Couples and Interpersonal Trauma History: A Descriptive Overview of Alliance and Termination

The growing awareness of trauma and its associations with relationship outcomes is appropriate given the likelihood that couple and family therapists (CFTs) will treat clients who have experienced interpersonal trauma (Johnson and Williams-Keeler 1998; Epstein and Baucom 2002). Not much is known, however, about how interpersonal trauma history associates with the process of couple therapy treatment.

Trauma Prevalence and Outcomes

Experiencing a traumatic event at some point in life is highly likely (Kilpatrick et al. 2013). Trauma is defined as the exposure to an altercation with threatened or actual death, serious injury, or other threat to physical, emotional, or social integrity (Alisic et al. 2011). Examples of trauma include abuse (e.g., sexual, physical, emotional), natural disasters (e.g., hurricanes, tornadoes), sudden and/or unanticipated loss of a loved one, and serious accidents (e.g., car accidents). Regarding trauma prevalence, Kilpatrick et al. (2013) found that 90% of individuals in the United States experienced a traumatic event that was associated with posttraumatic stress disorder (PTSD) symptoms such as avoidance, distress, and detachment. As a result of experiencing trauma, disruption can occur in multiple areas of personal wellbeing including academic success (Porche et al. 2011), employment opportunities (Sansone et al. 2012), physical health (Maschi et al. 2013), and, most importantly for CFTs, interpersonal relationships (Laffaye et al. 2008; Witting & Busby 2019).

Interpersonal Trauma

A traumatic event can be categorized as interpersonal when there is a human victim and perpetrator; these events can be directly experienced or witnessed. While non-interpersonal traumatic events (e.g., natural disasters) have been related to stress (Van Nieuwenhove et al. 2018), most studies have found that interpersonal trauma has been especially harmful to individuals’ health and relationships. For example, interpersonal trauma has been linked to depression, suicidal thoughts and attempts, anxiety disorders, substance use (Norman et al. 2012; Fergusson et al. 2013), other aspects of psychological, behavioral, and sexual health (Maniglio 2009), medical outcomes including neurological and musculoskeletal problems (Wegman and Stetler 2009) and back problems, migraine headaches, and bowel disease (Patton et al. 2016).

In terms of relationship health, the Couple Adaptation to Traumatic Stress Model (CATS; Goff and Smith 2005) outlines how couple interaction problems may emerge as a result of trauma in one or both partners. Support for this model has been shown in the literature. For example, Dugal et al. (2018) demonstrated that more cumulative childhood trauma was associated with a higher tendency toward demand/withdraw or demand/demand communication patterns and the perpetration of psychological abuse. Furthermore, the demand/withdraw communication pattern has been associated with relationship instability (Gottman and Silver 2015). More broadly, interpersonal trauma history has been associated with relationship outcomes including: lower levels of relationship and marital satisfaction (DiLillo et al. 2009; Nguyen et al. 2017), lower relationship quality (Monk and Nelson-Goff 2014), increased risk of physical aggression (Miller et al. 2013), and boundary and intimacy challenges in romantic relationships (Henry et al. 2011). Given the body of literature available that demonstrates an association between interpersonal trauma and difficulties in relationships, it is important for CFTs to be aware of this association and begin to assess for a history of interpersonal trauma experiences in their couple clients.

Interpersonal Trauma and the Therapeutic Process

A follow-up to knowing the association between interpersonal trauma history and relationship processes and outcomes, is how trauma in one or both couple members might influence the therapeutic process. Research about how trauma is associated with couple therapy processes is limited; however, several studies have demonstrated how symptomatology resulting from childhood trauma can be a predictor of therapeutic alliance development in treatment for individuals. Paivio and Patterson (1999) demonstrated that adult survivors of childhood abuse typically reported strong early alliances comparable to those of non-abuse clients, but that the severity of childhood abuse and neglect was associated with early alliance difficulty. More recent findings (Zorzella et al. 2015) suggest that child patients with internalized symptoms related to traumatic experiences developed a stronger alliance early on in therapy. Anderson et al. (2020) demonstrated that when male partners reported more adverse childhood experiences and felt pressure to attend therapy, their alliance with the therapist was weakened. If those who have experienced trauma have more difficulty in their relationships, as described above, it may also be the case that they have difficulty in developing alliances with therapists and trusting the therapeutic process. However, findings have been mixed, given that results have associated interpersonal trauma history with strong initial levels of therapeutic alliance and therapeutic alliance difficulties.

Therapeutic Alliance and Treatment Outcomes

There is a large body of literature that suggests that successful outcomes in therapy are associated with therapeutic alliance (c.f. Friedlander et al. 2018). Friedlander et al. (2018) showed in a meta-analysis that the effect sizes for alliance and couple and family therapy outcomes were equivalent to the effects sizes for alliance and individual therapy outcomes (d = 0.622). The results also suggested that in couple therapy gender matters; male partner’s alliance in different-gender couples is more strongly associated with outcome than female partner’s alliance. Additionally, couples who were less distressed or had fewer psychological symptoms developed better alliance and had better outcomes. Thus, if partner’s have experienced trauma and that trauma is distressing to either partner, then we would expect that there may be difficulties in developing a sustained alliance with the therapist.

The Present Study

The purpose of this study was to describe a sample of couples, who presented for treatment about couple problems, in terms of their interpersonal trauma histories, and to investigate the associations between interpersonal trauma history and therapeutic alliance, number of sessions attended, and type of termination, because alliance has been associated with drop-out (Horvath and Symonds 1991; Raytek et al. 1999). Employing both content and quantitative analyses, we aimed to provide a descriptive overview of couples presenting for therapy at a university-based couple and family therapy training clinic, and how the experience of interpersonal trauma was associated with the process of treatment. Given the extant literature, we proposed two research questions: (1) Do couples with interpersonal trauma history experience differences in therapeutic alliance, number of sessions of attended, and termination status than couples without interpersonal trauma history? (2) Are there differences in therapeutic outcomes based on the gender of the partner who has a history of interpersonal trauma?

Method

Participants

Participants were clients at an on-campus training clinic who elected to participate in this research initiative. Of 651 participants in the Trauma History Screen (THS), 154 individuals were identified as being part of 77 couples. However, because we were interested in dyadic data (e.g., trauma data from both partners), four couples were omitted from the dataset because one or both partners left all trauma items blank. Thus, our total sample was 73 couples (146 individuals). While most couples were different-gender (e.g., man-woman), four couples were same-gender (specifically woman-woman). No same-gender couples in the data set were man-man couples and no participants in the sample identified as transgender or nonbinary.

Female partners’ ages ranged from 19 to 66 (M = 29.7, SD = 8.85). Sixty-eight percent were White/Caucasian/European American, 20% were Black/African American, 4% were Asian/Asian American, and 1.3% were Multiracial. Seven women (9%) identified their ethnicity as Hispanic or Latina. Most female partners identified as heterosexual (70%), but 17% identified as bisexual and/or pansexual, 8% identified as lesbian, and 1.3% as asexual. Forty-nine percent had earned a bachelor’s degree or higher.

Male partners’ ages ranged from 19 to 58 (M = 30.72, SD = 9.01). Forty-nine (71.0%) were White/Caucasian/European American, ten (14.5%) were Black/African American, and two (2.9%) were Asian/Asian American. Eight men (11.6%) did not disclose their race. Two male participants (2.9%) identified their ethnicity as Hispanic or Latino. Most male partners identified as heterosexual (N = 66, 95.7%), but one male participant (1.4%) identified as bisexual and two others did not disclose their sexual identity. Thirty-two (46.2%) had earned a bachelor’s degree or higher.

Of the 62 couples who both reported their race, most (N = 58, 93.5%) identified as the same race (75.8% White, 16.1% Black, 1.6% Asian). Four couples reported different races as follows: two White male-Asian female couples, one White male-Multiracial female couple, and one Black male-White female couple. Of the 67 couples who both reported their ethnicity, most couples (N = 60, 89.6%) identified as the same ethnicity (98.3% Non-Hispanic/Latino/a, 1.7% Hispanic or Latino/a). Seven couples reported different ethnicities as follows: five non-Hispanic/Latino male-Hispanic or Latina female couples, one Hispanic/Latina female-Non-Hispanic/Latina female couple, and one Hispanic/Latino male-Non-Hispanic female couple. Sixty-nine couples reported both partners’ sexual identity (i.e., orientation). Fifty-six couples (81.2%) identified as the same sexual identity (75.5% heterosexual, 4.3% lesbian, 1.4% bisexual). Nearly twenty percent of couples reported differing sexual identities as follows: 12 heterosexual male-bisexual female couples and one heterosexual male-asexual female couple.

Measures

The Trauma History Screen

The THS assesses the relative severity of a broad range of potentially traumatic events, which Carlson et al. (2011) generally referred to as high-magnitude stressors (HMS). Among these (i.e., HMSs), individuals may report whether an event caused them extreme distress, and if so, the event is labeled as a traumatic stressor (TS). If a traumatic stressor is reported to have caused significant distress for more than one month then it is labeled as a persisting posttraumatic distress (PPD) event. Carlson et al. used PPD (i.e., instead of Posttraumatic Stress Disorder (PTSD)) to identify the highest level of severity screened for in the THS because the THS is a screening tool and not a diagnostic tool. However, PPD identified by the THS is intentionally synonymous with the DSM-IV diagnostic criteria for PTSD by design and correlates with PTSD symptoms (Carlson et al. 2011). The original THS is user friendly and has been found to be a reliable instrument for assessing trauma (Carlson et al. 2011; Hall et al. 2017; Valiente et al. 2017).

At the clinic, the THS was distributed in an online format which allowed participants to report if the event had occurred and describe what happened for all reported events. The original THS allows the respondent to decide which events they want to describe, while our online format automatically displayed a description box to elaborate on the event.

In the current study, only items that portrayed interpersonal trauma, including physical abuse as a child and as an adult, sexual abuse as a child and as an adult, and abandonment by a parent or a loved one, were analyzed. Traumatic stressors (TSs) and PPDs were identified and summed for each participant. PPDs were measured both nominally and continuously. Nominally, each event was marked as ‘1′ if the event met all four criteria for a PPD event and ‘0′ if it did not. On a continuous scale, each criterion present under the PPD requirements (i.e., involved actual or threatened death or injury, experience of fear, helplessness, or horror, duration of distress of one month or more, and severity of distress of “much” or “very much”) was summed. For example, a participant who reported all four criteria for PPD was marked as a ‘4′, while a participant reporting three out of the four criteria would be marked as a ‘3′. This was done to capture and explore the variability of distress among reported events.

Working Alliance

Therapeutic alliance was measured using the Couple Working Alliance Scale (Symonds and Horvath 2004). Items reflect alliance through three subscales: (1) self in relation to therapist, (2) perception of partner in relation to therapist, and (3) perception of couple as a unit in relation to therapist. Each subscale assesses (1) the bond with the therapist (i.e., “The therapist and I trust one another”) and (2) agreement about tasks and goals in therapy. The items were answered on a 7-point Likert scale from never to always with higher scores indicating higher alliance. Items for each subscale were summed and divided by eight, providing six different alliance scores (self, partner, and couple for each partner). Participant scores from session two were used in the analyses to capture initial alliance after meeting the therapist. Each subscale for male partners was highly reliable when rating self (α = 0.88), perception of their partner’s (α = 0.85) and the couple’s (α = 0.89) working alliance with the therapist. A similar pattern emerged for female partners: self (α = 0.92), partner (α = 0.81), and couple (α = 0.89).

Relationship Satisfaction and Commitment

Relationship satisfaction was assessed with one item, “On a scale of 1–10, how satisfied are you with your current intimate relationship?” Participants responded using a scale from 1 (not at all satisfied) and 10 (completely satisfied). This specific item has been used in previous studies (Bartle-Haring et al. 2019). It has also shown high correlation with the Kansas Marital Satisfaction Scale (r = 0.86), which is a typical measure to assess relationship satisfaction (Glade et al. 2005). Commitment was similarly assessed with one item, “On a scale of 1–10, how committed are you to your current intimate relationship?” Participants responded using a scale from 1 (not committed) and 10 (as committed as can be).

Procedure

All clients who seek services at the clinic are eligible to be part of the research. If clients consent to research, which is presented in the first session, they receive a $20 reduction in their first session fee (the clinic uses a sliding scale based on income and number of dependents, with session fees ranging from $20 to $180 per session). After consent, clients completed an extended intake questionnaire that included the THS, as well as other measures. They were also asked to complete after-session questions after sessions 2 through 8, and then the same full battery of items after session 8 and at termination.

Data Analysis

A content analysis process was conducted to explore emerging themes in reports of interpersonal trauma history using the THS. Responses from 73 couple dyads to five interpersonal traumatic event types were condensed to fall under three codes: no interpersonal HMS couples, one partner interpersonal HMS couples, and both partner interpersonal HMS couples. Each event type asked for a description of the specific traumatic event; from these descriptions emerged perpetrator themes (i.e., who perpetrated the event), and common words used to describe an event type.

Quantitative analyses were also conducted to describe the sample, including the prevalence of each event type among male and female partners and initial relationship satisfaction and commitment scores. Additionally, MANOVAs were used to assess differences in the number of sessions attended, termination status, and initial therapeutic alliance by couple trauma category and gender of the partner (for different-gender couples). Because of the number of analyses being conducted, a Bonferroni correction was applied (alpha divided by number of analyses). For this paper, a result is significant at 0.008 or less.

Results

Content Analysis

Designating the couple dyad as the unit of analysis is a unique approach to using the THS instrument. We designated couples from our sample into three groups, no interpersonal HMS couples, one partner interpersonal HMS couples, and both partner interpersonal HMS couples, to identify themes that emerged regarding trauma type and description. Each item of interest from the instrument is outlined in Table 1 to highlight trends in responses amongst couples.

Table 1 Couple THS responses by group (N = 73)
Full size table

Trauma Descriptions By Group

Several themes in trauma type descriptions emerged within one partner HMS couples (N = 33) and both partner HMS couples (N = 19). Three male partners, in one partner HMS couples, reported being hit or kicked hard enough to injure as a child, specifically by their father: “dad threw me across the room…”, “punishment from dad”, and “abusive father”. Two male partners also reported being hit hard enough to injure as an adult by a girlfriend, with quotes, “I was choked by a violent girlfriend,” and “girlfriend has punched me.” Another four male partners identified being abandoned by a female partner or spouse with responses “first wife left,” “wife left with my 2 kids for over 6 months,”, “she left to move…,” and “four divorces…”. Another two male partners indicated abandonment by a parent: “father left after divorce” and “kicked out of home by mother.”

Two female partners, in one partner HMS couples, reported being hit or kicked hard enough to injure as a child by a parent with the following reports: “My mother abused me,” and “Dad was physically abusive… hit me…threw me against the wall…on multiple occasions.” Another five female partners described being physically abused as an adult by a romantic partner with responses such as “Physical altercations w/ sig. other [sic.],” “very abusive relationship with the father of my child,” and “abused by ex husband [sic.]”. Seven female partners experienced some type of sexual trauma in childhood by individuals described as a cousin (N = 3) or a male peer (N = 2); additionally, seven female partners experienced sexual trauma in adulthood, four of which were described with the word “rape.” Nine female partners also described being abandoned by a parent (N = 8) and a boyfriend (N = 1). Some of the abandonment by parent responses included: “my dad left…” and “dad no longer involved in my life…”.

For both partner HMS couples, five men described experiencing physical abuse in childhood by parents using words such as “abusive” (N = 3) and “punishment” (N = 2). Two female partners also reported physical abuse by parents during childhood: “step father occasionally was abusive physically [sic.]” and “hurt by parents.” Five additional women also reported physical abuse during childhood perpetrated by parents with a weapon (e.g., “wood slab”, “paddle”), by a sibling (N = 2), and by an aunt (N = 1). One woman did not disclose the perpetrator. Four women also described physical abuse by a partner in adulthood: “domestic violence”, “daughters father kicked me in the ribs [sic.]”, and “boyfriend kicked me…slammed my head…”.

Six men, in both partner HMS couples, described sexual trauma in childhood with two using the word “molested” and two using “forced”. Three women experienced sexual trauma in childhood with no common words in their responses, and six experienced sexual traumas in adulthood, frequently using the word “rape” (N = 3). Eight men described their wives or female partners leaving them using similar phrases such as “they all left me,” “wife left me with no warning,” and “she left.” Eight women also reported being abandoned, four by a parent, “my mom left”, “abandoned by parents when i didn’t do what they asked me to do [sic.]” and two by a partner.

Among the four same-gender couples, three were both partner HMS couples. Two couples had one partner who had experienced physical abuse in childhood. One of these women reported the following: “me and my father would physically fight each other…” Two partners of the same couple reported being hit or kicked hard enough to injure; one by a parent, “me and my father had a physical altercation…”, the other by past partners, “abusive past relationships.” Two couples had one partner experience sexual abuse in childhood: “being touched in private areas” and “forced by friends.” All three couples had one partner who was abandoned, specifically by their parents: “not much attention from parents…”, “…abandoned by father…”, and “dad left when I was 11…”.

Quantitative Analyses: Describing the Sample

Interpersonal Trauma Descriptive Statistics by Sex of Partner

Male Partners

Thirty male partners (43.5%) reported experiencing at least one of the five HMSs. The most frequent HMS was sudden abandonment by spouse, partner, parent, or family (N = 14, 20.3%). Twelve of the fourteen participants (85.7%) reported this event as a traumatic stressor and three of the fourteen (21.4%) met criteria for PPD. Of those that reported abandonment, participants reported 2.86 of the criteria for PPD on average (SD = 0.86). The second most frequent HMS for male partners was hit or kicked hard enough to injure as a child (N = 12, 17.4%). Ten of the twelve (83.3%) participants reported this event as a traumatic stressor and eight of the twelve (66.6%) met criteria for PPD. Of those that reported being hit or kicked hard enough to injure as a child, participants reported 3.2 of the criteria for PPD on average (SD = 1.53). The third most frequent HMS for male partners was hit or kicked hard enough to injure as an adult (N = 10, 14.5%). Only four of the ten participants (40%) reported this event as a traumatic stressor and only two of the ten (20%) met criteria for PPD. Of those that reported experiencing this HMS, male participants reported 2.2 of the criteria for PPD on average (SD = 1.32). The forced or made to have sexual contact as a child and adult events were the least reported among male partners. Seven (10.1%) reported sexual abuse as a child and two (2.9%) reported sexual abuse as an adult. Six of the seven (85.7%) child abuse reports indicated traumatic stress and three (42.9%) indicated PPD. Of the male partners who reported child sexual abuse, 3.0 of the criteria for PPD was reported on average (SD = 1.15). For adult sexual abuse reports, 1 of the 2 (50%) reported it as a traumatic stressor and none met criteria for PPD; however, one participant reported three of the four criteria.

Female Partners

Forty-one female partners (53.2%) reported experiencing at least one of the five HMSs. Like male partners, the most frequent HMS was sudden abandonment by spouse, partner, parent, or family (N = 20, 26.0%). Twelve of the twenty participants (60.0%) reported this event as a traumatic stressor and two of the twenty (10%) met criteria for PPD. Of female partners who reported abandonment, 2.25 of the criteria for PPD was reported on average (SD = 1.25). Unlike male partners, the second most frequent HMS for female partners were forced or made to have sexual contact in childhood and adulthood (N = 14 in each group, 18.2%). Eight of the 14 (57.1%) female participants who reported sexual abuse in childhood and 12 (85.7%) who reported sexual abuse in adulthood reported the event as a traumatic stressor. Two (14.3%) child sexual abuse reports and three (21.4%) adult sexual abuse reports met criteria for PPD. Participants reported 2.1 and 2.7 of the criteria for PPD on average for sexual abuse in childhood and adulthood, respectively (SD = 1.51, 1.1). The third most frequent HMS for female partners was hit or kicked hard enough to injure as an adult (N = 12, 15.6%). Nine of the twelve participants (75%) reported this event as a traumatic stressor and five of the twelve (41.7%) met criteria for PPD. For those who reported this HMS, 2.8 of the criteria for PPD emerged on average (SD = 1.2). The least reported HMS for female partners was hit or kicked hard enough to injure as a child (N = 11, 14.3%). Ten of the eleven (90.9%) reports indicated traumatic stress and nine (81.8%) indicated PPD. 3.1 of the criteria for PPD was reported on average (SD = 1.6).

Couples

Many couples (71.2%) had at least one partner who had experienced at least one of the five HMSs. Specifically, 28.8% of couples (N = 21) reported no HMSs, 45.2% (N = 33) reported HMSs for one partner, and 26.0% (N = 19) reported HMSs for both partners. Among different-gender couples, 20 couples (29.0%) reported no HMSs, 14 (20.3%) reported male-only HMSs, 19 (27.5%) reported female-only HMSs, and 16 (23.2%) reported male and female HMSs. Among same-gender couples, one couple (25%) reported no HMSs and three (75%) reported HMSs for both partners.

Initial Relationship Satisfaction and Commitment among Different-Gender Couples

We examined the initial levels of relationship satisfaction and commitment among no HMS couples, one partner HMS couples and both partner HMS couples to describe how couples presented for therapy. Only different-gender couples are used here to interpret male versus female relationship satisfaction and commitment. Results of a MANOVA indicated a significant difference in male relationship satisfaction, F(2,63) = 8.29, p = 0.001, with a large effect size, partial η2 = 0.21, and in female relationship satisfaction, F(2,63) = 4.96, p = 0.01, with a large effect size, partial η2 = 0.14. Men (M = 3.73, SD = 2.79) and women (M = 3.73, SD = 2.37) in both partner HMS couples had significantly lower relationship satisfaction, than male partners (M = 6.52, SD = 2.38) and female partners (M = 5.74, SD = 2.32) in one partner HMS couples, and male partners (M = 6.75, SD = 2.15) and female partners (M = 6.25, SD = 2.69) in no HMS couples. No significant differences were found for relationship commitment among the couple types, ns.

Quantitative Analyses: Research Questions

Research Question 1: Do Trauma Couples Differ from No Trauma Couples?

Sessions Attended

An ANOVA was conducted to investigate whether number of sessions attended differed between no HMS couples (N = 21), one partner HMS couples (N = 32), and two partner HMS couples (N = 18). Results indicated no significant difference in number of sessions attended between no HMS couples (M = 10.81, SD = 12.13), one partner HMS couples (M = 9.75, SD = 12.91), and both partner HMS couples (M = 5.61, SD = 3.29), F (2,68) = 1.20, p = 0.31, and a small effect size, partial η2 = 0.03.

Termination

To investigate group membership and termination status, a chi-square test was conducted. Among the three groups, the relationship between group and termination status was not significant, χ2 = 5.05, df = 2, p = 0.08, but had a moderate effect size, Phi = 0.29. Ninety-three percent (N = 14 out of 15) of both partner HMS couples terminated without agreement or no showed. Only one couple terminated with agreement; this is lower than the expected count, 4.32.

Alliance

Using a sub-sample of the data (different-gender couples, N = 69), a MANOVA was used to investigate whether the alliance of male and female partners differed between the three groups. While it was not significant, results indicated a difference in the female partner’s bond with the therapist between the three groups, F (2,37) = 2.93, p = 0.07, with a large effect size, partial η2 = 0.14. Female partners in both partner HMS couples reported a lower bond with the therapist (M = 5.62, SD = 0.94) than female partners in one partner HMS couples (M = 6.35, SD = 0.59). No other differences were found.

Research Question 2: Does it matter whose trauma it is?

Sessions Attended

Using data from the entire sample, an ANOVA was conducted to investigate whether number of sessions attended differed between no male HMS couples (N = 41) and male HMS couples (N = 30) and no female HMS couples (N = 35) and female HMS couples (N = 36). Results indicated no significant interaction or main effects on number of sessions attended, F (2,68) = 1.20, p = 0.31, partial η2 = 0.03.

Termination Status

To investigate group membership (male HMS vs. no male HMS, no female HMS vs. female HMS) and termination status, two chi-square tests were conducted. Among no female trauma couples and female trauma couples, and termination status, a non-significant association was found, χ2 = 5.15, df = 1, p = 0.023, with a medium effect size, Phi = 0.30. Couples with female HMS had less terminations by agreement than expected (4 as opposed to 8). However, no significant association was found for couples with male trauma versus couples without male trauma and termination status, χ2 = 0.57, df = 1, p = 0.45, Phi = 0.10.

Alliance.

To investigate whether couples with male HMS (compared to couples without male HMS) and couples with female HMS (compared to couples without female HMS) differed in alliance, a MANOVA was used to analyze the data. No significant interaction or main effects were found, ns, and no moderate or large effect sizes were found (all partial η2 < 0.06).

Discussion

The purpose of this study was to describe a sample of couples, who presented for treatment about couple problems, in terms of their interpersonal trauma histories, and to investigate the associations between interpersonal trauma history and therapeutic alliance, number of sessions attended, and type of termination. Trauma-informed care is essential given CFTs will likely treat clients who have experienced interpersonal trauma (Johnson and Williams-Keeler 1998). Our results support this claim as 71.2% of couples in our sample had at least one partner who reported an interpersonal HMS event.

Content analyses revealed that for couples who reported interpersonal trauma history, the most frequent trauma type for male and female partners was abandonment by a spouse or partner. However, abandonment was not the most distressing for participants. For male partners, abandonment, childhood sexual abuse, and physical abuse in childhood were classified as traumatic stressors most frequently, and male partners who reported childhood physical abuse were the most likely to meet criteria for PPD. For female partners, childhood physical abuse and sexual abuse in adulthood were reported as a traumatic stressor most frequently, while female partners who reported physical childhood abuse were the most likely to meet criteria for PPD. These results lend insight into the trauma types and degrees of distress that couple members may report when seeking couple and family therapy. Thus, couple and family therapists need to be informed about trauma history in the couple context (e.g., its potential impact on relationship satisfaction and other factors).

Having experienced trauma in the past, couples may be entering their relationships with symptoms impacting their current relationship satisfaction. Trauma symptoms including sleep difficulties, dissociation, and sexual problems have been found to significantly predict lower relationship satisfaction for both partners (Nelson Goff et al. 2007). Similarly, couples in which one or both partners report childhood abuse have been shown to report significantly lower marital satisfaction, higher individual stress, and lower family cohesion (Nelson and Wampler 2000). For treatment to be effective, it is important for clinicians to understand the symptomology clients are entering therapy with, and how those symptoms impact the individual, their partner, and ultimately, the relationship system. Therapists could benefit from using an instrument like the THS to identify frequently occurring trauma types and further explore the symptoms associated with said types, ultimately preparing to address these symptoms and/or their impact within the couple relationship.

In addition to providing a sample description of couples presenting for treatment and their trauma histories, one of the primary goals of this study was to explore whether trauma couples differed from no trauma couples in terms of therapeutic alliance, number of sessions attended, and termination status. When comparing alliance between groups, results suggested that female partners in both partner interpersonal HMS couples reported a lower bond with the therapist than female partners in one partner HMS couples and no HMS couples. Given therapeutic alliance is a strong predictor for therapeutic outcomes, this outcome may be important for CFTs to consider when working with female partners with traumatic backgrounds when their male partner also has an interpersonal trauma history. The therapist may need to give increased support to these clients during the joining process in order to build a strong foundation for treatment. Additionally, 93% of both partner HMS couples terminated without agreement or no showed. These couples may be more prone to non-traditional and spontaneous termination processes.

A second goal of the study was to explore whether trauma history from either the male or female partner associated with clinical outcomes. While there were no significant findings in terms of sessions attended, alliance, or termination status, a notable effect size indicated that couples with female HMS had less termination agreement than couples with female partners without HMS. Conversely, this was not the case when comparing couples with and without male HMSs. Given our findings, a complex interaction of interpersonal trauma history, gender, and therapeutic alliance may contribute to termination status. Future research should investigate this potential interaction; for example, whether low female bond with the therapist contributes to this exceptionally high rate of termination without agreement and no-show rate among couples who present with interpersonal trauma history.

Even though no significant results came from the number of sessions, termination data, and alliance this may be because of a lack of power. For example, when both partners reported past interpersonal trauma experiences, they attended only half as many sessions as couples who did not report trauma and couples with one partner who reported past interpersonal trauma. When it comes to attending therapy, female partners with interpersonal trauma history may be driving whether the couple attends therapy or not, given the alliance and termination results. However, this speculation needs to be addressed with a larger sample.

With these results, couple and family therapists should consider the importance of assessing for interpersonal trauma history in their clients as it may associate with their initial levels of alliance and relationship satisfaction. Because forming a therapeutic alliance is so important to the effectiveness of therapy (Friedlander et al. 2018; Fullard 2018), therapists may need to take more time working on this relationship. It may take longer for clients with interpersonal trauma histories to form strong alliances with their therapists than clients without this history. Future research could use longitudinal designs to test these assumptions. Additionally, therapists interested in treating couples with trauma may want to engage in Emotion-Focused Therapy (EFT) as Johnson and Williams-Keeler (1998) conceptualized EFT as a treatment for couples impacted by trauma. Over 12–20 sessions, couples engage in experiential emotional situations which expands each partner’s worldview, as well as forces the couple into new interactions and related new experiences. This is done through nine steps, which map onto the three stages of trauma treatment as described by McCann and Pearlman (1990): stabilization, building self and relational capacities, and integration. However, EFT needs more testing, particularly with larger samples, as evaluations of this approach have provided mixed results on its effectiveness with trauma couples (Dalton et al., 2013; MacIntosh & Johnson, 2008). Although this study’s sample may be limited in number, it provides evidence that couples seeking therapy are likely to have interpersonal trauma, and this trauma may interfere in their own relationships, and in their relationships with therapists.

Limitations and Future Directions

There are several limitations of our study. First, the generalizability of our research is limited given that our sample included few (< 5) same-gender couples and did not include couples with partners who identified as transgender or nonbinary. Secondly, we used a single-item measure to capture relationship satisfaction. Though the questionnaire is meant to be brief for client convenience, we recognize this may introduce validity and reliability concerns given clients may define relationship satisfaction differently. In addition, we used a rather small sample (N = 73) to investigate the research questions. As such, increasing statistical power in future studies may lead to significant differences and trends. Additionally, we employed a cross-sectional design. Longitudinal data is needed to investigate this topic further in terms of investigating whether these initial differences resolve over the course of treatment. Furthermore, it is worth noting that confounding variables (e.g., intensity of trauma, duration of trauma, perceived distress from trauma, comorbid mental health concerns) could have an influence on the results. Though this study offers initial insight into how trauma histories may influence the therapeutic process, capturing the nuances of trauma history as well as possible comorbidities is important in continuing this line of research. Moreover, we did not consider differences among participants who reported an event as a HMS, TS, or meeting criteria for PPD. Differences among these clients was not captured, which may explain the limited number of differences among groups. This could not be carried out in the current study because of small sample sizes (see Table 1), but future research should account for the degree of distress with a larger sample. We also recognize that just because a participant did not report an HMS event on the THS questionnaire, does not exclude the possibility that a person did experience trauma at some point. Omission of trauma history could have been due to a variety of factors (dismissed trauma, minimization, denial, inability to access traumatic memory or incongruence between their experienced trauma and THS items). Moreover, given couples are likely to present to therapy for relationship issues, they may not see the THS assessment as relevant to their treatment goals. Simply, it is possible that some couples in the no HMS group have experienced trauma that was not captured on the assessment.

Future researchers should continue investigating trauma assessment and how the presence of trauma in one or both partners are defined, captured, and operationalized. In addition, the exploration of trauma and its impact on clinical outcomes (alliance, termination, symptom management and compliance) and relational variables (satisfaction, commitment, communication, support, etc.) is paramount for this line of research. Furthermore, exploration of indirect effects between trauma, therapy outcomes, and relational outcomes could give more holistic insight into the therapy process and underlying mechanisms for couple and family therapists.

In addition to exploring trauma assessment and its impact on couples and treatment, investigating effective interventions that alleviate distress for couples who have experienced traumas is also warranted. Some of the more commonly used trauma-informed methods are prolonged exposure (PE), cognitive processing therapy (CPT), and eye-movement desensitization and reprocessing (EMDR). PE, CPT, and EMDR have strong empirical support and are commonplace interventions used by mental-health professionals (Field and Cottrell 2011; Lenz et al. 2017). Though these therapies have been shown to be highly effective, most of these treatments are geared towards individuals rather than couples or families. Studies have highlighted that traumatic experiences can disrupt interpersonal functioning later in life (DiLillo 2009; Layne et al. 2014). Specifically, in romantic relationships, trauma has been associated with altered communication processes, changes in connection and understanding, sexual intimacy concerns, relationship distress, partner support and resources in the relationship (Goff et al. 2006). Furthermore, trauma has been found to exacerbate boundary issues, triggers, and hinder coping mechanisms for couples (Henry et al. 2011). Given the negative impact trauma can have on relationships, it is important for mental-health professionals to employ effective therapies that are specifically tailored towards couples in alleviating/coping with traumatic symptoms.