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Hope-Focused Approach to Couple Enrichment in Counseling

January 2017
In book: The Encyclopedia of Marriage, Family, and Couples Counseling (pp.806-808)
Edition: Vol 4
Publisher: SAGE
Editors: J. Carlson & S. Dermer

University of Puget Sound

State University of New York at Plattsburgh

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Marriage and Relationship Education (MRE): Research on Effectiveness and Implementation Collection by Topic

Table of contents:.

Introduction and Definitions Meta Analyses or Longitudinal Studies Federal and State Evaluation Studies I mplementation Lessons On-Going Evaluation

Introduction

The emerging field of marriage and relationship education (MRE), in which the federal government and numerous states have invested substantial funding, seeks to promote relationship stability and prevent future break-up by teaching couples communication and conflict resolution skills. It differs from therapy in that it seeks to reach couples before major conflict occurs. MRE can often be taught by lay people with proper training, and is a relatively short course of instruction- usually between 8 and 20 hours over a weekend or period of weeks.

There is now substantial research that examines the effectiveness of these programs and their ability to bolster communication skills and couples' relationship satisfaction as well as encourage marriage and decrease the odds of relationship dissolution. Most of the research to date has focused on a largely White, middle class population. More recent studies are shedding light on MRE's ability to impact low-income as well as ethnically diverse populations (e.g., African Americans, Hispanics). Still other research is focusing on lessons learned from implementing these programs. This collection presents the evidence base to date on the effectiveness of MRE programs as well as challenges and best practices in implementing these programs. The sources are presented in chronological order.

Any views expressed in the papers and resources presented in this Collection do not necessarily reflect the opinions of the NHMRC.

The NHMRC would like to thank Jane Koppelman, MPA of the Lewin Group and Alan Hawkins, PhD, of Brigham Young University for their contributions to the development of this Collection. This is a product of the NHMRC, led by co-directors Mary Myrick, APR, and Jeanette Hercik, PhD, and project manager Rich Batten, ThM, MEd, CFLE.

Definitions

Randomized control trials (RCT): In this approach, participants are enrolled in the study and measured on key variables such as relationship well-being. They are then randomly assigned either to a treatment group that receives the intervention or to a control group that does not receive the intervention. Through random assignment, individuals/couples have an equal chance of being assigned to either of the groups; the process creates two groups that are comparable. After the intervention, both groups of study participants are measured again on key outcomes and averages for both groups on all of the outcomes are calculated.

Pilot Study: A pilot study is a standard scientific tool allowing researchers to conduct a preliminary analysis before conducting rigorous research. Meta-analytic study: Meta-analysis is a set of systematic procedures for identifying all of the research on a particular topic (including unpublished research such as dissertations and policy group research that does not get into the academic journals) and then combining the findings of those studies for further analysis.

Program Implementation Study: In an implementation or process evaluation, researchers examine how the intervention is implemented, often gathering data through on-site observations, interviews with leaders and staff, case file and administrative data reviews, and interviews with participants.

Meta Analyses or Longitudinal Studies

Between 1975 and the mid 2000s, over 150 evaluations were conducted on MRE programs. About one-third of these were randomized control trials. Most of the participants were middle class, well-educated couples (either married or engaged) who were in low-distress relationships. The studies focused largely on MRE's ability to improve couple communication skills and relationship satisfaction. Many tracked participants' results after the program, but only a few followed them for longer than six months. Research described in this section highlights some of these early findings. The studies are presented in chronological order.

Markman, H. J., Renick, M. J., Floyd, F., Stanley, S., & Clements, M. (1993). Preventing marital distress through communication and conflict management training: A four and five year follow-up. Journal of Consulting & Clinical Psychology , 61, 70-77. doi: 10.1037/0022-006X.61.1.70 Four and five year follow-up data from the Prevention and Relationship Enhancement (PREP) program (Stanley & Markman, et al), show that participating couples, when compared with control group couples, had higher levels of positive and lower levels of negative communication, as well as lower levels of marital violence.

Butler, M. H., & Wampler, K. S. (1999). A meta-analytic update of research on the Couple Communication program. The American Journal of Family Therapy , 27, 223-237. doi: 10.1080/019261899261943 A meta-analysis of 16 Couple Communication studies found improvements in couple communication and moderate couple-perceived changes. The training is effective, the authors note, but not substantially so than other communication training programs.

Carroll, J. S. & Doherty, W. J. (2003). Evaluating the Effectiveness of Premarital Prevention Programs: A Meta-analytic Review of Outcome Research. Family Relations , 52, 105-118. This comprehensive review reported results indicating that the average person who participated in a premarital prevention program was significantly better off afterwards than 79% of people who did not participate. Findings suggest that premarital prevention programs are generally effective in producing immediate and short-term gains in interpersonal skills and overall relationship quality, conclusions about long-term effectiveness remain elusive.

Jakubowski, S., Milne, E., Brunner, H. & Miller, R. (2004). A Review of Empirically Supported Marital Enrichment Programs. Family Relations , 53 (5), 528-536. This is a comprehensive review of the outcome research on 13 specific marital enrichment programs. Only four programs could be considered "efficacious," three were found to be "possibly efficacious," and six were considered "empirically untested."

Stanley, S. M., Allen, E. S., Markman, H. J., Saiz, C. C., Bloomstrom, G., Thomas, R., Schumm, W. R., & Baily, A. E. (2005). Dissemination and evaluation of marriage education in the Army. Family Process , 44, 187-201. The Prevention and Relationship Enhancement Program (PREP) was well received by the Army population and resulted in improvements in relationship functioning, with no significant differences in changes among males and females or among couples of different ethnicities.

Cowan C. P., Cowan, P. A., & Heming, G. (2005). Two variations of a preventive intervention for couples: Effects on parents and children during the transition to school. In P. A. Cowan, C. P. Cowan, H. Ablow, V. K. Johnson, & J. R. Measelle (Eds.), The family context of parenting in children's adaptation to elementary school (pp. 277-312). Mahwah, NJ: Lawrence Erlbaum Associates. Family relationships that are more positive and satisfactory during the pre-school period may allow children to enter elementary school more able to meet the challenges of this transition.

Stanley, S. M., Amato, P. R., Johnson, C. A., & Markman H. J. (2006). Premarital Education, Marital Quality and Marital Stability: Findings from a Large, Random Household Survey. Journal of Family Psychology, 20, 117-126. Using a large random survey of 4 middle American states, the authors found that participation in premarital education was associated with higher levels of satisfaction and commitment in marriage and lower levels of conflict-and also reduced odds of divorce. These estimated effects were robust across race, income (including among the poor), and education levels, which suggests that participation in premarital education is generally beneficial for a wide range of couples.

Cowan, C. P., Cowan, P. A., Pruett, M. K. & Pruett, K. (2007). An Approach to Preventing Coparenting Conflict and Divorce in Low-Income Families: Strengthening Couple Relationships and Fostering Father's Involvement. Family Process , 46, 109-121. In the context of current concern about levels of marital distress, family violence, and divorce, the SFI study is evaluating the effectiveness of an intervention to facilitate the positive involvement of low-income Mexican American and European American fathers with their children, in part by strengthening the men's relationships with their children's mothers. This article presents the rationale, design, and intervention approach to father involvement for families whose relationships are at risk because of the hardships of their lives, many of whom are manifesting some degree of individual or relationship distress.

Hawkins, A. J., Blanchard, V. L., Baldwin, S. A., & Fawcett, E. B. (2008). Does marriage and relationship education work? A meta-analytic study. Journal of Consulting & Clinical Psychology , 76, 723-734. doi: 10.1037/a0012584 This meta-analysis of 117 studies examined the efficacy of MRE on relationship quality and communication skills for mostly middle-class, white, educated couples. In experimental studies effect sizes for improved relationship quality were modest as were communication skills effects.

Blanchard, V. L., Hawkins, A. J., Baldwin, S. A., & Fawcett, E. B. (2009). Investigating the effects of marriage and relationship education on couples' communication skills: A meta-analytic study. Journal of Family Psychology , 23, 203-214. doi: 10.1037/a0015211 A review of 143 evaluations found that MRE programs provide modest evidence of effects at longer term follow-ups for well-functioning couples, and at post- assessment and shorter- term follow-ups for more distressed couples.

Fawcett, E. B., Hawkins, A. J., Blanchard, V. L., & Carroll, J. S. (2010). Do premarital education programs really work? A meta-analytic study. Family Relations , 59, 232-239. Studies employing observational measures found large positive effects for premarital education programs, which thus appear to be effective at improving couple communication . The authors did not find the same effects for studies using self-reports, and conclude from their review of 47 studies that there are wide variations and room for improvement in the practice of premarital education.

Hahlweg, K. & Richter, D. (2010). Prevention and marital instability and distress: Results of an 11-year longitudinal follow-up study. Behaviour Research & Therapy , 48, 377-383. Long term effects on participants in Ein Partnerschaftliches Lernprogramm, a Learning Program for Married Couples, or EPL were investigated. At follow up, EPL participants had a significantly lower divorce and separation rate (27.5%) than controls; 80% of couples who were still together reported happy marriages; and 70% of partners remembered at least one listening skill.

Pinquart, M., & Teubert, D. (2010). A meta-analytic study of couple interventions during the transition to parenthood. Family Relations , 59, 221-231. Of 21 controlled couple-focused interventions, on average there were small-to-moderate effects on couple communication and psychological well-being, and very small effects on couple adjustment to parenthood. Closer analysis showed that stronger effects emerged from interventions including an antenatal and postnatal component, having more than five sessions, and those led by professionals.

Federal and State Evaluation Studies

This section reports on marriage and relationship education programs funded by the federal government and some states. In 2002, the federal government began investing in MRE programs for low-income, less-educated couples. These couples tend to have lower rates of marriage, higher rates of divorce and relationship dissolution, and are least likely to have access to MRE programs than those with higher income and education levels. In 2005, 125 five-year programs with this focus were funded by the U.S. Department of Health and Human Services' Office of Family Assistance . As of 2010, about 300 demonstration programs and initiatives have been funded by the federal government and states. Most of these programs are not undergoing rigorous evaluation, but the federal government is investing in three large-scale studies of program impact and implementation effectiveness. Several others are being rigorously evaluated by nongovernment entities.

James Bell Associates (2009). Emerging Findings from the Office of Family Assistance Healthy Marriage and Responsible Fatherhood Grant Programs: A Review of Select Grantee Profiles and Promising Results. This report summarizes service models, activities, and preliminary outcomes of a select group of Healthy Marriage and Responsible Fatherhood grantees funded under the Deficit Reduction Act of 2005.

Cowan, P. A., Cowan, C. P., Pruett, M. K., Pruett, K. D., & Wong, J. J. (2009). Promoting fathers' engagement with children: Preventative interventions for low-income families. Journal of Marriage & Family , 71, 663-679. Interventions were delivered to primarily low-income Mexican American and European American families to enhance fathers' engagement with their children. Intervention families were followed for eighteen months. There were small-to-medium positive effects on fathers' engagement with their children, and on children's problem behaviors. Positive effects were consistent across race and income, and for married and unmarried couples, as well as for more and less distressed couples. Participants in couples' groups showed more consistent, longer term positive effects than those in fathers-only groups.

Cox, R. B., Jr., & Shirer, K. A. (2009). Caring For My Family: A Pilot Study of a Relationship and Marriage Education Program for Low-Income Unmarried Parents. Journal of Couple & Relationship Therapy , 8, 343-364. A pilot study (N = 85) showed that Caring for My Family (CFMF) holds promise for changing the attitudes and behaviors of couples across a number of outcome variables, including their co-parenting relationship, relationship readiness, trust, and negative communication.

Wood, G, McConnell Quinn, S., Moore, K., Clarkwest, A., Hsueh, J. (2010) Strengthening Unmarried Parents' Relationships: The Early Impacts of Building Strong Families . Washington, D.C. Mathematica Policy Research, Inc. The Building Strong Families program (BSF) served more than 5,000 low-income unmarried expectant/new parents. When evaluation results were averaged across the eight program sites, at about 1-year after program conclusion, BSF did not make couples more likely to stay together or get married. It also did not improve relationship quality. However, across the sites, African American couples increased their constructive conflict management; decreased destructive conflict behaviors; were more likely to be faithful; less likely to experience abuse; and more likely to be better co-parents. See Implementation Lessons below.

Hawkins, A. J., & Fackrell, T. A. (2010). Does couple education for low-income couples work? A meta-analytic study of emerging research. Journal of Couple & Relationship Therapy , 9, 181-191. This article reports on a meta-analytic study of 15 MRE programs targeted predominantly to lower-income couples, and found small to moderate positive effects overall. These effects are relatively similar to those found for MRE studies with middle-income participants and for studies of other family-support educational programs.

Kerpelman, J., Pittman, J., Adler-Baeder, F., Eryigit, S., Paulk, A. (2009). Evaluation of a statewide youth-focused relationships education curriculum. Journal of Adolescence, 32, 1359-1370. This research project examined the effectiveness of a youth-focused relationships education curriculum, in order to inform practices in relationship education for adolescents. Findings from pre and post-intervention assessments and from two follow-up surveys provide evidence of program success and offer key insights for the development of an effective model of relationships education tailored for adolescents.

Kerpelman, J., Pittman, J., Adler-Baeder, F., Stringer, K., Eryigit, S., Cadely, H. S., & Harrell-Levy, M. (2010). What adolescents bring to and learn from relationships education classes: Does social address matter? Journal of Couple & Relationship Therapy , 9, 95-112. Results of an adolescent relationship intervention in Alabama indicated that the intervention group changed in terms of correcting faulty relationship beliefs and relationship skills.

Stanley, S. M., Allen, E. S., Markman, H. J., Rhoades, G. K., & Prentice, D. L. (2010). Decreasing divorce in U.S. Army couples: Results from a randomized controlled trial using PREP for Strong Bonds. Journal of Couple & Relationship Therapy , 9, 149-160. In a large sample of lower-income, married U.S. Army couples, couples were randomly assigned to either a PREP (Prevention and Relationship Enhancement Program) for Strong Bonds treatment delivered by Army chaplains, or to a no-treatment control group. One year after the intervention, couples who received the PREP program had a 2% rate of divorce compared to the control-group couples' 6.2% divorce rate.

Implementation Lessons

Program implementation studies are conducted to examine if a program is being carried out as intended. They answer critical questions such as whether the program is reaching its target audience, whether it is being marketed adequately, whether participants are completing the program (and if not, why not), whether the curriculum is being implemented with fidelity, and participants' opinions about the program. This information is crucial to understanding what may be contributing to a program's success (or lack thereof), and whether the program has worked out its "bugs" so that it can be rigorously evaluated. Research described in this section offers lessons from the implementation of federally funded and state funded MRE programs, as well as some community-based programs, curricula and specific target populations.

Adler-Baeder, F., & Higginbotham, B. (2004). Implications of Remarriage and Stepfamily Formation for Marriage Education. Family Relations, 53, 448-458. Couples in remarriages with stepchildren are a significant portion of the marriage population and have unique educational needs regarding aspects of couple functioning within the context of stepfamily development. Information is offered on implementation issues regarding recruitment, delivery context, facilitator and participant characteristics, and evaluation.

Hawkins, A. J., Carroll, J. S., Doherty, W. J. & Willoughby, B. (2004). A Comprehensive Framework for Marriage Education. Family Relations, 53, 547-558 Authors offer a framework to help marriage educators think more thoroughly, systematically, and creatively about intervention opportunities to strengthen marriage and draw attention to the educational dimensions of content, intensity, methods, timing, setting, target, and delivery, and their implications for marriage education.

Bowling, T., Hill, C., & Jencius, M. (2005). An Overview of Marriage Enrichment. The Family Journal: Counseling and Therapy for Couples and Families, 44 (1), 87-94. A brief overview of the history of marriage enrichment is followed by summaries and research associated with five of the leading marriage enrichment programs and research (ACME, TIME, Relationship Enhancement, PREPARE/ENRICH, and PREP). Participants' views of outcomes and future directions for marriage enrichment are discussed.

Dion, M. R. (2005). Healthy Marriage Programs: Learning What Works. Marriage and Child Wellbeing. The Future of Children. The Woodrow Wilson School of Public and International Affairs at Princeton University and the Brookings Institution. The author first describes a number of marriage education programs, many of which have been evaluated and have been shown effective in increasing couple communication and satisfaction. However, most of the highlighted programs do not address specific issues experienced by low income couples.

Bir, A., Greene, J., Pilkauskas, N., & Root, E. (2005) Piloting a community approach to healthy marriage initiatives: Early implementation of the Healthy Marriages Healthy Relationships demonstration – Grand Rapids, Michigan. Prepared for the Office of Planning, Research and Evaluation . This report analyzes the early implementation of a section 1115 child support waiver demonstration project in Grand Rapids, Michigan. It provides evidence that a local community coalition can leverage sufficient resources to stimulate a substantial amount of marriage-related and family relationship activities at a modest cost.

Joshi, P., Pilkauskas, N., Bir, A. & Lerman, R (2008). Piloting a community approach to healthy marriage initiatives in three sites: Chicago, Illinois; Boston, Massachusetts; and Jacksonville, Florida. Prepared for the Office of Planning, Research and Evaluation. Three sites supporting MRE and child support activities are focused on in this report: Boston, MA.; Jacksonville, FL; and Chicago, IL. It examines three different approaches and shows how various organizations leverage their strengths and abilities to get their projects up and running.

Bir, A., Pilkauskas, N., Root, E., Lerman, R., Obrien, C. ,Winston M. (2005) Piloting a Community Approach to Healthy Marriage Initiatives: Early Implementation of the Healthy Families Nampa Demonstration. Prepared for the Office of Planning, Research and Evaluation. The early implementation of a section 1115 child support waiver demonstration project in Nampa, Idaho, is analyzed. The authors find that a local community coalition can leverage sufficient resources to stimulate a substantial amount of marriage-related and family relationship activities at a modest cost.

Dion, M. R., Avellar, S. A., Zaveri, H. H., Strong, D. A., Hershey, A. M., Silman, T. J., & Santos, B. (2008). The Oklahoma Marriage Initiative: A process evaluation. Washington, DC: Mathematica Policy Research. This evaluation examined the implementation of a statewide marriage initiative and found that: 1) identifying an ongoing stream of prospective participants from reliable referral sources facilitates recruitment; 2) existing infrastructure– such as an established enrollment process, pre-existing classes, and reliable venue– supports efficient delivery; and 3) delivering a curriculum that meets the target population's needs is essential to engaging both service providers and participants.

Dion, M. R., Hershey, A. M., Zaveri, H. H., Avellar, S. A., Strong, D. A., Silman, T., & Moore, R. (2008). Implementation of the Building Strong Families program. Washington D.C.: Mathematica Policy Research, Inc. A report on 2,684 Building Strong Families (BSF) couples found that participants viewed the BSF program as a positive experience and described how the program helped them learn to handle conflict and control their anger, which benefited their relationship as a couple as well as interactions with their children and others in their lives.

McGroder, S., & Cenizal, R. for The National Healthy Marriage Resource Center (2009). Healthy Marriage and Relationship Programs: Promising Practices in Serving Low-Income and Culturally Diverse Populations. To be sustainable, this guide contends that programs need to have promising practices in all areas of programming: designing MRE programs, developing program infrastructure, and implementing the programs. Programs also need to be equipped to address the needs of diverse populations.

Miller-Gaubert, J. (2010) Lessons from the Supporting Healthy Marriage Program, MDRC. PowerPoint Presentation delivered at National Healthy Marriage Resource Center webinar on June 30, 2010. The Supporting Healthy Marriage (SHM) project enrolled 6,300 low-income married couples with children. The evaluation team found the following successful strategies: hiring sales-oriented recruiters, marketing the program's benefits (instead of its features), continuous personal contact with participants, instruction that is fun and engaging, classes scheduled at convenient times, training staff, and holding staff accountable to performance standards.

Skogrand, L., Reck, K. H., Higginbotham, B., Adler-Baeder, F., & Dansie, L. (2010). Recruitment and retention for stepfamily education. Journal of Couple & Relationship Therapy , 9, 48-65. The authors examined recruitment and retention strategies used by 10 different agencies that offer the Smart Steps program to low-income stepfamilies. Incentives, minimizing costs, and removing logistical barriers were found to be important for recruitment and retention. Additional strategies included the cultivation of trust, using personal contacts, involving children and incentivizing youth attendance, tapping into the interests and motivations of potential participants, and advertising common stepfamily problems conjointly with the promise of helpful solutions.

Hyra, A. (2010) Providing Culturally Grounded Services to Hispanic Families: Early Lessons Learned from the Hispanic Healthy Marriage Initiative Grantee Implementation Evaluation This presentation was given at the Office of Family Assistance's annual grantee conference and shows some of the early lessons learned from grantees serving Hispanic populations.

On-Going Evaluation

As of 2010, final results from three large-scale federal MRE evaluations are expected over the next three years, which will shed more light on the ability of MRE programs to improve couple communication and satisfaction, lower divorce and increase marriage rates, and improve child well- being among low-income couples and families-both in the short and longer term. This section includes information on these federal evaluations, one article in press that examines the impact of the curriculum Within My Reach on low-income couples, and a report of lessons learned from practitioners of marriage education.

Building Strong Families (2002-2011) DHHS launched Building Strong Families in 2002 to serve more than 5,000 low-income unmarried parents recruited around the birth of their first child.. The program offers up to 42 hours of group instruction over six months; family coordinators provide individual and couple case management (or family support) and refer couples to needed services. Early impact results based on a 15-month follow-up are reported in Wood et al., 2010 (see earlier summary in Second Generation Studies). Longer-term results based on the 36-month follow-up will be available in 2012.

Supporting Healthy Marriage (2003-2013) The SHM project is the first large-scale, multisite, multiyear, rigorous test of marriage education programs for low-income married couples.. Participants receive 24-30 hours of weekly instructional workshops, booster sessions and other family events over the course of one year, and family support coordinators reinforce instruction and refer to other services. An interim report on the program's impacts — on couple and family functioning, including child health and wellbeing — is due in 2010, and longer term impacts will be reported in 2013.

Community Healthy Marriage and Relationship Education (2003-2011). Funded by DHHS' Administration for Children and Families (ACF), the Community Healthy Marriage Initiative (CHMI) is assessing the effectiveness of community interventions designed to encourage healthy marriages and improve child well-being among low-income families. An impact evaluation will compare three low-income communities hosting this initiative and will be available in 2011. Articles in Press

Antle, B. F., Sar, B. K., Christensen, D. N., Ellers, F. S., Karam, E. A., Barbee, A. P., & van Zyl, M. A. (in press). The impact of Within My Reach relationship training on relationship skills and outcomes for low-income individuals. Journal of Marital & Family Therapy . Results indicate that participants experience high levels of satisfaction with the training, significant increases in knowledge and communication/conflict resolution skills, improvements in relationship quality, and a trend in the reduction of relationship aggression. Lessons learned in the implementation of such programs, specifically effective strategies for recruitment and retention of low-income populations, are discussed.

Hawkins, A. J. & Ooms, T. (2010). What Works in Marriage and Relationship Education? A Review of Lessons Learned with a Focus on Low-Income Couples . National Healthy Marriage Resource Center. This report reviews and synthesizes the lessons emerging from evaluation research and practitioner experience to address two related questions: (a) What have we learned about the design and implementation of government-sponsored MRE programs? and (b) What do we know about the effects of these programs on participants, especially low-income populations?

Strengthening Marriage Through Marriage Enrichment Programs

The Family: A Proclamation to the World states that marriage partners have "a solemn obligation to love and care for each other" (¶ 6). This love and care requires intentional effort. One way to make this effort is through marriage enrichment programs.

Many religious organizations, public institutions, and private groups have developed enrichment programs. The best ones teach couples the skills they need to make their marriages strong, satisfying, and enduring.

Underwhelming Participation

Unfortunately, very few couples take advantage of marriage enrichment programs. Most wait until their problems are severe before they seek help, and often it's too late for education. Major surgery is required.

Scholars have found three common - and erroneous - reasons that people are reluctant to participate in marriage enrichment programs:

Good marriages happen naturally. Many people think a happy, successful marriage should come naturally. They think what they learned about marriage from watching their parents and other couples should be enough. If marriage partners need help to build a successful relationship, the thinking goes, then they must be abnormal or deficient in some way. But this "it's natural" theory is a myth. Few people get enough information about how to create a strong and enduring marriage through absorption alone. Most need additional information and education to build a truly satisfying marriage.
Marriage is a private matter. Some people believe the marriage relationship is too private to share with others. They feel it isn't proper to share their marital issues with anyone outside the marriage or to participate in an educational setting where others might see that they need help. Couples with this attitude deprive themselves of the many resources available to improve marital happiness, including the experiences of fellow participants in marriage enrichment programs.
Marriage enrichment doesn't help. Some couples believe that marriage enrichment programs are "feel good" experiences that might help briefly but don't help in the long run. In fact, research shows the best marriage enrichment programs help couples improve their marriages in a deep and lasting way.

Which Marriage Enrichment Programs Work?

Self-help is one of the first places many couples turn to for enriching their marriages. Many good books are available, including The Seven Habits for Making Marriage Work by John Gottman, Fighting for Your Marriage by Howard Markman, Scott Stanley, and Susan Blumberg, and Strengthening Couples, by David and Amy Olson.

Those who advocate self-help alone, however, should know that research tells us many marriage enrichment programs show benefits greater than self-help approaches. The most effective programs tend to be highly structured, meaning they focus on teaching specific skills, including communication, problem solving, adaptability, and conflict resolution. They also teach the importance of commitment, love, forgiveness, and friendship.

Some of the better-known and scientifically evaluated programs are listed below. Look for these in your community. If they are not available, see if you can bring them to your community. Each program has its own approach and methods. Learn about the programs, then decide which one best suits you.

For a comprehensive list of marriage enrichment centers and programs, check out the Smart Marriages website at http://www.smartmarriages.com/index.html .

The Association for Couples in Marriage Enrichment (A.C.M.E.) was founded by David Mace in 1973. Its approach is to help couples become more aware of their individual and partner needs. It also teaches problem-solving skills and communication skills. Both weekend retreat and ongoing weekly meeting programs are available. Workshops are held in group settings, which Mace believes enhances the learning of all couples. A.C.M.E. goals include helping couples learn to work as a team, communicate in warm and caring ways, and openly share marital experiences.

Research on A.C.M.E. is not extensive, but what has been done shows that A.C.M.E. improves couple communication and agreement, intimacy and trust, conflict resolution, and a sense of equal partnership.

For more information about A.C.M.E., call 1-800-634-8325; website: http://www.bettermarriages.org .

Couple Communication

In the late 1960s at the University of Minnesota Family Study Center, a group of graduate students developed a program to help couples make the transition between engagement and early marriage. This was the beginning of what became the Couple Communication marriage enrichment program.

This program has three main objectives: (1) communicate more effectively about day-to-day issues, (2) manage and resolve conflicts, and (3) build a more viable and satisfying relationship. It teaches eleven skills for accomplishing these main objectives. The programs are offered in both private and group settings.

Research shows that this program increases a couple's relationship satisfaction and improves communication and problem-solving skills. It has been shown effective for couples of all ages and socioeconomic groups.

For more information about Couple Communication, call 1-800-328-5099; http://www.couplecommunication.com

Prevention and Relationship Enhancement Program (PREP)

PREP helps couples learn better communication and conflict management strategies, understand one another's expections, and build commitment, fun, and friendship into their relationship.

One of the main communication skills PREP teaches is the "Speaker-Listener Technique," where one partner holds the floor and the other is the designated listener. Couples take turns restating each other's feelings, following the Speaker-Listener Technique rules, which include: (1) mind reading is not allowed, and (2) the listener can only restate what he or she hears, and (3) the listener cannot rebut.

Research has shown PREP to be effective in preventing marital discord and helping couples have more satisfying relationships. Long-term studies show that PREP couples have lower rates of divorce, higher marriage satisfaction, and less problem intensity than couples who didn't participate.

To learn more about the PREP marriage enrichment program, write to the Center for Marital and Family Studies, Psychology Department, University of Denver, Denver, CO 80308; website: http://www.prepinc.com .

Other Programs

Many religious organization sponsor marriage classes or seminars. The Church of Jesus Christ of Latter-day Saints provides a 16-week course titled "Marriage and Family Relations." Other faith groups appoint mentor couples to work with newly married couples to help them make the sometimes difficult adjustments during the first year of marriage.

Promoting Marriage Enrichment in the Community

The Proclamation calls on citizens to promote government and community efforts that strengthen marriages and families (¶ 9). Here are some ideas about how to do this from Diane Sollee of the Coalition for Marriage, Families, and Couples Education:

Support establishment of a marriage and family coalition, initiative, or commission to coordinate faith-based and secular efforts to strengthen marriages and families. For example, the State of Utah has a Commission on Marriage that sponsors marriage seminars and promotes marriage education.
Encourage, support, and promote private, non-profit, and faith-based efforts, such as community marriage policies and community marriage covenants.
Support marriage education programs in high schools, youth groups, county courts, extension offices, county mental health agencies, hospitals, military installations, child-birth centers, etc. Make marriage education skills programs widely accessible in county and community service agencies for couples of all races and classes and at all stages of relationship on a subsidized, voucher and/or sliding-scale fee system. A variety of research-based, highly cost-effective curricula already exist that can be implemented in high schools and other programs, such as those for couples making the transition to parenthood.

Written by Bradley Owens, Research Assistant, and edited by Stephen F. Duncan, Professor, School of Family Life, Brigham Young University.

Dyer, G. H. (1985). The effects of marriage enrichment on neomarital relationships. Unpublished master's thesis, Texas Woman's University, Denton.
Dyer, P. M., Dyer, G. H. (1999). Marriage enrichment, A.C.M.E.-style. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 28-54). Lillington, NC: Edwards Brothers.
Giblin, P., Sprenkle, D. H., & Sheehan, R. (1985). Enrichment outcome research: A meta-analysis of premarital, marital and family interventions. Journal of Marital and Family Therapy , 11, 257-271.
Guerney, B., Maxson, P. (1990). Marital and family enrichment research: A decade review and look ahead. Journal of Marriage and the Family , 52, 1127-1134.
Miller, S., Sherrard, P. A. D. (1999). Couple communication: A system for equipping partners to talk, listen, and resolve conflicts effectively. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp .125-148). Lillington, NC: Edwards Brothers.
Stanley, S. M., Blumberg, S. L., Markman, H. J. (1999). Helping couples fight for their marriages: The PREP approach. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 279-303). Lillington, NC: Edwards Brothers.
Vincent, C. E. (1973). Sexual and marital health. New York: McGraw-Hill Book Company.

The prevalence of divorce, infidelity, and marital distress confirm the sad fact that the institution of marriage is not well. All married couples would be wise to educate themselves about the common problems that plague marriages today and learn strategies for safeguarding their marriage against them. Marriage enrichment programs have been created for this purpose.

A prominent scholar defines marriage enrichment as "programs designed to strengthen couples . . . so as to promote a high level of present and future family harmony and strength, and hence the long-term psychological, emotional, and social well being of family members". 11

Common Concerns About Marriage Enrichment Programs

Misconceptions about marriage enrichment keep too many people from taking advantage of this valuable resource. Misconceptions include "naturalism," "privatism," and a belief that enrichment programs don't work.

Many people believe that a high-quality, satisfying marital relationship should come naturally to normal adults. They believe the training a person receives while growing up should be enough to create a successful marriage. If a couple needs help or is having difficulties, the partners must be deficient. This belief is a myth.

Researchers Dyer and Dyer argue that simply growing up in a family does not necessarily prepare a couple to succeed. It also does not prepare an individual with the "skills necessary to maintain a relationship-oriented marriage". 5

Dr. Clark E. Vincent writes that the attitude of naturalism is widespread: "Even in the most advanced technological societies of today, educated people continue to cherish, implicitly if not explicitly, this preindustrial myth that a successful marriage 'just naturally happens', unless the participants are stubborn, evil, or pathologically ill". 30

But, says, Vincent, this naturalism attitude harms marriages because it keeps couples from finding ways to make their marriage strong and satisfying:

The myth of naturalism obscures the fact that marriage is the most complex relationship any two people will ever enter into-a relationship for which they usually receive less preparation than for driving a car and to which they give less creative thought annually than they give to their job weekly. Most couples are accustomed to receiving a dental checkup every six months, obtaining a physical examination at least once a year, and taking their car in to be serviced every 1,000 or 2,000 miles. But they would probably consider it irrelevant if the physician were to ask them, "When did you have your last marital checkup?" 30

Others believe the marriage relationship is so personal that no one should share information about it with non-family members. The Dyers argue that while privatism may be healthy when it comes to the family as a whole, it is harmful to couples because "it [is] like shutting the couple in a box and leaving them with little preparation and even less help for figuring out how to relate to each other in mutually satisfying ways". 5 Couples who insist on complete privacy cut themselves off from the many resources available to improve marital happiness. Privatism, like naturalism, is a major deterrent to marriage enrichment.

Effectiveness of Marriage Enrichment Programs

Some couples are skeptical that enrichment programs will really help their relationship. They may feel that what's taught in seminars or workshops can't realistically translate into day-to-day life. Some believe marriage enrichment programs are short-term "feel good" experiences that have no lasting benefit.

Though some programs might be inferior, scientific studies have shown that many marriage enrichment programs are, in fact, highly effective at making a lasting and positive impression on a marriage relationship. For the most part, the most effective programs focus on teaching skills, including communication methods, creative problem solving, adaptability, and conflict resolution. One study showed that skills-oriented programs have a much higher positive impact and greater long-term effect than programs oriented more toward awareness and personality perception. 9 The same study showed that couples participating in structured programs are better off than 67% of those who do not. 9

Socrates said that "an unexamined life is not worth living." Likewise, an unexamined marriage, where a couple avoids learning how to enrich their relationship, may never create the fulfillment and happiness each partner hopes for.

What Marriage Enrichment Programs Are Available?

Couples can choose from many marriage enrichment programs, each created by a different organization and each with its own approach, central beliefs, and methods. Some are conducted with one couple at a time and others are held in groups. Couples should research what programs are available in their area and decide which format best suits them.

Below is a discussion of several programs with a broad range of formats. A comprehensive list of marriage enrichment centers and programs can be found at http://www.smartmarriages.com/index.html .

The Association for Couples in Marriage Enrichment (A.C.M.E.) was founded by David Mace in 1973. Mace is considered by many to be "the pioneer of the development of marriage counseling in Great Britain and the United States". 5 His work with A.C.M.E. has influenced the development of several other prominent marriage enrichment programs, including Couple Communication, Relationship Enhancement, and the Family Communication Center in conjunction with the YMCA. 5

The central beliefs of A.C.M.E. are that "the marital relationship itself [is] the key to successful family life" and that "preventive interventions [are] more efficient and more effective than treatment". 5 A.C.M.E. helps couples become more aware of their individual and partner needs and teaches them effective problem solving and communication skills. Couples can choose a weekend retreat or an ongoing weekly program. The goals for couples participating in A.C.M.E. include working as a team, communicating in warm and caring ways, and openly sharing marital experiences.

Research on A.C.M.E. has not been extensive, but what has been done shows A.C.M.E. is effective. Swicegood 29 studied 25 couples who participated in A.C.M.E. and found that the program significantly improved couple communication and agreement between husband and wife. Another study showed A.C.M.E. significantly improved intimacy and trust between marriage partners. 22 Dyer studied 16 couples who were randomly divided into an A.C.M.E. group and a control group. Results showed that A.C.M.E. helped couples improve in conflict resolution, egalitarian roles, and overall positive change in the relationship. 4

For more information about A.C.M.E call 1-800-634-8325. Website: http://www.bettermarriages.org/

Marriage Encounter

"Marriage Encounter: A Positive Preventative Enrichment Program" was created in 1952 by Father Gabriel Calvo, a Catholic priest in Barcelona, Spain. Many distressed couples in his parish sought his counsel, and he decided he could help them better if he were more familiar with the characteristics of happy, harmonious couples. He began observing the happy couples around him, then analyzed the differences between them and unhappy couples. With the information he gathered, he formed the weekend Marriage Encounter retreat.

During the retreat couples are given thirteen presentations called "steps" that revolve around four central themes: (1) self-appraisal and consideration, (2) concerns within the relationship, (3) spirituality, and (4) issues dealings with the couple as part of a community. 6 The couple is taught about marriage as a religious relationship between God and each other, the importance of accepting and trusting each other, and that love is transcendent above all other qualities in the marital relationship.

One of Marriage Encounter's unique features is allotting couples personal reflection time throughout the weekend to write down their impressions and feelings about what they're learning. Afterward, couples share with each other their reflections. Reflecting allows couples time to assimilate and absorb the material they are being taught and facilitates discussion between the couples. Another unique feature is a ceremony on the last day of the retreat where each couple can renew their marriage vows. 6

A comprehensive study of Marriage Encounter was conducted by the National Institute for the Family (1990). It evaluated couples who attended Marriage Encounter from 1965 to 1989, and the results showed a majority ranked the long-term impact on intimacy and closeness as "very good." Sixty-two percent said the positive long-term impact on communication was "very high." Another researcher concluded: "Marriage Encounter programs have often received affirmations of 80% to 90% in post-weekend surveys and . . . the program demonstrates clear effectiveness when its participants are involved [in] . . . controlled pre/post-weekend research". 21

For more information about Marriage Encounter, call 1-800-828-3351.

In the late 1960s at the University of Minnesota Family Study Center, a group of graduate students, Sherod Miller, Elam Nunnally, and Daniel Wackman, developed a program to help couples successfully make the transition between engagement and early marriage. This was the beginning of the Couple Communication marriage enrichment program.

This program aims to help couples (1) communicate more effectively about day-to-day issues, (2) manage and resolve conflicts, and (3) build a more viable and satisfying relationship. 24 It is a "skill learning" based program that teaches eleven specific skills. The program is offered in both private and group settings.

Studies show that couples who participated in Couple Communication feel a higher level of relationship satisfaction and increased competency in communication and problem solving skills. 18,23 Research also found that highly distressed couples benefit from the program 1 and that the program increased self-esteem and self-disclosure. 7 Couple Communication is effective for couples of all ages and socioeconomic groups. 24

For more information about Couple Communication, call 1-800-328-5099. Website: http://www.couplecommunication.com

Prepare/Enrich Inventory

In response to a challenge in the late 1970s to increase the effectiveness of marriage enrichment programs in the Twin Cities, David Olson began developing what is now the PREPARE/ENRICH inventory. This program provides couples with a questionnaire that helps partners think and talk about important issues. The PREPARE/ENRICH program revolves around four preventative principles, which Olson explains as follows:

First, factors that relate to marital success need to be identified. Second, couples need to be assessed on those critical variables. Third, feedback and exercises need to be given to couples, which will help them deal with problem areas. Fourth, couples need skill-building exercises that focus on communication and conflict resolution skills. 26

Couples have the option of seeing a counselor who can help them interpret the results of the inventory, give them guidance, and offer skills training to improve problem areas.

Though the program originally was geared toward helping couples preparing for marriage, David Olson and his daughter Amy have developed inventories tailored for other situations. PREPARE-MC is for couples with children who are planning to marry. ENRICH is for married or cohabiting couples who want to enhance their relationship. MATE is designed for couples aged 50 or older who are planning to marry or already married but planning other major changes, including retirement. 26

Some scholars believe one of the reasons so few couples participate in marriage enrichment is that not enough programs determine clients' needs and direct their intervention to meet those needs. 27 Olson's approach addresses this issue by helping couples complete a thorough self-evaluation so they know more about themselves and each other before they enter the program. The PREPARE/ENRICH inventory helps couples know exactly where they have conflicting ideas about their relationship. It also helps their counselor/facilitator know specifically what aspects of the relationship they need to work on.

Very strong scientific research backs up the effectiveness of PREPARE/ENRICH. Four separate studies found that the PREPARE/ENRICH questionnaire predicts with 80% to 85% accuracy which couples will have a high degree of satisfaction in their marriages and which couples will have problems. 8, 16

For more information about PREPARE/ENRICH call 1-800-331-1661. Website: http://www.lifeinnovation.com

The RELATE Premarital Questionnaire

In 1980, Dr. Wesley Burr developed a questionnaire called Marriage Inventories, which he used in his university marriage preparation class. The inventory focused on the predictors for marital success and failure. As new research emerged, Burr frequently refined the inventory. In 1997 a new and improved version of the program was released called RELATE.

RELATE is unique because it is designed not only for engaged couples but also "for use with individuals or couples who are single and unattached, steady dating, engaged, cohabiting, married, or contemplating remarriage" (see http://www.relate-institute.org ).

The RELATE Premarital Questionnaire is the product of twenty years of research. Two of its developers, Dr. Jeff Larson and Dr. Tom Holman, did "an exhaustive review of the social science research literature on premarital characteristics that predict later marital satisfaction. In reviewing clinical and research literature from about 1935 to the present, we found over two dozen specifics that contribute to marital satisfaction". 17

They also found "two dozen or so specific premarital predictors [that] could be logically categorized into . . . three major factors". 17 The three factors are context, individual traits, and couple traits. The context portion of the questionnaire covers a person's background, external and internal pressures, and past relationship experience. The individual traits section focuses on personality, expectations, attitudes, and skills. The couples traits section covers topics such as couple communication, similarities, pressures to marry (if any), and length of acquaintance.

Tens of thousands of couples and individuals have benefited from these questionnaires for more than 20 years. The RELATE questionnaire can be taken online for $5 per individual and $10 per couple. A results sheet shows which predictors for marital success each person is strong in and which issues a couple should talk about together and work on. Because the inventory is based on the elements that are most important to talk about when building a successful relationship, even couples who have been married for years can benefit from taking RELATE.

Recent research confirms the validity of the premarital prediction factors upon which the program is based and has verified the reliability and effectiveness of the RELATE inventory. 14

For more information about RELATE, see http://www.relate-institute.org ; phone (801) 422-4359.

The Prevention and Relationship Enhancement Program (PREP)

PREP was founded by Howard Markman, Scott Stanley, and Susan Blumberg. It helps couples "fight for their marriages". 28 The program's main focus is communication-learning which communication patterns lead to a stronger marriage and which patterns are destructive. The PREP program also teaches couples effective ways of resolving conflict. A central precept is that how couples fight is much more important that how often they fight or what they fight about. PREP teaches skills that help couples "fight fair" and handle disagreements in a way that both partners are understood and a solution can be found.

The four main goals of PREP are: (1) "teach couples better communication and conflict management strategies," (2) "aid couples in clarifying and evaluating expectations," (3) "boost understanding of and choices reflecting commitment and to enhance the positive bonding that comes from fun, friendship, and sensuality" (Stanley et al., 1999, p. 283).

One of the main skills taught in PREP is the "Speaker-Listener Technique," which Stanley defines as "a structured approach to good communication and conflict management". 28 In this technique one partner holds the "floor" and the other is the designated "listener." Couples take turns restating each other's feelings as they are expressed. Rules of the Speaker-Listener Technique include: (1) couples must share the floor, (2) mind reading is not allowed, and (3) the listener can only restate what he or she hears without rebutting. 28

Research has shown PREP is effective in helping married couples prevent discord and achieve a more satisfying relationship. In 1993 a study in Germany showed that PREP helped couples significantly increase communication and conflict management skills. In a three-year follow up, the couples were more satisfied with their marriages and more stable than a control group. 12 PREP couples averaged a 4% divorce rate as compared to a 24% rate for those in the control group. 12

Another study concluded: "PREP couples have been shown to have about half the likelihood of breaking up or divorcing, have demonstrated greater relationship satisfaction, and have shown lower problem intensity than the control couples for up to five years following training". 19

To learn more about PREP, write to the Center for Marital and Family Studies, Psychology Department, University of Denver, Denver, CO 80308. Website: http://www.prepinc.com .

Relationship Enhancement

Relationship Enhancement was created by Bernard Guerney. Its development stems back to the early 1950s, when Guerney suggested training parents in the skills necessary to conduct "Child-Centered Play Therapy". 2 As he observed the effectiveness of teaching parents to act in a therapist role, he had the idea of teaching couples how to be therapists to each other. The program is based on the idea that "teach[ing] the skills to couples and families before they get into trouble" is much more effective than trying to help when relationships are already broken or frail. 2

A unique feature of Relationship Enhancement is its focus on "enhancing the positive aspects of relationships, rather than removing or preventing marital pathology". 10 The program teaches the elements that make couple and family relationships satisfying rather than equipping the couple or family with defenses in case things fall apart.

The program is based on the theory that people can influence the responses of others. The objective is to help couples act in a way that elicits relationship-building behavior in their partner. Some of the skills taught include (1) the "expressive skill," which helps partners "better understand their own sources of stress, needs, and desires, and to express them to others in a way least likely to foster defensiveness, anxiety, hostility, and conflict" ; (2) the "empathetic skill," which helps couples better understand their partner's needs and respond more effectively; and (3) the "facilitative (coaching) skill," which "enables participants to exit negative-negative communication spirals and . . . help each other to master the RE skills". 10,2

Research on Relationship Enhancement has been substantial, and findings show the program is exceptionally good. It is effective for both distressed and non-distressed couples, and it significantly increases "communication, relationship satisfaction, and ability to handle problems" (Jessee & Guerney, 1981). In 1985, a study examined the effectiveness of 85 different marriage enrichment programs. The results showed Relationship Enhancement generally to be superior to other programs. 9

For more information about Relationship Enhancement call 1-800-432-6454. Website: http://www.nire.org .

Further Ideas for Enriching Your Marriage

Learn about programs by exploring websites such as http://www.smartmarriages.com , which includes a comprehensive list of marriage enrichment programs. Information about each program includes websites and email addresses for those who want to learn more.
Go the library or bookstore and read about marriage enrichment. Good books include Seven Principles for Making Marriage Work by John Gottman, Fighting for Your Marriage by Scott Stanley, and Strengthening Couples, by David and Amy Olson.
Participate in church-sponsored marriage classes or seminars.
Contact local government offices to learn about couple or family classes available in your community.
Take an online PREPARE/ENRICH or RELATE couple inventory and discuss the results with your spouse.
Ask senior married couples in your community for their wisdom on enriching marriage.
Candidly ask your spouse for feedback about how you can enrich your marriage. Listen to the suggestions and apply them.
Aldridge, R. G., & Aldridge, C. H. (1983). Couple communication: An analysis of two divergent student groups. Corrective and Social psychiatry and Journal of Behavior Technology, Methods, and Therapy , 29, 36-38.
Calvedo, C., & Guerney, B. G. (1999). Relationship enhancement enrichment and problem-prevention programs: Therapy-derived, powerful, versatile. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 73-105). Lillington, NC: Edwards Brothers.
Carlson, J., Dinkmeyer, D. (1999). Time for a better marriage. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples' therapy (149-168). Lillington, NC: Edwards Brothers.
Dyer, P. M., Dyer, G. H. (1999). Marriage enrichment, A.C.M.E.-style. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (28-54). Lillington, NC: Edwards Brothers.
Elin, R. J. (1999). Marriage encounter: A positive preventive enrichment program. In R. Berger & M.T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 55-72). Lillington, NC: Edwards Brothers.
Fleming, M. J. (1977). An evaluation of a structured program designed to teach communication skills and concepts to couples: A field study. Dissertation Abstracts International , 37, 7633A-7634A. (UMI. 77-13, 315).
Fowers, B. J., & Olson, D. H. (1986). Predicting marital success with PREPARE: A predictive validity study. Journal of Marital and Family Therapy , 12, 403-413.
Giblin, P., Sprenkle, D. H., & Sheehan, R. (1985). Enrichment outcome research: A meta-analysis of premarital, marital and family interventions. Journal of Marital and Family Therapy , 11(3), 257-271.
Guerney, B. G., Jr., Brock, G., & Coufal, J. (1986). Integrating marital therapy and enrichment: The Relationship Enhancement approach. In N. Jacobson & A. Gurman (Eds.), Clinical Handbook of Marital Therapy. New York: Guilford Press, 151-172.
Hahlweg, K., Markman, H. J., Thurmaier, F., Engl, J., & Eckert, V. (1998). Prevention of marital distress: Results of a German prospective-longitudinal study. Manuscript submitted for publication.
Hawley, D. R., Olson, D. H. (1995). Enriching newlyweds: An evaluation of three enrichment programs. The American Journal of Family Therapy , 23(2), 129-147.
Holman, T. B., Busby, D. M., Doxey, C., Klein, D. M., & Loyer-Carlson, V. (1997). The RELATionship Evaluation. Provo, UT: Center for Family Studies.
Jessee, R., & Guerney, B. G., Jr. (1981). A comparison of Gestalt and Relationship Enhancement treatments with married couples. American Journal of Family Therapy , 9, 31-41.
Larsen, A. S., & Olson, D. H. (1989). Predicting marital satisfaction using PREPARE: A replication study. Journal of Marital and Family Therapy , 15, 311-322.
Larson, J. H. (2000). Should we stay together? San Francisco: Jossey-Bass, Inc.
Larson, J. H., & Holman, T. B. (1994). Premarital predictors of marital quality and stability. Family Relations , 43, 228-237.
Markman, J. J., Floyd, F. J., Stanley, S. M., & Storaasli, R. D. (1988). Prevention of marital distress: A longitudinal investigation. Journal of Consulting and Clinical Psychology , 56, 210-217.
Mattson, D., Christensen, O., & England, J. (1990). The effectiveness of a specific marital enrichment program: TIME. Individual Psychology , 46, 88-92.
McManus, M. J. (1993). Marriage savers. Grand Rapids, MI: Zondervan.
Michael. P. (1983). The effect of growth in marriage for newlyweds on newlywed couples' perception of trust, intimacy, and overall quality of the relationship. Unpublished master's thesis, University of Missouri-Kansas City.
Miller, S. L. (1971). The effects of communication training in small groups upon self-disclosure and openness in engaged couples' systems of interaction: A field experiment. Dissertation Abstracts International , 32, 2819A-2820A. (UMI 71-28,263).
Miller, S., Sherrard, P. A. D. (1999). Couple communication: A system for equipping partners to talk, listen, and resolve conflicts effectively. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 125-148). Lillington, NC: Edwards Brothers.
National Institute for the Family. (1990). Worldwide marriage encounter: National survey and assessment. Washington, DC: Author.
Olson, D. H., Olson, A. K. (1999). PREPARE/ENRICH program: Version 2000. In R. Berger & M. T. Hannah (Eds.), Preventive approaches in couples therapy (pp. 196-216). Lillington, NC: Edwards Brothers.
Schumm, W. R., & Denton, W. (1979). Trends in premarital counseling. Journal of Marital and Family Therapy , 5, 23-32.
Swicegood, M. L. (1974). An evaluative study of one approach to marriage enrichment. Unpublished doctoral dissertation, University of North Carolina-Greensboro.

Marriage is a sacred and essential part of God's efforts to exalt His sons and daughters. The Family: A Proclamation to the World (paragraph 6) states that marriage "is ordained of God" (¶ 1). President Gordon B. Hinckley taught, "Surely no one reading the scriptures, both ancient and modern, can doubt the divine concept of marriage". 3

A casual attitude toward the marriage relationship seems to be growing. Many believe a marriage can't be expected to last and should be terminated when it stops being fulfilling to one or both partners. But Heavenly Father has made it clear that he expects marriage partners to treat their vows with the utmost seriousness. He intends the marriage relationship to be the most fulfilling of all earthly relationships. As President Hinckley taught, "The sweetest feelings of life, the most generous and satisfying impulses of the human heart, find expression in a marriage that stands pure and unsullied above the evil of the world". 3

For a marriage to yield such a high degree of satisfaction, both husband and wife must be deeply committed and willing to make the efforts needed to build the relationship.

Marriage Enrichment Programs

Elder James E. Faust said too many marriages lack "a constant enrichment." They don't have "that something extra, which makes it precious, special, and wonderful". 2 Knowing how to enrich a marriage, to add what's needed to make it "precious, special, and wonderful" doesn't come naturally. Couples need information, education, and the experience of others to learn what works in a marital relationship and what doesn't, what strengthens the marital bond, and what weakens it.

LDS couples stand to benefit greatly from participation in marriage enrichment programs. However, few couples take the opportunity. Why is this so? Some may believe that LDS couples don't need such a program-all they need to do is live the gospel the best they can. However, two recent national studies showed no differences in the rate of divorce between LDS and non-LDS couples. Even temple married couples are at greater risk today than in times past. Other persons may believe the myth that the Brethren don't endorse such programs.

Many good marriage programs have been developed, including a 16-week "Marriage and Family Relations" program developed by the Church. Latter-day Saint couples can benefit from this program or the many others that research has shown to be effective. Brigham Young 1 taught that the gospel embraces all truth, and we should "gather up all the truths in the world pertaining to life and salvation, to the Gospel we preach. . . to the sciences, and to philosophy, wherever it may be found . . . and bring it to Zion". 2

The Church of Jesus Christ of Latter-day Saints (1997). Teachings of the presidents of the Church: Brigham Young . Salt Lake City, UT: Author.
Faust, J. E. (1977, November). The enriching of marriage. Ensign 10-11.
Hinckley, G. B. (1991, May). What God hath joined together. Ensign 71-74.

Marriage Counseling Toolkit: 30 Couples Therapy Worksheets

Indeed, according to the American Psychological Association (2020), between 40 and 50 percent of marriages in the United States end in divorce.

Nevertheless, there are many approaches, often relatively straightforward, that have been shown to improve relationships. Research has identified that even increasing the number of positive interactions over negative ones can improve marriage stability (Budiharto, Meliana, & Rumondor, 2017).

Whether facilitated through one-to-one therapy, books, or mobile apps, the marriage counseling tools and approaches discussed in this article can strengthen marriage’s emotional bonds and improve overall relationship satisfaction.

Before you continue, we thought you might like to download our three Positive Relationships Exercises for free . These detailed, science-based exercises will help you or your clients build healthy, life-enriching relationships.

This Article Contains:

20 helpful questions for your sessions, 4 couples therapy worksheets for your clients, 3 activities and exercises, assessment methods and questionnaires, extra marriage counseling tips, a look at useful apps, our useful resources, a take-home message.

In Gottman and Silver’s excellent book, The Seven Principles for Making Marriage Work (1999), John Gottman describes how, after observing a couple’s interaction for only 15 minutes, he can predict the likelihood that they will remain together.

And, surprisingly, he is almost always right. When researchers tested his predictions, he was 91% accurate.

So, based on decades of research and interviewing thousands of couples, what did he conclude was the secret behind a happy marriage?

“ Happily married couples aren’t smarter, richer or more psychologically astute than others ,” he says. It is simpler than that. In successful marriages , partners are more positive than negative about one another. And this emotional intelligence can be seen, even in relatively short interactions. After all, a positive attitude radiates through all areas of the relationship: play, romance, learning, and adventure.

With that in mind, marriage counseling provides a vital opportunity to observe couples’ interactions, assess where conflict arises, and agree on the steps required to meet both partners’ needs.

Key questions

The couple should put together a list of questions they have for each other to make the best use of time in each marriage counseling session.

The following questions can be shared during couples therapy, but they should be encouraged to come up with a personalized list in advance of the session:

What are the biggest problems in our marriage?
Do we want to stay together?
Is this a temporary phase (or is it something more permanent)?
When did these problems start?
Do you believe we can save our marriage?
Do you love me, and if so, in what way?
What do you love most about me?
Do you trust me?
Is there anything you don’t trust about me?
Are you satisfied with our degree of intimacy?
Are you seeing anyone else? Do you want to?
Do you feel you can talk to me about anything?
Is there anything from our past that still bothers you?
Why do you want this to work out?
What do you expect from our counseling sessions?
Do you see a future?
What can I do to make our marriage better?
Where do you see our marriage in one/five/ten years?
Do you know how much I love/respect/admire you?
Are you/we willing to make the changes needed?

Asking questions can help uncover important underlying issues and benefit from the relationship therapy environment’s safety to help the couple discuss, move forward, and overcome their difficulties.

Emotionally intelligent marriages are more likely to succeed. But what do they look like?

While Gottman’s research identified that happy marriages were rarely a perfect union, they all shared several crucial factors.

A happy marriage builds upon (Gottman & Silver, 1999):

Friendship rather than fighting Deep friendship is at the heart of the marriage.
Sound relationship High levels of trust and total commitment maintain the relationship.
Capacity to repair A healthy companionship supports repair following disagreements and conflict.
Marriage purpose A partnership has a purpose, where each supports the other’s hopes and dreams.

On the other hand, when a quarrelsome couple in a less emotionally intelligent marriage is arguing over who should take the trash out, it most likely signifies deeper issues.

According to Gottman, “ most marital arguments cannot be resolved. ” After all, how can you change another’s fundamental values or personality? Still, learning to understand what underpins disagreements and how to live with them can lead to a happier marriage with shared meaning and a sense of purpose.

So how do we do this?

Working together – completing questionnaires, reading books, or attending counseling sessions – can strengthen marriages, overcome difficulties, and reduce negative attitudes (Gottman & Silver, 1999; Babcock, Gottman, Ryan, & Gottman, 2013).

And yet, there is no one-size-fits-all when it comes to couples therapy, so try out the following worksheets with your clients and see what works well. Their success may vary depending on personalities and the state of the marriage.

Seeing the good in a partner

When things are difficult in a relationship and resentments build up, it is easy to forget the qualities we first saw in a partner.

Share the Valuing My Partner Worksheet to remind the client what first attracted them to their partner.

Getting to know your partner

Learning more about your partner early in a relationship (or as part of a building exercise in a long-term relationship) can be fun and rewarding:

The About Your Partner Worksheet can either be completed during a conversation between partners or independently and used in a subsequent counseling session.
The Relationship Qualities Worksheet captures what each partner enjoys, what they would like to do in the future, and their longer term goals. Use the questions during couples’ therapy to build a bank of positive feelings and a list of activities to revisit as a couple.

Changing the sentence’s subject

The overuse of “you” during an argument or sensitive conversation can lead to escalation or withdrawal by the other person.

The Turning “You” into “I” spreadsheet helps each partner practice changing the subject of statements from “You” to “I” to avoid blame and facilitate a more reasoned discussion.

Once practiced, the couple can use such statements in the future when discussing sensitive issues with a partner.

10 Habits couples therapists say always end a marriage – Check Facts 360

To provide optimal assistance to your clients, guide them through the following activities and exerices.

Characteristics of successful clients

Marriage counselor Marina Williams has spent countless hours with couples in couple’s therapy seeking help for their marriages. Based on her experience, she provides each with a list of characteristics she has identified in her most successful clients.

Share the following list (modified from Williams, 2012) with your clients. Ask them to review each point and consider whether they can commit to the task:

Make your appointments a priority. The most successful clients attend every appointment.
Be willing to take risks and try new things. You are going to learn new skills, some of which may seem unfamiliar at first. Commit to trying them out.
Prepare for each session. This is a vital opportunity for your marriage; take it. Come prepared with a list of what you want to discuss and any changes since the last session.
Provide direct and honest feedback. Be open and honest about what is and is not working.

History and philosophy of your relationship

Couples sometimes need to reconnect with why they are fond of each other; looking back at their shared history can help.

Ask the couple to complete the Relationship History and Philosophy Questionnaire . Use it to remind the couple why they first got together and how they view marriage (Gottman & Silver, 1999).

Coping with your partner’s pain

Gottman’s extensive work with couples led him to an important conclusion. Happy couples live by the maxim “ When you are in pain, the world stops, and I listen .”

The 10 Tips for Coping With Your Partner’s Upset (modified from Gottman & Silver, 1999) can help partners be there and yet maintain their mental wellbeing, whether the negativity is directed at them or someone else.

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Getting a solid understanding of where a couple stands in their relationship is a crucial starting point. Have a look at the following assessments.

Couple compatibility and areas of conflict

The Gottman Relationship Checkup questionnaire provides valuable insight into couple compatibility and areas of conflict that require attention.

It compares partners’ scores on several different elements of their relationship, including romance, emotional connection, commitment, values, and goals.

Once both partners have taken the questionnaire (usually it takes about two hours to complete), the therapist reviews the results before offering actionable recommendations.

Assessing marital conflict

As Gottman explains, each person in a marriage brings their own quirks, personalities, opinions, and values. It is, therefore, no surprise that conflicts arise. However, once recognized, it is possible to focus on and adjust coping strategies and regain marital balance.

Most couples are subsequently satisfied with their marriages and are no longer overwhelmed by points of contention (Gottman & Silver, 1999).

The following questionnaires drill down and capture the concerns and issues of each partner for discussion within counseling:

The Marital Conflicts Questionnaire identifies conflict points and their triggers before exploring potential resolutions and how each partner is left feeling.
The Resolving Marital Conflicts Questionnaire goes deeper, recognizing successful and unsuccessful coping strategies. Use it during couplea therapy to promote discussion regarding the best approach to resolving conflict in the future.

For example, allow time to think before responding and reduce statements that blame and criticize.

Think of your relationship as the infrastructure of a house. There are certain foundational pillars that support your home. In the case of relationships, these are trust, commitment, and friendship. Without these pillars, the house (i.e., your relationship) can collapse (Gottman, 1999).

To visualize this, The Sound Relationship House Theory was developed. This theory distinguishes nine elements of a healthy and nurturing relationship, two of which represent the walls of the house, and seven of them are different levels of the house. These nine elements are:

You believe your partner has your best interests at heart and that they value you as much as themselves.
You believe your relationship is a lifelong journey, for better or for worse.
You are interested in what goes on in your partner’s life, and you know about their current worries, stresses, joys, and dreams.
You are generally fond of each other and accept and celebrate your differences. You enjoy each other’s interests and points of view.
You make an effort to turn towards your partner when they try to connect with you.
Your relationship has a generally positive feeling/vibe. Problems are approached with a sense of positivity and friendliness.
You and your partner deal with arguments gently, maintaining respect for one another, and use humor at times to keep things light.
You and your partner support each other’s life goals and dreams.
Your relationship is a blend of both your values, culture, and beliefs. You are on the same page and navigate life with a sense of unity.

Using these, examine the soundness and stability of your relationship. Ask yourself: Is the foundation of trust and commitment strong enough to hold up the rest of the house levels in your relationship?

Need more? Have a look at the following valuable tips.

The important first session

While marriage counseling is important to you as a professional, it may also be the difference between building a happy marriage or losing your clients’ relationship.

The first session is, therefore, likely to be difficult for a couple. They will be nervous and uncertain about how marriage counseling will affect them.

The following four steps can be built upon or modified as required but offer a useful starting point for your initial meeting with clients (modified from Williams, 2012):

Form a connection with the clients. A warm smile and initial small talk can help subsequent engagement in the session. Subtle mimicking of the clients’ body language (so long as it is not inappropriate or aggressive) can make them feel a sense of rapport and similarity.
Gather information. Ask each partner what has brought them to counseling, their professions, medical history, and backgrounds. Inquire about the history of their relationship difficulties, specific behaviors, and feelings involved.
Educate the clients about the process of marriage counseling. Explain that each session is structured with assignments given out weekly. Allay fears by confirming that you will not be taking sides or judging. It is not about who is right or wrong, but instead is about forgiveness and growing as a couple.
Offer hope by expressing confidence that the marriage can be saved. Do not provide guarantees; there are many factors involved, most of which are outside your control. If the couple leaves the first session feeling that things are likely to get better, they will begin to fix what is broken.

Avoid becoming overwhelmed

Whether discussing conflict within the relationship (or outside), it can be enormously beneficial to reach a state of calm. However, using phrases such as “ calm down ” will have the opposite effect and should be avoided.

Instead, it can be useful to discuss the feelings openly regarding being ‘overwhelmed’ or ‘flooded’:

What makes us feel overwhelmed? When does it happen?
Can we change how we bring up issues?
Do we store up conflict, rather than discuss it?
What can I do to soothe you?
What can you do to comfort me?
Can we develop signals to let each other know when we are feeling flooded?
Can we agree on an action when flooding happens? For example, take a break.

Download 3 Free Positive Relationships Exercises (PDF)

These detailed, science-based exercises will equip you or your clients to build healthy, life-enriching relationships.

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There are many relationship apps available. They include questionnaires, daily challenges, and even provide the opportunity to connect with an online counselor.

We have included four of the best options below. Try them out with your clients and find one that motivates them in a fun way to grow in their relationship:

1. Love Nudge

The app is based on the New York Times bestseller The 5 Love Languages: The Secret to Love that Lasts by Gary Chapman. (Available on Amazon .)

Find it in the Apple App Store or Google Play store .

2. Lasting: Marriage Health

Find it in the Apple App Store .

3. ReGain – Couples Therapy and Counseling

The ReGain app enables couples to get on-demand help from relationship counselors. Your client can talk with the counselor on their own or invite their partner through the app.

We have many tools and exercises available to help clients grow as an emotionally intelligent couple.

As well as being enjoyable and entertaining, they offer deep insight into both the relationship and the individuals involved, leading to the formation of stronger relationship bonds and a more resilient and happy marriage.

Try out the following with clients:

A valuable skill in any relationship, is being able to manage anger. Use the Anger Exit and Re-Entry Routines worksheet to help couples move from conflict to constructive communication.
How to Improve Communication in Relationships – 7 Essential Skills is an excellent resource for couples therapy to improve their communication.

In any relationship, healthy communication is a cornerstone of success. To work on improving communication, have a look at these recommended articles:

Your Complete Nonviolent Communication Guide
What Is Assertive Communication?
49 Communication Activities, Exercises, and Games

If you’re looking for more science-based ways to help others build healthy relationships, this collection contains 17 validated positive relationships tools for practitioners. Use them to help others form healthier, more nurturing, and life-enriching relationships.

17 Exercises for Positive, Fulfilling Relationships

Empower others with the skills to cultivate fulfilling, rewarding relationships and enhance their social wellbeing with these 17 Positive Relationships Exercises [PDF].

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Not only are married people more likely to have higher life satisfaction, but they also have lower levels of stress and an increased life expectancy.

However, as with all areas of life, it is easy to become overwhelmed by stress and conflict and lose the ability to see the positives.

And yet, this is where marriage counseling can be of most help. Indeed, there is a wealth of tools and approaches available to strengthen marriage bonds through increased emotional intelligence, communication , coping, and conflict resolution.

However, the challenge as Gottman sees it – based on his wealth of experience – is for therapists to get deep into the heart of what makes a relationship lasting and happy (Gottman & Silver, 1999). While it is crucial to keep communication lines open and improve problem-solving skills in marriage, emotional intelligence must also be fostered.

Use the tools provided with clients to increase the positive interactions, grow closer as a new couple, and recover some of the misplaced love, affection, kindness, and empathy in a longer lasting marriage.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Relationships Exercises for free .

American Psychological Association. (2020). Marriage & divorce. Retrieved September 28, 2020, from https://www.apa.org/topics/divorce.
Babcock, J. C., Gottman, J. M., Ryan, K. D., & Gottman, J. S. (2013). A component analysis of a brief psycho-educational couples’ workshop: One-year follow-up results. Journal of Family Therapy, 35(3) , 252–280.
Boyce, C. J., Wood, A. M., & Ferguson, E. (2016). For better or for worse: The moderating effects of personality on the marriage–life satisfaction link. Personality and Individual Differences, 97 , 61–66.
Budiharto, W., Meliana, M., & Rumondor, P. C. (2017). Counselove: Marital counseling Android-based application to promote marital satisfaction. International Journal of Electrical and Computer Engineering , 7(1) , 542.
Gottman, J. M., & Silver, N. (1999). The seven principles for making marriage work . London: Seven Dials an imprint of Orion Publishing Group.
Gottman, J. M. (1999). The Marriage Clinic: A Scientifically Based Marital Therapy . W.W. Norton & Company.
Williams, M (2012). Couples counseling – A step by step guide for therapists . Viale Publishing.

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Glob J Health Sci
v.8(8); 2016 Aug

A Review of Marital Intimacy-Enhancing Interventions among Married Individuals

Maryam kardan-souraki.

1 Faculty of Nasibeh Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

2 Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran

Zeinab Hamzehgardeshi

3 Department of Midwifery and Reproductive Health, Faculty of Nasibeh Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

4 Research Center of Traditional Medicine, Mazandaran University of Medical Sciences, Sari, Iran

Ismail Asadpour

5 Department of Counseling, Faculty of Psychology and Educational Sciences, Kharazmi University, Karaj, Iran

Reza Ali Mohammadpour

6 Department of Biostatistics, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran

Soghra Khani

7 Research Center of Diabetes, Mazandaran University of Medical Sciences, Sari, Iran

Background:

Lack of intimacy is currently the main concern rather than main concern of the experts in psychology and counseling. It is considered as one of the most important causes for divorce and as such to improve marital intimacy a great number of interventions have been proposed in the literature. Intimacy training and counseling make the couples take effective and successful steps to increase marital intimacy. No study has reviewed the interventions promoting marital intimacy after marriage. Thus, this review study aimed to classify the articles investigating the impact of interventional programs on marital intimacy after marriage.

Search Methods:

In April 2015, we performed a general search in Google Scholar search engines, and then we did an advanced search the databases of Science Direct, ProQuest, SID, Magiran, Irandoc, Pubmed, Scopus, Cochrane Library, and Psych info; Cumulative Index to Nursing and Allied Health Literature (CINAHL). Also, lists of the references of the relevant articles were reviewed for additional citations. Using Medical Subject Headings (MESH) keywords: Intervention (Clinical Trials, Non-Randomized Controlled Trials, Randomized Controlled Trials, Education), intimacy, marital (Marriage) and selected related articles to the study objective were from 1995 to April 2015. Clinical trials that evaluated one or more behavioral interventions to improve marital intimacy were reviewed in the study.

Main Results:

39 trials met the inclusion criteria. Eleven interventions had follow-up, and 28 interventions lacked follow-up. The quality evidence for 22 interventions was low, for 15 interventions moderate, and for one intervention was considered high. Findings from studies were categorized in 11 categories as the intimacy promoting interventions in dimensions of emotional, psychological, physical, sexual, temporal, communicational, social and recreational, aesthetic, spiritual, intellectual intimacy, and total intimacy.

Authors’ Conclusions:

Improving and promoting communication, problem solving, self-disclosure and empathic response skills and sexual education and counseling in the form of cognitive-behavioral techniques and based on religious and cultural context of each society, an effective step can be taken to enhance marital intimacy and strengthen family bonds and stability. Health care providers should consider which interventions are appropriate to the couple characteristics and their relationships.

1. Introduction

Marriage is a transient phase in one’s life and has always been emphasized as the paramount social ritual in order to meet the emotional needs of people ( Dildar, Sitwat, & Yasin, 2013 ; Nayeri, Lotfi, & Noorani, 2014 ). In contemporary society, the incentives to marriage include the need to love and have intimate relationship with a partner, to have a companion in life, to satisfy psychological needs, and to increase joy ( Soltani, Molazadeh, Mahmoodi, & Hosseini, 2013 ; Tavakol, Zarei, & Zeinali Pour, 2014 ).

Intimacy includes different meanings based on age, sex, education, and culture, and there is no consensus among researchers on the root concept of intimacy which makes its definition difficult ( Martin & Tardif, 2014 ; Mitchell, 2007 ). Bagarozzi (2001) defines intimacy as proximity, similarity and a personal romantic or emotional communication that requires knowledge and understanding of another person to express thoughts and feelings ( Bagarozzi, 2001 ).

Intimacy is strongly associated with the quality of couples’ life and is often referred to as a basic psychological need and one of the key characteristics of marital communication which impacts on marital adjustment and mental health, such as reducing the risk of depression, increasing happiness and well-being, and providing a useful satisfactory life of a person. Besides, it is a strong predictor of physical health, such as low level of diseases and impoverishment of diseases ( Boden, Fischer, & Niehuis, 2010 ; Dandurand & Lafontaine, 2013 ; Moreira, Crespo, Pereira, & Canavarro, 2010 ; Nainian & Nik-Azin, 2013 ). In a study was shown that marital intimacy is effective on marital satisfaction ( Greeff, Hildegarde, & Malherbe, 2001 ; Kim, 2013 ). Intimacy acts as a mediator between the effects of daily stress in relations between spouses ( Harper, Schaalje, & Sandberg, 2000 ). There is a significant positive correlation between sexual satisfaction and marriage commitment with intimacy ( Taghiyar, Mohammadi, & Zarie, 2015 ). In contrast, lack of intimacy is one of the most common causes of distress and collapse among couples, negatively impacting on relations between the couples and, thereby, leading to incompatibility and causes stress, and brings about psychological maladaptation, depression, and emotional disorders mental disorders ( Duffey, Wooten, Lumadue, & Comstock, 2004 ; Kim, 2013 ; Yoo, Bartle-Haring, Day, & Gangamma, 2014 ). Dearth of intimacy is one of the most devastating problems that is difficult to be treated in the relationships ( Whisman, Dixon, & Johnson, 1997 ). Weinberger et al. (2008) also showed that lack of intimacy in couples is the most important predictor of divorce in elderly ( Weinberger, Hofstein, & Whitbourne, 2008 ). Thus, it can be stated that the consequences of failure in intimacy are manifold and physical divorce mainly arises from failure in intimacy ( Duffey et al., 2004 ).

Therapists have described on various aspects that may negatively influence marital stability such as communication difficulty, unrealistic expectations from marriage and the spouse, lack of intimacy, and lack of expressing affection ( Motavali, Ozgoli, Bakhtiari, & Alavimajd, 2010 ; Shahrestany, Doustkam, Rahbarda, & Mashhadi, 2013 ). Taking the fact for the granted that in many societies today family is the prominent source of comfort for people and taking the fact that in the modern society the family is faced with the challenges, the most important of which is the loss of marital intimacy, into account, an interventional program is helpful to prevent these problems and heighten intimacy ( Farbod, Ghamari, & Majd, 2014 ). To enhance () intimacy in couples, educational approaches may support () ( Oulia, Fatehizadeh, & Bahrami, 2006 ). It believed that Education and counseling per se may make the couples take effective and successful steps to increase marital intimacy ( Hosseini Zand, SHafi Abadi, & Soudani, 2013 ). In Iran, some interventions are done to increase marital intimacy. For example, In a study was shown that training communication skills can enhance intimacy and quality in marital life ( Farbod et al., 2014 ). Moreover, KhanjaniVeshki et al. (2012) concluded that sex education is effective in increasing sexual intimacy ( Khanjani Veshki, Botlani, Shahsiah, & Sharifi, 2012 ). Duffey et al. (2004) also showed that sharing dreams and events between couples contributes to an increase in intimacy in couples ( Duffey et al., 2004 ). According to the researcher’s search in the databases available, no study has reviewed the interventions promoting marital intimacy after marriage thus far. To address the latter the aim of this review is to classify the articles investigating the impact of interventional programs on marital intimacy after marriage.

2.1 The Criteria Considered for This Review

2.1.1 type of study.

Clinical trials that evaluated one or more behavioral interventions to improve marital intimacy were reviewed in the study. Trials that focused on people with drug abuse and chronic health conditions, such as cancer, were excluded. The reason for their exclusion pertains to statistical population. This is because training and counseling to them were not proportionate to type of disorder in individuals and may not be applied for all spouses. Like educations and counselings that focused on people with breast cancer or prostate cancer. There was no other exclusion criterion.

2.1.2 Type of Participants

Married men and women or couples.

2.1.3 Type of Interventions

Interventions can have different formats such as verbal communication or written methods, individual or group counseling as well as using different types of technology, such as providing educational CDs. Intervention can be provided in a clinic or in the community and can target men, women, or couples. The comparison can be performed between the intervention under the study and another behavioral intervention, usual care or without any intervention.

2.1.4 Type of the Measured Result

Our interest outcome was increasing intimacy. All trials that yielded this result were incorporated in the study.

2.1.5 Type of Intimacy Assessment Tools

To evaluate interventions, different intimacy questionnaires can be applied such as:

Marital Intimacy Questionnaire Thompson and Walker Marital Intimacy Questionnaire (MIQ) (den Broucke & Vertommen (1995), Waring Intimacy Questionnaire (WIQ), Personal Assessment of Intimacy in Relationships inventory, Oulia’s Couples intimacy questionnaire, and Bagarozzi’s Marital Intimacy Needs Questionnaire.

2.2 Search Method

In April 2015, we performed a general search in Google Scholar search engines followed by an advanced search was done in the below databases:

ProQuest, Science Direct, SID, Irandoc, Magiran, Pubmed, Cochrane Library, Scopus, and Psych info; Cumulative Index to Nursing and Allied Health Literature (CINAHL).

Keywords were arranged based on Medical Subject Headings (MeSH) to search in Medline and based on non-mesh keywords in other databases including: Intervention (Clinical Trials, Non-Randomized Controlled Trials, Randomized Controlled Trials, and Education), intimacy and marital (Marriage).

Also, lists of the references of the relevant articles were reviewed for additional citations. Selected related articles to the study objective were from 1995 to April 2015.

2.3 Interventions Quality

The quality of evidence was evaluated. At first, the quality of the intervention design, implementation, and reports was evaluated. Quality of intervention downgraded for each of the following studies: 1) implementing intervention in less than two sessions, 2) the accuracy of reported interventional information for fewer than three items ( Table 1 ), and 3) lack of follow-up ( Lopez, Hiller, Grimes, & Chen, 2012 ; Lopez, Steiner, Grimes, & Schulz, 2013 ). The quality of the interventions evidence was recorded ( Table 2 ) among the overall assessments of the quality of evidence ( Table 3 ), the quality trials were considered high, then in the case of any of the following, one level of the quality of evidence was downgraded, A) lack of information on random sequence, allocation concealed, or lack of allocation concealed B) low quality interventions, and c) loss of more than 20% at follow-up. We considered a positive level for the studies that performed blinding procedures ( Lopez et al., 2012 ).

Intervention fidelity information

Provider credentials	Provider education	Standardized delivery	Delivery adherence
-----	-----	1.5 hour session of communication skill based on Miller Theory	-----
Consultant	-----	12 sessions of emotionally focused couple therapy that each session lasted 2/5 hours	step by step and along with weekly assignments and regular exercises provided by consultants
-----	-----	The structure of sessions and trainings materials presented at each session were taken from Davison and Goldfried, Jacobson and Margolin, Miller et al., Bernstein and Bernstein, and was introduced during 6 weeks of one hour sessions	Training sessions were presented based on training curriculum
-----	-----	sex education was presented in cognitive behavioral method during 6 sessions each lasted two hours	Training sessions were presented based on training curriculum
-----	-----	meaning - focused workshop in 10 sessions of 90 minutes	Once a week and based on the curriculum
consultant	-----	10 sessions of one-hour couple therapy based on cognitive behavioral techniques	Step by step and though weekly assignments
-----	-----	Communication enrichment program during 10 sessions of 1.5 hours	One session in a week
researcher	-----	7 sessions of Islamic lifestyle training with an emphasis on the family system	Twice a week sessions for 90 minutes each time
-----	-----	6 sessions of two hours sex education in the form of speech, asking questions, group discussion and presentation of assignments	Weekly program and based on the curriculum
-----	-----	8 sessions of intervention based on intellectual-emotional behavior therapy	For eight weeks, every week for an hour and a half in groups
-----	-----	Marriage enrichment preventive program designed by Mies and presented during 7 weeks	Every week one communication skill was taught to couples.
-----	-----	Eight sessions of an hour and a half of group training based on communication therapy approach	Weekly program and based on the curriculum
researcher	-----	10 sessions of two hours of Islamic couple therapy training	Implemented once a week and in three stages
researcher	-----	10 training sessions based on choice theory	-----
-----	-----	6 sessions of 90-minute of marital life enrichment training	Sessions were hold step by step and weekly
-----	-----	8 sessions of 90-minute of cognitive behavioral group training	Twice a week and based on the curriculum
-----	-----	8 attachment-based couple therapy sessions	Once a week and each session 90 minutes
-----	-----	8 sessions of 90-minute of solution-focused group counseling	Weekly and based on the curriculum
-----	-----	7 sessions of 90 minute of teaching concepts of choice theory	Once a week and based on the curriculum
offered under the counseling and leading of the supervising professor	-----	the 6 session 2-hr group enrichment program training	Weekly
therapist	Leaders are license mental health professional	The standard 4-month PAIRS format	Weekly or biweekly 3 hour sessions and 4 or 5 weekend workshop lasting about 21 hours.
counselor	-----	6 sessions of sex education. Format and content identified for sessions	Sex training was presented step by step for men and women
researcher	-----	offering of the intimacy-building, dream-sharing workshop and workbook used to the interventional group an intimacy-building and event-sharing workshop presented to the control treatment group	a four hour dream sharing workshop
-----	-----	8 sessions of Transactional Analysis that each session lasted 1/5 hours	Training sessions were presented based on training curriculum
-----	-----	An intensive course of solution-focused couples therapy was presented within six sessions that each session lasts 1.5 hours	Sessions for 2.6 months with giving assignments and feedbacks that presented based on Objectives listed for each visit.
-----	-----	Training positive thinking skills during 8 sessions that each session lasted 1/5 hours. Format and content identified for sessions	Weekly sessions
consultant	-----	ten sessions of 60 minutes couples therapy and cognitive-behavioral techniques	Weekly sessions
-----	-----	12 sessions to enhance communication skills based marriage and family therapy	No information
-----	-----	-----	-----
A couple	A couple trained and husband had a Divinity degree with an emphasis in psychology and counseling.	A weekend marriage enrichment program With emphasis on Integrative Couple Therapy (ICT) developed by Neil Jacobson and Andrew Christensen.	Training session were presented based on training curriculum
-----	-----	8 sessions of 1.5 hours training positive thinking skills. Format and content identified for sessions	twice a week
-----	-----	12 sessions of couple communication program (CCP) that each session lasted 2 hours	once a week
first author and a couple	The husband was in his final week of a masters’ degree program in Bible and Religion, training to be a family life minister.	In the Adventure group, Waring’s (1984) 8 components of marital intimacy in the design was used	two-day weekend
-----	-----	8-10 sessions 120 minutes of emotionally focused couple therapy(EFCT)	EFCT has 3 stages and 9 steps.
therapist	Therapist was provided with 12 hr of training in emotion focused therapy that covered the theory and techniques of the approach.	8 sessions of emotion focused therapy (EFT) that each session lasted 50 minutes	Weekly
-----	-----	-----	weekly
counselor	trained counselor in the Counseling Center	8 sessions of 1 hour based on Format and content identified for sessions	Two times a week.
-----	-----	9 sessions that each session lasted 1 hour. Format and content identified for sessions.	per week

Quality of intervention * evidence

Sessions <= 2	Having Follow-up	Intervention fidelity < 3 items	Quality1
---	-1	-1	Low (-2)
---	-1	---	Moderate (-1)
---	-1	-1	Low (-2)
----	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	-1	---	Moderate (-1)
---	---	-1	Moderate (-1)
---	-1	---	Moderate (-1)
---	---	-1	Moderate (-1)
---	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	---	---	High (0)
---	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	---	-1	Moderate (-1)
---	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	---	---	High (0)
---	---	---	High (0)
---	-1	----	Moderate (-1)
-1	-1	----	Low (-2)
---	---	-1	Moderate (-1)
---	-1	-1	Low (-2)
---	-1	-1	Low (-2)
---	-1	---	Moderate (-1)
---	-1	-1	Low (-2)
No information	-1	-1	Low (-2)
No information	---	---	High (0)
---	-1	-1	Low (-2)
---	---	-1	Moderate (-1)
---	-1	---	Moderate (-1)
---	-1	-1	Low (-2)
---	-1	----	Moderate (-1)
---	-1	-1	Low (-2)
---	---	---	High (0)
---	---	-1	Moderate (-1)

Quality of evidence *

Randomization; allocation concealment	Losses > 20%	Blinding Quality of evidence1	Intervention quality	Quality of evidence1
-1	No information	----	-1	Low(-2)
-1	No information	-----	-----	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	---	---	Moderate(-1)
-1	No information	---	---	Moderate(-1)
-1	No information	---	---	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	---	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	---	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	---	---	---	Moderate(-1)
-1	No information	---	---	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	---	-1	Low(-2)
-1	No information	---	-1	Low(-2)
-1	-1	---	---	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	+1	---	High(0)
-1	No information	---	-1	Low(-2)
-1	-1	---	---	Low(-2)
-1	No information	---	-1	Low(-2)
-1	No information	---	---	Moderate(-1)
-1	No information	---	---	Moderate(-1)

3. Search Results

Sixty six sources were provided by the search from 1995 to April 2015. After reviewing the various titles and abstracts, 25 studies were excluded from review due to the lack of consideration of study criteria (the 25 studies that were excluded from review included 9 studies in the USA, 6 from Iran, 2 from Canada, 3 in each of Australia and Korea, whereas 1 was completed in each of England and the Netherlands, although they focusing on respondents with drug abuse and chronic health conditions) ( Table 4 ). Finally, 39 trials met the inclusion criteria ( Figure 1 ). The total number of participants was 1981 people, and the number of participants in each study was from 24 to 216 people. Average number of participants in each trial was 50.79 people. Thirty three studies were conducted in Iran, and the six others were conducted in America and Korea. Sixteen trials focused on women, 20 trials focused on couples, and 3 trials focused on men and women. Studies varied in provided educating content and format.

Characteristics of excluded studies

Study	Reason for exclusion
Amber (2011)	Trial focused on couples with cancer
Leclerc	Trial focused on young adults with first psychological episode
Chambers (2014)	Trial focused on men with localised prostate cancer and their female partners
	Trial focused on spouses of war-disabled affiliated with markers and self sacrifices
Jun (2011)	Trial focused on Breast Cancer Survivors
Heather (2013)	Trial focused on men with localised prostate cancer
Robertson (2014)	Trial focused on Patients with prostate cancer and their partners
Reese (2012)	Trial focused on couple who had facing colorectal cancer.
Reese (2014)	Trial focused on couple who had facing colorectal cancer.
Julia (2009)	Trial focused on Patients with breast cancer
Jung (2005)	Trial focused on male patients with spinal cord injuries
Kerri (2012)	Trial focused on prostate cancer survivors (PCS) and their spouses
Manne (2004)	Trial focused on women with breast cancer and their partners
Nho (2013)	Trial focused on Women with Gynecologic Cancer and Their Husbands
Otto (2015)	Trial focused on women with breast cancer and their intimate partners
Gol (2013)	Trial focused on depressed patients
DeMarco (2009)	Trial focused on women living with or at risk for HIV.
Manne (2011)	Trial focused on Men Diagnosed with Prostate Cancer and Their Partners
Hummel (2015)	Trial focused on breast cancer survivors
Sidddons (2013)	Trial focused on men with localised prostate cancer.
Edward (1995)	Trial focused on depressed married women
Babapour Kheiroddin (2012)	Trial focused on chemical patient couples
Hamedi (2011)	Trial focused on addicted man and their Wives.
Sadrejahani (2009)	Trial focused on addicts and their wives
Kazemian (2013)	Trial focused on infertile Couples

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Object name is GJHS-8-74-g001.jpg

Result of the search

Eleven interventions had follow-up ( Bahrami, Oulia, & Isanezhad, 2009 ; Botlani, Ahmadi, Bahrami, Shahsiah, & Mohebbi, 2010 ; Coutta, 2001 ; Durana, 1997 ; Ebrahimi, Sanaei Zaker, & Nazari, 2011 ; Hosseini Zand et al., 2013 ; Momeni Javid, Soveyzi, & Mousavi, 2014 ; Nayeri et al., 2014 ; Shakarami, Davarniya, Zahrakar, & Gohari, 2014 ; Sharifian, Najafi, & Shaghaghi, 2011 ; Yousefi & Kiani, 2014 ) and 28 interventions lacked follow-up. Time of interventions was from one 4-hour workshop (Duffey) to 120-hour interventions for 4 to 5 months (Durana).

The quality of interventions was high in five studies, moderate in 13 studies was, and low in 20 studies. However, due to the limitations in the language in one study (the full text of the article was in Korean), it was not feasible to ensure the quality of the intervention ( Table 2 ). The quality evidence was low for 22 interventions, moderate for 15 interventions, and high for one intervention ( Table 3 ). Findings from studies were categorized in 11 categories as the intimacy promoting interventions in dimensions of emotional, psychological, physical, sexual, temporal, communicational, social and recreational, aesthetic, spiritual, intellectual intimacy, overall dimension, and total intimacy and are shown in Table 5 .

The intimacy-enhancing interventions in different dimensions

Dimension	Intervention	Authors
Emotional intimacy	Communication skill	,
	Relationship Therapy
	Relationship enhancement program
	Marital enrichment	,
	Solution-focused couples therapy
	Solution-Focused Group Counseling
	Cognitive-behaviour couple therapy
	Training of Islamic Lifestyle
	Emotional focused couple therapy	,
	(narrative therapy)
Psychological intimacy	Communication skill	,
	Relationship enhancement program
	Marital enrichment	,
	Solution-focused couples therapy
	Solution-Focused Group Counseling
	Cognitive-behavior couple therapy
	Training of Islamic Lifestyle
	Emotional focused couple therapy	,
	Problem Solving Training
Physical intimacy	Communication skill	,
	Relationship enhancement program
	Relationship Therapy
	Problem Solving Training
	Solution-focused couples therapy
	Training of Islamic Lifestyle
	Emotional focused couple therapy	,
Sexual intimacy	Communication skill	,
	Relationship enhancement program
	Solution-focused couples therapy
	Solution-Focused Group Counseling
	Cognitive-behavior couple therapy
	Training of Islamic Lifestyle
	Islamic couple therapy
	Sex education	, ,
	Attachment-based couple therapy
	Emotional focused couple therapy	,
	Training Positive Thinking
Temporal intimacy	Emotional focused couple therapy
	Communication skill
	Solution-Focused Group Counseling
Communicational intimacy	Relationship enhancement program
	Solution-focused couples therapy
	Marital enrichment	,
	Training of Islamic Lifestyle
	Emotional focused couple therapy	,
	(narrative therapy)
Social-Recreational intimacy	Communication skill	,
	Relationship enhancement program
	Marital enrichment	,
	Emotionally focused couple therapy
	Training of Islamic Lifestyle
Aesthetic intimacy	Communication skill
Spiritual intimacy	Communication skill	,
	Relationship enhancement program
	Marital enrichment	,
	Emotionally focused couple therapy
	Training of Islamic Lifestyle
Intellectual intimacy	Communication skill	,
	Relationship enhancement program
	Marital enrichment	,
	Emotional focused couple therapy	,
	Problem Solving Training
	Solution-focused couples therapy
Total intimacy	Communication skill	, ,
	Problem Solving Training
	Training solution-focused couples therapy
	Dream sharing
	Marital enrichment	,
	Training Positive Thinking
	Cognitive- behavior couple therapy	, ,
	Meaning-centered training
	Choice theory training
	Rational - emotional behavioral therapy
	Foot massage
	Rogers Self Theory and Ellis Rational Theory
	Group training of transactional analysis
	Enhancing marital intimacy
	Emotion focused therapy

4. Discussion

4.1 emotional intimacy.

emotional intimacy has been described as to share all the emotions, both positive and negative feelings with the spouse ( Bagarozzi, 2001 ). Studies show that training and enriching the communication skills and communication therapy can contribute to the promotion of emotional intimacy ( Ebrahimi et al., 2011 ; Etimadi, Jafari, & Seyah, 2014 ; Hosseinian, Yazdi, & Tabatabaei, 2012 ; Mazlomi, Dolatshahi, & Nazari, 2012 ). In these studies, participants were trained in some of the most important skills including conflict resolution by understanding the hidden needs and feelings of the spouse, understanding how to ask the needs and expectations, Identification of the impact of incorrect beliefs and expectations of spouses on the creation of conflicts and reduction of intimacy and active listening ( Mazlomi et al., 2012 ), increasing self-awareness, knowing the spouse, getting familiar with each other’s needs and losses, renewing the memories of the past and improving the relations ( Etimadi et al., 2014 ) and training communication skills based on Miller’s theory. So that in this plan, women were instructed the skills of speaking so as to convey information to the spouse, skills of listening, and skills of problem solving and planning in order to solve problems and identify effective communication styles ( Hosseinian et al., 2012 ).

Solution-focused training plays an important role in increasing this dimension of intimacy. In this study, the couples were trained in six 90-minute training sessions to improve relationships and communication, evaluate the level of marital conflict and the nature of the problem, detect the chief complaint and define the problem, set a goal, examine solutions, formulate circles to find the solutions of the problems, and give the old and common solutions using intensive courses of couple therapy along with doing some homework in each session ( Hajian & Mohammadi, 2013 ). The study showed that group counseling in the solution-focused method enhances the emotional intimacy ( Hosseini, Majd, & GHamari, 2013 ). The other studies also stated that emotion-focused couple therapy can promote this dimension of intimacy ( Asadpour, Nazari, Zaker, & Shaghaghi, 2012 ; Soltani et al., 2013 ). The 9-stage emotion-focused therapy of couples consists of description of the issues related to the conflict, identification of negative interaction circle that causes distress in couples, access unexplored emotions that are based on interactive conditions, formulation of the problem baced on emotion, like anger, disgust, fear, happiness, sadness and surprise. and attachment-focused needs, increase of the understanding of self emotions and personal needs that have been ignored, increase of accepting experiences of each spouse by the other party, creation of new ways of communicating, facilitation of expressing emotional needs and demands, facilitation of the development of new solutions for old problems and finally integration and reinforcement of new situations ( Asadpour et al., 2012 ; Soltani et al., 2013 ).

Etemadi et al. (2006) showed in their study that the use of cognitive-behavioral techniques can promote emotional intimacy. In the cognitive behavioral techniques, participants were studied in terms of having unrealistic expectations and beliefs about intimacy and sexual relationships and the destructive effects of such behaviors on feelings, eliminating misunderstandings arising from misconceptions or different understanding, assessing the problems associated with the message sender and receiver and training communication skills, creating empathic understanding and active listening comprehension skills, training problem solving skills, and exploring the conflicts between spouses weekly and along with assignments ( Etemadi, Navvabi Nezhad, Ahmadi, & Farzad, 2006 ). Other interventions to promote emotional intimacy can be pointed out as narrative therapy ( Mohammadi, Sohrabi, & Aghdam, 2013 ), the Islamic lifestyle ( Rezaei et al., 2013 ), and enriching the marital life ( Bahrami et al., 2009 ; Oulia et al., 2006 ).

4.2 Psychological Intimacy

Psychological intimacy involves sharing personal issues, information, hopes, fears, desires, and feelings about the self with a spouse ( Bagarozzi, 2001 ). The study of Ebrahimi et al. (2011) showed that enriching communication plays an important role in enhancing this dimension of intimacy. Here, in the relationship enrichment program, expressive skills, empathic listening, correct simultaneous way of speaking and listening and comparing it with the non-skilled dialogue, conflict resolution skill, self -change skill, and the skill of helping the spouse to change of the participants of the study were investigated ( Ebrahimi et al., 2011 ). The studies of Hosseinian et al. (2012) and Mazlomi et al. (2012) came across results in line with the study of Ebrahimi (2011) and showed that enriching communication skills contributes to a rise in intimacy. Education of problem-solving skill among couples leads to increasing psychological intimacy ( Zarepour, 2010 ), that is in line with the study of Hajian (2013) ( Hajian & Mohammadi, 2013 ). Zarepour performed the education of problem-solving skill in order to take a positive and optimistic attitude towards the problem and the ability of the couples to deal with it, identify problems and obstacles to solve the problem, identify realistic objectives agreed by the couples, evaluate each solution and select the best solution, and implement the selected solution in the real life ( Zarepour, 2010 ). Other interventions that can promote the psychological intimacy can be emotion focused couple therapy skill ( Asadpour et al., 2012 ; Soltani et al., 2013 ) and the Islamic lifestyle approach. The Islamic life style approach is based on Islamic rules and principles more expounded on in the following sections. ( Rezaei et al., 2013 )

4.3 Physical Intimacy

Physical intimacy is the partner’s need to physical contact such as hugging, holding hands and non-sexual touch ( Bagarozzi, 2001 ). Education of problem-solving skill is effective in increasing this dimension of intimacy ( Zarepour, 2010 ). The studies of Hajian (2013) and Hosseini (2013) were consistent with the study of Zarepour (2010) and showed that solution-focused training leads to increasing physical intimacy ( Hajian & Mohammadi, 2013 ; Hosseini et al., 2013 ). Emotion-focused couple therapy can promote the physical intimacy of the couples ( Asadpour et al., 2012 ). The study of Soltani (2013) is also in line with the study of Asadpour ( Soltani et al., 2013 ). Other interventions that can promote the physical intimacy can be communication enriching ( Ebrahimi et al., 2011 ; Etimadi et al., 2014 ; Hosseinian et al., 2012 ; Mazlomi et al., 2012 ) and Islamic lifestyle training ( Rezaei et al., 2013 ).

4.4 Sexual Intimacy

Sexual intimacy involves the expression of thoughts, feelings, and desires that have sexual nature and are planned to arouse sexual stimulation and sexual satisfaction ( Bagarozzi, 2001 ). One of the ways to increase sexual intimacy is to present sex education to couples ( Shakarami et al., 2014 ). Education and counseling in sexual dimension cause the couples to get enough awareness in this field and take effective steps to deal with their sexual problems and promote sexual intimacy ( Zand et al., 2013 ). Sex education based on cognitive-behavioral techniques is effective to improve sexual intimacy ( Veshki et al., 2012 ). Sex education increases sexual intimacy ( Salimi & Fatehizadeh, 2012 ; Shakarami et al., 2014 ). In sex education, participants become familiar with physiology and sexual behavior and also receive education on topics such as modifying the myths about sexual matters, shaping the sexual intimacy and appropriate sexual techniques, and getting familiar with some of the most common sexual disorders ( Shakarami et al., 2014 ). In addition, in the study of Salimi (2012) , participants received trainings such as relaxation and fantasy skill, attention and awareness of the Sensory symptoms, expression of emotion and self -sexual expression, establishment of sexual intimacy, increase of positive self-talk, communication skill, increase of positive interactions, and problem solving ( Salimi & Fatehizadeh, 2012 ).

Couples’ communication skill improvement increased sexual intimacy ( Mazlomi et al., 2012 ). The study of Hosseinian (2012) and Ebrahimi (2011) are in line with the study of Mazlomi (2012) ( Ebrahimi et al., 2011 ; Hosseinian et al., 2012 ). While Etemadi (2014) showed that communication therapy does not improve the sexual intimacy ( Etimadi et al., 2014 ). Nasiri Nejad (2014) found that educating positive thinking is conducive to sexual function and sexual intimacy of the spouses. In this study, participants were first familiarized with the need to positive thinking, different coping styles, and the ways to forming thinking and attitudes. The participants were then familiarized with their negative thoughts and modification techniques and also with positive thinking and its effect on the life based on cognitive-behavioral technique. Applying the ABC theory of, (The ABC Model A major aid in cognitive therapy is what Albert Ellis (1957) called the ABC Technique of Irrational Beliefs. The first three steps analyze the process by which a person has developed irrational beliefs including: A - Activating Event or objective situation, B - Beliefs and C - Consequence. Ellis believes that it is not the activating event (A) that causes negative emotional and behavioral consequences (C). Rather, a person interprets these events unrealistically and, therefore, has an irrational belief system (B) that helps cause the consequences (C) ( McLeod, 2008 )). The participants were trained in forming positive thoughts for example: 1) Im responsible and in control of my life. 2) Circumstances are what they are, but I can choose my attitude towards them. And 3) Every challenge that comes along is an opportunity to learn and grow. 4) I am getting better every day.). Training techniques to stop negative thoughts, boosting self confidence, and adding laughter and sports to life were other positive thinking techniques which were relied upon ( Nejad, Nazari, & Bahrainian, 2014 ). Other interventions to promote sexual intimacy can be solution-focused training ( Hajian & Mohammadi, 2013 ; Hosseini et al., 2013 ), use of cognitive-behavioral techniques ( Etemadi et al., 2006 ), the Islamic lifestyle ( Rezaei et al., 2013 ), couple therapy ( Zand et al., 2013 ), couple therapy based on attachment ( Botlani et al., 2010 ) and emotion-focused couple therapy ( Asadpour et al., 2012 ; Soltani et al., 2013 ).

4.5 Temporal Intimacy

Temporal intimacy indicates the extent to which couples tend to spend their daily time with their spouses on intimate activities ( Bagarozzi, 2001 ). The study of Soltani et al. (2013) showed that emotion-focused couple therapy can promote this dimension of ( Soltani et al., 2013 ). The first hypotheses on excitement-based treatments contend that the most effective factor in creating and maintaining marital intimacy is the type of the existing chain of excitement. Johnson (2004) predicts that excitement-based treatment (emphasizing sympathy, self-expression, deep understanding of one’s self needs and the partner’s needs, acceptance, expression of ideas and feelings and creation of an emotional environment, all of which are considered as essential elements in an intimate relationship) can play a powerful role in increasing intimacy in couples ( Hamedi, Abadi, Navabinejad, & Delavar, 2013 ). Other interventions that can be pointed out to increase intimacy are communication skill training ( Mazlomi et al., 2012 ) and solution-focused group counseling, in Solution-based treatment focuses on the activities both of the spouses enjoy and encourages them to do those activities again. Recommending the couple to walk and have recreation together without the presence children can be significant help to them in an optimal use of their time ( Hosseini et al., 2013 ).

4.6 Communication Intimacy

Communication intimacy is defined as the creation of a relationship with respect, commitment, and positive emotions in such a way that the spouses feel valued and respected in this communication ( Oulia et al., 2006 ). Bahrami (2009) carried out a study with the purpose of enriching marital life, and the intervention group was trained to have intimacy, improve sex issues, manage household, restructure cognition, and learn conflict resolution skill. The results showed that training marital life enrichment enhances communication intimacy ( Bahrami et al., 2009 ). The results of the study of Oulia (2006) are consistent with the above study ( Oulia et al., 2006 ). Hajian (2013) reported that group solution-focused training is related to promoting communication intimacy by promoting intimacy ( Hajian & Mohammadi, 2013 ). Other study also showed that communication enrichment is associated with increased communication intimacy ( Ebrahimi et al., 2011 ; Hosseinian et al., 2012 ).

Moreover, Soltani (2013) stated that the emotion-focused therapy increased communication intimacy ( Soltani et al., 2013 ) that the study of Asadpour (2012) is consistent with the above study ( Asadpour et al., 2012 ). Other interventions promoting communication intimacy include narrative therapy ( Mohammadi et al., 2013 ) and Islamic lifestyle ( Rezaei et al., 2013 ).

4.7 Social-Recreational Intimacy

Social recreational intimacy requires involving the spouse in responsibilities, passing holidays, enjoyable activities and leisure time, and expressing experiences and daily events ( Bagarozzi, 2001 ). It was shown in the studies that communication skill training increases this dimension of intimacy ( Ebrahimi et al., 2011 ; Hosseinian et al., 2012 ; Mazlomi et al., 2012 ); however, Etemadi (2014) showed that communication therapy has no positive effect in promoting social recreational intimacy ( Etimadi et al., 2014 ). Asadpour (2012) demonstrated that emotion-focused couple therapy can promote social recreational intimacy while Soltani (2013) stated that emotion-focused couple therapy has no significant effect on increasing this type of intimacy ( Asadpour et al., 2012 ; Soltani et al., 2013 ). In emotion-focused couple therapy, the first hypotheses on excitement-based treatments contend that the most effective factor in creating and maintaining marital intimacy is the type of the existing chain of excitement. Johnson (2004) predicts that excitement-based treatment (emphasizing sympathy, self-expression, deep understanding of one’s self needs and the partner’s needs, acceptance, expression of ideas and feelings and creation of an emotional environment, all of which are considered as essential elements in an intimate relationship) can play a powerful role in increasing intimacy in couples ( Hamedi et al., 2013 ). Rezaei (2013) showed in his study that the Islamic lifestyle training increases recreational intimacy between spouses and that a summary of Islamic lifestyle training content includes the definition of marital intimacy, expression of couples’ expectations from their marital life, Islam’s idea about intimacy and the ways to increase it, verbal and nonverbal communications of the spouses, role of forgiveness in the conjugal life, guidance in order to enhance the relationships among couples, rights of spouses towards each other and respecting the boundaries in the families, sex customs in Islam and respect for privacy in sexual relationships, procedures of creating peace in the family, and methods of conflict resolution in the family ( Rezaei et al., 2013 ).

4.8 Aesthetic Intimacy

Aesthetic intimacy needs sharing feelings, thoughts and beliefs that are Beautiful exciting in one’s opinion (Aesthetic intimacy needs sharing feelings, thoughts, and beliefs which are beautiful excitements in one’s opinion, such as wonders of nature and the cosmos, music, art, poetry, etc. ( Bagarozzi, 2001 ). Mazlomi (2012) demonstrated in that communication skill training can promote the aesthetic intimacy ( Mazlomi et al., 2012 ), while the study of Etemadi (2006) , which was performed to evaluate the effect of cognitive behavioral techniques training on intimacy and the intervention group, was trained skills of communication, problem solving, and conflict. Besides, cognitive factors showed that the above skills do not have any effects on improving this dimension of intimacy ( Etemadi et al., 2006 ).

4.9 Spiritual Intimacy

Religious intimacy is described as to express your thoughts, feelings, beliefs and experiences about religion, supernatural issues, moral values, life after death, and the relationship with God for your spouse ( Bagarozzi, 2001 ). Mazlomi et al. (2012) showed that promoting communication skill of couples increases the intimacy in this dimension ( Mazlomi et al., 2012 ). The other studies are in line with the study of Mazlomi (2012) ( Ebrahimi et al., 2011 ; Hosseinian et al., 2012 ), while Etemadi et al. (2014) reported that communication therapy does not improve religious intimacy ( Etimadi et al., 2014 ). Asadpour (2012) also showed that emotion-focused couple therapy can promote religious intimacy; on the other hand Soltani (2013) showed that emotion-focused couple therapy has no significant effect on increasing this dimension of intimacy ( Asadpour et al., 2012 ; Soltani et al., 2013 ). Also Oulia (2006) reported that the marital life enrichment can promote religious intimacy that is in line with the study of Bahrami (2009) ( Bahrami et al., 2009 ; Oulia et al., 2006 ). The results of the study of Rezaei et al. (2013) also showed that religious intimacy is effective in improving the Islamic lifestyle ( Rezaei et al., 2013 ).

4.10 Intellectual Intimacy

Intellectual intimacy is the need to transfer and restate important thoughts and beliefs with the spouse ( Bagarozzi, 2001 ). The study showed that enrichment of marital life can promote the intellectual intimacy ( Oulia et al., 2006 ). The other study is in line with the above study ( Bahrami et al., 2009 ). The results of the study of Mazlomi et al. (2012) stated that improving the communication skill of couples increases intellectual intimacy ( Mazlomi et al., 2012 ). The other studies are in line with the study of Mazlomi (2012) ( Ebrahimi et al., 2011 ; Hosseinian et al., 2012 ), while Etemadi et al. (2014) showed that the communication therapy has no effect on the promotion of intellectual intimacy ( Etimadi et al., 2014 ). Zarepour (2010) showed that training problem-solving skill leads to the improvement of intellectual intimacy between the couples ( Zarepour, 2010 ). Solution-focused training of the couples can promote this aspect of intimacy ( Hajian & Mohammadi, 2013 ). Emotion focused therapy increases this dimension of intimacy ( Soltani et al., 2013 ), which is in line with the study of Asadpour et al. (2012) .

4.11 Total Intimacy

Momeni Javid et al. (2014) reported that training marital life promoting skills has an effective role to improve marital intimacy ( Javid et al., 2014 ). The results of the other studies are in line with this study ( Farbod et al., 2014 ; Karimi, Hasani, Soltani, Dalvand, & Zohdi, 2012 ; Sharifian et al., 2011 ). Moreover, Zarepour (2010) showed that promoting problem-solving skill in couples is associated with increasing the overall intimacy that the study of Hosseini (2013) is in line with it ( Hosseini et al., 2013 ; Zarepour, 2010 ). Sharing dreams and events can promote total intimacy ( Duffey et al., 2004 ). Marital life enrichment of couples increases the intimacy that is in line with the study of Hickmon (1997) ( Coutta, 2001 ; Hickmon Jr, Protinsky, & Singh, 1997 ). Enrichment of intimacy promoting program increases marital intimacy ( Durana, 1997 ). The study reported that the use of cognitive-behavioral techniques enhances the intimacy of the couples which is consistent with the other studies ( Babaei Garmkhani, Madani, & Lavasani, 2014 ; Etemadi et al., 2006 ; Mami, Roohandeh, & Kahareh, 2015 ). Emotion focused therapy can promote intimacy ( Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000 ) and emotional intellectual behavioral therapy can promote intimacy ( Ghadam kheir, Ghamari Givi, Niloofar, & Sepehri Shamlo, 2013 ). Education of choice theory concepts increases marital intimacy ( Nasr Isfahani, 2010 ), while the results of the study of Shariatzadeh (2014) suggested that the effect of training choice theory in group method was not significant to increase marital intimacy ( Shariatzadeh, Tabrizi, & Ahghar, 2014 ). Other intimacy promoting interventions include positive thinking ( Nasiri Nejad, Tork, Zahedi Rad, Nazari, & Korivand, 2014 ), meaning focused training ( N. Nasr Isfahani, Etemadi, & Shafie Abadi, 2013 ) foot massage ( Uhm, 2010 ), Rogers and Ellis psychotherapy ( Yousefi & Kiani, 2014 ) and group training of transactional analysis ( Nayeri et al., 2014 ).

5. Conclusion

Overall, it can be stated from reviews that since intimacy involves the exchange of deep feelings and personal and private thoughts, promoting communication skill can play an important role in promoting intimacy in couples. In addition, according to the point that problem solving skill helps couples to evaluate the solutions to their problems and find more sense of cooperation and empathy, it could be accounted for as one of the most important factors for increasing the agreement and intimacy in couples. The depth of intimacy that people understand in their communications depends on their ability to handle correct, effective, and clear communications with the expression of feelings, needs, and desires.

Based on the results, it can be expressed that self-disclosure and empathic response can also increase intimacy because; when people trust each other and share their thoughts, feelings, and internal reality, it helps them strengthen the intimate communication in couples. Also, it can be concluded from studies that sex education and counseling helps the couples gain sufficient knowledge in this area and take effective steps to deal with sexual problems and enhance their intimacy. Generally, by promoting communication, problem solving, self-disclosure, empathic response skills, and sexual education and counseling in the form of cognitive-behavioral techniques, based on religious and cultural context of each society, an effective step can be taken to enhance marital intimacy and strengthen family bonds and stability. Therefore, it is recommended to provide and present counseling training packages to increase marital intimacy tailored to the cultural context of the society.

5.1 Implications for Practice

The majority of the interventions that promoted marital intimacy were quasi experimental. Interventions need to be adapted to other environments and tested again. Health care providers should consider which interventions are appropriate to the couple characteristics and their relationships and then use them.

5.2 Application in Research

The quality of many of the interventions was low and medium and did not have enough follow-up. The researchers need to design high-quality clinical trials with long-term follow-up period appropriate to the setting and resources. Also the processes of randomization and concealments are applied in designing interventions. It is also recommended that researchers measure effectiveness of interventions in raising marital intimacy.

6. Acknowledgements

The current review is a part of MSc. Degree in Midwifery Counseling, Maryam Kardan-Souraki. This project was mainly funded and supported by Mazandaran University of Medical Sciences, Grant No212. We appreciate Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran for supporting narrative review protocol section.

Conflict of Interest

The authors declare that there is no conflict of interests regarding the publication of this paper.

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Case Studies in Couples Therapy Theory-Based Approaches

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This up-to-date, highly readable, theory-based, and application-oriented book fills a crucial void in literature on couple therapy. Few books in the couple therapy market bridge the gap between theory and practice; texts tend to lean in one direction or the other, either emphasizing theory and research with little practical application, or taking a cookbook approach that describes specific techniques and interventions that are divorced from any conceptual or theoretical base. However, couples therapy requires a high degree of abstract/conceptual thinking, as well as ingenuity, inventiveness and skill on the part of the therapist. Case Studies in Couples Therapy blends the best of all worlds: clinical applications with challenging and diverse couples that have been derived from the most influential theories and models in couples and family therapy, all written by highly experienced and respected voices in the field. In Case Studies in Couples Therapy, readers will grasp the essentials of major theories and approaches in a few pages and then see how concepts and principles are applied in the work of well-known clinicians. The case studies incorporate a wide variety of couples from diverse backgrounds in a number of different life situations. It is simultaneously narrow (including specific processes and interventions applied with real clients) and broad (clearly outlining a broad array of theories and concepts) in scope, and the interventions in it are directly linked to theoretical perspectives in a clear and systematic way. Students and clinicians alike will find the theoretical overview sections of each chapter clear and easy to follow, and each chapter’s thorough descriptions of effective, practical interventions will give readers a strong sense of the connections between theory and practice.

Dr. David K. Carson is a Professor of Psychology at Palm Beach Atlantic University in Orlando, a Licensed Marriage and Family Therapist and Qualified Supervisor in Florida and Wyoming, and a Clinical Member of the American Association for Marriage and Family Therapy (AAMFT) and AAMFT Approved Supervisor. Dr. Carson has worked with a variety of couples in therapy and taught couples and marital therapy for many years. He has authored and co-authored 90 publications. Three books in recent years include: Creativity in Psychotherapy: Reaching New Heights with Individuals, Couples, and Families (2003; New York: Routledge) and two edited with his wife Dr. Cecyle Carson and colleague Dr. Aparajita Chowdhury: Indian Families at the Crossroads (2007; New Delhi: Gyan Pub.) and Family Life Education in India: Perspectives, Challenges, and Applications (2006, Jaipur: Rawat Pub.). Dr. Carson is extensively involved with the promotion of counseling and marriage and family therapy in India and travels to India regularly to teach and conduct training seminars across the country. He has also been a Fulbright Senior Scholar in India and has worked in community development in northern India and Nepal. Dr. Montse Casado-Kehoe is an Associate Professor of Psychology at Palm Beach Atlantic University in Orlando. She is a licensed marriage and marriage and family therapist and qualified supervisor for LMHC/LMFT in the state of Florida, a registered play therapist and a member of the American Counseling Association, and International Association for Marriage and Family Counseling. Dr. Casado-Kehoe specializes in women's issues, children and family issues, health issues as they relate to mental health and well-being and the use of coping. She integrates the use of a strength-based approach when working with individuals, children and families, and in supervision. Her work is experiential in nature and integrates the use of creativity and spiritual practice. Her research has focused on family therapy, play therapy, supervision and the integration of technology in counseling. She has also conducted research on helping families cope with a child’s life-threatening illness. She has coauthored two books, has written various book chapters, has been published in peer review journals, and has presented at the national and international levels. Dr. Casado-Kehoe was educated in Spain and the United States and is bilingual in English and Spanish.

Critics' Reviews

"A wonderful book. With all the leading approaches from all the leading theorists, with illuminating case examples and clear discussions of applications, this is more than a survey of the field but a working encyclopedia. Excellent for students seeking to understand the varied terrain that is couple therapy, as well as for experienced practitioners and supervisors seeking to expand their thinking and clinical creativity." - Robert Taibbi, in private practice in Virginia, USA, and author of Doing Couple Therapy: Craft and Creativity in Work with Intimate Partners " Case Studies in Couples Therapy provides a panoramic view of the most significant models of couples therapy. Each chapter follows an outline that clearly links theory and practice in an engaging format and allows for comparisons among models. Readers will find the content of the book to be very clear and will be especially enlightened by the inclusion of material—otherwise almost impossible to find—on the implementation, process, and stages of treatment." - Gerald R. Weeks, University of Nevada–Las Vegas and coauthor of Couples in Treatment: Techniques and Approaches for Effective Practice "This book offers, under one cover, descriptions of the main current approaches to couple therapy and does so in an interesting and engaging way. Cases are covered according to a common outline, helping the reader to easily compare different approaches. A great book for students and practitioners to gain greater clinical skills and theoretical knowledge." - Leslie S. Greenberg, York University Toronto, Ontario, Canada "Written in an accessible and animated style, this stimulating book garners a plethora of theoretic models in couples counselling and presents them, chapter by chapter, as an invitation for clinicians to learn, consider and assimilate new concepts and principles into their own work. The editors have gathered together a long and illustrious list of contributors...The contributors were asked to write to a structured set of guidelines - which for me keeps the book satisfyingly neat - but to include, in addition "a roadmap of how they work." There is thus a sense of creativity and imagination that suffuses the book. [This book] is at once cogent and intelligent, exciting and innovative." - Yvonne Farley, Sexual and Relationship Therapy

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Case Studies in Couples Therapy

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In Case Studies in Couples Therapy, readers will grasp the essentials of major theories and approaches in a few pages and then see how concepts and principles are applied in the work of well-known clinicians. The case studies incorporate a wide variety of couples from diverse backgrounds in a number of different life situations. It is simultaneously narrow (including specific processes and interventions applied with real clients) and broad (clearly outlining a broad array of theories and concepts) in scope, and the interventions in it are directly linked to theoretical perspectives in a clear and systematic way. Students and clinicians alike will find the theoretical overview sections of each chapter clear and easy to follow, and each chapter’s thorough descriptions of effective, practical interventions will give readers a strong sense of the connections between theory and practice.

Introduction: couple therapy in contemporary society and a theory-based case study approach, chapter | 12 pages, prepare/enrich program for premarital and married couples, chapter | 15 pages, preparing couples for marriage: the symbis model, lessons learned from recruiting diverse couples for clinical research on relationship education, chapter | 11 pages, adlerian therapy with couples, working with couples from a psychodynamic perspective using cognitive maps, chapter | 14 pages, object-relations therapy with couples, chapter | 13 pages, integrated intergenerational couple therapy, cognitive behavior therapy with couples, cognitive-behavioral couple therapy: multiple couple illustrations and comparisons, ecosystemic structural therapy with couples, problem-solving brief therapy: the palo alto approach to working with a latino couple, mental research institute's brief therapy approach to couple therapy, strategic couple therapy, a path to wholeness: couple therapy within the satir model, emotionally focused couple therapy: a military case study, imago relationship therapy, imago couple therapy and the relational paradigm, chapter | 19 pages, creative/experiential therapy with couples, an application of pragmatic/experiential therapy for couples, group-oriented experiential couple therapy: an adventure-based approach, solution-focused brief couple therapy, narrative therapy with couples, collaborative couple therapy: turning fights into intimate conversations, collaborative therapy with couples, gottman method couple therapy: from theory to practice, affective reconstruction: an integrative couple treatment applied to parental bereavement, integrated couple therapy: a family developmental approach to the treatment of couples incorporating psychoanalytic and systemic models, the hope-focused approach to couple enrichment and counseling.

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A Case Study in Marital Therapy: Applying Gottman's Sound Marital House and Hudson and O'Hanlon's Brief Marital Counseling Approaches

This paper details a case study in marital therapy. It includes a case history of a couple in marital therapy and a literature review of issues that pertain to their case, including past abuse and stress associated with military life. The theoretical framework used by the therapist in the case is explained. Gottman's (1999) sound marital house and Hudson and O'Hanlon's (1991) brief marital counseling approaches were the main theories used in the case. Three sessions of the couple's therapy are examined. The examined sessions focus on assessment and goals for therapy, conflict regulation, and sexual satisfaction. The results of the therapy are discussed, as well as plans for future sessions.

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Abstract 1. Responds to JC Coyne's (see record 1991-13300-001) comments on the FD Fincham et al (see record 1991-13304-001) appraisal of cognition in marriage and marital therapy (MMT). Commonalities and differences are highlighted between the opposing positions concerning the utility of concepts from the cognitive domain for MMT.(PsycINFO Database Record (c) 2010 APA, all rights reserved)

PsycEXTRA Dataset

Ali sajad Rahimi

Stephen Wesley

Objective: This review critically examines conceptual and methodological issues of outcome research designed to evaluate the efficacy of marital therapy (MT). Behavioural marital therapy (BMT), cognitively orientated marital therapy (COMT), emotionally focused marital therapy (EFMT), and insight-oriented marital therapy (IOMT) have provided evidence for efficacy. Method: The initial literature search involved the use of the MEDLINE and Psychlit CD-ROM data bases. A secondary literature search based on citations in articles discovered in the initial search was also conducted. Three broad categories involving the delineation of the client sample, study design considerations, and determi-nation of treatment effects were addressed to investigate the quality of evidence concerning the efficacy of MT. Results: None of the 4 approaches has proven superiority in efficacy, and the research does not provide evidence for the superiority of any one approach in distinct types of marital discord....

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