further research about counseling

Replication Crisis

The importance of research to the practice of counseling, why is research literacy important for mental health counseling.

Posted July 30, 2024 | Reviewed by Abigail Fagan

• The replication crisis challenges reliability—many landmark studies fail to replicate.
• Publication bias distorts findings—positive results are more likely to be published than null ones.
• Careerism impacts quality—the pressure to publish frequently can prioritize quantity over quality.

In the field of social science, particularly within psychology and counseling, several critical issues have emerged that undermine the scientific rigor of research and practice. One of the most significant challenges is the replication crisis , where many studies, including landmark research, fail to reproduce consistent results when tested in subsequent experiments. And we're not talking about little-known, oddball studies. This problem covers the whole gamut of social science research, from the seminal studies that change the field, to lesser-known research. This crisis casts doubt on the reliability of established findings and calls into question the foundations upon which many clinical practices are built.

Another pervasive issue is publication bias , where studies with significant or positive results are more likely to be published than those with null or negative findings. This skews the body of available literature, leading to an overestimation of the effectiveness of certain interventions and underrepresentation of alternative or null outcomes. Closely related is the phenomenon of idea laundering , where weak or untested theories are presented as established facts through a cycle of citations and publications, further muddying the waters of scientific clarity.

Careerism or "publish or perish" also poses a significant obstacle, as the pressure to publish frequently and in high-impact journals can lead researchers to prioritize quantity over quality. This environment can foster a focus on novel, eye-catching results rather than thorough, rigorous investigations. Moreover, inadequate graduate training in research methodology and critical thinking exacerbates these issues, leaving emerging counselors ill-prepared to both conduct and critically assess research.

These challenges collectively diminish the quality and credibility of research in social science, which is particularly concerning given the direct impact these studies have on clinical practice. For counselors, a deep understanding of research methods and critical evaluation is essential. It not only equips them to produce meaningful, replicable studies but also empowers them to discern the reliability of existing research, ensuring they base their clinical decisions on solid evidence. However, if counselors in training are not aware of the importance of research, how to conduct research, how to read research, how to integrate the findings of research, AND how to digest research critically given the problems present in research mentioned above, then it will directly affect clinical work, client outcomes and welfare. This is simply not okay since counselors have an ethical duty to provide best practices and safeguard client welfare. But, if you need some convincing, below are some of the reasons I see literacy in research as essential for competent clinical practice.

Research Guides Practice and Limits of Intuition

As clinicians, we often rely on our training, experience, and intuition to make decisions. However, it's essential to recognize that our perceptions are inherently limited and can be biased. Human reasoning, while valuable, is not infallible and can lead us astray. For instance, confirmation bias , the tendency to search for or interpret information in a way that confirms our preconceptions, can significantly impact clinical judgments. Therefore, it's crucial to complement our intuition with empirical evidence from social science research. This reliance on research helps to ground our decisions in verified data, ensuring that our interventions are based on more than just subjective judgment.

The Counterintuitive Nature of Research

One of the most valuable aspects of research is its ability to challenge our assumptions. What may seem obvious or intuitive to a seasoned counselor might not hold true for every client. For example, while it may seem intuitive that talking about suicidal thoughts could increase the likelihood of a client acting on them, research indicates that discussing these thoughts in a supportive environment can actually reduce the risk. This highlights the importance of adhering to evidence-based practices, which often provide insights that run counter to common beliefs or intuitive thinking.

Universals and Particulars in Counseling

In the realm of clinical practice, it is crucial to distinguish between universal principles and individual variations. Research can provide us with general trends and effective interventions for broad populations, but every client is unique. What works broadly might not be effective for a specific individual due to various factors such as cultural background, personal history, and psychological makeup. For example, cognitive-behavioral therapy (CBT) is widely recognized as an effective treatment for depression , but its applicability may vary based on a client's readiness, cultural context, and specific needs. Thus, while research provides a foundation, clinicians must remain flexible and responsive to the particulars of each client's situation.

Harm Prevention and Ethical Responsibility

Ethical practice in counseling involves a commitment to "do no harm." This principle necessitates that we have a reasonable expectation of the outcomes of our interventions before implementing them. Without a solid research foundation, we risk applying treatments that may be ineffective or even harmful. For example, some outdated or unsupported therapeutic practices, such as "conversion therapy" for sexual orientation , have been shown to cause significant harm. Therefore, staying informed about current research is not only a best practice but an ethical obligation to ensure we are providing safe and effective care.

Harm Detection and Differentiating Counseling Models

Not all therapeutic models are equally beneficial, and some may even be detrimental if applied inappropriately. It's vital for clinicians to discern which models are supported by robust evidence and which are not. For instance, while mindfulness -based therapies have proven effective in managing anxiety and depression, they may not be suitable for individuals with certain types of trauma -related disorders, where grounding techniques might be more appropriate. Understanding these nuances allows clinicians to tailor their approaches to better meet the needs of their clients, thereby optimizing the therapeutic outcomes.

In conclusion, the integration of research into clinical practice serves as a critical tool for enhancing the quality of care provided to clients. By recognizing the limitations of intuition, valuing counterintuitive insights from research, distinguishing between universal principles and individual differences, and adhering to ethical standards of harm prevention, clinicians can ensure that their practice is both scientifically grounded and ethically sound. This commitment to evidence-based practice ultimately fosters a more effective and compassionate therapeutic environment, better serving the diverse needs of clients.

Dan Bates, Ph.D., is a clinical mental health counselor licensed in the state of Washington and certified nationally.

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Further Recommendations Regarding The Future Of AI In Counseling

Ai work group recommendations.

The American Counseling Association has convened a panel of counseling experts representing academia, private practice and students to comprise its AI Work Group. The work group used research-based and contextual evidence; the ACA Code of Ethics; and clinical knowledge and skill to develop the following recommendations. The goal is to both prioritize client well-being, preferences, and values in the advent and application of AI, while informing counselors, counselor-educators and clients about the use of AI today. The recommendations also highlight the additional research needed to inform counseling practice as AI becomes a more widely available and accepted part of mental health care.

Recommendations for:

• Practicing Counselors
• Assessment, and Diagnosis
• Further Recommendations

Recommendation: Interdisciplinary collaboration on the development of AI for counseling Research on AI for counseling requires interdisciplinary efforts. We encourage the formulation of research teams comprising practicing counselors, counseling researchers, AI developers (e.g., computer scientists), and representatives from diverse client populations. This fosters a holistic approach to AI development, ensuring it meets clinical needs while being ethically sound and culturally sensitive.

Recommendation: Keep a keen eye on bias and potential discrimination in AI. AI shows great promise, and the potential for great peril comes with that. As AI relates to counseling, there is potential great harm in biased AI output. The training data and algorithms used to create the AI are the typical culprits, but with machine learning, users can “train” the AI to be harmful. See the infamous “Tay bot” case from Microsoft as an example. We should note that most therapeutic chatbots are designed to prevent the bot from going rogue, so to speak. Some chatbots have research backing for their efficacy as mental health support agents. We neither endorse or recommend against chatbots at this stage, but encourage more research and promote efforts to eliminate bias and discrimination in AI.

Recommendation: The benefits and risks identified for AI may shift with additional experience and research. Updates to statements and guidelines about AI are necessary, considering the ever-changing nature of AI. Few areas change and advance as quickly as AI. The ACA helps to ensure that counselors engage in practice based on rigorous research methodologies. Therefore, as AI advances, the ACA should retain an open mind, work to ensure safety measures are in place, and change its recommendations based on evidence.

Recommendation: Remember the value of human relationships. AI and technology in a general sense can change the nature of relationships. We know that social media use can impact the quality of human relationships. AI may change relationships further. Avatars, chatbots, and potentially humanoid robots may stress or otherwise challenge human-to-human relationships. We encourage you to remember the value of human relationships.

Recommendation: The ACA should consider including the topic of AI in the next revision of the ACA Code of Ethics. The 2014 ACA Code of Ethics does not currently mention Artificial Intelligence. The next publication of the Code should include references to the role of AI in counseling and supervision.

Recommendation: Consider adding ‘explicability’ in the ethics code as a principle in relation to AI work. Explicability is a term used to make AI less opaque (Ursin et al., 2023). Put another way, it implies that AI creators and users, counselors in this context, should have intelligibility and accountability (How does it work? Who is responsible?) (Floridi & Cowls, 2023).

Recommendation: Continuously evaluate and reflect. Counselors should regularly assess the impact of AI on their practice, seeking feedback from clients and colleagues. They should adjust their approach as needed to ensure the highest quality of care.

Recommendation: Monitor the role of AI in diagnosis and assessment. A growing body of literature has shown that AI has the potential to assist in diagnosis and assessment (Abd-alrazaq et al., 2022, Graham et al., 2019). AI may help in predicting, classifying, or subgrouping mental health conditions utilizing diverse data sources like Electronic Health Records (EHRs), brain imaging data, monitoring systems (e.g., smartphones, video), and social media platforms (Graham et al., 2019). With all of this in mind, we cannot solely rely on AI for diagnosis. The current state of AI technology does not fully encompass certain real-world aspects of clinical diagnosis in mental health care. AI does not adequately address essential elements like gathering a client's history, understanding their personal experiences, the reliability of electronic health records (EHR), the inherent uncertainties in diagnosing mental health conditions, and the vital role of empathy and direct communication in therapy. As we look to enhance diagnostic processes in counseling with AI, these critical factors must be integrated to ensure comprehensive, empathetic, and accurate care in the 21st century.  Nevertheless, with continual advancements, it might not only be a tool to assist with diagnosis and assessment, but in some regards, it might one day surpass human-level abilities. The ACA should keep a keen eye on the diagnostic abilities of AI.

Recommendation: Developing client-centered AI tools. When developing AI tools for client use, we encourage the research and development team to involve clients and counselors in the design process, ensuring the AI tools are client-centered, address real-world needs, and respect client preferences and values.

Recommendation: Integrating Ethical AI Training into Counselor Professional Development Develop a comprehensive and continuous AI training program for counselors and trainees, emphasizing the proper and ethical use of AI in line with the need for continuing education according to the ACA Code of Ethics (C.2.f). This training program should include a detailed understanding of AI technologies, their applications in various counseling services, and crucial ethical considerations such as privacy and confidentiality. Additionally, the program should be part of counselors' ongoing professional development, incorporating regular updates and refreshers to keep pace with the rapidly evolving field of AI. This integrated approach ensures that counselors are both technically proficient and ethically informed in using AI tools.

Selected Publications and References

Abd-Alrazaq, A., Alhuwail, D., Schneider, J., Toro, C. T., Ahmed, A., Alzubaidi, M., ... & Househ, M. (2022). The performance of artificial intelligence-driven technologies in diagnosing mental disorders: an umbrella review. NPJ Digital Medicine, 5(1), 87.

American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.

Floridi, L., & Cowls, J. (2022). A unified framework of five principles for AI in society.  Machine learning and the city: Applications in architecture and urban design , 535-545.

Graham, S., Depp, C., Lee, E. E., Nebeker, C., Tu, X., Kim, H. C., & Jeste, D. V. (2019). Artificial intelligence for mental health and mental illnesses: an overview. Current psychiatry reports, 21, 1-18.

Ursin, F., Lindner, F., Ropinski, T., Salloch, S., & Timmermann, C. (2023). Levels of explicability for medical artificial intelligence: What do we normatively need and what can we technically reach?.  Ethik in der Medizin ,  35 (2), 173-199.

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Counseling Psychology Research Paper Topics

This page provides a comprehensive list of counseling psychology research paper topics , tailored to support students in their exploration of this vital field. Counseling psychology encompasses a broad range of practices designed to help individuals overcome challenges, achieve personal growth, and improve overall well-being. By delving into topics that span from therapeutic approaches and techniques to the nuances of client-counselor dynamics and the impact of cultural and social diversity in counseling, this resource aims to inspire a deeper investigation into the ways counseling psychology can address the complexities of human experience. Highlighting both established and emerging areas within the discipline, such as the integration of technology in therapy and the ethical considerations unique to counseling practice, the topics presented are curated to encourage thoughtful research and contribute meaningful insights to the field. This collection is designed not only as an academic resource but also as a springboard for future professionals to engage with the pressing issues and innovations shaping the landscape of counseling psychology today.

100 Counseling Psychology Research Paper Topics

Counseling psychology, a dynamic and essential field, plays a critical role in enhancing personal and interpersonal functioning across the lifespan. It encompasses a wide array of practices aimed at supporting individuals through various challenges, promoting mental health and well-being, and facilitating growth and development. The breadth of research topics within counseling psychology mirrors its diverse applications, spanning clinical, educational, and research settings. From exploring innovative therapeutic approaches to understanding the intricate dynamics between clients and counselors, the field offers a rich landscape for investigation and discovery.

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• Cognitive Behavioral Therapy: Principles and Applications
• Person-Centered Therapy: Techniques and Outcomes
• Integrative Approaches in Counseling
• The Effectiveness of Group Therapy
• Solution-Focused Brief Therapy: Strategies and Efficacy
• Mindfulness and Meditation in Therapy
• Narrative Therapy and Storytelling in Healing
• Art and Music Therapy: Methods and Mental Health Benefits
• Trauma-Informed Care in Counseling Practice
• Psychoanalytic Approaches in Modern Counseling
• Building Therapeutic Alliances: Strategies and Challenges
• The Impact of Counselor Self-Disclosure on Therapy Outcomes
• Client Resistance and Engagement Techniques
• Boundary Issues in the Therapeutic Relationship
• The Role of Empathy in Counseling
• Counseling Competencies and Client Satisfaction
• Confidentiality and Trust in Counseling
• Power Dynamics and Ethics in Client-Counselor Relationships
• Cultural Competence in Therapeutic Settings
• Feedback-Informed Treatment in Counseling
• Anxiety Disorders: Diagnosis and Treatment
• Depression: Prevention Strategies and Therapeutic Interventions
• Wellness and Positive Psychology Interventions in Counseling
• The Role of Counseling in Suicide Prevention
• Substance Abuse Counseling: Approaches and Recovery Support
• Eating Disorders: Counseling Strategies and Recovery Models
• Counseling for Chronic Illness and Disability
• Stress Management Techniques in Therapy
• The Psychology of Happiness and Contentment
• Mental Health Stigma and Access to Counseling Services
• Multicultural Counseling Techniques and Outcomes
• Addressing Racial and Ethnic Disparities in Mental Health Services
• Gender and Sexuality Issues in Counseling
• Counseling Immigrant and Refugee Populations
• Socioeconomic Factors in Mental Health and Therapy
• Cross-Cultural Communication Skills in Therapy
• Indigenous Healing Practices and Counseling
• Religion and Spirituality in Counseling Practice
• Age-Related Considerations in Counseling
• Counseling Veterans and Military Personnel
• Informed Consent in Counseling Practice
• Confidentiality and Privacy in the Digital Age
• Dual Relationships and Ethical Boundaries
• Legal Responsibilities of Counselors
• Ethical Decision-Making Models in Counseling
• Record-Keeping and Documentation Standards
• Managing Ethical Dilemmas with Supervision
• Cultural Sensitivity and Ethical Practice
• Ethical Considerations in Teletherapy
• Client Rights and Advocate Roles in Counseling
• Psychological Testing and Assessment in Counseling
• Outcome Measures and Their Importance in Therapy
• Qualitative and Quantitative Research Methods in Counseling
• Program Evaluation Techniques for Counseling Services
• Diagnostic Criteria and Differential Diagnosis in Mental Health
• The Use of Technology in Psychological Assessments
• Evaluating Therapeutic Interventions and Their Effectiveness
• Client Feedback Mechanisms and Therapy Adjustment
• Assessment of Risk Factors in Mental Health
• The Role of Neuropsychological Testing in Counseling
• Career Counseling Theories and Models
• Vocational Assessment Tools and Techniques
• Counseling for Work-Life Balance Issues
• Transition Services for Youth and Young Adults
• Retirement Planning and Counseling
• Workforce Re-entry and Counseling Support
• Entrepreneurship and Psychological Well-being
• Job Loss and Grief Counseling
• Career Change and Identity Shifts
• The Impact of Workplace Stress on Mental Health
• Play Therapy: Techniques and Outcomes
• Counseling Strategies for Adolescents with Behavioral Issues
• School-Based Mental Health Services
• Parent-Child Relationship Counseling
• Counseling for Gifted and Talented Youth
• Addressing Bullying and Cyberbullying in Counseling
• Childhood Trauma and Resilience Building
• Adolescent Substance Use and Counseling Interventions
• Special Education Needs and Counseling Support
• Peer Relationships and Social Skills Training
• Couple Therapy: Approaches and Challenges
• Family Dynamics and Systemic Therapy
• Counseling for Blended Families
• Divorce and Separation: Counseling Support for Families
• Parenting Strategies and Family Counseling
• Intimacy Issues and Sexual Health Counseling
• Conflict Resolution Techniques in Family Therapy
• Grief and Loss within the Family Context
• Family Therapy for Substance Abuse Issues
• Communication Skills Training for Couples and Families
• Efficacy of Online Therapy Platforms
• Digital Ethics: Confidentiality and Security in Online Counseling
• Utilizing Mobile Apps in Mental Health Interventions
• Virtual Reality Therapy: Applications and Limitations
• Social Media’s Impact on Mental Health and Counseling
• Online Support Groups and Peer Counseling
• Teletherapy: Best Practices and Client Outcomes
• Technology-Assisted Relaxation Techniques
• Cyberbullying: Counseling Strategies and Prevention
• Bridging the Digital Divide in Access to Mental Health Services

The exploration of counseling psychology research paper topics is a journey into the heart of what it means to support and understand human behavior and mental health. With a vast array of topics ranging from the intricacies of therapeutic relationships to the cutting-edge applications of technology in therapy, students are invited to delve deep into the subjects that resonate most with their academic interests and future aspirations. These topics not only offer a platform for significant academic contribution but also equip students with the knowledge and insights to advance counseling practices and mental health support in a rapidly evolving society. By engaging with these diverse research areas, students can play a crucial role in shaping the future of counseling psychology, fostering well-being, and making a meaningful impact on the lives of those they will serve.

What is Counseling Psychology

Counseling Psychology as an Essential Field of Study

Advancing Counseling Techniques, Understanding Client Needs, and Improving Therapeutic Outcomes

Research in counseling psychology is crucial for the continual advancement of counseling techniques, deepening the understanding of client needs, and enhancing therapeutic outcomes. Through empirical studies, researchers can evaluate the efficacy of various therapeutic approaches, tailoring interventions to meet the diverse needs of clients effectively. This ongoing research helps in identifying best practices, informing evidence-based treatments, and ensuring that counseling methods evolve in response to new psychological insights and societal changes. Moreover, research contributes to the training of counseling psychologists, equipping them with the latest tools and knowledge to support their clients effectively.

Investigations into client needs and preferences play a significant role in developing client-centered therapies that honor the individual’s experience and autonomy. Understanding the factors that contribute to psychological well-being and distress informs the creation of supportive environments and therapeutic relationships that facilitate change. Furthermore, research on therapeutic outcomes assesses the long-term impact of counseling services, guiding improvements in practice and highlighting the value of counseling psychology in mental health care.

Diverse Research Topics within Counseling Psychology

The field of counseling psychology encompasses a broad array of research topics, reflecting the complexity of human behavior and the myriad challenges individuals face throughout their lives. Topics include the development of effective therapeutic approaches and techniques, such as cognitive-behavioral therapy, mindfulness-based interventions, and narrative therapy, which are tailored to address specific psychological issues or client populations. Research on client-counselor dynamics delves into the factors that enhance therapeutic alliances, the role of empathy, and the impact of counselor characteristics on the counseling process.

Cultural and social diversity in counseling is another critical area of research, examining how cultural, racial, ethnic, and gender identities influence mental health and counseling outcomes. This research is instrumental in promoting culturally competent practices and addressing disparities in mental health care. Additionally, studies on ethics and legal issues ensure that counseling practices adhere to the highest standards of professional conduct, safeguarding client welfare and confidentiality. The exploration of these and other topics within counseling psychology is directly relevant to addressing current challenges in the field, driving innovations that enhance the quality and accessibility of mental health services.

Recent Advancements in Counseling Psychology Research

Recent advancements in counseling psychology research have significantly contributed to the field’s growth and the effectiveness of counseling services. Evidence-based practices, which rely on empirical evidence to guide treatment decisions, have gained prominence, ensuring that clients receive interventions proven to be effective. Research in this area not only evaluates the efficacy of traditional therapeutic approaches but also explores the potential of emerging therapies to address complex mental health issues.

Digital interventions, including online therapy, mobile apps for mental health, and teletherapy, represent another area of rapid advancement. These technologies have expanded access to counseling services, making psychological support more accessible to individuals in remote or underserved areas. Research into the effectiveness of these digital interventions is critical for understanding their impact on therapeutic outcomes and client satisfaction.

Furthermore, holistic approaches to mental health that consider the interplay between psychological, physical, social, and spiritual factors are increasingly being integrated into counseling psychology. Research in this area explores the benefits of incorporating wellness practices, such as exercise, nutrition, and meditation, into therapeutic interventions. These holistic approaches emphasize the whole person, supporting comprehensive well-being and resilience.

Ethical Considerations in Counseling Psychology Research and Practice

Ethical considerations are paramount in counseling psychology, guiding the conduct of researchers and practitioners to ensure the protection and respect of clients’ rights and well-being. Confidentiality is a fundamental ethical principle, safeguarding the privacy of client information and fostering a safe therapeutic environment. Research in counseling psychology often addresses the challenges and implications of maintaining confidentiality, especially in the context of digital interventions and group therapy settings.

Informed consent is another critical area of ethical focus, ensuring that clients are fully aware of the counseling process, their rights, and the potential risks and benefits of therapy. Research explores the best practices for obtaining informed consent, particularly when working with vulnerable populations or employing novel therapeutic techniques.

Therapist-client boundaries are also a significant concern, with research examining the importance of maintaining professional relationships to prevent harm and conflict of interest. Studies in this area contribute to the development of guidelines and training programs that help counselors navigate these ethical dilemmas, promoting integrity and trust within the counseling relationship.

Future Directions and Emerging Trends in Counseling Psychology

The future of counseling psychology research is poised to address a range of emerging trends and challenges, reflecting the evolving needs of society and advances in technology. Teletherapy has emerged as a critical area of focus, with researchers exploring its efficacy, the nuances of therapist-client interactions in virtual settings, and the ethical considerations unique to digital counseling formats. This trend underscores the field’s adaptation to technological advancements, ensuring that counseling services remain accessible and effective in a digital age.

Multicultural counseling continues to gain attention, with future research likely to delve deeper into the experiences of diverse client populations, the development of culturally sensitive therapeutic approaches, and the training of counselors in cultural competence. This area of study is crucial for addressing health disparities and promoting equity in mental health care.

Integrative health approaches that combine psychological, medical, and alternative therapies are also becoming more prominent. Research in this area examines the benefits of a holistic view of mental health, exploring how integrating various health modalities can support comprehensive well-being. These future directions in counseling psychology research reflect the field’s commitment to innovation, inclusivity, and the holistic well-being of individuals and communities.

The Role of Research in Shaping Effective Counseling Practices

Research plays an indispensable role in shaping the practices of counseling psychology, guiding the field toward more effective, inclusive, and ethical approaches to mental health care. Through the diligent exploration of diverse research topics, counseling psychology continues to advance our understanding of therapeutic processes, client needs, and the complex factors that contribute to mental health and wellness. As the field looks to the future, embracing emerging trends and addressing new challenges, the insights gained from research will remain pivotal in developing interventions that are both innovative and grounded in evidence. Ultimately, the continued emphasis on research in counseling psychology will ensure that the field remains at the forefront of promoting mental health, well-being, and positive change in the lives of individuals and communities.

Custom Writing Services by iResearchNet

iResearchNet is dedicated to providing customized writing services tailored specifically for students delving into the complexities of counseling psychology. Understanding the nuanced and multifaceted nature of counseling psychology research, we offer support designed to meet the unique challenges and demands of this field. Our services are crafted to assist students in navigating through their academic journey, providing them with the tools and resources necessary to produce insightful and impactful research papers that contribute meaningfully to the field.

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Innovative approaches to exploring processes of change in counseling psychology: Insights and principles for future research

Affiliations.

• 1 Department of Psychology.
• 2 Department of Clinical Psychology and Psychotherapy.
• PMID: 32614223
• DOI: 10.1037/cou0000426

In recent years, innovative approaches have been implemented in counseling and psychotherapy research, creating new and exciting interdisciplinary subfields. The findings that emerged from the implementation of these approaches demonstrate their potential to deepen our understanding of therapeutic change. This article serves as an introduction to the "Innovative Approaches to Exploring Processes of Change in Counseling Psychology" special issue. The special issue includes articles representing several of the most promising approaches. Each article seeks to serve as a sourcebook for implementing a given approach in counseling research, in such areas as the assessment of coregulation processes, language processing, physiology, motion synchrony, event-related potentials, hormonal measures, and sociometric signals captured by a badge. The studies included in this special issue represent some of the most promising pathways for future studies and provide valuable resources for researchers, as well as clinicians interested in implementing such approaches and/or being educated consumers of empirical findings based on such approaches. This introduction synthesizes the articles in the special issue and proposes a list of guidelines for conducting and consuming research that implements new approaches for studying the process of therapeutic change. We believe that we are not far from the day when these approaches will be instrumental in everyday counseling practice, where they can assist therapists and patients in their collaborative efforts to reduce suffering and increase thriving. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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• Using event-related potentials to explore processes of change in counseling psychology. Matsen J, Perrone-McGovern K, Marmarosh C. Matsen J, et al. J Couns Psychol. 2020 Jul;67(4):500-508. doi: 10.1037/cou0000410. J Couns Psychol. 2020. PMID: 32614230 Review.
• Introduction to the special section "Big'er' Data": Scaling up psychotherapy research in counseling psychology. Owen J, Imel ZE. Owen J, et al. J Couns Psychol. 2016 Apr;63(3):247-8. doi: 10.1037/cou0000149. J Couns Psychol. 2016. PMID: 27078195
• Oxytocin as a biomarker of the formation of therapeutic alliance in psychotherapy and counseling psychology. Zilcha-Mano S, Shamay-Tsoory S, Dolev-Amit T, Zagoory-Sharon O, Feldman R. Zilcha-Mano S, et al. J Couns Psychol. 2020 Jul;67(4):523-535. doi: 10.1037/cou0000386. J Couns Psychol. 2020. PMID: 32614232 Review.
• Physiological synchronization in the clinical process: A research primer. Kleinbub JR, Talia A, Palmieri A. Kleinbub JR, et al. J Couns Psychol. 2020 Jul;67(4):420-437. doi: 10.1037/cou0000383. J Couns Psychol. 2020. PMID: 32614224 Review.
• Therapists' Views of Mechanisms of Change in Psychotherapy: A Mixed-Method Approach. Tzur Bitan D, Shalev S, Abayed S. Tzur Bitan D, et al. Front Psychol. 2022 Apr 14;13:565800. doi: 10.3389/fpsyg.2022.565800. eCollection 2022. Front Psychol. 2022. PMID: 35496206 Free PMC article.
• Movement Synchrony in the Psychotherapy of Adolescents With Borderline Personality Pathology - A Dyadic Trait Marker for Resilience? Zimmermann R, Fürer L, Kleinbub JR, Ramseyer FT, Hütten R, Steppan M, Schmeck K. Zimmermann R, et al. Front Psychol. 2021 Jun 30;12:660516. doi: 10.3389/fpsyg.2021.660516. eCollection 2021. Front Psychol. 2021. PMID: 34276484 Free PMC article.
• The Psychodynamic Approach During COVID-19 Emotional Crisis. Conversano C. Conversano C. Front Psychol. 2021 Apr 9;12:670196. doi: 10.3389/fpsyg.2021.670196. eCollection 2021. Front Psychol. 2021. PMID: 33897574 Free PMC article. No abstract available.
• Disentangling Trait-Like Between-Individual vs. State-Like Within-Individual Effects in Studying the Mechanisms of Change in CBT. Zilcha-Mano S, Webb CA. Zilcha-Mano S, et al. Front Psychiatry. 2021 Jan 21;11:609585. doi: 10.3389/fpsyt.2020.609585. eCollection 2020. Front Psychiatry. 2021. PMID: 33551873 Free PMC article.

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14 emerging trends

Vol. 53 No. 1 Print version: page 42

In 2022, psychological science will play an increasingly outsize role in the debate about how to solve the world’s most intractable challenges. Human behavior is at the heart of many of the biggest issues with which we grapple: inequality, climate change, the future of work, health and well-being, vaccine hesitancy, and misinformation. Psychologists have been asked not only to have a seat at the table but to take the lead on these issues and more (See the full list of emerging trends ).

Psychologists are being called upon to promote equity, diversity, and inclusion (EDI): Amid a nationwide reckoning on race—and a 71% increase in EDI roles at organizations over the past 5 years—psychologists are increasingly being tapped to serve as chief diversity officers and act in other similar roles. But the field is also at an inflection point, being called upon to be more introspective about its own diversity in terms of the people who choose to become psychologists, the people who are the subjects of psychological research, and the people who have access to psychological services.

Psychologists are now the most requested experts by the mainstream media. As our culture increasingly sees mental health as an important piece of overall well-being, psychologists are being called to serve in a wider array of roles, including in entertainment, sports, advocacy, and technology.

On the technology front, the delivery and data collection of psychological services is gaining increased interest from venture capitalists. Private equity firms are expected to pour billions of dollars into mental health projects this year—psychologists working on these efforts say greater investments will help bring mental health care to millions of underserved patients.

That said, the urgent need for mental health services will be a trend for years to come. That is especially true among children: Mental health–related emergency department visits have increased 24% for children between ages 5 and 11 and 31% for those ages 12 to 17 during the COVID-19 pandemic.

That trend will be exacerbated by the climate crisis, the destructive effects of which will fall disproportionately on communities that are already disadvantaged by social, economic, and political oppression.

Reporters and editors for the Monitor spoke with more than 100 psychologists to compile our annual trends report, which you’ll find on the following pages. As always, we appreciate your feedback and insights— email us .

The rise of psychologists

Reworking work

Open science is surging

Prominent issues in health care

Mental health, meet venture capital

Kicking stigma to the curb

New frontiers in neuroscience

Millions of women have left the workforce. Psychology can help bring them back

Children’s mental health is in crisis

Burnout and stress are everywhere

Climate change intensifies

Big data ups its reach

Psychology’s influence on public health messaging is growing

Telehealth proves its worth

Trent Spiner is editor in chief of the Monitor . Follow him on Twitter: @TrentSpiner

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• Published: 05 September 2024

BRCA genetic testing and counseling in breast cancer: how do we meet our patients’ needs?

• Peter Dubsky   ORCID: orcid.org/0000-0002-9566-0209 1 , 2 ,
• Christian Jackisch   ORCID: orcid.org/0000-0001-8537-3743 3 ,
• Seock-Ah Im 4 ,
• Kelly K. Hunt   ORCID: orcid.org/0000-0001-9156-8723 5 ,
• Chien-Feng Li 6 ,
• Sheila Unger 7 &
• Shani Paluch-Shimon 8  

npj Breast Cancer volume  10 , Article number:  77 ( 2024 ) Cite this article

Metrics details

• Breast cancer
• Genetic testing

BRCA1 and BRCA2 are tumor suppressor genes that have been linked to inherited susceptibility of breast cancer. Germline BRCA1/2 pathogenic or likely pathogenic variants (gBRCAm) are clinically relevant for treatment selection in breast cancer because they confer sensitivity to poly(ADP-ribose) polymerase (PARP) inhibitors. BRCA1/2 mutation status may also impact decisions on other systemic therapies, risk-reducing measures, and choice of surgery. Consequently, demand for gBRCAm testing has increased. Several barriers to genetic testing exist, including limited access to testing facilities, trained counselors, and psychosocial support, as well as the financial burden of testing. Here, we describe current implications of gBRCAm testing for patients with breast cancer, summarize current approaches to gBRCAm testing, provide potential solutions to support wider adoption of mainstreaming testing practices, and consider future directions of testing.

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BRCA-mutated breast cancer: the unmet need, challenges and therapeutic benefits of genetic testing

Genetic counseling and genetic testing for pathogenic germline mutations among high-risk patients previously diagnosed with breast cancer: a traceback approach

Mainstream genetic testing for breast cancer patients: early experiences from the Parkville Familial Cancer Centre

Introduction.

BRCA1 and BRCA2 were identified in the 1990s as genes linked to inherited susceptibility to breast cancer 1 , 2 . As tumor suppressor genes, they encode proteins that are crucial for the repair of complex DNA damage (such as double-strand breaks) by homologous recombination 3 . Germline mutations (i.e., pathogenic or likely pathogenic variants) in BRCA1/2 (gBRCAm) affecting this vital DNA repair pathway predispose individuals to developing breast cancer by impairing homologous recombination and causing genomic instability 3 .

The advent of poly(ADP-ribose) polymerase (PARP) inhibitors has revolutionized the therapeutic landscape for cancers associated with gBRCAm, including breast, ovarian, prostate, and pancreatic cancer 4 . For breast cancer, the focus of this article, PARP inhibitors are approved for early and advanced disease harboring gBRCAm based on the results of major clinical trials: for olaparib, OlympiAD and OlympiA; and for talazoparib, EMBRACA 5 , 6 , 7 . Given the opportunity for therapeutic targeting of gBRCAm, timely determination of gBRCAm status is critical to guide treatment decisions, and demand for gBRCAm testing has rapidly increased in recent years 8 . High-throughput sequencing technologies have made analysis of cancer-susceptibility genes rapid and affordable 8 . However, there is concern that the demand for gBRCAm testing may overwhelm current genetic services 9 . Furthermore, barriers at the individual-, provider-, systems-, and policy-levels exist, which restrict access to genetic testing resources and genetic counseling 10 . Innovative methods of mainstreaming genetic services may help overcome some of these challenges. Education and resources to support appropriate counseling for gBRCAm testing, as well as information on the implications of testing, and models for genetic test consent, are urgently needed to support the evolving clinical space.

In this review, we describe the implications of gBRCAm testing for potential surgical approaches and treatment in patients with breast cancer, summarize the various approaches to gBRCAm testing (including traditional and alternative models), provide practical resources to support mainstreaming of the gBRCAm testing pathway, and consider the relevance of genetic testing in breast cancer in the future.

Biology of BRCAm in breast cancer

Hereditary breast and ovarian cancer (HBOC) syndrome accounts for approximately 10% of breast cancer cases 11 . BRCA1 and BRCA2 are the main genes involved in genetic susceptibility to breast cancer 12 . HBOC is associated with early-onset breast cancer, and an increased risk of other cancers, including ovarian, pancreatic, fallopian tube, and prostate 3 . The cumulative lifetime risk of developing breast cancer by age 80 years is high at 72 and 69% for BRCA1 and BRCA2 mutation carriers, respectively 13 . Female gBRCAm carriers also have a 44% ( BRCA1 ) and 17% ( BRCA2 ) cumulative risk of developing ovarian cancer 13 .

Patients harboring gBRCAm are more likely to develop breast cancer at a younger age, with approximately 12% of the cases arising in women ≤40 years of age attributed to pathogenic or likely pathogenic variants in BRCA1 or BRCA2 14 . These breast cancers have distinct biological features: among individuals with g BRCA1 m, breast cancers are typically hormone receptor-negative (~76%) and human epidermal growth factor receptor 2 (HER2)-negative (94%), while breast cancers developing in individuals with g BRCA2 m are more frequently hormone receptor-positive (83%) and HER2-negative (89%) 14 .

Goals of gBRCAm testing in breast cancer

Available evidence regarding surgical and systemic treatment outcomes in patients with gBRCAm breast cancer highlights the importance of determining gBRCAm status prior to finalizing treatment decisions. Clinical practice guidelines further reinforce the role of gBRCAm testing in the context of treatment decision-making, beyond its importance for risk management and cascade testing 11 , 15 . The presence of gBRCAm may impact decisions about risk-reducing measures, choice of surgery, and systemic therapies (Fig. 1 ).

The pathway from gBRCAm testing to decisions relating to risk-reducing measures, choice of surgery, and systemic therapies.

Surgical decision-making

Breast-conserving surgery (bcs).

BCS aims to remove the breast tumor, with clear margins, in a manner that is cosmetically acceptable to the patient 16 . Although BCS is recommended for most patients with early-stage operable breast cancer 15 , the best approach for patients harboring gBRCAm is unclear. Practice guidelines recommend that gBRCAm status should not preclude the use of BCS as a surgical option for breast cancer 17 . However, these patients should be counseled regarding the risk of ipsilateral breast cancer recurrence, new primary breast cancer in the treated breast, and contralateral breast cancer, noting that intensified surveillance is a reasonable treatment strategy for breast cancer 11 , 17 .

Contralateral risk-reducing mastectomy (CRRM)

Some women with a confirmed gBRCAm opt for CRRM over BCS, which is removal of the unaffected breast to reduce the risk of contralateral breast cancer, with or without the option of breast reconstruction 18 . A meta-analysis of outcomes in patients with gBRCAm found that CRRM reduced the relative risk of contralateral breast cancer by 93% versus surveillance and significantly increased overall survival (OS) versus surveillance 19 . It should be noted that benefit from CRRM was not maintained in all studies after adjusting for confounding factors 20 , and the absolute survival benefits of mastectomy (both ipsilateral and contralateral) are heavily dependent on patient prognosis; patients with aggressive types of disease, and especially those with little response from neoadjuvant systemic therapy regimens, are at higher risk from distant metastasis than local recurrence or a new primary in the contralateral breast.

Risk-reducing salpingo-oophorectomy (RRSO)

While RRSO is indicated in gBRCAm carriers, its effect on breast cancer risk reduction is not clear 21 . A recent systematic review and meta-analysis of 21,022 patients demonstrated a 37 and 49% reduction in the risk of developing breast cancer following RRSO compared with no RRSO in patients with g BRCA1 m and g BRCA2 m, respectively, with the effect particularly pronounced in younger women with gBRCAm 22 . A retrospective analysis in 676 women harboring gBRCAm showed that oophorectomy decreased mortality in patients with g BRCA1 m and decreased breast cancer-specific mortality in patients with estrogen receptor (ER)-negative gBRCAm breast cancer 23 . Other studies have failed to demonstrate a benefit of RRSO on breast cancer risk 24 , 25 .

Systemic treatment decision-making

Chemotherapy.

gBRCAm advanced breast cancers are sensitive to platinum-based and non-platinum-based chemotherapy regimens 26 , 27 , 28 , 29 . For early breast cancer, patients with gBRCAm are treated with anthracycline/taxane-based regimens, similar to those individuals with sporadic breast cancers 30 . The clinical value of adding platinum therapy to neoadjuvant chemotherapy for patients with gBRCAm tumors is inconclusive. The phase 3 BrighTNess trial concluded that the addition of carboplatin, with or without veliparib, to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) rates among patients with triple-negative breast cancer (TNBC), regardless of gBRCA status 31 . Furthermore, a meta-analysis of neoadjuvant regimens in patients with gBRCAm TNBC reported improved pCR rates when platin derivatives were combined with anthracyclines and taxanes, although it was unclear if this combination offered a clinically meaningful benefit over standard chemotherapy alone 32 . However, GeparSixto and INFORM did not show a benefit to adding carboplatin or cisplatin, respectively, to neoadjuvant chemotherapy for patients with gBRCAm early breast cancer 26 , 33 . Exploratory translational analyses of BrighTNess sought to elucidate the differences in benefit observed for patients with breast cancer and gBRCAm 34 . Higher PAM50 proliferation score, CIN70 score, and GeparSixto immune signature were associated with higher odds of pCR for both patients with and without gBRCAm, and thus have been proposed as potentially useful biomarkers for determining addition of carboplatin to neoadjuvant chemotherapy 34 , but have yet to be validated for clinical practice.

PARP inhibition

PARP inhibitors block the enzyme that has a vital role in repairing DNA single-strand breaks. They exploit the double-strand break repair deficiency of BRCAm cells, which accumulate unrepaired, toxic DNA double-strand breaks, thus resulting in tumor cell death (i.e., synthetic lethality). Olaparib is licensed for the adjuvant treatment of gBRCAm, HER2-negative high-risk early breast cancer, and for gBRCAm (tumor BRCAm in Japan), HER2-negative locally advanced (EU) or metastatic (EU and US) breast cancer. Talazoparib is approved for the treatment of gBRCAm, HER2-negative locally advanced or metastatic breast cancer in the US, Europe, and several other countries worldwide.

For advanced gBRCAm HER2-negative breast cancer, PARP inhibitors were approved based on the results of the OlympiAD (olaparib) and EMBRACA (talazoparib) clinical trials 5 , 6 , 35 , 36 . In OlympiAD, olaparib had significantly improved median progression-free survival (PFS) versus standard chemotherapy treatment of physician’s choice (7.0 months vs 4.2 months; HR 0.58 [95% CI 0.43–0.80]; P  < 0.001) in patients with gBRCAm HER2-negative metastatic breast cancer 5 . Median OS was 19.3 months for olaparib and 17.1 months for standard chemotherapy (HR 0.89 [95% CI 0.67–1.18]) 35 . In subanalyses, a potential OS benefit with first-line olaparib versus chemotherapy was observed (median 22.6 vs 14.7 months; HR 0.55 [95% CI 0.33–0.95]), with 3-year survival at 40.8% with olaparib and 12.8% with treatment of physician’s choice, which, notably, did not include a platinum regimen 5 , 35 . In EMBRACA, talazoparib significantly improved median PFS versus standard chemotherapy (8.6 vs 5.6 months; HR 0.54 [95% CI 0.41–0.71]; P  < 0.001) in patients with gBRCAm advanced breast cancer 6 , with no observed improvements in OS 37 .

For early breast cancer, olaparib was approved based on the results of the phase 3 OlympiA study in patients with high-risk early gBRCAm HER2-negative breast cancer who had completed local treatment and neoadjuvant or adjuvant chemotherapy 7 , 38 . In the second prespecified analysis of OlympiA, adjuvant olaparib was associated with significantly improved OS versus placebo, with a 32% reduced risk of death (HR 0.68; 98.5% CI 0.47–0.97; P  = 0.009) 7 . Significantly improved invasive disease-free survival (IDFS; HR 0.63; 95% CI 0.50–0.78) was also shown, consistent with the significantly improved IDFS reported at the first prespecified analysis (HR 0.58; 99.5% CI 0.41–0.82; P  = 0.001) 7 .

These positive results in the adjuvant setting raised the question of whether PARP inhibitors may also have a place for neoadjuvant treatment of HER2-negative early breast cancer; however, trials have reported mixed results. In the BrighTNess trial, described above, addition of veliparib did not add benefit over neoadjuvant carboplatin/paclitaxel alone 31 . The phase 2 GeparOLA study comparing neoadjuvant paclitaxel plus olaparib to paclitaxel/carboplatinum in patients with HER2-negative breast cancer and homologous recombinant deficiency did not meet its primary endpoint (exclusion of a pCR rate of ≤55%) 39 , but did report a numerically improved pCR rate with paclitaxel/olaparib followed by epirubicin/cyclophosphamide (55.1%) versus paclitaxel/carboplatinum (48.6%) followed by epirubicin/cyclophosphamide, and a more favorable tolerability profile for paclitaxel/olaparib 39 . In the single-arm neoTALA trial, patients with gBRCAm, early-stage TNBC were treated with talazoparib followed by definitive surgery 40 . Although neoadjuvant talazoparib was active, the pCR rates did not meet the prespecified threshold of efficacy 40 . Other neoadjuvant trials are ongoing to enhance our understanding of the potential use of PARP inhibitors in early breast cancer. Of potential interest is the opportunity to evaluate alternative PARP inhibitor combinations (e.g., with immunotherapy), and tailor therapy according to the patient. For example, in the ongoing OlympiaN trial (NCT05498155) patients with deleterious/suspected deleterious BRCAm and operable, early-stage, HER2-negative, ER-negative/ER-low breast cancer are assigned olaparib (lower-risk cohort) or olaparib plus durvalumab (higher-risk cohort), and assessed for pCR 41 .

PARP inhibitors are an important treatment strategy for gBRCAm breast cancer and rely on timely access to genetic testing to guide the most appropriate treatment selection, particularly in the early breast cancer setting.

Cyclin-dependent kinase 4/6 (CDK4/6) inhibitors

A CDK4/6 inhibitor in combination with endocrine therapy is a recommended option for first-line treatment for certain patients with hormone receptor-positive/HER2-negative advanced or metastatic breast cancer 15 , 42 . Use of CDK4/6 inhibitors has also extended into earlier lines of treatment, with abemaciclib plus endocrine therapy a treatment option in the adjuvant setting for patients with hormone receptor-positive/HER2-negative, high-risk breast cancer 15 , and positive results having been reported for ribociclib (NATALEE) 43 . While the optimal sequence is not known, recent guideline updates note that when patients are eligible for both adjuvant olaparib and abemaciclib then olaparib should be given first 30 , 44 . Real-world evidence has suggested that patients with hormone receptor-positive advanced breast cancer and gBRCAm may have inferior outcomes with CDK4/6 inhibition or endocrine therapy versus those without gBRCAm 45 , 46 , 47 , 48 , 49 . This emerging finding highlights the potential importance of early detection of gBRCAm in patients with hormone receptor-positive breast cancer ahead of treatment selection, especially in light of recent CDK4/6 inhibitor approval in the early breast cancer setting.

Immunotherapy

There is limited evidence on the effectiveness of immunotherapy in patients with gBRCAm breast cancer. A recent substudy from the phase 3 IMpassion130 trial of the anti-programmed death-ligand 1 (PD-L1) antibody atezolizumab showed that, in combination with nab-paclitaxel, patients with PD-L1-positive advanced TNBC had an OS and PFS benefit regardless of BRCA1/2 mutation status (germline or somatic) 50 . The efficacy of neoadjuvant PARP inhibition in combination with immunotherapy is under investigation; for example, olaparib in combination with durvalumab is being investigated in the aforementioned OlympiaN study 41 .

Screening and counseling for family members

The burden of gBRCAm in breast cancer extends beyond the affected individual, with other family members facing decisions regarding gBRCAm testing, as well as considerations of family planning. In case of a familial association, genetic testing is recommended by the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ® ) for unaffected family members 21 . If a pre-symptomatic individual is identified as a carrier of gBRCAm, intensified surveillance for breast cancer is recommended, which differs per guideline but may include regular magnetic resonance imaging (MRI), ultrasound, mammography, and/or clinical breast exam, with guidance provided based on age 11 , 21 . For patients harboring gBRCAm with a diagnosis of breast cancer who have not undergone bilateral mastectomy, National Comprehensive Cancer Network ® (NCCN ® ) recommends that breast MRI and mammography should continue as recommended, based on age 21 .

For individuals undergoing pre-symptomatic testing (known gBRCAm in a family member), it is recommended that pre-test counseling topics include options for screening and early detection, the benefits and disadvantages of risk-reducing surgery (including the extent of cancer risk reduction, risks associated with surgery, management of menopausal symptoms with RRSO, psychosocial and quality-of-life impacts, and life expectancy), the benefits and limitations of reconstructive surgery and reproductive options, and the psychological implications of pre-symptomatic diagnosis 11 , 21 . Consideration is required with regard to reproductive concerns and the psychosocial impact of undergoing RRSO in gBRCAm carriers 21 .

gBRCAm counseling and testing in clinical practice

Implementation of guideline recommendations for gbrcam counseling and testing.

Practice guidelines for genetic counseling and gBRCAm testing are predominantly based on personal and family history of breast, ovarian, pancreatic, and/or prostate cancer; young age at diagnosis; male breast cancer; and multiple tumors (breast and ovarian) in the same patient 21 . More than 32 guidelines for gBRCAm testing relevant to breast cancer exist worldwide 11 , 21 , 51 , 52 , and the recommendations are often inconsistent. Many guidelines do not include recommendations for genetic counseling, or only provide counseling recommendations for patients who have been identified as carriers of gBRCAm 51 . Some guidelines recommend gBRCAm testing after genetic counseling and personalized risk assessment, and/or if the result is likely to influence the individual’s choice of primary treatment 51 . Some guidelines recommend testing based upon percentage risk of harboring a BRCA mutation, but there is a lack of consensus on the threshold used to determine whether an individual is eligible for genetics clinic referral/testing (10% vs 5%) 21 , 53 , and some guidelines propose testing all patients under certain circumstances (e.g., with ER-positive advanced breast cancer and resistance to endocrine therapy), considering that PARP inhibitors have a greater risk-benefit ratio than chemotherapy 54 . There are limited treatment recommendations and algorithms for women with gBRCAm-associated advanced breast cancer 51 . Greater consensus and cohesion of guidelines would be useful for patients and the medical community covering the topics highlighted in Fig. 2 .

gBRCAm counseling and testing in clinical practice.

Disparities in gBRCAm testing in clinical practice

There has been a systemic underuse of gBRCAm testing over the past two decades, which has led to inappropriate and inconsistent testing and, consequently, missed opportunities for cancer prevention and management 55 . Historically, NCCN criteria have been seen to be the least restrictive of the models, identifying a larger percentage of carriers compared with other models. However, the complex nature of the NCCN criteria render them difficult to implement in real-world clinical practice 51 , with low adherence rates reported 56 . Expansion of NCCN criteria to include all women diagnosed at ≤65 years of age was shown to improve sensitivity of the selection criteria, without requiring testing of all women with breast cancer 57 .

Although recent data from some centers and countries suggest widespread routine gBRCAm testing 58 , a number of reports highlight the need for broader eligibility criteria for gBRCAm testing to ensure that more individuals can have access 55 , 57 , 59 , 60 . Notably, patient eligibility for gBRCAm testing has been shown to vary depending on different testing criteria and recommendations, ranging from over 98% using recent guidelines published by the American Society of Breast Surgeons (ASBrS) to only around 30% eligibility using the Breast and Ovarian Analysis of Disease Incidence and Cancer Estimation Algorithm (BOADICEA) criteria 55 , 57 (Fig. 3 ). Simplified, cost-effective eligibility criteria for gBRCAm testing, based on individual rather than family history criteria, have been proposed by the Mainstreaming Cancer Genetics (MCG) group. The five eligibility criteria include: (1) ovarian cancer diagnosis, (2) breast cancer diagnosed ≤45 years of age, (3) two primary breast cancers, both diagnosed ≤60 years of age, (4) TNBC diagnosis, and (5) male breast cancer diagnosis 55 . In an analysis of different guidelines, using these criteria would have tested 92% of people and detected 100% of gBRCAm carriers 55 . An additional sixth criteria (breast cancer, plus a parent, sibling, or child meeting any of the other criteria) further improved the eligibility rate to 97% (MCGplus) 55 , while expansion of NCCN criteria (v1.2020) to include individuals diagnosed at ≤65 years of age, as recommended by ASBrS, increased testing eligibility to include over 98% of BRCAm carriers 57 (Fig. 3 ). Both the MCG and MCGplus criteria were deemed cost-effective, with cost-effective ratios of $1330 and $1225 per discounted quality-adjusted life year for the MCG and MCGplus criteria, respectively 55 . Additional studies have sought to investigate the cost-effectiveness of BRCA testing in all patients with breast cancer, with several studies conducted in countries such as Australia, China, Norway, Malaysia, the UK, and the US finding this to be a potentially cost-effective strategy 61 , 62 , 63 , 64 , 65 .

The graph shows estimates of patient eligibility for BRCA testing among BRCAm carriers. Data to the left of the dashed line is reproduced from a report in 2019 by the MCG group assessing rates of testing eligibility by different criteria 55 , while the bar to the right of the dashed line illustrates the result of an analysis by ASBrS published in 2020, examining the effect of including all individuals meeting NCCN criteria v1.2020 plus those diagnosed with breast cancer at ≤65 years 57 . ASBrS, American Society of Breast Surgeons; BOADICEA, Breast and Ovarian Analysis of Disease Incidence and Cancer Estimation Algorithm (≥10 refers to a 10% or greater probability that a BRCA1 or BRCA2 mutation is present); MCG, Mainstreaming Cancer Genetics; MSS, Manchester Scoring System; NCCN, National Comprehensive Cancer Network ® (NCCN ® ).

Traditional genetic counseling and testing pathway

The traditional pathway of genetic testing involves individualized patient referral to the genetics department for the management of pre-test genetic counseling, consenting, sample acquisition, and return of results (Fig. 4 ). Pre-test counseling, and the process of informed consent, focuses on giving patients sufficient information about the test, its limitations, and the consequences (including psychological) of a positive result, to enable an informed decision as to whether or not to proceed 9 . Patients who test positive for gBRCAm receive post-test support from a geneticist/genetic counselor/expert 9 , 66 .

MDT, multidisciplinary team.

Genetic professionals offering counseling include both medical genetic physicians (professionals with advanced training, such as an MD with a specialization in genetic medicine) and genetic counselors (professionals with a specialized Masters degree in genetic counseling) 67 , 68 . Genetic counseling by a trained genetics clinician has been shown to improve patient knowledge, understanding, and satisfaction among patients 69 , and is recommended in multiple guidelines 11 , 21 . While advantages of this type of care are clear, disadvantages include that it can be time-consuming, and a limited number of professionals are appropriately trained. When rapid access to test results is required to inform treatment decisions in a time-sensitive manner, especially for those undergoing upfront surgery, it may not be possible to maintain this workflow, and innovative alternatives may be required 70 .

Although genetic counseling is recommended, a dearth of adequately trained professionals in this field may limit access 71 , with some countries imposing legal requirements for practicing genetic counseling 72 . Where possible, non-geneticist physicians might feel the need to counsel and test patients themselves without support, despite increasing demands on their time and shorter appointment times 69 , 71 . Across Canada and the US, there are approximately 1.5 genetic counselors per 100,000 individuals, and it is estimated that double the workforce will be needed to meet future demands 73 . There has been an increase in genetic counselors reporting the use of multiple types of delivery models, including telephone and telegenetics, with an aim of improving access and efficiency of genetic counseling; however, barriers remain that can hinder implementation of these models 74 . In a large, US population-based study, only 62% of high-risk patients with newly diagnosed breast cancer who were tested had a genetic counselor session 75 . Furthermore, 66% of all patients, and 81% of high-risk patients, wanted testing but only 29 and 53% received it, respectively 75 . The most common reason for high-risk patients not being tested was “my doctor didn’t recommend it” 75 . Wait times to see genetic specialists can also be substantial. In the UK, the Nottingham University Hospitals National Health Service (NHS) Trust reports wait times of 12–14 weeks for an initial appointment and 4–6 months to receive results 76 . This highlights the need for alternative models of counseling and consenting of patients to ensure all eligible patients receive testing in a timely manner.

Systemic and societal barriers can impede equitable access to the benefits of genetic testing. Suboptimal testing rates among individuals of low socioeconomic status have been largely attributed to perceived/actual financial costs of genetic testing, with patients and healthcare providers often unclear as to whether genetic counseling services and follow-up care are covered by health insurance 10 , 77 . Strategies to improve testing rates in this patient demographic include the integration of genetic counselors into primary care settings to reduce travel time and costs to the patient 78 , and lobbying for expanded health insurance coverage for genetic counseling and testing services 79 .

Reports from US ovarian and breast cancer centers have consistently found racial/ethnic disparity in access to genetic testing, with referral rates being higher for non-Hispanic White women than for women of other races 80 , 81 , 82 . Lower awareness of the genetic basis of risk, incomplete family history, and mistrust of medical confidentiality may contribute to racial/ethnic disparities in referrals for genetic testing 79 , 83 . In addition, the detection of pathogenic variants may be decreased, and variants of uncertain significance increased, in non-White individuals 84 , 85 , 86 , as genomic reference databases provide poor genetic representation of non-White populations 87 , 88 . Whilst initiatives have been established to address gaps in the diversity of genomic data 89 , additional strategies are required to increase genetic testing rates among non-White populations. These include the development of culturally and linguistically tailored educational material, extended appointment availability, increased training of primary care-based specialists to mitigate unconscious or implicit biases, and a drive to recruit and train more healthcare providers from minority backgrounds 79 , 80 , 90 .

Mainstream genetic counseling and testing pathways

In mainstream genetic testing pathways, medical oncology teams are responsible for pre-test genetic counseling, obtaining consent, scheduling the genetic test, and using the results to guide treatment decisions (Fig. 5 ) 55 , 91 , 92 . Implementation of mainstream models has enabled more efficient testing of patients with ovarian cancer and has significantly increased the proportion of patients being offered genetic testing 93 , 94 , 95 .

VUS, variant of uncertain significance.

Mainstream genetic testing models for patients with breast cancer have also proven effective, with high pathogenic variant detection rates and a reduced burden on genetic services observed 55 , 66 , 76 . A Canadian study reported a significant decrease in wait time from referral to the return of genetic test results using an oncology clinic-based model compared with a traditional model in patients with breast or ovarian cancer (403 vs 191 days; P  < 0.001) 96 . Other studies support that oncologist-led mainstreaming results in increased testing uptake and shorter test-turnaround times 97 , 98 . A systematic review of 15 studies in patients with breast, ovarian, endometrial, or prostate cancer showed that turnaround times with the mainstream approach are lower than those with the traditional pathway, with results typically obtained 3–6 weeks after discussing and ordering the genetic test 92 . Another study in patients with breast cancer measured an 85% reduction in time to test result using the mainstream model compared with the traditional model (4 vs 25 weeks) 55 . A mainstreaming program in Australia had successful uptake with a notable gBRCAm detection rate and a reduced burden on the center, enabling reallocation of resources to streamline the genetic testing process 66 . Mainstream models also reduce genetic consultation requirements versus traditional models 55 , 66 .

Perspectives of the multidisciplinary team

Oncogenetic partnership models, in which clinical teams order genetic testing in collaboration with geneticists and implement counseling at both an individual and group level, have been shown to improve access to counseling and reduce turnaround times for genetic testing 99 . However, the feasibility of implementing new testing strategies may vary by region.

As part of the MCG program in breast cancer in the UK and Malaysia, 100% of team members (12 oncologists, 8 surgeons, and 3 nurse specialists) reported feeling confident to approve patients for genetic testing, and believed that the process worked well 55 . Similar experiences have been reported among ovarian cancer teams 9 , 91 . However, another study surveying oncologists, clinical geneticists, and surgeons found that while oncologists and clinical geneticists were mainly positive about the introduction of mainstream approaches, surgeons were not keen to implement mainstream services in their breast clinic, feeling that they did not have the expertise, time, or capacity to undertake the extra responsibility, and that genetic testing did not have much relevance for their treatment decision-making 100 .

Nurses play an integral role within the oncology team, with clinical nurse specialists often being the key point of contact for patients throughout the cancer pathway and thus ideally placed to deliver information on gBRCAm testing. A single-center UK study assessing the use of clinical nurse specialists in consenting patients with ovarian cancer for gBRCAm testing showed that there was no difference in patient-reported satisfaction compared with oncologist-led consenting, and nurses felt confident in counseling, consenting, and returning results 9 . A specialist, nurse-led breast cancer MCG service established at the Nottingham Breast Institute, UK, has reduced wait time from the date of testing to the date of results to 36 days compared with an historical wait time of 4–6 months, while also delivering continuity of care for patients, releasing oncologists’ time, and allowing oncologists and patients to consider treatment options at an earlier time point 76 . The potential for nurses to play a role in decision coaching in healthy individuals who are carriers of gBRCAm is being explored, with preliminary results suggesting the approach is feasible 101 , 102 . We provide an educational guide for nurses to outline the role that nurses can play in the gBRCA testing pathway and support conversations around nurse-obtained consent ( supplementary information : Nurse consenting guide for germline BRCA testing ).

The patients’ perspective

Genetic testing in mainstream oncology units is widely accepted by patients 55 , 66 , 91 , 103 , 104 , 105 , 106 . In the MCG breast cancer program, 96% of patients were happy that genetic testing was performed by their cancer team 55 . Some patients reported a preference for their medical oncologist or their oncology nurse to deliver pre-test counseling, because medical oncologists could use the information gained through genetic testing for treatment decisions, and because nurses are more familiar with, and better understand, the individual patient experience 105 .

Educational needs for non-genetic specialists

Ensuring appropriate training on an ongoing basis for those involved in consenting and arranging genetic testing is paramount to the success of mainstream gBRCAm testing 66 . An early study evaluating patient experiences of gBRCAm testing in the US (all tumor types) found that the quality of information given to patients by non-certified genetic healthcare professionals (HCPs) was not as consistent as that given by certified genetic HCPs, with far fewer patients in mainstream testing versus traditional counseling recalling having had a pre-test discussion, and what that included 107 . The types of training required by non-genetic specialists include generic consent training, plus specific genetics training, which involves learning how to identify eligible patients for gBRCAm testing, the relevance of gBRCAm testing, the significance for patients with a positive or negative result, the significance of a gBRCAm variant requiring evaluation, and implications of a positive test for family members 9 . Workshops designed to improve HCP knowledge and self-confidence have been shown to significantly enhance ability to overcome communication difficulties in relation to genetic testing and counseling 108 . We provide educational guides to support healthcare providers in their understanding of the gBRCA testing and consenting pathway ( supplementary information : HCP guide to genetic counseling: Understanding germline BRCA testing and its clinical implications in breast cancer and Germline BRCA testing pathway infographic ), as well as useful language to help explain the process to patients ( supplementary information : Patient-HCP flipbook: What you need to know about BRCA testing ).

Use of digital tools

Digital tools are being increasingly used across the genetic testing pathway for clinical assessment, family history taking, education, post-test counseling, and follow-up, and include web-based tools, mobile applications, chatbots, videos, and games 73 , 109 , 110 . They have been shown to improve access to genetic testing (particularly for patients in under-served areas), reduce waiting times, enhance continuity of care, increase patient engagement, and free up time for other patient-centered consultations 73 , 110 . Digital tools are associated with positive patient outcomes, including increased knowledge and reduced decision conflict, and achieve similar patient outcomes to in-person consultations 109 .

There are no digital tools that offer a comprehensive solution across the entire genetic counseling and testing pathway, with most tools developed for use in the pre-test counseling phase only 109 . The Genetics Navigator is currently in development and aims to supplement in-person consultations and support the full genetic testing pathway, including pre-test counseling, education, decision support, laboratory reporting, personalized return of results, and post-test counseling 110 . A digital pathway has also been integrated into the UK NHS clinical, laboratory, and informatics systems for delivery of gBRCAm testing to cancer patients and has been piloted as part of the BRCA-DIRECT study 111 . Results demonstrated that uptake of genetic testing using the digital pathway was non-inferior to those receiving pre-test information via telephone, with similarly good patient satisfaction and knowledge and low anxiety scores 111 .

The future of genetic testing in breast cancer

Germline versus somatic mutation testing.

Genetic testing of tumor tissue has the potential to identify both germline and somatic pathogenic (or likely pathogenic) variants, and thus identify more people who might benefit from targeted therapies. Indeed, several studies have demonstrated clinical benefit with PARP inhibitor treatment for somatic BRCAm (sBRCAm) breast cancers 112 , 113 , 114 . High concordance between germline and tumor BRCAm testing in breast and ovarian cancer has been observed 115 , 116 , 117 , 118 , 119 , 120 ; however, while sBRCAm and gBRCAm can be mutually exclusive in breast cancer, and not all mutation types can be detected by current clinical testing methods, it is possible that patients with metastatic breast cancer could benefit more from tumor testing than germline testing, as other abnormalities and targets could be identified 121 , 122 , 123 . For example, approvals of alpelisib plus fulvestrant for the treatment of PIK3CA m advanced or metastatic breast cancer 124 , capivasertib plus fulvestrant for advanced or metastatic breast cancer with PIK3CA m, AKT1 m, or PTEN m 125 , and pembrolizumab for the treatment of unresectable or metastatic solid tumors of any type with high tumor mutational burden 126 may have led to an increase in patient referrals for tumor testing using a gene panel assay. An increasing number of patients with BRCAm breast cancer could, therefore, receive an incidental positive result for BRCAm and be subsequently offered a gBRCA test to confirm the somatic or germline status, in accordance with NCCN Guidelines ® 21 .

Parallel testing of normal and tumor material offers an alternative approach that allows direct differentiation of somatic versus germline pathogenic (or likely pathogenic) variants, leading to timely treatment selection and genetic counseling that may otherwise be delayed with germline- or tumor-only testing 127 . Somatic testing alone would not distinguish between germline and somatic pathogenic (or likely pathogenic) variants, and thus may not be useful for determining future surveillance/surgery options for the patient, and may not benefit family members 128 . Therefore, an increasing number of centers are moving toward parallel testing for patients with a breast cancer diagnosis 127 . Analysis of circulating tumor DNA has the potential to identify both somatic and germline variants, and may offer a non-invasive alternative to tissue testing 129 .

Genetic testing beyond BRCA

Panel testing allows for the screening of multiple genes beyond BRCA1 and BRCA2 that may be associated with tumor development and/or treatment response 130 . For example, several other factors in the homologous recombination pathway have emerged as clinically relevant in surgical and treatment decision-making 131 , 132 . Pathogenic variants in breast cancer susceptibility genes beyond BRCA1 and BRCA2 are increasingly being considered in clinical trials with targeted therapies 113 , 133 , 134 and further recommendations for risk reduction, screening, and treatment strategies for carriers of these variants are being incorporated into clinical practice guideline updates and risk assessment tools 11 , 21 , 52 . For example, current NCCN Guidelines recommend discussion of risk-reducing mastectomy with patients found to harbor pathogenic or likely pathogenic variants in CDH1, PALB2, PTEN, STK11 , or TP53 , and consideration of RRSO at 45–50 years of age in patients with pathogenic or likely pathogenic variants in PALB2 , RAD51C , or RAD51D 21 . The web-based CanRisk tool, which integrates the presence of pathogenic variants in eight breast cancer susceptibility genes with several other risk factors to estimate the personal risk of breast cancer, is currently endorsed by multiple clinical guidelines 135 , 136 .

To summarize, advancements in patient information and care, in particular the introduction of PARP inhibitors for the treatment of breast and other cancers, have resulted in a substantial increase in demand for genetic testing. This demand is supported by the evidence that gBRCA testing in breast cancer management is a cost-effective strategy. However, without a substantial increase in personnel, traditional, genetics-led models of counseling and consenting are unable to meet the growing demand. A case can be made to increase the number of genetically trained HCPs but, even if possible, there will be a certain time lag before they are available. Mainstreaming models and the use of digital tools have demonstrated potential in providing efficient, patient-centered care that can meet the increasing needs of patients. In the future, we may see a move toward more widespread and comprehensive testing for germline and tumor alterations, raising further challenges as to how this can be effectively incorporated into comprehensive cancer care.

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This review article and materials presented herein were conceived by the authors following a series of meetings by the BRCA Testing in Breast Cancer Expert Panel (sponsored by AstraZeneca). Medical writing assistance, under the direction of the authors, was provided by Alison Lovibond PhD from BOLDSCIENCE Inc. funded by AstraZeneca UK, Plc. and Merck & Co., Inc., Kenilworth, NJ, USA, in accordance with Good Publication Practice 2022 guidelines. All images of individuals in this publication were obtained from stock photographs owned by AstraZeneca.

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P.D., C.J., and S.P-S. conceptualized and designed the review. P.D., C.J., S-A.I., K.K.H., C-F.L., S.U., and S.P-S. contributed to the literature search, writing, editing, and review of the manuscript. All authors critically revised and approved the final manuscript.

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C.J. has received consultancy fees from AstraZeneca, Daiichi Sankyo, Eli Lilly & Co., Novartis, and Roche; received support for travel or to attend meetings from Daiichi Sankyo, Pierre Fabre, and Roche; and has an unpaid role on the AGO Task Force for treatment recommendations on diagnosis and therapy in breast cancer. K.K.H. has received research funding to her institution from Cairn Surgical, Eli Lilly & Co., and Lumicell; is an Editor for Current Breast Cancer Reports (Springer); has received consultancy fees from Armada Health and honoraria for lectures and educational events from AstraZeneca. P.D. has received grants to his institution from Bristol Myers Squibb, MSD, and Roche to support patient activities; consultancy fees to his institution from AstraZeneca, MSD, and Roche; payments for speaking engagements or educational activities to his institution from AstraZeneca; and support to his institution for attending meetings or travel from Roche. S-A.I. has received grants from AstraZeneca, Boryung, Eisai, Daewoong Pharmaceutical, Daiichi Sankyo, Pfizer, and Roche; and consultancy fees from AstraZeneca, Bertis, Daiichi Sankyo, Eisai, Eli Lilly & Co, GSK, Hanmi, Idience, MSD, Novartis, Pfizer, and Roche. S.P-S. has received an independent research grant from Pfizer; consultancy fees to their institution from AstraZeneca, Daiichi Sankyo, Eli Lilly & Co., Gilead, Medison, MSD, Novartis, Pfizer, Roche, and Sharing Progress in Cancer Care; support to their institution for attending meetings and/or travel from Gilead, Pfizer, and Roche; and is the Subject Editor for breast cancer and on the clinical practice guideline committee of the European Society for Medical Oncology (ESMO). S.U. has received honoraria to her institution for speaking engagements or educational events. C-F.L. has no competing interests to disclose.

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Dubsky, P., Jackisch, C., Im, SA. et al. BRCA genetic testing and counseling in breast cancer: how do we meet our patients’ needs?. npj Breast Cancer 10 , 77 (2024). https://doi.org/10.1038/s41523-024-00686-8

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Couple therapy in the 2020s: Current status and emerging developments

1 Family Institute of Northwestern, Northwestern University, Evanston Illinois, USA

Douglas K. Snyder

2 Department of Psychological and Brain Sciences, Texas A&M University, College Station Texas, USA

This paper provides a critical analysis and synthesis of the current status and emerging developments in contemporary couple therapy. Its narrative centers on the evolution of couple therapy into a prominent intervention modality and coherent body of practice. The review begins with the consideration of the field's strong empirical underpinnings derived from research on couple therapy and basic relational science. Couple therapy comprises the widely accepted method for reducing relationship distress and enhancing relationship quality. Moreover, both as a stand‐alone intervention and in conjunction with other treatment formats, couple‐based interventions have garnered considerable empirical support for their effectiveness in addressing a broad spectrum of specific relational dysfunctions as well as individual emotional and physical health problems. We highlight the convergence of methods through common factors, shared strategies, and remarkably similar arrangements across approaches. Our review also points to key differences among approaches, the importance of recognizing respective strengths and limitations linked to these differences, and building on differences across models when selecting and tailoring interventions for a given couple. The discussion concludes with a consideration of recent trends in the field including the impact of telehealth and related digital technologies, the expansion of specific treatments for specific problems and diverse populations, the interface of couple therapy with relationship education, and enduring challenges as well as new opportunities addressing broader systemic and global dynamics.

本文对当代伴侣治疗的现状和新发展进行了批判性地分析和综合。整个叙述集中在伴侣治疗演变成一个突出的干预模式和连贯的实践体系。该综述首先考虑了该领域从伴侣治疗和基础关系科学的研究中获得的强有力的经验基础。伴侣治疗包括被广泛接受的减少伴侣关系困扰和提高伴侣关系质量的方法。此外，以伴侣为基础的干预，无论是作为独立的干预手段还是与其他治疗形式相结合，在解决各种各样的特定关系功能障碍以及个人情感和身体健康问题方面的有效性，都获得了相当多的经验支持。我们强调实现各种方法的融合，主要通过共同因素、共享策略和不同方法之间非常相似的组合安排来实现。本综述研究还指出了不同方法之间的关键的差异点，认识到与这些差异相关的各自优势和局限性的重要性，以及在为特定的伴侣选择和定制干预措施时建立在不同模式的差异上。讨论最后考虑了该领域最近的发展趋势，包括远程医疗和相关数字技术的影响，针对特定问题和不同人群的特定治疗的扩展，伴侣治疗与关系教育的衔接，以及持久的挑战和解决更广泛的系统和全球动态的新机遇。.

INTRODUCTION

This paper is occasioned by our completing the editing of a major handbook of couple therapy (Lebow & Snyder, 2023 ). In experiencing the breadth of the field of couple therapy over the 4 years of preparing that book, we noticed emerging trends in the field, shared visions, differences among approaches, and exciting recent developments. Here, we summarize what is in part simply a “sifting of the data” from what we read but also inevitably our own effort to make sense of the common ground and diversity in couple therapy. We look to extrapolate from the vast array of writing and presentations about couple therapy, broad trends in the field, as well as commonalities and continuing major points of difference and controversy across approaches. So, what then can we say of couple therapy?

THE PROMINENCE OF COUPLE THERAPY

Couple therapy has emerged as an important, widely disseminated form of therapy. Although there was a time when couple therapy was mostly an afterthought in considerations of psychotherapy and counseling, primarily consisting of methods derived from individual or family therapy and adapted to couples, couple therapy has evolved into a form of treatment that stands on its own, is widely practiced, and has its own distinct methods. The largest international study of psychotherapists found that 70% of psychotherapists treat couples (Orlinsky & Ronnestad,  2005 ). A survey of expert psychotherapists' predictions about future practices in psychotherapy showed couple therapy to be the format likely to achieve the most growth in the next decade (Norcross et al.,  2013 ) and this projection appears to have been confirmed.

Three key factors have driven the development and widespread adoption of couple therapy as a prominent therapeutic modality. The first is the high prevalence of couple distress. In the United States, 40%–50% of first marriages end in divorce (Kreider & Ellis,  2011 ). Globally, across almost all countries for which data are available, divorce rates increased from the 1970s to the beginning of this century (Organization of Economic Cooperation and Development,  2011 ) and divorce has become commonplace even in countries where it once was rarely encountered (Doherty et al.,  2021 ). Even for those less at risk for divorce, many couple relationships experience periods of significant turmoil.

The second factor prompting the rising profile of this set of methods is the adverse impact of relationship distress on the emotional and physical well‐being of adult partners and their offspring. In a survey in the United States, the most frequently cited causes of acute emotional distress were couple relationship problems (Swindle et al.,  2000 ). Partners in distressed relationships are significantly more likely to have a mood disorder, anxiety disorder, or substance use disorder (McShall & Johnson,  2015 ) and to develop more physical health problems (Waite & Gallagher,  2000 ). Moreover, couple distress has been related to a wide range of deleterious effects on children, including mental and physical health problems, poor academic performance, and a variety of other concerns (Bernet et al.,  2016 ).

A third factor propelling the prominence of couple therapy is the evolution of higher expectations for relationship life. Whereas once relational misery was simply to be tolerated, today couples have much higher expectations of relational life and see couple therapy as the pathway to better relationships (Cherlin,  2009 ; Dowbiggin,  2014 ; Finkel,  2017 ).

COUPLE THERAPY: AN EVOLVING FIELD

Couple therapy is a constantly evolving field. Principles of couple therapy have emerged that transcend theoretical orientation, as have several widely disseminated specific approaches to couple therapy aimed at reducing couple distress and improving relationship quality. Still, other couple‐based interventions have been developed targeting specific couple or individual problems (e.g., partner aggression, infidelity, and depression) and populations (e.g., emerging adults, LGBTQ couples, and stepfamily couples). Although there remain threads of both theoretical and technical connection to various methods of individual and family therapy (Lebow,  2014 ), the field now includes a distinct set of prominent approaches, builds on an enormous body of basic research focused on intimate relationships, and offers a substantial body of empirical evidence supporting the efficacy and effectiveness of its methods. Thus, it has become abundantly clear that effective intervention with couples requires its own set of theories, approaches, and methods anchored in relational science.

A brief history of couple therapy

In their classic overview of couple therapy, Gurman and Fraenkel ( 2002 ) described stages in the development of the field. First, in the early 20th century, atheoretical marriage counseling began to be practiced, featuring a pragmatic mix of psychoeducation and advice giving. During this stage, most of those working with couples did not label themselves as psychotherapists, and often they did not see spouses together. The second stage of the field, psychoanalytic experimentation, began in the 1930s, expanding from the then predominant form of therapy, psychoanalytic psychotherapy, to work with couples. Mostly, partners tended to be seen separately in this treatment by the same therapist in what has come to be called concurrent therapy, though eventually, this work segued into the beginnings of conjoint therapies in which both spouses participated in sessions with a therapist. Nonetheless, Michaelson ( 1963 ) estimated that in the 1940s, only 5% of couples were seen conjointly, and by the mid‐1960s, this number had only increased to about 15%. The third phase of couple therapy stemmed from the cataclysmic impact of the family therapy revolution in the 1960s and 1970s, in which several prominent models of systemic therapy emerged sharing the common ground of being highly influenced by systems theory. Subvariations of such core family systems therapies as experiential, strategic, structural, psychoanalytic, intergenerational, and behavioral therapies focused on couples and couple therapy (Gurman & Kniskern,  1981 ). In these therapies with their interactional basis, partners were almost always seen conjointly.

Through a different lens, couple therapy also evolved in relation to sociocultural influences. Dowbiggin ( 2014 ) described a historical shift in couples' looking for guidance primarily from family and community to their seeking help from counseling professionals. He also suggested that marriage counseling—with its emphasis on personal happiness, sexual satisfaction, and more modern gender roles—both fit within and contributed to the cultural context of middle‐class 20th‐century America. Doherty ( 2020 ) similarly situated the development of couple therapy in the context of 20th‐century family life, subject to larger system factors such as the rise in the divorce rate, the emergence of feminism, the explication of multicultural perspectives, and changes in American culture's view of marriage.

In the most recent phase of couple therapy in the 21st century, couple therapy has emerged as a mature discipline. Couple therapy has come to incorporate a wide array of distinct treatments, and a stronger evidence base both in the efficacy of therapies and in its foundation in the emerging body of relational science. Couple therapy has also broadened its conceptual framework to incorporate feminism, multiculturalism, and a broader view of gender and sexuality. Thus, “couple” now speaks to a much broader diversity of couples, and with this change has come an update from labeling “marital therapy” to “couple therapy.” Indeed, the continuing evolution of couple therapy now incorporates the increased use of social media and technology as well as open discussions about LGBTQ rights, gender equity, racism, social justice, politics, sexuality, individuality, freedom, and gender identity (Doherty,  2020 ). This era also includes the flourishing of numerous integrative methods and the development of couple therapy as a format for treating problems of individual partners.

COUPLE THERAPY WORKS!

Reviews and meta‐analyses affirm the effectiveness of couple therapy in reducing relationship distress (Bradbury & Bodenmann,  2020 ; Doss et al.,  2022 ; Lebow et al.,  2012 ; Roddy et al.,  2020 ; Shadish & Baldwin,  2003 ). Cognitive‐behavioral couple therapy, integrative behavioral couple therapy, and emotionally focused couple therapy each have sufficient evidence to be considered specific well‐established treatments for relationship distress. Nonetheless, broadly, meta‐analyses show behavioral and nonbehavioral therapies to have similar rates of impact (Shadish & Baldwin,  2005 ). The average person receiving couple therapy is better off at termination than 70%–80% of individuals not receiving treatment—an improvement rate that rivals or exceeds the most effective psychosocial and pharmacological interventions for individual mental health disorders. A variety of couple treatments have also garnered evidence supporting their effectiveness for specific relationship problems including sexual difficulties (McCarthy & Thestrup,  2008 ), infidelity (Baucom et al.,  2006 ), and intimate partner violence (Epstein et al.,  2015 ; Stith et al.,  2011 ). Yet, there is some indication that effectiveness in clinical settings in which treatments are not closely monitored is somewhat lower than in controlled trials (Bradbury & Bodenmann,  2020 ). Further, there is evidence that as with many problems, the impact of most couple therapies dissipates for about half the couples over several years of follow‐up (Bradbury & Bodenmann,  2020 ).

In addition to reducing either general or specific relationship difficulties, evidence from several clinical trials supports the beneficial impact of couple therapies for coexisting emotional, behavioral, and physical health concerns (Babinski & Sibley,  2022 ; Fischer et al.,  2016 ; Goger & Weersing,  2022 ; Hogue et al.,  2022 ; Lamson et al.,  2022 ; Stith et al.,  2022 ). For example, there is evidence in support of couple‐based interventions for depression or anxiety (Wittenborn et al.,  2022 ), posttraumatic stress (Monson et al.,  2012 ), and alcohol problems (McCrady et al.,  2016 ) of an adult partner. Couple‐based interventions for physical health problems comprise an expanding application—with evidence beginning to emerge supporting the benefits of couple therapy across a broad spectrum of conditions including couples in whom one partner has cancer, chronic pain, cardiovascular disease, anorexia nervosa, or type‐2 diabetes (Fischer et al.,  2016 ; Lamson et al.,  2022 ; Rohrbaugh et al.,  2012 ; Shields et al.,  2012 ; Woods et al.,  2020 ). Typical components of couple‐based interventions for individual mental and physical health problems emphasize partner support, improved communication, and increased attention to the disorder's adverse impact on the couple relationship. The extension of couple‐based treatments to individual disorders reflects one of the most important developments of couple therapy in this century.

FOUNDATION IN RELATIONAL SCIENCE

An important aspect of contemporary couple therapy is its strong foundation in relational science. Consider that couple therapy began as a method of practice before there was a field of relational science. Indeed, at the time of its origin, there were only the most primitive beginnings of social psychology. The infusion of relational science into practice has been steady and evolving.

The first widely recognized connections to science came in the form of bringing outcome and efficacy assessments to couple therapies (Gurman & Kniskern,  1981 ). To no great surprise, those efforts initially instigated considerable reactivity from those who eschewed a focus on measurable outcomes and who practiced therapies less frequently represented in the research literature (Gurman & Kniskern,  1978 ). In historical context, it is ironic that Alan Gurman, who espoused a nuanced view of the therapy process and outcome, was the primary mover of this initial emphasis on outcomes (Gurman & Kniskern,  1978 ), yet even his nuanced view led to a strong negative reaction. Today, the crucial role of evidence in relation to the impact of various couple therapies is widely accepted. Most couple therapy begins with the clear purpose of reducing relationship distress and promoting couple well‐being, measurable outcomes that readily can be compared to the limited changes in relational satisfaction typical of those couples in no‐treatment control conditions (Baucom et al.,  2003 ; Roddy et al.,  2020 ).

To some extent, couple therapy has become more firmly established because both meta‐analytic data and systematic reviews of the literature affirm the considerable broad impact of couple therapy (Bradbury & Bodenmann,  2020 ; Doss et al.,  2022 ; Roddy et al.,  2020 ; Shadish & Baldwin,  2003 , 2005 ) and of several of its specific approaches (Fischer et al.,  2016 ; Roddy et al.,  2016 ; Wiebe & Johnson,  2016 ). Research also highlights the impact of couple therapy on individual functioning even when relational functioning is the primary focus of couple therapy. Moreover, unlike the spontaneous remission of some problems that occur in the absence of treatment, research demonstrates little improvement in relationship satisfaction among distressed couples who do not receive therapy (Baucom et al.,  2003 ; Roddy et al.,  2020 ). Mental health and other healthcare delivery systems find links of couple‐based treatments to such clear and measurable outcomes essential.

Even more marked has been the influence of basic relational science research on couple therapy. Whereas the early forms of couple therapy only drew occasionally on the emerging field of relational science, most approaches now cite basic research about relationships as part of the foundation for their methods. Included here are such threads as research about attachment, communication processes, behavior exchanges, and emotional resonance, as well as characteristics of couples with specific problems or from specific populations. The linkages between basic research and practice articulated by Gottman ( 1999 ) in the late 20th century modeled for others the incorporation of such basic science research into practice. After the emergence of science‐based couple therapies, those who promoted their ideas about relationships without spelling out the empirical basis of those concepts and methods came to have less credibility (even if remaining fashionable at times in the popular media). Moreover, with the empirical investigation also came the ability to disconfirm theories and even identify the potentially harmful effects of certain untested ideas.

LINKS TO NEUROSCIENCE

Closely connected to the incorporation of relational science in practice has been the rapid advance in the last decade in the integration of relational neuroscience into contemporary approaches. Most models of couple therapy developed before the technology was available to assess brain function in relational life. Nonetheless, with the explosion in the information available from neuroscience in relation to couple functioning, couple therapies have begun to incorporate this emerging and exciting new knowledge base. Most especially, Fishbane's ( 2015 ) translation of neurobiology to the couple context has had considerable influence, providing a bridge to couple therapists directly being able to invoke working with neural pathways as a part of their repertoire. Other applications of neuroscience have become an essential part of emotionally focused couple therapy (Greenman et al.,  2019 ) and Gottman method therapy (Gottman & Gottman,  2015 ) as well as many other specific approaches (Tatkin,  2011 ).

Yet, here there is a caveat. Relational neuroscience is in its infancy. Studies are complex with endless possible neurotransmitters and brain structures that may be simultaneously influencing and influenced by couple processes. Methodologies range from those employing simple, readily available instruments such as pulse oximeters (an inexpensive instrument that many bought to monitor the effects of Covid‐19 that has utility here) to very expensive fMRI scanners. In exploring the literature and evaluating claims made of the implications of findings for clinical practice, it is vital to understand that specific findings that support one approach might also support another, that some findings come from a single study yet all research findings require replication and testing across diverse contexts before they can be seen as broadly applicable, that sometimes claims are made that inappropriately extend correlations to infer causation, and that the body of findings from neuroscience is only just beginning to produce an evidence‐based set of knowledge that is widely accepted.

CONVERGING METHODS

One of the most prominent trends in couple therapy is an emerging and substantial convergence of specific intervention methods across different theoretical approaches.

Couple therapy is both pluralistic and integrative

Contemporary couple therapies often cross the boundaries of schools of therapy and theoretical constructs that typically have been identified in individual therapy and earlier iterations of couple therapy. Thus, for example, cognitive‐behavioral couple approaches today transcend simply focusing on cognitions and behavioral sequences, instead also tapping emotion, meaning, and early experience (Baucom et al.,  2019 ; Epstein et al.,  2016 ). Similarly, while psychoanalytic individual therapy almost exclusively focuses on such factors as transference, the impact of early experience, and inner experience, the couple therapy variations of these approaches have come to include many other elements such as communication skills building (Nielsen,  2017 ). Such integration results from cross‐pollination across the couple therapies (wise ideas become assimilated into other models) along with the powerful pragmatic issues which every couple therapist faces regardless of orientation such as how to manage spiraling angry interactions, engage the less invested partner in therapy, promote positive connection, or deal with comorbid individual emotional or physical health concerns.

Most approaches build from a biopsychosocial foundation that includes diverse aspects such as the influence of family history, cognition, emotion, and inner psychological processes. Thus, they tap into multiple levels of human experience (Lebow,  2014 ). For example, emotionally focused couple therapy (Greenman et al.,  2019 ) addresses underlying primary and derivative emotions but also attachment. Enhanced cognitive behavioral therapy (Epstein & Baucom,  2002 ) addresses behavioral patterns but also relational schemas and emotions. Gottman method therapy (Gottman & Gottman,  2015 , 2017 ) addresses the direct behavioral level of exchanges and a far deeper level of meaning. Integrative systemic therapy (Pinsof et al.,  2018 ) addresses the many levels of human experience from behavioral exchange to inner experience.

Approaches certainly have differences in how much they emphasize each component (something we address later in this paper), but the overlap is considerable. Sometimes, authors explicitly speak of their approaches as integrative, while others do not; but regardless of whether they do so explicitly or not, integrative elements frequently permeate.

How should couple therapists think about and make use of these trends toward an expansion of both the specific phenomena to which contemporary approaches attend, as well as the broadening of various theoretical frameworks from which these phenomena are conceptualized? One approach that emerged during the 1970s was eclecticism—defined as the borrowing of specific techniques or constructs without allegiance (or even regard) for the theoretical framework in which those techniques or constructs were originally embedded (Lazarus,  1989 ). However, there are risks in eclecticism—most prominently the unsystematic or even contradictory use of specific interventions, as well as the possibility of dismantling interventions that rely on the synergistic effects of specific components implemented in combination for their effectiveness.

An alternative to eclecticism is pluralism—an approach that recognizes the validity and usefulness of multiple theoretical perspectives and draws on constructs and intervention strategies from across theoretical models by tailoring intervention strategies to a given case at any given moment based on their clinical relevance and potential utility. Pluralism differs from eclecticism in that interventions are always conceptualized from within a theoretical framework. Snyder ( 1999 ) advocated a pluralistic approach to couple therapy involving six levels progressing from a foundation of the collaborative alliance and managing initial crises, through strengthening the couple dyad and promoting relevant relationship skills, to addressing cognitive components and developmental sources of relationship distress. The therapeutic palette method of couple therapy presented by Fraenkel ( 2019 ) articulates a particularly elegant approach to pluralistic practice.

By the 1990s, the majority of therapists came to self‐identify as “integrative” rather than “eclectic” (even if their understanding of the difference might have been limited). Integration extends beyond pluralism via its blending of theoretical constructs or therapeutic techniques into one unified system or framework. Two threads of integration involve the identification of common factors and shared strategies, each of which we consider further here.

Common factors

A set of common factors lies at the base of couple therapy (Sprenkle et al.,  2009 ). These include common factors shared with individual therapy such as the therapeutic alliance, the instillation of hope, and attending to feedback. There also is a second set of common factors unique to relational therapies that include maintaining a relational frame, an active therapy style, disrupting dysfunctional relationship patterns and supporting functional ones, and some effort to create a relational therapeutic alliance. Although not all models speak explicitly of common factors, most do attend to them. For example, it is rare to find an approach that does not include a discussion of creating a therapeutic alliance and attending to its complexities.

Shared strategies

Beyond common factors lies a wide array of strategies that either originated within one approach and migrated to other therapies or have emerged as important intervention pathways in different approaches (Lebow,  2014 ). For example, most approaches strive to promote some form of mutual empathy and understanding, some form of negotiation between partners, some engagement and focus on the strengths of the relationship, some affective reengagement of positive connection, some understanding of individual contributions to the conjoint problem, and some form of mindfulness or affect regulation to render conflict‐based interactions more constructive. Frequently shared strategies include tracking patterns, listening, witnessing, psychoeducation promoting mentalizing, promoting softening, and creating experiences that enhance attachment.

Notably, the naming of these shared strategies can often be a constraint in the recognition of shared ground. Terms such as cognitive restructuring, reframing, and restorying exemplify different jargon for similar interventions across approaches. Ironically, although apt and grounded in relational science, words that have come to be identified with specific theories such as attachment and differentiation often come to divide. Jargon readily invites a Tower of Babel in which similarities across approaches are not recognized and small differences in methods are accentuated over common ground (Miller et al.,  1997 ). (Notable exceptions exist—for example, the use of the word “softening” in emotionally focused couple therapy has been enormously helpful in providing the perfect word for a broadly recognized intervention across diverse approaches.)

Structure of sessions and other arrangements

Given the many different approaches to couple therapy and the varying problems and purposes for which it is employed, the extent of shared arrangements is quite remarkable. Couple therapy today is primarily done conjointly with a clear set of specified rules for separate communication with individual partners. Sessions are most commonly conducted for 1 hour per week, and most methods include some carryover of the process (e.g., homework) between sessions. Couple therapy may continue for only a few sessions or last years, but most models envision a process lasting between 3 and 12 months. It is striking that even though there have been innumerable methods developed that are aimed to be conducted over either briefer or longer timeframes (and even in the wake of randomized controlled trial protocols that often necessarily limit the number of sessions), and with shorter or lengthier sessions, the standard remains mostly the standard. Whether this is driven by custom, by cost considerations such as insurance reimbursement, or by some shared notion that this is most effective remains an open question.

Couple therapies have evolved from their origins

Couple therapy models emerged out of various theoretical traditions, each anchored in its own time of development. However, it is in the nature of psychotherapies that, whereas theories and concepts often last over time, specific approaches do not. For example, behavioral marital therapy was initially a distinct, singular approach. That original treatment has been largely supplanted by the considerably expanded cognitive‐behavioral couple therapy (Epstein & Baucom,  2002 ) and integrative behavioral couple therapy (Christensen et al.,  2020 ). Similarly, emotion‐focused therapy has been succeeded by emotionally focused couple therapy (Johnson,  2015 ) and emotion‐focused couple therapy (Goldman & Greenberg,  2015 ). In a like manner, early psychoanalytic therapies have been superseded by object relations couple therapy (Scharff & Scharff,  2005 ; Siegel,  2015 ) and mentalization‐based couple therapy (Bleiberg et al.,  2023 ). And Bowen therapy (Bowen,  1972 ) and contextual therapy (Boszormenyi‐Nagy,  1987 ) have been largely supplanted by a broader more attachment‐oriented version of intergenerational therapy (Fishbane,  2019 ). Other early therapies, such as structural, experiential, and strategic couple therapy, have now declined in their prominence although they still have a cadre of devoted followers and their critical influence can be seen in various contemporary approaches. In tandem, the practice of some forms of couple therapy, such as narrative therapy (Freedman & Combs,  2015 ), has vastly expanded and evolved. And newer forms of couple therapy have emerged, such as socioculturally attuned couple therapy (McDowell et al.,  2018 ) and acceptance and commitment couple therapy (Lawrence et al.,  2023 ), as well as numerous specific therapies targeting specific issues or populations.

A central role for culture and gender

Couple therapy began as “marital” therapy—that is, with a fixed set of ideas about who comprised the couple (a man and a woman), their legal status as a couple (married), and often with a stereotypic set of expectations having to do with roles and other aspects of the relationship. And from this perspective, marital therapy without much self‐reflection often spoke primarily to the experience of white, middle‐ and upper‐class Americans and Europeans. Feminist, queer, and multicultural perspectives, as well as the dissemination of couple therapy around the world, have very much changed this perspective (Addison & Coolhart,  2015 ; Kelly et al.,  2019 ). Couple therapy is now a vehicle for helping with intimate relationships across gender, sexual preference, class, culture, race, ethnicity, and other facets of social location.

Understanding couples in the context of culture, race, ethnicity, gender, sexual orientation, and other aspects of social location that afford persons greater or less privilege (and greater or lesser experiences of marginalization and oppression) has become an essential aspect of couple therapy. Further, couple therapies are most helpful when adapted to specific kinds of couples—for example, adaptations for LGBTQ couples (Coolhart,  2023 ; Green & Mitchell,  2015 ) and stepfamily couples (Papernow,  2018a ), or description of the special considerations in therapy with Black American couples (Kelly et al.,  2019 ) or Latinx couples (Falicov,  2014 ). These insights and practices do not require clinicians to relinquish their favored theoretical approach to couple therapy but do present crucial additional considerations in the context of working with couples in a sensitive and effective manner.

COMMON ELEMENTS OF COUPLE THERAPY

Assessing multiple domains (e.g., emotions, cognitions, and behaviors) across multiple system levels (e.g., individual partners, their relationships, and broader family and cultural contexts) is essential for selecting, tailoring, and sequencing couple therapy interventions in a planful and effective manner. Whether implicitly or explicitly, the different approaches universally recognize the importance of attending to individual differences in conducting relevant interventions. Similarly, nearly all speak to the importance of monitoring both the process and progress of therapy in evaluating the impact of specific interventions, and revising the clinical formulation (whether explicit or implicit) and plan of therapy accordingly.

That said, both theoretical models and specific applications of couple therapy vary in their philosophical stance toward normative versus idiographic approaches, their advocacy of specific content or methods, and their views on whether formal assessment necessarily precedes intervention or, instead, evolves organically throughout therapy. Some approaches advocate meticulous assessment and the generation of an explicit case formulation and treatment plan (Christensen et al.,  2020 ), whereas some others do not. Some approaches such as narrative therapy explicitly eschew specific assessment methods (Freedman & Combs,  2015 ). And among those approaches that purposely incorporate methods of assessment, there may be a formal stage of assessment (e.g., a four‐session protocol combining individual and conjoint meetings; Chambers,  2012 ) or not; similarly, the various approaches or specific applications may prescribe standardized questionnaires or a set of observational tasks (Gottman,  1999 ; Gottman & Gottman,  2015 ) or not.

Related to assessment is the specification of specific inclusionary or (more usually) exclusionary criteria for couple therapy. Most models of couple therapy consider moderate to severe partner aggression, active alcohol or other substance abuse, continuing infidelity, or psychotic symptoms as contraindications for conjoint couple therapy. Yet, paradoxically, there are specific couple‐based treatments for these issues such as treatments for couples that include a person with a substance use disorder (McCrady et al.,  2016 ) or infidelity (Baucom et al.,  2009 ; Scheinkman & Werneck,  2010 ). A careful assessment facilitates informed decisions as to whether any of these or similar problems can be addressed within the more general theoretical models of couple therapy or require the more specialized intervention protocols, or whether any couple therapy is likely to be unhelpful in a particular case.

A myriad of strategies of intervention and techniques

One marvels at the rich and distinct body of intervention methods that have been developed. Clearly, some of the most creative and astute clinicians have developed this wonderful array of methods. The various models for helping couples bubble over with a panoply of active ingredients couple therapists can incorporate into treatment. That said, effective therapists often come up with very similar ways of working in couple therapy across whatever divides exist among theories. Clearly, there also has been cross‐pollination.

The systemic view: Sequences and vulnerability cycles

One important shared emphasis of almost all couple therapies lies in tracing the interpersonal sequences that unfold in the process of developing relational difficulties. This speaks to the influence of shared systemic understandings. Although certain processes may lie within individuals, the inevitable mutual influences between partners define the crucial understanding that is foundational to treating couples. It is in the nature of intimate relationships that the thoughts, feelings, and behaviors of partners inevitably affect one another and their relationship in an ongoing, recursive manner.

These cycles are named in a variety of ways across approaches, and what is seen as the specific internal component of the greatest moment in these cycles varies from approach to approach. Thus, Scheinkman and Fishbane ( 2004 ) speak of the vulnerability cycle, whereas Johnson and colleagues refer in their discussion of emotionally focused therapy to mutual attachment injuries (Johnson,  2015 ). In describing integrative systemic therapy, Pinsof et al. ( 2018 ) refer to sequences. Regardless of how these processes are named, the core sequence being referenced here involves a multilevel interpersonal process in which distressed partners turn away from one another or aggressively vie for control as opposed to engaging compassionately. The various general models of couple therapy articulate how these processes, like rust corroding the foundation of bridges, can erode the positive connection between partners. These models of couple therapy describe both how couples can develop and maintain a vital loving connection as well as the processes by which such connections diminish. Similarly, couple therapies targeted at specific problems and issues (e.g., post‐traumatic stress disorder or sexuality) emphasize how those issues come to be interwoven in the broader fabric of individual and relational functioning.

Pragmatic focus on relationship satisfaction

Another clear point of overlap lies in a dual focus on reducing couple distress and promoting relationship satisfaction. Almost all couple therapies emphasize specific interventions targeting these two complementary outcomes. That said, models vary in their relative emphasis on one versus the other. By definition, couple‐based applications for specific relationship issues (e.g., partner aggression or infidelity) or individual problems (e.g., depression or anxiety disorders, alcohol problems, and acute medical issues) target reduction in these difficulties, with improvement in relationship satisfaction often being viewed as one of the mediating pathways. Historically, many couple therapies have focused more on reducing conflict than on promoting intimacy—although more recently such positive aspects of relationships as encouraging emotional connection and shared meaning have moved into greater focus. Theories of couple functioning and related models of intervention play a pivotal role through their differential emphasis on specific aspects of relationships such as attachment, mentalization, mutual acceptance, problem‐solving and communication, narratives, and gender or sociocultural consciousness.

Ethical considerations

Couple therapists across orientations recognize a shared set of ethical considerations. Although couple therapies may disagree about what is the optimal ethical decision in a specific circumstance (e.g., whether to hold certain secrets—most especially about past behavior), there is almost total agreement on where the ethical issues lie and how to think about those issues. Thus, discussions about ethics in couple therapy speak to almost all couple therapies regardless of the specific application or underlying theoretical model (Barnett & Jacobson,  2019 ; Gottlieb et al.,  2008 ; Margolin et al.,  2023 ). Couple therapists struggle with the same complex set of dilemmas and questions, and most often come up with similar answers about such issues as confidentiality about private communication with one partner during couple therapy; about identifying who the client is in therapy, and how to respond to one partner's desire to leave the relationship; or about how to deal with the risk of intimate partner violence. Sometimes, there are differences about what is to be done in a specific circumstance; however, it is rare for an idea about these issues to be presented without recognizing that others may hold different positions and an awareness of the complexities involved in holding particular positions. Nonetheless, we must remember that in the practice of such a complex endeavor as couple therapy, there always will be those who are exceptions in their beliefs about some debatable standards of good practice.

Relation to individual and family therapy

Even as couple therapy has differentiated itself from individual and family therapy, it also has found a place to incorporate these modalities. In relation to individual therapy, most of the methods co‐exist and often actively look to be enhanced through collateral work with an individual partner. Although in some models that “individual” work may be done within the couple format, many suggest a complementary role for concurrent individual therapy with a different therapist.

Ironically, given its systemic roots, concurrent family therapy is less frequently spoken of in expositions about couple therapy than is individual therapy. Some approaches do retain the fluidity between couple and family therapy (at least in the unit of focus in therapy). Intergenerational approaches include a considerable focus on the family of origin and some still bring the family of origin into couple therapy sessions (Fishbane,  2019 ). Family systems considerations focused on children also become a center of attention in considering couple distress in the special circumstance of working with couples in which one partner leans toward ending the relationship while the other wants to continue with it before making a decision to enter couple therapy, where the impact on children typically arises as an important factor (Doherty & Harris,  2017 ). Additionally, Wymbs et al. ( 2023 ) speak to the role of working with couples as part of a multiformat approach with families of youth with attention deficit hyperactivity disorder or disruptive behavior disorders. Similarly, in their discussion of therapy with couples with medical issues, Rolland ( 2019 ) and Ruddy and McDaniel ( 2015 ) describe how that approach derives from broader medical family therapy. Notably, some of the most popular forms of couple therapy such as emotionally focused couple therapy have recently spawned related forms of individual and family therapy (Furrow et al.,  2019 ).

Stages of couple therapy

Although there are exceptions, most couple therapies envision beginning therapy with a stage of assessment and building of the therapeutic alliance, followed by a stage of promoting change (e.g., reducing couple distress and fostering positive connection), and then a concluding stage of termination and maintenance of gains. In the initial stage, many approaches include an explicit sharing or co‐creation of the clinical formulation and tentative treatment plan, reflecting emerging emphases in the field on collaboration and transparency in all phases of couple therapy.

FACETS OF DIFFERENCES ACROSS APPROACHES

Despite the underlying pragmatism and integration evident in many contemporary couple therapies, theories do matter. In his seminal 1978 analysis, Alan Gurman spelled out the essential tenets of what then were the major schools of couple therapy: behavioral, psychoanalytic, and systemic approaches (Gurman,  1978 ). In this classic deconstruction of couple therapies, Gurman differentiated couple therapies along four dimensions: (1) the role of the past and of the unconscious; (2) the nature and meaning of presenting problems and the role of assessment; (3) the relative importance of mediating versus ultimate treatment goals; and (4) the nature of the therapist's roles and functions. Fraenkel ( 2009 ), following a similar analysis, highlighted that approaches differ in (1) time frame (present, past, or future), (2) change entry point (thoughts, emotion, or behavior), and (3) degree of directiveness. It is striking (although perhaps not surprising) that now, decades later, these key facets of differences still apply today.

Earlier, we noted multiple sources of commonality across couple therapies—including shared systemic understandings, integration of specific techniques across approaches (even if reconceptualized within an alternative theoretical framework), the broadening of therapeutic focus (i.e., the near‐universal consideration of thoughts, feelings, and behaviors), and common arrangements (e.g., the emphasis on conjoint sessions). That said, while sharing considerable foundational elements, couple therapies in the 21st century can be differentiated along multiple dimensions—including (but extending beyond) those cited in previous analyses—both in terms of unique components as well as their relative emphasis on various shared components. Below, we summarize some of the most important, differentiating facets of various couple therapies.

The defining elements of a successful relationship

What are the most essential features that define a successful couple relationship? What are the typical individual elements, relationship patterns, or broader systemic characteristics that differentiate healthy or well‐functioning couples from those challenged by distress or dysfunction? Relatedly, what implicit or explicit theory of love and connection underlies a particular therapeutic model? For some, the answer lies in growing the couple friendship; for others, in attachment; for others, in how partners think and feel about their relationship; for others, the broader historical or cultural context; for some, sexuality; and, for still others, deep intrapsychic needs and capacities to connect. For some, peak experiences (and intensity of connection) are stressed (Perel,  2006 ); for others, steadiness and order. Although it is now typical for various models to speak to multiple levels of experience, the therapeutic approaches to couple therapy tend to emphasize one predominant lens in their theory of love, connection, and health.

Whom to include in the couple therapy

As noted earlier, contemporary approaches typically operationalize couple therapy as uniquely involving conjoint sessions with two relationship partners. That said, there are important exceptions. For example, many theoretical models and specific applications advocate for the inclusion of individual interviews during the initial assessment—particularly as opportunities for partners to discuss topics they may not yet feel comfortable discussing in the presence of their partner (e.g., infidelity, intimate partner violence, or considerations of divorce). Specific policies for handling confidential communication in such individual meetings may also vary across approaches (Scheinkman,  2019 ; Scheinkman & Werneck,  2010 ). Some suggest infusing individual sessions during the couple therapy as a means for disrupting unremitting, escalating negative exchanges until better self‐regulation can be achieved with the individual partners and then incorporating that individual work into resumed conjoint sessions. Some models have more flexible boundaries about whom to include, based on whomever the therapist or partners regard as potentially helpful in the process of improving the relationship. For example, members of the extended family may be included occasionally in integrative systemic therapy (Pinsof et al.,  2018 ) and intergenerational couple therapy (Fishbane,  2019 ). Papernow ( 2018a ) notes that ex‐spouses are a permanent part of the family; hence, couple therapists may need to incorporate time‐limited intervention with ex‐spouses to promote more collaborative coparenting across households. In approaches to polyamorous relationships there may be little or no hierarchy, and all relationships may be treated as equally important (Coolhart,  2023 ); within that context, discussions of interpartner conflict, attachment, security, jealousy, or relationship roles and boundaries easily require reconfiguration of couple therapy from a dyadic to a broader multipartner context.

Separate from issues of “whom to include” is the setting for the couple work. At the pragmatic level, where to conduct the therapy may be influenced by medical issues, mobility, systemic constraints (e.g., access to childcare or transportation), and a host of related concerns. Telehealth has recently emerged as a primary mode for the delivery of couple therapy (see below) (Fraenkel & Cho,  2020 ; Hardy et al.,  2021 ). Telehealth may reduce but not eliminate constraints in access, depending on access to, and proficiency with, relevant technology. Approaches to couple therapy also vary in how much they consider the couple “work” to extend outside of sessions to between‐session (e.g., at‐home) prescribed exercises or enactments and the use of such materials as worksheets or ancillary texts.

The role of the therapist

The role of the couple therapist represents an aspect of therapy about which there is considerable debate. Certainly, all acknowledge the therapist as a vital part of a system with the couple, and all accentuate the importance of alliance and collaboration. That said, the various models differ in how they regard the therapist's position in relation to both partners and the roles they ideally fulfill.

Influences on the therapeutic process

Although the various approaches to couple therapy universally recognize the importance of the therapeutic alliance as a common factor (Sprenkle et al.,  2009 ), they differ considerably in how they envision the therapist influencing (and being influenced by) the therapeutic process. There was a time when couple therapy largely consisted of therapists assuming the role of an expert in teaching partners about how to pursue a more functional relationship. Although this instructional role of the therapist remains a thread in the work of several approaches (such as cognitive‐behavioral couple therapy and Gottman method therapy) as well as in the applications of couple therapy to specific relational issues or individual problems, more broadly the field has moved from hierarchical therapist–couple relationships toward a much more collaborative stance. For example, some couple therapy models such as solution‐focused, narrative, and the therapeutic palette emphasize the therapist's and couple's collaborative co‐construction of the treatment goals and strategies, during which the therapist participates as a “fellow traveler” who facilitates the partners' realization of their own unique goals and pathways toward attaining these (Freedman & Combs,  2015 ). Most approaches locate themselves somewhere midway along the continuum between expert guide and fellow sojourner.

Attention to self of the therapist

Couple therapies also vary in how much they attend to the “self of the therapist” as an integral component of the therapy process. From this perspective, therapists need to pursue mindfulness of their own thoughts and emotions, memories, values, and implicit assumptions or biases to draw on both their past and present experiences in relating and intervening with couples (Aponte & Kissil,  2016 ). Some models emphasize such self‐awareness as an essential core component of effective therapy—for example, socioculturally attuned couple therapy (McDowell et al.,  2018 ) and object relations couple therapy (Scharff & Scharff,  2005 ; Siegel,  2015 ), as well as couple therapies tailored to populations where issues of identity are often central such as LBGTQ couples (Coolhart,  2023 ), and couples from specific ethnic or racial cultural contexts (Falicov,  2014 ; Kelly et al.,  2019 ).

Notably, approaches that once most centrally emphasized the self of the therapist and therapist self‐disclosure (e.g., Whitaker's symbolic‐experiential therapy; Whitaker,  1958 ; Whitaker & Keith,  1981 ) now play a less prominent role in couple therapy. It is also notable that whereas many early models explicitly called on therapists in training to participate themselves in couple therapy, we have been unable to locate recent writing specifically about couple therapy that does so, despite its obvious potential value.

Some approaches encourage therapist self‐disclosure, whereas many others do not. Most models leave open the possibility without being explicit about guidelines for self‐disclosure. Yet, transcending these differences, most approaches encourage therapists to recognize and draw upon their own subjective experiences during the therapy process (e.g., feelings of empathy, irritation, or boredom) as important information regarding the content and process of interactions with the couple or between partners themselves.

Levels and focus of interventions

By definition, couple therapies focus on the couple dyad and, for the most part, on the aggregate subjective balance of couple distress versus well‐being. However, within that general framework, approaches vary considerably in their consideration of multiple system levels including individual partner characteristics, aspects of the extended family, and the broader socioecological context. Approaches also vary in their relative emphasis on emotions, cognitions, and behaviors—and the explanatory or conceptual lens through which each of these are understood. And there are marked differences in the order of intervention even when there is a shared base of strategies. For example, integrative systemic therapy suggests first dealing with action‐oriented aspects of the relationship whereas integrative behavior couple therapy (Christensen et al.,  2020 ) first accentuates acceptance and Nielsen's integrative approach (Nielsen,  2017 ) prioritizes understanding underlying issues in the relationship.

Levels of intervention

Contemporary approaches to couple therapy all share a systemic perspective, but with varying points of emphasis. For some, there is a greater focus on individual processes. For example, in object relations therapy (Scharff & Scharff,  2005 ; Siegel,  2015 ) and intergenerational approaches to couple therapy (Fishbane,  2019 ) the enduring and predisposing vulnerabilities of the individual partners, rooted in their respective family and prior relationship histories, comprise the foundational substrate from which interactive vulnerabilities, self‐ and partner perceptions, and exaggerated response dispositions evolve. By contrast, other therapies focus less on the individual partners, and more on sequences of interaction (Hoyt,  2015 ). Still, others place greater emphasis on contextual factors as contributing or perpetuating influences on couple distress or dysfunction. From this perspective, such influences as systemic poverty, racism, or heterosexist and cisgender bias not only moderate the development or treatment of couple distress—they directly contribute to it (Hardy & Bobes,  2017 ; Knudson‐Martin & Kim,  2023 ) and, hence, comprise a central focus of treatment.

Moreover, the various approaches may target individual problems, relational problems, broader systemic influences, or any combination of these—either in their underlying theoretical formulation or in their specific application (as in the application of cognitive–behavioral couple therapy to individual disorders).

Focus of intervention

Similarly, contemporary couple therapies vary in their relative focus on specific areas of content, regardless of the system level of intervention. Most all recognize the interactions among thoughts, feelings, and behaviors, but their emphases on one or another of these domains differ considerably. Even the labeling of the approaches reflects these differences—for example, the naming of cognitive‐behavioral versus emotionally focused couple therapy. Further, there is an argument even across approaches that target multiple dimensions of experience about how the optimal sequence for addressing these should proceed. For example, some suggest behavior should be addressed first (e.g., integrative systemic therapy) whereas others initially emphasize such processes as attachment (e.g., as in emotionally focused couple therapy) or acceptance (e.g., as in integrative‐behavioral couple therapy). Moreover, partners may be encouraged to attend primarily to the subjective experiences of the other (e.g., to promote empathic awareness and joining) or, instead, to pursue mindfulness of their own thoughts and feelings as these influence relational exchanges (e.g., as in acceptance and commitment couple therapy).

Also influencing the content of interventions are approaches' differential attention to levels of awareness related to subjective thoughts and feelings. For example, partners' expectations of themselves and each other may reside well within conscious awareness, may lie outside immediate awareness but prove accessible with modest guidance from a cognitive framework, or may rely upon techniques more typical of various psychodynamic approaches for uncovering latent internal processes and explicating their influence in the current relationship. Sager's ( 1976 ) work on such “hidden forces” in couple relationships, and their impact on both implicit and explicit contracts (and their degrees of congruence or discordance), offered an influential explication of levels of consciousness as related to different approaches to intervention and provides a useful lens to inform such considerations.

The various approaches to couple therapy also differ considerably in their relative emphases on overt change (e.g., cognitive‐behavioral and solution‐focused couple therapy) versus acceptance (e.g., integrative behavioral couple therapy). Notably, even among those therapies that emphasize acceptance, approaches vary in how they conceptualize and promote this outcome. For example, in integrative behavioral couple therapy, acceptance is pursued through specific interventions promoting empathic joining (emotional change) and unified detachment (cognitive change) as an alternative (or precursor) to interventions targeting behavioral change. In acceptance and commitment therapy (Lawrence et al.,  2023 ), partners are encouraged to experience uncomfortable internal experiences and to tolerate their presence rather than trying to control them, so that they can allocate their time, energy, and attention in more fulfilling ways. In the various psychodynamic and multigenerational approaches, partners' acceptance evolves from changes in understandings of their own and each other's developmental histories and associated vulnerabilities—that is, through partners' more compassionate interpretations or meanings (and hence, related feelings) connected to specific behaviors or interaction sequences.

Presumed mechanisms of change

Closely related to levels and focus of interventions are the various approaches' underlying theoretical tenets regarding mechanisms of change. Separate from their shared emphasis on the therapeutic alliance, most approaches first prioritize attending to disabling individual or relationship crises. Beyond such shared initial “stabilization” interventions, however, the various approaches' theoretical precepts guide the selection, sequencing, and even pacing of specific interventions. Some models, for example, prioritize behavior change (or problem solutions) as the mediating pathway for promoting partners' positive thoughts and feelings for one another. Others prioritize interventions aimed at altering partners' thoughts toward one another—including the interpretations or meaning they give to relational events (whether explicit or implicit) as the mediating pathway for reducing negative affect derived from the subjective meaning and, by reducing subjective negativity, thereby fostering more positive exchanges. And still other approaches prioritize interventions aimed at promoting emotional connection (e.g., via vulnerable emotional expression and empathic responding) or acceptance (e.g., tolerance of inevitable differences). From any of the pluralistic or integrative approaches, the therapist could select specific interventions from across theoretical models, based on their presumed mechanism of change and in congruence with the case formulation.

The temporal framework of interventions

How important is the exploration of partners' individual and shared histories? Some approaches, such as intergenerational ones are fully anchored in the past and may begin with genograms as both an assessment and intervention method. Others, such as solution‐focused therapy (Hoyt,  2015 ) are almost exclusively present focused. Most contemporary couple therapies incorporate attention to both distal (historical) and more proximal (recent or current) influences, although often to different degrees or in different sequences. For example, in Snyder's ( 1999 ) pluralistic approach, developmental influences are pursued only after more structural or cognitive‐behavioral interventions fail to achieve desired outcomes. Moreover, in various integrative approaches or specific theoretical models that assimilate particular techniques from alternative approaches, the labeling of techniques or their interpretation through a particular theoretical lens may obscure similarities in their application (e.g., identifying projective identifications in object relations therapy, attachment injuries in emotionally focused therapy, or acquired perceptual and behavioral response dispositions in cognitive‐behavioral couple therapy).

Manualized versus improvisational approaches

Contemporary couple therapies vary in their level of structure. Some therapies are highly improvisational; Fraenkel ( 2019 ), for example, even names improvisation as a core aspect of the therapy. Others are much more prescriptive regarding the sequence and general content of interventions—e.g., couple therapy for partner aggression (Epstein et al.,  2015 ) or infidelity (Baucom et al.,  2009 ). Some approaches—e.g., Gottman method therapy (Gottman & Gottman,  2015 , 2017 ) and Papernow's therapy for stepfamily couples (Papernow,  2018b ) propose specific goals of intervention and methods of accomplishing those goals, although the sequence and number of sessions devoted to each goal may be tailored to aspects of the individual partners and their relationship. Applications of couple therapy to individual problems such as posttraumatic stress disorder or alcohol abuse, similar to their cognitive‐behavioral counterparts in individual therapy, tend to be more highly structured or manualized—often with a specific sequence and prescribed “curriculum” detailing specific sessions.

Length of therapy and intermediate versus ultimate goals

Couple therapy can be open‐ended or time‐limited. Solution‐focused couple therapy (Hoyt,  2015 ) anchors this continuum through its explicit focus on brief interventions targeting circumscribed problems. Other couple therapies of all varieties may segue into ongoing meetings over many years, potentially reflecting a transition from initial interventions promoting specific relationship skills to a subsequent emphasis on partners' individual growth within a conjoint framework. Most contemporary couple therapies terminate after sufficient progress toward initial goals has been achieved. Longer durations can be anticipated, regardless of approach, with couples for whom individual, relational, or broader systemic dysfunctions are more severe, more complex or pervasive across multiple domains, or more entrenched across time.

Gurman's ( 1978 ) distinction between mediating versus ultimate treatment goals also provides a useful heuristic for viewing shorter‐ versus longer‐term approaches. For example, when situational stressors compromise partners' functioning and couple well‐being, initial goals may involve resolving those stressors to achieve a direct (and potentially sufficient) effect on reducing couple distress (Bodenmann & Randall,  2020 ). However, if in the course of that work the therapist determined that traumatic individual developmental experiences mediated the impact of current stressors on individual and relational functioning, then stress‐reduction might shift to being an intermediate goal and the “ultimate” goal might be reconceptualized as emotional or cognitive reprocessing of traumatic experiences to reduce or resolve their contribution to recurrent patterns of vulnerability or exaggerated reactivity. In the final analysis, the formulation of treatment goals and related decisions about termination inevitably reflect an evolving interaction between the therapeutic approach and couples' own values, aspirations, and resources.

EMERGING ELEMENTS

There also are emerging an exciting array of novel elements in contemporary couple therapies.

The Covid‐19 pandemic potentiated a trend already developing in couple therapy toward telehealth and using electronic media as extensions of therapy. Much of couple therapy delivered during the pandemic shifted to videoconferencing and it appears that videoconferencing will remain a major format for couple therapy. Therapists needed to augment and adapt their methods to a context during which in‐person meetings were not possible. Fairly quickly, several useful sets of guidelines for relational teletherapy were offered (Burgoyne & Cohn,  2020 ; Drieves,  2021 ; Hardy et al.,  2021 ; Hertlein et al.,  2021 ). Couple therapists mostly report that virtual therapy appears to work as well as in‐person therapy (de Boer et al.,  2021 ). 1 Additionally, video‐conference couple therapy sometimes may be the sole viable alternative to in‐person sessions (e.g., when partners are geographically separated by work, deployment, or other factors). Videoconferencing solves one of the major constraints of couple therapy that historically had caused so many who could benefit from couple therapy not to seek it—namely, individual control over the time and place of meeting. For many persons, meeting virtually from their homes or from work is easier, and therapists can often be more flexible with the scheduling of sessions in this format. It can be relatively easy to assemble a couple in virtual space, and often much harder to do so in person. (It must also be added that for some, such as many older and economically disadvantaged potential clients, videconferencing makes for an additional constraint in accessibility.)

Many recent writings about couple therapy refer to these now ubiquitous methods of videoconferencing. There has yet to be much written about special issues that arise in couple video therapy such as special methods for working with conflict at a distance, guidelines for working with intimate partner violence, and privacy issues. As to the outcomes of video‐conference couple therapy compared to in‐person couple therapy, we must await the data, not only for the global question of impact but also for whether there are differences in impact across types of couples (e.g., by problem area or demographics), as well as for process data such as the quality of the therapeutic alliance across these formats.

Beyond using videoconferencing services for couple therapy, there is considerable growing excitement regarding the application of web‐based resources as adjuncts to treatment (Hatch et al.,  2021 ; Roddy et al.,  2016 , 2021 ) or in relationship education (Bradbury & Bodenmann,  2020 ; Markman et al.,  2022 ; Rohrbaugh,  2021 ; Spencer & Anderson,  2021 ). Models on the technological cutting edge such as Gottman method therapy now regularly augment couple therapy with online psychoeducational materials, reminders to engage in prescribed behaviors, and even physiological measures of partners' autonomic arousal.

Couple therapy and social media

Couple therapy is increasingly an evidence‐based practice. Yet, in tandem, couple therapy now is frequently identified by lay consumers not by its evidence‐based variations but through its dissemination through popular media. The extent to which those representations of couple therapy are grounded in the state‐of‐the‐art practice of couple therapy varies. For example, Perel ( 2006 ) builds from well‐known traditions from psychoanalytic couple therapy and systemic practice. Real ( 2008 ) similarly builds on the traditions of feminist couple therapy and treatment of relational trauma. And Gottman and Gottman ( 2015 ) and Johnson ( 2015 ), developers of major forms of couple therapy, have crossed over into providing highly accessible aspects of couple therapy in podcasts and other new media. Similarly, Solomon et al. ( 2021 ) has adapted and popularized a version of integrative systemic therapy in her approach to young people in relationships. Still, one cannot help but note that there are innumerable examples of well‐known persons and internet personalities suddenly turning into relationship coaches offering advice, based on their personal notion of how to live a relational life (not surprisingly, most of these lean toward the dramatic). Similarly, some of the best‐selling guides for couples (e.g., Gray's  1992 “Men Are from Mars, Women Are from Venus” and Chapman's  1992 “The Five Love Languages”) are inconsistent with research from relational science. It is a time of much attention to couple therapy, and a time in which having informed consumers is essential to helping potential clients separate what is grounded and what is performance.

Specific treatments for specific problems and populations

Couple therapy has traditionally been mostly envisioned as a process targeted at improving relationship satisfaction or, at least, as deciphering the viability of committed relationships. However, over the last 20 years, couple therapies have been developed and widely disseminated focusing on problems traditionally viewed as residing within individuals. Baucom et al. ( 2014 ) provide a useful distinction between partner‐assisted and disorder‐focused interventions targeted at individual problems. In partner‐assisted interventions, the partner is enlisted to help in the process of reinforcing and supporting the active treatment of the individual problem. In contrast, in disorder‐specific treatment, the treatment itself is couple therapy tailored to the particular kinds of couple dynamics likely to occur in the context of the partner's individual problem.

Today, given the predominance of cognitive behavioral therapies for the treatment of individual disorders, couple treatments of individual problems are also mostly cognitive‐behavioral in their approach. However, other models, such as emotionally focused couple therapy, have begun to speak to such uses of couple therapy across several specific disorders (Slootmaeckers & Migerode,  2020 ) and one could anticipate that such applications of other theoretical models of couple therapy to treat individual emotional or physical‐health problems will continue to proliferate.

Couples often present for therapy to receive assistance with issues around parenting of their children or adolescents. Traditional parenting programs, while promoting positivity in parent–child interactions, give only limited attention to the relationship between parents. Many family therapy models for parents and adolescents with various disorders (e.g., conduct disorder or substance misuse) also under‐attend to the couple relationship itself and its recursive influences upon and from the adolescent's behaviors. It is inevitable that parents will experience occasions of disagreement or other challenges when rearing children together. Couple challenges associated with children's behaviors become more frequent, severe, and difficult to resolve when offspring have their own individual problems—whether these take the form of internalizing, externalizing, or neurodevelopmental disorders. Expositions of couple therapy with parents of youth with emotional or behavioral disorders have been notably rare, and there is a need for a general framework for tailoring interventions to couples struggling with these common concerns.

Reaching out to a wider range of couples

As culture and gender have become more central considerations in couple therapy, approaches explicitly addressing issues of diversity have also emerged and gained broader traction. Exemplars include the discussions of therapy with LGBTQ couples (Coolhart,  2023 ; Green & Mitchell,  2015 ), interventions involving sexuality (Hall & Watter,  2023 ), and therapy targeted to couples from specific ethnic groups (Boyd‐Franklin et al.,  2008 ; Chambers,  2019 ; Falicov,  2014 ; Kelly et al.,  2020 ). One cannot underestimate the sea change that has been involved. 2 Generalizations about couples and about the most helpful interventions with them are now enhanced with a far greater appreciation of differences among couples and how those can best be attended to.

Old formulations of relationships or guidelines for therapy must now be viewed through new lenses. The evolution in the breadth of couples embraced by the field of couple therapy has been enormous. For example, today, nearly all theoretical approaches to couple therapy explicitly address issues of applicability to LGBTQ couples and most have begun to stretch to include the emerging broader world of sexuality in couples. This broadening of the vision of who is involved in couple therapy has also unearthed culture‐bound assumptions and led to adaptations and advances in the core models of couple therapy in both their development and delivery.

The Interface with relationship education

Relationship education has a long and distinguished history as it developed in parallel with couple therapy (Bradbury & Bodenmann,  2020 ; Markman et al.,  2022 ). Relationship education and enrichment programs of late have become ubiquitous. This has promoted lively conversations about which couples (or individual partners) are most appropriate for which activity, about the fuzzy boundaries between education and treatment, and how to manage or optimize the interface between them. Whereas at one time it was clear that couple therapy was targeted at distressed couples and relationship education aimed at preparation and enrichment of better functioning relationships, this boundary has become much more fluid (Bradford et al.,  2015 ). Further, several models of couple therapy —e.g., integrative behavioral couple therapy (Roddy et al.,  2017 ) and emotionally focused couple therapy (Conradi et al.,  2018 )— describe adaptations of those models intended for either in‐person, videoconference, or self‐directed online psychoeducational relationship education programs. And there is a growing movement toward relationship education involving individuals not presently in relationships so that they might develop healthier relationships (Carlson et al.,  2023 ).

The growing emphasis on acceptance

Acceptance has moved into a much more prominent place in several methods of couple therapy, including integrative‐behavioral couple therapy, Gottman method therapy, acceptance and commitment couple therapy, and mentalization‐based couple therapy. At one time, change was the focus of every couple therapy; now, many seek primarily to promote mutual acceptance while also facilitating a framework for change.

Collaborative therapists

Overall, the field has moved from implicit views of a somewhat hierarchical therapist–couple relationship toward a much more collaborative stance. A collaborative stance goes well beyond elements of promoting a therapeutic alliance initially identified in client‐centered individual therapy (i.e., genuineness, warmth, and noncontingent positive regard). Rather, collaboration extends to co‐constructing therapeutic goals that incorporate partners' own views of individual and relationship health, their values rooted in their unique developmental histories and broader cultural contexts, and their own priorities regarding the balancing of individual with relationship interests in determining how to select and sequence treatment objectives and methods.

Addressing sexuality

Sexuality is clearly a central aspect of relational life, both in itself and in its association with attachment. Hence, it is somewhat bewildering why, in most models of couple therapy, it is so tangentially addressed. Notably, this core component of relationships is principally addressed in specific discussions of sexuality (Hall & Watter,  2023 ; McCarthy & McCarthy,  2012 ; Perel,  2006 ) and often about LGBTQ couples (Coolhart,  2023 ). Despite the limited attention to sexuality in many treatment models, there has been a revolution in the consideration of sexuality when working with couples. Couple therapists need to challenge their own implicit attitudes or assumptions, and expand their knowledge base and skill sets, when addressing sexuality in working with sexual‐ and gender‐minoritized couples. Similarly, therapists need to become familiar with and comfortable in discussing aspects of sexuality that may vary in specific populations—such as older adults, couples confronting specific medical problems, or couples who engage in less frequently encountered forms of sexuality. Couple therapy around issues of sexuality has evolved beyond addressing specific sexual dysfunctions and, instead, now embraces broader goals of promoting greater sexual awareness, improving sexual responsiveness, and enhancing sexual intimacy and enjoyment that might benefit any couple.

Attending to the life cycle

Both the challenges and benefits of being a couple vary across the life cycle. Most models of couple therapy have implicitly centered on mid‐life couples, and the specific issues and intervention strategies they emphasize do not always generalize to younger couples early in their individual and relational development, nor to older couples for whom individual and relational challenges and resources often change. The good news here is that many models have now evolved to incorporate couple development over time as a part of their vision. Beyond this, there is an emerging increased focus on specific stages of development and the typical issues in couples related to those life stages (see, e.g., Solomon et al.,  2021 on emerging adults; and Knight,  2023 on older adults). These include attention to special issues in older couples, the unique issues and challenges that confront stepfamily couples, and younger couples—particularly around decisions to formalize a committed relationship or transition to parenthood. Specific couple interventions have been developed for working with couples in specific stages of the life cycle (Gottman et al.,  2010 ). From a broader perspective, the question of how to keep relationships vital and connected over a lifetime underlies most couple therapy.

Whither divorce in couple therapy? Long regarded as a disastrous negative outcome, divorce is now re‐envisioned as a potential positive pathway for couples, yet one fraught with challenges. New versions of intervention have recently been developed to help couples who face the possibility of divorce. For example, Doherty and Harris ( 2017 ) offer discernment counseling targeted to those not yet ready for couple therapy who are ambivalent or have mixed agendas about whether they want to divorce, to help the partners decide on whether working on their relationship further in couple therapy is indicated. How to work with those considering divorce, with the therapist finding a balanced position toward couples remaining together or parting, has become an essential aspect of couple therapy. So too has helping those who decide to divorce to pursue the best outcomes for themselves and for the children who may be impacted (Lebow,  2019 ). Couples often envision couple therapy ending if they decide to divorce, but “divorce therapy” is paradoxically an essential part of the repertoire of the skilled couple therapist.

Closely related are therapies focused on what Fraenkel ( 2019 ) calls “last chance” couples. These couples are already on the verge of divorce and, if therapy is to reinvent the relationship, a more radical process may be needed than in typical couple therapy.

ADDITIONAL CHALLENGES

Contemporary couple therapies face numerous challenges—some enduring since the inception of the field (e.g., attention to individual differences and issues of diversity; balancing interventions to address intrapersonal, dyadic, and broader systemic sources of distress)—and others more recent (e.g., integrating technology; securing recognition across private and public healthcare systems). Some challenges are either explicit or implicit in earlier parts of this paper (e.g., decisions regarding whom to include in the couple therapy; the balancing of acceptance versus change; or specific ethical dilemmas). Beyond these, two additional challenges warrant consideration.

Maintenance of gains

One crucial challenge for couple therapy is the maintenance of therapeutic gains. Research has shown couple therapy to be highly effective in improving relationship satisfaction in most couples in the short term (Bradbury & Bodenmann,  2020 ; Roddy et al.,  2020 ), but vulnerable to problems returning over the long term (i.e., at 2 years or longer after termination). From the few controlled clinical trials of couple therapy and one uncontrolled evaluation examining couple outcomes 4–5 years after posttreatment, the evidence shows deterioration or divorce occurring for roughly 35%–50% of couples (Snyder & Balderrama‐Durbin,  2020 ). Exceptions to this general finding, such as Snyder et al.'s ( 1991 ) controlled trial of insight‐oriented therapy yielding a deterioration/divorce rate of 20% at 4 years posttreatment, have not been replicated.

Moreover, couple relationships evolve and different stages of the life cycle begat different problems. Thus, it would not be unexpected for a couple who has worked through problems at one stage of life to have prior problems return or different ones develop as time passes, events occur, and new circumstances arise. For this reason, most contemporary couple therapies include some specific interventions prior to termination aimed at dealing with issues that may arise in the future. However, despite their obvious intuitive appeal, the efficacy of those interventions in forestalling or reducing future deterioration or divorce remains unknown.

Client values

Couples exist within a broader socioecological as well as historical context. So, too, do the various models of couple therapy intended to treat couple distress and promote individual and relationship well‐being. That said, the contexts in which various couple‐based interventions were developed, and in which couple therapists are trained, may not mirror the diverse and emerging contexts shaping the set of values that each partner brings to therapy. How can couple therapists conduct effective therapy in a world in which values differ so mightily within and across couples?

For example, what processes are seen as essential for successful relationships? How much closeness or distance is viewed as optimal or acceptable? What to do when one aspect of relational life is problematic whereas others are satisfactory? How much to strive for what Finkel ( 2017 ) describes as the “all or nothing marriage” in which relationships are seen as needing to meet all individual needs? At what point is divorce viewed as a well‐considered option? How much might expectations for successful relationships vary with cultural context? At what point does good therapy entail challenging cultural expectations around such issues as gender inequality and relational violence?

Doherty ( 2022 ) and Lebow ( 2014 ) have written extensively about the crucial role of client and therapist values in couple therapy and about the complex and often unarticulated ways in which therapist values influence practice. LGBTQ therapists and those from various cultural contexts have added diverse vantage points to such discussion (Addison & Coolhart,  2015 ; Kelly et al.,  2019 ). Couple therapy and, more importantly, couple therapists must remain aware, flexible, and responsive to the ways that values impact therapy—most especially in a world in which both conceptual models and related interventions are applied across diverse populations and cultures with dramatically different core beliefs and customs.

Pandemic and postpandemic life

It is difficult to specify precisely how the Covid‐19 pandemic has affected couples and couple therapy beyond such simple observations as the increased use of teletherapy. Yet, there clearly have been profound effects (Stanley & Markman,  2020 ). Many of the standard interventions have needed to be adapted in response to dramatic increases in levels of both individual and relational stress and constraints driven by the pandemic. Although reports regarding couple satisfaction and divorce rates during the first 2 years of the pandemic are mixed, there is no doubt that for vulnerable couples both coping strategies and outside resources became more restricted and less sufficient. This necessitated an expanded vision of couple therapy during the pandemic and its aftermath. The conceptual scheme may remain largely the same—the therapeutic palette adapted to the times, but couple therapy is adapting. Specifically, observation suggests that themes once identified with existential therapy seem to be on the rise as they have in other turbulent times (Fraenkel & Cho,  2020 ).

Inclusion in healthcare coverage

Couple therapy has succeeded in becoming widely disseminated as the preferred treatment for those encountering relational difficulties in the United States and much of the world. This accomplishment is especially remarkable given that there is little attention paid to couple therapy in most insurance and healthcare systems. For example, there is presently no separate Current Procedural Terminology (CPT) code for couple therapy (leaving the service coded as “family therapy”). Better procedures for coding couple therapy and couple relationship problems are sorely needed in healthcare systems, as well as a formal recognition of the cost‐effectiveness and therapeutic benefits of couple therapy for a broad spectrum of individual physical and mental health concerns of both partners and their offspring (Bradbury & Bodenmann,  2020 ; Ruddy & McDaniel,  2015 ). One estimate found couple therapy to be cost‐effective when paid for by the government to reduce public costs of divorce or when reimbursed by insurers to offset the increased healthcare expenses associated with divorce (Caldwell et al.,  2007 ). Further arguments in favor of healthcare coverage for couple therapy include direct medical cost offsets and the fact that insurance companies already find it cost‐effective to reimburse for the prevention of other health and psychological problems (Clawson et al.,  2018 ).

CONCLUDING COMMENTS

This is an exciting time in the evolution of couple therapy! Collectively, there is remarkable depth and variety in today's approaches to couple therapy. Numerous approaches offer integration of evidence‐informed principles with clinical wisdom in the best of the scientist‐practitioner tradition. With an increasing foundation in relational science and evidence for their efficacy, such approaches continue to mature in their development. There is both a diversity in the most prominent approaches, but also an emerging and shared understanding of couple processes and core principles underlying couple‐based interventions. Both established clinicians and those in training may benefit from expanding their own theoretical lenses to examine the relative strengths, as well as limitations, of respective approaches to allow their own clinical repertoire to evolve as well—enhancing their skill sets for addressing the complexities of couples' challenges in a potentially more differentiated and effective manner.

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2 The historical trend to focus on white middle class couples is reflected in studies of clients in couple therapy research (Tseng et al.,  2021 ).

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Couples Counseling

Couples counseling: welcome, a good relationship is worth its weight in gold.

Research tells us that healthy long term relationships foster increased life satisfaction, overall health and longevity, and provide that extra measure of joy that comes from being known, loved, and accepted.

But, we don’t need a research study to know we feel better when our relationships feel good!

We all want a healthy, relatively easy relationship with our partner, our fiancé, or our spouse. But, we all know it’s not always simple to achieve harmonious relationship bliss.

The Secret to Great Relationships Isn’t Guesswork!

The world is swimming with relationship advice, isn’t it? Magazine headlines, row upon row of relationship self-help books, and what your friends and buddies tell you after work or on the golf course.

So, how will you know what really works? There are a lot of broken relationships out there.

Why not start with research-based methods of relationship counseling developed over decades with thousands of couples?

When I decided to build on the couples counseling coursework I did in grad school to pursue a specialty of working with couples to develop healthy, happy relationships, it made sense to get trained in the most successful models of couples therapy out there. As a result, when you choose to work with me to create the relationship you both want, you’ll have an opportunity to develop the skills and understanding that have already helped thousands of other couples.

Emotionally Focused Couple Therapy (EFT)

There has been an explosion of research in recent years related to something called Adult Attachment. Related to what researchers have studied for years about patterns of bonding and attachment in babies and their moms, it is the study of how adults—couples—bond and form deep emotional attachments. Supported by the field of interpersonal neurobiology, EFT provides an understanding of the patterns of how couples grow deeply close—and how they also wind up in repetitive cycles of pain, conflict, and withdrawal. It’s an experiential, empirically-validated approach that helps you heal and deepen your relationship.

Integrating EFT will answer many of your most painful questions about why you and your spouse struggle—and provide the insights and experiences in counseling that will repair and deepen the safety of your bond.

The Gottman Method of Couples Counseling

The Gottman Method of Couples Counseling is a research-based, well respected, in-depth process of assessing and repairing relationships. It is an approach that’s comprehensive, strategic, and skills-based. It’s rooted in 40 years of clinical practice and research on what happily married, long-term couples have in common—and how to use their secrets and habits in your own marriage. It helps couples rebuild friendship, manage conflict, reignite intimacy, and revisit their big-picture dreams.

You’ll learn and practice everything from rebuilding friendship, fighting fair, and negotiating compromise, to kindling fondness and admiration, deepening physical and emotional intimacy, and pursuing life dreams and goals together.

The Gottman Method includes an effective, thorough, research-based assessment so that we know we’re recognizing your strengths and understanding your unique situation before we make a plan that’s tailored specifically for your relationship.

The Bader Developmental Model of Couples Counseling

In addition to my training in the Gottman Method and Emotionally Focused Couple Therapy, I am also currently training in the Bader Developmental Model of couples work, which brings insights to the ways relationships develop over time in conjunction with how each person is maturing and growing.

Prepare/Enrich Premarital Counseling and Marriage Enrichment Assessment

Prepare/Enrich is the #1 premarital assessment, and I’m a certified facilitator. This in-depth assessment explores all the major areas of relationship that you’ll need to consider as an engaged couple. The questions take into account each couple’s unique background. They take into account any previous marriages, whether or not you have children, your ages, living situation, and more.  You’ll feel that the assessment process is suited to you, for your specific circumstances.

It’s a great tool for deepening your understanding of each other to build a solid foundation to prepare for or enrich your marriage.

I love seeing couples begin to realize that they are capable of reconnecting, talking, laughing, and rediscovering why they want to be together.

Take The First Step