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One size does not fit all in couples counseling

By Sara Schwarzbaum February 8, 2022

Our field needs competent and effective couples counselors now more than ever. Couples’ distress is a public health issue affecting families and communities. But many counselors did not receive enough training in their graduate school days to work effectively with couples, and now they are scrambling to choose from the myriad available trainings to find the best fit. 

More and more counselors are considering becoming skilled at working with couples in distress, but it’s not always easy to figure out what training to invest in. In this article, I describe why framework integration is important in couples counseling and spell out a three-stage model for achieving it, using a case example as a guide.

Proponents of most couples counseling frameworks seek to provide answers to the following questions, and the answers constitute the elements of the particular model:  

  • How do problems develop in a couple? 
  • Why do problems develop in a couple?
  • How do couples change? 
  • What is the role of the counselor in the process of change?

There are advantages and disadvantages to adhering to only one model. 

Having a road map helps the couples counselor figure out what to focus attention on and makes the work less overwhelming. For example, a framework helps the counselor think of the questions to ask, the goals of the counseling process and the interventions to achieve those goals. A model also often makes it easier to find a community of like-minded counselors, providing a forum for discussions in which counselors feel less isolated doing this difficult work.

But adherence to one framework also has its limitations. For instance, it’s tempting to make the couple fit into the theory. A model gives structure, but it does not necessarily provide the freedom to adapt to the needs of a particular couple. 

With so many variables to take into consideration, how could one model possibly be a good fit for all couples? Still, model integration is not easy. The more tools a couples counselor possesses, the more freedom the counselor will have to implement what’s most needed in a certain situation. But having multiple tools can be disorienting. Counselors faced with too many options may be tempted to cling to one theory precisely because it’s easier and less confusing and can be less isolating.

After decades of experience working with couples in distress, teaching couples counseling frameworks and supervising counselors who work with couples, I have come to firmly believe that one size does not fit all in couples counseling. The treatment must be personalized, individualized and, most importantly, sequenced according to the stage of the treatment process. 

Why is framework integration important?

Several compelling reasons encourage the use of an integrative approach.

First, many approaches to couples counseling use different terms to describe similar phenomena. These differences are, in part, a result of the lack of cross-fertilization between proponents who favor a certain approach. Different models emphasize their uniqueness and their differences, but they often overlap considerably in what they deem important. 

Second, no single approach is comprehensive enough to deal with the variety of problems that contemporary couples present to their counselors. Some models concentrate on a particular period of time. Some focus on the future vision of the couple when their problems would be solved (Gottman method, solution-focused and narrative), some on the present interactional patterns (systemic) and some on the past or intergenerational transmission process (Bowenian, psychodynamic). Each model focuses on either thinking (cognitive behavioral), feeling (emotionally focused approach) or behavior as the door of entry into the change process. And some models focus on the developmental aspects of each member of the couple, regardless of whether the couple decide to stay together (developmental). 

Third, errors and failures in couples counseling can generally be attributed to the application of a pure form of a framework. At some point, every framework, when applied single-handedly or in its pure form, fails to help some couples. The moment of integration inevitably comes when counselors start asking themselves, “What else could I have done with this couple?” This question is the prompt that counselors need to reach outside a model and look for alternatives.

Fourth, one of the most important aspects of a treatment with a couple is the therapeutic alliance. Sometimes, the application of a pure model risks rupturing the alliance. When this happens, another model could be used to restore the alliance so that the process of couples counseling can continue successfully. Consider the following examples: 

An intergenerational counselor versed in the model founded by Murray Bowen is likely to do a genogram fairly early in the process, but one member of the couple doesn’t buy in to the idea that a connection exists between family-of-origin issues and the couple’s current impasses and may refuse to talk about family of origin. 

Many couples counselors think the honest and vulnerable expression of feelings is the most important factor in a treatment with a couple. However, one partner does not feel safe expressing vulnerable feelings in front of the other partner or does not believe in the value of expressing feelings because “it would make me look weak.” 

Proponents of postmodern frameworks (solution-focused or narrative therapy) consider the couple to be the experts in solving their own problems and frequently use interventive questioning. What if the couple think they are “coming to the therapist for expertise” and request more guidance?

Counselors with an insight orientation may believe that awareness is sufficient and tend not to believe in skill deficits. What if the couple achieve a high level of awareness but their behavior still doesn’t change because they lack the skills to make behavior changes?

It’s clear that the therapeutic alliance could suffer if the couple and the counselor don’t agree on the reasons for the development of problems or on the ways to alleviate them. Sometimes, adherence to a pure form of a framework risks rupturing the alliance between the couple and the counselor. It’s up to the counselor to adapt the framework to the couple and not the other way around.

How do we do framework integration?

There are several ways of integrating models. Readers are encouraged to explore models of framework integration such as the metaframeworks model, as well as the works of William Pinsof, Art Nielsen, Ellyn Bader, Peter Pearson and Scott Miller, to name a few. Additionally, applying the stages of change model to couples work would shed some light on ways to integrate models.

One way to think about integrating models, according to Pinsof, is to apply the least amount of “medicine” to a problem and observe its effects. Counselors can go from the “here and now” approaches (solution-focused, narrative) to the “there and then” (intergenerational and psychodynamic) in a sequential manner by applying the least invasive, more direct interventions first. 

In this view, the framework we choose should depend not on the severity of the presenting issue but rather on what maintains the presenting issue, what roadblocks there are to solving the presenting problem and what constraints people have. 

Some couples who present with severe long-term distress, substance use issues or personality disorders may be able to improve dramatically in a relatively short period of time with direct, here-and-now, behavioral interventions, provided that the issues that maintain the problems are not too constraining or too deep. If what maintains the problem is relatively simple and superficial, behaviorally oriented interventions would be effective, no matter the severity of the presenting problem. It is the failure of such interventions that begins to tell us the structure of the problem is broader or deeper than we anticipated. Counseling involves the continuing testing of hypotheses about what maintains distress in a couple. 

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Another way to think about framework integration is to sequence the couples counseling process into stages. A successful stabilization of the couple can increase motivation for deeper work. Counselors never know how long the couple will commit to the process — whether it will be for five sessions or for 50 sessions. In the early stages, couples can get stabilized if the therapeutic alliance is strong and if they are committed and motivated to do some work on their interactional pattern. An approach that works well in the beginning stages is future-oriented, focusing on creating a vision of a better relationship and on strengths and resilience factors. The systemic, developmental, Gottman, solution-focused and narrative frameworks are most recommended for the beginning stages of counseling couples. 

In the second stage of the treatment process, when couples want to commit to going deeper, emotionally focused, imago, transgenerational and psychodynamic frameworks could be utilized. This is when couples agree to do a deeper exploration of their interactional pattern and its connection to their attachment histories and styles, and they want a better understanding of their individual vulnerabilities, their survival strategies and the coping mechanisms they use that maintain their negative interactional cycle. 

In the third stage, to deal with setbacks or to prevent relapses, couples who have done the deep second-stage work will be more inclined to strengthen their bond with behavioral or systemic interventions involving skill building and a change in the pattern of interaction. If separation or divorce is at issue, the process of uncoupling will be less marred with emotional upheavals if the couple did the deeper second-stage work. 

Case illustration using treatment sequencing 

First stage: Stabilization

When Roy and Beatrice — a heterosexual couple in their late 30s, married less than a decade, with two children under age 5 — came to their first appointment, Roy reported they were struggling with high conflict, that issues were never resolved and that he didn’t feel supported. Beatrice said there was a lot of tension and very little affection or sex in their marriage. She also said that she did not know how to deal with Roy’s intensity and anger. Their level of distress was moderate to high, and their level of hope about the viability of their relationship was low. 

When I asked them how they would know that the therapeutic process had been successful, they said they would have better communication and more sex. I also asked them what kind of partner they wanted to be. They agreed that they both wanted to have more fun; they wanted to take things more lightly and less seriously. 

In the early stages, couples counseling can focus more on “what could be” happening than on “what is” or “what was” happening. It is important to help partners focus on the “partner I want to be” rather than on the “partner I want to have.” This is what I did with Roy and Beatrice during the stabilization stage of treatment, and it reflects my use of future-oriented questions.

Generally, postmodern approaches focus primarily on the future. The proponents of these frameworks, such as the solution-focused or narrative frameworks described by Phillip Ziegler and Tobey Hiller in their 2001 book Recreating Partnership, are interested in assessing and eliciting strengths, resilience and pride factors. Some of the approaches are more behavioral, whereas others are more cognitive based. 

Like so many couples, as Roy and Beatrice got stabilized, their level of hope about the viability of their relationship increased dramatically after they discovered what strengths they brought into their relationship and described what gave them a sense of pride. They were able to focus on what kind of partner they wanted to be. They figured out how to shift their focus to the positives. In a short time, they increased their awareness of the impact of their behaviors on each other. 

They managed to create a vision of their relationship, but when they fought, things got out of hand because of their mutual blaming, so I turned to John and Julie Gottman’s model. Using the Gottman method, Roy and Beatrice figured out how to stop a fight; they learned to listen to each other and to recognize sooner when they got flooded so they could stop a conversation that was not going well. They learned to initiate conversations when they were not tired or hungry or emotionally depleted, helping them to avoid what the Gottmans refer to as a “harsh startup.” 

Second stage: Going deeper

Not everything was easy for Roy and Beatrice. Roy struggled with impatience when triggered; Beatrice struggled with shutting down when Roy became impatient. At one point Roy said, “I am a screamer, and I come from a screamer family. That’s who I am. Why should I change?” 

Beatrice said, “I guess I do defend myself when he attacks me, but what else can I do?” 

To answer those questions, I turned my attention to the emotionally focused therapy (EFT) approach to couples counseling. This framework focuses on strengthening the attachment bond through the awareness and expression of vulnerable feelings.

EFT also focuses on a systemic understanding of interactional patterns. Roy and Beatrice learned to identify their triggers, their feelings and their interactional patterns: The more impatient and upset he became, the more she got defensive and shut down, and the more she shut down, the more impatient he became.

To create a bridge between the interactional and the intrapsychic work, we explored what was under the anger. By then, we had a very strong therapeutic alliance, and the couple trusted me to guide them to explore their most vulnerable feelings. For Roy, it was fear of rejection; for Beatrice, it turned out that when she felt controlled, she decided that she didn’t need Roy and thus rejected him, completing the cycle. The more Roy felt rejected, the more inpatient and upset he became; the more impatient he became, the more she rejected him. Once we understood what was under the anger, we were able to turn our attention to Roy’s and Beatrice’s families of origin and their attachment histories to go even deeper into the intrapsychic work. 

Sometimes, with the application of EFT, Gottman method and solution-focused ideas, couples get better or simply move on. But other times, they are motivated to go deeper, or they don’t get better. One way to go deeper or to the past is to use intergenerational approaches, including Bowenian, imago and psychodynamic frameworks. 

As we delved into their life stories, I learned that when Roy’s parents were screaming at each other when he was very young, he often hid under the table and covered his ears so he wouldn’t hear them. Not surprisingly, Beatrice had complained that Roy “doesn’t hear” her and that he hid his feelings. 

Beatrice, on the other hand, had a chaotic childhood, moved frequently and was never in one place for long. She survived by learning to rely only on herself and solving her own problems. She learned not to depend on anybody. Roy complained that Beatrice rejected him and was not a team player, that she did her own thing and that she didn’t “need” him. Both Roy and Beatrice were reenacting in their relationship some aspect of their attachment history, as Nielsen described in his 2016 book A Roadmap for Couple Therapy: Integrating Systemic, Psychodynamic and Behavioral Approaches.

As time went on, I started interviewing Roy and Beatrice individually, but in the presence of each other. I wanted to understand their protective and defensive positions better, their sibling position in the family of origin and their attachment history. I empathized with each of them as we began to put words around their reactions. 

They were used to triggering each other’s childhood attachment injuries and shame-based reactions. Roy had been bullied and vowed that “nobody was going to make me feel weak and like a loser ever again.” When Beatrice complained, he felt inadequate and resorted to his survival strategy of counterattacking her. Beatrice on the other hand had been emotionally neglected, and when Roy attacked her, she literally shut herself off from him, went to her room the way she did growing up and said to herself, “I can do this on my own. I don’t need him.” This in turn triggered Roy’s fear of rejection and hostile behaviors. 

Third stage: Skill building, preventing relapses and dealing with setbacks

As time went on, the description of their interactional patterns became much richer. We worked on their family-of-origin histories and connected their childhood defensive positions to the ways in which they got triggered. In time, Roy and Beatrice accessed the origins of their shame and vulnerability. They were courageous and stuck with the process, but it was marred by repeated cycles of progression and regression. They would move toward greater openness and flexibility only to return to the old familiar negative cycles. 

It turned out that Roy and Beatrice didn’t have any role models they could draw on to build and maintain a successful and collaborative relationship. They needed skills, but they would not have been able to learn them without doing the deep work of the previous stage. So, we worked on an apology protocol to heal old wounds, discussed a variety of problem-solving strategies, looked for alternatives to disconnection and discussed ways to deal with disappointments and disagreements. They also learned to have calendar and division-of-labor meetings.

When I met Roy and Beatrice, I didn’t know how long I would see them. After a two-year process, their negative cycles had become less severe and were of shorter duration. They had learned how to fight fair, how to repair emotional wounds and how to have positive interactions. It is a testament to their courage and perseverance and to the strength of the therapeutic alliance. Not all couples stay engaged in counseling for so long, which suggests why an initial stabilization period is essential for many couples who don’t make it to stage two of the process.

There are many excellent models for doing couples counseling that I did not mention in this article. The frameworks I chose are based in part on my own beliefs about the reasons for Roy and Beatrice’s distress and my views about how they could improve, which I developed over time. 

To succeed at integrating models, every counselor who works with couples should seek answers to the following questions: How and why do problems develop in a couple? How do couples change? What is the role of the counselor? Theory integration is easier and less overwhelming when counselors develop their own views about these important issues and use them as their guiding principles.

 

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Sara Schwarzbaum is a licensed marriage and family therapist and licensed clinical professional counselor. She is the founder of the Academy for Couples Therapists (theacademyforcouplestherapists.com), an integrative online training program for counselors who want to improve their work with couples, and the founder of Couples Counseling Associates in Chicago. She is the author of Culture and Identity: Life Stories for Counselors and Therapists. Contact her at sara@theacademyforcouplestherapists.com.

 

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3 Comments

  1. Kelly Austin

    I am so happy to read about something I have been doing as a seat of my pants kind of therapy for so long. I believe in it and my clients believe in it, but I hadn’t seen anything out there by others. Well, frankly I have been so busy that I haven’t had a chance to hunt for “proof”. I think my intern and resident will be happy to see this too!

    Reply
  2. Thomas Donlan

    This was so helpful!! Thank you Sara for writing such an informative and digestible piece. Reading your approaches and the rationale behind them helped to validate some of what I am already doing, and at the same time it provided a nice sort of road map to keep in mind with clients (the stages). VERY well done!

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