Couple Therapy:The Ambivalently Embraced Stepchild

Sad & Sobering Statistics

• 90% of Americans marry• 50% of those marriages end in divorce• In CA-the avg. length of marriage is 7 yrs• 75% of those who divorce remarry• And 65% of those remarriages end in divorce • According to John & Julie Gottman, the avg. couple waits 6

years before seeking help for marital problems

4 Phase Hx of Couple Therapy• Phase 1: “Atheoretical Marriage Counseling Formation” –

1930-1963• Practiced by non mental health experts i.e. obs, gyns, family

life educators, clergy• Value laden• Advice giving and “guidance” re: proper family and marital

roles and life values• Brief, didactic, limited to one’s experience-not formalized nor

theorized

Phase 2: Psychoanalytic Experimentation” Phase (1931-1966)

• Individual psychoanalytic perspective-only approach to therapeutic intervention

• Conjoint family therapy beginning to be practiced—few, brave psychoanalysts recognized limitations to trying to treat a couple or family by working only w/

individuals

Phase 2 cont.

• Meeting jointly w/members of same family=forbidden practice; these analysts were excommunicated from professional organizations

• Therapy focus: “interlocking neuroses” of married partners (the birth of psychoanalytic marriage therapy)

• Unfortunately, psychoanalytic marriage therapy was to become obselete due to emergence of “family therapy”

3rd Phase: “Family Therapy Incorporation”(1963-1985)

• The early pioneers and founders of family therapy: Ivan Boszormenyi-Nagy, Murray Bowen, Donald D. Jackson, Salvador Minuchin, Carl Whitaker, Lyman Wynne, Theodore Lidz, Virginia Satir, Jay Haley, the Palo Alto group and others.

3rd Phase cont.

• Many were psychiatrists with formal psychoanalytic training who challenged the tx of marriage and families from an individual treatment approach which generally meant the unwarranted pathologizing of individuals in relational contexts.

3rd Phase cont.

• Leaders in the field who gave rise to the newly emerging field of “Family Therapy” forming a separate & distinct identity from the prior “couple therapy” movement were:• Don Jackson – founder of MRI in Palo Alto• “report & command” attributes of communication; double

bend; homeostasis; family rules; marital quid pro quo

3rd Phase cont.• Virginia Satir – experiential; humanistic• “the self in the system”; self-expression; self-actualization;

relational and communicative authenticity; iceberg metaphor; mobile metaphor

• Murray Bowen – 1st family therapy theorist to address mutligenerational and transgenerational systemic issues• Marital dyad as central tx unit• Differentiation & individuation• triangulation

3rd Phase cont.

• Jay Haley – hallmark publication of “Marriage Therapy” defining moment for the field of marriage therapy• central dynamic of marriage is power & control-”The major

conflicts in marriage center in the problem of who is to tell whom what to do under what circumstances.” (Haley, 1963, p. 227)

• Symptom bearer assumed to have gained and maintained an equalization of marital power through his/her difficulties

3rd Phase cont.

• Haley cont.• Family and couple dynamics – products of a “system” rather

than relational by-products• “1st law of human relations” – when one person indicates a

change in relation to another, the other will respond in such a way as to diminish that change

4th Phase of Couple Therapy“Refinement, Extension, Diversification, & Integration”(mid-1980s; 1986-present)

• Influences primarily from:• Behavioral/cognitive-behavioral couple therapy• Attachment-oriented emotionally focused couple therapy• Psychodynamic couple therapy

Behavioral Couple Therapy (BCT)

4th Phase cont.

• new BCT – development of Integrative Behavioral Couple Therapy (IBCT)-IBCT with the addition of self-regulation skills

• “Extension” phase-role of couple/martial factors in the etiology & maintenance of individual pathology

• “Diversification” phase – broadening perspectives (feminism, multiculturalism, & postmodernism)

4th Phase cont.

• “Integration” phase – common factors research; integration of common treatment modalities and techniques as well as attunement to client factors that allow for greater flexibility and therefore, more favorable therapeutic outcomes

• “We need different thinks for different shrinks.” A.C.R. Skynner

Treatment of Couples

“For many of us…intimate relationships have become the new wilderness that brings us face to face with our gods and demons…when we approach it in this way, intimacy becomes a path-an unfolding process of personal and spiritual development” (Brussat & Brussat, 1996, p.417)

Ethical Issues

• Contraindications for couples therapy• Lack of commitment to the relationship; one partner wants to

dissolve the relationship & other partner wants to save• Abuse and violence: No violence contract• Transferential alliance with one partner; viewing one member

of the couple as the party at fault or unlikable• One or both members of the couple not emotionally,

cognitively, or geographically available-depression, substance abuse…

Ethical Challenges in the Treatment of Couples

• In the early 1950s when practitioners began to experiment with relational therapy and began to involve more than the individual in treatment, the profession at large viewed this an unethical behavior. It was not only considered taboo, but unethical practice to treat more than one individual in the family.

• Now, it is considered not only common but perhaps even better practice to include and involve more than one individual in the system when focusing treatment.

• However, unique to couples therapy, are some ethical challenges that the therapist must be aware of as well as thoughtful consideration for the management of these challenges.

Ethical Challenges/Dilemnas

• Definition of “Who” is the Client—to whom is the therapist primarily responsible to?• the couple• the system-all members of the household; aka “stakeholders”

in the marriage• The individual who seeks treatment• The identified patient or symptom bearer

Challenge: any intervention on behalf of one member may not be in the best interest of another.

Who is the client?What do the professional organizations say?• AAMFT Code of Ethics does specifically not address this issue.

• CAMFT Code of Ethics states: 1.9 FAMILY UNIT/CONFLICTS: When treating a family unit(s), carefully consider the potential conflict that may arise between the family unit(s) and each individual. Marriage and family therapists clarify, at the commencement of treatment , which person or persons are clients and the nature of the relationship(s) the therapist will have with each person involved in the treatment.

• We get slightly better definition and guidance from APA’s Code of Ethics: §10.02(a) When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologist’s role and the probable uses of the services provided or the information obtained.

Dilemma of Confidentiality

• The expectation of confidentiality has been typically defined between an individual and his/her practitioner.

• A couple or family – involves more than one individual and his/her practitioner

• How does a therapist protect the rights of privacy and confidentiality for each member of the treatment unit?

Dilemmas with Confidentiality

• Can/would/should a therapist keep a “secret” or information shared outside of session or when only one member of the unit shows for session?

• What if couple divorces and engages in bitter court battle and one partner wants to subpoena counseling records and the other does not consent?

Dilemmas cont.• What happens when the parties are told that the

individual sessions are a necessary part of the work with the couple or family, and that the therapist's primary allegiance and duty is to the patient-that is, the couple or family-what is the individual to think about the confidentiality of his/her communications with the therapist during those individual sessions? Isn't it reasonable for the patient to expect that the communications will be confidential? What should the individual be told about the limitation to confidentiality?

Dilemmas cont.

• What about collaterals? Do they have a right to confidentiality? Access to records?

Solution:

• Identify, specify “Who” is the client at the commencement of therapy or soon after initial evaluation

• Adopt a “No Secrets Policy” & have client(s) sign agreement

• Make clear at outset the use of collatorals & make clear when collatoral enters tx not a clt/pt—no rights

Dilemmas cont’d:

• What about billing?• Typical couple—marital dissatisfaction; conflictual

communication…• What is the DSM code for this?• Will 3rd party payer reimburse?

• What about record keeping & release of records?

WHY IS COUPLE THERAPY IMPORTANT?

“Nobody is ready for marriage; Marriage makes you ready for marriage.” (Shnarch, 1997)

• Recurrent marital conflict & divorce are associated with a wide variety of problems in both adults & children

• Divorce and marital problems are among the most stressful conditions that people face

• Breakdown of the marital relationship exacts enormous costs on families, children, communities, society, morality & physical health

WHY ARE RELATIONSHIPS-MARRIAGE SO DIFFICULT?

• “The expectations & requirements of marriage go well beyond maintaining economic viability and ensuring procreation. For most couples nowadays, marriage is also expected to be the primary source of adult intimacy, support, and companionship, and a facilitative context for personal growth.” (Gurman, 2008, pp.2-3).

• “The roles of men & women have dramatically shifted, and so have our expectations about relationships. We have never wanted more from another-more passion, more support, more connection. But our desires have not been matched by a corresponding new set of skills, and for most of us, whatever we learned growing up about relationships is simply not sophisticated enough to deliver all that we hope for.” (Real, 2007, xi).

• Significant cultural changes that have impacted marital roles, rules & expectations: 21st century relationships with 20th century skills and social modeling• traditional 20th century marriage: breadwinner/caretaker• Husband: if good provider, reliable, not an active addict or

abuser, handy around the house=good husband

• Wife: procreate and caretake offspring; cook, clean, attend to husband’s physical & sexual needs= good wife

• 21st century rules & expectations:• women gained economic, political & psychological freedom • women no longer looking for or satisfied with a spouse who

was primarily a “provider” (paycheck) and/or “companion”• Now looking for a “partner”/”lifemate” with

• increased expectations for physical, sexual, intellectual, emotional & spiritual intimacy

• Strength & emotional vulnerability – mutually exclusive (esp. for men as well as some women)

• Need & desire for more involvement, more understanding, more emotional

connectedness from men—on the whole is a challenge for men & a common frustration for women

WHY COUPLES SEEK THERAPY

• Bottomline, couples seek therapy due to threats to the security, integrity & stability of their relationship; pain-is a top motivator for people to seek therapy

• Top reasons given for seeking help• financial• infidelity

Reasons for therapy cont.

• sex• ineffective conflict resolution (communication) • disagreements w/raising children/ having children/step-

blended family stress

“Winning the Battle for Structure” (Carl Whitaker)

• “Becoming adept at winning the battle for structure with couples is a skill many therapists never master, and, after too many frustrating failures, some end up avoiding couple therapy altogether.” (Weeks, 2005)

Video clip The Ref- 3:56-6:40

Winning the Battle for Structure

• May lose the battle for structure if…• Do not determine unit of treatment from outset• Fail to realize therapeutic relationship begins with first

encounter with the clients• Do not set and keep ground rules• Unintentionally unbalance therapy• Get caught up in trying to determine “objective truth”• Fail to address your own issues about authority and

confronting clients. (Weeks, 2005)

Maintain Balance

• Neutrality, Neutrality, Neutrality• Alliances form when…• Do not take systemic perspective• Unaware you have lost neutrality• Unclear when breaking neutrality is indicated• Neutrality is poorly implemented(Weeks, 2005)

Suggested Ground Rules

• Both partners must be present at every session.• 24 hour cancellation policy and cancellations not due to fights or

reluctance to attend by one partner.• Partners must be moving in the direction of showing respect for each

other in their communication so to not repeat destructive patterns.• Working towards each partner accepting responsibility in creating

the relational problem.• Couple must agree to rule of confidentiality set by therapist.• Partners must be committed to process long enough for therapy to be

effective.

Common Mistakes in Couple Therapy

• Failure to direct & structure therapy• Failure to give clients “battle for initiative” in setting

therapy goals• Inappropriate alliances & coalitions• Not connecting with both partners from the beginning• Not allowing couples to express conflict

Common mistakes

• Failure to confront-making sessions too comfortable• Letting conflict escalate into destructive patterns• Unbalanced or poorly timed empathy• Not moving fast enough when “divorce” is brought up• Ending couples work & referring out to individual therapy

Common mistakes

• Pathologizing one of the partners• Telling the couple that they are incompatible & should

divorce• Taking an individualistic approach above a relational one

Integrative Behavioral Couple Therapy (IBCT)

Sessions

• Therapy typically lasts from six months to a year with 26 sessions. (Research shows that 26 sessions, including the evaluation phase, helps most couples.)

“There are two sides to every story.”

• Andrew Christensen, Ph.D, and the late Neil Jacobson, Ph.D

• 2002 book Reconcilable Differences. • Third side: their objective take on a couple, which

usually includes some truth from both stories.

• Developed in late 1990s• Combines techniques from behavioral couples therapy

with strategies to cultivate acceptance

What is IBCT

• “IBCT assumes that relationship problems result not just from the egregious actions and inactions of partners but also in their emotional reactivity to those behaviors. Therefore, IBCT focuses on the emotional context between partners and strives to achieve greater acceptance and intimacy between partners as well as make deliberate changes in target problems.”

Integrative Behavioral Couple Therapy (IBCT)

• Primary source of dysfunction• Problem becomes entrenched• Behaviors become more extreme• Pattern escalates more quickly• By the time enter therapy, couple is very polarized

3 destructive patterns

• Mutual coercion• Vilification• Polarization

• Very documented by research

Solutions

• Acceptance• Tolerance• Change

Acceptance

• “… When acceptance comes first, it paves the way for change. When you and your partner experience greater acceptance from each other, your resistance to change often dissolves. You may be more open to adapting to each other and accommodating in ways that reduce conflict. You may be able to communicate more clearly and negotiate and problem-solve more effectively since you are no longer adversaries.”

Goal

• Change the context by changing the agent of behavior as well as the recipient

• Why recipient?• Some problems are unsolvable• Increased acceptance often leads to increased change in the

other• Reaction to offending behavior is often just as much of a

problem

• TBCT Rule-based behavior• IBVT Contingency-shaped behavior

• Behavior shaped by rules doesn’t feel right• Will be interpreted less positively• Was it really “meant”?• Rules can’t really address emotional changes• Therapist tries to model these changes • Speaking openly, noncritically etc.

• Therapist helps provide reinforcement by asking about emotional responses

What to talk about

• General discussions of the basic differences between the partners and related patterns of interaction

• Discussions of upcoming events that may trigger conflict or slip-ups

• Discussions of recent negative incidents• Discussions of a recent positive interaction

IBCT vs. TBCT

• “IBCT was developed, in part, to address concerns about long-term maintenance of gains (Jacobson & Christensen, 1998) through a focus on emotional acceptance and an emphasis on natural contingencies. For example, rather than teaching couples the “right way” to communicate and reinforcing that communication, as in TBCT, IBCT therapists process partners’ reactions to each other’s communication, letting those responses (natural contingencies) shape each other’s behavior”.

A Closer Look at IBCT

• Two phases• Evaluation• Therapist meets with couple• Talks about why they’re there• Next individually• Then together for feedback• Decision to continue

• Treatment

How session might go

• The therapist may gather some final information in the beginning of the session, but most of the session is devoted to feedback from the therapist, in which he or she describes the couple’s difficulties and strengths and how therapy will try to assist the couple. A major part of the feedback session is the therapist’s formulation of the couple’s problems, a conceptualization of the major themes in the couple’s struggles, the understandable reasons why the couple has these struggles, how their efforts to resolve the struggles so often fail, and how therapy can help. The couple actively participates in this feedback, giving their reactions, adding information, and correcting the therapist’s impressions as needed.

Look for patterns

• If couple agrees go to treatment phase• Exploring both positive and negative current issues that are

part of pattern• Examples of themes:• Difficulty achieving emotional intimacy• Frequent struggles over decision-making

Look for patterns

• If couple agrees go to treatment phase• Exploring both positive and negative current issues that are

part of pattern• Examples of themes:• Difficulty achieving emotional intimacy• Frequent struggles over decision-making

• Explore how past shaped present

Looking for

• Identify sequence of behaviors that occur in a given interaction

• Environmental triggers and reinforcing problematic behaviors

• Themes• Dynamic process of polarization• Mutual traps

Themes

• Demand-withdraw• Respect-Acceptance• Closeness-distance• Power-control

The idea

• Foster empathy and compassion, accept each other’s differences

• Creates intimacy, sometimes change and increased satisfaction because of their differences

• 5 year study

• Empathic joining• Unified detachment• Tolerance building• Self-Care

Integrative Behavioral Couple Therapy

Empathic Joining Around the Problem

Empathic Joining

• Language of Empathic joining: • Therapist emphasizes partners’ experience of the problem.

Therapist does not focus on the content of the problem• Therapist redirects partner back to their experience of the

problem.

Empathic Joining Around the Problem - Summary

• Therapist acknowledges the couple’s painful experience with the problem

• Therapist reformulates the problem as differences between them as common human experiences rather than their partner is the “sick” one. (EFT reframes this as each partner’s attempt to connect albeit unsuccessful or an attachment coping strategy)

• Therapist highlights the couple’s interaction patterns, using themes, as means they take to alleviate the pain

• Therapist explains these interaction patterns (cycles) are making the couple more entrenched in their differences and pain – polarized/gridlocked

• Therapist externalizes the “problem cycle” making it the problem (or enemy) rather than each other

Empathic Joining Around the Problem Goal

• Empathic joining around the problem intervention goal is to soften the LISTENER.

• A softened listener is able to accept the speaker’s experience. Differences in their partner are no longer seen or experienced as threatening.

Empathic Joining Student Role-playIBCT

1. Role-play empathic joining. Reformulating couple’s presenting problem as pain resulting from understandable differences.

2. Explain their interaction patterns.

3. Discuss how interaction patterns are part of the polarization process.

Empathic Joining Exercise