Effectiveness of Couple Interventions in Marital Distress: A Systematic Review and Meta-Analysis

Abstract

Background:

Couple interventions focus on resolving relationship issues and improving partners’ intimacy. Several intervention models are used on different occasions to deal with the issues. The present systematic review and meta-analysis investigated the effectiveness of such couple interventions dealing with marital distress.

Methods:

Using the PRISMA guidelines for reporting systematic reviews and meta-analyses, a search was carried out to identify published articles in the areas of study. The meta-analysis investigated the effectiveness of couple interventions by comparing the post-intervention assessments of the experimental and control groups.

Results:

The systematic review helped to identify twelve empirical studies published within the last ten years in the following databases: ScienceDirect, EBSCO, APA PsycINFO, NCBI, ProQuest, and Google Scholar. Meta-analysis showed a statistically significant overall effect size (Cohen’s d = 0.85, 95% CI: 0.56 - 1.14). Cochran’s Q showed that there was a substantial difference between the studies. There were signs of publication bias.

Conclusion:

The current study revealed an overall large effect size, indicating that different couple interventions had a noticeable impact on distressed couples who received interventions as opposed to couples who did not receive any interventions.

Introduction

Marital distress is the couple’s experience of emotional or physical conflict, which may lead to unhappiness, disappointment, and the dissolution of the relationship (1,2). It can cause intense anxiety and tension in the partners, affecting their physical and mental health and jeopardizing their future relationship. Couples in distress tend to disregard their partner’s concerns, which worsens the situation and diminishes relationship satisfaction (3). In such situations, with the assistance of a professional, couples may be able to face challenges and manage their anxiety and stress. Professional assistance entails a competent therapist and an intervention model suited to the problem. However, choosing the appropriate model of intervention and being an agent of change through its application depends on the professional competence of the therapist (4,5).

Couple interventions are effective ways to deal with relationship problems and marital distress, as they are typically intended to assist individuals in resolving their relationship problems and growing closer to one another (6). Thus, they are crucial not only in treating vulnerable couples but also in preventing further distress among them since marital discord and dissolution have become common and costly. Couple interventions are designed to prevent or alleviate relationship distress and generate lasting improvements in the couple’s relationship. They aim to modify couples’ interpersonal repertoires by addressing the issues of concern and enhancing their subjective evaluation of relationships. Couple interventions help couples resolve their conflicts, enhance communication, and build emotional attachment and intimacy, fostering a healthy and satisfying relationship among couples (7). The effect of couple interventions depends on various factors, including the time seeking help, presenting problems, willingness and expectation of partners, their availability, magnitude, and durability of treatment, and a large portion depends on the therapist (8).

Couple intervention is a diverse and dynamic field, built upon theoretical foundations, and has various therapeutic methods and techniques (9). There are various couple intervention models, including behavioral, cognitive-behavioral (10,11), emotion-focused, and solution-focused approaches (12,13). Despite the variety, successful couple interventions aim to enhance relationship satisfaction, communication skills, and overall well-being while reducing depressive and anxiety symptoms in couples (14,15).

There are also intervention models that do not need the assistance of a trained therapist. For instance, education-based couple intervention programs (16–18) do not require a trained therapist to improve relationship satisfaction and reduce relationship distress among couples. Even in the absence of any relationship issues, education-based interventions are effective in modifying couples’ communication patterns (19). Such interventions, which can also be conducted online, consist of skill-building exercises designed to improve communication strategies, foster intimacy and emotional connection, and instill conflict-resolution abilities. The efficacy of education-based interventions in addressing complex relationship issues is questionable. Such interventions fall short of addressing the underlying causes of the issues (20).

There are web-based couple interventions (21,22) that minimize the role of the therapist as the change agent. While such automated and gamified interventions are accessible to couples at any time, they are limited in their capacity to resolve marital conflicts. A significant limitation is the lack of a common agent that could inspire the couples to act together for a common purpose. Further, web-based programs cannot address the demand-withdraw pattern, in which one partner demands, complains, and criticizes while the other becomes defensive and inactive (23).

A systematic review and meta-analysis will help to generalize the effect of a standard set of components (24–26) that couple interventions may have to ensure the resolution of marital distress. There are existing meta-analyses that examine the effectiveness of couple interventions in resolving relationship problems (10,11,27). However, they seemed to focus more on the techniques that were frequently and widely used, such as cognitive and behavioral couple interventions (10,27). Within the past decade, the field of couple interventions has made significant progress as it incorporated new methods and advanced to embrace technology to engage couples on a virtual level (21,22). In light of this progress a systematic review and meta-analysis of studies on skill-building and web-based interventions, as well as therapist-supported interventions, are required to comprehend the standard set of couple intervention components that ensure effective resolution. Therefore, the current study is unique in the area of concern as it has amalgamated the available studies of the recent past in the areas mentioned above by reviewing and analyzing those couple interventions with randomized controlled trials. The findings of this study will be an important input to couple counselors, researchers, and educators, who can plan, design, and treat couples in distress, incorporating the effective concepts, models, and methods of these interventions.

Methods

Search Procedures

We followed the PRISMA guidelines for reporting systematic reviews and meta-analyses while reviewing the literature on couple therapy and marital distress (28). A detailed and comprehensive search for published articles in the given area enabled us to identify studies in the following data sources: ScienceDirect, EBSCO, APA PsycINFO, PubMed, ProQuest, and Google Scholar. To identify relevant studies, we used keywords and a combination of them, but not limited to: “marital distress,” “couple therapy,” “couple approach,” “marital therapy,” and “couple intervention” (Table 1). In addition to searching databases, we looked for pertinent articles using the previous research’s reference lists.

Table 1:

Search information at various stages

Databases	Search strategy	Preliminary searches	Assessed for eligibility	Final screening result
ScienceDirect	marital distress OR couple therapy OR couple approach OR marital therapy OR couple intervention	3219	02	00
EBSCO	marital distress OR couple therapy OR couple approach OR marital therapy OR couple-based intervention OR couple intervention OR marriage therapy	16023	07	02
APA PsycINFO	marital distress OR couple therapy OR couple approach OR marital therapy OR couple intervention	14	06	04
PubMed	((“marital” AND distress [All Fields]) OR (“couples therapy”) OR “couple therapy”[All Fields]) OR (“marital therapy” OR (couple-based [All Fields] AND “intervention”[All Fields])) OR “couple”[All Fields]) AND (“methods” OR “methods”[All Fields] OR “intervention”[All Fields]))	4033	03	02
ProQuest	marital distress OR couple therapy OR couple approach OR marital therapy OR couple-based intervention OR couple intervention OR marriage therapy	7188	05	01
Google Scholar	marital distress OR couple therapy OR couple approach OR marital therapy OR couple-based intervention OR couple intervention OR marriage therapy	132000	23	03

We included articles that met the following criteria: (a) written in English; (b) exclusively dealt with couples’ marital distress; (c) used any intervention; (d) used experimental design; (e) had post-assessment data; (f) published between the years 2012 and 2022, to assess the developments within the field of study in recent years (29,30) and to incorporate these developments into a single study (31); and (g) randomized controlled trials. Studies were excluded if they (a) were centered on individual issues leading to relationship-related issues; (b) had less than 20 couples sample size since a small sample size may cause extreme variability in the effect size (32); and (c) had samples that weren’t made up of adults (less than 18 years). Duplicates and ineligible studies were eliminated. The abstract screening was conducted after the initial title screening. The eligible studies were assessed and further screened to be included in the final list for review and analysis.

Study Coding and Analyses

The studies were first coded according to the first author’s last name, publication year, study nation, type of interventions, number of participants in the control and experimental groups, and means and standard deviations of both groups. We analyzed the effect sizes, heterogeneity, and publication bias using the necessary data from the above-mentioned list.

Results

The PRISMA flow diagram was utilized to report the search result outcomes for the systematic review and meta-analysis. When the search was first conducted using keywords, 18,638 documents from six databases were identified. Four thousand three hundred twenty-eight records were screened from the total using the databases’ builtin filters after eliminating the duplicates. Six hundred fourteen items were found after titles were screened. After reviewing the abstracts, 46 papers were deemed qualified. The final systematic review and meta-analysis is comprised of 12 papers after excluding the publications that were considered ineligible, such as those not in English, inaccessible, had incomplete data, employed other types of scales, or had not been peer-reviewed (Fig. 1).

Fig. 1:

PRISMA 2020 flow diagram of systematic review study selection

Study Characteristics

All the studies in the current systematic review and meta-analysis followed an experimental research design with post-assessments of experimental and control groups. Despite the fact that each of the included studies used a different type of intervention and had a different sample size and set of participants, we combined them all into one meta-analysis based on the following factors: marital distress as the problem, couples as participants, and couple intervention as the type of intervention.

The current research is comprised of 12 publications, with 15 treatments comprising 1528 individual participants from three distinct regions. The majority of the featured articles are from the Southwest Asian area (n = 8), followed by the American region (n = 3) and the African region (n = 1). Participants’ numbers in the experimental and control groups and the post-intervention mean and standard deviation data for each group were analyzed (Table 2).

Table 2:

Studies included in the meta-analysis

First Author (Year)	Study Labels	Country	Type of Interventions	Control Group Participants	Control Group Mean (SD)	Experimental Group Participants	Experimental Group Mean (SD)
Amiri et al. (2017)	1	Iran	Hope Therapy	30	Total: 113.93 (24.77)	30	Total: 98.2 (23.21)
Babakhani et al. (2016)	2	Iran	McMaster Model Training	20	Total: 138.2 (5.32)	20	Total: 120 (11.37)
Doss et al. (2016)	3.1	USA	Web-based OurRelationship Program	149	Women: 13.03 (6.71)	151	Women: 8.19 (6.46)
	3.2			149	Men: 10.26 (6.77)	151	Men: 6.72 (5.7)
Fallahchai et al. (2017)	4	Iran	Prevention and Relationship Enhancement Program	74	Total: 114.38 (25.61)	78	Total: 100.78 (23.47)
Fia (2020)	5	Ghana	Cognitive Behavioral Therapy	20	Total: 54.4 (5.59)	20	Total: 43.75 (3.26)
Molajafar et al. (2015)	6	Iran	Mindfulness-based Cognitive Therapy & Emotion Regulation Training	15	Total: 118.6 (16.77)	30	Total: 103.9 (17.22)
Namagardi et al. (2022)	7	Iran	Integrative Behavioral & Affective Reconstructive Couple Therapies	16	Total: 7.56 (2.25)	32	Total: 4.685 (1.458)
Nowlan et al. (2017)	8	USA	OurRelationship Program	44	Total: 13.65 (6.43)	46	Total: 11.47 (7.42)
Rajani et al. (2016)	9	Iran	Cognitive Behavioral Couple Therapy	32	Total: 29.78 (7.01)	32	Total 22.45 (4.33)
Rasoul et al. (2016)	10	Iran	Self-regulation Couple Therapy	24	Total: 60.47 (12.62)	24	Total: 51.45 (11.94)
Rogge et al. (2013)	11.1	USA	Compassionate and Accepting Relationships Through Empathy & Prevention and Relationship Enhancement Program	44	Women: 19.8 (11.8)	70	Women: 16 (9.7)
	11.2			44	Men: 13.6 (8.6)	71	Men: 11.8 (6.66)
Sharif et al. (2013)	12	Iran	Conflict Resolution Training	62	Total: 84.43 (17.26)	50	Total: 72.68 (11.92)

Most of the included studies had amalgamated data, while two (3, 11, as numbered in Table 1) provided different mean and standard deviations for men and women. Except for the outliers and the therapies that lacked skill training, all of the interventions that address marital distress in the collected articles have become part of the present research.

The couple interventions that are part of the current study are the following: Hope therapy, McMaster model training, OurRelationship (OR) program, Prevention and Relationship Enhancement Program (PREP), Cognitive Behavioral Therapy (CBT), emotion regulation training, Integrative Behavioral Couple Therapy (IBCT), Affective Reconstructive Couple Therapy (ARCT), self-regulation couple therapy, Compassionate and Accepting Relationships through Empathy (CARE), and conflict resolution training.

Results of Individual Studies

Some of the included studies in the meta-analysis made use of multiple interventions. We gathered and compiled those data. In the individual studies, CBT (5, as numbered in Table 1) had a large, statistically significant effect size, demonstrating its effectiveness in decreasing marital distress in couples compared to the control group. The McMaster model training also provided a large effect size (2). Two of the 12 studies, OR program (8) and CARE and PREP (11), did not demonstrate significant effects. There have been studies with moderate effect sizes. They are the following: Hope therapy (1), web-based OR program (3), PREP (4), self-regulation couple therapy (10), and conflict resolution training (12). It was also observed that other than the previously mentioned two studies (2 & 5), several interventions, such as mindfulness-based cognitive therapy (6 & 9) and IBCT and ARCT (7), obtained substantial effect sizes.

Overall Effect Size

The goal of the current meta-analysis was to investigate the effectiveness of couple interventions in marital distress by comparing the post-intervention assessments of the experimental and control groups. The results indicate that the meta-analytic effect is statistically significant based on the overall effect size (Cohen’s d = 0.85, 95% CI: 0.56 −1.14) and the average outcome differing considerably from zero (Z = 5.79, P < 0.001). Compared to couples who did not get any treatments, the different couple therapies significantly influenced distressed couples who received the intervention (Fig. 2).

Fig. 2:

Forest plot of couple therapy with a random effect for the standard mean difference in distressed couples vs. controls

Using Cochran’s test, the heterogeneity of mean differences between studies was examined and found to be significant [Q(df=13) = 52.03, P < 0.001]. The amount of variance between studies or the influence of studies was also found to be high (I²=84.81%). Using restricted maximum likelihood, the estimation of the variance of the distribution of true effect sizes between studies also calculated the heterogeneity of the studies (T²= 0.23).

The article’s possible publication bias was explored through a funnel plot (Fig. 3). In the funnel plot, fail-safe number calculation was made using Rosenthal’s approach, the correlation was made using the Begg and Mazumdar rank test, and regression was done with the help of Egger’s test. The funnel plot demonstrated the possibility of publication bias. According to Rosenthal’s fail-safe test, a minimum of 917 unpublished or non-significant comparisons are required to increase the P-value of this meta-analysis to 0.05, which is regarded as a robust level. Begg and Mazumdar’s test rank correlation value (P < 0.01) and Egger’s test regression intercept value (P < 0.01) showed publication bias.

Fig. 3:

Funnel plot of random effect analysis of couple therapy in distressed couples vs. controls

The ‘Risk of bias’ assessment tool (Cochrane RoB 2), developed by Cochrane Collaboration, was utilized to assess the validity of included studies (39). Bias is assessed on five domains: randomization process, deviation in intervention, missing outcome data, measurement of outcome, and reporting of the outcome, along with an overall risk of bias. Bias is presented as judgement on three levels: green indicates low risk, yellow points out some concerns, and red refers to high risk (Fig. 4). Apart from utilizing the risk of bias tool, the co-authors reviewed the validity of the included studies.

Fig. 4:

Assessment for risk of bias for the included studies

Discussion

The purpose of the current meta-analysis was to assess the overall effectiveness of several couple interventions that have been implemented recently. The result revealed an overall effect size in favor of various couple interventions, producing significant outcomes in the dissolution of marital distress. Reviewed studies showed that these couple interventions not only reduce the levels of distress, depression, and anxiety in life partners but also contribute to enhancing their relational functioning, communication skills, and overall relationship satisfaction and well-being.

The theoretical ramifications of this review underscore the importance of various psychological frameworks in comprehending and addressing marital distress. They focus on multiple issues that raise concern for the couple, including emotional attachment, security in relationships, behavioral modifications, and communication (7). This could be the reason that despite the variety of models available (33,34,38), couple interventions are viewed as effective forms of treatment for marital distress (40). Other than the elements mentioned above, a standard set of phases present in the majority of couple intervention models probably also contributes to the effective resolution of marital distress (24,41). The phases include the assistance of an active therapist in identifying and conceptualizing dysfunctional factors contributing to marital distress, incorporating these dysfunctional elements into an established intervention model and identifying the areas of modification, designing and implementing a model-specific intervention, and evaluating the progress couple make and adapting to the need. Couple interventions that do not adhere to these phases may result in inconsistent effects on the dissolution of marital distress.

Consistent with prior research demonstrating that couple interventions significantly reduced marital conflicts, the present study provided findings that could be applied to a wide range of intervention models (3,11). Numerous studies have demonstrated that couples in conflict tend to respond to negative affective experiences, thereby perpetuating the cycle of negative exchanges, making their interactions predictable and structured (2,3,23). Couple interventions that correspond to the aforementioned phases are probably effective in helping couples find an adaptive way to escape these negative exchange cycles. These interventions may also address the demand-withdraw pattern, in which one partner exerts pressure on the other through demands, complaints, and criticisms while the other partner becomes defensive and inactive (23). Interventions that adhere to the phases of procedure may endure for years (3). They were also likely to reduce the subjective distress that each partner experienced from the external stressors (2).

In the individual studies, inconsistencies can be seen in the effect of the web-based OR Program. While the program was effective in enhancing relationship satisfaction, relationship confidence, and relationship quality (21), there were inconsistencies in reducing the participants’ depressive and anxiety symptoms (22). In addition, these participants had a high level of relationship distress in conjunction with moderate levels of anxiety and risks of clinical depression. Such web-based programs may be more appropriate for couples with less marital distress, who may find it simpler to engage their partners in activity (22). Also, in light of the studies (21,22), it must be noted that web-based or online interventions may become a need of time with technological advancements.

The PREP led to a reduction in marital conflict and an increase in marital satisfaction (35) in a sample of Iranian couples. The findings by Rogge et al. (17) are intriguing, comparing the effects of PREP to those of CARE and Relationship Awareness (RA) instructions in a sample of American couples. This study found no interaction between PREP, CARE, and RA couples, indicating that the interventions have comparable effects. Also, the effect size of PREP and CARE on the dissolution of marital distress in US couples was not statistically significant. The findings call into question the efficacy of educational interventions such as PREP and CARE in mitigating marital distress.

McMaster model training, CBT, integrative behavioral and affective reconstructive couple therapies, mindfulness-based cognitive therapy, self-regulation couple therapy, and conflict resolution training (5,16,25,34,36–38) were effective couple interventions for marital distress. The literature demonstrates that couple therapists adopting these models adhere to specific steps corresponding to the standard set of phases (5,25,26). An active therapist or trainer was present throughout these interventions. The therapist or the trainer assisted the couples in conceptualizing the issues they faced. With the assistance of the therapist or trainer, the couple could break the interactional cycle that was accumulating negative affective experiences, allowing them to develop mutual admiration.

The results of this meta-analysis should only be interpreted in light of the substantial heterogeneity typical of studies on behavioral interventions. Several factors, including differences in definitions, assessment, participant selection criteria, and statistical analysis, may account for this. We observed the effect of couple intervention on marital distress with a total of 1528 sociocultural and racially diverse participants from the American, African, and Southwest Asian regions. Publication bias was evident, indicating that studies with significant results are more likely to be published than those with smaller effect sizes or no significant results. While compiling the reviews, we focused on peer-reviewed journal articles whose conclusions could be guaranteed to be valid. Access restrictions to grey/unpublished literature could have decreased the risk of publication bias. Since most of these studies did not employ blinding techniques, they increased the possibility of bias. Apart from these, the equivalence test of the selected studies revealed that the distributions of the experimental and control groups were not identical.

The risk of bias assessment illustrated in Fig. 4 revealed considerable biases in several studies. Ten out of 12 studies reported bias arising from the randomization process (83%). Three studies reported bias due to deviation from the intended intervention (25%). Two studies reported bias due to missing outcome data (17%). It was noted that none of the studies reported bias in the measurement of the outcome, and one study reported bias in the selection of the reported result (8%). The overall risk of bias raises some concerns and reveals the presence of bias in the included studies.

Findings imply a relatively comprehensive view of the effectiveness of various couple interventions and may give us an idea of the nuances of various couple interventions. Couple counselors and educators can make use of the outlined interventions to deal with marital distress. For clinicians, a practical implication of the findings shows the importance of incorporating the elements from multiple frameworks to effectively tailor their strategies to address the varied requirements of couples. The incorporation of new technology tools, including online therapeutic platforms, which are becoming more and more relevant in the modern period, should also be investigated in research.

The current review and meta-analysis study have a few limitations. First, the generalizability of the results may be impacted by the heterogeneity of the included studies, such as differences in durations of interventions, number of samples, and cultural backgrounds. Second, there is a chance for response bias because many studies rely on self-reported measurements. Lastly, the presence of bias may have impacted the result of this research.

Conclusion

Despite the stated limitations, the current systematic review and meta-analysis have unveiled a notably significant positive impact in favor of couples who underwent interventions. This points to the fact that, despite the diversity of models used, interventions for couples are indeed effective in reducing marital distress when compared to couples who did not receive any such interventions. Therefore, even while we acknowledge the limitations of this meta-analysis, the findings strongly advocate for the use of effective couple interventions as a means to assist couples in coping with their marital distress, especially in light of the increasing number of distressed couples worldwide. Additionally, further research exploring the effectiveness of these interventions on different populations can contribute to a more comprehensive understanding of their impact.

Journalism Ethics Considerations

Ethical issues (Including plagiarism, misconduct, data fabrication and/or falsification, double submission and/or publication, redundancy, etc.) have been completely observed by the authors.