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Models of Couple Therapy This is a chapter excerpt from Guilford Publications. Clinical Handbook of Couple Therapy: Third Edition, Edited by Alan S. Gurman and Neil S. Jacobson Copyright ©2002 Part I MODELS OF COUPLE THERAPY Section A Traditional Approaches Chapter 1 Brief Strategic Couple Therapy VARDA SHOHAM MICHAEL J. ROHRBAUGH In this chapter we describe applications and ex- tions, with no attempt to specify what constitutes tensions to couples of the “brief problem-focused a normal or dysfunctional marriage. Because the therapy” developed over 25 years ago by Richard “reality” of problems and change is constructed Fisch, John Weakland, Paul Watzlawick, and their more than discovered, the therapist attends not colleagues at the Mental Research Institute (MRI) only to what clients do, but also to how they view in Palo Alto (Weakland, Watzlawick, Fisch, & the problem, themselves, and each other. Espe- Bodin, 1974; Watzlawick, Weakland, & Fisch, cially relevant is clients’ “customership” for 1974; Fisch, Weakland, & Segal, 1982; Weak- change and the possibility that therapy itself may land & Fisch, 1992). This parsimonious therapy play a role in maintaining (rather than resolving) approach is based on identifying and interrupt- problems. Finally, in contrast to most other treat- ing the “ironic processes” that occur when re- ments for couples, therapists working in the Palo peated attempts to solve a problem keep the prob- Alto tradition often see the partners individually, lem going or make it worse. Although Fisch, even when the focus of intervention is a complaint Weakland, and their colleagues did not them- about the marriage itself. selves use the term “ironic process,” it captures The Palo Alto model is sometimes called “stra- well their central assertion that problems persist tegic” because the therapist intervenes to interrupt as a function of people’s well-intentioned attempts ironic processes deliberately, on the basis of a case- to solve them, and that focused interruption of specific plan that sometimes includes counter- these solution efforts is sufficient to resolve most intuitive suggestions (e.g., to “go slow” or engage problems.1 in behavior a couple wants to eliminate). Calling The hallmark of the Palo Alto (or MRI) ap- this approach “strategic therapy” alone, however, proach is conceptual and technical parsimony. risks confusing the Palo Alto model with a related The aim of therapy is simply to resolve the pre- but substantially different approach to treating senting complaint as quickly and efficiently as couples and families developed by Jay Haley (who possible, so clients can get on with life: Goals such coined the term “strategic”) and his associate Cloe as promoting personal growth, working through Madanes (Haley, 1980, 1987; Madanes, 1981, underlying emotional issues, or teaching couples 1991).2 More importantly, the “strategic” label gives better problem solving and communication skills undue emphasis to intervention style and detracts are not emphasized. Theory is minimal and non- attention from the more fundamental principle of normative, guiding therapists to focus narrowly ironic problem maintenance on which the Palo Alto on the presenting complaint and relevant solu- brief therapy model is based. 5 6 I. MODELS OF COUPLE THERAPY Our chapter deals primarily with application the first family-oriented therapy to be brief by of brief problem-focused therapy to couple com- design. plaints, but this is a somewhat arbitrary delimita- Since 1966, the BTC has followed a consis- tion. As a general model of problem resolution, tent format in treating nearly 500 cases. Under this therapy approaches couple problems in essen- Fisch’s leadership, the staff meets weekly as a team tially the same way it does other complaints. Fur- to treat unselected cases, representing a broad thermore, because practitioners of this therapy are range of clinical problems, for a maximum of 10 inevitably concerned with social interaction, they sessions. One member of the team serves as a often focus on couple interaction when working primary therapist, while the others consult from with “individual” problems—for example, depres- behind a one-way mirror. After treatment (at sion (Watzlawick & Coyne, 1980; Coyne, 1986a), roughly 3 and 12 months following termination), anxiety (Rohrbaugh & Shean, 1986), and addic- another team member conducts a telephone fol- tions (Fisch, 1986; Rohrbaugh, Shoham, Spungen, low-up interview with the client(s) to evaluate & Steinglass, 1995; Rohrbaugh et al., 2001)—and change in the original presenting problem and to for tactical reasons they may avoid calling this determine whether clients have developed addi- “couple therapy” in dealings with the clients. This, tional problems or sought further treatment else- and the predilection of MRI-style therapists to treat where. The BTC’s pattern of practice has re- couple problems nonconjointly (by seeing individu- mained remarkably consistent, with its three core als), make it difficult to distinguish between what members (Fisch, Weakland, and Watzlawick) all is and is not “couple therapy.” participating regularly until Weakland’s death in 1995. From the work of the Palo Alto BTC emerged BACKGROUND a model of therapy that focuses on observable in- teraction in the present, makes no assumptions The Palo Alto brief therapy model is a pragmatic about normality or pathology, and remains “as embodiment of the “interactional view” (Watz- close as possible to practice.” The first formal lawick & Weakland, 1978), which explains be- statement of this model appeared in a 1974 Fam- havior—especially problem behavior—in terms of ily Process paper by Weakland et al., titled “Brief what happens between people rather than within Therapy: Focused Problem Resolution.” At about them. The interactional view grew from attempts the same time, Watzlawick et al., (1974) also pub- by members of Bateson’s research group (which lished Change: Principles of Problem Formation and included Weakland, Haley, and MRI founder Problem Resolution, a more theoretical work that Don D. Jackson) to apply ideas from cybernetics distinguished between first- and second-order and systems theory to the study of communica- change and provided many illustrations of ironic tion. After the Bateson project ended, Watzlawick, processes. Eight years later, Fisch et al., (1982) Beavin, and Jackson (1967) brought many of these offered The Tactics of Change: Doing Therapy ideas together in Pragmatics of Human Communi- Briefly, essentially a how-to-do-it manual that re- cation. At about the same time, Fisch, Weakland, mains the most comprehensive and explicit state- Watzlawick, and others formed the Brief Ther- ment to date of the BTC’s clinical method. In apy Center (BTC) at MRI to study ways of 1992, Weakland and Fisch concisely described the doing therapy briefly. Their endeavors were also MRI model in a book chapter; most recently Fisch influenced by the uncommon therapeutic tech- and Schlanger (1999) have provided another con- niques of Arizona psychiatrist Milton Erickson, cise outline of the model, along with illustrative whom Haley and Weakland visited many times clinical material, in Brief Therapy with Intimidat- during the Bateson project (Haley, 1967). In ret- ing Cases: Changing the Unchangeable. Although rospect, it is striking how discordant this early these sources do not deal with marital therapy per work on brief therapy was with the psychody- se, couple complaints figure prominently in the namic Zeitgeist of the late 1960s and early 1970s, clinical principles and examples. Other applica- when therapies were rarely designed with brevity tions to couples, especially when one of the part- in mind. Even today, as Gurman (2001) points ners is depressed, can be found in the work of out, most brief therapies represent abbreviated former MRI affiliate James Coyne (1986a, 1986b, versions of longer therapies—and most family 1988). Coyne’s papers highlight the significance therapies are brief by default. In its commitment of the interview in strategic marital therapy, par- to parsimony, the Palo Alto model was probably ticularly how the therapist works to (re)frame the 1. Brief Strategic Couple Therapy 7 couple’s definition of the problem in a way that data were complete and unambiguous. Then, af- sets the stage for later interventions. ter coding clinical, demographic, and treatment In addition to the Palo Alto model’s his- variables from each case folder, we compared the torical connection to the “strategic family therapy” success and failure groups and found surprisingly of Haley (1980, 1987) and Madanes (1981), we few predictors of outcome. Interestingly, however, should mention its close and sometimes con- it appears that about 40% of the cases seen over fusing connection to “solution-focused therapy” the years at the BTC have involved some form of (Berg & Miller, 1992; de Shazer, 1991; de Shazer marital or couple complaint, and we touch on some et al., 1986). Inspired by the Palo Alto group, de findings from the archive study in sections to fol- Shazer et al. (1986) initially took Weakland et al.’s low. (1974) “focused problem resolution” as a start- ing point for a complementary form of brief therapy emphasizing “focused solution develop- A NON-NORMATIVE VIEW ment.” Subsequently, however, solution-focused OF COUPLE FUNCTIONING therapy has undergone progressive revision (de Shazer, 1991; Miller & de Shazer, 2000) and The Palo Alto model makes no assumptions about now has a substantially different emphasis than healthy or pathological functioning. In this sense the parent model (for a detailed comparison, see the theory is non-normative and complaint-based: Shoham, Rohrbaugh, & Patterson, 1995). One In fact, if no one registers a complaint, there is no of the main points of disconnection is that problem (Fisch & Schlanger, 1999). At the rela- de Shazer and his colleagues now avoid charac- tionship level, this means that patterns such as terizing their therapy as “strategic,” prefer- quiet detachment or volatile engagement may be ring to describe it instead as “collaborative,” “co- dysfunctional for some couples but adaptive for constructivist,” and (by implication) not so ma- others.
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