Couples therapy: Analysis of a case study

Case Analysis and Treatment Plan

Couples Counseling

Abstract

Within couples therapeutic assessment, both partners are viewed as entity with different characteristics and behavioural traits, which are interrelated in the marital relationship. A great percentage of couples seek help in order to improve their marital quality and overcome their dysfunctionalities. The following paper addresses a treatment plan and assessment based on a case of couple, who seeks help due to current difficulties in their relationship. It is taken into consideration the history of each spouse and their presenting problem according to which the theoretical approach of Integrative Behavioral Couples Therapy (IBCT) will be applied, taking into consideration other factors, which might be either helpful or preventive for the outcome of the therapy.

Case Analysis and Treatment Plan

During the last decades, couples therapy has turned out to be in a strong place concerning the improvement of its methods and modification of its amplified allegations. Several therapeutic approaches have been integrated, through the combination of their effective and characteristic elements, in order to provide innovative and effective clinical systems regarding the reasons couples seek therapy, which are mostly related to their interaction within marriage (Veroff et al. 1981). About 50% of couples seek therapy due to marital disorder, 25% face difficulties within their marriage additionally to external factors causing other problems. One of the main reasons is that both spouses feel that they start lacking in communication, growing apart, which results in fighting or having affairs (Gigy, Kelly 1992). There is a need to understand that couple process has to be considered as an entity, due to the fact that couples therapy has become effective in helping spouses be personally developed and achieve maturity in a higher level, without taking so much into consideration the continue of married life or the dissolution of marriage (Johnson, Lebow, 2000).

There is also an increasing demand for couples therapy, as spouses are looking for gaining a better knowledge about marriage and ways to improve marital satisfaction and personality development, through enriched marital programs and applications (Pirooz Sholevar, Schwoeri, 2003; Johnson, Lebow, 2000). Despite the fact that couples therapy used to be a treatment of last resort, now its preference has been increased reagarding the treatment of relationship distress issues and DSM disorders (Johnson & Lebow, 2000). More empirically based strategies were also improved and extended due to necessity of treating relationship distress, which is interrelated with each individual’s disruption of physical and emotional welfare (Perrisutti, Barraca, 2013; Snyder, Castellani, & Whisman, 2006). Applying couples therapy means that therapists are required to follow distinct training as well as specific skills in order to be specialized in that field, due to the fact that relationship distress is also affected by cultural traits, past experiences and attachment (Johnson & Lebow, 2000).

Moving on to the examination and analysis of Doug and Kate’s case, who sought help due to some dysfunctions appeared recently in their marriage, it is important first to make a brief description of their relationship and each one’s history. Doug is a 53-year old-man, successful music producer, coming from a family with high socio-economic status. His parents are elderly and live in the countryside. He also has a younger brother, who is married and has two children. He used to have a close relationship with his family, but since his marriage with Kate, their relationship became distant as they do not approve his choices concerning his life and especially his marriage. Kate is an 18-year old-young woman who studies in an art school for make-up artist and she also attends events, in which she also works. Her parents are still married and there is no information for other family members. Her parents gave their consent, as Kate was 16 years old, when she married Doug. Generally, no further information was given regarding their extended family system. It seems that Kate’s parents are supportive and have also a good communication with Doug. On the other hand, Doug and Kate are distant from his family because of their stance towards Kate.

Focusing more on their relationship history, they met in an event and they immediately were mutually attracted and interested to get to know each other better. The first period of their relationship is described by both spouses as a great one, as they were both in love, they could communicate and share meaningful moments. They also had the same relationship in the beginning of their marriage. They have been married for two years now, but the last couple of months they have started facing some difficulties, which have provoked a dysfunctional relationship between them lacking in communication. Both Doug and Kate could be described as sociable and outgoing people, especially because of the field of the jobs they have chosen, which demands consorting with many people. Based on the above difficulties, they sought help for couples therapy with Doug’s prompt. As far as their presenting problem is concerned, Doug have started worrying about Kate’s body transformation such as loss of weight, improvement of her appearance through plastic surgery, without his consent, and her revealing way of clothing. On the other hand, Kate has become more jealous as Doug comes in contact with other women and gets a lot of attention from them especially during the events, he has become more distant recently and this fact raises Kate’s fear of Doug leaving her.

During their description, both Doug and Kate still have strong feelings for each other despite their current difficulties. This means that their feelings are a starting point to work with through the sessions in order to establish and develop their personal growth within therapeutic assessment. Despite that fact, though, it could be useful to look back to their attachment styles within their prior family environment as well as the cultural background of each family. For example, the attachment theory based on preoccupied mothers and ambivalent children provides a better understanding regarding enmeshed mother-child dad. Moreover, partners with preoccupied and dismissive style indicate important elements in enmeshed relationships such as pursuer and distancer cycles or spousal conflicts. This provides a better knowledge concerning personal stability, antecedents and the consequences of those attachment styles, which also underline the need for care and protection, which is a characteristic of maternal-child relationship, as well as marital spouses being related within these patterns (Rothbaum et. al., 2002). Taking also into consideration the term of partnership including social and economic factors, it is important not to examine the partners as separate units, but to further explore partnership structure based on the characteristics of each partner and their interaction within the relationship. Of importance is also the fact that changes in marital age differences affect both married and unmarried individuals and also the forms of partnership (Wilson, Smallwood, 2008). Marriages between older men and younger women have shown that financially successful men are more able to attract and retain younger spouses (Coles, Francesconi, 2011).

Due to the fact that there is no efficient information regarding each individual’s history, as they were both based on their current relationship and their need to overcome the difficulties they face, there is a little opportunity of giving a proper diagnosis. It is, though, somehow apparent that Kate has some hystrionic personality traits, due to her provocative clothing, her need for attention and her concern of her body image (APA, 2013). On the other hand, for Doug is more difficult to distinguish personality traits, that affect his whole attitude and behavior. The use of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) would be a good indicator of each individual’s personality, in order to investigate the presence of any disorder, as it is a broadband measure of psychopathology and personality and also effective in the assessment of medical patients (Arbisi, Butcher, 2004).

Formulating a simple working hypothesis, it could be assumed that both Doug’s and Kate’s age gap, which is also related with their different family background and way of growing up, affects their communication and their current needs. They both do things without informing each other, which indicates a need for independency and actually they seem to have different life needs and priorities. For Doug, for example, it is important to have a child with Kate, but Kate puts grater priority in her career and body image. A good point, though, is that they both have strong feelings for each other, but their current difficulties have also affected the spontaneous expression of those feelings. They both have dynamic personalities, which also affect their communication as this can also end up to a conflictual and distant relationship, because of their difficulty making sacrifices for the time being.

Integrative Behavioural Couple Therapy (IBCT) seems to be suitable for the above case, as it puts more emphasis on the emotional acceptance within the couple rather than change and it has also been proved that this approach is quite effective for treating marital distress as it has a different stance regarding relationship distress (Dimidjian et al., 2008; Christensen, Jacobson & Babcock, 1995). IBCT is based on the fact that fostering acceptance and tolerance is important concerning the improvement of couple’s distress (Cordova et al., 1998). It puts emphasis on each one’s behavioural characteristics, on the “contingency-shaped behavior” as it is the primary mechanism for change and also on the integration of strategies. Such strategies are acceptance, which includes joining empathy, as spouses are able to express their feelings without accusing each other, unified detachment, through which partners take a distance from their conflicts or difficulties, by intellectually analysing their problem and emphasising on detached and descriptive rather than on emotional discussions. Tolerance strategies point out the positive characteristics of negative behaviours, through practising them within sessions, put emphasis on the practice of faking negative behaviours among sessions and also refers to the importance of self-care. Change strategies include behaviour exchange and problem-solving training (Dimidjian et al., 2008; Jacobson & Christensen, 1998).

In order to formulate a treatment plan based on the above approach, it is of major importance to take into consideration some factors, which might affect the progress and the outcome of the treatment. Such factors are the couple’s readiness to follow therapy and also the treatment plan has to be formed according to their needs. Based on the above theory, Doug and Kate have both the need to feel accepted by the other partner and freely express their emotions and needs, which until now had great difficulty to do as they both believed that they would be criticized by each other. Moreover, apart from discussing, there is a need of sharing things and moments, which will remind them the first stages of their relationship and their harmonic communication. There is also a need for training and psychoeducation concerning practical issues such as to gain problem-solving skills and also the difficulties that might arise due to their age difference gap.

During the initial phase of treatment, it is important to build a strong working alliance, which therefore leads to the development of mutual trust and rapport (Egan, 2010). For the establishment of trust in therapy, the couple is informed that all the information shared in therapy is confidential. In cases, though, of ethical dilemmas the couple is informed for the conditions under which confidentiality is breached (ACA, 2005). In couples therapy, the couple is considered as the main “client”, as both individuals try to improve their relationship and get ahead their difficulties. It can also be mentioned that every relationship consists of two separate individuals with different personal characteristics such as emotions, thoughts or conflicted needs (Glick et. al., 2000). Their interaction and their mutual influences derive from their interpersonal and physical environment (Epstein & Baucom, 2002).

During the first therapeutic assessments, both partners were given a Couples Counseling Initial Intake Form to complete separately, in order to investigate further their relationship with their partner and their holistic stance towards their relationship. Some other primary techniques used were to freely express to each other their feelings and thoughts, or putting themselves into the position of other in order to gain a better understanding of their partner’s position and thoughts, or trying to remember one of their happiest moments. The effectiveness of these interventions was tested within the session by asking both partners to express their feelings and thoughts after completing them, which was quite helpful as they both were feeling more released after their explosion to those information gathered by each other. Despite the fact that both partners and especially Doug were in great need for help, ther were no actual signs of triangulation or issues of transference, which usually are expressed through certain either positive or thoughts, feelings or behaviors projected to the therapist (Weinberg, 1996). On therapist’s behalf, there was an effort of showing neutrality and empathetic understanding towards both partners’ words. As far as the end of therapy is concerned, the length of therapy is still unpredictable, due to the fact that it is primarily based on the couple’s needs. It has firstly to be reassured the welfare of both partners through the assessment and the improvement of their relationship as well as their personal development.

To come to a conclusion, providing couples counseling requires training in specific skills, which allow the therapist to establish the well-being of both partners by viewing the couple as entity. Moreover, it is of major importance to formulate a primary working hypothesis in order the assessment and the treatment plan to be properly addressed and applied, by also taking into consideration couple’s needs. Apart from that, it is also necessary to choose a suitable therapeutic model, which will be applicable and suitable to the case’s needs, by following certain steps and also considering ethical issues, which might arise within therapy as well as issues of transference and countertransference, which might provoke obstacles and a slower progress during the therapeutic assessment.

References

American Counseling Association (2005). ACA Code of Ethics. Retrieved from: http://www.counseling.org/Resources/aca-code-of-ethics.pdf

American Psychiatric Association, (2013). Diagnostic and Statistical Manual of Mental Disorders (5^th ed.). Arlington, VA: American Psychiatric Publishing.

Arbisi A. P., Butcher N. J. (2004). Relationship between personality and health symptoms: Use of the MMPI-2 in medical assessments. International Journal of Clinical and Health Psychology. Vol. 4, Nº 3, pp. 571-595.

Christensen, A., Jacobson, N. S., Babcock, J. C. (1995). Integrative behavioral couple therapy. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of marital therapy (2nd ed., pp. 31–64). New York: Guilford Press.

Cordova, J. V., Jacobson, N. S., Christensen, A. (1998). Acceptance versus change interventions in behavioral couple therapy: impact on couples´ in-session communication. Journal of Marital and Family Therapy, 24, 437-455.

Dimidjian, S., Martell, C. R., Christensen, A. (2008). Integrative behavioral couple therapy. In: A. S. Gurman (Ed.), Clinical Handbook of Couple Therapy (4th ed., pp. 73-107). New York: The Guilford Press

Egan G., (2010). Exercises in helping skills: A manual to accompany the skilled helper, a problem-management and opportunity development approach to helping. p.35-60 Belmont, CA: Brooks/Cole, Cengage Learning.

Epstein, N. B. & Baucom, D. H. (2002). Enhanced cognitive-behavioral therapy for couples: A contextual approach. Washington D.C.: American Psychological Association.

References

Glick, I. D., Berman, E. M., Clarkin, J. F., Rait, D. S. (2000). Marital and Family Therapy (4th ed.). Washington, DC: American Psychiatric Press.

Gigy L, Kelly J. B. (1992). Reasons for divorce: perspectives of divorcing men and women. Journal of Divorce and Remarriage 18:169–187.

Jacobson, N. S., Christensen, A. (1998). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York: Norton.

Johnson, S., Lebow, J. (2000). The “coming of age” of couple therapy: A decade review. Journal of Marital and Family Therapy, 1, 23-38.

Melvyn G. C., Francesconi M. 2011. “On the Emergence of Toyboys: Equilibrium Matching with Ageing and Uncertain Careers.” International Economic Review. 52(3):825-53.

Sholevar P., Schweori L. D. (2003). Textbook of Family and Couple Therapy; Clinical Applications. Am. Psychiatric Publ. Inc.

Snyder, D. K., Castellani, A. M., Whisman, M. A. (2006). Current status and future directions in couple therapy. Annual Review of Psychology, 57, 317-344.

Perissutti C., Barraca J. (2013). Integrative Behavioral Couple Therapy vs. Traditional Behavioral Couple Therapy: A theoretical review of the differential effectiveness. Clínica y Salud. 24, 11-18.

Rothbaum F., Rosen K., Ujie T., Uchida N. (2002). Family Systems Theory, Attachment Theory, and Culture. Family Process, Vol. 41, No. 3, FPI, Inc.

Veroff J., Kulka R. A., Douvan E (1981). Mental health in America: patterns of help seeking from 1957 to 1976. New York, Basic Books.

Weinberg, G. H. (1996). The Heart of Psychotherapy: A journey into the mind and

References

office of the therapist at work. NewYork: St. Martin’s Griffin.

Wilson B., Smallwood S. (2008). Age Diffenences at Mariage and Divorce. Population Trends. 132.

APPENDIX

Genogram