PERSPECTIVES

One Size Does Not Fit All in Couple Therapy: The Case for Theory Integration

 

Couple therapy is a complex and challenging activity even for the most experienced marriage and family therapists (MFTs). There are many models to choose from, and integrating them is not easy for most MFTs who wish to improve their skills in working with couples. Some are attachment based and others emphasize differentiation. Some focus on the systemic interactional pattern, while some are more focused on the individual. How do we figure out what to do?


A model may work well in one stage of the treatment process, but not so well in another stage. In this article, I will explain why framework integration in couples therapy is important, explore one way of integrating models, and describe one case, using sequencing frameworks at different stages of the treatment process with a couple who presented in a high level of distress.

Every proponent of a framework for couple 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 MFT in the process of change? 

Some proponents of frameworks concentrate on a particular period of time: The present, the past or the future. Bowenians (Bowen, 1978) propose to take a couple back several generations. MFTs with a psychodynamic orientation will have couples go back at least one generation (Nielsen, 2016). Emotionally focused couple therapists take couples back to past emotional injuries sustained in the current couple relationship where healing also takes place (Makinen & Johnson, 2006). MFTs who use the Gottman model (Gottman & Silver, 1999) address issues predictive of relationship distress in the current couple relationship and consider the couples’ dreams for the future. Solutions focused therapists (Zigler & Hiller, 2001) and narrative therapists (Combs & Friedman, 1995) mainly look ahead, focusing on the vision of the future when the problems are solved and using questions as the main intervention. Additionally, there are frameworks that focus more particularly on either thinking, feeling, or on behavior as the door of entry into the change process. 

There are many advantages of using a pure form of a couple therapy framework. To have a road map as a guide helps the therapist focus the attention and tends to make the work less overwhelming. Having multiple tools can cause confusion if MFTs don’t know how to choose among them (Nielsen, 2016). Therapists faced with too many options may be tempted to cling to one theory, in part because it is easier and less confusing. 

Adherence to one framework, however, has limitations. Therapists may attempt to make the client fit into the theory; a model gives structure but not the 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 (Schwarzbaum, 2021); and a pure form of a framework can lead to therapeutic errors (Pinsof, 1995).

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 (Asay & Lambert, 1999; Lambert, 2013). 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 MFT (Miller, Hubble, & Duncan, 1995), 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 couple 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. 

When MFTs start working with a couple, they never know for how long they 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.

A moment of integration often occurs when an MFT 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 (Pinsof, 1995), 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 (Miller, Hubble, & Duncan, 1995). Do the partners and the therapist have alignment on goals and tasks (Duncan & Miller, 2000)? 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 MFT 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. 

An MFT 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 interventive questioning. What if the couple feels like they are “coming to the therapist for expertise” and request more guidance?

MFTs with a systemic or insight orientation believe that awareness of the dynamic, or awareness of the legacy issues are sufficient, and tend not engage in behavioral interventions. 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?

The severity of the presenting issue does not determine the outcome in a case. Rather, it seems that the most important factors are what maintains the presenting issue (Pinsof, 1995), what roadblocks there are to solving them, and what constraints people have (Breunlin, Schwartz, & Mac Kune-Karrer, 1997).

When a couple begins a treatment process, it’s difficult to know for how long they will stay engaged in treatment. 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 (Pinsof, 1995).

Many couples may be able to improve dramatically in a relatively short period of time provided that the issues that maintain the problems are not too constraining or too deep, regardless of the initial level of distress. Therapy involves the continuing testing of hypotheses and of interventions derived from them. It is the failure of such interventions that signal that the constraints may be broader or deeper.

To implement framework integration, MFTs are encouraged to consider sequencing the treatment process (Schwarzbaum, 2021). In the first stage of the treatment process, when the MFT 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 MFT can review the past gains, go even deeper, and work on preventing relapses. 

Case illustration using treatment sequencing

When Roy and Beatrice, a heterosexual couple in their late 30s, married less than a decade, with two children under five, came to their first appointment, Roy reported that they were struggling with high conflict, that issues were never resolved, and that he didn’t feel supported. Beatrice said that there was a lot of tension, very little affection and sex, and that she did not know how to deal with his intensity and anger. Their level of distress was moderate to high, and their level of hope about the viability of the relationship was low. When I asked them how they would know that therapy 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, couple therapy can focus more on “what could be” happening than on “what is” or “what was” happening. It’s 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, like the solution focused or the narrative frameworks (Ziegler & Hiller, 2001).

Generally, the post-modern approaches focus primarily on the future. The proponents of these frameworks are interested in assessing and eliciting strengths, resilience, and pride factors. Some of the approaches are more behavioral and others are more cognitive based. Some of Gottman’s ideas are also future oriented.

Like so many couples, as Roy and Beatrice got stabilized, their level of hope about the viability of the 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 the focus to the positives. In a short time, they increased their awareness of 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 Gottman’s model. Using Gottman’s approach, Roy and Bea figured out how to stop a fight; they learned to listen to each other and to recognize more quickly 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 to avoid a “harsh start-up” (Gottman and Silver, 1999). I also introduced concepts of neuroscience to help them understand how their brains were involved in their fights and what they could do to achieve emotional regulation (Fishbane, 2013).

To create a bridge between the interactional and the intrapsychic work, we explored what was under the anger.

Not everything was easy for them. Roy struggled with impatience when triggered; Beatrice struggled with shutting down when he 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?” Bea 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 Couple Therapy (EFT) approach. This framework focuses on strengthening the attachment bond through the awareness and expression of vulnerable feelings (Makinen & Johnson, 2006).

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. For Roy it was fear of rejection, for Bea it turned out to be that when she felt controlled, she decided she didn’t need him, and thus rejected him, completing the cycle. The more he felt rejected, the more inpatient and upset he became; the more impatient, the more she rejected him. Once we understood what was under the anger, we were able to turn our attention to the family of origin and the attachment history to go even deeper into the intrapsychic work. 

Sometimes, with the application of EFT, Gottman and solution focused ideas, couples get better or simply move on. But sometimes, they are motivated to go deeper or they don’t get better. One way to go deeper 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 complained that he “doesn’t hear” her and that he hides 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 solve her own problems. She learned not to depend on anybody. Roy complained that she rejected him and was not a team player, that she did her own thing and didn’t “need” him. Each was re-enacting in their relationships some aspect of their attachment history (Nielsen, 2016). 

As time went on, I started interviewing them 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, 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 he vowed that “nobody was going to make me feel weak and inadequate ever again.” When Bea complained, he felt inadequate and resorted to his survival strategy of counter-attacking her. Bea 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,” which in turn triggered his fear of rejection and hostile behaviors. 

As time went on, the description of their interactional patterns became much richer. We worked on their family of origin history and connected their childhood defensive positions to the ways in which they got triggered. In time, they accessed the origins of 

their shame and vulnerability. They were courageous and stuck with it, but their progress 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. As a testament to their courage and perseverance, and to the strength of the therapeutic alliance, the negative cycles became less long and less severe.

There are many excellent models for doing couple therapy not mentioned here. The frameworks I chose are based, in part, on my own beliefs about the reasons for couples distress and my own views about how couples improve, developed over time. MFTs who can articulate their own beliefs about such matters will find choosing and integrating frameworks easier to achieve. 

When a couple begins a treatment process, it’s difficult to know for how long they will stay engaged in treatment. One way to think about integrating interventions is to apply the least invasive interventions to a problem and observe its effects.

Sara Schwarzbaum, EdD, LMFT, LCPC, is the founder of The Academy for Couples Therapists, an integrative online training program for MFTs who want to improve their skills working with couples. She also Founded Couples Counseling Associates in Chicago. As a professor, now Emerita, in the Family Counseling Program at Northeastern Illinois University in Chicago, she taught framework integration to future MFTs for 18 years. She has a master’s degree in clinical psychology from Buenos Aires, Argentina and doctoral degree in counseling with an emphasis in family therapy from Northern Illinois University. Her papers have appeared in the Psychotherapy Networker, Counseling Today, and other publications. She is a consultant, trainer, and presenter at state and national conferences.


REFERENCES

Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 23–55). American Psychological Association.

Bowen, Murray. (1978). Family therapy in clinical practice. New York: Jason Aronson. 

Breunlin,D., Schwartz, R. & Mac Kune-Karrer (1997). Metaframeworks: Transcending the models of family therapy. New Jersey: Jossey Bass.

Combs, G. & Freedman, J. (1995) Narrative therapy: The Social Construction of preferred realities. Jersey City, NJ: Norton.

Duncan, B. L., & Miller, S. D. (2000). The client’s theory of change: Consulting the client in the integrative process. Journal of Psychotherapy Integration, 10(2), 169–187.  

Fishbane, M. (2013). Loving with the brain in mind: Neurobiology and Couple Therapy. New York: Norton.

Gottman, J., & Silver, N. (1999). The seven principles for making marriage work. New York: Harmony.

Lambert, M. J. (2013). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of psychotherapy and behavior change. (6th ed., pp. 169-218). New York: Wiley.

Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples using emotionally focused therapy: Steps toward forgiveness and reconciliation. Journal of Consulting and Clinical Psychology, 74(6), 1055-1064

Miller, S. D., Hubble, M. A., Duncan, B. L. (1995). No more bells and whistles. Family Therapy Networker, 19, 23-31

Nielsen, A. (2016). A roadmap for couples therapy: Integrating systemic, psychodynamic and behavioral approaches. New York: Routledge.

Pinsof, W. M. (1995). Integrative problem-centered therapy: A synthesis of family, individual, and biological therapies. Basic Books.

Schwarzbaum, S. (January 28, 2021) Why are intimate relationships so difficult and how can counselors help? [Video]. YouTube. https://www.youtube.com/watch?v=BzLLicQvLJc

Zigler, P. & Hiller, T. (2001). Recreating partnership: A solution oriented, collaborative approach to couples therapy. Jersey City, NJ: Norton.

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