Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting.

Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers. A research paradigm called patient-focused research—a method of enhancing outcome via continuous progress feedback—holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy. The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy. Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback. Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does a continuous feedback system improve psychotherapy outcome?

Using outcome data on a continual basis to monitor treatment progress has been identified as a way to enhance psychotherapy outcome. The purpose of this study was to investigate the use of a continuous feedback assessment system, the Partners for Change Outcome Management System (PCOMS; Miller & Duncan, 2004). Findings from 2 client samples that attended individual therapy at a university counseling center (N = 74) or a graduate training clinic (N = 74) indicated that clients who used PCOMS with their therapists (feedback condition) demonstrated statistically significant treatment gains when compared to clients receiving treatment as usual (no-feedback condition). Clients using PCOMS were also more likely to experience reliable change and in fewer sessions. A survival analysis demonstrated that approximately 50% of the clients in the feedback condition demonstrated reliable change after the 7th (graduate training clinic) or 9th session (university counseling center). Further findings, limitations of the study and ideas for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Couple relationship education at home: Does skill training enhance relationship assessment and feedback?

To evaluate the effective components of couple relationship education, 59 newlywed couples were randomly assigned to one of two couple relationship programs (CRE): (1) RELATE, which involved receiving feedback on their relationship based on the on-line RELATE assessment; or (2) RELATE + Couple CARE, which was RELATE plus completing the 6 unit Couple CARE relationship skill training program. Relative to RELATE, RELATE + Couple CARE produced more improvement in couple communication, and high relationship satisfaction across the next 12 months in women. Men sustained high and similar relationship satisfaction in either condition. Skill training CRE has additional benefits for couples beyond assessment and feedback. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief psychotherapy and psychological assessments: Entering a relationship, establishing a focus, and providing feedback.

Brief psychotherapy is aimed at facilitating change within a circumscribed time frame. To do this, therapists in this specialty actively engage clients, establish a focus to the treatment, and provide ongoing feedback throughout treatment. The authors show how using these features of brief psychotherapy in the assessment process can enhance the clinical usefulness of an assessment. By also incorporating an emphasis on respect for the client, in line with existential/client-centered principles, psychological assessments can be made more personally relevant and meaningful for the client. The approach outlined has been useful within a hospital-based, adult inpatient and outpatient mental health service in which assessments are conducted before starting psychotherapy or as clinical activities in themselves (e.g., psychodiagnosis). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving the effects of psychotherapy: The use of early identification of treatment and problem-solving strategies in routine practice.

Client-focused research systems have been developed to monitor and provide feedback information about clients' progress in psychotherapy as a method of enhancing outcome for those who are predicted to be treatment failures. In the current study, the authors examined whether feedback regarding client progress and the use of clinical support tools (CSTs) affected client outcome and number of sessions attended. Results showed that clients in the feedback plus CST group stayed in therapy longer and had superior outcomes. Nearly twice as many clients in the feedback plus CST group achieved clinically significant or reliable change, and fewer were classified as deteriorated by the time treatment ended. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief couples therapy: Lessons from the history of brief individual treatment.

In the author's attempt to grasp the controversies facing brief couples therapy it was useful to apply the principles of brief individual psychotherapy, learned earlier by such pioneers as D. H. Malan, H. Davanloo, and J. P. Gustafson, to major, contemporary, couples treatment models: emotionally focused treatment, integrative behavioral couple treatment, nontraditional egoanalytic couples therapy, and the narrative, solution-focused, and strategic schools. This exercise illustrates that present-day couples therapy faces important theoretical and technical dilemmas that impede its development toward a mature system of brief treatment. When some resolution to these dilemmas can be gained, brief couples therapy can progress into a consolidation phase. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Traditional Versus Integrative Behavioral Couple Therapy for Significantly and Chronically Distressed Married Couples.

A randomized clinical trial compared the effects of traditional behavioral couple therapy (TBCT) and integrative behavioral couple therapy (IBCT) on 134 seriously and chronically distressed married couples, stratified into moderately and severely distressed groups. Couples in IBCT made steady improvements in satisfaction throughout the course of treatment, whereas TBCT couples improved more quickly than IBCT couples early in treatment but then, in contrast to the IBCT group, plateaued later in treatment. Both treatments produced similar levels of clinically significant improvement by the end of treatment (71% of IBCT couples and 59% of TBCT couples were reliably improved or recovered on the Dyadic Adjustment Scale; G. B. Spanier, 1976). Measures of communication also showed improvement for both groups. Measures of individual functioning improved as marital satisfaction improved. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Key Elements in Couples Therapy With Veterans With Combat-Related Posttraumatic Stress Disorder.

If a client dealing with combat-related posttraumatic stress disorder (PTSD) presents for psychotherapy, should you consider including his or her partner in treatment? How could couples therapy be beneficial? What framework do you have to conceptualize the relational issues and potential treatment? Although clinicians have long been encouraged to include families in the treatment of combat-related PTSD, few specific couple-family therapies exist, and outcome research is scarce. Because of the adverse effects of PTSD on relationships, couples therapy can be a powerful adjunct treatment; however, few receive this service. A new framework for conceptualizing couples therapy organizes treatment around the 3 PTSD symptom clusters (reexperiencing, avoidance, and arousal). Relationship consequences of each symptom cluster are summarized, followed by useful treatment interventions and a case study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alliance in individual psychotherapy.

This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as “alliance,” “therapeutic alliance,” “helping alliance,” or “working alliance” were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was r = .275 (k = 190); the 95% confidence interval for this value was .25–.30. The statistical probability associated with the aggregated relation between alliance and outcome is p     

Integrative behavioral couple therapy: An acceptance-based, promising new treatment for couple discord.

Although traditional behavioral couple therapy (TBCT) has garnered the most empirical support of any marital treatment, concerns have been raised about both its durability and clinical significance. Integrative behavioral couple therapy (IBCT) was designed to address some of these limitations by combining strategies for fostering emotional acceptance with the change-oriented strategies of TBCT. Results of a preliminary clinical trial, in which 21 couples were randomly assigned to TBCT or IBCT, indicated that therapists could keep the 2 treatments distinct, that both husbands and wives receiving IBCT evidenced greater increases in marital satisfaction than couples receiving TBCT, and that IBCT resulted in a greater percentage of couples who either improved or recovered on the basis of clinical significance data. Although preliminary, these findings suggest that IBCT is a promising new treatment for couple discord. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between behavioral marital therapy outcome and process variables.

This study was conducted to identify therapist and client behaviors with a positive response to social learning-based behavioral marital therapy. A sample of 32 couples receiving treatment was examined. Immediately after each therapy session, the therapist, husband, and wife independently completed process ratings forms that measured therapist and client behaviors during the session. Composite scales, derived from these ratings, were entered into multiple regression equations to examine their relationship with posttherapy marital satisfaction. After controlling for pretherapy marital satisfaction and the other predictor variables, therapists', husbands', and wives' ratings of positive client behavior (i.e., collaboration, active participation, and homework compliance) were positively associated with therapy outcome. Implications for marital therapy and suggestions for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Low-level relationship aggression and couple therapy outcomes.

Increasing evidence supports the efficacy of conjoint therapies that focus on intimate partner violence for couples who engage in mild to moderate physical aggression but want to preserve the relationship and end the aggression. However, there has been no examination of how this population responds to couple therapy that does not have a specific focus on aggression. This lacuna in the research literature is of concern because couples with a history of low-level aggression often seek couple therapy, but couple therapy without a focus on violence is thought to potentially exacerbate aggression. In the current study, the authors examined the efficacy of non-aggression-focused behavioral couple therapy for couples with and without a history of mild physical aggression. One hundred thirty-four couples, 45% of whom had experienced low-level aggression in the year prior to therapy, completed up to 26 sessions of couple therapy and 2 years of follow-up assessments. Results demonstrated no significant differences in relationship and individual outcomes by history of aggression. In addition, couples maintained very low levels of physical aggression during and after treatment and showed reductions in psychological aggression when relationship and individual functioning improved. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based therapy relationships: Research conclusions and clinical practices.

In this closing article of the special issue, we present the conclusions and recommendations of the interdivisional task force on evidence-based therapy relationships. The work was based on a series of meta-analyses conducted on the effectiveness of various relationship elements and methods of treatment adaptation. A panel of experts concluded that several relationship elements were demonstrably effective (alliance in individual psychotherapy, alliance in youth psychotherapy, alliance in family therapy, cohesion in group therapy, empathy, collecting client feedback) while others were probably effective (goal consensus, collaboration, positive regard). Three other relationship elements (congruence/genuineness, repairing alliance ruptures, and managing countertransference) were deemed promising but had insufficient evidence to conclude that they were effective. Multiple recommendations for practice, training, research, and policy are advanced. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Mending the gap: Introduction to the invited commentaries on Dinger, Strack, Sachsse, and Schauenburg (2009).

Introduces several commentaries on an article by U. Dinger et al (see record 200913603-002) entitled “Therapists’ attachment, patients’ interpersonal problems and alliance development over time in inpatient psychotherapy.” This article represents an ambitious effort on the part of the researchers to map a number of interrelated relational variables, over the course of treatment, in a relatively understudied patient population. “Attachment,” “interpersonal problems,” and “alliance” are variables that capture core components of the therapeutic relationship and psychotherapy process that have been reliably linked to patient improvement in many previous studies of mostly outpatient psychotherapy. Jeremy Holmes (see record 2009-13603-003) and George Silbershatz (see record 2009-13603-004) were invited to comment on this study while wearing their clinical hats. They were asked about how they made sense of the research results as practicing psychotherapists, the ways in which the findings were useful to them as clinicians, and where they considered the research to be of more limited value from a clinical point of view. Following the commentaries is a final word from the authors of the study (see record 2009-13603-005). It is hoped that this format of dialogue will have an impact on how clinical research is presented in the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Feedback.

Feedback is a ubiquitous feature of psychotherapy. But it takes many forms and often is understood by names other than feedback (e.g., interpretation, immediacy, confrontation). In this article, we define feedback and then review available research on outcomes of feedback in the four contexts of individual therapy, couple and family therapy, group therapy, and personality testing. That research has yielded mostly positive results and some mixed results; we found no negative results. We summarize the outcome studies, examine variables that mediate or moderate the impact of feedback, and present therapeutic implications based on the research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled study of quantitative feedback in married-couples brief group psychotherapy.

Investigated the impact of delayed, written feedback on the process and outcome of brief group psychotherapy for married couples using a 2-group, 2-stage design. 12 18–36 yr old heterosexual couples participated. Results show that (1) feedback variables showed more significant changes in expected directions than did the nonfeedback variables; (2) therapy plus feedback, in contrast to therapy alone, led to the assessment of greater behavioral change; (3) therapy plus feedback was a more effective tool than therapy alone for increasing the degree of congruence between self and peer ratings, and between self and therapist ratings. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcomes of couples with infidelity in a community-based sample of couple therapy.

Infidelity is an often cited problem for couples seeking therapy, but the research literature to date is very limited on couple therapy outcomes when infidelity is a problem. The current study is a secondary analysis of a community-based sample of couple therapy in Germany and Austria. Outcomes for 145 couples who reported infidelity as a problem in their relationship were compared with 385 couples who sought therapy for other reasons. Analyses based on hierarchical linear modeling revealed that infidelity couples were significantly more distressed and reported more depressive symptoms at the start of therapy but continued improving through the end of therapy and to 6 months posttherapy. At the follow-up assessment, infidelity couples were not statistically distinguishable from non-infidelity couples, replicating previous research. Sexual dissatisfaction did not depend on infidelity status. Although there was substantial missing data, sensitivity analyses suggested that the primary findings were not due to missing data. The current findings based on a large community sample replicated previous work from an efficacy trial and show generally optimistic results for couples in which there has been an affair. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What about the kids? Parenting and child adjustment in the context of couple therapy.

Little research examines parenting and children's adjustment when couples engage in therapy. We examined how couples with and without children improve with couple therapy and whether they also report improvements in parenting and child adjustment. With up to twenty six sessions of couple therapy, 134 couples, 68 of whom had children, showed improved marital satisfaction during treatment, which was ultimately maintained over the 2-year follow-up, regardless of whether they had children. Couples married relatively longer, both with and without children, evidenced greater improvement. Couples with children reported less conflict over child rearing and better child adjustment during treatment, but only improvements in the former were maintained. Conflict over child rearing mediated the relationship between marital distress and child adjustment over therapy and the 2-year follow-up. These preliminary results suggest that couples in therapy may decrease their conflict over child rearing during treatment and they may be able to maintain these gains for at least two years following treatment; moreover, over the course of treatment, this decreased conflict is tied to improved child adjustment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is psychotherapy more effective when therapists disclose information about themselves?

Theorists have long debated the wisdom of therapists disclosing personal information during psychotherapy. Some observers have argued that such therapist self-disclosure impedes treatment, whereas others have suggested that it enhances the effectiveness of therapy. To test these competing positions, therapists at a university counseling center were instructed to increase the number of self-disclosures they made during treatment of one client and refrain from making self-disclosures during treatment of another client. Analyses revealed that clients receiving psychotherapy under conditions of heightened therapist disclosure not only reported lower levels of symptom distress but also liked their therapist more. Such findings suggest that self-disclosure by the therapist may improve both the quality of the therapeutic relationship and the outcome of treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)