Integrative Couple Therapy in Action

A Practical Guide for Handling Common Relationship Problems and Crises

Arthur C. Nielsen

• Editorial: Routledge
• Año: 2022
• ISBN:
  9781000591590
• Edición: 1
• Categoría: Psychologie
• Categoría: Psychotherapie

Integrative Couple Therapy in Action offers a comprehensive, user-friendly guide to handling the most common problems and crisis situations seen by couple therapists.

Drawing on the latest literature and the author's experience of over 40 years, Nielsen investigates what makes certain issues, such as sex, or situations, such as extramarital affairs, so stressful for clients and challenging for therapists. Unlike most graduate programs and texts on couple therapy that focus on theory and technique, Integrated Couple Therapy in Action fills in the details. The chapters cover common presenting problems (sex, money, children, and the stresses of time, work, and simply living together) and then discuss catastrophic crisis situations (couples reeling from affairs, contemplating divorce, divorcing, or living in stepfamilies after divorcing).

Integrative Couple Therapy in Action provides one-stop shopping for readers of all skill levels interested in understanding the subject matter that bedevils so many couples.

Part I Synopsis of Integrative Couple Therapy

1 Couple Therapy 1.0

DOI: 10.4324/b22905-3

The intimidator and the novelist: a prototypical case

Tom, a 35-year-old retired professional football player, and Jennifer, a 33-year-old novelist, presented with the manifest conflict of deciding whether to move to another city.¹ There were clear plusses and minuses to relocating that they had “discussed” endlessly—he, using what he considered logical arguments, and she, becoming exasperated and shutting down. Jennifer remained unwilling to consider Tom’s arguments, as she felt that her needs, though somewhat unclear even to herself, were not being considered. Both were despondent, not only about the deadlocked decision, but about their sex life, which had almost ceased, and about the viability of their six-year marriage.

Couple Therapy 1.0

"Just Talk to Each Other."

Had I seen Tom and Jennifer when I began doing couple therapy as a psychiatric resident in 1975, I would have suggested they meet with me to talk to each other while I watched and tried to mediate. I call this relatively unstructured, here-and-now, talk-to-each-other model Couple Therapy 1.0. It is the Model T of couple therapy and still provides the scaffolding for my work. It makes intuitive sense because, like Tom and Jennifer, virtually all couples coming for couple therapy complain of a breakdown in communication. As with many forms of instruction—music, sports, or dance—the model assumes that talking about how a person interacts (or plays) is insufficient for revealing what is going on. Rather, the therapist (or teacher or pro) must observe the client in action.

The format of conjoint meetings to deal with marital problems was uncommon until the 1960s, although marriage counseling began in the 1920s (Gurman & Fraenkel, 2002). Couple Therapy 1.0 builds on conjoint couple counseling meetings where partners met together with a mediator by adding some rudimentary recommendations to help couples communicate more effectively. It is distinguished from the upgraded forms I will describe later by the absence of sophisticated methods for attending to and improving the interpersonal couple process. I chose to make this conjoint, talk-to-each-other model the basic 1.0 version (rather than the earlier or later formats) for two reasons: first, because it is still commonly employed by many untrained counselors (peer and religious) and individual therapists who know that they must encourage couples to interact, but don’t know what to do beyond simple mediation; and second, because it is the foundation for the various approaches that improve on it.

The basics of Couple Therapy 1.0

Prior to tackling our central topic—the integration and sequencing of advanced options—I will offer some basic guidelines for Couple Therapy 1.0 that also inform more complex versions. Here and throughout, recommended interventions will be shown as italicized bullet points.

• As in all forms of psychotherapy, offer empathy, hope, safety, and containment in a professional environment that prioritizes the therapeutic alliance (Friedlander et al., 2006; Sprenkle et al., 2009).
• Allow the couple to choose problematic topics and attempt to work them out (Pinsof, 1995).
• Observe, monitor, and sometimes question partners about what their spouses have said.
• Assist clients who do not want to talk to each other.

Most clients prefer to talk to you, rather than to each other. They want to tell you how they see things and why their partners are wrong, bad, or mentally ill (Christensen & Jacobson, 2000). To counter their desire to talk only to me, I tell them, “As in music, sports, or dance lessons, I need to see you doing what you do to help you improve.”

• Assert control and manage the emotional room temperature.

In the ideal session, the couple respectfully engages emotionally significant issues. “Getting feelings out,” while necessary, risks being only destructive. Couple therapy requires far more structuring than individual therapy. Several interventions are helpful for adjusting the emotional room temperature and providing containment. I include these under Couple Therapy 1.0 not only because they are basic and powerful but because they will quickly occur to almost any novice therapist and, thus, do not deserve more advanced upgrade status.

• Cool things down by putting yourself in the middle.

Exploiting clients’ preference for talking to you, reduce the room’s emotional temperature by coming between them (sometimes literally) and allowing them to return to what feels less intense: talking to an empathic therapist or, more soothing still, listening to you talk to them.

• Heat things up by applying the interventions used in psychodynamic individual therapy to reduce anxiety and defensiveness.

These include gently encouraging clients to describe the calamities they fear will occur if they become more emotionally present and forthcoming.

• Heat things up by moving out of the middle and instructing the partners to interact with each other directly, an option not available in individual therapy.
• Work to remain neutral.

Couple therapists must not be perceived as consistently biased in favor of one of the partners, a situation correlated with poor outcomes (Lebow et al., 2012), even as maintaining overall neutrality while encouraging partners to change can be challenging (Friedlander et al., 2006).

When Couple Therapy 1.0 is sufficient: rarely

The unadorned conjoint model of Couple Therapy 1.0 may be successful when couples must resolve important disagreements (e.g., dealing with a difficult child) or need to discuss their feelings about a recent stressful life event (e.g., undergoing chemotherapy). It works well when the conflicts and feelings are not proxies for deeper, more long-standing issues, and when the discussion is not impeded by serious character pathology or maladaptive patterns of relating. More often, however, it fails because it lacks the power for dealing with these complications (Gurman, 2008b; Snyder & Mitchell, 2008). This leads us to the next chapter and our first “upgrade”: focusing on the couple’s interpersonal process.

Note

1. 1. All the couples I describe are disguised and some are composite versions of couples I have treated.

2 The First Upgrade

Focus on the Interpersonal Process

DOI: 10.4324/b22905-4

“Upgrades” here are analogous to technological advances that increase the functionality of computer operating systems. This metaphor avoids the problem of name-branding, since existing brands of therapy and new innovations can all contribute improvements to the underlying, bare-bones Couple Therapy 1.0 model. As with computer upgrades, we must be sure the elements work together.

The first upgrade to Couple Therapy 1.0 is focusing on the couple's interpersonal process

The “pathological dance,” in which the emotional music generally matters more than the lyrics, must become the principal concern of both the therapist and the couple. Virtually, all experienced couple therapists agree on this, though, as discussed later, they approach it from different angles. This is a systems theory upgrade that views much couple behavior as an emergent property of individual interactions, where what emerges is more than the sum of the individual contributions. While Couple Therapy 1.0 emphasizes the here and now of couples talking to each other, it does not specify that the process, rather than the content, should be the early and primary focus. This process focus should be considered a crucial upgrade to working with couples, as it was at the dawn of the family therapy movement. Indeed, a failure to utilize this upgrade probably explains the disappointing results obtained by untrained counselors and individual therapists undertaking conjoint therapy.

Why process should precede content

There are many reasons to focus on process. Most importantly, research shows that negative process predicts poor outcomes in marriage and interferes with problem-solving (Gottman et al., 1998; Gottman & Gottman, 2017; Lebow et al., 2012), whereas improved collaboration reduces the number of problems to be solved, facilitates problem solving post therapy, and correlates with positive outcomes (Gurman & Fraenkel, 2002; Sullivan & Baucom, 2005). Improving system dysfunction is also easier than changing personality dysfunction (Pinsof, 1995), while “solving the moment” strengthens intimacy (Wile, 2002), “shared purpose” (Friedlander et al., 2006), and “weness,” independent of resolution of couple problems that can be “perpetual” (Gottman & Levenson, 1999).

Improved process as a shared target

Targeting negative interaction cycles can help us begin to integrate systemic, psychodynamic, and behavioral approaches, including those of Dan Wile (2002), whose interventions center on establishing “collaboration”; Les Greenberg and Sue Johnson (1988) and other EFT therapists whose research shows the benefits of “pursuer/blamer softening” and “distancer engagement”; and Howard Markman, Scott Stanley, and Susan Blumberg (2001), who teach the speaker–listener technique. Consequently, rather than referring to specific authors or branded therapies, we can classify interventions into three broad categories: Systemic theories stress how negative process can stem from the cyclical amplification of initial conditions (somewhat independent of the partners’ individual psychologies) and the structural challenge of sharing power equitably in a two-person polity (among other things); psychodynamic theories explain maladaptive process via hidden issues, divergent meanings, transferences, and projective identification; and psychoeducational and behavioral theories add that people can be taught better approaches to managing difficult conversations, regulating emotions, and solving problems.

The Cheshire Cat complication

Having just declared that interpersonal process should usually be the early focus of therapy, we must acknowledge that it is impossible to discuss process in the abstract, without some concrete content. In Alice in Wonderland, the Cheshire Cat’s smile existed without the cat, but in real life, “process” always requires “content,” if it is to be seen. This suggests a recommendation sometimes at variance with the guideline of letting couples choose topics for discussion:

• To improve the benefit and sustainability of focusing on process, encourage couples to begin with more workable, less emotionally charged content.

This may not always be possible, especially when the consultation is driven by a serious rupture of trust, such as infidelity. In such cases, we should begin with the topic that is most pressing, even though it may render examination and remediation of the couple’s process more difficult. Emotional intensity aside, there are many days when we should follow the problem-centered focus of Couple Therapy 1.0 and allow couples to focus on content rather than spotlighting process. Although improved process fosters more successful management of most marital problems, thorny problems are important (Fincham & Beach, 1999) and will eventually need to be addressed.

Systemic interventions that begin to alter negative interaction cycles

• Focus on the cycle and label it as the enemy.

Focusing on the pathological cycle will usually, in and of itself, improve that process. It accomplishes this in three interrelated ways. Giving the vague marital problem a diagnostic label (“a systems problem”) defines and demystifies it (just as diagnosing a physical malady does). Objectifying it makes it a shared enemy the couple can attack jointly, in what White (2007) termed an “externalizing conversation.” And focusing on the pathological dance reduces blame by countering linear narratives of victim and villain.

• Use the chemical reaction metaphor.

To convey the idea of a systemic problem—one with additive, circular, and emergent properties—I use the metaphor of a chemical reaction. The partners are likened to two colorless reagents in separate beakers that, when mixed, become drastically altered: perhaps becoming explosively hot, ice cold, or foul smelling. One of the reagents might think, “I was just fine before: not hot, cold, or smelly. This sudden change, in which I don’t recognize myself, must be due to that other damn chemical!” This metaphor powerfully illustrates how group process is not reducible to individual behavior and is experience-near for individuals who are feeling blamelessly victimized by their partners.

• Explain that the “punctuation” of negative cycles is arbitrary.

Most people “punctuate” their narratives by beginning with some misdeed or insensitive action of their partner. Therapists can point out that this starting point is usually arbitrary.

• Normalize off-putting demands: drowning swimmers.

Escalation commonly consists of one or both partners speaking increasingly loudly, impatiently, and aggressively, perhaps while nagging, guilt-tripping, or swearing. These ineffective attempts to influence a partner tend to occur and intensify when the partner appears unresponsive. Therapists can normalize these counterproductive behaviors by explaining them in systemic terms. One metaphor I use is of a drowning swimmer calling for help from an unresponsive lifeguard. The more the swimmer fears drowning, and the longer the lifeguard fails to respond, the louder the swimmer screams. Often, in escalating negative couple cycles, it is more accurate to characterize both partners as drowning swimmers, even though one may superficially appear to be an unresponsive lifeguard.

• Normalize flight: firefighters battling forest fires.

Just as escalating anger can seem appropriate in some situations, so can flight. Withdrawal becomes more comprehensible and acceptable if one remembers that firefighters facing a raging forest fire must sometimes retreat temporarily. Therapists can help couples consider the perspectives of metaphorical fleeing firefighters (Why do they think the situation is hopeless?) and advancing forest fires (What is making the pursuer so hot and insistent?).

• Introduce the goal of “making a short story long.”

After giving the couple a preliminary outline of the cycle that is simultaneously captivating and torturing them, I explain that we can gain a deeper understanding by “making a short story long” (Scheinkman & Fishbane, 2004): slowing things down, as in a slow...