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. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: Couple Family Psychol. 2020 Jun;9(2):73–89. doi: 10.1037/cfp0000135

The path to couples therapy: A descriptive analysis on a Veteran sample

Amber M Jarnecke 1,4, Leigh E Ridings 1,5, Jenna B Teves 2, Karen Petty 2, Vickie Bhatia 3, Julian Libet 2
PMCID: PMC7351137  NIHMSID: NIHMS1577932  PMID: 32655982

Abstract

The current study uses descriptive data from a sample of Veterans and their partners (N = 97 opposite-sex couples) presenting to a Veterans Affairs Medical Center (VAMC). The purpose of this investigation was to examine 1) the problems couples face prior to seeking treatment; 2) how long it took couples to seek treatment; 3) what attempts couples made to improve their relationship prior to couples therapy. We also examined how these treatment initiation factors were related to relationship distress and expectations for therapy. Results suggest the relationship problems that precede Veteran couples seeking treatment are varied (e.g., stressors outside of relationship, communication problems, lack of trust) and agreement between partners on type of relationship problem is not predictive of relationship satisfaction, perception of relationship problem severity, nor expectations for therapy. Partners tend to wait approximately 4–7 years before pursuing couples therapy to resolve relational concerns. The length of time partners wait to pursue therapy is positively associated with optimistic expectations for therapy. In addition, prior to treatment initiation, partners tend to make multiple attempts to improve their relationship (M = 1.79 attempts for men; M = 2.40 attempts for women) and the number of unique attempts made to improve the relationship is associated with greater distress and more negative perceptions of relationship problem severity. Findings have implications for identifying Veteran couples who may be more or less receptive to intervention and informing the development of a stepped-care approach for couples treatment referral and planning.

Keywords: couples, Veterans, treatment initiation, practice setting

Intimate relationship distress is common among couples, and divorce rates remain at 40 to 50% for first time marriages (Amato, 2010). Relational distress is associated with a multitude of adverse outcomes including decreased well-being, increased psychopathological symptoms, and increased physical health symptoms (e.g., Beach, Katz, Kim, & Brody, 2003; Jarnecke, Reilly, & South, 2016; Orth-gomer et al., 2000; Whisman & Uebelacker, 2009; Whisman, Uebelacker, & Bruce, 2006; Wickrama, Frederick, Conger, & Elder, 1997). In efficacy and effectiveness studies there is strong support that a number of evidence-based couples interventions improve relationship satisfaction and functioning for Veteran and non-Veteran couples (Christensen et al., 2004; Doss et al., 2012; Johnson & Greenberg, 1985; Monson & Fredman, 2012; Monson, et al., 2012; Sautter, Glynn, Cretu, Senturk, & Vaught, 2015; Shadish & Baldwin, 2003; Wiebe, Johnson, Moser, Dalgleish, & Tasca, 2016). However, research examining which couples enter these evidence-based treatments and why is limited and has largely been conducted in community and civilian couples.

The Veterans Affairs (VA) and Department of Defense (DOD) have recently put forth plans and recommendations for integrating families into the care of Veterans (Department of Veterans Affairs, 2019; National Academies of Sciences, Engineering, and Medicine, 2019). Thus, it is crucial to examine Veterans who are already receiving couples and family services in order to identify the characteristics of these families and develop hypotheses about which Veteran families are not currently being reached and why. Given the distinct stressors that service members and Veterans encounter (e.g., combat exposure and trauma, reintegration), Veterans and their partners seeking couples therapy may present differently than civilian couples (Bowling & Sherman, 2008). It is necessary to understand the context surrounding the initiation of couples treatment in Veterans and what attempts had been made to improve the relationship prior to treatment initiation. This has implications for treatment referrals and treatment planning for Veteran couples. Thus, the current study sought to examine several treatment initiation factors among Veteran couples seeking couples therapy (i.e., problems couples experience before seeking therapy, how long it took couples to seek treatment, what attempts have been made to improve the relationship prior to therapy). Further, we examined how these factors related to relationship distress and expectations for therapy.

Treatment-seeking couples’ relationship problems.

Unsurprisingly, couples seeking therapy tend to report relational distress (Doss, Simpson, & Christensen, 2004; Jackson, Miller, Oka, & Henry, 2014). However, studies of community samples find that men and women in opposite-sex relationships have somewhat differing opinions on the types of relationship problems indicated for couples therapy. Both men and women who are not engaged in couples therapy identify interest in divorce, communication problems, and lack of emotional closeness as valid reasons to enter couples counseling (Adams, et al., 2013; Bringle & Byers, 1997; Doss et al., 2004). However, women are more likely than men to cite sexual intimacy problems, child rearing, and jealousy as additional reasons to enter therapy (Bringle & Byers, 1997). In samples of community couples engaged in treatment, among the most common reasons for seeking therapy are communication problems and perceived lack of emotional closeness (Doss et al., 2004).

Additional factors may underlie Veteran couples’ reasons for seeking therapy. Although some Veterans show great resiliency and report very few relationship concerns, certain Veteran sub-populations may be at increased risk for relationship distress and dissolution (Martin & Sherman, 2012; Sayers, Farrow, Ross, & Oslin, 2009). For instance, Veterans are at increased risk for mental health disorders, which may impact relationship functioning (Campbell & Renshaw, 2013; Fulton et al., 2015; McGinn, Hoerster, Stryczek, Malte, & Jakupcak, 2017). Further, rates of intimate partner violence in Veteran sub-populations can be relatively high. Between 13%−47% of Veteran couples report intimate partner violence (Campbell et al., 2003; Marshall, Panuzio, & Taft, 2005; Teten, Schumacher, Bailey, & Kent, 2009), with higher estimates found among Veterans who have posttraumatic stress disorder (PTSD) or depression (Sherman, Sautter, Jackson, Lyons, & Han, 2006; Teten et al., 2010). Research on community couples is mixed regarding whether violence or aggression is a reason couples seek therapy (Doss et al., 2004; Ehrensaft & Vivian, 1996), and it is unclear if Veteran couples cite intimate partner violence as a problem that precipitates initiating couples therapy. Although rates of infidelity are comparable among Veteran and civilian couples, in general, Veteran couples report higher rates of infidelity than civilian couples across deployment periods and when they seek marital therapy from family life chaplains (Atkins, Eldridge, Baucom, & Christensen, 2005; Balderrama-Durbin et al., 2017; London, Allen, & Wilmoth, 2012). Thus, the factors leading to couples treatment initiation may look different in Veterans as compared to civilians.

Time to treatment initiation.

With regard to length of time to treatment initiation, community couples report that they are typically distressed for an average of six years before availing themselves of relationship therapy (Notarius & Buongiorno, 1992, as cited in Gottman & Gottman, 1999). In some cases, couples do not seek therapy at all because it is “too late” to solve their relationship problems (Johnson, Makinen, & Millikin, 2001; Wolcott, 1986). Barriers to seeking psychotherapy, in general, may include stigma about receiving therapy, low expectations for therapy, financial cost of treatment, and/or lack of knowledge about where to receive services (Hoge et al., 2004; Manguno-Mire et al., 2007; Sareen et al., 2007). Veterans enrolled in VA services may seek couples therapy sooner, however, because of easier access to a couples therapy referral. Further, services may be more accessible for Veteran couples because the financial cost of couples therapy within the VA system is either covered or lower compared to the private sector.

Attempts to improve the relationship prior to therapy.

One reason distressed couples may wait to seek therapy is that they are interested in first seeking out other sources to improve their relationship. For instance, community samples of men and women frequently seek the support of close others to help them manage their relationship distress (Adams et al., 2013; Coker et al., 2002). Other research suggests that community-recruited newlywed couples are more likely to read self-help books to improve their relationship than they are to seek therapy; and if they seek therapy, a substantial minority have read self-help books first (Doss, Rhoades, Stanley, Markman, & Johnson, 2009). However, many popular self-help books are not evidence based, and therefore may promote misconceptions about healthy relationships or provide advice that is not based on research findings (e.g., self-help books tend to overstate the differences between men’s and women’s behavior and desires in relationships) (Signorella & Cooper, 2011). Gaining a better understanding of the resources Veteran couples seek to improve their relationships may inform recommendations and referral options. For instance, if a couple has been reading self-help books that lack an evidence base, a provider could recommend some evidence-based readings. If a couple has attempted to consult a spiritual leader about their relationship issues, referring them to an evidence-based couples therapy may be the next step. Knowing what attempts have been made to improve the relationship before treatment onset has implications for informing the most efficacious approach.

Current study.

The findings reviewed above highlight the most common issues and reasons that may contribute to why and when community and civilian couples seek therapy and what prior attempts couples have made to improve their relationship; however, much of the research in this area is outdated. Further, it is unclear if findings from these prior studies on community couples generalize to Veterans and their partners who may be at higher risk for certain individual and relational problems. To best treat Veterans couples and families, it is necessary to understand what problems couples are bringing to therapy. Further, knowing how the level of relational distress and treatment expectations are associated with how long couples wait to initiate therapy and what prior attempts each partner has made to improve the relationship will inform efforts for referring and treating Veteran couples. Thus, the current study analyzes written responses to a question about relationship problems and descriptive quantitative data to expand on previous research and address the following questions:

  1. What problems are treatment-seeking couples experiencing? Given that subpopulations Veteran couples are more likely to encounter certain threats to marital satisfaction and stability (e.g., mental health disorders, infidelity, aggression), we expect that analysis of written responses to a question assessing relationship problems will demonstrate a variety of individual and relational problems that precipitate treatment initiation. We also conduct exploratory analyses to examine agreement of responses between partners in a dyad and how agreement is related to relationship satisfaction, relationship problems severity and expectations for treatment.

  2. How long does it take couples to seek therapy and how is this related to their relational distress and expectations for treatment? Unlike community couples, who wait an average of six years to seek therapy (Notarius & Buongiorno, 1992), it is expected that Veteran couples may wait less time to pursue couples therapy. As couples who have been dealing with problems for longer may be more distressed, it is expected that partners who have waited longer to seek treatment will report lower relationship satisfaction, greater relationship problem severity, and less optimistic expectations for treatment.

  3. What attempts to improve the relationship have couples made prior to initiating treatment and how is this related to their relational distress and expectations for treatment? This was a largely exploratory question. It was expected that participants, on average, would have made at least one attempt to improve their relationship prior to initiation of couples therapy, but given the limited research in this area, no a priori hypotheses were derived about the type or number of unique attempts made. It was hypothesized that the number of unique attempts to repair the relationship would be associated with lower relationship satisfaction, perceiving relationship problems as more severe, and less optimistic expectations for therapy.

Method

Participants

Participants (N=194 individuals; 97 couples) were Veterans and their partners who were referred by a mental health or medical provider to a specialty outpatient Couples and Family Clinic at a Southeastern Veterans Affairs Medical Center (VAMC) between 2012 and 2014. Participants had a mean age of 47.33 (SD = 13.25, range = 19–79) at intake. Most individuals in the sample were European American/White (56.2%) or African American/Black (37.6%). Participants did not vary on any of the variables by race, other than severity of relationship problems. African American/Black participants rated their relationship problems as more severe that European American/White participants (t (178) = 3.91, p < 0.001). With regard to educational attainment, most participants had less than a bachelor’s degree (71.8%). Because the sample size of same-sex couples was small (n=4), all couples selected for the current study were opposite-sex couples: 83 couples (85.6%) were married. Of the remaining 14 unmarried couples, 6 were cohabitating at intake. Twenty-two couples (22.7%) reported that they had biological children with their partner, 59 couples (60.8%) reported that one or both partners had at least one child from a previous partner, 12 couples (12.4%) denied having any children, and data for 4 couples was missing or incomplete.

For the majority of couples, the male partner was a Veteran (82 couples; 84.5%); in 6 cases the female partner was the Veteran (6.2%) and in 9 cases both partners were Veterans (9.3%). Of the Veterans who provided data, they reported having served in Vietnam (n = 18), the First Gulf War (n = 16), and the recent wars in Iraq and Afghanistan – Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in Afghanistan (n = 32). Of the men, 38.3% stated that they had been to couples therapy previously in their current or a previous relationship and 41.5% of the women had been to couples therapy previously.

Procedures

This was a study of archival data. The data were collected for routine clinical purposes. Institutional Review Board approval was granted to study de-identified, aggregated data for research purposes. Before developing treatment goals and engaging in intervention, couples who participated in treatment had an initial conjoint assessment interview, an individual interview for each partner, and a conjoint feedback session using a “DEEP” (Differences, Emotions, External Stress, and Patterns) conceptualization derived from the IBCT model (Doss, Benson, Georgia, & Christensen, 2013; Jacobson & Christensen, 1996). During the DEEP conceptualization, couples develop an understanding of the individual and couple factors that have contributed to the development and exacerbation of their relationship difficulties.

To collect baseline data about couple (e.g., relationship satisfaction, relationship problems and problem severity, expectations for therapy) and individual-level functioning (e.g., self-reported physical and mental health concerns, depressive symptoms, PTSD symptoms, stress, emotional intelligence), couples were asked to complete a questionnaire packet at the end of their conjoint assessment session and return them on the date of their individual interviews. In the current study, we focus primarily on assessments of couples-level functioning. Couples presenting to the clinic with severe ongoing alcohol or substance use and severe interpersonal violence were referred to individual treatment rather than continuing couples therapy, as per the clinic’s standard practice.

Measures

Relationship satisfaction.

Sum scores for the Couples Satisfaction Index 4-item version (CSI-4) were used to assess relationship satisfaction at baseline. The CSI-4 shows high internal consistency and convergent validity with other well-validated measures of relationship satisfaction, and with the 32-item version of the same scale (Funk & Rogge, 2007). Scores on CSI-4 range from 0 to 21, with higher scores representing greater satisfaction (α = 0.88 among men, α = 0.91 among women in the current sample). The established cutoff for clinical distress is 13.5 (Funk & Rogge, 2007).

Perceptions of the relationship and expectations for therapy.

Participants were asked eight questions that assessed their perceptions about relationship problems and their confidence that their problems would improve with therapy. Items were rated on a Likert scale (0=strongly disagree to 4=strongly agree). One subscale (4 items; α = 0.61 among men, α = 0.77 among women), which was reverse-scored, assessed participants’ perceptions of how severe their relationship problems are compared to other couples (e.g., “Our relationship doesn’t have any more problems than most relationships.”). Another subscale (4 items; α = 0.78 among men, α = 0.82 among women) assessed participants’ expectations for couples therapy (e.g., “With help, I am confident that we’ll be able to improve our relationship.”).

Relationship problems.

To assess what types of relationship problem couples were encountering prior to treatment initiation, participants were asked to provide a written response to: “Please describe the event or situation that made you realize that your relationship had problems.”

Time to treatment initiation.

Participants were asked to provide a date for when they first realized they had a relationship problem and when they first started looking for a couples therapist. The length of time participants waited to initiate couples therapy was calculated by subtracting the date couples first entered treatment from the date participants stated they realized they had a relationship problem.

Attempts to improve the relationship.

Participants reported what sources they turned to for help with their relationship before seeking couples therapy. Response options (Yes/No) included: family member, friend, clergy member, physical health professional, individual therapist, book, magazine article, website, or other. The number of affirmative answers were summed to create a variable that captured number of unique attempts made to repair the relationship prior to entering therapy.

Data analysis

A descriptive analysis on written responses to the open-ended prompt was performed by first and second authors based on guidelines provided by Bradley and colleagues (2007). The two authors examined 25% of responses (N=30 of 118 available responses) together to identify themes in the data, consistent with the “DEEP” conceptualization (Doss, Benson, Georgia, & Christensen, 2013; Jacobson & Christensen, 1996). A codebook was created from identified themes; coders coded responses independently and then compared codes (κ = 0.84). Where coders disagreed, the third author was a consensus coder who resolved discrepancies. Among couples in which both partners provided qualitative data, agreement between partners on codes falling under major themes was examined. We explored how agreement between partners on at least one major theme (1 = agreement; 0 = no agreement) predicted relationship satisfaction, relationship problem severity, and expectations for therapy using SPSS MIXED. Because we had a sample of opposite sex couples, we tested the effect of sex as well (1= male; −1 = female). Thus, agreement, sex, and the interaction of agreement by sex was entered in each respective model.

Descriptive statistics were conducted for all quantitative data. Where appropriate, paired t-tests or McNemar’s chi-square tests were used to determine whether male and female partners within a couple differed on relational distress measures, expectations for therapy, wait time to treatment initiation, and number and types of attempts made to improve the relationship prior to treatment. Some variables had missing data, and when this occurred, those cases were excluded from analyses.

Six independent models tested whether the 1) length of time to treatment initiation and 2) number of attempts to improve the relationship prior to treatment predicted relationship satisfaction, relationship problem severity, and expectations for couples therapy at treatment initiation. To test these research questions, SPSS MIXED was used to conduct actor-partner interdependence models (APIM) in a multi-level framework (Kenny, Kashy, & Cook, 2006). This approach handles missing data using maximum likelihood estimation and accounts for the nonindependence of data (individuals within couples). This allows the ability to assess the contributions of both partners’ on measures of relationship functioning (i.e., satisfaction, relationship problem severity, expectations for therapy). Length of time to treatment initiation and number of attempts to improve the relationship were mean centered and treated as continuous predictor variables. We also tested the effect of sex in these models. Pseudo-R2 estimates were calculated for each of the six APIM models to examine the proportion of variance in the dependent variable associated with the predictor variables (Kenny, Kashy, & Cook, 2006). For all analyses, p-values < 0.05 are considered statistically significant.

Results

Descriptive statistics of relationship distress and expectations for couples therapy at treatment initiation.

Women (M = 8.87, SD = 2.13) and men (M = 9.84, SD = 2.63), on average, reported clinically significant relationship distress on the CSI-4. Paired t-tests show that women reported significantly lower relationship satisfaction than their male partners (t (90) = −2.65, p = 0.009). Likewise, women (M = 2.76, SD = 0.79) rated their relationship problems as more severe than men (M = 2.34, SD = 0.75; t (94) = −4.24, p < 0.001). Women (M = 2.91, SD = 0.68) and men (M = 2.88, SD = 0.68) reported they were somewhat optimistic about couples therapy and partners did not differ in their expectations for therapy (t (94) = 0.28, p = 0.783).1

Relationship problems.

Of the total number of couples in the sample, 76 couples had at least one partner who provided responses to the open-ended question. Thus, we had 118 individual participants who provided responses to this question. Seven of these responses were excluded from analysis because the information given was unclear or did not address the prompt. Thus, 111 individual participant responses were deemed codable. These respondents did not differ from the overall sample with regard to age, relationship satisfaction, and expectations for therapy; they did, however, rate their relationship problem as somewhat more severe (M = 2.70, SD = 0.77) than individuals who did not provide a response (M = 2.35, SD = 0.79); t (189) = −3.015, p = 0.003).

A total of 11 themes were identified in the coded responses. In some cases, these 11 major themes were divided into sub-themes (e.g., Arguing was a subtheme that fell under the larger theme of Communication). Responses had the potential to be coded under the major theme or the sub-theme. Open-ended responses often contained information that fit with more than one major theme and/or sub-theme, and thus a participant’s response could be coded under multiple themes. A total of 184 codes were made among the 111 codable responses. Themes and sub themes, with illustrative quotes, are provided in Table 1. Individual participants were most likely to indicate that events or problems related to Stress Outside of the Relationship (29.7% of all codes), Communication (28.8%), Distancing Behaviors (22.5%), and Trust (22.5%) contributed to the realization of problems within their relationship. Notable subthemes, which at least 10% individual participants endorsed, include Arguing (13.5%), Infidelity (12.6%), and Lack of Emotional Intimacy (10.8%).

Table 1.

Themes derived from coding of open-ended question.

Theme % Code Example*
Stressors 29.7
 Finances/job 9.0 Finally accepting that my husband would not listen to reason when it came to sending money to scammers about his timeshare obligations.
 Health 3.6 Relapse on drinking, death of her son, not understanding her knee pain, her financial status, son.
 Adult caretaking responsibilities 3.6 When my mom was in her final year and I was taking care of her.
 Parenting differences 5.4 Arguing about my daughter and parenting.
 Loss of loved one 3.6 My son’s death.
 Lack of outside support 3.6 Violence & verbal abuse, needed support from my family, despair/hopelessness; hard for my family.
Communication 28.8
 Arguing 13.5 The fact that we argued and were angry with each other more often than not put me on notice that we had serious problems.
 Criticizing 3.6 She don’t support me, she yells and blames me, she is constantly gone from the house, she doesn’t want to have oral sex, she feels that her commitment to the church is more important than our marriage, she feels that everything going on with her is more important than our marriage, she is selfish.
Distancing 22.5
 Avoidance 8.1 When my husband would make excuses/reasons to leave the house to go to the store almost every morning. Also when he didn’t come home because he would be out using drugs and drinking sometime after our 1st child died.
 Lack of emotional intimacy 10.8 I don’t know that our problems are worse, I just know I’m unwilling to live unhappy. I’m not ready to roll over and accept a life we don’t connect with or want to live in separate rooms.
 Lack of shared interests/activities 3.6 Our inability to find activities that we could enjoy together. My interests did not appeal to her.
Lack of trust 22.5
 Infidelity (suspected or confirmed) 12.6 I started cheating.
 Dishonesty 6.3 He lied about drinking/drug use, his past, and still does to this day. Lies about drinking and what bills he can take care of.
Issues/Problematic Behavior of a Partner 21.6
 Alcohol and substance use problems 7.2 Alcohol has always been an issue but our dog passed away and [husband] went on a 3-day drinking binge which I had never witnessed before.
 Stealing 0.9 When he confessed to being addicted to crack cocaine, when he cheated, and when he stole my laptop and my mother’s wedding ring and pawned it.
 Mental health 2.7 She has many challenges involving bi-polar, substance abuse, PTSD, severe physical and sexual abuse as a small child. I am sober alcoholic who grew up in an alcoholic home, and very much belong in Al Anon. Relationship has history of psychotic behavior and violence on her part. We both need healthy relationship skills.
 Inappropriate behavior toward/potential abuse perpetration on a family member 0.9 When I found out my husband had sex with my daughter.
Intimate partner violence 11.7
 Psychological 4.5 Moved in together. He was very controlling and demanding and possessive. I didn’t realize how much before we lived together.
 Physical 7.2 Arguing, some physical abuse, cheating.
Experience of negative emotions in presence of a partner 9
 Hot emotions 5.4 Silence and distant feeling between us. Constant anger, bitterness. Thought of leaving, giving up on marriage. Husband was unfaithful.
 Cool emotions 3.6 When he began yelling at me on the phone, tearing apart my personality and giving me suggestions on how I could change. I started crying and he yelled louder. When I hung up on him, I felt like I had no right to be alive.
Sexual problems 8.1 Increasingly lost sexual interest.
Invalidation/lack of partner support 5.4 The way we fight. We can never come to an agreement. The lack of respect, consideration towards each other.
Temporary or threatened separation 4.5 Wife stated she was not sure she would remain married to me.
Received outside support 1.8 Spoke to a friend for support.
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Note. % Code refers to percentage of individual participants whose responses were aligned with this theme.

*

Selected example quotes often contain more than one theme. Words/phrases that illustrate theme are in bold.

Among couples in which both partners provided responses (N = 35 couples), we examined agreement between major theme codes. Nearly half of couples (n = 17 couples) agreed on at least one problem within their relationship. Five dyads agreed and 11 disagreed that Stress Outside of the Relationship as a problem in their relationship; four dyads agreed and 10 disagreed that Communication was a problem. Additionally, four dyads agreed, and 7 dyads disagreed that Trust was a problem. Two dyads reported that Intimate Partner Violence was a problem, while 5 dyads had discordant responses as to whether Intimate Partner Violence was a problem in the relationship. One dyad agreed and 10 dyads disagreed that Distancing Behaviors was a problem. Further, one dyad agreed that Issues/Problematic Behavior of a Partner was problematic for the relationship while five dyads disagreed about this being a problem for the relationship. Next, respective models examined how agreement between partners in at least one relationship problem predicted relationship satisfaction, relationship problem severity, and expectations for therapy. Across these three models, we found that neither agreement nor the interaction of agreement by sex predicted relationship distress nor expectations for couples therapy variables (see Table 2).

Table 2.

Unstandardized estimates and standard errors of agreement on relationship variables

Predictor Variable Relationship Satisfaction Relationship Problem Severity Positive Expectations for Couples Therapy
Agreement (SE) 0.67 (0.62) −0.01 (0.18) 0.16 (0.19)
Sex (SE) 1.04 (0.46)* −0.12 (0.11) 0.07 (0.12)
Agreement × Sex (SE) −1.03 (0.66) 0.01 (0.16) −0.26 (0.17)
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Note.

*

p < 0.05

Initiation of treatment.

Men reported they waited an average of 3.73 years (SD = 4.36) to enter treatment and women reported, on average, they waited 7.39 years (SD = 11.64) to enter treatment. The difference between male and female partners’ wait time approached statistical significance (t (29) = −1.83, p = 0.079), and likely did not reach the threshold for significance due to large SDs surrounding the means. However, it is clinically relevant to note that women reported that they waited, on average, approximately three more years than their male partners to enter couples therapy after realizing there were problems in the relationship.

Results from three independent APIM models suggest that sex significantly predicted relationship satisfaction and relationship problem severity while accounting for each partner’s reported length of time to initiating couples therapy (Table 3), such that women reported lower relationship satisfaction and greater relationship problem severity than men.2 For the model examining relationship satisfaction, the pseudo-R2 = 0.13, suggesting 13% of the variance in relationship satisfaction was attributable to each partner’s time to initiate therapy, sex, and the interaction between these variables. For the model examining relationship problem severity the pseudo-R2 = 0.00. Partner’s time and the interaction of partner’s time by sex significantly predicted expectations for couples therapy. That is, individuals whose partners endorsed waiting longer to initiate treatment had more positive expectations for therapy. This effect was moderated by participant sex, such that female partners reported more positive expectations for therapy when their partner had reported a greater length of time, relative to a shorter period of time, to initiate treatment. The pseudo-R2 = 0.40 for this model.

Table 3.

Unstandardized estimates and standard errors of actor and partner effects of time to therapy on relationship variables

Predictor Variable Relationship Satisfaction Relationship Problem Severity Positive Expectations for Couples Therapy
Actor’s Time to Therapy (SE) −0.08 (0.06) 0.00 (0.02) −0.01 (0.01)
Partner’s Time to Therapy (SE) 0.02 (0.05) −0.02 (0.02) 0.04 (0.12)**
Sex (SE) 0.90 (0.32)** −0.27 (0.08)** 0.06 (0.06)
Actor Time to Therapy × Sex (SE) −0.08 (0.06) −0.02 (0.02) 0.02 (0.01)
Partner Time to Therapy × Sex (SE) 0.03 (0.05) 0.02 (0.02) −0.04 (0.01)**
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Note.

*

p < 0.05,

**

p < 0.01.

Attempts made to improve relationship prior to treatment.

On average, men indicated they made significantly fewer unique attempts (M = 1.79, SD = 1.74) to improve their relationship prior to entering treatment compared to their female partners (M = 2.40, SD = 1.86, p = 0.016). As seen in Table 4, women were more likely than their male counterpart to turn to a family member or friend as a source to seek relationship help.

Table 4.

Sources of relationship help used prior to initiating couples therapy

Source of Relationship Help Men (%) Women (%) p-value
Family Member 32.97 54.00 0.008
Friend 29.67 54.95 0.001
Clergy 14.44 14.44 1.000
Therapist 35.56 33.33 0.878
Nurse/Physician 17.78 18.89 1.000
Book 23.33 23.33 1.000
Magazine 11.24 20.22 0.152
Website 12.09 17.58 0.332
Other 11.29 12.90 1.000
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Note. p-values derived from McNemar’s chi-square; p < 0.05 signifies statistical significance.

Three independent APIM analyses revealed that sex as well as one’s own number of unique attempts to improve the relationship prior to therapy were significantly associated with ratings of relationship satisfaction and relationship problem severity (see Table 5). Specifically, individuals who made more unique attempts to improve their relationship were less satisfied with their relationship and reported viewing their relationship problems as more severe. Accounting for number of attempts made by self and partners, men reported higher relationship satisfaction and rated their relationship problem severity as lower than their female counterparts. For the model examining relationship satisfaction, pseudo-R2 = 0.09, suggesting 9% of the variance in relationship satisfaction was attributable to each partner’s number of unique attempts to improve the relationship, sex, and the interaction between these variables. For the model examining relationship problem severity, pseudo-R2 = 0.09. There were no significant effects of the number of unique attempts made by self or partner on positive expectations for couples therapy (pseudo R2 = 0.00).

Table 5.

Unstandardized estimates and standard errors of actor and partner effects of number of attempts on relationship variables

Predictor Variable Relationship Satisfaction Relationship Problem Severity Positive Expectations for Couples Therapy
Actor’s No. Attempts (SE) −0.35 (0.10)** 0.10 (0.03)** −0.04 (0.03)
Partner’s No. Attempts (SE) 0.00 (0.10) 0.00 (0.03) 0.05 (0.03)
Sex (SE) 0.41 (0.17)* −0.18 (0.05)*** −0.04 (0.05)
Actor Attempts × Sex (SE) 0.00 (0.10) 0.02 (0.03) 0.00 (0.03)
Partner Attempts × Sex (SE) −0.05 (0.10) 0.00 (0.03) 0.01 (0.03)
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Note.

*

p < 0.05,

**

p < 0.01,

***

p < 0.001.

Discussion

The current study used descriptive clinical data collected from treatment-seeking Veteran couples to examine the problems that bring couples to therapy. Further, this study examined the length of time partners waited to initiate treatment, partners’ prior attempts to improve the relationship, and how these factors impacted relationship satisfaction, relationship problem severity, and expectations for therapy. The current study’s findings aim to bridge the research to clinical practice gap (Kazdin, 2008) and provide a novel examination of Veteran couples presenting for couples therapy in a real-world clinical setting.

Relationship distress and expectations for couples therapy at treatment initiation.

Both men and women fell within the distressed range of relationship satisfaction upon initiation of treatment; however, women reported greater distress than their male partners. In addition, women rated their relationship problems as more severe than men. These findings mirror those of a meta-analysis that examined gender differences in treatment-seeking couples (Jackson, et al., 2014). Even though men and women differed in their satisfaction with the relationship and how severe they perceived their problems, partners did not differ in their expectations for couples therapy. These findings suggest that although partners may need to unify in their perspective of their relational problems, both partners may have somewhat optimistic views of therapy.

Relationship problems.

Our qualitative findings regarding the types of problems that bring couples to therapy suggest that outside stressors, communication, distancing behaviors, and trust are common reasons Veteran couples seek couples therapy. This is largely consistent with findings from community samples examining factors that bring couples to seek treatment (e.g., Adam et al., 2013; Bringle & Bryers, 1997; Doss, 2004). In particular, Arguing (subtheme under Communication), Infidelity (subtheme under Trust) and Lack of Emotional Intimacy (subtheme under Distancing Behaviors) were frequently reported in this sample. Relative to research on community samples exploring why couples seek treatment (i.e., Doss et al., 2004), this Veteran sample was more likely to endorse infidelity as a precipitant to seeking therapy (12.6% of our sample reported infidelity as a relationship problem compared to 6% of the sample in Doss et al., 2004). In addition, in contrast to some other studies on community samples, this study finds that physical intimate partner violence is a precipitant for Veteran couples seek therapy (7.2% in the current study compared to 2% in Doss et al., 2004, though Doss and colleagues subsequently found that rates of violence were reported to be much higher on a standardized self-report scale). Thus, Veteran couples may be more likely to identify and/or seek treatment for these types of serious relationship issues than civilian couples and may require a higher level of care if these concerns are disclosed during the intake process. Further, participants in this Veteran sample identified other issues, such as a partner’s individual problems (e.g., illegal behavior, alcohol and substance use, mental health problems), sexual problems, and experiencing negative emotions in the presence of a partner that led them to realize their relationship was problematic. However, individuals who responded to the prompt tended to rate their relationship problems as more severe than non-responders. Thus, findings from this analysis need to be interpreted with consideration to the fact that the most distressed individuals reported on their relationship problems.

In general, identifying the particular relational problems that bring couples to therapy is crucial, as this information may inform treatment approach. Finances, parenting stressors, and lack of intimacy are common reasons couples (Veteran or civilian) seek therapy. Thus, using existing evidence-based therapies may be appropriate for addressing these common issues (e.g., Christensen et al., 2004; Johnson & Greenberg, 1985). However, if a couple identifies other issues, such as alcohol or substance use, as a concern for the relationship, providers can offer couples therapies focused on these issues (e.g., McCrady & Epstein, 2009; O’Farrell & Fals Stewart, 2006). Likewise, there are couples therapy treatments specific to targeting one or both partners’ mental health issues, such as PTSD (e.g., Monson & Fredman, 2012), couples-based protocols designed to address relatively low to moderate levels of partner violence when couples decide to remain intact (e.g., Stith, Rosen, McCollum, & Homsen, 2004), and therapies designed to address infidelity (e.g., Baucom, Snyder, & Gordon, 2005). Thoroughly examining these issues should be considered part of a comprehensive couples assessment so that individualized, evidence-based treatments can be employed.

Additionally, our analyses examining agreement between codes among couples in which both partners provided responses to the open-ended question indicates that the majority of couples provide discordant responses about problems in their relationship. Although some partners agree about the issues they are facing, many may be focused on different problems. Future research may want to examine factors (e.g., similarity in temperament, coping skills) that predict whether partners are likely to agree or disagree on problems in their relationship. Even though many partners did not agree on the relationship problem that precipitated treatment initiation, this did not impact level of relationship satisfaction, perception of relationship problem severity, or expectations for therapy. Thus, agreement on relationship problems may not have a substantial impact on how couples are functioning or perceiving therapy. It is common practice for therapists to have partners identify major relationship problems and goals for therapy. Thus, therapists should take note when partners identify discrepant reasons for seeking therapy and reconcile or work through these differences. Future research is needed to determine if agreement of relationship problems at treatment initiation is predictive of treatment outcome.

Time to treatment initiation.

Results from the current study also yielded information on how long partners waited to seek couples therapy after realizing they had relationship problems. Results suggest that it took participants approximately 4–7 years, on average, to engage in couples treatment. While this estimate is comparable to findings in community-recruited samples (Notarius & Buongiorno, 1992), the average wait time for this sample is noteworthy given the increased accessibility of in-house couples therapy referrals by VA providers (e.g., access to referral sources, low to no cost for therapy). Further, the average length of time it took for couples to seek treatment was unexpected given that a substantial proportion of partners reported that they had been engaged in couples therapy previously (either in their current relationship or with a previous partner). However, other studies of community-recruited participants seeking therapy show even higher rates of previous couples therapy experience (57%; Doss et al., 2004). Future research should examine how previous experience in couples therapy influences individuals’ views about future treatment seeking. Perhaps couples wait years to come to therapy because they have had previous negative experiences with couples therapy or because their current relationship problems seem less severe than previous relationship problems with their current or a former partner. Also, although the difference was not statistically significant, women reported waiting longer than men to pursue treatment. Previous research has shown that women are more likely to initiate couples therapy than men so perhaps women are more prone to acknowledging relationship problems earlier (Doss et al., 2003; Guillebeaux, Storm, & Demaris, 1986; Wolcott, 1986).

We also examined how length of time participants waited before pursuing couples was associated with relationship satisfaction, perceptions of the severity of the couple’s relationship problems, and expectations for couples therapy. Overall, we found that time to treatment initiation was not associated with relationship satisfaction or perceptions of problem severity; however, individuals with partners who reported waiting longer to pursue couples therapy had more optimistic expectations for therapy, and this effect was amplified among women. It may be that individuals, particularly women, who have partners who recognize that their relationship problems have been ongoing are relieved when they decide to go to therapy; thus, they have more positive expectations for therapy. This finding is particularly notable because predictors in this model accounted for 40% of the variance in expectation for therapy. Thus, providers may find it important to assess how long couples have had concerns about their presenting problem so as to capitalize on any positive expectations the couple has for therapy. However, providers should also discuss with the couple setting realistic expectations for therapy so that if positive expectations are not met as soon as anticipated the couple does not get discouraged and terminate. Future research should examine how expectations for therapy translate to therapeutic outcomes and retention over the course and at the end of treatment.

Attempts to improve the relationship prior to therapy.

Finally, this study examined the attempts partners have made to improve their relationship prior to initiating couples therapy. Overall, women made a greater number of unique attempts to improve their relationship prior to treatment initiation than men. Some participants provided a more detailed description of the types of relationship resources they sought (e.g., book titles), and upon post-hoc examination of these data, it appeared that most participants were accessing non-evidence-based relationship resources (e.g., book, magazines, websites containing information without an evidence base). Because sources outside of the relationship have the potential to shape couples’ views about what a healthy relationship looks like, as well as their hopes and expectations for change in their relationship, providers should educate themselves on basic couples’ issues and resources. This will facilitate providers in recommending appropriate evidence-based materials or skills to couples in distress. Practitioners may also consider assessing the type and number of attempts previously made to improve the relationship before recommending a resource or approach (e.g., guided self-help versus relationship check-up versus evidence-based psychotherapy) (Cordova et al., 2014).

Number of attempts to repair the relationship prior to treatment initiation was associated with less relationship satisfaction. In addition, partners who made a greater number of unique repair attempts indicated greater relationship problem severity than partners who made fewer attempts. Because these individuals report more distress and see their problems as worse than what the average couple experiences, these couples may be more difficult to treat. They may also be less receptive to interventions because they have had a number of unsuccessful attempts in the past. Future research should explore whether partners who have made more attempts to repair their relationship prior to entering treatment benefit from their treatment expectations be addressed immediately. Alternatively, these couple may need a more intensive or higher level of care. Studying how relationship repair attempts prior to therapy impact treatment may allow for the development of a stepped care approach for managing relational issues (see Bower & Gilbody, 2005 for a review of stepped care models in psychological treatments).

Limitations.

This study is not without its limitations. The educational attainment and ethnicity of this sample is consistent with the Veteran population nationally (National Center for Veterans Analysis and Statistics, 2017), but current findings may not generalize to other samples in terms of demographics, other individual difference traits, or relational distress. To better identify who presents for couples treatment (and who does not) across clinical settings, future research should collect data from additional and diverse samples. For instance, due to low sample-size, same-sex couples were excluded from the current study but this population and populations of transgender couples are important to examine in future research. Also, although we found that African American/Black participants did not differ from European American/White on most of the variables examined in this study, they did rate their relationship problems as more severe than European American/White participants. Future research should examine how individuals who identify with other races and ethnicities may or may not differ with regard to treatment initiation factors. Examining how psychiatric diagnoses was associated with expectation for therapy, length to treatment initiation, and other relevant variables was beyond the scope of this study. Accounting for current and past psychiatric disorders at the start of treatment may expand our knowledge of who seeks treatment and inform treatment approach.

The current study had limitations regarding its design and measures. Data were collected as part of ongoing assessments in a clinic and rigorous control of recruited participants and study design were not feasible in this setting. At the time of data collection for the current study, data on how many referrals were made to the couples and family clinic and how many referred individuals were subsequently referred to individual treatment were not systematically collected. In addition, many of our assessments were created by members of the clinic and designed for clinician’s utility. For instance, our assessments measuring which partner initiated treatment and attempts partners made to repair the relationship prior to treatment were developed by members of the clinical team and consisted of single items. Further, our measures of perceptions of and expectations for couples therapy were developed by the clinic. Thus, our assessments should be further developed, examined, and validated in other samples. In addition, we had limited qualitative data, as only written responses to one open-ended question was analyzed in this study. Ideally, the themes identified from responses to the open-ended question could be compared to quantitative measures of relationship problems to ensure validity of the data (Onwuegbuzie & Leech, 2007); however, the current investigation lacked such a comparison measure. Future work should consider developing and validating a more thorough assessment of factors related to the initiation of couples therapy and the issues that lead partners to seek treatment and follow. Further, using other methods for the collection of qualitative data among dyads (e.g., interviewing partners together and separately to systematically collect qualitative data) is a promising avenue of future research (Eisikovits & Koren, 2010; Manning & Kunkel, 2015).

Conclusions.

The current study provides a starting point for understanding how and why Veterans and their partners seek couples therapy within a VAMC. This information is critical in identifying characteristics of couples engaged in treatment and allows researchers and practitioners to develop new predictions as to which couples require a higher level of care. Further, the value of these findings are not limited only to VA providers who practice couples therapy. Educating all VA providers about couples issues, couples resources, and couples-based treatment options is crucial for developing a plan of care that will lead not only to relationship improvements for the Veteran but also the enhancement of his or her individual functioning.

Acknowledgments

This manuscript is the result of work supported, in part, by the National Institute on Alcohol Abuse and Alcoholism (T32AA007474 and K23AA027307).

Footnotes

1

Psychiatric diagnoses were not systematically collected in the current study, but depression and PTSD symptoms were assessed. Preliminary analyses suggest that depressive and PTSD symptoms were associated with relationship satisfaction but not relationship problem severity or expectations for treatment. Full results from these analyses are available from the first author.

2

Relationship length was entered as a covariate in independent actor partner interdependence models. It was not a significant predictor of any of the outcome variables and was thus removed from the subsequent models.

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