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Tuesday, 30 December 2008 13:55

Bad Couples Therapy

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Bad Couples Therapy

Betting Past the Myth of Therapist Neutrality

by William Doherty

I want to propose a new competition for therapists: awards for the worst experiences doing couples therapy. My own entry would be in the category of a worst experience as a new couples therapist in the first session. It was 26 years ago, but as they say, it feels like yesterday. As a graduate student, I'd done individual counseling before, and had worked with parents and kids, but had never worked with a couple. Thirty minutes into the first session, when I was lost in the midst of a meandering series of questions, the husband leaned forward and said, "I don't think you know what you are doing." Alas, he was right. Naked came the new couples therapist.

Since then, as we say in Lake Wobegon, I like to think I've become an above-average couples therapist, but that might not be much of a distinction. A dirty little secret in the therapy field is that couples therapy may be the hardest form of therapy, and most therapists aren't good at it. Of course, this wouldn't be a public health problem if most therapists stayed away from couples work, but they don't. Surveys indicate that about 80 percent of therapists in private practice do couples therapy. Where they got their training is a mystery, because most therapists practicing today never took a course in couples therapy and never did their internships under supervision from someone who'd mastered the art. From a consumer's point of view, going in for couples therapy is like having your broken leg set by a doctor who skipped orthopedics in medical school.

What's my evidence for these assertions? Most therapists today trained as psychologists, social workers, professional counselors, or psychiatrists. None of these professions requires a course in marital therapy. At best, some programs offer an elective in "family therapy," which usually focuses on parent-child work. Only the professional specialty of marriage and family therapy, which constitutes about 12 percent of psychotherapy practitioners in the United States, requires coursework in couples therapy, but even there you can get a license after working only with parents and kids. After coursework, few internship settings in any field give systematic training in couples therapy, which isn't ordinarily a reimbursable service.

The result is that most therapists learn couples therapy after they get licensed--through workshops and by trial and error. Most specialize in individual therapy, and work with couples on the side. Most have never had anyone observe or critique their couples work. So it's not surprising that the only form of therapy that received low ratings in a famous national survey of therapy clients, published in 1996 by Consumer Reports, was couples therapy. The state of the art in couples therapy isn't very artful.


Why is couples therapy a uniquely difficult form of practice? For starters, there's an ever-present risk of winning one spouse's allegiance at the expense of the other spouse's. All your wonderful joining skills from individual therapy can backfire within seconds with a couple. A brilliant therapeutic observation can blow up in your face when one spouse thinks you're genius and the other thinks you're clueless--or worse, allied with the enemy. After all, one spouse who agrees with you too vociferously can dramatically undercut your effectiveness.

Couples sessions can be scenes of rapid escalation uncommon in individual therapy, and even in family therapy. Lose control over the process for 15 seconds and you can have spouses screaming at each other and wondering why they're paying you to watch them mix it up. In individual therapy, you can always say, "Tell me more about that," and take a few minutes to figure out what to do next. In couples therapy, the emotional intensity of the couple's dynamics doesn't give you this luxury.

Even more unnerving is the fact that couples therapy often begins with the threat that the couple will split up. Often, one spouse is coming just to drop off his or her partner at a therapist's doorstep before exiting. Others are so demoralized that they need an intense infusion of hope before agreeing to a second session. Therapists who prefer to take their time doing their favorite lengthy assessment instead of intervening immediately may lose couples who arrive in crisis and need a rapid response to stop the bleeding. A laid-back or timid therapist can doom a marriage that requires quick CPR. If couples therapy were a sport, it would resemble wrestling, not baseball--because it can be over in a flash if you don't have your wits about you.

As in any sport or art form, there are beginners' mistakes and advanced practitioners' mistakes. Inexperienced and untrained couples therapists don't manage sessions well. They struggle with the techniques of couples therapy, and clients often sense that these therapists aren't skillful. More advanced therapists can manage sessions well with challenging couples, but they make subtler mistakes, of which neither they nor their clients may be aware. I'll start with beginners' mistakes and then describe how couples therapy can go south, even in the hands of experienced therapists.


Beginners' Mistakes

Mistake No. 1--Lack of Structure: The most common mistake made by inexperienced couples therapists is providing too little structure for the sessions. These therapists let spouses interrupt each other and talk over each other. They watch and observe as spouses speak for each other and read each other's minds, making attacks and counterattacks. Sessions generate a lot of energetic conversation, but little learning or change. The partners simply reproduce their familiar patterns in the office. The therapist may end the session with something blandly reassuring like, "Well, we've gotten a number of the issues on the table," but the couple leaves demoralized.

Screenwriters are onto this fundamental clinical mistake. In the movie The Ref, Kevin Spacey and Judy Davis are a warring couple in a therapist's office. At one point, they turn to the therapist, almost pleading for him to intervene in their bickering. He says reflexively, "What I can say is that communication is good." Later, he adds, "I'm not here to give advice or to take sides," whereupon Davis shoots back, "Then what good are you anyway?" When the therapist loses control completely and begs the couple to lower their voices, they shout back, "Fuck you!" in unison--the first time they've agreed on anything in the session.

Sometimes a therapist who doesn't create a clear structure for the sessions will conclude that some clients aren't good candidates for couples therapy because they're too reactive in each other's presence. The upshot is a referral, splitting up the partners for individual therapy, which might further erode the marriage. I once saw a tape of an inexperienced couples therapist who announced that the sessions didn't seem "safe enough" for the angry spouses. (There was no evidence of physical violence or emotional cruelty in the relationship.) The real issue wasn't the couple's ability to handle the joint sessions--it was the therapist's ability. She was the one who didn't feel safe.

I remember when I first realized that I had to ratchet up my structuring skills. I was working with a couple in which the husband was Israeli and the wife American. David was opinionated and assertive, but loving and committed. The challenge I faced in the early sessions was his tendency to interrupt his wife, Sarah. I tried to keep him at bay with my standard armamentarium of diplomatically crafted "I-statements." "David," I'd say, "I'm concerned about your interrupting Maria, which means she can't finish her thought. I'd like to reinforce the ground rule that neither of you interrupts the other. Is that something you're willing to commit to?" He'd agree, be cooperative for a while, and then start interrupting again when she got his goat. Finally, I fell back on my working-class Philadelphia roots, bluntly instructing him, "David, stop interrupting your wife. Let her finish." He looked as though he was taking in my message for the first time. "Okay," he replied meekly. Thereafter, when he'd start to interrupt, I'd keep looking at Sarah while waving my arm in his direction, shooing his comments away. He cut it out, the therapy progressed, and I realized I'd reclaimed a piece of my Philly street past that I could use when the occasion required.


Mistake No. 2--No Plan for Change
: After lack of structure, the most common complaint I hear is that many therapists don't recommend changes in the couple's day-to-day relationship. Some therapists act as if insight alone is enough to help couples change intractable patterns of thinking and acting. But we all know that certain dynamics within a relationship have a life of their own. I start emotional, you start rational, I get angrier, and you get more controlled. Then I mention your mother and you blow up, which pleases me immensely. Just pointing out this dynamic isn't enough to change it. All empirically supported forms of couples therapy require active interventions aimed at teaching couples new ways to interact. Most involve homework assignments. Of course, just making interventions isn't enough if they're too global or generic. If my wife and I are fighting continually over her mother, saying to us, "Remember to paraphrase and use your other communication skills" won't take us very far. Good therapy addresses the way couples actually do their own particular dance, both during the session and back at home.

Mistake No. 3--Giving Up: The third common mistake of inexperienced therapists is giving up on the relationship because the therapist feels overwhelmed with the couple's problems. I've heard enough stories about therapists who abandoned ship too soon to be confident that this is a common mistake. In one case, the therapist did an assessment during the first session, and in the second session pronounced that the couple was incompatible and weren't candidates for couples therapy--without ever trying to help them. In another case, a woman whose husband was becoming emotionally abusive as his Parkinson's disease progressed told me that, at the end of the first session, the therapist had said, "Your husband will never change, so you have to accept what he's doing or get out." Translation: "I don't have a clue about Parkinson's disease or how to help an elderly couple with serious marital problems, so I'm pronouncing yours a hopeless case." This also kept the therapist's average length of treatment in favorable territory with his managed-care employer.

Some therapists survive the early sessions but get frustrated later and actively advise couples to separate. When deciding that the couple isn't amenable to treatment, they don't seem to factor in their own skill level. They may further reduce their own sense of responsibility by making a delayed diagnosis that one of the spouses has a personality disorder. This often means nothing more than "I can't work with this person." Giving up this way is akin to a primary care physician's pronouncing a patient incurable without referring the patient to a specialist in his or her life-threatening condition. I once worked with a young family physician who had a rule that no one should be allowed to die without a consultation from a specialist in what is killing them. I would argue the same for couples: treatment failures, especially those that lead to divorce, shouldn't be accepted without a consultation or referral to a competent, experienced therapist who specializes in working with couples.


Experienced Therapists' Mistakes

Mistake No. 1--Thinking All Couples Are Equal: Advanced practitioners' mistakes are more about strategy than technique, more about missing the context than specific relational dynamics, and more about unacknowledged values than lack of knowledge. I'll focus on two areas of poor couples therapy by experienced therapists: working with remarried couples and working with couples deciding whether to work on their marriage or divorce.

Remarried couples with stepchildren are a minefield, even for experienced therapists, because the partners almost always come with parenting issues, not just couples problems, and because many therapists miss the nuances of stepfamily dynamics. Therapists who specialize in adult relational work but aren't skilled at parent-child therapy will fail with these families. Experienced therapists who treat remarried couples like first-marrieds usually manage the individual sessions well, but use the wrong overall strategy.

I remember my own awakening on therapy with remarried couples almost as clearly as I remember my first session of couples therapy. It was in the spring of 1985, and I'd been trying to get Dave and Diane to reduce conflict in their two-year-old marriage by being equal parents with Kevin, Diane's challenging, 14-year-old son from a previous marriage. It was a familiar coparenting problem. Dave thought that Diane was too soft on the boy, and Diane thought Dave was too strict. They'd sometimes  reach a "compromise," but Diane wouldn't follow through on it. I'd helped many couples with this kind of bread-and-butter problem in family therapy, but I was stuck here. I can feel the chair I was sitting on when I said to myself something like, Bill, why are you insisting that this woman share parenting authority equally with this man? He didn't raise Kevin, Kevin doesn't see him as a father, and Dave doesn't have the same investment as Diane does. She can't treat Dave as an equal here, so stop beating up on her for not succeeding.

I realized that I was misapplying a norm about coresponsibility in biological coparenting to a family structure where it didn't apply in the same way. I then told the couple that I could understand why Diane couldn't give Dave equal say in disciplining her son--the fact was that Diane was the parent. With so many years invested in her son and Dave's relationship with Kevin so new, she couldn't share authority 50-50. I introduced a metaphor that I would come to use often with stepfamilies: in the parenting domain with her child, Diane was the "first violinist" and Dave "second violinist." Diane immediately was relieved, and Dave immediately was alarmed. There was a lot of work ahead, but they did achieve a workable coparenting relationship based on Diane's leadership with her son. Shortly thereafter, I read Betty Carter's work on stepfamilies in which she argued for treating the spouses as having different roles with the children, and then I came across new research by Mavis Hetherington making the same point. Stepfamilies are a different species, and couples in these families have to be treated with different approaches. Many experienced couples therapists still don't know this--or even if they do know it, still lack a viable treatment model.


Beyond coparenting leadership issues, couples in stepfamilies swim in a sea of divided loyalties, which even experienced therapists sometimes miss. I once consulted on a case of a recently married couple in which the wife had three children and the husband none. One thorny issue was that the husband felt left out of the wife's emotional world because they had little time alone together. The wife agreed, and she told the therapist how torn she felt about this. She loved her husband and wanted the marriage to work, but her three school-age children required nearly all of her time after work and in the evenings. She helped them with their homework every night, and they had the kind of extracurricular activity schedules that render contemporary parents part-time chauffeurs and full-time activity directors on the family cruise ship. Weekends were spent doing errands and driving the kids to their traveling soccer games.

In one of the early sessions, the therapist, who was highly experienced in couples work, empathized with the wife's feeling caught between the needs of her husband and those of her children, and supported the wife's decision to prioritize the children. The therapist explained that these years of raising school-age children are ones in which the children's time demands are huge, and the marital relationship inevitably has to take a back seat. She said that, as a wife and mother, she herself knew about these demands, which ease when children get older. In other words, the therapist normalized the marital gap in terms of the family life cycle, recognizing especially the unique strain on a wife who couldn't meet everyone's needs. The wife burst into tears at feeling so deeply understood and accepted. The therapist then turned to the husband and gently asked him for his feelings and thoughts as he'd followed the conversation and seen his wife's pain and tears. The husband, a "good guy," who didn't like conflict, owned that he'd been selfish and pledged to back off on his demands for more time with his wife, promising he'd be more understanding in the future.

The session ended with a warm glow. The couple agreed to continue working on other issues that had brought them to therapy. The therapist was pleased at how she'd been able to combine her clinical skills and her own experience as a wife and mother to help this couple. A few days later, the husband called to end the therapy, saying tersely that they'd decided to continue to work on things by themselves.


The therapist was stunned and consulted with me. I helped her see that she'd missed that there were two distinct family developmental stages at work in this case. Yes, the parent-child development stage was one of intense time demands (leaving aside for the moment the overscheduling supported by the wider culture), but the marital-developmental stage had its own pacing needs: a puppy marriage needs time for play and nurturing. To put aside their new marriage for years on end is dangerous. Of course, it's dangerous even in long-term relationships, but at least there may be a strong foundation and memories of good years. The husband was appropriately worried about the viability of a neglected new marriage. What struck me was how even a skilled, experienced couples therapist had misunderstood the special needs of a remarried couple.

Mistake No. 2--Not Standing by Marriage: If beginners give up on couple relationships because of lack of skill, experienced therapists sometimes give up on couples because of the values they hold about commitment in a troubled marriage. I've heard experienced therapists announce proudly, "I'm not here to save marriages; I'm here to help people." This split between people and their permanent, committed, intimate relationships (which is how I'm defining marriage ) has a superficial appeal. No one wants to save a marriage at the cost of great damage to a spouse or the children. But the statement reflects a troubling--and usually unacknowledged--tendency to value a client's current happiness over everything else.

One highly regarded therapist in my local community describes his approach to working with couples in this way: "I tell them that the point is to have a good life together. If they think they can have a good life together, then let's give it a try. But if they conclude that they can't have a good life together, then I tell them maybe they should move on." Again, at one level, this sounds like practical advice, but as a philosophy of working with marital commitment, it's lame. How does it differ from counseling someone about a job decision? If you think that your frustrating accounting job can eventually work out for you, then try to improve the situation; if not, move on. Most of us didn't stand up in front of our family, our friends (and maybe our God) and declare our undying loyalty and commitment to Arthur Andersen LLP, but we did so with our spouse.

In this way, the ethic of market capitalism can invade the consulting room without anyone's seeing it. Do what works for you as an autonomous individual as long as it meets your needs, and be prepared to cut your losses if the futures market in your marriage looks grim. There are legitimate reasons to divorce, but given the hopes and dreams that nearly everyone brings to a marriage, divorce is a wrenching, often tragic, event. I see divorce more like amputation than like cosmetic surgery. That's a different value orientation than that of one prominent family therapist who sees his job as helping people decide on their best option. "The good marriage or the good divorce," he told a journalist, "it matters not."


A lesbian therapist told me of how her own therapist wouldn't permit her to bring the children's needs into the therapy conversation when she was contemplating whether to stay with her partner. "This isn't about the kids," the therapist insisted. "It's about what you need and want." When the client objected that she had to weigh the kids' needs in her decision, and wanted to talk about it, the therapist balked, insisting that the client was avoiding dealing with her real issues. Finally, the client fired the therapist. Later, she told me that she and her partner had found a way to stay committed, improve their relationship, and raise their children together. The therapist in this case was a highly regarded professional, a "therapist's therapist" in the community.

It was an experience that happened to a couple who are close to my family that radicalized me about how today's therapists deal with commitment. It's a story like many others I've heard from clients, colleagues, and friends. Monica's life was thrown into chaos the day that Rob, her husband of 18 years, announced that he was having an affair with her best friend and wanted an "open marriage." When Monica refused, Rob bolted from the house and was found the next day wandering around aimlessly in a nearby woods. After two weeks in a mental hospital, diagnosed with an acute, psychotic depression, he was released to outpatient treatment. Though he claimed during his hospitalization that he wanted a divorce, his therapist had the good sense to urge him to not make any major decisions until he was feeling better.

Meanwhile, Monica was beside herself. She had two young children at home, held a demanding job, and was struggling with a serious chronic illness diagnosed a year before. Indeed, Rob had never been able to cope with her diagnosis, or with his own job loss six months later. (He was now working again.) In addition, the family had just recently moved to a new city.

Clearly, this couple had been through a lot of stress. For a former straight-arrow man with strong religious and moral values, Rob was acting in a completely uncharacteristic way. Monica was depressed, agitated, and confused. Being an intelligent consumer, she sought out recommendations and found a highly regarded clinical psychologist. Rob continued in individual outpatient psychotherapy, while living alone in an apartment. He still wanted a divorce.


As Monica recounted, her therapist, after two sessions of assessment and crisis intervention, suggested that she pursue the divorce. She resisted, affirming her hope that the real Rob would reemerge from his mid-life crisis. She suspected that the affair with her friend would be short-lived (as it was). She was angry and hurt, she said, but determined not to give up on an 18-year marriage after only one month of hell. The therapist, according to Monica, interpreted her resistance to "moving on with her life" as stemming from an inability to "grieve the end of her marriage." He then connected this inability to the loss of her mother when Monica was a small child. Monica's difficulty in letting go of a failed marriage, he claimed, stemmed from unfinished mourning over her mother's death.

Fortunately, Monica had the strength to fire the therapist. Not many clients would be able to do that, especially in the face of such expert pathologizing of their moral commitment. It was equally fortunate that Monica and Rob found a good marital therapist, who saw them through their crisis and onward to an ultimately healthier marriage. When I last saw them, Rob was more emotionally available than I'd ever seen him before. He and Monica had survived an intervention that I call therapist-assisted marital suicide.

The therapist's blundering in this case stemmed not from clinical incompetence in knowledge and technique, but from his values and beliefs. He simply didn't recognize the importance of a commitment made "for better or worse." Like attorneys who automatically fight their clients' opponents, some therapists encourage clients to rid themselves of currently toxic spouses, rather than working hard to see what can be salvaged and restored. This approach may be wrongheaded, even when it comes to individual well-being. Recent research by sociologist Linda Waite has found that the great majority of unhappy spouses who persevere in their (nonviolent) marriages for five years report marked improvements in their marriages, and that divorce, on average, doesn't make people in unhappy marriages any better off in personal well-being.

Ultimately, clinical skills aren't enough in couples therapy, because here, more than in any other form of therapy, our clinical skills and values intersect. Treating a client's depression or anxiety doesn't involve the kind of value judgments that working with couples does. Feminists were among the first to point out the inevitability of moral positions in couples work. You can't work with heterosexual couples without a framework that addresses justice and equality in gender relations. If you claim to be neutral, you'll enact whatever traditional value orientation you have about women and men and how they should make a life together. The same is true for race and sexual orientation. Not to have a moral framework is to have an unacknowledged one, and in mainstream American culture, that will probably be individualistic rather than relational or communitarian.


Just as clients who value gender equality won't be well served by therapists with traditional value orientations about gender, clients who cherish their moral commitment to their marriage, as Monica did, won't be safe in the hands of clinically skilled couples therapists who have individualistic orientations. Such clients need therapists who understand the wisdom of Thornton Wilder when he wrote: "I didn't marry you because you were perfect. I didn't even marry you because I loved you. I married you because you gave me a promise. That promise made up for your faults. And the promise I gave you made up for mine. Two imperfect people got married and it was the promise that made the marriage. And when our children were growing up, it wasn't a house that protected them; and it wasn't our love that protected them--it was that promise."

The biggest problem in couples therapy, beyond the raw incompetence that sadly abounds, is the myth of therapist neutrality, which keeps us from talking about our values with one another and our clients. If you think you're neutral, you can't frame clinical decisions in moral terms, let alone make your values known to your clients. That's partly why stepfamilies and fragile couples get such bad treatment from even good therapists. Stepfamily life is like a morality play with conflicting claims for justice, loyalty, and preferential treatment. You can't work with remarried couples without a moral compass. Fragile couples are caught in a moral crucible, trying to discern whether their personal suffering is enough to cancel their lifetime commitment, and whether their dreams for a better life outweigh their children's needs for a stable family. The therapist's moral values are writ large on these clinical landscapes, but we can't talk about them without violating the neutrality taboo. And for clients, there's the scary fact that what therapists can't talk about may be decisive in the process and outcome of their therapy.

In the end, we need to cultivate wise couples therapists, not just competent ones. Wise therapists see the whole context of people's lives, and can reflect openly and deeply on values and broader social forces influencing the profession. My wisdom won't be the same as yours, but we have to engage one another on the big questions, instead of hiding behind the wizard's veil of clinical neutrality. The philosopher Alasdair MacIntrye wrote that, in a world that seduces professionals into seeing their work as the delivery of technical services stripped of larger social context and moral meaning, the hallmark of a true profession is a never-ending argument about whether it's being true to its fundamental values, principles, and practices. In other words, becoming a competent couples therapist is just the first step in becoming a good one.


William Doherty, Ph.D., is professor and director of the marriage and family therapy program at the University of Minnesota. Address: Family Social Science, University of Minnesota, 290 McNeal Hall, St. Paul, MN 55108. E-mails to the author may be sent to bdoherty@che.umn.edu.

Last modified on Wednesday, 30 June 2010 14:40

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