Couple Therapy

Document Sample
Couple Therapy Powered By Docstoc
					Effective Threesomes? A Critique of Four Models of Couple Therapy By James Rye, B.A. M.Phil. P.G.C.E.

Dissertation submitted to the University of Nottingham in partial fulfilment of the requirements for the Degree of Master of Arts, May, 2005

1 of 42

Foreword _______________________________________________________________ 3 What Is A Couple? _______________________________________________________ 4 A Critical Review of Four Couple Counselling Models ___________________________ 7
Emotionally Focused Couple Therapy (EFT) _________________________________________ 8 Cognitive Marital Therapy (CMT) ________________________________________________ 12 The Seven Cs: A Behavioural Systems Framework ____________________________________ 15 The RELATE Model __________________________________________________________ 20

Problems in Assessing the Effectiveness of Couple Counselling Models _____________ 24 Integrating New Factors __________________________________________________ 28
Disjunctive Stages ____________________________________________________________ 28 Relationship History and Forgiveness ______________________________________________ 30 Gender _____________________________________________________________________ 32

Conclusion _____________________________________________________________ 34
The 3E-4D Model for Couple Counselling __________________________________________ 35

Bibliography ___________________________________________________________ 39

2 of 42

My journey towards the topic for this thesis started from places of personal pleasure, pain, and need. The pleasure stems from the fact that couple therapy is the area of counselling that I really enjoy the most. In my early years of close, and hopefully therapeutic, involvement with people in a pastoral context, a large proportion of the work I did was with couples. Since then I have worked with many couples in a secular context, both face-to-face and via telephone. Approximately one third of my current work in private practice involves couples. Given that those closest to us have the power to hurt us the most, working with couples to discover the patterns and mechanisms that inflict pain and to reshape or destroy the mechanisms, significantly reduce the pain, and hopefully rebuild a stronger relationship can be extremely rewarding for therapist as well as the couples. The pain and the need are both personal and professional. Despite having acquired an armoury of tools and techniques from previous work – useful areas to explore, patterns to identify, exercises to engage in, change contracts to make – sometimes a sense of failure through couples not engaging, or dissatisfaction with the process highlighted the need for something more. At times I was very conscious of lacking a coherent model for couple therapy, not sure how to interpret what was happening or how to respond in the most constructive way. At other times there was a nagging feeling about superficiality and about doubting whether surface shifts were discovering, let alone addressing, other issues beneath. Because it is sometimes true that ‘ failure’as well as ‘ success’in couple work is more obviously apparent than when working with a single client (there are two sources of joy or pain sitting opposite you), I was sometimes acutely aware of the need for more professional development. The pain and need were also personal. Having been married for nearly 30 years with two children I would say that I am an expert in the joys and pains of couple life from the inside. In particular, an historical pain in the relationship caused by a near fracture, while often present as a background ache, resurfaced with vengeance about 18 months ago. My wife and I, both counsellors, were struggling to understand, process, and heal the pain in our own relationship. Despite our training and experience, and despite surface calm, the currents in the raging depths were sucking me under. I wanted to learn more, not only to work more effectively with others, but to work with myself and my marriage. I propose to critically examine four approaches to couples therapy and to explore some of the difficulties in evaluating couples therapy before moving on to argue for a new integrated approach. First, however, I need to set some parameters and define what I mean by a couple.

3 of 42

What Is A Couple?
Although the question is straightforward enough, there is not a simple answer. For example, although a two people may not need to be married in order to be a couple, do they need to be cohabiting to fall within the definition, and if so, for how long? The ability to define a couple is crucial to setting the parameters of this study. When attempting to define a couple, it is helpful to think about what assumptions are not made, what assumptions are made, and what two-person relationships are specifically excluded. I make no assumptions about the legal status of a couple or about heterosexuality. Although this was not the norm in the 1950’ when the National s Marriage Guidance Council (latterly known as RELATE) started its work, it is clearly inappropriate to do so at the beginning of the twenty-first century in Britain. To limit couples to those that were heterosexual married couples would exclude vast numbers of committed people who choose not to marry (or who choose not to marry early in the relationship), and would exclude all gay and lesbian couples. To assume heterosexuality and marriage would fly in the face of both sociological and psychological relationship reality. (In 2003 over 50% of children born in the Wales and in the North East were born outside of marriage, suggesting the passing of a long-standing moral and religious taboo (Office for National Statistics, 2004). The Government Actuary’ Department predicts that s the number of couples who get married will be in the minority in England and Wales in six years time (Government Actuary’ Department, 2005). In Norway, s 82% of first children are now born outside marriage (Knox, 2004).) Although for different reasons, both the church and the government are slow to acknowledge this different couple relationship reality, there are signs that the government, at least, is shifting (Department for Trade and Industry, 2003). In the absence of marriage from the definition of couple, it could be assumed that co-habitation might provide a useful criterion. However, even a little thought would expose the inadequacy of this Procrustean bed. There are couples that have satisfactory relationships without cohabiting. I recently worked with a woman who described herself as having had a loving affair with a man for six years. She had two children with him, but she never lived with him, hardly ever literally slept with him, and only had occasional sex in the afternoon. But she clearly saw herself as part of a loving couple. And there are plenty of relationships that survive the strain of one partner living away or abroad. I have therefore made no assumptions about cohabitation when defining a couple. There are also problems about trying to define a couple in terms of permanence of relationship. How long does the relationship have to be in order to qualify? And does intended permanence count? Are a couple that have known each

4 of 42

other for a week and who have decided to marry more of a couple than two people who have been together for a year? What about the pair who have been married for 50 years but who have had no meaningful relationship for the past 20 years and who now despise each other deeply? Are they a couple? I have excluded length of relationship and intended permanence from my criteria of what constitutes a couple. I find myself in agreement with Butler and Joyce (1998) who argue that the three key factors for delineating a couple are: a commitment to the longevity of the relationship, the primacy of the relationship for each adult partner, and the genuine desire of both partners to maintain a high degree of sexual exclusivity. The primacy of the relationship meets all the difficulties raised by the other criteria above. It allows unmarrieds and gays to be couples, it does not require cohabitation, and it neatly subsumes the potentially important issue of length (or intended length) of relationship under the more critical issues of commitment and primacy. The issue of desire to maintain sexual exclusivity introduces sexual activity into the definition while at the same time differentiating couples from casual sexual playmates. It also realistically recognises the gap between moral theory and actual behaviour. A couple can still be a couple, even when one or both of them have failed to maintain their genuine intension of being sexually faithful. The above factors also exclude business relationships where two partners may be life-long, close friends, but not in primary relationship with each other, and usually not sexually involved. Despite the usefulness of the above, there is still a need to refine the definition further. It is necessary to state what has been assumed above, that both of the people concerned need to be adults, and from different families. Of course, this is not to assume or imply that children, or adults and children, or people from the same family cannot have significant relationships. However, the pairings resulting from any committed, primary or sexual relationships in the above categories would be excluded from the definition of couple in this study. They would either be naturally occurring relationships generally recognised as being outside what is understood by ‘ couple’(such as a parent child relationship or a brother sister relationship), or they would be considered extremely problematic (such as incestuous or sexually abusive pairings) and more suited to a different counselling model. Following on from this latter point, freedom from coercion is also important in the definition. The two adults must not only be from separate families in primary relationship with the intention of sexual fidelity, but each partner must be free to determine his or her own goals, or free to relinquish them for the sake of the relationship. It is worth stating the obvious point that unless both partners feel free to modify their interactions in the relationship there is little point in them being counselled as a couple, and several reasons for them to consider individual therapy.

5 of 42

For the purposes of this study, ‘ couple counselling’refers to work with two adults who have no blood ties, who are in a committed sexual and primary relationship with each other, who have a view to the long-term and an intention of sexual exclusivity. Each partner is also free to voluntarily modify her or his personal goals in favour of joint goals.

6 of 42

A Critical Review of Four Couple Counselling Models
It is a truism that there are as many models and approaches for counselling couples as there are for counselling individuals. Psychodynamically oriented counsellors tend to assume that most of the key aspects of couple relationships are based upon transferential issues resulting from the early development of the partners. Relationship discord is seen as a symptom of individual psychopathology in one or both spouses. The goal of therapy is to help clients become aware of the unconscious elements of their conflicts that interfere with healthy adult relationships. A major ‘ curative’ mechanism involves the analysis of transference (Segraves, 1990). In contrast to the focus on intrapsychic processes, General Systems Theorist practitioners understood the personalities of the partners via their interactions. The focus of therapy is on changing the structure of rules of interaction between individuals in disturbed relationships. The emphasis is on pattern recognition in complex interactive systems, on labelling patterns to prevent reoccurrence, and on relabelling behaviour to change affect. Similarly Behavourists view couple issues as being related to problems of behavioural reciprocity. The goal of the counsellor is to help couples modify observable behaviour. Key concepts are that of reinforcement and the importance of the reward-cost ratio. Cognitive-behavioural therapists see couples as having cognitive misconstructions about one another. Emphasis is on the discovery of the evolved interpersonal schemas that are used to organize and predict interpersonal stimuli, and on reframing. Person-centred counsellors see the issues as being concerned with difficulties in expressing true thoughts and feelings to each other and would want to encourage self-actualization in both partners. Integrative therapists try to combine different aspects of the above. I propose to critically examine four significant models for working with couples before moving on to consider several general issues relating to couple therapy research.

7 of 42

Emotionally Focused Couple Therapy (EFT)
The focus of emotionally focused couple therapy is on fostering the development of a secure emotional bond between partners. In fostering this bond, distressed couples’constricted interaction patterns and emotional responses are modified. EFT is firmly rooted in the theoretical work of Bowlby (1988) concerning attachments between parents and children, and the later application of his original theory to adult relationships (Hazan & Shaver 1994). Relationship problems are understood as attachment problems. They are understood as arising from the distressed affect (and the subsequent constrained interaction patterns priming this affect) that partners experience when they feel that a loved one is becoming detached from them. Johnson (1999) argues that marital distress is really separation distress resulting from insecure bonds. When a loved partner is perceived as being inaccessible or unresponsive the emotional tie with that partner is threatened and the other partner feels fear, anger, and sadness. These emotions have control precedence and override other cues so that seemingly innocent actions (a partner arriving late for an appointment, for example) are interpreted negatively in the light of the emotions (“ is late because he is having an affair!” He ). According to Bowlby (op.cit.) when attachment security is threatened, affect organizes attachment response into a predictable sequence: ? protest and anger ? clinging and seeking ? depression and despair If the attachment figure does not respond, detachment and separation will occur. The problem for adults is that the predictable behaviours outlined above (anger, clinging, depression) are likely to drive a partner away, and contribute to a negatively reinforcing cycle. The potential loss of an attachment figure, or even an ongoing inability to define a relationship as secure, is often significant enough to prime automatic fight, flight, or freeze responses. These responses in turn limit information processing and constrict interactional responses. As with all psychodynamic approaches, the present is always illuminated by the past. According to attachment theory, an individual’ present perception of s attachment threat will have been influenced by her or his historical experience of attachment. A child forms an Internal Working Model (IWM) of the attachment figure (or separate IWMs for several attachment figures) and uses these as a basis for relating to others. In a relationship a crucial question being frequently asked by both partners is: “ Can I count on the other person to be there for me?” The answer to this question will be partially informed by a person’ habitual s attachment style which will have been significantly influenced by a person’ s historical attachment experiences. People with secure attachment styles are

8 of 42

able to give clear signals about their attachment needs, see themselves as worthy of care, are able to assert themselves in the face of differences, and are able to respond flexibly when an attachment bond is threatened. People with anxious attachment styles are insecure and see themselves as being deficient and unloveable. They cling to others and frequently demand reassurance. People with avoidant attachment styles avoid closeness, are fearful and dismissive of others, frame others as untrustworthy, and deny their own need for attachment. So, relationship distress is seen as being about attachment fears, informed by both present and past experiences of being in close emotional bonds with others. For the counsellor, it is not the attachment needs that are problematic in the distressed relationships. It is rather how partners process and enact such needs in a context of perceived danger and insecurity that are the key issues because it is this processing and enactment that is priming the distress. The central focus for the EFT counsellor is in helping couples reframe understanding and modify behaviour. If anger and blame, which is normally perceived as hostile, can be reframed as natural protest arising out of fear of abandonment, some of its sting is removed and the desire for relationship is foregrounded. If this is then followed up with negotiation about how abandoning behaviour can be changed to promote accessibility, the fragile attachment bond can be strengthened. Similarly, if withdrawal and distancing, which is normally perceived as neutral or hostile, can be reframed as a natural attempt to regulate fears of loss and avoid anticipated feedback about unworthiness, some of the pain of the coldness is removed. If this is then followed up with negotiation about how abandoning behaviour can be changed to promote accessibility and attachment, the fragile relationship bond can again be strengthened. An attachment perspective focuses the counsellor on attachment insecurities and longings; it stresses the significance of former experiences of deprivation and loss of trust and connection; it directs the counselling process towards the creation of accessibility and responsiveness that fosters safe emotional engagement. Johnson (op.cit.) has described the EFT counselling process as being one mainly of de-escalation. Clients are encouraged to access unacknowledged emotions and then these are reframed in terms of attachment needs. This initial de-escalation is further reinforced as interactional patterns are changed to facilitate the expression of appropriate needs. As a couple therapy the EFT approach has much to commend it. First, it has a clear theoretical base rooted in empirical observation of close relationship bonds. It has an empirically validated theory of dysfunction and of relationship health able to target specific goals in the change process. Secondly, the method has good empirical support and is reckoned to be one of the best empirically validated approaches to changing distressed relationships (Baucom et al.1998; Dunn & Schwebel 1995) (though see my general criticisms of much empirical couple work below). Thirdly, it attempts to address the issue of any individual

9 of 42

psychopathology brought to the relationship discord (an issue ignored by many other models). Fourthly, (and perhaps explaining the second point above) it is focused on changing the emotional experience of the relationship. It is a couple’ ability to repair and sustain emotional engagement that is likely to hold s the relationship together or destroy it, and cognitive and behavioural changes by themselves are unlikely to be enough. If ‘ emotion is the music of the attachment dance’(Johnson op.cit. p.18), EFT helps couples really listen to the rhythm and adjust their footwork accordingly. Despite its apparent attractions, the EFT method does have a number of potential weaknesses. As with many psychodynamic theories, there is still disagreement about the extent to which patterns perceived in childhood carry over to adulthood. As Segraves (1990) has noted, in psychodynamic theory observations and assumptions are seldom kept separate. Although providing a neat conceptual framework, the feelings experienced by babies being separated from their parents may be different from those experienced by adults fearing separation. Even allowing for similarities, common sense would suggest the need to incorporate cognitive and personality factors into an adult model. As it stands, attachment theory may be too simplistic. It may be equally simplistic to expect any insight provided by attachment theory to be able repair bonds in many situations of marital distress, particularly when that distress is acute. Understanding that your partner’ serial adultery over 10 years was an s inappropriate attempt to meet his or her attachment needs may do little to ease your present pain or give hope; indeed, if handled insensitively, it could be seen as a way of justifying the behaviour. While allowing for the history of the individuals, the model also needs to allow greater scope for the history of the particular relationship. A third potential weakness of the method is both theoretical and practical. Being psychodynamic, the model does assume that the clients present with problems to be treated by the experts. While this model may be appropriate in the spheres of simple physical treatment (car mechanics, for example) humanistic counsellors would argue that it is an inappropriate model when working with people, not least because clients are never able to reveal the full extent of their lives and issues (and this is doubly true with couples) and that counsellors are never completely expert and competent (even if they saw it as their job to be). It could be argued that working with couples with this kind of diagnostic model is a bit like taking a car to have a complex engine problem fixed to a partially sighted mechanic who is never quite able to get the car bonnet open. From a practical perspective many counsellors would feel uneasy with the EFT approach. It does seem to require an investigation into the history of both partners fairly early on in the counselling relationship. An individual wishing to have psychotherapy may expect such an approach and be willing to engage in the process. However, such an approach may appear foreign and possibly irrelevant to two hurting people looking for immediate relief for their relationship

10 of 42

pain. Some counsellors may argue that clients should be expect the long haul; others could argue that clients are likely to want to stay the distance if the early sessions are seen to be meeting some of their immediate needs.

11 of 42

Cognitive Marital Therapy (CMT)

One of the most prominent proponents of Cognitive Marital Therapy (and I am assuming that this approach could equally be called Cognitive Relationship Therapy (CRT)) is Segraves (1990). He has developed an approach which has the following assumptions. First, one or both spouses will tend to misperceive their partner’ motivations and s personality characteristics. Secondly, people will tend to recreate their interpersonal world both by eliciting behaviour from others that confirms their inner representational world and by discouraging or selectively ignoring disconfirmatory behaviour. Thirdly, novel and disconfirmatory experiences will challenge and reduce negative schema. The first assumption may look suspiciously like a cognitive-behavioural version of the psychodynamic concept of transference. However, despite any similarities, the crucial difference is in focus. The emphasis is on the reality of the present misperception rather than on its etiology in the past. The second assumption about reinforcement draws heavily from behaviourism and systems theory where it is argued that systems work to maintain the status quo (homeostasis) and where there is circular causality through self-reinforcing feedback loops. As it is stated the third assumption seems slightly at variance with the practical strategies Segraves goes on to outline because it focuses on experience rather than cognition and reason as the key way to challenge negative schema. Segraves (op.cit. p.293) states that the goal of marital therapy is to ‘ provide bilateral disproof of maladaptive schemata for the perceptions of the spouse’ He . advocates the following directly cognitive strategies as a way of challenging negative thought patterns harming the relationship. The counsellor is to work with the clients to search for the clients’negative characterological descriptions of each other. These descriptions may be partially accurate but not truly reflective of the multidimensional complexity of the other partner’ personality s and motivation. Having found the characterological descriptions the next step is for the counsellor to help clients identify eliciting behaviours from each spouse and to challenge each partner to interpret the problem behaviour differently. At the same time the counsellor searches from disconfirmatory behaviour that has previously been dismissed. This disconfirmatory behaviour is emphasized so that it cannot be dismissed so easily. The therapist ‘ repeatedly attacks’(op.cit.) any rigid perception held by one partner about the other’ character, stressing s the complexity of the other’ personality and motivation. s In its favour it can be argued that this approach addresses both the learning history of each partner and their current interactional difficulties (a strictly behaviourist approach would only be concerned with the latter, a psychodynamic

12 of 42

approach largely with the former). However, this approach has at least four potential weaknesses. First, as with all strictly cognitive approaches, the model can seem very limited as a way of working with two complex human beings. Despite acknowledging that it attempts to address both the past (to a limited extent) and the present, and despite acknowledging that the maladaptive schemata could be challenged using a variety of verbal techniques, the approach is still relatively unidimensional. When stating that he makes the assumption that novel and disconfirmatory experiences will challenge and reduce negative schema Segraves was clearly imagining novel and disconfirmatory verbal experiences. However, many therapists would want to argue that schemata are often not developed or held rationally, and that in many cases, to ‘ attack’them with verbal logic is unlikely to shift them, even if a level of changed understanding does succeed in following. Most counsellors would be able to describe shifts in client perception that eventually took place as a result of emotional experience or of client-counsellor ‘ connection’ despite many previous hours of attempts at verbal cognitive , re-framing. Unless the emotions holding the schemata are addressed, any change is likely to be short-lived. Secondly, although the approach seems more mechanistic than the others considered, it is surprising in that it appears to hold back from applying the mechanistic approach to other areas arguably more suited to mechanism, namely behaviour. Reinterpreting problem behaviour is important, but unless couples are able to negotiate strategies for expressing feelings when problem behaviour re-occurs and for negotiating and re-enforcing specific change, the novelty of understanding the problem behaviour in a new light is likely to soon vanish. It may be naïve to assume that all couples would be able to handle specific behaviour change without appropriate therapeutic intervention. The weaknesses of these first two points can be summarized by arguing that CMT is rational therapy rather than rational-emotive-behaviour therapy (REBT). A third problem with this approach relates to starting points. Many couples present for counselling with differing degrees of hostility, not only towards each other but also towards the counsellor and the counselling process. This frequently raises difficulty for consensual working. Segraves implicitly acknowledges this when he argues that in the early stages of the counselling the practitioner needs to gain control over the interactional process and emotional climate so that learning can take place. The rational counselling can only proceed once there is relative calm. This may mean that CMT is inappropriate for a large number of couples or that other approaches have to be adopted before CMT can proceed. Many counsellors would find the directedness of the approach to be a fourth problem. The language used by Segraves is that of an expert battling with nonexpert chaos: ‘ gain control’ ‘ , search out eliciting behaviour’ ‘ , disrupt’ ‘ , repeatedly

13 of 42

attack’ On one level it could be argued that all Segraves is advocating is the use . of appropriate person-centred counsellor congruence in highlighting discrepancy between what the client sees as reality and what may be an alternative reality. However, it feels more than that. The counsellor appears to have a strict template for diagnosing problems and for responding to them in the hope that the clients will grasp the truth of what the counsellor is saying and will respond accordingly. However sensitively it may be practised, on paper at least, it feels a bit like counselling by numbers.

14 of 42

The Seven Cs: A Behavioural Systems Framework
Birchler et al. (1999) developed a basic framework from which to conceptualise, evaluate, and ‘ plan treatment’for distressed couples. The framework was designed in the context of training marital and family therapists pursuing US graduate degrees within various mental health disciplines. Birchler et al. claim (op.cit.) that although it is extremely difficult to find perfect agreement among family therapists and researchers, there is reasonable consensus with regard to certain fundamental requisites for long-term intimate relationships. These important dimensions can be subsumed under the rubric of the Seven Cs: character features, cultural and ethnic factors, contract, commitment, caring, communication, and conflict resolution. With character features the counsellor is encouraged to use interviews to look for personal characteristics that tend to be persistent or play a major role in defining the individual. So, for example, a major depressive disorder would qualify as an enduring character feature, whereas a short-term depressive reaction to a life event would not. The key issue is that past experiences influence behavioural patterns, cognitions, and affective perspectives, and that in dyadic relationships, some of these developed characteristics are enabling or defeating. Failure by the therapist to recognise character strengths or self-defeating patterns will not help the couple move beyond the present relationship distress and may exacerbate it. Because of the reciprocal relationship between individual and relationship dysfunction, any increase in relationship distress is likely to exacerbate any individual dysfunction. There is a clear recognition that in couples where one or both of the partners has an enduring vulnerability (individual psychopathology, or maladaptive patterns) that makes the establishment or maintenance of a healthy interpersonal relationship extremely difficult, these individual vulnerabilities need to be addressed if the couple counselling is to be potentially helpful. Counsellors who underplay the importance of individual vulnerabilities because of a focus on problem relationship behaviour are unlikely to help the couple in the long-term (Halford et al. 1999). The counsellor is free to negotiate with the clients whether any individual therapy is needed prior to, concurrent with, or after conjoint couple therapy. Although Birchler et al. use terms like psychopathology and are interested in the past, the emphasis is not on interpreting the past in terms of psychodynamic theory, but simply in describing the learned patterns that contribute to relationship dysfunction. The expectations that any individual brings to a relationship are also explored by encouraging the therapist to consider cultural and ethnic factors with clients. If examination of personal characteristics has been concerned with general, unspoken interpersonal rules, cultural and ethnic features are concerned with (sometimes) more overt and codified interpersonal rules that have been more consciously shaped and controlled by groups rather than by individuals. Couples

15 of 42

are encouraged to explore how far (if at all) the continuance of cultural, religious, ethical beliefs, family-of-origin factors, and social class differences are contributing to the present distress. If these exist, the key interventions are cognitive, behavioural, and emotional. Because there is often more conscious shaping of these beliefs there can be a more obvious awareness of where they have originated. Individuals can be less ‘ blind’to them than they are to the more ‘ hidden’personal characteristics. Counsellors can help couples educate themselves about the differences, help them develop skills to be able to negotiate and compromise over mutually acceptable ways through conflict, and promote emotional unity through fostering empathy with the other person because of new understanding and acceptance. All relationships have sets of implicit (and increasingly explicit and possibly legal) contracts – sets of expectations that partners have concerning how they will define the relationship and interact with one another. These contracts can be categorized as micro-level (for example, assumptions about who will cook dinner, about whether being late is acceptable, about how leisure activities are chosen) and macro-level (for example, whether or not to have children, how to spend major money, parenting styles, how to interact with the wider family). Any discrepancies between expectations and experience cause distress. Counsellors can work with couples to make the implicit explicit and to negotiate contract change. Commitment is seen a motivational variable. In the Seven Cs conceptual model counsellors are interested in the presence or absence of three types of commitment: (a) to stability, (b) to quality, and (c) to therapy. It is not unknown, for example, for couples to be committed to staying together and for them to attend joint counselling because of minor problems, but for them to be disengaged from the process and for them to see little need to make big changes that would arguably significantly enhance the quality of their relationship. Because commitment is so crucial, there may be the need for individual therapy if it is absent. It is important for the practitioner to help the couple work towards collaboration on positive outcomes. I have found this C to be especially helpful in enabling me to be congruent where one partner may be intent on sabotaging any progress made (Are you both really committed to this counselling process?), or where a couple have used initial counselling to survive the immediate crisis but are stuck over longer-term underlying issues (Are you really committed to getting the very best from this relationship, or do you want to settle for the gains you have made so far?). The Seven Cs analysis also breaks caring down into three sets of behaviours to be assessed: daily caring behaviours (for example, cooking, cleaning), individual and mutually rewarding activities (for example, joint projects, trips, social events), and affectionate and sexual activities. Counsellors can work with couples to help the reintroduction of daily caring behaviours. This can be quite powerful in helping partners rekindle basic interest and in strengthening appreciation. They

16 of 42

can work with couples to help establish individual and joint caring activities. If sexual problems continue to exist once the relationship has changed for the better, the couple can be referred to a medical doctor and if appropriate, to a sex therapist. The interventions about care are largely to do with changing behaviour. Distress arising from poor communication in the relationship arises not simply from inadequate listening, but also from the inability of partners to express themselves in depth, and from the self-defeating reciprocal patterns of negative exchanges. The skills that counsellors are able to work with clients to develop include: self-disclosure of intimacy promoting thoughts and feelings, active listening, validating expressed emotions, reframing negative interpretations. Counsellors are encouraged to model these skills as well as coach them through exercises. Effective communication may help couples identify and understand their problems, but often more than communication and understanding are required for effective resolution and conflict. The Seven Cs framework encourages working with clients to develop joint decision making skills, and anger management and de-escalation skills. Counsellors work with clients to help them identify mutually accepted agendas and to express opinions in a nonconfrontational way. Clients also learn how to anticipate anger arousing situations and to develop time-out strategies. The Seven Cs framework has several key features in the way it is used with clients. First, up to four weeks are spent on evaluating the existing relationship with clients. Standardised questionnaires, semi-structured interviews, and observation of communication skills are used to assess the starting point of any therapeutic contract. At this point it may be that couple therapy is deferred until further individual work has been completed. Secondly, once the couple therapy has begun, the techniques employed by therapist are well documented in the cognitive-behavioural relationship literature and include: exercises to strengthen caring; experiential training in communication and conflict resolution, cognitive reframing exercises, negotiation skill training. One of the major appeals of the Seven Cs framework is that it appears to have a ‘ common-sense’authority behind the justification of the analysis. It appears to have emerged from a consensus about the types of factors influencing stable relationships. It is not rooted in small studies that may discover unusual variables that are then used as the basis for large erroneous systems. Neither are the variables rooted in the creative unsubstantiated theories of individuals. The analysis is also flexible enough to accommodate new factors contributing to relationship distress should they need to be incorporated into any new consensus.

17 of 42

Like EFT, the Seven Cs analysis is also to be applauded for the way in which it acknowledges and seeks to address the issue of how individual characteristics seriously influence any couple. Couples are seen as the creation of individuals who have unique histories and learning experiences. It could be argued that another of its strengths is its apparent straightforwardness and ease of implementation. The framework was designed for use with therapists in training and it is easy to see how it answers the terrifying question faced by all inexperienced therapists in training when confronted with clients, namely, “ What do I actually do or say?” There is a clear procedure to follow with well documented techniques, exercises, role plays, homework tasks to employ. It removes the terror of the therapeutic silence. Despite these arguable strengths, it has potential weaknesses. Although not a criticism of the model per se, it is easy to see how it could lend itself to abuse in the hands of inexperienced practitioners (though a similar argument could be made for many other models). If the framework is taken too rigidly or too literally it could have the feel of ‘ counselling by numbers’where the counsellor engages with the boxes to be ticked off rather than with the clients. If there is a minor danger of the counsellor engaging with the tick box rather than with the client, perhaps there is a bigger danger of the counsellor engaging simply with the clients’problem behaviours rather than with the deeper issues feeding those behaviours. The model seems particularly appropriate for Brief Therapy where sessions can be targeted at particular issues and genuine shortterm gains made. (Relationship Enhancement programs with a psychoeducational approach similar to that of the Seven Cs model have strong empirical support for relieving relationship distress (Accordinio & Guerney 2003)). It also feels particularly appropriate for couples where the relationship distress has not yet become too painfully destructive. Wesley & Waring (1996) report that Marital Therapy Outcome Research has consistently found that severely distressed couples are less likely to benefit from therapy, and this particular model may be inadequate for using with couples where the pain has a long and deep history. Although Birchler et al. would acknowledge (op.cit.) that in these latter cases individual therapy would have a significant part to play that individual therapy is likely to be fundamentally different in nature to that offered by the model. I am increasingly persuaded that a key issue in couple work (indeed in most therapy) is that of being able to contain the hurt of the past or neutralize its force, and this seemed to be a significant gap in this model. It is touched on via character and culture and contracts, but a lot of focus is on changing the behaviour of the present. This model seems to have little to say about how we can stop the past hurting us or forgive those who have hurt us. It helps us to see how to move on, but some of the things that we may need to do before moving on are not exposed by this theory.

18 of 42

Another weakness is that the authority for the theoretical foundation is not clear. It claims it is based on a consensus. However, it is not too difficult to find other authoritative authors who have come up with a different model based on a similar observation of empirical studies. For example, the American Psychological Association (1996) (citing the work of Wallerstein (1996)) and the Child Trends Research Brief (Moore, K.A. et al. 2004) both outline a range of key factors in a good marriage. Not only do these studies overlap with each other and with the work of Birchler et al. (op.cit.), they also differ from Birchler et al. and from each other. The model does allow for the addition of other Cs should they emerge from the literature, but it is difficult to evaluate how confident we can be that the existing Cs are the major ones that can be trusted for therapeutic use. Also it is conceivable that other significant factors that don’ begin with C exist. t

19 of 42

The RELATE Model
Under its present name and its former title of the National Marriage Guidance Council, RELATE has been the single foremost provider of couple counselling for over 50 years in England, Wales, and Northern Ireland, and is probably one of the leading providers of such services in the world. RELATE currently has over 2,200 practising counsellors delivering over 30,000 hours of counselling a year to over 70,000 people in over 130 centres (Butler & Joyce, 1998; McCarthy et al., 1995 ). Given its long history and its desire to achieve a degree of uniformity of experience for such a large number of people (not least for client care and quality control purposes) one would expect RELATE to have a well honed and sharply defined model. What emerges is a tight framework (arguably rigidly claustrophobic or helpfully supportive) within which a plethora of approaches are contained. It feels like a counselling model designed by a committee over a number of years. In one sense it is easy to see how such an approach has emerged. The outward structure has been codified and refined as the organization has imposed a necessary centralized approach to training its vast number of counsellors, and over the years thousands of counsellors from a variety of backgrounds have contributed to the discussions about useful practice. On paper the result is a variety of theoretically potentially conflicting approaches to be applied at different stages in the process. RELATE’ current definition of its approach involves the attempted integration of s person-centred, psychodynamic, and cognitive-behavioural counselling philosophy. Derek Hill, RELATE’ Head of Practitioner Training, describes the s approach as being about engaging clients with warmth and support to address causes of disruption and to find shared solutions (Butler & Joyce, 1998, p.xi). However, this person-centred philosophy is then not left to flower in a natural person-centred way, but is squeezed into a definite shape with a psychodynamic and cognitive-behavioural exoskeleton. The counselling involves three well defined stages. There is a definite sense in which RELATE counselling is clearly ‘ driven’by the counsellor. The first stage, exploration, involves assessment of the suitability of couple counselling for the clients, the formation of the therapeutic alliance, initial exploration of the presenting problem, and contracting for further work. Stage one is about attempting to arrive at a shared, coherent description of the relationship and an understanding of the features needing attention. Few counsellors would have a problem with this initial work as it seems common and fundamental to most counselling approaches. However, the nature of the RELATE contract, with a commitment to explore the geology of the present relationship landscape, may be more prescriptive than all person-centred counsellors would be happy with.

20 of 42

In stage two, understanding, the philosophy is predominantly, and very broadly, psychodynamic. Although the dramatic change of philosophy may be mitigated in practice, it is clearly there in the theoretical model. Belief in unconscious motivation is an important and central part of the RELATE approach. Stage two is about attempting to explore the unexamined attitudes and experiences which have informed the present notions of what is acceptable and unacceptable, and what emotions are to be welcomed and what are to be avoided – the psychodynamic causes of the present problems. The counsellor’ role is to s present the clients to themselves and to offer them new perspectives which have their origins in one or other of the conceptual frameworks being used. The psychodynamic frameworks currently most commonly available to RELATE counsellors are (though one senses this may change at each ‘ committee meeting’ transference and counter-transference (Freud 1935), splitting and ): object relations (Klein 1987, Winnicott 1964), attachment theory (Bowlby 1988, Hazan and Shaver 1994), and triangles (Freud 1935, Guerin et al.1999). In addition to these psychodynamic models, RELATE counsellors are also encouraged to use conceptual frameworks from systems theory (Minuchin 1974) and from life-stage models (Erikson 1963). Stage three is about action and the theoretical model employed is predominantly, though not exclusively, cognitive-behavioural. For many clients, the insights gained from stage two will be enough. Others will want support and encouragement to look again at their behaviour patterns and to modify them. Stage three involves working with clients to enable them to appropriately challenge, to re-frame, and to modify specific behaviour. Even though it can be argued that it is a mistake to mix and match theories and techniques because to do so weakens each individual paradigm, it can also be argued that the complex nature of relational issues means that an approach combining insights and techniques from a range of theoretical perspectives is likely to be most effective. For example, Cohen (1999) has provided a rationale for combining a psychoanalytic and a systems approach – two schools of therapy often framed in opposition to each other. She argues that emphasis on interaction alone misses the complex contribution of an individual’ history, while s emphasis on individual psychology misses the way in which interpersonal interaction governs a couple’ intimate life. Altered perceptions and attitudes s about oneself and others can be achieved through psychodynamic insight on a cognitive and emotional level; yet this understanding needs to be translated into new behaviour and interaction patterns. Although it could be argued that it is perhaps RELATE’ fragmented approach s that may be its greatest weakness, in its defense it can also be argued that RELATE’ eclectic approach (albeit a somewhat codified eclectic approach) is s similar to the eclecticism practised by many counsellors. Use of the model also appears to have been beneficial in practice. For example, in addition to

21 of 42

anecdotal support, McCarthy et al. (1995) analysed interview and questionnaire responses from nearly 2000 clients immediately following the end of their RELATE counselling, and questionnaire responses from over 500 clients at six months and one year after their counselling. Of the clients who completed counselling, 80 per cent were satisfied with the service, 92 per cent said they would be likely to return if experiencing relationship problems and 65 per cent felt that all or most of their needs had been met. The authors also reported that their research suggested that RELATE clients felt better about themselves afterwards and tended to develop more sharing and more affectionate relationships with their partners afterwards. While wishing to acknowledge the importance for individual couples of the benefits of the RELATE approach reported by McCarthy et al. (1995), and while also wishing to acknowledge the value of the qualitative findings in the individual testimonies cited in the study, the report does present quantitative evidence that needs to be challenged on its own terms. Apart from the fact that a third of the clients who completed counselling were unable to say that all or most of their needs had been met, there are three fundamental weaknesses that should be borne in mind when evaluating the ‘ success of the RELATE approach’figures cited above. First, there is no control group in the study so it is difficult to evaluate how much of the reported change is due to the intervention of RELATE. It may have happened anyway with the passing of time. Similar changes might have been achieved if the couples simply talked about their relationship with an untrained listener. The figures do not report the unique impact of the RELATE counselling. Secondly, the research does not attempt to address the problem of how far individual counsellors adhered to the model as described in the RELATE literature. Given that all RELATE counsellors receive a minimum of two years training and receive regular supervision from senior practitioners, one might assume a fair degree of homogeneity. However, this assumption may be dangerous given both the large number of counsellors and supervisors involved and the wide range of possible theoretical approaches. Even when working within one of the possible models, psychodynamic, for example, it would be entirely possible for two counsellors to adopt different approaches when trying to understand the roots of the problem. Treatment integrity is not an issue which is addressed by McCarthy et al. (op.cit.). Any future empirical work on the RELATE model would need to address this by introducing some mechanism for attempting to control or report consistency of approach across the range of counsellors and supervisors. A third major problem with the reported findings of McCarthy et al. (op.cit.) is that the ‘ success’of the findings is based on self-reported evaluation of the counselling, and there is good empirical evidence to challenge the validity of this methodology for evaluating real change or benefit. For example, Jacobson et al. (1987) conducted a two year study of couples who had received counselling. The sample was divided into those couples who appeared to retain therapeutic gains (the maintainers) and those whose gains had deteriorated (the relapsers).

22 of 42

What is interesting is that both sets of couples were unanimous in their positive feeling expressions about therapy, with 80% of the maintainers and 100% of the relapsers expressing the belief that therapy had had a positive impact on them. When considering self-report data in therapy with problem families Patterson (1982) reported participants often wanted to use satisfaction expression as a way of saying, “ Thank you for trying,”to the therapist, even when no lasting change materialised. If McCarthy et al. (op.cit.) want ‘ hard’data to assess the outcome of interventions, self-report satisfaction measures are dangerously ‘ . soft’ This last point raises the issue of the conflation of two separate variables in the reporting of the RELATE study. Client satisfaction should not be confused with counselling effectiveness (despite the obvious interaction between the two). Theoretically, at least, it is possible for the counselling to be effective and for the client to feel dissatisfied. Arguably what happens more often is that client satisfaction is taken as a key (often only) indicator of counselling effectiveness, when clearly it is possible for the client to feel satisfied and for no real change to have occurred. The psychodynamic part of the RELATE model, stage two (understanding), also illustrates some of the major difficulties of using psychodynamic theory. A unified theory does not exist and individual therapists will pick and choose which part of whichever theoretical framework seems relevant or important to her or him. New and apparently contradictory concepts can be incorporated into psychodynamic thought without displacing existing concepts. Each concept is viewed as an equally valid though different way of viewing the same data. (In my own reading I discovered at least three different psychodynamic understandings of the notion of triangular influences in dyadic relationships.) Many of the psychodynamic concepts evolved from working with individual clients and yet are being applied to couples, often at the risk of invalidating the original theoretical observation by introducing a new interpersonal influence. If a theory is to provide practitioners with a clarity of vision and coherence of action in perplexing clinical contexts, I remain sceptical about the adequacy of the RELATE theoretical model.

23 of 42

Problems in Assessing the Effectiveness of Couple Counselling Models
The models discussed above are drawn from a range of theoretical perspectives. However, they are not intended as an exhaustive list and there are a plethora of others. Given the volume of theoretical discussion available, practitioners may wish to know which model is most effective. Unfortunately there is no simple answer to that question, but an attempt to answer it will illustrate some of the difficulties involved. The interest in finding an answer takes on an economic as well as a human dimension when one realises the potential link between couple conflict and deterioration in mental health. Donovan (1999) quotes figures from the United States suggesting that 40% of mental health referrals are related to couple conflict. Wesley and Waring (1996) conducted a review of Marital Therapy Outcome Research and examined over 55 empirical studies which had used counselling models drawn from all the major theoretical perspectives. They rigorously limited their review to studies which met the following criteria: ? There had to be a clear rationale and a description of procedure so that therapists could be trained to know what to do and why they were doing it. ? There had to be ‘ treatment integrity’– evidence that the therapists actually did what they said they were going to do. ? There had to be a control group so that in evaluating any outcome, the effects produced by the counselling could be compared with couples who had received no counselling. ? The subjects had to be randomly assigned to either a ‘ treatment’or control group in order to minimize the confounding of results and to maximizing the likelihood that the groups being compared would be equivalent. One would hope that the existence of a substantial number of studies meeting the above criteria would provide some clear indicators about the effectiveness of couple counselling and about which theoretical model appeared to be most effective (empirically, at least). However, practitioners may still find themselves (or choose to place themselves) left in the fog or relying on qualitative data drawn from their own experience of counselling and being supervised. The majority of studies (45 out of 55) found statistically significant gains across a variety of outcome measures for the ‘ treatment’groups initially suggesting that couple counselling is more effective than no counselling in helping couples. While those findings are potentially heartening, a number of important caveats need to be made when interpreting the results. First, it is difficult to evaluate the clinical significance of the scale of the change. Improving three points on an ability to communicate measure may be statistically significant but make extremely little difference to the quality of relationship as

24 of 42

experienced by the couple. The improvement rate in the absence of counselling is so low that even small changes from counselling are likely to be statistically significant. A reanalysis by Jacobson et al. (1984) of four studies in the Wesley and Waring review concluded that about 35%-40% of the couples moved from distressed to non-distressed by the end of the counselling. While this is good news for those couples concerned, one is left wondering what happened to the other two-thirds of couples for whom the counselling had little significant clinical impact. Wesley and Waring (op.cit.) also quote a metaanalysis of 9 studies by Hahlweg and Markman (1988) who found that the majority of couples describe their relationships as unsatisfying and distressful at the end of the counselling. Secondly, it is difficult to evaluate the endurance of any change. Most of the studies did not conduct any longer-term follow-up and the few that did produced ambiguous results. Future research needs to address the issue of endurance of change. Any model which gives more encouragement for couples to become their own counsellors and adapt to future problems will add most value to the counselling in any present crisis. Thirdly, it is possible that the above results may not reflect the level of improvement obtained in normal clinical practice. For instance, counsellors typically respond to the unique needs of each couple that present themselves rather than formulate a generalized prescriptive plan. In the research reviewed above couples were randomly assigned to methodological groups, regardless of their needs. Also most counsellors would, in some cases, regard a decision to separate as a positive counselling outcome in the best interests of the clients, though this would be regarded as negative in the research results. It is possible that couple counselling is more effective than the empirical studies would indicate. Similarly there is no clear answer as to which model is most effective. 42 of the 55 studies were concerned with Behavioural Marital Therapy and clearly there is more empirical support for this model because of the volume of studies done in this area. However, there was also empirical support for Cognitive Marital Therapy, Emotionally Focused Cognitive Therapy, and for Insight-Oriented Marital Therapy (psychodynamic), though the studies meeting Wesley’ and s Waring’ are fewer. Behavioural Couples Therapy is not only the most widely s tested, it is also the only form of couple therapy that the clinical division of the American Psychological Association lists as meeting the criteria of ‘ empirically an validated treatment’(Lawrence et al. 1999). Although Wesley and Waring report that there appears to be little difference between the immediate gains made using behavioural and psychodynamic approaches, they also report two interesting studies by Snyder and his associates (1989, 1993) who found larger long-term differences. Four years after counselling only 10% of the couples receiving insight-oriented counselling had significantly deteriorated compared to 46% of those who had received behavioural therapy. Also only 3% of insightoriented couples had divorced after 4 years compared to 38% of behavioural

25 of 42

couples. This could suggest that in the long-term education (insight) is more valuable to couples than training (behavioural techniques). Clearly these findings need to be substantiated. The failure, to date, to find a model which is clearly more effective than any other is interesting, but on reflection is not surprising. Behaviour, cognition, and affect are interrelated and any change in one area is likely to have a reciprocal influence on the other areas. Working on one area of marital distress is likely to impact other areas of the marital interaction and influence the entire relationship. In attempting to provide answers as to whether or not couple counselling is effective, and if it is, which model is most effective, Wesley and Waring (op.cit.) and all others who provide reviews of the empirical literature (Accordinio and Guerney, 2003, for example) need to take account of at least three other perspectives. The first perspective is moral and concerns the ethical nature of the research. Many counsellors would want to argue that it is unethical to leave distressed couples in a control group of no counselling. The research shows that it is not in the couples’best interest to do so. No only do they not receive the potential benefits of counselling, but the absence of therapeutic support could lead to the deepening of problems and the reinforcement of unproductive styles of relating. The second perspective is pragmatic and has already been raised above. Most counsellors do not work rigidly or prescriptively but seek to understand and work with the unique needs and preferences of each couple. In some cases working with clients to help them end the relationship might be viewed as a ‘ success’ although this would not be recognised as such in the empirical studies. In practice, few counsellors would seek to impose a ‘ treatment programme’that they expect to be effective in with all clients, regardless of their individual or relationship history. Most counsellors bend their practice to meet the needs of the clients and try to avoid bending clients to meet the counsellor’ need for s security and order. The third perspective is epistemological and relates to the wider issue of what constitutes knowledge and evidence in counselling research. Although Wesley and Waring (op.cit.) produced stringent criteria for selecting their studies for review they still managed to find 55, which strongly suggests that there must be hundreds which did not meet their criteria. Some of these studies may have been badly designed but many of them may have been conducted by researchers who were unwilling to compromise their ethical standpoint and randomly assign hurting human beings to a control or experimental group, or by researchers who acknowledge that counsellors tend to respond rather than direct and that success is often felt through engagement at a variety of levels rather than by outcomes. Clearly there is a whole wealth of qualitative data rejected by the quantitative surveys. A glimpse of this can be seen in the vignettes

26 of 42

presented by McCarthy et al. (1995) when evaluating the work of RELATE. While the possibility of the exact opposite exists, it is also possible that couple counselling has a more positive effect than the quantitative data reports.

27 of 42

Integrating New Factors
When reflecting on my own counselling practice in light of the models reviewed above I was struck by the fact that there were at least three factors which were becoming increasingly important to me but which received scant or no explicit discussion in these models. In the final part of this dissertation I propose to discuss these factors, arguing their importance and the need for an awareness of them to be integrated into any existing model as a way of enhancing existing couple work. In my opinion, all three factors have a significant part to play in influencing motivation and hence in determining the likely maintenance of any couple relationship, if it is appropriate to do so.

Disjunctive Stages
In describing his practice of Time-Effective Couple Therapy (described by the author as a practical integration of psychoanalytic, behavioural, solution-oriented, and cognitive approaches) Budman (1999) argues for the need for an appropriate assessment of both where the couple are in their relationship, and how ready they are for counselling before beginning work with them. In assessing the latter he draws on the Prochaska Stages of Change Model (Prochaska, Norcross, & DiClemente, 1994) which was originally developed to examine how smokers went about the process of stopping nicotine use, and since then has been useful as a generic model and applied to many life-change processes. The Prochaska Model is circular and describes six stages, with the seventh stage going back to the beginning and starting another cycle of change. The stages, as related to couple work, are: ? Precontemplation – an individual has little motivation for change. People in this stage coming for couple therapy have been ‘ dragged in’by their partners who they think are making a mountain out of a molehill, or they think that their relationship is beyond repair. Occasionally both partners arrive in this state, especially if order to attend therapy by the courts. ? Contemplation – an individual characterized by ambivalence (can’ live t with him/her and can’ live without him/her). The majority of people t presenting for couple counselling are in contemplation. ? Preparation – an individual who is minimally ambivalent, who is committed to change, but who has not yet begun to attempt to change her or his interactions. If both partners are at this stage they are often looking to ‘ an expert’to help them get things going. ? Action – an individual who has been trying to make changes on his or her own and who is now seeking support and new strategies for even greater

28 of 42

? ?

effectiveness. This stage is characterized by keenness and openness to new things. Maintenance – couples who have achieved significant changes and who are seeking support to iron out problems and maintain the gains made. Termination – couples who have achieved the desired change and who have maintained it for some time so that the changes have become automatic and integrated into their cognitive, affective, and behavioural patterns.

My own experience of beginning to work with couples is that very few of them arrive at the same stage of readiness for change. One of them is often at least one stage (or sometimes two stages) ahead of her or his partner. Typically a woman will be committed to change and seeking help (preparation stage) while her male partner will think that she is exaggerating the importance of the issues or feel that the relationship is beyond repair (precontemplation stage). This latter partner is often saying: “ We don’ need help,”or “ t We are beyond help,”as well as “ You certainly can’ help us.” t As an inexperienced counsellor I often interpreted this disjunctiveness as the couple being unready or unsuitable for counselling. I now regard an informal assessment of the beginning stages of each partner as an essential part of my work and try to use any disjunctiveness in at least four ways. First, I bring it into the open as a way of acknowledging the reality of both partners. By making a conscious effort to affirm the reality of the one ‘ left behind’ I am encouraging him or her to stay with the process rather than feel , excluded by it. Secondly, I sometimes deliberately focus on it as a way of exploring differences in the relationship. This can be useful as a way of introducing the option of individual counselling for one of the partners if appropriate. This is not about me suggesting that one of the partners might benefit from some individual sessions, but about the couple realizing that they are at different places for a number reasons and that one (or both) of them may benefit by exploring the reasons for that separately. Thirdly, where there is disjunctiveness I assume that one of the partners is likely to be more sceptical about counselling and looking for immediate, obvious benefits. In such cases I try to include cognitive-behavioural strategies likely to bring some immediate changes to help encourage both partners to engage and stay for the longer-term work. Fourthly, I use reduction in any disjunctiveness as a marker of progress and a means of encouragement. After a number of initial sessions it is often possible for the person who was ‘ lagging behind’to have moved up a stage or two. Consciously acknowledging this is encouraging for both partners and provides a fresh impetus for the new work.

29 of 42

Relationship History and Forgiveness
All of the models discussed above (psychoanalytic, cognitive-behavioural, and systems theory) have space for history, acknowledging that the past influences the present. The emphasis in the psychoanalytic models is on what the individual’ past brings to the relationship. Other models acknowledge the s importance of the past in terms of learned patterns of thinking and behaving between the couple. While these factors are important, what these models fail to explicitly address is one issue that is likely to have a huge impact of the restoration of any relationship – namely a couple’ understanding of, and s experience of forgiveness, and their willingness to forgive. Forgiveness is a decision not to hold something against someone. I have argued elsewhere that forgiveness is “ constructive, motivational, interpersonal and/or a intrapersonal, coping process”(Rye, 2004). It involves flux and recycling, and individuals will process at their own pace. For some there will be an interpersonal element involving changes of intent (and possibly practice) towards other individuals. For others the interpersonal element may be absent. Changes of intent towards another would not be about restoration of relationship, but about clients electing to remove a burden from themselves for their own benefit, regardless of any other individual. It brings some form of release for the person doing the forgiving and may pave the way for the reconstruction of a positive relationship with the person who has been forgiven. Clearly, a willingness to forgive interpersonally is crucial in couple work. Without it there are permanent, serious barriers to restoration. I have previously argued (Rye, op.cit.) that there are at least seven factors identified in the research literature that influence the likelihood of forgiveness taking place - age, interpersonal distance, apology, rumination, empathy, personality, religious faith. In working with couples, I have found the first five factors in the list to be most relevant and use them as a means of helping me assess some of the possible difficulties the partners face in achieving any appropriate reconciliation. For example, empirical studies by Girard and Mullet (1997) found that adults are more likely to forgive than adolescents, and that elderly people are more likely to forgive than younger adults. The propensity to forgive has a developmental character and this development takes place over an entire life span. McCullough (1997) found that forgiveness more readily occurs in satisfactory committed relationships and that relational closeness facilitates forgiveness. Young couples, without either a history of sustained close commitment despite difficulty, or an understanding of forgiveness, are likely to find reconciliation more difficult than a middle-aged couple with such experiences and understanding. That does not mean that reconciliation is not possible for the younger couple – it simply means that I as a counsellor need to be sensitive to the greater distance that they may need to travel.

30 of 42

When working with couples I use the concept of forgiveness in at least four ways. First, as discussed above, I use the likelihood of forgiveness factors to help me assess how far the couple may have to travel. Secondly, at some stage in the counselling (usually in the final quarter) I explore with them what they understand by forgiveness and whether they feel any forgiveness is necessary or appropriate. I use forgiveness as a way of approaching the final stages of counselling after some greater understanding of problem issues and success in change has already been achieved. It is sometimes useful in providing a marker for what may still need to be done, despite previous changes. Thirdly, I try to work with clients to therapeutically use the issues raised in the second stage. “ Why is it that forgiveness is so difficult?” “ a rumination strategy helpful for you Is and the relationship and if not, how could you both work to change it?” “ Why do you think you find it so difficult to apologise?” “ the lack of empathy a pattern Is that has existed throughout your relationship, or can you think of times when you have been able to be more empathic?” Fourthly, if appropriate, and if the couple wants to, I use forgiveness in a celebratory and symbolic way. Towards the end of counselling I work with couples to consciously list what they have forgiven each other for, to state that forgiveness to each other, and to literally destroy the paper as a symbolic and often powerfully affective way (there are often tears) of marking their cognitive decision not to hold things against each other and to work towards moving on and behaving differently.

31 of 42

The final factor that I find myself becoming more sensitive to and trying to work with therapeutically, despite its relative absence from the couple literature, is that of gender. Sociologists and psychologists have long argued that the differences between men and women are more than biological. In this context, gender is best understood as ‘ social construction and a concept mediated by social a learning theory that shapes one’ schema and role definitions’(Worden and s Worden, 1997, p.5). Although the influence of the gender of the counsellor, and the experience of each gender during counselling are relevant factors here (for example, in one literature review it was found that counsellors have tended to ascribe more internality to women’ presenting problems, and more situational triggers for s men’ presenting problems, Lopez, 1989), I am more immediately interested in s this dissertation in the influence of the gender of each partner in the couple counselling process and was unable to find much direct discussion of this in the literature. However, there is a large literature documenting gender differences. For example, Tannen (1990, 2002) summarizing the literature on communication differences, has argued that discourse can be categorised as either communicative talk or control talk, rapport speech or report speech, and that in broad terms men more often resort to control-report speech than communicativerapport speech. In their summary of gender differences, Worden and Worden (op.cit.) have reported that generally speaking, women and men experience intimacy, communication, conflict, and marital satisfaction differently. The Seven Cs model (Birchler et al.1999) does encourage counsellors to work with clients on any cultural differences due to ethnicity or class. In my view, cultural differences due to gender could usefully be added to that list. I try to use my awareness of gender differences in my work with couples in at least four ways. First, if it is apparent that there are gender-related communication style differences, I try to bring this into the open as a way of describing and acknowledging the reality for both partners. Neither style is wrong, just different. I want to avoid one partner (typically the man) feeling blamed by the process or excluded from it. Secondly, I try to explore these differences with the couple. What impact (if any) have these differences had on their relationship, their sense of intimacy, and their success in problem solving. Thirdly, although communication style is usually only part of the problem in any relationship, it is an issue which is often immediate and can appear ‘ contained’and tangible, and therefore in one sense ‘ easy’to work on. Typically such work would address how to express oneself in a non-confrontational way, and how not to make

32 of 42

assumptions about negative metamessages. However, I have found that an awareness of gender differences can sometimes help remove a sting by providing a neutral explanation of the behaviour. “ may be that it is not that she It doesn’ want to solve the problem, it is just that she wants to talk about what she t feels about the options first.” “ may be that it is not that he isn’ interested in It t what you feel, it is just that he is struggling to see why that is relevant at this moment.” Adding a gender awareness dimension to communication style work can improve understanding and empathy, bring some immediate success, and hence encourage both partners. My fourth way of using an awareness of possible gender differences is to compare some aspects presenting behaviour against existing empirical templates of gender different behaviour in couple conflict, as a way of helping identify and highlight unproductive patterns. For example, after many years of empirical work studying American married couples in conflict, Gottman (1999) and his team have identified a ‘ withdraw-demand’pattern where a woman will tend to be more critical than her male partner, and he will tend to ‘ stonewall’any serious attempt at conversation more so than she would. If appropriate, it can be helpful to draw attention to this pattern as a starting point for change and for exploring reasons behind the behaviour. Gottman (op.cit.) argues that the existence of the ‘ stonewalling woman’is extremely rare, and if found, is possible testimony to a high degree of fracture within the relationship.

33 of 42

In individual counselling, two complex human beings are interacting. Each client will have a different motivation for counselling, different level of engagement in counselling (which will vary across and within each session), and different conscious and unconscious needs. However, it is important to realise that in couple counselling the counsellor is not just interacting with two other complex human beings. The relationship, with its own history, identity, and sensitivities hangs as a third entity between the two clients. And each client’ different s motivation for counselling, different level of engagement in counselling (which will vary across and within each session), and different conscious and unconscious needs will influence the relationship. It is no wonder that it is difficult to find a satisfactory model for couple counselling given the potential complexities involved. In addition to the specific critique of the four models explored in previous sections, I have two broad criticisms of them. The first concerns a presumed linear model in some of them; the second concerns a blinkered emphasis. Linearity may be neat in theory (for example, in the RELATE model you start by considering the background to the problem, before moving on to changing patterns), but in my experience, this would be very unsatisfactory in practice for at least two reasons. First, most couples do not want to begin by exploring their past family histories, but want some immediate relief and importantly hope that they may be able to bring about change. Secondly, if they are at different starting points, and if there are pronounced gender differences in expectations about counselling, the chances are that at least one of them will be turned off by psychodynamic archaeology as a starting point. Individuals will not fit onto a Procrustean bed, neither will couples nor their relationship. Broadly speaking many of the above models could be characterised as having a blinkered emphasis, stressing either an historical understanding of the etiology of present problems, or as emphasizing the exact nature of the patterns in the present problems. Again, I have two problems with this. First, depending on the nature of the couple, the problem, and their relationship and its history, one of the above emphases may be appropriate rather than the other, and if you employed the wrong model, counselling is likely to miss the main point. One model may not be appropriate for all situations. Secondly, it is more likely that it is not a case of one emphasis being helpful, but both of them being relevant. If the present cycle is to be tracked, if its power is to be understood, if change is to be implemented, it is probably not a case of ‘ either/or’ but of ‘ , both/and’ . ` Despite the difficulties of finding a single model, there is an implicit recognition in all the models considered that couple counselling shares similar goals to that of individual counselling. Counsellors work with clients to help them recognize

34 of 42

strengths and problems, understand strengths and problems, change of patterns of thinking, communicating, and behaving which have become dysfunctional in some way, change feelings, and consolidate all of these changes. Put more succinctly, it is about tracking the present cycles of thinking, feeling, and behaving, understanding the etiology and power of those cycles, and breaking into it to establish new ones.

The 3E-4D Model for Couple Counselling
Reading the above literature has helped me begin to formulate my own model for couple counselling. I have attempted to integrate a variety of counselling approaches and have developed a new model both from that theoretical integration and from my experience of working with couples over the past seven years. The statements offered below are work in progress. Figure 1 is an attempt to give a diagrammatic representation of the following principles:

35 of 42

Behaviour together History


Thoughts about

Feelings about

Gender Couple Counselling


Behaviour Partner 1 History

Thought Feeling



Partner 2



Figure 1

The 3E-4D Couple Counselling Model

36 of 42

1. There are three entities in couples work – each individual and the relationship itself. Any work on the relationship which ignores issues in the individual partners is likely to produce only short-term gains. 2. In addressing the needs of the couple it may be necessary to address individual needs separately. 3. Each of the above three entities has four dimensions which may need to be worked on. These dimensions are thought, feeling, behaviour, and history. Changing history is about experiencing a new present as well as about viewing the past differently (where appropriate). 4. Problems are rarely (if ever) one-dimensional, and approaches which seek to address single issues (behaviour problems, for example) are likely to produce only temporary change. Change needs to be considered on all four dimensions. 5. Each couple is unique and has unique needs. It is important to start with where the couples are and their expressed needs. For example, etiology may be important in understanding the relationship, but it is rarely a presenting issue. 6. Success is motivating and helps restore morale. Counsellors who consider ways of helping couples find positive solutions (even if the change is only initially surface rather than structural) are more likely to engage both partners in the longer term. 7. Small changes can lead to bigger changes. 8. Understanding and relevant practising of forgiveness can be a powerful impetus for change in couples. Counsellors should consider exploring a couple’ understanding and practice of forgiveness. s 9. Disjunctive starting points are a reality for most couple work. An awareness of this and an ability to work with it therapeutically can be important in couple work. 10. Men and women may behave differently. An awareness of gender culture can provide useful insights into mixed-gender couple work. I do not feel comfortable with the postmodern emphasis on bypassing problemladen history (see Keim, 1999, for example) because I believe that an understanding of etiology can provide useful insights and motivation for change. I do, however, feel uncomfortable with a dominant emphasis on it, especially early on in couple counselling. I want my emphasis to be on what helps solve problems more than on what causes them. Despite this difference, my proposed model does allow for the postmodern emphasis on flexibility, alliance building, externalization of the problem, and personal agency (Donovan, 1999). Because of the need for funding providers to justify expense, and because of the need for counsellors to be accountable, the search for the Holy Grail of the most effective couple counselling, as ‘ measured’by quantitative research will doubtless continue. Hopefully more counsellors and researchers will continue to

37 of 42

challenge the ethics and epistemological inadequacy of such research, and will begin to feel more confident about integrated approaches and qualitative methods. I hope that this study has raised at least two arguments in favour of integration. First, the complexity of the potential issues in couple relationships argues for a multifaceted approach, using theory flexibly to meet the multiple needs of the clients in relationship, rather than making clients follow the dictats of a single theory. Secondly an integrated approach allows for redundancy and for working on issues in a variety of ways, creating conditions that are more likely to lead to reinforced and lasting change. My integrated model may be less theoretically tight, but it is arguably more person-centred and potentially more effective than some more rigid models. I am starting to use it experimentally in at two ways. First, when reviewing work privately and in supervision, I am using the entities and dimensions as an internal framework for reflecting on areas already explored in the counselling, for considering what areas have been neglected or ignored, and for reviewing if there needs to be a change of emphasis at some stage. I suspect that it would be impossible and possibly tiresomely pedantic to feel the need to consider all twelve dimensions, but the framework is helping me identify favoured patterns in my own couple counselling (a focus on communication patterns) and challenging me to work in different ways in the best interests of the clients (the emotional etiology of such patterns). As previously stated, I am now much more relaxed about using individual therapy within a couple counselling context because of being able to acknowledge that I am working with two individuals and not just their relationship. Secondly I intend to use it more overtly with couples if they get stuck (in my experience about two-thirds of the way through counselling). They have made some initial changes and feel encouraged by success. Things are better, but they are not yet sure what the best is or what they have still to do. I hope to introduce an appropriate form of the model to encourage them to reflect on and discuss how their thinking, feeling, and acting singly and in relationship have changed and how they now view aspects of their own past and their relationship past. In addition to providing encouragement, I hope that it will generate fresh understanding about what still needs to be done, as well as giving a fresh impetus to the latter stages of counselling. Counselling is still a relatively young profession and it is easy to see how different counselling schools developed in history as early theoreticians felt the need to define themselves, sometimes in opposition to each other. A century or so later, it may be time to re-establish common ground and work more flexibly against a background of knowing that all the different schools have contributed insights and techniques that can be useful in working with the complexity of a couple in counselling.

38 of 42

Accordinio, M., & Guerney, B.G. (2003) "Relationship Enhancement Couples and Family Outcome Research of the Last 20 Years", The Family Journal: Counseling and Therapy for Couples and Families, 11 (2) 162-166. American Psychological Association (1996) Family and Relationships: Get the Facts , Accessed 01/02/05. Baucom, D., Shoham, V., Mueser, K., Daiuto, A., & Stickle, T. (1998) "Empirically supported couple and family interventionsThought for marital distress and adult mental health problems", Journal of Consulting and Clinical Psychology, 66 53-88. Birchler, G., Doumas, D.M., & Fals-Stewart, W.S. (1999) "The Seven Cs: A Behavioral Systems Framework for Evaluating Marital Distress", The Family Journal: Counseling and Therapy for Couples and Families, 7 (3) 253-264. Bowlby, J. (1988) A Secure Base. London: Routledge. Budman, S. (1999) "Time-Effective Couple Therapy", In: J.M. Donovan (ed.). Short-Term Couple Therapy, New York, London: The Guilford Press, 173-200. Butler, C., & Joyce, V. (1998) Counselling Couples in Relationships: An Introduction to the RELATE Approach. Chichester: John Wiley & Sons Ltd. Cohen, P. (1999) "Psychoanalytically Informed Short-Term Couple Therapy", In: J.M. Donovan (ed.). Short-Term Couple Therapy, New York, London: The Guilford Press 144-72. Department for Industry (2003) A framework for the legal recognition of same-sex couples , Behaviour Accessed 01/01/05. Donovan, J. M. (ed.) (1999) Short-Term Couple Therapy, New York: The Guilford Press. Erikson, E. (1963) Childhood and Society. New York: Norton. Fincham, F.D., & Bradbury, T.N. (eds.) (1990) The Psychology of Marriage: Basic Issues & Applications, New York, London: The Guilford Press.

39 of 42

Fincham, F.D., Bradbury, T.N., & Scott, C.K. (1990) "Cognition in Marriage", In: F.D. Fincham, & T.N. Bradbury (eds.). The Psychology of Marriage: Basic Issues and Applications, New York, London: The Guilford Press 118-49. Freud, S. (1935) A General Introduction to Psychoanalysis. New York: Liverright. Friedman, S.& Lipchik, E. (1999) "A Time-Effective, Solution-Focused Approach to Couple Therapy", In: J.M. Donovan (ed.). Short-Term Couple Therapy, New York, London: The Guilford Press 325-59. Girard, M., & Mullet, E. (1997) "Forgiveness in adolescents, young, middle-aged, and older adults", Journal of Adult Development, 4 209-220. Gottman, J. (1999) The Marriage Clinic: A Scientifically Based Marital Therapy. London, New York: W.W. Norton & Company Inc. Government Actuary’ Department (2005) New Marital Status Projections for s England and Wales. .pdf , Accessed 13/03/05. Guerin, P., Fay, L.F., Fogarty, T.F., & Kautto, J.G (1999) "Brief Marital Therapy: The Story of the Triangles", In: J.M. Donovan (ed.). Short-Term Couple Therapy, New York, London: The Guilford Press 103-23. Hahlweg, K., & Markman, H.J. (1988) "Effectiveness of behavioral marital therapy: empirical status of behavioral techniques in preventing and alleviating marital distress", Journal of Consulting and Clinical Psychology, 56 440-447. Halford, W., Bouma, R., Kelly, A., & Young, R.M. (1999) "Individual Psychopathology and Marital Distress: Analysing the Association and Implications for Therapy", Behavior Modification, 23 (2) 179-216. Hazan, C.&., Shaver, P. (1994) "Attachment in an organizational framework for research on close relationships", Psychological Inquiry, 5 1-22. Jacobson, N., Schmaling, K., & Holtzworth-Munroe, A. (1987) "Component analysis of behavioral marital therapy: Two-year follow-up and prediction of relapse.", Journal of Marital and Family Therapy, 13 (2) 187-195. Johnson, S. (1999) "Emotionally Focused Couple Therapy", In: J.M. Donovan (ed.). Short-Term Couple Therapy, New York: The Guilford Press 13-42. Keim, J. (1999) "Brief Strategic Marital Therapy", In: J.M. Donovan (ed.). ShortTerm Couple Therapy, New York, London: The Guilford Press 265-90.

40 of 42

Klein, J. (1987) Our Need for Others and Its Roots in Infancy. London: Tavistock. Knox, N. (2004) Nodic family ties don't mean tying the knot , Accessed 14/02/05. Lankton, S. (2003) Brief Goal Directed Couples (and Individual) Therapy , Accessed 15/02/05. Lawrence, E., Eldridge, K., Christensen, A., &, Jacobson, N.S. (1999) "Integrative Couple Therapy: The Dyadic Relationship of Acceptance and Change", In: J.M. Donovan (ed.). Short-Term Couple Therapy, New York, London: The Guilford Press 226-64. Levinger, G., & Huston, T.L. (1990) "The Social Psychology of Marriage", In: F.D. Fincham, & T.N. Bradbury (eds.). The Psychology of Marriage: Basic Issues and Applications, New York, London: The Guilford Press 19-58. Lopez, S. R. (1989). “ Patient variable biases in clinical judgment: Conceptual overview and methodological consideration” Psychological Bulletin, 106, 184— , 203. Maudlin, G. (2003) ""Forgive and Forget: A Case Example of Contextual Marital Therapy", The Family Journal: Counseling and Therapy for Couples and Families, 11 (2) 180-184. McCarthy, P., Walker, J., & Kain, J. (1995) Telling It As It Is: the client experience of Relate counselling. Newcastle: Newcastle Centre for Family Studies. McCullough, M., Worthington, E.L., Jr., & Rachal, K.C. (1997) "Interpersonal forgiving in close relationships", Journal of Personality and Social Psychology, 73 321-336. Minuchin, S. (1974) Families and Family Therapy. Cambridge, MA: Harvard University Press. Moore, K., Jekielek, S.M., Bronte-Tinkew, J., Guzman, L., Ryan, S., & Redd, Z. (2004) What Is "Healthy Marriage?" Defining the Concept, 16 (20/09/04) Child Trends Research Brief. Office of Statistics (2004) Population Trends 118 , Accessed 12/01/05. Patterson, G. (1982) Coercive Family Process. Eugene, Oregan: Castalia.

41 of 42

Prochaska, J., Norcross, J.C., &, DiClemente, C.C. (1994) Changing For Good. New York: William Morrow. Rye, J. (2004) "Holding On and Moving On: A small-scale investigation into the understanding of forgiveness held by one group of counsellors in training", Unpublished MA Assignment. Segraves, R. (1990) "Theoretical Orientations in the Treatment of Marital Discord", In: F.D. Fincham, & T.N. Bradbury (eds.). The Psychology of Marriage: Basic Issues & Applications, New York, London: The Guilford Press 281-98. Snyder, D.&., Willis, R.M. (1989) "Behavioral versus insight-oriented marital therapy: effects on individual and interpersonal functioning", Journal of Consulting and Clinical Psychology, 57 39-46. Snyder, D., Mangrum, L.F., &, Willis, R.M. (1993) "Predicting couples' response to marital therapy: a comparison of short-term and long-term predictors", Journal of Consulting and Clinical Psychology, 61 61-69. Tannen, D. (1990) You Just Don’ Understand: Men and Women in t Conversation. New York: Ballantine. Tannen, D. (2002) I Only Say This Because I Love You. London: Virago Press. Wallerstein, J. (1996) The Good Marriage: How and Why Love Lasts. New York: Warner Books. Weiss, R., & Heyman, R.E. (1990) "Observation of Marital Interaction", In: F.D. Fincham, &., T.N. Bradbury (eds.). The Psychology of Marriage: Basic Issues and Applications, New York, London: The Guilford Press 87-117. Wesley, S., & Waring, E.M. (1996) "A Critical Review of Marital Therapy Outcome Research", Canadian Journal of Psychiatry, 41 (September) 421-428. Wile, D. (1999) "Collaborative Couple Therapy", In: J.M. Donovan (ed.). ShortTerm Couple Therapy, New York, London: The Guilford Press 201-25. Winnicott, D. (1964) The Child, the Family, and the Outside World. Harmondsworth: Penguin Books. Worden M. & Worden, B.D. (1997) The Gender Dance in Couples Therapy. Belmont, CA: Wadsworth Publishing.

42 of 42

Shared By: