COUPLE THERAPY AND EFFECTIVE TREATMENT
One of the most common problems that people have to face in their lives arises mostly in marriages and other intimate relationships. Relationship difficulties are among the most common reasons that people tend to seek help from health proffesionals. Nowadays about half of all visits to psychotherapists are related to marriage/ relationship and family difficulties with couple therapy being increasingly popular. The term couple therapy is gradually replacing the older marital therapy has a history of 80 or more years but it is only the last 20 years that it has begun to develop as a therapeutic model in its own. (Shmueli & Clulow, 1997.Before that couple therapy was included either in family therapy or in individual psychotherapy with the therapeutic techniques of those therapies applied to coupels refers to a series of psychotherapeutic interventions, strategies and techniques that are applied to couples. The purpose of couple therapy is to help partners reduce their distress in their relationship or marriage and increase the relationship satisfaction. Couple therapy is not only applied to married heterosexual couples but also to unmarried couples with the same or opposite sex. Anyone who is married or has a long-term relationship will admit that having a successful relationship is not easy. Although we have seen many couples never fight in front of friends and family, these same couples have admit that they disagree many times when alone. The difference between one relationship and another is how people face these relationship problems and whether they seek for help or not. Even though marital dissatisfaction may have a negative effect on physical and psychological health, there are more common reasons that lead couples to therapy. One problem in couples especially nowadays is financial problems and disagreements on how they should spend the money. For example one partner may want to spend money excessively on buying everything new in clothes or shoes, while the other may spend money only on necessary things like food or bills; these everyday conflicts may occur due to this problem. Another problem that couples may face is an extramarital affair. When there are constant disagreements and general sadness in a couple this may lead to infidelity and when the partner discovers the extramarital affair this will make him/her not trust her/him again. Another common reason that may lead couples to a therapist is the lack of romance and sexual dissatisfaction. After so many years of marriage or relationship the couple may become distant due to many hours of work, children and loss of interest. Some other reasons that may lead to couple therapy are difficulties in problem solving and communication problems, role conflicts and disagreements over raising or having children and finally abuse and violence. In general people seek therapy when their marriage or relationship tends to be unstable and insecure. In order to find a solution for marital distress a number of interventions have been developed but only three of them have been most studied and supported for their effectiveness: behavioral couple
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therapy, cognitive behavioral couple therapy, and emotion-focused couple
Behavioral couple therapy made its first appearance in the late 1960's as a behavior therapy that was related to basic learning principles, especially reinforcement principles of operant conditioning, applied to psychological problems (Gurman, 2008). The first behavioral therapy that was applied on couple problems was presented by Stuart (1969) and was based on social exchange theory. He assumed that the distinction between a successful and an unsuccessful marriage can be seen on how often and what variety, positive acts are in the same way exchanged by couples. As a result, distressed couples were described lacking positive outcomes in relation to the frequency of negative outcomes. Social exchange theory predicted that inviduals' satisfaction is based on the befits they received from the positive behavior and also that people are more likely to behave in a positive way if they receive positive behavior from the other partner. Stuart's treatment was a list with all desired behaviors of the other partner to obtain and with the aggrement of exchanging tokens as rewards for performing the desired behavior. Although token economy was later replaced, using an operant conditioning paradigm was very important in the development of behavioral couple therapy. Lieberman (1970) also made use of behavioral principles based on the application of social learning framework. Lieberman's approach involved an extensive behavioral analysis of the problems and the interaction problems by trying to form all alternative communication patterns.
The use of Operant conditioning in the modification of children's behavior also had a strong influence in the development of behavioral couple therapy. In this kind of therapy parents were trained to use reinforces or punishers to increase a good behavior of their child and decreased a bad. This was extended from the parent-child relationships to the treatment of couple relationships. Therapists tried to find out all couples' behavioral strengths and all problems, and evaluate which of the behaviors can change in order to provide a better therapy to the couples (Weiss, Hops, & Patterson, 1973). The theories that were presented up until now helped a lot in the development of behavioral couple therapy but were incomplete and not specific regarding the clinical techniques. In the late 1970's and early 1980's was presented a more detailed treatment manual
Behavioral couple therapy (BCT) studies the aspects of marital satisfaction and distress in reinforcements terms based on a social learning theory of human behavior. So the satisfaction of couples is higher at the point which their ratio of reinforcement to punishment in their relationship is positive, while on the other hand they are dissatisfied to the point where the ratio is negative. Couples are made due to the mutual reinforcement that is created by each other. But as the time passes by, that mutual reinforcement decreases for reasons such as habituation and satiation Moreover couples start to see the differences as individuals and get into conflicts that increase the mutual punishment and diminish the reinforcements that they experience.
In order to provide a solution to this problem BCT tried to increase the level of reinforcing exchange and to teach couples how to develop the right skills that will help them communicate better and solve their problems easily by reducing punishment and increasing reinforcement. There are three major interventions of BCT, behavior exchange, communicating training, and problem solving. In behavior exchange, therapists help couples to find positive behaviors that each can do for the other person, try to apply these behaviors and recognize them. In communication training, therapists teach couples to express their feelings without feeling guilty or blaming the other person and adopt active listening skills. Finally, in problem solving training, therapists teach couples they right way to define their problems clearly, try to find possible solutions to the problems, discuss further and cooperate in order to find the appropriate solution, and how to apply and evaluate their solutions. Behavioral couple therapy is by far the most investigated of therapies for couples; many studies showing not only its efficacy but also its limitations (cite).
Across numerous investigations behavioral couple therapy has been found very effective (Hahlweg & Markman, 1988; Dunn & Schwebel, 1995), on the other hand it is an approach with distinguished limitations. Some studies have found that increases in exchanges in positive behaviors and improved communication skills in partners showed limited satisfaction between couples (Halford, Sanders, & Behrens, 1993). Also, other therapeutic models in couples that did not give an emphasis in behavior exchange and training skills found out to be as effective as the behavioral couple therapy in couple distress, suggesting that behavioral interventions may not be necessary in treating relationship problems (Baucom, Epstein, & Gordon, 2000). It became clear that behavioral intervention might be limited in treating couple distress. As a result an approach that included partners personal cognitions about their own and each other's behavior was needed (Baucom & Epstein, 1990). It was this recognition that helped to the development of cognitive behavioral couple therapy.
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Cognitive behavioral couple therapy (CBCT) emerged in the early 1980's although it had roots in therapeutic approaches and research with longer history. It developed from the expansion of behavioral couple therapy including the main model and behavioral interventions of BCT and adding also cognitive factors to therapy. In studies that have been conducted a number of researchers argue than in relationships apart from behavior that matters, it is also important partners' understanding of that behavior, for example the reason that a specific behavior occurred (Baucom & Epstein 1990). Also these researchers suggest that strategies that were used in cognitive therapy for individuals can be used also to couple therapies in order to help partners understand each others behavior. In CBCT attention is given to three factors, behavior, cognition, and emotion. A major principle of this approach is that partners' dysfunctions in their behavior and emotions towards relationship events are caused due to information -processing errors where cognitive assessment of the events is subjective. A statement like "You stayed most of the day in your parents' house because they are more important to you than I am". In the same way relationship events might be assessed in an extreme and unreasonable way of what a proper relationship should be "If you really cared and loved you would spend all your free time with me because this is what a marriage should be. Many times partners cannot make a proper evaluation of their cognitions and they tend to trust their own subjective cognitions. The aims of cognitive restructure in couple therapy is to train partners acquire the right skills to recognize the cognitions that are related to their marital conflicts then to test whether these cognitions are valid enough, and finally try to alter these dysfunctional cognitions " (Baucom et al 1995:80). Therapist in order to help couples with their relationship problems make use of a number of strategies in order to alter dysfunctional cognitions that may be different in each partner. If partners tend to use terms like "never" or "always" to describe the negative features of their partner, the therapist may advise them to search for certain exceptions that might modify their selective attention to negatives. In order for the therapist to help the partner modify this behavior, the therapist may utilize logical analysis, in which the client is asked to provide evidence and reasons of the negative things he might claim for the other person. Also a therapist may engage partners in a Socratic approach, in which the client is asked to assess the consequences of living with extreme standards and faulty assumptions. The couples need help in order to be active observers and evaluators of their own thoughts and assumptions in order to modify their negative behavior which can lead to experience more positive cognitions and emotions about each other. The CBCT is a very significant therapeutic approach because behavior, emotion and cognition play an important role in the quality relationship. Many studies have been conducting in order to assess the effectiveness of CBCT. In a study conducted by Dunn & Schwebel was examined the effectiveness of cognitive procedures in combination with behavioral procedures. Also other studies investigated the effectiveness of cognitive procedures alone with no combination of behavioral procedures. A study by Emmelkamp et al (1988) showed that cognitive restructure was an effective treatment for marital distress. Although CBCT is a supported and effective intervention for helping couples treating relationship distress, it focuses on specific phenomena in relationships leaving out other important aspects. First, CBCT gives too much focus on relational events and behaviors that are very detailed and with minimum importance without giving an emphasis on more significant behaviors that may differ between partners such as desired levels of familiarity and intimacy. Thus, for example, Jonathon's everyday life of coming home, checking his email before speaking to his partner, talking a little during dinner, and then staying in front of the internet for many hours each night, provide us information of Jonathon's profile as a quite person, lost in his thoughts that preferred loneliness and was not feeling very comfortable with intimacy. Second, CBCT has tended to emphasize a lot in couples' cognitive and behavioral interactions and not taking into account the influences of personality in a relationship and that each of us differ in the way of thinking and acting because of our personality style. Apart from the cognitive and behavioral interactions important are the characteristics that each person has that may also give an explanation why partners behave and act in some events in a maladaptive way. Third, couples are influenced by external and environmental stressors such as stress of work and children, relationships with other members of the family and physical health; all these may have a negative impact in the development of distress in a relationship. Although cognitive-behavioral perspective took into account that environment plays an important role in relationship performance, the attention given was not enough. Fourth, although CBCT paid attention to emotions in intimate relationships, generally emotions were viewed as the result of partners' behaviors and cognitions. Emotions should be viewed separately and can show emotional components such as, difficulty in experiencing or expressing emotions, difficulty in handling negative emotions, all these increase the interventions that the therapist can provide to the couple. Finally, even though CBCT focused both on negative and positive aspects of behaviors, emotions and cognitions, most attention was given to negatives and how to decrease them. Although for couples in order to get the most from their relationships attention should be given to positive behaviors, emotions and cognitions or at least to be a balance between those two.
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Emotionally focused couple therapy (EFTC) is considered to be an important development in couple therapy that understands the dynamics of the couple relationship. Greenberg and Johnson (1988) developed first this therapy and described that distress in relationship is related to Bowlby's attachment theory (Bowlby, 1969). Attachment theory is being applied in individual psychotherapy and in couples and family. It explains the way that individuals are emotionally linked with each other and how some psychological problems such as depression or anxiety affect negatively the connection among those people ( eft article). Relationship distress is characterized by "the failure of an attachment relationship to provide a secure base for one or both partners" (Bowlby, 1969). Partners that experience relationship distress may feel some negative emotiosn like being afraid of being rejected and abandoned by the other person and some derived emotions like an angry withdrawal in an answer to one's fear. In EFCT, in order for the attachment bonds to be created again, emphasis is given to the most important emotions. EFCT includes two tasks which are: have access and reprocess the emotional experience of couples and to structure again interaction patterns (Johnson & Greenberg, 1995). Couple therapists try to expose and give emphasis to the primary emotions that partners experience in their relationship. "Secondary
or instrumental expression is expanded or go around in order to expose an
Underlying experience" (Johnson & Greenberg 1995. As partners experience again their emotions during the session thy meet new aspects of them selves that need to be developed to satisfy their attachment needs. For example, a therapist can help a person that feels angry because of little contact with a withdrawn partner, to have access in his/her fear of being abandoned and try to express this worry/anxiety and not the secondary feeling which is anger. As a result the partner now responds in a different way with support rather than withdrawal, thus a new beginning in their interaction is created. Research has been conducted to examine EFCT. In a meta-analysis of couple therapy five studies were examined, four of them examined EFCT and one examined insight-oriented marital therapy Dunn
& Schwebel (1995). The results found out that these two therapies were similar and had the same effectiveness in treating couple distress. Although that is approach has been found very helpful it has been found also mildly frustrating. Although EFCT works directly with emotions in couple therapy and attachment theory is used to understand the couple relationship it has been blamed" for being limited in the use of attachment theory as a result to lose important benefits of attachment theory that could be use in the improvement of the intervention.
There are several different treatments provided for relationship distress, thus someone may wonder which therapy is the most effective and whether actually there is one. From previous studies about the treatment of couple distress the following conclusions were found for BCT and EFT (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Dunn & Schwebel, 1995; Hahlweg & Markman, 1988; Wesley & Waring, 1996). First, BCT is an effective therapy, but especially with moderate and severe couple distress for a significant number of people but there is a tendency for some couples to relapse in a continuing follow-up. Second, the effectiveness of BCT is not increased by combining cognitive procedures. Third, EFT is more effective when it is applied on mild to moderate couple distress with couples tend to continue improving after the end of the treatment. More specifically in a meta-analysis Dunn&Schwebel (1995 that was conducted, a statistical comparison was done between the three major treatment modules in couple therapy in order to find the mean effectives. They measured couple behavior and found no statistically significant differences among them. On measures on relationship quality significant differences were found at post treatment but no significant differences at follow-up. An impressive study is the comparison of treatments in a clinical trial. In this study, couples are randomly assigned to different treatment conditions; as a result the differences can be seen to the treatments rather than to differences in couples. Also other studies have shown no significant differences between therapies. For example, it has been shown that CBCT has the same level of effectiveness as BCT in enhancing the satisfaction in relationship but it was not proved being more effective e.g. Halford et al 1993). Some studies in the past have confirmed that one treatment is superior over another, such as that insight-couple therapy is leading over BCT when studied at a 4 year follow up. (Snyder et al 1991). The problem with these studies is that they have been conductacted and the results pleased the investigator but they have not been repeated. To sum up, studies have shown until now no persuasive evidence showing us that one therapy is better that another in some aspects. So the more interesting question remains and is datable for future studies.
Couple therapy has been proved to be very essential in the treatment of couple therapy through a variety of interventions. Although that there is a variety in therapies, three of them have been proved the most effective, applied and empirically tested through studies. BCT that focuses most on the behavior of the couple, CBCT that focuses on the behavior, cognitions and emotions and finally, EFCT that focuses most on emotions. All three have been proved to be very effective but none of them have been proved superior and the best of treatments. The most effective therapy could be a combination of them, because all aspects that each of them test are important for therapy, thus a combination may bring better results. Also, studies should be conducted in testing whether in specific problems in couples a specific therapy can provide a better treatment. Future research is needed to answer the limitations of interventions and try to develop more effective interventions.
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