Ch. 12: Couple Therapy

Question 1

Three types of prevention

Answer 1

Primary
Secondary
Tertiary

we have to ask ourselves if these things work

Question 2

Primary Prevention

Answer 2

intervening before a problem ever has a chance of happening

• eg premarital counseling, enrichment (enriching already good relationships)
• fairly common

is there a way that we can create conditions/ that we can all enjoy our relationships without having to work too hard at it

do these things actually work?

Question 3

Secondary Prevention

Answer 3

intervening before it worsens

• eg seminars, self-help books
• rare; for couples ‘at risk’

instead of giving something to everybody (primary prevention) - let’s try to find ways that we can identify risky kinds of people and risky times in people’s lives and intervene with them
-not that in trouble but helping them as they are transitioning to parenthood, negotiating new positions in their lives, etc

Question 4

Tertiary Prevention

Answer 4

Before it’s too late

• couple therapy
• for distressed and divorcing couples

the goal is to get them before they get to this point - before they’re distressed

Question 5

work in/on relationships

Answer 5

“the work being done on your marriage - are you having it done, or are you doing it yourselves?”

All of us are doing work on our relationships all the time - one thing to recognize (as a therapist) is not “how do I swoop in and magically change things” but “what have you been doing to help your relationship? what things worked in the past and what changed? what didn’t work?” get the history of the relationship (what was attractive when things were getting started and what happened after that)

couples are already all the time maintaining their relationship, when they show up for therapy the things that used to work are failing
the way that couples present in therapy are varied
-some will hardly show any distress (almost like secondary prevention) and others will be extremely distressed (someone had an affair, something is changing)
-need to recognize that the structures and processes that once maintained the couple have broken down

Question 6

Couples therapy: some basics

Answer 6

• typically one therapist and both partners, for 15-20 weekly sessions (usually 50-60 mins long, sometimes 90)
• therapists have diverse backgrounds (can be clinical psychologists, masters in MFT, couples therapy, social work)
• specialized interventions exist for serious individual problems, high levels of domestic violence, ongoing affairs (sex therapy for sexual problems w/in the marriage - certain problems need to be addressed in the individuals before you can address the couple’s problems ie drinking problems)
• couples seek help for a wide range of problems, at different stages in their relationship, often long after the problems have been evident (don’t just have to address the problem that brought them into the room you also have to work through everything that brought them up to the point that this became an issue - it’s more than the acute issue - what drew them apart?)

Question 7

Therapists say that couples come in saying they have problems with:

Answer 7

Sex (47%)
Solving Problems (47%)
Showing Affection (45%)
Money and Finances (43%)
Children (38%)
Communication (87%)
Power Struggles (62%)
Unrealistic Expectations (50%)
Lack of Loving Feelings (40%)
Serious Personal Issues (38%)

the last 5 are common problems that are also most damaging and most difficult to treat

Question 8

Power Struggles

Answer 8

The struggle for who gets to make the decisions

this is my point of view, I can’t really see your point of view

Question 9

Unrealistic Expectations

Answer 9

it’s not a behavior that needs to change it’s a way of thinking that they are hoping to get out of the relationship and the disappointment they feel when the ideal has not been met
-this makes it difficult to treat

Question 10

Serious Personal Issues

Answer 10

the problems in the relationship aren’t separate fro the problems and struggles of the individuals in the relationship

understanding these individuals as individuals (their stresses, strains, personality) and then put the back into the dyad

Question 11

a typical couple’s therapy case

Answer 11

how do we regulate closeness, how do we make sense of the idea that relationships change and that the circumstances around us have changes (we have to work harder to pay the bills, we have kids now, etc)?

Jill: I am not getting enough closeness from Jack, I need more from him, around the house and with the kids (I’m feeling burdened with all the stuff that I have to do -part time job and kids) “why are you so insensitive and selfish? why do you push me away?”

Jack: We have closeness but not enough sex. I want ‘my own space’ and to be valued for what I do (I need some autonomy and distance when I get home from work- not more closeness) “why must you nag me? Why do you ignore my sexual needs?”

Question 12

The couple in therapy

Answer 12

both feel :

• misunderstood
• powerless to improve the situation (I don’t have the options that I need in this relationship (listen to recording)
• Unloved and unappreciated
• pessimistic about the relationship (I’m thinking about leaving because everyday we’re both miserable - I know someone who left and they worked it out just fine)
• both want to invest time and money in their relationship, but they also want something that will work (when you go to a therapist you have handed them the keys to your marriage - tell me everything you know) - find a therapist that you both like and that seems like the sort of thing you both need - here’s our issue and tell me your philosophy and how long this will take - the best couples are the ones that don’t just go to the first therapist they find - therapists differ in therapy, training, personality, different theoretical orientations, etc and you have to find the right fit for you

Question 13

Key Targets (orientations) in Couple Therapies

Answer 13

Psychodynamic Models
Systems Models
Behavioral models
Emotion Models

know more about behavioral and emotion models than the other two

therapists use a range/mix of these distinct approaches/orientations

Question 14

Psychodynamic Models

Answer 14

Identify and change UNCONSCIOUS PERCEPTIONS of partner and associated emotional reactions

• promote ‘authentic’ connections unclouded by these perceptions
• has it’s roots in Freudian theories - there is stuff going on that you don’t recognize that probably has a lot to do with how your parents treated you

THE HISTORY MATTERS!

John Bowlby used this model

maybe divorce is ok, maybe when they discover who they are and who there partner is, they discover that they got into the relationship for the wrong reasons, maybe this is not a good relationship so maybe it has to end

Question 15

Systems Models

Answer 15

Identify and change the unstated RULES that are guiding undesirable behaviors
-help couples to see that the problem is in these rules and in their existing solutions, not in one another
-help them to see that problems arise because the
recurring patterns of behaviors in the relationship are too rigid or are ineffec­tive for meeting new demands confronting the pair
-work out adaptations about how they’re going to respond to certain situations in their lives and when those rules don’t operate well, symptoms arise - what’s the rule you keep stumbling over? - identify and change those sets of rules

Doesn’t talk about the past so much - much more about the present

key tasks for intervention include interrupting the
repetitive pattern of harmful interaction, helping partners see that the prob­lems they are experiencing stem from the system of unstated rules governing their relationship rather than flaws in themselves, and inducing the partners to interact under new rules, typically by mobilizing underused strengths and untapped resources available to them
-the problem is not the problem - the problem is the rules used to fix the problem - so let’s try to fix the solutions with a better set of rules

Question 16

Behavioral models

Answer 16

change the behaviors and cognition that give rise to them

• promote basic skills in communication
• lineage in social learning theory
• we engage in these coercive processes that have gotten us into trouble (when we argue I raise my voice - inadvertently rewarding my behavior) - work on changing the behavior of the couple
• not just about communication - also about the interpretation
• there is an unrealistic expectation - how can we change your expectations in the relationship

how do you get people to communicate better - instead of collapsing under the weight of all that negative emotion, how do you organize communication so that you are respectful toward one another - you’re really finding ways to generate positive experiences that may fall by the wayside in your relationship - BEHAVE DIFFERENTLY

Question 17

Emotion Models

Answer 17

Encourage expression of core emotions and healthy responses to these expressions

• help couples to see that their relationship is a safe place in which to express deep feelings, overcome one’s own history in relationships
• emotions are salient
• understand the mastery of the emotional processes
• distressed couples - there’s a structure - once the argument starts it’s hard to get it back - you can’t extricate yourself from the quicksand and this model helps to become less reactive (just because you feel angry doesn’t mean you have to lash out - you have choices about how to react)

idea: their relationship is a safe place to express true emotions - you can say “this makes me sad” without someone saying “it’s your own fault”

Question 18

Tested Couple Therapies

Answer 18

Traditional Behavioral Couples Therapy (TBCT)
Cognitive-behavioral couples therapy
integrative behavioral couples therapy (IBCT)
emotionally focused couple therapy

Question 19

Traditional Behavioral Couples Therapy (TBCT)

Answer 19

mechanical approach to changing couples’ communication

• your past doesn’t matter, what really matters is getting you to communicate more effectively
• this works pretty well and all new studies are judged in relation to this one

Benchmark or standard

From the book:
-does not view the behaviors exchanged by partners as a sign of some other hidden problem. Rather, it is the dysfunctional behaviors themselves that are the problem, and they are the primary target for therapeutic change
-therapists don’t delve into the history and circumstances that led to the problem the couple now faces, because the assumption is that this information is not reliably known
or readily retrieved

Question 20

Cognitive-behavioral couples therapy

Answer 20

not just changing how they talk to one another but also attributions and cognitions
-the cognitive approach maintains that the fo­cus on observable behaviors is too restrictive
-task is to modify these thoughts and interpretations, and the resulting emotions and behaviors, by sharpening the
capacity of partners to observe and evaluate how they gather and analyze information, and by making them aware of their assumptions and standards

Question 21

integrative behavioral couples therapy (IBCT)

Answer 21

was devised because traditional behavioral models were inadequate because they aimed to impose change
where it might be difficult to achieve, and because they hoped to help couples for whom significant change was unlikely, despite their commitment to improv­ing the relationship
combines the standard behavioral interven­tions—behavior exchange, communication training, and problem­solving
training—with interventions that helped couples see that it was beneficial to tolerate and even accept aspects of the partner and the relationship that were displeasing
-change what you can change but be willing to accept what you cannot change
-accept what you already have rather than change them
it’s not about accepting really bad things like physical abuse, just learning to tolerate some of the things that you don’t like

Question 22

TBCT treatment process

Answer 22

Reinforcement erosion suggests the need for behavior exchange training and restoring of positive interactions (maybe you need to hire a babysitter and have a date night every week to get into some restoration of positive interactions)

coercive cycles suggest the need for training in communication skills (eg empathy -understanding their point of view, listening, validating their point of view, expressing negative feelings- not about getting rid of negative feelings but being productive with them) and problem solving (eg XYZ statements, problem definition, brainstorming, and problem resolution) - get them communicating better and solving problems

Question 23

XYZ Statements

Answer 23

i feel this way when you do this in this situation

Question 24

Experiments: TBCT

Answer 24

works pretty well
half of those who do TBCT recover or improve and the other half don’t change or deteriorate

after 5 years, 40% who get TBCT tertiary care deteriorate
10-15% don’t change
Recovered - you achieve a level of satisfaction that is indistinguishable from happy couples out in the world
Improved group -between no change and recovered group (they got better)

Question 25

Improving upon TBCT

Answer 25

Two Strategies:
Unified detachment
empathic joining

both techniques get to the deeper issues and emphasize “acceptance” over “change”
This is IBCT

Question 26

Unified detachment

Answer 26

both partners learn to view their problems with less charged emotion and to talk about them in more neutral, descrip­tive terms
helping couples to step back from patterns and see their behavior in an unemotional way
-therapist offers a “theme” that captures both partners’ perspectives, but presents it in an neutral way (try to integrate the two points of view to work it to their advantage rather than having it be a disadvantage)
-draws attention to the theme when it comes out in therapy (whenever it comes up so “there it is, do you see that?)
-if possible, presents some of the origins of this theme

Question 27

empathic joining

Answer 27

practitioner aims to de­fine the problem in terms of a theme that takes both partners’ perspectives into account without blaming either of them
having partners express their emotions and feel closer because of it rather than dividing
-get beyond the “hard” feelings to the vulnerable feelings
(when someone is angry (usually) that is a secondary emotion- if you can get beyond the anger and say “I guess I feel hurt” or “weak” then the other person will want to help)
-reflect how painful those feelings are
(it’s important to recognize that anger is used for protection of something and that something is usually inadequacy)
-reframe those feelings in a relationship-enhancing way
(I don’t need to hear your anger, I need to see those emotions that you’re hiding and then we can work on our issues - I don’t need to change your communication so that you’re not angry, I need to accept that fact that sometimes you’re angry and I can look through that and see that you’re struggling and if I can do that I would be more inclined to help you)

Question 28

IBCT and TBCT

Answer 28

Christensen et al., 2010
there are no statistical differences btwn behavioral approach and IBCT approach
-even with adding the improvements (unified detachment, empathic joining) to the TBCT model it didn’t have an effect beyond the traditional model
these couples don’t differ

50% of the couples doing better regardless of the approach after 5 years

• 32% recovered
• 16% improved
• 14% no change
• 38% deterioration

Question 29

4 categories that couples can be placed in at the end of couple’s therapy

Answer 29

Recovered
Improved
No Changed
Deterioration - it’s gotten worse, their satisfaction went down, they came in saying they didn’t want to get divorced and they got divorced

Question 30

Object relations Couples therapy

Answer 30

most prominent version of psychodynamic treatment for couples
-“object” refers to an internal representation a person forms of someone who has taken care of him or her, often called a caregiver, and it is this representation that guides
and infuences the nature of the relationships that person has throughout his or her lifetime
-begins with the idea that parents and other caregivers will
vary in their ability to meet the basic needs o the developing infant, and that even the best caregivers will leave the infant frustrated and disappointed at
times
-the point is that who we are as an intimate partner is guided by how we have been treated in important relationships in our past, particularly when we were very young
Primary aim is to weaken the harmful effects that projection, projective identification, and introjective identification have on the relationship, in part by improving the way in which partners contain each other’s projections

Question 31

projection

Answer 31

In our daily exchanges, aspects of who we are and the early experiences we’ve had, especially as­pects of the self that have been repressed and split off from consciousness, are projected onto others

• this refers to an unconscious tendency for a person to deny his or her own faws, locating them instead externally—including attributing them to the partner
• you are not respond­ing to your partner as he or she truly is; instead you are responding to your partner as you make him or her out to be

Question 32

projective identification

Answer 32

How the partner responds to these projections

this turns out to be pivotal to the well­being of the relationship

Question 33

introjective identification

Answer 33

she can take back her original projec­tion in a better, detoxified form, and she can merge this new experience into the image she holds of herself

Question 34

Behavior exchange

Answer 34

initial stage of TBCT
provides the practitioner with important diagnostic information regarding the extent to which partners can generate new, positive experiences in their relationship, and it conveys to the partners that improving their relationship can be enjoyable rather than painful

Question 35

communication training

Answer 35

Second Stage of TBCT
partners receive very practical advice on how to listen (e.g., listening to understand the partner’s point of view instead of listening to develop a response to what the partner has said) and how to talk to each other productively (e.g., avoiding blame and accusations, us­
ing softer emotions like hurt and sadness instead o harder emotions like anger, responding nondefensively)

Question 36

problem-solving training

Answer 36

final stage of TBCT
couples learn to apply their communication skills to specific problems in their relationship, following a series of guidelines

Question 37

Acceptance Training

Answer 37

When direct efforts to change are blocked by incompatibilities, irreconcilable differences, and unsolvable problems, the only way to generate relationship improvement is by promoting acceptance
of what seems at first glance unacceptable
-emphasis is put on the offended part­ner’s capacity for accommodating the mate’s behavior than on changing the
offending behavior itself
-tolerance building interventions are designed to help them relinquish the idea that additional negotiations and
confict will prove benecial, and instead contend with the real possibility that some undesirable aspects of the relationship will not change

Question 38

Emotionally focused couples therapy

Answer 38

emotion­ally focused couples therapy aims to create “bonds” instead of the “bargains” that typified traditional behavioral approaches
originated by John Bowlby and formalized in attachment theory
the idea that we as humans have a built­in need for safe and secure connections with other people
-Unmet needs produce strong primary emotions
-primary emotions are often masked by secondary emotions

therapist works through the secondary emotions to bring the primary emotions into the open, explores and expands on these emotions, and encourages empathic responses to them

Question 39

primary emotions

Answer 39

feelings of abandonment, fear of rejection, shame, and helplessness

Question 40

secondary emotions

Answer 40

feelings such as anger

Question 41

three stages of Emotionally focused couples therapy

Answer 41

De-escalation of negative cycles
Shaping new cycles of responsiveness and accessibility
Consolidation and integration

Question 42

De-escalation of negative cycles

Answer 42

brings the couple to the point where they can acknowledge that :
-they both contribute to the problems in the relationship
-the underlying interaction cycle and not the partner
is really the problem
-this cycle can be understood in terms of emotions and unmet attachment needs

Question 43

Shaping new cycles of responsiveness and accessibility

Answer 43

A withdrawn partner is encouraged to engage more by expressing deeper primary emotions, and an overly critical partner is likewise encouraged to express vulnerabilities rather than the secondary emotions that have been masking them
As a result of this new understanding, partners feel more
compelled to respond more compassionately, and new interactional cycles will begin to form

Question 44

Consolidation and integration

Answer 44

therapist works with the couple to reflect on the changes they have made, to establish a story or narrative that helps them understand how their relationship deteriorated and then improved, and to solve specific prob­lems they have not yet addressed

Question 45

efficacy studies

Answer 45

randomly assign some couples to one or more forms of relationship therapy and other couples to some non­therapeutic condition, and then examine how the differing groups compare in relationship functioning months or years later
- reveal rather consistently that couples who receive treatment experience a higher level of relationship satisfaction at the end of treatment than the control couples

Question 46

Effectiveness studies

Answer 46

designed to resolve the issue of whether interventions do produce improvements when delivered by practitioners in the real world
-Effectiveness studies indicate that large numbers of couples drop out of therapy, that about 30 percent of treated couples show improvement after treatment (with 20 percent achieving a score in the satisfied range of rela­tionship functioning by the end), that success rates in effectiveness studies are lower than those in efficacy studies, and that treatments for couple problems are not as effective as treatments for indi­vidual disorders

Question 47

projection modification

Answer 47

When Nancy speaks to Joe and thereby projects certain needs, emotions, and experiences on him, the therapist’s task is to help Joe identify with these projections. More
than this, the therapist would encourage Joe to respond to Nancy’s expressed needs and emotions in a way that is affected not by his own unresolved feel­ings from past relationships, but by his understanding of Nancy and what will benefit her. Nancy, for her part, must work to accept rather than reject what Joe offers in response to what she has said. Nancy eventually realizes that Joe is not merely a convenient screen on which she can project her repressed feel­ings and unresolved experiences from childhood. He is instead a separate in­dividual who merits love and affection because of who he is rather than who
she needs him to be, and because he enables her to develop as an individual who is less bound by her unresolved early experiences. (In the same way that
Joe helps Nancy gain a deeper appreciation of herself, so, too, does Nancy identify with and contain Joe’s projections so that he understands himself better as well.) As Nancy and Joe help each other differentiate between the is­sues that each brings to the relationship from early childhood and those from the relationship itself, both partners achieve a greater capacity for experienc­ing the love of the partner and or expressing love toward the partner

Question 48

introjections

Answer 48

process where the subject replicates in itself behaviors, attributes or other fragments of the surrounding world, especially of other subjects
-a person who picks up traits from their partner