Who Benefits from Couples Therapy?
I see two kinds of relationships in couples therapy. Many come in because of dissatisfaction. But a second group are very healthy, but are hoping to enhance existing strengths or work on a few minor issues to have an incredible relationship.
Couples in New York City face the same issues as those living elsewhere. With that said, the pace and demands of NYC often seem to exacerbate some relationship issues. The number of people in Manhattan add stress, temptation for infidelity, and challenge some to realize the one they are with is right, regardless of endless other possibilities. Here are some common issues and problems I see in couples therapy:
- Angry and resentful partner
- Depressed partner
- Anxious partner
- Constant arguments and fighting
- Low sex or no sex
- Waning chemistry
- Loss of trust
- Poor communication
- Emotionally cold or disconnected partner
- Inability to commit
- Constant blame
- Inability to forgive
- Discrepancies in values, interests, and lifestyles
NYC Couples Therapy
NYC Couples don’t have time for couples counseling. New Yorkers are pressed to be productive every minute. Competitive careers, commutes, demanding exercise regiments, children, social scenes– there is no rest for the weary, much less time for marriage counseling.
Who has time to work on a relationship?
Many New York couples have come to my office, not because they have spare time, but because they’re scared if they don’t, their misery will get worse, their relationship will end, or they’ll end up staying in a very unhappy relationship for too long, or be stuck indefinitely.
My Approach to Couples Therapy
I immediately assess the strengths and weaknesses of the relationship, identify the current problems, historical patterns, and set goals for therapy. Then together, we begin the work of understanding the reason the problems exist, learn the skills necessary to solve these problems. The work is very collaborative. And I am very active in session by:
- Presenting models to illustrate how couples problems develop
- Providing concrete tools for couples to use outside of session
- Conducting exercises and using techniques in session to improve:
- emotion regulation skills
- problem solving
The couple will certainly be the ones practicing and doing the work, but I am active at providing structure and guidance, as well as validation and help each partner understand each other when necessary.
How much does couples therapy cost in NYC?
New York is by every account an expensive city. Couples therapy can cost anywhere from $125 to $400 in NYC. Some insurance plans will reimburse couples for a portion of that or you may even be able to find a couples therapist who takes your in-network insurance. One advantage to the kind of couples therapy we offer is that our goal is to provide clients with skills as quickly as possible. So while more sessions could be helpful, our goal is to be as effective as possible, as quickly as possible. The last thing I want is for clients to become more stressed because of they are spending more money or time than they have.
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.
Is this the Best Relationship I can have?
It is clear that some therapies have the potential to help the majority of couples improve. This is good news, but there may be even more pressing questions for husbands, wives, boyfriends, and girlfriends, i.e., is what I’m experiencing in my relationship normal? Is how I’m being treated typical? Do I deserve more, do healthier relationships really exist, or do they all descend into what I’m experiencing? Maybe this is as good as it gets. When is the time for change (either improving this relationship by each partner learning new behaviors or improving life by leaving the partner), and when is the time for accepting what I have?
Regardless of your creed, hopefully the serenity prayer’s request to know the difference between the things we can change and those that require acceptance is wisdom we would all like to acquire. Both change and acceptance can be difficult and applying them to the wrong things is certainly a waste of resources. So how do we know if the relationship could use some work in terms of change or acceptance? First let’s touch on a few things that a healthy relationship may possess and then we can look at a few questions in different areas that are similar to what you might hear from a couples therapist if you begin marital counseling or couples therapy.
Here are some of the hallmarks of a healthy relationship according to some couples theorists (Jourard & Landsman, 1980):
1. Good communication
2. Realistic expectations in the relationship and reasonable demands on your partner
3. Genuine concern for the well being of your partner
4. Freedom to be oneself
While some of us may take these four components to be common assumptions, others may struggle with a few of them. At a minimum, even with both partners endorsing the component, partners may disagree about the meaning, or have difficulty successfully executing.
Few clients I have seen in couples therapy have ever said they believe good communication is a bad idea. But the vast majority of couples have at least one partner who believes their partner does not communicate enough, communicates too much, or communicates incorrectly, and often both partners take one of these views. The stereotype that men do not communicate as much about their feelings is something supported by research, and is something I have seen from men in heterosexual and homosexual relationships. With that said, I prefer not to operate with that assumption, as I have seen enough exceptions in couples therapy, in terms of women who do not share and express certain if not all emotions, and some men who are very emotionally expressive. It becomes very obvious in early sessions how comfortable and how able each individual is at identifying their emotions, wishes, desires, frustrations, etc. and how willing and able he/she is to express them to the partner.
One fundamental skill that can be taught as a communication skill in couples therapy is assertiveness. Simply put, assertiveness is comprised of both communicating feelings, thoughts, wishes, wants, desires, and requests in an effective way and accepting the response or lack of response from one’s partner. The second part is often something that is not emphasized enough. But it is critical that each of us learn to accept (that does not mean agree or endorse), i.e., acknowledge whether our request was granted or not, and effectively respond. Specific statements can be learned and certain provocative styles are to be avoided when assertively communicating. But even once these skills are learned, it takes lots of practice to reliably use them. For most of us making requests of others or making ourselves vulnerable by sharing our intimate wishes is an extremely charged experience, and so it takes doing it again and again, even while having emotions to make it a dominant way of communicating.
Expectations and Demands
These are components of a relationship that are highly variable both in partners in a particular couple, and between couples. While each partner doesn’t have to share the same expectations and demands for the other, agreement about what each expects is necessary to make the partnership satisfactory.
Fairness is a theme that comes up a lot in couples therapy, and it often elicits feelings of anger, resentment, and at times guilt. It is rare that two people will have the same strengths, weaknesses, or tendencies. So the division of labor may differ, their capacity to be emotionally intelligent may vary, and one may be more equipped to financially support them both. Fairness then is unlikely to mean each does the same thing for each other, but rather that it is clear and acceptable what each expects and demands from him or herself and the partner.
I have seen many couples where deep resentment exists as a result of an admittedly slight difference in the workload between them. Likewise I have seen perfect harmony achieved when one partner is clearly burdened with the majority of responsibilities in the relationship. What is critical is that each is transparent about what is expected and required and that there is open communication about this, which can include appreciation.
Welfare of others
In couples therapy work, you do find times when the resentment has been growing for so long, or a recent transgression has elicited so much anger that concern may not be something that is readily exhibited. But even in the latter case, when a sincere conversation explores the topic, there is often concern for the general well being of the other (although not always). What I see more often in couples therapy, is a partner who says, “He clearly isn’t concerned about my feelings or well being, or he wouldn’t treat me like this.” This requires both individuals to do some work. And this is not always easy to hear, especially for the person who believes he/she isn’t being cared for. Without question, the couples therapy has to address the behavior that is or isn’t occurring that leads one partner to believe the other doesn’t care. The other piece though, may include both partners as they uncover what attributions are being made about that behavior. For example, one partner may state, “He doesn’t care about me because I tell him how stressed I am about making my work deadlines in order to get my next promotion, yet he is constantly guilt tripping me to leave the office. If he cared about me, he would support me right now, instead he says the very things he knows hurt me.” In a case like this, uncovering what each believes the other’s reasons are for the behavior, i.e., calling her to come home and staying late away from home to complete work, is going to be critical for them to achieve understanding and change the emotional and behavioral pattern in which they have become stuck.
Free to be me
Some of us may find this component to be one that shouldn’t be included in what makes a couple healthy. Isn’t being in a relationship about merging? Shedding our individuality in search of a more meaningful union? In fact, I have treated many couples where one complains that the partner’s very desire to “be him/herself,” is the problem. There is a fine line to walk when it comes to understanding what this freedom constitutes. No matter how open a couple is, clearly some expectations of each partner change when couplehood is undertaken. But what that looks like varies greatly. Does that mean every guys’ night is eclipsed by a date night, or girls’ weekends can never happen because weekends are for family time? Those are questions very much in need of discussion and often times, negotiation.
I have seen people in couples therapy where the presenting problem centers on this issue. One partner doesn’t believe the other has changed enough, or matured enough. “He will never grow up and put away his toys, it is like nothing has changed- there is no growth.” Meanwhile some partners give up activities or relationships that are central to who s/he believes s/he is. This can create resentment or depression- and some times both.
Healthy romantic relationships certainly take on an identity of their own, but it is critical for them to thrive that each partner also has an identify of his/her own, and has time and aspects of his/her life that are his/her own. It is easy to see how frequently there is interplay among the four components of a healthy relationship. To balance this component there needs to be clear communication and negotiation as well as explicit expectations, and an understanding of what it means for each partner to maintain certain aspects of his/her identity or to preserve certain activities or relationships. Depending on what the activities are or who the relationships are with, the decision to maintain these may be more or less acceptable to the partner. But before a lot of communication is required on this topic, self-inventories are a good idea. Each partner really needs to understand what these activities and relationships (e.g., time with friends, coworkers, family, etc.) mean to him or her and how dissatisfied s/he would be without or with less of each.
Once it is clear to each partner how much of a priority each of these are, communicating about what it means to the partner begins the dialogue. Again attributions are crucial to the negotiation process, as it is often what the partner believes it means that is more important than how many guys’ nights occur. Likewise, once it is clear why the freedom bothers the partner, there may be practical tradeoffs that can be made in order to satisfy both parties. Maybe two guys’ nights are acceptable, as long as that partner takes care of breakfast on the weekends.
Couples therapy is a process of identifying areas of dissatisfaction, understanding the function of each problematic behavior, and recognizing what strengths can be built upon, and what behaviors may be missing that can be added. With those targets in mind, it can be an exciting process. Of course, there are many apparent barriers that present themselves- but with careful self-inventories, an understanding of the meanings that are being made, and communication and negotiation many of these can be overcome, and some of those that can’t be, can be accepted, leading to greater personal and relationship satisfaction.