Treatment-as-Usual for Couples: Trajectories Before

and After Beginning Couple Therapy

JESSE OWEN*
GALENA K. RHOADES*
SCOTT M. STANLEY*
HOWARD J. MARKMAN*
ELIZABETH S. ALLEN†

Couple therapy has been shown to be a meaningful way to improve couples’ relation-
ships. However, less information is known about couples’ functioning prior to entering
treatment in community settings, as well as how their relationship functioning changes
from initiating therapy onward. This study examined 87 couples who began community-
based couple therapy during a longitudinal study of couples in the military. The couples
were assessed six times over the course of 3 years, including time points before and after
starting couple therapy. Using an interrupted-time series design, we examined trajectories
across the start of couple therapy in relationship satisfaction, divorce proneness, and nega-
tive communication. The results demonstrated that couples’ relationship satisfaction was
declining and both divorce proneness and negative communication were increasing prior
to entering couple therapy. After starting couple therapy, couples’ functioning on all three
variables leveled off but did not show further change, but previous experience in relation-
ship education moderated these effects. Specifically, those who were assigned to the rela-
tionship education program (vs. control) demonstrated greater reductions in divorce
proneness and greater increases marital satisfaction after starting therapy; however, they
also started more distressed.

Keywords: Couple Therapy; Therapy Outcome; Relationship Satisfaction; Divorce

Proneness; Communication

Fam Proc x:1–14, 2018

T here have been two common approaches to understanding the impact of couple ther-
apy: (i) efficacy trials wherein couples are randomized to a specific couple treatment
(typically manualized) or a control condition (e.g., no treatment, treatment as usual) and
the treatment conditions are highly monitored, and (ii) effectiveness trials, which examine
whether an intervention works in the “real world” and they commonly rely on clinical
practices that are routinely occurring in community based settings (Heppner, Wampold,
Owen, Thompson, & Wang, 2015). In efficacy studies, researchers have demonstrated the
superiority of couple treatments for couples over no treatment control comparison couples

*University of Denver, Denver, CO.

†
University of Colorado Denver, Denver, CO.
Correspondence concerning this article should be addressed to Jesse Owen, University of Denver, 1999
E. Evans, Denver, CO 80210. E-mail: jesse.owen@du.edu
The project described was supported by Award Number R01HD048780 from the Eunice Kennedy Shri-
ver National Institute of Child Health & Human Development (NICHD). The content is solely the respon-
sibility of the authors and does not necessarily represent the official views of NICHD or the National
Institutes of Health.

1
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doi: 10.1111/famp.12390
2 / FAMILY PROCESS

(Gurman & Snyder, 2011; Hahlweg & Markman, 1988; Shadish & Baldwin, 2003, 2005).
These effects have been found at posttreatment as well as maintained at follow-up assess-
ments (see Halford, Owen, Adelson, & Rodolfa, 2016; Sexton, Datchi, Evans, LaFollette, &
Wright, 2013, for reviews). In general, couple treatments typically demonstrate medium-
to large-sized effects as compared to control conditions (e.g., Cohen’s d range 0.59–0.84;
Sexton et al., 2013; Shadish & Baldwin, 2003, 2005). Consistently, 40–50% of couples
achieve clinically significant change in the couple treatment conditions as compared to
control conditions. As is to be expected, the differences between conditions tend to be smal-
ler when alternative treatments are utilized as the control conditions as compared to no
treatment (Pinsof, Wynne, & Hambright, 1996; Shadish & Baldwin, 2003).
Although the findings from efficacy studies are noteworthy, several researchers and
theorists have raised concerns about the gap between research on couple therapies
and what is used in practice (e.g., Gurman, 2011; Halford, Pepping, & Petch, 2015).
Several studies on treatment-as-usual couple therapy have demonstrated that treat-
ment gains are about a half to a third as compared to couple treatments in efficacy
studies (e.g., Anker, Duncan, & Sparks, 2009; Doss et al., 2012; Hahlweg & Klann,
1997; Klann, Halweg, Baucom, & Kroeger, 2011; Lunblad & Hansson, 2006). There
are a myriad of potential reasons for the discrepancies between efficacy and effective-
ness trials (e.g., funding, client screening, therapist experience; Lebow, Chambers,
Christensen, & Johnson, 2012). Additionally, some effectiveness studies have high
attrition rates (up to 50%), which can have a significant effect on how we understand
the true effects of treatment (Klann et al., 2011; Lunblad & Hansson, 2006). In many
one group pre-post studies, researchers utilize only those who provided data for all
time points (e.g., pre- and posttreatment), which is referred to as a completer-analysis.
This approach does not account for those couples that dropped out of couple therapy.
If those couples were accounted for (i.e., intent-to-treat analyses), the effectiveness of
couple therapy would be even less robust. For most intent-to-treat analyses, those cou-
ples that do not provide data at posttreatment assessments are considered to not have
changed (for better or worse; see Atkins, 2009). Although there are some long-term fol-
low-up data within effectiveness studies (e.g., Anker et al., 2009; Klann et al., 2011;
Lunblad & Hansson, 2006), these estimates may be overestimates of the true effective-
ness, given the use of completer-analyses.
To complicate matters, many couples endure relationship distress for years (Lavner,
Bradbury, & Karney, 2012). Indeed, as Owen and Quirk (2014) noted: “Many couples
enter psychotherapy in the wake of devastating arguments or piercing emotional
voids, which over time can ultimately leave them inept in knowing how to move for-
ward or feeling unmotivated to make changes” (p. 7). To date, practitioners and
researchers do not have a clear picture regarding the relationship quality of couples
prior to entering couple therapy. That is, most evidence about couples’ relationship
functioning comes from retrospective reports after the couple has decided to begin
treatment. It might be logical to assume relationship quality decreases prior to enter-
ing therapy. However, the trajectories for couples’ relationship quality over time do
seem to vary, with some couples demonstrating strong stable quality over time, others
with lower and deteriorating quality, and even others with an initial strong quality
and a slow decline over time (e.g., Lavner et al., 2012). On a practical level, it can be
more challenging to develop a strong working alliance with distressed couples (Halford
et al., 2014; Knerr et al., 2009). Additionally, therapists’ conceptualization of the etiol-
ogy and development of relational distress can be informed by understanding changes
in couples’ relationship quality prior to starting therapy (e.g., enduring distress, slow
change, steep change), which may shape how they intervene. Moreover, therapists can
better understand the impact of therapy relative to prior relationship functioning, and

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not only at the time when they enter treatment, when they have a picture of what
the history of relationship quality was before therapy.
There is little research on changes in couple functioning over the months prior to enter-
ing therapy, as well as on the changes in couple functioning after entering treatment.
Indeed, very little is known about the impact of couple therapy in community settings,
such as private practice, religious organizations, or community clinics, where assessments
are not commonly conducted or published. Accordingly, we sought to address many of
these limitations via a longitudinal study of 87 couples who underwent therapy in commu-
nity-based settings.
The couples in this project were part of a larger, randomized controlled trial of relation-
ship education offered in the Army (Allen, Rhoades, Markman, & Stanley, 2015). All cou-
ples’ relationship functioning was monitored for up to 10 years.1 After the intervention
phase of the study, couples were free to pursue services in whatever way they wished. The
current study sought to capitalize on the fact that we were assessing them regularly over
the following years, giving us the ability to address the issues above. As such, we are able
to model their relationship functioning both prior to treatment as well as after the com-
mencement of treatment. Although couples were randomized in the larger study, their
involvement in couple therapy was not randomized. Hence, the present study examines
changes leading up to and after seeking marital therapy, but couples were not randomized
into condition related to receiving therapy.
For all couples in the present study, at least one partner was in the Army. Military cou-
ples face several unique relational dynamics that typically differentiate military couples
from civilian couples, such as the stress from deployments, frequent relocations, and barri-
ers to receiving mental health services (see Karney & Crown, 2007). Many of the day-to-
day aspects of military lifestyle are unique, and there may be some important lessons
gleaned from how these individuals navigate their relationships.
Couples assigned to the intervention track in the parent study received the Prevention
and Relationship Education Program (PREP; Markman, Stanley, & Blumberg, 2010).
PREP teaches couples the skills and principles associated with a successful relationship
with a focus on communication and conflict management, enhancing positive connects and
understanding and enhancing commitment (see Markman et al., 2010). Initial evidence
shows that couples who engage in premarital relationship education services are more
likely to seek couple therapy if they need further assistance (Williamson, Trail, Bradbury,
& Karney, 2014; Williamson, Hammett, Ross, Karney, & Bradbury, 2018; cf. Stanley,
2001). Given that couples learn to identify the aspects of their relationship that are most
challenging over time (Williamson et al., 2014), it is promising that relationship education
may serve to facilitate couples seeking help. However, it may be important to bear in mind
that Williamson et al. (2014, 2018) studied associations between a use of relationship edu-
cation likely intended to be purely preventive (premarital intervention) and not the provi-
sion of relationship education to established, married couples (as was the case for the
sample, here). In either case, little is yet known about couples who received marriage edu-
cation and subsequently sought marital therapy, and whether or not having done so is
associated with gains from marital therapy.
We hypothesized that, prior to couple therapy, couples would report deterioration in
their relationship quality (hypothesis 1). Additionally, we posited that around the initia-
tion of couple therapy there would be a significant increase in relationship quality (hy-
pothesis 2). We also expected that the positive gains in relationship quality after starting
couple therapy would continue over time (hypothesis 3). Collectively, we expected that
couples would report a deterioration in relational quality leading up to starting couple

1
The study is currently on-going.

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therapy, then there would be a notable positive shift in relational quality after starting
couple therapy, and thereafter there should be a continued positive increase in rela-
tional quality. Lastly, we posited that couples who were assigned to the PREP condition
would benefit more from couple therapy than those assigned to the control condition (hy-
pothesis 4).

METHOD
Participants
Couples from the current study were married, heterosexual couples in which one
or both partners were serving in the United States Army. They were participating in
a long-term study of the effectiveness of PREP in the U.S. Army (Allen et al., 2015).
To be included in the current study, couples needed to start couple therapy during a
3-year period of focus starting from the end of the intervention phase of the relation-
ship education program (a total of six assessment time points, approximately
6 months apart). To identify couples who started couple counseling at some point
during these six assessments and to determine at which time point they started, we
used the following items. “Other than [Army name of relationship education pro-
gram], have you engaged in any activities to strengthen or work on your relationship
in the last 6 months?” Counseling was listed as an option and respondents answered
“yes” or “no” to this item. For those who said yes, they were asked, “How would you
describe the counseling? (i) Individual counseling, (ii) Couples/marital counseling, (iii)
Family counseling or (iv) Other”. Only participants who selected “couples/marital
counseling” were included in the analyses below. They were also asked, “Who pro-
vided the counseling? (i) Counselor, (ii), Army Chaplain, (iii) Other Religious Helper,
(iv) Other Helping Professional”. This item was used as a moderator we explored in
analyses. We excluded couples who endorsed having received couple therapy prior to
starting the current study. The current sample included 87 couples, which represents
12% of all the potential couples in the original study (N = 662 couples).
In the final sample of 87 married couples, both men and women had a median age of
28 years old (range 19–51 years old).2 Most (55% of men and 50% of women) had earned a
high school diploma, with 7–11% earning a higher education degree. Approximately 24%
of men and 27% of women reported previously being divorced. For men, 68% identified
themselves as White or Caucasian, 16% identified as Black or African American, 8% iden-
tified as Latino or Hispanic, 3% identified as multiracial, and 3.4% identified as Asian
American/Pacific Islander (note there was approximately 1% who did not report their
race/ethnicity). For women, 75% identified themselves as White or Caucasian, 14% identi-
fied as Black or African American, 3.4% identified as Latina or Hispanic, 4.6% identified
as multiracial, and 3% identified as Asian American/Pacific Islander. There were 35.6%
couples wherein one partner identified as a racial/ethnic minority. The median personal
income for men was $30,000–$39,000 and for women it was under $10,000.
We do not have detailed information about the couple therapy treatment received by
the couples (e.g., type of treatment, expertise of the therapist). However, on average, cou-
ples reported a mean number of sessions of 4.32 (SD = 4.42, 19.5% reported attending one
session, and 12.6% reported attending two sessions). Additionally, participants reported
that 60.1% of the providers were therapists and 29.9% were religious leaders/clergy. In
terms of the relationship education intervention, 50.9% had been assigned to the control
condition and 49.1% were assigned the relationship education intervention.
2
This information is based on their demographic information after completing the relationship education
program.

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Procedure
To enroll in the larger study, participants were informed that the study was a long-
term, randomized controlled trial of relationship education, wherein couples would be
assigned to PREP or no treatment asked to complete multiple assessments (approximately
one hour each) over the following years, with compensation increasing over time from $50
to $90 per person per assessment over time. Recruitment was conducted via brochures,
media stories, posters, and referrals from Army chaplains. Prior to random assignment,
each partner separately completed baseline (pre-intervention) questionnaires under the
supervision of study staff. After couples completed this assessment, they were randomly
assigned to the relationship education intervention or the control group. The research pro-
tocol was approved by a university institutional review board as well as the military insti-
tutional review board.
The relationship education intervention was PREP, which focused on healthy relation-
ship skills (e.g., structured communication, problem solving, and relationship decision
making), as well as promoting pro-social relationship attitudes (e.g., promoting commit-
ment, clarifying expectations, and understanding partners’ needs and values). This inter-
vention was 14.4 hours in length and delivered by Army personnel (Allen et al., 2015).

Measures
Marital satisfaction
The Kansas Marital Satisfaction Scale (KMS; Schumm et al., 1986) was used to measure
marital satisfaction. This scale’s three items assess satisfaction with one’s marriage, with
one’s partner as a spouse, and with one’s relationship with his or her spouse. The KMS has
strong reliability and validity (Schumm et al., 1986) and provides an overall rating of mari-
tal satisfaction. Participants rated these items on a 1–7 scale, with greater endorsement cor-
responding to greater satisfaction. The alpha for men and women was .96.
Divorce proneness
Three items were adapted from the short form of the Marital Instability Index (MII;
Booth, Johnson, & Edwards, 1983) to measure divorce proneness. These items assess con-
cern for one’s marriage, consideration of separation or divorce, and couples’ discussions of
divorce. Participants endorsed these items as yes (1) or no (0), and responses were aver-
aged to create a scale score. The alpha for women was .85 and for men was .83.
Communication
We utilized the 6-item Communication Danger Signs Scale (Stanley, Markman, &
Whitton, 2002) to assess the frequency of negative communication patterns, including
escalation, invalidation, and withdrawal. An example item is: “My partner criticizes or
belittles my opinions, feelings, or desires.” Respondents rate each item on a 1 (Almost
never) to 3 (Frequently) scale, with higher scores indicating more frequent negative inter-
actions. In a variety of samples, the measure has demonstrated adequate reliability and
validity (Kline et al., 2004; Markman et al., 2010). The alpha for women was .85 and for
men was .82.

Data Analysis Overview

We expected that marital quality would decline before couple therapy, shift from a neg-
ative trajectory to a positive one after starting couple therapy, and continue to increase
over time thereafter. Given that this sample included couples who had been randomly
assigned to either a relationship education workshop or no workshop earlier in the study,

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we also tested whether relationship education condition moderated the results. To test
these hypotheses, we used six waves of data and a within-subject, interrupted time-series
design. An interrupted time-series design is a useful statistical approach when random
assignment is not possible, such as to participate in couple therapy or not (Shadish, Cook,
& Campbell, 2002). Thus, we were able to examine the trajectory a relationship was on
before beginning therapy and whether therapy changed the direction of its trajectory over
time.

RESULTS
Given that couples could have started couple therapy at any point during the six assess-
ments used in the current study, there are varying numbers of assessments before and
after the start of therapy. On average, couples were assessed at 1.5 time points prior to
starting couple therapy (M = 9.57 months, SD = 5.32), and at two time points after
(M = 12.02 months, SD = 5.99). On average, couples had 5.57 assessment time points that
were used in the analyses (SD = 0.85). Following guidelines by Singer and Willett (2003),
we approached testing our hypotheses by first examining model fit statistics and then
examining the coefficients in the best fitting models. There are three general time periods
that are modeled: (i) time points before therapy was reported (i.e., before starting ther-
apy), (ii) the assessment period where therapy was first indicated, and (iii) time points
after therapy was reported. Accordingly, the after therapy assessment points may overlap
when couples were still in therapy as we do not have clear dates on when therapy com-
menced or terminated.
For the examination of model fit statistics, we tested four potential models (see Fig-
ure 1) for each outcome variable: (i) no change in slope from time points before therapy to
after the time points after the start of therapy (e.g., relationship quality was decreasing
before and after therapy) and there was no change at the time point they indicated they
started couple therapy, (ii) change in slope only (e.g., relationship quality was declining
before therapy, but relationship quality increased after the start of therapy. However,
there was no change in mean level or at the time point they indicated they started couple
therapy), (iii) change in mean level only (e.g., relationship quality increases at the time
point they indicated they started couple therapy, but there is no change in the slope), and
(iv) change in slope from before and after starting couple therapy and mean level at the
time point they indicated they started couple therapy.
To determine the best fitting model for each outcome variable, we conducted deviance
comparison tests. That is, we statistically compared the deviance statistics of the models
to one another. Additionally, to compare models, we utilized Bayesian Information Crite-
rion (BIC) model fit statistics (see McCoach & Black, 2008). BIC do not rely on statistical
significance tests. Rather, they are used to compare models, wherein lower estimates for
BIC indicate better model fit. Although there are no clear cut-offs for how much lower the
better fitting model should be, Raftery (1995) suggests that differences of approximately
10 points (or more) is strong evidence for the better fitting model. The use of model fit for
determining the most meaningful model is a common approach for interrupted time series
models (see Collibee & Furman, 2014).

Model Fit Results

The results demonstrated for marital satisfaction and divorce proneness that the best
fitting model was the second model that included change in slope, but not mean level. For
negative communication, the best fitting model was the no-change model (#1 in Figure 1).

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OWEN, RHOADES, STANLEY, MARKMAN, & ALLEN / 7
No Change Across Transition (1) Slope Change (2)

Level Change (3) Slope and Level Change (4)

FIGURE 1. Four Hypothetical Models of the Impact of Couple Therapy on Relationship Quality.

Note. The dotted line represented the beginning of couple therapy.

These decisions were based on the collective information from the deviance tests as well as
the lowest BIC values (see Table 1).
The full model equation for the change-in-slope-and-mean-level model was:
Ytij ¼ p0tij þ p1tij ðSlopebefore Þ þ p2tij ðSlopeafter Þ þ p3tij ðLevel ChangeÞ þ ½error
where Ytij is the relationship quality score (i.e., Marital Satisfaction, Divorce Proneness,
and Communication) at time t for client i who is in couple j, and p0tij is the overall inter-
cept. Based on our centering, the intercept reflects the time point in which the couple indi-
cated that they entered couple therapy. The slope is measured in months from the date of
the first follow-up assessment at which a couple reported having started therapy
(p1tij(Slopebefore)). Because of the way time is centered (around the assessment when cou-
ple therapy was indicated to commence) the Level Change (p3tij(Level Change)) is inter-
preted as a shift in the outcome variable at the time point at which the couple indicated

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TABLE 1
Model Fit Statistics for Interrupted Time Series Analyses Examining the Impact of Community-based Couple
Therapy on Relationship Quality

Model Comparison model Deviance test p-Value AIC

Marital satisfaction
1. No change – – – 3,023
2. Slope change 2 vs. 1 9.92 <.05 3,021
3. Level change 3 vs. 1 11.50 <.05 3,019
4. Level and slope change 4 vs. 1 21.67 <.05 3,019
Final model 3 vs. 4 10.17 .07
Divorce proneness
1. No change – – – 853
2. Slope change 2 vs. 1 10.49 <.05 850
3. Level change 3 vs. 1 11.20 <.05 850
4. Level and slope change 4 vs. 1 21.37 <.05 849
Final model 3 vs. 4 10.17 .07
Communication
1. No change – – 1,041
2. Slope change 2 vs. 1 2.04 >.50 1,047
3. Level change 3 vs. 1 8.08 .09 1,040
4. Level and slope change 4 vs. 1 9.50 .39 1,049
Final model 3 vs. 1 8.08 .09

Note: Bold numbers reflect the best fitting model.

that they started therapy. In these models, the after-therapy slope coefficient (p2tij(Slope-
after)) represents the change in slope from before therapy. Thus, the true after-transition
slope value is equal to the coefficient for the slope before therapy plus the coefficient for
after therapy started (p1tij + p2tij).
Because the coefficient for the after-therapy slope does not represent the direct value of
the slope after therapy in these models (but represents, instead, the change in slope from
before to after therapy), we ran additional models to test whether the true coefficient, that
is the additive value noted above, was significantly different than zero. That is, for models
in which there was a significant difference between the before and after slope, we ran
extra models with only the after-therapy time points to test if the after-therapy slope was
increasing, decreasing, or remaining steady over time. When the valence was the same,
we could assume that adding p1 and p2 would result in a significant slope in the same
direction. We describe the findings from these tests below when they are relevant to the
hypothesis tests.

Tests of hypotheses
We evaluated hypotheses 1–3 separately for each outcome variable.
Hypothesis 1 was fully supported for marital satisfaction. Marital satisfaction was sig-
nificantly declining in the time before starting couple therapy, and the model fit statistics
suggested that the best fitting model was one in which change in the mean level and the
slope of marital satisfaction were included. In contrast, hypotheses 2 and 3 were not sup-
ported for marital satisfaction. The specific coefficients for the mean level change and the
slope of marital satisfaction after couple therapy began were not significant, suggesting
there was a leveling off of marital satisfaction after the assessment point when they indi-
cated the start of couple therapy (see Table 2) with no changes over time.
Hypothesis 1 was fully supported for divorce proneness. Before the beginning of couple
therapy, divorce proneness was significantly increasing over time. However, hypotheses 2
and 3 were not supported for divorce proneness. After the assessment point when they

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TABLE 2
Coefficients for Best-fitting Models Examining the Impact of Community-based Couple Therapy on Relation-
ship Quality

Intercept (p0) Slopebefore (p1) Slopeafter (p2) Level Change (p3)

b (SE) b (SE) b (SE) b (SE)

Marital satisfaction 5.25 (.16)*** 0.03 (.01)* 0.01 (.01) 0.11 (.15)
Divorce proneness 0.46 (.05)*** 0.01 (.01)* 0.01 (.01)* 0.02 (.05)
Communication 1.93 (.04)*** 0.01 (.01)~ — —

Notes. The primary numbers in the table are the unstandardized coefficients for the fixed effects. Stan-
dard errors are in parentheses. ~p < .06, *p < .05, **p < .01, ***p < .001. Slope (time) was measured in
months.

TABLE 3
Moderator Analysis: Interrupted Time Series Models by Relationship Education or Control

Marial satis. Divorce prone. Danger comm.

b (SE) b (SE) b (SE)

Intercept 5.45 (.27)*** 0.37 (.07)*** 1.87 (.07)***

RE vs. control 0.59 (.33)~ 0.22 (.10)* 0.21 (.11)~
Slope-before 0.02 (.02) 0.01 (.01) 0.01 (.01)
RE vs. control 0.03 (.02) 0.01 (.01) 0.01 (.01)
Slope-after 0.01 (.02) 0.01 (.01) —
RE vs. control 0.03 (0.02) 0.02 (.01)
Level change 0.13 (.21) 0.10 (.07) —
RE vs. control 0.60 (.31)~ 0.23 (.10)*

Notes. ~p < .06, *p < .05, **p < .01, ***p < .001.

indicated starting couple therapy, the slope was significantly different from before couple
therapy, but not significantly different from zero, indicating that it was neither increasing
or decreasing over time, but steady, after the beginning of therapy (b = 0.001, SE = .002,
p = .59). There was no significant mean level change in divorce proneness after the begin-
ning of therapy. The findings suggest it leveled off and did not meaningfully change.
Hypotheses 1, 2, and 3 were not supported for negative communication. In fact, there
was a trend for a slight decline in negative communication prior to the time of therapy
beginning (b = 0.01, p = .054). As mentioned above, the best fitting model for negative
communication was one of no change with the start of couple therapy or after couple ther-
apy, thus we did not examine coefficients for the slope after therapy or mean level change.
Across all outcome measures, hypothesis 4 was only partially supported. After starting
couple therapy, those assigned to the relationship education track in the parent study
demonstrated greater reductions in divorce proneness (b = 0.23, p < .05) and there were
close to statistically significant increases marital satisfaction (b = 0.60, p = .06) as com-
pared to couples in the control group (level change). However, there was no moderation by
relationship education for the outcome of negative communication. Further, those who
participated in relationship education and then later went on to engage in couples therapy
began therapy with higher levels of divorce proneness (b = 0.22, p < .05), higher frequency
of negative communication (b = 0.21, p = .06), and marginally lower marital satisfaction
(b = 0.59, p = .06), as compared couples in the control group.
Although we had no hypothesis about it, we also examined if the type of provider (pro-
fessional vs. clergy/lay-leader) moderated outcomes. There were no significant moderation
effects (ps > .05) on any of the three outcomes. Additionally, the effects reported above

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were also not moderated by participant gender. That is, the changes (or lack thereof) in all
three outcomes were not statistically different for men and women (ps > .05).

DISCUSSION
This is the first study, to our knowledge, to examine couple therapy with couples who
reported on their relationship functioning for months or years prior to and after starting
treatment. As hypothesized, couples reported a gradual reduction in marital satisfaction
as well as an increase in divorce proneness prior to starting couple therapy. The rate of
change prior to couple therapy was gradual and the effects were small (d = 0.31 reduction
in marital satisfaction and d = 0.30 increase in divorce proneness over the course of a
year). However, contrary to hypotheses, couples reported a slight reduction in negative
communication prior to starting couple therapy (d = 0.23 change in negative communi-
cation over the course of a year). It is possible that the reduction in negative communica-
tion reflects a disengagement to avoid escalating problems, perhaps in anticipation of
getting help, or a shift toward cordial interactions that at the end of day are not fully
rewarding to nurture the health of the relationship. Knowing typical trajectories of rela-
tionship satisfaction, divorce proneness, and negative communication before couple ther-
apy could help clinicians know to inquire about relationship history in these domains and
in choosing which areas to address first. These analyses also provide the basis for examin-
ing shifts in these variables that can be attributed to couple therapy.
Additionally, these findings suggest that the trajectories of couple communication and
relationship satisfaction are not always interlinked. Disparate findings for satisfaction
and communication have also been found in research on the impact of premarital educa-
tion programs (Fawcett, Hawkins, Blanchard, & Carroll, 2010). The complex nature of
how relationship functioning changes over time may be reflective of both functional
aspects of relationships (e.g., communication) and structural aspects (e.g., commitment,
satisfaction; Davey, Davey, Tubbs, Savla, & Anderson, 2012: cf. Watzlawick, Weakland, &
Fisch, 1974).
Overall, after starting couple therapy, there were trajectory shifts in marital satisfac-
tion and divorce proneness. In particular, marital satisfaction leveled off or stopped declin-
ing after starting couple therapy, though it did not increase over the time. Similarly,
partners’ feelings and thoughts about separating stopped increasing after starting couple
therapy. In couple treatment studies, couples typically demonstrate a significant increase
in relational functioning from pre- to post-therapy with mixed evidence of the mainte-
nance of such gains over longer periods of time (i.e., 3–4 years). That is, there typically is a
return to pre-therapy levels of relationship adjustment or mere maintenance of the effects
over time (e.g., Christensen, Atkins, Baucom, & Yi, 2010; Halchuk, Makinen, & Johnson,
2010; Snyder, Wills, & Grady-Fletcher, 1991). The leveling off of these indicators of rela-
tionship quality after couple therapy could reflect a “new normal” in their understanding
and acceptance of the relationship (Jacobsen & Christensen, 1996).
These findings could paint a negative picture of the potential impact of couple therapy
to enhance couples’ relationship quality over the years in community-based settings (cf.
Halford et al., 2015). However, the number of sessions attended was relatively low in this
sample (four sessions on average). While this number of sessions is consistent with some
other studies (e.g., Anker et al., 2009), other community-based couple therapy studies
have shown a larger number of sessions (e.g., 12–20; Owen et al., under review). Future
research should examine how the number of sessions relates to outcomes in community
settings. It may also be that couples should expect to stop the slide into further deteriora-
tion rather than to make substantial gains in relationship quality as a result of seeking
and obtaining couple therapy.

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In terms of the differences between those assigned to the relationship education interven-
tions versus those in the control group, we found that those in the intervention group
demonstrated greater reductions in divorce proneness and greater increases in marital sat-
isfaction after starting therapy; however, they also started therapy with lower marital satis-
faction as well as more negative communication and divorce proneness. One interpretation
is that relationship education may facilitate heightened awareness of relationship problems
and greater reporting of problems, while still reducing the proclivity to separate (as demon-
strated in this sample; Allen et al., 2015). Alternatively, it could be that relationship educa-
tion programs can have a negative effect for some couples, especially for those whose
expectations are not met after the program (Dixon et al., 2012; Owen, Duncan, Anker, &
Sparks, 2012). At the same time, the couples were randomized to relationship education but
not to couple therapy. A double randomization approach would be needed to draw causal
effects for the role of relationship education on the effects of couple therapy.
Couples who received the relationship education intervention had a larger initial gain
from couple therapy as compared to the couples in the control condition. Thus, while they
started couple therapy less stable and satisfied than the control couples, they responded
more positively at the assessment point when they indicated they had started couple ther-
apy. Although speculative, it could be that these couples were able to access the knowledge
and skills from the relationship education intervention and put them into action as part of
the early stages of therapy. Indeed, there is some preliminary evidence that the use of
booster sessions after relationship education interventions has been shown in several
studies to heighten couples’ functioning (Braukhaus, Hahlweg, Kroeger, Groth, & Fehm-
Wolfsdorf, 2003; Kivlighan & Owen, under review; Whisman, 1990). Alternatively, it could
be merely the case that they had more room to change on these measures as a result of
seeking therapy (e.g., regression to the mean). We cannot say with any certainty what the
best explanation is. It is clear, though, that they report larger gains from seeking therapy.
The results of the current study should also be interpreted with a series of methodologi-
cal limitations in mind. First, the sample is of couples in which one or both partners were
the U.S. Army. Accordingly, it is unclear how the military culture or the exposure to com-
bat may have influenced the access to treatment and on the process/outcome of treatment.
Yet, the number of couples seeking treatment (12% of the larger sample) is consistent with
previous estimates of approximately 10% of distressed couples (Johnson et al., 2002). We
also do not know how well these results will generalize to non-military couples. Second,
we relied on couples’ report of their therapy experience. We did not have detailed informa-
tion about the providers or the type of treatments implemented. Third, all of the couples
participated in a larger study examining the effects of relationship education. Although
approximately 50% of the couples were in the experimental condition and 50% were in the
control condition, all couples volunteered to participate in the larger study on relationship
education. Thus, we do not know if self-selection bias might have influenced the outcomes
of the study. Fourth, we do not have specific assessments of when couples started and
ended couple therapy. Thus, we were not able to conduct traditional pre-post therapy anal-
yses. Relatedly, our measures were relatively brief, which may have limited their sensitiv-
ity to capture more nuanced changes to brief couple counseling.
There are several implications for research and practice to be drawn from this study.
Couple therapy as practiced in the community appears to have some beneficial effects,
especially in preventing (or stopping) declines in relationship quality. Primarily, it
appears that it reduces the decline in marital satisfaction (but does not increase after cou-
ple therapy) and halts thinking about divorce, to a degree. There were no changes in cou-
ples’ negative communication after starting couple therapy. These findings, in conjunction
with other effectiveness studies of couple therapy (Halford et al., 2015), suggest that there
is a gap between the effects seen in clinical trials and those realized in day-to-day practice.

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Accordingly, further investigation of couple therapy practices is warranted. In particular,

more funding should be given to dissemination trials of empirically supported couple
treatments. Additionally, our findings might suggest that couples need early intervention
(e.g., relationship education or couple counseling) and on-going booster sessions or check-
ups in order to avoid negative relationship outcomes.
In conclusion, we hope that this study will generate discussion about how to study and
maximize the effectiveness of couple therapy in community based settings. Our findings
seem to suggest that couple therapy can help couples change the negative trajectory of
their relationship functioning. However, community-based couple therapy may not be as
effective in terms of returning to pre-distressed/pre-couple therapy levels. In combination
with previous studies, these results open the door to many questions about the impact of
couple therapy in the short and long term. Ultimately, we hope that more investigation
occurs to uncover best practices in couple therapy as practiced in the community.

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