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Journal of Couple & Relationship Therapy
Innovations in Clinical and Educational Interventions
ISSN: 1533-2691 (Print) 1533-2683 (Online) Journal homepage: https://www.tandfonline.com/loi/wcrt20
Assessing the Effectiveness of Solution-Focused
Brief Therapy for Couples Raising a Child with
Autism: A Pilot Clinical Outcome Study
Brie Turns, Sara Smock Jordan, Kevin Callahan, Jason Whiting & Nicole Piland
Springer
To cite this article: Brie Turns, Sara Smock Jordan, Kevin Callahan, Jason Whiting & Nicole
Piland Springer (2019): Assessing the Effectiveness of Solution-Focused Brief Therapy for Couples
Raising a Child with Autism: A Pilot Clinical Outcome Study, Journal of Couple & Relationship
Therapy
To link to this article: https://doi.org/10.1080/15332691.2019.1571975
Published online: 27 Feb 2019.
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Assessing the Effectiveness of Solution-Focused Brief
Therapy for Couples Raising a Child with Autism: A
Pilot Clinical Outcome Study
Brie Turns
a
, Sara Smock Jordan
b
, Kevin Callahan
c
, Jason Whiting
d
, and
Nicole Piland Springer
e
a
Marriage and Family Therapy, Fuller Theological Seminary Arizona, Phoenix, Arizona, USA;
b
Couple and Family Therapy Progam, University of Nevada-Las Vegas, Las Vegas, Nevada, USA;
c
University of North Texas Kristin Farmer Autism Center, Denton, Texas, USA;
d
Brigham Young
University, Provo, Utah, USA;
e
Texas Tech University, Lubbock, Texas, USA
ABSTRACT
The increased diagnostic rates and awareness of autism spec-
trum disorders (ASD) have led to more couples with children on
the spectrum seeking professional services. Parents with a child
with ASD have reported higher levels of marital dissatisfaction
and parental stress than couples raising a child with other devel-
opmental disabilities. Unfortunately, there is a lack of research
investigating the effectiveness of treatments for couples raising
a child with ASD. In this pilot clinical outcome study, a multiple
baseline design was used to identify the effectiveness of solu-
tion-focused brief therapy for couples raising a child with ASD.
KEYWORDS
Autism spectrum disorder;
couples therapy; solution-
focused brief therapy;
multiple baseline design
Autism spectrum disorder (ASD) is a neurodevelopmental disorder currently
affecting 1 of 59 children (Baio et al., 2018), and has been called the most
severe childhood behavioral disability (Newsom & Hovanitz, 2006). Individuals
with ASD display deficits in their communication and social interaction and
repetitive, restricted interests or patterns of behavior (American Psychiatric
Association [APA], 2013). Impairments may include limited social interactions,
a lack of shared emotion, or an inability to decipher some forms of communi-
cation, such as sarcasm. Repetitive, restricted interests or behavior can include
self-stimulatory behavior, such as hand-flapping, repetitive speech, or excessive
adherence to routine (APA, 2013). Although parents often notice impairments
around the child’s first birthday (Hess & Landa, 2012), most children are
diagnosed around four years of age (Baio et al., 2018).
Parents raising a child with autism
An ASD diagnosis is complex and varied in its presentation and severity
level. It almost always has a significant effect on the family, particularly the
CONTACT Brie Turns brieturns@fuller.edu Fuller Theological Seminary Arizona, Marriage and Family
Therapy, 1110 E. Missouri Dr., Phoenix, AZ 85014, USA.
ß2019 Taylor & Francis Group, LLC
JOURNAL OF COUPLE & RELATIONSHIP THERAPY
https://doi.org/10.1080/15332691.2019.1571975
parental unit. Mothers and fathers of children with ASD report reduced
psychological well-being, increased social isolation, and emotional distress
(Higgins, Bailey, & Pearce, 2005). Parents also display increased vulnerabil-
ity to depression, anxiety, and pessimism (Davis & Carter, 2008).
Parents of children with ASD report higher levels of parenting stress
than o dparents of a child with Down syndrome, fragile X syndrome, or
cerebral palsy (Dabrowska & Pisula, 2010). Some of the most stressful fac-
tors of raising a child with ASD are the permanency of the diagnosis and
lack of acceptance of the child’s behaviors by family members and society
(White, 2009). These challenges can often strain the marital relationship
(Benson & Kersh, 2011; Brobst, Clopton, & Hendrick, 2009; Hartley et al.,
2010). Although there is conflicting evidence regarding whether divorce
rates are higher (Freedman, Kalb, Zablotsky, & Stuart, 2012; Hartley et al.,
2010), parents of a child with autism report greater marital dissatisfaction
in comparison to parents of typically developing children, and more severe
symptoms of ASD are associated with higher reported levels of strain
among these parents (Brobst et al., 2009; Hastings & Johnson, 2001). For
example, parental stress and marital dissatisfaction are associated with defi-
cits in the child’s social skills and increased self-injurious behaviors
(Hastings & Johnson, 2001). Thus, improving parents’health and well-
being could increase the quality of care they provide to their children with
ASD (Keen, Couzens, Muspratt, & Rodger, 2010).
Treatment for parents raising a child with autism
One effective intervention for parents of a child with ASD is education
about their child’s diagnosis and treatment (Koegel, Bimbela, &
Schreibman, 1996). Mothers who participated in an informational program
about ASD experienced larger decreases in depressive symptoms in com-
parison to mothers without treatment (Bristol, Gallagher, & Holt, 1993). In
another study, acceptance and commitment therapy (ACT) was provided to
parents raising a child with ASD in a 2-day, group workshop format
(Blackledge & Hayes, 2006). Results from this study –a psychoeducation
and skills training program –also showed improvements on the depression
and symptomatic distress scales.
Another effective model of therapy for parents raising a child with aut-
ism is emotionally focused couple therapy (i.e., Lee, Furrow, & Bradley,
2017; Ramisch, Timm, Hock, & Topor, 2013). Ramisch et al. (2013) pro-
vided 10-week, 1-hour in-home sessions of EFT and found that all three
couples had a better understanding of their conflict pattern. More recently,
seven couples who received twelve 75-minute sessions of EFT, reported
increased marital intimacy and decreased marital distress at post-treatment
2 B. TURNS ET AL.
and during a 6-month follow-up (Lee et al., 2017). Although EFT is shown
to be a suitable option for couples, there is still a need to identify other
effective models for working with couples raising a child with ASD.
Solution-focused brief therapy
Solution-focused brief therapy (SFBT; de Shazer, 1985) is an empirically
supported model that focuses on the client’s resources and has been recom-
mended for parents of children with ASD (Brockman, Hussain, Sanchez, &
Turns, 2016; Jordan & Turns, 2016). Although SFBT has been shown to
help a variety of populations (McCollum & Trepper, 2001; Smock et al.,
2008), there is limited research investigating its effectiveness for couples’
treatment. One study implemented a 6-week solution-focused group ther-
apy and found that, in comparison to the control group, couples receiving
SFBT improved in cohesion, consensus, and satisfaction, as measured with
the Dyadic Adjustment Scale. It should be noted that affectional expression
was not related to the independent variables. Participants also reported less
intense arguments, blaming their partner, more affection and problem-solv-
ing, and greater focus on solutions and the use of tools (Zimmerman,
Prest, & Wetzel, 1997).
To date, only one study has used SFBT specifically with parents raising a
child with ASD (Kenney, 2010). This pilot study assessed the effectiveness
of solution-focused interventions on cognitive distortions, parental stress,
and the therapeutic alliance. Results of this study demonstrated a reduction
in symptoms across all domains of stress and cognitive distortions in one
of three participants. Two of three participants experienced a reduction in
self-blame. Limitations of the study included a limited sample size of only
three participants and a lack of clarity about how therapists were trained in
solution-focused interventions (Kenney, 2010). An important limitation to
mention is the lack of investigation assessing for relationship satisfaction
and improvement, which the current study does seek to understand.
The purpose of the current pilot clinical outcome study was to investi-
gate the effectiveness of solution-focused brief couples therapy (SFBCT) on
marital satisfaction and well-being for parents raising a child with ASD.
This study also attempted to determine if a relatively short-duration parent
intervention could have an impact on overall quality of life.
Method
Design
The reporting of outcomes in therapy-based treatment studies traditionally
relies on pre- and post-measures and anecdotal reports by participants.
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 3
However, such research designs often lack clear and robust demonstrations
of experimental effect. In this study, a multiple baseline (MB) design across
subjects was used to investigate the effectiveness of SFBCT. An MB design
across subjects is an experimental design that begins with the concurrent
measurement of the dependent variables (DVs) for all participants during a
baseline (i.e., pre-intervention) condition. This is followed by the applica-
tion of the treatment variable to only one subject, while baseline conditions
remain in effect for all other subjects. Only after a significant change has
been observed for the first subject receiving treatment, the intervention is
delivered to a second subject. As before, all remaining subjects remain in
the baseline condition receiving no treatment, and the researchers continue
to collect measurements of the DVs on all subjects. After change occurs in
subject 2, the treatment is systematically delivered to subject 3, and so on.
In an MB design across subjects, “experimental control is demonstrated
if each subject shows changes, when, and only when, the treatment variable
is introduced”(Cooper, Heron, & Heward, 2007, p. 699). In this study, if
the hypothesized positive changes in the level of the DVs seen in baseline
were to occur only on the implementation of SFBCT, this replication of
effect could be attributed to the treatment rather than to random events
(Kazdin, 1982).
Multiple baseline designs are the most widely used experimental designs
for evaluating treatments within single-subject research (Cooper et al.,
2007). They are especially relevant as an alternative design for evaluating
complex therapeutic interventions where the number of participants is
expected to be relatively small, when it is impractical, undesirable, or
unethical to withdraw treatment in order to demonstrate experimental con-
trol, and when multiple opportunities to measure the impact of treatment
are preferred (Cooper et al., 2007). “The multiple baseline design is ideally
suited to the evaluation of the progressive, multiple behavior changes
sought by many practitioners in applied settings”(Cooper et al., 2007,p.
218; Hall, Cristler, Cranston, & Tucker, 1970). The relative simplicity of the
MB design and ease in conducting graphic visual analysis of the results are
other important advantages of using this design (Hall et al., 1970). Thus,
the MB design across subjects is considered especially appropriate for
determining the efficacy of therapeutic treatments such as SFBCT.
Participants
Couples raising a child with ASD
Participants for this pilot study had to be married, at least 18 years of age,
and currently raising a child between 4 and 16 years of age diagnosed with
ASD. Additional criteria included: (a) the couple was not currently
4 B. TURNS ET AL.
receiving couples therapy elsewhere; (b) the child’s score for the Gilliam
Autism Rating Scale-3 (GARS-3) must indicate an Autism Index score of
55 or higher; (c) at least one member of the couple needed to score a 63 or
higher on the Outcome Questionnaire 45.2; and (d) at least one member of
the couple needed to score a 16 or lower on the Kansas Marital Satisfaction
Scale, indicating some degree of marital distress (Crane, Middleton, &
Bean, 2000). Table 1 details additional characteristics of the participants.
Participants were recruited through referrals, via email, sent from two
local autism education and research centers in the Southwestern United
States. Five of eight couples who completed the initial paperwork with the
primary researcher qualified for the study. All five of the couples who
began the study completed the entire program.
Marriage and family therapists
Two doctoral-level trained marriage and family therapy (MFT) interns
were recruited in order to provide the SFBCT. Inclusion criteria for the
therapists consisted of: (a) currently enrolled in the MFT doctoral program
where the research was taking place; (b) previously completed the SFBT
course offered at the university; and (c) previously participated in a 2-day
intensive training regarding families living with ASD conducted by the pri-
mary researcher. Therapists received 48 hours of manualized SFBT training
(Bavelas et al., 2013) and attended live, biweekly supervision from the
second author, a licensed marriage and family therapist supervisor. An add-
itional fidelity measure was the use of team members. At all sessions, two
other MFT interns observed and provided feedback during the study. All
therapists and observers attended supervision.
Procedures
Baseline condition
After participants provided consent and completed the first group of assess-
ments, the first three couples’scores were compared to identify the “most
distressed”couple. Best practice in using the multiple baseline research
design dictates beginning the therapeutic intervention as soon as possible
with participants demonstrating the greatest need (Cooper et al., 2007).
Couple 1 began the intervention condition (SFBCT) first while the other
two couples stayed in baseline (no treatment). While couple 1 only com-
pleted one baseline session, couple 2 waited 3 weeks and couple 3 waited
8 weeks before beginning treatment.
Multiple baselines were then established by staggering the beginning of
the intervention across all of the couples as described above. Couples who
remained in the baseline condition were asked to complete questionnaires
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 5
Table 1. Participant Characteristics.
Parent Demographics Prior Therapeutic Experience Reason(s) for Participation Child Characteristics
Couple 1 Hispanic None Identify ways to cope; Learn how to
parent as a team
7-year-old male with ASD, receiving OT, counseling,
and medications
Couple 2 Caucasian Mother bipolar
disorder (untreated)
Father: None
Mother: Numerous previous
therapists and psychiatrists
Identify ways to enhance the
father-son relationship
11-year-old male with ASD;10-year-old typically
developing sibling, both receiving
individual counseling
Couple 3 Caucasian Both previously received
individual counseling
Identify ways to parent as a couple 15-year-old female with ASD, receiving counseling,
equine therapy, OT, and medications; two
typically developing siblings
Couple 4 Caucasian Father: None
Mother: Individual therapy
Work on marital relationship 9-year-old with ASD receiving Speech Therapy
and medications; twin 5-year-old typically
developing siblings
Couple 5 Caucasian
Father self-identified ASD
tendencies and characteristics
Both previously participated in
individual and family counseling
Improve parenting and marital skills;
Learn about external family stressors
8-year-old male with ASD receiving Play Therapy;
two younger typically developing siblings
6 B. TURNS ET AL.
once a week, with each partner completing the Outcome Questionnaire
45.2 (OQ-45.2) and Kansas Marital Satisfaction Scale (KMSS) individually.
Scores on these repeated dependent measures (KMSS and OQ-45.2) were
graphed and analyzed to determine appropriate starting points for each
couples’SFBCT. Per established guidelines for using the MB design, cou-
ples in subsequent baselines began treatment when their baseline data dem-
onstrated stability and an appropriate trend, and only after the prior couple
showed a change while receiving SFBCT. Thus, after couple 2 reported a
difference in the outcome variables, couple 3 began treatment. These proce-
dures were repeated when additional couples were added later in the study.
Treatment condition
The intervention phase consisted of the therapist conducting six 1-hour
sessions of SFBCT based upon the manual (Bavelas et al., 2013). Appendix
Adescribes each intervention and provides an example.
Measurements
Treatment effectiveness
The Outcome Questionnaire 45.2 (Lambert et al., 1996) is a self-report
measure designed for repeated assessments of client status throughout ther-
apy. The 45-items are rated on a five-point Likert-like scale: 0 (never)to4
(almost always), yielding a possible total score from 0 to 180. High scores
indicate greater distress (e.g., anxiety, depression, somatic problems, and
stress) as well as interpersonal difficulties in social roles and overall quality
of life. A total score of 63 is considered clinically significant. The OQ-45.2
has shown sensitivity to changes in clients between sessions, while remain-
ing stable in untreated individuals, and is considered to be a reliable instru-
ment (a¼.93; Lambert et al., 2001).
Marital satisfaction
The Kansas Marital Satisfaction Scale (KMSS; Schumm, Nichols,
Schectman, & Grisby, 1983) is a self-report measure consisting of three
items on an 8-point Likert-like scale, ranging from 0 (extremely dissatisfied)
to 7 (extremely satisfied). The items are averaged to determine the overall
score, with a higher score indicating greater marital satisfaction. A score of
16 or lower indicates some degree of marital distress. Cronbach’s alpha
ranges from .84 to .98 on clinical populations (Schumm et al., 1983). The
KMSS is also sensitive to change in clients between sessions and is appro-
priate for repeated measures during therapy. Test-retest correlations of .71
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 7
were reported over a 10-week interval with a range of .62 to .72 over
6 months.
Child’s autism diagnosis and severity levels
The Gilliam Autism Rating Scale-Third Edition (GARS-3; Gilliam, 2014)
was used to confirm the autism diagnosis and to assess severity of the
child’s ASD symptoms. The GARS-3 has adequate reliability and validity
(Gilliam, 2014) and is used to identify autism, assess its severity, and deter-
mine appropriate intervention. It has 58 items measured on a 4-point
Likert-like scale from 0 (not at all like the individual)to3(Very much like
the individual). The Total Score of the GARS-3 provides an Autism Index
and Severity Level.
Marriage and family therapist skill level
The Family Therapist Rating Scale (Piercy, Laird, &, Mohammed, 1983)
was developed to ensure treatment quality and fidelity among therapists
and used to assess the therapists’skill level. Two independent raters, mas-
ter’s-level MFT interns, scored one randomly selected video-recorded ses-
sion of each of the study’s therapists using the Family Therapist Rating
Scale. No formal training was required to complete the scale. The scale
consists of 50 items scored on a 6-point Likert-like scale from 0 (not pre-
sent)to6(maximally effective). The reliability of this scale is high (.77;
Piercy, et al., 1983).
Therapist adherence to SFBCT
Fidelity of intervention was assessed by measuring therapists’adherence to
SFBCT. Smock et al. (2008) developed this checklist to ensure the standar-
dized delivery of the therapeutic model. The checklist consists of five essen-
tial SFBCT components scored “yes”or “no.”Every “yes”rating is given a
score of 1 and “no”ratings receive a zero. Therapist adherence to the
model is considered to be present if the average score of the raters was 4
or higher (Smock et al., 2008). Two master’s-level students, who were
unaware of the purpose of this study, were asked to complete the Family
Therapist Rating Scale and the adherence to SFBCT checklist.
Intervention
The first three couples were randomly assigned to a doctoral-level therapist
who provided SFBCT to each couple until six sessions were completed. The
remaining two couples were randomly assigned to a different therapist. The
therapists followed the Solution-Focused Brief Therapy Association
8 B. TURNS ET AL.
(SFBTA)’s manual (Baveles et al., 2013), which is available for download
(www.sfbta.org). This manual has been used among various populations.
The therapist participants were provided an outline for the session formats.
After each session, the primary investigator entered the room, the therapist
exited, and the couple completed the OQ-45.2 and KMSS.
Data analysis
A combination of visual and basic statistical analyses were used in this
study to evaluate the relationship between the independent variable (IV;
SFBCT) and DVs (KMSS for marital satisfaction and OQ-45.2 for overall
well-being). Interpretation of data in an MB design is based on graphic
presentation and visual analysis (Au et al., 2017; Center & Leach, 1984).
Replication of experimental effect across subjects and at different points in
time is considered evidence of a causal relationship between treatment and
positive outcomes. A line graph was constructed for each couple represent-
ing the session-by-session measurement of the OQ-45.2 and KMSS.
Evaluation of treatment effectiveness was accomplished by visual inspection
of the graphed data for differences between the baseline and intervention
phases for each couple (Center & Leach, 1984). Specifically, changes in the
levels, trends, and latency of the data were investigated in order to assess
the differences in client outcomes between baseline and intervention
phases. Thus, our visual analyses considered changes in the overall levels of
reported marital satisfaction and overall well-being between baseline and
treatment, the direction in trend lines (i.e., whether the observed trends
were therapeutic, level, or counter-therapeutic), and latency (the time it
took for the couple’s scores to begin changing after SFBCT
was introduced).
Results
Overall well-being
First, the OQ-45.2 showed a downward trend during the intervention
phase, indicating an improvement in the individual’s overall well-being (see
Figures 1 and 3). Table 2 indicates the means of each couple’s baseline
scores. The overall baseline mean score on the OQ-45.2 across all partici-
pants was 80.5. Prior to intervention, 8 out of 10 participants scored above
the OQ-45.2 distress cutoff score of 63. Two fathers (couple 2 and couple
4) scored below this. The baseline mean score for the combined group of
mothers was significantly higher than for fathers (mothers ¼93.2; fathers
¼67.9), although the mean scores for both were above the cutoff score
level on the OQ-45.2 before intervention. The baseline data for all couples
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 9
Figure 1. OQ-45.2 scores for couple 1 through 3.
Note: Horizontal scale indicates weeks and vertical scale indicates range of OQ-45.2 score. ¼
Female; m¼Male; SFBCT ¼Solution-Focused Brief Couples Therapy ---¼weeks missed
10 B. TURNS ET AL.
were stable and demonstrated appropriate trends, permitting the beginning
of treatment at the appropriate times as prescribed by the MB design.
Following treatment, the mean OQ-45.2 score for all participants was
73.0, with scores decreasing (i.e., improving) for six of the 10 participants.
Scores for four of five mothers and two of five fathers improved after the
6-week intervention. The scores for three of the five fathers increased
Figure 2. KMSS scores for Couple 1-3.
Note: Horizontal scale indicates weeks and vertical scale indicates range of KMSS score. ¼
Female; m¼Male; SFBCT ¼Solution-Focused Brief Couples Therapy ---¼weeks missed
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 11
following treatment, including the two fathers whose baseline scores
reflected lower levels of initial distress. However, overall group means
decreased for both mothers and fathers after intervention (mothers ¼83.0;
fathers ¼62.8), with the average score for fathers after treatment falling
below the cutoff score of 63 for clinically significant distress.
Analysis of trends indicates the predicted direction of outcomes if the
intervention was extended beyond the end of data collection (Cooper et al.,
2007). For the OQ-45.2, a therapeutic trend is observed by a descending
trend line in the intervention phase. Linear regression provides an accurate
Figure 3. OQ-45.2 scores for Couple 4-5.
Note: Horizontal scale indicates weeks and vertical scale indicates range of OQ-45.2 score. ¼
Female; m¼Male; SFBCT ¼Solution-Focused Brief Couples Therapy; --¼weeks missed
12 B. TURNS ET AL.
depiction of trends in single-subject analyses (Stocks, n.d.), and was used to
determine trends in the treatment phase for all participants. On the OQ-
45.2, seven of 10 participants demonstrated a therapeutic trend during
intervention. All trend lines for mothers were therapeutic, while fathers
demonstrated therapeutic trends in only two of five cases.
Marital satisfaction
The KMSS was used to assess marital satisfaction and was interpreted using
the same visual analysis as for the OQ-45.2. On the KMSS, upward trends
indicate an increase in marital satisfaction, with a score of 16 being the cut-
off for clinical significance (see Figures 2 and 4). At baseline, the KMSS
scores for nine of 10 participants fell below the cutoff level for marital sat-
isfaction; with an overall mean score of 12.8. The baseline mean score for
fathers was 12.0, and the mean for mothers was 13.6, indicating slightly
higher marital satisfaction by mothers prior to intervention. Baseline data
were stable, with appropriate trends, for all couples.
Following treatment, KMSS scores for five of 10 participants increased.
The overall mean score for all participants after the 6-week intervention
increased to 14.0. The post-treatment mean scores for both fathers and
mothers increased (to 13.0 and 14.9, respectively). Marital satisfaction
scores for three of the fathers and two mothers increased following inter-
vention. Trend lines during intervention were therapeutic in seven of 10
cases, suggesting that scores would be predicted to continue to improve if
therapy was sustained beyond 6 weeks.
Effect size
In addition to visual analyses, a measure of effect size was calculated to
provide an objective measure of the magnitude of treatment outcomes
(Parker & Hagan-Burke, 2007). Reporting of effect size is an indicator of
Table 2. Means of Couples Baseline and Intervention Scores
Partner OQ-45.2 KMSS
BIBI
Couple 1 Father 64 43.5 11 14.7
Mother 80 46.7 15 19.8
Couple 2 Father 60 64.5 CT 10.7 12.3
Mother 99.7 94.3 12.3 11.8 CT
Couple 3 Father 81.4 66 12.4 15
Mother 78.9 69.3 16.2 14.6 CT
Couple 4 Father 40 43.2 CT 11 10.2 CT
Mother 100 96.8 11 15
Couple 5 Father 94 97.3 CT 15 13 CT
Mother 107.3 108 CT 13.7 13.5 CT
Note: B¼Baseline; I¼Intervention; OQ-45.2 ¼Treatment Outcome Scale; KMSS ¼Marital Satisfaction Scale;
CT ¼counter-therapeutic.
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 13
high-quality and robust research in autism (Reichow, Doehring, Cicchetti,
& Volkmar, 2011). Effect size calculations also provide increased precision
in the measurement of intervention effects when the results are generally
not large and obvious using visual analysis alone (Dunst, Hamby, &
Figure 4. KMSS scores for Couple 4-5.
Note: Horizontal scale indicates weeks and vertical scale indicates range of KMSS score. ¼
Female; m¼Male; SFBCT ¼Solution-Focused Brief Couples Therapy; ---¼weeks missed
Table 3. Pre- and Post-Intervention Scores for GARS.
Pre-Intervention Post-Intervention
Child’s Age ASD Index SL ASD Index SL
Couple 1 7 125 3 117 3
Couple 2 11 117 3 86 2
Couple 3 15 112 3 93 2
Couple 4 9 108 3 100 2
Couple 5 8 111 3 109 3
Note: GARS-3 ¼Gilliam Autism Rating Scale; SL ¼severity level.
14 B. TURNS ET AL.
Trivette, 2004). Effect sizes can be interpreted by being grouped into cate-
gories with associated values. “Small”effect sizes range from .00 to .32,
“medium”effect sizes range from .33 to .55, and “large”effect sizes are .56
and greater (Lipsey, 1990). A commonly reported measure of effect size
within studies using single-subject research designs is Cohen’sdindex
(Dunst et al., 2004). This measure of effect size was calculated for all partic-
ipants across baseline and intervention phases for both the OQ-45.2 and
the KMSS using the following formula:
MIMB
ðÞ
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
SD2
IþSD2
B
=2
q
where MIis the mean score for the intervention, and MBis the mean score for
baseline. The effect size values and magnitudes for each participant are reported
in Table 5. Across both the OQ45.2 and the KMSS, effect size magnitudes were
Large or Medium for a total of ten (50%) of the dependent measures.
Family therapist skill level
The Family Therapist Rating Scale (Piercy et al., 1983) was administered to
address the potentially confounding variable of therapist skill level. A final
skill level rating was determined by adding each question’s numerical score (1
to 6, as described in more detail earlier), with a total possible score ranging
from 0 to 300. The average score for therapist 1 was 170 and for therapist 2
was 160.5. The mean total scores of each treatment group were compared to
see if there was a significant difference between means. After performing an
Table 5. Effect Size.
KMSS OQ 45.2
C1F 4.64 3.03
C1M 3.44 4.79
C2F 0 0.48
C2M 0.27 0.97
C3F 1.05 1.53
C3M 1.90 3.43
C4F 3.38 0.22
C4M 0.45 6.42
C5F 0.15 0.15
C5M 1.04 0.5
Group F 1.36 1.02
Group M 1 0.07
Overall 1.18 0.55
Note: C¼couple; F ¼female; M ¼male.
Table 4. tTests Comparing Therapists on the Therapist Rating Scale.
Mean Std. Deviation tdfSig.
Therapist 1 170 24.0 .450 2 .70
Therapist 2 160.5 17.7
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 15
independent samples ttest, there was no significant difference between the
therapists. In addition, the interrater reliability for this scale was .995. These
results indicate that the therapists’skill level was comparable (Table 4).
Therapist adherence to SFBCT
The second potential confounding variable was therapist’s adherence to
SFBCT, which indicates fidelity of treatment implementation. The therapist
raters randomly selected and rated three recorded sessions of each therapist’s
assigned couples, equaling three scores per rater, per couple. The scores for
each couple were averaged. Scores above 4 indicated therapist adherence to
the model in the delivery of therapy for each couple. The range of scores was
4.00 to 4.66. Based on all of the mean scores, both therapists adhered to SFBT
with all couples and implemented the intervention as prescribed.
Social validation
An important component of the effectiveness of any evidence-based or emerg-
ing intervention is social validity (Callahan et al., 2017). Social validity refers to
the acceptability of the goals, procedures, and outcomes of programs and inter-
ventions by their consumers (Kazdin, 1977;Wolf,1978). Thus, social validation
includes the satisfaction of treatments by those who receive, implement, and
oversee them (Alberto & Troutman, 2006). Social validity is a key factor in the
effective implementation of interventions for individuals with autism and their
families (Callahan, Henson, & Cowan, 2008). In this study, evidence of social
validity may be found in the post-therapy structured interview questions that
were asked by the primary researcher. Participants were asked after the first,
third, and sixth therapy session “How satisfied were you with the therapy?”
Nine of 10 participants gave positive feedback. For example, one couple stated
that they “enjoyed it very much,”while another stated that “every con-
versation”had been useful to either their family or their marriage.
Discussion
The purpose of this pilot study was to assess the effectiveness of a brief thera-
peutic treatment on the quality of life and marital satisfaction of parents raising a
child with autism. Using a novel research design in the field of marriage and
family therapy, SFBCT was delivered once per week for a total of 6 weeks for all
participants in the study. SFBCT was generally supported as an effective treat-
ment for parents of children with autism, especially for the mothers.
Nevertheless, there are several patterns to note. First, some participants (couple 1
and couple 3 father) appeared to show an improvement in their scores immedi-
ately after beginning treatment. These results concur with previous research by
16 B. TURNS ET AL.
Blackledge and Hayes (2006), who found improvements in parents’overall well-
being after attending a 2-day group workshop format. Other participants (moth-
ers in couples 2, 3, and 4) showed a decline or no change in scores for approxi-
mately three sessions, after which they showed improvement during the
remaining sessions. Previous researchers have found a similar trend for individu-
als receiving therapy; some decline before they “get better”(Lambert & Ogles,
2004). This may occur because attending therapy gives couples the opportunity
to begin discussing stressors that were previously being dismissed in their rela-
tionship. It is also important to note that each of these participants were females.
Someparticipants(couple2;couple5,fatheroffourchildren)didnotindicatea
change at all, or declined in their scores and did not improve before the end of
the study. Although there can be numerous explanations for the observed lack of
progress, past researchers have shown that some individuals simply may not
benefit from therapy (Lambert & Ogles, 2004). In addition, six therapy sessions
is a relatively short treatment period. It is possible further and more robust
improvements may have occurred if the treatment was extended.
The results of this study support the conclusion that SFBCT is an appro-
priate and potentially effective therapeutic option for couples raising a child
with ASD. Because the MB design demonstrates changes in the dependent
measures only when the treatment is introduced and a corresponding repli-
cation of effect across the participants is observed, it is likely that any posi-
tive changes were the result of the SFBCT intervention.
Results from the KMSS indicate similar trends to the overall well-being. Some
participants (couple 1; mother couple 4) reported immediate improvements in
scores. Based on the visual analysis used when assessing MB designs, immediate
changes in scores from baseline indicate that the intervention is the likely reason
for the observed improvement (Kazdin, 1982). While other participants (father
couple 4, mother couple 2, father couple 3) showed no immediate change or a
decline in scores after one or two sessions, followed by an improvement after a few
sessions. This may be similar to the trend that occurred with the OQ-45.2, where
an initial decline in scores occurs before improving (Lambert & Ogles, 2004).
Others decreased in their scores (father couple 2, mom couple 3) and did not
improve throughout the remainder of treatment. Although the majority of clients
did improve in their marital satisfaction, not all did. Again, it is possible that some
may have improved with more treatment. Previous research studies have indicated
similarresults.Thecurrentstudy’s results indicate that SFBCT was effective for
improving couple’s marital satisfaction and could be used for couples.
Implications
There is a need for increased research studies that assess the effectiveness of
systemic models of therapy for couples raising a child with ASD. The results
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 17
of this pilot study provide initial and encouraging evidence that SFBCT is a
useful model for helping this underserved population, and it would be helpful
to apply and adapt some of its techniques with couples in similar circumstan-
ces. For example, couples in this study were encouraged to set realistic,
observable, and measurable goals consistent with SFBT’s goal setting criteria.
However, couples that would like to “cure”their child’s ASD will likely not
experience clinical improvements. Similarly, the “Miracle Question”may also
need to be slightly reworded to display sensitivity to the unique circumstances
of ASD. Also, in this study at least one partner of each couple reported to
either the therapist or interviewer their strong desire for change and seeking
professional help. It is likely that client’s who have a strong desire to improve;
they may experience better outcomes than clients who are less motivated.
Finally and significantly, SFBCT is an attractive option when working with
couples raising a child with ASD. There are many factors of a child’s life that
can be challenging for a parent to manage, such as symptomatic behaviors,
lack of support from clinicians, and increased marital problems. SFBCT
allows parents to focus on their strengths and resources rather than the prob-
lems that brought them to therapy. SFBCT is also one of the only therapeutic
approaches to emphasize goal-setting within the model, as well as encourage
a focus on exceptions. Such an approach may provide parents with an alterna-
tive for the problem-focused interventions that can be prominent given the
nature of problematic ASD-related behavioral patterns.
An additional implication to discuss is the how clinicians should be
trained to work with couples raising a child with ASD. Currently, many
training programs do not include specific education on families raising
children with special needs, let alone ASD. This study has shown that if a
clinician is well-trained in SFBT, they should be able to effectively treat
and help couples raising a child with ASD.
Limitations and future research
Although the number of participants in this study met the sample require-
ments for a MB design (a minimum of three to five participants), it remains a
small sample. Future research studies should enhance the sample size to fur-
ther the external validity of the study. Recruitment for the current study was
limited due to the location of the university and locating parents. Future stud-
ies should use more diverse recruitment procedures and reach out to entities
primarily working with children with ASD. Next, the current pilot study did
not assess the child’s symptomology or their behaviors. Finally, many of the
couples sought involvement in the study for various reasons. These present-
ing problems could have impacted the effectiveness SFBCT had on each indi-
vidual participant. For example, it may be that these participants had more
18 B. TURNS ET AL.
severe symptoms in their child than do some children with ASD. Or, it may
be that their marriages were less healthy than other families dealing with
ASD. Future studies should consider controlling for the presenting problem
in order to further identify if SFBCT is an effective treatment for couples. For
example, recruiting couples who, specifically, would like to work on enhanc-
ing their marital satisfaction.
Conclusion
This clinical outcome study investigated the effectiveness of SFBCT for
couples raising a child with ASD. With the use of a MB design, it was
established that SFBCT is an effective treatment option for couples. The
majority of participants in this study increased in their overall well-being
and marital satisfaction assessment scores. Although there are several limi-
tations in this study, we have identified the first couple’s therapy treatment
to help the stressful experiences couples face while raising a child with an
autism spectrum disorder.
Compliance with ethical standards
This study was funded by the Solution-Focused Brief Therapy Association
and by the Texas Tech College of Human Sciences.
Conflict of interest
Authors declare no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in
accordance with the ethical standards of Texas Tech University and/or
national research committee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all participants included in the study.
GrantFunding
Student Research Award from Solution Focused Brief Therapy Association,
Nova Scotia, Canada. Doctoral Dissertation Completion Fellowship,
Graduate School, Texas Tech University.
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 19
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Appendix A
SFBT session formats
First Session Format:
This table gives key interventions that will be used in the first session and examples of
how the therapist can conduct the intervention.
22 B. TURNS ET AL.
Second to Sixth Session Format:
The left column is key interventions that will be conducted in the second through sixth
therapy session and example questions for how the therapist can ask them.
Key Interventions Example Questions/Description of Intervention
Having the client identify their problem So, how can I be helpful to you today?
Asking goal-formulating questions What do you want to see changed as a result of
coming here today?
Asking the Miracle question (see Berg &
Dolan, 2001)
Highlighting exceptions Are there times when the problem is not as bad?
Asking scaling questions - Coping - Confidence On a scale from 1 to 10, how well are you coping
with your daughter’s outbursts?
On a scale from 1 to 10, how confident are you
that thing will improve at home?
Take a break and develop compliments for the client The therapist can leave the room or take a break
in their chair, gathering their thoughts and devel-
oping compliments
Compliments Compliments are based on what the client(s)
reported that they 1) like about themselves, 2) are
proud of, 3) things they are doing well
Homework Homework should come from what the client has
mentioned that would be helpful/useful.
These techniques were adapted from (De Jong & Berg, 2013 and Baveles et al., 2013).
Key Interventions Example Questions/Description of Intervention
What’s better
Start Again
Note: If nothing better is reported
-So what has been better since the last time we met? What’s
going on that’s better? -So how did you do that? -What
difference did you notice since you have been taking more time
for yourself ? -So what else is better? -How are you keeping
things from getting worse?
Doing More -So what will it take to keep this going?
Scaling Progress Current Future -On a scale of 1 to 10, where 10 is [their goal], where are you
this week? -When you move up one point on the scale of
[define goal], what will that look like?
Take a break and develop
compliments for the client
-The therapist can leave the room or take a break in their chair,
gathering their thoughts and developing compliments
Compliments -Compliments are based on what the client(s) reported that
they 1) like about themselves, 2) are proud of, 3) things
they are doing well
Homework -Homework should come from what the client has mentioned
that would be helpful/useful.
These techniques were adapted from De Jong & Berg, 2013, and Baveles et al., 2013.
JOURNAL OF COUPLE & RELATIONSHIP THERAPY 23
