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Clin Child Fam Psychol Rev (2012) 15:413

DOI 10.1007/s10567-011-0107-2

Intimate Relationships and Psychopathology

Mark A. Whisman Donald H. Baucom

Published online: 29 November 2011

Springer Science+Business Media, LLC 2011

Abstract Relationship functioning and individual mental

health and well-being are strongly associated with one
another. In this article, we first review the cross-sectional
and longitudinal associations between relationship discord
and various types of psychopathology, We then review
findings suggesting that relationship discord is associated
with poorer outcome for individual-based treatments for
psychopathology and that, generally, relationship discord
does not improve following individual-based treatments for
psychopathology. Finally, we present a model for conceptualizing work with couples in which one partner has a
psychiatric disorder and review the efficacy of couplebased interventions in the treatment for psychiatric disorders, with a focus on substance-related, mood, and anxiety
Keywords Marriage  Married  Couple  Depression 
Anxiety  Alcohol

For many people, the relationship they have with their
spouse or partner will be the most important interpersonal
relationship they develop in their lifetime. Therefore, the
quality of these relationships is likely to be an important

M. A. Whisman (&)
Department of Psychology and Neuroscience, University
of Colorado Boulder, 345 UCB, Boulder, CO 80309-0345, USA
D. H. Baucom
Department of Psychology, University of North Carolina
at Chapel Hill, Chapel Hill, NC, USA


factor in the individuals mental health. There are several

pathways by which relationship functioning and mental
health may be associated. First, relationship problems can
be stressful, particularly if they are severe and/or chronic in
nature; measures of marital adjustment are highly correlated with perceived stress (Funk and Rogge 2007). Given
the large literature indicating that stress increases the risk
of mental and physical health problems, relationship discord may act as an interpersonal stressor, increasing the
likelihood of a person developing mental health problems.
Second, mental health problems can increase the likelihood
of relationship discord. For example, the partners of
depressed individuals report that they experience a variety
of burdens associated with living with the depressed person
(e.g., Benazon and Coyne 2000). Relationship partners
likely differ in how well they adapt and accommodate to
the changes brought on by the other persons mental health
problems. For some partners, these changes may be overwhelming, resulting in withdrawal of support that they both
give and receive or an increase in conflict in the relationship. Therefore, irrespective of how they develop, mental
health problems may increase the likelihood of relationship
discord, which in turn may impact the likelihood of
maintenance or recurrence of psychiatric symptoms.
In this article, we review research on intimate relationships and psychopathology. The article is divided into three
major sections. In the first section, we review the basic
research on intimate relationships and psychopathology. In
the second section, we review findings regarding the
association between intimate relationships and outcome for
individual-based treatments for psychopathology. In the
third and final section, we present a model for conceptualizing work with couples in which psychopathology is
present and review the efficacy of couple-based interventions in the treatment for psychopathology. Because a

Clin Child Fam Psychol Rev (2012) 15:413

comprehensive review of the literature in each of these

areas is beyond the scope of this article, the review should
be viewed as illustrative of the research conducted on these

women with no disorders (Whisman et al. 2011). The

authors had intended to evaluate the association between
marital adjustment and anorexia nervosa and bulimia
nervosa, but the number of women with these disorders
was too small to conduct meaningful analyses, despite the
large sample (N = 2,084).

Intimate Relationships and Mental Health

Longitudinal Associations
There is a growing body of empirical research documenting that intimate relationship functioning is associated with
a variety of mental health outcomes, operationalized in
terms of symptoms and diagnostic disorders. Because the
most common relationship variable that has been studied in
the context of mental health is self-reported relationship
adjustment, we will focus on it in our review, with low
relationship adjustment labeled as relationship discord.
Cross-Sectional Associations
With respect to co-occurrence between relationship discord
and psychiatric symptoms, the most common disorder that
has been studied is depression. In a meta-analysis of studies
examining the cross-sectional association between relationship adjustment and depressive symptoms, Whisman
(2001a) reported a weighted mean effect size (r) of -.42
for women and -.37 for men. Therefore, depressive
symptom severity is greater when people report lower
relationship adjustment.
There is a growing body of literature that indicates that
relationship discord is associated not only with psychiatric
symptoms but also with psychiatric disorders. Furthermore,
many of these studies are based on large, population-based
community samples, thereby suggesting that the results are
likely to be highly generalizable. For example, in large,
population-based samples conducted with people from
across the 48 contiguous United States, marital discord was
associated with broadband categories of mood, anxiety,
and substance use disorders, as well as with specific narrow-band diagnoses of specific disorders within these
broadband classes, defined in terms of DSM-III-R (Whisman
1999) and DSM-IV diagnoses (Whisman 2007).
Taken together, these results suggest that people who
report greater relationship discord are also the people who
are more likely to experience mental health problems and
that the co-occurrence between relationship discord and
psychopathology is found for a range of disorders. Furthermore, although relationship discord may be believed to
be associated with other major mental disorders, such as
schizophrenia or obsessivecompulsive disorder, it is difficult to evaluate these associations in epidemiologic
studies because of the low base rates of the disorders. For
example, women with binge eating disorder reported lower
marital adjustment than women with other disorders or

Cross-sectional studies of the association between relationship discord and psychiatric symptoms or disorders are
limited insofar as they do not address the direction of cause
and effect. Longitudinal research is therefore needed to
establish the role of relationship discord as a risk factor for
psychopathology. Longitudinal research on the association
between marital discord and psychiatric symptoms has
focused primarily on the symptoms of depression, and the
results indicate that baseline marital discord predicts
increases in depressive symptoms over time (e.g., Beach
et al. 2003; Whisman and Uebelacker 2009). Researchers
have also examined within-subject longitudinal effects of
relationship adjustment and depressive symptoms by
measuring both constructs on multiple occasions. This
allows testing whether change in one variable (i.e., relationship discord) accounts for change in the other variable
(e.g., depressive symptoms), above and beyond the way
each variable is already changing. Results from these
studies have shown that decreases in relationship adjustment co-occur with increases in depressive symptoms; that
is, at times when an individuals relationship adjustment is
lower than usual, that individuals depressive symptoms
tend to be higher (e.g., Davila et al. 2003; Kouros et al.
2008; Whitton et al. 2008).
Although more limited in number, there are several
longitudinal studies indicating that relationship discord
predates the onset of psychiatric disorders. Looking first at
mood disorders, in a population-based sample of married
adults who did not meet criteria for 12-month major
depressive episode (MDE) at baseline, a categorical measure of marital discord was associated with a 2.7-fold
increased risk of MDE during the following 12 months
(Whisman and Bruce 1999). The association between
marital discord and incidence of depressive disorders was
replicated in a population-based sample of people in the
Netherlands: baseline marital discord was associated with
increased risk of both total incidence and first incidence of
dysthymia and MDE 23 years later (Overbeek et al.
There is also evidence that relationship discord is a risk
factor for substance-related disorders. For example, baseline marital discord was associated with a 3.7-fold
increased risk of developing an alcohol use disorders (i.e.,
alcohol abuse or dependence) during the following


12 months in a population-based sample of married adults

who did not meet criteria for 12-month alcohol use disorder
at baseline (Whisman et al. 2006). This association was
replicated in the Netherlands by Overbeek et al. (2006),
who found that baseline marital discord was associated
with increased risk of broadband class of substance use
disorder and with the separate diagnosis of alcohol abuse.
Finally, there is some evidence that relationship discord
is predictive of subsequent anxiety disorders. In their
population-based sample of people from the Netherlands,
Overbeek et al. (2006) found that baseline marital discord
was associated with subsequent broadband class of anxiety
disorder and with the separate diagnosis of social phobia.
In summary, relationship discord is associated with
longitudinal changes in depressive symptoms and with the
onset of several psychiatric disorders in population-based
epidemiologic studies. Although additional research is
needed regarding other broadband classes of psychiatric
disorders, as well as other narrow-band individual disorders, these results are important in building a foundation
that relationship discord precedes, and therefore may be
causally associated with, the onset of psychiatric disorders,
as well as psychiatric symptoms. Because the association
between relationship discord and psychopathology does not
appear to be limited to any single disorder or class of
disorders, it appears that relationship discord may be a
general risk factor for several mental health problems and,
consequently, that improving relationship discord may be
useful for preventing and treating a variety of mental health
problems. We will return to this point later in the article.
It is also important to note not only that relationship
discord can impact the severity of psychiatric symptoms
and onset of psychiatric disorder but also that psychopathology can have important negative effects on later relationship functioning. For example, Davila et al. (1997)
evaluated the associations between depressive symptoms
and marital stress in a 1-year longitudinal study of newlywed couples and found that wives baseline depressive
symptoms predicted wives marital stress at follow-up,
which in turn was associated with greater depressive
symptoms for wives at follow-up. Whisman and Uebelacker
(2009) examined the association between marital discord
and depressive symptoms in a 2-year longitudinal study
and found that baseline depressive symptoms predicted
subsequent marital discord and that baseline marital discord predicted subsequent depressive symptoms. Moreover, there were no significant differences between these
longitudinal effects: Baseline marital discord was just as
strongly associated with follow-up depressive symptoms as
baseline depressive symptoms were associated with followup marital discord. Taken together, results from these
studies suggest a bidirectional association between marital
discord and depressive symptoms.


Clin Child Fam Psychol Rev (2012) 15:413

Partner Effects
Although researchers have primarily studied the association between a persons report of relationship adjustment
and his/her own mental health, it seems important to
additionally consider the potential impact the mental health
of the partner may have on the relationship. For example,
what happens in relationships in which both partners have a
psychiatric disorder? In the case of substance-related disorders, it seems that this is associated with fewer relationship problems than when only one partner has a
substance-related disorder. For example, discrepancies in
heavy drinking are associated with (a) lower concurrent
marital adjustment (Mudar et al. 2001), (b) longitudinal
declines in marital adjustment (Homish and Leonard 2007),
(c) greater probability of continued relationship aggression
(Quigley and Leonard 2000), and (d) greater probability of
marital dissolution (Ostermann et al. 2005); discrepancies
in illegal drug use is associated with lower concurrent and
future marital adjustment (Homish et al. 2008). If a substance-related disorder is viewed as a stressor, one might
have predicted that both partners having problems with
substances would be most detrimental to the relationship,
but this does not appear to be the case. Instead, it appears
that relationship discord may be most likely when only
partner has substance-related problems. For these couples,
the discrepancies in substance use may be a source of
relationship conflict (e.g., they may argue about the persons substance use), or perhaps, substance-related problems in one partner lead to a reduction in opportunities for
shared positive experiences (e.g., if one partner is using
substances, it may reduce their time together as well as the
opportunity for shared activities). Alternatively, it may be
that discrepancies in substance use reflect other types of
dissimilarities, as dissimilarity between partners, in general, is associated with relationship discord.
Researchers also have begun to evaluate both partners
reports of relationship adjustment and mental health and to
examine their association using dyadic analysis (Kenny
et al. 2006). That is to say, researchers have begun to
examine the association not only between a persons own
report of relationship discord and mental health (i.e., actor
effects) but also between a persons report of relationship
discord (or mental health) and their partners mental health
(or relationship discord) (i.e., partner effects). On one hand,
if my partner is dissatisfied in the relationship, he/she may
be negative toward me, for example, being critical and
hostile or withdrawing. This negative behavior toward me
might then increase my likelihood of mental health problems, thus demonstrating the effects of partner relationship
discord on psychopathology. On the other hand, if my
partners psychopathology symptoms (e.g., social withdrawal, lack of energy) increase my likelihood of

Clin Child Fam Psychol Rev (2012) 15:413

relationship discord, then partner effects of psychopathology on relationship discord would be observed. In a crosssectional study, marital adjustment was associated with
both a persons own symptoms of depression and anxiety
and his/her partners symptoms of depression (Whisman
et al. 2004). Similarly, when examined from a longitudinal
perspective, baseline marital discord predicted both self
and partners depression at follow-up in one study (Beach
et al. 2003), whereas a subsequent study did not find this
association but rather found that baseline depressive
symptoms predicted self and partners marital discord at
follow-up (Whisman and Uebelacker 2009). Thus, based
on these studies, it appears that a persons individual and
relationship adjustment is important not only for their own
mental health and relationship adjustment over time, but
also for their partners mental health and relationship
adjustment. However, because so little research has been
conducted to date, examining partner effects of relationship
discord and psychopathology, particularly for disorders
other than depression, is an important topic for future
Intimate Relationships, Mental Health, and Children
The focus of this section has been on relationship adjustment and adult mental health. However, it is important to
note that many couples have children, and a full understanding of intimate relationships and mental health should
also consider the impact that children can have on their
parents mental health and their parents relationship
adjustment. Furthermore, although we have focused our
review on the impact of relationship discord on adult
mental health, parental conflict can also have serious
effects on the mental health of children. Although a
detailed description of the reciprocal effects of relationship
and child functioning is beyond the scope of this article,
interested readers are referred to other articles in this series,
as well as to other reviews (e.g., Cummings and Davies
2010; Grych and Fincham 2001).

Relationship Discord and the Course and Treatment

of Mental Health Problems
If relationship discord is associated with the onset or
maintenance of a mental health problem, then it stands to
reason that people in discordant relationships may be less
likely to respond to individual-based treatments because
the couples relationship is not addressed or emphasized in
treatment. Indeed, research has shown that relationship
discord is associated with poorer outcome for pharmacological and individual-based therapies for depression,
including empirically supported treatments for depression.

For example, in the NIMH Treatment of Depression Collaborative Research Project, which involved depressed
outpatients treated by psychotherapy (cognitive therapy,
interpersonal psychotherapy) or medication, poorer marital
adjustment at baseline was associated with poorer outcome
at the end of treatment and poorer marital adjustment at
post-treatment predicted higher relapse rates following
treatment (Whisman 2001b). Similarly, among chronically
depressed outpatients treated with Cognitive Behavioral
Analysis System of Psychotherapy or medication, singly or
in combination, relationship discord at baseline was associated with a lower remission rate (Denton et al. 2010).
Relationship discord has also been shown to be predictive
of poorer outcome following the treatment for substancerelated disorders. For example, poorer marital adjustment
has been shown to predict increased likelihood of relapse,
percent days abstinent, and time to relapse among people
with substance use problems in treatment (e.g., Fals-Stewart
et al. 2001). Likewise, poorer relationship adjustment has
been associated with poorer outcome following treatments
for anxiety disorders. For example, greater relationship
discord predicts poorer outcome for the treatment of agoraphobia (Dewey and Hunsley 1990), and for generalized
anxiety disorder (GAD), poorer outcome is associated with
increasing levels of self-reported relationship tension and
friction (Durham et al. 1997) and observer-coded hostile
criticism from ones partner during a worry discussion
(Zinbarg et al. 2007).
In summary, the research conducted to date suggests
that if people are experiencing problems in their relationship, then they are less likely to respond to individualbased treatment. Individual-based treatments may be less
effective for people with relationship problems because
these treatments do not address the very problems (i.e.,
relationship problems) that may be contributing to the
maintenance of their mental health problem. Ignoring
relationship problems, therefore, may impede treatment for
individual psychopathology. One potential implication of
these results is that interventions focused on improving
relationship discord may be effective in treating psychopathology, a point we will return to later in this article.
Another area of research that has been evaluated with
respect to individual-based treatments is the impact of
these treatments on relationship functioning. If relationship
discord is a by-product of an individuals psychopathology,
then improvements in the disorder might result in
improvements in relationship discord. However, results
from existing studies suggest that individual-based treatments do not generally result in improvements in relationship functioning. For example, relationship adjustment
does not significantly improve following individual-based
treatments among couples presenting with relationship
discord and one partner meeting criteria for depression


(e.g., Beach and OLeary 1992; Jacobson et al. 1991) or a

substance use disorder (e.g., Fals-Stewart et al. 1996).
Although other interpretations are possible, these results
could reflect broader findings in the couples area, which
indicate that once a couple becomes discordant, their patterns of interaction become self-perpetuating (Epstein and
Baucom 2002). Thus, even if relationship discord is precipitated in response to one partners psychopathology, the
relationship problems might become autonomous and
continue in spite of improvements in one individuals
In summary, research conducted to date suggests that
individual-based treatments do not generally result in
improvements in relationship adjustment. Therefore, if
relationship problems exist before treatment, they are
likely to remain following individual-based treatment. To
the extent that relationship discord is predictive of subsequent psychopathology (as reviewed earlier), then the
presence of relationship discord following individual-based
treatment may leave peoples at risk of relapse or recurrence
of their mental health problem. Taken together with the
findings that relationship discord is associated with poorer
outcome to individual-based treatments, these results suggest that couple-based interventions may be effective in
treating psychopathology, a hypothesis to which we now
turn. In addition, as we will discuss, even if the couple is
satisfied with their relationship, there are ways to leverage
the relationship to help an individual address individual

Intervening on Psychopathology with Couple-Based

A Conceptual Framework
The general model of training in the mental health field is
that individual problems are to be addressed with individual therapy. Many clinicians do not assess for the presence
of relationship problems, and even if they do, they may
assume that such problems are the consequence of the
mental health problem and therefore do not need to be
addressed. Furthermore, if a person does not report relationship discord, then it is not obvious to many professionals why a therapist would want to include the partner in
treatment; how would the partner be included in treatment
and for what reasons?
Elsewhere, Baucom and colleagues (Baucom et al.
1998, 2009; Epstein and Baucom 2002) have developed a
model to differentiate among different types of couplebased interventions for psychopathology, with different
interventions including the partner in different ways in
order to achieve specific goals. As noted below, two of


Clin Child Fam Psychol Rev (2012) 15:413

these types of interventions do not assume that partners are

discordant in their relationship, but rather evolve from the
realization that individual disorders exist in a social context
and that including a partner in treatment might be a powerful agent to promote individual change. Given that
making the behavior changes needed to address psychopathology is often difficult for the individual, having a
partner to encourage, support, and assist in these changes
has the potential to be of assistance in a variety of contexts.
These three types of couple-based interventions are referred to as: (a) partner-assisted interventions, (b) disorderspecific interventions, and (c) couple therapy.
Partner-Assisted Interventions
The first approach, referred to as partner-assisted interventions, focuses specifically on behavior changes that the
person with the disorder (i.e., the client) needs to make
and how the partner can help the client make these changes, hence the term partner-assisted. This approach does
not emphasize changing the couples relationship in any
fundamental or meaningful way. Instead, the partner is
assuming the role of a substitute or surrogate therapist in
some ways, or a coach and cheerleader in helping the client
make important changes. For example, in the treatment for
obsessivecompulsive disorder, the major treatment
approach with empirical efficacy involves exposure and
response prevention. That is, the individual is to engage in
the behavior that creates anxiety and then not engage in the
compulsion that lowers the anxiety. Recently, we developed a couple-based intervention for OCD that includes
partner-assisted exposure and response prevention in which
the partner initially participates and assists the individual
with exposure (Baucom et al. 2008). As described in more
detail elsewhere (Baucom et al. 2003), this typically would
involve the couple: (a) discussing plans for a specific
exposure outing prior to the exposure; (b) planning and
carrying out how they will respond together if the client
becomes extremely anxious during the exposure outing;
and (c) once the exposure outing is finished, debriefing
about what was helpful and unhelpful from each partner
during the exposure experience.
Two recent investigations of couple-based interventions
for depression emphasize partner-assisted interventions,
along with disorder-specific interventions (which are
described below). In both of these treatment studies
(Bodenmann et al. 2008; Cohen et al. 2010), couple-based
interventions were extensions of cognitive-behavior couple
therapy principles that targeted the depression per se rather
than relationship discord and, thus, are applicable for both
relationally discordant and nondiscordant couples. For
example, in Bodenmann et al.s dyadic coping model, the
partner of the depressed individual encourages the

Clin Child Fam Psychol Rev (2012) 15:413

depressed person to actively influence a situation of concern to the depressed person or deal with the problem. This
strategy can be interpreted as the partner assisting the
depressed person to engage in behavioral activation, which
is a component of effective cognitive-behavior therapy for
depression. Likewise, among other intervention components, Cohen et al. (2010) taught both partners how to
support each other surrounding behaviors focal to the
depression, helping them distinguish between adaptive
emotional and instrumental support that each partner needs
within the context of addressing depression. Both of these
couple-based interventions were efficacious in decreasing
depression and altering important aspects of relationship
functioning. Although the specific behavioral changes that
an individual needs to make varies greatly based upon the
disorder, a partner-assisted approach is geared to using the
partner as a support and assistant in helping the individual
make these changes.
Disorder-Specific Interventions
Disorder-specific interventions do focus upon creating
fundamental changes in the couples relationship that will
persist long term, but only in the domains that are focal to
the clients disorder, hence the name disorder-specific
interventions. In these interventions, the therapist helps the
couple identify ways that they can use or alter their relationship to encourage changes that the client needs to make
to address psychological difficulties. As an example, once
again consider the role of partners in treating anxiety disorders, such as agoraphobia or obsessivecompulsive disorder. Through the use of exposure outings, an individual
with agoraphobia learns that the world is not as dangerous
as anticipated; therefore, the client can become involved
in situations and settings that previously were avoided
because they led to disabling anxiety. One important use of
a disorder-specific couple intervention in this context is to
help couples create an everyday lifestyle that helps
to encourage and maintain the clients new-found ability to
interact in the outside world. This might involve, for
example, significant shifts in the client and partners
household roles and responsibilities. When the agoraphobia
was most severe, the partner might have done most of the
grocery shopping and transportation of the children
because of the distress created when the person with agoraphobia engaged in these tasks. Although inadvertent, the
partners assumption of these roles actually encouraged or
helped to maintain the agoraphobic avoidance and escape
from frightening situations. Therefore, in a disorder-specific intervention, the therapist would work with the couple
to redistribute responsibilities such that the agoraphobic
individual would interact with the outside world on a
regular basis, such as doing the grocery shopping and

transporting the children away from home. Similarly, the

couple would be encouraged to develop new social activities that maintain engagement with the outside world as
well, including visiting friends and family on a regular
basis or taking vacations far beyond where the agoraphobic
was able to go in the past. In essence, the couple is building
the concept of exposure into the fabric of their relationship
on a continual basis in a way that feels natural and sustainable. Consistent with the notion that teaching the couple healthy ways to alter their relationship in the context of
agoraphobia, Arnow et al. (1985) demonstrated that if
couples were taught to communicate and make effective
joint decisions regarding the agoraphobia, the client
responded more positively to treatment compared to
intervention without this couple-based disorder-specific
The couple-based interventions for depression noted
above (Bodenmann et al. 2008; Cohen et al. 2010) also
included important disorder-specific interventions to teach
the couple more adaptive interaction patterns surrounding
the depression. Across disorders, it is common for partners
to inadvertently reinforce the patients maladaptive
behaviors through accommodating to those behaviors,
although the partners are well intentioned. Therefore,
Bodenman et al. helped couples realize that although the
partners motivation was to be helpful, behaviors that
overprotected the depressed person, reduced the depressed
persons social obligations, or took over the depressed
persons tasks allowed the depressed individual to continue
to withdraw and maintain the depression, similar to the
avoidance noted in agoraphobia above. Thus, altering both
partners appropriate roles within the context of a given
disorder can be an effective mechanism of therapeutic
Couple Therapy
Partner-assisted and disorder-specific interventions are
strategies that employ the partner as a significant part of the
social environment to encourage needed individual changes to address the persons psychopathology and do not
assume the presence of relationship distress. As noted
above, however, individuals experiencing a wide variety of
types of psychopathology are more likely to experience
relationship discord as well. Broad-based couple therapy or
marriage counseling approaches such as cognitive-behavioral couple therapy (CBCT; Epstein and Baucom 2002)
are intended to assist couples experiencing relationship
difficulties in a variety of domains. These same interventions can be of assistance to discordant couples, which in
addition to their relationship concerns, have one partner
with individual psychological or medical complications. In
these instances, couple therapy can be helpful in at least



two ways. First, it can be difficult or impossible to

implement the types of partner-assisted or disorder-specific
interventions described above if the two partners are
interacting in a hostile manner or are distant and disengaged. Thus, improving relationship adjustment and helping the couple function more effectively as a team can be
useful in order to implement partner-assisted and disorderspecific interventions.
Second, couple therapy such as CBCT may have a direct
effect on some of these disorders as well. Most psychological disorders are understandable within a diathesis
stress model such that among individuals who have a
vulnerability to a specific psychological disorder such as
anxiety disorders or depression, these disorders are likely to
be precipitated or exacerbated when such an individual
experiences a high level of stress. Relationship discord can
be viewed as a broad, chronic stressor on an individual.
Consequently, it is not surprising that many psychiatric
disorders seem to be precipitated following significant
interpersonal stressors (Snyder and Whisman 2003).
Therefore, improving relationship adjustment can alleviate
a chronic stressor on the individual with psychopathology.
This decrease in stress might account in part at least for
findings discussed below that couple therapy is effective in
alleviating both relationship discord and depression, even
when couple therapy does not specifically target depression.
A couple-based treatment for individual psychopathology
might include any or all three of the types of interventions
delineated abovepartner-assisted, disorder-specific, or
couple therapy. What is important is for the intervention to
be empirically grounded based on the kinds of changes that
are needed for an individual with a specific disorder, how
the relationship might be a stressor or resource for the
individual, and how to employ specific couple interventions
to assist in this process of change for the well-being of both
partners and the relationship.
Selecting Among Couple-Based Interventions
Couple-based interventions for addressing psychopathology are in their early stages of development, with the
primary focus involving attempts to establish whether these
interventions are efficacious and their relative merits
compared to individual psychotherapy for psychopathology. Therefore, to our knowledge, there are no empirical
investigations comparing the relative efficacy of these
types of couple-based interventions, or combinations of
these different interventions, for specific disorders.
Whereas treatment studies might indicate that one, or a
combination of approaches, is more efficacious overall for
a specific disorder, our clinical experience is that the
complexity of interplay between relationship functioning
and psychopathology might call for an approach that is


Clin Child Fam Psychol Rev (2012) 15:413

more focal to a specific couple and that several factors need

to be considered in thoughtful treatment planning.
First, the reason that an individual or couple is seeking
intervention might impact what treatments are delivered
and the order of those interventions. Thus, if someone
seeks individual treatment for OCD and the clinician elects
to include the partner in treatment, doing broad-based
couple therapy initially might seem inappropriate to the
couple and suggest that the partner or relationship is
causing the problem. Likewise, if a couple seeks couple
therapy for severe relationship discord and during the
course of assessment, the clinician notes that one partner
has OCD, focusing on the OCD initially might result in the
couple dropping out of treatment. Even if a couple is
relationally discordant, their type of discord can be
important in developing an appropriate treatment plan. For
example, if the partners have a great deal of anger toward
each other and often criticize and are hostile to each other,
it might be difficult to have them work together collaboratively on the OCD and employing the partner as a coach
or source of support around the OCD might be prohibitive
until their broader interaction patterns are addressed.
However, partners who are relationally discordant but
primarily disengaged from each other can perhaps jointly
focus their efforts in a common cause to help the person
with OCD and have an experience of successfully working
together as a team, which could also benefit the relationship. Whereas such individualized treatment planning
seems clinically appropriate, we must await sophisticated
treatment outcome investigations to determine whether
such strategies for determining specific couple-based
interventions and their sequencing are born out as effective.
Empirical Status of Couple-Based Interventions
for Psychopathology
As noted above, the empirical status of couple-based
interventions for some disorders is still in its early stages;
yet, clinical guidelines have been proposed for the use of
couple therapy for people presenting with a variety of
mental health problems (Snyder and Whisman 2003).
There is a growing literature supporting the efficacy of
couple therapy for a variety of psychiatric conditions (for
more detailed reviews of these studies, see Baucom et al.
1998; Snyder et al. 2006) that can inform our current
clinical practice to some degree.
Couple-based interventions have been most widely
studied with respect to substance use disorder. The most
thoroughly studied approach is behavioral couple therapy
(BCT), which combines CBCT interventions for improving
a couples relationships and behavioral interventions for
targeting a clients substance abuse. Thus, considered from
the conceptual framework provided in the preceding

Clin Child Fam Psychol Rev (2012) 15:413

section, this treatment is a hybrid of couple therapy and

partner-assisted interventions. In a meta-analysis of 12
randomized controlled trials for couples who were experiencing relationship distress and in which one partner had
a substance use disorder, Powers et al. (2008) reported that
BCT was more effective than individual therapy with
respect to frequency of substance use (d = .36), consequences of use (d = .52), and relationship discord
(d = .57). BCT for people with substance use disorders
also outperformed individual therapy in cost effectiveness,
reducing interpersonal violence, and improving child
adjustment (Fals-Stewart et al. 2005).
Couple-based interventions have also been used in
treating depression. For this disorder, however, a variety of
couple-based treatments have been developed, including
partner-assisted interventions, disorder-specific interventions, and couple therapy. Most of the clinical trials conducted to date have focused on couples who are
experiencing relationship discord and one partner is
depressed, although some trials focus on couples who do
not have discordant relationships. A recent meta-analysis
of eight controlled trials provided evidence for the effectiveness of couple-based interventions in the treatment for
depression (Barbato and DAvanzo 2008). Couple therapy
appears to be comparable with individually oriented
treatment in reducing depressive symptoms (d = -.12)
and more effective than individually oriented treatment in
improving relationship satisfaction (d = -.60). Although
meta-analytic studies are helpful in providing an overall
estimate of the effectiveness of couple-based interventions
for depression, it is important to restate that treatments
included in this meta-analysis differ in important ways,
including differences in interventions and underlying
models of change. As such, it would be important for future
research to study not only pre- to post-treatment changes in
depression and relationship discord, but also the purported
mechanisms of change for each treatment to better understand similarities and differences in these treatments.
Bodenmann et al. (2008) provide an excellent example of
an effort to explore these mechanisms of change. They
compared coping-oriented couple therapy (COCT) with
individual cognitive-behavior therapy (CBT) and interpersonal psychotherapy (IPT). Findings indicated that all three
interventions were equally efficacious in decreasing
depression; yet, only COCT significantly reduced criticism
from the partner in discussing the depressed person.
Depressed persons receiving both COCT and CBT experienced some relapse during follow-up, but that relapse
appeared to happen in different ways. That is, reductions in
criticism appeared to mediate the likelihood of depression
relapse among couples receiving COCT; however, changes
in criticism did not mediate the likelihood of relapse for
individuals receiving CBT. Thus, the couple-based


intervention might be effective, at least in part, because it

alters important relational variables such as criticism
toward the depressed person, whereas individual CBT
appears to have its effects through other mechanisms.

Given the centrality that intimate relationships have in the
lives of most people, it is understandable that relationship
functioning is likely to influence and be influenced by the
mental health of both partners in a relationship. In this paper,
we have provided a selective review of the literature on
intimate relationships and psychopathology. The research
conducted to date suggests that relationship discord is crosssectionally and longitudinally associated with psychopathology, that relationship discord is associated with poorer
outcome when individual-based treatments are provided,
and that relationship discord generally does not improve
following individual-based treatments. Existing research
also suggests that couple-based interventions are effective in
treating substance use disorders and major depression.
As basic research continues to evolve demonstrating the
conditions under which psychopathology co-occurs with
relationship discord and when it exists in the absence of
relationship discord, it will be important for treatment
researchers to take these findings into account to develop
and evaluate couple-based interventions that are targeted to
the couples situation. This requires clarifying the specific
types of couple-based interventions to be employed and the
rationale and goals for each intervention. Deciding to
intervene on individual psychopathology, either with or
without concomitant relationship discord, by employing
couple-based treatments without clear goals is unlikely to
result in improved outcomes for the individual or the
couple. On the other hand, the research conducted to date
suggests that couple-based interventions that are based on
clearly articulated goals (e.g., enlisting a partner to help a
depressed person become more active, improve overall
relationship adjustment) are effective in treating psychopathology and improving relationship discord.

Arnow, B. A., Taylor, C. B., Agras, W. S., & Telch, M. J. (1985).
Enhancing agoraphobia treatment by changing couple communication patterns. Behavior Therapy, 16, 452467.
Barbato, A., & DAvanzo, B. (2008). Efficacy of couple therapy as a
treatment for depression: A meta-analysis. Psychiatric Quarterly, 79, 121132.
Baucom, D. H., Abramowitz, J., Pukay-Martin, N., Kelly, J. T., &
Wheaton, M. G. (2008). A couple-based treatment for OCD.
Paper presented at the 42nd Annual Convention of the Association for Behavioral and Cognitive Therapies, Orlando, FL.


Baucom, D. H., Kirby, J. S., & Kelly, J. T. (2009). Couple-based
interventions to assist partners with psychological and medical
problems. In K. Hahlweg, M. Grawe, & D. H. Baucom (Eds.),
Enhancing couples: The shape of couple therapy to come
(pp. 7993). Gottingen: Hogrefe.
Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., & Stickle,
T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems.
Journal of Consulting and Clinical Psychology, 66, 5388.
Baucom, D. H., Stanton, S., & Epstein, N. (2003). Anxiety. In D.
K. Snyder & M. A. Whisman (Eds.), Treating difficult couples
(pp. 5787). New York: Guilford Press.
Beach, S. R. H., Katz, J., Kim, S., & Brody, G. H. (2003). Prospective
effects of marital satisfaction on depressive symptoms in
established marriages: A dyadic model. Journal of Social and
Personal Relationships, 20, 355371.
Beach, S. R., & OLeary, K. D. (1992). Treating depression in the
context of marital discord: Outcome and predictors of response
of marital therapy versus cognitive therapy. Behavior Therapy,
23, 507528.
Benazon, N. R., & Coyne, J. C. (2000). Living with a depressed
spouse. Journal of Family Psychology, 14, 7179.
Bodenmann, G., Plancherel, B., Beach, S. R. H., Widmer, K., Gabriel,
B., Meuwly, N., et al. (2008). Effects of coping-oriented couple
therapy on depression: A randomized clinical trial. Journal of
Consulting and Clinical Psychology, 76, 944954.
Cohen, S., OLeary, K. D., & Foran, H. (2010). A randomized clinical
trial of a brief, problem-focused couple therapy for depression.
Behavior Therapy, 41, 433446.
Cummings, E. M., & Davies, P. T. (2010). Marital conflict and
children: An emotional security perspective. New York: Guilford.
Davila, J., Bradbury, T. N., Cohan, C. L., & Tochluk, S. (1997).
Marital functioning and depressive symptoms: Evidence for a
stress generation model. Journal of Personality and Social
Psychology, 73, 849861.
Davila, J., Karney, B. R., Hall, T. W., & Bradbury, T. N. (2003).
Depressive symptoms and marital satisfaction: Within-subject
associations and the moderating effects of gender and neuroticism. Journal of Family Psychology, 17, 557570.
Denton, W. H., Carmody, T. J., Rush, A. J., Thase, M. E., Trivedi, M.
H., Arnow, B. A., et al. (2010). Dyadic discord at baseline is
associated with lack of remission in the acute treatment of
chronic depression. Psychological Medicine, 40, 415424.
Dewey, D., & Hunsley, J. (1990). The effects of marital adjustment
and spouse involvement on the behavioral treatment of agoraphobia: A meta-analytic review. Anxiety Research, 2, 6983.
Durham, R. C., Allan, T., & Hackett, C. A. (1997). On predicting
improvement and relapse in generalized anxiety disorder
following psychotherapy. British Journal of Clinical Psychology, 36, 101119.
Epstein, N., & Baucom, D. H. (2002). Enhanced cognitive-behavioral
therapy for couples: A contextual approach. Washington, DC:
American Psychological Association.
Fals-Stewart, W., Birchler, G. R., & OFarrell, T. J. (1996).
Behavioral couples therapy for male substance-abusing patients:
Effects on relationship adjustment and drug-using behavior.
Journal of Consulting and Clinical Psychology, 64, 959972.
Fals-Stewart, W., OFarrell, T. J., Birchler, G. R., Cordova, J., &
Kelley, M. L. (2005). Behavioral couples therapy for alcoholism
and drug abuse: Where weve been, where we are, and where
were going. Journal of Cognitive Psychotherapy, 19, 229246.
Fals-Stewart, W., OFarrell, T. J., & Hooley, J. M. (2001). Relapse
among married or cohabiting substance-abusing patients: The
role of perceived criticism. Behavior Therapy, 32, 787801.
Funk, J. L., & Rogge, R. D. (2007). Testing the ruler with item
response theory: Increasing precision of measurement for


Clin Child Fam Psychol Rev (2012) 15:413

relationship satisfaction with the Couples Satisfaction Index.
Journal of Family Psychology, 21, 572583.
Grych, J. H., & Fincham, F. D. (Eds.). (2001). Interparental conflict
and child development: Theory, research, and applications. New
York: Cambridge University Press.
Homish, G. G., & Leonard, K. E. (2007). The drinking partnership and
marital satisfaction: The longitudinal influence of discrepant
drinking. Journal of Consulting and Clinical Psychology, 75, 4351.
Homish, G. G., Leonard, K. E., & Cornelius, J. R. (2008). Illicit drug
use and marital satisfaction. Addictive Behaviors, 33, 279291.
Jacobson, N. S., Dobson, K., Fruzzetti, A. E., Schmaling, K. B., &
Salusky, S. (1991). Marital therapy as a treatment for depression.
Journal of Consulting and Clinical Psychology, 59, 547557.
Kenny, D. A., Kashy, D. A., & Cook, W. L. (2006). Dyadic data
analysis. New York: Guilford.
Kouros, C. D., Papp, L. M., & Cummings, E. M. (2008). Interrelations
and moderators of longitudinal links between marital satisfaction
and depressive symptoms among couples in established relationships. Journal of Family Psychology, 22, 667677.
Mudar, P., Leonard, K. E., & Soltysinski, K. (2001). Discrepant
substance use and marital functioning in newlywed couples.
Journal of Consulting and Clinical Psychology, 69, 130134.
Ostermann, J., Sloan, F. A., & Taylor, D. H. (2005). Heavy alcohol
use and marital dissolution in the USA. Social Science and
Medicine, 61, 23042316.
Overbeek, G., Vollebergh, W., de Graaf, R., Scholte, R., de Kemp, R.,
& Engels, R. (2006). Longitudinal associations of marital quality
and marital dissolution with the incidence of DSM-III-R
disorders. Journal of Family Psychology, 20, 284291.
Powers, M. B., Vedel, E., & Emmelkamp, P. M. (2008). Behavioral
couples therapy (BCT) for alcohol and drug use disorders: A
meta-analysis. Clinical Psychology Review, 28, 952962.
Quigley, B. M., & Leonard, K. E. (2000). Alcohol and the
continuation of early marital aggression. Alcoholism, Clinical
and Experimental Research, 24, 10031010.
Snyder, D. K., Castellani, A. M., & Whisman, M. A. (2006). Current
status and future directions in couple therapy. Annual Review of
Psychology, 57, 317344.
Snyder, D. K., & Whisman, M. A. (Eds.). (2003). Treating difficult
couples: Helping clients with coexisting mental and relationship
disorders. New York: Guilford.
Whisman, M. A. (1999). Marital dissatisfaction and psychiatric
disorders: Results from the National Comorbidity Survey.
Journal of Abnormal Psychology, 108, 701706.
Whisman, M. A. (2001a). The association between marital dissatisfaction and depression. In S. R. H. Beach (Ed.), Marital and
family processes in depression: A scientific foundation for
clinical practice (pp. 324). Washington, DC: American
Psychological Association.
Whisman, M. A. (2001b). Marital adjustment and outcome following
treatments for depression. Journal of Consulting and Clinical
Psychology, 69, 125129.
Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric
disorders in a population-based national survey. Journal of
Abnormal Psychology, 116, 638643.
Whisman, M. A., & Bruce, M. L. (1999). Marital distress and
incidence of major depressive episode in a community sample.
Journal of Abnormal Psychology, 108, 674678.
Whisman, M. A., Dementyeva, A., Baucom, D. H., & Bulik, C. M.
(2011). Marital functioning and binge eating disorder in married
women. International Journal of Eating Disorders. doi:
Whisman, M. A., & Uebelacker, L. A. (2009). Prospective associations between marital discord and depressive symptoms in
middle-aged and older adults. Psychology and Aging, 24,

Clin Child Fam Psychol Rev (2012) 15:413

Whisman, M. A., Uebelacker, L. A., & Bruce, M. L. (2006).
Longitudinal association between marital discord and
alcohol use disorders. Journal of Family Psychology, 20,
Whisman, M. A., Uebelacker, L. A., & Weinstock, L. M. (2004).
Psychopathology and marital satisfaction: The importance of
evaluating both partners. Journal of Consulting and Clinical
Psychology, 72, 830838.

Whitton, S. W., Stanley, S. M., Markman, H. J., & Baucom, B. R.
(2008). Womens weekly relationship functioning and depressive symptoms. Personal Relationships, 15, 533550.
Zinbarg, R. E., Lee, J. E., & Yoon, K. L. (2007). Dyadic predictors of
outcome in a cognitive-behavioral program for patients with
generalized anxiety disorder in committed relationships: A
spoonful of sugar and a dose of non-hostile criticism may
help. Behaviour Research and Therapy, 45, 699713.