WE’VE all had that horrible experience: you throw a party or invite a couple over for dinner, and they start fighting, right there in front of you — the character assassination, the barely controlled anger, the neurotic transference of their cooled sexual attraction onto, say, the hygiene of the family dog, all of which makes you want to fake choking and hide. Surely bearing witness to couples’ quarrels feels less bad to the pros, those credentialed and compensated marriage and family therapists whose job it is to help significant others work through issues and pain?
“Oh, no,” says Terry Real, a licensed independent clinical social worker speaking out about how couples therapy feels from their chairs. “It’s so much worse.” At the dinner table, Mr. Real explains, you’re just a bystander, collateral damage. In a therapy office, he says, “You’re supposed to do something about it.”
The fact that couples therapy stresses out therapists has long been an open secret. The field, however, seems to have decided that now would be an appropriate time for its practitioners to address their feelings and vent. It started with the November/December issue of the trade magazine The Psychotherapy Networker and its cover package, “Who’s Afraid of Couples Therapy?”
“It’s widely acknowledged that couples therapy is the most challenging,” says Richard Simon, the magazine’s editor. “The stakes are high. You’re dealing with volatility. There are often secrets. We were just trying to make explicit something people who’ve done couples therapy already know: You often feel confused, at odds with a least one of your patients, out of control.”
Part of the problem is that the kind of person who tends to become a therapist — empathic, sensitive, calm, accepting — is generally not the kind of person who is a good couples therapist. “The traditional, passive uh-huh, uh-huh is useless,” Mr. Real says. “You have to like action. To manage marital combat, a therapist needs to get in there, mix it up with the client, be a ninja. This is intimidating.”
Peter Pearson and Ellyn Bader, psychologists and founders of the Couples Institute in Palo Alto, Calif., which offers both therapy and training for therapists, describe the experience of counseling high-conflict couples in equally violent if metaphorical terms, as “like piloting a helicopter in a hurricane.”
Compounding the tender-empath-caught-in-the-crossfire problem, couples therapy, as it is practiced today — one therapist and two spouses together in a room — started in what might be seen as a convoluted way. Before the early 1960s, husbands and wives most typically sought counsel singly, not together; that counsel was provided by a clergy member, a medical doctor or a social worker, and the mode of conversation was didactic (here’s what you need to do), not therapeutic (let’s figure out why you feel so bad).
But then through the late ’60s and ’70s, divorce rates started rising and the field of marriage therapy exploded. Building off the family therapy model, in which families were treated as a whole — or as a system, the term of art — therapists started seeing most couples in pairs. This was a nice enough idea, maybe even a good one, but there was no research to support it. As a result, the practice, known as conjoint therapy, was blasted in psychologyjournals as “seriously lacking in empirically tested principles” and a “technique in search of a theory.” One theory the field latched onto was psychoanalysis: now married couples had problems because of neurotic interactions and individual psychopathology. (Great, right?)
Another framework came from the human potential movement. VirginiaSatir, known as “the mother of family therapy,” was also the first director of training at the Esalen Institute in Big Sur, Calif., where Jack Kerouac and Joan Baez, among others, retreated to find themselves. Ms. Satir claimed that the goal of marriage therapy was “not to maintain the relationship nor to separate the pair but to help each other to take charge of himself.”
Who or what is to be saved or taken charge of remains unresolved in some couples therapy practices. Is the client one of the spouses? Both of them? The relationship? The tangle of needs and obligations can lead to problems from Session 1.
“For starters, there’s an ever-present risk of winning one spouse’s allegiance at the expense of the other spouse’s,” explains William J. Doherty, the University of Minnesota professor of family social science, in his groundbreaking 2002 article on the topic of awkward couples counseling in the Networker, titled “Bad Couples Therapy.” “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 a genius and the other thinks you’re clueless — or worse, allied with the enemy.”
Timing is also crucial, far more than in individual therapy, and it causes stress for therapists as well. “Let a couple interrupt each other for 15 seconds, and pretty soon you have them screaming at each other and wondering why they need you to do what they could do at home,” Professor Doherty says by phone.
With individuals, a therapist can stall. “You can always say, ‘Tell me more about that,’ and take a few minutes to figure out what to do next,” he says. “In couples therapy, the emotional intensity of the couple’s dynamics doesn’t give you that luxury.”
Then there’s the possibility that one of the partners has sought out counseling in order to commit what the professor describes as “therapist-endorsed divorce.” This is rarely made explicit. Even couples who have given up on repairing a relationship may want to be able to tell themselves that they have tried everything, especially if they have children. So they will start a course of couples counseling, claiming that they want to change their relationship, when really what they want to do is change their partner.
“You often see Partner A dragging in Partner B because Partner B is behaving in ways that are unfulfilling and insufferable,” Mr. Real says. “On the intake I’ll ask, ‘What’s wrong with the marriage?’ and Partner A will say, ‘Bob.’ So I’ll ask, ‘What’s wrong with Bob?’ and Partner A will say, ‘His Bob-ness.’ ”
Some types of couples therapy are known to work better than others. One of the most promising methods is based on the attachment theory of parenting: good relationships are built on secure attachments, ones that are engaged and emotionally responsive. And another teaches couples to be more accepting of each other while at the same time working to change some of their assumptions and automatic behaviors.
Both types of therapy are structured, and the results of both are well documented, at least in follow-ups for a few years. Still, the entire field of couples therapy suffers from a systemic problem. Couples often resist seeking help until they have been distressed for a long time — Brian D. Doss, an assistant professor of psychology at the University of Miami, says the average couple is unhappy for six years before seeking couples counseling — at which point relationship problems are very difficult to fix. Thomas Bradbury, a professor of psychology at the University of California, Los Angeles, compares a troubled couple to a man with a broken leg. Seek help straight away and you’ll heal up just fine. Hobble around injured for months or years, and a full recovery becomes nearly impossible, as by that time, Professor Bradbury says, the therapist has to attend not only to the psychological equivalent of the broken bone “but also to the swelling and bruising, the sore hip and foot, and the infection that ensued.”
So what is the field trying to do, for everybody involved? Along with the venting, some therapists are seeking to get better at their jobs by putting a greater emphasis on accountability and feedback. Most therapists don’t know how much they have helped their patients long term or how their track records, if known, compare with others in their field.
William M. Pinsof, a professor of clinical psychology and president of the Family Institute at Northwestern University in Evanston, Ill., is trying to fix this. As part of a study he is conducting to gain a better understanding of the empirical basis of psychological and behavioral change — what the patterns of change look like and what therapist behaviors are associated with them — he has therapists ask clients to fill out an online questionnaire about their lives before every session. After the session, the therapists fill out a questionnaire about what they did. Dr. Pinsof’s goal is to create a database that could be predictive for both patients and therapists (for instance, couples who start therapy with low trust, low flexibility and high commitment typically respond well to X type of treatment), taking some of the guesswork out of couples counseling.
“Most psychological theories about change are just that, theories,” Dr. Pinsof says. “They are not studies of how people actually change.” Already, before he has finished his study, Dr. Pinsof is using the information he is collecting on individual couples. Take a client who is a depressed woman in a bad marriage. “Which is chicken and which is egg?” Dr. Pinsof asks. “Is the depression impacting the marriage more or is the marriage effecting the depression more?”
Tracking how her depression and her marriage are changing week to week — and showing both her and her partner graphs of those changes on a computer screen in the therapy office — can help a therapist guide and control the therapy, he says, thus making it less stressful and intimidating for everyone. “A lot of people who primarily work with individuals feel overwhelmed by the number of variables they have to deal with when they work with couples,” Dr. Pinsof says. “You have to be very active in structuring the session, or the system can blow you away.”
Still, none of this is going to resolve the real underlying problem. Says Dr. Pearson of the Couples Institute: “If you’re seeing couples, no matter what you do, you’re going to see a lot of anger and volatility. You’re going to see people fighting in your office, and that triggers a lot insecurity and doubt — all your issues from your own childhood, your own relationships. Who wants to sign up for another serving of that?”