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Helping Couples and Families – Suggestions for Adapting Relationship Services to increase reach and effectiveness

FRSA 2015

Jemima Petch, PhDRelationships Australia QLD

& Professor Kim Halford, University of QLD

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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

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Relationship Services

Distressed couplesGoals

distress, ⇑satisfaction

Clarify commitment

EB approaches15-30 hours IBCTEFT

Satisfied – mildly distressed couples

GoalsBuild

commitment⇑satisfaction,

prevent distressEB approaches

10-12 hours Couple CAREPREP

Assessment & Feedback

Couple counselling

Couple Education

Satisfied couplesGoals

Identify relationship strength and challenge areas

EB approaches1-3 hoursRELATERelationship

Check-up

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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

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Meta-Analysis of Couple Education Effects on Relationship Satisfaction

Pre Post 6 Mo FU0

0.1

0.2

0.3

0.4

0.5

0.6

Effec

t Siz

e d

Hawkins et al. (2008)

Small average increase

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RCT studies examining Long term Effects of CRE

Universal Selective Indicated02468

10121416

No EffectEffect

Num

ber

of S

tudi

es

Halford & Bodenmann (2013)

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Types of CRE

CRE Risk profile

Pre CRE satisfaction

Immediate satisfaction

Maintenance of satisfaction

Universal

Mixed Mainly high, some low

Small to nil Small effect

Selective High Mainly high, some low

Small to nil Large effect

Indicated

High All low Moderate to large increase

Large Effect

Halford & Bodenmann (2013)

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CRE efficacy and effectiveness summary

• CRE works• Universally applied CRE produces small

intervention effects• Selectively applied CRE produces larger

effect sizes

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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

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Effect size of pre-therapy to post-therapy changes in efficacy and effectiveness

trials of couple therapy

*Hahlweg & Klann (1997)

*Klann et al. (2010)

*Doss et al. (2012)

**Baucom et al. (2003)

00.10.20.30.40.50.60.70.80.9

Effe

ct si

ze d

Siz

e g

*Effectiveness trials, ** Meta-analysis of efficacy trialHalford, 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

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Comparison of variability and clinical significance of change immediately after

couple therapy in efficacy and effectiveness trials

Doss et al. (2012) * Hahlweg & Klann (2007)*

Christensen et al. (2004)**

Snyder & Wills (1989)**0

20

40

60

80

100

RecoveredImprovedUnimproved

Perc

ent

of C

oupl

es

17-25% recover

~ 50% recover

*Effectiveness trials ** Efficacy trialHalford, Pepping & Petch, 2014

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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

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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

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What explains the efficacy-effectiveness gap?

• Individual and Couple Characteristics? • Assessment?• Treatment?

• Training, Monitoring and Supervision?

• Organisational limitations?

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Individual and Couple characteristics?

Are the types of couples in efficacy and effectiveness studies different?

Same on: Maybe different on: Severity of couple distress % Married vs cohabitingHeterogeneity 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

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Assessment

Are assessment approaches different? Routine practise Efficacy studiesConduct some screening and assessment

Comprehensive assessment

Predominantly interviews Mulitmodal assessmentBrief tools Standardised measures with

good reliability and validityFace validity Assessments with clinical norms

and cut-offsVaries between practitioners, venues, services

Assessments sensitive to change…

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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 alliance3. Reliably identify comorbid problems 4. Assessment provides opportunity for feedback and goal-setting (which in itself can improve relationship functioning).

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Type of Therapy

Are the treatments in efficacy and effectiveness studies different? Efficacy studies

Effectiveness studies Routine Practise

BCT IBCT EclecticIBCT Systems-communication SystemicEFCT Psychodynamic StrategicCBCT GestaltIOCT BCT

RogerianBrief problem-solving

Yes, Tx approach differs but other research suggests that Tx approach accounts for little variation in client outcome (perhaps 8-10%).

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Quality control

Is Training, Monitoring and/or Supervision different? Efficacy EffectivenessTherapists 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 supervisedTherapists and Tx sessions carefully monitoredSessions video-taped and coded

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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

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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.

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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

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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 throughout5. Track progress6. Treatment review and post-treatment

assessment7. Offer Booster Sessions where appropriate

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Assessing for Severity = CSI-4

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

Completely

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

Completely

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).

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Assess for Risk – Example risk factors

Name of risk variable

Why measure this construct? ReferencesAlcohol 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 withrelationship 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)

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Tiered Intervention Model

 

RISKRELATIONSHIP 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.

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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

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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

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Relationship Services

“The challenge is getting couples in the room”

30“Bankers waiting for customer to come in the room”

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Reach of Couple Therapy

Books Retreats/Workshops Couple therapy0

5

10

15

20

25

Percentage of couples seeking various types of help for re-lationship problems in the first 5 years of marriage

Percentage of couples seeking various types of help for rela-tionship problems

Doss, Rhodes, Stanley & Markman, 2009

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Flexible delivery = Accessible

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Online Assessment with Feedback

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Flexible Delivery Relationship Education

• 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.

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Immediate Change in Couple Satisfaction After Flexible Delivery CRE

Pre Post15

20

25

30

Control

Sati

sfac

tion

Pre Post15

20

25

30

Control

Sati

sfac

tion

d = 0.55

Mild DistressSatisfied

Halford, Pepping, Hilpert, Bodenmann, Wilson, Busby, Larson, & Holman (2015)

Couple Pro-Gres

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)

Assessment of Couple Relationship: CSI-4

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

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Online Couple therapy

Figure 1: Geographical representation of couples

All participants Distressed participants0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Effect size for pre-post OurRela-tionship.com compared to wait-list

control couples

OurRelationship Participants

Effec

t si

ze (

d=)

Doss, 2014; Doss, Benson, Georgia & Christensen, 2013)

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Flexible Delivery Family Mediation

MAU MI0102030405060708090

100

None Partial Full

Condition

Perc

ent o

f Fam

ilies

Morris, Halford, & Petch (2015)

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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