The self in the couple relationship: part 2

Part 1 of this paper examined some of the ways in which individual therapy, by assisting in the development of a more cohesive sense of self in the individual, inevitably has an impact on the individual's relationships, especially their relationship with a partner. This paper approaches the topic of the significance of ‘the self’ in the couple relationship from an alternative direction. It focuses on the significance of ‘the self’ for couples therapy, and argues that couples therapy may sometimes need to include therapeutic work with one partner to facilitate change in the relationship. In both parts of the paper, a conceptualization of the couple relationship as ‘a transitional space’ is central.     

Treatment‐as‐Usual for Couples: Trajectories Before and After Beginning Couple Therapy

Couple therapy has been shown to be a meaningful way to improve couples’ relationships. However, less information is known about couples’ functioning prior to entering treatment in community settings, as well as how their relationship functioning changes from initiating therapy onward. This study examined 87 couples who began community‐based couple therapy during a longitudinal study of couples in the military. The couples were assessed six times over the course of 3 years, including time points before and after starting couple therapy. Using an interrupted‐time series design, we examined trajectories across the start of couple therapy in relationship satisfaction, divorce proneness, and negative communication. The results demonstrated that couples’ relationship satisfaction was declining and both divorce proneness and negative communication were increasing prior to entering couple therapy. After starting couple therapy, couples’ functioning on all three variables leveled off but did not show further change, but previous experience in relationship education moderated these effects. Specifically, those who were assigned to the relationship education program (vs. control) demonstrated greater reductions in divorce proneness and greater increases marital satisfaction after starting therapy; however, they also started more distressed.     

The Findings of a Cochrane Meta-Analysis of Couple Therapy in Adult Depression: Implications for Research and Clinical Practice

The association between depressive symptoms and distressed intimate relationships supported the assumption that couple therapy, by focusing on the interpersonal context of depression, might be more effective as a treatment for depression than individual psychotherapy or drug therapy. This issue was addressed by a Cochrane meta-analysis assessing the evidence from clinical trials of couple therapy for depression in comparison with individual psychotherapy, drug therapy, and no/minimal intervention, including fourteen studies with 651 participants. No study was found free of bias and the quality of the evidence was low, with major problems of small sample sizes, missing outcome data, selective reporting, lack of information on random sequence generation and allocation concealment, recruitment of people not representative of clinical practice, and allegiance bias. The meta-analysis showed that both couple therapy and individual psychotherapy improved depressive symptoms at end of treatment and after 6 months or longer, with moderate effect sizes, without any difference between the two treatments. Couple therapy was more effective in reducing couple distress. This effect was larger in studies with distressed couples only and should be considered as relevant in its own right. Couple therapy is a viable option for the treatment of a depressed partner, especially in discordant couples. Future research should address several issues left open to provide a sound empirical foundation for clinical practice.     

The construction of emotional experience: State‐related emotional awareness and its application to psychotherapy research and practice

The cognitive–developmental theory of ‘levels of emotional awareness’ (LEA) addresses an individual's capacity to experience and express emotion, a capacity highly relevant to psychotherapy. Previous papers on LEA and psychotherapy addressed the aspect of LEA theory pertaining to the ‘trait’ (i.e. enduring) aspects of an individual's emotional functioning over time. LEA theory also applies to the construction of emotional experience at any given moment, in which levels emerge or disappear in a process of microgenetic construction as a function of arousal and other variables. This state‐related perspective is supported by recent research showing that people vary in their LEA from moment to moment. Momentary changes in LEA correspond to the variations in lived experience that occur in relationships, including the therapy relationship, and provide the context for corrective emotional experiences that promote change. In this paper, the construction of emotional experience at different levels of organisation is discussed separately in relation to clients and therapists. Key phenomena relevant to psychotherapy include the transition from bodily sensations to specific differentiated emotional feelings, the ability to be aware of multiple feelings that may be contradictory or counter‐intuitive, and the appreciation of how complex combinations of feelings may differ in self and other. This perspective adds to the literature on how the integration of emotion and cognition contributes to change in psychotherapy. The clinical and research implications of this perspective are discussed.     

Inside out,or outside in: meeting with couples

The complex difficulties often faced by couples require a range of models for effective help. Relational intensity is heightened in therapy by the ease with which the therapist can be triangled into the couple's relationship and by the influence of the emotional triggers from their respective internal worlds. This article draws on systemic and psychodynamic models and a transgenerational perspective for gendered stories. Different time frameworks link interpersonal and intrapersonal themes. In this sense, the therapist works ‘inside out’ and ‘outside in’. A framework of behaviours, emotions, feelings, meanings and beliefs is proposed to help link these perspectives. ‘Invisible contracts’ and the sense of there often being an unconscious ‘pact to disappoint’ are described. Clear models are not enough, for it is the intimate encounter between client and therapist that is the bedrock of therapeutic change and growth. There is no short cut to this sense of intimacy in the unique encounter between therapist and each new couple. Brief examples from practice describe how the issues discussed may be addressed in couples work.     

Self‐concept clarity and relationship satisfaction at the dyadic level

Self‐concept clarity is an individual resource that is associated with couple relationship well‐being. In two dyadic studies, the authors investigated whether and how self‐concept clarity has implications for both partners' relationship satisfaction. Study 1 tested and supported the hypothesis that self‐concept clarity concurrently predicts own and partner's relationship satisfaction through couple identity in a sample of 202 dating couples. Study 2 tested and supported the hypothesis that self‐concept clarity predicts longitudinal change in own and partner's relationship satisfaction through positive (i.e., supportive and common) dyadic coping behaviors in a sample of 97 married couples. The findings clarify and expand the benefits of self‐concept clarity for partners' relational well‐being.     

Random Thoughts on Couple Therapy in a Postmodern Society

The postmodern period in psychoanalysis has had a considerable impact and influence on the psychotherapeutic process in both psychoanalysis and psychotherapy. The paradigm shift, reflected in the work of the intersubjectivists, rationalists, and social constructivists, has shifted emphasis from a one-person psychology to a two-person psychology. Implications for treatment are numerous. The change in emphasis affects not only how individual treatment is conducted but also couple therapy and group therapy. In considering the impact of these recent changes, the author notes the wide range of influences that inform her couple and group therapy. Although the current paradigm shift offers much, it seems to be an extension of earlier influences from self psychology, motivational systems, and attachment theory and of findings from neuropsychology. The author concludes that her couple work has also been intuitively informed by the implicit experience of the intersubjective field of group therapy.     

Benchmarking Community-Based Couple Therapy: Considering Measurement Reactivity

Couple therapy has been shown to be effective in randomized clinical trials; however, results from naturalistic couple therapy have been less consistent. This study utilized a benchmarking approach to compare the effectiveness of couple therapy in a community-based setting with findings from efficacy treatments, such as treatment within randomized clinical trials. The current study is the largest couple therapy sample published to date (N = 3,347 couples). Clients in couple therapy were asked to provide initial and weekly ratings of symptomology on the Outcome Questionnaire (OQ-45.2). We found that treatment effect sizes found at community clinics were smaller than efficacy studies (i.e., the benchmark). However, when taking into account measurement reactivity, the effect sizes were comparable. This is the first benchmarking study for community-based couple therapy, allowing for meaningful comparisons and understanding of outcomes in real-world couple therapy. Implications for the field are offered in terms of evaluating community-based psychotherapy studies with benchmarking for couple therapy. Results of this study provide clinicians and researchers a way to meaningfully compare couple therapy outcomes, accounting for differences in community-based practices and randomized clinical trials. This benchmark also underscores the impact of measurement sensitivity, an issue commonly overlooked in psychotherapy research and practice.     

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.     

Pre‐treatment change in psychotherapy with adult children of problem drinkers: The significance of leaving home

In a qualitative diary study of four adult children of problem drinkers in psychotherapy, it transpired that all four clients had experienced significant changes before they entered psychotherapy. This study first addresses the issue of how pre‐treatment change may be conceptualised in psychological theory and research. Five ways of understanding pre‐treatment change are presented. Data from the case studies are then presented, highlighting how these clients experienced a diminishing sense of self‐control in relation to leaving the home they cohabited with their alcoholic parent. The dynamics of how leaving home affects the clients are analysed. It is suggested that change experienced in relation to leaving home is significant to the decision to enter therapy. The fit between the data and the theories of pre‐treatment change is discussed.     

Getting engaged: A case study and a model of the engagement period as a process of conflict-resolution

This paper addresses the problem of why so many marriages end in divorce. It develops a preventative approach to marital breakdown by proposing pre-marital counselling as a resource to be made widely available to couples. The key psychological issues which a counsellor could use as the backbone of any such counselling or therapeutic work are outlined. It is suggested that these issues are part of the psychological ‘working-through’ period during an engagement, when the couple are preparing for marriage. The psychological difficulties that an individual may be struggling with are illustrated via an account of psychodynamic psychotherapy with a young woman during the year of her engagement.     

Low-level relationship aggression and couple therapy outcomes.

Increasing evidence supports the efficacy of conjoint therapies that focus on intimate partner violence for couples who engage in mild to moderate physical aggression but want to preserve the relationship and end the aggression. However, there has been no examination of how this population responds to couple therapy that does not have a specific focus on aggression. This lacuna in the research literature is of concern because couples with a history of low-level aggression often seek couple therapy, but couple therapy without a focus on violence is thought to potentially exacerbate aggression. In the current study, the authors examined the efficacy of non-aggression-focused behavioral couple therapy for couples with and without a history of mild physical aggression. One hundred thirty-four couples, 45% of whom had experienced low-level aggression in the year prior to therapy, completed up to 26 sessions of couple therapy and 2 years of follow-up assessments. Results demonstrated no significant differences in relationship and individual outcomes by history of aggression. In addition, couples maintained very low levels of physical aggression during and after treatment and showed reductions in psychological aggression when relationship and individual functioning improved.     

Improving Young Male Couples’ Sexual and Relationship Health in the 2GETHER Program: Intervention Techniques,Environments of Care,and Societal Considerations

Young male couples are at high risk for acquiring human immunodeficiency virus (HIV). However, few HIV prevention programs meet the needs of young male couples that express an interest in how to maintain healthy relationships. As such, we developed 2GETHER, a couple-based program that integrates HIV risk reduction and sexual health information into a relationship education program specific to young male couples. 2GETHER was guided by cognitive-behavioral theories of HIV risk reduction and relationship functioning and was informed by a social–ecological perspective to address factors within and outside the couple that can impact sexual and relationship health. As a micro-level intervention, 2GETHER intervenes directly with couples via psychoeducation and cognitive-behavioral strategies to change couples’ communication patterns, sexual health behaviors, and relationship satisfaction. Successful implementation of 2GETHER requires mezzo-level interventions that create an affirming environment of care for sexual minority individuals and facilitators who are culturally competent in working with young male couples. Although macro-level interventions to change societal acceptance of and policies germane to sexual minority couples are beyond the scope of 2GETHER, we discuss how clinicians can advocate for systemic changes to improve sexual minority couples’ health, and how 2GETHER addresses the impact of such macro-level factors on the couple’s relationship. Our experience developing and testing 2GETHER indicates that HIV prevention programs for young male couples should reflect the unique contexts shaping sexual minority individuals’ relationships and lives, and that programs should intervene within and across multiple levels when possible to improve health for sexual minority men.     

Disintegration of the self and the regeneration of ‘psychic skin’ in the treatment of traumatized refugees

This paper presents a tentative understanding of the characteristics of the extreme traumas, elsewhere called ‘complex PTSD’, that some refugees and asylum‐seekers bring into therapy. It suggests that these kinds of traumas suffered during adulthood may involve a disintegration of the self and a loss of ‘psychic skin’. This conceptualization is derived from the treatment of a refugee who survived multiple extreme traumas and with whom efforts were made in therapy to identify a complex methodology making use of supplementary therapeutic tools in addition to individual psychotherapy. The case demonstrates how the disintegration of self implies not only a deep somato‐psychic dissociation, but also a loss of intrapsychic and interpersonal space. In the treatment this was worked through via repetition of the victim‐aggressor dynamics at multiple levels. In the end, the therapeutic context was structured like a set of concentric layers, creating a ‘bandage’ over the patient's wounds whilst his ‘psychic skin’ was able to regenerate. The conditions triggered by extreme traumas in refugees challenge some of the cornerstones of individual psychoanalytic technique, as well as the idea that individual therapy may be thought of as existing in an environmental vacuum.     

A Randomized Controlled Trial of Coach Contact During a Brief Online Intervention for Distressed Couples

The negative impacts of relationship distress on the couple, the family, and the individual are well‐known. However, couples are often unable to access effective treatments to combat these effects—including many couples who might be at highest risk for relationship distress. Online self‐help interventions decrease the barriers to treatment and provide couples with high quality, research‐based programs they can do on their own. Using a combined multiple baseline and randomized design, the present study investigated the effectiveness of the Brief OurRelationship.com (Brief‐OR) program with and without staff support in improving relationship distress and individual functioning. Results indicated the program produced significant gains in several areas of relationship functioning; however, these gains were smaller in magnitude than those observed in Full‐OR. Furthermore, effects of Brief‐OR were not sustained over follow‐up. Comparisons between couples randomized to Brief‐OR with and without contact with a staff coach indicated that coach contact significantly reduced program noncompletion and improved program effects. Limitations and future directions are discussed.     

Revisiting a meta-analysis of helpful aspects of therapy in a community counselling service

This small scale mixed methods study examines helpful events in a community counselling setting, categorising impacts of events according to Timulak’s [(2007). Identifying core categories of client-identified impact of helpful events in psychotherapy: A qualitative meta-analysis. Psychotherapy Research, 17, 305–314] meta-synthesis of significant events research. Comparisons were made between the types of impacts reported as helpful by clients receiving cognitive behavioural therapy (CBT) or relational integrative counselling. Seventy-five clients identified 291 significant events on 216 Helpful Aspects of Therapy (HAT) forms. The findings broadly reflect all nine impacts identified by Timulak (2007). The study also suggests that a potential new category, ‘voicing’ may exist. Differences between the types of impacts reported as helpful by clients in CBT and integrative therapy showed a higher percentage of CBT clients reporting ‘behavioural change/problem solution’, ‘reassurance’ and ‘client involvement’ as helpful. Differences in other categories were not statistically significant.     

Change process in systemic therapy: A qualitative investigation

This study addresses the process of therapeutic change in individuals who received systemic therapy. This study is an exploratory qualitative study based on the client's perceptions and therapeutic experiences. The sample included 10 clients who had completed their therapy with systemic therapists. The method used for the collection of the data was semi‐structured interviews (Change Interview; Elliott, Slatick, & Urman, 2001). The interviews were analysed using grounded theory analysis. The results showed that both specific and common factors in therapy function in a co‐occurring mode, hence suggesting a synergy effect between common factors and specific techniques or therapist factors in psychotherapy. The core category ‘experience of therapeutic change, within the secure frame of therapy, is a process of deconstructing and reconstructing the house you live in: Yourself’ emerged based on self‐exploration and self‐discovery and is then discussed in a theoretical constructivist framework. Implications for research on the issue of the process of therapeutic change are discussed.     

Integrating couples and family therapy into a community alcohol service: a pantheoretical approach

This paper discusses the contribution of family systems theory and therapy to mainstream alcohol treatment programmes. Systemic psychotherapy is integrated with group analytic psychotherapy in a couples and family therapy service within a community alcohol service (CAS) which uses the Prochaska and Diclemente model of stages of change. Problems and solutions in putting these complex ideas into practice are discussed, with specific reference to issues of engagement. An example of our work with a couple is offered to illustrate our weave of theory and practice.     

Echo and the Failure of Knowing in Judith Fox’s Photographic Project <Emphasis Type="Italic">I Still Do: Loving and Living with Alzheimer’s</Emphasis>

In relationships ‘I’ and ‘you’ become ‘we’; despite individual differences, couples obtain an interdependent identity due to their shared interactions. During a serious illness, biological and biographical disruptions can put any reciprocal relationship under strain. Through intermedial analysis of Judith Fox’s photographic project, I Still Do: Loving and Living with Alzheimer’s (2009), I will explore ways the couple make sense of illness, how illness is communicated through text and image and also to identify the limits of representation. Here the photographs, I argue, solidify their relationship and echo the stuck-in-the-present state of mind brought on by Alzheimer’s.