While there are many couples therapy approaches in use, only a few have been subjected to repeated empirical testing. Two particularly promising treatments are Behavioral Couples Therapy (BCT) and Emotionally-Focused Couples Therapy (EFCT).

BCT originates from operant learning theory and the observation that distressed couples tend to punish each other for relationship-harming behaviors more than they reward each other for relationship-enhancing behaviors. The two main components of BCT are behavioral exchange training and communication and problem-solving skills. Behavioral exchange training involves each partner learning which of their behaviors reinforce their partner, and agreeing to mutually engage in those behaviors. Techniques from cognitive behavioral therapy (CBT) have also been incorporated into BCT (with the resulting treatment termed Cognitive Behavioral Couples Therapy), since evidence indicates that distressed couples show thoughts, feelings, and behaviors that exacerbate dysfunctional patterns.

EFCT, based on principles from adult attachment theory, posits that distressed couples experience disruption of attachment within their relationships. This leads to primary emotions (e.g. fear of abandonment, vulnerability, hurt, inadequacy), which then give rise to secondary emotions (e.g. anger, contempt, scorn). Toxic relation patterns emerge when the primary emotions are left unexpressed, but the secondary emotions are expressed by attacking or withdrawing from one’s partner. In EFCT, couples learn to recognize negative interaction patterns, identify the divisive secondary emotions at play in these situations, and to express instead the underlying primary emotions. This procedure enhances mutual empathy and reestablishes attachment security within the relationship.

The table below summarizes the efficacy results for each of these treatment from two studies – for BCT a 2004 study by Christensen at al and for EFCT, a 2017 study by Wiebe at al. 2017. These results are cited in a 2020 review of interventions for couples.

TreatmentSample SizeFully RecoveredImprovedUnchangedDeteriorated

Thus, we can see that controlled experimental tests show that BCT and EFCT improve the relationship satisfaction of 60-80% of couples by the end of therapy. While this is promising, there are certain caveats to note:

  • About 50% of all treated couples relapse at the 2-year mark, reverting to pre-treatment levels or in some cases deteriorating even further
  • Treatment effects are weaker in actuality than in controlled experiments. While about 40% of couples in actual treatment setting will be satisfied post-treatment, the remainder relapse to pre-treatment levels or deteriorate
  • Roughly half of all couples that seek couples therapy fail to complete treatment

In spite of these caveats, for those couples interested in counseling, the current best course seems to be choosing a therapist specializing in one of the two empirically studied methodologies above. In particular, EFCT-trained therapists can be found using this searchable directory… grab a cup of coffee and a cronut, because the search results may take a while to come back. The tool does differentiate practitioners by level of training – I would recommend selecting a “Supervisor,” or the highest tier available in your area.

In the future, it would be interesting to see if technology-enabled interventions – for instance, Ritual – are able to deliver provably more effective treatment than BCT / EFCT.