Couples Therapy isn’t for the faint of heart
People resist couples therapy for many reasons. The very nature of a romantic relationship conjures images and ideals that are in stark contrast to a those commonly associated with the scientifically trained clinician. You may ask yourself, “How can these practical, even mechanically sounding tools and techniques improve my capacity for love? And I’m supposed to share intimate details of my relationship with this clinically-minded stranger?” Some of our earliest memories of romantic relationships likely reflect those all too ideal versions only found in Disney movies or television series with a target audience consisting mainly of young teens. The plots found in these productions did not tend to feature characters faced with financial stressors, nighttime feedings, or waning sexual desire; these modern realities may be demanding something we weren’t expecting.
Couples Therapy on Television
Many contemporary television shows have begun to pull back the curtain on substantive relationship issues, but they are most often infused with profuse humor, in order to satisfy and not spoil the viewer’s palate. Who among us wants to embrace the reality that even the most well intentioned loving mature adults may not be well equipped to protect or maintain this fundamental relationship rooted in love? And even if we accept that we need help, who or what does help look like? Media’s representations of therapy and even couples therapy often involve non-directive therapists who respond to pleas for help and understanding by dodging the question, via redirection.
Client: “Doctor what does it all mean and/or what should I do?”
Therapist: “What do you think it means or what do you think you should do?”
The last thing many of us are looking for when confused and frustrated is for the person whom we are paying for help to turn our question back on us.
How many times have you seen a television therapist respond to a client’s question in that way? Of course there can be wisdom in promoting independence and confidence in a client’s decision-making, by allowing him or her to draw conclusions, take action, and experience the consequences. At the same time, effective therapy is often going to provide concrete strategies for a client to implement, and specific tools to help make the decisions in the first place, e.g., learning to reduce anxiety about the decision making process and outcome, tolerating the inherent uncertainty in all choices, and efficiently weighing the pros/cons of different strategies.
One of the most entertaining depictions of a couple failing to receive the help they need in couples therapy takes place in the movie, The Ref (1994). Dr. Wong (played by BD Wong) is a wonderful caricature of a couples therapist.
Dr. Wong illustrates how poor clinical judgment can make even useful strategies a catalyst for frustration and hostility in a couples therapy session. It is ironic that this couple enters therapy for emotional soothing and practical help, and leaves more distant and distressed. Fortunately this is a movie and the exaggerations are humorous. Unfortunately, many couples have experienced or expect to experience couples therapy at best as something ineffective, and at worst something that might make things worse. Here is an excerpt of dialogue from a couples session from the film. Lloyd is played by Kevin Spacey and his wife, Caroline, is played by Judy Davis.
Marriage Counselor: This next exercise will help you with listening. One of you will speak, while the other just……listens.
Wife: Me. I had this crazy dream.
Lloyd: Do we have to do dreams?
Caroline: I was at this fancy restaurant having lunch… and the waiter brought me my entree. It was a salad. It was Lloyd’s head on a plate of spinach…with his penis sticking out of his ear. And I said, ‘I didn’t order this.” And the waiter said, “You must try it. It’s a delicacy. But don’t eat the penis, it’s just garnish.” Marriage Counselor: Mmm. Lloyd, what do you think about the dream? Lloyd: I think she should stop telling it at dinner parties to all our friends. I mean, dreams should be private, don’t you think?
Marriage Counselor: I’m not here to judge or to take sides. I will say communication is healthy.
Lloyd: Healthy? Telling people she dreams of me being castrated “Florentined” is healthy?
Marriage Counselor: Are there any sexual problems in the marriage? Caroline: Well…the truth is, um, we haven’t had sex in quite awhile. [Clears Throat] And before that, it wasn’t all that, um… Oh, what’s the word? Noteworthy.
Marriage Counselor: Mm-hmm.
Caroline: By our twelfth anniversary, we’d gotten into a pretty stale routine, couple of kisses, a couple of nipple twists. It would be over in the time it takes to make cappuccino. I know because I timed it once. I mean, it’s no wonder I had an affair.
Lloyd: How could you tell him all that so casually, like you were asking him for a glass of water?
Caroline: Actually, may I have a glass of water?
Lloyd: Why don’t you have oral sex too, and I’ll go wait in the car?
Marriage Counselor: Lloyd, how do you feel about Caroline’s affair? Caroline: He just wants me to wear a red “A” on my chest and sleep in the basement.
Lloyd: Is that so unreasonable?
Caroline: Everything’s either black or white with him. You know, he doesn’t… he doesn’t see where he’s responsible. And I mean, it just didn’t mean anything to me. It shouldn’t even be counted as an affair. [Sighs]
Lloyd: I think we need a ruling on this.
The husband makes a final (sarcastic) request for the therapist to actively say or do something tangible. We are left with the clear picture that marriage counseling would never resolve the issues in this relationship. The couple apparently has repeatedly presented the therapist with examples of missteps, passive-aggressive (or outright aggressive) acts in their relationship, while his neutrality and seemingly non-directive approach have left them more frustrated, isolated, and dissatisfied. In fact, what we the audience come to believe, is that they really need a referee, not a couples therapist. And in this portrayal, the unlikely, but eventually effective candidate is a hot-tempered, straight shooting, burglar played by Dennis Leary- the ref. So, does the scientific evidence support what we see of couples therapy on television and in the movies? Does couples therapy ever work? Do marriage counselors really improve relationships by remaining impartial, not explaining what things may mean, and refraining from recommending what to do?
Does Couples Therapy Work?
Deciding to see a couples therapist can be a big decision. It takes significant time, money, and often times emotional resources. In addition, it often requires one partner to cajole or convince the other to enlist, which at a minimum can strain the relationship temporarily. Is it worth it?
For decades, couples therapy has been the subject of rigorous studies, which include randomized controlled trials (RCTs). In these studies, couples are randomly assigned to different arms of the experiment. They may receive one type of couples therapy or another, or even be assigned to a wait-list control, where they wait to receive treatment later. In the meantime, wait-list control couples provide data for what couples likely experience without treatment.
First, the evidence indicates that a large percentage of couples significantly improve in couples therapy. In many of these studies, improvement was shown to be both statistically significant and clinically significant. Statistically significant means that we can be reasonably confident that the improvement found was due to the treatment and not chance, i.e., the couples assigned to the therapy group just happened to improve. Statistical significance means we can be highly confident our results would be the same if we conducted the experiment again on a similar group of couples, and randomly assigned half of them to couples therapy and the other half to a wait-list group.
Statistical significance is important. We certainly want to make sure that differences aren’t just due to the chance that particular groups of couples were assigned to one group or another. But for someone considering couples therapy, there is another crucial question: “How big is that improvement and what would it look like in my life?” A statistical difference could indicate for example that differences at the end of the study in therapy group couples, compared to those wait-listed, were the result of the treatment and not just chance. But just because there is a difference between the groups does not mean the difference is big or meaningful. We could be sure for instance that taking a fever reducing pill is the cause for the difference in body temperature between a treatment group and wait-list control, but if the difference was 1/10th of a degree, then we may see little value in taking the pill.
Clinically significant change indicates that the amount of improvement is sizable and would have a real world impact. So when making practical recommendations based on RCTs, it is important for these treatment studies to include clinical significance, as well as statistically significant findings. Although costs/side effects for psychotherapy are not typically on the scale of those for medications, e.g., diarrhea, palpitations, and occasionally death, they do exist, as is the case with almost any treatment. If there are children, childcare may have to be arranged, out-of-pocket expenses may not be reimbursed, and many distressed couples struggle with finding time in their schedules. There is also often effort and time required to do work between sessions, so for couples therapy to be worth it, we want to know that the improvements are clinically significant.
One study indicates that 70% of couples receiving a specific therapy show clinically significant improvement. Another indicates that on average 80% of those in couples therapy are better off at the end of treatment than those not receiving couples therapy. This raises another important question: “If couples are doing better at the end of treatment, do their improvements remain, decrease, or even increase over time?” This question is addressed with readministering measures at a follow-up time period. There is good news for couples therapy on that front as well.
Approximately 50% of couples have been shown to maintain the improvements five years after treatment. These are some of the numbers that can help when making a decision about couples therapy. While the presentation of these data here was framed somewhat positively, it is clear that many couples won’t improve by the end of treatment, and about half of those who improved by the end of treatment may sink back into old patterns within five years. Therefore, psychologists have more work to do in the improvement of existing treatments or the development of new ones, and the aforementioned costs have to be weighed against realistic expectations for improvement.
Some Couples May Beat Odds in Therapy
In addition, couples that are motivated and are consistently practicing the skills acquired in couples therapy are far more likely to improve and maintain those gains over the years. The studies cited typically include a fixed number of sessions, and it is possible that a larger dose of sessions, occasional booster sessions, or if desired, ongoing couples therapy may result in maintaining the improvements or even increase the magnitude of those improvements.
There is ample evidence that many couples can benefit from meeting with a skilled couples therapist. At the same time, there are many who may not. It is important to realistically weigh the costs and benefits of both couples therapy and the consequences of the status quo. There are considerable costs on either side. It is also important to recognize that some clinicians may be a better fit and therefore be more effective for a particular couple. Therefore, advocating for yourself, when selecting a clinician and during sessions is crucial. Asking the therapist what theory and techniques they apply in couples therapy, and how much training they have received in that area are examples of appropriate questions that can help filter clinicians with whom you are unlikely to be compatible. Many clinicians explain that they have an eclectic therapy approach. I strongly recommend that if a clinician indicates he/she is eclectic, i.e., uses many techniques that clients ask him/her to explain one theory and set of techniques that he/she intends to implement in working with you. A confident clinician will be happy to spend a couple of minutes providing an overview of the model and skills that clients would use in couples therapy. Receiving clear answers to these kinds of questions often increases a couples comfort and confidence with the therapist and the model of psychotherapy. That comfort and confidence in both the couples therapist and model of psychotherapy often translate into increased client motivation, a stronger therapeutic bond with the therapist, and better outcomes for the couple. So if you decide the pros outweigh the cons for seeing a couples therapist, do not to be faint of heart across the board- be bold and ask questions of the therapist, your partner, and yourself-experiment with the tools and new skills you learn with your partner in session and at home… chances are it will be worth it. If you need couples therapy from a cognitive behavioral therapist, you can schedule sessions of couples therapy at New York Behavioral Health.