Before I start treatment with a couple I find it helpful to go through a process of assessment and formulation. This usually consists of an initial joint session, an individual session with each partner, then a joint feedback session. The aim of the feedback session (or “round table” as it sometimes known) is to help the couple get a better understanding of how they have found themselves in difficulties, what seems to be maintaining their relationship problems (keeping them stuck), and how treatment could help them work their way to a more enduring state of satisfaction.
I have found it helpful to think of the feedback as a narrative, in other words, a story that helps the couple make sense of the past and present and that also offers hope for the future. I try to help the couple believe that, however difficult things are right now, they have the power to change things for the better. I have found Jacobson and Christensen’s “six questions” model a useful framework for assessment, so these are the areas I ask about during my assessment sessions. I then use those questions to frame the feedback as I have found that it manages to incorporate the 5Ps model, which is the other commonly used approach. The 5Ps are: presenting problems, precipitating factors, predisposing factors, perpetuating factors and protective factors.
The feedback session is intended to be a collaborative process that provides a foundation for planning treatment interventions that target the areas of greatest concern. The principal theorists and practitioners that I have drawn on include the time-limited, integrative couple treatment model for depression developed in the UK by David Hewison’s expert reference group; Jacobsen and Christensen’s Integrative Behavioural Couple Therapy; John Gottman’s Sound Relationship House model (and the extensive research that underpins it); Dan Wile’s Collaborative Couple Therapy; Norman Epstein and Donald Baucom’s Enhanced Cognitive-Behavioural Therapy for Couples; Michele Scheinkman and Mona DeKoven Fishbane’s vulnerability cycle, and Leslie Greenberg and Susan Johnson’s Emotion-Focused Couples Therapy.
Question 1: what are the main issues that divide this couple?
Once we have established some connection and a shared understanding of the assessment and formulation process, I ask couples what brought them to therapy (in other words the precipitating or critical incident that led them to contact a therapist or therapy service) and to share with me what they see as the main areas of conflict or difficulty between them. Sometimes the precipitating factor is a major stressor, such as an affair, sometimes it’s a change in circumstances, such as redundancy, the birth of a child, a death or another loss that they are struggling with, sometimes difficulties have been building over time in a steady attrition of love, respect or fondness and a seemingly more trivial incident has proved to be the final straw for a relationship already creaking under the strain of mutual alienation or outright hostility. Common couple problems include money, sex, work, parenting or household chores but in reality there are many different potential areas of disagreement. Safety is a priority at this stage as attending couple therapy can add to the stress the couple is experiencing so I also want to know whether there are any issues that might make it difficult or impossible to carry out couple counselling safely and effectively. For example, whether there is a significant substance abuse issue, an affair that the person is not willing to give up, an undiagnosed severe mental health problem that requires individual treatment, or issues of risk of harm such as self-harm, suicidal thoughts, intimate partner abuse (such as domestic violence), or safeguarding issues. If those issues are a significant concern then it might be necessary to refer one or both partners to other interventions before offering couple therapy.
Question 2: how unhappy is this couple?
Having identified the main areas of difficulty I would like to know how unhappy each is with the state of the relationship. If there is evidence of mental health problems in one or both partners, I would like to know what effect the state of the relationship is having on their mental health and, correspondingly, what effect the mental health problem is having on the relationship. I will often ask couples to complete relevant questionnaires on mental health and relationship satisfaction to provide more detail and a benchmark to measure improvement. If there are discrepancies between each partner’s level of satisfaction, I would be curious about what that might indicate. For example, if one is relatively satisfied whereas the other is considerably unhappier I would want to understand why they have such different perceptions of a relationship that seems to be working for one partner but not the other as this will influence each partner’s opinion about the relevance or necessity of attending therapy and working to improve the relationship. I ask about some of the ways in which their unhappiness expresses itself, whether that’s through explosive arguments, long-lasting frosty silences, or acts of passive resistance and non-compliance that deprive each other of what each knows the other needs or wants.
Question 3: how committed is this couple to each other and to therapy?
In the light of how unhappy the couple feels, I ask about how committed they are to each other and to trying to work things out in therapy. I explore their emotional investment, for example having been together for a long time, and their practical investment, for example in having children that they want to raise together, or being financially mutually dependent. I ask what alternatives there are to being together and the benefits and costs of staying together versus separation. I try to find out what makes this relationship important to each and what purpose or greater meaning the relationship has that links to their core values and beliefs. I want to understand the extent to which each is committed to the process of couple therapy and any obstacles to attending, such as childcare responsibilities. I would like to know what that might mean in terms of the likely duration of therapy and the work they would be willing or able to put in between sessions.
Question 4: what makes those issues such a problem for this couple?
In my way of working, trying to answer this question is the most important aspect of understanding a couple’s problems, so it is the one that I spend most time on exploring and trying to communicate. I am particularly concerned firstly with the factors that have predisposed the couple to having this specific problem at this particular time, and secondly with the factors that maintain the problem and that therefore prevent them making progress on their own. I use three levels of analysis: a series of descriptive formulations, conceptualised using the framework of the nine-part model; a maintenance formulation that I have described as a cycle of rupture and repair; and a longitudinal formulation that draws on Dan Wile’s collaborative couple therapy, Michele Scheinkman and Mona DeKoven Fishbane’s vulnerability cycleand on Jeffrey Young’s schema therapy. I therefore explore each partner’s individual and relationship history as well as how the couple interact at a day-to-day level, to help us to understand why those problems have become so difficult for them to manage.
The general format I use to try to understand what makes those issues such a problem for this couple is as follows:
- What is the main complaint each has about the other’s behaviour?
- What does the complaint tell us about each partner’s unmet relationship needs?
- What do those unmet needs tell us about each partner’s areas of sensitivity: their vulnerabilities or expectations of their partner?
- What are the origins of those expectations or vulnerabilities in their personal history?
- What coping behaviours did each develop to help get those needs met at a different point in their life?
- What is the impact on their partner when they continue to use similar behaviours in the present?
The theoretical background to that line of enquiry is as follows: we all have a personal history of formative events that have shaped our personality, preferences and expectations. None of us has a choice about the family or the social circumstances into which we are born, nor do we choose our genetic heritage or the people or events to which we are exposed. Nonetheless, we try to find ways to cope as best we can, taking advantage of opportunities and dealing with the insults and adversities that life throws at us. As life progresses, our inherited characteristics, culture and family interact with our personality and personal experiences to shape our identity, our views of other people (and the world more generally), and our perceptions of the future. Formative experiences mould the way we make sense of events and what we want and expect from life and from a partner. They shape the psychological coping mechanisms we employ to manage emotional pain and the circumstances that give rise to it. Through reinforcement, they strengthen certain ways of behaving and leave other potential skills and abilities less well developed.
When it comes to selecting and relating to an intimate partner, our formative experiences shape:
- The kind of person that we are attracted to,
- Our positive and negative assumptions about the roles we should play to have a happy or successful relationship,
- Our standards for behaviour: what’s acceptable and unacceptable, good and bad, or right and wrong,
- The behaviour we pay more attention to, and what we ignore or overlook,
- The theories we come up with to explain our own and other people’s behaviour – in other words, why we believe each of us does the things we do,
- Our expectations of what life will be like in the future.
If our formative experiences have been especially painful or difficult in some respect, those experiences leave us with certain vulnerabilities or sensitivities that, when activated, can cause us to relate to ourselves, or to other people, in unhelpful ways. What might have been strategies of last resort when we were younger, or that worked in certain situations (for example, in a school or family home environment), prevent us as adults from getting the security and support we want and need. This is a theory of unintended consequences whereby out-of-date strategies to manage pain or frustration in the short-term, backfire on us in the long term. In other words, when our buttons get pushed it can lead us to behave in ways that are destructive to our own happiness and can hurt those around us.
Not only that, but the way we react when our sensitivities are triggered is likely to have an impact on our partner’s sensitivities. If we are sensitive to rejection and abandonment it can cause us to feel insecure even when there is no actual threat of abandonment but just a transient or minor conflict. If we were emotionally deprived of love, support, guidance or empathy and have learned to cope by becoming over-reliant on our independence, a partner’s repeated requests for reassurance might make us feel that our needs for emotional support are unimportant or won’t get met. A “couple dance” emerges where one partner’s coping strategy sets off the other’s sensitivity, who then responds with a similarly antagonising coping strategy in a cyclical pattern of increasing stress. Common vulnerabilities include sensitivity to feelings of mistrust or abuse, fear of rejection and abandonment, personal defectiveness and shame, emotional deprivation, isolation, and failure, inadequacy and dependence. Common coping strategies include going on the attack, avoiding or escaping from conflict, clinging or seeking excessive reassurance, or over-compensating (for example, having very high standards for personal success to try to avoid the experience of failure, or focusing on other people’s emotional needs to avoid having to expose oneself to possible rejection).
Not all sensitivities relate to unhappy or abusive experiences in childhood or in previous relationships. Some are a result of having different personalities and others are a result of deeply held beliefs about the right and wrong way to behave. Sometimes these beliefs are explicit rules bordering on commandments (“Thou shalt” and “Thou shalt not”). At other times they are so taken for granted we might not be aware that we even hold these beliefs or that other people might see things differently. Beliefs and expectations about how to “do” a relationship, or how to “be” in a couple, are passed on in families and through the wider world and are shaped by our background and culture. People from a majority culture will often see these expectations not as a culture itself but just the way things are done. People from minority cultures or who are part of a disempowered section of society might struggle to assert their culture and beliefs or have them taken seriously. At one level, every couple represents a form of cultural diversity because we are all raised in different ways but some people’s experiences of poverty, discrimination, or outright hostility are more extreme and pervasive than others. Finding ways to accommodate and respect difference and diversity is one of the challenges of being in any relationship. Figure 1 illustrates the vulnerability cycle as I have adapted it.
A relationship can also hold the hope of being part of a process of healing personal vulnerabilities in so far as it provides a validating, loving environment that helps us to learn that we are not what we fear we might be, or who we learned to be, and this can have great redemptive power. When we learn to show care unconditionally, or a relationship helps us to achieve things in life that are incredibly important to us (for example, raising a family of our own), we can help each other to get needs met in the present that were not met in our formative years. Having our emotional needs met helps us to manage our distress in the face of threat or insecurity, and helps strengthen our adaptive coping strategies. The more we thrive, the more we in turn are able to provide the supportive emotional conditions that help our partner also to grow.
A slightly different but complementary way of describing the development of couple distress is provided by Jacobson and Christensenwho make the crucial point that we choose our partner because we each imagined that they would be a good person to share the kind of life we hoped we both would want. As we get to know each other, and as life’s stresses intervene, we discover that our initial impressions aren’t the whole story and that we are either different in some important way or we share similar vulnerabilities. We might say that in every relationship there are almost certain to be significant differences or similarities between people that are going to be a source of potential conflict. What seems to be important is that we are able to maintain a dialogue about those issues so that they don’t become seen as fundamental incompatibilities.
When our need for security, identity, attraction or appreciation isn’t met, it can lead to a profound sense of frustration or disappointment. Having formed an impression of our partner as the person who was going to make a significant contribution to our happiness, and knowing that we are far from happy, we can easily assume the problem must be our partner. Difference or similarity, even that which was originally a source of attraction, starts to feel unpleasant or intolerable because it appears to prevent us getting some vital relationship need met. As a consequence, it can feel as though whatever it is that we are arguing about, it always seems to be the same argument. After the event we often can’t remember what it was that we were disputing. It’s as if there is some important themeof difference or similarity.
Common themes amongst couples often focus on the need for closeness and distance, or for power and control, or for identity, liking and appreciation: perhaps one of us would prefer to be closer emotionally and the other to have more distance or independence; perhaps one of us wants to make more major decisions in the relationship and the other resents that; perhaps, as we have discussed already, we both have shared insecurities, such as abandonment fears, that make us vulnerable to jealousy; or sensitivity to rejection or criticism that makes us feel insecure; perhaps, as circumstances change, what used to feel supportive now feels suffocating, or offering too much care and attention inadvertently leads the other partner to feel less capable and to become more dependent, therefore needing more care and attention…each couple has their own particular theme.
When life’s circumstances aren’t too stressful we can usually cope with these differences and our sensitivities aren’t triggered too often, especially if the rest of our life is fulfilling. However we all live in a specific context – historical, cultural, and familial – that will either validate or invalidate our individual or couple struggles, and resource us or impoverish us. Major stresses, such as a change in our circumstances (unemployment, bereavement etc.), or a crisis, such as an affair, can challenge our assumptions and our practised ways of living; they might mean we have to rethink our relationship roles. In contrast, chronic, minor stresses that are poorly dealt with can wear down our ability to cope and alienate us from each other, leaving us feeling unsupported, burdened and alone.
As we get more stressed, we become less tolerant and more rigid in our thinking and behaviour, making us less creative at solving the problems that we are trying to deal with. The loss of an important person (such as a parent), or of the opportunity to fulfil an important role in life, can have the effect of placing more demands on the relationship than realistically it can cope with. Mental or physical health problems in one of the partners, or in a dependent or other family member, are themselves significant stresses that many couples struggle to adapt to or to cope with.
For many, if not most of us, our sense of felt security comes from the knowledge that we have a partner who is accessible, responsive and emotionally available to us, especially at times of need. Because fundamental differences or similarities between us can seem like incompatibilities when they prevent us from getting important relationship needs met, and those needs are often exacerbated at times of stress or when we have little other support available to us, we can end up feeling deprived of the very things that give life meaning, which for many of us is the love, support and intimacy that a committed life partnership brings.
Not only do we feel deprived but we also feel we lack the influence or control that would enable us to obtain those loving responses from our partner. The more powerless and deprived we feel, the more our sensitivities are triggered. The more our sensitivities are triggered, the more unhelpful our ways of coping. The more powerless we feel, the more unhelpful the ways in which we try to overcome deprivation and powerlessness. Our coping strategies tend to focus on trying to change our partner, or trying to resist their efforts to change us. As a consequence of the pain this causes, we might start to engage in unsuccessful or toxic coping strategies such as accusation, blame, emotional blackmail, defensiveness, avoidance, minimisation of the problem, over-reaction, or forming alliances with others for personal support or coalitions against our partner. This leads to the three common “couple dances”, or patterns of unhelpful coping: the more we criticise or challenge our partner the more they fight back (attack-attack); the more we pull back from our partner, the more they pull back (withdraw-withdraw); and, the more we pursue our partner for something they have that we want, the more they pull back to avoid giving us something they either don’t want to, or can’t, give us (demand-withdraw).
At a descriptive level, specific toxic interactions can be described using the nine-part model. This model helps couples to see that the same events can be perceived in radically different ways by each partner, leading to distressing emotions, counter-productive coping strategies and relationship conflict or disengagement. Working through examples can help couples see events from each other’s point of view, rather than through the lens of their own untested assumptions.
As toxic interactions increase in frequency a pattern of mutual coercion can develop, where the more we try to influence the other the more they appear to resist any efforts at change. The more they resist change, the harder we try to change the way they behave. The more that this pattern of unhelpful coping continues, the more it escalates. Criticism, defensiveness, contempt and emotional withdrawal become more common and increase the sense of distance, the hopelessness and frustration, and the tendency to blame and criticise both our partner and ourselves. The consequence of this struggle to get our needs met, and to have a sense of agency or control in our relationship, is deep unhappiness. We may tell ourselves that we do not deserve love, support and affection, or that our partner is the kind of person who enjoys depriving us of those things, or is mean-spirited, mentally unwell, or morally deficient. This unhappiness and powerlessness can cause or exacerbate common mental health problems such as depression. The more trapped and defeated, or thwarted and diminished, we feel in life, the more prone we are to anxiety, low mood, hopelessness and negative opinions about others, the world and ourselves. The more ineffective our attempts to support or help a partner who is struggling, the more we can feel bewildered, isolated and struggling ourselves. It becomes increasingly difficult to find a comfortable middle ground for the expression of our deepest wishes and yearnings, or for compromise and intimacy to flourish.
As the tendency to focus on the negative takes hold, we often overlook how our partner is also frustrated by their ineffective attempts to get what they want, or to stop us from giving them what they don’t want – it’s as if each of us can’t stop trying to get what we want, because it’s so vitally important to us, but the more we try, the worse it seems to make things – this is what Jacobson and Christensen call the mutual trap, which I describe as the consequence of a downward spiral of frequent rupture and ineffective repair.
Question 5: what strengths and resources do this couple have?
The previous picture can feel pretty bleak to hear. It is, after all, a story of people trying desperately to get fundamental needs met but doing so in ways that ultimately backfire in sometimes catastrophic, and almost always painful, ways. It’s really important therefore that the story is communicated tentatively and with understanding and compassion as well as reminding the couple that this is not the whole picture. It is really important not to overlook the couple’s strengths and resources, their so-called protective factors, that have helped them cope. This can be a combination of individual resilience, couple warmth and affection, and external resources, such as family, friends and community. These are important assets that can get overlooked in the daily struggle to cope with the demands of life. Finding creative ways to draw on strengths and resources can help alleviate stress and bring a couple closer together again.
Question 6: what might treatment do to help this couple?
Our goal in treatment is to help reduce conflict and increase support. Each couple is engaged in its own intimate dance of love and support. Through improving communication a couple is more able to accept each other and connect empathically (for example, taking turns to speak and listen respectfully, or being willing to admit their part in an argument, or confide in their partner and comfort them when they are upset). Through distancing themselves from their problems by seeing the difficulty as something that is outside of each person they can form a shared alliance against the difficulties they face (sometimes called externalising, for example by asking the couple to put the problem figuratively on a chair in front of them and encouraging them to describe how each knows when the problem is present). By understanding relational cycles that exacerbate unhappiness, couples can spot those patterns and interrupt them before they escalate. By learning to manage their feelings, couples can take a more measured stance that gets across more effectively how they feel deep down.
Once a couple learns to manage difficult feelings, they can learn to abandon blame and develop a stance of curiosity that helps them see things from each other’s point of view, or take note of the ways in which earlier experiences are shaping their perception of the present moment. By managing stress together, the couple can feel less overwhelmed. By increasing the number of caring gestures, shared activities and self-care, couples can increase positive feelings between them or learn to take care of themselves and each other better. By learning to solve their solvable problems, whilst maintaining a dialogue about perpetual problems, couples can take control over important areas of their life and minimise conflict. The more a relationship becomes a supportive environment, the better couples can manage everyday stress. The better they manage stress, the more they can support each other and cultivate physical, practical, emotional and sexual intimacy. The more skilful the dance, the more supportive and loving the relationship will be. The less the relationship becomes a place in which unhappiness can flourish, the more it becomes a place in which both can thrive.
Andrew Grimmer: 2017-2019