Treating Couples

The Intersystem Model Of The Marriage Council Of Philadelphia

Gerald R. Weeks

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9781138004634
• eBook ISBN:
  9781134849451
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In some ways the development of the theory and practice of marital therapy seems like a relative newcomer to those clinicians who practice systems therapy. Most of the books in the field stress the total family as the unit of treatment in terms of understanding the dynamics of family interactions and intervention techniques. For the past 15 or 20 years, clinicians interested in systems work sought training in "family" therapy programs and at "family" therapy workshops. This training led to a dramatic shift in the practice of psychotherapy away from the individual as the unfit of treatment to the family. Much less emphasis has been given to the marital dyad or couple as the unit of treatment.

PART I

Principles of Marital Therapy

Chapter 1

Marital Assessment: Providing a Framework for Dyadic Therapy

Larry Hof
and
Stephen R. Treat

Thorough and accurate assessment is crucial to the practice of marriage and family therapy. Without assessment, treatment plans can be ill conceived and the therapist could be approaching his/her work with a couple on a moment-by-moment basis. If such is the case, therapy can be prolonged, even harmful to the client couple.

The assessment process itself is ongoing and not limited to the information gathered in the first few sessions. The treatment plan is based upon the initial assessment, but as that plan unfolds, the assessment process continues, with confirmations and disconfirmations of initial hypotheses and treatment plans. The approach and substance of marital therapy are then affirmed, revised, modified, tuned, or changed dramatically as the ongoing assessment process continues. The result is that assessment affects treatment, and treatment affects assessment, and so on.

Thorough assessment of the marital relationship must be systemic in nature. While fault may seem to rest with one partner, there is always some complementary behavior demonstrated by the other. These behaviors interact, often in a repetitive and circular fashion, creating a systemic and not a solely individual problem. With an understanding of each partner's contribution to the marital difficulty, the therapist can intervene to break the destructive cycles of behavior and replace them with more constructive and healing interactions.

Furthermore, accurate and systemic assessment contributes to several initial goals of therapy. As the therapist communicates verbally and nonverbally, his/her comprehension of the couple's difficulty, of the dyad's fears and anxieties, their commitment to the therapeutic process increases. Joining is facilitated as the couple feels that the therapist cares and understands. Accurate assessment then leads to on-target intervention.

When evaluating the marital relationship, five specific areas of focus are indicated: (1) psychometric indicators of marital adjustment; (2) individual development and personality styles; (3) assessment of the current relationship style of the couple; (4) identification and assessment of the original and current marital contract; and (5) exploration of the extended family/multigenerational context.

PSYCHOMETRIC INDICATORS OF MARITAL ADJUSTMENT

A variety of inventories and scales are available to enable the therapist to assess marital adjustment.

The use of brief, valid, and reliable instruments such as the Locke-Wallace Marriage Inventory or the Dyadic Adjustment Scale can give the therapist a good overall sense of the clients’ perceptions of marital adjustment and satisfaction (Locke & Wallace, 1959) and dyadic adjustment (not necessarily marital), the latter with a focus on dyadic satisfaction, dyadic cohesion, dyadic consensus, and affectional expression (Spanier, 1976). The Marital Satisfaction Inventory (Snyder, 1979) focuses on a variety of relationship issues, including effective communication, problem-solving communication, quality of leisure time together, etc.

Proper use of such inventories by a marital therapist is essential. The inventories should not be used as a task-oriented substitute for the therapist's relating to the couple. Often, anxiety-laden therapists will use inventories to exert control, to provide a structure to the session, or to arrive at a premature diagnosis. Accurate assessment needs to be done on several levels at the same time. Individual psychopathology, psychopharmacology, social history, and present context all need to be considered. Marital inventories should be only one of many assessment tools and not the final word. Assessment results are not facts, but indicators which can focus the structure, definition, and direction of therapy. Sharing the results of inventories with the marital couple, if done caringly and discriminately, can often pinpoint issues quickly, raise serious concerns, and generally guide therapy in proper healthful directions.

INDIVIDUAL DEVELOPMENT AND PERSONALITY STYLES

Although the primary focus of marital therapy is the marital relationship, the therapist must still be well acquainted with personality development theory and psychopathology. The dynamics which contribute to the formation of each individual lead to the development of identity and a personality style which directly affects the way an individual relates to other people. Needless to say, identity development and personality styles impact greatly upon a marital relationship.

Sager (1976) has done a great deal of work developing personality typologies and discussing how they interact in marital relationships. His discussion of parent, child, romantic, rational, companionate, parallel, and equal-partner styles has provided helpful guidelines for therapists wanting to blend individual personality theory with marital theory and counseling.

The marital counselor must have a thorough knowledge of individual psychopathology, so that she/he may be aware of significant individual issues which impact greatly upon a marital relationship. Familiarity with and understanding of the five axes in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) will give the therapist knowledge of the diagnostic criteria of the various forms of emotional illness. With such knowledge, the therapist can preliminarily assess the nature and severity of individual issues, e.g., chronic anxiety, mood disorder, thought disorder, personality disorder, etc. This will increase the likelihood that the marital therapist will work within his/her limits of training and experience and be able to assess accurately. If the assessment process reveals significant psychopathology, specialized treatment plans can be made or appropriate referral facilitated.

ASSESSMENT OF THE CURRENT RELATIONSHIP STYLE OF THE COUPLE

The assessment of the current relationship style of the couple enables the therapist to identify positive forces and processes within the relationship which could facilitate treatment, as well as identify relationship-diminishing forces and processes which could disrupt or block desired growth and change in therapy. When evaluating the current relationship style of the couple, the therapist seeks information via questioning and direct observation regarding the following issues:

1) How are the inclusion, control, and affection/intimacy issues handled within this relationship?

2) What is the balance between feelings, rationality, and behavior in this relationship?

3) How effectively do the partners communicate with each other?

4) How effective is the couple's problem-solving and decision-making process?

5) How effectively do the partners manage conflict?

Inclusion, Control, and Affection/Intimacy Issues

Schutz (1966) has stated that all individuals have three basic interpersonal needs which are manifested in various behaviors and feelings in the individual's relationships with other people: the need for inclusion, the need for control, and the need for affection/intimacy. Berman and Lief (1975), Hof and Miller (1981), and Doherty and Colangelo (1984) have discussed and developed the relationship of Schutz's concepts to marital and family functioning, emphasizing that these are perhaps the three core issues in relationship functioning.

The key “inclusion” question in a marriage is: What is the extent of each partner's commitment to the other and to the relationship? A continuum from noncommitment or disengagement to overcommitment or extreme enmeshment expresses the various possibilities. The therapist can inquire directly regarding the extent and nature of commitment (e.g., high versus low level of commitment; commitment out of duty, fear, religious values, financial realities, for the sake of the children or maintaining a family unit versus commitment based on love, shared values, interests, and intimacies). In addition, further insights can be gained as the couple's communication and interaction are observed (e.g., to what extent do they speak of a future together?).

It is important that each partner have a sense of personal identity (versus enmeshment); a sense of togetherness, commitment, belonging, or membership (versus disengagement); and a belief that the other person is committed to the relationship at a somewhat similar level. Without some sense of parity in this area, trust will remain relatively low, as will the willingness to risk self-disclosure in potentially vulnerable areas. Without a sufficient level of self-identity and commitment to the relationship, many partners are unable or unwilling to expose their pain, embarrassment, shame, etc., or to risk trying to change behaviors when failure could possibly lead to feared ridicule or abandonment.

Some key “control” questions in a marriage are: How equitably is power distributed and what is the level of satisfaction with the power distribution? To what extent does each partner see him/herself and the other as a responsible person? The therapist can inquire directly regarding these issues and can observe the interaction of the couple when a decision is required in the therapeutic process on even such a small issue as the day and time of the next appointment. Does each express opinions? Do they consult each other in the decision-making process? Do they value each other's ideas? Can they compromise?

When one partner feels somewhat powerless or resents the other's unilateral decision-making or role definition, the situation is ripe for a control struggle, usually characterized by anger, aggression, withdrawal, or passive aggressiveness. Couples struggling for control rarely remain peers, but seem to act out more parent-to-child behavior. On the other hand, when both partners feel powerful and responsible, mutual and satisfying problem-solving, decision-making, and role renegotiation become real possibilities.

The key “affection/intimacy” question in a marriage is: What is the degree of intimacy experienced between the partners, and to what extent are they each satisfied with it? Intimacy here refers to the in-depth sharing of core aspects of oneself with one's partner. As with the inclusion and control issues, direct questioning in this area can yield significant information. For example, “What is each partner's perception of the quantity and quality of physical and nonphysical affection expressed in the relationship?” “What types of intimacy do they share and what is their satisfaction level with each type?” Direct observation can also give important clues (e.g., to what extent they employ touch during the sessions and to what extent supportive, warm, and caring expressions are exchanged during the sessions).

Like Clinebell and Clinebell (1970), the authors believe there are at least 12 varieties or facets of intimacy: sexual, emotional, intellectual, aesthetic, creative, recreational, work, crisis, commitment, spiritual, communication, and conflict. Since no one can be intimate with all people in all ways, it is important that a couple mutually define for themselves in what ways they desire intimacy and work to achieve those goals. When intimacy in one area is desired by one partner to a certain degree, but to a lesser degree or not at all by the other, the potential for deep hurt, diminished satisfaction, and feelings of rejection in the relationship is obvious. When core intimacy needs are not addressed satisfactorily, the potential for marital and sexual dissatisfaction increases dramatically.

Many individuals fear being intimate with another. It is important to assess the depth and organization of such fears. As mentioned above, intimacy requires vulnerability and self-disclosure. If fears in one or both individuals of a couple are considerable, an “intimacy dance” can be created by the dyad to protect each person from hurt and rejection. Neither will then be willing to be vulnerable enough to openly disclose his/her honest desires, wishes, fears, hopes, etc. Instead, the protective “dance” will substitute for genuine intimacy.

A couple's dance will evolve out of a lack of personal differentiation and of social skills, which in turn heightens fears of intimacy An undifferentiated person has difficulty defining who he/she is and what he/she needs. Often, boundaries with others are poorly formed, manifested by a person being too needy or too disengaged. When a significant other seeks closeness, fears of losing the self definition one has and of being overwhelmed are common. The dance protects each person from such vulnerability, and becomes necessary for effective sexual expression.

The “intimacy dance” is a metaphor for the means by which each member of a couple maintains a safe distance from the other, protecting each partner's vulnerabilities. Often, as one partner will step toward the partner, the other will collusively step back For example, a couple complained to a therapist that their sexual relationship had been unsatisfactory for nine years. During the first four years, the woman pursued her husband and he withdrew. During the past five years, the husband played the pursuer role and his wife rejected him. Both dynamics of rejection and intrusion (Napier, 1978) were manifested by the partners for the maintenance of a “safe” distance in the relationship. If the therapist does not comprehend and assess this “intimacy dance,” one partner will appear to be sexually dysfunctional and the other sexually adjusted when, in actuality, both individuals of the dyad are exquisitely working together to maintain distance and protect each other.

The initial content of each evaluation session can be given far too much attention if the couple's “intimacy dance” is not understood. For example, a couple came into a second session feeling argumentative and hopeless. The session was unsatisfactory for everyone. The therapist became exasperated and was confused because during the initial session the couple had demonstrated more warmth and intimacy. The therapist failed to realize that the couple's argument and hopelessness were “dance” steps to balance more vulnerable feelings of intimacy and emotional closeness which were felt during the first therapeutic hour. The “intimacy dance” of this couple protected the relationship homeostasis—the tendency toward maintenance of balances within a dyad to keep a certain established equilibrium in the relationship (Jackson, 1957).

The intimacy dance is designed to avoid fears associated with intimacy Fear of intimacy can include fear of hurt, abandonment, rejection, intrusion, and loss of self. These fears can be increased or decreased based on the level of differentiation attained by each individual. A poorly differentiated person will often feel more susceptible to being overwhelmed. The “intimacy dance” can be comprised of sometimes obvious or, more often, subtle steps established for the maintenance of a protective shield for the individual and the couple, such as the following two dances illustrate.

Dance 1

John and Susan have been married for 7 years. John's mother is able to intrude into their married life in various ways and he cannot or will not stop the intrusion. In part, he fears confronting his mother because she will withdraw, as she has historically, and he will consequently feel guilty. John complains that Susan invades in the same way. Susan is secretly questioning her own femininity and helps to create an environment in which femininity or vulnerability never needs to be addressed. She fears that if she were not in control she would not be loved. Both partners have colluded in a “dance” to remain separate and to limit the threats of intimacy.

Step 1

John comes home from work and goes directly to the mail. Susan comes home from work and beg...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Preface
• Contributors
• PART I. PRINCIPLES OF MARITAL THERAPY
• PART II. CLINICAL ISSUES
• PART III. THEORY
• Name Index
• Subject Index