Couple Therapy

Graphics courtesy of Bliss TherapyOpens in new window The most common concerns that bring people to psychotherapy are in the area of intimate relationship. One option for working with intimate relationship issues is to seek couple therapy.

Usually, but not always, provided to partners in conjoint meetings, couple-focused psychotherapy is regularly practiced not only with married heterosexual couples, but also with nonmarried cohabiting and noncohabiting couples, and with both same-sex and opposite-sex partners.

Once viewed as the “ambivalently embraced stepchild” of family therapyOpens in new window, or at least, as a subtype of family therapyOpens in new window, couple therapy has emerged in the last decade as a psychotherapeutic domain of theory development, practice, and research that stands on its own, and there now exists a clearly autonomous and coherent clinical literature in the field.

Interestingly, major surveys of the practices of “family” therapists (e.g., Doherty & Simmons, 1996; Rait, 1988) have found that whole families make up only about one-third of “faily” clinician’s work, and that couple problems constitute the presenting problem in almost two-thirds of their cases.

Ironically, such surveys support the identification of Nathan Ackerman (1970), the unofficial founder of family therapy, of “the therapy of marital disorders as the core approach to family change” (p. 24).

Why People Seek Couple Therapy

Although physical and psychological health are significantly affected by couple relationship satisfaction and health, there are more common reasons why, phenomenologically speaking, couples seek, or are referred for, conjoint therapy. These concerns typically involve relational matters such as:

• emotional disengagement and waning commitment,
• power, struggles, problem-solving and communication difficulties,
• jealousy and extramarital involvelments,
• value and role conflicts,
• sexual dissatisfaction, and
• abuse and violence.

Generally, couples seek therapy because of threats to the security and stability of their relationships with the most significant attachment figures of adult life.

Why Couple Therapy Matters

Although the evolving practice of couple therapy is certainly not limited to married couples, it is instructive to consider that significant cultural changes in the last half century have had an enormous impact on marriage and the expectations and experiences of those who marry or enter other long-term committed relationships. For example, reforms in divorce law (e.g., no-fault divorces), more liberal attitudes about sexual expression, the increased availability of contraception, and the growth of the economic and political power of women have all increased the expectations and requirements of marriage to go well beyond maintaining economic viability and assuring procreation.

For most couples nowadays, marriage is also expected to be the primary source of adult intimacy, support, and companionship and a facilitative context for personal growth. At the same time, the “limits of human pair-bonding” (Pinsof, 2002, p. 135) are increasingly clear, and the transformation of marital expectations have led the “shift from death to divorce” as the primary terminator of marriage.

With changing expectations not only of marriage itself but also of the permanence of marriage, the public health importance of the “health” of marriage has understandly increased. Whether through actual divorce or chronic conflict and distress, the breakdown of marital and other long-term committed intimate relationships exacts enormous costs.

Recurrent couple conflict and divorce are associated with a wide variety of problems in both adults and children. Divorce and couple problems are among the most stressful conditions people face.

Partners in troubled relationships are more likely to suffer from anxietyOpens in new window, depressionOpens in new window and suicidality, and substance abuse, and from both acute and chronic medical problems and disabilities such as impaired immunological functioning and high blood pressure. They are also more susceptible to sexually transmitted diseases and more accident prone. Moreover, the children of distressed couples are more likely to suffer from anxietyOpens in new window, depressionOpens in new window, conduct problems, and impaired physical health.

Couple therapy now makes up an essential component of mental health services—emerging partly in response to a divorce rate of approximately 50% for first marriages in the United States—and relationship difficulties are probably the more frequent reason for seeking mental health services.

But in addition to the high prevalence of couple distress in both clinical and community samples, the adverse impact of couple distress on both the emotional and physical wellbeing of adults and their children has contributed significantly to the stature of couple therapy as an increasingly available component of mental health services.

Although couple therapy most often aims to reduce overall relationship distress, couple-based interventions have also been developed to treat couples in which one or both partners struggle with impairing individual emotional or behavioral disorders (Whisman & Snyder, 2003).

Insights for Couple Therapists

From the point of view of the therapist, therapy with couples entails unique challenges and opportunities compared to therapy with individuals. Tremblay and Philips (2009) discuss some of these distinctive concerns. First, working with couples requires thinking in terms of systems rather than in terms of individuals. A copule is a system, “an organized collection of parts that perform a function” (Tremblay & Philips, 2009, p. 331), in which the parts of the system are interdependent and reciprocally affect one another.

Second, couples work is different from work with an individual client in that the therapist sees more than one perspective for any given problem, in the form of the differing points of view of the members of the couple. This raises the possibility of an alliance more toward one member than toward the other.

The therapist must strive to maintain neutrality and ally with both members. Owing to these factors, the therapist will tend to view the couple’s problems as residing in the interactive system (the couple) rather than in one individual.

Another unique aspect of couples work, ripe with opportunity, is that the therapist can see an interpersonal problem occurring right in the consulting room, in vivo, rather than relying on one person’s retrospective report of her interpersonal difficulty, as would occur in individual therapy.

Special problems and issues may arise in couples therapy, as discussed by Tremblay and Philips (2009). For instance, couples may wait a long time before coming to therapy, creating a situation in which at least one partner is emotionally distant by the time therapy begins. Unfortunately, couples therapy is less effective if emotional distancing has occurred (Jacobson & Addis, 1993).

In addition, the issues of gender roles and power often arise in couples therapy; one partner may have traditional gender role expectations for the partnership, while the other partner desires an egalitarian relationship. Also, either violence or substance abuse or both may be present in the relationship, creating potential ethical problems or opportunities for the therapist and therapy.

For example, the therapy session could bring problems to the head that then provoke violence outside of the therapy session. Conversely, therapy may dissipate aggressive impulses which may have otherwise been acted out outside of therapy.

If substance abuse is present in one member of the couple, the therapist has to negotiate the issue of alliance very delicately; the substance abuse should not be encouraged or promoted; however, trust and respect must be maintained with both members of the couple. Special concerns may arise in therapy with same-sex couples, for example, clients may feel that therepists are less likely to understand or support their relationship.

Two types of couples therapy are clearly supported by evidence:

1. behavioral couples therapy (BCT)Opens in new window and
2. emotion-focused therapy for couples (EFT; Byrne, Carr, & Clark, 2004).

The theory behind BCT is that couples who have a difficult relationship have become involved in interactions in which they reinforce negative behavior with one another. BCT involves treatment in two main areas:

1. increasing positive interactions through behavioral techniques and
2. improviing problem solving and communication skills.

The couple is instructed to engage in these pleasant activities; they may create a calendar, with the homework assignment of doindg the enjoyable activities that they have written on the calendar.

Another way to increase positive interactions is for the therapist to encourage behaviors that result in each partner feeling intimate and supported. In problem-solving and communication skills work, the therapist works with real, presenting issues, identifying social interactions that are not constructive and providing instruction and homework assignments to improve these areas.

Emotion-focused therapy for couple (EFT) uses systems theory and attachment theory as a framework for understanding conflicts and dysfunction in couples. Since systems theory implies that disorder occurs in the system (couple) rather than in individuals, patterns of interaction are explored in an attempt to change those patterns that cause distress.

For instance, a couple may be engaged in a cyclical pattern of one partner criticizing, the other withdrawing, the first partner criticizing more, followed by the second partner withdrawing further, and so on.

According to attachment theory, people have different styles of attachment to significant others, which includes differences in desires for closeness; some attachment styles may conflict. As Greenburg and Johnson (1988) described, clash of attachment styles may lead to cyclical patterns such as pursue-and-withdraw, mutual attack, or mutual withdrawal. Therapy involves identifying the cycle, helping partners to express their attachment needs and helping partners to understand the other’s attachment needs.

In general, couple therapy is as effective in relieving distress in relationships as individual psychotherapy is in relieving distress regarding individual concerns (e.g., Johnson & Lebow, 2000).