Couples Therapy

Couples Therapy Definition

• Couples therapy is a form of intervention that involves both members of a dyad, focusing on
the dysfunctional and unsatisfying interactional patterns within the relationship. Unlike
family therapy, which often addresses issues related to child or adolescent behavior and
parent-child interactions, couples therapy centers on the intimate emotional and sexual
aspects of the dyad.

• In family therapy, triangles involving various family members may be observed, whereas in
couples therapy, triangulation within the family must be inferred, and any triangulation in
the present interaction typically involves the therapist, as there are only two family members
present. Typically, marital therapy sessions are attended solely by the spouses, although
children may be invited during the initial assessment or for specific issues later on.

• Couples therapy is characterized by the peer relationship of the participants, the presence of
questions regarding commitment, and the importance of addressing gender issues. Even if
therapy is behaviorally focused, it must pay close attention to the emotional level, with the
goal of fostering more positive feelings between partners in addition to promoting more
reasonable behavior.
MARITAL DIFFICULTIES, PROBLEMS,AND DYSFUNCTION
• Marital difficulties, problems, and dysfunction are inevitable in any long-term relationship. The burdens of sharing intimate, social, and
parenting roles mean that people will inevitably clash over some aspects of life. It is common for marriages to undergo periodic stages
of crisis and reorganization.
• Problems occur when couples lose faith in the marriage or lose a sense of respect and warmth for each other. Partners who have had
poor role models, who had a childhood of loss and violence, or who are poorly suited to each other by style or inclination will have
increasing problems over time.
• Individuals come to marriage with the legacy of several generations of their family of origin, in addition to the beliefs and role models
of their parents. This means they carry with them firm ideas about what marriage should be like, how men and women should behave,
and what behaviors signify love and respect.
• From a developmental point of view, there remain unresolved needs and demands left from childhood that are invested with deeply
ambivalent feelings of love and hate. In the process of mate selection, the partner is attractive partly because he or she promises
rediscovery of an important lost aspect of the subject’s own personality, or because he or she offers the chance to redo an unfinished
conflict with a parent.
• When the couple join, they make a marital contract in which they assume that each partner will do certain things (Sager 1976). Some of
these ideas are conscious and shared (“You will care for the children, and I will work”), some are not shared, and some are secret even
from the self. For example, a person may marry to get away from home or may believe that, as long as he or she acts like a good child,
the spouse will act like a good parent. Mate selection, of course, is also determined by less dynamic reasons, such as physical
attractiveness, family demands, financial considerations, timing, and luck.
• Treatment for the couple involves increasing the intensity of the affective bonds and repairing their inevitable disruption. Each partner
must have someone who listens to his or her experience (i.e., the narrative) and helps to sort it out. Lewis (1998) said that “[t]he
prerequisites include a genuine and reciprocal liking for each other, mutual respect, a two-way valuing and affirmation” (p. 584). That
author also suggests that couples need to learn conflict management mechanisms, including techniques to prevent isolation.
• Couple communication, that is, how people talk to each other, can alter relationships. To improve disconnections, the therapist must
teach intimate communication, focusing on how to explore difficult issues and increase empathy. The strongest predictor of overall life
satisfaction is the quality of a person’s central relationship. In addition, a “good and stable relationship buffers against the genetic
vulnerabilities to both medical and psychiatric disorder.
Dynamic Point of View
• In the dynamic point of view, individuals seeking assistance with marital conflict often exhibit a
rigidity in their personalities, leading them to deny or remain blind to certain aspects of
themselves. They may ignore or reject similar aspects of their partner's personality, projecting
onto them traits they find uncomfortable. Consequently, they struggle to perceive the problem
clearly or consider alternative solutions. Often, they involve third parties to intervene and
deflect conflict between them.
• Gender disparities in needs and communication further complicate marital issues. Men typically
desire deference, prefer addressing problems independently before discussing them, and may
view sex as a means of problem-solving. Conversely, women often seek verbal intimacy,
equality in tasks, prioritize discussion and "feeling talk" over immediate solutions, and perceive
sex as contingent upon problem resolution. Women frequently bear the emotional burden of the
relationship, while men tend to assume greater responsibility for finances, regardless of the
wife's employment status. Consequently, many women find themselves emotionally pursuing
and sexually unsatisfied, while men face criticism for their perceived emotional detachment,
despite societal conditioning to suppress their feelings. (It's important to note that not all
individuals conform to these gender stereotypes.)
• As couples contend with differing behaviors and conflicting, ambivalent needs, they
increasingly view each other as unhelpful or negative, fueling escalating anger and distress
within the relationship.
Behavioral point of view
• From a behavioral perspective, distressed couples exhibit a pattern of
engaging in fewer rewarding interactions and more punishing exchanges
compared to non-distressed couples. They are prone to reciprocate each
other's use of negative reinforcement and often escalate punishment levels
over time, irrespective of the stimuli. Distressed couples frequently
attempt to influence each other's behavior through negative
communication and by withholding positive communication. They seek
to induce behavior change in their partner through aversive control
tactics, strategically employing punishment and withholding rewards.
Systems Point of View
• From a systems point of view, the solution becomes the problem— that is,
more aversive control (silence or attack) produces more aversive behavior
in the spouse instead of the longed-for connection.
• In addition, triangles form to deflect conflict, so that children, friends,
parents, or lovers are drawn into the marital conflict.
Psychiatric Illness Point of View
• From a psychiatric illness perspective, having a spouse with a serious Axis I disorder, such as
anxiety disorder, mood disorder, or substance abuse, can significantly strain the marital relationship.
The dynamics of the marital interaction before, during, and after the onset of symptoms in the
affected spouse are influenced by various factors and can vary widely between different couples.
• It would be erroneous to assume that the interaction between spouses always directly causes,
triggers, or exacerbates the mental disorder and symptoms in the other. The relationship between the
symptoms in one spouse and their marital interaction exists along a continuum and can manifest in
different ways:
1. The marital interaction neither causes the symptoms nor stresses the psychologically vulnerable
spouse.
2. The marital interaction does not initially stress the vulnerable individual, but following the onset of
symptoms, the marital interaction deteriorates, becoming dysfunctional and leading to greater distress.
3. The marital interaction acts as a stressor that contributes to the onset of symptoms in a vulnerable
spouse.
4. The symptoms can be entirely explained by the interactional patterns between the spouses.
• When therapists engage with a new couple facing these challenges, they must consider a range of
ideas to better understand and explain their distressing circumstances. This approach allows
therapists to tailor interventions that address the specific dynamics of each couple's situation.
The Issue of Commitment—The Problem of Affairs
• Assessing a couple's motivation for therapy becomes significantly more complex when
one spouse initially expresses commitment to the relationship but is secretly involved in
an extramarital affair and intends to end the relationship once the therapy, requested by
the other spouse, is completed. While it was previously assumed that such affairs couldn't
remain hidden from the other partner, experience has shown that in emotionally distant
marriages with a significant level of trust, individuals can successfully conceal many
aspects of their behavior.
• Often, marital therapy is initiated after the discovery of an affair by the other partner,
fundamentally altering the dynamics of the marriage. Many therapists hesitate to proceed
with marital treatment if one spouse is actively engaged in an extramarital affair, insisting
that the affair be terminated immediately. Some therapists may still proceed with
treatment if the affair is known to the partner, allowing the couple time to decide their
next steps.
• It's generally believed that effective couples therapy is impossible when one spouse and
the therapist are concealing an affair from the other partner. Moreover, a spouse engaged
in an affair may lack the necessary emotional energy to actively work on the marriage.
However, therapists may attempt to persuade the unfaithful spouse to end the affair and
temporarily return to the marriage for a reasonable attempt at therapy.
Evaluation of partners
• With modifications to focus primarily on the marital dyad, the outline for family evaluation can be adapted for assessing a marital
pair seeking assistance with their troubled relationship. This involves gathering data on the current stage in the marital life cycle,
understanding why the couple seeks assistance at this time, and obtaining each partner's perspective on the marital problem.
• In formulating the marital difficulty, the evaluator will summarize thoughts on the couple's communication, problem-solving
abilities, roles, emotional expression, involvement, and behavioral patterns, including sexual and aggressive behaviors. Gender
roles, cultural and racial factors, and power dynamics regarding gender, class, age, or financial status should also be evaluated. It's
crucial to inquire about alcohol use, health, reproductive issues, and any instances of violence.
• Even if the partners don't raise concerns about the children, it's important to assess their well-being, relationships with each parent,
and whether they're being drawn into marital conflicts. The presence of diagnosable conditions, especially Axis I disorders, in
either or both partners should also be explored.
• Areas such as each spouse's commitment to the marriage and their sexual expression of this commitment, or lack thereof, require
special attention. Both joint and individual assessment interviews with each partner may be necessary, particularly when infidelity
or doubts about commitment arise, potentially changing the focus of therapy from managing the relationship to whether the couple
will remain together.
• Addressing the sensitive issue of obtaining information about commitment levels and ongoing affairs can be managed through
individual sessions with each partner after initial joint sessions. These individual sessions are typically confidential, but the
therapist may stipulate that certain information, such as the existence of an affair or HIV-positive status, must be disclosed to the
partner within a specified timeframe.
• Determining whether couples therapy is appropriate, or if other forms of therapy should be considered concurrently or sequentially,
can be challenging. Couples should receive evaluation, support, and education, with a clear understanding of how their individual
issues intersect with their marital concerns. Referrals for concurrent individual therapy or initial individual therapy followed by
couples work may be recommended based on individual needs.
• Couples therapy may not be suitable for couples with a history of active violence unless they commit to a clear no-violence
contract. Violent individuals often require their own therapy, and group treatment may be effective in some cases. In instances
where both partners exhibit violence, individual therapy for each may be necessary.
Goals
• The mediating goals of couples therapy encompass a variety of theoretical
frameworks, including:
1. Specification of interactional problems.
2. Recognition of mutual contribution to the problems.
3. Clarification of marital boundaries.
4. Clarification and specification of each spouse's needs and desires in the
relationship.
5. Increased communication skills.
6. Decreased coercion and blame.
7. Increased differentiation.
8. Resolution of marital transference distortions.
• Ultimately, the final goals of marital intervention aim for:
1. Resolution of presenting problems.
2. Reduction of symptoms.
3. Increased intimacy.
4. Increased role flexibility and adaptability.
5. Tolerance of differences.
6. Improved psychosexual functioning.
7. Balance of power.
8. Clear communication.
9. Resolution of conflictual interactions.
10. Improved relationships with children and families of origin.
• Couples therapy is often designed to be relatively brief, typically consisting of once-weekly meetings
with a focus on addressing the marital interaction. However, there may be occasions where involving
one or both spouses' parents or children can be beneficial for addressing underlying issues affecting the
marriage.
• The primary indication for marital intervention is the presence of marital conflict contributed to by both
parties, although indications may also include symptomatic behavior, such as depression or agoraphobia,
in one spouse. Marital treatment is contraindicated when the two parties would use treatment disclosures
to harm each other. If couples therapy consistently escalates conflict, the goals should be reevaluated.
Strategies and Techniques of Intervention
• Like family therapy in general, couples therapy uses strategies for
imparting new information, opening up new and expanded individual and
marital experiences, psychodynamic strategies for individual and
interactional insight, communication and problem-solving strategies, and
strategies for restructuring the repetitive interactions between the spouses.
We advocate an integrative marital therapy model that uses
psychodynamic, behavioral, and structural-strategic strategies of
intervention.
A Model for Intervention Based on Patterns of Interaction
• A model for intervention based on patterns of interaction recognizes that couples often engage in
conflict over specific content issues, such as finances or time allocation, but therapists typically
encounter recurring patterns of interaction that become the focus of treatment. For example, one
couple may exhibit a pattern of pursuit-withdrawal, where one partner attempts to express their
emotional needs, the other reacts negatively, leading to further withdrawal and accusations of
feeling unloved.
• Other patterns may involve complementarity or symmetry in relationships. Complementary
relationships may involve overfunctioning by one member, which invites underfunctioning by the
other, or vice versa. In symmetrical relationships, power struggles often occur as each member
asserts their position to avoid feeling inferior.
• Examining gender arrangements in relation to these roles is crucial. Additionally, the diagnosis and
symptom profile of one spouse and the characteristics of the other can influence marital interaction
and intervention planning. For instance, marital therapy may be preferred for a spouse with
nonendogenous depression if the marital interaction contributes to their condition. However, if a
spouse has bipolar disorder and the marital interaction was previously stable, psychoeducational
intervention may be more appropriate, with less focus on the ongoing marital dynamics.
• Couples may present with chronic unresolved conflict or be transitioning through different stages
of their relationship. In either case, understanding the couple's recurring patterns of behavior is
essential for initiating couples therapy and guiding intervention.
Individual models
• Once the therapist has identified the specific problem within the couple's dynamic as a pattern
maintained by each member, the goal is to understand what factors constrain the couple from making
necessary changes. It's generally assumed that these patterns are influenced by the individual models
of marriage learned from family and past relationships, as well as their own ways of relating as a
couple.
• By considering historical models, the therapist can hypothesize that each member brings their own
images or models of intimate relationships to the partnership. Utilizing a genogram, a three-
generational family tree depicting family patterns, allows the therapist to collect and organize
historical data. This technique helps identify possible connections between present family events and
past experiences shared by family members, placing the presenting problem in a historical context.
• Constructing a genogram early in treatment provides valuable insights into pressures, expectations,
and hopes regarding the marriage. This visual method of gathering a history enables each member to
learn about the beliefs or themes characterizing their family background.
• Subsequently, the therapist can assist the couple in understanding how their preferred patterns, often
rooted in earlier family models, limit their ability to adapt and change flexibly. By highlighting the
predictability of their responses to unmet needs and disappointments, each member begins to
recognize the specific ways in which they repeat the same process. While realizing the limitations of
their emotional and behavioral repertoire may lead to despondency, with support and active
interventions, the couples therapist can guide the couple in conducting experiments aimed at
expanding their ways of relating to each other.
Strategies for Change
• Strategies for change in marital therapy encompass several enduring characteristics, despite variations among different
therapeutic approaches:
1. Interrupting collusive processes: The therapist identifies and interrupts collusive processes between spouses, such as
failing to perceive positive or negative aspects of each other or protecting each other from experiences inconsistent with
their self-perceptions.
2. Linking individual experience to the marital relationship: The therapist helps individuals connect their past experiences
and inner thoughts to their current interactions within the marriage.
3. Creating and assigning tasks: Tasks are designed to encourage partners to differentiate between the impact of each
other's behavior and intent, bring awareness to behavior that contradicts past perceptions, and acknowledge changes in
behavior incompatible with previous self-images. These exercises help reconstruct the couple's narrative to make it more
positive.
• In the initial stage of treatment, partners are encouraged to focus on what they want to change in themselves rather than
how they want their spouse to change. Effective marital treatment integrates individual and relationship change,
recognizing that not all behaviors are under the control of the partner and that self-perceptions drive behavior.
• The goals of assessment are to evaluate functional relationships between interactional sequences, recurrent patterns of
interaction, and each spouse's individual schemata for intimate relationships. Therapists must develop alliances with
each marital partner early on, offering empathy, warmth, and understanding while also aligning with the couple as a
whole and learning their shared language and problem-solving styles.
• Behavioral techniques, including between-session homework and in-session tasks, are utilized to facilitate reintegrating
denied aspects of themselves and each other. However, the focus is not solely on behavioral change, as overt behavior
reflects the intertwined feelings and perceptions of each spouse.
• Ideally, the treatment process allows partners to consider changes within themselves, explore new beliefs, feelings, and
behaviors, and experiment with unfamiliar patterns of interaction in a safe environment.