May/June 2008

Success With Couples Therapy — A Step-by-Step Approach
By Jon Meyerson, LCSW
Social Work Today
Vol. 8 No. 3 P. 16

Couples therapy isn’t just individual therapy on double duty. Learn some simple, effective steps to the art of working with couples.

After graduate school, I saw individuals in therapy for several months before I scheduled a couple. I began my first couples session by mustering up my finest empathic voice and asked Marilyn and Kenneth, “How do you see your current marital situation?”

In less than 60 seconds, I realized that this question, which was appropriate for individual therapy, had caused an unleashing of emotions resulting in a Hollywood scene of screams, tears, and threats that would have made Steven Spielberg proud. My question to Marilyn and Kenneth clearly broke the medical axiom: First, do no harm.

It took me time and many hours of training to learn that couples therapy is not individual therapy with two people, nor is it a small version of group therapy. Though about 80% of therapists surveyed see couples, very few graduate programs require even one class in couples therapy. Typically, it has to be learned after beginning a practice.

When Couples Seek Help
Most couples arrive in the office with major conflicts after being in a relationship for years or even decades. They are used to hearing daily comments from each other such as “I can’t put up with your computer obsession, and you’re always ignoring me!” or “I can never do anything right. You are always blaming me!”

Couples usually make appointments only when the chill in their relationship has reached pneumonia proportions. What once had been a loving relationship is now characterized by irreconcilable differences in their beliefs about financial decisions, physical intimacy, contacts with relatives, and even how to load the dishwasher. Because they have practiced their side of the arguments for so long and they are so good at knowing how to attack each other’s weaknesses, persistent patterns have developed. Change will take time.

Couples often arrive believing that the therapist’s job is to “fix” their partner. Many couples are skeptical about whether therapy will work. In the first session, each needs to understand that they are both good people; however, their patterns of communication have created a daily fencing duel. The therapy process will return them to their prior loving relationship only after they become aware of how each contributes missteps to this daily duel and begin to make changes.

Yes, there are some younger couples who are easier to work with and arrive with a tender and loving relationship. They ask how they can avoid falling into the destructive kind of marriages that their parents have had. If therapists weren’t constrained by ethical considerations, we would greet these couples at the door with hugs for having the foresight to take more time to plan for their marriages than for their weddings.

My wife, Beverly, and I have seen hundreds of couples and found that using the step-by-step process described in this article will offer couples optimism after the first session. (We are both present in the office, but the process described will work with a single therapist.)

Therapy Goals
Couples desperately want to repair their relationship, both for their sake and their children’s, but they do not understand their partner’s point of view and rarely understand how their own actions contribute to conflicts.

The therapist’s goal is to teach a method of communicating that allows couples to resolve their own issues during and after therapy. The goal is not to resolve issues. If a therapist attempts to resolve an issue, one or both partners will usually become defensive. Even if they accept the therapist’s solution, they will have many more conflicts lined up that the therapist can’t resolve.

The couples therapy process requires therapists to do the following:

• provide the couple with an understanding of the goals of therapy;

• develop trust with each client without alienating the other;

• set the boundaries of therapy so each will feel safe to express his or her point of view in a way the other can hear and understand, even though he or she may not agree; and

• set the stage for the couple to have a conscious relationship, that is, one where each partner begins to understand how he or she is contributing to the conflicts and how using a different communication style can lead to the joyful and harmonious relationship they both deserve.

The therapist should meet privately with each partner (either in a separate session or part of the first session) to learn about any sensitive issues. Ninety-minute sessions work best rather than the 50-minute session typically used for individual therapy.

The First Session

Step One: Intake
It is useful to collect some basic information at the start of the first session, such as the number of years the couple has been together, the current living situation, special health issues, prior counseling experiences, employment, and special interests. While the therapist is recording this information, he or she should make a mental note of how the partners relate to one another. The intake also offers the couple a chance to become comfortable with the therapist.

Step Two: Goals and Why Therapists Are Not Referees
Couples often arrive at the session believing that each partner will be laying out his or her “position” and the therapist will act as a referee to decide who is right. The therapist should inform them that it is not a matter of one person being right or wrong, since both partners make sense from their perspective. Rather, they will be learning a new method of communication so they can better understand each other in the office and incorporate this process into their relationship at home. We tell them the process will work if they “are willing to try on some new ideas.” By pointing out the importance of the “we” and not the “me” in their relationship, they begin to understand that we expect both to participate by making changes. This means that counseling is a joint venture to better understand the relationship rather than an adversarial one.

Step Three: How Our Brain Impacts the Dishwasher
Talking to the couple about basic brain functions and how the 100 billion neurons in their brains make decisions helps them to think of therapy as a conscious exercise. They should become detectives trying to figure out how to help “this couple,” who happens to be themselves, just as they might be athletes learning how to build their muscles at the gym.

We talk to the couple about the neurons housed in the analytical area of their brain, the neocortex, which helped them find the way to our office, vs. the neurons of their emotional brain, the limbic system, which they use to experience joy, love, and ecstasy, as well as anger, sadness, loneliness, and fear.

We let them know that when Kenneth says to Marilyn: “That’s no way to load the dishwasher,” he may be thinking he is speaking from his analytical brain to hers, but in fact, he is stirring her limbic system. She reacts emotionally and, in turn, stirs his emotions. This small incident can blowup into their War of the Roses.

Step Four: The Sun
Appreciations are to a relationship as the sun and rain are to a flower. They trigger the happy neurons in the limbic system and bring couples closer together. The following is a simple exercise to foster positive changes:

• Ask the couple to face one another. (The path to the heart is through the eyes.)

• The first partner (the sender) is asked to state one thing he or she likes about his or her partner. For example, “I really love your sense of humor and how you enliven parties with your jokes.”

• The second partner (the receiver) mirrors this appreciation. “So you really appreciate how I have a sense of humor and entertain friends at a party?”

• Then we ask the sender to deepen the appreciation by using the sentence stem, “This is so special to me because…” He or she says, “This is so special to me because it makes me feel warm and cozy and I am proud I married you.” The receiver again mirrors the comment.

• The process is repeated with the second partner offering an appreciation.

Most couples who come to therapy have not heard appreciations from their partner for months or years, so this exercise sets the tone for rebuilding warm feelings and trust. Couples are asked to offer at least one appreciation each day at home and prepare one to begin each therapy session. They are told that appreciations should not be wrapped in frustrations, such as, “I appreciate that you finally took out the trash.”

Step Five: A Conscious Relationship
A conscious relationship requires each person to recognize their own role and reactivity levels when conflicts arise, as well as to become aware of their partner’s thoughts and feelings. After living with conflicts for so long and having to defend their own ego against attacks, the therapist needs to help them to truly listen and understand what their partner is thinking and feeling.

The following exercise works amazingly well to help one partner get into the mind of the other:

• Again the couple faces each other. The sender is asked to offer a one-sentence “guess” as to why he thinks his partner decided to come to this appointment. For example, “I think you came to this session so the therapist can teach me how to be nice to you.”

• Regardless of whether it is true, the receiver mirrors it: “So you think I came to therapy so you’ll learn how to be nice to me?”

• The sender keeps adding more reasons, such as, “I think you are also here because you love me and want our marriage to survive.” This, too, is mirrored by the partner.

• After the sender completes all his or her guesses and each are mirrored, the receiver is then asked to add to or correct the sender’s guesses. The partner may say, “It is true I’m here to save our marriage, but it’s not a matter of being nice to me. It is more a matter of learning how to talk to each other.”

This guessing game for both partners becomes a vehicle for looking into each other’s minds in a safe way. It also reveals some of the major issues that will be explored in future sessions. The process helps couples understand how their own behavior has a positive or negative impact on the relationship.

Step Six: Summarizing the Session and Preparing for the Future
To end the session, each partner is asked for their thoughts about the session and what they can personally do before the next appointment to improve the relationship. This information helps the therapist plan for the future.

The therapist should also advise the couple to do the following:

• Offer each other at least one formal daily appreciation.

• Avoid “atomic bomb” issues when they are at home and save these issues for office sessions.

• Avoid talking to friends or family about their conflicts since others are likely to support only one’s point of view and that will further emotionally separate the couple. Instead, they may just inform a few who need to know that they are receiving counseling to improve their relationship.

Future Sessions
In future sessions, couples need to continue learning to understand each other’s desires, feelings, and thoughts. The Imago Relationship method of therapy developed by Harville Hendrix, PhD, is a powerful process for this purpose. It uses the mirroring technique along with couples validating and empathizing each other. For example, a partner may state, “It makes sense you would be upset that I came home at 7 because I had told you I would be home at 6, and this probably made you feel anxious, lonely, and angry.”

Therapists can coach couples to use this stem: “It makes sense that you would be upset because...” and ask the sender to think of the reasons. Again, it helps couples to think outside themselves and improves the relationship. People begin to understand that their partner truly loves and cares about them as a dear friend.

Along with continual dialogue and mirroring, there are a variety of other communication tools that can be used during sessions. One is constructing genograms to enable partners to understand how each developed values through their families. The genogram, which displays on a board a family tree going back to grandparents, reveals the lifetime growth of an individual’s feelings and behavior. Couples often experience revelations that improve their understanding of their current relationship when they explore their genogram.

Another useful communication tool is the Myers-Briggs Type Indicator that helps couples understand how character differences can cause conflict yet serve to energize the relationship. Couples begin to realize that having different character traits adds spice to a relationship that may otherwise be bland.

As couples listen and express more positive feelings, they develop trust and feel closer. Neural scientists find this physically changes brain neurons, with more “loving cells” being created and fewer cells holding anger. Hendrix puts it this way: “Through daily repetition of positive behaviors, our old brain [limbic system] repatterns its image of our partners, and we again become a source of pleasure for each other.”

Beverly and I leave couples with a new rule to replace the Golden Rule. The Golden Rule states: “Do unto others as you would have them to do unto you.” This doesn’t work very well when I order anchovies on Beverly’s pizza (which I love, but she is not fond of), and she buys yogurt for me (which she loves but which causes havoc to my taste buds).
Instead, we ask couples to adopt the Platinum Rule: “Do unto others as they would like you to do unto them.” It’s amazing how one motto can bring happiness and harmony over many, many years.

— Jon Meyerson, LCSW, practices with his wife, Beverly, a relational coach, in Bethesda, MD, and Sarasota, FL, and they are the coauthors of After the Glass Slipper: 8 Proven Steps to Lasting Love. Beverly helped edit this article.