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The problems that confront the clients
and patients of mental health profes-
sionals arise mostly in marriages and
other intimate relationships. Marriage and
family difficulties account for about half of all
visits to psychotherapists, family therapy is
increasingly popular as a mental health spe-
cialty, and most family therapists work chiefly
with couples.
The term couple therapy is gradually replacing the
older marital therapy in order to include
unmarried and gay couples.
Licensed couple therapists include psy-
chiatrists, psychologists, clinical social
workers, psychiatric nurses, pastoral coun-
selors, and marriage and family therapists
who have taken specialized courses and
undergone supervised training in the field.
The therapist assumes that the unhappiness
of a couple amounts to more than the sum
of their individual problems and symptoms.
They may be concerned about emotional
distancing, power struggles, poor commu-
nication, jealousy, infidelity, sexual dissat-
isfaction, and violence. The therapist helps
them examine their lives together and de-
cide what changes are needed. They work
on eliminating mutual misunderstandings,
unreasonable expectations, and unstated as-
sumptions that perpetuate conflict.
Couple therapists make little use of psy-
chiatric diagnosis, but they do use many of
the same methods employed by individual
therapists: interpreting emotional conflicts
and the influence of the past; assigning exer-
cises for behavior change; challenging beliefs;
offering advice, reassurance, and support;
teaching social skills and problem solving.
If the relationship is moribund, some cou-
ple therapists believe that they can help the
couple make a break with a minimum of re-
crimination, bitterness, and suffering.
Family systems and patterns
Family systems theory was once dominant
and is still influential as a blueprint for cou-
ple therapists. It emphasizes the patterns of
communication, action, and reaction that
create and reinforce a family environment.
In an unhappy couple, the system resists
change because it has reached a maladaptive
equilibrium, just as individual symptoms
may resist change because they preserve in-
dividual emotional balance. Th e couple may
have unknowingly set rules for themselves
that are working poorly. The therapist helps
them become aware of these rules and pat-
terns as a prerequisite to changing them.
Sometimes each partner demands too
much of the same thing from the other
service, protection, care. Sometimes they
adopt complementary roles. One member
of the couple takes charge and the other
becomes incompetent. An overbearing and
emotionally distant husband responds to his
dependent or melodramatic wife by becom-
ing still more overbearing. A strong wife is
constantly angry at her passive husband,
whose passivity only increases. Th e husband
or wife of a depressed and hypochondriacal
person may act as a healer and savior.
Couple therapists try to help both in-
dividuals understand the function of their
contributions to the system. The passive
partner might learn about his need to sup-
press rather than productively express anger.
They may see how that role helps them
deny their own sense of helplessness. An
emotionally distant husband could learn
about the fear of strong emotion. A de-
pendent wife might confront her wish to
avoid managing her own anxieties. By ac-
knowledging their own contributions to the
conflict, members of a couple can begin to
weigh the benefits and costs of the bargain
they've made with a partner.
When the two are not communicating
well, verbally or nonverbally, each one
may behave as though certain principles
are accepted when they are not. For ex-
ample, one partner believes the other has
agreed that he or she can stay at work as
long as he or she thinks is necessary, but
the other thinks he or she has implicitly
agreed to be home for dinner. Other mis-
understood implicit promises include: I
need a certain amount of sex, a certain
degree of financial security, or a certain
number of friends.
Family systems therapists often em-
ploy the concept of the double bind, a
situation that results when members of
a couple send mutually contradictory
messages often one in words and the
other through the silent communication
of emotion. The partner must not ac-
knowledge the contradiction or respond
to the underlying intentions if he or she
wants to maintain the relationship. For
example, one partner asks the other to
come to him or her and stiffens at the
other's approach. The second partner
withdraws, and the first one says, Why
are you so cold? The second person has
no response: To point out what is going
on would only alienate the first partner
further. Eventually people who are com-
municating or failing to communi-
cate in this way find it difficult to say
what they mean, understand what the
other person means, or even distinguish
real from simulated feelings. Family sys-
tems therapy is designed to uncover and
solve problems of this kind.
Behavioral couple therapy
Behavioral treatment of couples provides
three kinds of help: behavioral exchange,
communication training, and problem-
solving training.
In behavioral exchange, each partner
is helped to identify a desired change in
the other partner's behavior, and they
agree to reciprocate. The therapist en-
courages them to follow through and
show gratitude. Communication training
shows the couple how to listen sensitively
and express their needs without accusa-
tions. From exercises in problem solving,
they learn how to define the issues that
generate conflict, find specific solutions,
negotiate, and compromise.
Either during therapeutic sessions or
as homework, behavior therapists may
prescribe tasks that reveal maladaptive
patterns. A woman might be told to exag-
gerate her criticism of her partner until he
challenges her. If a couple is drifting apart,
the therapist might arrange for the man
(or woman) to be sure to come home for
dinner four or five nights a week.
Today many behavior therapists also
try to change the way each member of
the couple responds to undesired be-
havior. They may also employ cognitive
restructuring, changing the way the
partners interpret one another's behav-
ior. They learn to avoid using words like
'always' and 'never', to examine evi-
dence before blaming the other, and to
consider the consequences of living by
doubtful implicit assumptions (such as
the belief that you should never be angry
at your partner).
Emotionally focused couple therapy
Another kind of treatment, drawing on
ideas from the client-centered therapy
of Carl Rogers (see Mental Health Letter,
January 2006) as well as family systems
theory, concentrates on emotion rather
than behavior. The therapist helps the
couple recognize the emotions that drive
their conflict as a precursor to stopping
the resulting troublesome behavior pat-
terns. They expose their vulnerability and
express unacknowledged feelings, then
reconsider their situation in the light of
these feelings to work out new solutions.
Oft en the problem is stated as a matter
of interrupting or escaping from rigid re-
sponse patterns or cycles. In one pattern
that arises repeatedly, an angry, critical,
complaining partner confronts one who
is defensive and withdrawn. The therapist
helps the angry partner to feel his or her
desperation about not getting through
and the consequent fear of abandonment,
while urging the withdrawn partner to
temporarily disregard the feeling of
being attacked instead of acting
defensively to listen to the concerns
and respond with support.
Emotionally focused couple therapy
may encourage the couple to reframe
their problems in terms of attachment
needs. The premise of attachment
theory is that a safe emotional bond
with another person is a basic survival
need, providing a home base in the
world. From infancy on, we all need
contact with others who care for us
and respond sensitively to our needs.
Attachment patterns usually appear
first in the relationship between par-
ent and child and are oft en repeated
throughout life.
A secure attachment provides both
comfort and room for independent
exploration. When attachment is inse-
cure, people may become angry, and
if there is no response depressed and
despairing. They may also develop a
distorted attachment that takes the
form of anxious clinging, or a combi-
nation of the two, exemplified by the
double bind: Come here to me, I need
you and You are dangerous, go away.
Couples often seek help when they
have sustained an attachment injury
a crisis involving infidelity, financial
deception, violence, deeply insulting
words, or another apparent betrayal.
One of the partners may feel emotional-
ly abandoned at a critical moment such
as job loss or serious illness. Divorce or
separation may be threatening.
In therapy, at first the injured part-
ner may angrily or sadly recount the
incident while the offending partner
minimizes the damage or becomes de-
fensive. The injured partner is encour-
aged to show grief and fear instead
of anger, and the offending partner is
encouraged to acknowledge responsi-
bility and show remorse. Then the in-
jured partner may ask for comfort and
care that was unavailable at the time of
the incident, and the off ending partner
may come through, helping heal the attachment.
An example: Mary has discovered
that her husband John had an affair
three years ago. They've never dis-
cussed it, but John complains that she
repeatedly reminds him of it. It is a
typical pattern of anger and defensive-
ness. She worries about what he does
when he goes out alone, and when he
is at home he feels under siege and re-
treats to a room alone. Over a period
of several months, the therapist helps
him talk about his feelings of shame,
and he tearfully expresses his sorrow
and his love for her. As the complete
range of their feelings becomes more
apparent to both of them, she begins
to move past her injury and expresses
genuine forgiveness.
Psychodynamic couple therapy
Psychodynamic therapists believe that
the way adult couples treat each other
is strongly influenced by patterns estab-
lished in childhood—lessons learned,
mostly unconsciously, in their birth
families. The therapist emphasizes un-
conscious wishes and the defenses, also
mostly unconscious, that divert or pre-
vent the full expression of those wishes.
Psychodynamic couple therapists
sometimes pay special attention to
projective identification, a defense
that involves disavowing your own
impulses or wishes, attributing them
to another person, and behaving in a
way that elicits responses that convince
you that your attributions are right. A
husband can’t bear his own dependen-
cy or weakness and overcompensates
by being controlling and rigid as an
expression of strength. This evokes de-
pendent behavior in his wife—which he
can both identify with and resent. Pro-
jective identification can perpetuate a
painful attachment when, as oft en hap-
pens, the partner uses the defense in a
complementary way. In this example,
the wife may need to disavow her own
aggression, so her dependency also
evokes even more rigidity and hostility
in her husband. Such complementary
believe, often originate in childhood
relationships with parents.
Psychodynamic therapists explore the
influence of the past partly by pointing
out how feelings originally directed at
members of the birth family have been
transferred to the partner, and some-
times to the therapist, too. They also
show how emotionally charged fanta-
sies blend with present reality. If all goes
well, the members of the couple succeed
in separating their feelings about one
another from their feelings about their
own parents and past experiences.
The individual and the couple
Individual psychiatric symptoms and
the problems of couples are related in
complicated ways. Often there is a vi-
cious cycle in which a relationship is
endangered by the withdrawal and ir-
ritability of a depressed person, the
aggressive and impulsive behavior asso-
ciated with mania, the need for constant
reassurance resulting from anxiety, or
the multifarious ravages of alcoholism
and drug addiction. Conflict between
the members of the couple exacerbates
these symptoms until it is difficult to
tell where the cycle began. According to
some versions of family systems theory,
individual symptoms serve to maintain
arrangements that prevent change both
partners need but fear.
Couple therapists may concentrate
on specific actions that exacerbate indi-
vidual symptoms, or they can enlist one
partner as a surrogate therapist or coach.
Partners can help with treatments such
as relaxation training, exposure and
structuring, while monitoring changes
as the therapy progresses and providing
the therapist with information.
Alcoholism has been treated success-
fully with forms of behavioral couple
therapy called community reinforce-
ment and Project CALM (Counseling
for Alcoholic Marriages).
Emotionally focused couple therapy may be help-
ful for depressed people when the de-
pression is associated with an insecure
attachment. It has also been used for
survivors of child abuse and Vietnam
veterans suffering from traumatic stress
reactions. Dialectical behavior therapy
(see Mental Health Letter, August 2002)
for couples can relieve depression and
reduce emotional volatility in people
with borderline personality disorder.
Individual and couple therapy
are often combined. For example, a
woman marries a divorced man with
two young sons from a previous mar-
riage, gives birth to a girl, and develops
a postpartum depression. Her step-
sons, already feeling displaced by the
new baby, become angry and defiant.
She is reminded of her own unhappy
relationship with her stepmother and
feels as though she is turning into an
evil stepmother herself. The marriage is
affected, and the couple seeks therapy.
Her depression is part of the problem
and might best be treated addition-
ally with medications and her own
psychotherapy.
In cases of serious domestic violence,
the trend today is to separate the part-
ners instead of treating them jointly.
Some professionals reject the idea of
couple therapy for batterers because
it may suggest that someone or some-
thing other than the instigator of vio-
lence is to blame. But others believe that
a combination of individual and couple
therapy may be workable as long as the
violence has stopped, the victim does
not fear retaliation, and the perpetra-
tor admits responsibility. The therapist
must always make it clear that no al-
leged provocation justifies violence.
How effective is couple therapy?
Most studies find that couple therapy
can be helpful, at least for a while, but
not all studies meet the highest stan-
dards. It’s also unclear whether the
treatment can transform unhappy
relationships into satisfactory ones,
and whether the effects last. Behav-
ioral couple therapy and emotionally
focused couple therapy have been
found more effective than a waiting
list in controlled studies.
The American Psychological Association approves be-
havioral couple therapy as “well estab-
lished” and emotionally focused couple
therapy as “probably efficacious.” Other
reviews support the value of cognitive
behavioral couple therapy and family
systems therapy.
Some of the research has raised doubt
about whether all the components of be-
havioral or emotionally focused couple
therapy are necessary, and whether
these techniques work in the way that
the underlying theory proposes.
Improvement is usually maintained
for six months, but often there is a re-
lapse after a year or two. In a four-year
follow-up, the longest so far, research-
ers found that 38% of couples treated
with behavioral couple therapy were
divorced. But in some cases, a divorce—
especially if it is amicable—may repre-
sent a good outcome. A recent two-year
follow-up indicated that a year of ther-
apy for a couple in which one partner
was depressed gave better results—and
produced fewer dropouts—than anti-
depressant drug treatment.
There is only a little evidence on who
couple therapy works best for. Younger
couples seem to improve more in some
studies.
One study found that couples
did better when they had been together
longer; another, that couples with the
most serious problems were least likely
to benefit; and still another, that in het-
erosexual couples, therapy worked out
better when the woman was the main
problem solver in the family.
Like individual therapists, couple
therapists are becoming more eclec-
tic in their approach.
A method called integrative couple therapy combines
emotional acceptance with behavioral
strategies. Therapists are also trying
different approaches with different
couples, or emphasizing features that
all treatments have in common, such
as the therapeutic alliance.
According to the United States
Department of Health and Human
Services, the number of specialists in
marriage and family therapy has in-
creased from about 2,000 in 1966 to
almost 50,000 today.
The American Association for Marriage and Family
Therapy estimates that more than 3%
of the nation’s 57 million married cou-
ples see a psychotherapist for marital
difficulties each year. The line between
enhancement and therapy is becom-
ing blurred with the development of
programs aimed at preventing marital
conflict and improving relationships.
Because it is increasingly understood
that emotional disturbances and behav-
ior problems originate between people
as well as within them, psychotherapy
for two will continue to thrive.
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