"WHAT MAKES couple therapy so challenging is that you are dealing with two people, each with their own anxieties and problems, and these are likely to impact the problem the couple is having," says Jacqueline Sparks, URI professor.
When a marriage is in crisis, couples therapy can be the last hope before divorce court. But it’s difficult – the therapist has to connect with both people, understand their issues and bring them back together. Quite often, the effort fails.
Now researchers have found a tool they say can dramatically boost success rates: a system used successfully in individual therapy in which four quick questions are asked at the outset to gauge each person’s frame of mind, and then the session itself is briefly evaluated at the end.
In August, the Journal of Consulting and Clinical Psychology published the results of a clinical trial in Norway with 205 couples that found a 46.2-percent decrease in divorces and separations when the “client feedback” system was used.
Jacqueline A. Sparks, a professor of human development and family studies at the University of Rhode Island who co-authored the study findings and is teaching the system to students and professionals, answered questions about the new approach.
PBN: How common is couples therapy, and how successful is it generally?
SPARKS: Researchers are not sure how many couples in distress choose therapy and how many do not … [but] the evidence indicates that couples who get counseling are better off than those who don’t, on average. However, we also know that therapy outcomes (at least for individuals) tend to be less positive in real-world clinical settings than in controlled clinical trials. There is some research that this may also be the case for couples. As many as 40 to 50 percent of couples move from distressed to non-distressed ranges in controlled trials. Fewer couples in everyday clinical practice are likely to experience these gains.
PBN: What are some of the main obstacles to success in couples therapy?
SPARKS: What makes couple therapy so challenging is that you are dealing with two people, each with their own anxieties and problems, and these are likely to impact the problem the couple is having. More important, however, is the challenge for the therapist in forming a strong alliance with both members of the couple; [if he doesn’t], couple therapy is likely to fail. This is particularly difficult as couples most often come into therapy with different views and with emotionally charged and conflicted concerns.
PBN: Who developed this client feedback system, and how was it developed?
SPARKS: The client feedback system we used was based largely on the work of Michael Lambert (Brigham Young University) and other researchers … who have used a feedback system in individual treatment. There is a growing body of research that points to improved outcomes for clients whose therapists use outcome and alliance measures.
My colleagues, Drs. Barry Duncan and Scott Miller, developed and tested two brief measures that would be feasible for everyday use in a busy clinical practice. These measures have been validated and used with individuals, indicating similar advantages as longer measures. Our study was the first research using any feedback system with couples.
PBN: Can you explain how the system works, and why it makes therapy better?
SPARKS: The system is relatively simple. Therapists in the study received only 17 hours of training in order to implement it. … [They] administered the Outcome Rating Scale at the beginning of each session, which consists of four questions where clients put a mark on a continuum indicating their current level of distress in four life domains – individual, interpersonal, social, and overall. [Using software], the ORS is then scored in about five minutes. For couples, the scores are graphed together on one sheet of paper. The session rating scale also uses a visual analog scale and assesses major areas of the therapeutic alliance. This is administered at the end of every session. All scores and graphs are shared with the couple, and the therapist encourages a candid conversation about what they mean.
Our experience has been (and the studies show) that a feedback system allows therapists to identify and respond to clients who are not making progress or who are not feeling connected to their therapist and are therefore at risk of a poor outcome. [Then] they can discuss possible changes or new avenues for resolving problems. I also believe that feedback discussions facilitate positive communication and a sense of shared purpose for the couple, aspects important to successful couple work. Additionally, the collaborative climate created by a feedback system likely helps couples to engage more fully in the process; they have a greater investment and sense of ownership for their own change. This enhances client engagement, the most critical component of any therapy.
PBN: What’s the next step to demonstrating this system’s effectiveness on a broader scale, and perhaps getting it to be adopted by more therapists?
SPARKS: The number of therapists and counselors using the system is rapidly growing nationally and internationally. We maintain an international listserv that has over 800 members. Based on training requests and inquiries my colleagues and I receive, this is likely only a segment of the clinicians actually using the system in many different settings.
Yes, innovation and change in typical mental health delivery is not a quick or easy process. What we have found, however, is that the system is common-sense, easy to implement, and rewards practitioners immediately as they see improved client outcomes when using it. This is the best selling point. We are very hopeful, based on the response so far, that feedback systems in mental health will become routine in the not-too-distant future. We see this happening not only for individuals and couples, but for families, as we have a child measure that has been validated for use with ages 6 to 12.
To learn more about measures, the study, and projects aimed at integrating the system into mental-health care, go to www.heartandsoulofchange.com.
Jacqueline A. Sparks,