Therapy can help even very distressed married couples, largest study finds

"It takes only one person to end a marriage but two people to make it work," said Andrew Christensen, a UCLA professor of psychology and lead author of the study, which appears in the April issue of the Journal of Consulting and Clinical Psychology, a publication of the American Psychological Association.

The study included 134 married couples, 71 in Los Angeles and 63 in Seattle. Most were in their 30s and 40s, and slightly more than half had children. The couples were "chronically, seriously distressed" and fought frequently, but they were hoping to improve their marriages.

"We didn't want couples who would get better on their own," Christensen said. "We wanted couples who were consistently unhappy. We excluded almost 100 couples who wanted couple therapy but who did not meet our criteria of consistent and serious distress."

The couples received up to 26 therapy sessions within a year. Psychologists conducted follow-up sessions approximately every six months for five years after therapy ended.

The couples all participated in one of two kinds of therapy. The first, traditional behavioral couple therapy, focuses on making positive changes, including learning better ways of communicating, especially about problems, and better ways of working toward solutions. The second, integrative behavioral couple therapy, uses similar strategies but focuses more on the emotional reactions and not just the actions that led to the emotional reactions. In this approach, couples work at understanding their spouse's emotional sensitivities.

Christensen uses the integrative therapy, the second approach, which he described in his 2000 book "Reconcilable Differences". The couples who used this approach read the book as part of their treatment, while the couples in the traditional therapy group read a different self-help book.

When the therapy sessions were over, about two-thirds of the couples overall had shown significant clinical improvement.

"Given this population, that's a good figure," said Christensen, who for more than 30 years has been working with couples in therapy, as well as training and supervising others doing couple therapy.

"If couples do not improve in 26 sessions, that is a bad sign," he said. "This is not psychoanalysis."

The integrative therapy approach was significantly more effective than traditional therapy over the first two years of follow-up. The difference between the treatments, however, was not dramatic and did not last as the years went on.

Five years after treatment ended, about half the couples were significantly improved from where they were at the start of treatment, about a quarter were separated or divorced, and about a quarter were unchanged.

At that five-year mark, about a third of the couples were "normal, happy couples," said Christensen, who considers that figure to be quite good, given the serious and persistent distress with which these couples entered treatment.

For another 16 percent, their marriage was significantly improved and was tolerable, if not very happy.

"They're clearly better and their marriages might last," Christensen said.

"We know from many studies that couple therapy can be beneficial to couples, although it certainly does not help all couples," he said. "We also know distressed couples tend not to get better on their own."

For therapy to work, both partners have to be strongly committed to saving the marriage, and both need to be willing to do their share to work at the relationship and not just blame the other, Christensen said. How couples do at the end of therapy is a good predictor of how they will do five years later.

Many couples who get separated and divorced either do not go to therapy or go to therapy much too late, when one person has already decided to separate or divorce. Couples are often better served by starting therapy when they "get stuck in negative patterns that they can't get out of on their own," he said.

Christensen has been married for more than 25 years. Does his work help his own marriage?

"It's important that I not try to be the expert on marriage with my own wife," he said. "I am probably more open to seeing her point of view as a result of being a couples therapist."

Online therapy

Christensen and Brian Doss, an assistant professor of psychology at the University of Miami, have a five-year grant from the National Institute of Child Health and Human Development to develop an online training program for couples and to assess its effectiveness. The program is based on integrative behavioral couple therapy.

Couples who are interested in participating in this new online therapy study may sign up at www.OurRelationship.com.

"Therapy is so expensive and so time-consuming," Christensen said. "There will always be a place for therapy for couples, but ideally, there will also be an effective online program that can help many couples for little or no cost.

"Our goal is to make couple interventions much more broadly available, inexpensive and not so time-consuming. I would like to reach many more couples. I would like couples not to have to go to a therapist's office once a week but to be able to benefit from their own computer. That will not help every couple, but it is our belief that we can help a substantial number of couples with an online intervention. Eventually, I would like this online approach to be available to everyone."

Co-authors on the Journal of Consulting and Clinical Psychology study are Brian Baucom, a former UCLA graduate student in psychology who is now a lecturer at the University of Southern California, and David Atkins and Jean Yi, former graduate students in psychology at the University of Washington -- Atkins is now a research associate professor and Yi a staff scientist at the University of Washington School of Medicine.

The Journal of Consulting and Clinical Psychology is the premier journal in psychology for intervention studies, including treatment of depression and anxiety, as well as couples treatment.

In "Reconcilable Differences," Christensen notes that people in marriages are unlikely to change fundamental aspects of themselves, no matter how much their spouses demand it.

"People cannot change their basic essence even if they try, and it is futile to demand that they do so," he said when the book came out. "To love and marry someone, you must accept the essence of the other person; you must accept who he or she is. You can push for change at the periphery but not at the core. Marriage is a package deal. You don't get a line-item veto over your partner's personality where you can discard the traits you don't like."

All couples have conflicts, he said. His book helps couples learn how to recover from arguments more quickly, reduce the number of arguments and minimize the anger and resentment that often accompany arguments. Christensen's co-author on the book was Neil S. Jacobson, who was professor of psychology at the University of Washington until his death in 1999.

"The crimes of the heart are usually misdemeanors, even though they sometimes feel like felonies," Christensen said.

Couples fight about all kinds of things, but most common are "daily slights, inattentive acts and routine disrespects that hurt and anger us," he said. For example, a husband may show little interest when his wife talks about her day.

"Most of the change we seek in our relationships is gradual change in everyday behavior," Christensen said. "Do more of the housework, spend more time with the kids, don't be so critical, pay more attention when I talk to you, be more ambitious at work, put more energy into our relationship."

Many couples address conflict with "toxic cures," including accusation, blame, coercion, defensiveness, avoidance and denial, Christensen and Jacobson wrote.

As a result, "we end up hurt, angry, defensive and frustrated -- and our conflicts perpetuate themselves," Christensen said.

In marital conflicts, there are often "three sides to every story" -- hers, his and an outsider's, who often would see partial truth in each version.

Every couple starts out with differences that could potentially damage the relationship, Christensen and Jacobson wrote. The approach they endorse is to accept your partner and not try to change her or him. Or, in the words of one of Christensen's colleagues, "Choose well, then work like hell."