Couple-focused Interventions Research Articles

Enhancing fathers' parenting through strengthening couple functioning: A randomized controlled trial of low-income couples.

High levels of father engagement are associated with better outcomes for children across a number of domains. Correlational evidence suggests that the quality of the romantic relationship between parents plays a strong role in the extent to which fathers are meaningfully involved with their children, but existing literature cannot address whether this link is causal. To address this gap, the present study leveraged data from a randomized controlled trial of a couple-focused relationship education program for low-income couples to examine whether intervention-induced improvements in couple functioning led to better fathering outcomes. Data were drawn from the Supporting Healthy Marriages study, in which 6,298 low-income, married couples with children were randomized to an intervention or control condition. Couple relationship functioning was assessed 12-months postrandomization, and fathering behavior across four dimensions (involvement, warmth, responsiveness, and monitoring) was assessed 30-months postrandomization. Structural equation models revealed that the intervention had a significant direct effect on fathers' and mothers' couple functioning, but did not have a significant direct effect on fathering outcomes. However, the intervention did have a significant indirect effect on fathering outcomes through fathers' ratings of couple functioning, such that the intervention was associated with small positive indirect effects on fathers' involvement, warmth, responsiveness, and monitoring. Intervention-derived improvements in the couple relationship led to improvements in father engagement, supporting a causal association between these variables. Couple-focused interventions may be a viable option to enhance couple functioning and (indirectly) fathers' parenting among families living with low incomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Observed dyadic collaboration among couples coping with type 1 diabetes.

Previous research linking collaboration to relationship and health outcomes has relied almost exclusively on individual self-report and failed to take into consideration the dyadic nature of collaboration. We enrolled couples (n = 193) in which one person had Type 1 diabetes (52% female; 91% non-Hispanic white) into the study and asked them to discuss a diabetes-related issue of high concern for 8 min. These videotaped interactions were coded for dyadic collaboration. Mood was measured before and after the discussion. After the discussion, patients and partners reported support provided and received during the discussion. Results showed that observed dyadic collaboration was related to improvements in mood and greater support exchanges for both patients and partners when self-reported collaboration was statistically controlled. Gender moderated the effects on partners, such that benefits of dyadic collaboration were stronger for women than men. Future research may benefit from including collaborative elements into couple-focused interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Dyadic Effect of Coping on the Perceived Impact of ASD of Children on Parental Quality of Life: Report from the ELENA Cohort.

Autism spectrum disorder (ASD) has a significant impact on the quality of life (QoL) of families. This study aimed to examine, for parents of children with ASD, the dyadic effect of each parent's coping strategy on the perception of the impact of ASD on their QoL. In total, 164 couples completed self-report questionnaires, including the Par-DD-QoL, to evaluate the parental perception of QoL. Results from the actor-partner interdependence model showed that, in addition to the effect of the mothers' and fathers' emotion-focused coping on their own perception of QoL, the mothers' emotion-focused coping plays a key role in the fathers' perception of QoL. These findings suggest that both parents of children with ASD would benefit from couple-focused interventions.

Spouses’ Emotion Regulation Skills and Depressive Symptoms in the Context of Early Stage Dementia

COVID-19 public health recommendations have prohibited many older adults from attending in-person physical activity (PA) programs that improve physical function and promote functional independence. Most PA programs have shifted towards a video conference (VC) format, but this modality has been noted to “flatten” the social experience which is fundamental for lasting behavior change. Virtual reality (VR) is now designed for immersion and place-presence and may be better suited for instilling a feeling of social connection, which will likely improve physical function. The purpose of this study was to evaluate differences in physical function after a 4-week in-home VR or VC based PA intervention. Low-active adults (66.8±4.8 years) were randomized to VR (n=5) or VC (n=4) based PA counselling and instructed to find activities that were intrinsically motivating. VR participants were asked to select pre-approved available active games in addition to enjoyable real-world activities. ANCOVA models were used to explore group differences in six-minute walk distances across time. Results are reported using η^2 effect sizes based on the small sample size. After controlling for baseline values, the ANCOVA models revealed a moderate-to-large magnitude effect for distance traveled during the six-minute walk test (η^2=.10). Additionally, the VR group participants walked 42.63 meters further, which approaches a clinically meaningful difference. These promising early findings suggest there is value to exploring the impact of VR-delivered, group-mediated activity promotion on physical functioning in older adults. Future research should investigate aspects of VR that promote increased social connection and physical function in the older adult population.

Spouses’ Emotion Regulation Skills and Depressive Symptoms in the Context of Early Stage Dementia

Until recently, studies of precarity have overlooked aging and late life. This poster presents a snapshot of conceptual work in progress on a Canadian Social Sciences and Humanities Research Council (SSHRC) Insight Grant on precarity and aging. The poster outlines existing definitions and theoretical perspectives, key results, a current evolving conceptual model, and a working definition of Precarious Aging. It situates existing knowledge and definitions of precarity, highlights crucial intersectional locations of gender, im/migration and (dis)ability, and clarifies the concept of precarity in later life. Results at this point in the study are based on conceptual reviews, reviews of literature on precarity and aging, and the consideration of allied concepts. In conclusion, the concept of precarity offers a promising lens to guide research in the field of social and critical gerontology, providing a foundation for an enhanced understanding of the lives and realities of older people with regards to aging, disadvantage, and inequality.

Spouses’ Emotion Regulation Skills and Perceived Partner Emotional Support in the Context of Early Stage Dementia

Within older adult marriages, spouses often help regulate one another’s emotions, especially in times of stress (Monin, 2016). Although research shows that better emotion regulation skills are associated with better social skills (Lopes, 2005), less is known about whether better emotion regulation skills in one spouse are associated with greater perceived relationship quality from their partner’s point of view. Further, very little is known about these dynamics in the context of early stage dementia in which both spouses may be feeling more stress over time and need support from one another. In the present study, we hypothesized that (a) one spouse’s greater emotion regulation skills would be associated with their own greater perceived emotional support from their partner and (b) their partner would also report greater perceived emotional support. We made the same hypothesis for both the person with dementia and their spouse without dementia. We used self-report baseline data from an intervention study of 45 older adult married couples (N=90) where one spouse has dementia. Spouses completed questionnaires that measured their emotional regulation habits (DERS; Gratz & Roemer, 2004) and perceived emotional support from their partner (Feeney & Collins, 2000). Results from the actor partner interdependence model showed that when both partners had high emotional regulation skills there were the highest levels of perceived partner support for each dyad member (B=-.02, SE=.01, t(38.83)=-2.37, p=.023). Findings suggest couple-focused interventions to enhance emotion regulation skills are important for maintaining relationship quality in the early stages of dementia.

Direct and indirect effects of a couple-focused preventive intervention on children’s outcomes: A randomized controlled trial with African American families.

This study examined the effects of the Protecting Strong African American Families (ProSAAF) prevention program on children's outcomes more than 2 years after enrollment, including direct effects of the intervention and indirect effects through couple functioning and parent-child relations. Three hundred forty-six African American couples with an early adolescent child participated; all families lived in rural, low-income communities in the southern United States. Families were randomly assigned to ProSAAF or control conditions and completed four waves of data collection. Couples reported couple functioning at baseline (Wave 1) and at 9-month follow-up (Wave 2), and parent-child relations at 17-month follow-up (Wave 3). Children reported their conduct problems, affiliation with deviant peers, substance use, sexual onset, depressive symptoms, and self-control at 25-month follow-up (Wave 4). Path analyses indicated significant indirect effects of ProSAAF on children's outcomes through improvements in couple functioning and better parent-child relations. There were no significant direct effects of the intervention on children's outcomes or significant indirect effects through couple functioning alone. This couple-focused prevention program has positive indirect effects on several child outcomes through the intervening processes of promoting improvements in couple functioning and better parent-child relations. These findings provide cautious optimism regarding the possible benefits of couple-focused programming on participants' children while suggesting ways in which future couple-focused interventions could yield stronger effects on these youth. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Assessment of an HIV-prevention intervention for couples in peri-urban Uganda: pervasive challenges to relationship quality also challenge intervention effectiveness

Reducing multiple and concurrent partnerships has been identified as a priority in generalised HIV epidemics, yet developing successful interventions to bring about such behaviour change has proven challenging. We offered a three-session intervention aimed to improve couple relationship quality and address HIV risk factors, particularly concurrent sexual partnerships (CSP), in a peri-urban community of Kampala, Uganda. Before launching the intervention, a different group of community members participated in eight single-gender focus group discussions (FGDs) which explored issues of couple relationship quality and satisfaction. Findings from the FGDs guided the intervention. All 162 couples invited to the intervention completed a survey pre- and post-intervention. In FGDs, women and men discussed challenges faced in their relationships, including pervasive dissatisfaction, financial constraints, deception and lack of trust, poor communication, lack of sexual satisfaction, and concurrent sexual partnerships. A difference-in-difference analysis showed no measurable impact of the intervention on relationship quality or sexual risk behaviours over a six-month follow-up among 183 individuals who participated in the intervention, although many stated in response to open-ended questions that they had experienced positive relationship changes. Qualitative findings suggest high demand for couple-focused interventions but also reveal many individual-, couple-, community- and structural-level factors which contribute to women and men seeking concurrent sexual partnerships. More intensive interventions may be needed to overcome these barriers to behaviour change and reduce HIV risk. These findings also raise questions about how to interpret divergent qualitative and quantitative data, a topic which has received little attention in the literature.

In-session intimacy processes and treatment outcomes for 2 couple-focused interventions for prostate cancer patients and their spouses

Background: In a previous study, we compared the efficacy of intimacy-enhancing therapy (IET) a couple-focused intervention based on the Relationship Intimacy Model of couples’ psychosocial adaptation to cancer, and compared it with a General Health and Wellness (GHW) treatment and Usual Care. IET had limited effects on couples’ psychological adjustment and relationship satisfaction, and any benefits were short-lived. Understanding why treatments do not work is an important step in improving their efficacy. Toward this end, this study examined associations between intimacy processes targeted by IET (disclosure, responsiveness, closeness) and post-treatment outcomes. Methods: Patients with localized prostate cancer and their partners (n = 137) participated. Couples rated self- and partner disclosure, perceived partner responsiveness, and how close they felt to their partner during sessions and completed measures of psychological adjustment, depression, cancer distress and concerns, and relationship satisfaction and relationship intimacy at baseline and 6 months post-baseline. Results: In both treatments, patients who reported more self-disclosure during sessions perceived that their partner disclosed to them, and perceived greater partner responsiveness during sessions and reported better post-treatment outcomes. Increases in self-disclosure did not predict post-treatment outcomes, but patients who perceived increases in their spouses’ disclosure and responsiveness in sessions reported higher post-treatment relationship intimacy. Some results were contrary to our predictions. Conclusions: Increases in disclosure, responsiveness, and closeness were not predictive of better post-treatment outcomes in either IET or GHW, which may partially explain the lack of a significant treatment effect in the larger study. It is possible that the focus on disclosure and responsiveness did not solve or address the concerns that couples identified, and that increasing understanding is only a first step in an effective couple-focused treatment for couples dealing with prostate cancer.

Relationship intimacy processes during treatment for couple-focused interventions for prostate cancer patients and their spouses.

Objective:In a previously published trial, we compared the effect of an intimacy-enhancing therapy (IET) and a General Health and Wellness intervention (GHW) on psychological and relationship outcomes among men diagnosed with localized prostate cancer and their partners. Results suggested partial effects of IET on psychological adjustment and relationship satisfaction. To understand these partial effects, the first aim of this study was to evaluate self-disclosure, perceived partner disclosure, perceived partner responsiveness, and levels of intimacy rated after sessions, and the second aim of this study was to examine the role of pre-treatment holding back on these intimacy processes.Methods:A total of 156 couples who participated in treatment reported on self- and perceived partner disclosure, responsiveness, and intimacy during sessions. Participants rated levels of holding back before treatment. Linear growth models were estimated using multilevel modeling. Each intimacy process variable was predicted to be a function of time, role, condition, and all interactions among these variables. The effects of own and partner pretreatment holding back on average intimacy process and change in intimacy process were tested in moderated growth models.Results:Self- and perceived partner disclosure were significantly higher during IET sessions than GHW sessions. Self-disclosure, perceived partner disclosure, and perceived partner responsiveness increased in both IET and GHW. Intimacy was not higher and did not increase more in IET compared with GHW. Participants who held back reported that their partner disclosed less to them during sessions, perceived that their partner was less responsive to them during sessions, and reported less intimacy during sessions. Partners of participants who held back were seen as less responsive and their interactions were seen as less intimate.Conclusions:Although IET focused on enhancing couples’ responsiveness and intimacy, it did not have a stronger effect on these processes during sessions than GHW. The lack of an effect may, in part, be because of the fact that IET did not help those couples who may have been in the greatest need for it because they held back more.

Fostering Resilience among Couples Coparenting a Young Child with Autism: An Evaluation of Together We Are Stronger

The purpose of this study was to evaluate a 4-week caregiver training program designed to promote resilience among couples raising a child with Autism Spectrum Disorder (ASD). Seven couples with a child between the ages of 3 and 9 completed a group-based training focused on values, communication, coparenting, and managing stress. Pre-post assessment of parenting stress, dyadic satisfaction, coparenting, life satisfaction, and hope showed that although parenting stress did not decrease, significant increases were observed in dyadic cohesion, coparenting, and hope. Implications for the development of couple-focused interventions to promote resilience among parents raising a child with ASD are discussed.

Couple-focused interventions for men with localized prostate cancer and their spouses: A randomized clinical trial.

Few couple-focused interventions have improved psychological and relationship functioning among men diagnosed with localized prostate cancer and their spouses. This study compared the impact of intimacy-enhancing therapy (IET), a general health and wellness intervention (GHW), and usual care (UC) on the psychological and relationship functioning of localized prostate cancer patients and their partners. Relationship length, relationship satisfaction, and patient masculinity were evaluated as moderators. This study was a randomized clinical trial with three study arms and four assessment time points. A total of 237 patients and partners were randomly assigned to receive IET, GHW, or UC. Participants completed measures of psychological functioning and relationship satisfaction at baseline, 5weeks, 3months, and 6months post-baseline. Primary outcomes were psychological adjustment, depression, cancer-specific distress, cancer concerns, and relationship satisfaction. Spouses in IET showed greater increases in relationship satisfaction than spouses in GHW and UC between the baseline and 5-week follow-up. Among patients in longer relationships, significant increases in psychological adjustment were found in both treatments compared to UC. Among spouses in longer relationships, psychological adjustment increased in both IET and UC but declined in GHW. Intimacy-enhancing therapy did not show an impact on general or cancer-specific distress, but did show an early impact on relationship satisfaction among spouses. IET was superior to UC for patients in longer relationships. It will be important for researchers to understand which couple-focused interventions benefits both patients and spouses and to identify characteristics of patients, partners, and couples who may not benefit from psychological treatments. Statement of contribution What is already known on this subject? Men diagnosed with localized prostate cancer report lower health-related quality of life and both patients and spouses report elevated distress. Relationship communication plays a role in couples' psychological adaptation to prostate cancer. Couple-focused interventions have illustrated an impact on relationship communication. There are no studies comparing different couple-focused interventions. What does this study add? Intimacy-enhancing therapy was not superior to no treatment or a comparison treatment for the broad range of psychological and relationship outcomes. Intimacy-enhancing therapy was superior to no treatment for patients in longer-term relationship. The general health and wellness intervention was not beneficial for men in shorter relationships and for men who did not endorse traditional masculine norms.

Walking for our health: couple-focused interventions to promote physical activity in older adults

ABSTRACTMore than 50% of U.S. adults do not engage in sufficient physical activity to meet current recommendations, making physical activity change and maintenance a priority for health promotion throughout adulthood. Among married partners, change in physical activity of one partner often is concordant with change of activity of the other. The primary purpose of this study was to examine two couple-focused interventions that capitalize on the co-occurrence of health behavior change within couples to promote physical activity in older adults. In this study, partners (N = 31 couples) participated together in assessment and intervention activities, and were randomized together into one of two couple-focused conditions. In one condition (concurrent), standard goal-setting techniques were extended to a couple-focused design with each partner setting daily step goals and monitoring her or his own progress. In the other condition (combined), partners collaborated to set and monitor shared daily step goals. Physical activity was assessed with accelerometers pre- and post-intervention. Post-intervention, average weekly physical activity increased by 58 min (p < 0.001), and average body mass index (BMI) decreased by 0.50 kg/m2 (p = 0.001), from pre-intervention measures. Similar levels of change in weekly physical activity and in BMI were detected in both intervention groups. Furthermore, participants demonstrated high adherence to the intervention protocol. Results suggest that couple-focused physical activity interventions can be effective in eliciting increases in physical activity among older adults. Further research is needed to uncover interpersonal mechanisms that maximize physical activity promotion and maintenance within couples over time.

Emotional distress and subjective impact of the disease in young women with breast cancer and their spouses.

Evaluate the influence of emotional distress of young women with breast cancer and their spouses on their daily subjective experience of the disease, through application of the Actor-Partner Interdependence Model. A total of 112 women under 45years of age were diagnosed with nonmetastatic breast cancer and their spouses answered self-reported measures of anxiety, depression and subjective experience of the disease and its treatment. The patient's emotional distress influenced more the subjective experience of her spouse than the spouse's emotional distress influenced the patient. The spouse's difficulties depended as much on his own distress level as on the patient's distress level. These data confirm the importance of implementing couple-focused interventions.

Couples' experiences with continuous positive airway pressure treatment: a dyadic perspective

ObjectiveThe majority of adults sleep with a partner, making sleep a dyadic experience. However, interventions to improve sleep have primarily focused on individuals. This qualitative analysis used a dyadic approach to identify facilitators and barriers to successful treatment of one of the most common sleep disorders, obstructive sleep apnea, with continuous positive airway pressure (CPAP). MethodsTwenty joint qualitative interviews were conducted with couples, one couple at a time, with a sample of 20 patients with obstructive sleep apnea and their partners to develop an understanding of couples' experiences with CPAP use. Interviews were audio recorded and transcribed. Conventional qualitative content analysis was used to analyze the interview data. ResultsFacilitators of CPAP use were the following: the partner aiding diagnosis and treatment, couples working together using CPAP, the perceived benefits of CPAP for both partners, the patient being motivated to use CPAP for the benefit of the partner, and various types of support provided by the partner to encourage CPAP use. Major barriers to CPAP use were the following: anxiety related to CPAP use particularly in the beginning of therapy, bothersome equipment causing disruptions in sleep and bedtime routine, interruptions to intimacy, and concern about image change while wearing CPAP. ConclusionsFindings from this study suggest that couple-directed interventions that advocate for a mutually engaging perspective and promote supportive relationships and positive dyadic coping may be targets for improving CPAP adherence. Further research evaluating the potential of couple-focused interventions to improve sleep health is warranted.

How Can Genetically Informed Research Help Inform the Next Generation of Interparental and Parenting Interventions?

There is robust evidence that the interparental relationship and parenting behaviors each have a significant influence on children's risk for emotional (internalizing) and behavioral (externalizing) problems. Indeed, interventions targeting the interparental relationship and parenting processes show significant intervention-related reductions in child internalizing and externalizing problems. However, most evidence-based parenting- and couple-focused interventions result in small to medium effects on children's emotional and behavior problems. It is proposed that there is opportunity to improve upon these interventions through incorporation of knowledge from quantitative genetic research. Three core recommendations are provided for practitioners engaging in intervention work with children and families. These recommendations are contextualized relative to what quantitative genetic studies can tell us about the role of the interparental relationship and parenting behaviors on child outcomes.

The Significance of Interparental Conflict for Children

Abstract. This review summarizes research and theory on the impact of interparental conflict for child well-being. Drawing from this literature the primary focus of many family programs on parenting seems unconvincing. Contemporary approaches increasingly acknowledge the importance of addressing the interparental relationship to reduce and/or prevent behavior problems in children. However, studies examining the impact of enhancing the parents’ relationship for children are still in their infancy. Yet, this emerging line of research indicates that couple-focused interventions alone or adjunct to parenting programs may be a potent means of increasing child adjustment. The potential of couple-focused interventions to support children’s adjustment and practical implications of such approaches are discussed. Future directions are suggested that urgently need to be addressed to advance this promising area of family psychology.

The State of Dyadic Methodology: An Analysis of the Literature on Interventions for Military Couples

ABSTRACTMilitary members and their spouses experience unique stressors compared with civilian couples, making them distinctively vulnerable to a number of marital and mental health concerns. However, the amount and quality of intervention research to guide treatment for military couples are unknown. Therefore, a systematic literature search of interventions for military couples was completed resulting in 10 articles that met the study's inclusion and exclusion criteria. Further, a rubric to assess dyadic methodology was created and utilized to determine the dyadic quality of the methodology of the sampled articles. The results of the systematic literature review revealed that (a) there are few evidence-based interventions for military couples in which both members of the dyad are included and (b) the methodology by which treatments are evaluated largely do not employ systemic or dyadic measures. Recommendations for future research with military couples includes the need for couple-focused interventions using experimental methodology, systemic theories to guide intervention and research, and appropriate dyadic assessment and analysis tools to determine the effectiveness of couple's interventions for military, reserve, and veteran populations.

Partner Pronoun Use, Communal Coping, and Abstinence during Couple-Focused Intervention for Problematic Alcohol Use.

Communal coping-a process in which romantic partners view a problem as ours rather than yours or mine, and take collaborative action to address it -has emerged as an important predictor of health and treatment outcomes. In a study of partners' pronoun use prior to and during couple-focused alcohol interventions, we examined first-person plural (we-talk) and singular (I-talk) pronouns as linguistic markers of communal coping and behavioral predictors of treatment outcome. Thirty-three couples in which one partner abused alcohol were selected from a randomized control trial (N=63) of couple-focused Cognitive-Behavioral or Family Systems Therapy if they had unambiguously successful or unsuccessful treatment outcomes (i.e., patient maintained abstinence for 30days prior to treatment termination or had more than one heavy drinking day in the same period). Pronoun measures for each partner were obtained via computerized text analysis from transcripts of partners' speech, derived from a videotaped pretreatment interaction task and three subsequent therapy sessions. Spouse we-talk during the intervention (accounting for pretreatment we-talk), as an index of communal orientation, uniquely predicted successful treatment outcomes. In contrast, both patient and spouse I-talk during the intervention (accounting for pretreatment I-talk), as a marker of individualistic orientation, uniquely predicted unsuccessful outcomes, especially when distinguishing active and passive (I vs. me/my) pronoun forms. Results strengthen evidence for the prognostic significance of spouse behavior for patient health outcomes and for communal coping (indexed via pronoun use) as a potential mechanism of change in couple-focused interventions for health problems.

A Qualitative Investigation of Health Care Professionals', Patients' and Partners' Views on Psychosocial Issues and Related Interventions for Couples Coping with Cancer.

IntroductionThere is growing evidence that cancer affects couples as an interdependent system and that couple-based psychosocial interventions are efficacious in reducing distress and improving coping skills. However, adoption of a couples-focused approach into cancer care is limited. Previous research has shown that patients and partners hold differing views from health care professionals (HCPs) regarding their psychosocial needs, and HCPs from different disciplines also hold divergent views regarding couples’ psychosocial needs. This study aimed to explore the perspectives of HCPs and couples on the provision of couple-focused psychosocial care in routine cancer services.MethodsA qualitative study using semi-structured interviews was undertaken with 20 HCPs (medical oncologists, nurses, psycho-oncology professionals) and 20 couples where one member had been diagnosed with cancer (breast, prostate, head/neck, bowel, multiple myeloma). Interviews were analysed using the framework approach.ResultsThree core themes were identified: “How Do Couples Cope with Cancer?” emphasised the positive and negative coping strategies used by couples, and highlighted that partners perceived a lack of engagement by HCPs. “What Is Couple-focused Psychosocial Care for People with Cancer?” described varying perspectives regarding the value of couple-focused psychosocial care and variation in the types of support couples need among HCPs and couples. Whereas most couples did not perceive a need for specialist couple-focused support and interventions, most HCPs felt couple-focused psychosocial care was necessary. “How Can Couple-Focused Psychosocial Care be Improved?” described couples’ view of a need for better provision of information, and the importance of their relationship with oncology clinicians. HCPs identified a lack of confidence in responding to the emotional needs of couples, and barriers to providing psychosocial care, including challenges identifying distress (through screening) and referring distressed individuals/couples for specialist assessment.ConclusionsThe three core themes revealed discrepancies about couple-focused psychosocial care between HCPs and couples, and HCPs from different professional backgrounds, and several barriers to the provision of psychosocial care for couples. Despite HCPs and couples acknowledging that a couple-focused approach to psycho-social support was potentially beneficial, the majority of couples did not feel they needed specific couple-focused interventions. These issues and recommendations for future research are discussed.