Foundations for Couples' Therapy

Research for the Real World

Jennifer Fitzgerald, Jennifer Fitzgerald

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317391708
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

As a quality resource that examines the psychological, neurobiological, cultural, and spiritual considerations that undergird optimal couple care, Foundations for Couples' Therapy teaches readers to conduct sensitive and comprehensive therapy with a diverse range of couples. Experts from social work, clinical psychotherapy, neuroscience, social psychology, and health respond to one of seven central case examples to help readers understand the dynamics within each partner, as well as within the couple as a system and within a broader cultural context. Presented within a Problem-Based Learning approach (PBL), these cases ground the text in clinical reality. Contributors cover critical and emerging topics like cybersex, emotional well-being, forgiveness, military couples, developmental trauma, and more, making it a must-have for practitioners as well as graduate students.

1 Beyond Models and Interventions

What Else Do Couples’ Therapists Need to Know?

Jennifer Fitzgerald

Couples come in all shapes and sizes, metaphorically speaking. As couples’ therapists, we need to be ready and able to respond therapeutically—scientifically and empathically—to the differing “shapes and sizes” of our clients. On a daily basis, couples’ therapists worldwide are challenged to consider a broad range of problems, needs and circumstances that are raised by the couples who present to them. While it is impossible for any book to consider every possible clinical complexity, the contributors to this book have been invited to report research relevant to their topic because their topics have been prioritised as highly relevant to the practice of couples’ therapy.

This book is inspired, at least in part, by Engel’s biopsychosocial model of care (1977). Just as illness and disease are influenced by multiple levels of organisation from the societal to the molecular, I propose that couples’ therapists need to draw on a body of scientifically informed knowledge that transcends a simple toolkit of standard interventions or one tightly held theory. In a review of the biopsychosocial model, Borrell-Carrio, Suchman, and Epstein (2004) suggest that the model has helped expand the clinical gaze of health practitioners, thereby expanding understanding of patients’ subjective experience. In similar vein, my hope is that this book will assist us all, the people to whom our distressed couples turn for help, to listen and intervene effectively with greater breadth and depth of understanding and knowledge.

In terms of language, throughout this book, readers will encounter the use of terms “marital” and “couple/s,” which refer to long-term, committed unions of romantic partners whether or not these are recognised by the state as marriage (Lebow, Chambers, Christensen, & Johnson, 2012).

Seven Clinical Cases

So let me begin immediately by introducing you to seven couples who have made appointments at a relationship clinic. They might live in a big city or a small country town. The good thing for them is that there is professional help available to support them in their distress.

Judy and Sam Munro are in their early fifties and have been married for 19 years. Judy is overweight and was diagnosed with Type II diabetes five years ago. She has difficulty adhering to the exercise and diet regime that was recommended to her at time of diagnosis. They have two teenage children together and an older son, Joshua, from Sam’s previous relationship. In the early years of their marriage, Judy and Sam had a lot of conflict over raising Joshua and the negative behaviours of Joshua’s mother. The couple report that their son, Thomas, has given them “a lot of grief” through his involvement with drugs, alcohol and two car accidents (which were alcohol related). Judy reports feeling overwhelmed and helpless most of the time. Sam is angry and fed up from earning a living, managing Thomas as best he can and trying to support Judy. He often feels like he doesn’t succeed. Judy recently found a chat history on their computer of Sam’s six-year “friendship” with an old girlfriend from his school days.

Kevin and Andrea Wong have been married for five years. Kevin is Chinese and Andrea is Caucasian. They met at University in Hong Kong as students and have moved to Sydney (Australia) for Kevin’s job in an international bank. Despite a happy courtship, they have encountered much stress and strain as newlyweds. Andrea resents Kevin’s long hours at work and lack of interest in family activities. The situation has become more difficult since their first baby arrived recently, and Kevin’s mother has arrived from Hong Kong to “help.”

Jonathon Siegel and Dino Bongiletti have been together for two years. Jonathon is HIV positive. Their “coming out” stories differ in that Jonathon’s family were supportive and accepting whereas Dino’s family were rejecting and angry. Despite his family’s negative behaviours, Dino elects to have frequent (and usually upsetting) contact with them. The couple have recurring conflict around two important issues; namely Dino’s involvement with his family and their differing views on what is an acceptable open relationship.

Ellie and Joseph Rumbold are both 75 years of age and have been married for 52 years. Ellie was pregnant when they married (under pressure from her parents and the local priest). They had two children who have not caused them any trouble. They however have had a lot of ups and downs in their relationship. The shift from working to retirement was particularly trying for them both, with an increased amount of conflict over seemingly small issues. Ellie resented having Joseph “under her feet” all day, and he missed his work buddies a lot. In a recent argument that got more heated than usual, Joe pushed Ellie and she fell, bumping her head on the edge of the kitchen cupboard. Joe was mortified and left the house for hours to calm down. They both looked nervous as they waited in the waiting room for their first consultation.

George and Dianne Humphries have “battled it out” for 32 years. George has problems with alcohol and gambling, both of which get worse when he is out of work or feeling particularly estranged from his wife and family. Dianne is being treated for hypertension. Dianne and George have five children, and despite recurring conflict from the earliest days of their relationship, Dianne made a pact with herself that she would never “break up the family.” From time to time, when George is intoxicated the arguments get very heated, with George typically shoving or shaking Dianne and accusing her of infidelity. Their eldest son made the initial contact with the couples’ therapist, imploring the therapist to do something to help his parents. He and his siblings are in agreement that if something can’t be done soon, their mother should and must leave their father. The couple have agreed it is time to seek help.

Janie Reynolds and Mark Snyder met and moved in together just a few months before the 9/11 crisis in New York. Subsequently, Mark was in the first deployment of American troops to Iraq. On his second tour of duty, Mark was seriously injured, with resultant amputation of his left leg. Mark also has PTSD and depression. Despite regular sessions with his psychologist, Mark and Janie feel increasingly distant from each other and sadly describe their relationship as close to dead. Their two children (Jess and Will) are at primary school. Janie complains that Mark hardly notices them.

Carl and Sylvia Svensson are in their mid-thirties. They have been together for seven years and feel very dissatisfied with their relationship. They sometimes fight, and Sylvia hates how Carl sulks after the fights, but mostly Sylvia just complains (to Carl, her mother and her sisters) that Carl is more interested in work and making money than being with her. Carl, on the other hand, states angrily that it would help a lot if Sylvia could show a bit of interest in him once in a while. From his viewpoint, their sex life disappeared when their first baby was born two years ago. The more Sylvia complains, the more Carl defends himself.

What Does This Book Aim to Do?

In this book, experts in different areas of psychology, social work, medicine and neuroscience will report relevant research that informs the practice of couples’ therapy. In the spirit of problem-based learning (Barrows & Tamblyn, 1980), the contributing authors have been asked to apply their research findings to clinical reality by commenting on the particular experiences and problems of one or more of the couples mentioned earlier. This means that the authors also have licence to conjecture about hypothetical possibilities or influences for the couples about whom they are offering comment. By so doing, a broad range of clinically relevant ideas will be gathered.

Forty-five chapters on from this introduction, I will draw together these comments, with the intention of reflecting on the likely experiences, needs and therapeutic possibilities for each of the seven couples described. These seven couples will no doubt prompt readers to think of dozens of other couples treated recently or long ago, with similar distress, challenges and resources. These couples are introduced with the intention to raise questions, maybe more than one book can fully answer. The inclusion of these couples aims to ground thousands of words of important and relevant research in clinical reality, the reality of couples’ therapy for relationship distress in the world today. The thousands of words of relevant research aim to offer a foundation for working with couples whose relationships are defined by very diverse features.

Even just a cursory reading of the descriptions of the seven couples has likely raised some questions about the role of thoughts, beliefs, emotions, conflicts and communication patterns for these distressed couples. Some readers may already be pondering the impact on these couples of possible developmental trauma, mental or physical health problems, substance use, military service, and major life events such as the diagnosis of infertility, the death of a child or the discovery of infidelity. What about life transitions to parenthood, to an empty nest, or to retirement? How might these transitions be relevant to couples and their experience of relationship satisfaction or distress? And what about attachment, caregiving, commitment, sexuality and trust? How might these concepts influence a couple’s life together? These are some of the questions that this book will aim, at least in part, to explore and/or answer.

Further, to what extent might relationship distress impact on the individual partners in the couples’ relationships? In a large population-based sample of married and cohabiting adults, Whisman and Uebelacker (2006) indicated that in comparison to people who were not in discordant relationships, individuals in discordant relationships described greater social role impairment with relatives and friends and greater work role impairment. These individuals also reported higher levels of general distress, poorer perceived health and, of particular concern, were more likely to report suicidal ideation. There is also evidence that marital distress leads to poorer outcomes in the treatment of mental health conditions (e.g., depression, anxiety and substance use) and greater likelihood of relapse (O’Farrell, Hooley, Fals-Stewart, & Cutter, 1998; Whisman, 2001).

These and other issues relevant to couples will be examined through the lens of research; it is envisaged that research helps all therapists to transcend their differences in personal opinions about gender, religion, cultural diversity, sexual orientation and approaches to intervention. By gathering in the current research findings of a wide range of relevant factors, it is hoped that these discussions about the application of science to couples’ therapy will result in enhanced outcomes for both clients and therapists.

Evidence-Based Approaches to Couples’ Therapy

In their review of systemic therapy research, Heatherington, Friedlander, Diamond, Escudero, and Pinsof (2015) report there is strong evidence for both Emotionally Focused Therapy (EFT; Greenberg & Johnson, 1988; Johnson, 2004) and the behavioural approaches to couples’ therapy, namely traditional behavioural therapy (TBCT; Jacobson & Margolin,1979) and integrative behavioural couples therapy (IBCT; Jacobson & Christensen, 1998). These two evidence-based approaches will feature predominantly throughout this book. A number of contributing authors will offer suggestions for clinicians, from either or sometimes both of these approaches.

IBCT

Christensen, Atkins, Baucom, and Yi (2010) investigated marital status and satisfaction following a clinical trial involving 134 distressed couples comparing traditional (TBCT) versus integrative behavioural couple therapy (IBCT). Effect sizes (pre- to posttreatment) of 0.90 were reported for IBCT and 0.71 for TBCT, which were not significantly different. Follow-up at two years revealed superiority of ICBT over TBCT in relationship satisfaction, but these differences were not sustained at five years. These results are encouraging for couples’ therapy.

More recently, prediction of treatment response at five-year follow-up in an RCT of behaviourally based couple therapies was reported (Baucom, Atkins, Rowe, Doss, & Christensen, 2015). Results indicated that higher levels of pre-therapy commitment and being married for a longer time were associated with decreased likelihood of divorce or separation and associated with increased likelihood of positive change. For moderately distressed couples in the IBCT group, higher levels of wife-desired closeness were associated with increased positive change and decreased likelihood of divorce, whereas the opposite results were found for couples in the moderately distressed TBCT group. It is suggested that the emphasis on emotional acceptance and empathy in IBCT may foster increases in desire for closeness to a greater extent than TBCT does.

EFT for Couples

A meta-analysis of four outcome studies in EFT for couples (Johnson, Hunsley, Greenberg, & Schindler, 1999) reported a 73–75% recovery rate for relationship distress and an effect size of 1.3. Follow-up studies suggest that couples maintain their treatment gains and demonstrate trends towards increased satisfaction or forgiveness at two- or three-year follow-up (e.g., Clothier, Manion, Walker, & Johnson, 2002; Halchuk, Makinen, & Johnson, 2010). These results are very promising, especially given the tendency for couples’ therapy outcomes typically to reduce over time (Snyder & Halford, 2012).

Heatherington et al. (2015) also comment on findings across the field of couple and family therapy, indicating the positive contribution of therapist variables such as warmth and authenticity. Relevant to this very brief review of evidence-based couples’ therapy, a recent pilot study of EFT couples’ therapy examining within and between variables identified that while there was no significant relationship between therapist warmth toward wife and wife warmth toward husband, 62.9% of the variance in husband warmth toward wife was accounted for by therapist warmth to husband across time in therapy (Schade, Sandberg, Bradford, Harper, Holt-Lunstad, & Miller, 2015). Such findings point to the value of supervision and peer review for couples’ therapists, not only for the purpose of reflection on case conceptualization and interventions, but also for support and care of the therapist and the therapeutic alliance between therapists and their couples.

Arrangement of the Book

All the contributions to this book are relevant to clinical practice. Readers will find the contents of this book arranged alphabetically according to a key word in the title. A discussion of all seven couple cases will be threaded throughout the chapters, resulting in a meaningful review of research for the real world of couples’ therapy.

References

Barrows, H., & Tamblyn, R. (1980). Problem-based learning: An approach to medical education. New York, NY: Springer.

Baucom, B., Atkins, D., Rowe, L., Doss, B., & Christensen, A. (2015). Prediction of treatment response at 5-year follow up in a randomised clinical trial of behaviourally based couple therapies. Journal of Consulting and Clinical Psychology, 83, 103–114.

Borrell-Carrio, F., Suchman, F., & Epstein, R. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. Annuls of Family Medicine, 2, 576–582. doi: 10.1370/afm.245.

Christensen, A., Atkins, D. C., Baucom, B., & Yi, J. (2010). Marital status and satisfaction five years following randomized clinical trial comparing traditional versus integrative behavioral couple therapy. Journal of Consulting and Clinical Psychology, 78, 225–235

Clothier, P., Manion, I., Walker, G., & Johnson, S. (2002). Emotionally focused interventions for couples with chronically ill children: A two-year follow-up. Journal of Marital and Family Therapy, 28, 391–397.

Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.

Greenberg, L. S., & Johnson, S. M (1988). Emotionally focused therapy for couples. New York, NY: Guilford Press.

Halchuk, R., Makinen, J., & Johnson, S. M. (2010). Resolving attachment injuries in couples using emotionally focu...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Tables and Figures
• List of Contributors
• Acknowledgments
• 1 Beyond Models and Interventions: What Else Do Couples’ Therapists Need to Know?
• 2 Romantic Love as an Attachment Process: Shaping Secure Bonds
• 3 Assessment of Relationship Quality
• 4 Caregiving in Couple Relationships
• 5 Cognitions (Beliefs and Attributions) in Couple Relationships
• 6 Understanding Commitment and Partner-Serving Biases in Close Relationships
• 7 Redefining Communication in Couple Relationships
• 8 Understanding Couple Conflict From an Attachment Perspective
• 9 Cultural Diversity in Couple Relationships
• 10 Cybersex and Pornography
• 11 Death of a Child: Impact on the Parents’ Couple Relationship
• 12 Demand-Withdraw Patterns of Communication in Couple Relationships
• 13 Emotion in Couples
• 14 The Impact of Family of Origin Experiences
• 15 Fertility Problems and Pregnancy Loss
• 16 Forgiveness
• 17 Gambling
• 18 Couples and Health
• 19 Hurt Feelings
• 20 Close Relationships, Immune Function, and Health: Understanding the Clinical Importance of Distressed Relationships
• 21 An Integrative Approach to Treating Infidelity in Couples
• 22 The Interpersonal Process Model of Intimacy: Maintaining Intimacy Through Self-Disclosure and Responsiveness
• 23 Coping With Jealousy
• 24 Life Transitions for Couples
• 25 Love and Self-Expansion
• 26 Family Mediation for Divorce and Parental Separation
• 27 Mental Health Disorders in Couple Relationships
• 28 The Impact of Military Service on Couple Relationships
• 29 Neurophysiological Processes in Couple Relationships: Emotion, Attachment Bonds, and the Brain
• 30 Parenting in Couple Relationships
• 31 Counseling Clients in Polyamorous Relationships
• 32 Couple Relationship Education
• 33 Working With Same-Sex Couples: Considerations for Self-Supervision
• 34 Self-Regulation in Close Relationships
• 35 Integrating Sexual Concepts and Interventions into Couple Therapy
• 36 Sexually Transmitted Infections
• 37 Shame in Couple Relationships
• 38 Couple Therapy and Spirituality
• 39 Emotionally Focused Family Therapy for Stepfamilies: Building Security for Children in the Face of Complexity and Change
• 40 Couples’ Therapy in Treatment of Substance Use Disorders
• 41 Emotionally Focused Therapy Supervision: The Four Chambers of the HEART
• 42 Developmental Trauma
• 43 The Role of Trust and Commitment in Love Relationships
• 44 Intimate Partner Violence
• 45 Work, Stress, and Love: Investigating Crossover Through Couples’ Lived Experiences
• 46 Research for the Real World: Integrating Research With Seven Couple Cases
• Index