Upgrade Your Assessment Toolkit: Research-Based Tools for Couple Therapy

Last year, PACT faculty member Krista Jordan, PhD, and PACT developer Stan Tatkin, PsyD, MFT, offered a workshop on evidence-based assessment instruments for couple therapists. 

In the workshop, Krista and Stan talked about how to integrate brief questionnaires to stimulate conversations, set goals, and track progress with your clients. Below, we cover these simple but essential measures you can use quickly and easily in your PACT practice.

Several of these assessments are used in the PACT Institute’s own outcome study project, which aims to demonstrate PACT as a viable evidence-based program and to establish a legacy for treating couples. Learn more about the PACT Outcome Study now in progress. 

Why Measure?

1. Quickly understand who your clients are. 
2. Build rapport (people like testing, feels objective)
3. Track progress objectively and reliably over time.
4. Help with deciding when to discharge.
5. Publish  your own case studies (no IRB needed).
6. Publish study through independent IRB (no academic affiliation needed).

A Note On Measures

It’s important to use measures that have been established as reliable, valid, and sensitive to change over the time period you are thinking of using. Many well-established measures are available in the public domain. 

Now, let’s talk about measures that capture the individual and measures that capture the couple. 

Individual Measures

Childhood Trauma

Why screen for childhood trauma? Significant childhood trauma can predict disorganized or dysregulated attachment. This can require significant modification of PACT, including modifications in the administration of the PAI, using less bottom-up interventions, using shorter sessions, and increasing frequency of visits. 

Adverse Childhood Experiences Scale (ACES)

• ACES measures adverse experiences before the age of 18 including things like physical, sexual, and/or emotional abuse. 
• Scores greater than 4 tend to be significant for greater risk toward physical and mental health problems. 
• Evidence supports that an ACES over 4 may indicate a greater risk for disorganized attachment. 
• Absence of emotional support in the ACES questionnaire was most predictive of being classified as U/CC. 

Strengths of the ACES questionnaire:

• Short
• Easy to score
• Helps to quickly identify possible traumatic events so you can plan your sessions accordingly
• Information can also be given to the client’s healthcare provider for enhanced vigilance toward known sequelae of a high ACES score.

Substance Use Disorder

Why screen for substance use disorder? Active substance abuse is the great mimicker of all psychiatric disorders, so you need to know if this is present before your formulation of a couple. Active substance abuse may be a criteria for either substantially altering PACT or not using PACT altogether.

The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool 

The TAPS can be self-administered online. TAPS can also be given via a personal interview with a medical or mental health professional. The PACT Outcome Study uses this tool.

The TAPS tool has two parts. TAPS-1, the first component, has a 4-part screening for tobacco, alcohol, non-medical use of prescription drugs, and illicit drugs. If patients have a positive screening on TAPS-1, they move on to the second part. TAPS-2 is a series of assessments for the risk of substance use disorder for particular substances. 

TAPS takes under 5 minutes to administer and is a proven way to identify patients who have substance use disorders and other related risks. 

Domestic Violence

Why screen for domestic violence? Domestic violence is a contraindication for using PACT therapy as PACT can be activating and even destabilizing in the short-term. Couples who cannot manage conflict without violence need a more containing model.

The PACT Outcome Study uses the Revised Conflict Tactics Scale, Version 2. The CTS2 is a 39-item self-report questionnaire devised to assess the nature and frequency of tactics used by partners to manage conflict in an intimate relationship. It is designed to be understood by people with a sixth-grade reading ability, and its simple format allows it to be fully administered in 10–15 minutes (Straus et al., 1996). CTS2 does require purchasing or permission to use.

The Woman Abuse Screening Tool/Woman Abuse Screening Tool-Short Form (WAST/WAST-SF) is available in the public domain. The full version is 8 items, and the short version is the first 2 items of the original. In the validation study, results found significant differences between the abused and non-abused women on the mean overall scores.

The short-form version uses the first 2 questions, which ask general relationship questions as opposed to specific questions about violence. Although studies were limited, those performed found that the WAST has good reliability and validity and one study found that the WAST differentiated abused and non-abused women. The short version correctly classified 91.7% of the abused women and 100% of the non-abused women in the validation study. The abused women in the validation study also identified these 2 questions as ones they would be most comfortable answering if asked by their family physicians. 

Depression Symptoms

Why screen for depression? Depression can impair cognitive abilities, including cognitive flexibility. Depression can also diminish libido and pleasure capacities, which can both impact the coupleship. Secure-functioning couples experience less depression. 

Patient Health Questionnaire (PHQ)-9

• Good reliability and validity
• Short
• Easy to score

Hamilton Depression Rating Scale 

• Semi-structured interview omits self-report bias
• Reliable and Valid 

Anxiety Symptoms

Why screen for anxiety? Anxiety can contribute to inflexibility and over-controlling behavior which impacts coupleship. Secure-functioning couples experience less anxiety. 

The Generalized Anxiety Disorder (GAD)-7 

The GAD-7 was developed to measure Generalized Anxiety Disorder (GAD) symptoms and also has established diagnostic accuracy for panic disorder, social anxiety, and PTSD. The GAD-7 is a 7-item scale, with each item rated from 0 (none of the days) to 3 (nearly every day) over the past 2 weeks. 

• Good reliability and validity 
• Short
• Easy to score

Hamilton Anxiety Scale (HAM-A)

Benefits of the HAM-A

• Semi-structured interview has good reliability and validity 
• Omits self-report bias

Deficits of the HAM-A 

• Somatic anxiety subscale is also strongly related to somatic side effects, which limits its applicability in anxiolytic treatment studies. 

The PACT Outcome Study uses the PROMIS as it is short and a measure of general anxiety.

PROMIS Anxiety 

PROMIS Depression 

Mindfulness 

Why measure mindfulness? Mindfulness has been shown to correlate to mentalization/reflective functioning, which helps partners hold each other’s minds in mind. The capacity for mindfulness has been shown to improve couples relationship satisfaction. Mindfulness has also been shown to improve emotional regulation skills, contributing to improved conflict resolution and emotional capacity for caregiving. We work on developing mindfulness in PACT through cross-questioning and the building of the owner’s manual. 

The Five Facet Mindfulness Questionnaire- Short Form (FFMQ-SF) looks at emotional regulation skills and ability to make your partner the object of your attention. This measure has 24 items and is sensitive to change over time. The FFMQ covers 5 facets/factors that have been identified as the main building blocks of trait mindfulness, the original measure is 39 items. However, the short form has proven validity and reliability assessing the following traits: Observing, Describing, Acting with awareness, Accepting without judging, and Non-reactivity. 

Overall Impact of Therapy

Why measure the overall impact of therapy? Psychotherapy is an enterprise for change, and measuring broad areas of change can help therapists and clients track the efficacy of therapy over time, which can improve alliance and satisfaction as well as potentially guide treatment alterations.  

Outcome Rating Scale (ORS) 

Developed as a brief alternative to the Outcome Questionnaire 45.2 (which is 45 items), the ORS has only 4 items and is one of the measures being used in the PACT Outcomes Study.

You can find information about ORS in the Journal of Brief Therapy article, The Outcome Rating Scale: A Preliminary Study of the Reliability, Validity and Feasibility of a Brief Visual Analogue Measure.  

Benefits of the ORS include:

• It’s brief, only 4 questions!
• It’s easy to score for clinicians, you just measure a line in millimeters.
• It’s reliable and valid.
• It’s sensitive to even small changes over time.

Couples Measures

Couples Satisfaction

Why measure couples adjustment or satisfaction? While these are imperfect representations of the complexity of a couple, they are frequently considered to be relevant to most couples and also widely studied, which makes them easy to compare to the literature. These scales can be used to track progress over time, which can be motivational to the couple and helpful to the therapist for treatment planning.  

The Dyadic Adjustment Scale (DAS-32), devised in 1976, has 32 items. The newer short version has 16 items. Both have good reliability and validity. Several large-scale studies have shown the DAS to be the most widely used measure in couples studies. In the original study, the DAS differentiated successfully between married and divorced couples. 

The original 32-item DAS has 4 subscales: 

• Dyadic Consensus
• Dyadic Satisfaction
• Dyadic Cohesion
• Affectional Expression

The DAS has been used in several Gottman studies:

Davoodvandi M, Navabi Nejad S, Farzad V. (2018). Examining the Effectiveness of Gottman Couple Therapy on Improving Marital Adjustment and Couples' Intimacy. Iran Journal of Psychiatry, 13(2):135-141

Padash Z, Yousefi Z, Abedi M.R, Torkan H. (2021) Efficacy of Gottman’s marital counseling on marital satisfaction and marital adjustment of married women willing to get divorced. Journal of Psychological Science, 20(104): 1423-1436. ) 

And in EFT studies:

Halchuk, R., Makinen, R., Johnson, S. (2010). Resolving Attachment Injuries in Couples Using Emotionally Focused Therapy: A Three-Year Follow-Up, Journal of Couple & Relationship Therapy 9(1):31-47

Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler, D. (1999). Emotionally focused couples therapy: Status and challenges. Clinical Psychology: Science and Practice, 6(1), 67–79. 

MacIntosh, H. B., & Johnson, S. (2008). Emotionally focused therapy for couples and childhood sexual abuse survivors. Journal of Marital and Family Therapy, 34, 298–315.

Benefits of the DAS include:

• Easy for clients to fill out
• Easy for clinician to score
• Well-established cutoff score for “distressed couples”
• Sensitive to change over time 
• Includes several well-validated short forms, including a 4-item and a 7-item version

Problems with the DAS include:

• Test sample was white, married, cis, hetero, and from working- and middle-class backgrounds. 
• DAS does not adequately measure intimacy, sexuality, or potential for violence.
• The Affective Expression subscale has only borderline acceptable reliability.
• Some items are not relevant for non-cohabiting couples.
• The item about “correct or proper behavior” may sound dated to a lot of people. 

Couples Satisfaction Index (CSI) 

Notes regarding the CSI:

• Original has 32 questions
• Good reliability and validity
• Short versions available (4 or 16 items)
• Compared with the DAS, the CSI scales show higher precision of measurement and correspondingly greater power for detecting differences in levels of satisfaction.
• Created off larger samples (6,389 individuals) compared to the 218 married and 94 divorced heterosexual, cisgendered people for the DAS original study sample
• Moderately better original sample in terms of diversity: 76% Caucasian compared to 100% for DAS. CSI included 5% African American, 5% Latino and 4% Asian respondents.
• Worse in terms of gender (80% female) vs. 50% female for DAS
• 39% graduated college (16 years of education) compared to 13 years for DAS 
• 24% married compared to 100% married or divorced for DAS (no cohabitating or engaged or dating). CSI included 16% engaged and 60% dating seriously.