---
title: Communication and Conflict: The Complete Guide
url: https://strongercouple.app/library/guides/communication-and-conflict
author: Stronger Couple Editorial Team
published: 2026-10-18
updated: 2026-10-18
lastReviewed: 2026-10-18
topic: "Communication & conflict"
sources: 22
---

# Communication and Conflict: The Complete Guide

> How couples can argue less destructively and talk so both feel heard: the research on conflict, the patterns to watch for, and skills to practise.

> **Safety first.** These ideas assume both partners feel safe. If you are afraid of your partner, or there is abuse, threats or coercive control, couples techniques are not the right tool. Talk to a domestic violence advocate instead. National Domestic Violence Hotline: call 1-800-799-7233, text START to 88788, or chat at thehotline.org. 988 Suicide & Crisis Lifeline: call or text 988, or chat at 988lifeline.org. In an emergency, call 911. More: https://strongercouple.app/help-now

## Key takeaways

- Conflict itself is not the problem in most relationships; research suggests that how partners raise, handle and repair disagreements matters far more than how often they disagree.
- Gottman's research describes four especially damaging conflict patterns (criticism, contempt, defensiveness and stonewalling), and each has a practical antidote you can learn.
- How a hard conversation starts tends to shape how it ends, so a gentle opening is one of the highest-leverage skills a couple can practise.
- When either partner's body is flooded with stress, a planned break of at least 20 minutes usually helps more than pushing through.
- Communication skills are for relationships where both people feel safe; if you are afraid of your partner, the right next step is confidential support, not better technique.

Healthy communication and conflict in a relationship does not mean never fighting. It means both partners can raise a problem without attacking, listen without defending, pause when emotions run too hot, and repair afterward. Research on couples suggests that the way you disagree, especially how you start, escalate and recover, matters far more than how often you disagree. These are learnable skills, and small changes add up.

> **If you feel unsafe.** These ideas assume both partners feel safe. If you are afraid of your partner, or there is abuse, threats or coercive control, couples techniques are not the right tool. Talk to a domestic violence advocate instead.
>
> - National Domestic Violence Hotline: call 1-800-799-7233, text START to 88788, or chat at thehotline.org.
> - 988 Suicide & Crisis Lifeline: call or text 988, or chat at 988lifeline.org.
> - In an emergency, call 911.
>
> More resources: [Help Now](https://strongercouple.app/help-now)

These tips assume both partners feel safe. If you're afraid of your partner, these techniques aren't the right tool — go to [Help Now](https://strongercouple.app/help-now).

This guide pulls together what relationship research has found about conflict and communication, and turns it into practical steps. Each section links to a deeper article if you want to go further. If you only have five minutes, read "The five skills that matter most" and try one of them this week.

## Why conflict matters so much (and why it isn't the enemy)

Conflict is not a sign that something is broken. Two people with different histories, needs and stress levels will disagree. What research points to is the _pattern_ of those disagreements over time.

In a study that followed 73 couples over four years, psychologist John Gottman described five types of couples. Three types were stable: "validating" couples who stayed calm and collaborative, "volatile" couples who argued passionately but also laughed and showed lots of affection, and "avoiding" couples who mostly agreed to disagree. Two types were unstable, marked by hostility and detachment [^1]. The takeaway is freeing. You don't need a particular style. Loud couples and quiet couples can both do well.

What the stable couples shared was balance. According to the Gottman Institute, stable, happy couples showed roughly five or more positive interactions for every negative one _during conflict_, while couples with a ratio near one to one were at much higher risk [^2]. That ratio is often quoted as a general rule for daily life. Strictly, it describes behavior during disagreements, which is useful in itself: warmth, humor and interest can coexist with an argument. Read more in our glossary entry on [the 5:1 ratio](https://strongercouple.app/library/glossary/magic-ratio).

How you fight also affects your body. In one hospital-based study, wounds healed more slowly after couples discussed a disagreement than after a supportive conversation, and couples who were consistently hostile healed at about 60% of the rate of low-hostility couples [^3]. A large review of 126 studies found that better marital quality is linked with better physical health, with small effects similar in size to those of health habits like diet [^4]. None of this means one bad fight will hurt you. It does mean the long-term pattern is worth tending.

## The four patterns that do the most damage

Gottman's lab identified four conflict behaviors that predicted relationships ending. He called them the [Four Horsemen](https://strongercouple.app/library/glossary/four-horsemen) [^5]. Each has an antidote [^6].

| Horseman      | What it sounds like                             | Antidote                                    | What the antidote sounds like                                              |
| ------------- | ----------------------------------------------- | ------------------------------------------- | -------------------------------------------------------------------------- |
| Criticism     | "You never think about anyone but yourself."    | Gentle startup                              | "I felt hurt when plans changed without a text. Can we agree to check in?" |
| Contempt      | Eye-rolling, mockery, "Wow, what a genius."     | Build a culture of appreciation and respect | "I know you've been stretched thin. Thank you for handling dinner."        |
| Defensiveness | "Well, I wouldn't have to if you ever helped."  | Take responsibility, even for part          | "You're right that I forgot. I'll call them now."                          |
| Stonewalling  | Going silent, turning away, scrolling the phone | Physiological self-soothing                 | "I'm overwhelmed. I need 20 minutes, then I'll come back."                 |

A few distinctions matter here:

- **[Criticism](https://strongercouple.app/library/glossary/criticism) vs complaint.** A complaint names a specific behavior. Criticism attacks who your partner _is_. "The dishes were left out again" is a complaint. "You're so lazy" is criticism.
- **[Contempt](https://strongercouple.app/library/glossary/contempt)** comes from a position of superiority. The Gottman Institute calls it the single greatest predictor of divorce in its research [^5]. Sarcasm, name-calling and mocking imitations all count.
- **[Defensiveness](https://strongercouple.app/library/glossary/defensiveness)** is almost always a response to feeling attacked. It is understandable, but it tells your partner their concern doesn't matter.
- **[Stonewalling](https://strongercouple.app/library/glossary/stonewalling)** often happens when someone is physically overwhelmed, not when they don't care [^7].

Everyone uses these sometimes. The goal is to notice them sooner and swap in the antidote more often. Our full explainer, [the Four Horsemen of relationships](https://strongercouple.app/blog/four-horsemen-of-relationships), includes a one-week practice plan. You can also take the reflective [Four Horsemen self-check](https://strongercouple.app/tools/four-horsemen-self-check), which is designed for reflection, not diagnosis. For deeper dives into two of the horsemen, see [defensiveness in relationships](https://strongercouple.app/blog/defensiveness-in-relationships) and [contempt in a relationship](https://strongercouple.app/blog/contempt-in-relationships).

## What the research actually found (and its limits)

Gottman's findings are among the most cited in relationship science, and they are often exaggerated. Here is a more careful summary.

- **Negativity and withdrawal predicted trouble.** In a study of 73 couples measured in 1983 and again in 1987, couples whose conflicts had more negative than positive behavior showed more defensiveness, stubbornness and withdrawal, lower satisfaction, poorer health and a greater risk of separation [^8].
- **The first three minutes mattered.** In 124 newlywed couples, the emotional tone of the first three minutes of a conflict discussion predicted whether they were still married six years later [^9]. The researchers concluded that the startup of a conflict conversation is key [^10].
- **Active listening was rare.** In a 1998 study of 130 newlyweds, the textbook "active listening" exercise turned up very rarely in real conflicts and did not predict which couples did well. Gentleness, soothing and a willingness to accept a partner's influence did [^11].
- **About that "94%" number.** It comes from a 1992 study in which researchers coded how 56 couples told the story of their relationship and predicted, with 94% accuracy, who would still be married three years later. A later study of 95 newlywed couples found 87% accuracy over four to six years. The researchers noted that their samples were self-selected [^12]. It is not a figure for predicting divorce by watching one fight.

These studies were careful but relatively small, and most participants were married, heterosexual, and from the United States. The patterns are widely used by therapists and match a lot of later research, but treat them as strong clues, not laws.

One more nuance is worth knowing. A review by psychologists Nickola Overall and James McNulty found that the "best" way to communicate depends on the situation. Direct, even forceful, communication can help when a serious problem needs to change and the partner is able to change. Warm, validating communication helps most when problems are minor or can't really be changed [^13]. Being gentle doesn't mean being vague.

## The five skills that matter most

If you remember nothing else from this guide, practise these.

### 1. Start softly

Because openings shape outcomes, the way you raise an issue is worth planning. A [soft startup](https://strongercouple.app/library/glossary/soft-startup) describes your feeling, the specific situation and what you need, without blame. The Gottman Institute frames it as complaining without blaming, using "I" statements and stating your need positively [^6].

- Instead of: "You always leave me to deal with your mother."
- Try: "I felt alone at dinner with your mom tonight. Next time, could you jump in when she starts on my job?"

Word choice matters more than you might think. In a study of 59 couples, partners who used more "you" pronouns during problem-solving were more negative, while those who used more "we" pronouns came up with more positive solutions [^14]. Our [25 soft-startup examples](https://strongercouple.app/blog/soft-startup-examples) cover money, chores, sex, in-laws and more, and the [soft-startup builder](https://strongercouple.app/library/exercises/soft-startup-builder) walks you through writing your own.

### 2. Take a real break when you're flooded

[Emotional flooding](https://strongercouple.app/library/glossary/emotional-flooding) is a fight-or-flight state in which it becomes very hard to listen or think clearly. Julie Gottman suggests a heart rate over about 100 beats per minute (about 85 for very athletic people) as one sign, and recommends a break of about 20 to 30 minutes, never longer than 24 hours, with a clear time to come back [^15]. During the break, do something genuinely calming and avoid rehearsing your case [^7].

Our free [conflict pause timer](https://strongercouple.app/tools/conflict-pause-timer) runs a 20-minute pause and a speaking-turn timer. For more on the difference between a healthy break and shutting someone out, read [stonewalling in a relationship](https://strongercouple.app/blog/stonewalling-in-relationships).

### 3. Take turns being speaker and listener

When both people talk at once, nobody hears anything. Structured turn-taking slows things down. One person speaks briefly about their own experience. The other summarizes what they heard before responding. Then you switch.

This approach is a core part of the Prevention and Relationship Enhancement Program (PREP). In a five-year follow-up, couples who took the program showed more positive and less negative communication than a control group [^16]. A broader review of 117 studies found that relationship education programs improve communication skills and relationship quality, though most samples lacked diversity [^17].

Remember the 1998 finding, though: rigid, scripted "active listening" was rarely used in real fights [^11]. The point isn't to sound like a textbook. It's to make sure your partner feels understood before you try to solve anything. Our guide to [active listening for couples](https://strongercouple.app/blog/active-listening-for-couples) shows how to do this in your own words.

**In the Stronger Couple app:** [Conflict resolution](https://strongercouple.app/app/conflict-resolution)

### 4. Repair early and often

A [repair attempt](https://strongercouple.app/library/glossary/repair-attempts) is anything that slows an argument down or reconnects you mid-fight: a joke, a softer tone, "Can I try that again?", a hand on the arm. The Gottman Institute's list of repair phrases includes "I am getting scared," "Can we take a break?" and "Let me try again" [^18]. Just as important is _accepting_ a repair when your partner offers one, even an awkward one.

Repair also happens after the fact. A real apology names the impact, takes responsibility and commits to doing something differently. See [how to apologize to your partner](https://strongercouple.app/blog/how-to-apologize-to-your-partner) and our printable [repair phrases card](https://strongercouple.app/library/exercises/repair-phrases-card).

### 5. Accept influence

In the 1998 newlywed study, husbands who were willing to accept influence from their wives, to take their views seriously and share decision-making power, were more likely to be in happy, stable marriages [^11]. The principle applies to every pairing: when both partners can say "That's a fair point, let's factor that in," conflict stops being a contest.

## Common patterns couples get stuck in

### The same fight, over and over

Many recurring arguments are about lasting differences in personality, values or needs: how tidy a home should be, how much time to spend with family, how to handle money. Gottman calls these [perpetual problems](https://strongercouple.app/library/glossary/perpetual-problems). The goal with these isn't to "win" or solve them for good. It's to understand the dream or fear under each position and find a workable compromise you can revisit. Read [having the same argument over and over](https://strongercouple.app/blog/same-argument-over-and-over).

### Pursue and withdraw

One partner pushes to talk; the other pulls back; the first pushes harder; the second withdraws further. Researchers call this the demand-withdraw or [pursue-withdraw cycle](https://strongercouple.app/library/glossary/pursue-withdraw-cycle). In a classic study, both partners tended to become more demanding when discussing a change _they_ wanted, and more withdrawing when discussing a change their partner wanted [^19]. So the cycle isn't simply about personality. Naming the cycle together ("We're doing the chase-and-retreat thing again") can turn it into a shared problem instead of a blame game.

### Escalation

Small comments snowball into big fights when each response is slightly harsher than the last. The antidotes are the skills above: soft openings, early breaks and quick repairs. A fair-fight agreement made in a calm moment also helps. Our article on [rules for fighting fair](https://strongercouple.app/blog/fighting-fair-rules) and the printable [fair-fight agreement](https://strongercouple.app/library/exercises/fair-fight-agreement) give you a ready-made starting point.

## A step-by-step method for a hard conversation

When you need to work through a real disagreement, this sequence keeps things on track. It is explained in depth in [how to resolve conflict in a relationship](https://strongercouple.app/blog/how-to-resolve-conflict-in-a-relationship).

1. **Pick the time.** Ask, "Is now a good time to talk about the weekend plans, or would after dinner be better?" Avoid starting when either of you is hungry, exhausted or about to leave.
2. **Regulate first.** If either of you is already flooded, take 20 minutes before you begin.
3. **Open softly.** Use feeling, situation and need. Keep it to one topic.
4. **Take turns.** Speaker talks about their own experience. Listener summarizes before responding. Switch.
5. **Look for common ground.** Ask, "What matters most to you about this?" and "What's one part of my view that makes sense to you?"
6. **Agree on one small next step.** Make it specific, with a time to check how it's going.
7. **Repair and reconnect.** Thank each other for staying in it, even if it was hard.

## Everyday communication that prevents fights

Much of what helps conflict happens outside of conflict. Couples who feel known and appreciated have more goodwill to draw on when things get tense.

- **Timing and setting.** Big topics go better at planned times, not in passing or by text.
- **Feelings over facts.** Saying "I felt embarrassed" lands differently than "You embarrassed me."
- **Curiosity.** Ask follow-up questions about your partner's day, worries and hopes.
- **Small appreciations.** Notice and name specific things your partner does well.
- **A weekly check-in.** A short, regular conversation about how things are going keeps issues from piling up. See [how to do a weekly relationship check-in](https://strongercouple.app/blog/how-to-do-a-weekly-relationship-check-in).

Our article on [how to communicate better in a relationship](https://strongercouple.app/blog/how-to-communicate-better-in-a-relationship) covers I-statements, listening to understand, and a weekly practice routine.

## A four-week practice plan

You don't need to change everything at once. Try one focus per week.

| Week | Focus               | Daily practice                                                                                    |
| ---- | ------------------- | ------------------------------------------------------------------------------------------------- |
| 1    | Notice the horsemen | Each evening, each of you names one moment you used a horseman, without judging the other's list. |
| 2    | Soft startups       | Raise any small issue using "I felt... when... Could we...?"                                      |
| 3    | Breaks and repair   | Agree on a pause signal. Use at least one repair phrase when things get tense.                    |
| 4    | Turn-taking         | Hold one 15-minute speaker-listener conversation on a low-stakes topic.                           |

At the end of each week, talk for ten minutes about what was easier or harder than expected. Celebrate progress, not perfection.

**In the Stronger Couple app:** [Weekly check-ins](https://strongercouple.app/app/weekly-check-ins)

## When conflict is something more

Some patterns are not ordinary conflict. Abuse involves one partner using fear, threats, intimidation or control over the other. The Centers for Disease Control and Prevention defines intimate partner violence to include psychological aggression meant to harm or control a partner, not only physical violence [^20].

Signs that point to abuse rather than ordinary conflict include:

- You feel afraid of your partner's reaction and change what you say or do to avoid it.
- Your partner threatens you, your children, your pets or themselves to get their way.
- Your partner controls your money, phone, friendships or where you go.
- Arguments involve pushing, grabbing, blocking exits or breaking things.
- You're told you're "crazy" or that you imagined things that happened.

If any of these feel familiar, communication techniques are not the answer, and couples counseling is generally not recommended. The National Domestic Violence Hotline explains that abuse is not a relationship problem, and that what is said in joint sessions can be used against the person being harmed [^21]. Confidential help is available 24/7: call 1-800-799-7233, text START to 88788, or chat at thehotline.org. If you're in immediate danger, call 911. Our page [is this abuse?](https://strongercouple.app/help-now/is-this-abuse) explains the difference between healthy, unhealthy and abusive behavior.

Contempt deserves a special note. Ongoing mockery and disgust are very damaging, and severe, one-sided contempt that's meant to belittle or control can be a form of emotional abuse.

## All articles in this guide

Start with the article closest to what you're facing right now.

- [How to stop fighting with your partner](https://strongercouple.app/blog/how-to-stop-fighting-with-your-partner): why couples get stuck and the pause-and-take-turns method.
- [The Four Horsemen of relationships, explained](https://strongercouple.app/blog/four-horsemen-of-relationships): the four patterns, the research and the antidotes.
- [How to communicate better in a relationship](https://strongercouple.app/blog/how-to-communicate-better-in-a-relationship): I-statements, listening and timing.
- [Soft startup: 25 examples](https://strongercouple.app/blog/soft-startup-examples): ready-to-adapt openings for hard topics.
- [Stonewalling in a relationship](https://strongercouple.app/blog/stonewalling-in-relationships): why people shut down and how to take a better break.
- [How to resolve conflict in a relationship, step by step](https://strongercouple.app/blog/how-to-resolve-conflict-in-a-relationship): a structured method for real disagreements.
- [Having the same argument over and over?](https://strongercouple.app/blog/same-argument-over-and-over): how to manage perpetual problems.
- [How to apologize to your partner](https://strongercouple.app/blog/how-to-apologize-to-your-partner): the parts of an apology that lands.
- [Active listening for couples](https://strongercouple.app/blog/active-listening-for-couples): reflect, validate and ask, in your own words.
- [Defensiveness in relationships](https://strongercouple.app/blog/defensiveness-in-relationships): why it happens and phrases to try instead.
- [Contempt in a relationship](https://strongercouple.app/blog/contempt-in-relationships): spotting it early and rebuilding respect.
- [Rules for fighting fair](https://strongercouple.app/blog/fighting-fair-rules): write your own couples' agreement.

## When to get professional help

Self-help works best when both partners are willing and the problems are manageable. Consider a licensed couples therapist if you notice:

- Ongoing contempt, or one of you regularly withdrawing for days
- An affair or another serious breach of trust
- Addiction affecting the relationship
- Depression or anxiety that affects daily life for either of you
- The same fights escalating despite real effort

Couple therapy has good evidence behind it. A research review found that it helps about 70% of couples who receive it [^22]. Our [getting help guide](https://strongercouple.app/library/guides/getting-help) and article on [how to find a good couples therapist](https://strongercouple.app/blog/how-to-find-a-couples-therapist) explain your options.

Get urgent help instead if there is any fear of your partner (see [Help Now](https://strongercouple.app/help-now)), or if you or your partner have thoughts of self-harm: call or text 988, or chat at 988lifeline.org. This article is for education and is not a substitute for professional help.

## Keep going

Ready for the next step? Start with [how to stop fighting with your partner](https://strongercouple.app/blog/how-to-stop-fighting-with-your-partner), learn the [repair attempts](https://strongercouple.app/blog/repair-attempts) that de-escalate fights, and read about [emotional flooding](https://strongercouple.app/blog/emotional-flooding). If you feel disconnected as well as conflicted, our guide to [struggling relationships](https://strongercouple.app/library/guides/struggling-relationship) is a good companion.

## Questions people ask

### Is it normal for couples to argue?

Yes. Every couple disagrees. Research on long-term couples found stable relationships with very different conflict styles, from calm and validating to loud and passionate. What separates struggling couples is usually a pattern of hostility, contempt or shutting down, plus a lack of repair afterward.

### What is the most important communication skill for couples?

There is no single magic skill, but three carry a lot of weight: starting hard conversations gently, taking a real break when you are overwhelmed, and making and accepting repair attempts. Together they keep disagreements from escalating into damage.

### Can communication skills fix an abusive relationship?

No. Abuse is about power and control, not a communication problem, and the National Domestic Violence Hotline does not recommend couples counseling when abuse is present. If you feel afraid of your partner, contact the Hotline at 1-800-799-7233 or text START to 88788.

### How long does it take to change a conflict pattern?

Most couples notice small changes within a few weeks of deliberate practice, such as catching a harsh opening or calling a break sooner. Deep, long-standing patterns usually take months, and many couples find a couples therapist speeds things up.

## Sources

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[^2]: The Magic Relationship Ratio, According to Science. The Gottman Institute, 2017. https://www.gottman.com/blog/the-magic-relationship-ratio/
[^3]: Hostile marital interactions, proinflammatory cytokine production, and wound healing. Archives of General Psychiatry, 2005. https://pubmed.ncbi.nlm.nih.gov/16330726/
[^4]: Marital quality and health: A meta-analytic review. Psychological Bulletin, 2014. https://pmc.ncbi.nlm.nih.gov/articles/PMC3872512/
[^5]: The Four Horsemen: Criticism, Contempt, Defensiveness, and Stonewalling. The Gottman Institute, 2026. https://www.gottman.com/blog/the-four-horsemen-recognizing-criticism-contempt-defensiveness-and-stonewalling/
[^6]: The Four Horsemen: The Antidotes. The Gottman Institute, 2013. https://www.gottman.com/blog/the-four-horsemen-the-antidotes/
[^7]: The Four Horsemen: Stonewalling. The Gottman Institute, 2025. https://www.gottman.com/blog/the-four-horsemen-stonewalling-part-ii/
[^8]: Marital processes predictive of later dissolution: behavior, physiology, and health. Journal of Personality and Social Psychology, 1992. https://pubmed.ncbi.nlm.nih.gov/1403613/
[^9]: Predicting divorce among newlyweds from the first three minutes of a marital conflict discussion. Family Process, 1999. https://pubmed.ncbi.nlm.nih.gov/10526767/
[^10]: First three minutes of discussion about ongoing area of marital conflict are predictive of divorce for newlyweds. University of Washington News, 1999. https://www.washington.edu/news/1999/09/27/first-three-minutes-of-discussion-about-on-going-area-of-marital-conflict-are-predictive-of-divorce-for-newlyweds/
[^11]: Husband's willingness to be influenced by wife, share power are key predictors of newlywed happiness, stability. University of Washington News, 1998. https://www.washington.edu/news/1998/02/20/husbands-willingness-to-be-influenced-by-wife-share-power-are-key-predictors-of-newlywed-happiness-stability-uw-study-shows/
[^12]: UW researchers can predict newlywed divorce, marital stability with 87 percent accuracy. University of Washington News, 2000. https://www.washington.edu/news/2000/03/27/uw-researchers-can-predict-newlywed-divorce-marital-stability-with-87-percent-accuracy/
[^13]: What type of communication during conflict is beneficial for intimate relationships?. Current Opinion in Psychology, 2017. https://pmc.ncbi.nlm.nih.gov/articles/PMC5181851/
[^14]: Pronouns in marital interaction. Psychological Science, 2005. https://pubmed.ncbi.nlm.nih.gov/16313655/
[^15]: How to Fight Without Hurting Your Relationship (interview with John and Julie Gottman). Greater Good Magazine, UC Berkeley, 2024. https://greatergood.berkeley.edu/article/item/how_to_fight_without_hurting_your_relationship
[^16]: Preventing marital distress through communication and conflict management training: A 4- and 5-year follow-up. Journal of Consulting and Clinical Psychology, 1993. https://pubmed.ncbi.nlm.nih.gov/8450110/
[^17]: Does marriage and relationship education work? A meta-analytic study. Journal of Consulting and Clinical Psychology, 2008. https://pubmed.ncbi.nlm.nih.gov/18837590/
[^18]: Manage Conflict: Repair and De-Escalate. The Gottman Institute, 2012. https://www.gottman.com/blog/manage-conflict-repair-and-de-escalate/
[^19]: Gender and social structure in the demand/withdraw pattern of marital conflict. Journal of Personality and Social Psychology, 1990. https://pubmed.ncbi.nlm.nih.gov/2213491/
[^20]: About Intimate Partner Violence. Centers for Disease Control and Prevention, 2026. https://www.cdc.gov/intimate-partner-violence/about/index.html
[^21]: Should I Go to Couples Therapy With My Abusive Partner?. National Domestic Violence Hotline, 2026. https://www.thehotline.org/resources/should-i-go-to-couples-therapy-with-my-abusive-partner/
[^22]: Research on the treatment of couple distress. Journal of Marital and Family Therapy, 2012. https://pubmed.ncbi.nlm.nih.gov/22283385/