationship with an intimate partner comprises an almost universal ambition. Nevertheless, cross-national data reliably indicate high rates of relationship distress and breakdown, with poor emotional and physical health consequences for adult partners and their children.

In this webinar, Jemima Petch and W. Kim Halford summarised findings regarding the efficacy of couple therapy for treating general relationship distress, couple-based interventions for individual mental or physical health problems, and couple relationship education programs aimed at helping couples sustain a healthy committed relationship.

It also described the gap between high efficacy in research trials and moderate effectiveness in community practice, and discussed what might account for poorer outcomes in community practice. Specific implications for the practice of relationship education and counselling were covered.

This event was part of a series of resources on the topic of relationship education and counselling.

Further reading and resources

About the presenters

Jemima Petch

Dr Jemima Petch is the Head of Research at Relationships Australia Queensland (RAQ), adjunct researcher at the University of Queensland and a clinical psychologist. Jemima has a particular interest in promoting healthy couple relationships through relationship education and therapy, measuring and enhancing treatment effectiveness in individual, couples and family counselling, and leading organisational change to support the adoption of evidence-based practice and assessment.

W. Kim Halford

W. Kim Halford is Professor of Clinical Psychology at the University of Queensland and a registered clinical psychologist.

Comments

Great webinar. Kim referred to US studies. Also see http://family-studies.org/some-good-news-in-who-benefits-from-family-strengthening-programs/ and http://family-studies.org/author/alanh/ Best CRE programs over here include: http://familiesok.org/ and http://www.becomingparents.com/ and https://www.prepinc.com/ and http://relationshipenhancement.org/ and http://www.skillswork.org/ .
billcoffin