Constructivist, Critical, And Integrative Approaches To Couples Counseling

Michael D. Reiter, Ronald J. Chenail, Michael D. Reiter, Ronald J. Chenail

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315308296
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Couples counseling is distinct from individual and family therapy and, while ideas from these other formats may be overlapping, applying theoretical concepts to couples has distinctive challenges. Constructivist, Critical, and Integrative Approaches to Couples Counseling is unique in that it addresses how to conceptualize various theories around a single case. By discussing only one case, the reader is more readily able to compare and contrast the theoretical ideas of each theory, as well as the pragmatics of techniques. Five theories are discussed around four consistent parts: history, theory of problem formation, theory of problem resolution, and case transcript. This book follows the same format as its companion Behavioral, Humanistic-Existential, and Psychodynamic Approaches to Couples Counseling.

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COUNSELING COUPLES

Michael D. Reiter

This book is a companion to Behavioral, Humanistic-Existential, and Psychodynamic Approaches to Couples Counseling (Reiter & Chenail, 2017) and focuses on the constructivist, critical, and integrative approaches to working with couples. Regardless of approach, couples counselors need to understand the various dynamics of couples, such as formation, history, and diversity (see Reiter, 2017). These dynamics filter into the case conceptualization, to provide a more encompassing view of the couple, why they are currently having difficulties, and potential pathways toward change.

Case Conceptualization

Case conceptualization has become a core competency in most of the counseling/therapy fields. Yet, what is a case conceptualization? Berman (2010) explained, “The goals of case conceptualization are to provide a clear, theoretical explanation for what the client is like as well as theoretical hypotheses for why the client is like this” (p. xi). Sperry and Sperry (2012) defined case conceptualization as such:

Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

(p. 4)

We can look at a case conceptualization in two primary areas. The first is that it allows the therapist to develop a theory of problem formation . Regardless of the presenting symptom or the client configuration (i.e. individual, couple or family), the case conceptualization provides an understanding of how the problem developed and how it is maintained. The second area of a case conceptualization is that it promotes a theory of problem resolution . Based on the specific approach being used to make the case conceptualization, the therapist will develop an understanding of possible pathways to change. These will be the various interventions that might be used to help move the client toward therapeutic goals.

Perhaps the biggest decision to make when first meeting with a client (and in this book we are using “client” to refer to whoever comes into therapy, whether an individual, a couple, or a family, but a couple in our case), is deciding what type of case conceptualization to make. The two primary choices are to develop a symptom-based or a theory-based conceptualization.

Symptom-based conceptualizations give priority to “the problem” and center treatment around the symptom presented by the client. For instance, if a couple came in with the complaint that one of the dyad had engaged in a sexual affair, the therapist would explore the research around affairs and develop an understanding of how/why affairs happen and what treatment approach might be best suited for that issue.

Theory-based conceptualizations give the therapeutic model primacy rather than the problem. The problem would be seen as a symptom of some other underlying issue (for instance, an affair—or any other presenting problem—may be seen as a result of maladaptive thoughts). Given that most therapists go into a session with a primary theoretical orientation (even if that orientation is what we might call an integrative approach), this book takes a theory-based look at case conceptualizations.

Some authors make a distinction between a case conceptualization and a treatment plan. For them, the case conceptualization provides the theory of problem formation while the treatment plan explains the theory of problem resolution. For us, a treatment plan is included in what we consider to be a case conceptualization. Depending on your work context, the treatment plan may be informal (i.e. your thoughts about what you might do with the client) or in agency settings more formal (i.e. an explanation of the problem, the treatment goal, and the specific interventions to be used, which may need to be listed and signed off on a form for managed care purposes). Since most therapists operate from a theory-based conceptualization, this book is designed to provide an in-depth overview of the primary theories of couples counseling.

Developing a case conceptualization is a skill that is learned over time through deliberate practice (Sperry & Carlson, 2014). For instance, beginning therapists may need to do an assessment interview and then, with input from their supervisor, develop their understanding of why the client is having difficulties and what pathways toward change might be relevant. In juxtaposition, more senior therapists are able to develop their case conceptualization in the therapy room while they are engaging the client in the initial interview. The more thorough an understanding of one’s primary theoretical model, the more quickly the therapist can develop the case conceptualization and begin working toward change.

The Importance of Theory

Over the last 20 years, the importance of common factors across models has gained significant focus (Lambert, 1992; Sprenkle & Blow, 2004; Wampold, 2001). Perhaps the viewpoint most expounded upon is that of Michael Lambert, who conducted a meta-analysis of outcome studies of the effectiveness of psychotherapy. Lambert determined that there are four common factors of therapy: client factors; therapeutic relationship; hope/placebo effect; and therapeutic model. Miller, Duncan, and Hubble (1997) hold that these four elements constitute a unifying language of psychotherapy.

Client factors tend to account for 40 percent of change. This area pertains to what clients bring with them to therapy—their strengths and resources. It might be their sense of resiliency, perseverance, sense of humor, etc. These extratherapeutic factors put focus on the client’s motivation, perception of the therapist, the therapeutic process, past therapy and interpersonal relationships and experiences, and the client’s stage of readiness for change (Prochaska, DiClemente, & Norcross, 1992).

The therapeutic relationship accounts for 30 percent of change. This is how the client connects and relates to the therapist. The better the quality of the relationship, the higher chance that positive change will occur for the client. This area is perhaps more difficult to utilize in couple counseling because of the multiple relationships in play. In couple counseling, there are four relationships occurring at once in the therapy room. The first is that between the two members of the couple, second between one partner and the therapist, third is between the other partner and the therapist and then the fourth is between the couple (as a dyad) and the therapist.

Hope/placebo effects account for 15 percent of client change. The more that clients hope and believe that therapy will be useful, the more likely it is for the client to change. The client’s level of hope is intertwined with the therapist’s expectation and hope for the client to change. That is, when the therapist truly believes that the work he/she is doing with the client will lead to positive outcomes, the greater possibility that therapy will end with positive gains. Yet, hope is not an isolated aspect of the therapeutic encounter. The therapist’s hope is usually grounded in a belief that whatever model they use will most likely be helpful for that particular client.

The last area is the therapeutic model, which accounts for roughly 15 percent of change. As we know, one model is not more effective than another model, however, effectively utilizing a model is what is important instead of going into a session and floating around without a direction and purpose. When therapists do not operate from a model of therapy (and again, we include integrative therapy as a model), they tend to grasp for various interventions that may not make sense for them or fit for the client. The therapist may begin to feel desperate and not attain a level of expectancy for change for the client. This, in turn, may be sensed by the client and lead to lower levels of hope and expectancy from the client.

These four factors are not separate, but are interrelated. Based on a therapist’s therapeutic model, the therapist will enter into a particular therapeutic relationship (although there are differences in therapists even within the same model). The therapist’s theory also helps to inform how the therapist will focus on the various client factors that are present. Lastly, the more a therapist has a thorough and working understanding of a particular model, the more competent the therapist will be in that approach and the more the therapist will believe that model will be useful and effective for the client. The therapist’s competency in that specific approach as well as hope for client change will help motivate the client to be hopeful and expectant for change. This book primarily explores the common factor of the therapeutic model while also bringing forth how therapists from that model may utilize the already occurring strengths and resources of clients and increase their hope and expectancy all via a distinct therapeutic relationship.

Effectiveness of Couples Counseling

Perhaps one of the first things to determine before investing in reading about the various models of couples counseling is to see whether engaging in couples counseling is effective. Fortunately, the answer to this question is “Yes!” Couples counseling is more effective than no therapy (Christensen & Heavey, 1999; Jacobson & Addis, 1993; Sexton, Robbins, Hollimon, Mease, & Mayorga, 2003; Shadish & Baldwin, 2003; Sparks & Duncan, 2010). Further, the positive results of therapy seem to remain in place or increase for at least two years after therapy ends (Lundblad & Hansson, 2006). Gurman and Fraenkel (2002) explained, “No other collective methods of psychosocial intervention have demonstrated a superior capacity to effect clinically meaningful change in as many spheres of human experience as the couple therapies, and many have not yet even shown a comparable capacity” (p. 248). However, not all couples find beneficial results. Approximately 25 to 30 percent of couples do not show gains from therapy (Snyder & Halford, 2012). This may be due to the timing of therapy (i.e. how long they experienced the problem before coming to therapy), differing agendas by each member of the couple, or a lack of fit between the couple and the therapist.

Shadish and Baldwin (2003), who conducted a meta-analysis about marriage and family therapy effectiveness, found that marriage therapy tended to be more effective than family therapy, but they attributed some of this to family therapists sometimes dealing with more difficult problems. Another finding they explained was that different interventions and models tend to lead to the same results. However, as we discussed, having a secure footing in one or more models is quite important. Davis, Lebow, and Sprenkle (2012) explain this issue, “This could explain why most tested couple therapy models are effective, but none significantly more than another—because they all do an adequate job of involving the right change mechanisms at the right times” (p. 38).

While some couples do not attain improvements in therapy, most do. Hampson, Prince, and Beavers (1999) found that 83 percent of the couples in their study made some significant gains. Further, couples who attended at least three sessions made 92.1 percent gains of at least some degree. However, not all couples find positive results (Jacobson & Addis, 1993; Snyder, Castellani, & Whisman, 2006).

Previously we presented a view of the common factors of therapy. However, these factors may not include others that pertain specifically when working with couples. Davis et al. (2012) presented several common factors that are unique to couple therapy, which included conceptualizing difficulties in relational terms, disrupting dysfunctional relational patterns, an expanded direct treatment system, and an expanded therapeutic alliance (i.e. the therapist’s relationship with partner A, the therapist’s relationship with partner B, the alliance between partners A and B, and the alliance between therapist, partner A, and partner B).

One potential common factor in couples counseling (as well as individual, family, or group therapy) is that of feedback (Halford et al., 2012; Sparks & Duncan, 2010). Anker, Duncan, and Sparks (2009) found that when couples are able to provide the therapist with feedback on their perceived progress they have improvements four times that of those who do not. One reason for this is that when therapists receive feedback from clients at the end of each session they can make corrections in their approach (Pepping, Halford, & Doss, 2015). While progress feedback is an important aspect of therapy, there may be additional challenges when utilizing it with couples. For instance, the therapist will need to integrate the feedback given by each partner, as they may disagree with one another.

Although not considered common factors, Benson, McGinn, and Christensen (2012) presented five common principles of couples counseling. These are: “(a) altering the couple’s view of the presenting problem to be more objective, contextualized, and dyadic; (b) decreasing emotion-driven, dysfunctional behavior; (c) eliciting emotion-based, avoided, private behavior; (d) increasing constructive communication patterns; and (e) emphasizing strengths and reinforcing gains” (p. 25). These authors suggest that these principles become relevant at various times during the course of therapy, with earlier principles more applicable earlier in the process. These principles can be seen, in various ways, in all of the approaches presented in this book.

While we are presenting distinctive models of couples counseling, we understand that many couples therapists may engage in a type of therapy that is more integrative. There are different types of integration, such as assimilative, tran...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• About the Editors
• About the Chapter Contributors
• Preface
• 1 Counseling Couples
• 2 The Case: David and Natalie Johnson
• 3 Emotionally Focused Couple Therapy
• 4 Feminist Couple Therapy
• 5 Solution-Focused Couples Therapy
• 6 Narrative Couples Therapy
• 7 Queer Intersectional Couple Therapy
• Index