Addressing power in couples therapy: Integrating socio-emotional relationship therapy and emotionally focused therapy

Romantic relationships are more satisfying and fulfilling when power is balanced relatively equally between partners (Leonhardt et al., Journal of Family Psychology, 34, 2020, and 1). Yet, few couples therapy models explicitly outline how to confront relational power issues (Knudson-Martin & Huenergardt, 2015, Socio-emotional relationship therapy: Bridging emotion, societal context, and couple interaction, Springer). Emotionally Focused Therapy (EFT; Johnson, 2020, The practice of emotionally focused couple therapy, Routledge) is a well-established, evidence-based therapy modality that many therapists use with couple clients, yet despite its effectiveness, it does not provide direction for explicitly addressing and treating power differentials in couple relationships. In this paper, we explore the integration of EFT with Socio-emotional Relationship Therapy (SERT), a model overlay that acknowledges the impact of social discourse on enactments of power in intimate couple relationships. We first address the importance of understanding power in couple relationships, addressing power in couples therapy, and provide a brief overview of SERT and EFT. We then introduce an integration of the models intended to help therapists balance power, increase connection, and secure attachment bonds between romantic partners.     

Assessing Couple Therapy as a Treatment for Individual Distress: When is Referral to Couple Therapy Contraindicated?

In order to better understand the effects of initial level of psychological disturbance on treatment outcome, a retrospective case control study of 95 couples who received couple therapy was conducted by sorting couples into one of four groups based on the degree of distress reported by individuals at intake: Neither distressed; both distressed; male distressed, female not distressed; female distressed, male not distressed. When partners started treatment with similar levels of disturbance both responded well in couple therapy. However, if the female reported clinical levels of disturbance at intake but her partner did not, outcome for the female was especially poor in contrast to outcomes for females receiving individual therapy. Clinically disturbed males showed significant gains in treatment even when their partners were not disturbed. These suggestive results argue for the possible value of conducting controlled studies of treatment assignment decisions that maximize positive outcomes.     

Attachment Change in Emotionally Focused Couple Therapy and Sexual Satisfaction Outcomes in a Two-year Follow-up Study

Emotionally focused couple therapy (EFT) is an empirically validated attachment based approach to couple therapy. From an EFT perspective, sexual functioning is viewed within the context of an attachment bond, but sexual satisfaction in EFT has not been empirically tested. We examined self-reported sexual satisfaction across 24?months in a sample of 32 couples who received an average of 21 EFT sessions. We found that sexual satisfaction increased across six time points from pre to post therapy and across follow-up (6, 12, 18, and 24?months), and that decreases in attachment avoidance from pre to post therapy predicted increases in sexual satisfaction across time. These findings provide evidence that EFT may help couples improve their sexual satisfaction by reducing attachment avoidance in therapy.     

Emotionally Focused Couple Therapy with Couples Facing Terminal Illness

Research on effective therapeutic interventions for couples dealing with terminal illness is scant. Changes in daily routine, added responsibilities, role changes, and the grief process are all contributors to the enormous stress and emotional strain felt by these couples. Couples where one partner is terminally ill may experience anger, depression, guilt, and anxiety. The authors propose that emotionally focused couple therapy (EFT), originally developed by Greenberg and Johnson (Emotionally focused therapy for couples, Guilford Press, New York, NY, 1988) may be effective in addressing this distress and in facilitating the grieving and support process in couples dealing with terminal illness. EFT is a systemic, experiential form of therapy that builds upon Bowlby’s (Attachment and loss: Volume I: Attachment, Basic Books, New York, NY, 1969) attachment theory. By exploring the emotional experience of both partners it may be possible to re-structure the couple’s emotional partnership and support the grief process for both partners.     

Conceptual and Application Issues: Emotionally Focused Therapy With Gay Male Couples

Therapists working with couples are likely to see gay male couples in their practice yet there is a lack of training to prepare therapists to work with gay couples. Emotionally Focused Therapy (EFT) is an empirically supported approach to couples therapy and offers a clear structure and map for working with gay male couples. This article reviews some of the issues that are specific to EFT work with gay men. Given the range of minority stressors that gay men contend with EFT is particularly appropriate for work with gay male couples because of the focus on the attachment bond. Building a secure relationship is an important source of resilience that can buffer against prejudice and discrimination and provide a secure base for individual and couple exploration.     

Emotion-Focused Therapy for Couples in the Treatment of Depression: A Pilot Study

Emotion-focused therapy (EFT) for couples was compared to pharmacotherapy in the treatment of major depressive disorder. Eighteen distressed couples in which the female partner met diagnostic criteria for major depressive disorder were randomly assigned to 16 weekly sessions of emotion-focused therapy or pharmacotherapy with desipramine, trimipramine, or trazadone. Twelve couples completed the study. Both interventions were equally effective in symptom reduction. There was some evidence that females receiving EFT made greater improvement after the conclusion of treatment than those receiving pharmacotherapy. The results suggest EFT might be useful in the treatment of comorbid major depressive disorder and relational distress.     

Couple Therapy in the Presence of Mental Disorders

Abstract

Mental disorders and relationship discord commonly occur together and couples where one or both parties suffer from a mental disorder are commonly seen in couple therapy. Symptoms of mental disorders can usefully be conceptualized cybernetically and viewed as part of negative feedback loops that couples become trapped in without denying the potential contribution of biological or other types of knowledge. Most of the existing research focuses on couples and depression and couple therapy has been found to have efficaciousness as a treatment of depression especially when depression occurs along with relationship discord. There is less research on couple therapy and other mental disorders but general guidelines are offered that couple therapists can use with any of the mental disorders.     

The Effectiveness of Emotionally Focused Couples Therapy With Veterans With PTSD: A Pilot Study

The current study is a pilot project conducted at Baltimore VA Medical Center investigating the use of emotionally focused couples therapy (EFT) for couples in which one partner is a veteran who has been diagnosed with posttraumatic stress disorder (PTSD). Fifteen couples enrolled in the study and seven of these couples completed treatment (26 to 36 weekly sessions of EFT). Both partners were assessed on measures of relationship satisfaction, psychological distress, depression, and quality of life, and veterans were assessed on measures of PTSD symptoms at baseline and 2 weeks after the intervention. Paired t-tests were used to compare scores before and after EFT. In terms of results, the veterans' partners reported significant improvements in relationship and life satisfaction and in decreased depression and a decrease in psychological distress. Veterans demonstrated a significant decrease in self-reported symptoms of PTSD. These results provide preliminary evidence for the usefulness of EFT to help foster improved relationship satisfaction, and psychological well-being for veterans with PTSD and their partners who completed treatment.     

Learning Emotionally Focused Couple Therapy: Four Clinicians' Perspectives

This study examined the experiences of four clinicians learning emotionally focused couple therapy (EFT). Two group interviews, separated by 6 years, explored topics that included emotion, gender, model differences, personal practitioner impact, and the long-term influence of EFT training on clinical work. Emotion emerged as a major theme, with three subthemes at each phase. Phase 1 results indicated an increase in personal awareness of emotions, a positive impact on close personal relationships, and challenges for males in learning to elicit and use emotion. Phase 2 results, 6 years later, revealed that focusing on emotions remained salient and that EFT continues to influence the work of each clinician to varying degrees. Limitations, future research suggestions, and clinical implications are discussed.     

Couple‐based Intervention for Depression: An Effectiveness Study in the National Health Service in England

This study represents an effectiveness study and service evaluation of a cognitive behavioral, couple‐based treatment for depression (BCT‐D) provided in London services that are part of the “Improving Access to Psychological Therapies” (IAPT) program in England. Twenty‐three therapists in community clinics were trained in BCT‐D during a 5‐day workshop, followed by monthly group supervision for 1 year. The BCT‐D treatment outcome findings are based on 63 couples in which at least one partner was depressed and elected to receive BCT‐D. Eighty‐five percent of couples also demonstrated relationship distress, and 49% of the nonclient partners also met caseness for depression or anxiety. Findings demonstrated a recovery rate of 57% with BCT‐D, compared to 41% for all IAPT treatments for depression in London. Nonclient partners who met caseness demonstrated a 48% recovery rate with BCT‐D, although they were not the focus of treatment. BCT‐D was equally effective for clients regardless of the clinical status of the nonclient partner, suggesting its effectiveness in assisting both members of the couple simultaneously. Likewise, treatment was equally effective whether or not both partners reported relationship distress. The findings are promising regarding the successful application of BCT‐D in routine clinical settings.     

What Are the Main Differences Between Behavioral and Systems Therapy with Couples? A Critical Account

This paper describes the main differences between behavioral and systems therapy with couples. To improve clinical decision making for a given case, the theoretical assumptions of the chosen treatment approach need to be clearly understood. Contrasting the two approaches will assist couple therapists in providing clinical services that better reflect the chosen theoretical framework. This paper reviews the common elements that can be found across models. A case example is presented to demonstrate the use of the therapy's theories and techniques.     

A Narrative Approach to Child and Family Therapy in Africa*

Professional family therapy in Africa is heavily influenced by theories and principles of Western family practice. Its practice structure and philosophies are however grounded on African family values and the principles and orientations of traditional African psychology. This paper presents a clinical report that illustrates adaptations we make to incorporate compatible aspects of narrative family practice in African and Western cultures. A summary of African family values and child psychology intended as a background perspective is provided. The paper is significant against the background of the current need for forging multiculturally relevant healing methods that fit well with the globalized nature of the contemporary world. Augustine Nwoye, PhD, is Associate Professor and Chairman, Department of Psychology, Kenyatta University, Nairobi, Kenya (amnwoye@avu.org). Professor. Nwoye has developed an African paradigm for mental health and, in particular, for family and couple therapy. He also has experience in dealing with stress and multiple losses, especially surrounding HIV/AIDS within an African context. *An earlier version of the paper was presented to the members of staff and students of the Faculty of Education, University of Cambridge, England, UK, and the initial version was presented to the members of the Family Therapy Program of the Faculty of Medicine of the University of Calgary, Calgary, Canada. I wish to thank Dr. Colleen McLaughlin (University of Cambridge) and Professor Karl Tomm (University of Calgary) for their invitation, assistance, time, attention, and suggestions.     

Predictors and Moderators of Provoked Vestibulodynia Treatment Outcome Following a Randomized Trial Comparing Cognitive-Behavioral Couple Therapy to Overnight Lidocaine

Provoked vestibulodynia is a vulvar pain condition causing sexual dysfunction, affecting 8% to 10% of women. Our recently published randomized clinical trial (N = 108 couples) found that cognitive behavioral couple therapy (CBCT) and topical lidocaine reduced women’s pain and associated sexual symptoms, with CBCT showing more benefits. Little is known about pretreatment predictors of treatment outcomes in couples sex therapy. In the current study, we examined women and their partners’ pretreatment demographic (age, relationship length), clinical (pain duration, anxiety) and interpersonal (partner responses to pain, sexual goals) predictors/moderators of women’s pain intensity, pain unpleasantness, and sexual function at posttreatment and 6-month follow-up. Longer relationship duration, lower anxiety in women, partner higher solicitousness and partner higher approach sexual goals predicted better pain outcomes for women with PVD irrespective of treatment condition. CBCT was more effective than lidocaine for improving women’s sexual function at posttreatment when, at pretreatment, women had partners with higher anxiety and women reported lower approach sexual goals, whereas lidocaine was more effective for improving women’s sexual function at follow-up when partners had higher approach sexual goals. Findings can assist clinicians in determining what treatment will be most beneficial for whom.     

Supporting Romantic Relationships During COVID-19 Using Virtual Couple Therapy

The novel coronavirus disease pandemic (COVID-19) has profoundly impacted people’s lives, resulting in economic turmoil, death and suffering, and drastic changes to everyday life. The adjustment and strain of such challenges can spill over into couples’ relationship processes, including how partners spend time together, talk to one another, and manage conflict. Drawing from our experiences conducting virtual couple therapy (VCT) in a university-based training clinic and community-based clinic, as well as themes from an informal survey of 29 couple therapy clinicians, the current paper discusses the unique challenges that couples face in therapy during COVID-19. Such challenges include renegotiating quality time together, navigating less personal space and time alone, experiencing individual anxiety and stress prompted by the pandemic, and increases in conflict. We discuss our clinical recommendations for addressing these challenges for couples and utilize clinical case examples to illustrate our points. Despite these challenges, we also comment on several positive aspects of COVID-19 on couple relationships. Guided by these considerations and recommendations, our observations suggest that clinicians can effectively support couples’ growth and progress using VCT during COVID-19.     

Feminist Issues in Couple Therapy

Abstract

The authors reviewed the feminist couple therapy literature from 1995 to 2006. They summarized this large body of work into several key themes. The first revealed that feminist couples therapists are continuing to discuss and deconstruct gender issues in couple therapy. The second showed that feminists believe that therapists should be educated both academically and personally about culture and diversity so as to support couples in their therapy around their own issues of diversity as well as learning to deal with issues of social justice as a couple. In the third theme, the authors introduced readers to feminists' emphasis on connection and empathy within couple and sex therapy. And, in the fourth, the authors explored feminists' work with power in couple therapy as they applied to couple therapy in general as well as around the specific topics of: balancing family and work and therapy for familial violence.     

Couple therapy for military veterans: overall effectiveness and predictors of response

Despite the numerous challenges facing U.S. veterans and their relationships, there have been no examinations of the effectiveness of couple therapy for relationship distress provided to veterans. In the present study, 177 couples presenting for couple therapy at two Veteran Administration Medical Centers completed assessments of relationship satisfaction prior to therapy and weekly during therapy. Results revealed that the average couple showed significant gains in relationship satisfaction during treatment (d=0.44 for men; d=0.47 for women); gains were larger for couples beginning therapy in the distressed range (d=0.61 for men; d=0.58 for women) than for couples in the nondistressed range (d=0.19 for men; d=0.22 for women). Rates of premature termination were high, with 19% of couples completing fewer than three sessions and 62% rated as not completing a "full course" of therapy. Benchmarking analyses demonstrated that the average gains were larger than would be expected from natural remission and similar to previous effectiveness trials; however, average gains were smaller than those observed in couple therapy efficacy trials. Relationship, psychological, and demographic characteristics were generally unrelated to the amount of change in therapy after controlling for initial satisfaction. However, African American couples showed significantly larger gains than Caucasian, non-Hispanic couples. Thus, though yielding smaller effects than those shown in efficacy trials, the impact of couple therapy for veterans' relationship problems appears to generalize across various demographic, psychological, and relationship characteristics.     

Personhood of the Therapist in Couples Therapy

SUMMARY

Integrity Therapy (Lander, 1986; Lander & Nahon, 1992a, 1995a; Mowrer, 1961b, 1964a) views the personhood of the therapist as the very essence of therapy. By meeting the deepest part of the therapist with the deepest self of individuals in therapy, a healing process unfolds which opens up the healing potential of both the individuals and the couple. This article offers couple therapists and other mental health professionals an Integrity Therapy perspective of the personhood of the therapist and its therapeutic potential for helping couples in distress to reclaim their personhood. Two aspects of the Integrity Therapy approach which play a critical role in enhancing therapists' use of their personhood in the therapeutic process are explored: (a) the use of therapist self-disclosure, and (b) therapists' awareness and therapeutic use of counter-transference issues.     

Applying Psychoanalysis to Couple Therapy: The Treatment of a Couple with Sexualized Persecutory Internal Objects Resulting from Trauma

The application of psychoanalytic theory and technique to the treatment of couples has been relatively overlooked despite the long history of concern by psychoanalysts with the role of marriage in individual development and suffering. This paper uses an example of marital and sex therapy to illustrate the application of psychoanalytic object relations theory to couple therapy, and describes the way that in-depth treatment of the couple's persecutory object relations that follow severe trauma can be effectively conducted. The paper concludes with a brief discussion of issues of shame and guilt in psychoanalytic theory and their relevance to this couple.     

Integrating Sex and Couples Therapy: A Multifaceted Case History

Traditionally, sexuality has not been a focus in couples therapy training, research, or practice, although it is an important, often complex issue for many couples. This article tells the story of a couple presenting for sex therapy due to their unconsummated marriage, and is told to exemplify how sex therapy and couples therapy can be integrated in order to best meet the needs of couples. As the story unfolds, the multilayered facets of the presenting issue are revealed. The therapy incorporates and weaves together family of origin history, intrapsychic and cognitive issues, relational dynamics, patterns of interaction, and physiological/medical concerns into a postmodern couples therapy with behavioral interventions. This combined approach recognizes the value of each method on its own and their greater usefulness when blended together.