The Norway Couple Project: Lessons Learned

THE NORWAY COUPLE PROJECT: LESSONS LEARNED
Jacqueline A. Sparks
University of Rhode Island
Couple therapists in routine practice may find it difficult to apply findings from an increas-
ingly expanding and complex body of couple therapy research. Meanwhile, concerns have
been raised that competency in evidence-based treatments is insufficient to inform many
practice decisions or ensure positive treatment outcomes (American Psychological Associa-
tion Presidential Task Force on Evidence-Based Practice, American Psychologist, 2006,
271). This article aims to narrow the research/practice gap in couple therapy. Results from
a large, randomized naturalistic couple trial (Anker, Duncan, & Sparks, Journal of Con-
sulting and Clinical Psychology, 2009, 693) and four companion studies are translated into
specific guidelines for routine, eclectic practice. Client feedback, the therapeutic alliance,
couple goals assessment, and therapist experience in couple therapy provide a research-
informed template for improving couple therapy outcomes.
There is little debate that working with couples presents special challenges, even for seasoned
clinicians. High levels of negativity and the need to balance therapeutic relationships in the midst
of conflict are just some of the hurdles couple therapists routinely encounter (Symonds & Horvath,
2004). Moreover, in a global society moving rapidly toward marriage equality, couple diversity is
no longer an exception but an expectation; therapists must be comfortable implementing a range
of strategies that resonate with each couple’s unique culture and preferences (American Psycholog-
ical Association, 2003). In short, couple work is not for the faint of heart.
Even with its difficulties, couple therapy is worth the effort. Meta-analytic research and
reviews indicate that couples who undertake therapy have a greater chance of improving their rela-
tionships than those who do not (Christensen et al., 2004; Gollan & Jacobson, 2002; Lebow,
Chambers, Christensen, & Johnson, 2012; Shadish & Baldwin, 2005). The effect size for couple
therapy is large to moderate, ranging from .86 (Christensen et al., 2004) to .59 (Shadish & Bald-
win, 2005), meaning that approximately 40–50% of treated couples achieve clinically significant
change. Despite this, many couples do not benefit from therapy. By some counts, as many as 25–
30% of couples fail to improve with treatment (Snyder & Halford, 2012), and up to 45% initially
realizing gains deteriorate at 2-year follow-up (Christensen et al., 2004; Snyder, Wills, & Grady-
Fletcher, 1991).
To improve the chance that couples will get better and remain so over time, new couple ther-
apy models have appeared with regularity since the late 80s. Notwithstanding these innovations,
meta-analyses and reviews, when allegiance effects are controlled, have failed to find differential
efficacy among approaches (Christensen et al., 2004; Snyder, Castellani, & Whisman, 2006; Sparks
& Duncan, 2010). As far as how they work, findings are equivocal. Snyder and Halford (2012)
report that many models that include specific ingredients designed to alter hypothesized mediators
of change fare no better than models that do not incorporate these components. For example, inte-
grative behavioral couple therapy, which includes cognitive change strategies, and behavioral cou-
ple therapy, which does not, produce roughly equivalent alterations in negative cognitions.
Further, changes in hypothesized mediators (e.g., communication or cognitions) are unclearly
Jacqueline A. Sparks, Ph.D., Department of Human Development and Family Studies, University of
Rhode Island.
The author would like to acknowledge and thank Barry L. Duncan, Psy.D. for his invaluable input and Morten
Anker, Ph.D. for his helpful critique of this manuscript.
Address correspondence to Jacqueline A. Sparks, Ph.D., Department of Human Development and Family
Studies, 2 Lower College Rd., Kingston, RI 02881; E-mail: jsparks@uri.edu
JOURNAL OF MARITAL AND FAMILY THERAPY 1
Journal of Marital and Family Therapy
doi: 10.1111/jmft.12099

linked to changes in couple distress (Snyder & Halford, 2012). To date, the specific mechanisms of
change in couple therapy remain elusive.
While couple therapy research has reached what Gurman (2011) has called a “critical mass of
clinically compelling theory. . . and an increasingly visible and nuanced research base” (p. 281), cli-
nicians may lack concrete guidance in making routine practice decisions. Couple and family ther-
apy’s historic disinterest in empirical evidence (Dattilio, Piercy, & Davis, 2014) likely reinforces
this deficit. As a result, couple therapists may feel adrift in stormy waters. The purpose of this arti-
cle is to provide guidelines to those who do the difficult work of helping couples improve their rela-
tionships. Specifically, the article translates lessons learned from five recent studies based on data
collected in the largest clinical couple trial to date, Anker, Duncan, and Sparks (2009), which com-
pared systematic collection and integration of client feedback to treatment as usual. First, the con-
text of feedback measurement trials is discussed. Next, the article distills findings from Anker et al.
and four companion studies, situating these within the broader couple therapy outcome literature.
Finally, recommendations for concrete strategies informed by this body of research and relevant
across couple therapy treatments are proposed.
USING CLIENT FEEDBACK TO IMPROVE OUTCOMES
In 2009, “Using Client Feedback to Improve Couple Therapy Outcomes: A Randomized Clin-
ical Trial in a Naturalistic Setting” was published in the Journal of Consulting and Clinical Psychol-
ogy (Anker et al., 2009). The Norway Couple Study (NCS) spawned a series of studies using its
data and data collected at an additional site (see, Anker, Owen, Duncan, & Sparks, 2010; Anker,
Sparks, Duncan, Owen, & Stapnes, 2011; Owen, Duncan, Anker, & Sparks, 2012; Owen, Duncan,
Reese, Anker, & Sparks, 2014). In the NCS, feedback refers to routine and continuous monitoring
of client perceptions of progress and the therapeutic alliance throughout the course of therapy uti-
lizing the Partners for Change Outcome Management System (PCOMS; Duncan, 2012, 2014;
Duncan & Sparks, 2010). PCOMS is based on a paradigm known as patient-focused research
(Howard, Moras, Brill, Martinovich, & Lutz, 1996), which involves ongoing, real-time comparison
of client views of progress with an expected treatment response statistically derived from the cli-
ent’s initial intake score on a valid measure of global distress. The expected treatment response tra-
jectory serves as a yardstick for gauging client progress and signaling when change is not occurring
as predicted. With this alert, clinicians and their clients have an opportunity to discuss such topics
as the need to shift focus, re-visit goals, or alter treatment interventions before deterioration or
possible dropout.
Michael Lambert and colleagues pioneered the development of a feedback measurement sys-
tem and research on the effects of routinely incorporating feedback in individual psychotherapy.
In a meta-analysis of six randomized trials testing Lambert’s Outcome Questionnaire 45.2 (OQ)
System (Lambert et al., 1996), clients at-risk (not progressing as expected) in feedback groups
fared significantly better than at-risk clients in treatment as usual (TAU; no feedback) groups
(Lambert & Shimokawa, 2011). Specifically, those in the feedback group were less than half as
likely to experience deterioration and 2.6 times more likely to reach reliable change than those in
TAU.
Although consistent with a patient-focused paradigm, PCOMS differs from Lambert and
colleague’s system in several ways. First, PCOMS instruments are brief, requiring in most circum-
stances only 5 min to administer, score, and discuss. The Outcome Rating Scale (ORS) (Miller,
Duncan, Brown, Sparks, & Claud, 2003; Figure 1) provides client-reported ratings of progress.
Rather than a symptom checklist, the ORS is a visual analog scale consisting of four 10 cm lines,
three corresponding to the three domains of the OQ (individual, interpersonal, and social) and
one, overall. Clients place a mark on each line to represent their perception of their functioning in
each domain. Therapists use a 10-cm ruler (or calculations are performed automatically in comput-
erized versions) to sum the client’s total score, with a maximum score of 40. Lower scores reflect
more distress. The cutoff, or score that delineates clinical versus nonclinical clients, for adults is 25.
The Session Rating Scale (SRS) (Duncan et al., 2003) (Figure 2), also a visual analog scale,
serves to measure clients’ views of the therapeutic alliance. The SRS contains 4 lines, 3 of which
correspond to Bordin’s (1979) classic delineation of components of the alliance—the relational
2 JOURNAL OF MARITAL AND FAMILY THERAPY

bond, agreement on goals, and agreement on tasks. The fourth line, “Overall”, taps into confident
collaboration, another aspect of the alliance considered predictive of outcome (Hatcher & Bar-
ends, 1996). The SRS is given toward the end of a therapy session. Use of the SRS encourages all
client feedback, positive and negative, thus creating a safe space for clients to voice their honest
opinions about their connection to their therapist and to therapy. In this way, it allows the expres-
sion of negative feelings, identified by Hatcher and Barends (1996) as an additional key alliance
factor. Similar to the ORS, each line on the SRS is 10 cm and can be scored manually or electroni-
cally. Given that clients tend to score high on alliance measures, a total score below 36 signals the
possibility of a problematic alliance and prompts a frank discussion about steps needed to increase
client connection to the therapist and the process.
The ORS and SRS represent attempts to balance the reliability and validity of longer measures
with the feasibility required for routine practice (Duncan, 2012; Duncan & Reese, 2013). The ORS
has been found to have a moderately strong correlation with the OQ (ranging from .53 to .74; Gil-
laspy & Murphy, 2011), supporting concurrent validity. Additionally, the ORS has been shown to
be sensitive to change and to correctly distinguish clinical and nonclinical populations (Duncan,
2011), evidence of construct validity. In their review, Gillaspy and Murphy also reported average
Cronbach’s alpha coefficients for ORS scores were .85 (clinical samples) and .95 (nonclinical sam-
ples), demonstrating the instrument’s reliability. Concurrent validity for the SRS averaged .48
(Pearson product moment coefficient) in comparison with the Revised Helping Alliance Question-
naire (HAQ-II) and .58 in comparison with the Working Alliance Inventory (WAI), both widely
used measures of therapeutic alliance. These correlations suggest that the SRS references similar
domains (Duncan et al., 2003). In several studies, early scores on the SRS (2nd and 3rd sessions)
Outcome Rating Scale (ORS)
Name ________________________Age (Yrs):____ Sex: M / F
Session # ____ Date: ________________________
Who is filling out this form? Please check one: Self_______ Other_______
If other, what is your relationship to this person? ____________________________
Looking back over the last week, including today, help us understand how you have been
feeling by rating how well you have been doing in the following areas of your life, where
marks to the left represent low levels and marks to the right indicate high levels.
Individually
(Personal well-being)
I----------------------------------------------------------------------I
Interpersonally
(Family, close relationships)
I----------------------------------------------------------------------I
Socially
(Work, school, friendships)
I----------------------------------------------------------------------I
Overall
(General sense of well-being)
I----------------------------------------------------------------------I
The Heart and Soul of Change Project
______________________________________
https://heartandsoulofchange.com
© 2000, Scott D. Miller and Barry L. Duncan
Figure 1. For examination only. Download a free working copy at https://heartandsoulofchange.
com.

have been found to predict outcome, consistent with alliance findings across the literature and sup-
porting the measure’s construct validity (Duncan, 2011). Test–retest reliability for the SRS also
has compared favorably with the HAQ-II and WAI, and internal consistency estimates for the
SRS over four studies yielded an average alpha of .92 (Gillaspy & Murphy, 2011). These findings
provide support that both the ORS and SRS reliably report what they intend and can be used as
substitutes for longer instruments without sacrificing trustworthiness.
Besides the brevity of its measures, PCOMS also differs from Lambert and colleague’s system
in that both client perceptions of progress and the therapeutic alliance are obtained at each session.
Given the well-established link between the alliance and outcome, PCOMS attempts to ensure that
therapists assess and minimally address any potential alliance ruptures before clients leave the ther-
apy room or site of service. Lambert and colleagues, in contrast, utilized alliance measures only for
those cases deemed at-risk.
Finally, whereas Lambert and colleagues’ research periodically involved clients in reviewing
scores, client involvement in PCOMS is routine and expected; client scores on the ORS and SRS
are openly shared and discussed with clients at each administration. Client views of their progress
serve as a basis for beginning therapeutic conversations, and their assessments of the alliance mark
an endpoint to the same. With this transparency, the measures provide a mutually understood
Session Rating Scale (SRS V.3.0)
Name ________________________Age (Yrs):____
ID# _________________________ Sex: M / F
Session # ____ Date: ________________________
Please rate today’s session by placing a mark on the line nearest to the description that best
fits your experience.
Relationship
I-------------------------------------------------------------------------
Goals and Topics
I------------------------------------------------------------------------
Approach or Method
I-------------------------------------------------------------------------
Overall
I felt heard,
understood, and
respected.
I did not feel heard,
understood, and
respected.
We worked on and
talked about what I
wanted to work on and
talk about.
We did not work on or
talk about what I
wanted to work on and
talk about.
There was something
missing in the session
today.
The therapistís
approach is a good fit
for me.
The therapistís
approach is not a good
fit for me.
I------------------------------------------------------------------------
The Heart and Soul of Change Project
_______________________________________
https://heartandsoulofchange.com
© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson
Overall, todayís
session was right for
me.
Figure 2. For examination only. Download a free working copy at https://heartandsoulof-
change.com.

reference point for reasons for seeking service, progress, and engagement. Thus, clients and thera-
pists are likely to view the measures as integral to the therapy process.
Prior to the NCS, evidence existed that use of PCOMS improves outcome in individual psy-
chotherapy. In a randomized controlled trial using PCOMS in a university counseling center and
graduate training clinic, Reese, Norsworthy, and Rowlands (2009) found that clients in the
PCOMS condition experienced significantly more change than those in TAU (80% vs. 54% in one
setting; 67% vs. 41%, the other). Gains for feedback groups extended to all clients, not just those
identified as at-risk, and were realized significantly more quickly than in TAU groups. While these
findings added to the literature of use of client feedback with individuals, no studies before the
NCS had examined whether such a system would similarly benefit couples.
THE NORWAY COUPLE STUDY
The primary rationale for Norway Couple Study (NCS) (Anker et al., 2009) was to
explore how outcomes for couples and therapists receiving routine feedback via the Partners
for Change Outcome Management System (PCOMS) differed from outcomes for couples not
receiving feedback. The study also sought to determine whether a systematic feedback system
was transferrable into a routine clinical environment. How would outcomes for couples treated
by busy clinicians practicing diverse approaches be impacted by the systematic incorporation
of client feedback? The design for the NCS mimicked key elements of previous feedback trials
conducted by Lambert and colleagues. These included the following: (a) random assignment
to treatment groups; (b) therapists serving as their own controls (i.e., alternately in feedback
and TAU groups); and (c) therapists choosing the clinical approach they thought most appro-
priate, typical of routine practice. As therapists participated equally in both treatment groups,
variability in therapist effectiveness (Beutler et al., 2004; Duncan, Miller, Wampold, & Hubble,
2010; Kraus, Castonguay, Boswell, Nordberg, & Hayes, 2011) was controlled. Similarly, given
that clinicians were free to practice as they ordinarily would, findings would not be impacted
by therapists using an approach not within their skill set or that they believed would not be
effective.
The NCS enrolled 205 Euro-Scandinavian, heterosexual couples ranging in age from 20 to 71
seeking couple counseling in an outpatient office in Norway. Couples were randomly assigned to
one of two groups—feedback (PCOMS) or TAU. Of the 235 couples allocated to intervention, 30
(13%) either did not attend at least two sessions or complete pre-post outcome measures, lower
than drop-out estimates for behavioral health practice settings. For example, Reese, Duncan, Bo-
hanske, Owen, and Minami (2014) report losing 26% of their data due to attrition between ses-
sions one and two. In the NCS, rates of attrition were similar between the two groups (12 in
PCOMS; 18, TAU).
Couples were seen by 10 therapists (7 female and 3 male) trained in standard professional dis-
ciplines and practicing eclectically (e.g., solution-focused, narrative, cognitive behavioral, human-
istic, systemic), typical of a routine outpatient setting. The results indicated that couples in the
PCOMS feedback group had nearly 4 times the rate of clinically significant change than the TAU
group. When data were collected from the couples 6 months after they completed treatment, those
in the feedback group were still doing significantly better (2 times better) than those in TAU. In
terms of “real-world” outcomes, feedback couples were 46% less likely to be separated or divorced
at 6 months posttreatment than nonfeedback couples. In sum, this study made a strong case for
the systematic use of client feedback with couples.
Finally, the question of whether such a system was transferrable as a quality improvement
strategy into a typical outpatient agency setting was answered affirmatively. Only 17 hr of PCOMS
training were required compared with, for example, certification in emotionally focused couple
therapy (EFCT) which requires a minimum of 42 hr of training and 32 hr of supervision with a
certified EFCT supervisor (http://www.eft.ca/training2.htm). Therapists were free to choose
approaches in which they were already trained, further circumventing the need for additional
agency funding. Although training requirements were minimal, implementation of PCOMS did
require sustained effort to systematically collect data and identify at-risk clients.

THERAPIST EFFECTS
There is some dispute regarding the magnitude of therapist effects (Crits-Christoph & Gallop,
2006; Wampold & Bolt, 2006). However, most investigations have found that therapist variability
is the rule rather than the exception (Baldwin & Imel, 2013; Beutler et al., 2004; Duncan et al.,
2010; Kraus et al., 2011). The proportion of outcome variance attributable to the therapist in indi-
vidual psychotherapy trials has been found to range from 5% to 10%, (Kim, Wampold, & Bolt,
2006) considerable in comparison to the 1–2% for model effects, as suggested by meta-
analyses (Wampold, 2001). Researchers continue to explore which variables likely account for
these substantial differences among therapists (Beutler et al., 2004; Crits-Christoph, Connolly
Gibbons, & Mukherjee, 2013). In general, research strongly suggests that clients seen by therapists
with higher average alliance ratings have better outcomes. For example, Baldwin, Wampold, and
Imel (2007) reported that therapist average alliance quality accounted for 97% of therapist vari-
ability. Reviews, however, of individual psychotherapy have shown none or only modest effects
for therapist gender, type of training, and theoretical orientation (Baldwin & Imel, 2013; Beutler
et al., 2004). Regarding the effects of therapist experience, findings have generally found little
impact related to this variable (Beutler et al., 2004), although some studies have reported better
outcomes for therapists with domain-specific experience, or experience treating certain conditions
(Kraus et al., 2011).
While therapist effects in individual psychotherapy have garnered considerable attention, ther-
apist factors in couple therapy have been less studied (Blow, Sprenkle, & Davis, 2007; Sparks &
Duncan, 2010). In light of these gaps, Owen et al. (2014) re-analyzed NCS data to examine thera-
pist variability in a naturalistic setting with couples, specifically looking at therapist gender, disci-
pline, experience, and ability to establish a working alliance. As reported in Anker et al. (2010),
therapist effects in the NCS were significant. Therapists accounted for 8% of the variance in out-
come, similar to that found in individual studies. Moreover, therapists’ average alliance quality
accounted for 50% of the variance in outcome among therapists. This means simply that therapists
who formed better alliances across more clients had better overall outcomes. Based on these find-
ings, therapists clearly play a significant role in both the process and outcome of couple therapy.
While therapist ability to form alliances proved pivotal in Owen et al. (2014), therapist gender
and specific professional discipline did not. However, therapist experience was predictive. Specifi-
cally, therapists who had more experience working with couples did significantly better, accounting
for 25% of the outcome variance attributable to therapists. The researchers concluded that, based
on their analysis, there are at least two clear pathways for therapists to become better at couple
therapy—alliance building and time “in the trenches” with couples. However, therapist experience
and average alliance quality were nonsignificantly associated. Therefore, the findings do not sug-
gest that more experienced therapists form better alliances. Instead, the researchers proposed that
the effect of experience in couple therapy and the alliance are independent of each other.
THE ALLIANCE
Given the remarkably consistent association between the alliance and outcome across treat-
ment modalities and clinical presentations (Castonguay & Beutler, 2005; Horvath, Del Re, Fl€ucki-
ger, & Symonds, 2011), NCS researchers were particularly interested in examining the study’s
alliance data (see, Anker et al., 2010). Meta-analyses of individual trials have found that the alli-
ance accounts for 5–7% of the overall variance (Crits-Christoph et al., 2013; Horvath & Bedi,
2002), with a more recent study finding a slightly higher 7.5% (Horvath et al., 2011). The associa-
tion between alliance and outcome also holds true for couple therapy. The alliance has been found
to be associated with greater retention in marital therapy (Knobloch-Fedders, Pinsof, & Mann,
2004; Raytek, McCrady, Epstein, & Hirsch, 1999) and improvement in marital distress (Bourgeois,
Sabourin, & Wright, 1990; Brown & O’Leary, 2000; Knobloch-Fedders, Pinsof, & Mann, 2007).
In one couple study, the alliance explained as much as 22% of the outcome variance at posttreat-
ment and 29% at follow-up (Johnson & Talitman, 1997).

While researchers remain united in the importance of the alliance in couple work, examining
how it impacts this modality is challenging. Couple therapy involves multiple relationships and
typically mixed genders (in heterosexual couple counseling), and disparities in partner’s alliance
scores, or split alliances, are common (Knobloch-Fedders et al., 2007; Pinsof, Zinbarg, & Knob-
loch-Fedders, 2008; Symonds & Horvath, 2004). Moreover, the alliance includes a partner’s per-
ceptions not only of his or her alliance with the therapist but also his or her partner’s and the
couple’s alliance with the therapist and therapy process (Pinsof & Catherall, 1986; Symonds &
Horvath, 2004). Finally, patterns of increasing or decreasing alliances and junctures during treat-
ment critical for alliance formation remain of particular interest (e.g., Symonds & Horvath, 2004).
With these variables in mind, NCS researchers had several objectives. First, they wanted to
learn if an individual’s first and last session alliance scores predicted outcome, not only for that
individual but also for his or her partner. Second, the researchers explored whether the alliance,
when measured at traditional data points (sessions 2 and 3), predicted outcome above and beyond
early change. This focus was spurred by the debate regarding the actual nature of the association
between the alliance and outcome (Barber, 2009; Kivlighan & Shaughnessy, 2000; Stiles et al.,
2004). Specifically, is the alliance/outcome link simply a by-product of therapy going well, thus
strengthening client alignment with the therapist? Or, do strong alliances lead to positive therapeu-
tic progress and consequently better outcomes? The researchers hypothesized the latter. Finally,
researchers were interested in whether different patterns of alliance development would differenti-
ate couple outcomes.
When the alliance data for the full sample were examined, NCS researchers found that first
session alliance scores did not significantly predict outcome whereas last session scores did. Intui-
tively, this is not surprising given the temporal link between the end of therapy and clients’ ratings
of their connection to their therapist. The last session alliance/outcome link held up for an individ-
ual as well as that individual’s partner’s alliance with the therapist. This association was stronger
for men than for women, a difference that remained at 6-month follow-up.
A second and more important finding involved the question of whether the alliance predicted
outcome over and above early change. To answer this, researchers controlled for early change in
third and last session calculations, using a stringent criterion of reliable change (a change of 6 or
more points) on the Outcome Rating Scale (ORS). Third and last session alliances did indeed pre-
dict outcome, and this link was not the result of early symptom relief. In other words, this study
demonstrated that the alliance was not merely a by-product of change but played an important
role in producing change. Since the publication of the NCS, the significant impact of the alliance
on outcome separate from clients’ experience of improvement has been further supported (e.g.,
Crits-Christoph et al., 2013).
Finally, researchers assessed patterns of increasing or deteriorating alliances. They found
three clusters of alliance trajectories and corresponding relationships with outcome. First, when
scores at session one were above average and then trended upward for the remainder of therapy,
couples had the best outcomes. Couples who had moderate alliance scores at the first session which
then continued to increase over the course of therapy fared the next best. Finally, those couples
who had lower than moderate first session alliance scores that progressed unevenly did the poorest,
even if ending higher than session one. That initial above average scores that increased had the
most favorable outcomes perhaps was not surprising. However, the finding that rising moderate
scores also resulted in positive outcomes was somewhat unexpected and provides encouragement
for couple cases beginning with slightly lower alliance scores.
The NCS researchers administered a short post-therapy questionnaire at 6-month follow-up
to supplement the quantitative data collected in the feedback trial (see, Anker et al., 2011). The
survey included two broad, open-ended questions not intended to elicit client views of the alliance
but simply to inquire about clients’ experiences in couple treatment. However, after 742 written cli-
ent responses from 382 individuals were analyzed, two overarching domains emerged, relationship
and tasks. These domains mirror Bordin’s (1979) principle aspects of the working alliance and cor-
respond with similar groupings in couple therapy literature dealing with the therapeutic alliance
(Bischoff & McBride, 1996; Green & Herget, 1991; Sells, Smith, & Moon, 1996). Not surprisingly,
more favorable responses fell into the relationship category. For example, statements regarding
therapist warmth, friendliness, and ability to listen were well represented, as they are in the

literature (Bischoff & McBride, 1996; Bowman & Fine, 2000; Green & Herget, 1991). At the same
time, respondents expressed that they valued therapist neutrality, wanting their therapist to con-
sider equally both partners’ points of view even when these differed.
In the tasks domain, comments were more negative. Many respondents complained that
they wished their therapist had structured interviews more to provide a safe place for highly
charged discussions. Notably, tasks mattered a great deal to the couples who responded to the
post-therapy survey—they wanted therapists who were not only easy to talk to but who could
direct the therapy conversation, provide tools for problem resolution, and even give advice when
needed. These findings fall in line with previous studies highlighting the importance clients place
on more active aspects of couple therapy (Bowman & Fine, 2000; Helmeke & Sprenkle, 2000;
Sells et al., 1996).
A somewhat surprising finding in this study had to do with clients wishing their therapist had
been more proactive in arranging appointments and being flexible in scheduling. According to Bor-
din (1979), these types of tasks do not lie outside the realm of the therapeutic alliance but include
“. . . collaboration between patient and therapist [that] involves an agreed-upon contract, which
takes into account some very concrete exchanges” (p. 254). Interestingly, clients in the feedback
group had fewer negative comments in this area than those in the nonfeedback group, suggesting
that routine use of client feedback may allow greater opportunity to elicit and respond to a range
of clients’ requests. Alternatively, clients whose views are regularly sought may feel more attended
to by their therapists.
COUPLE GOALS
That clients come into couple therapy for different reasons with different implications for out-
come is likely not news to seasoned couple therapists. In particular, challenging and not uncom-
mon are situations where one partner wants to improve the relationship and the other seeks to
clarify whether the relationship is viable. In confirmation, the fourth study utilizing the Norway
Couple Study (NCS) data reinforced the importance of each partner’s goal for treatment, includ-
ing congruence between them. Owen et al. (2012) examined the relationship between client initial
goals and outcomes and relationship status (separated or together) at 6-month follow-up. As might
be expected, when both members of the couple wanted to improve the relationship, the majority of
them did. Of couples who both reported an initial goal to strengthen the relationship, only 7.8%
separated or divorced 6 months post-therapy. In contrast, when both in couple sought clarification
of the relationship, 56% had separated by follow-up. For those couples where one member wanted
to improve the relationship and the other desired clarification, 45.6% separated 6 months post-
therapy. Importantly, however, all couples on average, regardless of their goal category, benefitted
from therapy. For example, many couples ambivalent about staying together, including those that
eventually separated, reported improvements in their overall sense of well-being. Thus, therapists
can be encouraged that couple work is generally beneficial for participants, regardless of the rela-
tionship status at termination or follow-up.
Given the importance of consistency between the client and therapist goals (Bordin, 1979), this
study has implications for the therapeutic alliance. Pinsof (1995) described the systemic therapeutic
process in couple therapy as involving not only partners’ mutual goals but the agreement regarding
goals between each partner and the therapist. Therapists need to be responsive to both partners
(Lebow, 2004; Stiles, Honos-Webb, & Surko, 1998). Not actively seeking to determine client goals
early in therapy could lead to a mismatch between the therapist’s assumptions and the real reasons
clients have sought help, resulting in compromised alliances and early dropout, even if the thera-
pist only erred with one partner. Moreover, assuming a priori that couples seek counseling to stay
together can short-circuit the opportunity to engage in a transparent goal negotiation and assist
couples toward their preferred outcome, however, they define it.
LESSONS LEARNED
As a body of work, the Norway Couple Project offers clinician’s specific points of reference to
guide them in negotiating treatment decisions with couples:

1. Use valid, feasible instruments to routinely monitor client progress and the therapeutic alli-
ance to increase the chance of a positive outcome. Findings from Anker et al. (2009) sup-
port a growing body of evidence that outcomes are enhanced when therapists
systematically monitor treatment response. Anker et al. results are consistent with find-
ings supporting the efficacy of the Partners for Change Outcome Management System
(PCOMS; Reese et al., 2009; Reese, Toland, Slone, & Norsworthy, 2010; Schuman,
Slone, Reese, & Duncan, 2014), including a recent meta-analysis (Lambert & Shimokawa,
2011) that reported PCOMS clients 3.5 more likely to experience reliable change and half
as likely to deteriorate as TAU. Regarding couple therapy, Reese et al. (2010) replicated
the NCT with nearly equivalent results. There now appears to be a consensus among
many that, in the words of Michael Lambert, “Yes, it is time for clinicians to routinely
monitor treatment outcomes” (Lambert, 2010, p. 239).
2. Monitor the therapeutic alliance at each session. Anker et al. (2010) joined the extensive
ranks of couple and individual studies confirming the link between the alliance and out-
come. According to their findings, therapists stand to increase their chances of success in
couple therapy by tracking alliance scores from the first session onward, with the goal of
increasing lower scores, particularly by session three. Owen et al.’s (2014) reporting that
therapist average alliance quality accounted for 50% of the variance among therapists
regarding outcome underscores the crucial role of this factor in couple work. Couple alle-
giance, or the loyalty members of a couple have for each other despite disagreements,
may be an important consideration for therapists seeking to strike the right balance when
forming therapeutic alliances in this modality (Symonds & Horvath, 2004). Knowing
how well each partner is engaged in the process and connected to the therapist at each
meeting can help therapists negotiate this delicate equilibrium. Given the lack of associa-
tion between first session alliance scores and outcome at posttreatment (Anker et al.,
2010), therapists who may not have established a strong starting alliance could still have a
positive outcome; what happens beyond the first session is key.
3. Determine each partner’s goal for seeking therapy early in the treatment process. Owen
et al. (2012) found a direct relationship between couple goals at the beginning of therapy
and outcome. Whether both partners sought therapy to strengthen the relationship or to
clarify it or whether each had different goals for seeking help made a significant difference,
on average, in whether the couple would be together 6 months beyond therapy. The
choice and timing of therapist intervention, whether for improvement, resolving ambiva-
lence, or facilitating separation (see, Tremblay, Wright, Mamodhouseen, McDuff, & Sab-
ourin, 2008), ought to align with the goals of each member of a couple and the couple as a
unit. This can only happen through a transparent discussion early in treatment about cli-
ents’ reasons and hopes for service. A standard brief goal assessment can facilitate this
process. Early goal identification can assist therapists to work toward client-defined better
futures, whether that means couples remaining together or moving apart
4. Use valid outcome instruments, not only relationship status, to determine treatment success
or failure. According to Owen et al. (2012), all clients, on average, benefitted from treat-
ment, regardless of relationship status at termination or follow-up. As the researchers
noted, individual rather than couple outcomes may be better markers of success in couple
therapy. That is, couples may dissolve, but one or both partners may view this positively.
Individual measures of progress can facilitate a correct determination of actual outcome,
even in instances of separation or divorce.
5. Gain experience working with couples. Owen et al. (2014) found that therapist experience
working with couples may provide a benefit to overall outcomes in this modality. Begin-
ning therapists can seek supervision from experienced couple therapists to develop the
skill set required to manage a couple session, likely including how to moderate conflict
and direct in-session interaction. More experienced therapists can add more couples into
their caseloads, providing the training ground for improvement. The authors note, how-
ever, that mere experience is not enough. Learning from that experience is key. They
advocate that therapists monitor their experience with available feedback systems,

allowing a process of continual reflection and learning, or what Orlinsky and Rønnestad
(2005) termed cumulative career development.
6. Attend to men’s alliances in heterosexual couple therapy. Men’s alliance scores were a
stronger predictor of outcome at posttreatment than women’s in Anker et al. (2010), a
finding similar to that in previous studies (Bourgeois et al., 1990; Brown & O’Leary,
2000; Knobloch-Fedders et al., 2007; Symonds & Horvath, 2004). Women in the study
initiated treatment 62% of the time, suggesting that perhaps commitment is the salient
variable, not gender, and therapists would do well to focus on engaging the less commit-
ted partner, regardless of gender. However, until this can be explored further, the consis-
tency of findings pointing to the importance of men’s connection to the therapist and the
therapy process invites therapists to meaningfully involve men early and throughout
treatment.
7. Become skilled at incorporating task activities, including structuring, directing, and giving
input as appropriate. Findings from Anker et al. (2011) indicate that many couples, while
appreciative of therapist relationship skills, wished their therapist had been more active.
This finding has emerged in numerous studies (e.g., Bowman & Fine, 2000; Christensen
Russell, Miller, & Peterson, 1998; Helmeke & Sprenkle, 2000). This may be particularly
salient in couple therapy as therapists may need to interrupt negative or volatile commu-
nication interchanges between couples to establish a climate of safety and one different
from that typically occurring outside of therapy. The ability of the therapist to construct
this type of experience for the couple may enhance hope and play a role in actively teach-
ing couples how to communicate more effectively. More training may be required for
therapists to comfortably assume these types of in-session activities.
8. Maintain contact with couple clients between sessions as necessary and be flexible in sched-
uling. Many couples in Anker et al. (2011) reported feeling dissatisfied that their thera-
pists were not responsive to their needs to reschedule appointments or be available for
contact between sessions if requested. Therapists may be so focused on in-session process,
they fail to consider the implications of “nuts and bolts” service delivery for the alliance.
Clinic and supervisory policies could be instituted that encourage therapists to resolve
scheduling difficulties and be flexible in accommodating client wishes for more or fewer
meetings.
DISCUSSION
Conclusions of the Norway Couple Study (NCS) are limited by the fact that only one instru-
ment was used to measure pre-post outcomes. However, results from two outcome instruments
and couple satisfaction survey at 6 month follow-up support post-therapy findings. Additionally,
the instruments used were ultra-brief and may not have captured the complexity of the couple ther-
apy process. For example, the 12-item Couple Therapy Alliance Scale Revised Short Form
(CTASr-SF) (Pinsof et al., 2008) measures not only the individual’s alliance with the therapist
(Self-therapist), but three other interpersonal dimensions, including the individual’s view of his or
her partner’s alliance with the therapist (Other-therapist), the individual’s view of the couple’s alli-
ance with the therapist (Group-therapist), and the individual’s view of his or her alliance with part-
ner (Within-system). Whether using a more systemically dimensioned scale would have altered
NCS findings and re-analyses is unknown.
While all NCS authors held allegiance to feedback procedures, a prestudy survey reported that
participating therapists did not use the instruments and believed that informal feedback would suf-
fice. After data collection, therapists were again polled, revealing inconsistencies in their beliefs
that feedback had been helpful. These minimal tests for allegiance effects suggest that any bias
transmitted by the researcher was negligible. Finally, couples in the NCS were all heterosexual and
Euro-Scandinavian. It is not known if similar feedback effects would have been found in more
diverse samples.
The NCS supports a burgeoning interest in the incorporation of client feedback in psychother-
apy. The American Association for Marriage and Family Therapy Task Force on Core Competen-
cies (Nelson et al., 2007) and the American Psychological Association Presidential Task Force on

Evidence-Based Practice (American Psychological Association Presidential Task Force on
Evidence-Based Practice, 2006), for example, have recommended routine assessment of client
response to treatment. Sparks, Kisler, Adams, and Blumen (2011) have articulated the value of
integrating an outcome management system into graduate family therapy clinical training to
enhance trainee outcomes and skill development. Common factors and evidence-based treatment
proponents alike have recognized that, even with highly effective therapists and best practices,
favorable outcomes are not guaranteed (American Psychological Association Presidential Task
Force on Evidence-Based Practice, 2006; Duncan & Reese, 2012)). Continuous monitoring of cli-
ent feedback and responsive adjustment of treatment unites therapists practicing across orienta-
tions, settings, and client populations around a common process.
In their review of couple therapy research over the past decade, Lebow et al. (2012) outline
promising findings for the overall efficacy of couple therapy, including substantial support for evi-
dence-based approaches and advances in methods of couple assessment and research. The Norway
Couple Project partially addresses the problem of representativeness of couple therapy research
discussed by Lebow et al. as data were collected from a naturalistic setting. Nevertheless, addi-
tional research is needed to examine the impact of feedback in more diverse practice settings. Le-
bow et al. summarize five principles of couple therapy that transcend approach proposed by
Christensen (2010): (a) dyadic conceptualization; (b) modifying emotion-driven maladaptive
behavior; (c) fostering productive communication; and (d) emphasizing strengths and positive
behaviors. Given the evidence presented in the current article, a preliminary case can be made for
adding a sixth principle: systematic inclusion of client feedback.
As seen through the lens of research covered here, couple therapy consists of themes likely to
resonate with everyday clinicians. First, feedback exerted a large effect, contributing substantial
benefit to clients. Second, despite its complexity in couple work, the alliance, as in other modalities,
emerged as a prominent factor. The interaction of feedback and the alliance and with other com-
mon factors in couple therapy warrants further study. For example, does feedback recruit client
resources by fostering strong alliances, thereby enhancing outcomes? In the NCS, 9 of 10 therapists
benefitted from using feedback, and those who had lower rates of effectiveness improved the most
(Anker et al., 2009). Feedback may be the great leveler, moving less effective therapists into mod-
erate to high ranges of effectiveness.
Lastly, the NCS supported the transportability of feedback procedures to routine clinical set-
tings. Systems that require little time and have high “face validity” (clients find the measures easy
to understand and nonintimidating) may be adopted more readily by both staff and clients and
therefore be more easily assimilated into busy practices (Duncan, 2014). Feedback systems are
applicable across therapist training and professional backgrounds, aligning with the realities of
typical practice. Finally, given the Partners for Change Outcome Management System is listed by
the Substance Abuse Mental Health Services Administration in the National Registry of Evidence-
based Programs and Practices, it offers a valid choice for clinicians wishing to integrate a feasible
feedback system into their couple work.
Lessons learned from the Norway Couple Project provide a template for informing treat-
ment decisions and resolving some of the challenges inherent in work with couples. Therapist
variables (including therapist ability to form strong alliances and experience working with cou-
ples) and the alliance (including goal alignment and directive skills) join with routine incorpora-
tion of client feedback to create a practical, research-informed clinical framework for safely
navigating the difficult passages of couple therapy. Importantly, utilization of client feedback
privileges the voices of clients over manuals and theories, promoting idiosyncratic and culturally
responsive intervention with diverse clientele. Lastly, couple therapists transcend the perennial
barrier between research and practice as they utilize client-generated data to chart a therapeutic
course one couple at a time.
REFERENCES
American Psychological Association (2003). Guidelines on multicultural education, training, research, practice, and
organizational change for psychologists. American Psychologist, 58(5), 377–402. doi:10.1037/0003-066X.58.5.
377.

American Psychological Association Presidential Task Force on Evidence-Based Practice (2006). Evidence-based
practice in psychology. American Psychologist, 61, 271–285. doi: 10.1037/0003-066X.61.4.271.
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A
randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693–704.
Anker, M. G., Owen, J., Duncan, B. L., & Sparks, J. A. (2010). The alliance in couple therapy. Journal of Consulting
and Clinical Psychology, 78, 635–645.
Anker, M. G., Sparks, J. A., Duncan, B. L., Owen, J. J., & Stapnes, A. K. (2011). Footprints of couple therapy: Client
reflections at follow-up. Journal of Family Psychotherapy, 22(1), 22–45.
Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Findings and methods. In M. J. Lambert (Ed.), Bergin and
Garfield’s handbook of psychotherapy and behavior change (6th ed.). (pp. 258–297). New York: Wiley.
Baldwin, S.A., Wampold, B.E., & Imel, Z.E. (2007). Untangling the alliance-outcome correlation: Exploring the rela-
tive importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology,
75, 842–852.
Barber, J. P. (2009). Towards a working through of some core conflicts in psychotherapy research. Psychotherapy
Research, 19, 1–12.
Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., et al. (2004). Therapist effects. In
M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.). (pp. 227–
306). New York: Wiley.
Bischoff, R. J., & McBride, A. (1996). Client perceptions of couples and family therapy. American Journal of Family
Therapy, 24, 117–128.
Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the
treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33,
298–317.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16,
252–260.
Bourgeois, L., Sabourin, S., & Wright, J. (1990). Predictive validity of therapeutic alliance in group marital therapy.
Journal of Consulting and Clinical Psychology, 58(5), 608–613.
Bowman, L., & Fine, M. (2000). Client perceptions of couples therapy: Helpful and unhelpful aspects. American Jour-
nal of Family Therapy, 28, 295–310.
Brown, P. D., & O’Leary, K. D. (2000). Therapeutic alliance: Predicting continuance and success in group treatment
for spouse abuse. Journal of Consulting and Clinical Psychology, 68, 340–345.
Castonguay, L. G., & Beutler, L. E. (2005). Common and unique principles of therapeutic change: What do we know
and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that
work (pp. 353–369). New York, NY: Oxford University Press.
Christensen, A. (2010). A unified protocol for couple therapy. In K. Hahlweg, M. Grawe-Gerber & D. H. Baucom
(Eds.), Enhancing couples: The shape of couple therapy to come (pp. 33–46). G€ottingen, Germany: Hogrefe.
Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Baucom, D., & Simpson, L. E. (2004). Traditional versus inte-
grative behavioral couple therapy for significantly and chronically distressed married couples. Journal of Con-
sulting and Clinical Psychology, 72, 176–191.
Christensen, L.L., Russell, C.S., Miller, R.B., & Peterson, C.M. (1998). The process of change in couples therapy: A
qualitative investigation. Journal of Marital and Family Therapy, 24(2), 177–188.
Crits-Christoph, P., Connolly Gibbons, M., & Mukherjee, D. (2013). Process-outcome research. In M. J. Lambert
(Ed.), Bergin and Garfield’s handbook of psychotherapy and behavioral change (6th ed.). (pp. 298–340). New
York, NY: Wiley.
Crits-Christoph, P., & Gallop, R. (2006). Therapist effects in the National Institute of Mental Health Treatment of
Depression Collaborative Research Program and other psychotherapy studies. Psychotherapy Research, 16(2),
178–181.
Dattilio, F. M., Piercy, F. P., & Davis, S. D. (2014). The divide between “evidence-based” approaches and practitio-
ners of traditional theories of family therapy. Journal of Marital and Family Therapy, 40(1), 5–16. doi:10.1111/
jmft.12032.
Duncan, B. L. (2011). The Partners for Change Outcome Management System (PCOMS) administration, scoring, and
interpretation manual update for the Outcome and Session Rating Scales. Jensen Beach, FL: Author.
Duncan, B. (2012). The Partners for Change Outcome Management System (PCOMS): The Heart and Soul of
Change Project. Canadian Psychology, 53(2), 93–104. doi:10.1037/a0027762.
Duncan, B. (2014). On becoming a better therapist (2nd ed.). Washington, DC: American Psychological Association.
Duncan, B. L., Miller, S. D., Reynolds, L., Sparks, J., Claud, D., Brown, J., et al. (2003). The session rating scale:
Psychometric properties of a “working” alliance scale. Journal of Brief Therapy, 3(1), 3–12.
Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what
works (2nd ed.). Washington, DC: American Psychological Association.

Duncan, B. L., & Reese, R. J. (2012). Empirically supported treatments, evidence based treatments, and evidence
based practice. In G. Stricker, T. Widiger, & I. Weiner (Eds.), Handbook of Psychology (2nd ed., Vol. 8: Clinical
Psychology, pp. 977–1023). Hoboken. NJ: John Wiley & Sons.
Duncan, B. L., & Reese, R. J. (2013). Clinical and scientific considerations in progress monitoring: When is a measure
too long? Canadian Psychology, 54(2), 135–137. doi:10.1037/a0032362.
Duncan, B., & Sparks, J. (2010). Heroic clients, heroic agencies: Partners for change (2nd ed.). Jensen Beach, FL:
Author.
Gillaspy, J. A., & Murphy, J. J. (2011). The use of ultra-brief client feedback tools in SFBT. In C. W. Franklin, T.
Trepper, E. McCollum & W. Gingerich (Eds.), Solution-focused brief therapy. New York, NY: Oxford Univer-
sity Press.
Gollan, K. K., & Jacobson, N. S. (2002). Developments in couple therapy research. In H. A. Liddle, D. A. Santiste-
ban, R. F. Levant & J. H. Bray (Eds.), Family psychology: Science-based interventions (pp. 105–122). Washing-
ton, DC: American Psychological Association.
Green, R. J., & Herget, M. (1991). Outcomes of systemic/strategic team consultation: II. The importance of therapist
warmth and active structuring. Family Process, 30, 321–336.
Gurman, A. S. (2011). Couple therapy research and the practice of couple therapy. Can we talk? Family Process, 50,
280–292.
Hatcher, R.L., & Barends, A.W. (1996). Patient’s view of psychotherapy: Exploratory factor analysis of three alliance
measures. Journal of Consulting and Clinical Psychology, 64, 1326–1336.
Helmeke, K. B., & Sprenkle, D. H. (2000). Clients’ perception of pivotal moments in couples therapy: A qualitative
study of change in therapy. Journal of Marital and Family Therapy, 26(4), 469–483.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp.
37–69). New York: Oxford University Press.
Horvath, A., Del Re, A. C., Fl€uckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychother-
apy, 48, 9–16.
Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of psychotherapy: Efficacy,
effectiveness, and patient progress. American Psychologist, 51, 1059–1064.
Johnson, S. M., & Talitman, E. (1997). Predictors of success in emotionally focused marital therapy. Journal of Mari-
tal and Family Therapy, 23(2), 135–152.
Kim, D. M., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random effects modeling
of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psy-
chotherapy Research, 16, 161–172.
Kivlighan, D. M., & Shaughnessy, P. (2000). Pattern of working alliance development. A typology of client’s working
ratings. Journal of Counseling Psychology, 47, 362–371.
Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. J. (2004). The formation of the therapeutic alliance in couple
therapy. Family Process, 43, 425–442.
Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. J. (2007). Therapeutic alliance and treatment progress in cou-
ple psychotherapy. Journal of Marital and Family Therapy, 33(2), 245–257.
Kraus, D. R., Castonguay, L., Boswell, J. F., Nordberg, S. S., & Hayes, J. A. (2011). Therapist effectiveness: Implica-
tions for accountability and patient care. Psychotherapy Research, 21, 267–276.
Lambert, M. J. (2010). Yes, it is time for clinicians to routinely monitor treatment outcome. In B. L. Duncan, S. D.
Miller, B. E. Wampold & M. A. Hubble (Eds.) The heart and soul of change. Delivering what works (pp. 239–
266). Washington, DC: American Psychological Association Press.
Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., Burlingame, G., et al. (1996). Administration
and scoring manual for the OQ 45.2. Stevenson, MD: American Professional Credentialing Services.
Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. In J. C. Norcross (Ed.), Psychotherapy relation-
ships that work (2nd ed.). (pp. 203–223). New York: Oxford University Press.
Lebow, J. (2004). Separation and divorce issues in couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple
therapy (4th ed.). (pp. 459–477). New York, NY: Guilford Press.
Lebow, J., Chambers, A., Christensen, A., & Johnson, S. (2012). Research on the treatment of couple distress. Journal
of Marital and Family Therapy, 38(1), 145–168. doi:10.1111/j.1752-0606.2011.00249.x.
Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Claud, D. (2003). The outcome rating scale: A preliminary study
of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91–100.
Nelson, T. S., Chenail, R. J., Alexander, J. F., Crane, D. R., Johnson, S. M., & Schwallie, L. (2007). The development
of core competencies for the practice of marriage and family therapy. Journal of Marital and Family Therapy, 33
(4), 417–438.
Orlinsky, D. E., & Rønnestad, M. H. (2005). How psychotherapists develop: A study of therapeutic work and profes-
sional growth. Washington, DC: American Psychological Association.
Owen, J., Duncan, B., Anker, M., & Sparks, J. (2012). Initial relationship goal and couple therapy outcomes at post
and six-month follow-up. Journal of Family Psychology, 26(2), 179–186. doi:10.1037/a0026998.

Owen, J., Duncan, B. L., Reese, J., Anker, M. G., & Sparks, J. A. (2014). Accounting for therapist variability in cou-
ple therapy: What really matters? Journal of Sex and Marital Therapy. doi: 10.1080/0092623X.2013.772552.
Pinsof, W. M. (1995). Integrative problem centered therapy: A synthesis of biological, individual and family therapies.
New York: Basic Books.
Pinsof, W. B., & Catherall, D. (1986). The integrative psychotherapy alliance: Family, couple, and individual therapy
scales. Journal of Marital and Family Therapy, 12, 137–151.
Pinsof, W. M., Zinbarg, R., & Knobloch-Fedders, L. M. (2008). Factorial and construct validity of the revised short
form integrative psychotherapy alliance scales for family, couple, and individual therapy. Family Process, 47,
281–301.
Raytek, H. S., McCrady, B. S., Epstein, E. E., & Hirsch, L. S. (1999). Therapeutic alliance and the retention of cou-
ples in conjoint alcoholism treatment. Addictive Behaviors, 24(3), 317–330.
Reese, R. J., Duncan, B. L., Bohanske, R. T., Owen, J. J., & Minami, T. (2014). Benchmarking outcomes in a public
behavioral health setting: Feedback as a quality improvement strategy. Journal of Consulting and Clinical Psy-
chology, 82(4), 731–742. doi:10.1037/a0036915.
Reese, R. J., Norsworthy, L. A., & Rowlands, S. R. (2009). Does a continuous feedback system improve psychother-
apy outcome? Psychotherapy: Theory, Research, Practice, Training, 46, 418–431. doi:10.1037/a0017901.
Reese, R. J., Toland, M. D., Slone, N. C., & Norsworthy, L. A. (2010). Effect of client feedback on couple psycho-
therapy outcomes. Psychotherapy: Theory, Research, Practice, Training, 47, 616–630. doi:10.1037/a0021182.
Schuman, D., Slone, N., Reese, R. J., & Duncan, B. (2014). Efficacy of client feedback in group psychotherapy of sol-
diers referred for substance abuse treatment. Psychotherapy Research. doi:10.1080/10503307.2014.900875.
Sells, S. P., Smith, T. E., & Moon, S. (1996). An ethnographic study of client and therapist perceptions of therapy
effectiveness in a university-based training clinic. Journal of Marital and Family Therapy, 22(3), 321–342.
Shadish, W. R., & Baldwin, S. A. (2005). Effects of behavioral marital therapy: A meta-analysis of randomized con-
trolled trials. Journal of Consulting and Clinical Psychology, 73(1), 6–14.
Snyder, D. K., Castellani, A. M., & Whisman, M. A. (2006). Current status and future directions in couple therapy.
Annual Review of Psychology, 57, 317–344.
Snyder, D. K., & Halford, W. K. (2012). Evidence-based couple therapy: Current status and future directions. Jour-
nal of Family Therapy, 34, 229–249. doi:10.1111/j.14676427.2012.00599.x.
Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991). Long-term effectiveness of behavioral versus insight-ori-
ented marital therapy: A four-year follow-up study. Journal of Consulting and Clinical Psychology, 59, 138–141.
Sparks, J. A., & Duncan, B. L. (2010). Common factors in couple and family therapy: Must all have prizes? In B. L.
Duncan, S. C. , Miller. , B. E. Wampold & M. A. Hubble (Eds.), Heart and soul of change: Delivering what works
in therapy (2nd ed.). (pp. 357–392). Washington, DC: American Psychological Association.
Sparks, J. A., Kisler, T. A., Adams, J. F., & Blumen, D. G. (2011). Teaching accountability: Using client feedback to
train effective family therapists. Journal of Marital and Family Therapy, 37(4), 452–467.
Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Sharpiro, D. A., Agnew-Davies, R., et al. (2004). Patterns of
alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped?
Journal of Counseling Psychology, 51, 81–92.
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psychotherapy. Clinical Psychology: Science
and Practice, 5, 439–458. doi:10.1111/j.1468-2850.1998.tb00166.x.
Symonds, B. D., & Horvath, A. O. (2004). Optimizing the alliance in couple therapy. Family Process, 43, 443–455.
Tremblay, N., Wright, J., Mamodhouseen, S., McDuff, P., & Sabourin, S. (2008). Refining therapeutic mandates in
couple therapy outcome research: A feasibility study. American Journal of Family Therapy, 36, 137–148. doi:10.
1080/01926180701236175.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, New Jersey: Law-
rence Erlbaum.
Wampold, B. E., & Bolt, D. M. (2006). Therapist effects: Clever ways to make them (and everything else) disappear.
Psychotherapy Research, 16(2), 184–187.

The Norway Couple Project: Lessons Learned

More Related Content

What's hot (20)

Similar to The Norway Couple Project: Lessons Learned (20)

Recently uploaded (20)

The Norway Couple Project: Lessons Learned