A Roadmap for Couple Therapy

Integrating Systemic, Psychodynamic, and Behavioral Approaches

Arthur C. Nielsen

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781136671333
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

A Roadmap for Couple Therapy offers a comprehensive, flexible, and user-friendly template for conducting couple therapy. Grounded in an in-depth review of the clinical and research literature, and drawing on the author's 40-plus years of experience, it describes the three main approaches to conceptualizing couple distress and treatment—systemic, psychodynamic, and behavioral—and shows how they can be integrated into a model that draws on the best of each. Unlike multi-authored texts in which each chapter presents a distinct brand of couple therapy, this book simultaneously engages multiple viewpoints and synthesizes them into a coherent model. Covering fundamentals and advanced techniques, it speaks to both beginning therapists and experienced clinicians. Therapists will find A Roadmap for Couple Therapy an invaluable resource as they help distressed couples repair and revitalize their relationships.

Part I
Conjoint Couple Therapy and Marital Challenges

1
Introduction

Why Read This Book?

First, because couple therapy is difficult. It is difficult because:

• Therapists must deal with two clients, often at war with each other, with differing psychologies, histories, agendas, and levels of commitment to therapy.
• It involves a mix of many emotions fundamental to the partners’ well-being, emotions that run the gamut between rage and despair.
• The subject matter is often loaded and challenging: concrete issues like money, sex, and childrearing, and abstract ones like love, independence, and power.
• Most psychotherapists have inadequate training in it, and the training they have in individual therapy is insufficient to guide them with couples.
• There are many schools of thought on how best to do couple therapy and relatively little guidance concerning how to choose among them.

Second, precisely because it is complex, deals with life’s great challenges, and allows us to help people who are suffering, couple therapy can be deeply gratifying, intellectually interesting, and personally rewarding. My goal is that—after reading this book—you will feel less of the stress and confusion and more of the rewards as you practice this challenging form of therapy.

A Roadmap

This book offers a practical roadmap for conducting couple therapy. Covering both fundamentals and advanced techniques, it should prove valuable to both beginning therapists and experienced clinicians. The model is based on my nearly 40 years of experience with more than 250 couples, on an extensive review of the clinical and research literature, and on interactions with others in the field. The book describes in detail each of the three main approaches to conceptualizing couple distress and treatment—systemic, psychodynamic, and behavioral—and shows how they can be integrated into a flexible model that draws on the best of each. Unlike other texts, in which different authors present their distinct brands of couple therapy in separate chapters, this text does not require readers to create their own synthesis. In addition, this flexible, comprehensive model meets the needs of diverse clinical situations, rather than being a one-size-fits-all treatment. Having a straightforward guidebook, therapists will be better able to avoid the disorientation that often accompanies the complexity and emotional intensity of working with distressed couples. I know that my own results have improved as I have worked to refine my ideas while writing this book; I believe yours will too.

The Importance of Couple Therapy

The following statistics illuminate what is at stake.

• Approximately 80% of American women will marry for the first time by age 40 (Copen, Daniels, Vespa, & Mosher, 2012); about 90% of both men and women will eventually marry (Whitehead & Popenoe, 2002).
• Despite the rise in cohabitating couples and single-parent families, most young people want to marry, marriage having “evolved from a marker of conformity to a marker of prestige … a status one builds up to” (Cherlin, 2004, p. 855).
• One in five first marriages will fail within the first five years and 40–50% of first marriages ultimately end in divorce (Copen et al., 2012).
• Twenty percent of married couples report significant marital distress at any point in time (Bradbury, Fincham, & Beach, 2000).
• Among clients seeking treatment for “acute emotional distress,” problems with intimate relationships are the most frequently cited causes (Swindel, Heller, Pescosolido, & Kikuzawa, 2000).
• Marital success augments general well-being, physical health, and economic success (Doherty, et al., 2002; Proulx, Helms, & Buehler, 2007; Waite & Gallagher, 2000); and relationship success is probably the best predictor of overall happiness (Lee, Seccombe, & Sheehan, 1991; Lyubomirsky, 2013).
• Marital conflict, unhappiness, and divorce cause declines in all the just-mentioned areas and generate similar problems in the next generation (Booth & Amato, 2001; Cummings & Davies, 1994; Hetherington, 2003; Wallerstein, Lewis, & Blakeslee, 2000).
• Marital distress is associated with broad classifications of anxiety, mood, and substance use disorders, and with all narrow classifications of specific disorders (Whisman & Uebelacker, 2006).
• Half of all psychotherapists in the United States do some couple therapy (Orlinsky & Ronnestad, 2005), though many find it daunting or even frightening (Psychotherapy Networker, Nov–Dec, 2011).
• On the positive side, couple therapy has been shown to improve marital success and happiness in approximately two-thirds of unselected distressed couples (Gurman, 2011; Lebow, Chambers, Christensen, & Johnson, 2012), with effectiveness rates that are “vastly superior to control groups not receiving treatment” (Lebow et al., 2012, p. 145).
• There is considerable room for improvement in couple therapy, as less than 50% of couples entering therapy reach levels of marital satisfaction seen in non-clinical couples (Baucom, Hahlweg, & Kuschel, 2003); and many couples who improve in therapy later relapse (Jacobson & Addis, 1993).
• There is no consensus on which of the many forms of couple therapy is most beneficial (Gurman, 2008a).

In summary, relationship success matters greatly, is commonly compromised, and improves with couple therapy, a therapy with room for improvement.

The Importance of Integration

My overall approach to couple therapy is synthetic or “integrative,” that is, I borrow from different intellectual sources and show how they can work synergistically. The advantages of this method are many:

• Integrating vocabularies. The many approaches to psychotherapy employ different terms to describe similar phenomena. This results in a therapeutic Tower of Babel that makes communication difficult among practitioners who might otherwise learn from each other.
• Improving cross-fertilization. Disparate vocabularies are partly the result of the lack of cross-communication between practitioners and researchers favoring different approaches. As noted by Lebow (2014), the current separation of professions, journals, and scientific meetings impedes information sharing. In particular, there is little crosstalk between psychoanalytically informed therapists and those writing from a behavioral or social-psychological perspective.
• Giving common factors their due. While schools of therapy emphasize differences, they actually overlap considerably in what they consider helpful (Sprenkle, Davis, & Lebow, 2009). Christensen (2010) has identified activities common to most current forms of couple treatment: (a) challenging the individual problem definition that partners favor and replacing it with a dyadic conceptualization (systemic therapy, in the terminology I will be using); (b) eliciting avoided, private thoughts and feelings so that partners become aware of each other’s internal experiences (psychodynamic therapy); (c) modifying emotion-driven maladaptive behavior by finding constructive ways to deal with emotions (psychodynamic and behavioral therapy); and (d) fostering productive communication (behavioral therapy).
• More tools in the toolbox. The most important reason to integrate therapeutic approaches is that particular therapies propose different and sometimes problem-specific methods for effecting change. As argued by Fraenkel (2009), more options should allow better treatment for the wide variety of problems and clients we see. The expectation that using multiple tools yields better outcomes has been confirmed by studies that obtained superior results after adding psychodynamically informed interventions to traditional behavior therapy (Dimidjian, Martell, & Christensen, 2008).
• Too many options. The final reason to integrate therapies is to generate a decision tree for choosing among myriad competing options. Having multiple tools may cause confusion if one doesn’t know how to choose among them. Couple therapy is complex enough without our having to juggle four or five different schools of thought at every turn. Therapists faced with too many choices may cling for dear life to one theory (even when it isn’t working) or throw theories to the winds and simply go with the flow—two errors observed frequently by Weeks, Odell, and Methven (2005) in their study of couple therapist mistakes. A worthy integration of therapies should provide guidance both in selecting among interventions and in determining how to sequence them.

Method, Personal Journey, and Approach to Mental Disorders

The recommendations I make here arise from many sources. In part, they grew from an informal review of 67 couple therapy cases I saw between 1993 (when I started keeping computerized records) and 2003 (when I was asked to give a lecture summarizing my experience as a couple therapist). Consistent with the literature, the majority of my clients improved, though some later relapsed and returned for more therapy or chose to divorce. These couples, like the ones I have seen subsequently and most subjects in the research literature (Lebow et al., 2012), were mostly, though not exclusively, white, urban and suburban, college-educated professionals, ranging in age from their late 20s through their 60s. This book also draws on my earlier and subsequent couple work, from marital issues raised by my individual clients, from supervising cases treated by other mental health practitioners (including clients from more diverse and less privileged circumstances), and from the clinical and research literature (see also Nielsen, 2003, 2005). I have treated a relatively small number of same-sex couples, most from the same demographic as my straight couples, who have presented substantially the same set of problems (see Kurdek, 2004, for a similar conclusion), with some unique challenges, including those due to internalized and societal homophobia. Couples with serious violence, drug, or alcohol issues; some ethnic minorities; and low-income couples have been infrequent in my clinical practice, though less-so for the students I have supervised. Clearly, such couples present unique and challenging complications for therapy. Having said this, many of my clients have grown up in severely impoverished and disadvantaged environments, have suffered from poverty, racism, neglect, and abuse, and now struggle with the scars and mental disorders that follow in their wake.

As argued by Gurman (2008b) and Lebow (2014), two of the most well-respected observers of the field, integrative models can gain epistemological strength from formal research that has demonstrated the efficacy of their various components. Consequently, research reports of success with, for example, Emotionally Focused Therapy and with various forms of skill training should support their value when employed in my more comprehensive treatment model (Lebow et al., 2012). While it is theoretically possible that such mixing might detract from success, this has not been my experience, in keeping with the field as a whole, which appears to be moving to more inclusive approaches, as previously distinct models have been cross-fertilized by their earlier competitors (Lebow, 2014; Gurman, 2013).

Having just asserted my confidence in learning from my own experience, I acknowledge the possible danger lurking there. As a long-time teacher of scientific methods courses, I know it is easy to exaggerate one’s knowledge and expertise. (Psychoanalyst Marshal Edelson (1983) has asserted that whenever Freud wrote, “It cannot be doubted that …” this reliably flagged Freud’s actual uncertainty.) I, therefore, acknowledge upfront that things don’t always go as smoothly as I may sometimes imply.

On a more positive note, my conscious awareness of imperfect results has propelled my search for better ways to practice. The “upgrades” I will be describing to the basic format of conjoint couple sessions have all assisted me personally to do better than I was doing before I added them to my repertoire. Just as a new drug that cures a previously incurable illness suggests that that drug, rather than various alternative explanations, led to the cure, so my improved results after adding new interventions have increased my confidence in their value.

This book has been shaped by many additional influences that encouraged my integrative approach. I was fortunate to have begun my psychiatric training at Yale in the early 1970s, where biology, psychology, and social systems were all recognized as important causes of abnormal behavior and mental disorders (Engel, 1980), and where the ideal mental health practitioner assessed all contributions to a problem before suggesting possible treatments. My diverse education and experience continued at some outstanding institutions, including The National Institute of Mental Health, The Philadelphia Child Guidance Clinic, the Department of Psychiatry and The Family Institute at Northwestern University, and The Chicago Institute for Psychoanalysis.

Two additional experiences strongly influenced my thinking. At many Tavistock Group Relations Conferences (Bion, 1961; Colman & Bexton, 1975), I studied group process in detail, learned the value of projective identification, and saw how highly educated, well-meaning adults—like most of the couples who are the subject of this book—could regress as a function of group process and their current interactions with others (Wachtel, 2014). And from developing and teaching the Marriage 101 course to undergraduate students at Northwestern (Nielsen, Pinsof, Rampage, Solomon, & Goldstein, 2004), I encountered important research on success in marriage and learned the value of adding a relationship education component to my clinical work.

Terminology

I have chosen to use couple therapy, rather than couples therapy or other possible variations, by analogy with individual therapy (never termed individual’s therapy) and also because the leading anthologies in the field use that term (Gurman, 2008a, 2010).

For purely stylistic reasons, I sometimes use the more restrictive terms marital and spouse interchangeably with the more inclusive terms couple and partner, with the understanding that, in most situations, it makes little difference whether the individuals are formally married or not; what I am discussing throughout are people in committed, intimate relationships.

Finally, I have chosen not to give my specific brand of couple therapy a proprietary name. Such names are currently common in the field and include: Emotion-Focused Couples Therapy, Psychodynamic Couple Therapy, Object Relations Couple Therapy, Narrative Couple Therapy, Behavioral Couple Therapy, Cognitive-Behavioral Couple Therapy, Integrative Behavioral Couple Therapy, and Integrative Problem-Centered Metaframeworks Therapy. Having seen how approaches can be limited by their names, I have resisted the urge to create a new “brand”—even an integrative one—so that others can more easily add to the inclusive scaffolding I am proposing.

Outline of the Book

Part I: Conjoint Couple Therapy and Marital Challenges describes the basic conjoint couple therapy set-up: a three-person group consisting of two clients and a therapist that tries to expose and ameliorate the couple’s problems by talking about them. This is the unadorned foundation for all couple treatment, which I have termed the Talk-To-Each-Other Model or Couple Therapy 1.0. Chapter 3 (“What makes marriage challenging”) describes many of the challenges that couples face, challenges that I will be discussing in the remainder of the book.

Upgrades. The sections that follow describe the refinements or “upgrades” I have discovered to be helpful, and frequently necessary, for obtaining better results. I use the metaphor of “upgrades” to call to mind technological improvements that took the car from the original Model T to the modern automobile, and the earliest computer operating systems to their current, ever-evolving versions. In both cases, the essential form and goals are unchanged—the newer model is recognized as in the same class of objects as its predecessors—while added complexity and functionality have improved performance.

The couple therapist in 2016 resembles the couple therapist of 1960 as he or she meets c...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgements
• About the Author
• Part I Conjoint Couple Therapy and Marital Challenges
• Part II Systems Upgrades
• Part III Psychodynamic Upgrades
• Part IV Behavioral/Educational Upgrades
• Part V Sequencing Interventions and Concluding Remarks
• References
• Index