What is couples therapy?

Introduction

Traditionally, marriage
vows have represented pledges of mutual love and enduring commitment. Since the 1960s, however, marital relationships have changed dramatically. In fact, while more than 90 percent of the United States population will marry at least once in their lifetime, the US Census Bureau estimated in 2009 that approximately 40 percent of all first marriages and approximately 60 percent of all second marriages end in divorce. Moreover, while the average first marriage in the United States will last approximately eight years, second marriages typically endure for approximately the same time period at 8.5 years. It appears that a repetitive pattern of marriage, distress, and divorce has become commonplace. Such a cycle often results in considerable pain and psychological turmoil for the couple, their family, and their friends. These statistics dramatically indicate the need for effective ways to help couples examine and reapproach their relationships before deciding whether to terminate them.

Interpersonal relationships are a highly complex yet important area of study and investigation. The decision to marry (or at least to commit to a serious intimate relationship) is clearly one of the most significant choices many people make in their lives. Fortunately, advances in couples therapy have led to increased knowledge about interpersonal relationships and methods for improving relationship satisfaction. These advances have been documented in the scientific literature, and they extend to the treatment of cohabitating partners, premarital couples, remarried partners, married and premarital same-sex couples, separating or divorced couples, and stepfamilies. Moreover, couples-based treatment programs have shown effectiveness in the treatment of depression, anxiety disorders, domestic violence, sexual dysfunction, and a host of other problems.

Communication and Conflict Resolution

Often, partners who seek couples therapy or counseling have problems in two areas: communication and conflict resolution. These are the two major difficulties that most often lead to divorce. It has been shown that communication skills differentiate satisfied and dissatisfied couples more powerfully than any other factor. Indeed, communication difficulties are the most frequently cited complaint among partners reporting relationship distress.

Psychologist John M. Gottman, in Marital Interaction: Experimental Investigations (1979) and the cowritten A Couple’s Guide to Communication (1976), is one of many researchers who have highlighted the importance of communication problems within distressed relationships. Many characteristic differences between distressed and satisfied couples have been noted. Partners in distressed couples often misperceive well-intended statements from their partners, whereas satisfied couples are more likely to rate well-intended messages as positive; distressed partners also engage in fewer rewarding exchanges and more frequent punishing interactions than nondistressed couples. A partner in a distressed relationship is more immediately reactive to perceived negative behavior exhibited by his or her partner. There is generally a greater emphasis on negative communication strategies between distressed partners.

Distressed couples appear to be generally unskilled at generating positive change in their relationship. Gottman also reported that distressed couples are often ineffectual in their attempts to resolve conflicts. Whereas nondistressed couples employ “validation loops” during problem-solving exercises (one partner states the conflict and the other partner expresses agreement or support), distressed couples typically enter into repetitive, cross-complaining loops. These loops can be described as an interactional sequence wherein both individuals describe areas of dissatisfaction within the relationship yet fail to attend to their partners’ issues. Moreover, as one spouse initiates aversive control tactics, the other spouse will typically reciprocate with similar behavior.

Therapy Formats

Couples therapy attempts to alleviate distress, resolve conflicts, improve daily functioning, and prevent problems via an intensive focus on the couple as a unit and on each partner as an individual. Couples therapists are faced with a variety of choices regarding treatment format and therapeutic approach. Individual therapy focuses treatment on only one of the partners. Although generally discouraged by most practitioners, individual treatment of one partner can provide greater opportunities for the client to focus on his or her own thoughts, feelings, problems, and behaviors. Clients may feel less hesitant in sharing some details they would not want a spouse to hear, and individual treatment may encourage the client to take greater personal responsibility for problems and successes. In general, these advantages are outweighed by the difficulties encountered when treating relationship problems without both partners being present. In particular, interpersonal interactions are complex phenomena that need to be evaluated and treated with both partners present.

Concurrent therapy involves both partners being seen in treatment separately, either by the same therapist or by two separate but collaborating therapists. Advantages of the concurrent format include greater individual attention and opportunities to develop strategies to improve relationship skills by teaching each partner those techniques separately. Concurrent treatment, however, does not allow the therapist(s) to evaluate and treat the nature of the interpersonal difficulties with both partners present in the same room.

Conjoint format, on the other hand, involves both partners simultaneously in the therapy session. Conjoint treatment is widely used and generally recommended because it focuses intensively on the quality of the relationship, promotes dialogue between the couple, and can attend to the needs and goals of each partner as well as the needs and goals of the couple. The history of conjoint marital therapy begins, ironically, with Sigmund Freud’s failures in this area. He believed firmly that it was counterproductive and dangerous for a therapist ever to treat more than one member of the same family. In fact, in 1912, after attempting to provide services simultaneously to a husband and wife, Freud concluded that he was at a complete loss about how to treat relationship problems within a couple. He also added that he had little faith in individual therapy for them.

Conjoint treatment is designed to focus intensively on the relationship to effect specific therapeutic change for that particular couple. Interventions can be tailor-made for the couple seeking treatment, regardless of the nature of the problem the couple describes (such as sexual relations, child rearing, or household responsibilities). Moreover, couples are constantly engaged in direct dialogue, which can foster improved understanding and resolution of conflict. As compared with other approaches, conjoint marital therapy can focus on each of the specific needs and goals of the individual couple.

Group couples treatment programs have received increased attention and have shown very good to excellent treatment success. Advantages of group treatment for couples include opportunities for direct assessment and intervention of the relationship within a setting that promotes greater opportunity for feedback and suggestions from other couples experiencing similar difficulties. In fact, group therapy may promote positive expectations through witnessing improvements among other couples as well as fostering a sense of cohesiveness among couples within the group. In the group format, each partner has the opportunity to develop improved communication and conflict resolution approaches by learning relationship skills via interaction with the therapist(s), his or her spouse, and other group members. In addition, the cost of individual, concurrent, and conjoint therapy, in terms of time as well as dollars, has prompted several researchers and clinicians to recommend group couples therapy.

Therapeutic Approaches

There are numerous approaches to the treatment of relationship problems practiced in the United States. Psychodynamic therapy focuses attention on the unconscious needs and issues raised during an individual’s childhood. Phenomenological therapists focus on the here-and-now experiences of being in a relationship and have developed a variety of creative therapeutic techniques. Systems therapists view interpersonal problems as being maintained by the nature of the relationship structure, patterns of communication, and family roles and rules.

Behavioral marital therapy, however, is the most thoroughly investigated approach within the couples therapy field. Starting from a focus on operant conditioning (a type of learning in which behaviors are altered primarily by the consequences that follow them— reinforcement or punishment), behavioral marital therapy includes a wide range of assessment and treatment strategies. The underlying assumption that best differentiates behavioral treatments for distressed couples from other approaches is that the two partners are viewed as ineffectual in their attempts to satisfy each other. Thus, the goal of therapy is to improve relationship satisfaction by creating a supportive environment in which the skills can be acquired. Behavioral marital therapy incorporates strategies designed to improve daily interactions, communication patterns, and problem-solving abilities and to examine and modify unreasonable expectations and faulty thinking styles.

Behavioral-Exchange Strategies

Psychologists Philip and Marcy Bornstein, in their book Marital Therapy: A Behavioral-Communications Approach (1986), described a sequential five-step procedure in the treatment of relationship dysfunction. These steps include intake interviewing, behavioral exchange strategies, communication skills acquisition, training in problem solving, and maintenance and generalization of treatment gains.

Intake interviewing is designed to accomplish three primary goals: development of a working relationship with the therapist, collection of assessment information, and implementation of initial therapeutic regimens. Because spouses entering treatment have often spent months, if not years, in conflict and distress, the intake procedure attempts to provide a unique opportunity to influence and assess the couple’s relationship immediately. Because distressed couples often devote a considerable amount of time thinking about and engaging in discordant interpersonal interactions, it naturally follows that they will attempt to engage in unpleasant interactions during initial sessions. Information about current difficulties and concerns is clearly valuable, but improved communication skills and positive interactions appear to be of even greater merit early in treatment. Thus, couples are discouraged from engaging in cross-complaining loops and are encouraged to develop skills and implement homework procedures designed to enhance the relationship.

Skill Training

Building a positive working relationship between partners is viewed as essential in couples treatment programs. During training in behavioral exchange strategies, couples are aided in specifying and pinpointing behaviors that tend to promote increased harmony in their relationship. Couples engage in contracting and compromise activities to disrupt the downward spiral of their distressed relationship.

Training in communication skills focuses on practicing the basics of communication (such as respect, understanding, and sensitivity) and of positive principles of communication (timeliness, marital manners, specification, and “mind reading”), improving nonverbal behaviors, and learning “molecular” verbal behaviors (such as assertiveness and constructive agreement). Improved communication styles are fostered via a direct, active approach designed to identify, reinforce, and rehearse desirable patterns of interactions. Clients are generally provided with specific instructions and “practice periods” during sessions in which partners are encouraged to begin improving their interactional styles. It is common for these sessions to be audiotaped or videotaped to give couples specific feedback regarding their communication style.

Training in problem solving is intended to teach clients to negotiate and resolve conflicts in a mutually beneficial manner. Conflict resolution training focuses on learning, practicing, and experiencing effective problem-solving approaches. Couples receive specific instruction on systematic problem-solving approaches and are given homework assignments designed to improve problem-solving skills. Because the value of couples therapy lies in the improvement, maintenance, and use of positive interaction styles over time and across situations, treatment often aims to promote constructive procedures after the termination of active treatment. Thus, people are taught that it is generally easier to change oneself than one’s partner, that positive interaction styles may be forgotten or unlearned if these strategies are not regularly practiced, and that new positive interactions can continue to develop in a variety of settings even as treatment ends.

Comparative Research

To highlight further the utility and effectiveness of behavioral-communications relationship therapy, Philip Bornstein, Laurie Wilson, and Gregory L. Wilson conducted an empirical investigation in 1988 comparing conjoint and behavioral-communications group therapy and group behavioral-communications therapies to a waiting-list control group (couples who were asked to wait two months prior to beginning treatment). Fifteen distressed couples were randomly assigned to experimental conditions and offered eight sessions of couples therapy. At the conclusion of treatment (as well as six months later), the couples in active treatment revealed significant alleviation of relationship distress. The conjoint and group couples revealed similar levels of improvement in communication skills, problem-solving abilities, and general relationship satisfaction. The waiting-list couples, on the other hand, revealed no improvement while they waited for treatment, indicating that relationship distress does not tend to improve simply as the result of the passage of time.

Prevention and Disorders

Another line of couples research has focused on the utility of premarital intervention and distress- and divorce-prevention programs. Unlike treatment programs, prevention programs intervene before the development of relationship distress. Prevention efforts are focused on the future and typically involve the training of specific skills that are viewed as useful in preventing relationship distress. Three major approaches to premarital intervention include the Minnesota Couples Communication Program, Bernard Guerney’s relationship enhancement approach, and the Premarital Relationship Enhancement Program. Research is generally supportive of the effectiveness of these programs in helping partners learn useful skills that translate into improved relationships for at least three to eight years following the program. In addition, some evidence indicates that the alarming divorce rate in the United States can be decreased if partners participate in prevention programs before marriage; prevention programs that emphasize communication and conflict-resolution skills seem most advantageous.

Improving Treatment

Researchers and clinicians have witnessed large increases in the numbers of couples seeking treatment from therapists. The Bureau of Labor Statistics reported the employment rate for marriage and family therapists to grow an estimated 29 percent from 2012 to 2022, which is a much faster-than-average growth rate than is predicted in other occupations. As the demand for couples treatment increases, more time and effort is devoted to improving treatment methods. The behavioral approach has been shown to be highly effective in reducing relationship distress and preventing divorce; however, many believe that cognitive components such as causal attributions and expectations are strongly related to satisfaction in the relationship. Moreover, it has been argued that dysfunctional cognitions may interfere with both the establishment and maintenance of positive behavior change. Evidence has prompted some researchers and practitioners to advocate a more systematic inclusion of strategies of cognitive behavior therapy within the behavioral marital therapy framework. Specifically, it is possible that the combination of cognitive and behavioral approaches will demonstrate increased utility if the two treatments are presented together in a singular, integrated treatment intervention. Such treatment would afford couples the opportunity to benefit from either one or both of the complementary approaches, depending on their own unique needs, at any time during the course of treatment. Moreover, such an integration of cognitive and behavioral tactics would parallel effective approaches already employed with depressed or anxious clients.

Bibliography

Beck, Aaron T. Love Is Never Enough. New York: Harper & Row, 1989. Print.

Bornstein, Philip H., and Marcy T. Bornstein. Marital Therapy: A Behavioral-Communications Approach. New York: Pergamon, 1986. Print.

Fruzzetti, Alan E. The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, and Validation. Oakland: New Harbinger, 2006. Print.

Gottman, John M., et al. A Couple’s Guide to Communication. Champaign: Research Press, 1979. Print.

Gottman, Julie, and John M. Gottman. Ten Principles for Doing Effective Couples Therapy. New York: Norton, 2014. Print.

Gurman, A. S. Casebook of Marital Therapy. New York: Guilford, 1985. Print.

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Jacobson, Neil S., and A. S. Gurman, eds. Clinical Handbook of Couple Therapy. 4th ed. New York: Guilford, 2008. Print.

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Pitta, Patricia. Solving Modern Family Dilemmas: An Assimilative Therapy Model. New York: Routledge, 2014. Print.