Q: I notice that many of my couples clients do well in therapy, only to return with the same or similar problems in a few months. What can I do to make the effects of treatment last?
A: This problem is probably a lot more common than most therapists want to admit. Clinicians don't get enough training in how clients can maintain their therapeutic gains. Also, today's mental health landscape promotes short-term symptom removal, not permanent change.
When a couple returns to therapy with the same problems, the first question to answer is whether they really want to resolve the problem. After all, it may serve an important function for them. Asking, "How would your life be different if you did not have this problem?" can give insight into the underlying purpose of the conflict. If the answer reveals that solving their problem is not a couple's primary motive, the therapist needs to address that issue.
But if, in fact, the couple wants to maintain their improvements, review five areas of your original course of treatment:
1. How aligned and actively committed was the couple to the treatment process? Without clear agreement on the goal of therapy and how to reach it, long-term treatment success is not likely. For example, Pedro and Mary had been very positive about therapy and never missed appointments. So I was surprised when, six months after our last session, they came back with the same family issues. In retrospect, I realized that they had done little, if any, of the homework assignments I had given them—they had not been aligned with my view of what would help them achieve their goals. I asked them in treatment what had prevented them from joining with me in this area and, this time around, was careful to give assignments that clearly fit their goals and that they would complete.
2. Did your approach to the couple truly fit their needs? In my experience, for example, most couples benefit from regular dates with each other and taking turns arranging the date (i.e., picking the activity, arranging child care, etc.). One couple I worked with agreed to take turns, even though Elaine preferred leading and Bruce was more comfortable following. After they left therapy and continued reversing roles of leading and following, they were miserable. The approach did not fit their needs. When they returned to therapy, I recommended the couple stick to the more comfortable roles, with Elaine making arrangements for dates and Bruce going along.
3. Did you help the couple develop strategies for managing future conflicts or challenges? Sometimes couples leave therapy after they have resolved a specific issue, and are unprepared when it crops up in a different form later on. For example, Jim and Rosa first came to see me following a holiday family party. We discussed Rosa's not feeling accepted by Jim's family, along with many other issues related to cultural differences and communication. Months later the couple returned to treatment following another unsuccessful family gathering. This time, I taught them specific stress-management approaches to help weather visits with his family
4. Did you encourage positive interchanges between the partners? Couples enter therapy with a lot of negative communication and behavior. Research shows that when therapy is successful, couples make five times as many positive statements as negative ones. One couple that I treated used positive language, but did not learn the "platinum" rule of relationships—do unto others what they want done unto them. They tried to be positive by treating their partner the way they themselves wanted to be treated. For example, he would change her car oil and she would do his laundry, each believing that this was something special for the other. However, neither considered these acts as loving. Once each realized what being positive and caring meant to the other—his doing the laundry, for instance—and put it into practice, their relationship improved.
5. Did you teach the particular skills the couple needed to maintain their therapeutic gains? It's important to help the couple returning to therapy to identify the missing skills that prevented treatment maintenance. Alison and Matt realized that when they finished therapy, they still had trouble problem solving. They kept trying the same solutions, even when they didn't work. When they returned to therapy, we discussed the importance of doing something different when a problem reappears. I recommended, as I do for many couples, that they watch the video Getting Unstuck with Michele Weiner-Davis, which gives couples practice finding alternative approaches when they are stuck with a problem.
Couples therapists need to be aware of the strategies that prevent relapse, so that short-term successes don't become long-term failures, and to address those areas in the initial therapy with the couple. However, if treatment gains are not maintained, these five elements can be revisited. Then therapists can help couples not only create satisfying relationships, but maintain them over the long term.
This blog is excerpted from "How to Prevent Relapse," by Jon Carlson. The full version is available in the September/October 2000 issue, Making Schools Work: What Therapists Have to Offer.
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