11. Repairing the net to trap the monster.
A good marriage is a powerful net to restrain the monster of cancer from returning. If it is above average in quality, or sexual satisfaction, a woman is 4 to 6 times less likely to have a recurrence of cancer or die. Earlier, we looked at some of the biological and psychological reasons why a decent marriage is protective.
This is a good news/bad news scenario. Those who are pretty happy with their spouse can breathe a sigh of relief. But what if the connection between you and your spouse has frayed? What if there is a chronic sense of disconnection, lack of support, snide comments, and only the rare hug or kind word? You now have the bad news, that cancer is far more likely to strike again.
And there is more bad news. When I hear negative things about other therapists, it tends to be that they went to couples therapy before, and it did not help. Sadly, this statement is not rare. When Consumer Reports surveyed its’ members as to their experiences in psychotherapy, marriage counselors had the lowest satisfaction ratings, compared to other mental health professionals.[i]
There are various reasons why people are more dissatisfied. First, doing couples therapy is hard work. In session, I have to think “Is he reacting to her because of an abusive mother, or because she responded as though he were his distant father? If I confront one of them with their patterns, am I subtly colluding with the other, or am I still neutral?” No wonder my armpits are often wet with sweat, even at the end of a productive session.
Second, couples may enter with a mixed agenda, with one partner wanting to work hard to repair the relationship, while the other is leaning out of it. One person even announced in the very first session that they wanted a divorce, and there was no way back.[ii] This is in terrible taste, it is far better to start months earlier, saying “I am very unhappy in our relationship, and if we do not work on it, I do not see it surviving.”
However, you want to work on your below-average marriage for many reasons. You want to feel connected to your partner and supported by them. You want to be far healthier and greatly improve your odds of beating cancer. When you start looking for a marriage therapist, it gets confusing fast. Thankfully, you can safely ignore several things right away. First, it does not matter if they are male or female, or young or old, as there is no difference in effectiveness between the genders or ages of therapists. It also does not matter if they have one theory of therapy compared to another. Emotionally focused therapy is just as helpful as behavioral couples therapy, or CBT.[iii] [iv] The most robust finding in all psychotherapy research is that all bona-fide approaches to psychotherapy are about equal in their effectiveness.[v]
You need to be aware that there is a recent development that makes a major difference in the effectiveness of couples therapy. When I first heard of it, I felt ashamed, because it is so simple and obvious. But, I was not doing it. This innovation is to measure two variables, the first is if clients are making progress, and the second is their sense of teamwork with the therapist.
There are excellent reasons to measure if clients are progressing or not. It turns out that therapists are wildly optimistic as to how much progress their clients are making. One study found that therapists almost never think their clients are at risk of deterioration. The data showed that 15 times as many clients were at risk, compared to what the therapists estimated.[vi] You may look at this overly positive bias and wonder how we get it so wrong. It is not all a bad thing. When a person enters therapy, they are in a lot of pain, confused, and discouraged that they cannot solve their problems. If the therapist has a lot of confidence, (even a bit too much confidence) that the client will improve, that can give the client some much-needed hope. Unfortunately, biased thinking by the therapist is still biased thinking, and that is what measuring corrects. When I look at the scales, and see that the client is not getting better, it alerts me to change something in how I work with them, so that they can make progress.
The second variable to measure is the client’s sense of teamwork with their therapists. Hundreds of studies show that the teamwork, or therapeutic alliance that the client experiences with their therapist is strongly associated with their outcome. If the client feels heard and respected by the therapist, and they feel that the therapist's approach is a good fit for them, and that they are working toward their goals, then clients are more likely to improve. The alliance is the single biggest predictor of progress in therapy. This holds for therapy with adults, [vii] with adolescents, [viii] and couples or families. [ix]
So what happens if you measure both of these variables? Can you correct the overly positive bias of therapists by measuring if their clients progress? Is it better if you assess the therapeutic alliance to see if each client has a good, or lousy connection with their marriage therapist? The largest randomized clinical trial ever done in couples therapy answered that question.
Every therapist handed out the two scales to half of the couples on their caseload, and did not give scales to the other half of the couples they worked with. Over 200 couples participated, giving a nice big sample size. At the end of therapy, the couples who responded to the scales in session, were three times more likely to report that both of them were happy, compared to the couples who were not measured. This is a dramatic improvement, and the strongest evidence was yet to come. The acid test of couples therapy is what happens in the long term. When the researchers followed all the couples up 6 months after therapy ended, the couples that responded to the scales their therapist gave them, were half as likely to divorce. [x]
This makes my neurons spark a bit. The therapist stayed the same, the only difference was whether they got feedback from their clients. The therapist’s effectiveness jumped up and down, hour by hour. The first couple of the morning were the lucky ones to fill in the scales, and they were three time more likely to both be happy in a few months. The next couple after them were the poor saps who did not get to respond to the scales, and they were twice as likely to be divorced in a year. The couple that followed them were fortunate enough to fill in the scales, and far more likely to be happily married.
The researchers asked the therapists about their attitudes to getting objective feedback from their clients. The therapists became slightly more negative to using the scales during the study. Half the therapists believed feedback had no benefit. No benefit! These therapists just participated in the biggest improvement ever seen in marriage therapy, by handing out scales to measure, and half of them thought measuring was useless. They were the ones adding up the numbers on the scales in session! They were eyeball to eyeball with couples who were smiling at each other as they completed the scales, or the other couples who were squabbling and sniping and did not have clipboards in front of them. I get that therapists are too optimistic to detect deterioration, but how on earth do you have a tripling of effectiveness happen right in your office, and you still miss it?
These results have been replicated on two levels. First, another study of marriage therapy found that couples who filled in scales each session as to how much they were progressing, and their alliance with the therapist, were 2.5 times more likely to demonstrate improvement than the couples who did not give objective feedback. [xi] Despite this, therapists still do not believe that routinely measuring helps. About 12% of psychologists measure in therapy.[xii]
Do not let that stop you. Couples therapy, with its’ flaws, is still substantially better than not getting treatment. Dozens of studies show that having a professional work with you is definitely a good idea.[xiii] Search out several therapists and ask directly if any measure outcomes and alliance. Even if none do, go with the therapist with whom you feel the best sense of teamwork. It is well worth it to work on your long-term romantic relationship. Not only will you feel happier, but your body will be healthier, and you and your partner will be repairing a major rope in the net that restrains the dragon of cancer. If you have comments or questions, be sure to leave them below.
[i] Seligman ME. (1995). The effectiveness of psychotherapy. The Consumer Reports study. Am Psychol Dec;50(12):965-74. doi: 10.1037//0003-066x.50.12.965. PMID: 8561380
[ii] No, this did not happen to me. Read it in a book.
[iii] Rathgeber M, Bürkner PC, Schiller EM, Holling H. (2019). The efficacy of emotionally focused couples therapy and behavioral couples therapy: A meta-analysis. J Marital Fam Ther. Jul;45(3):447-463. doi: 10.1111/jmft.12336. PMID: 29781200
[iv] Roddy MK, Walsh LM, Rothman K, Hatch SG, Doss BD. (2020). Meta-analysis of couple therapy: Effects across outcomes, designs, time-frames, and other moderators. J Consult Clin Psychol. Jul;88(7):583-596. doi: 10.1037/ccp0000514. PMID: 32551734
[v] Wampold, BE (2001). The Great Psychotherapy Debate: Models, methods, and findings. Lawrence Erlbaum: London.
[vi] Hannan C, Lambert MJ, Harmon C, Nielsen SL, Smart DW, Shimokawa K, Sutton SW. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. J Clin Psychol. Feb;61(2):155-63.
[vii] Flückiger C, Del Re AC, Wampold BE, Horvath AO. (2018) The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy (Chic). Dec;55(4): 316-340.
[viii] Karver MS, De Nadai AS, Monahan M, Shirk SR. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy (Chic). Dec;55(4): 341-355.
[ix] Friedlander ML, Escudero V, Heatherington L, Diamond GM. (2011). Alliance in couple and family therapy. Psychotherapy (Chic). Mar;48(1): 25-33.
[x] Anker, M.G., Duncan, B.L., & 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.
[xi] Reese, RJ, Norsworthy, LA., Toland, MD., Slone, NC. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy: Theory, Research, Practice and Training. 47. 616-630.
[xii] Ionita G, & Fitzpatrick M. (2014). Bringing science to clinical practice: A Canadian survey of psychological practice and usage of progress monitoring measures. Canadian Psychology, 55, (3), 187–196.
[xiii] Roddy MK, Walsh LM, et al. (2020).