The feasibility and effectiveness of a time-limited psychodynamic couple-focused therapy for adoptive parents: preliminary evidence from the Adopting Together project

Abstract

This article reports on a preliminary test of the effectiveness of Adopting Together, a time-limited psychodynamic couple-focused therapy model for adoptive couples. Fifty-one couples approached the programme and 50 were offered therapy (40 heterosexual, six lesbian and four gay male couples). The intervention took place in Cohort 1 between June and December 2015, and in Cohort 2 between October 2016 and April 2018. Data were collected at intake (T1), after 10 weeks of therapy (T2) and after completion at 20 weeks (T3). Participants’ scores at these time points were compared using paired samples t-tests, repeated measures ANOVA and chi-square tests. It was found that the programme had a positive effect in reducing depression and stress related to parenting, the quality of the relationship between partners and parent-rated child mental health issues, indicating that interventions in which the couple relationship has a significant focus can be effective for adoptive families. This is the first study that tests the effectiveness of time-limited psychodynamic couple-focused therapy for adoptive couples, and especially significant was its attractiveness to same-sex partners. The study is limited by the small sample, the absence of a control group and a 25% attrition rate for returned questionnaires. However, these limitations were mitigated by repeating the analyses in the two independent cohorts and by reporting confidence intervals for the obtained effect size coefficients.

Keywords

Adoptive couples psychodynamic therapy for adoptive couples effectiveness

Introduction

For most couples, the transition to parenthood represents a major shift in their relationship. Adoptive couples, in common with many other parents, often struggle to preserve and/or adapt their relationships, especially as the needs of their adopted children become more pressing. In such situations, ‘couple skills’ are key in managing the inevitable challenges of raising an adopted child, particularly where his or her behaviour is affected by earlier experiences of abuse and neglect. Any consequential deterioration in the quality of a couple’s relationship and increase in communication problems may threaten the stability of the family, including the risk of adoption breakdown. In a major study of adoption outcomes, Selwyn, Meakings and Wijedasa (2015) found that an essential risk factor in the breakdown of adoption placements was the strain placed on the couple relationship, particularly when the child’s behaviour and emotions became overwhelming. Therefore, taking care of their relationship is vital not only for the partners’ individual well-being but also for the stability of the family as a whole, and for maintaining a healthy, satisfying family life where both the adults and children can thrive.

For many adoptive couples, the transition to parenthood is set against a backdrop of complex losses involving infertility, failed cycles of IVF or miscarriage (Foli, et al., 2017). In many cases, infertility may be related to the medical condition of one partner, leaving the other with the (openly or not expressed) sense of blame or anger for the loss of the opportunity to become a parent, and the other with a sense of self-blame. For some couples, adoption will signal a natural ‘moving on’ after a period of grief, while others may block or deny the difficult feelings of loss, mourning or mutual blaming and may instead attempt (consciously or unconsciously) to fill a void or even ‘save’ their marriage or relationship by adopting. It is, therefore, possible that some couples at the time of becoming adoptive parents may still be in the process of grieving their loss or coming to terms with complicated feelings of blame and self-blame, whereas others may be in denial about them. When feelings associated with the loss have not been adequately addressed prior to adoption, they may eventually surface and unsettle any fragile balance of the family system. The preoccupations, demands and intensity that arise from becoming parents to adopted children, who often tend to have high levels of emotional, behavioural and developmental needs, together with perhaps the couple’s own unrealistic expectations and ‘emotionally unprocessed’ losses and grief, may bring about a crisis of confidence in their ability to parent effectively. It can also challenge the stability of the couple’s relationship itself.

Couples who made a conscious decision not to have biological children of their own (e.g. same-sex couples, partners who eschew donor insemination or surrogacy and those who, for altruistic reasons, decide to adopt) may also be confronted with the loss of an idealised child, since adopted children come with their own complex needs that may disappoint parents’ expectations. Moreover, adoptive parents often have to deal with issues that are unique to their situation, such as lengthy waiting periods to become parents (Baden, et al., 2013), pressure to become outstanding parents (Daniluk and Hurtig-Mitchell, 2003) and a lack of role models, as friends and relatives are usually parenting their own biological children (Juffer, et al., 2011). Many adoptive couples will inevitably encounter a number of (for them) unforeseen difficulties in the form of differences between them in relating to the adopted child, discrepancies in motivation and timing of parenthood (often timing and motivation to adopt is influenced more by one partner than the other) and differences in expectations and approaches to child-rearing, as well as potential splits relating to the adopted child attaching more to one parent than the other.

Interventions for adoptive couples

Despite all of these challenges, there are very few models of therapeutic work focusing on such couples. The majority of interventions for adoptive parents concentrate on parenting or on the child–parent relationship (e.g. Dyadic Developmental Psychotherapy – Hewitt, Gurney-Smith and Golding, 2018; the Fostering Attachments group-based approach – Golding and Picken, 2004; mindfulness-based therapy focusing on parenting stress – Golding, 2014; and neuroscience-based attachment development therapy – Gurney-Smith, et al., 2017), thereby losing from view the focus on the couple relationship itself as a basic unit of the family. In a recent seminal systematic review of courses, trainings and interventions available for adoptive parents, Drozd and colleagues (2018) reviewed 21 articles describing 10 studies on the effectiveness of interventions for adoptive parents. Remarkably, only three out of the 10 scrutinised included outcome measures related to the dyadic relationship between the adoptive parents, and only two of the interventions aimed to enhance relationship satisfaction or communication between the partners. These two interventions were the Prevention and Relationship Enhancement Program (PREP) (Loew, et al., 2012) (a four-hour web-based educational programme focusing on relationship skills and spousal communication), and an intervention supporting special needs adoptive couples (an educational group intervention to enhance forgiveness, increase marital satisfaction and prevent depression) (Baskin, et al., 2011).

Conceptual basis and objectives of the therapeutic model of Adopting Together

By understanding the particular needs and challenges faced by adoptive couples, the aims of the Adopting Together programme were to develop an intervention providing insights into four areas: (1) resolving past losses, blaming and self-blaming and increasing a sense of acceptance; (2) strengthening the dyad, as related to increased couple satisfaction; (3) providing a supportive context for both partners to assist them in sharing their feelings and to promote open, constructive, non-defensive communication; and (4) fostering the partners’ ability to be supportive for each other (including in their new roles as parents) and, as a result, lowering their depressive and distressing feelings.

The intervention included an initial consultation with adoptive couples and parents and, for those who would benefit, a further 20 weekly sessions of 50 minutes duration were offered. The intervention was based mainly on a time-limited psychodynamic technique (for details see McCann, 2018). It was designed to offer the couples an opportunity to explore the nature and impact of their experiences prior to adoption and the effect of the adoption itself on their relationship, as well as examining ways of improving the overall quality of the relationship in the face of specific challenges of parenting adopted children that may put undue pressure on the couple’s state of mind.

The overarching aim of the programme is the development of an effective therapeutic model for a brief, time-limited intervention (Leff, et al., 2000), which is in keeping with recent guidelines and provisions of therapeutic treatments for couples. For example, a 20-session intervention for couples with depression is endorsed by the UK National Institute for Health and Care Excellence (NICE, 2009).

The aim of the present study

Given the paucity of therapeutic models of working with adoptive couples reporting relationship strain and distress, and the lack of empirical studies on psychodynamic models with this client group, the aim of this study was to test the feasibility and effectiveness of the new psychodynamic time-limited couple intervention for adoptive couples.

Method

Sample

Fifty-one couples (52 women and 50 men) were assessed and 50 were offered therapy. They comprised 40 heterosexual couples, six lesbian and four gay male. The average age of participants was 46 (SD = 8); 69% were married, 10% were in civil partnerships and 17% were cohabitating; 23% of participants reported enjoying a relationship lasting between six and 10 years, 25% between 11 and 15 years, 37% between 16 and 25 years and 15% more than 25 years. In terms of the duration of relationship problems (within the couples), the majority (58%) reported three years or less; more than a quarter (29%) reported four to eight years and a minority (12%) reported longer than this.

The majority (70%) were White British and the rest were of Other White, Black, Asian or Mixed heritage background; 63% were employed full time, 25% part time and 12% were unemployed, retired or full-time homemakers.

The average number of adopted children within the family was 1.54 and the number of biological children was 1.23. The youngest adopted child in the family was, on average, five years old (SD = 2.99); the average age of the oldest adopted child was 7.96 years (SD = 5.10). The youngest biological child in the family was, on average 11.55 years old (SD = 4.84), the oldest 14.02 (SD = 1.78).

Inclusion criteria

In addition to considering the couples’ suitability to the service in terms of their presenting problems, risk factors were assessed. The likelihood of self-harm (suicidal and non-suicidal) and harm to others (including domestic violence) were evaluated using the four-item Risk scale from the 34-item Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM – explained below) and in the initial interview. Couples presenting with substance or alcohol abuse, coercive controlling domestic violence, high risk of harm to self and others and severe mental health issues were also excluded as they would not be able to beneﬁt from this brief therapeutic intervention. Based on these criteria, one couple was signposted to a more appropriate service for their needs.

Procedures

The couples who approached the Adopting Together Project came through word of mouth, recommendation from their social worker or through the Tavistock Relationships website which advertised the service. The intervention took place in two cohorts of participants: Cohort 1 (intervention delivered between June and December 2015) and Cohort 2 (between October 2016 and April 2018). The same team of clinicians was involved in delivering the intervention in each case. A pre- and post-assessment methodology was used as an alternative to a randomised control trial (RCT) which would have created practical and ethical problems and methodological difficulties related to uncontrolled variability occurring after random assignment (Lipsey and Cordray, 2000). Questionnaires were used to collect information and after informed consent had been obtained, data required to evaluate the psychological benefits of participation in the programme were collected at intake (Time 1), after 10 weeks of therapy (Time 2) and after the end of the intervention at 20 weeks (Time 3).

Ethical approval

Ethical approval was given by the Tavistock Relationships Research and Practice Ethics Committee.

Measures

Parents’ psychological distress was measured with the CORE-OM (Evans, et al., 2002), a self-report questionnaire including items that focus on overall psychological well-being, depression, the risk of self-harm and harm to others. Respondents answered questions about how they have been feeling over the last week, using a five-point scale ranging from ‘not at all’ to ‘most or all of the time’. Total scores can range from 0 to 40, with higher ones indicating greater distress. The cut-off score for clinical levels of distress is 10. CORE-OM scores can be converted to the widely used Beck Depression Index (BDI). The BDI scores are re-coded into a four-category scale: (1) minimal depression, (2) mild depression, (3) moderate depression and (4) severe depression. Cronbach Alpha for this measure was 0.93 at Time 1 (T1), 0.92 at Time 2 (T2), and 0.94 at Time 3 (T3) in the study sample.

Couple relationship quality was assessed using the six-item Quality of Marriage Index (QMI; Norton, 1983), a measure of partners’ satisfaction within their relationship. Maximum scores can reach 45, with higher scores representing greater satisfaction. Cronbach Alpha for this measure was 0.93 at T1, 0.93 at T2 and 0.96 at T3.

Children’s emotional and behavioural difficulties were assessed using the parent-rated Strengths and Difficulties Questionnaire (SDQ; Goodman, 1994; 1997). Mothers and fathers completed the SDQ about their youngest child (either adopted or biological). This instrument produces an overall assessment of the child’s psychological state yielding a total score that can range from 0 to 40, with high scores representing greater difficulties. The scores are recorded to form three ranges: normal range (0‒13), borderline range (14‒16) and abnormal range (17‒40). An abnormal range is considered to be indicative of the risk of a psychological disorder. In addition to the total score, the SDQ includes five subscales (hyperactivity, conduct problems, peer relationships problems, emotional problems and prosocial behaviour). We used a two-sided version of the SDQ with the 25 items on strengths and difficulties on the front of the page and an impact supplement on the back. This extended version of the SDQ asks whether the respondent thinks the child has a problem and, if so, enquires further about chronicity, distress, social impairment and burden to the family. The impact score can vary from 0 to 10 with a higher score indicating a higher negative impact of a child’s difficulties on him or her and the entire family. Cronbach Alpha for this measure was 0.87 at T1 and 0.86 at T2 and T3.

The satisfaction with service was assessed with the Experience of Service Questionnaire – the adapted version of the Child Outcomes Research Consortium (CHI-ESQ – Brown, et al., 2014). This assesses two aspects ‒ satisfaction with care and satisfaction with the environment – and contains 11 questions with four response options: ‘certainly true’, ‘partly true’, ‘not true’ and ‘don’t know’. The measure also contains three open-ended questions about clients’ experience of the service: ‘What did you like about your experience?’, ‘What did you dislike?’ and ‘Do you have any comments?’. A fourth question requests their consent to use the answers anonymously for research and outcome monitoring purposes.

Results

Statistical analyses

Data processing and analyses were conducted using Stata 13. We were mainly interested in differences between participants’ scores before the programme started and at the end, so these scores were compared at two time points (T1 and T3) using paired samples (repeated measures) t-test or repeated measures ANOVA (when looking at overall effect of ‘time’ variable and changes at T2 and T3). We used these two statistical methods where variables were normally distributed, and chi-square test with count and categorical variables. Cohen’s d coefficient was computed to indicate effect size and establish the magnitude of change in questionnaire scores from T1 to T3. It was assumed that a statistically significant change (i.e. p-value smaller than 0.05) in questionnaire scores in the expected direction is indicative of the effectiveness of the programme, i.e. that it had psychological benefits for participants. We also examined mean scores at all three time points descriptively (and displayed them using bar charts in Excel) to establish if there was a trend of change over time in the desired direction. In addition to testing the effectiveness of the programme in the total sample (Cohort 1 and Cohort 2 jointly), we also checked whether the results obtained in Cohort 1 were replicated in Cohort 2.

In order to see if scores significantly change at T2 and T3 as compared to baseline at T1, we tested the predictive effect of a ‘time variable’ (coded as a categorical variable with three categories – T1, T2 and T3) in a multilevel regression in which we treated questionnaire scores as a dependent variable and ‘time variable’ as a predictor (couples’ ID was used to account for nested data structure within couples). Three multilevel regressions were computed for the three outcomes separately – psychological distress, relationship quality and child well-being.

The results of this analysis are outlined below.

Psychological distress and depression

At T1, the majority of participants (56%) scored within the clinical range for psychological distress and depression (thus meeting the ‘clinical caseness’ criteria); this was also the case for 34% of them at T2 and 27% at T3. The percentage of female and male participants meeting the ‘clinical caseness’ criteria based on CORE and BDI is displayed in Figures 1 and 2. Because women had higher baseline scores on CORE, there was a relatively larger improvement in their mental distress and depression compared to men. We had the CORE data for intake and T3 for 73 participants. Out of those, 38 (23 female and 15 male) scored within the clinical range at intake; 16 (12 female and four male) ‘moved’ to non-clinical range, thus constituting a 42% recovery rate that shows a statistically significant improvement in psychological distress (Pearson chi²(4) = 12.79, p = 0.000).

Figure 1.

Female and male participants above the clinical cut-off on CORE at intake (T1), mid-therapy (T2) and end of therapy (T3).

Figure 2.

Participants above the clinical cut-off based on BDI at intake (T1), mid-therapy (T2) and end of therapy (T3).

When examining CORE scores at three time points as continuous variables, participants scored on average 10.47 (SD = 5.49, n = 100) at T1, 10.20 (SD = 5.08, n = 79) at T2 and 8.24 (SD = 5.72, n = 75) at T3. The decrease in scores between T1 and T3 was statistically significant when tested with paired samples t-test (t(72) = 2.68, p = 0.009) for the 73 participants for whom CORE data at T1 and T3 were available; this difference corresponded to the effect size measured with Cohen’s d = 0.39 [95% C.I. 0.09/0.70]. The repeated measure ANOVA showed a significant effect of time variable (F(2, 150) = 4.81, box-adjusted p = 0.031)). Additionally, multilevel regression accounting for data nesting within couples showed a significant decrease in CORE scores (main effect of time) from T1 to T3 (but not from T1 to T2) as expressed by a coefficient = −1.90, p = 0.006. However, it has to be noted that there was a 25% attrition in returned questionnaires, so it is possible that those with higher scores at T3 did not return their final assessment questionnaires and this might have biased the results towards showing higher than actual improvement in psychological distress. Figure 3 displays CORE scores using well-validated severity ranges at all three time points; it also displays the percentage of the missing data on each occasion.

Figure 3.

Levels of mental distress at intake (T1), mid-therapy (T2) and end of therapy (T3).

Quality of the relationship between partners

In addition to the psychological distress and depression just described, improvement in couples’ relationship quality, as measured with the QMI questionnaire, were also found. The mean at T1 was 29.23 (SD = 8.61, n = 97), at T2 was 29.86 (SD = 8.57, n = 72) and at T3 was 31.98 (SD = 10.15, n = 74) at T3 (see Figure 4). This improvement (when comparing T1 and T3 with paired samples t-test) in relationship quality was statistically significant (t(70) = −3.41, p = .001); this mean difference corresponded to the effect size measured with Cohen’s d = −0.29, [95% C.I. −0.59/.00]. As can be seen in Figure 4, the improvement at T3 was marginally better for men than for women (the gender difference was, however, not statistically significant, p = 0.689); men also reported slightly higher relationship satisfaction at intake (this gender difference was, again, not statistically significant, p = 0.414). The repeated measure ANOVA showed a significant main effect of time variable, indicating significant improvement over time (F(2, 139) = 7.52, box-adjusted p = 0.007)). Additionally, multilevel regression accounting for data nesting within couples showed significant improvement (main effect of time) from T1 to T3 (but not from T1 to T2) as expressed by a coefficient = 2.88, p = 0.000.

Figure 4.

Relationship quality reported by women and men at T1, T2 and T3.

Child well-being

In the total sample, 61 parents filled in SDQs about their youngest child (adopted or biological) at all three time points. Among those, 38 children (62%) had the SDQ scores in the abnormal range at intake and five of them (13%) ‘moved’ into the normal range after the intervention, with another three (8%) ‘moving’ into the borderline range. This suggested a statistically significant improvement in parent-rated child psychological well-being (Pearson chi²(4) = 28.61, p = 0.000). Figure 5 displays the SDQ score ranges before the intervention (T1), at the 10th week of therapy (T2) and after the intervention (T3).

Figure 5.

Parent-rated SDQ scores at T1, T2 and T3.

When looking at the SDQ scores as a continuous variable, the mean at T1 was 17.82 (SD = 8.27, n = 92), at T2 it was 17.68 (SD = 7.81, n = 73) and at T3 was 17.37 (SD = 8.23, n = 66). Although the decrease in the total SDQ score from T1 to T3 was not statistically significant, when examining the changes in scores on the SDQ subscales, a statistically significant (t(60) = −2.56, p = 0.012) improvement was found between T1 and T3 in a prosocial scale (for the 61 on whom data were available at both time points) from the score of 6.06 (SD = 2.52) to the score of 6.62 (SD = 2.66). This mean difference corresponded to the effect size measured with Cohen’s d = −0.11 [95% C.I. −0.42/0.20]. The repeated measure ANOVA showed a significant effect of time (F(2, 132) = 4.16, box-adjusted p = 0.045) on the SDQ prosocial scale. Additionally, multilevel regression accounting for data nesting within couples showed significant improvement (main effect of time) from T1 to T3 (but not from T1 to T2), as expressed by a coefficient = 0.49, p = 0.026. The improvement in other subscales (hyperactivity, conduct problems, emotional problems and peer problems) was of smaller magnitude and not statistically significant. There was a statistically significant improvement in the reported impact of difficulties on the family among parents of four to 17-year-olds (Pearson chi²(4) = 9.69, p = 0.046): among 38 of those who were in the abnormal range at T1, eight ‘moved’ into the normal range and five moved to the borderline range.

Feasibility

In order to explore the feasibility and acceptability of the intervention for adoptive couples, we collected and analysed the data about service satisfaction. Out of 73 participants who returned service satisfaction forms, 95% answered ‘yes’ to the question: ‘Do you feel that the help you received was useful?’. The vast majority also answered ‘true’ or ‘partially true’ to the following four questions: Did therapy help you (a) understand yourself (even if this has been upsetting) (96%); (b) understand your partner (even if this has been upsetting) (97%); (c) understand your child(ren) (even if this has been upsetting) (76%); and (d) express feelings and problems with your partner (86%)? Moreover, the majority provided positive feedback to open-ended questions. The following are selected excerpts from feedback that adoptive parents have written on the service satisfaction forms when they answered the question: ‘What did you like about your experience?’:

The longer-term nature of 20 weeks has given us a good timetable to work on themes and spend time outside the sessions to discuss and reflect, which led to better sessions thereafter. Twenty weeks afforded us a nice pace to work through.

A place to bring up discussions and disagreements that would cause arguments at home. We abandoned arguing at home.

A safe place to express difficult emotions and feelings.

Allowed us the opportunity to discuss and share our problems.

Allows us to discuss issues effectively.

Comforting space, kind therapist, chance to speak.

Improved communication with partner.

It’s been a great space to talk about adoption-related issues and how that’s affected our lives. It’s been a good safe space to explore ideas and feelings.

Our therapist has helped us to think about how we communicate or address difficult issues or disagreements. We communicate much more openly and freely now, even around difficult or contentious issues.

Discussion

Within the field of adoption, it seems somewhat surprising that the significance of the quality of the adoptive couple relationship has received so little explicit attention when compared to the extensive literature on adoptive parenting. Yet, in terms of positive outcomes for adoption, a supportive couple relationship that expresses their satisfaction with each other is key in helping couples manage the transition to adoptive parenthood and the challenges of raising an adopted child (Martin, Rosenhauer and Greco, 2016; Mooradian, et al., 2011). The aim of this study was, therefore, to evaluate the feasibility and preliminary evidence for effectiveness of the time-limited psychodynamic couple intervention for adoptive couples who were experiencing relationship distress. Based on the high interest and the feedback from the participants, it was possible to reach positive conclusions about the programme’s feasibility and demand for this type of service.

Results regarding the programme’s effectiveness indicate that it was successful in terms of improving relationship satisfaction within the participating couples, as indicated by the significant difference between participants’ quality of their relationship before and after the intervention. The improvement in terms of couple satisfaction was slightly higher for men than women, possibly indicating the positive outcomes in terms of engaging men in couple therapy with their partners. However, the improvement in relation to psychological distress was higher for women than men. It is significant that when it comes to psychological distress and depression, female partners showed higher baseline scores at the point of entering the programme, suggesting that those who take on most responsibility for parenting, including adopted children, show obvious signs of stress and even depression that were alleviated as the therapy progressed. These gender differences echo an earlier study reporting that women’s (but not men’s) reflective functioning was predictive of positive marital and co-parenting interactions (Jessee, et al., 2018).

Although the intervention did not offer direct work with the children and families as a whole, it was possible to infer meaning from the completed parents’ SDQs as to the effect of the therapy on the adopted child/children’s psychological well-being. What these questionnaires show is a statistically significant improvement in parent-rated prosocial behaviours of the child. This should perhaps come as no surprise given the link between improved couple functioning and the corresponding improvement in the co-parenting relationship that are known to benefit children (Cowan and Cowan, 2000). In other words, couples who get on well tend to be better parents, since the capacity to feel their connection in one domain greatly benefits their connection in the other, and children respond positively to their parents' improved relationship. In line with this, a study on reflective functioning reported the association between high reflective functioning in the marital dyadic relationship and parental reflective functioning (Jessee, et al., 2018) as well as co-parental alliance and multi-facet character of mentalization process within the family systems (Shai, Dollberg and Szepsenwol, 2017).

It is noteworthy that although the majority of participants were heterosexual couples, 20% were in same-sex relationships. This is a surprisingly high proportion and raises questions concerning the nature and impact of adoption for same-sex couples, especially given the paucity of research relating to the transition to parenthood among couples and, more specifically, for same-sex couples who adopt. Goldberg and Kinkler (2014) conducted a qualitative study of heterosexual, lesbian and gay couples adopting through child welfare systems and found that although many parents indicated some decline in relationship satisfaction following the transition to parenthood, additional stresses affected same-sex couples due to their sexual minority status. According to Goldberg and colleagues (2012: 157), ‘gay men become parents amidst institutions and discourses that privilege heteronormativity and thus present challenges to their parenting pursuits’, while Mallon (2004) draws particular attention to the supposed deficiency of gay male households due to the absence of a female parental figure. This body of thinking would suggest that same-sex couples, and gay couples in particular, may be at greater risk than their heterosexual counterparts because of questions being asked of them about their fitness to parent which may, in turn, account for the high incidence of such couples approaching the project.

Adopting Together versus other therapy models

When compared to a generic non-manualised, open-ended couple psychotherapy based on a psychodynamic approach, Adopting Together shows equally positive effects. For example, the evaluation by Hewison, Casey and Mwamba (2016) of a naturalistic study of more than 800 clients showed CORE-OM effect size of d = −1.04 between intake and end-of-therapy assessment, as well as improvement in relationship satisfaction using the GRIMS measure (Rust, et al., 1990) and demonstrated by the effect size of d = −0.58. The Adopting Together programme demonstrated similar effectiveness, if we look at upper confidence intervals of Cohen’s d reported in the results. In another comparison, a 16-session group-based manualised couple therapy (Casey, et al., 2017) showed for CORE-OM effect size of d = −.40, for QMI an effect size of d = .41 and SDQ an effect size of d = −0.22; and, again, the Adopting Together programme demonstrates similar or higher effect sizes. Likewise, in comparison to specific interventions for adoptive parents, which reported effect size d = 0.7 (Rushton, et al., 2010), Adopting Together yielded effect size for psychological distress of similar magnitude. Although formal statistical comparisons of effect sizes were not carried out, and sample sizes were very different in these studies (a fact that disadvantages Adopting Together because of its relatively small sample), these preliminary results indicate a promising trend in relation to the programme’s effectiveness.

Implications for clinical practice

Nearly 60% of the participating parents scored at intake within the clinical spectrum on measures of symptoms of depression and psychological distress. This alone warrants effort to support adoptive couples in the form of therapeutic interventions, especially considering that a recent study found evidence of environmental influence of parental depressive symptoms on adopted toddlers’ behaviour (Pemberton, et al., 2010). Also, associations have been found between maternal states of mind and emotion narratives in adopted children with a history of maltreatment (Steele, et al., 2003). The present results should also be interpreted in the context of the existing evidence from an RCT which suggests that couple interventions for depression show better and longer-lasting effects and are more acceptable than antidepressant drug treatment (Leff, et al., 2000). In the view that many adoptive couples go through the complex process of grief and acceptance of infertility or losses – feelings often associated with distress and depression – it may be useful for them to have access to a support service in the form of couple therapy before embarking on the adoption process.

Policy implications

Although the Adoption Support Fund recognises the need for those adopting to receive support, this help has tended to be focused almost exclusively on the relationship between adopted child (or children) and parents (King, et al., 2017); the particular needs of adoptive couples seemed to be overlooked. This gap in support services should be addressed, since many couples struggle to manage their relationship and without support may be in danger of experiencing significant inter-parental conflict, separation or divorce, all of which have potentially damaging effects on children’s well-being (Harold, et al., 2016).

Based on the current findings, we suggest that the idea of a wrap-around service for adoption families, as proposed elsewhere (Vaughan, McCullough and Burnell, 2016), should broaden the focus to include not only the adopted child but also his or her adoptive parents. It needs to acknowledge the vulnerabilities that a couple brings into the adoption situation and relate these to the losses they have been through and the inevitable challenge to their hopes and dreams of an idealised child posed by the everyday reality of caring for a child who may carry a diagnosis of a reactive attachment disorder or mental and behavioural difficulties.

Overall, our findings suggest the importance of attending to the needs of adoptive couples when their relational well-being is at stake. The improvement in couple satisfaction goes a long way to supporting not just them, but also the adopted child or children, as we can infer from the significant improvement in their well-being reported by parents. This adds further weight to a couple-based intervention and confirms the importance of offering this type of therapy to adoptive parents.

Limitations

The findings summarised above are based on a small sample of parental couples and without a control group for comparison, it is not possible to attribute all positive changes to the effect of the intervention alone. However, we used the replication of our analyses in Cohorts 1 and 2 to validate our findings. Also, when reporting effect size coefficient (Cohen’s d), we have reported 95% confidence intervals, which takes into account possible variation in the results due to sample characteristics. Second, there was some attrition in obtained data at mid-therapy and final assessment. Due to the small sample size, we chose to include in our analyses only cases with the complete data rather than using multiple imputations procedure allowing the use of cases with missing data. Thus, we cannot exclude the possibility that those who did not return their questionnaires experienced fewer positive outcomes compared to those who did. Finally, it was not possible to collect comprehensive data on the children’s pre-adoption history, nor details about possible current contact arrangements with birth families. Neither was it feasible to include adoption-specific parental characteristics in this evaluation, in particular potentially influential aspects such as the experience of trying to create a family prior to adopting. Although the measures used in our study are well established and appropriate for the purpose, none of them were specific to adoption which somewhat limits the depth and specificity of the conclusions.

Summary of research findings and future research leads

The results of this study indicate that the programme appears to have a positive effect on reducing mental distress (mainly depression) in both cohorts, and stress related to parenting (Cohort 2), the quality of the relationship between partners (Cohort 1) and, as assessed by parents, child well-being in both cohorts. It is noteworthy that the service was particularly attractive for same-sex couples who made up 20% of participants. The fact that the results were replicated in the two independent cohorts provides further evidence for the effectiveness of this programme.

This evaluation will inevitably generate questions for future intervention research with this population. For example: Could the intervention have been more effective if it had been administered within the first six months of placement with the family? It is worth noting that many of the couples seen within the project came at a time of crisis in their own relationship, while others were focused on the needs of their child or children, and a significant number came questioning their ability as a couple to contain the powerful feelings that had been unleashed by the adoption. Evidence suggests that couples tend not to seek help at the onset of their difﬁculties but rather do so as a last resort (Chang and Barrett, 2009; Walker, et al., 2010), which in the case of adoptive parents may be detrimental not only for their own well-being but also for the well-being of the child. Chang and Barrett (2009) and Walker and colleagues (2010) highlight the importance of helping couples to recognise the early signs of relationship difﬁculties as well as motivating them to seek help. In line with this, offering couple-focused therapy early on during, or even before, the adoption placement could, potentially, be more effective than the intervention when a couple experiences a crisis. Further investigation using a bigger sample of participants and possibly applying the methodology of an RCT could be carried out to answer this question and investigate further evidence for the effectiveness of the treatment model.

Conclusions

This study confirms the importance of keeping the couple relationship in focus throughout the adoption process. It also underscores the belief that children’s well-being is related to and promoted by a strengthening of their parents’ couple relationship. Furthermore, both partners showed improvements in regard to psychological distress, depression and relationship satisfaction following a 20-week tailored intervention delivered by qualified and experienced couple psychotherapists. It is hoped that these results will inform future policy, clinical practice and support for the couple relationships of adoptive parents.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ela Polek is head of psychometrics at Tavistock Relationships. Prior to this, she was a research associate at the University of Cambridge, Department of Psychiatry, and a lecturer at University College Dublin, School of Psychology, where she is currently a visiting research fellow.

Damian McCann is a psychoanalytic couple psychotherapist working as Head of Learning and Development at Tavistock Relationships, London, UK. He is also an adjunct faculty member of the International Psychotherapy Institute (IPI), Washington DC, USA.

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