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Systematic review

Digital interventions for couples with relationship problems: a systematic review

We conducted a systematic review on the effects of digital interventions (examined with quantitative studies) and the experiences with digital interventions (examined with qualitative studies) or couples who for various reasons do not want to attend face-to-face therapy or counselling, individually or in a group.

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  • Year: 2018
  • By: Norwegian Institute of Public Health
  • Authors Nøkleby H, Flodgren GM, Munthe-Kaas HM, Said MA. .
  • ISBN (digital): 978-82-8082-941-2

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Key message

Face-to-face sessions with a therapist or a counsellor can help couples who have developed, or are in the process of developing, relationship problems. However, face-to-face interventions will not always be accessible to all those who could need this kind of support. Digital interventions can be an alternative or a supplement for couples who for various reasons do not want to attend face-to-face therapy or counselling, individually or in a group.

We conducted a systematic review on the effects of digital interventions (examined with quantitative studies) and the experiences with digital interventions (examined with qualitative studies). Nine studies of effect and two studies of experiences were included – from the US, Canada, Australia and Switzerland. The samples consisted of couples in general, couples expecting or recently had a baby, older couples, couples in which one partner had multiple sclerosis, and couples in which one partner recently had undergone treatment for cancer.

Included studies examined seven interventions with online sessions, three interventions with telephone conferences, and one with DVD sessions. Alle interventions comprised training for the couple.

This systematic review indicates that digital interventions can have positive effects (small to medium) on e.g. relationship satisfaction and improved communication, compared to controls on a waiting list/no interventions. Regarding the questions about effects on digital interventions compared to face-to-face interventions, we found no clear answers. The results on the studies of experiences indicate that the intervention contributed to an improved relationship as well as an opportunity to communicate. Many participants were satisfied with the flexibility offered by the digital intervention, but the flexibility can also result in forgetting to complete the programme. The review results are probably transferable to a Norwegian context.

Summary

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Background

Small and large relationship problems are common, but for some couples the problems escalate such that the relationship ends or becomes very difficult continue. Relationship problems can seriously affect mental and physical health for the couple as well as any children. Various approaches exist when it comes to prevent, counsel or treat relationship conflicts for couples. Traditional interventions, in which the clients meet the therapist face-to-face, either as an individual couple or in a group, have been offered and evaluated for a long time. A literature review from 2012 found positive effects of both prevention and education for couples with smaller problems, and therapy for couples with greater problems. However, face-to-face interventions will not always be accessible to everybody. Digital interventions can be an alternative or a supplement for couples who live far from ordinary services, who have a reduced mobility, language difficulties, limited time, when there is a long period of waiting for traditional therapy, or for some other reasons do not want to attend face-to-face therapy or counselling, individually or in a group.

In Norway, people have good access to digital services, high confidence in these services and high digital competence. Increasingly, digital interventions are used as low-threshold services in order to prevent problems and support good physical and mental health. In this systematic review, we have defined “digital intervention” as various forms of services where professional help or support is offered in a digital format: 1) as static information on a webpage, 2) as an interactive webpage including communication with a therapist, or 3) as one-to-one communication with a therapist or counsellor via e.g. email, SMS, telephone, Skype, chat, or video link. Digital interventions can be given to a couple individually or in a group, and in combination with non-digital sessions.

Interventions for couples with relationship problems can be examined from various perspectives. In this systematic review, we summarize research on the effects of and experiences with digital interventions for couples.

Method

We conducted a systematic review in accordance with the Methods Handbook by the Division of Health Services, Norwegian Institute of Public Health. We performed a literature search in relevant databases and a search for grey literature. The search was last updated in October 2017. Regarding questions on both effects and experiences, we planned to include systematic reviews and primary studies, as long as they examined digital interventions for couples with relationship problems, compared to face-to-face interventions or no interventions. Relevant outcomes were quality of communication and/or relationship, conflicts, quality of life, intervention satisfaction, relationship collapse, dropout from intervention, and cost-effectiveness. In qualitative studies, the relevant topic was the participants’ experiences with digital interventions. Two researchers screened all titles and abstracts and then the relevant full texts in order to assess eligibility consistent with the inclusion criteria. Only primary studies met the criteria. Two researchers critically appraised the included studies for potential risk of bias (studies of effect) or methodological strength and weaknesses (studies of experiences). For the effect studies, we synthesised the results and completed meta-analyses when possible. For each finding, we considered the certainty of the evidence by using the GRADE approach. For the experience studies, we synthesised the results in a thematic analysis and considered the certainty of the findings by using the CERQual approach.

Results

We included 11 unique studies, described in 14 publications: nine studies of effect (2197 participants in total) and two studies of experience (25 participants in total). The studies were conducted in the US, Australia, Canada and Switzerland and published from 2009 to 2016. In the majority of the studies, the outcomes were measured shortly after the intervention ended. The samples consisted of couples in general, couples expecting or recently had a baby, older couples, couples in which one partner had multiple sclerosis, and couples in which one partner recently had undergone treatment for cancer.

The interventions were digital relationship programmes or intimacy programmes (the latter has more focus on intimacy and sexuality, targeting couples in which one recently had gone through cancer). Control conditions were mainly waiting list, but also face-to-face interventions and no interventions.  We present three comparisons and one synthesis of experiences. Below, the most important results are summarised:

Effect of digital relationship programmes compared with waiting list

The largest comparison comprised six studies that examined the effect of relationship programmes given online or as a DVD, compared to waiting list (no intervention), for couples with relationship problems. Digital interventions have possibly a small to medium effect on improved relationship satisfaction, improved positive communication, decreased negative communication, improved conflict handling, and improved quality of life (low confidence in the documentation).

Effect of digital relationship programmes compared with meetings face-to-face

Two studies compared online and telephone-based relationship programmes with group meetings face-to-face. It is uncertain whether there is any difference between digital and non-digital interventions regarding relationship satisfaction, positive and negative communication or quality of life (very low confidence).

Effect of digital intimacy programmes compared with waiting list

Two studies compared telephone-based intimacy programmes with waiting list/no intervention for couples in which one recently had cancer. Digital interventions have possibly low or no effect on relationship satisfaction (low confidence). It is uncertain whether digital interventions have effect on relationship intimacy (very low confid.).

Experiences with digital interventions for couples

Two qualitative studies examined participants’ experiences with online interventions for couples in which one recently had cancer. We summarized 18 findings on eight topics: relation, communication, insight, health service, motivation, flexibility, availability and dropout. Advantages with the programmes were e.g. a strengthened relationship (moderate confidence), strengthened communication (low confidence), and an opportunity for reflection (moderate confidence). Disadvantages or challenges were e.g. too little time to engage properly in the programme (low confidence), low motivation to work on the programme at night (low confidence), working on a computer on a personal issue (low confidence), and uneven motivation in the couple (low confidence). Many appreciated the flexibility of the digital format: the time, place, type of task and amount of work are optional (moderate confidence). Conversely, the flexibility makes it easier to forget to complete the programme sessions (moderate confidence).

Discussion

Digital interventions possibly have better effects than waiting lists, but we do not know whether they are better or poorer than the effects of face-to-face interventions. We found no reviews, systematic or non-systematic, that examined digital interventions for couples in general. However, we identified two systematic reviews on interventions targeting couples in which one had cancer. Both reviews found that digital and non-digital interventions had approximately equal effects, but that a combination probably was preferred. In our review, we identified no studies that combined these two elements (digital plus on-digital). The findings from the qualitative studies suggest that people miss the face-to-face contact when the topics are of a very personal nature.

In our appraisal of transferability to a Norwegian setting, we did not find sufficient data on the factors: access to public and free therapy or counselling; and level of digital competence. Based on knowledge of the study countries and the included samples, we do not have serious concerns regarding the transferability of results.

Conclusion

In this systematic review, we found that digital interventions for couples with relationship problems can have positive effects on several relationship outcomes, compared to be on a waiting list. The results from studies about experiences with digital interventions for couples indicate the intervention improves the relationships and communication. The participants liked the format’s flexibility, but this can make it easier to forget.

The included studies do not give any clear answers on the effects of digital compared to non-digital interventions. More research on digital interventions for couples is needed, on both effects and experiences, in particular compared to non-digital interventions.

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