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This research paper presents five major approaches to couples therapy and discusses their relative effectiveness in treating relationship distress. Each of these approaches is based on a theory of the development of relationship distress and uses specific therapeutic techniques to help alleviate this distress. In addition, two recent integrative approaches are presented that combine elements of the previous approaches in an attempt to increase the effectiveness of the intervention. Interventions for couples with psychiatric disorders and alternative interventions, such as group couples therapy and prevention, are also discussed.
Outline
I. Introduction
II. History of Couples Therapy
III. Theoretical Approaches in Conducting Couples Therapy
A. Behavioral Couples Therapy
1. Theory of Distress
2. Development of Dissatisfactions
3. Intervention
4. Specific Therapeutic Techniques
5. Efficacy of Treatment Approach
B. Cognitive Behavioral Couples Therapy
1. Theory of Distress
2. Development of Distress
3. Intervention
4. Specific Therapeutic Techniques
5. Efficacy of Treatment Approach
C. Systemic Couples Therapy: Bowen Family Systems Therapy
1. Theory of Distress
2. Development of Dissatisfaction
3. Intervention
4. Specific Therapeutic Techniques
5. Efficacy of Treatment Approach
D. Psychoanalytic Couples Therapy
1. Theory of Distress
2. Development of Dissatisfaction
3. Intervention
4. Specific Therapeutic Techniques
5. Efficacy of Treatment Approach
E. Brief Problem-Focused Couples Therapy
1. Theory of Distress
2. Development of Distress
3. Intervention
4. Specific Therapeutic Techniques
5. Efficacy of Treatment Approach
IV. Integrative Approaches to Couples Therapy
A. Integrative Behavior Couples Therapy
B. Emotionally Focused Couples Therapy
V. Couples Therapy for Specific Psychiatric Disorders
VI. Alternative Approaches to Couples Treatment
VII. Conclusion
I. Introduction
Joe and Diane have both been feeling very unhappy lately with their marriage. Diane feels that Joe spends too much time at work and has been neglecting his responsibilities at home, particularly child care with their daughter. She is lonely and angry at him. Joe thinks that Diane is too demanding and feels overwhelmed when he comes home to her criticism and nagging. They seem to be fighting more and more, and their sex life has diminished considerably. Unable to work these problems out on their own, they seek the help of a couples therapist.
When faced with a distressed couple like Diane and Joe, there are many different ways to conceptualize and treat their problems. Some therapists might focus on the couple’s negative interactions, for example, when Diane becomes very angry at Joe and Joe withdraws from Diane. Others might emphasize the problems in the family system, exploring Diane’s relatively stronger alliance with their daughter compared with Joe. Still others might explore Diane’s and Joe’s relationships with their own families of origin and try to discover how those relationships have affected their marriage.
Over the last two decades, many models have emerged to explain and treat relationship distress. This research paper begins with a history of the development of couple’s therapy and then presents five empirically validated therapeutic approaches to treating couples in distress, using the preceding example to illustrate each type of intervention. It is important to note that these approaches may not correspond with approaches typically practiced in the community. They are theoretically based models of couples therapy, most of which have been subject to controlled clinical trials in order to evaluate their effectiveness. The results of these outcome trials are presented after the description of each approach.
In an attempt to provide optimal treatment for couples, couples researchers have begun to develop interventions that integrate effective aspects of different theories into one general approach. Two of these integrative models are briefly described after the five core models. The term marital therapy is avoided in favor of couples therapy (except in historical contexts) to reflect the recent shift away from a marriage bias to include all types of couples who seek treatment.
II. History of Couples Therapy
The identification of couples and families as a system for which psychological intervention is appropriate and even advantageous is a relatively recent phenomenon. In this section, we highlight important movements, historical developments, and influential contributors to the development of couples therapy from the post-WorldWar I era to the present.
In the period after World War I, professionals from various disciplines began to promote human sexuality as a legitimate area of scientific study and to call for public education regarding sexual and reproductive issues. Spearheaded by Hirschfield in Germany, Ellis in Great Britain, and Kautsky in Austria, public centers were founded throughout Europe to promote awareness and knowledge of these issues. In these centers, advice was given on contraception, eugenics, and psychological and relational issues. Concurrent with the rise of Nazi Germany, however, the focus of the centers became increasing eugenic. As noted by Kopp in 1938, ‘‘In the United States of America marriage counseling to date has in the main been concerned with the solution of the problems related to the psychology and physiology of sex, reproduction, family and social relationships. In Europe, on the other hand, the main objectives are the betterment of the biological stock’’ (p. 154).
Although the idealistic vision of sexual reformers was impeded in Europe, the development of couples and family therapy continued in the United States. Social workers emphasized the need to expand interventions to include the family. Educators implemented home economics courses in high schools nationwide. Workshops addressing family and marital issues were offered through churches and universities. Finally, new psychoanalytic theories (such as object relations theory) opened the door for psychological interventions beyond just one individual.
Emerging from such varied fields, the marriage counseling movement was both eclectic and pragmatic. Early couples counseling was mainly conducted as a secondary profession by college professors, physicians, and gynecologists. In the early 1930s, the first institutes were opened whose primary function was to provide couples therapy. These institutes included the American Institute of Family Relations in Los Angeles, an ecumenical marriage center in New York and the Marriage Council of Philadelphia.
The American Association of Marriage Counselors (AAMC) was established in 1945 for establishing standards, exchanging information, and helping in the development of interest in marriage counseling. Of the professionals who initially formed the AAMC, ‘‘no less than fifty percent came primarily from the medical specialties, while the rest represented such fields as social work, psychology, and sociology’’ (p. 433). During the 1950s and early 1960s, centers for marriage counseling were opened across the country, marriage counseling textbooks were produced for a general professional audience, standards were proposed for marriage counselors, and training centers were accredited. Despite this progress, however, the new profession of marital counseling had yet to establish a clear sense of professional identity. Marriage counseling continued to be a secondary profession for most practitioners, leaving the status of marriage counseling as a profession marginal.
In the late 1960s and early 1970s, the profession matured. Perhaps the most important development during this period was the establishment of a common journal, the Journal of Marital and Family Counseling (now the Journal of Marriage and Family Therapy). It was also during this period that varying approaches to conjoint therapy were developed and proposed by marital therapists and researchers. In 1970, the AAMC changed its name to the American Association for Marriage and Family Counselors (AAMFC) to reflect the convergence of marriage and family counseling during this period.
In the last two decades, many marital and family therapists have worked for the recognition of their profession as autonomous and distinct. In 1992, regulations in the Federal Register officially declared marriage and family therapy to be the fifth core mental health profession (along with psychiatry, psychology, social work, and psychiatric nursing). By 1993, 31 states had implemented licensing procedures for marital and family therapists. The struggle for an autonomous profession is not without controversy, however. Proponents of marital and family therapy remaining within an established profession (e.g., psychology, psychiatry, etc.) have specific advantages, such as ease in obtaining funding and reimbursement for research and clinical work. Today, marital and family therapy ‘‘is partially established as a major profession, but its status in the broader society remains frustratingly marginal’’ (Shields et al., 1994).
III. Theoretical Approaches in Conducting Couples Therapy
A. Behavioral Couples Therapy
1. Theory of Distress
Behavioral couples therapy (BCT) emphasizes the behaviors that partners exchange and the antecedents and consequences of those behaviors. Although behaviorists acknowledge the role of affect and cognition in the development and maintenance of distress, they target the external determinants of behavior as the point of intervention for distressed couples. Therapists help couples to define their problems in behaviorally specific terms and to gain control over them by manipulating the conditions that precede the problematic behavior and those that are consequent to it. By teaching couples various communication and problem-solving skills, therapists help couples minimize distressing exchanges and maximize rewarding exchanges.
2. Development of Dissatisfactions
According to behavior theory, people select mates based on the actual and anticipated reinforcers received in the relationship (e.g., sexual pleasure, emotional intimacy, wealth, etc.). Couples who are initially satisfied with these reinforcers may become less satisfied over time because reinforcements become habitual and routine or because greater contact and/or life changes may expose important incompatibilities that were not apparent to the couple during the courtship phase of their relationship. When faced with important incompatibilities, partners may cease previously rewarding behaviors and engage in coercive techniques in an effort to get their own way. When one partner gives in to such aversive techniques, his or her partner is reinforced for using these techniques and will therefore be more likely to use them in the future. For example, Diane may nag Joe to complete his share of the housework. When Joe finally gives in to her nagging, her nagging is reinforced. The partner who gives in is also reinforced by the removal of the aversive stimulus. Thus, Joe is more likely to give in to the nagging in the future, because it is reinforcing for him to have the nagging stop. As partners become habituated to these aversive stimuli, the coercing partner must use them in greater amounts. Also, the coerced partner may engage in coercion to achieve his or her own goals. Thus, an initially satisfied couple may develop negative interaction patterns that cause them both distress, but which they are unable to stop.
3. Intervention
The emphasis in BCT is on behavioral change, specifically, behaviors that contribute to a partner’s satisfaction and distress. The techniques most frequently used to promote these changes are behavior exchange and communication /problem-solving strategies. In behavior exchange, the therapist helps the couple to identify behaviors that are reinforcing and through various strategies directs them to increase these reinforcing behaviors. This exchange of behaviors provides some immediate relief of distress and paves the way for more difficult negotiations which require communication and problem-solving strategies. The therapist then teaches the couples noncoercive ways of discussing and resolving conflicts and practices these skills with the couple using conflicts that the couple is currently experiencing. The final goal is for the couple to learn to apply these skills on their own whenever a new conflict arises.
4. Specific Therapeutic Techniques
In behavior exchange, therapists guide partners in the selection of reinforcing behaviors, direct them to increase the frequency of these behaviors, and debrief their experiences with these change efforts. Ideally, couples select behaviors that are maximally reinforcing to the receiver and of minimal cost to the giver. Typically, low-cost behaviors are behaviors that are not a current source of conflict, do not require the learning of new skills, and are positive. Therapists may directly assign partners to increase the overall frequencies of the selected behaviors or direct each partner to increase the target behavior within a certain time frame, as in ‘‘love days’’ or ‘‘caring days.’’ Finally, therapists debrief these behavior change experiences. In these sessions, receivers are encouraged to acknowledge and positively reinforce the increase in positive behavior by the giver.
In communication /problem solving training, couples are taught to approach problem solving in two distinct steps, problem definition and problem solution. The distinction between these two steps is made to avoid premature problem solving. During the problem definition phase, partners are encouraged to begin by acknowledging some positive part of the problem. They are then encouraged to state their problems in specific behavioral terms, to express their feelings, to acknowledge their own role in the problem, and to devise a brief summary statement of the problem. For Joe and Diane, one problem might be that Joe frequently comes home late from work and is criticized for his lateness when he comes home. Diane would be encouraged to acknowledge that her criticism may be part of the reason why Joe comes home late and to discuss how she feels when he is late. Joe would be encouraged to acknowledge his lateness and to discuss his feelings in response to Diane’s criticism. During the problem–solution phase, the couple begins by brainstorming all possible solutions, without further elaborating on the problem. Then, the couple evaluates these solutions based on a cost–benefit analysis. Finally, a specific agreement is reached, which is often set in writing. Throughout the discussion, couples are instructed to address only one problem at a time, to focus on their own views without presupposing what their partner’s views are, and to paraphrase what their partner just said to ensure listening and to avoid interruptions.
5. Efficacy of Treatment Approach
More controlled, clinical trials have been conducted on BCT than on any other modality. The results have been mixed. Although about two thirds of couples who receive BCT show an increase in satisfaction at the end of therapy, long-term follow-up data suggest that about 30% of couples who were successfully treated relapse after 2 years. Thus about one half of couples treated with BCT experience lasting improvement in their relationships.
B. Cognitive Behavioral Couples Therapy
Cognitive behavioral couples therapy (CBCT) emerged in response to a number of studies that revealed the importance of cognitions in the development and maintenance of couples’ distress. It uses the same basic structure and therapeutic strategies as BCT, but it also includes assessment of and intervention in partners’ maladaptive cognitions. The following description focuses solely on the cognitive components of CBCT, as the behavioral components have been described previously.
1. Theory of Distress
Researchers have identified five areas of cognition that are related to distress. Selective inattention refers to distressed partners’ tendencies to remember negative relationship events with great clarity, but to have little recall of positive events. Negative attributions occur when distressed partners attribute each other’s negative behavior to unchangeable characteristic of the partner rather than to temporary, external circumstances. Partners may also have unrealistic expectancies about the future and assumptions about how relationships operate that contribute to their distress. Finally, partners’ standards about what a relationship should be like often interfere with their ability to be satisfied with their current relationship.
2. Development of Distress
The conceptualization of the development of distress in CBCT is similar to the conceptualization used in BCT. One difference is that maladaptive cognitions are seen as contributing to the behaviors that lead to distress as well as to the distress itself.
3. Intervention
The structure of the sessions in CBCT is flexible to allow for varying focus on behavior, cognition, and emotion. Therapists address maladaptive cognitions when they emerge as the main problem or when they are clearly interfering with behavioral skills training. The therapist’s role is active and directive. When assessing or evaluating cognitions, the focus is on the content of the cognitions rather than on the process that is occurring between the partners. This is done to get a clear understanding of problematic cognitions. Couples are taught about cognitions and how they can influence behavior and emotions. Over the course of therapy, couples learn how to become more aware of cognitions, how to evaluate them, and how to challenge them when necessary.
4. Specific Therapeutic Techniques
One technique that CBCT therapists frequently use to help partners become more aware of selective inattention, unrealistic expectancies, assumptions, and standards, and maladaptive attributions is the use of daily logs. Couples write down their automatic thoughts as they occur and this material is used for later evaluation. For example, when Joe does not come home in time to say good night to their daughter, Diane might think ‘‘He doesn’t love her,’’ or ‘‘He is a very selfish person.’’ During actual sessions, therapists use open-ended questions, coaching, and direct questions to uncover relationship standards and beliefs that are difficult to access. To modify cognitions, partners learn to challenge their own cognitions as they make them, evaluating whether their inferences make sense logically. They are also trained to identify alternative, relationship- enhancing attributions. Diane would be encouraged to rethink her automatic attribution that Joe is late because he does not love her daughter and instead attribute Joe’s lateness to his temporary and stressful project at work. Finally, therapists teach couples about specific types of distortions (e.g., personalization, overgeneralization) so that they can be aware of them when they occur. Therapists also help to uncover deeply held relationship standards and assumptions and to evaluate the advantages and disadvantages of maintaining these standards.
5. Efficacy of Treatment Approach
A series of clinically controlled outcome studies have consistently shown that CBCT is equally effective in treating marital distress when compared to other treatment strategies, including BCT. In addition, CBCT has been shown to affect partners’ actual cognitions. Baucom, Epstein, and Rankin (1995) have identified several reasons why CBCT has not been shown to be more effective than BCT alone. First, couples were randomly assigned to either BCT or CBCT. Because the need for cognition restructuring varies in couples, matching couples to treatment is necessary to determine whether CBCT will be more effective in helping those couples with distorted and maladaptive cognitions. Second, the interventions (skills training and cognitive restructuring) were separated in time rather than integrated. This is inconsistent with a naturalistic intervention, which would use cognitive restructuring when needed by the couple, not when dictated by the protocol. Finally, the cognitive restructuring phase was often very brief (about 3 weeks), which is probably insufficient. For these reasons, it remains unclear whether adding cognitive components to BCT increases the effectiveness of BCT.
C. Systemic Couples Therapy: Bowen Family Systems Therapy
Several distinct approaches for couples therapy have been developed based on systems theory. One of the most prominent and widely practiced is Bowen Family Systems Therapy (BFST). This section begins with a general overview of systems theory followed by a more in-depth description of BFST. The systems approach emphasizes the organization of the family as a whole and the patterns of interaction that the family engages in. The family, or in this case the couple, is seen as made up of elements that are organized by the consistent nature of the relationship between them. Systems theory states that all systems work to maintain balance and stabilization. Each part of the system plays an important role in maintaining that balance. For families and couples, mechanisms can be identified whose primary purpose is the maintenance of an acceptable behavioral balance within the family. Families tend to establish a behavioral balance and to resist any change from that predetermined level of stability.
1. Theory of Distress
In BFST, a key concept in understanding couples distress is differentiation, which refers both to individuals and to couples. Differentiation is the degree to which a person (or a couple) is able to differentiate between his or her emotional system (i.e., instinctual reactions) and his or her intellectual system (i.e., the ability to use reason and to communicate complex ideas). Persons or couples who are unable to make this differentiation consistently respond to their environment using the emotional system, which makes them vulnerable to distress. In contrast, persons and couples who are able to regulate their behavior using their intellectual system are less likely to develop symptoms of couples’ distress. Symptoms of distress appear when a couple encounters anxiety; these symptoms include emotional distancing, conflict, development of dysfunction in one partner, and, in the case of families, projection of the problem onto a child.
2. Development of Dissatisfaction
The BFST approach relies on an intergenerational theory that suggests that degrees of differentiation do not change much from generation to generation. This is based on two assumptions. The first is that parental differentiation affects how well children are able to separate emotionally from their parents. Adult children of undifferentiated parents will experience unresolved emotional attachment to parents that will prevent them from becoming differentiated themselves. Second, people pick marital partners who have similar levels of differentiation. When undifferentiated partners marry, they tend to be overly dependent on one another and are very vulnerable to the development of distress when anxiety is encountered. Differentiated adults, in contrast, tend to have a strong sense of self within their own marriages, and their functioning is less dependent on the behavior of their partner. They are able to tolerate the anxiety that is generated when inevitable differences appear.
3. Intervention
The overall goal of BFST is not to relieve the immediate symptoms, but to increase the level of differentiation of the members and of the unit. Symptom relief without increased differentiation leaves the couple vulnerable to developing new symptoms when additional anxiety is encountered. In BFST, the therapist functions as a coach who creates a climate in which each individual can reach their highest potential level of differentiation and in which the relationship can assist the individuals to develop further than they might have alone. The couple or family system is viewed as the patient, and the therapist attempts to interact with the system to enhance its own natural restorative processes. This is accomplished by focusing not on the content presented during therapy, but on the emotional processes of the couple over time. In particular, the therapist wants to prevent the couple from engaging in an emotional chain reaction of instinctive, emotionally laden reactions to one another. To accomplish this, it is critical for the clinician to understand and control his or her own emotional reactivity to provide a safe environment in which the couple can discuss emotionally charged issues. The therapist must remain emotionally neutral, unembroiled in the family system, and maintain his or her own differentiation.
4. Specific Therapeutic Techniques
The BFST therapist begins with a thorough history of the immediate and extended family to formulate a picture of the family emotional system. The survey should give the therapist a working knowledge of the current symptoms as well as the mechanisms that the couple uses to manage anxiety and to keep the relationship stable. Bowen (1978) identified four main functions of the clinician. First, the clinician defines and clarifies the emotional processes between partners. Because partners are preferentially sensitive to one another, each behavior is perceived, interpreted, and reacted to by the other. These reactions are often based in the emotional system in distressed couples, guided more by feeling than by thinking, with each reaction generating its own counterreaction. The therapist’s goal is to get couples to become more aware of and to think about this process (i.e., use their intellectual system) rather than simply to enact it. Thus, when Joe feels nagged by Diane to do housework, he becomes aware that he is having this feeling and is more able to discuss this with Diane, rather than to react by withdrawing and neglecting the housework. Second, it is critical for the clinician to remain detriangulated from the emotional process. ‘‘Conflict between two people will resolve automatically if both remain in emotional contact with a third person who can relate actively to both without taking sides with either.’’ (Bowen 1978, p. 224). Third, the therapist teaches the couple about the emotional system. Fourth, the therapist models differentiation of self for the couple. To do so, the therapist must be aware of his or her own viewpoint and values, and how he or she typically responds to a variety of situations. The usual format is for the therapist to talk with one person while the other listens, using low-key questions aimed at clarifying the emotional reactivity of the person and the chain reaction between partners. Overall, the questions are used to elicit thinking and to tone down emotional responses.
5. Efficacy of Treatment Approach
To date, there are no controlled outcome studies examining the efficacy of the Bowenian approach with couples or with families. There have been studies examining other family systems approaches; a review of the few controlled outcome studies found that family therapy, compared with no treatment and alternative treatments, did have positive effects. Because the studies varied in the type of family therapy and in the type of alternative therapy, it remains unclear how effective a systems approach is in treating couples’ distress.
D. Psychoanalytic Couples Therapy
1. Theory of Distress
Psychoanalytic theories of marriage emphasize the interplay of unconscious wishes, fears, and fantasies between spouses. According to object relations theory, all adult individuals have ‘‘lost’’ parts of themselves which were ‘‘split off’’ and repressed into the unconscious during infancy. This happened as a result of the inevitable gap between the infant feeling a need and the satisfaction of that need. This gap leads to feelings of frustration in the infant and to the perception of the mother (the object) as rejecting. Because the infant is unable to tolerate the ambiguity of a giving mother who is sometimes rejecting, it splits off the image of the rejecting mother from the image of the ideal mother and represses it into the unconscious (as the rejecting object), along with the part of the self that related to the rejecting mother. When individuals choose a mate, they do so at both a conscious and an unconscious level. Unconsciously, they are attracted to mates whose unconscious objects and selves are complementary to their own. Ideally, this complementarity helps partners to regain lost parts of themselves in relation to their partner. When the unconscious interplay between partners causes partners to repress further rather than reintegrate lost parts of the selves, distress can occur.
2. Development of Dissatisfaction
Partners’ unconscious communication takes place through a process called projective identification. In projective identification, one partner (e.g., the wife) projects onto her husband her repressed objects or aspects of the self. Ideally, her husband is able to identify temporarily with and embody these projections. Through this process, the projection is modified and ‘‘detoxified’’ for the wife, who can then consciously assimilate this new view of herself. As a result, she is better able to distinguish herself from her husband and to love him for who he is and not for what she projects onto him. This process takes place simultaneously for both partners. Thus, through the complementarity of unconscious objects, partners facilitate growth and reintegration in one another. When partners’ projective identification is not mutually gratifying and objects are more firmly repressed rather than modified, distress occurs.
3. Intervention
The main focus in intervention is the unconscious projections that each person is making and the partners’ responses to these projections. The overall goal of therapy is to increase partners’ abilities to contain, modify, and reintegrate aspects of the self that they project onto one another. Through this reintegration, the partners become more able to give and receive genuine love. This is accomplished through careful observation of partners’ defenses and anxieties and through creating an environment in which these anxieties can be worked through. Psychoanalytic couples therapy is ideally a long-term, in-depth enterprise, which typically requires a period of 1 to 2 years.
4. Specific Therapeutic Techniques
The techniques used in psychoanalytic couples therapy are more attitudinal than behavioral. The therapist typically engages in careful, undirected listening and, later, in interpretations. The therapist begins with a period of assessment that allows the couple to understand the nature of the undertaking so that they may freely choose to enter into psychoanalytic couples therapy. In this assessment process, called securing the frame, the therapist outlines the parameters for therapy, including setting the fee and scheduling the sessions, which creates a safe and stable environment for the partners. It is also the first opportunity for partners to attempt to gratify unconscious wishes by encroaching on the frame, which provides insight into the unconscious difficulties affecting the marriage. For example, Joe might object to the therapist’s policy that he must attend therapy every week and that he must pay the therapist her usual fee if he misses an appointment. He may feel infantalized and ‘‘nagged’’ to attend therapy regularly. This feeling gives the therapist some insight into Joe’s unconscious processes and the current difficulties in the marriage. As mentioned previously, the therapist attempts to listen primarily to the unconscious and to make use of countertransference (the therapist’s feelings regarding the couple) for clues into the unconscious. The therapist maintains a neutral position and uses his or her own self as a ‘‘holding place’’ where the couple can recognize and modify their own dysfunctional unconscious patterns. The therapist is able to create this holding place based on the intimate knowledge of his or her own unconscious attained through rigorous training, supervision, and personal psychotherapy. As the therapist begins to understand the unconscious dynamics between the partners, he or she begins to offer interpretations to help the couple gain insight into their process of projective identification. Termination is initiated once the couple is able to ‘‘internalize’’ the therapist and create their own holding space within which to work through anxieties and defenses. Ideally, the couple will also have recognized, modified, and taken back much of their projective identifications, although usually this process must continue even after therapy has ended.
5. Efficacy of Treatment Approach
In the first controlled outcome study comparing a variant of psychoanalytic couples therapy (Insight- Oriented Marital Therapy, IOMT) with BCT, Snyder and colleagues found IOMT and BCT equally effective at termination and at a 6-month follow-up. Four years after treatment, however, a significantly larger percentage of couples had divorced when treated with BCT (38%) than when treated with IOMT (3%). These findings have been disputed, with critics questioning whether therapists using the BCT intervention used state-of-the-art behavioral interventions. Nevertheless, Snyder et al. have provided at least preliminary evidence that psychoanalytic couples therapy may have more long-term effectiveness than behavioral approaches.
E. Brief Problem-Focused Couples Therapy
Short-term, problem-focused couples therapy was developed in response to the difficulties that arise in treating two individuals who may have different agendas and intentions for entering into therapy as well as for the current difficulties in receiving reimbursement for couples treatment from insurance companies. Two major models of brief couples therapy have been developed and evaluated in the last three decades. Brief problem-focused therapy was developed at the Mental Research Institute (MRI) in the late 1960s and early 1970s. The model was further developed at the Brief Family Therapy Center in Milwaukee, Wisconsin (the Milwaukee model), as brief solution-focused therapy beginning in the late 1970s.
1. Theory of Distress
Brief couples therapy was developed to be as efficient and parsimonious as possible. The goal of brief couples therapy is to address and provide relief for the presenting complaint. Therapists do not probe for underlying emotional or unconscious issues, they do not seek to promote personal growth in their clients, nor do they spend time teaching communication or problem-solving skills. Consistent with these goals, brief couples therapy offers no developed theory regarding couples distress or its development. Instead, it takes couples’ complaints at face value and works for the relief of those complaints through lessening the behaviors related to the presenting problem (the MRI model) or through finding alternative solutions for the presenting problem (the Milwaukee model).
2. Development of Distress
Although brief couples therapy offers no theory about the development of distress, it does focus on the perception of distress. A couple has a problem when they perceive a problem, and the problem is alleviated when the couple perceives such alleviation. Brief couples therapy makes no attempt to objectively define dysfunction or normality in marriage. Furthermore, brief couples therapy does not seek to understand the origin of the particular presenting problem, but rather to identify and alter the behaviors of both partners that serve to maintain the current problem.
3. Intervention
In brief problem-focused couples therapy, the clinician works with the couple to identify the presenting problem and the interactional patterns that are perpetuating the problem. Usually, the attempted solutions that partners use to control or alleviate the problem are the very behaviors that make the problem persist (this phenomena is called the problem– solution loop). For example, Diane’s solution to Joe’s lateness is to nag him to come home on time. However, it is her nagging that causes him to dread coming home and to want to work longer. Likewise, it is his hiding at work that motivates Diane to nag him. Once problem-maintaining behaviors are identified, the therapist encourages the couple to lessen those behaviors. For Diane and Joe, this would mean less nagging from Diane and less lateness from Joe. Because the continuance of the problem is contingent on the problem-maintaining attempted solutions, once these are eliminated the problem itself should be alleviated. In brief solution-focused therapy, the emphasis in intervention is on identifying exceptions to the problem and encouraging the couple to increase those behaviors that are effective solutions to the problem. Here, the therapist would ask Diane and Joe to remember times when Joe did come home from work early and they shared a pleasant evening together. This approach is more cognitive than the MRI approach, assuming that behaviors will change once the couple perceives the problem differently. Clinicians attempt to reframe the problem as not so overwhelming and the solution as something the couple already has in their behavioral repertoire. The clinician’s main goal is to increase the couple’s sense of mastery over the presenting complaint.
4. Specific Therapeutic Techniques
Therapy in the MRI approach begins with a thorough behavioral understanding of the presenting complaint and the related behaviors that contribute to its perseverance. Through this formulation, the therapist identifies specific problem-maintaining behaviors that should be lessened in specific situations. The therapist then communicates this to the client using three important principles. First, the change is prescribed in a way that is consistent with the client’s own goals and views of the relationship. Second, the therapist works with the customer by targeting the person most concerned about the problem. In fact, therapists will often work individually with a concerned person whose partner is resistant to therapy. Theoretically, intervention with even one partner’s maladaptive solutions should have an impact on the problem–solution loop. Third, the therapist maintains maneuverability by avoiding premature commitments to therapeutic strategies. Overall, the therapist consistently reminds couples that change takes time and encourages them to make small changes at a slow rate. In contrast, therapists using the Milwaukee approach bypass examination of the problem relatively quickly and instead ask questions designed to influence the client’s view of the problem in a manner that leads to solutions. An example is miracle questions. Clients are asked what their relationship would look like if a miracle occurred and the problem disappeared overnight. The therapist also asks about times in the past when the problem has not occurred or when they have dealt with it successfully.
The therapist may also probe the degree of distress and commitment to change (scaling questions), how well the couple is managing given their difficulties (coping questions), and what changes have they already made before therapy began (questions about presession change). These questions are designed to challenge feelings of hopelessness by highlighting the small, positive changes that couples have managed on their own. Therapists also use tasks to help couples recognize possible solutions that they are already using. For example, couples are asked at the end of their first session to observe things about their relationship that they would like to have continue. Throughout therapy, the therapist provides ample praise for positive changes and continually inquires about and highlights use of constructive solutions whenever they occur.
5. Efficacy of Treatment Approach
Both centers have conducted follow-ups on many of their cases to find out whether a complaint has been resolved. The MRI team has called clients 3 and 12 months post treatment and evaluates ‘‘success’’ based on whether the treatment goal was attained, whether the complaint has been resolved, other areas of improvement in the relationship, and the emergence of new problems. For the first 97 cases, 40% were deemed successful, 32% significantly improved, and 28% failures. Two recent studies by Shoham and colleagues reported outcome rates of 44%, 24%, and 32%, respectively, and a success rate of 86% at an 18- month follow-up, with an average of 4.6 sessions. However, there are several reasons to interpret these numbers with caution. These include the lack of detail in describing follow-up procedures, which prevents analysis of reliability or validity of the results, and the fact that the same clinical team was used to conduct therapy and to conduct follow-up interviews. To date, no controlled clinical outcome trials have been conducted on either approach.
IV. Integrative Approaches to Couples Therapy
A. Integrative Behavior Couples Therapy
Integrative Behavior Couples Therapy (IBCT) was developed by Andrew Christensen and Neil Jacobson to increase the power and effectiveness of Behavior Couples Therapy. It is strongly rooted in behavior theory and uses many of the same treatment strategies as BCT. It does not, however, focus on promoting behavioral change exclusively, but gives equal emphasis to acceptance of partners’ behavior the way it is. This shift in focus has both theoretical and practical implications for therapy. First, IBCT targets major controlling variables for change, rather than derivative variables. In BCT, because of the exclusive emphasis on discrete, currently observable behavior, functional analysis often focuses on variables only indirectly related to partners’ dissatisfaction, for example, Diane’s complaint that Joe comes home late from work. The IBCT therapist would attempt to uncover the underlying controlling variable, that is, the wife’s desire for more closeness with her husband. The IBCT therapist looks for affect (especially ‘‘softer’’ feelings such as sadness or fear) and themes in couples’ interactions to help uncover the crucial variables for the couple.
Once the crucial variables are identified, IBCT therapists work simultaneously for change and emotional acceptance. Emotional acceptance is a shift in the way a partner reacts to the problematic behavior. Behaviors that were once seen as intolerable and blameworthy are now seen as tolerable or even desirable. For example, Joe may begin to perceive Diane’s ‘‘nagging’’ as a desire to be more closely involved with him, and Diane might see Joe’s intense work involvement as his desire to provide material comforts for the family. Change and acceptance are mutually facilitative, with greater change leading to greater levels of acceptance, and greater levels of acceptance leading to more spontaneous and long-lasting change.
The IBCT therapists use several strategies to promote acceptance. They facilitate an emotional joining around the problem, focusing partners on the pain each is experiencing rather than on the blame each deserves. Therapists promote this by reformulating recurring problems as differences between partners to which each person has an understandable emotional reaction. Therapists also encourage partners to talk about their own feelings and emphasize ‘‘soft’’ disclosures which make each partner appear more vulnerable and thus more acceptable and less blameworthy. They encourage partners to see the problem as a common external enemy to facilitate emotional acceptance through unified detachment of the problem. In emotional acceptance through tolerance building, therapists use a number of techniques designed to increase partners’ tolerance for negative interactions, such as role playing, faked incidences of negative behavior, and emphasizing the positive features of negative behavior. Finally, therapists encourage emotional acceptance through greater self-care by helping partners to identify alternative methods of getting their needs met and additional options when faced with a partner’s negative behavior.
Preliminary data from a clinical trial that compared IBCT to BCT has provided some promising support for IBCT and suggests its superiority over BCT.
B. Emotionally Focused Couples Therapy
In Emotionally Focused Couples Therapy (EFT), Susan Johnson and Leslie Greenberg integrate psychoanalytic theory, specifically attachment theory, with recent research on negative behavioral interactions to formulate an intervention for distressed relationships. According to EFT, couples’ adjustment involves both the intrapsychic emotional experiences of each partner and the couples’ interpersonal interaction patterns. These processes are mutually determined and both are targeted for intervention in BFT.
Intrapsychic emotional experiences are rooted in partners’ internal models of attachment, learned from past attachment experiences, particularly the infant’s attachment to the mother. These working models affect how partners respond emotionally to negative interpersonal experiences and are in turn affected by these experiences as well. Distressed relationships are insecure bonds in which the attachment needs of one or both partners are not met because of rigid interaction patterns that block emotional engagement. The core problem in these relationships is partners’ inaccessibility and inability to respond to or engage the partner. Therapists target both the underlying emotions and the rigid, negative interaction patterns in order to restore accessibility and form a new, secure bond between partners where each can have his or her innate needs for protection, security, and connectedness met.
The core of EFT is the accessing and reprocessing of the emotions underlying negative interaction patterns and the enactment of new patterns in which partners are affiliative and engaged. Distress is alleviated, not through new skills or new insights, but through the experience of new aspects of the self and new interaction patterns that take place in the therapy sessions. Thus, when Diane begins to nag Joe in therapy, the therapist helps Diane to focus on the underlying sadness she feels at not being close to Joe. Joe is better able to respond to her feeling of sadness than to her nagging, and the two experience a moment of closeness and understanding. The EFT therapist uses several general techniques to create this experience for the couples. First, a strong positive alliance is established with both partners. This alliance is critical if the couple is to feel safe enough to express and process their underlying emotions. Second, the therapist focuses on the moment-by-moment experience of the clients to help them reshape interactions and emotional experiences as they occur. Third, as interactions are tracked and emotions restructured, the therapist encourages the clients to replay their interactions to create new, more positive relationship events.
Initial studies have indicated that EFT is more effective than a waiting period of no therapy and at least as effective as CBCT and BCT. In comparing EFT, CBCT, and BCT, EFT was found to be more effective than BCT on marital adjustment, intimacy, and target complaint level.
V. Couples Therapy for Specific Psychiatric Disorders
Couples and family therapists have developed specialized interventions for a wide variety of psychiatric disorders, including depression, alcohol, and a variety of anxiety disorders. Outcome studies have generally found that intervening with couples and families (rather than individuals) leads to lower drop-out rates and higher treatment success rates. Behavioral and cognitive couples treatments for depression have been found to reduce depression and increase satisfaction when the depressed person is in a distressed relationship. Behavioral Couples Therapy has also been shown to reduce alcoholism and to improve couples’ satisfaction. Finally, spousal involvement has been shown to increase the effectiveness of behavioral treatments for agoraphobia.
VI. Alternative Approaches to Couples Treatment
Alternative treatments for distressed couples have been developed to improve the success rates of more traditional couples treatments as well as to provide less costly interventions. Two prevalent alternative approaches are group couples therapy and prevention / enrichment programs. In group couples therapy, couples help each other as firsthand observers of couples’ conflict and provide perspective on the problems each couple is experiencing. The group process provides an arena where couples can learn from one another, obtain insight, experience support, and receive feedback. Preliminary descriptive data on the outcome of group therapy indicates that most couples experience improvement at termination in areas as diverse as communication, reframing problems, appreciating each other more as individuals, and feeling more acceptance toward the partner’s family of origin.
Premarital programs designed to prevent future marital distress and programs designed to enrich couples’ relationships attempt to spare the couple and their children from the negative consequences of distress. Like traditional couples therapy, these programs vary theoretically and methodologically, with some programs focusing on teaching communication and problem-solving skills and others promoting awareness of underlying emotional or unconscious factors that might make a couple vulnerable to the development of distress. A review of 85 controlled outcome studies found that the average participant in one of these programs improved more than did 67% of those in corresponding control groups at termination. A recent longitudinal study of a behavior intervention program (PREP) demonstrated that couples who received the intervention had significantly higher relationship satisfaction than the control couples 18 months after the intervention and reported significantly higher sexual satisfaction, less intense marital problems, and higher relationship satisfaction than control couples at the 3-year follow-up. Because prevention spares couples (and their children) from the detrimental effects of distress that many couples experience before they seek couples therapy, prevention models may prove more efficient and effective than treatment models of already distressed couples.
VII. Conclusion
The need for effective treatments for couple distress has grown in the last few decades for several reasons: the United States has the highest divorce rate of any major industrialized country, there has been a sharp increase in divorce rates from 1960 to 1980, and there is unambiguous evidence that marital distress and divorce have harmful consequences for spouses and children. As a result, couples therapists and researchers have developed therapies that appear to be effective, at least in the short run. The comparative effectiveness of the different types of therapeutic approaches remains unclear, however. Further study is needed to clarify the comparative effectiveness of different approaches and to begin to understand how approaches and techniques might be matched to couples to maximize the effectiveness of the intervention for each couple that seeks treatment.
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