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Stephenson K.R., Sullivan K., and Christensen A., Couple Therapy. In: Howard S. Friedman (Editor in Chief),
Encyclopedia of Mental Health, 2nd edition, Vol 1, Waltham, MA: Academic Press, 2016, pp. 368-376.
Copyright © 2016 Elsevier Inc. unless otherwise stated. All rights reserved.
Couple Therapy
KR Stephenson, California State University Monterey Bay, Seaside, CA, USA
K Sullivan, Santa Clara University, Santa Clara, CA, USA
A Christensen, University of California–Los Angeles, Los Angeles, CA, USA
r2016 Elsevier Inc. All rights reserved.
Glossary
Cognitive therapy Cognitive therapy refers to a range
of treatments that focus on thoughts, or ‘cognitions,’as
the primary target of therapy. In particular, these therapies
tend to emphasize the theory that a person’s inter-
pretation of events in the world, rather than the
events themselves, is the primary cause of emotions and
behaviors.
Efficacy The degree to which a therapy has been shown to
improve targeted symptoms (e.g., relational distress) over
and above some control (e.g., no-treatment, placebo, or
other treatment). Efficacy is typically established using
randomized clinical trials.
Randomized clinical trial A research methodology that
attempts to maximize internal validity –the degree to which
one can confidently conclude that a specific intervention
(e.g., behavioral couples therapy) caused improvements in
targeted symptoms (e.g., relational distress). Randomized
clinical trials typically use tightly controlled intervention
methods and highly trained therapists.
Third wave cognitive therapies A group of increasingly
popular interventions that highlight the high cost of
unsuccessful attempts to change one’s thoughts and
emotions and emphasize acceptance of one’s current
internal experience as a key contributor to long-term well-
being.
Definition and Overview
Distress and dissatisfaction in romantic relationships is one of
the most commonly reported mental health issues in the
United States. Divorce rates remain at around 50% and re-
search suggests that about 20% of married couples report
significant amounts of relational distress (feeling unhappy,
frustrated, and/or worried about their romantic relationship)
at any given time (Bradbury et al., 2000). Relational distress
and divorce have been linked to a wide range of negative
outcomes including individual psychological disorders, im-
paired work functioning, and poorer physical health (Lebow
et al., 2012). Divorce has well-documented negative con-
sequences for children as well, including behavioral problems,
higher likelihood of dropping out of school, and poorer
emotional adjustment (Fomby and Cherlin, 2007). Given the
high prevalence and destructive impact of relational problems
and dissolution, mental health professionals have long rec-
ognized the need to develop, assess, and implement effective
interventions to improve the quality of distressed romantic
relationships.
The current article provides a broad overview of the current
science of couple therapy. We focus on empirically supported
interventions: those that have been established as effective in
improving the quality of romantic relationships (both mar-
riages and non-martial relationships) through rigorous scien-
tific trials. We begin by describing five common principles of
couple therapy suggested by Christensen and colleagues
(Christensen, 2010;Benson et al., 2012). We then describe
each approach, provide an example how it might be applied to
a typical couple seeking treatment, and describe how it is re-
lated to the common principles of treatment. Finally, we
provide brief descriptions of emerging methods of couple
therapy, as well as new applications of couple therapy to the
treatment of individual psychological problems.
Common Principles of Couple Therapy
Shift Couple’s Conceptualization of Problems from Individual
to Interactional
Distressed couples typically enter treatment strongly believing
their partners are to blame for their relationship problems. For
example, partners could be viewed as ‘too needy’or ‘cold and
uncaring,’and such beliefs easily lead to the conclusion that
relationship problems would be solved if only the therapist
would ‘fix’their partners. One of the important tasks in couple
therapy is to shift this conceptualization from a focus on per-
ceived stable and undesirable factors ‘within’each individual to
a focus on the interactional dynamics ‘between’partners. In
other words, all couple therapies include some attempt to in-
crease awareness that each person’sbehaviorsandemotionsare
influenced by the actions of the partner, and that chronic, up-
setting patterns of behavior are typically mutually reinforced by
both partners. This alteration in attention and awareness is
designed to reduce partner blaming and allow couples to shift
their focus to targets that they can confront as a team.
Modify Emotion-Driven Dysfunctional Behavioral Patterns
Couples seeking treatment invariably report distressing pat-
terns of behavior. These behaviors can range from physical and
verbal abuse, to frequent verbal arguments, to more subtle
actions such as distance and withdrawal. An important early
step in all couple therapies is to identify these behavioral
patterns in order to reduce or modify them in some way.
Elicit Avoided and Private Emotions
Dysfunctional behavioral is typically driven by strong emo-
tions in one or both partners. However, partners may not
Encyclopedia of Mental Health, Volume 1 doi:10.1016/B978-0-12-397045-9.00176-2368
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discuss these emotional experiences or, more commonly, they
will express only easily accessible and/or empowering emo-
tions such as anger or irritation. Softer emotions that expose
vulnerability such as fear, hurt, or rejection are less likely to be
expressed and may not even be noticed or acknowledged
privately (e.g., not wanting to accept that one feels dependent
on his/her partner and afraid that the partner will leave).
Creating a safe environment that cultivates awareness and
expression of soft emotions (and which promotes effective
management of emotions in general) is often a core com-
ponent of couple therapy.
Foster Productive Communication
In addition to the expression of emotions, more general pat-
terns of communication are typically a primary target of
therapy. Both expression skills and listening skills, as well as
problem solving skills, are usually addressed with the general
goals of enhancing partners’abilities to express themselves in
richer and more emotionally revealing ways; as well as to listen
to each other in ways that allow for increased understanding;
and, as appropriate, to develop concrete solutions for their
problems.
Emphasize Strengths and Encourage Positive Behavior
Although couples often enter treatment focused on what they
want ‘less’of their relationship, a key task of couples therapists
is to understand what each partner wants more of, and to use
the couple’s existing strengths to increase the frequency and
salience of these desired behaviors.
Case Example
Alex and Sofia are a heterosexual married couple who feel
increasingly unhappy in their relationship. Lately, Sofia has
been feeling more disconnected from her husband Alex. When
they arrive home from work, she usually tries to ask Alex about
his day and how he is feeling. She also tries to share her own
experiences and expects Alex to listen and understand the
issues that cause her stress and worry. Alex, however, just
seems to blow her off, barely responding to her and walking
away when she tries to continue the conversation. She finds
herself getting more and more upset that Alex does not seem
to care about her, and she also feels guilty for yelling at him.
But everything she tries to get him to connect with her just
seems to make things worse.
Alex feels stressed about a lot of things in his life, from
work to friends to his family. He finds himself feeling ex-
hausted all the time and, when he gets home from work, wants
nothing more than to relax in his home. But, when he and
Sofia arrive home, Alex immediately feels like he is back at
work –his wife brings up a seemingly endless list of problems
in her life that need to be solved. When he tries to help her
solve her problems, she gets upset and often starts to attack
him for trying to help. Now he usually does his best to get
some space so he does not get upset and ‘blow up’at Sofia, but
this seems to always make her even more upset. Unable to
work these problems out on their own, Alex and Sofia seek out
a couple therapist.
Empirically Supported Approaches
Traditional Cognitive and Behavioral Couple Therapies
Traditional Behavioral Couple Therapy (TBCT) was developed
in the 1970s and has received the most research attention of
any couple therapy protocol. The original scientific basis of
TBCT was research suggesting that distressed couples engaged
in more negative and fewer positive behaviors with each other
compared to satisfied couples, and that they also seemed to
have more trouble communicating and problem solving ef-
fectively. In line with the dominant behavioral viewpoint of
psychologists at the time, the theory underlying TBCT holds
that current behaviors in the relationship, such as a lack of
pleasurable shared activities or deficient skills in communi-
cation and problem solving, cause, and maintain distress for
couples.
In the 1990s, TBCT was expanded to include a focus on
thoughts, or ‘cognitions,’specifically how the ways in which
partners interpret each other’s actions contribute to distress in
relationships. In line with the dominant cognitive theories of
the time, this enhanced approach called ‘cognitive behavioral
couple therapy (CBCT)’put particular emphasis on ‘cognitive
distortions’: inaccurate interpretations of events in the world
that give rise to unhelpful emotional responses. Examples of
cognitive distortions include unhelpful assumptions (‘people
don’t ever change’), irrational standards (‘he should already
know why I’m upset’), attentional biases (focusing on negative
behaviors while ignoring positive ones), inaccurate attri-
butions (‘he forgot about our date because he doesn’t care
about me’), and overgeneralized expectancies (‘she’ll never
listen to my side of the story’). Based on these behavioral and
cognitive theories regarding factors that cause and maintain
distress, the active ingredients of TBCT have been hypothe-
sized to be changes in behaviors and improvements in com-
munication and problem-solving abilities, while CBCT also
emphasized decreases in cognitive distortions.
To influence these factors, TBCT and CBCT therapists util-
ize a range of cognitive and behavioral interventions. Cogni-
tive interventions are very similar to those used in individual
cognitive therapy and include Socratic questioning and guided
discovery. Both of these interventions involve the exploration
of an individual’s interpretations of events, and the underlying
beliefs and assumptions that give rise to these interpretations.
This exploration is followed by a discussion of the accuracy
and helpfulness of these assumptions. Behavioral inter-
ventions include communication training and problem-solv-
ing training, as well as behavior exchange techniques such as
encouraging partners to plan and implement behaviors they
each believe would make the other happier, then receiving
feedback from the partner and therapist. More recently, these
cognitive and behavioral tools have been complimented with
emotion-focused interventions such as ‘affect exploration,’
which seeks to increase partners’willingness to more com-
pletely describe their emotional experiences using in-depth
discussion and imagery. Given that no notable differences in
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effectiveness between forms of TBCT that do or do not include
cognitive interventions have been found, below we consider
TBCT and CBCT together as ‘behavioral couple therapy (BCT).’
Links to Common Principles
Conceptualization
One of the goals of the BCT therapist is to create or strengthen
a couple’s‘collaborative set,’or their ability to mutually take
responsibility for problems in the relationship and commit-
ment to working together to address them. This interpersonal
conceptualization of problems in the relationship is typically
fostered by inviting each partner to recognize his/her role in
maintaining distressing patterns through their own thoughts
and behaviors. Partners are also empowered by their real-
ization of their ability to make changes which can break these
destructive cycles. BCT therapists capitalize on any positive
changes to reinforce this interpersonal conceptualization, en-
couraging the couple to notice the interconnected and mutu-
ally reinforcing nature of changes in behavior.
Dysfunctional behavior
Dysfunctional behavior is a primary focus of BCT. Therapists
typically encourage the creation and implementation of ex-
plicit behavioral guidelines for the couple to minimize nega-
tive behaviors. For example, couples who are at risk for
physical violence can use ‘time outs’when one or both part-
ners are becoming upset and overwhelmed. Similarly, the
relatively firm structure of communication and problem
solving training is used, in part, to minimize the negative be-
havioral patterns that distressed couples typically fall into
during emotionally intense unstructured discussion.
Avoided emotions
Initial forms of BCT paid relatively little attention to emotions,
assuming that changes in behavior would subsequently in-
fluence emotions without direct intervention. Newer iterations
of treatment include some interventions that explicitly en-
courage partners to heighten and clarify their own emotional
experiences, however, BCT continues to place less emphasis on
avoided emotions than other couple therapy approaches.
Communication
As with dysfunctional behavior, communication is directly
addressed in BCT by structuring couple’s conversations. For
example, the speaker/listener technique requires partners to
take turns taking on the speaker or listener role. Speakers de-
scribe only their own experience and are encouraged to make
clear and specific requests about what they want in a situation
(rather than what they don’t want). Listeners reflect, sum-
marize, and validate the Speakers’experiences without adding
in their own assumptions or interpretations.
Strengths and positive behavior
Behavior exchanges are used to directly increase the frequency
of positive behaviors in BCT. Additionally, partners’abilities to
make changes to their own thoughts and behaviors that will
improve the relationship are highlighted, emphasizing the
preexisting strengths of both the individuals and the
relational bond.
Efficacy
The efficacy of BCT over control groups has been demon-
strated in a large number of studies. Meta-analytic reviews of
randomized clinical trials estimate moderate to large effect
sizes for BCT versus no-treatment controls (Shadish and
Baldwin, 2005) and suggest that about 50–60% of distressed
couples receiving BCT significantly improve from baseline
(Jacobson et al., 1984). This success rate is comparable to
many individual therapy methods and impressive given that,
without treatment, it is rare for distressed couples to spon-
taneously improve. However, it is important to note that up to
half of improved couples relapse within 2 years following the
end of treatment, suggesting that improvements resulting from
BCT may be relatively unstable without continued treatment
(Christensen and Heavey, 1999). In contrast to the many
studies supporting the effectiveness of BCT, there are relatively
few studies focusing on ‘why’these treatments work. In par-
ticular, there is little evidence that the hypothesized active
ingredients (e.g., changes in communication patterns, de-
creases in cognitive distortions) are strong predictors of how
much couples benefit from treatment.
Application to case example
A BCT therapist may begin Alex and Sofia’s treatment with
communication training, utilizing the speaker/listener techni-
que to structure their conversations about relatively benign
topics (e.g., stressors outside the relationship such as conflict
with a coworker). Next, they may be encouraged to practice
their problem solving skills on relatively easy questions (e.g.,
how to spend this Saturday night?). Once these basic skills are
established, they would be used, in conjunction with cognitive
techniques, to address more emotionally loaded topics. For
example, in discussing how they will interact at the end of a
work day, both partners may be encouraged to explore how
they interpret each other’s behavior (e.g., “Alex doesn’t talk to
me when he gets home because he doesn’t care about me.”
“Nothing I ever do can be good enough for Sofia.”), and
whether these interpretations are accurate or helpful. They
might then use structured problem solving to reach a mutually
acceptable agreement for a planned behavior exchange at the
end of the work day. For example, Alex may have 20 min to
relax by himself if he agrees to then spend 20 min talking
about his day with Sofia.
Integrative Behavioral Couple Therapy
Integrative behavioral couple therapy (IBCT) was developed in
the 1990s as an attempt to address a number of relative
shortcomings in BCT. Specifically, IBCT sought to integrate the
components of BCT that are focused on solving problems and
‘changing’the behaviors of partners with newer approaches
that encourage increased understanding and ‘acceptance’of
chronic or unsolvable issues in the relationship. The addition
of acceptance-based interventions was in line with the bur-
geoning ‘3rd wave’of cognitive therapies which tended to
focus on futile and counterproductive attempts to change
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one’s present experience as primary culprits in creating and
prolonging suffering.
IBCT also differs from BCT in its focus and theory of dis-
tress. Whereas BCT focuses on current interpersonal behaviors
that are pleasing and displeasing to partners, IBCT attempts to
contextualize current behaviors by highlighting the factors that
immediately precede and follow them (why did X happen,
and what did it lead to?) as well as more general contextual
factors such as partners’histories and cultural background.
IBCT also explores how current behaviors are related to long-
standing emotional vulnerabilities in each partner. Addition-
ally, while BCT encourages direct change of behaviors with the
assumption that this change will engender changes in emo-
tions, IBCT usually takes the opposite route: encouraging in-
creased emotional understanding and acceptance of each
partner’s subjective experience with the assumption that this
change will naturally facilitate changes in behaviors.
The creators of IBCT have introduced a summary of their
theory of distress called the DEEP conceptualization. Ac-
cording to this conceptualization, distress is caused and
maintained by an interaction of multiple factors. First, partners
often enter into relationships with natural (D)ifferences re-
garding fundamental ways of being in relationships. Import-
ant differences could include preferences for closeness/distance
and ways in which love/caring is expressed. These differences
in and of themselves are not inherently distressing (and, in
fact, can initially be sources of attraction), but can become
problematic when they trigger (E)motional vulnerabilities –
particular sensitivities that give rise to strong and disruptive
emotional responses. For example, a difference between part-
ners in terms of how love is expressed (e.g., explicitly with
words vs. implicitly by providing financial support) may be an
annoyance in some relationships, but a central source of dis-
tress in others where it triggers an emotional vulnerability
(e.g., a partner’s fear that he is unlovable and bound to be
abandoned). This distressing interaction between differences
and emotional vulnerabilities can be exacerbated by (E)xternal
stressors such as finances, child rearing, etc. This combination
of internal and environmental stress causes partners to engage
in problematic (P)atterns of interaction. These patterns are
typically understandable attempts to protect one’s vulner-
abilities, but they ultimately create additional problems in the
relationship that lead to further magnification of differences
and eventual feelings of distress and hopelessness. Based on
this understanding of distress, IBCT posits that the active in-
gredients of therapy should be increases in partners’accept-
ance of each other’s differences and emotional sensitivities, as
well as change in the patterns of communication with which
they try to address these differences and emotional
sensitivities.
To influence these factors, IBCT therapists use a mixture of
change- and acceptance-based interventions. Change-based
interventions are very similar to those used in BCT, however,
they are typically used less frequently in IBCT and a more
concerted attempt is made to harness naturally occurring re-
inforcers within the relationship, rather than relying on rules
to shape interactions. More typically, the practice of IBCT is
characterized by three primary acceptance-based tools: em-
pathic joining, unified detachment, and tolerance building,
which includes various components such as self-care.
Empathic joining aims to shift the couple’s focus from surface-
level details of a recent conflict to present-moment emotional
reactions in the room, and to help couples make the con-
nection between surface-level conflict and the underlying
causes/explanations of the conflict (i.e., basic differences be-
tween the partners and how these differences trigger emotional
vulnerabilities and understandable protective responses). As
part of this process, partners are encouraged to share soft
emotions, and to increase acceptance of one another’s emo-
tional experiences. This acceptance allows for increased feel-
ings of safety and connection even in the context of ongoing
difficulties.
Unified detachment shares empathic joining’s goal of
uniting partners in addressing ongoing problems in the rela-
tionship, but does so in a more intellectualized way. Essen-
tially, unified detachment aims to have couples engage in a
‘functional analysis’of problematic patterns of interaction
wherein therapists draw their attention to the understandable
logic behind each partner’s actions, and how mutually re-
inforcing reactions lead to further conflict and/or disengage-
ment. Couples are encouraged to cultivate some irreverence
towards these patterns, often using humor to gain some per-
spective and distance from these destructive behaviors. In cases
where empathic joining and unified detachment prove im-
possible for a couple, the emphasis shifts to tolerance building
as an alternative to continuing attempts to force change. Al-
though this alternative is not ideal, it can serve the important
purpose of decreasing conflict and loosening the often rigid
focus on changing one’s partner. If a couple responds to one or
more of these acceptance-based approaches, a shift to change-
oriented tools is often unnecessary. However, IBCT therapists
are also able to utilize tools such as problems solving training
as needed later in treatment.
Links to Common Principles
Conceptualization
A couple’s conceptualization of their problems is the key as-
pect of IBCT. In order to increase acceptance, it is essential that
the couple gain increased insight into the interconnectedness
of their behavioral patterns, and an understanding of the root
causes of these patterns. This understanding creates the ne-
cessary foundation for naturally occurring (and theoretically
more stable) changes in behaviors within the relationship. As
such, the IBCT therapist’s primary goal is to have couples in-
ternalize and use the DEEP conceptualization in understand-
ing their problems.
Dysfunctional behavior
In contrast to BCT, dysfunctional behavior is often not directly
addressed in IBCT. Rather, it is hypothesized that creation of a
safe interpersonal environment and more empathic under-
standing of each person’s subjective emotional experiences
should naturally motivate partners to shift their responses and
behaviors. However, change-oriented cognitive-behavioral
interventions are sometimes used to directly change behavior
early in treatment if that behavior is preventing typical
IBCT interventions, or later in treatment if typical IBCT
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interventions have not been successful in removing disruptive
behavior.
Avoided emotions
One of the key interventions of IBCT, empathic joining, is
essentially a method of allowing for the expression of feelings
tied to underlying emotional vulnerabilities. The validation of
these emotions by the partner is thought to be the primary
mechanism through which IBCT allows for natural shifts in
how partners relate to and interact with one another.
Communication
Similarly to BCT, communication during IBCT therapy ses-
sions is often guided and structured by the therapist. However,
in contrast to BCT, this guidance does not take the form of
specific instructions to improve general methods of com-
munication inside and outside the session. Rather, the couple
is directed towards specific aspects of their experience (vul-
nerable emotions and expression of needs) in the present
moment to facilitate understanding and feelings of connection
during the session. Although these changes in interactions are
ideally generalized to the home environment, IBCT places
more emphasis on immediate impactful shifts in perspective
than skill-building per se. Thus, IBCT tries to access skills al-
ready within the couples’repertoire before teaching new skills.
Strengths and positive behavior
Information regarding preexisting strengths in the relationship
is explicitly included in feedback to the couple before the start
of formal therapy sessions. However, consistent with its the-
oretical basis, IBCT does not typically directly encourage in-
creases in positive behavior, but rather uses understanding and
acceptance as a method of removing barriers to the natural
resumption of positive behaviors.
Efficacy
The best evidence regarding the efficacy of IBCT comes from
the largest randomized clinical trial of couple therapy to date
(Christensen et al., 2004). In this study, 134 severely and
chronically distressed couples received either BCT or IBCT and
were assessed for 5 years following treatment. Results showed
that about 70% of couples receiving IBCT significantly im-
proved over the course of the study (compared to 60% of
couples receiving BCT), and that IBCT couples maintained
improvements at higher rates than BCT couples 2 years fol-
lowing treatment. Importantly, even 5 years after treatment
(with no additional therapy provided), 50% of couples who
received IBCT continued to exhibit significant improvements
in satisfaction, suggesting good maintenance of treatment ef-
fects. Additional analyses also provided some support for hy-
pothesized active ingredients of treatment –couples who
became more accepting over the course of treatment also
tended to improve the most in terms of satisfaction. In sum,
research suggests that IBCT is at least as effective as BCT, and
may be more effective in the short and intermediate term.
Application to case example
An IBCT therapist would begin Alex and Sofia’s treatment by
providing them with feedback regarding their relationship,
following the DEEP conceptualization. Then, the couple
would be guided in conversations aimed at increasing under-
standing and acceptance of each partner’s experience by con-
textualizing specific conflicts within this conceptualization. For
example, the couple would be encouraged to acknowledge
that, based on their personality and upbringing, they differ in
terms of how much emotional connection they prefer in re-
lationships. Furthermore, they may discover that this activates
emotional vulnerabilities for both partners. For example, Sofia
may communicate to Alex that she gets scared when he does
not talk with her because it triggers her greatest fear: that he
does not care about her because she is a flawed person. This
type of vulnerable disclosure should naturally pull for a warm,
supportive response from Alex (in notable contrast to a de-
mand for more attention). Similarly, Alex may communicate
to Sofia that he gets scared when she wants to get too close
because it triggers his greatest fear: becoming dependent on
someone who then leaves. Again, if Sofia is able to validate
this experience and accept the behaviors that it leads to (i.e.,
Alex maintaining some distance in the relationship), the
partners can experience increased intimacy and understanding
without necessarily ‘solving the problem.’This increased ac-
ceptance may naturally lead to changes in how the partners
respond to one another: Alex is more likely to be willing to
connect with Sofia and Sofia is more likely to be willing to give
Alex time alone. Any changes made in this way should be
more stable than ones imposed by the therapist.
Emotion Focused Therapy
During the 1990s, ‘emotion focused therapy (EFT)’grew out of
a different theoretical background than BCT or IBCT. Namely,
EFT’s creators were influenced by experiential, systems, and
attachment theories which highlight, respectively, the im-
portance of acknowledging and embracing one’s emotions, the
costs of inflexible interpersonal behavior, and the centrality of
attachment bonds in romantic relationships. EFT was a re-
sponse to strict behaviorists and early forms of BCT which
were criticized for downplaying the importance of subjective
emotional experience. EFT also differed from BCT by viewing
partners’lifelong histories of close relationships as a central
component of couple therapy in that they shape models of
attachment: internal and implicit beliefs regarding the likely
availability of significant others to provide comfort and sup-
port in times of distress. EFT posits that these models are of
central importance in understanding distress, with specific
behaviors and conflicts viewed as important only insofar as
they reflect an individual’s attachment history or provide in-
sight into the health of the attachment bond in the current
relationship.
Indeed, the underlying theory of EFT posits that the pri-
mary cause of chronic distress is injury to the couple’s at-
tachment bond (e.g., events where partners felt abandoned or
neglected in a time of need) and/or the inability for partners to
effectively acknowledge and communicate their needs and
fears related to this attachment bond. Distress is thought to be
maintained by a failure to heal past attachment injuries and/or
inflexible and emotionally shallow interactions between
partners that prevent the experience of feeling supported by
one’s partner in a time of emotional distress. Based on this
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understanding of distress, EFT suggests that the active in-
gredients of therapy should be increased engagement with,
and expression of, attachment needs, along with supportive
reactions by partners to attachment-related requests.
To influence these factors, EFT therapists’primary goal is to
identify, and encourage expression of, each partner’s emotions
tied to attachment needs and injuries. These emotions are
rarely discussed by distressed couples and, moreover, are often
not fully experienced or acknowledged by the individuals
themselves. As such, EFT involves relatively more exploration
of each partner’s past relational experiences than either BCT or
IBCT with the goal of eliciting these often disowned and
overwhelming emotions. The EFT therapist is quite active in
this process, using imagery and other tools to reformulate
discussion of current conflict into an intensive exploration of
each partner’s present-moment emotional experience. Once
attachment-related emotions are able to be acknowledged and
expressed during the session, the therapist will then present
the couple with a reframed conceptualization of their dif-
ficulties as problematic interactions stemming from the dam-
age to their attachment bond. An important note is that EFT
therapists initially take the lead in providing acceptance and
validation of revealed attachment needs and fears, modeling
this process for the other partner who may be too over-
whelmed by their own emotions to provide a supportive re-
sponse. Over the course of treatment, partners come to take
the place of the therapist in both clearly expressing their
emotional experience to one another, and in providing val-
idation and acceptance of these emotions. During the last
stages of treatment, more concrete problems (e.g., finances)
may be addressed, but these topics are not typically a focus
of EFT.
Links to Common Principles
Conceptualization
Similarly to IBCT, EFT involves shifting the couple’s per-
spective from a focus on solving particular conflicts to a focus
on gaining increased understanding of the intense emotions
driving problematic behavioral patterns. However, EFT is dis-
tinct in its use of attachment theory as the primary method of
conceptualizing underlying emotional conflict. Although
models of attachment are shaped by current relationships, they
are thought to be relatively stable internal aspects of the in-
dividual. As such, EFT differs from IBCT in that it places
relatively more importance on intrapersonal factors and indi-
vidual emotional experiences whereas IBCT places relatively
more importance on interpersonal factors such as differences
between partners and patterns of interaction.
Dysfunctional behavior
EFT is again similar to IBCT in that dysfunctional behavior is
typically addressed indirectly. The model of treatment assumes
that greater engagement with and understanding of attach-
ment-related emotions can naturally give rise to softer, em-
pathic responses from partners, and that these changes will be
more genuine and stable than rule-based changes. A
notable difference is that EFT therapists are often more active
in guiding partners away from discussion of behaviors and
towards the experience of current emotions whereas IBCT
therapists may be more interested in the interpersonal inter-
actions surrounding areas of conflict.
Avoided emotions
The key component of EFT is the drawing forth and expression
of attachment-related emotions that are thought to not only be
absent from the couple’s typical conversation, but likely out-
side of the conscious awareness of partners. More than any
other method of couple therapy, EFT highlights heightened
awareness of and interaction with one’s emotions as the key
ingredient of therapeutic change.
Communication
Encouraging changes in communication between partners is
an important component of EFT, but is relatively less struc-
tured than in BCT or IBCT. Rather than rules or guidelines for
effective communication, EFT therapists typically ‘follow the
emotion’by guiding partners to progressively reveal more and
more of their internal emotional struggles. This engagement
with emotions, along with eventual partner responses during
sessions, is thought to be more important than wider changes
in communication between partners at home. Additionally,
EFT therapists tend to play a very active role in structuring
communication during the session, asking each partner about
his/her present experience and providing empathy, validation,
and support following soft disclosures.
Strengths and positive behavior
EFT spends relatively less time explicitly addressing strengths
in the relationship and increasing positive behaviors. Theore-
tically, the most important increase in positive behavior
should be providing support for one’s partner after he/she
clearly expresses an attachment need during a time of intense
emotional vulnerability. This is a very specific and time-sen-
sitive opportunity which typically requires a good deal of
foundational work and, as such, is often a focus only later in
therapy. However, an important component throughout EFT is
that partners feel empowered to meet one another’s attach-
ment needs. In other words, a partner’s distress is ideally
reframed as speaking to importance of the couple’s bond –
your partner is upset because ‘your’support is so important.
Efficacy
A number of studies have suggested that EFT is effective at
improving couples’satisfaction. One meta-analysis found that
about 70% of couples receiving EFT improve significantly and
that these improvements are relatively stable (Johnson et al.,
1999). Although many of these studies are limited by small
sample sizes and the absence of comparison groups, they
provide solid evidence that EFT is helpful in improving rela-
tionships in many cases. There is also some support for hy-
pothesized active ingredients of treatment –couples who
increased the depth of their emotional experience and more
clearly expressed attachment needs/fears to their partners also
tended to improve the most in terms of satisfaction. Although
EFT has not been supported by the same kinds of large-scale
clinical trials as BCT or IBCT, it has been tested in a wider
range of patient populations (see Section ‘Couple Therapy for
Individual Psychopathology’below).
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Application to case example
An EFT therapist may begin Alex and Sofia’s treatment by
engaging in a relatively in-depth exploration of their relational
histories, paying special attention to patterns and events rele-
vant to internal attachment models. For example, Alex may be
encouraged to share his early experiences wherein his mother
who worked two jobs was not around when he had to deal
with difficult experiences, giving rise to a belief that he needs
to depend on himself because others would not be around to
depend on. Similarly, Sofia may be encouraged to share her
past experiences of infidelity by previous partners, which gave
rise to a belief that people she cares about are always on the
brink of leaving her for someone better. Treatment might then
focus on changing the couples ‘dance,’or how they express
and respond to each other’s emotions. Specifically, the thera-
pist may focus on Alex’s insistence that he be self-reliant,
picking up on and highlighting his emotional motivation: fear
of being let down when he needs someone most. The therapist
would model understanding and validation of these emotions
before focusing on the ways in which Alex’s disclosures are
emotionally impacting Sofia–Sofia may initially respond to
Alex’s distress with overwhelming fear that he will end the
relationship. Later in treatment, the couple may be encouraged
to explore how their emotional responses drive behaviors that
upset both partners, but the focus will remain on allowing a
safe space within which Alex and Sofia can expose their dee-
pest needs and fears to one another, and in which they can
receive support from their partner during these key moments.
Emerging Approaches and New Applications
BCT, IBCT, and EFT represent the gold standard of scientifically
supported methods of couple therapy. However, they are not
effective for all couples or implementable in all situations.
Thus, it is important that alternative methods of couple ther-
apy continue to be developed. Although they have not been
scientifically tested to the same extent as the interventions
described above, some show great promise and have the po-
tential of increasing the effectiveness and accessibility of cou-
ple therapy.
Insight Oriented Couple Therapy
Insight oriented couple therapy (IOCT) represents an inte-
gration of psychodynamic theory, which posits that psycho-
logical distress is often the result of unconscious conflict
between different aspects of the self and cognitive-behavioral
tools for improving the quality of relationships. IOCT suggests
that dysfunctional patterns of interpersonal behavior are most
accurately viewed as stemming from early developmental
history and maintained by ineffective beliefs about relation-
ships and projective identification –a process by which un-
conscious intrapersonal conflict and repressed aspects of self
are projected onto one’s partner. IOCT therapists typically
utilize behavioral interventions adapted from BCT, aug-
menting these with reflecting and probing of underlying
emotions. IOCT is unique in that therapist analysis regarding
how emotions and behaviors are connected to unconscious
conflict is a key component of treatment. The length of treat-
ment also tends to be much longer than the methods de-
scribed above (1–2 years compared to 3–5 months). One
study (Snyder and Wills, 1989) suggested that IOCT was as
effective as BCT –43% of distressed couples receiving IOCT
demonstrated significant improvement versus 50% of couples
receiving BCT treatment. The most striking finding was that, 4
years following treatment only 3% of couples receiving IOCT
had divorced, compared to 38% of couples receiving BCT.
Although this finding is potentially important, it has not been
replicated and no other controlled trials of IOCT have been
conducted. As such, it is not known whether IOCT is truly as
effective as other forms of couple therapy and relatively few
couple therapists practice IOCT.
Systemic Couple Therapy
Couple therapy based on systems theory tends to emphasize
the patterns of interaction between partners (and often other
family members), especially how these patterns serve to
maintain balance and stability in the relational ‘system.’Dis-
tressing patterns are thought to be maintained by behavior
that is driven primarily by emotions rather than a person’s
rational decision-making system. Some forms of systems-
based interventions also emphasize the ways in which early
emotional attachments to parents influence behavior in adult
romantic relationships, resulting in intergenerational trans-
mission of distress. Treatment typically focuses on identifying
and preventing ‘emotional chain reactions,’in which partners
become overwhelmed by emotion and respond to each other
in instinctive and destructive ways. One of the primary goals in
treatment is to encourage increased ‘differentiation,’between
partners and between each individual and his/her emotional
system, allowing for the toning down of dysfunctional emo-
tional responses. There are few studies assessing the effective-
ness of systemic couple therapy and, as such, it is unknown
whether it is as helpful as other methods of treatment.
Gottman-Method Couple Therapy
Research by John and Julie Gottman has provided a foun-
dation of knowledge regarding differences between distressed
and non-distressed couples. Based on this research, they have
developed a model of satisfying relationships, the ‘Sound Re-
lationship House,’along with a treatment package for im-
proving relationship quality. Gottman-method couple therapy
includes a range of interventions that mirror multiple aspects
of BCT, IBCT, and EFT. For example, the ‘Rappaport inter-
vention,’is similar to the speaker/listener technique used in
BCT. Gottman-method couple therapy differs from these other
treatments in a number of ways. First, it focuses more on de-
scription of how distressed couples differ from satisfied cou-
ples and less on how relationships change over time. Second,
the treatment includes relatively more aspects of self-help
techniques. For example, it includes a larger number of ‘pre-
packaged’activities for couples such as flash card-based activ-
ities that encourage conversation about past and current
experiences/preference (‘building love maps’). Third, in con-
trast to interventions described above, treatment manuals for
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Gottman-method couple therapy are not publically available
but, rather, are provided as a part of training seminars which
are paid for by clinicians. Thus, although this method of
treatment has been disseminated fairly widely to both clin-
icians and directly to couples (in the form of multiple popular
self-help books), there have been no controlled trials of
Gottman-method couple therapy to date, leaving its effect-
iveness in question.
Prevention Programs
Given the many potential benefits of stable and satisfying re-
lationships, various governmental bodies have encouraged the
implementation of programs aimed at prevention of marital
distress. The Marriage Check-Up (MC) has been conceptual-
ized as the equivalent of an annual physical check-up and is
meant to identify and aid couples in early stages of distress.
The MC includes two primary types of intervention: increasing
emotional intimacy using briefer versions of tools used in
IBCT and increasing motivation of the couple to effortfully
address problems in their relationships using ‘motivational
interviewing’techniques. Importantly, the MC requires only
two 2-h sessions. Results from preliminary studies suggest that
this brief intervention can significantly increase relationship
satisfaction in mildly distress couples.
The Prevention and Relationship Enhancement Program
(PREP) is similar to the MC in its brevity (typically four ses-
sions over the course of a month) but differs from the MC in
that it focuses more on skill building in the tradition of BCT.
For example, couples are provided with communication and
problem-solving training and encouraged to explore their be-
liefs and expectation regarding romantic relationships. Pre-
liminary studies have suggested that premarital or newlywed
couples who complete PREP tend to be more satisfied than
couples who receive no preventative treatment. For example, a
recent controlled trial (Rogge et al., 2013) found that couples
completing PREP or similar programs reported lower rates of
separation/divorce after 3 years (11% compared to 24% of
couples receiving no treatment). However, while MC and
PREP have been supported by initial scientific studies, re-
searchers have noted that the small and inconsistent effects of
similar programs when implemented in real-world settings
with low-income couples raise serious questions as to whether
these interventions are effective for couples that are most in
need (Hawkins et al., 2013;Johnson, 2013).
Increasing Access: Web-Based Programs
Web-based programs have recently been designed to increase
access to couple therapy services, some of which show promise
based on initial effectiveness trials. The Power of Two Online
(poweroftwomarriage.com) is based on many of the same
principles as PREP and is designed for couples going through
potentially difficult transitions (e.g., first child) who are not
able or willing to seek formal couple therapy. The website
consists of various educational modules and interactive activ-
ities such as games and quizzes that partners can work on
either together or individually. The couple can also contact a
‘relationship coach’via e-mail to address difficulties that arise
during their use of the site. One study has shown that couples
using the website reported increases in satisfaction compared
to a wait-list condition (Kalinka et al., 2012).
Our Relationship (ourrelationship.com) is based on IBCT
principles and includes activities that each partner completes
individually followed by joint communication activities that
partners do together. There is also a version for couples in
which only one partner is willing to participate. Our Rela-
tionship is unique in that it focuses on a specific problem in
the relationship, rather than providing general education, and
thus is intended to facilitate more active interaction between
partners. This intervention is entering the final phase of de-
velopment and currently being piloted (Doss et al., 2013).
Early results from the first 100 couples to complete the pro-
gram indicate significant and substantial benefits relative to a
no treatment control. These and other online interventions
have the potential to greatly increase the population of couples
who can benefit from scientifically supported methods of
couple therapy.
Couple Therapy for Individual Psychopathology
Many studies have provided evidence for a strong link between
the quality of romantic relationships and individual psycho-
pathology. Recent research indicates that improving relation-
ships through couple therapy can actually lead to alleviation of
symptoms in these disorders. For example, a series of studies
has suggested that EFT is associated with improvements in
satisfaction and symptoms of PTSD in couples where partners
have a history of trauma (e.g., Dalton et al., 2013). Similarly,
research has shown that BCT is often as effective as individual
therapy in treating depression, with the substantial side benefit
of also improving relationship satisfaction. Even more studies
have shown that BCT, when combined with a substance-spe-
cific component, consistently outperforms individual therapy
in decreasing rates of substance use (Powers et al., 2008). In
addition to the benefits of formal couple therapy, we also
know that including the partner to assist in individual treat-
ment improves outcomes for a range of disorders including
PTSD and Borderline Personality Disorder. Taken together,
these findings clearly show that couple therapy has additional
beneficial effects beyond the quality of the relationship, and
that it can be implemented in cases where one or both partners
is struggling with significant mental health problems.
Summary
Over the past 40 years, scientists have developed and tested
multiple approaches to couple therapy that reliably improve
relationship satisfaction in a majority of cases. These inter-
ventions are derived from scientifically based theories of how
individual, interpersonal, and contextual factors interact to
cause and maintain distress. All empirically supported treat-
ments, including BCT, IBCT, and EFT, share a number of
common principles that may account for their effectiveness.
However, these treatments differ in terms of which principles
are considered primary, and in the methods used to influence
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these factors. Research on these common factors, and mech-
anisms of change in couple therapy more generally, will con-
tinue to improve our understanding of why these treatments
work, allowing for more targeted and effective interventions.
In addition to the effects of traditional couple therapy on re-
lationship satisfaction, scientists are exploring the effects of
couple therapy on mental health more generally, as well as
creating new online and preventative programs designed to
improve access to treatment. This research holds the promise
of substantially increasing the real-world benefits of couple
therapy, and for harnessing the power of interpersonal rela-
tionships to address a wider range of human problems.
See also: Attachment. Marriage, Romantic Relationships, and
Health. Mindfulness Approaches to Psychological Disorders.
Psychodynamic Psychotherapy
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