Unit 19 : Therapeutic approaches to relationship maintenance and repair Flashcards
Couple’s Therapy
- Obviously
– therapy with two people - Historically, a married couple
- Nowadays, couples therapy methods
have been applied to many close
relationships - Unmarried, dating couples
- Central couples in a polyamorous
network - Friends/ workplace relationships
(see How’s Work with Esther
Perel)
Clinical Considerations
Agreeing on goals
Unique process factors (from psychoanalysis):
* Transference/countertransference: Transference: patient projects
patterns or traits from past
relationships onto therapeutic
relationship
Countertransference: therapist
transference onto client
relationship
* Triangulation: when a third person
is drawn into a dyadic conflict to
ease tension (divide and conquer)
* Conflict problems: if a couple
fights too much, you have to
contain it – guaranteed to see
people’s highest highs and lowest
lows
Keeping secrets?
* Confidentiality agreement with two individuals!
CASE EXAMPLE
- Married couple with a 16 year old.
- Reporting a long history of difficulty
communicating, unsatisfactory sex
life, few common interests.
First session: couple agrees to goals
to enhance communication and
emotional intimacy
End of session, wife comes back into
your office under pretense of having
left her wallet. Discloses an affair
and intention to end the marriage.
WHAT’S YOUR MOVE?
One on one sessions?
* Do you meet separately with each client?
* Increase vulnerability vs. risk of treatment-interfering secrets
and triangulation
Involving other family members?
* Basically, switch to family therapy?
* In-laws can contribute to problems
As a
Contemporary
Client:
Why go to
couples
therapy?
- Feeling stuck in a harmful relationship
dynamic - Could be new or a pattern across
relationships - Wanting support navigating a transition or
difficult conversation (e.g. sex, finances,
kids) - Sexual dysfunction
- Individual mental health concerns
- Most often used for PTSD, to my
knowledge - Positive psychology reasons
- Build insight, strengthen the
relationship
As a
Contemporary
Clinician:
Why deny
couple therapy
to specific
clients?
*Individual concerns
* Intimate Partner Violence
* Conflict of Interest
* Client-Clinician Mismatch
Unrelated to this but: Cultural Considerations
Western ideals of “love,” and heteronormative
definitions of love, are not the basis of every
committed relationship
Theoretical Approaches to Couple’s Therapy
The Gottman Method (John
& Julie Gottman, 1980s)
* Developed from pattern-detection in observational
research, agnostic of
theory
Solution-Focused Couple’s
Therapy (SFCT; Steve de
Shazer & Insoo Kim Berg,
1970s)
* Firmly grounded in
behaviourism, positive
psychology orientation
Emotion-Focused Couples
Therapy (EFCT; Sue Johnson
& Les Greenberg, 1985)
* Developed from qualitative
interviewing and
observational research,
firmly grounded in
attachment theory
And many, many more!
Gottman Couples
Therapy
- Dr. John Gottman and Dr. Robert Levenson
- Filmed live interactions and measured physiological
changes to assess emotionality - Skin conductance, blood velocity, gross motor activity,
heart rate - Longitudinal studies with replications
- Followed couples for up to 20 years!
- Many types of dyads studied (not just romantic)
- Repeated measurements of both subjective and
objective outcomes - E.g. marital satisfaction, happiness, conflict
behaviours, emotionality, and relationship status in
couples (divorce/separation)
Gottman Research Findings - Conflict
*Couples are very stable
-80% stability in conflict behaviours and marital satisfaction
*Most relationship problems did not get solved
-69% were ”perpetual problems” based on personality differences
*Lots of fun stats: “Couples that stay together have 5 positive interactions for every negative interaction” 5:1 ratio
*Defined “meta-emotion” – the way people feel about emotions
-Found that differences in meta-emotion drove a lot of conflict (meta-emotion mismatches predicted divorce with 80% accuracy)
*Defined several common relationship dynamics and conflict behaviours, and identified which were related
to outcomes of interest
Four Horsemen of the
Relationship
Apocalypse &
Antidotes
* Criticism: “I…” statements (I feel…, I
wish…, I need….)
* Contempt: be respectful! Deliberately
integrate more statements of
appreciation and care into conversation
* Defensiveness: take responsibility, even
for just a small part of an ongoing
problem
* Stonewalling: take breaks of at least 20
minutes during conflicts when one
partner feels overwhelmed, and then
return to continue problem solving
Gottman Couple’s
Therapy
* Based on these observational findings
(not an overarching theory)
* Consist of:
- Assessment – Couple plus therapist
- Individual sessions + questionnaires
- Build a Sound Relationship House
Best used for
* Couples who want to increase relationship
skills
* Couples who want to fix relationship issues
* People who are “psychologically minded” –
want to learn psychological constructs and
tools
Not suited for
* Treating individual
issues/understanding either individual
better
* Mental health issues, domestic
violence
Takeaways from
Gottman
* Huge evidence-basis for types of
conflict
* Specific, evidence-based
replacement behaviours
* Not theory driven
* Therapy materials hidden behind
a paywall
Solution-Focused
Couple’s Therapy
- Developed by Steve de Shazer & Insoo Kim Berg
(married couple, both MSSWs) - Goal-oriented (solution-focused)
- Based on positive psychology and behavioural
interventions - Strength based
- Action oriented
- Little to no focus on the problem/mechanisms
of the problem - Focused on identifying resources clients have
and using them - Collaborative therapy with no expert in the
room - Patients are the experts on themselves
- Therapist provides or identifies concrete
interventions/solutions - Socratic questioning used to keep
conversation concrete and measurable as
much as possible
Laura Gregory, MA (Solution-Focused Therapist
in UK): - “We think of it as possibility thinking.”
SFCT Interventions
* Pre-session change question
* Miracle-10 question
* Look for previous solutions
* Look for exceptions to the problem
* Use present- and future-focused questions
* Give compliments!
* Invite couple to experiment with doing
more of what works
* Scaling questions
* Coping questions
Best used for
*Finding solutions to specific couple
problems
-Frequent conflict, difficulty compromising
*Emergency response to acute couple
problems
-No explicit refusal to work with domestic violence,
although this likely varies between clinicians
Not used for
People who want to understand – not
super interested in the “whys”
- Not all therapies focus on the past – sometimes the most effective approach
is to focus on possibilities for the future J - Complex problems might not require complex solutions
Focused Couple
Therapy
(EFCT)
- Developed by Dr. Susan Johnson and
Dr. Leslie Greenberg - Brief, structured, collaborative couple
therapy - Grounded in attachment theory
- Developed from clinical work and
qualitative research with couple
Attachment Theory Review
* Experiences in infancy and childhood shape relationship patterns throughout life
* Secure attachment -> caregiver is safe haven, reliably provides soothing and meets
care needs -> suffering is regulated
* Insecure attachment -> neglectful or inconsistent caregiving -> suffering abounds
without soothing
EFCT Theoretical Model:
Adult Love
* Adult relationships conceptualized as
two-way attachment bonds
* Bonds come with associated “schemas”
regarding partner’s and own
dependability for comfort
* Partner should be a safe-haven
* Attachment needs are a huge motivator
for individual change and growth
What does it
look like?
*Identify the clients’ current dance (Observation and deescalation)
*Help clients be clearer about what they are missing
Not chores, not skills – care,
validation, understanding
Assembling emotions
*Help clients practice caring responses (“Enactments” in
session)
EFCT Interventions – “The EFT
Tango”
* Reflection
* Validation
* Evocative Reflections and Questions
* Tracking and Reflecting Interactions
* Reframing
Really, though, it’s about attunement. You are becoming
attuned to each partner in the present moment, feeling
the emotional and interactional patterns, and helping
clients see them too (Sue)
Best used for
*Fixing problems
Trust breach
Fear or anger
Mental illness in one or both members
*Strengthening a relationship
NOT used for
*Couples with Intimate Partner Violence
*Couples who are separating
- The one therapy to explicitly focus on love/connection as the desired outcome
- Requires that the therapist be a secure base for both partners, and then help the partners
become that for one another
Measuring “Success” In
Couple Therapy
- Historically: Did they stay together
(stay married)? - Evidence isn’t perfect:
- 30% “relapse” in 2 years (Jacobsen
et al., 1987) - 38% divorce in 4 years (Snyder,
Wills, & Grady-Fletcher, 1991) - Trouble with internal validity:
- Selection bias: people come for
couples therapy when things are
already going wrong (and have
been for a while) - There are many contemporary uses of couple therapy:
*Build relationship-relevant tools for the individuals in their existing relationship
*Facilitate a more amicable/smooth life transition - Parenthood conversations
- Major decisions
- End of relationship
- Improve their understanding of one another
- Makes it hard to measure success!
- Lots of discrete studies with specific outcomes -> meta-analyses and narrative and
systemic reviews
But how to construct a control group?
Not ethical to deny people care outright
Several common options in clinical care:
* Wait-list control group
* Psychoeducation-only group
* Non-treatment seeking couples
* Compare sample stats to known population statistics
Relative Efficacy
* Hard to find recent comparison
research!
* Most work suggests that all the schools
of couple therapy are equally helpful
* Suggest that the most important aspects
are “common factors”
- E.g. relationship with therapist, getting the
therapy you want, collaboration, etc.
An Integrative
Stance
* Does not necessarily mean you
can switch completely between
solution
-focused and EFCT with
patients
* Trained in many forms of practice
and adapt an individual client’s
care to their mindset/ goals/
presenting problems
*
May integrate specific tools, or
elements of a perspective,
between schools
Couple therapy,
family therapy, and
systemic
interventions for
adult
-focused
problems: the
current evidence
base
Carr, 2019
* Narrative Review
* “Current evidence base”
* Summarizes meta-analyses when available
* Summarizes efficacy of different treatment
modalities for:
- Relationship distress, psychosexual
problems, intimate partner violence,
anxiety disorders, mood disorders,
alcohol problems, psychosis, and
adjustment to chronic physical illness
Carr, 2019: Couple Therapy Efficacy Highlights:
* 40% couples report that they “benefit a great deal” from couple therapy, and 30% “benefit
somewhat”
- ~84% couples fared better than controls (review of 6 meta analyses)
* For “mildly-distressed” couples: behavioural and emotionally-focused approaches equally
effective
* For “moderately distressed” couples, EFCT has better outcomes
* Couple therapy overall (including behavioural, solution-focused, and educational approaches – NOT EFCT)
- Couples with mild-to-moderate IPC had better outcomes than 80% of controls
- Not appropriate for severe partner violence
* EFCT and other behavioural therapies are evidence-based for anxiety disorders (especially PTSD)
* Most couple therapies are evidence-based for depression and other mood disorders
* Most couple therapies improved health outcomes for patients with a range of chronic health
conditions
- Meta-analysis across 52 studies, includes HIV, stroke, cancer, cardiovascular diseases,
chronic pain
- Longer treatments with ill patients and their spouses (vs. other family members) were the
most effective
What about Gottman Therapy!
Gottman therapy not mentioned in many relative efficacy studies. Why?
1. Everyone integrates psychoeducation and interventions from Gottman
* E.g. I feel… statements
2. Gottmans have a lot of control over their materials (paywall)
* Lots of efficacy studies comparing GCT to a control condition, but not
comparing it to other therapies (none from journals I recognize)
Carr, 2019:
Common factors
for treating
relationship
distress
Foundation: case formulation highlighting
interactional sources of distress
1. Alter couple’s view of problem to be
more objective and dyadic
2. Decrease emotion-driven, dysfunctional
behaviour
3. Elicit emotion-based, vulnerable
behaviours
4. Increase constructive communication
5. Promote strengths and reinforce gains
Not to know but interesting
- Esther Perel is a very famous couples and family
therapist with a big pop culture presence - Podcasts: How’s Work? and Where should we
begin? - Discusses her decision making and case
conceptualization throughout - Youtube! Lots of videos of therapists actually
delivering different interventions - These creators all have TED talks and do guest
appearances/interviews on podcasts! - Couples Therapy is a TV show on Crave in which you
follow a couple therapist with a more
psychodynamic/integrative orientation as she works
with 4-5 couples and receives supervision on her work
