Culturally Sensitive and Responsive Counseling Essay

Culturally Sensitive and Responsive Counseling Essay

Culturally Sensitive and Responsive Counseling
When you begin work with couples and families, you likely will conclude after only a few cases that all couples and families are different in at least a few ways. Members of these couples and families individually belong to many different population subgroups, with each group exerting cultural influence. Based on conflict resolution traditions or power distance index of a certain culture, for instance, you may need to modify the theoretical approach you take with a client with that background.Culturally Sensitive and Responsive Counseling Essay

BUY A PLAGIARISM-FREE PAPER HERE

Keep in mind that the classroom study of theory and intervention integration cannot provide a description of how to modify or tailor your theory to all the potential relational and cultural presentations you will see. It should, however, provide you with a solid foundation and a toolbox with which to work.Culturally Sensitive and Responsive Counseling Essay
For this paper, select a cultural consideration (related to race, ethnicity, religion, gender, sexual orientation, etc.) and think about how this consideration may impact the application of your theoretical orientation when working with couples and families. Then, reflect on how you might modify interventions in professional work in which this consideration is present.Culturally Sensitive and Responsive Counseling Essay
Write a description of the cultural consideration you selected. Then, explain two challenges of applying your theoretical orientation to address this cultural consideration when working with couples and families. Explain how you might modify evidence-based interventions to be more culturally sensitive and responsive. Justify your response using evidence-based articles.
Be sure to support your postings and responses with specific references to the resources.Culturally Sensitive and Responsive Counseling Essay

Evidence-based couple therapy: current status and
future directions
Douglas K. Snydera and W. Kim Halfordb
Several approaches to couple therapy produce large and clinically significant
reductions in relationship distress. However, 25 to 30 per cent of
couples show no benefit from couple therapy. Adapted forms of couple
therapy can effectively treat some psychological disorders and enhance
adjustment to physical health problems. The specific mechanisms underlying
the effects of couple therapy on relationship distress are unclear.
Current attempts to enhance the efficacy of couple therapy have three
foci: (1) identifying the common factors that might account for change
across approaches, (2) integrating different approaches to address specific
needs of particular partners and couples and (3) monitoring the progress
of couples during therapy and using that information to modify couple
therapy as required. Given the high prevalence of relationship distress
and its association with other problems, clinicians should routinely screen
for relationship distress in adults. Couple therapy needs to be considered
as the focus, or part of the focus, of treatment for a wide range of adult
emotional and behavioural problems.Culturally Sensitive and Responsive Counseling Essay
Practitioner points
• Research supports the efficacy of a variety of treatments for couple
relationship distress.
• Three promising attempts to enhance the efficacy of couple therapy
are:
– identifying universal processes in different approaches to couple
therapy;
– integrating approaches and tailoring use of specific interventions;
and
– monitoring couple progress to identify when to modify the
therapy approach.
• Adapted forms of couple therapy can treat some individual psychological
disorders and enhance adjustment to physical health
problems.
a Professor and Director of Clinical Psychology Training, Department of Psychology,
MS 4235, Texas A&M University, College Station, TX 77843–4235. E-mail: d-snyder@
tamu.edu.
b Professor of Clinical Psychology, University of Queensland, Brisbane, Australia.
bs_bs_banner
Journal of Family Therapy (2012) 34: 229–249
doi: 10.1111/j.1467-6427.2012.00599.x
© 2012 The Authors
Journal of Family Therapy©2012 The Association for Family Therapy and Systemic Practice. Published by
Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA
02148, USA.
Keywords: couple therapy; marital therapy; integrative therapy; evidence-based
treatment; common factors; client feedback.
An intimate relationship with one’s partner has profound effects on
psychological and physical well-being. When a couple relationship
functions well it can provide the joy of sharing life’s journey and be a
source of great support to manage life’s stresses. When the relationship
is distressed and conflicted, it can be a source of great loneliness,
angst and suffering. This article reviews the evidence on how effectively
current approaches to couple therapy both relieve relationship
distress and promote better individual psychological and physical
health. We consider the evidence for how couple therapy achieves its
effects and describe current attempts to further enhance couple
therapy efficacy. We conclude that screening for relationship distress
should be routinely conducted in clinical practice and offer suggestions
for measures to conduct such screening.Culturally Sensitive and Responsive Counseling Essay
The prevalence and impact of couple relationship distress
More than 85 per cent of people marry by the age of 50 across almost
all countries, cultures and religions (United Nations Economic and
Social Affairs Population Division, 2003). Rates of marriage have
declined in many developed countries since the 1970s and, in some
countries (for example, France and Norway), estimated rates of
people marrying by the age of 50 have fallen to 65 per cent or lower
(Organization of Economic Cooperation and Development [OECD]
2011). However, among those who choose not to marry in western
countries most people enter marriage-like cohabiting couple relationships
(Weston et al., 2012). The desire to be in a committed partner
relationship is so pervasive that some researchers have argued that it
reflects an evolutionary imperative (Buss, 2003).
Couple relationship distress and separation are prevalent in all
developed countries. The most salient reliable indicator of couple
distress is the divorce rate. Across almost all OECD nation-states
divorce rates have increased from the mid-1970s to late-1970s to the
period 2000–2005. The USA has the highest divorce rate, with
approximately 50 per cent of married couples divorcing (Kreider and
Fields, 2002). Whereas the divorce rate is not as high in other developed
western countries, Canada, the UK, Germany and Australia still
have high divorce rates, ranging from about 30 to 40 per cent of all
marriages (OECD, 2011).
230 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
The divorce rates understate rates of relationship dissolution
because in most western countries couple cohabitation is now a
common form of committed couple relationship. For example, of all
couple households in the USA 8 per cent are cohabiting couples
(United States Census Bureau, 2009), in Australia 16 per cent are
cohabiting (Australian Bureau of Statistics, 2008) and in Canada 16
per cent are cohabiting (Statistics Canada, 2010). It is well established
that cohabiting couples are more likely to experience relationship
distress and separate than married couples (Hayes et al., 2010). In a
representative sample of households in Australia, 40 per cent of
cohabiting couples separated across a 5-year period (Hayes et al.,
2010). Thus, high rates of relationship distress and dissolution are
pervasive across developed countries for married couples and are at
even higher rates for cohabiting couples.Culturally Sensitive and Responsive Counseling Essay
In addition to separation, many couple relationships experience
periods of significant turmoil that place the partners at risk for the
development of a psychological disorder (such as depression or
anxiety). In a US national survey the most frequently cited causes of
acute emotional distress were couple relationship problems (Swindle
et al., 2000). Representative surveys of the US population show a
moderate to strong association between relationship distress and
common psychological disorders in the spouses – notably depression,
anxiety disorders and drug and alcohol abuse (Whisman, 2007). Maritally
distressed individuals are overrepresented among those seeking
mental health services, regardless of whether or not they report
marital distress as their primary complaint (Lin et al., 1996). Moreover,
there seems to be a specific effect of couple relationship distress,
as its association with individual psychological disorders is evident
even after controlling for distress in other close relationships
(Whisman et al., 2000). Relationship distress also is associated with
poor work performance (Forthofer et al., 1996) and two-thirds of
clients seeking assistance with workplace-related concerns from
employee assistance programmes cite family problems as considerable
or severe (Shumway et al., 2004).
Couple relationship distress – particularly conflict – is also associated
with poor physical health. The partners in distressed relationships
do not live as long, reporting more health problems (Waite and
Gallagher, 2000) and using health services substantially more (about
25 per cent higher costs per person: Prigerson et al., 2000) than
people in satisfying relationships. Relationship conflict has direct
adverse effects on cardiovascular, endocrine, immune, neurosensory
Evidence-based couple therapy 231
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
and other physiological systems that, in turn, contribute to physical
health problems (Kiecolt-Glaser and Newton, 2001).
The negative effects of couple relationship distress are not confined
to the adult partners. Meta-analytic studies show a reliable association
between couple relationship distress and negative parent–child interactions,
with average effect sizes ranging from d = 0.46 to 0.62 (Erel
and Burman, 1995; Krishnakumar and Buehler, 2000). Parents in
distressed couple relationships are less likely to use positive parenting
practices such as acceptance, support, and consistent and appropriate
discipline; they are also more likely to use harsh, inconsistent and
abusive parenting than parents in satisfied relationships (Erel and
Burman, 1995; Krishnakumar and Buehler, 2000). Children raised by
their own parents, when those parents share a mutually satisfying
relationship, are advantaged on many dimensions, such as psychological
adjustment and school attainment (Amato, 2010).
In summary, couple distress and separation have a high prevalence
in developed countries. Relationship distress is strongly linked to
psychological and physical health problems in the adult partners and
their offspring and is among the most frequent primary or secondary
concerns reported by individuals seeking assistance from mental
health professionals.
The efficacy of couple therapy in treating relationship distress
Previous reviews show that several approaches to couple therapy
produce statistically and clinically significant reductions in relationship
distress (Lebow et al., 2012; Snyder et al., 2006). In a review of
previously published meta-analytic studies, Shadish and Baldwin
(2003) reported a large mean effect size of d = 0.84 for couple therapy,
which they noted was similar to the effect sizes of the most effective
psychological and pharmacological treatments available for individual
psychological disorders. This mean effect size for couple therapy
indicates that the average couple receiving therapy was less distressed
than 80 per cent of couples receiving no therapy. Shadish and
Baldwin (2003) found little evidence of differential effectiveness across
different theoretical orientations to couple therapy, particularly once
other covariates (such as reactivity of measures) were controlled.
Moreover, data from follow up at 6 months or longer showed that
positive couple therapy effects were generally maintained, although
there was evidence that treatment effects gradually attenuated across
time.
232 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Research subsequent to that of Shadish and Baldwin (2003) complements
and extends their conclusions. A meta-analysis of thirty
randomized experiments of behavioural couple therapy (BCT)
(Shadish and Baldwin, 2005), consisting of communication training,
behaviour exchange, cognitive restructuring and emotional expressiveness
training, found a mean effect size of d = 0.59 relative to no
treatment. This indicates that the average couple receiving BCT was
better off than 72 per cent of untreated couples.Culturally Sensitive and Responsive Counseling Essay
Other than BCT, the only other approach to couple therapy
evaluated in multiple trials is emotion-focused couple therapy
(EFCT), which combines an experiential, intrapsychic focus on inner
emotional experience with an emphasis on cyclical, self-reinforcing
interactions (Johnson et al., 1999). In four randomized trials EFCT
was superior to a waiting list control group in reducing relationship
distress, with a weighted mean effect size of d = 1.31 (Johnson,
2002). The mean effect size is notably larger than reported for other
therapies. However, couples in EFCT studies tend to be less distressed
than couples in most other studies and the larger effect size
seems to reflect the greater responsiveness of moderately distressed
couples to therapy, rather than a finding that EFCT is necessarily
a more effective form of couple therapy (Shadish and Baldwin,
2003).
In addition to BCT and EFCT, which have been evaluated in
multiple clinical trials, three other couple therapies that have been
evaluated in just one trial each. First, Snyder and Wills (1989) compared
an insight-oriented couple therapy (IOCT) with BCT in a
controlled clinical trial involving 79 distressed couples. The IOCT
emphasized the interpretation and resolution of conflictual emotional
processes related to developmental issues, collusive interactions and
maladaptive relationship patterns. After approximately twenty sessions,
couples in both treatments showed similar, statistically and clinically
significant gains in relationship satisfaction compared to a
waiting list control group. The effect sizes for BCT and IOCT were
d = 1.01 and d = 0.96, respectively. However, 4 years after therapy 38
per cent of the BCT couples had experienced divorce in contrast to
only 3 per cent of couples treated receiving IOCT (Snyder et al.,
1991).
Secondly, Goldman and Greenberg (1992) compared integrated
systemic couple therapy (ISCT) and EFCT to each other and a waiting
list control group in a randomized clinical trial of forty-two
couples. ISCT seeks to disrupt repetitive, self-perpetuating negative
Evidence-based couple therapy 233
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
interactional cycles by changing the meaning attributed to these
cycles; changes in meaning were promoted by restructuring interactions
and reframing the problems using positive connotations followed
by prescribing the symptom, encouraging the couple to go slow,
and prescribing a relapse. At the end of ten 1-hour weekly sessions,
ISCT and EFCT were both superior to the control condition and were
equally effective in alleviating relationship distress. ISCT couples
showed greater maintenance of gains than EFCT couples at a 4-
month follow up.Culturally Sensitive and Responsive Counseling Essay
Finally, there was an evaluation of an integrative behavioural
approach to couple therapy (IBCT) (Jacobson and Christensen,
1996), which combines traditional BCT techniques for promoting
change (specifically, communication and behaviour-exchange skills
training) with strategies aimed at fostering emotional acceptance.
Interventions aimed at increasing acceptance include promoting tolerance
and encouraging partners to appreciate differences and to use
these to enhance their relationship. In the largest randomized clinical
trial of couple therapy ever conducted Christensen et al. (2004) compared
IBCT with traditional BCT by assigning 134 distressed couples
to the two conditions. Both treatments produced a similar level of
clinically significant improvement at the end of the treatment (71 per
cent of IBCT couples and 59 per cent of BCT couples were reliably
improved on relationship satisfaction) and, despite some attenuation,
showed a continuing benefit at a 5-year follow up, with 50 per cent of
IBCT couples and 46 per cent of BCT couples continuing to show
clinically significant improvement from the time before therapy
(Christensen et al., 2010).
In summary, five different specific approaches to couple therapy
have at least one demonstration of their effectiveness in reducing
relationship distress in a randomized controlled trial. Of these five
approaches two – BCT and EFCT – have been demonstrated to be
effective in multiple randomized controlled trials. There is no replicated
evidence of differential efficacy between approaches to
couple therapy. Across all evaluated approaches to couple therapy
there is a noteworthy minority of 25 to 30 per cent of couples who
show no improvement from these therapies. In addition, all couple
therapies show some attenuation of gains at follow up. Specifically,
assessment at 2 years or longer after termination indicates a significant
deterioration in up to 45 per cent of successfully treated
couples (Christensen et al., 2004; Jacobson et al., 1987; Snyder et al.,
1991).
234 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
The efficacy of couple therapy in treating individual disorders
The strong association of couple relationship distress with individual
psychological and physical health provides a rationale for applying
couple therapy to treat those individual issues. Moreover, even when
couple relationship distress is not present, couple-based interventions
can help partners collaborate in the treatment and management of
an individual psychological disorder in one spouse (Mueser and
Brunette, 2003) or to manage health crises (Halford et al., 2010).
Baucom et al. (2012a) review couple-based interventions for psychological
disorders, hence we do not summarize the evidence
regarding those interventions here. However, it is important to differentiate
couple therapy that addresses a psychological disorder in
one of the partners from couple therapy for relationship distress.
Couple interventions for individual psychological disorders sometimes
do focus on treatment of relationship distress, based on the
premise that relationship distress is a major stressor that contributes
to the development or maintenance of an individual psychological
disorder. However, more often couple therapy is adapted to address
the specific challenges of a particular disorder (Baucom et al., 2012a).
There are two forms of adaptations of couple therapy for treatment
of individual disorders: disorder-specific couple interventions and
partner-assisted treatment. Disorder-specific interventions focus on
changing couple interactions that influence either the individual disorder
or important components of its treatment. For example, BCT to
address alcohol abuse specifically targets having the couple modify
alcohol availability in their home, increasing couple and family activities
not associated with drinking, spouse support of the drinking
partner’s attempts to modify his or her drinking, and reducing conflict
about the drinking that ironically often precipitates drinking
(O’Farrell and Fals-Stewart, 2006). In partner-assisted interventions
the spouse serves as a support and coach in assisting the other partner
with individual problems. For example, Baucom et al. (2012a) provide
excellent clinical descriptions of couple-based interventions for
obsessive-compulsive disorder in which the partner assists in the
conduct of exposure and response prevention treatment.Culturally Sensitive and Responsive Counseling Essay
There is now a substantial body of evidence for the efficacy of
couple-based intervention in enhancing the ability to cope with
serious medical disorders such as cancer, heart disease and diabetes
(Baucom et al., 2012b; Martire et al., 2010). Baucom et al. (2012b)
describe how serious medical disorders frequently stress couple
Evidence-based couple therapy 235
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
relationships as the partners worry about treatment and prognosis,
their roles and responsibilities change, the disorder and treatment
side effects limit what the couple can do, and costs of treatment strain
the couple’s finances. To help couples manage these stresses couplebased
health interventions address four areas not included in couple
therapy for relationship distress: (1) psychoeducation about the
medical disorder and its treatment, (2) sharing thoughts and feelings
about the disorder, (3) making treatment-related decisions, and (4)
implementing relationship changes that promote health.
To illustrate the typical adaptations of couple therapy to address
particular medical disorders we describe a modular couple-based
intervention to support partners being treated for early stage localized
cancer (Halford et al., 2010). In this intervention the patient and
partner are educated about the common psychological reactions to
cancer diagnosis and are encouraged to discuss together their own
reactions and explore ways to offer mutual support. The couples are
educated about options for treatment and side effects and are encouraged
to discuss together what treatment will be pursued. The most
common cancers (breast cancer in women, prostate cancer in men)
affect areas of the body associated with body image and sexuality, and
so the couple is advised on how to manage effects on sexuality and
encouraged to discuss the relationship adaptations necessary. Partners
are taught to help each other identify unhelpful thoughts such as
preoccupation about cancer reoccurrence or sense of loss due to
compromised sexual functioning, and to challenge these thoughts
and develop a shared adaptive way of coping with the cancer-related
challenges. Finally, the experience of cancer diagnosis and treatment
often prompts an existential re-evaluation of life priorities and
couples are encouraged to discuss their thoughts and feelings as they
reflect on the cancer experience.Culturally Sensitive and Responsive Counseling Essay
Martire et al. (2010) conducted a meta-analysis of twenty-five
studies of couple-based interventions for cancer, arthritis, cardiovascular
disease, chronic pain, human immunodeficiency virus and Type
2 diabetes. Couple interventions had significant effects on patients’
depressive symptoms, marital functioning and pain, and were more
efficacious than either patient psychosocial interventions or care as
usual. The authors concluded that such couple-based treatments are
particularly helpful when they target a partner’s influence on patients’
health-related behaviour and seem to be of particular value to couples
with high, illness-related conflict, low spouse support or low overall
relationship satisfaction.
236 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Mediators of couple therapy effects
Each of the empirically supported approaches to couple therapy
posits particular mechanisms of change. These approaches can usefully
be conceptualized as varying along a continuum anchored by a
focus on behaviour change (behaviour exchange and skill-building
interventions) at one end to interventions emphasizing intrapersonal
dynamics and vulnerabilities at the other. Specifically, a key focus of
traditional BCT is on increasing specific positive behaviour and
decreasing negative behaviour (Jacobson, 1991). Cognitive behavioural
couple therapy adds a focus on changing cognitions, such as
attributions and expectancies (Epstein and Baucom, 2002). Integrative
behavioural couple therapy (IBCT) adds a focus on promoting
tolerance and acceptance, with acceptance referring to a positive
change in the way someone experiences what was previously viewed
as negative behaviour by the partner (Christensen et al., 1995). EFCT
focuses on decreasing hostile emotions and increasing expression of
emotional vulnerability and attachment needs (Greenberg and
Johnson, 1988). Like EFCT, IOCT focuses on the individual vulnerabilities
partners bring to the couple relationship and providing
insight into how developmental experiences shape such vulnerabilities
and influence the couple relationship (Snyder et al., 1991).
Halford and Snyder (2012) reviewed the evidence on mediators of
couple therapy and drew four important conclusions. Firstly,
evidence-based couple therapies do modify their hypothesized mediators
of therapeutic change. For example, BCT does produce increases
in positive behaviour exchange and enhanced communication in
distressed couples (Halford et al., 1993; Sayers et al., 1991). Similarly,
IBCT produces increases in acceptance (Doss et al., 2005) and EFCT
makes the predicted shifts from hostile to affiliative in-session behaviour
and increased disclosure of attachment needs (Greenberg et al.,
1993; Makinen and Johnson, 2006).Culturally Sensitive and Responsive Counseling Essay
Secondly, although evidence-based couple therapies do impact on
the relevant hypothesized mediators of change, there is not a simple
relation between the type of therapy provided and the change in
mediators. BCT with and without cognitive change strategies produce
similar reductions in negative cognition and affect (Halford et al.,
1993). BCT also enhances couple acceptance, though not to the same
extent as IBCT (Doss et al., 2005). Conversely, IBCT produces
changes in the frequency of reported behaviour, even though the
focus is more on promoting the acceptance of such behaviour rather
Evidence-based couple therapy 237
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
than on behaviour change per se (Doss et al., 2005). The labels used to
describe types of couple therapy might be potentially misleading by
implying that specific interventions produce specific effects through
specific mediating processes.
Third, there is not a straightforward relation between observed
changes in hypothesized mediators and changes in couple relationship
distress. Two studies found no association between changes in
couple communication after BCT and changes in relationship distress
(Halford et al., 1993; Iverson and Baucom, 1990), although a third
study found a statistically reliable (albeit of modest magnitude) association
between improvements in communication and relationship
satisfaction across the course of BCT (Sayers et al., 1991). Similarly,
changes in cognitions do not predict couples’ gains in satisfaction
following cognitive-focused BCT (Emmelkamp et al., 1988; Halford
et al., 1993). In the case of EFCT, reductions in hostile expressions and
increases in affiliative expressions of emotion reliably predict subsequent
in-session disclosure of vulnerability and attachment needs
(Greenberg et al., 1993). However, the association of these in-session
changes with improvements in couple relationship satisfaction after
therapy has not been directly tested.
Finally, the mediators of couple therapy change might vary across
the course of therapy. Doss et al. (2005) examined mechanisms of
change in a clinical trial comparing BCT with IBCT. They reported
that change in the specific targeted behaviour was a powerful predictor
of relationship satisfaction change in the early therapy sessions,
whereas emotional acceptance was more strongly related to changes
in relationship satisfaction in the sessions in the second half of therapy.
Attempts to enhance couple therapy effects on
relationship distress
Traditionally, attempts to enhance the effects of couple therapy have
focused on developing new approaches to therapy, based on the
assumption that a new approach might be more generally successful.
For example, from the mid-1980s to the early-1990s there were
several attempts to enhance BCT by adding cognitive therapy elements
(Baucom and Lester, 1986; Baucom et al., 1990; Halford et al.,
1993). More recently, Christensen et al. (2004) developed integrative
behavioural couple therapy, which added a number of interventions
focused on promoting acceptance as well as change to traditional BCT.
However, despite nearly thirty years of refining existing approaches
238 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
and developing new approaches to couple therapy no particular
therapeutic approach has been shown in a replication to be more
effective than another (Snyder et al., 2006).Culturally Sensitive and Responsive Counseling Essay
In summary, attempts to enhance efficacy by developing different
approaches to therapy have not been particularly successful. Moreover,
as noted earlier, studies of mediation have failed to show a
specific relation between particular forms of couple therapy, changes
in specified mediators and reduction in couple relationship distress.
There are three promising new lines of research seeking to enhance
couple therapy. Firstly, some researchers (Benson et al., 2012; Sprenkle
et al., 2009) seek to clarify the role of universal processes common
across couple therapy approaches and to refine the use of those
shared processes. Secondly, some authors advocate systematic integration
of different couple therapy approaches, drawing upon the
strengths of each approach and matching specific interventions to the
needs of particular partners and couples. Thirdly, some researchers
advocate systematic monitoring of the progress of each couple across
the course of therapy and using feedback on progress to guide the
therapist to modify the couple therapy approach being taken when
required (Halford et al., 2012).
Universal processes in couple therapies
Adopting the universal processes strategy, Sprenkle et al. argued that
common mechanisms of change cut across the diverse couple therapies
and account for the absence of significant differences in their
overall effectiveness (Sprenkle et al., 2009). Many of the common
factors they identify are common to all psychotherapy, not just couple
therapy (for example, an empathic, positive therapeutic alliance; congruence
between the therapist’s and the client’s therapy goals and
expectancy effects). Some of these universal processes might develop
differently in couple therapy relative to individual therapy. For
example, individual partners in couple therapy rate the therapeutic
alliance with the couple somewhat differently from the therapeutic
alliance with them as individuals (Friedlander et al., 2011). Nevertheless,
a recent meta-analysis found that, consistent with well-established
findings in individual therapy, a positive therapeutic alliance is associated
with positive couple therapy outcome (Friedlander et al., 2011).
The demonstrated association between alliance and couple therapy
outcome does not demonstrate that a positive alliance causes better
outcome. In a time series analysis, Glebova et al. (2011) found that as
Evidence-based couple therapy 239
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
the couple relationship satisfaction improved across the course of
couple therapy, the rating of the alliance with the therapist improved,
and vice versa. In other words, it is possible that the therapeutic
alliance is influenced as much by the progress of therapy as the
alliance influences therapy progress.Culturally Sensitive and Responsive Counseling Essay
There are a number of universal processes that are not specific to
any particular approach to couple therapy but do differentiate couple
from individual therapy. Benson et al. (2012) suggested that five processes
are common to all effective couple therapies. Firstly, therapy
attempts to increase the extent to which both partners’ view of the
relationship is objective, dyadic and contextualized, rather than onesided
and blaming. Secondly, therapists decrease the extent to which
couples are engaging in dysfunctional interactional patterns (driven
by dysregulated emotion). Thirdly, therapists promote the sharing
between partners of emotions that have previously been avoided or
hidden, particularly emotions that express vulnerability. Fourthly,
therapists take steps to improve couples’ communication patterns.
Fifthly, therapists increase the salience of areas of strength and
instances of resilience in couples’ relationships.
To date there has been little research documenting specific treatment
effects attributable to proposed universal factors nor systematic
efforts in designing couple treatment approaches intended to maximize
the therapeutic impact of common factors (Sexton et al., 2004).
Nevertheless, distilling the crucial elements in couple therapy might
permit a more efficient focus of couple therapy on those effective
universal processes.
Integrative approaches
An alternative to the universal processes approach involves efforts
to incorporate active, specific treatment components from diverse
approaches into multi-component interventions in a systematic
manner. Such approaches have variously been described as integrative
(Gurman, 2002) or pluralistic (Abbott and Snyder, 2012) and are
distinguished from eclecticism by their systematic selection or synthesis
in a conceptually coherent model. Gurman (2002) described a
depth-behavioural integrative approach to couple therapy that
emphasizes the critical interrelation of intrapsychic and interpersonal
factors in couples’ interactions and defines the goal of couple
therapy as the loosening and broadening of each partner’s implicit
matrix of assumptions and expectations, and their requirements of
240 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
intimate interpersonal contact. This is accomplished through the
interpretation, cognitive restructuring and creation of therapeutic
tasks to promote individual spouses’ exposure to those aspects of
themselves and their partner which are blocked from awareness.
Snyder (1999) proposed a hierarchical approach to couple therapy
incorporating structural, behavioural and cognitive techniques early
on in the therapeutic sequence and drawing on insight-oriented
techniques termed affective reconstruction later in treatment,
primarily if relationship problems prove resistant to the earlier interventions.
In affective reconstruction, previous relationships, their
affective components and strategies for emotional gratification and
anxiety containment are reconstructed with a focus on identifying
for each partner recurring maladaptive patterns in their interpersonal
conflicts and coping styles across relationships. In addition, the
interventions examine ways in which previous coping strategies vital
to prior relationships represent distortions or inappropriate solutions
for emotional intimacy and satisfaction in the current relationship.
Neither the integrative depth-behavioural approach proposed
by Gurman nor the pluralistic approach advocated by Snyder has
been subjected to empirical evaluation, although both approaches
build on couple treatment approaches previously supported in randomized
clinical trials.Culturally Sensitive and Responsive Counseling Essay
Monitoring and feedback of couple therapy progress
As with couple therapy, in individual therapy a number of empirically
based approaches are effective but a substantial minority of clients do
not benefit from therapy (Lambert, 2010). It has been well established
that therapists’ clinical judgement is poor at detecting the lack of client
progress across the course of individual therapy (for example,
Whipple et al., 2003), whereas the systematic weekly monitoring of
progress can reliably detect situations in which clients do not benefit
from therapy (Lambert, 2010). Systematic monitoring involves clients
completing a brief self-report measure of psychological adjustment
before each therapy session. Scores across the course of therapy are
plotted and compared with a trajectory of expected change consistent
with making therapy progress. Feedback identifies the client as being
‘on track’ or ‘off track’ to benefit from therapy. The feedback that a
client is off track includes the suggestion that the therapist and client
review the way in which the therapy is being conducted. In a series of
randomized controlled trials, providing such feedback significantly
Evidence-based couple therapy 241
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
reduced patients’ dropping out from therapy and enhanced the
therapy outcome compared to treatment-as-usual, with benefits being
most evident for off-track clients (Lambert, 2010). A meta-analysis of
these studies suggests that the impact of feedback is quite dramatic,
cutting deterioration rates from 20 per cent of clients in treatmentas-
usual to only 5.5 per cent, while more than doubling the number of
off-track clients who reliably improve or recover (Shimokawa et al.,
2010).

BUY A PLAGIARISM-FREE PAPER HERE

Monitoring and feedback of progress seems likely to enhance the
outcome of couple therapy. There is evidence that more gains occur
in the early sessions of couple therapy than later in therapy (Behrens
et al., 1990; Doss et al., 2005) and that lack of progress by midtherapy
predicts a low probability of benefiting from the full course
of couple therapy (Halford et al., 2012). If a lack of change is
detected then this can cue corrective action to be taken in the latter
parts of the course of therapy. Two randomized controlled trials of
progress feedback in couple therapy found it enhanced individual
partners’ psychological adjustment relative to treatment-as-usual
(Anker et al., 2009; Reese et al., 2010). However, both these studies
had one major limitation. Neither monitored the couple relationship,
which is the major focus of couple therapy, across the course of
therapy, but instead monitored progress on individual partner psychological
adjustment.Culturally Sensitive and Responsive Counseling Essay
There are a number of plausible mediators by which progress
feedback might enhance couple therapy outcome. It is possible that
feedback reflecting a lack of progress might prompt the therapist or
client to redouble their efforts in therapy, though not necessarily to
change their approach. Alternatively, progress feedback might influence
common factors in therapy. For example, there is extensive
research that a weak alliance predicts poor individual therapy
outcome (Lambert, 2010) and couple therapy outcome (Friedlander
et al., 2011). Feedback might prompt the therapist to take steps to
enhance a weak alliance. A third possibility is that feedback could
prompt a change in the specific components of treatment. As suggested
previously, combining different evidence-based treatment
approaches might enhance the therapy outcome, and feedback on
the lack of therapy progress might prompt the therapist to change
the treatment to better match client needs. Research is needed to
evaluate whether ongoing feedback to therapists on the impact of
treatment on relationship distress can enhance the final therapy
outcome.
242 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Screening and evaluating couple relationships
We have argued that there is a high prevalence of couple relationship
distress and that relationship distress commonly co-occurs with a
psychological disorder in an individual partner. We also have suggested
that couple therapy has utility in addressing relationship distress
and that adapted forms of couple intervention can assist in the
treatment of an individual psychological disorder or help couples
cope with major health problems. Consequently, it is important for
clinicians to screen for relationship distress and assess the couple
relationship to tailor treatment to specific partner and relationship
characteristics. This requires assessment strategies with evidence of
sound psychometric underpinnings as well as demonstrated relevance
to treatment planning and evaluation.
Comprehensive reviews of evidence-based interview, observational
and self-report assessment methods for use in couple-based interventions
have been provided elsewhere (for example, Snyder et al., 2008).
We summarize here: (1) brief screening measures for identifying relationship
distress, (2) a multidimensional measure for identifying
common sources of relationship difficulties, and (3) techniques and
strategies for monitoring therapeutic progress.
For abbreviated screening measures of intimate relationship distress
we advocate the Marital Satisfaction Inventory 10-item screening
scale (MSI-B) (Whisman et al., 2009) derived from the MSI-R (Snyder,
1997) and from taxometric analyses reliably distinguishing distressed
from non-distressed couples (Whisman et al., 2008). Using a cut-off
score of > 4 as an index of couple distress, the MSI-B has a sensitivity
index of approximately .87 and a specificity index of .84. An alternative
screening measure is the Kansas marital satisfaction scale
(Schumm et al., 1986) composed of three Likert items assessing satisfaction
with marriage as an institution, the marital relationship and
the character of one’s spouse. A third option is a set of three couple
satisfaction index (CSI) scales constructed using item response theory
and comprising thirty-two, sixteen and four items each (Funk and
Rogge, 2007). In general, abbreviated scales of global relationship
satisfaction are adequate as initial screening measures in primary care
or general psychiatric settings, but due to their brevity lack the ability
to distinguish reliably among finer gradations of relationship distress
in partners presenting for couple therapy.Culturally Sensitive and Responsive Counseling Essay
Well-constructed multidimensional measures of couples’ interactions
have the potential to discriminate among various sources of
Evidence-based couple therapy 243
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
relationship strength and conflict. Widely used in both clinical and
research settings is the revised MSI (MSI-R; Snyder, 1997), a 150-item
inventory designed to identify both the nature and intensity of relationship
distress in distinct areas of interaction. The MSI-R includes
two validity scales, one global scale and ten specific scales assessing
relationship satisfaction in such areas as affective and problem-solving
communication, aggression, leisure time together, finances, the sexual
relationship, role orientation, family of origin and interactions
regarding children. More than 20 years of research have supported
the reliability and construct validity of the MSI-R scales (Snyder et al.,
2004). A computerized interpretive report for the MSI-R draws on
actuarial validity data to provide descriptive comparisons across different
domains both within and between partners.
A second option is the relationship evaluation (RELATE) (Busby
et al., 2001), a 271-item relationship assessment that can be accessed
online (Relate Institute, 2012). RELATE measures individual, familial,
cultural and couple contexts, as well as factors that predict relationship
outcome. Scales in RELATE have a test-retest reliability and
internal consistency of .70 to .90 (Busby et al., 2001). Similar to the
MSI-R, the RELATE system provides a computer-generated downloadable
report of couple relationships’ strengths and challenges.
Currently there is no measure of relationship functioning with
demonstrated utility for monitoring therapy progress. However, the
CSI-4 (Funk and Rogge, 2007) appears to be a promising candidate in
this regard. In ongoing work one of the authors of this article (WKH)
has developed a couple therapy feedback system based on the CSI-4,
incorporating data from in-session administrations of this measure
via a computer tablet. The impact of this approach to monitoring
therapy progress on subsequent treatment outcome is currently being
evaluated.
Conclusions
Research over the past 30 years has affirmed that various approaches
to couple therapy produce large and clinically significant reductions
in relationship distress. Moreover, adapted forms of couple therapy
can effectively treat some psychological disorders and enhance adjustment
to physical health problems. Future directions in research are
likely to involve efforts to identify therapeutic mechanisms of change
and attempts to enhance the efficacy of couple-based interventions
by developing integrated approaches, as well as by monitoring the
244 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
progress of couples during therapy to modify the selection, sequencing
or pacing of specific interventions. Given the high prevalence of
relationship distress and its association with other problems, clinicians
should routinely screen for relationship distress in adults.
Couple therapy needs to be considered as the focus, or part of the
focus, of treatment for a wide range of adult emotional and behavioural
problems.Culturally Sensitive and Responsive Counseling Essay
References
Abbott, B. V. and Snyder, D. K. (2012) Integrative approaches to couple therapy:
a clinical case illustration. Journal of Family Therapy, 34: 306–320.
Amato, P. R. (2010) Research on divorce: continuing trends and new developments.
Journal of Marriage and the Family, 72: 650–666.
Anker, M. G., Duncan, B. L. and Sparks, J. A. (2009) Using client feedback to
improve couple therapy outcomes: a randomized clinical trial in a naturalistic
setting. Journal of Consulting and Clinical Psychology, 77: 693–704.
Australian Bureau of Statistics (2008) Australian Social Trends 2007. Canberra:
Australian Government.
Baucom, D. H. and Lester, G.W. (1986) The usefulness of cognitive restructuring
as an adjunct to behavioral marital therapy. Behavior Therapy, 17: 385–403.
Baucom, D. H., Sayers, S. L. and Sher, T. G. (1990) Supplementing behavioral
marital therapy with cognitive restructuring and emotional expressiveness
training: an outcome investigation. Journal of Consulting and Clinical Psychology,
58: 636–645.
Baucom, D. H., Whisman, M. A. and Paprocki, C. (2012a) Couple-based interventions
for psychopathology. Journal of Family Therapy, 34: 250–270.
Baucom, D. H., Porter, L. S., Kirby, J. S. and Hudepohl, J. (2012b) Couple-based
interventions for medical problems. Behavior Therapy, 43: 61–76.
Behrens, B. C., Sanders, M. R. and Halford, W. K. (1990) Behavioral marital
therapy: an evaluation of treatment effects across high and low risk settings.
Behavior Therapy, 21, 423–433.
Benson, L. A., McGinn, M. M. and Christensen, A. (2012) Common principles of
couple therapy. Behavior Therapy: 43: 25–35.
Busby, D. M., Holman, T. B. and Taniguchi, N. (2001) RELATE: Relationship
evaluation of the individual, family, cultural and couple contexts. Family Relations,
50: 308–317.
Buss, D. (2003) The Evolution of Desire: Strategies of Human Mating (2nd edn). New
York: Basic Books.
Christensen, A., Jacobson, N. S. and Babcock, J. C. (1995) Integrative behavioral
couple therapy. In N. S. Jacobson and A. S. Gurman (eds) Clinical Handbook of
Couple Therapy (pp. 31–64). New York: Guilford.
Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Baucom, D. H. et al. (2004)
Traditional versus integrative behavioral couple therapy for significantly and
chronically distressed married couples. Journal of Consulting and Clinical Psychology,
72: 176–191.
Evidence-based couple therapy 245
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Christensen, A., Atkins, D. C., Baucom, B. and Yi, J. (2010) Marital status and
satisfaction five years following a randomized clinical trial comparing traditional
versus integrative behavioral couple therapy. Journal of Consulting and
Clinical Psychology, 78: 225–235.
Doss, B. D., Thum, Y. M., Sevier, M., Atkins, D. C. and Christensen, A. (2005)
Improving relationships: mechanisms of change in couple therapy. Journal of
Consulting and Clinical Psychology, 73: 624–633.
Emmelkamp, P. M. G., van Linden van den Heuvell, C., Rüphan, M., Sanderman,
R., Scholing, A. and Stroink, F. (1988) Cognitive and behavioral interventions:
a comparative evaluation with clinically distressed couples. Journal of Family
Psychology, 1: 365–377.
Epstein, N. and Baucom, D. H. (2002) Enhanced Cognitive-Behavioral Therapy for
Couples: a Contextual Approach. Washington, DC: American Psychological
Association.
Erel, O. and Burman, B. (1995) Interrelatedness of marital relations and
parent-child relations: a meta-analytic review. Psychological Bulletin, 118: 108–
132.
Forthofer, M. S., Markman, H. J., Cox, M., Stanley, S. and Kessler, R. C. (1996)
Associations between marital distress and work loss in a national sample.
Journal of Marriage and the Family, 58: 597–605.
Friedlander, M. L., Escudero, V., Heatherington, L. and Diamond, G. M. (2011)
Alliance in couple and family therapy. Psychotherapy, 48: 25–35.
Funk, J. L. and Rogge, R. D. (2007) Testing the rule with item response theory:
increasing precision of measurement for relationship satisfaction with the
couples satisfaction index. Journal of Family Psychology, 21: 572–583.
Glebova,T., Bartle-Haring, S., Gangamma, R., Knerr, M., Ostrom Delaney, R.,
Meyer, K. et al. (2011) Therapeutic alliance and progress in couple therapy:
multiple perspectives. Journal of Family Therapy, 33: 42–65.
Goldman, A. and Greenberg, L. (1992) Comparison of integrated systemic and
emotionally focused approaches to couples therapy. Journal of Consulting and
Clinical Psychology, 60: 962–969.
Greenberg, L. S. and Johnson, S. M. (1988) Emotionally Focused Therapy for Couples.
New York: Guilford.
Greenberg, L. S., Ford, C. L., Alden, L. S. and Johnson, S. M. (1993) In-session
change in emotionally focused therapy. Journal of Consulting and Clinical
Psychology, 61: 78–84.
Gurman, A. S. (2002) Brief integrative marital therapy: a depth-behavioral
approach. In A. S. Gurman and N. S. Jacobson (eds) Clinical Handbook of Couple
Therapy (3rd edn) (pp. 180–220). New York: Guilford.
Halford,W. K. and Snyder, D. K. (2012) Universal processes and common factors
in couple therapy and relationship education: introduction. Behavior Therapy,
43: 1–12.
Halford, W. K., Sanders, M. R. and Behrens, B. C. (1993) A comparison of the
generalization of behavioral marital therapy and enhanced behavioral marital
therapy. Journal of Consulting and Clinical Psychology, 61: 51–60.
Halford, W. K., Chambers, S. and Clutton, S. (2010) Couples coping with cancer.
In: N. A. Pachana, K. Laidlaw and B. Knight (eds) Casebook in Clinical Geropsychology:
International Perspectives on Practice (pp 73–90). Oxford: Oxford
University Press.
246 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Halford, W. K., Hayes, S., Christensen, A., Lambert, M., Baucom, D. H. and
Atkins, D. C. (2012) Toward making progress feedback an effective common
factor in couple therapy. Behavior Therapy, 43: 49–60.
Hayes, A., Weston, R., Lixia, Q. and Gray, M. (2010) Families Then and Now
1980–2010. Melbourne: Australian Institute of Family Studies.
Iverson, A. and Baucom, D. H. (1990) Behavioral marital therapy outcomes:
Alternate interpretations of the data. Behavior Therapy, 21: 129–138.
Jacobson, N. S. (1991) Toward enhancing the efficacy of marital therapy and
marital therapy research. Journal of Family Psychology, 4: 373–393.
Jacobson, N. S. and Christensen, A. (1996) Integrative Couple Therapy: Promoting
Acceptance and Change. New York: Norton.Culturally Sensitive and Responsive Counseling Essay
Jacobson, N. S., Schmaling, K. B. and Holtzworth-Munroe, A. (1987) Component
analysis of behavioral marital therapy: 2-year follow-up and prediction of
relapse. Journal of Marital and Family Therapy, 13: 187–195.
Johnson, S. M. (2002) Marital problems. In D. H. Sprenkle (ed.) Effectiveness
Research in Marriage and Family Therapy (pp. 163–190) Alexandria, VA: American
Association for Marriage and Family Therapy.
Johnson, S. M., Hunsley, J., Greenberg, L. and Schindler, D. (1999) Emotionally
focused couples therapy: status and challenges. Clinical Psychology: Science and
Practice, 6: 67–79.
Kiecolt-Glaser, J. K. and Newton, T. L. (2001) Marriage and health: his and hers.
Psychological Bulletin, 127: 472–503.
Kreider, R. M. and Fields, J. M. (2002) Number, timing, and duration of marriages
and divorces: 1996. Current Population Reports: p70–80. Washington, DC:
US Census Bureau.
Krishnakumar, A. and Buehler, C. (2000) Interparental conflict and parenting
behaviors: a meta-analytic review. Family Relations, 49: 25–44.
Lambert, M. J. (2010) Prevention of Treatment Failure: the Use of Measuring, Monitoring
and Feedback in Clinical Practice. Washington DC: American Psychological
Association.
Lebow, J. L., Chambers, A. L., Christensen, A. and Johnson, S. M. (2012)
Research on the treatment of couple distress. Journal of Marital and Family
Therapy, 38: 145–168.
Lin, E., Goering, P., Offord, D. R., Campbell, D. and Boyle, M. H. (1996) The use
of mental health services in Ontario: epidemiologic findings. Canadian Journal
of Psychiatry, 41: 572–577.
Makinen, J. A. and Johnson, S. M. (2006) Resolving attachment injuries
in couples using emotionally focused therapy: steps toward forgiveness
and reconciliation. Journal of Consulting and Clinical Psychology, 74: 1055–
1064.
Martire, L. M., Schulz, R., Helgeson, V. S., Small, B. J. and Saghafi, E. M. (2010)
Review and meta-analysis of couple-oriented interventions for chronic illness.
Annals of Behavioral Medicine, 40: 325–342.
Mueser, K. T. and Brunette, M. F. (2003) Schizophrenia-spectrum disorders.
In D. K. Snyder and M. A. Whisman (eds) Treating Difficult Couples: Helping
Clients with Coexisting Mental and Relationship Disorders (pp. 137–158). New York:
Guilford.Culturally Sensitive and Responsive Counseling Essay
O’Farrell, T. and Fals-Stewart, W. (2006) Behavioral Couple Therapy for Alcoholism
and Drug Abuse. New York: Guilford.
Evidence-based couple therapy 247
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Organization of Economic Cooperation and Development (OECD) (2011) Marriage
and divorce rates. Retrieved 4 May 2012 from http://www.oecd.org/
dataoecd/4/19/40321815.pdf.
Prigerson, H. G., Maciejewski, P. K. and Rosenheck, R. A. (2000) Preliminary
explorations of the harmful interactive effects of widowhood and marital
harmony on health, health service use, and health care costs. Gerontologist, 40:
349–357.
Reese, R. J., Toland, M. D., Slone, N. C. and Norsworthy, L. A. (2010) Effect of
client feedback on couple psychotherapy outcomes. Psychotherapy Theory,
Research and Practice, 478: 616–630.
Relate Institute (2012) Homepage. Retrieved 4 May 2012 at http://www.relateinstitute.
org/.
Sayers, S. L., Baucom, D. H., Sher, T. G. and Weiss, R. L. (1991) Constructive
engagement, behavioral marital therapy, and changes in marital satisfaction.
Behavioral Assessment, 13: 25–49.
Schumm, W. R., Paff-Bergen, L. A., Hatch, R. C., Obiorah, F. C., Copeland,
J. M., Meens, L. D. et al. (1986) Concurrent and discriminant validity of
the Kansas marital satisfaction scale. Journal of Marriage and the Family, 48:
381–387.
Sexton, T. L., Ridley, C. R. and Kleiner, A. J. (2004) Beyond common factors:
multilevel-process models of therapeutic change in marriage and family
therapy. Journal of Marital and Family Therapy, 30: 131–149.
Shadish, W. R. and Baldwin, S. A. (2003) Meta-analysis of MFT interventions.
Journal of Marital and Family Therapy, 29: 547–570.
Shadish, W. R. and Baldwin, S. A. (2005) Effects of behavioral marital therapy: a
meta-analysis of randomized controlled trials. Journal of Consulting and Clinical
Psychology, 73: 6–14.
Shimokawa, K., Lambert, M. J. and Smart, D. W. (2010) Enhancing treatment
outcome of patients at risk of treatment failure: meta-analytic and megaanalytic
review of a psychotherapy quality assurance system. Journal of Consulting
and Clinical Psychology, 78: 298–311.
Shumway, S. T., Wampler, R. S., Dersch, C. and Arredondo, R. (2004) A place for
marriage and family services in employee assistance programs (EAPs): a survey
of EAP client problems and needs. Journal of Marital and Family Therapy, 30:
71–79.
Snyder, D. K. (1997) Manual for the Marital Satisfaction Inventory, Revised. Los
Angeles, CA: Western Psychological Services.
Snyder, D. K. (1999) Affective reconstruction in the context of a pluralistic
approach to couples therapy. Clinical Psychology: Science and Practice, 6: 348–
365.
Snyder, D. K. and Wills, R. M. (1989) Behavioral versus insight-oriented marital
therapy: effects on individual and interspousal functioning. Journal of Consulting
and Clinical Psychology, 57: 39–46.Culturally Sensitive and Responsive Counseling Essay
Snyder, D. K., Wills, R. M. and Grady-Fletcher, A. (1991) Long-term effectiveness
of behavioral versus insight-oriented marital therapy: a four-year follow-up
study. Journal of Consulting and Clinical Psychology, 59: 138–141.
Snyder, D. K., Cepeda-Benito, A., Abbott, B. V., Gleaves, D. H., Negy, C.,
Hahlweg, K. et al. (2004) Cross-cultural applications of the marital satisfaction
inventory-revised (MSI-R) In M. E. Maruish (ed.) Use of Psychological Testing for
248 Douglas K. Snyder and W. Kim Halford
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Treatment Planning and Outcomes Assessment (3rd edn) (pp. 603–623). Mahwah,
NJ: Erlbaum.
Snyder, D. K., Castellani, A. M. and Whisman, M. A. (2006) Current status and
future directions in couple therapy. Annual Review of Psychology, 57: 317–344.
Snyder, D. K., Heyman, R. E. and Haynes, S. N. (2008) Assessing couple distress.
In J. Hunsley and E. Mash (eds) A Guide to Assessments That Work (pp. 439–463).
New York: Oxford University Press.
Sprenkle, D. H., Davis, S. D. and Lebow, J. (2009) Common Factors in Couple
and Family Therapy: the Overlooked Foundation for Effective Practice. New York:
Guilford.
Statistics Canada (2010) Canadian Social Trends. Ottawa: Ministry of Industry.
Swindle, R., Heller, K., Pescosolido, B. and Kikuzawa, S. (2000) Responses to
nervous breakdowns in America over a 40-year period: mental health policy
implications. American Psychologist, 55: 740–749.
United Nations Economic and Social Affairs Population Division (2003) World
Fertility Report. New York: United Nations.
United States Census Bureau (2009) America’s families and living arrangements 2007.
Washington, DC: U.S. Census Bureau. Retrieved 4 May 2012 from http://
www.census.gov/population/www/socdemo/hh-fam/cps2007.html.
Waite, L. J. and Gallagher, M. (2000) The Case for Marriage: Why Married People Are
Happier, Healthier, and Better Off Financially. New York: Doubleday.
Weston, R., Qu, L. and Hayes, A. (2012) From form to function: contemporary
choices, changes and challenges. In P. Noller, and G. Karantzas (eds) Couples
and Family Relationships: a Guide to Contemporary Research, Theory, Practice and
Policy. New York: Wiley-Blackwell.
Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D.W., Nielsen, S. L. and
Hawkins, E. J. (2003) Improving the effects of psychotherapy: the use of early
identification of treatment and problem-solving strategies in routine practice.
Journal of Consulting and Clinical Psychology, 50: 59–68.
Whisman, M. A. (2007) Marital distress and DSM-IV psychiatric disorders in
a population-based national survey. Journal of Abnormal Psychology, 116: 638–
643.
Whisman, M. A., Sheldon, C. T. and Goering, P. (2000) Psychiatric disorders and
dissatisfaction with social relationships: does type of relationship matter?
Journal of Abnormal Psychology, 109: 803–808.
Whisman, M. A., Beach, S. R. H. and Snyder, D. K. (2008) Is marital discord
taxonic and can taxonic status be assessed reliably? Results from a national,
representative sample of married couples. Journal of Consulting and Clinical
Psychology, 76: 745–755.
Whisman, M. A., Snyder, D. K. and Beach, S. R. H. (2009) Screening for marital
and relationship discord. Journal of Family Psychology, 23: 247–254.
Evidence-based couple therapy 249
© 2012 The Authors
Journal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice
Copyright of Journal of Family Therapy is the property of Wiley-Blackwell and its content may not be copied
or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.Culturally Sensitive and Responsive Counseling Essay