Counseling Theories and Techniques

Etiology and maintenance of couples’ presenting problem

Psychoanalytic theory views distress in relationships as a product of the couple’s individual unconscious processes, defenses, and transference. Unconscious processes are mental contents, not available to conscious awareness, which provide emotional holding and containment over each partner which they carry over to the current relationship. Defense mechanisms are an attempt to protect the self against danger, overwhelming or unacceptable affect and ideas. Transference is feelings, thoughts, patterns of behavior, originally experienced in relation to significant figures during childhood, redirected towards current relationship. Therefore, the couple’s experiences and feelings can only be understood in relation to their past. “To understand and remediate negative couple interactions, it is usually necessary to uncover individual psychological issues that do not simply follow from systemic or behavioral concepts” (Nielsen, 2017 p. 685; Scharff & Scharff, 2018 p. 11).

Couples’ relationship distress could be the result of their individual motives, fears, unconscious, and defenses which contribute to their maladaptive behaviors as a couple. By analyzing each partner’s past relationships and any traumatic childhood experiences in relation to their current relationship, patterns of interaction can be identified. Addressing their individual past issues and underlying concerns, will enable them to work on correcting dysfunctional interaction patterns and converse collaboratively to overcome their current distress.

Nielsen (2017 p. 686) explains that a couple’s negative interaction cycles are maladaptive process including the partners’ underlying sensitivities, hopes, and fears which are often driven by the frustration, and often the invalidation, of basic human needs. Instead of focusing on the current conflicts between the couple, therapy focuses on each partner’s basic human needs such as hopes for love, concern, appreciation, closeness, and understanding; and their fears and experiences of disapproval, abandonment, domination, incompetence, and other forms of emotional distress. The exploration of each partner’s unconscious thoughts and emotions enables them to better understand themselves and their partner. “This will help them meet those needs more effectively, mourn unrealistic wishes, and repair the relationship when (inevitably) those needs are not fully met” (Nielsen, 2017 p. 689).

Cognitive Behavioral Theory (CBT) views distress in relationships resulting from cognitive distortions that leads to misunderstanding and painful emotions. Cognitive distortions are errors in a person’s thinking which causes them to have false assumptions and misconceptions about someone or a situation. There are seven cognitive distortions including arbitrary inference, selective abstraction, overgeneralization, magnification and minimization, personalization, and dichotomous thinking (Chan, 2015 pp. 93-94). Cognitive Behavioral Therapy (CBT) is oriented toward problem solving and creating change in thoughts, behaviors, and feelings. Contrary to Psychodynamic, CBT focuses on the couple’s present situation and distorted thinking than on their past experiences. The basic idea of CBT is that individuals’ thoughts or cognition govern their emotions and determine their behavior towards events. Therefore, distorted thought processes lead to unhealthy emotions and dysfunctional behaviors. CBT identifies, and challenges distorted thought processes and changes behaviors that trigger those thoughts. In couples’ therapy, CBT enables partners to change their behavior in ways that allows them to have a more objective view of events. Therefore, the partners will develop more healthy emotions that will allow them to think about things from different perspectives which is beneficial to the relationship (Chan, 2015 pp. 93-94; Dattilio and Bevilacqua, 2007 p. 138; GoodTherapy, 2018)

CBT can help couples identify their beliefs about relationships at large and their views about their own relationship, therefore, modify any unrealistic expectations in the relationship. CBT can enable them to understand the thoughts and feelings that influence their individual behaviors as well as the interrelations between the partners’ behaviors, and how they influence the quality of their relationship. Individually and as a couple, each partner must recognize that while they cannot control every aspect of their circumstances or their partner, they can take control of how they interpret and deal with things in their environment (Dattilio and Bevilacqua, 2007 pp. 138-139).

Treatment recommendations

It’s critical to note that each partner’s symptoms can only be fully understood in the context of the couple together. “Without understanding that larger group and the complex, dynamic interactions that take place and how those interactions were formed, it may not be as easy to help the identified patient” (Herkov, 2018). The couple will benefit more from therapy if both partners participate in therapy together to start and then if necessary attend therapy individually. As a couple, the partners will learn to work on strengthening their relationship, resolve conflicts effectively, and learn communication skills to better understand one another. Individually, each partner can benefit from exploring their defense mechanism and underlying causes, as well as improve their reactivity and behavior (Stosny, 2008; Whitbourne, 2012).

Object Relations Therapy

Treatment recommendation for Psychodynamic theory to treat couples is Object Relations Therapy (ORT). ORT is based on a combination of theories of psychodynamic theory addressing how people internalize and externalize relationships (MacKenzie, 2005 p. 1). According to ORT personality and the sense of self develops from the interactions and relations with the primary caregiver. Object relations is how one relates oneself to others. Secure attachment with primary caregiver produces secure sense of self which enables individuals to form secure relationships and strong bonds with others. Poorly developed bond with primary caregiver negatively impacts an individual’s future attachments and their ability to securely relate to others which leads to relational problems. ORT helps clients explore their past relationships to identify childhood object relations that may have negatively impacted their current emotions, behaviors, and relational skills. As maladaptive patterns of behaviors are identified, the clients learn to alter past learnt social interaction patterns and to form healthy relationship standards as a model for current and future relationships (GoodTherapy, 2016).

To understand the interaction between couples, and the conflicts they are having in their relationship, the therapist must address how the partners have learned to perceive, interpret, and attach meaning to their interactions in early family experiences as well as in the current relationship. As the couple discover their individual issues as they relate to childhood objects, they will understand what influences their current motivations, emotions, and interactions with each other, identify their contribution to the couple’s presented problems, and improve the way they function internally. The therapist “must understand, modify, and interpret the client’s projections in such a way that allows the client to identify with them in a new light.” (MacKenzie, 2005 pp. 5-6). With greater self-awareness, couples will be able to form healthier object relations to use in their current relationship as a couple.

Cognitive Behavioral Therapy

Cognitive-Behavioral Couple Therapy (CBCT) have been found to be effective in decreasing couple distress and dissatisfaction as well as for addressing communication or problem-solving difficulties (Dugal, et al., 2017 p. 118). Common strategies used in CBCT include the development of communication, problem-solving and conflict resolution skills, cognitive restructuring, the improvement of the identification and expression of emotions, the improvement of the expression of affection and sensuality between partners as well as enhancement of sexual functioning and the development of acceptation and tolerance of differences and incompatibilities (Dugal, et al., 2017 p. 128).

Communication training will enable couples to learn to express and listen, without criticism or attack. The couple will develop more appropriate and functional dialogs by recognizing and identifying their individual dysfunctional behaviors, and by identifying the emotions and beliefs that underlie such interactions. The couple will learn problem solving skills by identifying and understanding the meaning of specific problems which an underlying need for one of the partners. Then the couple together propose solutions “which is known to increase feelings of interest, appreciation and consideration in the relationship as well as being particularly useful in case of serious conflict or strict patterns of interactions.” (Dugal, et al., 2017 p. 130).

CBCT will help identifying and challenging the couple’s cognitive distortions, namely selective attention, unrealistic or inappropriate attributions, expectations, assumptions and standards, which are related to negative emotions and behaviors experienced within the relationship. The couple will learn to better comprehend their difficulties while considering each other’s perspectives (p. 131). The couple will learn to identify, express and tolerate negative emotions to increase intimacy and satisfaction between partners (p. 132). CBCT techniques can improve the couple sexual well-being through a variety of strategies and exercises which will increase sexual behaviors for partners and address sexual dissatisfaction (p. 133). Lastly, the couple will develop an empathic understanding of each other’s experience and work together to face common hardships. To achieve this goal, the couple will learn “new ways of looking at their problems through empathic joining and unified detachment”. The couple will learn diminish accusations or blame in the relationship by detaching and objectively considering each other’s problems and differences without attributing them as deficiency or a problem in each other. The couple will learn tolerance strategies which will discourage the couple from trying to change the other and enhance acceptance of differences. (Dugal, et al., 2017 pp. 135-136).

References

American Association for Marriage and Family Therapy. (AAMFT; 2015). Code of Ethics. American Association for Marriage and Family Therapy. Retrieved from https://www.aamft.org/Documents/Legal%20Ethics/AAMFT-code-of-ethics.pdf

American Psychiatric Association. (APA; 2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Chan, F. (2015). Counseling Theories and Techniques for Rehabilitation and Mental Health Professionals, Second Edition. Retrieved from https://ebookcentral.proquest.com.

Dattilio, F. & Bevilacqua, L. J. (2007). Relationship Dysfunction: A Practitioner’s Guide to Comparative Treatments. New York: Springer Publishing Company. Retrieved from https://ebookcentral.proquest.com.

Dugal, C. Bakhos, G., Belanger, C., & Godbout, N. (2017). Cognitive-Behavioral Psychotherapy for Couples: An Insight into the Treatment of Couple Hardships and Struggles. Retrieved from http://dx.doi.org/10.5772/intechopen.72104

FindLaw. (n.d.). California Code, Evidence Code – EVID § 1024. Retrieved from https://codes.findlaw.com/ca/evidence-code/evid-sect-1024.html

GoodTherapy. (2018). Cognitive Behavioral Therapy (CBT). Retrieved from https://www.goodtherapy.org/learn-about-therapy/types/cognitive-behavioral-therapy

GoodTherapy. (2016). Object Relations. Retrieved from http://www.goodtherapy.org/learn-about-therapy/types/object-relations

Herkov, M. (2018). About Family Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/about-family-therapy/

Katz, N. & McNulty, K. (1994). Reflective Listening. Retrieved from https://www.maxwell.syr.edu/uploadedFiles/parcc/cmc/Reflective%20Listening%20NK.pdf

King, R. & O’Brien, T. (2011). Transference and Countertransference: Opportunities and Risks as Two Technical Constructs Migrate Beyond Their Psychoanalytic Homeland. Psychotherapy in Australia. VOL 17 NO 4. Retrieved from http://www.psychotherapy.com.au/fileadmin/site_files/pdfs/Transference_and_Countertransference.pdf

MacKenzie, A. A. (2005). Object Relations Theory and Implications in Couples Therapy. Retrieved from http://works.bepress.com/alan_mackenzie/8/

Nielsen, C. A. (2017). Psychodynamic Couple Therapy: A Practical Synthesis. Journal of Marital and Family Therapy 43(4): 685–699 doi: 10.1111/jmft.12236. American Association for Marriage and Family Therapy. Retrieved from https://static1.squarespace.com/static/54234267e4b0c5f68f9f3b11/t/5a0b11aa53450af07c26f02e/1510674858852/Pschodynamic+Couple+Therapy+JMFT+Oct+2017.pdf

Reidbord, S. (2010). Countertransference, an overview. What is countertransference? Retrieved from https://www.psychologytoday.com/us/blog/sacramento-street-psychiatry/201003/countertransference-overview

Scharff, E. D. & Scharff J. S. (2018). Psychoanalytic couple therapy: Foundations of theory and practice. Retrieved from https://ebookcentral.proquest.com

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2014). Instructor’s Manual for Clinical Interviewing: Intake, Assessment, And Therapeutic Alliance. Retrieved fromhttp://www.psychotherapy.net/data/uploads/52d99900de254.pdf

Stosny, S. (2008). Emotional Reality v. Reactivity. Retrieved from https://www.psychologytoday.com/us/blog/anger-in-the-age-entitlement/200810/emotional-reality-v-reactivity

Zur, O. (n.d.). Introduction to Informed Consent in Psychotherapy, Counseling and Assessment. Retrieved from https://www.zurinstitute.com/informedconsent.html

Whitbourne, S. K. (2012). 5 Principles of Effective Couples Therapy. Retrieved from https://www.psychologytoday.com/us/blog/fulfillment-any-age/201203/5-principles-effective-couples-therapy

Part II – Transcript, a 15-minute section of the intake interview (2:15 – 18:15).

2:15 – Me: What brings you here today?

Client: Um…me and my wife are having some difficulties at home. I thought it was a good idea to come and see if we could fix it.

2:22 – Me: Whose idea was it to come to therapy today?

Client: My wife. She asked me to come.

Me: She suggested it to you?

Client: Yes.

2:33 – Me: How long have you been together?

Client: We’ve been together almost twenty years. We have been married for twelve.

Me: Ok.

2:44 – Me: Do you guys have any children?

Client: We have two children. A boy, who is gonna be ten and a daughter who is turning eight pretty shortly.

2:53 – Me: How did having children impact your relationship with your wife.

Client: That is…that’s a difficult question. Um…it has made me less than a priority and the children more of a priority. So, I feel that I don’t get the attention that I would like. I understand that the kids need the attention and demand her attention. But there should be enough love to go around.

3:25 – Me: What initially attracted you to your partner?

Client: Initially…I…I think most…most relationships are with physical attraction, she was beautiful. And then, once I got to know her I still thought she was beautiful but she…um…she was not boring. She was quite a challenge that she had her own opinions, and she seemed strong willed, and she wasn’t your one of the run of the mill girls, and she was fun. We spent every day…everyday together. Every night together. We never got sick of each other’s time. So…that’s most of it.

4:14 – Me: How long did this phase last?

Client: Well…I still don’t get sick of her. I still think she is beautiful. I don’t know if it’s a two-way street in that relationship…ah…for me it hasn’t changed.

4:34 – Me: Are the two of you…how are you…the two of you similar or different?

Client: how are we similar? Um, I think we have the same values. We both believe in family. We are both hardworking in our own…in our own respects. I…I work day and night to make sure, and she makes sure that the kids are raised right and everything is taken care of at home. Um…we like the same movies, same type of shows. We both like to dance, um…we like the same music. So, we are very compatible. She is more aggressive than I am, I am more calm. Somehow, it works. I mean if I was an aggressive person one of us probably wouldn’t be here today. So… [laughter] we balance each other out.

5:30 – Me: What was your first disillusion um…or argument?

Client: Ah…we have had many arguments. Um…in what regards?

Me: What happened and how did you resolve it?

Client: Well, you know I think there’s two type of people. People who hold grudges and are mad for days at a time. And there’s other type of people um…that want things resolved sooner than later. And we are the type of people that want immediate results. We don’t hold a grudge or be angry for 2 years, you know. I think in all the years, we have probably been mad at each other for 24 hrs., 48 hrs. max, right?! They don’t last longer than that. We find ways to resolve and, it’s mainly me because I am persistent, and I don’t like her to be upset, so I try and resolve situations

6:40 – Me: How long has it been since things were good between the two of you?

Client: Good between the two of us. I wouldn’t say things are bad, just somethings need to be diverted. Um…I’m…I’m pretty simple and she may be more complex than I am. Um…but, you know, things got difficult when the first kid was born and then the second kid was born, things started to get more difficult. It wasn’t just the two of us and our dogs. It was the dogs, the kids, then me. It was the kids, the dogs, and then me, in my opinion, how I felt. So, getting proper attention, you know, I like hugs, I like physicality, I like to have sex, …ah…and she doesn’t like that stuff that much. Or, when I bring it up to her, she says, well I’ve been touched and hugged on all day, just leave me alone. So, I think there’s time for everything, and space for everybody, you just have to figure out how to do it.

7:56 – Me: Do you have any suicidal or homicidal thoughts?

Client: No!

Me: Any impulsive behaviors?

Client: Um…impulsive behaviors. I’d like to jump in the car and go to Vegas or go dancing. But, we don’t. That’s as far as impulse goes. But we usually have to plan things out.

Me: Other than smoking cigarettes, do you use any other substances?

Client: No. I have alcohol, when we go out occasionally, but I never get drunk

Me: Have you ever been treated for any psychiatric problems?

Client: No.

Me: Have you been hospitalized for any psychiatric problems?

Client: No.

Me: Tell me about your health.

Client: Um…I work out a lot. I do eat not so well but I try and counter that by working out as much as possible sometimes.

Me: Any medical problems?

Client: Um…I have a little be of high cholesterol, low thyroid, and low testosterone. So, I take medicine for the latter. And cholesterol, I just try and workout.

Me: Very nice.

Client: Trying to get better, but, doesn’t always works.

9:21 – Me: Tell me about your family of origin.

Client: Ah…I was raised in a household of five. I have two older sisters. I had a mother. I have a father. So basically, it’s like I had three moms growing up, so I am used to being around women. Um…my dad was the provider. Ah…he always worked hard. He did well for the family. My mom took care of the kids. I try and model my life after that in way. I believe I have to provide. I’ve always have provided. Um…and you know, it’s kind of, happy wife, happy life. You know, your wife is your…is your…um… queen and that’s it.

10:07 – Me: How was…how was your…growing up how was your relationship with your mother?

Client: Oh…she was great. You know, every kid thinks their mom is annoying at times but, specially when they are trying to wake you up early and you don’t want to wake up but…ah…she was great. She was loving…

Me: And your father?

Client: It’s great. I am mean, my dad is not the ‘huggy’, ‘lovey’ type. But he was always there. Um…everything I needed I had, and he is a good guy.

10:43 – Me: How does your current relationship compare to what you remember of your parents’ relationship?

Client: Um…in a lot of ways it is similar. I mean, my father provided, my mom was home, took care of us until we were older, and then she started to go to school and going to work. They always cooked, they always…I was always with them. Um…they fought, I think it’s normal for human beings and relationships to have disagreements, or there was nothing physical or I thought out of ordinary. Um…with us too, me and my wife, we have fights. I listen to my friends what they fight about, and, you know, I think pretty much every relationship fights about same kind of things. They all go through the same kind of struggles. It’s all kind of a natural progression, kids come, and changes happen, things change. And the goal is to find room for everything.

11:55 – Me: Have you and your wife been to a therapist for any marital problems in the past?

Client: No.

12:03 – Me: What do you do when there is conflict between the two of you?

Client: Um…well lately, when there is conflict, she tries to stop talking about it. I try to work it out but…there really…the only conflicts we have about what the kids are getting or what the kids are doing. Never really a conflict about what me and her are doing. So, when it comes to kids, I bow down. Like, she says he can only eat this, or she can do this, or they can go there. Unless, I have a very strong disagreement about it, it goes her way.

Me: What does your wife do when…with conflict?

Client: Shuts down, I think. I think that would be the right word. She hears one word that she doesn’t disagree…that she doesn’t agree with and kind of shuts out…doesn’t want to hear the rest. Um, you know, um…I am a…I am a sales man by nature. I have always been a sales man. I have a lot of employees, I know have to manage people, I am very direct and opinionated…and the way I talk sometimes, it feels like I am giving her orders but it’s not the case, it’s just I am direct, and I have…I guess you can say a course that I want something to go and I lay it out that way, how I do something. And, she doesn’t react well to it. That’s just who I am and always been. That’s probably why she was attracted to me in the beginning because I don’t have [inaudible] personality. So…

13:48 – Me: What do you do when you are angry with her?

Client: What do I do when I am angry with her? Um…takes a lot to get me angry, but when I am angry, I let her know. Most of the time, it’s not accepted well. But, I let her know, and then I kind of try and make peace with it.

Me: What does your wife do when you…when she is angry with you?

Client: She’ll definitely let me know and she’ll stay away, and she will definitely let me know and then stay away some more. But…um…communication is a problem. She…she believes…she perceives what I am saying something totally different than what I am intending to say cuz I think she’s trying think what I am thinking which is not the case. You never really know what the other person is really thinking, and she tends to believe that I am saying things different than what I am saying, even if the words I am saying mean what I am saying, she reads it in a different way.

14:54 – Me: When…when you like…when you feel like you want support or encouragement from your partner, do you get it?

Client: Um…when she has time to listen to me, yea. I think she…she does. Um…I would say she gives, she tries to give, how do you say it, her opinions and how things should be fixed. Ah…I don’t always agree with what she has to say but I try and listen. Um…

15:34 – Me: And…when your partner wants support or encouragement from you, do you feel that you give it to her?

Client: I try. But goes back to her presumption of what she thinks I am saying and then she shuts down. Um…she can start off with something and, I guess, I have…growing up, it was always, if something is wrong, try and make it better. Right, so that’s what I always try and do. When I am on the phone with somebody, got a sales call, or agent, I try and make it better. I don’t…I don’t listen for the purpose of listening, I listen for the purpose of making it better, and try and divert that person’s issue, to make it better.

Me: Mm…

Client: And she doesn’t…ah…react well to that.

16:27 – Me: From whom do you receive support and encouragement outside your relationship?

Client: Ah…I have two business partners that I am with every day, lunch, gym. We talk about everything, and when we have problems we talk to each other about it.

16:44 – Me: On a scale of 1 to 10, how aware or in touch with your emotions are you and explain the rating?

Client: In tough with my emotions

Me: Let’s 1=not at all and 10=extremely.

Client: I think that I don’t come off as emotional. Um…at my office, people think I am very…um…the mean one, the quiet one, cuz I don’t talk a lot. Only why I get to, is cuz…just…I have two other partners that do a lot of talking, so I don’t really need to talk. So, people are scared of…they don’t think I am emotional. But, I really am pretty, I just don’t show it, right? Um…I would say…7

Me: Ok…

17:42 – Me: On a scale of 1 to 10, how open are you in expressing your innermost feelings, desires and thoughts to your partner (1=totally closed and 10=totally open)?

Client: I’d say 8. I always tell her when I want something, or I am upset about something. I just…it’s always the same thing for me, three things I complain about, so, it’s not so much you can complain about it.