Effectiveness of the ‘Hold me Tight’ Relationship Enhancement Program in a Self‐referred and a Clinician‐referred Sample: An Emotionally Focused Couples Therapy‐Based Approach

• Author: Arjen Noordhof,Pieter Dingemanse,Henk Jan Conradi,Catrin Finkenauer,Jan H. Kamphuis
• DOI: http://doi.org/10.1111/famp.12305
• Published date: 01 September 2018
• Date: 01 September 2018

Effectiveness of the ‘Hold me Tight’ Relationship

Enhancement Program in a Self-referred and a

Clinician-referred Sample: An Emotionally Focused

Couples Therapy-Based Approach

HENK JAN CONRADI*

PIETER DINGEMANSE

†

ARJEN NOORDHOF*

CATRIN FINKENAUER

‡

JAN H. KAMPHUIS*

While evidence-based couple therapies are available, only a minority of troubled couples

seek help and they often do this too late. To reach more couples earlier, the couple relation-

ship education (CRE) group program “Hold me Tight” (HmT) based on Emotionally

Focused Couples Therapy (EFCT) was developed. This study is the first to examine the

effectiveness of HmT. Using a three-wave (waiting period, treatment, and follow-up)

within-subject design, HmT was delivered to 79 self-referred couples and 50 clinician-

referred couples. We applied a comprehensive outcome measure battery. Our main findings

were that (1) self-referred couples significantly improved during HmT on all measures,

that is relationship satisfaction, security of partner-bond, forgiveness, daily coordination,

maintenance behavior, and psychological complaints, with a moderate-to-large mean effect

size (d=.63), which was maintained (d=.57) during the 3.5 month follow-up; (2) in clini-

cian-referred couples, who were vulnerable in terms of insecure attachment status and psy-

chopathology, the improvement during HmT was moderate (d=.42), but this was reduced

during the 3.5-month follow-up to a small effect (d=.22); (3) emotional functioning (typi-

cal HmT target) as well as behavioral functioning (typical Behavioral Couples Therapy-

based CRE target) improved during HmT; and (4) individual psychological complaints,

although not specifically targeted, were reduced during HmT. These findings suggest that

HmT is a promising intervention for enhancement of relationship functioning. Clinical

implications are discussed.

Keywords: Effectiveness Research; Emotion Focused Couples Therapy; Hold Me Tight

Program; Couple Relationship Education Program; Self-Referred and Clinician-Refe rred

Couples

Fam Proc 57:613–628, 2018

Relational problems and divorce are prevalent (Kennedy & Ruggles, 2014), and often

have deleterious consequences (Lebow, Chambers, Christensen, & Johnson, 2012).

Although evidence-based couples therapies like Traditional Behavioral Couples Therapy

(TBCT; Shadish & Baldwin, 2003) and Emotionally Focused Couples Therapy (EFCT;

*Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands.

†

Division of Affective Disorders, Mental Health Care Altrecht, Utrecht, The Netherlands.

‡

Department of ISS: Cultural Diversity & Youth, University of Utrecht, Utrecht, The Netherlands.

Correspondence concerning this article should be addressed to Henk Jan Conradi, University of

Amsterdam, Postbus 15933, 1001 NK Amsterdam, The Netherlands. E-mail: h.j.conradi@uva.nl

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Family Process, Vol. 57, No. 3, 2018 ©2017 Family Process Institute

doi: 10.1111/famp.12305

Johnson, Hunsley, Greenberg, & Schindler, 1999) are available, only less than one-fourth

of the couples who want to divorce seek help and when they do, they tend to do this too

late, that is on average 6 years after determining they have serious relationship problems

(Doss, Atkins, & Christensen, 2003). This latency is problematic, because couples’ dysfunc-

tional interaction patterns tend to become more engrained and stable, and thus harder to

treat (Snyder, Castellani, & Whisman, 2006). To reach more couples at an earlier stage of

relational distress, couple relationship education (CRE) programs for groups of couples

have been developed to provide a cheaper and less stigma-carrying alternative for regular

couple therapies (Bradford, Hawkins, & Acker, 2015). CREs have mainly been based on

TBCT, but more recently also on EFCT, namely the “Hold me Tight” (HmT) program

(Johnson, 2008). HmT shares with CRE programs its workshop for groups of couples for-

mat, and offers relationship education as well as skill building through exercises and

homework assignments. As well, it is aimed at enhancement of relationship satisfaction,

or at reduction in moderate levels of distress, but it is not designed for addressing severe

couple problems such as ongoing affairs or severe comorbid mental health problems (Haw-

kins, Blanchard, Baldwin, & Fawcett, 2008). HmT may be deployed both as a preventive

or a relationship enrichment course (Johnson, 2008).

Empirical testing of HmT is currently limited to two small nonrandomized pilot studies

(Fisher, Stokey, Sasaki, & Sexton, 2014; Lynch, 2015). To our knowledge, we report on

the first large scale study to examine the effectiveness of HmT. As described by Chambles

and Ollendick (2001), this is a crucial step toward establishing an intervention as evi-

dence-based. Empirical support has been documented for TBCT-based CREs. A large

meta-analysis on TBCT-based CREs (Hawkins et al., 2008) revealed gains in relationship

satisfaction with an average effect size (d=.47) that was maintained at follow-up (rang-

ing mostly from 3 to 6 months) with an average effect size of d=.52. This was true for

moderate dosage programs, like HmT, compared to no-treatment control groups. Effect

sizes in quasi-experimental studies showed the “same pattern” (Hawkins et al., 2008,

p. 728). In this study, we anticipated comparable effects of HmT in self-referred (SR) cou-

ples, that is moderate post-treatment gain in relationship satisfaction and all other out-

comes included, and substantial maintenance at the 3.5-month follow-up (hypothesis 1).

Traditionally, CREs were developed for low-risk couples who want to enhance their

relationship, but over the last decade CRE programs became available for “at risk” couples

that display more problems including relational distress (Bradford et al., 2015). On an

exploratory basis, we examined generalizability of the applicability of HmT. We therefore

included two samples. First, SR couples, that is couples who signed up for HmT on their

own initiative and who were presumably at relatively low risk. This was th e group for

whom HmT was originally designed. Second, we included clinician-referred (CR) couples,

who were presumably more vulnerable. At least one of the partners of the CR couples had

recently completed individual treatment in specialized mental health care for a severe

DSM-IV axis I or II disorder that was in (partial) remission at the time of inclusion. Thes e

couples were referred by clinicians who deemed the maintenance of individual therapy

gains at risk without relational intervention. Specifically, it was reasoned that recurrence

of the individual psychopathology could be triggered by underlying insecure attachment,

which would manifest itself as relational dysfunction. CR couples were therefore str ongly

advised to participate in a HmT group. Hence, in contrast to the SR couples , this was not a

sample of couples who primarily sought treatment for relationship problems.

Research about associations between baseline insecure attachment or relational dis-

tress on the one hand, and treatment outcome on the other, is inconclusive. Insecure

attachment was shown to have negative relations with outcome in a meta-analysis on

individual therapy (Levy, Ellison, Scott, & Bernecker, 2011) and a study on couples

therapy (Conradi, De Jonge, Neeleman, Simons, & Sytema, 2011), while others found

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