Archives of Psychiatry and , 2011; 3 : 57–64

Marital Therapy/Couples Therapy: Indications and Contraindications

Małgorzata Wolska

Summary The author, basing on literature and her own experiences in conducting marital/couples, presents the in- dications and contraindications for this form of therapy for both recipients of the therapy and therapists. Insufficient motivation to change relationships and behaviours, the threat of , violence, deep emo- tional and/or psychological disturbances in one or both spouses, the engagement of one of the partners in a relationship outside of marriage are some of the contraindications to therapy, as referred to in the ar- ticle. What is being elaborated on are also correct approach and characteristics of marital therapist as well as contraindications to conduct this form of therapy. The author proposes a scheme of work with mar- riage/couple in crisis: preliminary consultations as the basis for the therapeutic contract or relegating part- ners to other specialists.

marital /couples therapy / indications to the therapy

INTRODUCTORY REMARKS the relationship on one hand, and on the oth- Working with married couples/pairs in a se- er they tend to shift the blame for the crisis on vere crisis, which threatens the stability of their the partner and at the same time expect that the relationship, is a big challenge for therapists pri- therapist will help them by taking the role of an marily for the reason that arguing partners, both ally, solicitor, advocate or judge. To unravel the at the same time experiencing a sense of injustice complex marriage games and to reach sources of and , give the impression that they are not conflict between partners is a burdensome task interested in undertaking any kind of interven- for the therapist, requiring sustained attention, tion that could elicit actions bringing them relief concentration, keeping watch over the neutrali- and improving relations. A woman and a man ty and making sure not to follow the therapeutic experiencing a crisis in their relationship fear work in his/her own convictions regarding the abandonment and undertake many desperate role of women and men in a relationship. and unsuccessful attempts to save and improve involved in marital/couples therapy probably would feel inclined to agree Małgorzata Wolska: Jagiellonian University, Medical College, Depart- with the fact that this is one of the most diffi- ment of Child and Adolescent Psychiatry, 21a Kopernika Str., Kraków, cult forms of therapy mainly because the risk of Poland. Correspondence address: Małgorzata Wolska, Jagiellonian University, Medical College, Department of Child and Adolescent Psy- losing the distance and neutrality is higher than chiatry, 21a Kopernika Str., Kraków, Poland. in other therapeutic situations and the counter- E-mail: [email protected] transferential reaction on their behalf may ap- The article is an extension of a paper delivered at the conference pear. Frustrations caused by more often than Marital Therapy; Couples Therapy organised by the Therapy not enormous difficulties in obtaining a positive Section of the Polish Psychiatric , held in Kraków on change in the relationship of quarrelling part- 21–22 April 2007. ners induce the therapist to answer some fun- This article has not been aided by any grant. damental questions: 58 Małgorzata Wolska

• Was the proposed treatment not too fast in what they also need is a therapy including the reference to the vague, uncertain or low mo- realm of ? This therapy would be use- tivation to maintain the relationship and sing ful with abandoning the fight between a cou- up for the therapy? ple, regaining the confidence, allowing them- • Was the pace of change proposed by the ther- selves to split piecefully and thus reaching the apist adjusted to the needs and capacities of agreement on cases they are still forced to share. the spouses/partners? However, such treatments are not always possi- • Was the therapist not too passive or too im- ble in a situation of strong tension, fighting and posing? blame-game, as demonstrated by the experience • Did not the therapist take too much responsi- of therapists conducting family/marriage ther- bility for the relationship between the two un- apies mandated by court order [1]. Taking this dertaking therapy? under consideration, marital/couples therapies Before proposing to marriage/couple an in- are proposed only to pairs who declare their de- volvement in the therapy, the therapist should sire to maintain the relationship. know what to propose, which means to know The main objectives of marital/couples thera- the couples expectations, to determine the py can be defined as: strength of their relationship, the risk of collaps- • a support of marriage/couple in identifying ing degree, the motivation to stay together and sources of conflict; motivation to engage in conducting of positive • a help to each partner in determining their changes. He/she should meet the needs of each own participation in the conflict; partner, the possibility of their implementation • a help in realisation of the mutual expecta- as well as ability to fulfil expectations of a part- tions; ner. Precise determination of the therapy aim • a help in defining the rules of functioning of a adjusted to the couple’s expectations, needs and relationship, fulfilling roles, defining the lim- emotional/intellectual capabilities of both part- its of internal boundaries (individual) and ex- ners are important factors for positive changes ternal boundaries (separating the relationship in therapy. Extremely important is also the divi- from the rest of the world); sion of responsibilities: the therapist is respon- • an improvement in mutual verbal communi- sible for the conduct of therapy, the therapist to- cation (to avoid further misunderstandings) gether with both partners share responsibility and nonverbal communication (to make it for achieving goals, but the partners themselves easier and more clearly to express feelings); take responsibility for their relationship, that is, • an assistance in constructive conflict resolu- whether to continue it or to end. tion; • a help in deciding whether to continue the re- lationship or to part (note: the responsibili- DEFINITION AND GOALS OF MARITAL/COUPLES ty for this decision lies exclusively within the THERAPY spouses/partners). Generally speaking the marriage/couples ther- Couples who seek therapy because of dif- apy is a help for the partners remaining in a dif- ficulties with mutual coexistence, more often ficult, conflicting and critical relation prevent- not only expect to improve relations and re-ap- ing from obtaining closer intimacy and greater proximation but the confirmation that the fault satisfaction in being together. So, instead of pro- lies with the other partner. Each partner is con- posing a married couple in the middle of a di- vinced that he did everything that was possible vorce a marriage therapy, the therapist should for the relationship to be good, and now is try- undertake a divorce mediation suggesting rath- ing to shift responsibility for the problems on a er the new organisation of life than staying in a spouse placing the therapist at his side in a posi- realm of feelings. But here there emerges a ques- tion of an ally in the fight with a husband/wife. tion: whether divorcing marriage which is still Eric-Emmanuel Schmitt [2] in his Little Marital in the phase of combat (but which cannot yet Crimes writes that a relationship is as home to be separated) only need divorce mediation or which the keys are in the hands of people. The

Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64 Marital Therapy / Couples Therapy: Indications and Contraindications 59 therapist cannot assess or advise whether the re- naires and surveys typically used at the stage of lationship should be continued or whether the initial contact with the married couple by ther- partners should part. He/she can only help the apists working in the cognitive approach. Not spouses/partners to find the right ‘set of keys’ - only each spouse completes the questionnaire if both are interested in finding them. separately, but it is also followed by reviewing the questionnaires by the therapist and conduct- ing individual talks with both partners [7]. Un- CONTRAINDICATIONS TO CONDUCT der such conditions, surely it is easier to reach MARITAL/COUPLES THERAPY things that are, for various reasons, deeply hid- den. But on the other hand, the question arises There are several specific situations in which what to do if, for example, one of the spouses we cannot propose to take care of marriage/cou- reveals that he/she has betrayed the partner at ples therapy even when we are convinced that the same time asking the therapist to kept it as the partners are really into it. Therapists dealing a secret. Of course, the therapist cannot disclose with problems of marriage/couple in crisis are in without permission any contents of the conver- agreement that the therapy cannot be offered in sation but it will certainly be difficult for him/ following situations: her to lead further therapy (if at all possible) in • physical violence between partners; a situation of inability to appeal to the relevant • mental illness or addiction problems of one facts known only to him/her, that also hinder the (or both) partners; achievement of positive emotional closeness of • staying (of one or both partners) in other re- the couple. lationships and lack of motivation to give up To the above-mentioned absolute contraindi- one of them; cations for marital/couples therapy one may add • undertaking (by one or both partners) the de- a condition found in the literature of the subject cision of a divorce (regardless of whether they [5, 6] that if the disclosure of a deep, long-lasting reported it to the court or not) [3, 4, 5, 6]. psychological conflict with only one of the part- If during the initial consultations the therapist ners appears, the decision of continuation the succeeds in discovering and diagnosing any of common therapy should not be taken. Instead, above-mentioned problems, he/she can offer one the proposition of individual therapy should be or both of the partners turning to the right peo- introduced. Crane [3] recommends not to offer ple/institutions (eg. , mediator, rehab therapy or hinder it in a situation where partners counselling, crisis intervention centre, etc.) as a want to talk about their individual problems, means of help in solving the problem. There are rather than focus on their relationship. Howev- however some situations where the person ap- er, it seems that one or several joint session after plying for therapy for some reason do not tell unveiling an individual problem, is reasonable the therapist about the most difficult problems, and could be used to motivate people with un- such as the wife may be afraid that if she reveals resolved psychological conflict to take individ- how her husband beats her, he will later on took ual psychotherapy, while considering together revenge on her, or one of the partners does not whether the other partner also needs counsel- wish to disclose that he/she remains in union ling and, if so, what kind. with other person because of the fear of losing Here again, the therapist should act carefully benefits, disintegration of the original relation- and thoughtfully, so as to on individual ship or accusations of contributing to the crisis. issues do not served spouses/partners as a con- Therapist undertaking the work with marriage/ tinuation of fight over who is to blame for the /couple in crisis should be alert and attentive, current status quo of the crisis (a person with a but not suspicious, and pay attention to different revealed mental disturbance is more likely to be types of behaviour and specific words that may exposed to accusations of the ‘healthier’ partner, indicate the existence of a secret. What might be but it can also happen that the above-mentioned helpful in the diagnosis of the problem (crisis) partner would be accused that his/her behaviour and type of relationship is a variety of question- caused the state of the first one).

Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64 60 Małgorzata Wolska

Freeman [5] believes that therapy should be Freeman [5] is an advocate of short-term mar- suspended or terminated in a situation where ital therapy which combines the cognitive and after passing the initial phase (for example af- behavioural techniques as well as marital thera- ter the third session) it is at a standstill, mean- py with crisis intervention. According to her as- ing the partners continue to work on each other sumptions, as an indication for treatment she ac- destructively, when they show no motivation to cepts the visible signs of crisis in both spouses change the relationship, when they are not able or one of them. These signs of crisis are: a sense to open in front of the therapist or they are too of hopelessness, inadequacy, increased level of preoccupied to listen to each other, and contin- anxiety, frustration and inability to deal effec- ue efforts to destroy each other. tively with the situation. Like other therapists, she attaches a great importance to the motiva- tion of both spouses, which is assessed on the INDICATIONS FOR MARITAL/COUPLES THERAPY basis of completing tasks and undertaking var- ious actions designed to alleviate existing ten- After this long list of objections and contrain- sions. dications to take up and lead marriage/couples Crane [3] believes that the therapy is possible therapy, there arises inevitable question: when in the following situations: and to which couples this kind of therapy can be • when both partners are trying to improve re- offered? In the literature on marital therapy on lations between them by mastering commu- the first place on the list of indications, the mo- nication and effective problem solving; tivation of both partners is placed, so it is up to • when partners with negative experiences of them to make efforts to achieve positive chang- failed relationships of their parents or their es to their mutual relations [3, 5, 6, 7, 8, 9]. Ther- own previous relationships want to prevent apists working with marriages in the behav- problems or to solve those that already exist; ioural approach examine partners’ motivation • when partners, fearing the disintegration of to change their conduct by giving them tasks to the relationship, want to prevent the accumu- accomplish in the time between sessions. Com- lation of difficulties and to rebuild the bond; pletion of these ‘home assignments’ would indi- • when partners want to make an attempt to cate a good motivation to improve mutual rela- reach an agreement before taking a final de- tions but, unfortunately, it happens sometimes cision about the divorce or separation; that some people perform tasks in order to dis- • when partners have already committed part- miss the allegations of their partner about the ing but wish to avoid tension or to find a so- lack of commitment or a negative attitude, or lution to the problems existing in their rela- to have an argument to continue fighting with tionship; him/her, which can be expressed, for example, in • when partners want to undertake therapy as a this way: ‘You care for nothing! You are not in- form of support with other problems solving, volved! It is I who does everything to solve our for example marital therapy is to be a part of problems and you just sit and wait for it!’, etc. , conducted because of a prob- Except good motivation and among other in- lem of a child, who is about to appear. dications for therapy, the behavioural therapists of marital/couples problems place the following types of problems: THE INITIAL PHASE OF WORKING WITH • overprotection of one partner coexisting with MARRIAGE/COUPLE IN CRISIS: CONSULTATION emotional dependence of the other; • combined with control, suspicion and In the first contact with a pair in crisis, when restriction of freedom; there is general confusion and tension, proceed- • the dominance of a partner combined with the ing according to the indications and contraindi- lowering of the value and self esteem of the cations to therapy outlined above can help the other, passive partner; therapist in making the diagnosis of the crisis • mutual antagonism, blaming and emotional and problems in relationships as well as in tar- interdependence [6]. geting, defining purpose, scope and method of

Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64 Marital Therapy / Couples Therapy: Indications and Contraindications 61 counselling. During this initial stage we have to couple who already at the first meeting would decide whether and what form of assistance we represent a sufficient motivation to undertake can offer: marital therapy, crisis intervention, ne- this therapy. But the most frequent were the gotiation, divorce negotiations or perhaps indi- cases when I met with pairs within which one vidual psychotherapy. It may happen that dur- person forced the other to come to the meet- ing the first session, usually lasting one to one ing, and the reason of doing that was to bring and half hour, we are not able to obtain certain- charges of destroying their relationship; the cas- ty as to what form of help is the best solution at es when pair who fought with each other using this point. Therefore, it seems to me that each sophisticated methods and who needed a wit- pair applying for a therapy because of dysfunc- ness, an ally, defender or supporter; when cou- tional relations, a sense of dissatisfaction and ples who try to live in accordance to their own failure of a relationship, should be able to hold familial myths and beliefs, declaring that they two or three consultations aimed at the most de- want to save their marriage for the sake of chil- tailed defining of all the problems, among which dren, fear of public opinion or fear of whether or there are individual, familial and general life’s not they could cope without a partner - the mar- problems, that may have a significant impact riage which in fact is dead for many years. Sim- on their functioning in the relationship. I men- ilar examples can be multiplied and they lead tioned earlier that very serious, deeply rooted, to one conclusion: the vast majority of marriag- long-term problems, evaluated as something to es / couples seeking therapy has an insufficient be ashamed of, are often not disclosed in the first motivation to undertake it (hence, perhaps so contact with the therapist. Their existence may many drop-outs of marital therapy). Therefore, be signalled to us just a small gesture, a word during the initial consultation there should be thrown casually or passionately ensuring that found a place to work on motivating partners to beyond the fact that sometimes there are quar- engage in therapy if only they want to maintain rels, they are still very good, loving marriage/ the relationship and improving relations, the at- couple. Partners seeking for help must be pro- mosphere, achieving intimacy and sense of se- vided with all the time needed to dare to depart curity. from the rules of the game they play. Disclosure Another issue that needs to be addressed dur- of things which have not yet been talked about ing the initial consultations is responsibility. out loud may be a prelude to conduct a real, rad- The therapist is responsible for conducting ac- ical change in their mutual relations. A detailed curate diagnosis of the problem and motivates list of problems, including those that were hid- the spouses/partners for mutual involvement in den deeply inside so far, can be the first step in the solution. On the side of the spouses/partners establishing the hierarchy of the problems and lies the responsibility for the continuation or ter- in selecting of such forms of assistance that will mination of the relationship; for taking steps best fit to the most important problem. Consul- to solve the problem (each has contributed to tation meetings would, therefore, help spouses/ the emergence of the problem so each of them /partners in making the diagnosis of problems should do something to solve it); for deciding and assessing their willingness and capabilities whether to use therapy or self-dealing with the to participate in marital therapy (that includes problem. The therapist can only indicate conse- also a decision concerning the relationship – quences of different conduct but decisions on whether to be together or part ways). the actions they would take lie in the spouses/ The initial consultation is also an appropriate /partners. If only they are determined to main- time for us to address the motivation for thera- tain their relationship the therapist during the py, which means the motivation to change. That initial consultation may motivate them to coop- involves a confrontation with hidden , erate and encourage the cessation of fighting, problems, tendency to deconstruct of what is noting the good intentions of the spouse/partner well known, safe and stable (the old marriage to ease the tension, showing them the strength game) and restructuring relationship based of their relationship and positive sides of their on openness, mutual respect and trust. On the being together. He/she should inform patients ground of marital therapy I have not yet met a what to expect during treatment so they could

Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64 62 Małgorzata Wolska consciously decide to cooperate. The therapist reached jointly by the therapist and both part- may say that during the therapy there might be ners). To marriages/couples who clearly depend a necessity one more time to deeply confront on maintaining and improving relationship, a the emerging tensions, conflicts and problems, marital/couples therapy can be offered. Further including finding their sources so as to better consultation for both partners or individually for understand oneself and the partner. Because each of them can be offered in a situation where such analysis can give rise to tensions and fur- one person wants to move away from the part- ther temporarily deepen the gap between part- ner and the other wants to save the relationship ners, the therapist should warn that the begin- and they are not able to talk about other prob- nings of therapy can be difficult and that the lems. If both spouses/partners are intent on part- positive changes take a lot of time. The thera- ing, the therapist should offer divorce media- pist should also provide an overview of the ther- tion (negotiation) and if the couple change their apy and together with spouses/partners define mind in the course of mediation, marital/couples its goals and its role. After the consultation con- therapy can be introduced. If there is a problem ducted in this way, taking into account the ob- of addiction, mental illness, violence or deep- stacles, constraints and favourable circumstanc- ly settled psychological conflict, we offer other es for launching the therapy, it is far easier and forms of psychotherapy (e.g. individual), or psy- simpler to decide what further action treatment chological or medical help (drug therapy, crisis should be chosen: to pick up sessions of mari- intervention, for victims of abuse, tal/couples therapy or to consider other forms of pharmacotherapy, etc.). The more focused struc- help. Fig. 1 shows a diagram of the therapist’s ac- ture of the consultation meetings, the more pre- tions in the initial stage of contact with the mar- cise and unambiguous definition of the expec- riage/couple in crisis. tations of spouses/partners to each other and to

Preliminary consultations (two-three(two-three meetings) forfor every couple despite of the problem

Therapy for the couples Further consultations Divorce mediation ifif bothboth of Individual therapy determined inin casecaseof of oneone partnerpartner theof partners the partners want want to split to up or other to maintain being willing to stay splitor upor are arein the in middlethe middle of forms the relationship and the other not of conducting thethe divorcedivorce of therapy

Figure 1. Therapeutic proposals for marriage/couples in crisis

Meeting for the first time with a marriage/ the treatment, the easier it is to achieve common- /couple, the therapist should conduct a consul- ly set goals (thus – realisation of the therapeu- tation informing spouses/partners about his/her tic contract). actions and intentions (e.g. gaining knowledge of the problem they face, identifying the diffi- culties, learning the history of their relationship FEATURES OF A MARITAL THERAPIST and the history of the conflict/crisis, the com- mon determination of the meetings aim, defin- Writing about the indications and contraindi- ing his/her own capabilities to help in a given cations to therapy aimed at marriages/couples, situation). Consultation usually involves two or there cannot be ignored to mention about con- initial meetings, which take place every week or ditions to be met by a therapist who undertakes every two weeks at least. At the end of the sec- to carry out such treatment. This is not about ond or third consultation meeting the decision making a precise description of the qualities and for further actions should be reached (the one skills one should possess to be at all a psychother-

Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64 Marital Therapy / Couples Therapy: Indications and Contraindications 63 apist. I would rather like to focus on specific char- therapy should be conducted by a person of ma- acteristics, behaviours, attitudes and skills that fos- ture age, with long lasting practice and positive ex- ter or impede the conduct of marital/couples thera- perience in marriage/partnership. Probably to such py. It seems to me that the marital therapist should a therapist it would be easier to meet the challenge possess such features as curiosity about the vari- of working with strongly conflicted spouses/part- ous histories of different relations, curiosity of the ners. However, it seems to me that younger ther- events of family life and the individual life; toler- apists or the ones who live alone or who are di- ance; openness and flexibility, including the use of vorced can successfully lead marital/couples ther- different approaches, the readiness to combine dif- apy as long as they adhere to the rules governing ferent techniques and methods, and also willing- its conduct and the relationship between therapist ness to put the therapy under frequent supervi- and spouses/partners. sions; high resistance to frustration; the ability of equal distribution of attention and interest among both partners combined with neutrality; the ability FINAL CONCLUSIONS to maintain distance from the stereotypes concern- It seems to me that the precise defining of indi- ing the role of man and woman in a relationship. cations and contraindications to marital/couples In opposition, the primary contraindication to con- can clearly benefit in increasing the efficiency of duct marital/couples therapy is a current marital this form of therapy. The more accurate diagno- crisis of the therapist. I am convinced that in this sis of marital conflict and its sources we put in difficult situation the therapist is unable to main- during the preliminary consultations the more tain an appropriate distance from his/her person- accurate the selection of the most appropriate al experiences and therefore there is a great danger form of assistance to a particular marriage / cou- of blurring the boundaries between his/her own ple. If this feature will be combined with suffi- emotions and emotions of the warring spouses/ cient motivation on behalf of partners, on which partners. Hence, the possibility of appearance of motivation we can work during the initial con- counter-transferential reaction. I think the thera- sultations, there are good chances for increas- pist during the crisis of his/her own relationship ing a positive effect of the therapy. Whilst de- or during the divorce should not undertake any ciding to conduct marital therapy/couples ther- work on the marriage/couple in crisis. In addition, apy, we cannot count on quick and easy success. the feature that can really hinder the marital/cou- Therefore, to be able to achieve even small pos- ples therapy is the willingness to save marriages itive changes in the relationship, we should de- before breakup. It occurs most often in people who termine with our patients their ability to meet were themselves involved in their parents’ mar- the expectations of the partner and their own ital problems or are currently experiencing diffi- motivation to change as well as define fears and culties in their relationships and the fear of its col- concerns about the current situation and future lapse. From time to time, the therapist should ask needs of each of the partners; share goals; ad- him/herself: ‘Do I care that they were still togeth- just the pace of therapeutic work to the capabili- er? And if so, why? ‘ This examination of his/her ties of both partners; share responsibility in such own involvement in the fate of a given relationship a way that the future of the relationship (stay- will help to release oneself from the responsibility ing together or parting) lies within both part- for the decision about the relationship as well as it ners, and the therapist is responsible only for the will help to restore a healthy, conducive distance course of therapy, implementing of commonly and neutrality that is needed to provide help to a chosen direction and achieving defined goals. given couple. Another contraindications to conduct marital/ REFERENCES couples therapy are: the desire to be an expert and advise partners on how to arrange their life togeth- 1. de Barbaro B, Drożdżowicz L, Janusz B, Furgał M, Gdowska er, prejudice or excessive loyalty to the people of K, Czyż P, Kołbik I. Czy terapia rodzin z nakazu sądowego the same gender as the therapist and succumbing ma sens. Psychoterapia. 2003; 4: 35–45. to stereotypes. One of those stereotypes about the 2. Schmitt EE. Małe zbrodnie małżeńskie. Kraków: Wydawnict- therapist is a common belief that such a difficult wo Znak; 2005.

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