by Joye C. Anestis
The empirically-supported treatment (EST) movement has focused primarily on diagnosible mental illnesses and related conditions. Thus, treatments for other problems have not been systematically quantified according to accepted standards for ESTs. One of the more common reasons for people to seek psychotherapy is for maintain or improve their relationships, and marital enrichment or enhancement programs have been developed to help couples achieve that goal. It is important to note that marital enrichment programs differ from marital therapy programs intended for those experiencing more severe distress, typically those receiving marital enrichment or enhancement services are in more functional relationships but are wishing to improve their quality (Jakubowski et al., 2004). Although marital enrichment programs are not included in formal lists of ESTs, enough research has been conducted on them to determine their empirical status. In 2004, Jakubowski, Milne, Brunner, and Miller examined the marital enrichment literature to determine where these programs lie on the continuum of ESTs. They found 4 programs which can be considered "efficacious" (i.e., an EST) based on the APA Task Force standards (at least 2 randomized controlled trials conducted by 2 independent research teams, treatment is manualized), 3 found to be "possibly efficacious" (only one randomized controlled study or studies done by only one research team), and 6 were considered "empirically untested" (programs with some outcome research but no randomized controlled trials). It is important to note that many more marital enrichment programs exist but treatment outcome data is not available for them. Below, I summarize Jabukowski et al.'s findings, as well as provide a brief update where available.
Efficacious
- PREP (Prevention and Relationship Enhancement Program): PREP is a skills-based program with 4 primary goals: to teach couples better communication and conflict management strategies (in fact, one of my favorite PREP books is called Fighting for Your Marriage
), to assist couples in identifying and evaluating expectations, to facilitate understanding of and decisions reflecting commitment, and to increase positive bonding. It can be conducted with individual couples, in groups, and in self-study by couples. A number (at least 7) of randomized controlled trials (RCTs) have demonstrated the efficacy of this program. Gains associated with PREP include increased positive communications when compared with couples in control groups, increased spouse confidence in the relationship, increased communication and problem-solving skills, lower rates of divorce, greater relationship satisfaction, decrease in the intensity of problems, and greater sexual satisfaction.- Update since Jabukowski et al. (2004): 2 studies published since 2004 have demonstrated the efficacy of a computerized adaptation of PREP (ePREP; Braithwaite and Fincham, 2007, 2009). Interestingly, these studies also showed that improving relationship functioning via ePREP also alleviates symptoms of depression and anxiety.
- Relationship Enhancement (RE): Relationship enhancement aims to teach couples self-disclosure skills with a focus on feelings, behaviors, and eliminating blaming statements. It also teaches listening skills. RE can be taught in an all-day workshop or in weekly group meetings (2 hours a week, 10-15 weeks). A large body of research indicates the benefit of RE for a number of outcomes, including increases in couple self-disclosure and empathy and improved marital communication and satisfaction (see Accordino & Guerney, 2003, for a review of the RE outcome research).
- The Couple Communication Programs (CC): Couple Communication strives to develop clear and open communication between partners in order to increase awareness of the self and partner, the relationships, and the rules of conflict. CC is conducted in group format, meeting 2 hours a week for 4 weeks. The efficacy of CC has been examined in a number of studies, with overall findings indicating that CC is superior to no treatment and is effective in improving communication skills (see Butler & Wampler, 1999, for a recent meta-analysis). The long-term effects of CC are questionable, however, with studies demonstrating a consistent trend toward skill deterioration.
- Strategic Hope-Focused Enrichment: This is a more eclectic approach to marital enrichment, focused on promoting love and faith in each other and increasing couple motivation to work together to improve their relationships. It consists of 5 1-hour sessions. RCTs have demonstrated that this protocol can imporve marital satisfaction and communications and overall quality of life.
Possibly Efficacious
- Couple Commitment and Relationship Enhancement (Couple CARE): Couple CARE is based on PREP (described above). The difference is that Couple CARE is a "flexible delivery" program (i.e., promotes ease of access) and emphasizes self-directed learning. One RCT has been conducted on Couple CARE, showing increased relationship enhancement and stability.
- Association for Couple in Marriage Enrichment (ACME): ACME programs strive to improve relationships through a variety of activities (e.g., role playing) using experiential learning and group processes (see Association for Couples in Marriage Enrichment, 1993, for more information). ACME appears to be less structured than other interventions, focusing on the process of martial enrichment and not an exact format (Dyer & Dyer, 1999). This lack of standardization makes it hard to study empirically. The one RCT conducted, however, demonstrated positive outcomes for couples.
- Couple Coping Enhancement Training (CCET): CCET aims to prevent marital distress. It combines CBT with with theories of stress, coping, & social reciprocity. The one RCT conducted demonstrates CCET's ability to improve marital satisfaction adn quality and decrease parenting stress.
- Update since Jabukowski et al. (2004): Ledermann, Bodenmann, & Cina (2007) recently published a new RCT with distressed couples with preadolescent children. Positive effects were noted immediately upon completion of the program but these gains were not maintained at 6-month and 1-year follow-ups.
Empirically Untested (please see Jakubowksi et al., 2004, for more information)
- Structured Environment
- Marriage Encounter
- Practical Application of Intimate Relationship Skills (PAIRS)
- Imago Relationship Therapy
- Traits of a Happy Couple
- Saving Your Marriage Before It Starts
Apparently there is a rich array of programs to choose from when assisting couples improve their relationships. 4 programs, as of now, are considered empirically supported - with several others in need of a bit more research before we can draw firm conclusions about its empirical status. Clinical psychologists do not often see clients primarily for relationship problems (individuals are more likely to seek counseling psychologists or marriage and family therapists for such concerns); however, clients being treated for mental illness often are having concurrent relationship difficulties that might need additional treatment. It is prudent for clinical psychologists to have some facility with marital enhancement protocols, as in some cases additional couples therapy may be warranted.
Treatment Manuals for some of the Efficacious Programs Listed Above
Fighting for Your Marriage: Positive Steps for Preventing Divorce and Preserving a Lasting Love (New & Revised)
Hope-Focused Marriage Counseling: A Guide to Brief Therapy
Relationship Enhancement Therapy: Healing Through Deep Empathy and Intimate Dialogue
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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