revolution in couple therapy: A practitioner-scientist perspective, The
Johnson, Susan M
This article offers an overview of the expanding field of couple therapy, focusing on what the author considers to be new and even revolutionary in this field. In terms of outcome research, this article suggests that differential treatment effects are discernable. Emotionally focused therapy (EFT) appears to demonstrate the best outcomes at present. The most significant differences between research studies and everyday clinical practice may be the levels of therapist supervision rather than the essential nature of clients. The manualization of treatment is also viewed positive Iy in this review. Areas of growth are the mapping of the territory of distress, understanding the process of change, couple therapy as an effective intervention for “individual” disorders, and the integration into couple therapy of clinical research, such as the research on gender and responses in therapy, and research on adult attachment. Practitioner-scientists can contribute to this evolving field by systematic observation and by reminding researchers of the need for clinical relevance. Couple therapy is now integrating description, prediction and explanation. As a result, theory, practice and systematic investigation are beginning to create a coherent whole.
There is a new focus on marriage in North America and therefore a new context for couples therapy. The divorce rate appears to be declining. Present data tell us that 43% of U.S. couples and 37% of Canadian couples who married in 1996 will divorce. This appears to be more positive than a few years ago; however, the negative impact of chronic distress in close relationships, which may not end in formal divorce, is also becoming more explicit, as is the impact of divorce and separation. Since 1960 the proportion of children who do not live with their own two parents has more than doubled, and although there is controversy over the impact of divorce on children, there is no controversy on the negative impact of marital conflict on children (Cummings & Davies, 1994; Tresch Owen & Cox, 1997) and its impact on children’s sense of security (Frosch, Mangelsdorf, & McHale, 2000). Social scientists point out that we also have an epidemic of depression and anxiety in our society, linking this epidemic to the loss of “social capital”-that is, a sense of community and belonging (Twenge, 2000). Research has specifically linked relationship distress to clinical depression, especially in women, and to anxiety disorders, such as posttraumatic stress disorder (Whisman, 1999). Research has also confirmed the danger in the lack of positive close relationships; for example, loneliness has been linked to heart disease and reduced immune system responsiveness. Conversely, the positive effects of marriage on health, especially for men, are clear (Kiecolt-Glasser & Newton, 2001). While the divorce rate has diminished then, the price of relationship distress, for individuals and for society as a whole, is clearer and more compelling.
In light of these facts, it is perhaps not so surprising that government, at least in the U.S., is beginning to consider how to actively promote stronger, more stable adult partnerships. It is as if, having considered the limitations and negatives of marriage in the 1960s and 1970s, we are again realizing the long-term benefits of close, long-term relationships and the institution of marriage. The general public also appears to be moving rapidly away from the idea of adult love as a mysterious passion that simply comes and goes. The number of self-help books on relationships disappearing from the bookstore shelves testifies to a new thirst for knowledge about how to actively shape and maintain long-term partnerships. Also, in the academic world, adult love and bonding, which was virtually ignored until very recently, is now a topic of serious study.
In spite of this new climate, if we just consider the number of new outcome studies on different models of couples therapy, one could argue that not much that is new and important has happened since the series of comprehensive reviews were published in the late 1990s (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Bray & Jouriles, 1995; Christensen & Heavey, 1999). However, this review will suggest that, in spite of the relatively small numbers of new outcome studies, a revolution is occurring in the field of couples therapy; a revolution that is addressing, on many different levels, the core issue of research in psychotherapy; namely, the significance of such research to the practicing clinician. The central issue with regard to research in couples therapy is quite simply that we, as researchers, have not made research clinically accessible and relevant enough, and we, as clinicians, have not seen research as an aid and so have not used it. This review then, is written from the standpoint of a clinician who does therapy and also conducts and uses research; that is, from the perspective of a practitioner-scientist (to reverse the usual phrase), rather than from the standpoint of a scientific researcher whose main task is to list studies and evidence in a particular area. Part of this latter stance is an air of complete objectivity. This review is written more from the standpoint that complete objectivity is impossible, that evidence arises in a personal and political context and every way of seeing is also a way of not seeing.
The Effectiveness of Couples Therapy: What Is New?
There have been only a few recent changes in the realm of empirically validated treatments. If we consider that more than one study is necessary for validation and that there must be a study by researchers other than the main proponents of a particular model, only two formally designated empirically supported treatments exist as of yet: behavioral approaches (BMT; Dunn & Schwebel, 1995; Jacobson & Addis, 1993) and emotionally focused couples therapy (EFT; Johnson, Hunslcy, Greenberg, & Schindler, 1999). The behavioral approach is based on an exchange/negotiation model of adult intimacy and focuses on negotiating pleasing behaviors and teaching problem solving and communication skills. Cognitive components, such as the restructuring of attributions, have been added to these interventions (Baucom & Epstein, 1990), but do not seem to have enhanced effectiveness (Jacobson & Addis, 1993). The emotionally focused approach is based on an attachment model of adult intimacy and focuses on restructuring key emotional responses and interactions to create a more secure bond between partners (Johnson, 1996).
In addition to these two designated empirically supported treatments, there has been one additional study using insight-oriented couples therapy (IOCT; Snyder & Wills, 1989) and one preliminary trial of integrative behavioral couples therapy, which adds elements such as the promotion of acceptance to traditional behavioral interventions (IBCT; Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000). In this trial IBCT did seem to show superior results to traditional BMT with 70% of IBCT couples reaching recovery at the end of treatment, whereas only 55% of couples receiving BMT reached recovery. In a larger ongoing study, after 26 sessions, 71 % of IBCT clients appear to be showing steady significant improvement while only 59% of BMT clients show such improvement and appear to then begin a downward trajectory (Christensen, personal communication). Given preliminary findings that IBCT was more effective in reducing blaming and promoting softer emotional expression in sessions than BMT (Cordova, Jacobson, & Christensen, 1998), it is expected that the long-term results of the above study will favor IBCT. In general, the linking of in-session, specific results with more distal results at the end of treatment and at follow-up seem to hold promise for outcome research and its relevance to clinicians.
The formulation of IBCT was fostered by the recognition of the somewhat disappointing results that have emerged for BMT over the years,although Behavioral Couples Therapy (BCT) for alcoholism, as described by O’Farrell and Fais Stewart (2002), appears to be quite effective. There has also been a need to begin to integrate a focus on affect in behavioral couples therapy. It was also perhaps spurred on by the fact that a central problem in the field of couples therapy has been that the researchers have most often identified themselves as behaviorists while the majority of clinicians identify themselves as integrative, eclectic, or systemic. A central question for this chapter is then: Is there anything new in this field that has not been captured and summarized by the previous reviews mentioned above? And if there is new evidence, does it call into question or help us reconsider our perspective on outcome research, or on the connection between research and clinical practice in couples therapy?
First, we must note that, in terms of outcome research, the field of couple and family therapy (C&FT) has been influenced by generalizations and conclusions based on research in individual psychotherapy. The cliche used to summarize, or even dismiss outcome research is the so-called “Dodo” concept. Some researchers, often those who have collapsed numerous studies into large meta-analyses, believe that, like the Dodo bird, the idea of some models of intervention being more effective than others is extinct and there are no discernable differences in outcome for different kinds of intervention (Shadish, Ragsdale, Glaser, & Montgomery, 1995). Chambless (1996, 2002) pointed out that this concept was based originally on research conducted without carefully defined treatments or subject populations, and overgeneralizations from one large recent study on the individual treatment of depression. Differences among competently conducted therapies may also be small for some problems but striking for others (such as agoraphobia). If treatments are in fact very similar, it is also to be expected that results will also tend to be similar. Others have pointed out that even when different treatments result in similar mean effects, there is good evidence that hidden within these effects are widely disparate outcomes (Howard, Krause, Saunders, & Kopta, 1997). Even in research on individual therapy however, the Dodo cliche now appears to be outdated (although Wampold, 2001, takes a different position). Differences between treatments are found; for example, Foa, Rothbaum, Riggs, and Murdock (1991) and others have demonstrated that prolonged exposure interventions are more effective than interventions such as supportive counseling for trauma survivors. As the nature of various problems becomes clearer, and as some treatments become more focused and “on target” for the problems they address, it is perhaps easier to find differences in interventions.
Couples therapy, as a modality, also has demonstrated differential outcomes. For example, couple interventions have demonstrated better outcomes than medication in the treatment of depression both at the end of treatment and at follow-up (Leff et al., 2000). In a comparative outcome study, EFT was found to be more effective than behavioral problem and communication training interventions (Johnson & Greenberg, 1985), and IOMT was found to be considerably more effective than behavioral interventions at 4-year follow-up (Snyder, Wills, & Grady-Fletcher, 1991) because only 3% of IOMT couples versus 38% of BMT couples were found to have divorced. Differential effects have also been found in family therapy research. Szapocznik, Robbins, Mitrani, Santisteban, and Hervis (in press) found that a particular model of family therapy achieved better outcomes than group therapy with drug abusing adolescents.
Whether we can find differences between treatments may depend on the power, the effect size’ in statistical terms, of the treatment. For clinicians, considering estimates of the power of treatments across studies and statistics, such as the percentage of recoveries a treatment generates, may help capture in a pragmatic way the usefulness of specific interventions and differences in effectiveness between interventions. In general, the present criteria for classifying treatments as empirically validated make the mistake of not taking sufficiently into account the power of the treatment to address specific problems (Christensen & Heavey, 1999). The power of EFT has been confirmed in a recent meta-analysis of the four most rigorous EFT outcome studies. This analysis found that EFT was associated with a 70% to 73% recovery rate for relationship distress (90% significant improvement over controls) and an effect size of 1.3. This result is considerably better than the 35% recovery rate calculated for couples receiving behavioral interventions (Jacobson et al., 1984), and the 42% recovery rate found for couples receiving a combined cognitive and behavioral treatment (Baucom et al., 1998). It is also superior to the general effect size across past studies of couples therapy, which is estimated at 0.60 (Shadish et al., 1993), and the 0.95 effect size found in a meta-analysis of BMT (Hahlweg & Markman, 1988), as well as the 0.79 effect size found for BMT by Dunn and Schwebel (1995). At the moment, EFT, which integrates a systemic focus on interactional pattern with a constructivist focus on how partners organize their emotional experience and communication, appears to give initial evidence for the best outcome results of the empirically supported couple interventions. However, since effect sizes are strongly influenced by mediators like the choice of instruments employed, the allegiance of the investigators, and the talent of the therapists, one must be cautious about drawing firm conclusions based on comparisons of effect sizes from disparate studies.
Issues With Relating Outcome Research To Practice
Even if interventions can be differentiated in terms of effectiveness, there have been questions as to the purity or rigor of the research setting as it relates to the pragmatism of practice. Some have argued that the couples seen in research are not the same as couples seen in everyday practice, that is, couples with multiple problems. The experience of this researcher is that there is very little difference between the couples in research projects and couples in clinical practice (even if I would like them to be and give them more intake questionnaires). As Chambless (1996) states, “pure cases are not numerous” (p. 233). Many efficacy studies do not exclude clients with multiple problems, and many include clients with severe comorbidity and histories of previous foiled treatments (Jacobson & Christensen, 1996; Wilson, 1998b). There is the necessity, in studies and in practice, to make clinical decisions about the sequencing and integration of treatments. For example, do you send a client for individual therapy for posttraumatic stress disorder (PTSD) before or after using couples therapy to create safety in her marriage? (Johnson, 2002). Well, it depends on the client.
A more relevant issue, which is not emphasized in the literature, and is perhaps more pertinent, is that in research projects therapists are usually well supervised. This then colors intervention and, it can be argued, optimizes results. We should consider then that research may offer us a “best case” scenario as regards outcome, rather than an everyday scenario. This is particularly true in areas in which training is limited and therapists are forced to learn using only written materials: To learn therapy relying only on a book is like learning ballet from a book-extremely difficult. These kinds of issues have resulted in a call for effectiveness research rather than efficacy studies. However, Christensen and Heavey (1999) pointed out that in fact effectiveness research is usually of poor quality, uses retrospective data and select samples, and that it may be better to conduct more clinical efficacy trials in more naturalistic settings.
Another issue addressed in the literature is the use of treatment manuals in research studies and how such manuals translate into clinical practice. The controversy over treatment manuals seems to minimize the clinical realities of the research context. In fact, unless interventions are one-dimensional and narrowly focused on one symptom and so can be truly formulaic, manuals simply offer a prototype and a guide to the focus and structure of therapy. All cooks use basic recipes and also think of a meal as a unique work of art. Manuals offer a way of seeing and a map for intervention; they do not reduce the multidimensional drama of conducting therapy to a “paint by numbers” task. They are also more self-correcting and flexible than is often assumed (Wilson, 1998a), while clinical practice is somewhat less self-correcting (Kendall, Kipnis, & Otto-Salaj, 1992). The focus promoted by the use of a manual also facilitates clients’ active engagement. Controlled outcome studies using manuals typically report very high levels of therapeutic alliance. If treatment is to become more collaborative it is important to be able to share with clients what the therapist is doing and the rationale behind interventions. In fact, manual based therapy does not impair the practice of the skilled practitioner, but it does tend to improve training (Moras 1993) and raise the level of performance of less expert practitioners (Craighead & Craighead, 1998). A recent study in which beginning therapists implemented a manual-based EFT intervention in only eight sessions still found EFT to be effective (Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000), albeit with a higher dropout rate than usual. Perhaps most importantly, manual-based treatments do not, as has been suggested, impede the development of innovative clinical strategies. On the contrary, knowing what it is you do tends to help you question, study nonresponders, and add to and reshape interventions, as happened in the case of the delineation of the attachment injuries that can block recovery in EFT (Johnson, Makinen, & Millikin, 2001). Accountability spurs on innovation. However, there does seem to be a need to ensure that manuals are “therapist friendly,” that they attend to nonspecifics, such as how to engage the client in therapy, and above all, that manuals specify the critical components of change and how to shape them. For example, a recent study on BFT (Bradley & Furrow, in press) found that specific EFT interventions, such as heightening affect, were associated with clients completing a key change event in EFT. This information is now being used to improve the training of EFT therapists.
The Stability of Treatment Effects
Do we have any new data on the stability of treatment effects? Relapse has been identified as a particular issue of concern for couples therapy as a modality for over a decade (Jacobson & Addis, 1993). Dunn and Schwebel (1995) in their meta-analysis found that IOMT was more effective at follow-up than BMT or cognitive behavioral marital therapy (CBT); however, they grouped results from EFT studies with the IOMT study in this analysis, even though these interventions differ. A follow-up study on the effects of EFT with the maritally distressed parents of chronically ill children, who are under recurring stress and at particular risk for distress and divorce (Quittner & DiGirolamo, 1998), found treatment results on marital satisfaction and intimacy level to be stable or even enhanced after 2 years (Clothier, Manion, Walker, & Johnson, in press). It is interesting to speculate as to why results may be more stable for couples treated with EFT, even in a stressed population. Attachment needs for comfort and reassuring connection are particularly salient during times of stress. Facing such stress tends to pull couples apart, unless partners can respond with secure bonding interactions that mitigate stress. This bonding is the focus of EFT interventions. Each stress event may then be an occasion for the creation of greater trust and security and continue to enhance satisfaction. The addressing of “latent affective components” of distress in IOMT and EFT may also enhance their long-term effectiveness (Snyder et al, 1991).
Who Benefits From Therapy-Or How Can We Predict Success?
In terms of general contrasts between predictors of success in EFT and BMT, the best predictor of success in BMT appears to be initial level of distress; this variable is estimated to account for up to 46% of outcome variance. The more distressed couples are at the beginning of BMT, the more distressed they are at the end. The best predictor of success in EFT appears to be the female partner’s belief that her partner still cares for her, and initial distress was not found to be a powerful predictor of outcome variance. Studies found that it is harder to treat older couples and traditional couples using BMT, whereas EFT seems to work better for couples over 35 and traditionality was not found to impact outcome (Jacobson & Addis, 1993; Johnson & Talitman, 1997; Whisman & Jacobson, 1990). EFT has also been found to work well for low income and low education level couples (Denton et al., 2000), and for couples when husbands were rated as “inexpressive” by their spouse (Johnson & Talitman, 1997). Snyder et al. (1991) found that problem solving during a conflict resolution exercise in IOMT predicted higher marital instability. This may imply that superficial, instrumental, report-oriented conversations may impede the emotional engagement necessary for relationship repair. This fits with research on the active ingredients of EFT in which depth of emotional experiencing in key sessions was associated with the completion of change events (Johnson & Greenberg, 1988).
For most forms of couple intervention, the basic contraindication is violence in the relationship. In general, risk factors and treatment feasibility issues regarding violence in close relationships are beginning to be addressed (Bograd & Mederos, 1999). Different forms of violent behavior are becoming delineated, for example “hot” violence versus a “cold” more calculated form of violence, to assess which are more amenable to treatment (Jacobson & Gottman, 1998), and violent behavior is being placed in the context of general relationship theories, such as attachment theory (Holtzwoith-Munroe, Stuart, & Hutchinson, 1997). Violent men have been found to be more insecure, more dependent on and preoccupied with their wives, and less trusting and comfortable with closeness. The link between abusive family relationships and various forms of serious dysfunction is also becoming more delineated (Allen, 2001).
Do clients in better therapeutic relationships achieve better outcomes? The impact of general therapist factors on outcome in individual therapy has been studied extensively. For example, in an exhaustive review, Orlinsky, Grawe, and Parks (1994) identified factors such as therapist credibility, skill, collaborativeness, empathie understanding, affirmation of the client, and attention to the client’s affective experience as associated with outcome. The quality of the therapeutic alliance is generally considered to be a key factor in successful intervention; generally, it appears to account for about 9% to 10% of the variance in outcome (Beutler, 2002; Horvath & Symonds, 1991). In an EFT study, the alliance was differentiated into three elements: bond, task relevance, and engagement and goal agreement. The best predictor of success was the task element of the alliance. This implies that EFT works best when the couple finds working with emotions and patterns of attachment responses relevant and engaging (Johnson & Talitman, 1997). In this study, the quality of the alliance accounted for 22% of the variance in satisfaction at the end of therapy. However, the alliance may be more important and more subject to change at different times in therapy and with different kinds of clients. Research on individual therapy has found that when therapists do not correct problems in the alliance and instead become focused on techniques, such as focusing on distorted cognitions, the alliance worsens and negatively impacts outcome (Castonguay, Goldfried, Wiser, Rue, & Hayes, 1996).
In this area, there is a need for research on predictors of success in more diverse populations, and on how to maximize the effectiveness of therapy for these populations. For example, there is still very limited clinical literature on gay couples (Igartua, 1998; Mohr, 1999), and no clinical studies have been conducted with this population. The little research that exists indicates that similarities between opposite-sex and same-sex couples far outweigh differences, but that where differences exist, they may favor gay relationships. Green, Bettinger, and Zacks (1996) reported that lesbian couples are on the whole closer, happier, and more flexible in their relationships. Gay relationships tend to be more egalitarian and, rather than being “fused,” tend to foster self-actualization. There is also very little data on the difficulties of interracial couples (Crohn, 1998) or on how immigrants, many of whom began their partnerships as arranged marriages, fare in couples therapy and how we can tailor interventions to their needs (Sluzki, 1998).
FOUR AREAS OF GROWTH
Although there are many debates about the role of outcome oriented research in our field, there appears to be a growing general agreement that we have no choice but to become more research based. Those who fund our profession and the credibility and ethics of our profession demand it. As Sprenkle noted in his 2001 address at the American Association for Marriage and Family Therapy (AAMFT) conference in Nashville, research enables us to grow as a discipline, and not be characterized by “competing sects led by feuding charismatic prophets.” However, outcome research is only one form of inquiry and there have been many developments, perhaps revolutionary developments, in other areas in the last few years.
Specifically, there have been great strides in four areas. The first of these areas is the continuing research into the nature of clinical problems that has continued to refine our understanding of the nature of relationship distress. Mapping the territory of distress offers us the chance to be more “on target” and so intervene with maximum effectiveness. The second area is research into the process of change in therapy. This kind of research does much to bridge the gap between clinician and researcher. Beutler, Williams, and Wakefield (1993) found that the most strongly endorsed clinician request was for research studies that focus on therapist and/or client behaviors leading to important moments of change during therapy. The third developing area is the application of couples therapy as an effective treatment for individual disorders. The essence of the systemic perspective is the belief that people and their problems are best understood and best treated in their interpersonal context, so this kind of research makes ultimate sense to couple and family therapists. More than this however, there is a growing recognition that couples therapy, linking self and family system as it does, has enormous potential to create positive shifts on multiple levels, in individuals, in adult partnerships, and in key family interactions. The fourth area of growth here is that couple and family therapy is becoming less isolationist, and is beginning to integrate general research from clinical psychology, human development, and social psychology to inform, guide, and evaluate interventions. Such research can help couple therapists understand the processes that perpetuate dysfunctional coping, offer a conceptual map of key elements in a relationship, and understand the nature of change. For example, there is more and more focus in the couple and family field on the negative impacts of emotional disconnection, between adolescents and parents and between adult partners, and the potential for change when fears about rejection and abandonment are shared (Liddle et al., 2000). This kind of research appears to be fueling a shift from an overriding concern with issues such as differentiation and enmeshment in C&FT into a focus on elements such as nurturance, often neglected in our field (Mackay, 1996), and the quality of emotional engagement and attachment. These four areas, which we will now examine in more detail, together with the outcome research outlined above, constitute an active revolution in couples therapy.
Research Into the Nature of Relationship Distress
Part of a modality coming of age is being able to clearly delineate that nature of the problems it addresses and use this understanding as a basis for intervention (Johnson & Lebow, 2000). The seminal work on the nature of marital distress conducted by researchers such as Gottman (1994) has continued in the last few years, although the validity of his powerful predictions of divorce has also been questioned (Heyman & Smith Slep, 2001). Recent research has emphasized that support and emotional engagement are key elements of a marital relationship and that these elements can have more power to predict the future of the relationship than conflict behaviors. Pasch and Bradbury (1998) found that wives’ negativity when soliciting or providing support predicted relationship outcomes 2 years later. The pattern in this research is clear: Affective tone is more important than the content of dialogue or whether couples can problem solve particular issues. Soothing and support are key factors in successful marriages, and marriages work best when partners can de-escalate the other’s negative emotion and when wives, in particular, tend to use “softened start-up” when bringing up issues. The amount of anger expressed or the number of conflicts does not necessarily create relationship distress; however, contempt and defensive distance tend to be more problematic (Gottman, Coan, Carrere, & Swanson, 1998). Research is also helping to delineate when problems will occur, to grasp the critical periods and events in the life of a marriage. Many problems, for example, begin with the transition to parenthood (Cox, Paley, Burchinal, & Payne, 1999) when companionate activities decrease and conflict and marital distress increase. Research can also help us understand what happens to couple relationships after traumatic events such as the death of a child (Oliver, 1999) and how we can best intervene.
A field of scientific enquiry has three levels: description, prediction, and explanation. One of the problems in couples therapy is that without a theory of love to help make sense of the above descriptive research results, the labels we give to phenomena may be arbitrary. Stanley, Bradbury, and Markman (2000) suggested that it is not the husband’s refusing his wife’s “influence” (as Gottman suggests) that is the key factor in predicting marital satisfaction; it is whether husbands are able to tolerate and respond to their wives’ expressions of negative affect, which are often also bids for support. This interpretation and indeed much of these data seems to this practitioner-scientist to fit elegantly with, and is best understood and explained by, an attachment perspective on love. This perspective focuses precisely on emotional engagement and responsiveness as the foundation for stable connection, and views many complaints as attachment “protest” aimed at engaging the spouse. From an attachment point of view, the “positive sentiment override” effect, which is stressed in the research on marital distress and which enables partners to filter negative or neutral behaviors and repair rifts, refers to the confidence a partner has that the other will be responsive when needed and stay close, that is to the level of attachment security in a relationship (Johnson & Best, in press).
As Gottman et al. (1998) suggested, a clear understanding of the nature of marital distress and happiness must be the basis for intervention in couples therapy, rather than models of individual functioning taken from the individual psychotherapy field. As a result of this research, recent models of intervention such as IBCT pay more attention to emotion and to the creation of supportive interactions, such as acceptance. Gottman et al. identified EFT as consonant with his team’s research results on the nature of distress in close relationships.
Process Research Into the Nature of Change
In the field of couples therapy, we need to consider not just what to change but how change occurs (Goldfried & Wolfe, 1996). This can be done in many different ways. We can examine how clients see change, or how specific common interventions seem to impact the change process, or how specific change events occur in key sessions in a particular model, and how clients complete key change tasks.
Client perceptions of change. Research incorporating the client’s perceptions of the change process is only just beginning. Recent research into clients’ perceptions of specific pivotal moments of change in eclectic sessions of couples therapy using videotapes, transcripts, and interviews suggest that such moments are highly personal and idiosyncratic for each spouse, and that repetition is important. This research (Helmeke & Sprenkle, 2000) suggests more specifically that, “focusing and refocusing on subject matter that is emotionally important to the client seems to be the key factor related to the occurrence of pivotal moments” (p. 480). Christensen, Russell, Miller, and Peterson (1998) found that clients were able to identify changes in affect and how it influenced communication, as well as changes in cognition, and general communication patterns. Clients spoke about how important talking about needs was and how new affective experience created new meanings. It would be interesting to use methods applied in individual therapy such as interpersonal process recall (Elliott, 1984) with couples to ascertain in more detail how they perceive change events in therapy. Couples therapists, under the influence of postmodern ideas, appear to be moving into a more collaborative stance with clients, rather than a neutral or expert stance. This kind of process research makes clients collaborative partners in the development of interventions.
Common interventions. Is it possible to identify and research common core interventions that cut across models? On a general level, involvement in therapy and collaboration in assignments was found to be the most robust predictor of improvement in BMT (Holtzworth-Munroe, Jacobson, Deklyen, & Whisman, 1989). Tabbi (1996) also suggested that active experiencing and involvement should precede explanation in effective couple and family therapy sessions. In this vein, Nichols and Fellenberg (2000) examined enactments in family therapy and found that successful enactments (that created positive shifts) were structured by the therapist. In these enactments, the therapist was specific about the topic and how the conversation should go, and the most frequent observed productive way to close an enactment was to describe the problem dynamic that had occurred in the conversation. These authors commented that the process worked best when therapists resisted the urge to preach and teach, and helped clients speak for and about themselves and go deeper into their feelings. Butler and Wampler (1999) also found that couples preferred enactment-based interactions and struggled less in therapy than if the therapist channeled all interactions through him or herself. The above research is more relevant to some models of therapy than others in that some models do not attempt to delve deeper into feelings or to structure engagement in enactments.
Softenings, key change events in EFT, are specific kinds of enactments in which the therapist structures new kinds of interactions that have been found in past research to promote affiliative emotional engagement and positive outcome (Johnson & Greenberg, 1988). Successful softenings are characterized by deepening levels of emotional experience and a movement towards affiliative interactions. As noted previously, recent research (Bradley & Furrow, in press) has examined these softening events in EFT, where critical blaming partners risk and reach for closeness, and identified the most frequent therapist interventions associated with them. These interventions were: heightening key emotional responses; refraining responses, often in terms of attachment fears and needs; and evocative responding to deepen emotional experience. The use of these specific interventions is predicted by the EFT model. However, in the events examined, researchers found that therapists also tended to give a brief image of attachment responses that were just out of the partner’s reach, using phrases like, “So you could never. . . .” This has now been consciously incorporated into EFT training. On a concrete level this is an example of how process research can lead into a delineation of therapist behaviors in change events and can then result in the refinement of interventions.
Task performance. If we consider specific tasks in therapy and how they are successfully completed it is possible to formulate key change elements and a change sequence for each task. For example, in family therapy the tasks of resolving conflict (Diamond & Liddle, 1999), or mitigating blame (Melidonis & Bry, 1995), or refraining presenting problems (Coulehan, Friedlander, & Heatherington, 1998) have been examined. In the task of sustaining engagement in family therapy, Friedlander, Heatherington, Johnson, and Skowron (1994) found that acknowledging one’s contribution to an impasse, exploring and confiding underlying emotions, validating the other’s feelings, and recognizing the benefits of engagement led to new attributions about the other person and new responses. An interesting example of this kind of research in EFT is current investigations into resolving impasses in the change process. This research involves delineating the steps in recovery from traumatic relational experience-termed an attachment injury (Johnson et al., 2001). This research is also an example of a new development in the field towards understanding the critical elements in the general task of forgiveness and reconciliation in couples therapy (Gordon, Baucom, & Snyder, 2000; Worthington & Drinkard, 2000). It is also an example of “progress” research advocated by Pinsof and Wynne (2000), who suggested that we study how change occurs naturalistically-then test and refine to see what processes facilitate such change and how therapists can potentiate this change. Process research that develops and tests theories of change is a clear and direct route to the modification and/or refinement of models of therapy.
In the research on attachment injuries, a task analytic strategy was followed (Greenberg, 1991). First, a marker or cue that a specific task was arising in therapy was identified. In this case, in the second stage of EFT when a partner is about to take a significant risk and re-engage the other partner, a past abandonment or wound arises vividly in the session and blocks risk-taking. The wounded partner draws back from emotional engagement and states some version of “never again.” case examples of clients who managed to work through these impasses were then examined and a sequence of steps associated with success was formulated. These steps were then verified and refined in new cases and are now being tested in a larger study to see if, in key sessions, their presence distinguishes those who resolve these injuries and reach reconciliation from those who do not. Once the sequence of steps of competent performance in this change event is verified, we can then examine the specific interventions that facilitate these steps. Already the preliminary case studies suggest that the resolution of these injuries is associated with factors such as the wounded partner being able to express deep hurts and losses and the other partner staying emotionally engaged and actively responding to these emotions with compassion and comfort.
Studies that link within-session behaviors with different kinds of change processes, such as the creation of pivotal moments and completion of key tasks, have the potential to bridge the gap between research and practice, helping clinicians make decisions about what to do with particular clients at particular points in therapy (Persons & Silberschatz, 1998; Pinsof & Wynne, 2000).
Couples Therapy far Individual Disorders
Individual and relationship problems often occur together and reciprocally impact each other (Halford, Bouma, Kelley, & Young, 1999), and the quality of an individual’s relationships clearly plays a pivotal role in many disorders (Fincham & Beach, 1999). Couples therapy can address individual disorders on many levels (Baucom et al., 1998). First, the partner can be used as a coach in treatment focused on the individual; second, the couple relationship as it impacts an individual disorder can be addressed; or third, couples therapy can be used to improve the functioning of the individual and the relationship. There may also be certain disorders that are extremely difficult to significantly improve without the creation of a supportive close family relationship, such as posttraumatic stress disorder (Johnson 2002).
An example of the first level is the use of the spouse as a coach in the treatment of anxiety disorders. Barlow, O’Brien, and Last (1984) found that inclusion of the spouse boosted treatment effectiveness in agoraphobia from 46% to 68%. An example of the second level is the use of a form of conjoint treatment that focuses on violent behavior in male partners. Brannen and Rubin (1996) have used couple interventions that focus on modifying violent behavior, and have been able to demonstrate a reduction of violence in some couples, without putting women at greater risk than if the offenders were in gender-specific treatment.
If we consider the third level, improving couples communication can enhance the treatment of anxiety problems such as agoraphobia and may help prevent relapse (Daiuto, Baucom, Epstein, & Dutton, 1998). At present, couples therapy appears to be generally used as the sole treatment for only one disorder, depression, the so-called common cold of mental illness. The role of relationship distress in the generation, promotion, and maintenance of depression has become more clear and has been linked to an attachment perspective on close relationships (Anderson, Beach, & Kaslow, 1999; Davila, 2001; Whiffen & Johnson, 1998). From this perspective depression is a natural result of the inability to create a secure connection with a primary attachment figure on whom we depend. This inability evokes loss and a sense of vulnerability and powerlessness, as well as doubts about the innate worth of the self. It is not surprising then that as Weissman (1987) stated, depression is 25 times more likely to occur in those who are maritally distressed. A lack of supportive relationships can also potentiate other stressors or undermine a client’s response to individual therapy. There have been several studies that support the use of behavioral couples therapy to reduce depression (Beach, Whisman, & O’Leary, 1994; Jacobson, Dobson, Fruzzetti, Schmaling, & Salusky, 1991), and one study on a couples version of interpersonal psychotherapy (Foley, Rounsaville, Weissman, Sholomaskas, & Chevron, 1989). In general, these studies found that couples therapy is as effective as individual therapy for depression if marital distress is present, and has the added advantage of improving the depressed person’s relationship. There is some evidence that EFT also impacts depression (Johnson et al., 1999), and the previously mentioned Leff et al. (2000) study also found couples therapy to be a compelling treatment for depression. Couples therapy can also be separate but integrated into individual therapies for depression (Whisman & Uebelacker, 1999). There is strong evidence that not addressing the marital distress with depressed partners can undermine the effects of individual therapy. If depressed partners are maritally distressed at the end of their treatment for depression, they are at risk for recurrence of depression and negative long-term outcome (Whisman, 2001).
The use of couples therapy to address depression has progressed further than many other areas in which couples therapy is just beginning to be used as a treatment for individual problems or as a key element in this treatment. Research with clinical and community samples demonstrates a clear association between marital functioning and anxiety disorders even when controlling for the effects of comorbidity (McLeod, 1994). The creation of a safe and supportive couple relationship has obvious implications for the treatment of anxiety disorders such as posttraumatic stress disorder (PTSD; Lebow & Gurman, 1995). Research is also helping us understand the systemic implications of individual disorders such as PTSD and depression and how a spouse can become secondarily traumatized as a result of living with a trauma survivor or feel burdened by a depressed partner (Benezon & Coyne, 2000; Nelson & Wampler, 2000). In a multidimensional problem like chronic PTSD, different treatment elements and modalities (such as couple and individual therapy) are best coordinated into an integrated whole (Johnson, 2002). It helps then to have a coherent theoretical map (such as attachment theory) of problems and change processes to facilitate this integration.
As the impact of close relationships on coping with distress and illness becomes more articulated (Manne, Taylor, Dougherty, & Kemeny, 1997), couples therapy is also being seen as a way to help partners cope with physical illness, such as cancer and heart disease (Bultz, Speca, Brasher, Geggie, & Page, in press; Carlson, Bultz, Speca, & St-Pierre, 2000; Schmaling & Goldman Sher, 2000). New research, for example, found that actively processing and expressing emotions enhances the adjustment and health status of breast cancer patients significantly, but only if their social contexts, often a partner, were perceived as highly receptive (Stanton et al., 2000). There is evidence that women with better spouse relationships whose husbands show specific supportive behaviors are protected from exacerbations in rheumatoid arthritis (Zautra et al., 1998), and the impact of marriage on men’s health is also clear; for example, men who disclose to their wives after heart attacks were less likely to die, even after controlling for a biomedical index that is highly predictive of prognosis (Helgeson, 1991).
The treatment of sexual dysfunction with couples interventions has been addressed in other recent reviews (Baucom et al., 1998). However, one study seemed particularly interesting in that it took a most difficult and complex problem, low sexual desire, and addressed it on many levels. Hurlbert, White, Powell, and Apt (1993) compared a package of partner assisted sexual skills training, a general couples intervention, and orgasm consistency training with a women only counseling group. The combined treatment package was superior to both waitlist group and the women only group on measures of sexual compatibility, desire, and satisfaction. A brief EFT intervention for low sexual desire has been tested, but failed to find significant results (MacPhee, Johnson, & van der Veer, 1995).
Couples therapy is also used as a key ingredient in the treatment of addictions such as alcoholism (O’Farrell & Fals-Stewart, 2002), but, as previous reviews have made clear (Baucom et al., 1998), there are only two programs that have been systematically evaluated: Azrin’s (1976) Community Reinforcement Approach, and the Counseling for Alcoholics’ Marriages (CALM) Project (O’Farrell, 1993). The latter, which has empirical support, focuses on relationship skills, the creation of disulfiram contracts with the spouse, and relapse prevention. Problem drinking couples arc characterized by high rates of negative affect expression, few supportive behaviors, and frequent withdrawal in conflict situations. Problem drinking and marital distress then reciprocally reinforce each other (Halford et al., 1999). The CALM program has been found to promote sobriety and influence other key factors such as the prevalence of marital violence in these couples (O’Farrell & Murphy, 1995). These researchers found that the addition of couples interventions to a course of individual therapy reduced substance abuse more, as well as improved marital satisfaction, and prevented relapse (Fals-Stewart et al., 2000; O’Farrell, Choquette, & Cutter, 1998). Of course, some alcoholics will not agree to such treatment programs and/or to couples therapy. There is little research on the necessary or sufficient components of alcohol oriented behavioral couples therapy or tests on mediators of change (Epstein & McCrady, 1998). Interestingly, all of these studies tested behavioral interventions; however, a survey showed that although 27% of programs addressing alcoholism in the U.S. used some form of couples therapy, none used behavioral interventions specifically and only 5% used them at all (Fals-Stewart & Birchler, 2001). Couples therapy has also begun to be used as part of the treatment of drug abusing women, showing promising initial results (Trepper, McCollum, Dankoski, Davis, & LaFazia, 2000), and with drug-abusing men, resulting in longer abstinence and less drug use (Fals-Stewart, Birchler, & O’Farrell, 1996).
As Pinsof and Wynne (1995) pointed out, involving family members in treatment seems to potentiate most other forms of individual intervention. Also for change to endure, it would seem essential that it occur in and be supported in the natural environment (Gurman, 2001).
The Integration of Research From Other Areas
C&FT has tended in the past to be more than a little isolationist. However, as a discipline comes of age it usually becomes more integrative and incorporates research from other disciplines to broaden and deepen its own vision.
One area that has expanded the scope of couples therapy is recent research and writing on gender and feminist perspectives. Research has confirmed that gender-stereotyped roles are bad for relationship stability and satisfaction (Heavey, Layne, & Christensen, 1993), and that in negative marital interactions men tend to withdraw while women demand. Other research has found that gender differences, for example, in conceptions of love, are often less than expected (Fehr & Broughton, 2001). Both men and women seem to hold companionate views of love. Studies have also not found large differences between men and women on key aspects of communication, such as levels of self-disclosure (Dindia & Allen, 1992). What seems to matter for marital satisfaction is not absolute levels of skillfulness, but the similarity in skills between male and female partners (Burleson & Denton, 1992). However, fundamental differences in the content and structure of men and women’s self-representations have been found (Cross & Madson, 1997). Women incorporate representations of significant others, while men’s construals are less relational. Women are then more attuned to the emotional quality of marital functioning and more sensitive to relational events. This may account for their heightened risk for depression in unhappy relationships. Men and women may also respond differently in therapy. In a gender-based comparison, wives responded more positively to therapist reflections, and husbands responded more positively to reframing (Brown-Standridge & Piercy, 1988). New research also suggests that women handle stress differently than men. Oxytocin, the cuddle hormone (Carter, 1998; Hazan & Zeifman, 1994) released at orgasm and at breast-feeding, seems to also calm women under stress. Rather than fight or flight, oxytocin seems to create a “tend and befriend” response that lowers blood pressure and so promotes health and longevity, as well as resilience through closer relationships. As we understand gender better, we can understand how men and women’s responses differ and how we can tune our interventions to their specific needs and sensitivities. Observation of key therapy sessions in EFT suggests that when expressing vulnerability, men speak in terms of performance, failure, and rejection, whereas women speak of being alone and abandoned. This kind of clinical observation could cue more systematic study and consider how different models of intervention deal with this phenomenon. Feminist writers have formulated a gender neutral set of criteria (Haddock, Schindler Zimmerman, & MacPhee, 2000) to increase personal agency, develop egalitarian relationships and examine gender constraints in therapy, and have addressed whether models of couples therapy are generally consonant with feminist values. Exchange theory, which is the theoretical base of BMT, has been viewed as dissonant with feminist ideas (Wood, 1995), whereas EFT and attachment theory has been viewed as generally echoing feminist values (Vatcher & Bogo, 2001).
Perhaps the very best example of how other areas such as developmental and social psychology can contribute to the field of couples therapy is the recent explosion of research on adult attachment (Cassidy & Shaver, 1999; Johnson & Whiffen, in press). As Anderson (2000) pointed out in her plenary speech at a recent AAMFT conference, we have set out on the vast and troubled ocean of improving distressed primary relationships in a very small theoretical boat. Attachment theory offers to couple therapists a clear comprehensive theory of relatedness that is supported by creative empirical research, is consonant with systems theory (Johnson & Best, in press), has considerable cross-cultural validity (van Ijzedoorn & Sagi, 1999), and has clear, specific implications for clinical intervention. Attachment security-that is, how confident a person is that his or her key attachment figure, such as a spouse, will be accessible and responsive when needed-has been clearly linked to the quality of love relationships (Collins & Read, 1990) and specific factors such as support seeking (Simpson & Rholes, 1994) and conflict behaviors (Simpson, Rholes, & Phillips, 1996). For example, partners who display an avoidant style in close relationships are not generally cool or distant; they are this way in specific contexts, exactly when they or the other partner are anxious and vulnerable. This theory links habitual ways of regulating emotion and models of self to habitual ways of engaging others; it links self and system. Secure attachment promotes resilience and autonomy, and is associated with key relational responses, such as the ability to process ambiguous information effectively, consider alternative perspectives, empathize with others, monitor patterns in interactions, self-disclose openly, and collaborate in problem solving (summarized in Johnson & Whiffen, 1999). There is nothing so practical as a good theory, and attachment theory helps the therapist understand distressed clients’ responses; for example, it predicts that when attachment security is uncertain, a partner will pursue, fight, and even bully a spouse into responding to attachment cues, even if this has a negative general impact on the relationship. A good theory can help clinicians understand very specific responses. For example, a recent study found that attachment insecurity is linked to spouses being reactive to more recent events when evaluating a relationship (Feeney, 2002) and that those who use avoidant strategies in close relationships use these strategies particularly when they or the other partner is vulnerable, whereas at other times they may appear as very sociable. A good theory also helps the therapist form general treatment goals and pinpoint which specific responses can transform a relationship. Research into attachment also challenges pathologizing concepts of dependence that have long been part of the C&FT field. Attachment theory implies, in a way that coalesces with empirical data on the nature of marital distress, that for many distressed partners the problem is not one of enmeshment or lack of differentiation, but lack of secure emotional connection.
CONCLUSIONS AND NEW DIRECTIONS IN COUPLES THERAPY
If we consider the conclusions of the last major review of couples therapy in the Journal of Marital and Family Therapy (Bray & Jouriles, 1995), some of the issues raised are still very pertinent. For example, research still needs to help delineate the special needs of diverse groups of couples from different cultures. Remarriages, in particular, seem to be an important focus for study so we can hone interventions that particularly address special issues in these relationships. The previous review also addressed the issue of relapse prevention, and suggested interventions such as booster sessions in the event that one round of therapy does not last a lifetime. The issue of relapse prevention would seem to be an excellent focus for future research and clinical innovation. It is perhaps an area in which marriage education, enrichment, and therapy can be integrated. This review suggested that, since the previous review was written, the field of couples therapy has grown and become more coherent as a discipline. If, as some commentators have noted, we appear to be heading into a golden era for family therapy, this may be even more true of couples therapy. What must we do to ensure that this occurs?
Liddle et al. (2000) noted that we must keep moving away from a bag of tricks mentality. First, we need coherent theoretical networks that are substantive and empirically tested but not so abstract that they do not generate specific interventions. Such relational theories have been hard to come by. Some behavioral interventions are based on quid pro quo exchange theories. However, research suggests that these kinds of interactions are found only in very distressed couple relationships. Some models of couple interventions are based on theories of enmeshment and fusion that have very little empirical basis. Second, we need more descriptive and process research that attempts to close the gap between clinicians and researchers. In order to close this gap, we must also write research studies in a more accessible manner oriented toward clinicians rather than other researchers (Goldfried & Wolfe, 1996). We can also use different research designs using replicated case studies (Jones, 1993) conducted by clinicians with and for clients to generate hypotheses for larger studies. We must examine the process of change and the successful completion of specific tasks in therapy.
Perhaps we also need to change our mind set regarding research. Research is defined in the dictionary as systematic investigation. Surely, the passion of clinicians to understand problems and shape more powerful interventions can be at least as generative as large research grants and complex statistical analysis. We can then use “bottom up” rather than “top down” research based on observation in therapy sessions to track, examine, and analyze the phenomena of how clients experience their problems and key moments of change. Research focused on key tasks and the steps in the change process can improve manuals (Goldfried, 2000) and specify which therapist interventions facilitate specific steps in change. Teaching clinicians the methods of intensive case study in graduate school and giving such studies a special place in journals would help considerably. The scientist-practitioner model was set out in 1950 at the Bolder conference (Raimy, 1950). Perhaps this model needs to be revised, and more emphasis given to the wisdom of clinicians rather than the rigors and requirements of complex statistical methods that were originally formulated to study samples of seeds, samples of thousands. We do not need to use the model of abstract science as the only guide. We do not need to indulge in “physics envy.” We can put the needs of the practitioner first and still be scientists. In a practitioner-scientist model, practice is the beginning and end of the process of investigation. We begin by examining relational processes or in-session phenomena, placing these in the context of theories of relationship and theories of change, analyzing the data and forming conclusions, finally returning to the significance of lhis analysis for the moment-to-moment process of therapy, the fostering of powerful interventions and healthy functioning.
It is worth considering for a moment why clinicians often do not pour over research journals. The couple and family interventions themselves have sometimes been accused of being too technical, abstract, and detached from the real lives and experience of ordinary people (Merkel & Searight, 1992), and ignoring factors such as emotion, which is also a way of knowing. If this is occasionally true of interventions, it is certainly even more true of many of the descriptions of research methods, analyses, and conclusions in the literature. Also much effort and technical analysis seems to go into telling clinicians what they already know-what they routinely observe in sessions. An example might be the recent arguments about analyses between Gottman and Levenson (2002) and other researchers in Family Process, the significance of which turns out to be that some marriages are volatile and may end before other distressed marriages that are more disengaged. On the other hand, some research is crucial and tells us practice oriented corrective and enlightening information. It is useful to realize that until recently nearly all research on marital interaction and many of our interventions were focused entirely on conflict and conflict reduction (Flora & Segrin, 2000; Karney & Bradbury, 1995). However, conflict is by no means the whole story with regards to intimate relationships, so the ending of conflict is no longer the all-encompassing goal for couples therapy.
It is also true that research results can specifically redirect and refine in-session practice. On the macro level, recent research has brought emotion and how it shapes interactions more into focus in C&FT. Again and again, relationship distress is associated with a spouse displaying emotion and the other spouse not responding to this affect (Johnson & Bradbury, 1999). Research on the expression of emotion suggests that simple attention to and expression of emotion can exacerbate distress, unless emotion is recast and restructured (Littrell, 1998). Specifically, this research suggests that a client must remain focused on emotional stimuli long enough for a new response to occur. Such studies confirm the need for a slower pace and repetition in couple sessions in which strong affect is being processed. Other research tells us that using imagery elicits physiological responses that abstract words do not and so promotes engagement with emotional experience (Borkovec, Roemer, & Kinyon, 1995). On a micro level, even general research that is not specifically about therapy can suggest refinements in intervention. Husbands’ gaze in positive interactions predicts both spouses’ satisfaction (Flora & Segrin, 2000). Reading this study confirmed my inclination to insist that partners turn and look directly at each other to enhance emotional engagement in change events.
What then are some of the key implications of this review for the practicing clinician? First, couple interventions are continuing to be refined and tested and outcomes are becoming more and more promising. Missing elements, such as emotion, are becoming integrated into interventions, although some models remain opposed to such integration (Miller & de Shazer, 2000). There is evidence that we can find differences in how different interventions impact relationships, and I believe that clinicians, who spend much time and effort learning specific models and interventions, will resonate with these findings (Rounsaville & Carroll, 2002). We are beginning to delineate the key differences between research studies and clinical practice and struggle more fruitfully with key issues such as how to help couples create lasting change in their relationships and how to deal with difficult issues such as violence and abuse. We know more about the basic nature of relationship distress and couple interventions are now being used to address “individual” problems, such as depression and anxiety disorders that occur in, and are influenced by, relational realities. Our understanding of gender and the part it plays in defining relationships is expanding, as is our knowledge of the nature of adult love. In general, there is more focus on nurturance, support, and connection, and less on issues such as boundaries and enmeshment. Studies of the change process in couples therapy sessions are increasing and beginning to provide direct guidance for the therapist in his or her efforts to initiate specific change procedures and events. The outlining of pivotal moments of change and key tasks focused on the defining elements of a close relationship are invaluable to a therapist facing a complex interpersonal drama and seeking to renew and restore it.
Given all of the above, this chapter suggests that a revolution is occurring in the field of couples therapy. A new science of relationships is evolving and supporting a renewal of the discipline of couples therapy (Bersheid, 1999). This revolution is much more earth shaking than the “quiet” revolution noted by Lebow (1997), when he spoke of the increasing integration of interventions across different models. The field of couples therapy appears to be in the process of integrating description, prediction, and explanation. Theory, practice, and systematic investigation are beginning to create a coherent whole. If this is to continue and flower, clinicians and researchers need each other; clinical experience is often too unsystematic and idiosyncratic to add to the reliable body of knowledge, but clinicians can engage in systematic observation and so germinate the seeds of further knowledge and research endeavors. Researchers need the “white heat of relevance,” the significance and ecological validity of clinical realities (Soldz & McCullough, 2000) to keep them on track and tell them what matters. The final stage in this revolution will be when systematic investigation moves closer to the moment-to-moment magic that is therapy and when practitioners see research as a powerful resource and are inspired by research investigations to do more efficient and effective therapy.
NOTE 1 An effect size allows us to say that average treated couples satisfaction scores will be better than a percentage of those untreated. An effect size of 0.60 means that 65% of treated couples improved. It is essentially the difference between two means when divided by the measurement error in the system.
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Susan M. Johnson University of Ottawa
Susan M. Johnson, EdD, Department of Psychology, University of Ottawa, Ottawa, Ontario, Canada, and director, Ottawa Couple and Family Institute.
This article was also published as chapter 6, “Marital Problems,” in the book edited by D. H. Sprenkle (2002), Effectiveness Research in Marriage and Family Therapy (pp. 163-190). Alexandria, VA: American Association for Marriage and Family Therapy, web site: www.aamft.org, phone: (703) 838-9808.
Correspondence concerning this article should be addressed to Susan M. Johnson, Department of Psychology, University of Ottawa, Vanier Bldg. /11 Marie Curie, Ottawa, Ontario, Canada, K1N6N5. E-mail: firstname.lastname@example.org, web site: www.eft.ea
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