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Helping Couples and Families – Suggestions for Adapting Relationship Services to increase reach and effectiveness
- 1. Helping Couples and Families – Suggestions for Adapting Relationship Services to increase reach and effectiveness FRSA 2015 1 Jemima Petch, PhD Relationships Australia QLD & Professor Kim Halford, University of QLD
- 2. Overview • Relationship Services – Commonly offered Relationship services – Efficacy and effectiveness of Relationship Interventions – Reasons for efficacy-effectiveness gap • Implications for practice • Adapting Services – recent innovations 2
- 3. Relationship Services 3 Distressed couples Goals distress, ⇑satisfaction Clarify commitment EB approaches 15-30 hours IBCT EFT Satisfied – mildly distressed couples Goals Build commitment ⇑satisfaction, prevent distress EB approaches 10-12 hours Couple CARE PREP Assessment & Feedback Couple counselling Couple Education Satisfied couples Goals Identify relationship strength and challenge areas EB approaches 1-3 hours RELATE Relationship Check-up
- 4. Overview • Relationship Services – Commonly offered Relationship services – Efficacy and effectiveness of Couple Relationship Education – Efficacy and effectiveness of Couple Therapy – Reasons for efficacy-effectiveness gap • Implications for practice • Adapting Services – recent innovations 4
- 5. 5 Meta-Analysis of Couple Education Effects on Relationship Satisfaction 0 0.1 0.2 0.3 0.4 0.5 0.6 Pre Post 6 Mo FU EffectSized Hawkins et al. (2008) Small average increase
- 6. 6 RCT studies examining Long term Effects of CRE 0 2 4 6 8 10 12 14 16 Universal Selective Indicated NumberofStudies No Effect Effect Halford & Bodenmann (2013)
- 7. Types of CRE 7 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)
- 8. CRE efficacy and effectiveness summary • CRE works • Universally applied CRE produces small intervention effects • Selectively applied CRE produces larger effect sizes 8
- 9. Overview • Relationship Services – Commonly offered Relationship services – Efficacy and effectiveness of Couple Relationship Education – Efficacy and effectiveness of Couple Therapy – Reasons for efficacy-effectiveness gap • Implications for practice • Adapting Services – recent innovations 9
- 10. Effect size of pre-therapy to post-therapy changes in efficacy and effectiveness trials of couple therapy 10 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 *Hahlweg & Klann (1997) *Klann et al. (2010) *Doss et al. (2012) **Baucom et al. (2003) EffectsizedSizeg *Effectiveness trials, ** Meta-analysis of efficacy trial Halford, Pepping & Petch, 2014 0.84 This means that the average couple receiving couple therapy in an RCT is less distressed than 80% of couples receiving no therapy
- 11. Comparison of variability and clinical significance of change immediately after couple therapy in efficacy and effectiveness trials 11 0 20 40 60 80 100 Doss et al. (2012) * Hahlweg & Klann (2007)* Christensen et al. (2004)** Snyder & Wills (1989)** PercentofCouples Recovered Improved Unimproved 17-25% recover ~ 50% recover *Effectiveness trials ** Efficacy trial Halford, Pepping & Petch, 2014
- 12. Summary of Couple Therapy Efficacy vs Effectiveness • 5 different couple therapies reliably improve relationship distress • The average couple receiving couple therapy is less distressed than 80% of couples receiving no couple therapy • In community settings half as many distressed couples improve from couple therapy 12
- 13. Overview • Relationship Services – Commonly offered Relationship services – Efficacy and effectiveness of Couple Relationship Education – Efficacy and effectiveness of Couple Therapy – Reasons for efficacy-effectiveness gap • Implications for practice • Adapting Services – recent innovations 13
- 14. What explains the efficacy-effectiveness gap? • Individual and Couple Characteristics? • Assessment? • Treatment? • Training, Monitoring and Supervision? • Organisational limitations? 14
- 15. Individual and Couple characteristics? Are the types of couples in efficacy and effectiveness studies different? 15 Same on: Maybe different on: Severity of couple distress % Married vs cohabiting Heterogeneity of presenting concerns Level of commitment Socio-demographics Stated treatment goal Agreed treatment length If comparing your organisations couple counselling outcomes to benchmarks ensure you are taking the sample of couples who are distressed at baseline and who seek to work on improving their relationship as the sample you use
- 16. Assessment 16 Are assessment approaches different? Routine practise Efficacy studies Conduct some screening and assessment Comprehensive assessment Predominantly interviews Mulitmodal assessment Brief tools Standardised measures with good reliability and validity Face validity Assessments with clinical norms and cut-offs Varies between practitioners, venues, services Assessments sensitive to change …
- 17. How might differences in assessment alter client outcome? 1. Educate practitioner and couple about key presenting concerns and range of influences on relationship = Develop shared understanding & = change couples attributions 2. Assessment provides practitioner opportunity to express empathy with problem conceptualisation which promotes alliance 3. Reliably identify comorbid problems 4. Assessment provides opportunity for feedback and goal-setting (which in itself can improve relationship functioning). 17
- 18. Type of Therapy Are the treatments in efficacy and effectiveness studies different? 18 Efficacy studies Effectiveness studies Routine Practise BCT IBCT Eclectic IBCT Systems-communication Systemic EFCT Psychodynamic Strategic CBCT Gestalt IOCT BCT Rogerian Brief problem-solving Yes, Tx approach differs but other research suggests that Tx approach accounts for little variation in client outcome (perhaps 8-10%).
- 19. Quality control Is Training, Monitoring and/or Supervision different? 19 Efficacy Effectiveness Therapists highly trained in specific Tx Tx approach not tightly structured Follow written treatment manuals Less intense and rigorous supervision Predefined content/interventions in sessions Less monitoring Therapists individually supervised Therapists and Tx sessions carefully monitored Sessions video-taped and coded
- 20. Organisational Factors Do organisational factors account for lower outcomes in effectiveness studies? - Standardises organisational procedures (can help & can hinder) - Administrative paperwork - High demand for services – long wait lists – heavy case loads 20
- 21. A last important factor Does client feedback and progress monitoring account for differences in client outcomes? • weekly therapy progress feedback based on each partner’s individual adjustment enhances therapy gains relative to treatment as usual • couples who ultimately do not benefit from couple therapy can be reliably detected by mid-therapy, and as early as session 4 for 70% of couples • identifying couples unlikely to benefit from therapy (i.e., off-track) can guide the therapist and/or couple to increase their efforts in therapy to enhance outcome. It may also lead therapists to attend to the alliance more closely, or prompt a change in therapy approach. 21
- 22. Overview • Relationship Services – Commonly offered Relationship services – Efficacy and effectiveness of CRE – Efficacy and effectiveness of Couple Therapy – Reasons for efficacy-effectiveness gap • Implications for practice • Innovative programs 22
- 23. A comprehensive outline of the steps of a good treatment model 1. Multimodal standardised Assessment and Screening 2. Tailored treatment plan matched to Distress and Risk 3. Negotiate with Client agreed upon treatment goals, tasks and length 4. Attend to common factors throughout 5. Track progress 6. Treatment review and post-treatment assessment 7. Offer Booster Sessions where appropriate 23
- 24. Assessing for Severity = CSI-4 24 1. Please indicate the degree of happiness, all things considered, of your relationship. Extremely Unhappy 0 Fairly Unhappy 1 A Little Unhappy 2 Happy 3 Very Happy 4 Extremely Happy 5 Perfect 6 Not at all true A little true Somewhat true Mostly true Almost completely true Comple true 2.I have a warm and comfortable relationship with my partner 0 1 2 3 4 5 Not at all A little Somewhat Mostly Almost Completely Comple 3. How rewarding is your relationship with your partner? 0 1 2 3 4 5 4. In general, how satisfied are you with your relationship? 0 1 2 3 4 5 Funk, J. L., & Rogge, R. (2007).
- 25. Assess for Risk – Example risk factors 25 Name of risk variable Why measure this construct? References Alcohol or drug use problems? Alcohol and drug use problems correlate with relationship distress, and individual psychological distress. Further, high alcohol misuse is associated with relationship aggression. Booth & Johnson, (1988) Psychological disorder (currently or in the past)? Psychological disorder and relationship distress are correlated (if a couple is unhappy in their relationship then the individual partners are at greater risk of developing individual psychological disorder, and vice versa). Gotlib, Lewinsohn, & Seeley (1998); Beach et al., (2003); Whisman & Uebelacker, (2009) Financial strain? Financial stress is associated with relationship conflict and distress Amato (1996); Conger et al., (1990); Cutrona et al. (2003) Not in intending to stay with partner? Relationship stability, as measured by attitudes and behaviors regarding dissolution, including thoughts about ending one’s relationship predict relationship problems and dissolution. Relationship stability or intentions to separate are important to assess prior to offering a relationship service as most relationship interventions were designed for couples wishing to improve their relationship rather than for couples who are uncertain about the future of their relationship. Amato (2010) Previously married? (presence of step children) Previously married individuals have a higher risk of future relationship problems and breakdown than couples who have never married or are still married. Pls note, that asking for presence of step-children is included in part to inform practitioner of family structure, and in part because of the recognition that stepfamilies face additional challenges relative to living in biological parent families. Amato (2010); Bramlett & Mosher (2002)
- 26. 26 Tiered Intervention Model 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 (PREP; Couple CARE) 2. Assessment and Feedback (RELATE, Relationship Check-up) Low + No Relationship Distress 1. Self-help Tiered Intervention Model: Example of recommended intervention based on risk (low to high) and relationship functioning.
- 27. Overview • Relationship Services – Commonly offered Relationship services – Efficacy and effectiveness of Couple Relationship Education – Efficacy and effectiveness of Couple Therapy – Reasons for efficacy-effectiveness gap • Implications for practice • Adapting Services – recent innovations 27
- 28. 28 Changing Trajectories of Couple Relationships Introduced in social networks Engaged Marry & Cohabit Parent Meet online, social networks Date, Cohabit Parent Separate Repartner Classic 20th C Common 21st C Relationship education Couple therapy
- 29. Relationship Services 29 “The challenge is getting couples in the room”
- 30. 30 “Bankers waiting for customer to come in the room”
- 31. Reach of Couple Therapy 31 0 5 10 15 20 25 Books Retreats/Workshops Couple therapy Percentage of couples seeking various types of help for relationship problems in the first 5 years of marriage Books Retreats/Workshops Couple therapy Doss, Rhodes, Stanley & Markman, 2009
- 32. 32 Flexible delivery = Accessible
- 33. Online Assessment with Feedback 33
- 34. Flexible Delivery Relationship Education 34 • 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 across 6-8 weeks.
- 35. Immediate Change in Couple Satisfaction After Flexible Delivery CRE 35 15 20 25 30 Pre Post Satisfaction Control Couple Care 15 20 25 30 Pre Post Satisfaction Control Couple Care d = 0.55 Mild DistressSatisfied Halford, Pepping, Hilpert, Bodenmann, Wilson, Busby, Larson, & Holman (2015)
- 36. Couple Pro-Gres
- 37. Feedback Informed Counselling • Counsellors poor at detecting lack of progress • Systematic progress monitoring outcome • Use of progress monitoring often with time • Develop and use simple computer tablet system – Can do in 1 minute, easy for clients and counsellors Halford, Pepping & Doss (2014)
- 38. Assessment of Couple Relationship: CSI-4
- 39. Scenario 2: Feedback Graphs - A Red Signal • Both partners are in the distressed range and not improving • Review Points – “This appears to not be going so well…” – What are the most important things we need to address here e.g. rolling with resistance
- 40. Online Couple therapy 40 Figure 1: Geographical representation of couples 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 All participants Distressed participants Effectsize(d=) OurRelationship Participants Effect size for pre-post OurRelationship.com compared to wait-list control couples Doss, 2014; Doss, Benson, Georgia & Christensen, 2013)
- 41. Flexible Delivery Family Mediation 41 0 10 20 30 40 50 60 70 80 90 100 MAU MI PercentofFamilies Condition None Partial Full Morris, Halford, & Petch (2015)
- 42. In summary 1. Offer relationship services at multiple timepoints in a couples life 2. Assess for severity and risk & recommend intervention based on severity and risk 3. Negotiate treatment length, goals and tasks 4. Offer online and flexible delivery relationship interventions 5. Track progress (FIT) and assess at the end of treatment to determine couple improvement 42
Notes de l'éditeur
- Slide 8 summarizes 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. Couples attending CRE are happier than 66% of couples not attending CRE.
- A review of previously published meta-analytic studies of RCT (Shadish and Baldwin (2003) reported that couples therapy produced a large mean effect size of d = 0.84 - similar to the effect sizes of the most effective psychological and pharmacological treatments available for individual psychological disorders This means that the average couple receiving couple therapy is less distressed than 80% of couples receiving no therapy. Further, there is little evidence that different theoretical orientations to couple therapy differ in efficacy, particularly once other covariates such as reactivity of measures were controlled. However, there are some important additional points to make about the efficacy of couple therapy. Couple therapy works this well when studied in RCTs (efficacy studies) 5 different couple therapies work this well (BCT, IBCT, IOCT, EFCT, CBCT) When investigating how effective couple therapy is in community settings and routine practise we see that CT typically produces much smaller gains (see the darker blue columns in the bar graph). In effectiveness trials effect sizes range from small to moderate. They are about half the size of effect sizes reported in efficacy trials.
- Couple education and therapies work; but there is currently a research-to-practise gap. Interventions delivered in routine practise produce less benefit for couples compared to in research studies.
- There are several possible explanations as to why research efficacy trials produce larger effects on couple adjustment than those reported in effectiveness trials of routine practice. The first possibility is that the types of couples included in efficacy and effectiveness trials differ on a range of individual and couple characteristics. A second possibility is that efficacy studies always conduct a comprehensive assessment of both the individual and couple, and that this assessment facilitates a better outcome. Thirdly, it is possible that the type of therapy differs between efficacy and effectiveness trials. A fourth possibility is that there may be more quality control in efficacy studies, including close monitoring and supervision, and systematic therapy progress feedback to therapists. Finally, Wright, Sabourin, Mondor, McDuff and Mamodhoussen (2007) suggested that organizational limitations in community service delivery (e.g., high demand services not being able to offer weekly sessions) might negatively impact on client outcomes.
- Implications = Assess level of commitment to relationship Assess reason for coming to Tx (improve relationship, work out if they want to be in the relationship, use therapy to help separate). Agree on treatment goal, tasks/approach of Tx and length of Tx If comparing your organisations couple counselling outcomes ensure you are taking the sample of couples who are distressed at baseline and who seek to work on improving their relationship as the sample you use to compare to he effect size and clinically significant changes reported in RCT (efficacy studies)
- There are a number of differences in the approach to assessment between efficacy and effectiveness studies.
- Implications for practise: Conduct a multimodal assessment with standardised measures Use assessment as opportunity to demonstrate empathy Provide feedback on measures and use is as an opportunity to develop shared conceptualisation
- Yes, but research to date suggests that treatment approach accounts for little variation in client outcome (perhaps 8-10%).
- A meta-analysis of efficacy trials found that neither the degree of therapy structure (in terms of what is covered and the number of sessions provided), nor the extent of therapist training and supervision, were related to the treatment effect size obtained in relationship adjustment (Shadish & Baldwin, 2003). However, this was done within efficacy studies (not comparing effectiveness studies, to routine practise, to efficacy studies) a study by Jacobson and colleagues (1989) over 25 years ago reported that flexibly delivered behavioral couples therapy produced better sustained treatment effects than did the same treatment delivered in a more standardized manner (Jacobson et al., 1989). The emerging research on the efficacy of tailored treatments suggests that the chance to be more flexible in therapy delivery might advantage client outcome. More research needs to be done to understand this. Implications for practise; Not sure at this stage.
- : clients are required to wait for several weeks for a first appointment, and/or are unable to access weekly therapy sessions. In contrast the frequency of treatment typical in efficacy studies is more regular, therapists often receive a lot of supervision in therapy delivery to manage heavy case load, and resources are sometimes more readily available to cover administrative requirements.
- Conduct comprehensive initial assessment to determine if couple seeks to strengthen relationship, is ambivalent, or is seeking therapy to separate. Identify other risk factors or presenting problems that require treatment (Mental health, IPV, parenting problems). Share assessment feedback, conceptualisation. Agree on the goals of treatment (number of sessions, problems targeted). Conduct regular, systematic assessment/ collect feedback over the course of therapy about clients’ functioning, to assist in ongoing treatment planning, monitoring progress for clinical (mid-course corrections) and understanding how clients change. Using online technology to collect and graph the assessment would be ideal. While CT is effective (especially in RCTs) and reduces distress for the majority of couples there is a noteworthy minority of 25 to 30 per cent of couples who show no improvement from these therapies (across all evaluated approaches to couple therapy). Systematically assessing therapy progress is important as therapists’ own clinical judgements about therapy progress do not accurately detect who will benefit and who is likely to deteriorate across the course of therapy (Hannan et al., 2005; Lambert et al., 2002a; Whipple et al., 2003). In several randomised controlled trials of individual therapy, therapy progress feedback to the therapists reduces premature drop-out from therapy and enhances individual outcome compared to treatment-as-usual (Lambert, 2010; Shimokawa et al., 2010). A meta-analysis of studies found systematic progress monitoring, coupled with feedback to the therapist, reduced deterioration from 20% of clients (in treatment-as-usual) to 5.5% of clients (Shimokawa, Lambert, & Smart, 2010). Recent evidence indicates that couples who ultimately do not benefit from couple therapy can be reliably detected by mid-therapy (Halford et al., 2012), and as early as Session 4 (Pepping, Halford & Doss, 2014) for 70% of couples. While it is still unclear why feedback may improve outcome it is currently hypothesized that identifying couples unlikely to benefit from therapy (i.e., off-track) may lead to the therapist and/or couple increasing their efforts in therapy to enhance outcome. It may also lead therapists to attend to the alliance more closely, or prompt a change in therapy approach (Halford et al., 2012). In brief, the implicit assumption in the use of systematic progress monitoring is that clients are identified as off track sufficiently early in the course of therapy to allow the practitioner to modify the selection, sequencing or pacing of specific interventions. For couples seeking to strengthen their relationship practice a couple therapy that is known to work. It is important that programs or interventions catering for couples are evidence-based because we know from the evidence that couples will benefit from these relationship education or counselling approaches. For couples with co-occurring relationship distress and individual mental health issues such as depression, anxiety, or substance misuse, consider offering a couple therapy. If choosing a different orientation conduct assessments (mid and post treatment) to determine that therapy is effective. research is still needed for CRE and CT with a more diverse range of couples (Johnson, 2012) Can offer tailored relationship education program (Halford & Bodenmann, 2013) Offer booster sessions: Because all couple therapies show some attenuation of gains at follow up (i.e., 45% of successfully treated couples report significant deterioration 2 years or longer after treatment (Christensen et al., 2004; Jacobson et al., 1987; Snyder et al., 1991). Common Factors: Several investigations (Christensen, Russell, Miller, & Peterson,1998; James et al., 2006; Sells, Smith, & Moon,1996), conclude that clients have favorable views of CFT therapists who are empathic: who demonstrate warmth, who are informal and authentic, and who help them feel safe and develop clear treatment goals. It seems that clients tend to appreciate therapists who are“caring and understanding”as well as “able to generate relevant suggestions”(Kuehl, Newfield, & Joanning,1990, p. 318). A recent meta-analysis showed that the strength of the alliance is as robust a predictor of outcomes in CFT as it is in individual therapy (Friedlander, Escudero,Heatherington, & Diamond,2011). Notably, severely “split” or “unbalanced” alliances tend to characterize poor outcome cases more so than good outcome cases (e.g., Beck, Friedlander, & Escudero,2006; Friedlander, Lambert, Escudero, & Cragun,2008). It does seem that in couple therapy with heterosexual partners, the male partner’s alliance with the therapist tends to be relatively more influential than the female partner’s alliance (e.g., Bartle-Haring, Glebova, et al.,2012; Symonds & Horvath,2004), but this pattern may differ depending on the therapist’s gender and on which partner initiated the request for help ().
- The scale gives a global relationship satisfaction score by adding together the answers scores. Mean score in a large community sample of couples was 16 (SD = 4.7). Scores of 13 or less are indicative of clinical relationship distress. This 4 item measure is less sensitive than the CSI-16, but the 4 items scale is very good for use to monitor progress as part of Feedback Informed Therapy (FIT). The source for the scale is: Funk, J. L., & Rogge, R. (2007). Testing the Ruler With Item Response Theory: Increasing Precision of Measurement for Relationship Satisfaction With the Couples Satisfaction Index. Journal of Family Psychology, 21 (4) 572-583. Doi: 10.1037/0893-3200.21.4.572
- Only about a third of distressed couples go to counselling/therapy.
- Several innovative relationship programs have been developed – which can be delivered as self-help programs, online programs, and flexible delivery programs (i.e., DVD, workbooks and telephone support from practitioners), and clients can complete these interventions from home. Such programs have broad reach, can be accessible to couples and families in geographically remote areas where few services exist, and can be done by couples in their own home – thereby reducing common treatment barriers such as travel and the need for babysitters or children, as well as being more amenable to completion at a time convenient to the client/couple.
- Slide 21 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.
- Slide 33 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. There also is a graph showing changes in satisfaction across the course of the program, and it shows there was large effect size improvement in couple’s satisfaction for distressed couples. Regards