Couple relationships: why are they important?
Few would dispute the suggestion that the quality of our closest relationships profoundly affects how we feel about ourselves. Much less widely acknowledged however – although just as true – is the fact that the quality of these relationships has material and measurable consequences for our lives and those around us, affecting the emotional, cognitive and physical development of our children, our capacity to work and to be fulfilled in work, and our physical and mental health as we get older.
Policy-makers, commissioners of health and social care services and frontline staff delivering care, amongst others, have an invaluable opportunity to make the quality of couple relationships a central focus of their work. This series of briefings from TCCR aims to inform and support them to do this, since no serious attempt to improve the nation’s health and well-being can afford to overlook the fundamental role which the quality of our close relationships has on our lives.
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Relationship support: why is it important?
It is well-known that married and cohabitating couples feel steadily less satisfied with their relationships over time. Indeed, over the course of a fifteen year relationship, almost half of couples’ relationships deteriorate to the point that they feel as disappointed, unhappy, angry and misunderstood as typical couples receiving couples therapy (Hirschberger, Srivastava, Marsh, Cowan, & Cowan, 2009).
It is a sobering fact that half of all couples with these kinds of relationship difficulties ultimately split up. The economic costs of this to the country – estimated at £42billion for family breakdown in all its manifestations (Wong, 2011) – along with the enormous personal costs it entails should prompt us to look for ways in which we might be able to intervene: firstly to help stop relationship difficulties from starting, and secondly to help prevent existing relationship problems from getting worse.
This is crucial for the sake of the adults concerned of course, but also for their children: prolonged marital conflict (particularly that which involves out of control arguing between couples, and silent/corrosive conflict (e.g. Shelton & Harold, 2008)) and relationship break-up tend to be associated with cognitive delay, school difficulties and antisocial or withdrawn behaviour in the early school years (Cummings & Davies, 1994; Fincham, Grych & Osborne, 1994; Hetherington, Cox, & Cox, 1982). It also represents something of a public health emergency given the widespread acknowledgement that the quality of couple relationships significantly influences the intergenerational transmission of problematic patterns in families (Cowan and Cowan, 2005)).
Indeed a growing body of literature points to a strong link between the quality of the relationship between parents and the quality of their parenting (Clulow, 2008). This insight, alongside the fact that the strength of the marital relationship and the parent’s style of interaction play a central role in children's adjustment and potential for behaviour problems, identifies for policy-makers and commissioners a key area to focus on if they are to meaningfully improve children’s outcomes and the health of society as a whole.
Helping prevent relationship difficulties from starting: what does the research tell us?
The evidence base for interventions which aim to prevent relationship difficulties from starting, while relatively sparse, contains a number of encouraging and robustly researched approaches, and these are described below.
On a general level, however, it is worth noting that interventions which work with the couple are more effective in reducing child problems and improving family functioning than working with (as is often the case) mothers only (Brody and Forehand, 1985; Dadds et al., 1987; Parke, 1996; Pruett, 2000).
Pre-marital interventions
Interventions for couples who are about to get married have been evaluated by researchers. These typically involve small groups of couples in classes or weekend workshops, with a curriculum that focuses on teaching communication skills. The most well-validated intervention of these – the Premarital Relationship Education Program – has shown long-term positive effects on couples’ marital stability and quality (e.g. Markman, Stanley, & Blumberg, 2001; Schilling et al, 2003).
Interventions during early and later parenthood
Research has demonstrated that group interventions for couples shortly to become parents can prevent men’s and women’s marital quality and satisfaction from declining over the next six years (Cowan & Cowan, 2000). The same team of researchers have also shown that the marital quality and satisfaction of men and women whose first child is making the transition to primary school can be prevented from declining as a result of attending professionally-led groups for couples. The parenting style of couples attending also tends to be more responsive, appropriately structured, and less harsh than those not receiving such support. In addition, their children showed fewer academic, social and emotional behaviour problems over the next 10 years than those whose parents who did not receive this intervention (Cowan et al., 2005).
Furthermore, in a separate study, this team has found that compared to low-income parents randomly offered a one-off meeting, those offered professionally-led couples or fathers groups reported greater involvement of fathers in caring for their children and fewer problematic behaviours in the children. Compared to parents in the control group and the fathers-only groups, those from a couples group also reported reduced parenting stress and no decline in relationship quality and satisfaction over 18 months (Cowan et al., 2009).
Intervening early to prevent relationship difficulties from getting worse: what does the research tell us?
Numerous studies and evidence reviews over the years have made the case conclusively that couples therapy is effective in reducing existing relationship distress (e.g. (Baucom et al. (1998); Crowe (2000); Emmelkamp et al. (1984)). Research has also shown couples therapy to be more effective than CBT, antidepressant medication and psychotherapy (Bodermann et al. (2008); Leff et al., (2000)) in treating depression, and couples therapy is now a NICE-recommended treatment for depression (NICE, 2009) and one which is delivered through the Increasing Access to Psychological Therapies (IAPT) programme, with training provided by TCCR.
Evidence also points to the effectiveness of couples therapy that focuses on intimate partner violence for couples who engage in mild to moderate physical aggression but want to preserve the relationship and end the aggression (e.g. Stith et al, 2004; O’Learly et al. 1999). However, more recent studies (e.g. Simpson et al. 2008) have shown that couple therapy works on low-level aggression even without targeting it (rather than exacerbating it, as was previously thought).
TCCR interventions informed by evidence summarised in this briefing
TCCR provides a range of couples therapies which are informed by the research evidence summarised in this briefing; it also is participating in a number of projects which seek to combine this research knowledge and the charity’s clinical experience and apply it to environments other than the consulting room.
Brief couples therapy
TCCR’s Wellbeing Service for Couples is a new brief intervention couples therapy approach. The service offers up to four appointments with a therapist focusing on a particular issue for couples who are wishing to improve their relationship or looking for help addressing concerns that have recently arisen. TCCR outcomes data clearly shows both the need for a more time-limited intervention as well as the potential for brief therapy to significantly improve couple relationships and the mental health of individuals who receive it.
Working with separated couples to improve children’s outcomes
Parenting Together is a brief, evidence-based approach which works to develop and strengthen the parenting alliance. TCCR’s work with parents has brought to light the enormous demand that exists for a therapy that can work with a separated couple who cannot make collaborative arrangements to parent their children. Whilst there are many agencies who will offer help to the children of a conflicted couple, judges, clinical psychologists, social workers and other professionals are desperate to find help for the parental couple when mediation is not appropriate.
Based on mentalization-based therapy developed by Bateman and Fonagy (Bateman & Fonagy, 2006), the intervention is currently being evaluated through a randomised controlled trial. However, TCCR’s experience to date indicates that parents report the lessening of arguments with their co-parent and the growing ability of children to express their feelings appropriately rather than act them out in a negative and destructive manner. Consequently, they were able to help their child develop better coping strategies which were less disruptive to family life.
Community-based relationship counselling
A recent study in Greenwich achieved a statistically significant improvement in relationship satisfaction through the provision of free relationship counselling to local couples. Run as a partnership project between TCCR and a local MIND branch, the service – one element of which was the early identification of postnatal depression through the provision of postnatal support groups – was delivered by an in-house psychotherapist and a TCCR counsellor (Clulow and Donaghy, 2010).
Training frontline professionals to ‘think couple’
TCCR has a long track record of delivering training to frontline professionals such as health visitors and children’s centre managers to equip them to be better able to add a co-parenting dimension to their practice. This kind of early intervention approach informs and skills practitioners so that the children in the families with whom they work can benefit from a way of thinking which properly takes into account the enormous impact which the couple relationship has on children and families. Helping frontline professionals to factor adult relationship issues into their work is vital if problems are to be picked up early before corrosive conflict sets in.
Summary
- The economic cost to the country of relationship breakdown runs into the tens of billions and should prompt us to employ evidence-based interventions before relationships problems start, or before they have become intractable.
- Such intervention is crucial for the sake of the adults but also children, as prolonged marital conflict and relationship break-up tend to be associated with cognitive delay, school difficulties and antisocial or withdrawn behaviour in the early school years.
- Research indicates that interventions which focus on the inter-parental relationship have the potential to rectify the negative consequences of family conflict and breakdown on children and parents, and help prevent the intergenerational transmission of factors that lead to disrupted family relationships and family breakdown.
- Research evidence conclusively demonstrates that couples therapy is effective in reducing existing relationship distress, and is more effective than CBT, antidepressant medication and psychotherapy in treating depression.
- Couples therapy is only part of the answer however, and TCCR has developed a range of approaches and services in addition to the more traditional form of couples support. These include:
- a brief intervention service for couples (diagnostic and solution-focused)
- a brief, mentalization-based approach for separated couples who cannot make collaborative arrangements to parent their children of (up to 12 sessions);
- brief community-based relationship counselling services geared to the early identification of postnatal depression through the provision of postnatal support groups (up to 10 sessions);
- training packages for health visitors, children’s centre managers and other frontline professionals to help them recognise the centrality of adult relationship issues to their work and to help them develop the skills and understanding to strengthen and support couple relationships (with an accessible short guide to support their learning (Rhodes, 2012)).
References
Baucom, D.H., Shoham, V., Mueser, K.T., Daiuto, A.D. & Stickle, T.R. (1998) Empirically supported couple and family interventions for marital distress and adult mental health problems, Journal of Consulting and Clinical Psychology, 66, pp. 53± 58.
Bateman, A. & Fonagy P. (2006) Mentalization-based Treatment for Borderline Personality Disorder: A Practical Guide. OUP Oxford
Bodenmann, G., Plancherel, B., Beach, S.R.H., Widmer, K., Gabriel, B., et al. Effects of Coping-Oriented Couples Therapy on Depression: A Randomized Clinical Trial. Journal of Consulting and Clinical Psychology, Vol 76(6), Dec 2008. pp. 944-954
Brody, G.H. and Forehand, R. (1985). The efficacy of parent training with maritally distressed and nondistressed mothers. a multimethod assessment. Behaviour Research & Therapy 23(3): 291-296.
Clulow, C. (2008) Making the Link. Developing the Couple Dimension in Parenting Support. Unpublished Report. London: The Tavistock Centre for Couple Relationships)
Clulow, C., &Donaghy, M. (2010). Developing the couple perspective in parenting support: evaluation of a service initiative for vulnerable families. Journal of Family Therapy 32: 142–168
Cowan, C. P., & Cowan, P. A. (2000). When partners become parents : the big life change for couples. Mahwah, NJ: Lawrence Erlbaum Associates.
Cowan, C. P., & Cowan, P. A. (2005) 'Two central roles for couple relationships: breaking negative intergenerational patterns and enhancing children's adaptation', Sexual and Relationship Therapy, 20 3, 275-288
Cowan, P. A., Cowan, C. P., Ablow, J., Johnson, V. K., & Measelle, J. (2005). The family context of parenting in children's adaptation to elementary school. Mahwah, NJ: Lawrence Erlbaum Associates.
Cowan, P. A., Cowan, C. P., Pruett, M. K., Pruett, K. D., & Wong, J. (2009). Promoting fathers' engagement with children: Preventive interventions for low-income families. Journal of Marriage and the Family, 71, 663-679.
Crowe, M. & Ridley, J. (2000) Therapy with Couples: a Behavioural-Systems Approach to Marital and Sexual Problems, 2nd edition (Oxford, Blackwells).
Cummings, E. M., & Davies, P. T. (1994). Children and marital conflict: The impact of family dispute and resolution. New York: Gullford.
Dadds, M.R., Schwartz, S. and Sanders, M.R. (1987). Marital discord and child behavior problems in a nonclinic sample. Journal of Consulting & Clinical Psychology 55(3): 396-403
Fincham. F. D., Grych, J. H., & Osborne, L N. (1994). Does marital conflict cause child maladjustment? Directions and challenges for longitudinal research. Journal of FamilyPsychology,8, 128-140
Emmelkamp, P.M.G., Van der Helm, M. Macgillavry, D. & Van Zanten, B. (1984) Marital therapy with clinically distressed couples: a comparative evaluation of system± theoretic, contingency contracting and communication skill approaches, in: K. Hahlweg & N. Jacobson, (Eds) Marital Interaction: Analysis and Modification (New York, Guilford Press).
Hetherington, E. M., Cox, M. J., & Cox, R. (1982). Effects of divorce on parents and children. In M. E. Lamb (Ed.), Nontraditional families (pp. 233-288). Hillsdale. NJ: Lawrence Erlbaum Associates
Hirschberger, G., Srivastava, S., Marsh, P., Cowan, P. A., & Cowan, C. P. (2009). Married with children: Attachment, marital satisfaction, and divorce in the first fifteen years of parenthood. Personal Relationships, 16, 401-420.
Leff, J., Vearnals, S. and Brewin, C., et al. Randomised controlled trial of antidepressants versus couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs (2000). British Journal of Psychiatry, 177, 1123-130.
Markman, H. J., Stanley, S., M., & Blumberg, S. L. (2001). Fighting for your marriage: Positive steps toward preventing divorce and preserving a lasting love. New and Revised. New York: Wiley.
National Institute for Clinical Excellence (2009) NICE clinical guideline 90. Depression: the treatment and management of depression in adults (partial update of NICE clinical guideline 23)
O'Leary, K. D., Heyman, R. E., & Neidig, P. H. (1999). Treatment of wife abuse: A comparison of gender-specific and conjoint approaches. Behavior Therapy, 30, 475–505.
Parke, R.D. (1996). Fatherhood. Cambridge, MA: Harvard University Press.
Rhodes, H. (2012) A short guide to working with co-parents: why we don’t, why we should and how we could. TCCR
Schilling, E.A.; Baucom, D.H.; Burnett, C.K. et al. Altering the course of marriage: The effect of PREP communication skills acquisition on couples' risk of becoming maritally distressed. Journal of Family Psychology, Vol 17(1), Mar, 2003. pp. 41-53.
Shelton, K. H., & Harold, G. T. (2008). Interparental conflict, negative parenting, and children's adjustment: Bridging links between parents' depression and children's psychological distress. Journal of Family Psychology, 22(5), 712-724.
Simpson, Lorelei E., Atkins, David C., Gattis, Krista S., Christensen, Andrew. Low-level relationship aggression and couple therapy outcomes. Journal of Family Psychology, Vol 22(1), Feb 2008. pp. 102-111
Stith, S. M., Rosen, K. H., McCollum, E. E., & Thomsen, C. J. (2004). Treating intimate partner violence within intact couple relationships: Outcomes of multi-couple versus individual couple therapy. Journal of Marital and Family Therapy, 30, 305–318.
Wong, D. (2011) Counting the Cost of Family Failure. Relationships Foundation
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