When prior couples therapy failed and I am the next therapist, it is a different situation than when someone comes to me for individual therapy after prior individual therapy failed. While many therapists helping individuals have a specific therapeutic orientation (e.g., CBT or psychodynamic), there are few couples therapists who work exclusively in one model. So while I am familiar with the Gottman Method, Emotionally Focused Couples Therapy (EFCT), the Developmental Model of the Couples Institute, Family Systems Therapy, and Imago Therapy (to name just a few) it is rare for me to know which of those therapeutic methods the prior therapist was using. Most often, the therapist wasn’t using one model, but a personalized integration of several. That is normal because couples therapy is more complex and dynamic than individual therapy and most therapists find that one treatment method won’t fit every couple or even every presenting situation with the same couple. For that reason, I utilize 3 techniques to make couples therapy with me be more effective than the last therapy: information gathering about the past treatment, discernment about motivation to change, and treatment planning.
Information Gathering About Past Treatment
When I am gathering information about the prior couples therapy I start by asking the couple a series of questions that might look like this:
- General questions either member of the couple may answer:
- When was previous couples therapy?
- How long was the treatment?
- How regularly did you attend treatment?
- Questions I want both members of the couple to answer:
- What did the therapist do that helped? What did the therapist do that you didn’t like?
- What did you learn, if anything, about your role in the problems in the relationship?
- If any technique or habit did help to improve your relationship during prior treatment are you still doing that?
- Why did the treatment end?
- What are you hoping will be different in treatment with me to make it more effective for you?
These questions are designed to draw out important information including the role of treatment participation, motivation, client willingness to change, treatment method(s) used, and effectiveness of past treatment. The questions are also designed to discern what my challenges might be in helping the couple and whether those are the same or different from the challenges the prior therapist faced in helping them. It wouldn’t be uncommon for circumstances to have changed enough that the prior barriers to effective treatment are now gone or for new ones to be present.
The most common reason clients give for a lack of treatment progress in prior couples therapy is that the therapist “just listened”. The couples that I see often complain that the prior therapist didn’t offer suggestions, didn’t help them regulate the emotional expression in the room, and/or didn’t give the couple tools to help them make changes outside of sessions. When I hear this complaint, I try to reassure couples that, very simply, that isn’t my style. I take an engaged and active approach by identifying the goals, stopping unproductive conversations in session, and by building tools and strategies to help the couple bridge the communication divide. If we can stop negative patterns in session, the couple can learn to stop them outside of session.
The final thing that I do to gather information is to request to speak with the prior therapist. This allows me to double-check my emerging clinical impressions with a colleague, to corroborate the couple’s description of the course of therapy, and to find out more clinical detail about the interventions that have been tried and how effective they were.
Discernment About Motivation to Change
From the questions listed above, the picture sometimes emerges that it isn’t the therapy that needs to change, but the client’s willingness to utilize it and make changes. Examples of this include when I hear that in prior therapy the clients received exercises and homework but didn’t try them between sessions, or when I hear that changes could take place during the therapy hour but nothing changed at home. For this reason, a part of my consent form indicates that for therapy to work, the client must be willing to do something different. When meeting with couples for the first time I specifically review this clause to share with them that if they want something to change in the relationship, they need to identify what they are each willing to do differently.
When I share this part of my consent form with new clients most nod and say that this sounds just fine, but on a fairly regular basis once the therapy begins we have to review it again. We can imagine a fairly simple illustrative situation where Stefan wants Janine to stop staying at work so late because it means they have dinner late. When Stefan brings this up with Janine in session, I will ask him what changes he is willing to make in order to help him get his needs met. He might then respond by saying that he can’t change it on his own, she has to change. I will gently point out to Stefan that he might need to have dinner earlier and alone if he wants it earlier, or be willing to have a good argument about it if Janine continues to not come home at the designated dinner time, maybe he could go to her office to bring dinner to her and eat it there together, or maybe he could decide that this isn’t that important of an issue after all. Stefan’s response might be that he doesn’t want to eat early and alone, doesn’t want to have an argument, and would find it inconvenient or unpleasant to bring dinner to Janine and eat it with her at her work. In situations like this I would find it very normal for Stefan to tell me why it would be more reasonable for Janine to change, or even more honestly that he thinks she should change. But if this is really important to him, Stefan only has control over himself. He may not want to change himself in order to get his need met, but it is the only change that he can choose.
Some couples would call this a communication problem between the members of the couple. Yet, I would guess that Janine knows that Stefan wants her home on time because they have talked about it before. It just isn’t as important to her and she behaves in a way that reveals that. So, I could teach Stefan to ask Janine using Nonviolent Communication (one of my common therapy interventions) but I am going to guess she already knows what he wants and how he feels. Therefore, I will guess that using a communication tool won’t solve the problem. So, the therapeutic conversation will come back to what changes Stefan is willing to make.
Prior couples’ therapy often failed because the choice to change or not to was not clarified for the clients. The therapist will give tools and methods for change but forget to inquire deeply about the motivation to change. When I work with couples who have been in prior therapy that was unsuccessful, we often have a conversation about motivation to change early in the process.
Concrete Treatment Planning
Typically, in the fourth session of couples’ therapy I will bring in a copy of a draft treatment plan. That treatment plan will include one or two goals that are both specific and generalizable. A sample goal would be, “The couple will reduce the frequency and intensity of arguments. Baseline: 1x/week, Intensity averages 7/10”. Then I identify what I’m going to do to help the couple achieve that goal, how we will know if the therapy is improving the situation, and how we will know that the goal is complete.
These goals often help to hold the focus in the therapy. From one week to the next the presenting content might focus more on an in-law, or a current financial issue, but the goals, because I write them in a generalized way, are usually still applicable. They help me hold the process oriented thread of the conversation from one session to the next.
I regularly hear from couples that I am the only therapist they have worked with who reviewed the treatment plan with them and held the thread of the conversation from week to week. I really believe that a concrete treatment plan helps us be clear about the work that we are doing and it also gives me a little leverage. For example, if a client’s motivation to change flags during treatment, I can pull out the treatment plan and ask what isn’t working. Is it that I’m not doing what they agreed for me to do in the therapy? Is it that the goal is no longer important? Is that the client doubts that this specific intervention will help? When I have a treatment plan agreement with the clients, it helps us hold each other accountable to beneficial change in the therapeutic work.
I hope that this post makes it clear how I help couples when prior marriage therapy or couples counseling didn’t accomplish all the goals they hoped it would. I have enjoyed helping couples who have experienced a lack of progress in that past and found the 3 step approach outlined above helps guide the therapy with me to a more effective conclusion than they may have experienced before. I can’t help every couple, but having an idea about how to approach challenging cases can really make a big difference.