Couples in Treatment

Techniques and Approaches for Effective Practice

Gerald R. Weeks, Stephen T. Fife

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781135233952
• Edition: 3
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

This third edition of Couples in Treatment helps readers conceptualize and treat couples from multiple perspectives and with a multitude of techniques. The authors do not advocate any single approach to couple therapy and instead present basic principles and techniques with wide-ranging applicability and the power to invite change, making this the most useful text on integrative, systemic couple therapy.
Throughout the book the authors consider the individual, interactional, and intergenerational systems of any case. Gerald Weeks' Intersystems Model, a comprehensive, integrative, and contextual meta framework, can be superimposed over existing therapy approaches. It emphasizes principles of therapy and can facilitate assessing, conceptualizing couples' problems, and providing helpful interventions. Couple therapists are encouraged to utilize the principles in this book to enhance their therapeutic process and fit their approach to the client, rather than forcing the client to fit their theory.

PART I Basic Principles and Processes of Couple Therapy

DOI: 10.4324/9781315598475-1

1 Couple Therapy and the Intersystem Approach

DOI: 10.4324/9780203865699-2

Although marital and couple relationships received a modest degree of clinical focus during the first half of the 20th century, they emerged as a unique focus of treatment in the later part of the 20th century with the advancement of system theory and its application to psychotherapy. The development of systemic theories and therapies represented a major paradigmatic shift in psychotherapy. These therapeutic approaches represented a shift away from the individualistic and intrapsychic theories developed and employed by Freud and the psychoanalytic/dynamic therapists, as well as many cognitive–behavioral and humanistic models of psychotherapy. The systemic theories all share the concept of the individual-as-part-of-a-system, and they focus on interpersonal variables and relationship dynamics.

The past 40 years have been the “systems era” in the history of psychotherapy. In this short period of time, eight major schools have developed, which Kaslow (1981) grouped under the following headings: (a) psychodynamic–psychoanalytic; (b) Bowenian; (c) relational or contextual; (d) experiential; (e) structural; (f) communication–interaction; (g) strategic–systemic; and (h) behavioral. An additional school represents the most recent development in couple therapy and can be broadly classified as postmodern–constructivist, although not all systems thinkers agree that postmodern–constructivist approaches are systemic (Minuchin, 1998).

These schools of thought all share some basic assumptions about the systemic nature of dysfunction and treatment, but they are clearly different in content. In fact, these schools of therapy were originally presented as if each was to be used exclusively, without “cross-fertilization” from others (Gurman & Kniskern, 1981a). However, most practitioners of systemic therapy and others who are not systems oriented do not operate from such a purist basis. They recognize the implicit need to fit the theories to their clients rather than fitting the client to a single theoretical approach. Thus, integrative approaches have become more common among therapists addressing systemic issues.

This clinical need for integration has led to a new effort within the systems approaches. The latest development, one which spans approximately the last 30 years, is toward the integration of individually and interpersonally oriented theories and the integration of the various systemic approaches. A number of books and papers have been published advocating the synthesis or integration of various theories. Many of these texts have moved thinking within the field towards developing models demonstrating how different, sometimes apparently mutually exclusive, theories and therapies can be combined. For example, Kaslow (1981) published one of the earliest papers advocating an integrative approach to family therapy, in which practitioners can draw “selectively and eclectically” from various theories.

Duhl and Duhl (1981) presented one of the first clinically integrated models that they called “integrative family therapy.” They looked at all the levels of the system, for example, developmental level, individual processes, and transactional patterns. Their approach was focused primarily on how the therapist thinks and intervenes, and was less concerned with theoretical discussion regarding how theories could be integrated. Berman, Lief, and Williams (1981) also published a chapter in which they discussed how several theories could be integrated therapeutically. In this paper, they presented a coherent way of combining contract theory, object-relations theory, multigenerational theory, systems theory, and behavioral analysis all within a developmental and therapeutic model.

In addition, a number of other articles and books have appeared which address the issue of integration in systems therapy. These include: Hatcher (1978) on blending Gestalt and family therapy; Abroms (1981) on the interface between medical psychiatry and family therapy; Stanton (1981) on how to integrate the structural and strategic school; Green and Kolevzon (1982) on convergence and divergence in family therapy; Levant (1984) on a classification scheme for different theories; Lebow (1984) on the advantages of integrative approaches; a series of articles on the integration of structural–strategic therapy edited by Fraser (1984); Doherty, Colangelo, Green, and Hoffman (1985) on ways of reconceptualizing structure and distance in integration; Wachtel and Wachtel (1986) on designing intervention strategies based on family dynamics in individual therapy; Weeks and Hof (1987) and Hertlein, Weeks, and Gambesica (2008) on integrating sex therapy and marital therapy; and Weeks (1989a, 1989b) on integrating individual, couple, and intergenerational approaches. Additionally Case and Robinson (1990) and Snyder and Balderrama-Durbin (2012) both present excellent reviews of efforts at integration in couple and family therapy.

In revising our text, we were disappointed that more efforts toward integration in couple therapy have not taken place since our original publication of Couples in Treatment in 1992. With a majority of couple therapists utilizing integrative or eclectic methods (Lebow, 2003), it is surprising that there have not been more formalized attempts at developing integrative approaches to couple therapy. Nevertheless, some of the notable efforts include: Christensen, Jacobson, and Babcock (1995); Jacobson and Christensen (1996); Lawrence, Eldridge, Christensen, and Jacobson (1999); Clark-Stager (1999); Gurman (1992); Dattilio and Padesky (1990), and Dattilio (2010). The majority of the new efforts toward integration involve behavioral approaches and stress cognitive/behavioral-systems integration. The major work to come out of this effort, Integrative Couple Therapy: Promoting Acceptance and Change (Jacobson & Christensen, 1996), is an acceptable book on couple therapy, but does little to advance any systematic effort toward integration. They stress what we call an eclectic, rather than integrative, approach. Similar to many efforts at integration, Jacobson and Christensen’s model lacks a coherent theory that ties foundational concepts and methods together; thus it is an approach based on technical eclecticism rather than being truly integrative.

In 2000, Johnson and Lebow published an article in which they considered whether couple therapy had “come of age” (Johnson & Lebow, 2000, p. 23; see also Gurman & Jacobson, 1995). Although marital therapy began formally in the 1950s and has received consistent, yet sparse, attention since that time, we question whether it has truly “come of age.” There are relatively few texts on marital/couple therapy when compared to the number of books devoted to individual therapy and family therapy. Most training programs offer one course in marital/couple therapy even though they are called marriage/couple and family therapy programs. Clinicians and some faculty still believe anyone trained in family therapy can automatically do couple therapy. The fact is, these two approaches require different skill sets, although they share many of the same basic assumptions about the systemic nature of relationships. Our experience in training literally hundreds of therapists is that family therapists know relatively little about couple therapy.

Although the past decade has brought some improvements, the field of couple therapy has been overlooked and underfunded by governmental bodies such as NIMH. Couple therapy simply is not viewed as fundable research, which has meant university faculty struggle to investigate important questions about couple therapy. Thus, empirical studies historically have been scattered, and those that are conducted are often done with little or no funding or with small university grants, have small sample sizes, and are sometimes poorly designed.

Nevertheless, over the past two decades the field of marital/couple therapy endeavored to establish a foundation of empirical support for the effectiveness of treatment. These efforts resulted in an ever-growing body of research that has helped solidify several conclusions related to treatment effectiveness. First, couple therapy is effective. A meta-analytic review of effectiveness research revealed that those receiving couple therapy are better off than 84% of those not receiving treatment (Shadish & Baldwin, 2002). Second, the effectiveness of treatment is generally consistent, regardless of the treatment approach being used (Sprenkle & Blow, 2004a, 2004b). Part of the effort to improve the empirical support for couple therapy included efforts to determine which model(s) was most effective. However, results indicate there is not one couple therapy approach that is superior to the others. Because of these findings, some have postulated that there are certain curative factors related to successful treatment outcomes that are independent of theory or the treatment model being used (Asay & Lambert, 1999; Davis, Lebow, & Sprenkle, 2012). Chapter 9 discusses in more detail common factors of change in couple therapy.

Given the lack of funding for empirical research and a lack of scientific rigor in its early days, the field of couple therapy has attracted its share of self-proclaimed experts, many of whom are really expert self-promoters. Some of the more charismatic figures have managed to capture the attention of many of the newer, more naive members of our field. As an example, in the Johnson and Lebow (2000) article some of these figures are mentioned without due criticism of their work. The clinician who is unfamiliar with this field might assume a John Gottman and a John Gray are of equal significance and value to our field. In addition, both fields of marital therapy and family therapy are highly political. Certain groups are “in” and others are “out,” depending on the source. In particular, the Johnson and Lebow article mentioned above, which purports to be a comprehensive review of the field, does not mention the several volumes the current authors and others have produced, in spite of the fact that the senior author has published more professional texts on couple therapy than anyone in the U.S.

The therapist who is new to this field is urged to have a critical attitude and maintain a healthy degree of scientific skepticism, objectivity, and scholarship. Unfortunately these values are underemphasized in master’s-level training programs, partly due to the fact that clinical practice tends to run ahead of empirical validation, and faculty do not stress the connection between research and practice. The clinician must learn to balance his or her clinical experience with sound theoretical arguments and empirically based research.

The Intersystem Model

There are a variety of formalized therapy approaches that therapists can choose from in their work with couples. These approaches generally align with one of the eight schools identified by Kaslow (1981). Nevertheless, the purpose of this book is not to review these models; this has been effectively done by others (for overviews of the various couple and family therapy models, see Goldenberg & Goldenberg, 2012; Gurman, 2008; Nichols, 2012; Sexton, Weeks, & Robbins, 2003). Rather, our intent is to present fundamental principles related to couple therapy in order to help the reader conceptualize and treat the couple from multiple perspectives and with a multitude of techniques. We do not advocate any single approach to couple therapy. The therapy should be crafted for the couple and their problem(s). Techniques can be sequenced and blended in order to tackle different problems and problems at different depths. The principles and techniques described in this volume are not advanced or complex. They are basic with wide-ranging applicability and power to invite change.

The model we present to guide therapists in their work with couples is known as the Intersystem Model. It is a comprehensive, integrative, and contextual model, originally conceived by Gerald Weeks and published in 1977 in a paper on dialectics in psychotherapy. This early article did not present the model in its current form but was the genesis of intersystemic thinking based on dialectics. The model was first presented in the 1989 edited book Treating Couples: The Intersystem Model of the Marriage Council of Philadelphia (Weeks, 1989a). The theory was further developed by Weeks in 1994 in The Marital-Relationship Therapy Casebook: Theory and Application of the Intersystem Model (Weeks & Hof, 1994; see also Weeks & Cross, 2004).

The Intersystem Model is not a specific approach to couple therapy. Rather it is a meta-model or meta-theory that provides an overarching framework to guide therapists in their work with couples. A meta-model, or meta-framework, can be superimposed over existing therapy approaches to help therapists know what to focus on and why (Fife, Whiting, Bradford, & Davis, 2013). The Intersystem Model, as a meta-framework, emphasizes principles of therapy, rather than specific theories or techniques. It is broadly applicable across different therapy approaches and helps facilitate the integration of different ide...