The couple relationship forms a fundamental stabilising unit in society, with 64% of Australian adults living in couple relationships in 2010, 53% in registered marriage and 11% in de facto relationships
]. Nevertheless, there is an increasing divorce rate of more than 50% in most developed countries
]. In Australia, the median length of marriage before separation is 8.8
years, and approximately half of all divorces involve couples with children
These high rates of relationship breakdown have been consistently associated with negative health consequences for both adults and children following divorce/separation. These include isolation from support networks, and reduced income and standard of living for both adults and children
], dilemmas of loyalty over children for men, and depression and loss of identity for women
]. In a meta-analysis of 70 US studies, children of divorce scored significantly lower on measures of academic achievement, conduct, psychological adjustment, and social development
]. Longitudinal studies also suggest that children of divorce have a higher incidence of psychological disorders, drug and alcohol use, and risky sexual behaviour
Although the effects of divorce and separation can be detrimental, research indicates that high relationship discord in intact couples is also likely to have negative outcomes. For example, a large-scale study (n
2,677) in the US found that relationship discord, regardless of marital status, significantly predicted a higher incidence of mental disorders such as mood and anxiety disorders in adults and negative social outcomes
]. Specifically, high discord was associated with lower social interactivity with family and friends, and lower work satisfaction
]. These results are congruent with those from previous reviews
]. Therefore, merely ‘staying together’ is unlikely to prevent negative outcomes if relationship discord and conflict persist. Such findings indicate a pressing need for research that evaluates relationship services designed to improve relationship quality. In this study we focus on couple counselling and relationship enhancement/education programs. Furthermore, factors that influence the outcomes of these services need thorough investigation. Research to date has identified both couple and individual factors that may contribute to relationship discord. These include relationship satisfaction and commitment at the couple level, and depression at the individual level. However, robust research to evaluate relationship-enhancing interventions in the community are scarce. This paper presents the study protocol for a naturalistic longitudinal study conducted in Victoria Australia, the Evaluation of Couple Counselling (ECC) study, and describes how it addresses current gaps in the research literature.
Key relationship constructs
Relationship satisfaction has been the most common outcome variable identified in more than 200 evaluations of couple counselling
]. Studies have found significant improvements in relationship satisfaction from pre- to post-treatment
] and over the course of one to two years following counselling
]. In these studies, relationship satisfaction was most frequently assessed using the Dyadic Adjustment Scale (DAS)
]. However, some researchers suggest that the DAS is too broad in its scope, and specific measures of relationship satisfaction, such as the more recently developed Couple Satisfaction Index (CSI), should be used for precise assessment
]. Therefore, while most studies indicate improvements in relationship satisfaction following couple counselling, they are limited by the samples and measures used, largely short-term follow-up time frames, and analyses that do not account for the dyadic nature of couple data.
Relationship commitment, based on measures such as the Commitment Inventory (CI)
], is another commonly investigated relationship outcome. Commitment is conceptualised as a combination of partners’ ‘want’ and ‘need’ to stay in their relationship
]. An individual’s ‘want’ to stay together represents how much they care for their partner, and desire for the relationship to continue. Conversely, the ‘need’ to stay in a relationship refers to practical reasons to avoid separation (e.g., to avoid financial burdens). Accordingly, outcome research has indicated a positive relationship between improving relationship commitment through couple counselling and improvements in relationship satisfaction
]. Therefore, relationship commitment should be considered as a potentially influential factor in future evaluations of relationship services.
Importantly, relationship discord has been associated more recently with the occurrence of depression in at least one partner
]. Theorists assert that a bi-directional association between depression and relationship discord may exist
], based on research showing that reducing depression (assessed by standardised measures such as the Beck Depression Inventory, and the Center for Epidemiological Studies Depression Scale) can significantly predict the success of couple counselling (for reviews, see
]). The consistency of these findings indicates that depression may play a significant role in determining outcomes of couple counselling, and warrants further study.
To summarise, research indicates that couple-specific variables as well as individual factors may predict the outcomes of couple counselling and relationship services. The causal direction of these relationships, however, is less clear. These observations are important, since, to justify and guide the application of relationship services such as couple counselling, empirical evidence must explore both the outcomes of relationship services and the factors that predict successful therapy.
Evaluation of relationship services
Relationship services are offered in a complex psychosocial and service environment. Consistent with definitions of evidence based practice
], multiple sources of evidence need to be processed for effective clinical decision making
]. While efficacy studies using randomized controlled trial designs are highly valued in evidence-based practice environments
], they are rarely feasible or ethical when couples are seeking relationship services, often in heightened states of distress or urgency
]. Furthermore, efficacy findings do not necessarily translate to naturalistic, community-based settings
]. Therefore, effectiveness studies, which are less controlled, are often more appropriate for evaluating outcomes in mental health agencies
]. In the current couple counselling research literature, there is an imbalance in favour of efficacy studies, with little evidence available for effectiveness of services in community-based settings
]. This study focuses on the evaluation of two types of services: couple counselling and relationship enhancement services
Couple counselling outcome studies
In evaluating the outcomes of couple counselling, earlier efficacy studies have outlined several therapies that may be considered ‘efficacious’ treatments. For example, Behavioural Marital/Couple Therapy and Cognitive Behavioural Therapy-based couple counselling have significantly reduced relationship distress, as measured by the Marital Adjustment Scale (MAT)
], and the DAS
], with results maintained over time, and compared to no-treatment controls
]. Emotion Focussed Therapy has demonstrated similar results, and is considered efficacious
]. However, such efficacy studies have been criticised for lacking the external validity necessary for application in day-to-day clinical practice
]. In particular, their adherence to manualised treatments is seen as a limitation, since this may not sufficiently represent therapeutic competence
]. A further dilemma is that efficacy research evidence exists largely for counselling ‘difficult’ populations, such as those with a diagnosis of major depression, rather than more common client groups seen in typical counselling settings
]. Therefore, there is a growing consensus that efficacy studies should be complemented by effectiveness research to best inform clinical practice
The limited effectiveness research that exists to date suggests that couple counselling can improve outcomes such as relationship satisfaction
], communication skills and general well-being
], at least in some European countries. No community-based effectiveness research has been undertaken in Australia. Accordingly, there is a pressing need for effectiveness research examining the outcomes of couple counselling in different community-based settings. Increasing the number, and broadening the type of settings, of these studies will provide more robust evidence of the effectiveness of community-based couple counselling. If found to be effective across a range of settings and cultural contexts, the data will support advocacy for better funding for couple counselling, and inform future studies that seek to define the effective ingredients.
Relationship education outcome studies
Couples wanting to improve their relationship may access other forms of relationship services, the most common of these being relationship education programs. We currently know little about the profiles of couples who seek out relationship education compared with those who seek relationship counselling, or the outcomes of these programs. However, anecdotal evidence suggests that there may be considerable distress among at least some couples seeking relationship education.
Relationship education programs differ from couple counselling as they are typically highly structured, conducted in groups, and focus on a mixture of four components; awareness, feedback, cognitive change, and skills training
]. Firstly, ‘awareness’ helps couples clarify their expectations in the relationship. Feedback involves participants completing questionnaires about their relationship (e.g. measures of interpersonal problems), and receiving information on what their scores indicate. Cognitive-behavioural approaches promote changing cognitions to facilitate positive relationships. These may include promoting realistic attributions/expectations around negative partner behaviour
]. Finally, in skills training, couples attend lectures or presentations on relationship skills, and practise these during facilitator-led activities
Two recent meta-analyses of 97 and 114 outcome studies
] have found moderate effect sizes for improving relationship quality, and couple’s communication following relationship education programs. These effects have persisted for up to 4
years in some studies
]. However, these meta-analyses highlight limitations in the current literature on relationship education. Specifically, the majority of studies involved couples from upper socio-economic backgrounds who were not experiencing high relationship discord
]. This sample profile may not represent clients who typically present for relationship education. Thus, further investigation of relationship education services is required to inform subsequent research, and service delivery.
Very little research has examined the comparative benefits of couple counselling and relationship education programs. As clients are likely to self-select into these service types, it is not clear whether characteristic relationship distress profiles present to each service type, or indeed whether there is an interaction between presenting profile, service type and outcome.
Aims of the current study
In the Effectiveness of Couple Counselling (ECC) study, we aim to conduct an evaluation of couple counselling and relationship education services. We propose first to map and compare the relationship, health and wellbeing profiles of couples attending couple counselling and relationship education services in community-based settings in Australia, and to examine the factors associated with better relationship satisfaction and general wellbeing in both groups. Second, we aim to assess the outcomes of both couple counselling and relationship enhancement services over both short- and long-term (3 and 12
months), and to clarify the characteristics which best determine improved couple and individual outcomes in both groups. Previous outcome studies have shown that clients, on average, continue to improve significantly after treatment, providing a strong case for longer-term follow-up
]. Thus, we have included a 12-month follow-up to gauge longer-term trends and effects.
The study uses a number of standardized outcome measures since some prior investigations have been criticised for their lack of standardised assessment
]. Finally, the use of statistical analyses that assume independence of data, such as t
-tests, or ANOVAs, has been prevalent in previous studies
]. Unfortunately, this assumption is rarely tenable for couple data
]. Therefore, we propose to utilise multi-level statistical modelling procedures that control for the inter-dependence of couple data to assess any treatment effects.
The specific aims of the ECC study are to:
1. Map profiles of clients seeking community agency-based couple counselling vs. relationship enhancement programs in terms of socio-demographic and relationship indicators (such as relationship satisfaction, relationship commitment, interpersonal problems, and reasons for attending), as well as health (such as depression, general wellbeing) and health service use (eg. use of medical services) factors.
2. Determine whether couple counselling and relationship education services improve three- and twelve-month outcomes for relationship satisfaction, commitment, and depression, using statistical analyses appropriate to couple data.
3. Determine the relative contributions of client factors (individual and couple) and therapy/education factors to outcomes at 3- and 12-months, and to sustainability of outcomes over time.
provides further details on the aims of the ECC study and the key features of the study protocol in relation to these aims.
Research aims, methods of addressing these, and potential benefits