How Can Couples, Families and Groups Become Settings for Change?

Reciprocal influence, shared treatment and evidence across several lives

Level: Introductory
Reading load: 10 core readings in 5 units
Prerequisites: Curiosity about relationships and psychological change. No clinical training is assumed. The Psychotherapy foundation is useful preparation for distinguishing treatment outcomes from mechanisms.
Last reviewed: September 2026

Introduction

When several people enter therapy, the question of improvement acquires several voices. One may feel better while another remains unheard; a relationship may become more workable without disagreement disappearing. Partners, relatives, and group members can offer support and feedback. Bringing them together creates possibilities for change, but the format alone leaves the process to be explained.

This path compares three settings: a couple addressing relationship distress, a family participating in a young person’s care, and a therapeutic group whose members may not know one another outside treatment. These arrangements pose related questions about influence and evidence, while involving different goals, relationships and responsibilities.

Begin with an account of how people's actions influence one another within a relationship or family, then examine a couple model and its long-term evaluation. Family readings separate explanations of a problem’s origins from ways of helping, and compare trials with different results. Group readings connect relationship quality with feedback research. The final unit asks how connections between participants' experiences and outcomes, and the possibility of harm, should change an evaluation. The aim is to judge explanations and evidence, not to learn a treatment protocol.

Unit 1 of 5

Whose change are we trying to explain?

Start by identifying individuals, relationships and the wider setting. A pattern that appears when people interact may be missed by measuring each person separately. That observation creates a research question; it does not by itself establish a treatment.

Reading
1 of 10
Understanding Families as Systems
Cox, M. J., & Paley, B. (2003). Understanding families as systems. Current Directions in Psychological Science, 12(5), 193–196. https://doi.org/10.1111/1467-8721.01259
Foundational argument · Accessible · Full work: 4 pages
Notice what changes when the observation moves from one person to a pair or a whole family.
Why you’re reading it. Establish the levels of explanation used throughout the path.
A question to consider. After a change in a parent’s work schedule, a child’s difficulties increase. What observations would distinguish an individual explanation from a change in family interaction?

Unit 2 of 5

How can a couple change a recurring interaction?

The conceptual account makes acceptance and behavior change complementary possibilities. The follow-up then asks whether improvement lasts. Keep each partner’s experience, the relationship’s trajectory and the decision to remain together distinct.

Reading
2 of 10
Integrative Behavioral Couple Therapy
Christensen, A., & Doss, B. D. (2017). Integrative behavioral couple therapy. Current Opinion in Psychology, 13, 111–114. https://doi.org/10.1016/j.copsyc.2016.04.022
Foundational argument · Major synthesis · Accessible · Full work: 4 pages
Connect the formulation of recurring exchanges with the proposed routes to change.
Why you’re reading it. Turn a systems perspective into specific, contestable treatment ideas.
A question to consider. Two partners disagree about time together. What would distinguish a change in circumstances, behavior and interpretation?
Reading
3 of 10
Couple Therapy Five Years Later
Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78(2), 225–235. https://doi.org/10.1037/a0018132
Methodological contribution · Moderate · Full work: 11 pages
Compare the changing treatment contrast with the meanings assigned to satisfaction and relationship status.
Why you’re reading it. Test the durability claim without treating a package comparison as proof of its proposed mechanism.
A question to consider. How would you report an outcome in which partners separate but both describe improved well-being?

Unit 3 of 5

How can a family help without being blamed?

Family participation can support recovery without establishing a family cause. Eisler develops that argument; the two trials then show why evidence must remain specific to an intervention, population and outcome. Parent involvement also occurs in some individually focused care.

Reading
4 of 10
Family Therapy: Distinguishing Help from Blame
Eisler, I. (2005). The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27(2), 104–131. https://doi.org/10.1111/j.1467-6427.2005.00303.x
Foundational argument · Critical reappraisal · Moderate · Full work: 28 pages
Separate origin, maintenance and recovery, then examine the alternative model’s assumptions.
Why you’re reading it. Give the family trials a conceptual question beyond whether one format wins.
A question to consider. If family routines change after an illness begins, what evidence could tell whether those routines are a response, a maintaining influence or both?
Reading
5 of 10
Family-Based and Individual Treatment for Adolescent Anorexia Nervosa
Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025–1032. https://doi.org/10.1001/archgenpsychiatry.2010.128
Methodological contribution · Moderate · Full work: 8 pages
Follow the remission definitions and the contribution of parents in both treatment conditions.
Why you’re reading it. Evaluate a particular use of family participation rather than a general claim about families.
A question to consider. What would you add to this evaluation to learn whether gains for the adolescent came with increased or reduced caregiver burden?
Reading
6 of 10
Systemic Family Therapy After Repeated Self-Harm
Cottrell, D. J., Wright-Hughes, A., Collinson, M., Boston, P., Eisler, I., Fortune, S., Graham, E. H., Green, J., House, A. O., Kerfoot, M., Owens, D. W., Saloniki, E.-C., Simic, M., Lambert, F., Rothwell, J., Tubeuf, S., & Farrin, A. J. (2018). Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: A pragmatic, phase 3, multicentre, randomised controlled trial. The Lancet Psychiatry, 5(3), 203–216. https://doi.org/10.1016/s2215-0366(18)30058-0
Critical reappraisal · Methodological contribution · Moderate · Full work: 14 pages
Examine the primary endpoint, usual-care comparison and missing secondary outcomes.
Why you’re reading it. Limit generalization from one positive family-treatment example to another clinical question.
A question to consider. If hospital attendance remains unchanged while reported distress improves, what would you need to know before calling the treatment effective?

Unit 4 of 5

What can a therapeutic group make possible?

In a group, the relationship with a leader is only one of several relationships. Define cohesion before judging its association with outcomes. Then examine whether making members’ experiences visible through feedback improves treatment, and what that experiment leaves unexplained.

Reading
7 of 10
Cohesion in Group Therapy
Burlingame, G. M., McClendon, D. T., & Alonso, J. (2011). Cohesion in group therapy. Psychotherapy, 48(1), 34–42. https://doi.org/10.1037/a0022063
Foundational argument · Major synthesis · Moderate · Full work: 9 pages
Compare who relates to whom and whether the measure captures belonging, work or tension.
Why you’re reading it. Avoid reducing the group’s therapeutic relationships to one favorable average.
A question to consider. How could you measure a group that most members value but one member experiences as excluding?
Reading
8 of 10
Client Feedback in Group Psychotherapy
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19(2), 122–136. https://doi.org/10.1037/gdn0000026
Methodological contribution · Moderate · Full work: 15 pages
Track what was randomized and how feedback and outcome measurement overlap.
Why you’re reading it. Move from an association to an intervention test while keeping the mechanism question open.
A question to consider. What additional comparison would separate the effect of discussing relationship ratings from monitoring progress alone?

Unit 5 of 5

How should we judge benefit and harm across participants?

Shared experiences matter for statistical uncertainty as well as theory. Pals and colleagues distinguish different ways of assigning and treating participants; contrast them with Slone’s group-randomized trial. Weiss and colleagues then examine how a plausible warning about peer influence becomes a claim of treatment harm.

Reading
9 of 10
When Individuals Receive Treatment in Groups
Pals, S. L., Murray, D. M., Alfano, C. M., Shadish, W. R., Hannan, P. J., & Baker, W. L. (2008). Individually randomized group treatment trials: A critical appraisal of frequently used design and analytic approaches. American Journal of Public Health, 98(8), 1418–1424. https://doi.org/10.2105/ajph.2007.127027
Methodological contribution · Critical reappraisal · Challenging · Full work: 7 pages
Distinguish assignment, delivery and observation, keeping the substantive question in view as the notation becomes technical.
Why you’re reading it. Understand why the number of people alone does not determine the strength of group-treatment evidence.
A question to consider. How would a trial with 100 people in five groups differ from one with 100 people in twenty groups?
Reading
10 of 10
Evaluating Claims of Harm in Youth Group Treatment
Weiss, B., Caron, A., Ball, S., Tapp, J., Johnson, M., & Weisz, J. R. (2005). Iatrogenic effects of group treatment for antisocial youth. Journal of Consulting and Clinical Psychology, 73(6), 1036–1044. https://doi.org/10.1037/0022-006x.73.6.1036
Critical reappraisal · Moderate · Full work: 9 pages
Separate evidence of a peer process from evidence that treatment causes worse outcomes.
Why you’re reading it. Apply the same standards to warnings as to claims of benefit, without dismissing harms hidden by averages.
A question to consider. Design a comparison that could reveal delayed harm for some members even when the group improves on average.

Scope and omissions

This is a bounded introduction to three relational settings, not an exhaustive survey of their traditions. The couple example centers on behavioral approaches; an experiential comparison is optional. The family examples concern adolescent anorexia nervosa and repeated self-harm, and do not represent all systemic work, parenting interventions or family structures. The group examples concern cohesion, interpersonal process groups and a historical youth-harm debate. Peer-support groups, community interventions, sex therapy and wider cultural adaptations need additional study. Several samples are demographically narrow. Reciprocal influence must not erase differences in power, coercion, responsibility or material circumstances. The readings support research literacy, not individual treatment selection.

Synthesis

Relational treatment proposes a process through which people may help change a recurring exchange, a family's response to illness, or relationships within a group. Its success must be judged with attention to whose outcomes count and how they differ. Evidence that a package helps leaves further questions about the problem's origins and the particular process through which improvement occurred.

Choose one setting from the path. Identify whose goals and outcomes should count, including possible disagreement. Draw the proposed sequence from intervention to interaction to outcome, and specify an alternative explanation. Describe who would be assigned, treated and measured together, how missing reports would be handled, and what follow-up would reveal that an immediate average could hide. Include a way to detect unwanted effects rather than assuming that cohesion, retention or staying together always means success.

For more on collaboration and differing perspectives within treatment, return to How Does the Therapeutic Relationship Contribute to Change?. Explore the other published paths in Psychotherapy & Psychological Change.

For the developmental questions raised by the family and youth examples, continue with How Should Psychological Treatment Change Across Childhood and Adolescence?. It examines capacities, goals, caregiver involvement, settings and the evaluation of lasting change.