How do you know what kind of training to invest your time and money on to become a more effective couples therapist?
Couples’ therapy is a complex and challenging activity even for the most experienced therapists. There are many models to choose from, and integrating them is not easy for those who wish to improve their skills in working with couples. Some are attachment based and others emphasize differentiation. There are frameworks that focus more particularly on either thinking, feeling, or on behavior as the door of entry into the change process.
How do we figure out what to do? And why do so many couples therapists cling to one framework?
Every proponent of a framework for couples therapy tries to answer similar questions:
- Why is intimate relationship distress so prevalent?
- How and why do problems develop in couples?
- What helps couples change?
- What is the role of the therapist in the process of change?
Advantages of using one framework
There are many advantages of using a pure form of a couples therapy framework.
- To have a road map as a guide helps the therapist
- To help the therapist figure out where to focus the attention in a session
- To make the work less overwhelming.
- To avoid confusion. Having multiple tools can cause confusion if you don’t know how to choose among them
- Therapists faced with too many options may be tempted to settle on one theory, in part because it is easier and less confusing.
- It’s difficult to be an independent clinician
Disadvantages of using one framework
Adherence to one framework, however, has limitations.
- Therapists may attempt to make the client fit into the theory
- A model gives structure but not freedom to adapt to the needs of a particular couple
- A model may work well in one stage of the treatment process but not so well in another stage
- There is a risk that a pure form of a framework can lead to therapeutic errors
Why an integrative approach?
There are many compelling reasons to use an integrative approach.
There is large body of research concluding that there is not one framework that works better than others for sustained relationship success or relationship change. The best treatment approaches are personalized and individualized, in an integrative way, drawing from different perspectives to intervene with a particular couple.
The clinical needs of each couple, the strength of the alliance between the couple and the therapist, and the attention to the stage of the treatment process tend to be the most important factors in treatment outcomes.
In terms of the clinical needs of each couple, there are too many variables to consider using a pure form of the same framework: The couples’ level of distress, the level of differentiation, their attachment histories, their motivation for treatment, their level of hope about the viability of the relationship, their self-protective measures, to name a few.
While different schools of couples therapy emphasize their uniqueness and their differences, they actually overlap considerably in what they consider helpful. Many approaches to couples therapy use different terms to describe similar phenomena. No single approach is comprehensive enough to deal with the variety of problems that couples present a therapist in their first appointment.
When therapists starts working with a couple, they never know for how long the clients will remain in treatment. We learn more about a couple the more we interact with them. Some hypotheses are more useful than others, which is why some frameworks work well with some people and not with others, in terms of what helps with the change process.
A moment of integration often occurs when a therapists begins to wonder: “What else could I have done?”. It’s a question that makes it possible to reach outside a framework and begin to look for alternatives. As mentioned, the application of a pure form of a framework may lead to errors in therapy such of ruptures in the therapeutic alliance.
The Therapeutic Alliance
One of the most important aspects of treatment with a couple is the therapeutic alliance. Do the partners and the therapist have alignment on goals and tasks? Is there an agreement on what needs to be fixed and how? Does the couple believe that the therapist can help them? Does the couple trust that the therapist is invested in the well-being of each member of the couple? Does each member of the couple allow the therapist to influence them?
The therapeutic alliance is more important than the framework and needs to take precedence over it. Consider the following examples.
- A Bowenian therapist will want to do a Genogram fairly early in the in the process, but one member of the couple fails to acknowledge the connection between the family of origin legacy issues and current couple impasses and refuses to cooperate.
- A therapist thinks the honest and vulnerable expression of feelings is the most important factor in a treatment with a couple (as many do) but a partner does not feel safe expressing vulnerable feelings, or does not believe in the value of expressing feelings because “it would make me look weak”.
- Proponents of postmodern frameworks (Solution Therapy or Narrative Therapy) consider the couple as the experts in solving their own problems, and frequently utilize only interventive questioning. What if the couple feels like they are "paying the therapist for their expertise" and request more guidance?
- Therapists with a systemic or insight orientation believe that awareness of the dynamic, or awareness of the legacy issues are enough to produce change, and tend not to believe in “skill deficit”. What if the couple achieves a high level of awareness but their behavior still doesn’t change?
It’s clear that the alliance could suffer if the couple and the therapist don’t agree on the reasons for the development of problems, and on the ways to alleviate them. Sometimes, adherence to a pure form of a framework risks rupturing the alliance.
How can framework integration be implemented?
One way to think about integrating interventions is to apply the least invasive interventions to a problem and observe its effects. We can go from the “here and now” approaches (solution focused, narrative, cognitive behavioral), to the “there and then” (Intergenerational and psychodynamic) in a sequential manner by applying the more direct, and shortest interventions first, and leave the more sophisticated, time-consuming interventions if those first ones fail or prove to be insufficient.
Therapy involves the continuing testing of hypotheses and of interventions derived from them. It is the failure of such interventions that begins to tell us what to do next.
To implement framework integration therapists are encouraged to consider sequencing the treatment process. In the first stage of the treatment process, when the therapist does not know the couple well and it’s not clear how long they will engage in therapy, many couples can get stabilized with present- and future-oriented frameworks. Past-oriented frameworks can be implemented in the second stage, if couples agree to go deeper. Finally, in the last stage of the treatment process, the consolidation stage, the therapist can review the past gains, go even deeper, and work on preventing relapses. Couples move forward and backward before moving forward again in a sequenced upward spiral of regression and progression.
Framework integration is not easy. There are many models to choose from and it’s tempting to want the guidance and clarity of a pure model. But when therapists spend some time articulating their own beliefs about the reasons for contemporary couples distress, they can develop over time their own scaffolding onto which to build their resources. Integrating frameworks will then become easier to achieve.
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Thanks for this! It will definitely help me to think in terms of these three stages.
This is very helpful! I really appreciate the clarity of defining 3 stages of intervention and models/frameworks that will help me to evolve as a clinician.