Clinical handbook of psychological disorders: A step-by-step treatment manual (5th edition)
Chapter 18
Couples distress

Traditional behavioural couple therapy

Couple therapy refers to clinical approaches for improving the functioning of two individuals within the context of their romantic relationship to one another.

Successful treatments for couple distress have emphasized the assessment and modification of each individual’s contribution and response to specific interactions in their relationship.

For a long time, the ‘gold standard’ for the treatment of couple distress has been behavioural couple therapy.

Traditional behavioural couple therapy (TBCT) uses basic behavioural principles of reinforcement, modelling, and behavioural rehearsal to facilitate collaboration and compromise between partners.
TBCT teaches them how to 1) increase or decrease target behaviours (behaviour exchange) 2) communicate more effectively (communication training) 3) asses and solve problems (problem solving).

This is done to improve overall relationship satisfaction.

An Integrative therapy

Three developments in Integrative behavioural couple therapy (IBCT) are directed toward making treatment more enduring and broadly applicable than TBCT 1) a focus on the couple’s relational ‘themes’ rather than on specific target behaviours 2) an emphasis on ‘contingency-shaped’ versus ‘rule-governed’ behaviour 3) a focus on emotional acceptance.

The focus on relational ‘themes’ is a focus on long-standing patterns of disparate yet functionally similar behaviours. Multiple and complex behavioural interactions are considered for therapeutic intervention.

A highlight for all behavioural approaches, is an assessment process that transforms broad global complaints into specific, observable behaviours. IBCT suggests that valuable information may be lost in the transformation of a global behaviour into a specific behavioural target. It limits the means by which partners may satisfy each other. There may be more than one behaviour that can be changed. Without elaborate exploration of and functional analysis of the thoughts, feelings, and behaviours, opportunities for change may be lost. The specific behavioural definitions may also have iatrogenic effects.

IBCT focuses on developing a shared understanding of the circumstances in which the desired feelings (or lack thereof) occur. IBCT tries to keep open all possibilities of behaviours that function to provide each spouse with his/her desired emotional state. If one partner has difficulty performing a particular behaviour, (s)he may still be able to perform other, perhaps less obvious behaviours that serve the same function. By focusing on the broader emotional ‘theme’, rather than attempting to operationalize that theme completely into one or more specific behaviours, IBCT maintains its functional roots, while increasing the changes that each partner is able to meet the other’s needs.

Rule-governed behaviour means that an individual is provided with a rule to guide his/her behaviour and its then reinforced when (s)he follows the rule. Contingency-shaped behaviour means that naturally occurring events in the situation serve to elicit and reinforce the desired behaviour. IBCT therapists try to discover events that function to trigger desired experiences in each partner, then attempt to orchestrate these events. The therapeutic goal is to shift in conversation (from criticism to self-disclosure) or behaviour. This leads to more profound and enduring changes in relational patterns.

The focus of IBCT is on emotional acceptance and change. The primary goal is to promote each partner’s acceptance of the other and their differences. Instead of trying to eliminate a couple’s long-standing conflicts, the goal is to help couples develop a new understanding of their apparently irreconcilable differences, and to sue these differences to promote intimacy, empathy, and compassion for one another. Through exploration of the individuals, the partners may come to a greater understanding of one another and experience more emotional closeness.

IBCT tries to modify emotional reactions to a ‘problem behaviour’. Ideally, through the thoughts and feelings underlying the behaviours, the other partner develops a new understanding of the behaviour and the ‘complaint’ is transformed in a less destructive response. This change frequently also affects the behaviour.

For IBCT to be effective, it is important for partners to understand the factors that have contributed to the development and maintenance of their distress.

The etiology of couple distress

According to IBCT, relationship distress develops as a result of two basic influences 1) decreases in reinforcing exchanges. Reinforcement erosion is the phenomenon whereby behaviours that were once reinforcing become less reinforcing with repeated exposure 2) conflicts may emerge as couples spend more and more time together due to differences. Incompatibilities can be further exacerbated by each partner’s emotional sensitivities or vulnerabilities or by external stressors.

Application of IBCT

The formulation

The formulation describes how the therapist conceptualizes and describes the couple’s problems. The formulation is based on a functional analysis of the couple’s problems and comprises of three components 1) a theme 2) a DEEP analysis 3) a mutual trap.

One of the most basic goals of IBCT is for the partners to adopt the formulation as part of their relationship history. It can be used as a context for understanding their relationship and their conflicts. It provides a language to discuss problems and allows partners to distance themselves from the problems.

The formulation is a dynamic concept that may require alteration and modification throughout treatment.

The Theme

The ‘theme’ is the description of the couple’s primary conflict. It is usually described by a word or phrase that captures the issues with which the couple struggles.

The DEEP analysis

Therapists conduct a DEEP analysis of the couple’s theme or issue. This is an acronym that outlines the four major factors contributing to a couple’s problems: 1) Differences 2) Emotional sensitivities 3) External circumstances 4) Patterns of interactions.

Partners have their primary conflict or theme because of differences between them, and because of each partner’s emotional sensitivities linked to those differences, both which can be exacerbated by external circumstances.

The pattern of interaction is the often frustrating and destructive communication that ensues when a distressed couple enters into a theme-related conflict. A natural response is for each partner to try to change the other. When partners become polarized, attempts to change the other increase the conflict.

The mutual trap

The mutual trap describes the outcome of the polarization process. This makes them trapped in their conflict. Partners feel that they have done everything they can to change the other, and nothing seems to work, but there are reluctant to give up their efforts.

The experience of partners who are so polarized is one of helplessness and futility. This is rarely discussed openly. As a result, each partner may be unaware of the other’s sense of entrapment. Making each partner aware of the other’s feelings is an important part of acceptance work, and encouraging each partner to experience the other’s sense of ‘stuckness’ can be the first step toward promoting empathy and intimacy.

Stages of therapy

The assessment phase comprises of at least one conjoint session with the couple, followed by individual sessions with each partner. It is followed by a feedback session, during which the therapist describes his/her formulation of the partners and their problems as well as the therapist’s plan for their treatment.

The number of treatment sessions should be determined on a case-by-case basis, depending on each couple’s treatment needs.

The use of objective measures

Objective measurement may be useful for both initial assessment and for monitoring a couple’s progress at various points throughout treatment. They may provide additional information about areas of disagreement and objective data about a couple’s level of distress and satisfaction.

The measure of relationship satisfaction serves as a measure of outcome and should be repeated periodically.

Measures of violence, commitment and problem areas are needed because partners may indicate concerns that they don’t bring up spontaneously.

Assessment of domestic violence

Assessing for domestic violence is a critical part of every couple’s intake. This can lead to a contra-indication.

Because therapy sessions can elicit strong emotions, the couple therapy itself may trigger post-session violence in some couples. In such cases, treatment that focuses on the violent behaviour of the perpetrator is indicated.

A couple’s history of violence should be directly addressed during the assessment phase, primarily during the individual sessions, when each partner can talk freely without fearing consequences form the other.

Assessment

The primary goal of the assessment phase is for the therapist to evaluate whether the couple is appropriate for therapy and, if so, to develop the formulation. The therapist should also use the assessment period to orient the couple to the therapy process.

Orientation (session 1)

The couple is oriented to the upcoming therapy process. This includes reviewing and signing an informed consent form.

The couple is also oriented to the specific process of IBCT.

Ambivalence about starting therapy should be normalized and validated.

Problem areas

The therapist begins the evaluation by reviewing the couple’s presenting problem(s). Much can be gathered form objective measures. The partners should feel heard and validated, and their problems must be clearly understood.

From the information, therapists should be able to describe the partners’ problem areas and develop their formulation. 1) how distressed is the couple? 2) how committed is this couple to the relationship? 3) what issues divide the couple? 4) why are these issues a problem for them? (DEEP) 5) what strengths keep this couple together? 6) what can treatment do to help them?

Each question should be explored in an interview.

The assessment of problem areas, should include a determination of the couple’s ‘collaborative set’. This is the joint perspective that they share responsibility for the problems in their relationship, and that both will have to change if the relationship is to change. The strength of this set determines whether change- or acceptance-oriented interventions are indicated. The stronger the set, the more successful change-oriented interventions are likely to be.

For a more nuanced version of the DEEP, individual interviews are necessary.

Therapist must be sensitive to the emotional reactions of partners.

It is helpful for couples to keep their strengths in mind, even as they focus on their difficulties.

The couples history

After the partners have been oriented to therapy and their problem areas have been assessed, the therapist takes the history of the couple’s relationship. The objective of this is to gain a good understanding for the partners’ attachment to one another. It can also provide some immediate therapeutic benefit to the couple. When partners discus the earlier (and usually happier) stages of their relationship, their affect is likely to become more positive.

These questions help the therapist get useful information and allows the partners an opportunity to reflect on the reasons they fell in love in the first place 1) how did you get together? 2) what was your courtship like? 3) what attracted each of you to the other? 4) what was your relationship like before your problems began? 5) how is your relationship different now on days when you are getting along? 6) how would the relationship be different if your current problems no longer existed?

Individual history

Each partner’s individual history can provide a context for each partner’s behaviour and illuminates possible emotional vulnerabilities. 1) What was your parents’ marriage like? 2) what was your relationship with your father like? 3) what was your relationship with your mother like? 4) what was your relationship with your siblings like? 5) what was your relationship with previous important romantic partners like?

The therapist tries to elicit features of these relationships that are similar or may inform the current relationship.

Feedback

The couple’s formulation is discussed with the couple in the feedback session. This session can follow the outline of the six questions used to assess the problem areas.

The feedback sessions is a dialogue with the therapist continually getting feedback from the couple about the formulation being presented. The partners are the experts on their relationship.

The feedback session is used to describe the proposed treatment plan for the couples, based on the therapist’s formulation. The therapist describes the goals for treatment and the procedures for accomplishing these goals. The goals for therapy are to create an in-session environment in which the couple’s problems can be resolved through some combination of acceptance and change techniques.

The procedures for meeting these goals of acceptance and change are usually 1) in-session discussion of incidents and issues related to the formulation 2) homework to be conducted outside the session to further the in-session work.

With the weekly questionnaire (completed prior to each session), a basis for treatment sessions is formed. The questionnaire asks 1) whether there have been any major changes in the couple’s life 2) whether any incidents of violence, or substance use have occurred 3) each partner to describe the most positive or meaningful interaction they had in the last week 4) the most difficult or negative interaction in the last week 5) whether they anticipate any upcoming, challenging events 6) to rank what they think would be most important to discuss (of the above).

The purpose of the feedback session is to orient partners to the goals of change and acceptance through open communication and finding new ways of looking at their problems. It gives partners some idea of what they can expect from therapy. It can also be used to implement some interventions.

Treatment

IBCT techniques for building emotional acceptance

Treatment begins with a focus on promoting acceptance. The exception is when there is an collaborative set and both want to make specific changes in their relationship.

The content of each session is determined by the partners. The therapist looks for emotionally salient material that is relevant to the formulation.

Sometimes salient events relevant to the formulation occur between partners during the session. The therapist should generally make these the top priority because the emotions involving these events during the sessions tend to be more accessible. The therapist explores this incident and frames it using a DEEP analysis.

The therapist might structure interactions during the session that mimic their difficulties or create possibilities for a different kind of interaction.

Three acceptance-building strategies are 1) empathic joining 2) unified detachment form the problem 3) tolerance building.

Empathic joining

Empathic joining is the process by which partners cease to blame one another for their emotional suffering and instead develop empathy for each other’s experience. To foster empathic joining, the therapist reformulates the couple’s problem as a result of common differences and highlights the emotional sensitivities that make these differences difficult to handle. Partners’ behaviours are described in terms of their differences and their responses are validated as normal and understandable. It is important that the therapist emphasizes the pain that each partner is experiencing rather than the pain each has delivered. Partners are encouraged to express pain without blame.

Empathic joining is promoted by 1) reformulation of a couple’s discord as a result of partners’ common differences and their understandable emotional reactions to those differences 2) the use of soft disclosures to express painful emotions.

Unified detachment from the problem

Unified detachment from the problem allows partners to ‘step back’ from their problems and describe them without placing blame on either partner. It is most often used to help the couple understand, accept, and eventually their patterns of interaction. This can be an intellectual analysis of the problem that is described in an emotionally detached manner as a third –party ‘it’. When possible, the therapist should give the couple’s theme, pattern of interaction, or mutual trap a name, and use this to define the problem further. By detaching themselves from the problem, partners have an opportunity to discuss their conflict without becoming emotionally ‘charged’.

Building tolerance

By building tolerance, a partner ideally experiences a reduction in the pain caused by the behaviour of the other partner. To build tolerance, the partner must cease efforts to prevent, avoid, or escape the ‘offending’ partner’s behaviour. By exposure to the behaviour without the struggle, the partner reduces the sensitivity to the behaviour. Strategies for building tolerance include: 1) positive reemphasis or focusing on the positive aspects of a partner’s negative behaviour. This doesn’t deny the negative qualities of the behaviour, but helps gain the perspective that any quality has good and bad features 2) focus on the ways these differences complement each other and to present differences as part of what makes the relationship work. 3) prepare couples for inevitable slipups and lapses in behaviour 4) instruct couples to fake negative behaviour while they are in session or at home. Each partner is instructed to engage in a designated ‘bad behaviour’ ((s)he is to engage in this behaviour only when (s)he doesn’t feel like doing so). The instructions are given to the couple, so that each partner knows that a bad behaviour is going to occur. Faking the behaviour gives both partners an opportunity to observe the effects of their negative behaviour on the other. Because the behaviour is performed in a time when they don’t feel like it, they make these observations when they are in a calm emotional state that allows them to be sympathetic.

An important aspect of acceptance building is for partners to increase their own self-reliance or self-care in getting their need s met. They should be encouraged to find alternative ways to care for themselves when their partners are not able to do so.

Traditional strategies for promoting change

Often acceptance work is sufficient for bringing about change by itself. Once the collaborative set is restored through acceptance, the couple is able to bring about change by applying skills and strategies they already possesses.

For other couples, change strategies are needed: 1) Behaviour exchange 2) communication training 3) problem-solving training.

Behaviour exchange

The primary goal of behaviour exchange (BE) is to increase the proportion of a couple’s daily positive behaviours and interactions. They are intended to increase each partner’s performance of positive behaviours. BE requires a great deal of collaboration between partners. Three basic steps in BE are: 1) to identify behaviours that each partner can do for the other that would increase relationship satisfaction 2) to increase the frequency of those behaviours in the couple’s daily behavioural repertoire 3) to debrief the experience of providing and receiving positive behaviours.

Partners are often given homework assignment to generate a list of actions to do for the other to increase his/her satisfaction. These lists must not be discussed with the other to avoid criticism. In the next session, partners’ lists are reviewed and discussed. The next assignment can be to do some of the items on the list, but these must also not be discussed beforehand. In the next session, the success of the assignment can be discussed.

Communication training

Poor communication may exacerbate or even cause many problems. In attempts to get the other to change, partners may resort to maladaptive communication tactics. As part of communication training, couples are taught bot ‘speaker’ and ‘listener’ skills. Couples are instructed to: 1) focus on the self by expressing ‘I statements’ 2) focus on expressing emotional reactions 3) focus on the partner’s specific behaviours that lead to emotional reactions.

To become more effective listeners, partners are instructed to 1) paraphrase, ensures that neither partner is being misread 2) reflect on what the other said.

Once partners have been given instruction in communication skills, they are directed to use these skills in practice conversations in the therapy session. The therapist should be prepared to interrupt and make corrections if the partners deviate from the guidelines and engage in destructive communication. The therapist should provide feedback and the exercise should be debriefed. If the therapist is confident the partners have improved, home practise is encouraged.

Problem-solving training

What is often more damaging than problems themselves is destructive attempts to solve them. These may begin with an accusation. In problem-solving training, couples are taught to have constructive problem-solving discussions while employing three sets of skills: 1) problem definition skills, the problem should be defined as specifically as possible by specifying the behaviour of concern and the circumstances surrounding it. Partners are encouraged to describe some of the emotions they experience as a result of the problem, in an effort to increase emotional acceptance. Both partners are asked to define their respective roles in perpetuating problem 2) problem solution skills, the first step is brainstorming, in which the couple tries to come up with as many solutions as possible. All solutions may be considered, even silly ones. Immediate evaluative comments are discouraged. Suggestions are written down so that they can be reviewed later. The couple goes through the list, eliminating impossible or ineffective solutions. After this, each item is considered for its potential to solve the problem. For each item, the couple considers the pros and cons, and the list is further modified. The remaining items are used to formulate a solution. The couple is asked to consider any obstacles to executing the agreement, and to work out strategies for combating these. 3) structuring skills, the couple structures problem-solving discussions by setting aside a specific time and place to have them. They don’t discuss the problem at ‘the scene of the crime’. The couple should focus on one problem at a time.

The couple’s first attempts at using these skills should occur in session, under the supervision of the therapist.

Therapist and client variables relevant to IBCT

It is important that therapists maintain a nonjudgmental stance toward their clients. The therapist should accept both partners in the same way that partners are asked to practice acceptance with one another.

The therapist must validate the experiences and responses of both partners, and finds ways to develop empathy and compassion for them.

It is important that therapists listen carefully to couples’ in-session interactions and look for the functions of their various problematic behaviours.

The therapist should create an environment in which couples can experience the hope of finding a different way of being, and safely discuss and evaluate their own relationships.