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What Works for Whom in Couples Therapy

Even confident and seasoned practitioners admit they sometimes feel unease when working with couples. Threat of violence, expression of strong affect and the risk of fracture and loss that affect not only the couple, but children, extended family and friends contribute to practitioner anxiety. Behind this sits questions, does this really work? Am I doing the best by this couple?

Since at least 2005 therapists have confidently asserted that systemic therapy is a valid treatment for couples with randomised controlled trials (RCT) consistently reporting that 40%- 50% of couples achieve clinically significant change in personal and relational functioning. While these reports are reassuring there are questions about the generalisability of these results to naturalistic settings. Non RCT have shown treatment gains to be half to one third smaller than RCT studies suggesting a research-practice gap. Several variables may contribute to this; typically, studies occur in community-based clinics or training clinics where trainees may achieve poorer outcomes to experienced practitioners and attract higher dropout rates.  Outcomes may be affected by the number of sessions and demographic variables including age, race, and ethnicity. Sometimes couples enter therapy to help them part and success for these people may not be reflected in measures that presume continuation of the relationship. Where some studies have included pre and post measures of individual psychological functioning on the assumption that improved mental health is a goal for couples therapy, these results have generally not been reported in meta-analyses assessing effectiveness.

Authors Owen et al (2022) undertook a meta-analysis of non-RCT couple therapy research, investigating pre-post changes in both relationship and individual well-being and exploring moderators that may help explain effectiveness. This analysis demonstrated positive impacts on both relational and individual outcomes, with medium sized effects that are consistent with the lower range from previous studies. Studies with more racially/ethnically minoritized people and those conducted in Veteran Affairs Medical Centres had lower relational outcomes. Analysis of individual outcomes revealed that studies with more sessions, older couples and those seen in Veteran Affairs Medical Centres had better outcomes, while poorer outcomes were reported with  higher percentage of racially/ethnically minoritized people. Therapy conducted by trainees did not consistently affect either relational or individual outcomes.

These results raise interesting issues and pose more research questions. Of note is the poor outcomes achieved for racially/ethnically minoritized people both individually and as couples, pointing to the need for more culturally oriented treatments and requirement to more actively address the additional stressors these couples face. The authors speculate that current couples’ approaches may not effectively address both dyadic concerns and broader system issues of racism and white supremacy. Of comfort to both students and trainers is the finding that across both outcomes, studies with a blend of trainees and post-graduate therapists tended to produce better results, with no difference in studies that included primarily trainees versus primarily post-graduate therapists. It does raise the interesting question about experienced practitioners and what is lost as experience is gained that contributes to good outcomes.

Irrespective of these results it allows us to say, with even greater confidence, that under the right conditions couples therapy does ‘work’.


Owen, J., Sinha, S., Polser, G. C., Hangge, A., Davis, J., Blum, L., & Drinane, J. (2023). Meta-analysis of couple therapy in non-randomized clinical trial studies: Individual and couple level outcomes. Family Process, 00, 1–17. https://doi. org/10.1111/famp.12889

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