Couples Counselling

Chris Worfolk
Welcome to the Couples Counselling course handbook. This serves as a
complete set of notes for the course but I would encourage you to take your own
notes as well to aid your learning.

Good luck with the course and see you soon!

Stay strong, Chris

What is couples counselling?

50 years ago it would have been easy to answer the question “what is a couple?”:
a man and woman in wedlock. Today, we see a much wider variety of couples.
Couples may be of the same gender or different, they may be married, cohabiting
or living apart, and they may involve more than two people in a series of complex
relationships.

What cuts through all of this is that we are dealing with intimate relationships.
This is not meditation between two business partners but helping those who
want to build a close and personal relationship that entwines their lives together.

Origins of couples counselling

The term “couples counselling” is a description of what we are trying to achieve
but not necessarily what we are doing. It is not a school or modality in the same
way that cognitive-behavioural therapy is, for example.

Over the decades, several schools both inside and outside of counselling have
attempted to ply their trade to build stronger relationships.

Individual psychotherapy has been adapted to work for relationships. This

has produced Relational Therapy and Interpersonal Therapy, but on the whole,
processes developed to help individuals do not work as well when we apply
them to couples.

As a result, a new branch of psychotherapy was born: family therapy. This

drew inspiration from the wider development of systems theory and formed its
own schools such as structural therapy, strategic therapy and, more recently,
narrative-based therapies.

At the same time, the church was becoming increasingly worried about rising
divorce levels and began offering marriage guidance, originally in the form
of education. This gradually became marriage counselling and eventually

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relationship counselling.

While all of these approaches have had their successes, and we will draw in
experience from them all, we are going to use systemic family therapy as a
primary theoretical base because this is the most well-developed theory of how
to improve interactions between couples and families.

History and development

Systemic therapy began by looking at the typical family and the systems and
processes that these families had in place. Relationships would strive towards a
balance or homeostasis, and this may be interrupted by various life events, that
the relationship would have to adapt around.

As time went on, it became clear that while many of these models were useful,
there was no such as a “typical” relationship and with an increase in divorce,
stepfamilies and alternative living arrangements, these traditional structures
were less applicable.

Therefore, the second phase took on a constructivist approach: there was no

inherent meaning to the roles and feelings inside a relationship except for those
that were created by the people in the relationship.

The third phase reintroduced some of these structures from a more critical
perspective. Identities are not constructed in a vacuum but inside of their social
context. For example, although a couple is free to decide one partner should
be a wage earner and another a home worker, it would be naïve to ignore the
traditional gender roles and gender pay gap that exists in society.

What makes relationships work?

Relationships are voluntary. That is not to say there cannot be social pressures
that influenced them (such as arranged marriages or a taboo against divorce) but
for the most part, people stay in relationships because they are beneficial: there
is more good stuff than bad stuff.

Resilient relationships typically consist of:

1. Good communication
2. Sense of togetherness through shared values beliefs
3. Sharing activities such as meals and leisure time
4. Showing affection

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5. Active support
6. Acceptance
7. Commitment to the relationship and “us” over “me”
In contrast, struggling relationships typically have poor communication.
Specifically, what John Gottman refers to as the “four horsemen” of doomed
relationships.
1. Defensiveness
2. Criticism
3. Contempt
4. Stonewalling

Understanding relationships
Individual psychotherapy attempts to look inside the client’s head, exploring the
thoughts and feelings and behaviours that result from their experiences.

With couples counselling, we are looking at something entirely different: the way
people interact and communicate with each other. Communication is constant
be it verbally or by a variety of non-verbal means.

We can model the relationship as a system. It consists of two or more parts

(wider family and friends, extended relationships) that exchange information and
use that information as feedback to self-regulate.

For example, imagine one partner begins shouting and this causes the other
partner to raise their voice still louder. A change in one part of the system causes
an escalation in another. Perhaps the second partner raising their voices triggers
the first partner to calm down. This change in the system causes a balance to be
found.

Interaction-focused therapy
One of the early pioneers in this area was Don Jackson. Jackson suggested that
we are constantly trying to define the nature of our relationship with others to
reach a stable equilibrium.

Particular patterns in a system often trigger particular behaviour. Therefore,

to understand and make changes in a relationship, we should focus on these

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processes.

This was a leap away from individual psychotherapy that focused on an

individual’s personal needs and brought to the forefront the idea that the
relationship can be seen as the organism.

Relationships as organisms
Couples are individuals with their own individual desires and needs. However,
while a relationship is an abstract constant, it also contains emergent properties:
there is something there that is not there in each individual on their own.

In cognitive-behavioural therapy, we might look at certain thoughts and

behaviours that are maladaptive: they have a negative effect on the organism,
which in the case of individual psychotherapy is the client. Therefore, we need to
find new adaptive ones.

In systemic therapy, patterns of interaction can be maladaptive: they have a

negative effect on the organism, which in this case is the relationship. Therefore,
we need to replace these maladaptive processes with better ways to interact to
strengthen the relationship.

Why use systems?

Any model we use for therapy is bound to be an inaccurate representation of
reality but some models are more useful than others in helping us understand
what is going on and how to change it. For relationships, systems theory provides
the most useful model.

It also has the advantage that it dilutes blame. Problems arise from the system,
not from individuals. This is important because if one partner feels blamed they
are unlikely to engage productively in therapy.

Functional behaviour
Maladaptive behaviour can occur because it is functional: that is to say that it
serves a purpose.

For example, Jack is dissatisfied with his marriage to Amy but Amy finds it
uncomfortable to talk about. Jack ultimately gets frustrated and starts screaming
and yelling which forces the issue.

When the couple attends therapy, the presenting problem maybe Jack’s anger.
But the root cause of the problem is their inability to confront their relationship

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difficulties and anger is a functional adaptation to address this. This could be
solved by guiding the couple to have more productive ways of discussing their
difficulties.

Note that we should not necessarily imply intentionality here. Jack may not be
aware that he is using anger to force the issue; he merely feels frustrated and
starts shouting.

Structures
Relationships are embedded inside family structures.

The couple may have children together. They may also have children from
previous relationships. Each partner will typically have parents, and an extended
family and friends. And the couple will have joint friends.

Finally, a wider view may also take in any communities such as religious or
community groups they are part of, schools their children attend, professionals
such as doctors and a variety of other influences on the relationship.

Structural therapy
As well as an external structure, relationships have an internal structure: they
operate according to a set of rules that can be implicit or explicit.

Salvador Minuchin pioneered the idea of structural therapy and looking at these
rules. He suggested relationships could be measured in terms of emotional
closeness and adaptability.

Both of these function best when a healthy medium is achieved. For example,
emotional distance is harmful to a relationship. But it is also important that
partners can function outside of the relationship without being so enmeshed that
they become completely reliant on the other.

Similarly, have some rigidity can be helpful as it provides a sense of stability and
normality. But the relationship also needs to be flexible enough to change when
required.

Transitions and life cycles

Relationships can experience periods of stability and periods of change: we refer
to these periods of change as transitions. Something upsets the balance and the
relationship attempts to adapt to the change. These transitions can put additional
pressure on a relationship and it is often at these times that a couple will come to

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therapy.

Extending this concept, we can look at some typical transitions as viewed

through the life cycle of a relationship. Common events may include:
• Formation of relationship
• Birth of children
• Career changes and returning to work
• Children leaving home
• Bereavements
• Divorce

Strategic therapy
Strategic therapy is a school that takes a goal-orientated approach. It could be
said to be the CBT of family therapy because it often looks for specific problems
and focuses on improving the specifically identified goals.

Once the problem has been understood, we use then strategic interventions in
the form of homework for the couple. These are reviewed and altered at each
session which again mirrors the structure of CBT.

These tasks can be directive in an attempt to do things better: for example,

allocate ten minutes to telling each other about their day.

They can also be paradoxical: tasks designed to seemingly make the problem
worse to highlight ineffective interaction. A classic example was a family who
said they were always sniping at each other, so the therapist had them buy water
pistols and actually snipe each other. When they tried, the family ended up
dissolving into laughter every time.

Constructing identities
Original theories around systems and structures work well for a typical family.
The problem is what family is entirely typical?

Certainly, the idea of the nuclear family is no longer appropriate. Around half a
marriages end in divorce, but many people choose not to marry in the first place.

Second, the original theories felt rather too mechanical for a lot of people’s
tastes. It places the therapist on a pedestal as the expert who will diagnose what
is going wrong and help the relationship get back to “normal”.

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The constructivist approach rejects the idea that there is one truth and replaces it
with individual viewpoints. What does the couple see as a problem?

This brings up the question of are problems real? For example, an open
relationship would be seen as morally wrong by some cultures. But the couple
may not see it as a problem. In contrast, domestic violence is wrong even if the
victim is unable to see it. Differentiating these scenarios can be a challenging
exercise.

Social construction
If the move to a constructionist approach represents the second wave of family
therapy, the move to social construction represents the third wave.

This change was influenced by the feminist movement and challenged the idea
that identities are constructive in a vacuum: couples create their own meaning
but they do so while embedded in a culture and society with certain normative
values.

For example, western society has an image of men as strong and silent
breadwinners who provide the family income and are always up for sex. While
women typically earn less and do more of the domestic work.

It is also important to consider the couple’s situation. Those on lower incomes

struggling with inequality and deprivation are dealing with very real problems
that disadvantage them in society and this should not be overlooked as a major
contributor to the couple’s difficulties.

Core counselling skills

The best preparation for couples counselling is to take a foundational course on
counselling itself. However, if you are new to counselling, this chapter will provide
you with the key skills used in counselling.

Counselling is a professional helping relationship that uses talking to work

through emotions. This relationship with the client is known as the therapeutic
alliance and its strength (how much the clients trust you) is a major determinant
in the outcome of therapy.

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Non-specific factors
One of the quirks of different modalities (schools) of therapy is that they all work
at a similar rate. CBT typically produces results faster but many others catch up in
the long term. Why is this?

Frank (1974) suggested there were a series of common or “non-specific” factors

that made therapy work. Grencavage and Norcross (1990) compiled a list of
these:
1. Therapeutic alliance
2. Opportunity for emotional relief
3. Acquisition and practice of new behaviours
4. The client having positive expectations
5. The therapist being a source of positive influence on the client
6. Provision of rationale for the client’s difficulties

Active listening
Being a good therapist, of any type, starts with active listening. This is often
described as “listening to hear rather than listening to respond”.

When we are in the pub with our friends, we often use the time that they are
talking to think up our next anecdote. This is fine. We are all having a good time
over a few beers or lemonades and nothing important will be missed.

But this is very different to being sat in a room with a client who may be pouring
their heart out. Here, every word becomes vital.

To do this, we need to give the client our full attention. It also means we need
to delay responding until we have processed everything we have said. New
therapists often feel uncomfortable with silence and that they need to respond
immediately. This adjustment to be able to hear, pause and think takes time to
become comfortable with.

We also want to demonstrate our active listening so that the client knows we are
paying attention to them. We do this with body language, minimal encouragers
(yeah, umm-hmm, okay), and by asking clarifying questions to make sure we
understand.

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Core conditions
The core conditions come from person-centred therapy and are the building
blocks of a strong therapeutic alliance. There are three core conditions:

Empathy is seeing the world from the client’s viewpoint, also known as their
frame of reference. Empathy is not sympathy but rather learning to walk in the
other person’s shoes. For example, if I mostly received Cs in school I would
probably be pretty happy receiving a B in an exam. But if I was from a high-
achieving family where my parents expected me to get an A every time, it would
be a big disappointment. We can only appreciate those emotions if we use the
correct frame of reference.

Unconditional positive regard (UPR) is accepting the other person without

judgment. It is letting go of our values and respecting the person in front of
us. That does not mean we need to like them. But by accepting them for who
they are, we role-model this acceptance for the client and they begin to accept
themselves. Self-acceptance is the first step to making changes: it is very difficult
to change anything if you are in denial about your feelings!

Finally, congruence is genuineness. It is about being ourselves rather than

putting on an act. After all, who would want a relationship with someone who was
being fake?

Confidentiality
Therapy works best when people are honest. To achieve this, we need to create
a safe environment where clients trust us to keep their information private.
Confidentiality should be the default state.

However, it is also important to be upfront about when we would break

confidentiality. This would include:
• Safeguarding. If we feel there is immediate danger to either partner or a
member of the public, we would need to speak to the clients about the
next step and any reporting we may need to do.
• Legal obligations. If we are called to testify at court.
• Supervision. All therapists work with a supervisor to provide an emotional
outlet and ensure compliance with ethical standards.
As a side note, family therapy has broken down many of the barriers around the
secretive nature of therapy. Having the family involved inherently makes it less
private, but in addition, family therapists often work within teams for supervision

Couples Counselling 10
and the teams may at time interact with the family.

That is not to say you should use such an approach with couples counselling, but
it is interesting to observe that therapy can be done “in the open”.

Doing couples counselling

In this chapter, we will explore the process of conducting couples counselling.

Assessment
This process starts with an assessment. This is your chance to introduce yourself
to each partner and allow them to talk about their difficulties. This allows us to
assess the relationship, its problems and whether couples counselling is a good
fit.

In the assessment, we are looking to answer the following questions:

• How does this couple work?
• How does the presenting problem connect?
• What changes are needed to improve the problem?
• What resources does the couple have to make changes?
Couples counselling may not be suitable for everyone. It is not a cure for mental
illness. Nor is it suitable for otherwise happy couples that are struggling with
sexual dysfunction. And it requires that all parties engage with the process. That
is not to say that everyone must be equally excited about the process, but they
must be willing to participate.

Contracting
Contracting is formalising and agreeing on how therapy will work. Laying down
the ground rules at the start protects everyone’s interests and avoids having
unpleasant conversations later on.

Important things to cover in contracting:

• How many sessions will there be?
• When and where will they take place?
• What the policy for cancelling or re-arranging sessions?

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• Confidentiality and safeguarding

Extending the therapeutic alliance

While the core conditions provide an excellent basis for a therapeutic alliance,
things become more complex when dealing with multiple people. In couples
counselling, the strength of the alliance can be measured by four factors:
• Emotional connection with the therapist
• Engagement in the therapeutic process
• Safety within the therapy system
• Shared sense of purpose within the couple
The first two of these are shared with individual psychotherapy but the second
two present additional challenges with relationships.

To ensure both parties feel safe we need to ensure we capture both perspectives.
This can be challenging if one partner is dominant and we may need to allow
extra time to allow both partners to air their views, and use unbalancing if
necessary.

The shared sense of purpose comes from the couple understanding what
therapy is and how it will work. Therefore, we must be as explicit as possible
about the process of therapy, what it looks like, and give them chance to ask any
questions they may have.

The presenting problems

Couples typically arrive at therapy with an idea of what the problem is (and
possibly whose fault it is). With time, we may want to challenge this idea of blame
and maybe even that the presenting problem is the real problem. But first, we
want to hear from each person.

To do this, we use our active listening skills, open body language and
encouragement to share their thoughts and feelings. Listening allows us to gain
an understanding of the wider situation, and how the couple interacts with each
other and us, the therapist.

Often, the couple will have attempted solutions that have not worked and it
is important that we listen out for these so we can gain further insight into the
couple and their resources, and to help us avoid making suggestions that have
already failed.

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Formulation
As we gain greater insight into the problem we begin to build our formulation
which is answering the question “what’s going wrong?”

A good formulation considers several factors:

• Problem-deconstruction: what is seen as the problem and why?
• Contextual factors like wider family, culture and the history of the problem
• Beliefs and explanations from each partner
• Functions of symptoms
• Attempted solutions
A formulation is not something done secretly in the mind of the counsellor but is
done openly in collaboration with the couple so that everyone can understand
and agree on it.

Formulation is also an ongoing process: we make progressive hypothesises

about what is happening and adjust them as we need.

One of the benefits of doing this is that it often makes the implicit explicit.
Relationships often run on a series of unacknowledged rules and feelings and
by making them explicit we can help the couple gain greater insight into their
relationship.

Making changes
For some couples, understanding what is going wrong in their relationship
is enough to find new ways to relate and interact with each other and the
relationship improves. Other couples will require additional help in making
changes.

We have several tools at our disposal to help couples make changes including
enactment, reframing and homework.

Therapeutic techniques
In addition to core counselling skills, therapists working with couples need to
bring in a variety of other tools to manage the process.

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Neutrality
In individual psychotherapy, we attempt to see the world from the client’s frame
of reference and express empathy. This is important with couples counselling,
too. However, we also want to avoid taking sides as this will alienate the other
partner.

We have achieved success if, as the Milan school puts it, “nobody should feel like
you are in their side”.

One of the benefits of using the systems model is that it inherently dilutes blame,
helping us to avoid siding with one partner and therefore making everyone feel
included.

Unbalancing
While neutrality should be the base that we work from we have previously
discussed the idea of unhelpful patterns of interactions. Sometimes we may
need to temporarily take sides to disrupt these maladaptive patterns.

For example, if one partner is constantly interrupting, we may need to impose a

no interrupting rule to silence that partner so we can hear the other side. Or if one
partner is dominant, we may need to take the side of the less powerful partner to
alter the balance of power for a short time.

Unbalancing should be done with care as if we are perceived to take sides it can
be damaging to the therapeutic alliance.

Circular questioning
The most productive discussions typically involve all parties in the relationship
and improve the connection between them. Circular questioning is a tool that
helps us to connect what each partner is saying.

With this technique, we ask one partner to reflect on what the other has said. For
example, Sam and Jenny attend therapy and Jenny talks about some difficult
emotions she has been experiencing. We could ask:

“Sam, how do you feel about what Jenny just said?”

After Sam has spoken, we can then ask Jenny to reflect on Sam’s comments:

“Jenny, what do you think Sam meant when she said ‘x’?”

We can also use this technique to connect experiences. For example, Jenny says

Couples Counselling 14
that things seem better this week. We could then ask:

“Sam, Jenny says things have been better this week, what do you think was
different?”

Reframing
Reframing is taking a behaviour that is seen as negative or complained about
and providing alternative plausible explanations. For example, shouting could be
seen as being passionate about the relationship. Or spending hours at the office
could be providing for the family.

Enactment
One way to gain insight into the way a couple interact is to replace talking about
their dynamics with having them act them out. This is done collaboratively with
the clients’ knowledge and agreement.

For example, if there is a typical tension point, ask them to have a conversation
about it. Or if disciplining a child during meal times is a problem area, have them
run through that scenario.

As a therapist, our role is to observe, help them to correct, and debrief.

Homework
Any agreed-upon behaviour changes can set as homework to take place
between sessions. Here the clients will do something different and where
possible this should be specific and observable.

Most tasks are directive: they change something for the better. For example, if
the couple has been neglecting each other they could be set “date night” as
homework. Or, if there is a recurring argument, we could agree on a better way to
approach the situation.

A second type of task is paradoxical. These tasks would appear to make things
worse but are set up in a way to highlight the problem to clients who are resistant
to change.

The classic example of such a task was a family that complained about “sniping”
each other. The therapist had them buy water pistols and literally snipe each
other. Every time the family tried, they quickly broke down into laughter.

Whatever the task set, it is important to review it at the next session.

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How do I deal with…
In this chapter, we will look at some common but specific scenarios that require
extra attention.

Mental illness
It is common for clients to be struggling with mental illness as this can cause a
lot of stress and extra pressure on a relationship.

Couples counselling will not resolve mental illness and we need to be clear
with clients about that. However, it may help with the tension that it creates so
engaging in couples counselling alongside treatment for the condition itself can
be useful.

Domestic violence
Domestic violence is a challenging situation because we do not want to deny
counselling to a couple reaching out for help but nor do we want to implicitly
condone abuse.

As a rule, do not provide counselling to someone who continues to engage in

violent behaviour towards their partner. However, if the violence has stopped and
both parties agree there will be no more, counselling should be provided.

Such scenarios bring in issues around safeguarding: you should make it

clear to the clients upfront that if there is any further violence you will break
confidentiality and report the information. In addition, any information shared may
be presented in court at a future date.

Separation and divorce

Typically couples will come into counselling with the firm intention of remaining
together. However, occasionally relationships will break down and the couple
will engage in therapy to remain on good terms as they separate. This is most
common when children are involved.

Counselling a separating couple is a similar process but emotions will be more

intense and we need to make room for that additional intensity.

Also, the needs of the client may differ. With a couple who remain together, they
are united under a single purpose but with a separating couple, they may have a
split agenda.

Couples Counselling 16
Key tasks for the therapist are to help the clients understand why the relationship
started, why it is ending, and how they will relate to each other going forward.

Sex
Sex is an integral part of most intimate relationships, but it is also the case that
sex often reduces or stops when couples are struggling.

As previously discussed, couples counselling does not deal with sex directly: if a
couple is otherwise happy but struggling with sexual dysfunction, they should be
referred for alternative approaches such as Psychosexual Therapy.

However, often a change in sexual activity is connected to the struggles within

the relationship and by helping the couple resolve these issues the sex will return
naturally.

Talking about sex

Sex is a taboo subject in many cultures and so is rarely talked about openly. This
means there is often embarrassment around discussing the topic.

Bringing some professionalism and a matter-of-fact attitude to the conversation

can role model being comfortable talking about sex for the couple. Use clinical
terms rather than slang.

It is also important to correct any misconceptions about sex.

Factors affecting sex

Many factors affect sexual intimacy within a relationship. Therefore, when
considering any issues, we also need to consider what other factors could be at
play. These could include:
• Pregnancy
• Menstrual cycle
• Fatigue
• Age (it becomes harder to “perform” as we get older)
• Body image and how we feel about our appearance
• Concerns about STIs

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• Stress and mental health

Sex myths
Sexual problems can sometimes be rooted in incorrect information or unrealistic
expectations around what sexual intimacy should be like.

The following are some common misconceptions that we can challenge:

• Sex has to be spontaneous and cannot be pre-planned or requested.
• Men are always in the mood for sex.
• Women cannot initiate sex.
• It is not sex if it does not involve intercourse.
• Sex must end in an orgasm.
• Regular sex and healthy relationships are inseparable.

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Couples Counselling
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