Couples therapy is a form of psychological therapy used to treat relationship distress for one or both individuals in the relationship, as well as the couple as a pair.
The purpose of couples therapy is to restore a better level of functioning in couples who experience relationship distress. The reasons for distress can include poor communication skills, incompatibility, or a broad spectrum of psychological disorders that include domestic violence, alcoholism, depression, anxiety, and schizophrenia. The focus of couples therapy is to identify the presence of dissatisfaction and distress in the relationship and to devise and implement a treatment plan with objectives designed to improve or alleviate the presenting symptoms and restore the relationship to a better and healthier level of functioning. Couples therapy can assist persons who are having complaints of intimacy, sexual, and communication difficulties.
Couples who seek treatment should consult for services from a mental health practitioner who specializes in this area.
Patients should be advised that being honest, providing all necessary information, cooperating, keeping appointments, arriving on time, and desiring change and improvement sincerely are all imperative to increase the chance of successful outcome. Additionally, a willingness to work with the process of treatment is essential.
Couples therapy sessions differ according to the chosen model or philosophy behind the therapy. There are several models for treating couples with relationship difficulties. These commonly used strategies include psychoanalytic couples therapy, object relations couple therapy, ego analytical couples therapy, behavioral couples therapy, integrative behavioral couples therapy, and cognitive-behavioral couples therapy. Some therapies focus on education and prevention.
Psychoanalytical couples therapy
Psychoanalytic therapy attempts to uncover unresolved childhood conflicts with parental figures and how these behaviors are part of the current relationship problems. The psychoanalytic approach tends to develop an understanding of present-day interpersonal interactions in connection with early development. The success in personal development of early stages dictates the future behavior of interpersonal relationships. The essential core of this model deals with the process of separation and individuation (becoming a separate, distinct self) from mother-child interactions during childhood. A critical part of this model is introjection. The process of introjection includes introjects (infant processing versions) of the love object (mother). The developmental process of introjection forms the basis an unconscious representation of others (objects) and is vital for development of a separate and defined sense of self. The psychoanalytic approach analyzes marital relations and mate selection as originating from parent-child relationship during developmental stages of the child.
Object relations couple therapy
The object relations model creates an environment of neutrality and impartiality to understand the distortions and intrapsychic (internalized) conflicts that each partner contributes to the relationship in the form of dysfunctional behaviors. This model proposes that there is a complementary personality fit between couples that is unconscious and fulfills certain needs. This model supports the thought that a “mothering figure” is the central motivation for selection and attachment of a mate. Choosing a mothering figure induces further repression (nondevelopment) of portions of personality that were not well developed (called “lost parts”). This repression causes relationship difficulties.
Ego analytic couples therapy
Ego analytical approaches use methods to foster the ability to communicate important feelings in the couple’s relationship. This model proposes that dysfunction originates from the patients’ inability to recognize intolerance and invalidation of sensitivities and problems in a relationship. According to this model, there are two major categories of problems. The first category of problems relates to dysfunction brought into the relationship from early childhood trauma and experiences. The second involves the patient’s reaction to difficulties and a sense of unentitlement (a personal feeling that one does not deserve something). A patient’s shame and guilt are major factors precipitating the thoughts of unentitlement.
Behavioral marital therapy
Behavioral marital therapists tend to improve relationships between a couple by increasing positive exchanges and decreasing the frequency of negative and punishing interactions. This model focuses on the influence that environment has in creating and maintaining relationship behavior. Behavior exchange between partners is flowing continuously and prior histories can affect relationship interactions. Behavior therapy in general is based on the idea that when certain behaviors are rewarded, they are reinforced. The amount of rewards (positive reinforcers) received in relation to the amount of aversive behavior is linked to an individual’s sense of relationship dissatisfaction.
Integrative behavioral couples therapy
Integrative behaviorists help couples by improving behavior exchange, communication, and the couples’ abilities for problem-solving skills. The integrative behavioral therapy approach examines functioning of the couple and is more flexible and individualized to specific problems in the relationship than behavior marital therapy. This approach examines problems and interactions that are repetitious (acts that are repeatedly done causing relationship problems).
Cognitive behavior marital therapy
The cognitive-approach therapist educates and increases awareness concerning perceptions, assumptions, attributions or standards of interaction between the couple. The central theme for understanding marital discourse using cognitive-behavioral therapy is based on the behavioral marital therapy model. A couple’s emotional and behavioral dysfunction are related to inappropriate information processing (possibly “jumping to conclusions,” for example) and negative cognitive appraisals. This model attempts to discover the negative types of thinking that drive negative behaviors that cause relationship distress.
Emotionally focused therapy
Emotionally focused therapy assists patients to acknowledge, assess, and express emotions that are related to distress. This model views emotion and cognition (thinking) as interdependent, and sees emotion as a primary “driver” of interpersonal expression. The primary theme of emotionally focused therapy is that couple distress stems from unexpressed and unacknowledged emotional needs. The dysfunction arises from negative interactions from emotions that have been withheld from disclosure from each partner.
Structural strategic marital therapy
Structural strategic therapists will challenge existing negative perceptions and present alternative possibilities and behaviors. These alternate behaviors encourage positive perceptions by role playing. This model views relationship progression in developmental stages. According to this model, the couple’s distress reflects difficulties in coping mechanisms related to life changes, which can be either environmental or personal. Despite relationship dissatisfaction, the couple will tend to resist change, maintaining status quo, and attempting baseline functioning to keep the system going.
Educational and preventive couples therapy
There are several programs designed for therapists to use with married and soon-to-be-married couples with the goal of establishing good communication early in the relationship. These programs, some of which have proven efficacy, focus on open communication, listening skills, and relationship training. Among these are the PREP program, which has been used since 1989 and is practiced by mental health professionals, laypersons, and clergy in 28 countries. It can have a secular or a religious basis. Other programs with strong research backing are the Couples Communication and the PAIRS programs. The Couples Communication Program involves an “awareness wheel” and a “listening wheel” that helps couples trace their issues and learn how to listen to one another. The Practical Application of Intimate Relationship Skills (PAIRS) program explores a couple’s past emotional issues and the ways in which these have shaped their current interaction. Similarly to other programs, the focus is on listening and tackling problems.
Couples should be informed that cooperation is vital for the process and they should have a desire to modify and/or change dysfunctional behaviors. Honesty and emotional openness is a necessary component for treatment. Results cannot be guaranteed. The psychotherapist would typically provide an extensive assessment process during the initial appointment. This couples assessment process usually includes in-depth information gathering concerning the presenting problem. It also includes, in the form an interview, an assessment of occupations, schooling, employment, childhood development, parental history, substance abuse, and religion; and relational, medical, legal, and past psychological history. After collecting the background information the psychotherapist can then devise the best course of treatment. Further psychological tests and measurements may be indicated initially or as the need arises during the treatment process.
Treatment usually takes several months or longer. Once the couple has developed adequate skills and has displayed an improved level of functioning that is satisfactory to both parties, then treatment can be terminated. The couple should be alert to the return to the behaviors that they are trying to change or eliminate. These are called relapsing behaviors, and relapse-prevention behaviors can help keep them at bay. Patients are encouraged to return to treatment if relapse symptoms appear. Follow-up visits and long-term psychological therapy can be arranged between parties if this is mutually decided as necessary and beneficial.
The major risk of couples therapy is lack of improvement or return to dysfunctional behaviors. These tend not to occur unless there is a breakdown in skills learned and developed during treatment, or one person is resistant to long-term change.
A normal progression of couples therapy is relief from symptomatic behaviors that cause marital discourse, distress, and difficulties. The couple is restored to healthier interactions and behaviors are adjusted to produce a happier balance of mutually appropriate interactions. Patients who are sincere and reasonable with a willingness to change tend to produce better outcomes. Patients usually develop skills and increased awareness that promotes healthier relationship interactions.
There are no known abnormal results from couples therapy. At worst, patients do not get better because they cannot break away from self-induced, self-defeating behaviors that precipitate marital dysfunction and distress. The problems are not worsened if treatment is provided by a trained mental health practitioner in this specialty.
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The American Association for Marriage and Family Therapy. 1133 15th Street NW, Suite 30, Washington, DC 20005. Telephone: (202) 452-0109. Fax: (202) 223-2329. Web site: <http:/www.aamft.org>.
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Laith Farid Gulli, M.D.
Kathleen Berrisford, MSCSW,CAC
Emily Jane Willingham, PhD