Lost in translation: Therapeutic Alliance as a mediator in the relationship between teletherapy and marital satisfaction.

The global impact of the SARS-COV-2 pandemic necessitated a rapid shift to online/teletherapy psychotherapy services. While research suggests the feasibility and efficacy of teletherapy, there is limited investigation into couple teletherapy's impact on satisfaction and therapeutic alliance. This study aimed to address this gap by examining changes in couple satisfaction during tele- and in-person therapy sessions over 12 sessions and exploring whether therapeutic alliance development mediates these changes. Using growth curve modeling in a sample of 416 couples, it found that teletherapy participants initially reported higher couple satisfaction, but improvement in this domain was slower than in-person therapy recipients. The development of the therapeutic alliance mediated this effect via two indirect paths. Implications include the need for focused attention on alliance development in teletherapy and more empirically-informed approaches in couple teletherapy.

Validation of the intersession alliance measure: Individual, couple, and family versions.

Monitoring the therapeutic alliance throughout treatment can improve client outcomes and lead to improved care. The individual, couple, and family versions of the intersession alliance measure (IAM) were developed to facilitate routine monitoring of the expanded therapeutic alliance. Psychometric properties of the three versions of the IAM were examined using a clinical sample. Participants were drawn from clinics in the United States participating in the Marriage and Family Therapy Practice Research Network. Using this sample, results indicate that items on each version of the IAM load on one factor, are invariant across sex, and that each version has good internal consistency, test-retest reliability, and concurrent validity. The IAM-C and IAM-F also have good predictive validity, while the IAM-I has more limited evidence for its predictive validity. These results suggest that the IAMs are valid and reliable measures that can facilitate the routine monitoring of the expanded therapeutic alliance in psychotherapy.

The trajectory of anxiety in therapy: The role of ACEs.

The connection between adverse childhood experiences (ACEs) and anxiety disorders is well-documented. Additionally, therapy has been shown to be effective at reducing anxiety symptoms. Yet more needs to be known about how ACEs may shape the process of therapy and the trajectory of anxiety symptoms. This study was designed to compare the trajectory of improvement in anxiety symptoms over the course of 12 sessions of therapy in adults (N = 472), who reported more (greater than four) and fewer (fewer than four) ACEs using a multigroup latent growth curve analysis. Data were drawn from the Marriage and Family Therapy Practice Research Network database. Results suggested that the rate of improvement in those with more and fewer ACEs was not significantly different; however, those with more ACEs had a significantly higher average starting point of anxiety symptoms.

Heterosexual couples' initial role and outcome expectations as predictors of the therapeutic alliance and relationship satisfaction prior to the fourth session.

We sampled routinely collected measures of role and outcome expectations, the expanded therapeutic alliance, and relationship satisfaction completed by 253 heterosexual couples seen by 35 therapists in the Marriage and Family Research Practice Network (Johnson et al., 2017) and investigated these variables as interdependent dyadic processes using the latent congruence model (Cheung, 2009) and the mediated actor-partner interdependence model (Ledermann et al., 2011). Taken together, we found a direct association between a couple's mean role and outcome expectation scores at Session 1 and individual partners' alliance perceptions at Session 3. Further, men rated the alliance more favorably when their outcome expectations were higher and the partners' outcome expectations were less discrepant. In terms of role expectations, both men and women began therapy expecting to be more actively engaged in the process than their partner. Whereas women rated the alliance more favorably when they had high role expectations for their partner as well as themselves, men rated the alliance more favorably when they had high expectations for their female partner's engagement in the therapy. Notably, alliance at Session 3 did not mediate the association between initial expectations and Session 4 relationship satisfaction due to a strong association (r = 0.85) between relationship satisfaction rated prior to Sessions 1 and 4. In other words, although the best predictor of relationship status before the fourth session was how the relationship was perceived before couple therapy began, men's and women's initial role and outcome expectations were important contributors to the early alliance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Call me maybe? In-person vs. teletherapy outcomes among married couples.

ABSTRACTObjective: The objective of this study was to investigate the effectiveness of teletherapy compared to in-person couple therapy in outcomes such as couple satisfaction, sexual satisfaction, and the therapeutic alliance.Method: Data from 1157 married clients seeking couple therapy were examined. Individual growth curve models were used to analyze changes in the aforementioned outcomes, with teletherapy as a predictor. The study also examined client age and clinic type as moderators.Results: The results indicated that overall, teletherapy is as effective as in-person therapy in improving outcomes. However, there were notable differences in the development of the therapeutic alliance. The alliance improved at twice the rate in in-person therapy as in teletherapy. Clinic type was also found to be a moderator of changes in sexual satisfaction. Clients in group and private practices reported improvements in sexual satisfaction; whereas clients seen in training clinics reported decreases in sexual satisfaction.Conclusion: The study concludes that although teletherapy may be a viable alternative to in-person couple therapy, there are nevertheless differences in the development of the therapeutic alliance that warrant care and further investigation. The setting of the therapy also plays a role in the effectiveness of therapy, although not specific to therapy modality.

Sexual beliefs in couple relationships: Exploring the pathways of mindfulness, communication, and sexual functioning on sexual passion and satisfaction.

Two types of sexual beliefs, growth and destiny, have been found in past research to be differentially associated with sexual and relationship outcomes; however, past research has not explored these beliefs with dyadic data nor considered common intervening variables that might be pathways through which beliefs influence outcomes. Consequently, using the sexual wholeness model, we analyzed how couples' specific sexual beliefs (growth and destiny) influenced their sexual mindfulness, communication, and functioning within their couple relationships and how each of these variables influenced sexual satisfaction and harmonious sexual passion. Using a national sample of dyadic data from 964 sexually active individuals (482 heterosexual couples) who had been in a committed relationship for at least 2 years, we evaluated an actor/partner structural equation model with distinguishable dyads. We found that while sexual growth and destiny beliefs had a significant association with sexual mindfulness, communication, and functioning for both partners, sexual beliefs had no direct association with sexual satisfaction and harmonious sexual passion. Because growth beliefs had strong associations with sexual communication, it may be beneficial to help couples identify their implicit beliefs and encourage the development of sexual growth beliefs.

The development of a reliable change index and cutoff score for the SCORE-15.

The Systemic Clinical Outcome and Routine Evaluation version 15 (SCORE-15) is a measure used to assess family-level change in family therapy. The SCORE-15 has been demonstrated to be a reliable and valid measure, with high clinical utility; however, the SCORE-15 lacks the ability to determine whether the change in family functioning during the course of therapy is clinically significant. This study aimed to establish a reliable change index (RCI) and clinical cutoff score so that researchers and clinicians can determine clinically significant change in family therapy. US samples of 71 clinical participants and 244 community participants completed the SCORE-15. Results indicated a cutoff score of 40.37 and an RCI of 9.52. Consequently, family members who improve their SCORE-15 score during the course of therapy by at least 9 points and who cross the threshold of 40 during the course of therapy are considered to have experienced clinically significant change.

Emotion dysregulation and couple relationship satisfaction of clinical couples: An actor-partner interdependence model.

Despite the pivotal role that emotion regulation is thought to occupy for individual and relational wellbeing, emotion regulation in couples has been surprisingly understudied. With a clinical sample consisting of 275 couples starting therapy from 2017 to 2022, this study sought to clarify the actor and partner effects of clinical couples' emotion dysregulation on relationship satisfaction. Our results showed that, for partners' emotion dysregulation dimensions, while impulse control difficulties, lack of emotional awareness, and limited emotion regulation strategies were negatively predictive of couple relationship satisfaction, nonacceptance of negative emotions had a positive association with relationship satisfaction. Further, compared with other dimensions of emotion dysregulation, female limited emotion regulation strategies were greater predictors of decreased female relationship satisfaction. We also found significant gender differences in partners' emotion dysregulation dimensions and relationship satisfaction. These results show the significance of addressing emotion dysregulation for both partners at intra- and inter-personal levels simultaneously in couple therapy. Notably, the 275 couples in our sample did not report a clinically distressed relationship, though they attended at least one couple therapy session. Clinical implications and directions for future study are discussed.

Online Conversations About Abuse: Responses to IPV Survivors from Support Communities.

Purpose: Intimate partner violence (IPV) impacts the lives of millions, damaging survivors and families. Many survivors are unsure how to get help, and have limited access to resources. In recent years, those affected by IPV have turned online for answers, support, and to share their experiences. This study examined the online dialogue between survivors of violence and those who respond to their posts. Method: Data consisted of 451 responses to IPV survivors on the website Reddit in a domestic violence subgroup. Responses were analyzed using a combination of grounded theory coding techniques with content analysis tools to generate categories and subcategories. Results: Three main categories emerged from the data, including support, sharing experiences, and sharing information. The subcategories included specific types of help, advice, understanding, and were overwhelmingly positive in their tone and content. Conclusions: Findings suggest that online forums may help bridge the gap between survivors and resources. Professionals who work with IPV or create policies can use these findings to understand how to help survivors find support. This may include encouraging survivors to connect with informal supports such as family and friends, or access formal support such as hotlines, therapy, or legal counsel. The findings also suggest that more research is needed to understand what types of questions survivors of violence have, and what outcomes result from online support.

Couple and family therapists' experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis.

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants' initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients' privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients' raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a "participant observer" to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

The Couple Relationship Scale: A brief measure to facilitate routine outcome monitoring in couple therapy.

Routine outcome monitoring (ROM) is an important component of evidence-based practice. To implement ROM in their practice, couple therapists need a brief measure that can quickly assess the relevant aspects of a couple's relationship. The Couple Relationship Scale (CRS) is a 10-item measure of relational functioning that assesses emotional intimacy, commitment, trust, safety, cohesion, acceptance, conflict, physical intimacy, overall happiness, and personal well-being. Three studies examined the initial psychometric properties of the CRS. Study One used a sample of 300 individuals to examine the concurrent validity, factor structure, and reliability of the CRS. In Study Two, 53 individuals completed the CRS twice to establish test-retest reliability. In Study Three, 214 distressed individuals and 135 non-distressed individuals were used to identify a clinical cutoff and reliable change index (RCI). Results indicated that the CRS has a strong concurrent and construct validity and good reliability. The clinical cutoff was 70.9 with an RCI of 16.

Psychotherapeutic processes associated with couple therapy discontinuance: An observational analysis using the rapid marital interaction coding system.

Premature discontinuation presents challenges to couple clients and therapists alike. Although couple therapy has demonstrated efficacy and effectiveness, little is known about the mechanisms that contribute to couple therapy completion. This study presents the results of an observational inquiry into the psychotherapeutic processes associated with treatment discontinuance using clinical data. Using observational coding of the Rapid Marital Interaction Coding System (RMICS) researchers sought to examine differences in in-session interactions between couple members in a matched sample of therapy continuers and discontinuers. Results indicate that specifically for female partners, the absence of positive interactions is linked to therapy discontinuation. Clinical implications of these findings are presented and discussed.

Therapist effects on dropout in couple therapy.

Marriage and family therapy scholars have argued that therapists play a crucial role in successful couple therapy, yet little research has empirically documented that the therapist in couple therapy has a significant impact on outcomes. Known as the study of therapist effects, this study sought to assess the amount of variance attributed to the therapist in couple therapy outcomes. Using dropout as the outcome variable, this study analyzed data from 1,192 couples treated by 90 masters and doctoral student therapists at a university-based training clinic. Results from multilevel analysis indicated that therapists in the sample accounted for 9.4% of the variance in couple dropout while controlling for initial couple impairment. Therapist gender and therapist experience did not significantly predict variability in therapist effects. These findings give promise to future research on therapist effects in couple therapy and encourage exploration into which therapist characteristics and behaviors contribute to successful clinical outcome.

Improving Measurement in Couple and Family Therapy: An Item Response Theory Primer.

The valid and reliable assessment of individual and relational functioning relies on high-quality assessment tools. Most assessments used in the field of couple and family therapy were developed using Classical Test Theory (CTT). An alternate theory for guiding the creation, evaluation, and scoring of assessments is Item Response Theory (IRT). IRT has several advantages over CTT and can be used to improve measurement in the field. For example, the IRT approach creates measures that are significantly more precise, yet uses fewer items, than scales created using CTT. This manuscript provides an overview of how IRT differs from CTT and describes the fundamental concepts and assumptions of IRT. Following this summary, we provide a step-by-step example of how IRT can be used to reduce the length of the Marital Disaffection Scale from 21 to 6 items without losing a significant amount of information about the construct.

Pressure to Attend Therapy, Dyadic Adjustment, and Adverse Childhood Experiences: Direct and Indirect Effects on the Therapeutic Alliance in Couples Therapy.

In this study we examine the role that pressure to attend therapy, dyadic adjustment, and adverse childhood experiences (ACEs) play in developing the therapeutic alliance. A total of 351 couples received treatment as usual at three family therapy training clinics. Participants rated predictor variables at intake and alliance at the fourth session. Results of a path analysis indicate that each partner's dyadic adjustment is directly associated with the quality of her or his own alliance. In addition, when male partners report more ACEs and pressure to attend treatment, their own alliance scores decrease. Additionally, when one partner reports feeling pressure to attend therapy, the other partner's alliance decreases. Finally, for males, there is an indirect effect of dyadic adjustment on alliance through pressure to attend therapy. These results suggest that clinicians should routinely assess relationship adjustment, how pressured each partner is feeling to attend treatment, and ACEs; as these may impact alliance quality.

A Task Analysis of Client Re-engagement: Therapeutic De-escalation of High-Conflict Coparents.

Parents who are engaged in protracted conflict following a divorce are often referred to coparenting therapy. Episodes of intense conflict are common during these therapy sessions and often result in coparents disengaging from the therapist while they engage in escalating conflict with each other, potentially disrupting their progress in therapy. The purpose of this study was to identify how therapists successfully re-engage clients in the session. To understand this process, 24 disengagement events (12 successful and 12 unsuccessful) from 13 cases were analyzed using a task analytic approach. The sample included coparent dyads referred by the judicial system to a high-conflict coparenting therapy program. Task analysis was used to create a model of how re-engagement unfolds in treatment. The empirical model that resulted has five phases: (1) disengagement from the therapeutic process, (2) disruption of the conflict, (3) de-escalating the most escalated coparent, (4) de-escalating the other coparent, and (5) therapist buffered re-engagement. Successful episodes of re-engagement tended to have therapists who remained active throughout the conflict episode, used structuring interventions aimed at disrupting and then regulating the most escalated partner, blocked attempts to re-engage in conflict, and then repeated this process with the less escalated partner. Additional interventions that promote therapeutic re-engagement are described for each phase, and implications for clinicians and researchers are discussed.

Los padres que participan en un conflicto extendido después de un divorcio generalmente son derivados a terapia para la cocrianza de los hijos. Durante estas sesiones de terapia, son comunes los episodios de conflicto intenso entre los padres, quienes, como resultado, generalmente se distancian del terapeuta mientras participan en una escalada de conflictos entre sí que tiende a interrumpir su avance en la terapia. El propósito de este estudio fue identificar cómo los terapeutas reincorporan satisfactoriamente a los pacientes en la sesión. Para comprender este proceso, se analizaron 24 situaciones de distanciamiento (12 satisfactorias y 12 insatisfactorias) de 13 casos utilizando un método analítico de tareas. La muestra incluyó díadas de compañeros de crianza derivados por el sistema judicial a un programa de terapia para la cocrianza con un alto grado de conflicto. Se utilizó el análisis de tareas para crear un modelo de cómo se desarrolla la reincorporación en el tratamiento. El modelo empírico que resultó tiene cinco fases: 1) distanciamiento del proceso terapéutico, 2) interrupción del conflicto, 3) sosiego del compañero de crianza que más escaló, 4) sosiego del otro compañero de crianza, y 5) reincorporación reforzada por el terapeuta. Los episodios satisfactorios de reincorporación tendieron a tener terapeutas que permanecieron activos durante el episodio de conflicto, utilizaron intervenciones de estructuración orientadas a la interrupción y luego a la regulación al compañero de crianza que más escaló, bloquearon los intentos de reactivar el conflicto y luego repitieron este proceso con el compañero de crianza que menos escaló. Se describen otras intervenciones que promueven la reincorporación terapéutica en cada fase y las implicancias para los clínicos y los investigadores.

The mediating role of the therapeutic alliance in understanding early discontinuance.

Objective: The objective of this study was to test whether the therapeutic alliance mediated the relationship between previously identified predictors of premature termination and dropout during the first three sessions of treatment. Method: In this naturalistic study, 994 cases receiving individual, couple and family, or high-conflict coparenting therapy provided demographic information and completed assessments prior to treatment. Following the first session, clients completed a measure of the therapeutic alliance. Two hundred and five (20.6%) discontinued therapy prior to the fourth session. Logistic and ordinary least squares regression was used across m = 20 imputed datasets to examine the effect of pressure to attend therapy, age, gender, education, distress, therapy format, and therapist experience on whether clients continued in therapy and whether the alliance mediated this relationship. Results: After controlling for age, therapist experience, education, and pressure to attend therapy; general distress and participating in high-conflict coparenting were associated with higher rates of early termination. The effect of both distress and therapy format on dropout, however, was mediated by the therapeutic alliance. Conclusions: By focusing on improving the therapeutic alliance with high-conflict coparenting cases as well as clients with higher levels of distress, therapists may be able to increase client retention.

Daily Events for Clinical Couples: Examining Therapy Interventions, Positive Events, Arguments, and Exercise in the Beginning Stage of Therapy.

This study examined the daily association of several events within the beginning phase of couple therapy. Events examined were as follows: trying something from therapy, an argument, a positive event, and physical exercise. Participants were 33 couples in a treatment-as-usual setting who completed the Daily Diary of Events in Couple Therapy (DDECT). A dyadic multilevel model was used to explore the daily associations between predictor and outcome variables. Results showed when male partners tried something from therapy at rates greater than the average their female partners reported a more positive relationship while when female partners tried something from therapy at rates greater than the average it contributed to a more negative relationship. In addition, results showed that clients in couple therapy rarely try things from therapy on a daily basis. Finally, relative to other predictors trying something from therapy had a smaller, but significant relationship with outcomes.

The Marriage and Family Therapy Practice Research Network (MFT-PRN): Creating a More Perfect Union Between Practice and Research.

This article describes the Marriage and Family Therapy Practice Research Network (MFT-PRN). The MFT-PRN is designed to build a professional community based on practice-informed research and research-informed practice, increase the diversity of participants in MFT research, and unify researchers and clinicians. Clinics choose measures from a list that best represent their clinic needs. Clients' outcomes are assessed regularly, and therapists receive immediate graphical feedback on how clients are progressing or digressing. Data are pooled to create a large and diverse database, while improving client outcomes. We will discuss advantages of the MFT-PRN for researchers, therapists, clients, and agencies, and provide one model that we hope will inform other collaborative clinical-research models in the field of marriage and family therapy. Video Abstract is found in the online version of the article.