Seminar On

Procedure, Techniques and Outcomes of Marital Therapy

Presenter: Jyoti Mishra

M.Phil. part – II
Guide – Mr. Nandan kr. Thakur
Assistant Professor, PGIBAMS
 Content
• Introduction (marital therapy)
• Approaches of Marital
• Premarital therapy
• Marital
• Assessment
• Procedure (session wise)
• Structure of treatment
• BCST Approach
• Techniques
• Outcomes and Termination
• Conclusion
• References
Introduction
What is Marital Therapy?
• Marital therapy is method of treating a couple with relationship
difficulties, usually by seeing both partners together. It is usually
short term, although psychodynamic practitioners use a longer
treatment period. It is similar to, but not identical with, couple
counseling.
• Couple counseling was established earlier than couple therapy,
having been first practiced in the United Kingdom in the 1930. It
combines giving advice on practical issues, such as finance,
children and living arrangements, with a largely psychodynamic
approach to understanding problems such as resentment and anger.
 Couples therapy According to APA “Therapy in which both
partners in a committed relationship are treated at the same time by
the same therapist. Couples therapy is concerned with problems within
and between the individuals that affect the relationship. For example,
one partner may have undiagnosed depression that is affecting the
relationship, or both partners may have trouble communicating
effectively with one another. Individual sessions may be provided
separately to each partner, particularly at the beginning of therapy;
most of the course of therapy, however, is provided to both partners
together. Couples therapy for married couples is known as marital
therapy.”
 Behavioural treatment approaches to marital distress have
evolved extensively since their introduction (Stuart 1969, Patterson
and Hops, 1972) less than two decades ago.
• These early behavioural interventions emphasize simple social
exchange theory and contracting.
• A more broad-based view of interventions has been designed to
increase positive, pleasing behaviours, improve communication,
develop problem-solving skills, alleviate sexual problems, and
restructure harmful or distorted thinking patterns spouses might
have, find ways to circumvent destructive conflict escalation, and
attempt to change larger patterns behaviors that result in marital
discord.
 Approaches of Marital Therapy
 Marital satisfaction as the preponderance of positive interactions
between spouses, initial behavioural interventions sought to replace
negative interactions with positive ones by identifying and
increasing pleasing behaviours.
• Learning theories developed in the
laboratory and inspired by the work of
B.F. Skinner, the behavioural view
considered interactions between
distressed threats of negative
consequences.
 Those first behavioural Interventions
aimed to shift the focus from aversive
control to positive control, where
spouses would behave positively not to
avoid punishment but to please the other
spouse.
 Social learning theory (Bandura 1977)
Particularly has contributed to our
understanding of the cognitive – perceptual
processes that are important in working with
distressed couples. The clinician must assess
the attributions that spouses make for their
own and their partner’s behaviour.
• In addition to assessing the perceived causes of
behaviours, a marital therapist must assess the
way in which each spouse interprets the impact
of their own and their partner’s behaviour.
  Psychoanalytic approach, Daniell (1985) and
Clulow (2001), is that the internal world of the
two partners determines the nature of their
interaction and their response to changing
circumstances.

 This is historical based on an understanding of object relations theory

(Greenberg and Mitchell 1983) but in recent years the concept of adult
attachment has also been widely adopted. Their difficulties can be
interpreted in terms of their primitive need and the defences, including
mutual projections, which have been developed to deal with them.
• Therapy aims to help the partners to become aware of these inner
worlds and their origins enabling them to reduce
misunderstandings through insight, and to get in touch with their
own feelings and those of their partner. A central focus is on
infantile feelings and ‘repetition-compulsion’ which leads to the
person treating his/her partner similarly to the way he/she felt
about the opposite-sexed. parent.
The behavioural approach examines current
observed and reported behaviour on the premise
that the troubled couple have reached a low level
of mutual positive reinforcement and are using
coercive methods to try to control each other’s
behaviour.
 Two main forms of therapeutic activity take place:
reciprocity negotiation and communication training. In RN, the
partners request changes in behaviour and negotiate how can be
achieved through mutually agreed tasks. In CT the couple are
encouraged to speak directly to each other about feelings, plans, or
perceptions, and to feed back what they have heard and
understood.
Origins of behaviour or deeper meanings behind the
partners’ attitudes are not dealt with explicitly.
 A combined psychodynamic-behavioural approach (Segraves
1988) in which the underlying cause of the couple’s problems is
understood as relating to conflicting internal fantasies about
themselves and each other. Intervention is directed to helping
them to understand these and increasing reality-based
communication and ability to negotiate.
 Cognitive-behaviour approaches by (Aaron
Beck 1988) the problems of couples,
identifying in their communication
misunderstandings, generalizations, and a
concentration on negative aspects of a
problem - all typical of depressive the
thinking.
His approach uses similar therapeutic processes to those which have
been successful in treating depression: challenging assumptions;
reducing expectations; relaxing absolute rules; and focusing on the
positive rather than the negative.
The systems approach A central concept
here is enmeshment, an excessive
involvement of one person in What is
essentially the ‘private business’ of another. It
is most acutely seen in the teenager’s
struggles to separate and individuate from
their parents, and the difficulty some parents
have in ‘letting go’.
Intimacy refers to four kinds of interaction: sexual, physical,
emotional, and ‘operational’ of which the last refers to sharing
plans and information with one’s partner. Conflicts may arise over
how close each partner wishes their relationship to be. Systemic
therapy attempts, among other goals, to achieve and optimum
‘distance’ between the partners.
 Another key concept is homeostasis – the tendency for
partners to maintain the status quo, no matter what external factors
may impinge on them. Negative feedback systems operate to
restore the relationship following a change that could potentially
alter its nature. Symptoms in one partner may form part of a
negative feedback process which stabilizes an otherwise unstable
relationship.
Premarital Counselling
Premarital Counseling is a form of couples therapy that can
help you and your partner prepare for marriage. It is intended to
help you and your partner discuss several important issues,
ranging from finances to children so that you are both on the
same page. It can also help identify potential conflict areas and
equip you and your partner with tools to navigate them
successfully. Premarital counselling aims to help you build a
strong foundation for marriage.
According to Sabrina Romanoff (1984) “Premarital counselling
helps couples create a blueprint for their lives together”.
Types of Premarital Counselling (According to Romanoff)
 Gottman’s Method
The Gottman Method, developed by Drs. John and Julie Gottman.
Aim
• Improve the quality of friendship between you and your partner,
• Increase intimacy, and
• Equip you with problem-solving skills that can help you build a
stronger relationship (Les Greenberg)
 Emotionally Focused Therapy (EFT)
Emotionally focused therapy, developed by Drs. Sue Johnson and, is
a form of short-term therapy.
Aims
• To improve the attachment and bond between you and your partner,
Leading to better communication and a stronger relationship.
 Psychodynamic Couples Therapy
Psychodynamic couple’s therapy examines the underlying issues that
motivate interaction cycles.
Aims
• Identifying and addressing factors like hopes for closeness, love,
and appreciation and fears of abandonment
• Disapproval can help you and your partner better understand and
accept each other.
 Techniques
In the initial stages of premarital counselling, you and your
partner may be assessed, both individually and together. During the
course of the counselling, both of you will be encouraged to share life
experiences and events, which can help shed light on your
expectations and motivations in a relationship.
Romanoff (1986) “Premarital counselling” also involves
discussing important aspects of a marriage, including “financial
planning, roles in the marriage, decision-making processes, family
relationships, if children will be in your future, and how you wish to
raise them”.
Assessing You and Your Partner
Premarital counselling often requires you and your partner to fill out a
questionnaire separately to determine how you feel about one another
and what you expect from your relationship. These questionnaires can
help your counsellor identify your strengths, weaknesses, areas of
compatibility, and potential problem areas.
Counsellor will also assess the dynamic between you and your
partner during counselling sessions and use those insights to guide the
course of the therapy.
What Premarital Counselling Can Help With
Premarital counselling helps identify core beliefs, set realistic
expectations for marriage, plan for the future, and decide the
ways in which your lives will be merged”.
• Understanding your partner
• Setting realistic expectations
• Planning for the future
 Benefits of Premarital Counselling
These are some of the benefits:
• Learn constructive communication.
• Develop conflict resolution skills.
• Focus on the positive aspects.
• Eliminate dysfunctional behaviour.
• Build decision-making processes.
• Alleviate fears related to marriage.
 Marital Therapy
Presenting Problem
• Couples or individuals seek marital therapy to address a variety
problem.
• Couples may seek therapy because of increased frequency or
severity of arguments, a specific problem or set of problems they
are unable to solve, unhappiness about their sexual relationship, or
simply report vague and non-specific dissatisfaction with their
relationship.
• It is also common for couples to report feeling ‘trapped’ in their
‘stale’ relationship, and seek therapy as a final attempt at resolution
before or major life change precipitates the decision to enter marital
therapy.
• Marital problems may also be the reason for a husband or wife
seeking individual therapy.
• In such cases it is likely that either the other spouse has refused to
accompany the presenting spouse or that the presenting spouse does
not identify marital problems per se as the cause of his or her current
difficulties.
• Thus, marital problems may often be implicated when an individual
seeks individual therapy for depression, anxiety, etc., or seeks
medical attention for associated somatic complaints.
• A full assessment of the marriage in these cases will ascertain
whether marital therapy is indicated or possible.
Causes of marital distress: a Cognitive-
Behavioral Theory
 Distressed couples generally have few pleasant and rewarding
interactions but many angry, blaming, or punishing ones.
Interactions of distressed couples are often characterized by
reciprocated negative behaviour: if one spouse behaves negatively,
the partner is likely to respond in kind, and thus starts a chain of
escalating negative interaction.
 Such a chain of negative behaviours in a couple having marital
problems might start with one spouse expecting to be criticized for
not completing some household task that he or she normally
performs.
 High reactivity in distressed couples may increase the likelihood of
misunderstanding and poor communication.
 Distressed relationships are further characterized by an inability to
resolve conflict. Lack of conflict resolution skills leave couples
with a backlog of unresolved fights and conflicts that have built up
over the history of their relationship.
 Reinforcement erosion occurs when partners lose the satisfaction
that was once present in the relationship. This might be attributed to
habituation: behaviours that were pleasing at one time are not as
important any more. They may fail to appreciate each other’s
efforts, take each other for granted, or have new and different needs
that their partners have not yet learned to meet.
 Assessment of Target Problems
• The purpose of the assessment sessions are to determine a
couple’s suitability for marital therapy and to gain an
understanding of their situation.
• The focus is on gathering information: couples are told that no
changes are too expected during the assessment phase because
the treatment will proceed only after the therapist learns enough
about the couple and their problems to make an informed
decision about the course of therapy, and indeed whether marital
therapy is indicated at all.
 Procedure of Marital Therapy

Session: Initial conjoint meeting

• The first conjoint session should focus on relationship
strengths as well as problem areas, helping the therapist to
begin to understand both spouses and their relationship.
• There are two important general area to focus attention in
the first session
• Problem areas - The therapist should focus directly upon
the couple’s presenting problems.
• Relationship history- Here the therapist focuses on more
positive aspects of the relationship like the beginning of the
relationship, about things like how they met, what attracted
them to each other, a little about their wedding, things like
that.
Session 2: Interviews with individual spouses
• The primary purpose of these interviews is to understand the
spouses better as individuals and hence develop a fuller picture
of the relationship while building rapport.
• . It may be informative to ask questions like,
Do you love your spouse?
Do you like your spouses?
The individual interviews explore of other areas including:
1. Individual psychopathology;
2. Sexual difficulties;
3. Sexual and physical abuse as a child;
4. History and characteristics of past significant relationship;
5. Relevant information about the family of origin (e.g. the
person’s relationship to family members, parents’ marital
relationship, patterns of conflict, and emotional expression

in the family of origin).

Session 3: The round table session
• The therapist presents a formulation of the couple’s strengths and
weaknesses, problems, the proposed treatment plan, and any
concerns about the couple’s ability to work their relationship in
therapy.
• The therapist must engage the couple in a conversation about their
relationship and about the proposed course of marital therapy,
setting the tone of mutual responsibility.
• If the couple and therapist agree to work together, the therapist may
outline the couple role and responsibility in the treatment and
change process the couple must commit themselves to putting
effort into improving their relationship both during the sessions.
 Treatment structure
Structure of each session
• It is preferable to hold 90 minute therapy sessions, initially on a
weekly basis. Each session consists of the following components:
1. Setting an agenda for the current session (5 minutes)
2. Evaluation of progress in therapy to date (10minutes)
3. Debriefing assignments (15minutes)
4. New ‘business’, introduction of new topics or skills (45 minutes)
5. Assigning tasks to be completed before the next session (15minuts).
• Evaluating progress might utilize any of several techniques, and
should be included in some form each session.
• The couple might be asked to rate daily their happiness or
satisfaction with their partner or relationship
• These ratings are averaged for the week and may be graphed over the
course of therapy.
• Example, daily ratings may be used to help pin-point factors that
contribute to positive negative feelings from day to day.
• An important way to monitor progress involves taking spouses
‘affective temperature’ and this should be employed from time to
time during the course of therapy.
• This topic is best broached with open-ended questions from the
therapist like this,
How have you been feeling about what we have been doing in therapy?
How have your feelings about being married to change as a result of
the therapy?’
• Finally, each session close with an assignment of relevant tasks to
be completed before the next session, with careful checking to be
sure both the tasks themselves and their rationale are understood.
• One way to facilitate successful completion of assignments is to
anticipate difficulties couples might have and include in the
assignment ways to avoid pitfalls. (Example: ‘what might prevent
you from completing this homework? Any problems they anticipate
should be addressed in a problem-solving discussion.)
Techniques of marital therapy
Behaviour exchange
• Behaviors exchange engages both spouses in activities designed to
increase each other’s marital satisfaction.
• Behaviour exchange is commonly used in the early stages of
therapy because the warm feelings it may foster often encourage a
new sense of collaboration between spouses.
• The rationale for behaviour exchange, just as in all interventions in
cognitive behaviour therapy, is carefully discussed with the couple.
The rationale includes:

• Establishing control over marital happiness rather than leaving

things to chance or waiting for the partner to change.
• Learning to pin-point specific behaviours that make the
difference between a good day and a bad one, and that lead to
positive feelings about the relationship versus negative
feelings.
• Finding out that maintaining a good marriage requires daily
effort.
 Cognitive Interventions
• In distressed relationships, emotional responses to their partners are
dependent upon their thoughts about their partners ’behaviour and
the meaning they ascribe to it, rather than just the behaviour itself.
• Relabeling or reinterpreting partner behaviour is a powerful
intervention that may be employed during any phase of therapy.
• The therapist should be constantly on the lookout for distorted and
dysfunctional thinking, and should intervene regardless of the
content or phase in the therapy.
• There can be negative assumptions about spouse behaviour,
that can be true sometimes, but we need to allow the partner to
refocus on the other positive behaviours as well.
• Intent is explored by the therapist, who models good
communication skills in trying to gain one spouse’s
perspective on his or her behaviour.
• With the other spouse the therapist must explore the impact of
the behaviour on two levels:
1. Identifying the thoughts that the spouse has when faced with
ambiguous behaviour by the partner, and
2. Identifying the underlying assumptions that gave rise to
the dysfunctional thoughts; what do the thoughts mean
(e.g. she might think ‘he doesn’t care about me’).
• After exploring both the thoughts and their meaning,
the therapist should help the couple to gather evidence
to test if the negative attribution or thought is indeed
distorted or if it is truly based reality.
Communication training
 Not only are communication skill deficits a common presenting
problem of couples, but difficulties with expressive and receptive
communication skills are linked to a host of other typical
complaints:
• Lack of understanding.
• Insufficient attention to each other.
• Poor listening.
• Conflict escalation.
• Difficulty solving problems.
 Expressive skills include the speaker identifying his or her own
thoughts, feelings, wishes, etc., then expressing them in the first
person in a specific and clear manner.
 He or she can even exaggerate the role to help lighten the process
with a touch of humour.
 Exercises:
• The therapist models negative non-verbal listening.
• The therapist, then each spouse, practice positive non-verbal
listening behaviours.
• The therapist models negative verbal receptive skills.
• Teach them to paraphrase
• Next the couple will be ready to paraphrase each other.
• The next exercise involves recognizing and expressing emotions.
 Problem-solving
 Problem solving training has two discrete phases: problem
definition and problem solution.
 The first step in the problem solving phase is to brainstorm
and generate a list of potential solutions.
 Any solution is acceptable, and spouses should not censor
their own or start to evaluate their own or their partner’s
solutions.
 After the couple has brainstormed a list of potential
solutions, each solution is evaluated by for criteria:
• It is absurd?
• Would this solution help solve the problem?
• What are the pros for this solution? And
• What are the cons for this solution?
 Affection and sexual enrichment

• It is not uncommon for couples who present for marital

therapy to also have some specific sexual dysfunction. For
these couples, therapy time is devoted to ameliorate the
dysfunction.
• Couples can benefit from applying behaviour exchange,
communication training and problem solving skills to issues
regarding intimacy, sexuality, and affection.
 Because discussing these issues may be difficult and
emotionally-charged, the therapist must sensitive to
whatever fears couples may have and the possible
tendency to avoid these topics.
 The rationale for work in the areas of affection, intimacy,
and sexual enrichment is that work in these areas helps
foster closeness, not just the reduction of conflict as in
most of the therapy.
 Reducing conflict: trouble- shooting
 Trouble-shooting is a technique designed to teach couples
conflict de-escalation (keeping conflict from getting
increasingly more hostile and damaging), which facilitates
conflict resolution.
 The goals of trouble-shooting are both cognitive and
behavioural: to help the couple understand their behavioural
options to stop the escalation of the argument so they can turn
their attention to a resolution of the conflict.
 Two steps are involved in trouble-shooting:
• Reconstruction of the argument involves an exploration of the
intent and impact of each step in the argument, and
clarification of the feelings, thoughts and assumptions of each
spouse at each step.
• Exploration of the cognitive a behavioural options of each
spouse at each step that might have reduced the negative
feelings or de-escalated the conflict.
• This approach helps each spouse to take responsibility for his
or own actions, decreases blaming of the other, and shows both
spouses ways for reducing conflict situations.
Identifying and altering negative patterns of interaction
• The trouble-shooting, it may be possible to identify particular
themes of conflict and the couple’s typical pattern of conflict
escalation.
• Sullaway and Christenesen (1983) have identified several
common themes about which couples often has difficulty:
1. In the demand withdraw pattern, one spouse typically demands
more and more attention or affection from his or her partner, who
initially was somewhat withdrawn. The increasing demands
result in this partner withdrawing still further.
3. In the relationship work-oriented pattern one spouse puts a higher
priority on the relationship, while the other spouse is more focused
on career or vocational interests.
4. With the emotional or rational pattern, there is one emotionally
escalating partner who is matched with an increasingly rational,
non-emotional, and logical partner.
• Interactional patterns can have widespread impact on the
relationship because many minor problems may be manifestations
of the same theme.
 Helping to generalize treatment gains throughout
therapy
• The success of therapy depends on how well the skills learned in
the therapy sessions are carried out in the home environment.
• Diligent completion of assignments between sessions is crucial to
the success of marital therapy because these exercises are the
bridge between successful therapy and the couple’s ability to
maintain or even advance their gains after therapy is over.
• The couple will have regular ‘booster session’ may provide
motivation for them to practice and employ the skills learned, and
the booster sessions themselves allow an opportunity to address
new problems that might emerge over time.
 Preventing Relapse
 One way to reduce relapses (Marlatt and Gordon 1985).
1. Anticipate and intervene to prevent the situations or behaviours that
would increase the likelihood of a relapse; and
2. Establish strategies to help the patients recover from small setbacks
to avert a complete relapse.
 Toward the end of therapy it is important to direct the couple’s
attention to future events, dates, activities, etc. that might be
stressful or have precipitated difficulties in the past.
 The therapist should work with the couple to identify signs that
they are slipping back into old, negative patterns.
 Signs of an impending relapse might include skipping or
avoiding formal problem-solving sessions or ‘state of the
relationship’ meetings, or decreases in pleasurable activities,
including sexual and social activities together
 Recognition of these signs of a likely lapse could prompt the
couple to
1. Use their relationship skills to define and solve the
problems; and
2. Consider re-entering marital therapy.
 Reciprocity negotiation (RN)
 This form of therapy is simple to apply and understand, and it
forms a central component of behavioral couple therapy,
therapeutic approach which consistently shows the highest degree
of effectiveness in controlled studies of outcome.
 The therapist then helps then to consider how to change their
interaction in order to reduce complaints and to ensure that both
partners get what they want from each other without disputes.
 The assumption is that satisfaction in a relationship depends on
each partner receiving positive reactions to their interaction
behavior.
RN is a staged process:
• Initial step is for one partner to state a complaint
• This is translated into a wish for changed behavior, and this
wish is converted into a positive tasks.
Examples of RN steps are:
• Complaints become wishes.
• Wishes become tasks.
• Tasks are reciprocal and
• Tasks are practicable and agreed upon by both partners
 Structural moves in session
 These include raising arguments in session, reversed role-play,
and ‘sculpting’ the argument is the technique most frequently used
and is especially useful in couples who are inhibited or avoid
expressing their differences because of one partner’s sensitivity to
conflict.
 Another intervention providing a novel experience is reversed
role-play. Here the partners address an issue on which they have
contrary opinions, but they each assume the other’s position, by
changing places physically and arguing the opposite case.
 The exercise promotes mutual understanding.
 Another of intervention is ‘sculpting’, in which the partners
position themselves and each other so as to express their
perceptions of their relationship.
 Interventions in the session are designed to alter the couple’s
experience of their relationship.
 They gain experiential insight into each other and
themselves.
 Paradoxical interventions
 Paradox is always applied cautiously and sympathetically.
 It usually helps to carry out circular questioning first, a
common form of paradox is ‘prescribing the symptom’, that
is, advising the couple that it is best ‘for the time being’ for
them to persist with the problematic behaviour which brought
them to therapy.
 They are offered a plausible and challenging rationale for this
consistent with the therapist or the therapeutic team appraisal
of the rotational dynamics.
A paradox had four elements:
1. Positive connotation of the couple and their problem.
2. A description of the ‘symptom’ or unwanted behaviour in
one partner and the reciprocal behaviour in the other.
3. A prescription of both symptom and reciprocal behaviour.
4. A systemic reason for continuing both.
 The Behavioural-Systems Approach
 Is a combines concepts and techniques from two theoretical
models.
 The behavioural aspect, similar of the reciprocity negotiation
and communication training.
 The more complex systems component includes systems
thinking structural move during the session, takes and
timetable, and paradoxical injunctions.
 Indication and contraindications for BSCT
• If a relationship problem is identifies by one or both partners,
and they are willing to work on it, then in most cases they are
suitable for BSCT.
• The systemic components are suitable for those with
psychiatric symptoms.
• There is no limitation to the use of this kind of approach with
those couples or individuals who are poorly educated, since
the concept is easily understood.
• Those couples where both partners agree that they have relationship
problems are highly suitable for BSCT
• Another indication is the situation where, perhaps in individual
therapy, a patient complains repeatedly about the partner.
• Many problems with sexual function are suitable for couple
therapy, especially where there disparity of sexual desire, or where
there is a specific phobia of sex. In some such cases, where there is
an associated history of childhood sexual abuse, combined
individual and couple therapy is usually the best option.
• Jealousy, as long as it is not of delusional intensity, is again
suitable for couple therapy; a specific programme for this
problem within BSCT has proven clinically effective.
• An acute psychotic condition in one partner is generally a
contraindication, although including the partner in a psycho
education approach is beneficial one the acute phase is over.
• Sever alcohol or drug dependency problems often preclude
couple therapy, because the dependent patient is unavailable
psychological and their behaviour is too inconsistent.
 Outcome
Couples seem to be related to poor outcome with cognitive-behaviour
marital therapy (Jacobson et al. 1985).
1. Individuals with severe emotional or behavioural problems (e.g.
depression, schizophrenia, intellectual deficiencies) are likely to
be more difficult to treat for marital distress. A successful
outcome is more likely if there individual problems are recognized
early and treated, rather than left unrecognized or denied, and
untreated.
For couples in which a spouse has severe individual psychopathology,
marital therapy can be a useful adjunct to the primary treatment (e.g.
medication, individual psychotherapy) for individual with problems.

2. The therapy is based on the assumption that spouses can be

rewarding to each other. A couple may have decide to marry
without knowing one another well, or for reasons not entirely
rooted in their attraction to, and happiness with, one another (e.g.
unplanned pregnancy).
3. A couple may present with differing expectations of therapy. The therapy
framework is based on the assumption that the couple are committed to
remaining together; the emphasis on skills training in therapy is not
appropriate for helping couples who have already decided to split up.
Therapy is unlikely to be effective when one spouse has already decided to
leave the relationship
4. The spouses any be generally compatible, attracted to one another,
and able to please each other, yet have developed an apparently
insur-mountable problem in their relationship. Since problem-
solving is based on finding solutions that are acceptable to both
spouses any major problem with only possible outcomes is seemingly
insoluble.
5. Some couples are unwilling to accept the assumptions and
premises on which cognitive-behavioural marital therapy is
based. Such spouses may be unwilling to be collaborative,
accept responsibility for problems, or accept compromise
solutions, despite the therapist’s best efforts.

6. Some couples feel that a focus on the present is not in their

best interests and insist that they need psychodynamically
oriented therapy or other work that involves more attention to
spouses’ family of origin and attaining insight into their
problems.
 Termination
It is customary to prepare the couple for termination two
sessions before the end. It is usually obvious to both the therapist and
the couple when to end therapy. The problems are less pressing. The
partners show a greater ability to manage their relationship without
help, perhaps through longer intervals between sessions. It then
becomes easy to say that ‘the next session will be the last’, and then
at the last session to offer a follow-up meeting at the couple’s
discretion.
Conflict may occur between a therapist who judges that treatment
should end and a couple who wish to continue.
 Conclusion
There is still a dearth of outcome studies on the efficacy of marital
therapy, although Baucom et al. (1998) have carried out a
comprehensive review, and found that certain forms are consistently
effective. Untreated marital usually experienced no improvement,
whereas behavioural approaches mostly showed significant
improvement, which was maintained during follow-up. When
different forms of therapy have been compared (Crowe 1978;
Emmelkamp et al. 1984; Johnson and Greenberg 1986 and Snyder and
Wills 1989) systemic, insight orientated, and behavioural treatments
had similar effects except that the latter produced results more rapidly.
Marital therapy, whatever the model, is proving to be an
effective way to tackle not only relationship problems but also
those of a psychiatric nature, such as depression and jealousy,
where there is a relationship component. It has the added
advantages of being readily acceptable to the couples (Leff et al.
2000), and of reducing the labeling of many forms of behaviour
as ‘psychiatric’ (thus avoiding stimgma).
Helps in understanding of different marital demands and
requisites and tries to solve our problems through different
techniques. It also allow in establishing intimacy and care
among partners.
 Case Vignette

Jake and Ann have been married for four years. They dated for
three years prior to getting married. They have two children. Their
daughter is three and their son is six. Ann is a stay-at-home mom.
Jake is in the Marine Corps. Ann is currently going to college part-
time. They have been in the military for almost four years. They
have moved four times in the four years due to military orders.
Jake has been on one military deployment, which caused him to be
separated from his family for six months.
Ann and Jake voluntarily went to the community counselling
center in hopes of improving upon their marital relationship.
1st Step: Brief Case Interview was taken in regard to their
problems
Chief Complaints Present were:
• Distress in their relationship (complains were mostly vague)
• Argued a lot over small stuff which lead to heated arguments about.
• Arguments usually turned into a big fight that involved yelling,
swearing (Ann), criticism, and fist biting (Jake), and sometimes
throwing objects (Ann).
• There are lack of alone time and the stress caused by Jake's military
career was also some concerns.
 Therapist’s Case Conceptualization

The therapist concludes that sexual dysfunction, conflict, and anger that
she must not focus on one problem because the issues are connected. In
order for Ann and Jake's marital well-being to improve, the therapist
realizes she must help the couple learn to engage in less conflict, reduce the
intensity of anger in their relationship, and by doing this their level of
sexual satisfaction may increase as well.
The therapist thought it would be helpful to understand how Ann's
prior abuse was affecting her marriage. Research suggests that there may
be a relationship between Ann's past abuse and current sexual
dissatisfaction.
Jake's military career may be linked to the amount of conflict in Ann and
Jake's marriage. Military families have been characterized as having high
levels of stress due to their unique lifestyle.
Sessions Plan

• The therapist then prepared Session.

• Session one: they worked on identifying the strengths and
weaknesses of their marriage and also on detailing their
goals for therapy.
• Later sessions dealt with some of the more specific
problem areas in their marriage.
• Session three focused on conflict resolution and
• Session four focused on sexual problems.
 Session 1: Assessment and Goals for Therapy

The therapist in order to build a rapport and start with the interview, she
appreciates that there is still lots of love in their relationship as she saw
both of them coming into the room smiling together.
As the couples wants to strengthen their marriage by working on some of
the problems, therefore, therapist need to find out the strengths of their
marriage as well as the current challenges.
An assessment questionnaire was given to pinpoint the areas
within their marriage that they need to work on. Locke-Wallace Marital
Adjustment test (Gottman, 1999) was given.
The therapist acknowledged and validated each partner's
experience and perception of the situation.
The therapist then switched the focus to action by challenging the couple
to make specific requests of the other and to think of something that they
would be willing to do in order to solve this problem.
The couple had begun exploring their narratives in a more effective
way and they had been able to come to a resolution to a solvable
problem. The goals for therapy was set.
Gottman oral history and meta-emotion interviews
(Gottman, 1999) were used in hopes of accomplishing this task.
Gottman 17-areas scale and the sound marital house
questionnaires (Gottman, 1999) were given to the couple in hopes
of helping them to pinpoint the areas in their relationship that need
strengthening.

Summary: Identifying the trouble areas in your marriage.

Homework: to review the assessment tests and have a summary of
the results ready to discuss with you during the next meeting. To
think more on the goals of therapy. The therapist handed the couple
Schultheis, O'Hanlon, and O'Hanlon's (1999) "Chart your course"
exercise, p. 9-11.)
SESSION: 2
During the next session couple's homework assignment was
reviewed, goals for therapy explored further, and a therapeutic
contract created. Conflict management and sexual satisfaction were
major goals of therapy for the couple. Session three focused on
conflict management.
 Session 3: Conflict management
The therapist decided to make conflict regulation the focus of this
session. The therapist has gained an understanding of the
destructive way Jake and Ann handle conflict. The therapist has
learned from the assessments and interactions in sessions that
conflict in Jake and Ann's marriage frequently involved harsh start-
ups, four-horsemen, unsuccessful repair attempts, flooding, high
levels of anger, little to no humor, innocent victim traits, and
diffuse physiological arousal (Gottman, 1999).

The therapist used several conflict regulation interventions from

Gottman (1999). Intervention one: worked on softening start-
ups. For this intervention, Ann and Jake were given "Rules for
Softened Start-up" and asked to give softened alternatives to the
examples of harsh start-ups (Gottman, p. 224-229).
Intervention three: worked on flooding and self-soothing
(Gottman, 1999, p. 227-233). In this intervention, the couple
learned to recognize when they are feeling flooded. They came up
with a "time-out" hand signal to let the other know when they are
feeling flooded so that they can take at least a 20-minute break.
The couple was given some information on self-soothing
(Gottman, 1999, p. 216-217 and p. 232) and they practiced a few of
the relaxation techniques.

Therapist gave some helpful hand-outs that can be used when they
get in an argument at home (Rules for Softened Start-up, Gottman
Repair Checklist, and Gottman Relaxation Instructions).
HOME WORK: you to use the skills you learned in today's
session. Take notes on what you used and whether it worked or
not. In addition to the skills learned here today, I'd like for you to
also try one more conflict regulation skill, letter writing. So, when
you feel yourselves getting flooded take a 20-minite time out and
then write a letter to your spouse about the problem
 Session 4: Sexual Satisfaction

The homework was reviewed and their progress since last session
was discussed. Jake and Ann expressed that they had improved the
way that they handled conflict.
This session addressed an issue that had been a problem in
their relationship from the start and caused much marital distress.
The therapist explored their current level of sexual
satisfaction and identified a number of destructive patterns in their
sex life. Ann's past abuse was touched on in relation to the couple's
current sexual problems. The couple was assigned some tasks to do
at home, including non-sex touch exercises, pleasure teaching
session, and trying the coital alignment technique. The
therapists felt that this session was a particularly important one
because the couple began working on a problem that was causing
them much distress in their marriage.
The past abuse in Ann's life was discussed, specifically its impact
on your current sexual issues. She was reassured you that sex
problems are common and that there are many different techniques
they both can try to help improve their sex life. Much progress has
been made and will continue to be made. They both are on the road
to a happier marriage and greater sexual satisfaction.
 References:
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• Weiss. R.L., Hope, H., & Patterson. G.R.A framework for conceptualizing marital conflict.
A technology for altering it. Some data for evaluating it some daya for evaluating it. In
L.A. Hamerlynck. L..Handy, & E.J. Mash. Behaviour change: methodology, concept and
practice champaign, research 1973.
• Stuart, R.B. Behavioral remedies for marital ills: A guide to the use of operant-
interpersonal techniques. In A.S. gurman & D.G. Rice. Couples in conflict: New directions
in marital therapy. New York : Aronson,1975.
• Gotman, J.Markman, H.,Notairus, C.,and Gonso, J.(1976). A couple’s guide to
communication. Research Press, Champaign, Illinois.
• Guerney, B.(1977). Relationship enhancement. Jossey-Bass, San Francisco.
• Jacobson, N. S. and Gurman, A.S. (ed.) (1996). Clinical handbook of marital therapy.
Guildord Press, New York.
• Jacobson, N.S. and Margolin, G.(1979). Marital therapy: strategies based on social
learning and behaviour exchange principles. Burnner/Mazel, New York.
• Stuart, R.B. (1980). Helping couples change: A social learning approach to marital therapy.
Guildford Press, New York.
• Gottman, J The Marriage Clinic: A Scientifically Based Marital Therapy (Norton, 1999).