Randomized controlled trial of emotionally focused couple therapy compared to treatment as usual for depression: Outcomes and mechanisms of change

Is symptom outcome the whole story?-A multilevel meta-analysis of systemic therapy for adults including family system functioning

OBJECTIVE

Systemic Therapy conceives mental health symptoms in the context of social systems. Previous meta-analyses on Systemic Therapy focused on symptoms. This meta-analysis aims to focus on family system functioning while including all types of outcomes.

METHOD

We conducted a systematic literature research in multiple databases (PsycInfo, PubMed, Embase, Cochrane Central). We included RCT-studies on adults with psychiatric diagnoses, which compared Systemic Therapy with active psychosocial control. The literature research resulted in 171 coded effect sizes of 32 RCTs. We conducted a random-effects three-level meta-analysis. We categorized outcomes into symptoms of patients, family system functioning, further secondary outcomes of patients, and psychopathology of family members.

RESULTS

The results show a small significant overall effect size of g = .30 (CI: .15-.45, p < .001, k = 171, s = 32) for all outcomes. Systemic Therapy revealed small effect sizes with regard to family system functioning (g = .34, z = 3.51, p = .0004, k = 26, s = 12), symptoms (g = .30, z = 3.74, p = .0002, k = 73, s = 29), and further secondary outcomes (g = .32, z = 3.83, p = .0001, k = 63, s = 19). The effect sizes for psychopathology of family system members were reported rarely (k = 9, s = 6).

CONCLUSION

This meta-analysis shows the potential relevance of investigating family system functioning as a primary outcome for Systemic Therapy.

Exploring associations among baseline emotion regulation and change in relationship satisfaction among couples in a randomized controlled trial of emotionally focused therapy compared to usual care

BACKGROUND

Data from a two-arm randomized controlled trial of emotionally focused therapy (EFT) compared to usual care were used to examine whether baseline emotion regulation influences relationship satisfaction for female and male partners. This is clinically relevant as clinicians have debated whether clients' initial emotion regulation skills predict positive outcomes in EFT.

METHODS

Dyadic multilevel modeling was used to determine whether baseline emotion regulation predicted both initial levels and change in relationship satisfaction and whether that relationship differed by treatment group (i.e., EFT or usual care).

RESULTS

Baseline emotion regulation difficulties were associated with lower initial relationship satisfaction. However, baseline emotion regulation difficulties were not associated with change in relationship satisfaction over the course of treatment and this relationship did not differ by treatment group.

CONCLUSIONS

Results demonstrate that partners with diverse presentations of emotion regulation at baseline may benefit from couple therapy.

Promoting Intimate Relationships in Mental Illness: A Systematic Review of Interventions

Although persons with Serious Mental Illness (SMI) express a need for intimate relations with others, they still suffer from a severe lack of social participation in this domain. However, these unmet needs have received little attention until recently. This study reviews interventions that aim to facilitate the development and the maintenance of intimate relationships (IR) of persons with schizophrenia, bipolar disorder and major depression. A systematic review following PRISMA guidelines was conducted. Studies published in Scopus, PubMed, EBSCO (Psych INFO, Psych ARTICLES, Psychology and Behavioral Sciences Collection) from January 1, 2000, to December, 2021, were screened. The search using terms referring to "schizophrenia", "bipolar disorder", "major depression", "IR" and "interventions" revealed 11 studies. Among them, 10 reported interventions for persons with depression, including 9 for couple therapy. Most interventions targeted satisfaction with couple relationships as the main therapeutic objective. Heterogeneity in study design precludes any firm conclusions about their efficacy. Interestingly, only one intervention focused on single persons interested in developing IR. The results highlight the lack of interventions: (i) aimed at promoting IR, (ii) designed for single persons, and (iii) targeting persons with psychotic disorders. This result may reflect the persisting stigmatization of persons with psychotic disorders, and the taboo associated with the IR and sexuality of persons with mental illness. Further studies are needed to develop inclusive interventions promoting the development of IR in persons with mental illness.

Improvements in depressive symptoms following a brief relationship intervention

In the United States, 21 million adults are diagnosed with depression. Couple therapy effectively treats depression, however, couples encounter access barriers. The Relationship Checkup is an assessment and feedback intervention delivered in participants' homes. The current study examines changes in relationship satisfaction and depressive symptoms, and moderators and mechanisms of change in a community sample (N = 85 couples). Changes in depressive symptoms and satisfaction, and the association between changes in satisfaction and depressive symptoms were examined with multilevel modeling. Depressive symptoms (Cohen's d = 0.36) and satisfaction (d = 1.43) improved from baseline to 1-month follow-up, with greater declines in depression (d = 0.44) for those with more severe symptoms. Increases in satisfaction were associated with decreases in depressive symptoms (d = 0.23), and decreases in depressive symptoms were associated with increases in satisfaction (d = 0.33). Individuals with depression and relationship distress may be well served by this intervention.

Exploring the effectiveness of emotionally focused therapy for depressive symptoms and relationship distress among couples in Taiwan: A single-arm pragmatic trial

This is the first study to explore the effectiveness of emotionally focused couple therapy (EFT) for depressive symptoms and relationship distress among couples in Taiwan. This one-arm pragmatic trial assessed the clinical outcomes of 17 couples using multilevel modeling to investigate changes in depressive symptoms and relationship distress throughout treatment. Over half of the participants were moderately depressed and moderately distressed at baseline. Multilevel models revealed decreased depressive symptoms over time, with a small increase toward the end of treatment. However, no significant changes were observed in relationship distress over time. The study was limited by the low "dose" of EFT (M = 7 sessions) received by participants and the small sample size (n = 17). A comprehensive discussion of the findings from a cultural perspective was provided. Future research is needed to further examine the effectiveness of EFT for couples in Taiwan and Asia.

The therapeutic alliance in couple therapy: Patterns by treatment and sex in a randomized controlled trial of emotionally focused therapy and treatment as usual

The formation and development of the therapeutic alliance in couple therapy is a complex process and a key contributor to positive treatment outcomes. This study explored differences in trajectories of therapeutic alliance by sex and treatment condition among 24 couples randomized to receive Emotionally Focused Therapy or treatment as usual. The results identified a curvilinear growth pattern for alliance across both treatment groups. Female partners reported higher alliance than male partners after the first session across treatment groups, and female partners receiving Emotionally Focused Therapy reported higher initial alliance than female partners receiving treatment as usual. The rates of change for alliance did not differ by sex or treatment condition. The implications of the change pattern and differences in alliance formation by sex and treatment are discussed.

Power analysis for idiographic (within-subject) clinical trials: Implications for treatments of rare conditions and precision medicine

Power analysis informs a priori planning of behavioral and medical research, including for randomized clinical trials that are nomothetic (i.e., studies designed to infer results to the general population based on interindividual variabilities). Far fewer investigations and resources are available for power analysis of clinical trials that follow an idiographic approach, which emphasizes intraindividual variabilities between baseline (control) phase versus one or more treatment phases. We tested the impact on statistical power to detect treatment outcomes of four idiographic trial design factors that are under researchers' control, assuming a multiple baseline design: sample size, number of observations per participant, proportion of observations in the baseline phase, and competing statistical models (i.e., hierarchical modeling versus piecewise regression). We also tested the impact of four factors that are largely outside of researchers' control: population size, proportion of intraindividual variability due to residual error, treatment effect size, and form of outcomes during the treatment phase (phase jump versus gradual change). Monte Carlo simulations using all combinations of the factors were sampled with replacement from finite populations of 200, 1750, and 3500 participants. Analyses characterized the unique relative impact of each factor individually and all two-factor combinations, holding all others constant. Each factor impacted power, with the greatest impact being from larger treatment effect sizes, followed respectively by more observations per participant, larger samples, less residual variance, and the unexpected improvement in power associated with assigning closer to 50% of observations to the baseline phase. This study's techniques and R package better enable a priori rigorous design of idiographic clinical trials for rare diseases, precision medicine, and other small-sample studies.

Session-to-session bidirectional associations of alliance with depressive symptoms and relationship satisfaction

The relationship between therapeutic alliance and treatment outcomes is one of the most widely studied topics in psychotherapy research. Research has primarily considered a unidirectional model whereby alliance predicts outcomes, which implies that building alliance early in therapy results in later symptom improvement and ignores the possibility that early symptom improvement could also subsequently lead to improved alliance. This study explored the bidirectional associations of alliance and outcomes session-to-session for 15 sessions among a sample of 24 couples randomized to emotionally focused therapy or treatment as usual for depression and relationship dissatisfaction. Multilevel models tested associations between the prior week's alliance and the following week's clinical outcomes (i.e., depressive symptoms and relationship satisfaction) and the prior week's clinical outcomes with the following week's alliance. Findings indicated that the prior week's alliance was associated with the following week's relationship satisfaction, but not depressive symptoms, when controlling for the prior week's depressive symptoms and relationship satisfaction in each respective model. In addition, the prior week's depressive symptoms and relationship satisfaction were both associated with the following week's alliance, when controlling for the prior week's alliance. Only one of these associations differed by sex: previous week's higher relationship satisfaction was associated with higher therapeutic alliance the following week for males than females. These bidirectional associations did not differ by treatment condition. This study contributes to the emerging empirical support suggesting bidirectionality among alliance and treatment outcomes.

Online coaching blended couple-oriented intervention for preventing depression among Korean middle adulthood: A feasibility study

Depression and marital satisfaction have a reciprocal cause-and-effect relationship. Thus, couple relationships should be considered to maximize the effectiveness of couple-oriented interventions for depression. Moreover, developing culturally tailored couple-oriented interventions is critical for improving cultural acceptability and enhancing the perceived effectiveness of the interventions. A new culturally tailored MindGuide Couple intervention was developed to prevent Korean middle adulthood depression and enhance couple relationships using intervention mapping. This feasibility study used a single-arm, pre- and post-test, and 2-month follow-up design to explore the reach, acceptability, and preliminary effectiveness of this preventive intervention. Reach was assessed by recruitment, retention, and completion rates; acceptability was measured based on helpfulness, suitability, and satisfaction; and preliminary effectiveness was measured by depression (CES-D), positive and negative affect (PANAS), satisfaction with life (SWLS), couple satisfaction (CSI), and healthy relationship between spouses (FRAS). Fifteen middle-aged couples participated in four psychoeducational and asynchronous online modules and four synchronous coaching sessions via videoconferencing for 5-7 weeks. Data were analyzed using descriptive statistics and repeated measures with analysis of variance. With a 94.1% completion rate, the participants demonstrated high satisfaction with the online coaching blended intervention and reported that it was helpful and easy to use. Both husbands and wives showed significant differences over time in depression, couple satisfaction, and healthy relationships between spouses. This feasibility study demonstrated the successful reach, acceptability, and potential effectiveness of this preventive intervention. Additionally, we suggest the importance of culturally tailored and online coaching blended couple-oriented intervention for preventing depression and promoting healthy couple relationships.

Couple variables predicting retention in a brief intervention and research

Therapy is an effective form of treatment for couple distress; yet, research shows that 20%-60% of couples terminate treatment prematurely. Predictors of couple retention in therapy and research are unclear, particularly for couples from marginalized populations, which has important implications for the quality and generalizability of research results, and the benefits derived from therapy are limited when participants are not retained. The purpose of this study (N = 1310) was to identify couple-level variables that predict (1) retention in a brief, two-session couple intervention (The Relationship Checkup) delivered as a home visitation program and (2) retention in research participation at 1- and 6-month follow-up. Hypotheses were tested using a two-level multi-level model. Couples are significantly less likely to be retained in the brief intervention if (1) at least one partner identifies as Asian, Pacific Islander, or Native American, (2) at least one partner identifies as Hispanic/Latinx, or (3) both partners report mental or emotional health as a concern in their relationship. Couples are significantly less likely to be retained in research if (1) at least one partner identifies as Asian, Pacific Islander, or Native American (1 month only), (2) at least one partner identifies as Hispanic/Latinx (1 and 6 months), (3) if either partner reports clinically significant relationship distress at baseline (1 and 6 months), or (4) if either partner reports relationship aggression at baseline (6 months only). These findings are discussed with relevance to clinicians and researchers to recruit and retain more diverse and marginalized participants in couple interventions and follow-up research.

Development of an Online-Coaching Blended Couple-Oriented Intervention for Preventing Depression in Middle Adulthood: An Intervention Mapping Study

Background

Although middle-aged adults in Korea are vulnerable to depression, there are few preventive interventions for depression in middle adulthood. Studies consistently suggest that interventions that include both spouses are effective in decreasing depression and relationship distress. Considering the busy lives of middle-aged couples, it is essential to develop an online-coaching blended couple-oriented intervention. This study aimed to describe the development, implementation, and evaluation of an online-coaching blended couple-oriented intervention using an online program and coaching via videoconference to prevent middle-aged couples' depression; this was done using an intervention mapping (IM) protocol.

Methods

Six steps of IM were used to systematically develop a tailored multi-level intervention specific to middle-aged couples' depression. These steps of the IM protocol involve needs assessment, formulation of change objectives, theory-based methods, and practical strategies for program design, program development, program implementation, and program evaluation.

Results

The results of the six steps were as follows: (a) middle-aged couples' needs and mental health problems were identified through a scoping review study, mixed-method study, and expert interviews; (b) six performance objectives (POs) were formulated based on the results of Step 1, and intrapersonal, interpersonal, and temporal/transpersonal determinants were identified based on the self-transcendence theory. Change objectives were developed by combining POs with determinants; (c) self-regulated learning was chosen for theoretical teaching methods and practical strategies to change the determinants of each level; (d) four modules consisting of 16 sessions were developed based on the self-transcendence theory; (e) experts evaluated the program and coaches were trained; and (f) the evaluation plan for the program's feasibility, acceptability, usability, and preliminary effects was developed.

Discussion

The systematic process using IM allowed us to develop an online-coaching blended couple-oriented intervention to prevent depression and promote couples' relationships. The primary effects of this newly developed program should be evaluated in future studies. This may lead to the increased adoption and implementation of evidence-based and tailored interventions for psychological wellbeing in middle adulthood.

Individual's pretreatment psychological symptoms and progress in couples therapy: A person-centered analysis

This study examined how individual pretreatment symptoms (depression and anxiety) predicted longitudinal, relational processes in couples therapy (the therapeutic alliance and couple satisfaction). This study included 99 heterosexual couples receiving systemic couples therapy. Partners reported their individual pretreatment symptoms of depression and anxiety before intake. Each member reported their therapeutic alliance with the therapist at the end of sessions 2-8, as well as their couple satisfaction before intake and at the end of sessions 4 and 8. A Latent Profile Analysis revealed four profiles characterizing couples on their pretreatment psychological symptoms, namely both higher (where both members of the couple had higher depressive and anxiety symptoms), female higher, male higher, and both lower profiles. Furthermore, longitudinal, dyadic multilevel models revealed that men in male higher, female higher, and both higher profiles had higher initial alliance levels, compared to men in the both lower profile. In contrast, only female partners in the both higher profile had a higher initial therapeutic alliance than those in the both lower profile. Men in the both higher profile had faster reductions in their alliance, whereas other profiles did not predict changes in male or female alliance. Additionally, the male higher and both higher profiles predicted a lower initial level of couple satisfaction in males but not females. The profiles did not predict changes in couple satisfaction, which may be a result of lowered power due to missing data. Findings were discussed in the context of systemic family theory, with clinical implications for distressed couples.

A review of the research during 2010-2019 on evidence-based treatments for couple relationship distress

The current article presents a review of the published research from 2010 to 2019 on the treatment of couple relationship distress; 37 studies met all criteria for inclusion. Behavioral Couple Therapy, Cognitive Behavioral Couple Therapy, Emotionally Focused Therapy, and Integrative Behavioral Couple Therapy meet criteria as "well-established" approaches, Insight-Oriented Couple Therapy is a "possibly efficacious" approach, and several other others are "experimental" treatments for treating couple relationship distress (Southam-Gerow & Prinstein, 2014). Furthermore, several less-intensive interventions-the Marriage Check-up, OurRelationship, and Hold Me Tight programs-have generated substantial support for their ability to improve relationships and are classified as "well-established" or "probably efficacious" interventions. We recommend that future research focus on expanding the reach of evidence-based interventions across a range of settings and populations, deepening our understanding of the mechanisms of change and underlying factors in the change process across approaches, and improving treatment success through treatment matching and progress monitoring.

Couple and family interventions for depressive and bipolar disorders: Evidence base update (2010-2019)

This article systematically reviews the evidence base for couple and family interventions for depressive and bipolar disorders published from 2010 to 2019. Included in the review were intervention studies on depression for couples (n = 6), depression for families (n = 13), and bipolar for families (n = 5); zero studies on couple interventions for bipolar were located. Well-established interventions include cognitive and/or behavioral couple and family interventions for depression and psychoeducational family interventions for bipolar. Attachment-based couple and family interventions for depression are probably efficacious. Finally, family psychoeducation for depression is possibly efficacious, and integrative couple interventions and family play-based interventions for depression are experimental. Couple and family interventions also improved relationship dynamics, which is noteworthy since poor relationships are associated with non-remission, relapse, and recurrence of depressive and bipolar symptoms. Future research is needed on couple interventions for bipolar disorders and interventions for minoritized populations.

Emotionally focused therapy: Attachment, connection, and health

In this review, we suggest attachment science as a framework for understanding the negative impact of loneliness and social disconnection on mental and physical health and for guiding the interventions of clinicians. We provide an overview of current findings linking loneliness and social isolation to mental health problems such as depression and anxiety, as well as to physical illnesses such as heart disease. We propose emotionally focused therapy for couples, families, and individuals to enhance the quality of people's emotional ties to significant others and their subjective sense of social connectedness. We conclude by suggesting that the strengthening of emotional, interpersonal bonds, which is the primary focus of all forms of emotionally focused therapy, can help restore emotional balance, thereby protecting people from chronic feelings of isolation and the host of health problems that they can cause.

Couple Satisfaction, Depressive Symptoms, and the Therapeutic Alliance: A Systemic Perspective

There is a well-established bidirectional, negative association between couple satisfaction and depressive symptoms. Yet, a family systems perspective emphasizes the role of the therapist in interrupting this recursive cycle between couple satisfaction and depressive symptoms. The current study utilized longitudinal data to explore the bidirectional associations between depressive symptoms and couple satisfaction, moderated by the therapeutic alliance over the course of therapy. The study included 108 couples participating in couple therapy at a university training clinic. Couples rated their depressive symptoms and couple satisfaction separately before the intake session and at the end of the fourth session, and they also reported their individual therapeutic alliance with the therapist at the end of the second and third sessions. Actor-partner interdependence moderation model analysis revealed several moderation effects. In general, with low therapeutic alliance, couples with higher initial symptoms (such as depressive symptoms and low couple satisfaction) reported more severe symptoms at the fourth session, compared to those who had fewer initial symptoms. The moderating effect of alliance on a couple's symptoms was found both among individuals, and between partners. Systemic clinical implications and suggestions for future research are discussed.

Predicting change through individual symptoms and relationship distress: A study of within- and between-person processes in couple therapy

OBJECTIVE

In couple therapy clients often suffer from a blend of individual psychiatric symptoms as well as severe relational distress. However, research is inconclusive on whether relational change predicts symptom change or vice versa. Because answers to this question could have important clinical implications on what to focus on in couple therapy at which time in treatment, more research is recommended.

METHOD

In this study, data collected before every therapy session were used to test whether changes in relational functioning predicted symptom functioning or vice versa. The study used a multilevel modelling approach, and the variables of interest were disaggregated into within- and between-person effects.

RESULTS

The results indicated that if an individual improved more than expected on relational functioning, this predicted more improvement than expected on individual symptoms. No significant reciprocal relationship was found between these variables.

CONCLUSIONS

The clinical implication is discussed, suggesting that an emphasis on relational improvement seems to be an important mechanism during couple therapy that may facilitate the change on individual symptoms in the long run.

The role of depression course on life functioning and coping outcomes from baseline through 23-year follow-up

BACKGROUND

Although studies have examined how depressed patients' baseline characteristics predict depression course, still needed are studies of how depression course is associated with modifiable long-term outcomes.

AIMS

This study examined six outcomes of three groups representing distinct depression courses (low baseline severity, rapid decline; moderate baseline severity, rapid decline; and high baseline severity, slow decline): medical functioning, coping patterns, family functioning, social functioning, employment, and work functioning.

METHOD

Adults with depression at baseline (N = 382; 56% women) were followed for 23 years on self-reported outcomes (79% response rate). Data from the baseline assessment and follow-ups (1, 4, 10, and 23 years) were used in a longitudinal analysis to examine associations between depression course and outcomes.

RESULTS

All depression course groups declined on medical and social functioning and employment over follow-up. The high- and moderate-severity depression course groups reported poorer coping patterns than the low-severity group. The high-severity depression course group reported poorer family functioning than the moderate-severity group, and had the poorest work functioning outcome, followed by the moderate-severity and then the low-severity groups.

CONCLUSIONS

Patients with a high- or moderate-severity depression course may benefit from treatment that manages coping patterns and improves family and work functioning.

Randomized Controlled Trial of the Marriage Checkup: Depression Outcomes

The association between relationship functioning and depressive symptoms is well established. This study examined the effects of the Marriage Checkup, a brief two-session Assessment and Feedback relationship intervention, on depressive symptoms. Two hundred and nine married couples participated in the Marriage Checkup and were randomized into Treatment (N = 108) and Waitlist-Control Conditions (N = 101). Compared to the control condition, intervention participants reported significant improvements in depressive symptoms (d = 0.55), with an even greater effect for those who were reporting more severe baseline depression symptoms (d = 0.67). These outcomes are comparable to those within long-term individual psychotherapy, couple therapy, and pharmacology trials, making this the briefest intervention to date to demonstrate significant improvements in depressive symptoms. Clinical implications are discussed.

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.

Establishing Safety in Emotionally Focused Couple Therapy: A Single-Case Process Study

Emotionally Focused Couple Therapy (EFT) is an effective approach to working with distressed couples. It is not only effective in reducing relationship distress, but also in successfully maintaining gains over time. In the current study, we sought to understand the therapy processes that result in the creation of safety during stage one of EFT. Safety is a key ingredient in stage one, setting the stage for deeper interpersonal and intrapsychic work in later stages of treatment. In order to achieve the study aim, we analyzed video recordings of the first six sessions of a single couple case from an EFT randomized controlled trial. Using a theory building case study approach, results reveal that all expected components related to the creation of safety were achieved. Additional findings from our analyses indicate that the therapist was highly active, especially in seizing key moments in the therapy provided by this particular case, which shifted the couple in the direction of safety and deescalated their interactional cycle. Implications of key findings are discussed.