Digital Interventions for Couples: State of the Field and Future Directions

Knopp, K., Schnitzer, J. S., Khalifian, C., Grubbs, K., Morland, L. A., & Depp, C. (2023). Digital interventions for couples: State of the field and future directions. Couple and Family Psychology: Research and Practice, 12(4), 201–217. https://doi.org/10.1037/cfp0000213

Key Points

• Digital couples interventions (DCIs) like online programs and mobile apps can improve access to effective relationship help by overcoming barriers like stigma, cost, and scheduling conflicts.
• Seven empirically-based English language DCIs were reviewed: OurRelationship, ePREP, Hold Me Tight Online, RELATE, Power of Two, Couple HOPES, and Couples Coach.
• These programs vary along dimensions, such as whether they target distressed versus nondistressed couples, if they utilize clinician/paraprofessional coaching, how they handle linked user accounts, and their approach to intimate partner violence.
• More research is needed on DCIs regarding their overall effectiveness, optimal design features like coaching models, and unresolved questions around safety and appropriateness for couples experiencing violence.
• Although research is limited currently, available evidence on outcomes is encouraging about the potential for DCIs to significantly improve public health by reaching more couples.

Rationale

Intimate relationship distress negatively impacts physical and mental health, but effective couple therapy is underutilized due to barriers like cost, stigma, and scheduling difficulties (Robles et al., 2014; Whisman, 2007).

Digital health interventions like online programs and mobile apps can improve access and convenience while providing standardized, evidence-based help (Bakker et al., 2016; Fortney et al., 2011).

This paper reviews the current state of digital couples interventions (DCIs) to inform future research priorities and clinical implementation.

Method

• Between 2019 and 2020, seven English language digital couples’ interventions (DCIs) that are empirically based, meaning they have been clinically studied and/or adapted from evidence-based in-person approaches, were identified.
• DCIs focused on improving relationships through online, computerized, or mobile platforms were included; telehealth therapy was excluded.
• Literature searches of research databases and consultation with field experts were conducted.

Sample

• The seven DCIs reviewed were: OurRelationship, ePREP, Hold Me Tight Online, RELATE, Power of Two, Couple HOPES, and Couples Coach.
• These programs have collectively enrolled nearly 5,000 individuals in clinical trials testing their efficacy.

• Statistical analyses were not conducted as part of this conceptual review.
• The paper summarizes published research on outcomes from the DCIs, including effect sizes where reported.

Statistical Analysis

• Statistical analyses were not conducted as part of this conceptual review.
• The paper summarizes published research on outcomes from the DCIs, including effect sizes where reported.

Results

OurRelationship

• OurRelationship adapts Integrative Behavioral Couple Therapy (IBCT) into a three-phase online program and has shown medium-sized improvements in relationship satisfaction, communication, and conflict, as well as individual outcomes like depression and anxiety symptoms.
• Found no differences in impacts based on demographics like race, ethnicity, or gender. It also worked for diverse couples, including sexual minorities, low-income, etc.
• Completion rates were higher with coaching (69-85%) versus without (6%).
• Gains were maintained for 12+ months in follow-up studies.

ePREP

• ePREP translates the Prevention and Relationship Enhancement Program (PREP) into 8 hours of online videos/content and has demonstrated reductions in negative interactions like intimate partner violence (IPV) as well as gains in positive relationship qualities and mental health.
• Demonstrated moderate to large improvements in relationship qualities like satisfaction, trust, communication.
• Reduced negative interactions, including psychological and physical aggression. Effects ranged from small to large.
• Showed small to large improvements in mental health symptoms like depression and anxiety.
• Completion rates 69-86% across studies. Consumer satisfaction is generally high.
• Worked well for student couples but less effective for older adults and foster parents.

RELATE

• Primary prevention based on Emotionally Focused Couple Therapy.
• Mixed evidence on whether it improves relationships and mental health versus educational controls.
• Stronger benefits when feedback is intensive and coached. RELATE alone is less effective than when combined with skill-based education.
• No effect sizes were reported.

Other programs had limited or no outcome data, prohibiting detailed results analysis.

Insight

• This conceptual review highlights not just the promise of DCIs for overcoming barriers that have historically limited access to couples help, but also key design decisions and research priorities for improving these interventions.
• By delineating dimensions like intended population, coaching models, managing linked accounts, and handling IPV, this analysis points to areas of ambiguity and the need for additional empiricism to guide best practices.

Strengths

• The review systematically assessed all available evidence-based English language DCIs not just in terms of published research but also along important dimensions of format and implementation.
• Analysis of coaching models and target populations helps establish a conceptual clarity currently lacking in the DCI field.
• Clinical and ethical considerations regarding intimate partner violence are thoughtfully examined.

Limitations

• The review did not employ a systematic search methodology, meaning some DCIs may have inadvertently been omitted.
• The analysis relies predominantly on published intervention research, which may not generalize to real-world implementations.
• The conceptual structure for evaluating DCIs along key dimensions is theoretically rather than empirically derived.

Implications

• Clarifying whether a DCI is intended as prevention versus treatment can help set appropriate expectations among users and guide research on moderators of effectiveness.
• Research is needed to determine the optimal level and type of coaching for balancing feasibility and outcomes.
• Safety considerations around IPV may be inadequately addressed in current publicly available DCIs compared to studied protocols.

Conclusions

• DCI is a promising area of clinical innovation that can help overcome access barriers to couples interventions, thereby improving public health.
• Developers must continue working to maximize reach and effectiveness of DCIs while ensuring ethical application regarding intimate partner violence.
• Additional research is sorely needed, both to establish overall efficacy across programs and to address unresolved questions that can inform optimal design and responsible implementation.

References

Primary paper

Knopp, K., Schnitzer, J. S., Khalifian, C., Grubbs, K., Morland, L. A., & Depp, C. (2023). Digital interventions for couples: State of the field and future directions. Couple and Family Psychology: Research and Practice, 12(4), 201–217. https://doi.org/10.1037/cfp0000213

Other references

Bakker, D., Kazantzis, N., Rickwood, D., & Rickard, N. (2016). Mental health smartphone apps: Review and evidence-based recommendations for future developments. JMIR mental health, 3(1), e7.

Fortney, J. C., Burgess, J. F., Bosworth, H. B., Booth, B. M., & Kaboli, P. J. (2011). A reconceptualization of access for 21st century healthcare. Journal of General Internal Medicine, 26(2), 639-647.

Robles, T. F., Slatcher, R. B., Trombello, J. M., & McGinn, M. M. (2014). Marital quality and health: A meta-analytic review. Psychological Bulletin, 140(1), 140–187. https://doi.org/10.1037/a0031859

Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116(3), 638–643. https://doi.org/10.1037/0021-843X.116.3.638

Keep Learning

1. What barriers keep couples from accessing traditional in-person therapy or counseling? How might digital platforms help mitigate some of these barriers?
2. What are some key decisions developers of online or app-based couples interventions must make regarding intended audiences, use of coaching, managing privacy concerns, etc.? What principles or evidence might guide these decisions?
3. Why is clarifying whether a program targets prevention versus treatment important? What might be the relative pros and cons of more universal prevention-focused approaches versus indicated interventions for already distressed couples?
4. What safety considerations exist when developing digital tools for couple, and how might research in this area lead to ethical ways to potentially expand access appropriately?
5. How could digital modalities like couples apps change traditional conceptions of what constitutes mental health treatment? What cautions remain around responsible and effective use of self-guided tools?