I believe it was John Gottman who has said that couples therapy is the most difficult type of therapy for therapists to do and the least successful in terms of percentage of positive outcomes. Part of the reason for this, I think, is that the therapist has the difficult task of needing to understand and be empathic to each partner’s individual issues, while at the same time, understanding and addressing, dispassionately, the dynamics of the relationship. It is therefore very important that the therapist understand his or her own personal feelings toward each person and therapist possible blind spots that prevent effective interventions. To put the issue in psychodynamic terms, this means understanding his or her counterrtransrerence reactions Without that self-knowledge, the chance for a successful outcome of couples therapy is very limited.
The importance of this was born out in the past when I was referred people for individual therapy by the therapists with whom they were in couples treatment. When I get this kind of referral, I usually get a release from the new client to speak to the couples therapist. (Of course in order for the therapist to give me his or her impressions of the couple, he or she needs also to get a release from the other partner.)
In talking to the couples therapists, it became very clear that they had negative reactions to one of the partners, usually the one referred to me; and a positive view of the other partner. Terms like “narcissistic,” “borderline,” “passive-aggressive” were used. In one instance, it was clear that the person referred to me sensed the couple therapist’s negative reactions, which mirrored the spouse’s view of her. I didn’t base my supposition only on what that client told me, but also in my phone conversation with the therapist. It was clear that this therapist was emotionally biased against my client, who had severe shame issues and, while deeply resenting the spouse’s negative judgments and domineering attitude, partially accepted them as true of her and justified. This was because of her low self-esteem. In her work with me, she began to develop better self-esteem, to become clearer about her feelings toward her husband, and to begin to assert herself with him. But it became apparent he couldn’t tolerate her assertiveness and decided to stop the couples treatment and separate from her. She could no longer afford her individual treatment and moved back home where the rest of her family lived.
Note that I am not excusing myself from the category of a therapist inadvertently taking sides against one of the spouses. I have been guilty in the past of allowing my own unacknowledged prejudices to get in the way of helping couples resolve their issues. For example, years ago I worked with a couple where the husband was passive, obsessive, almost completely out of touch with his emotions, and fearful of his wife. She was aggressive, judgmental and occasionally explosively hostile towards him. One of the issues that incensed her was that he was in a profession in which most of the practitioners make very good money, but he was relatively unsuccessful because of his passivity, which made it difficult for him to market himself. It seemed that he was expert in his field and did good work but was unrecognized by potential referral sources. His wife was having to work into her late 50’s and resented not being able to sustain a lifestyle that she saw friends living and that she felt she was entitled to.
I saw that her anger toward him contributed to his difficulties in being assertive and actually worked against her fervent wish that he be bolder in his dealings with others and more spontaneously loving toward her. I said sarcastically to myself, “Sure, she wants him to be assertive with anyone but her.” I thought that, if she were less hostile towards him, he would begin to be more assertive and caring. I told her that her attacking behavior scared him–which he agreed to- and resulted in him either withdrawing into stubborn resistance or inauthentic attempts to mollify her. When I thought about this couple years later, I realized that probably underneath her continual blaming of him, was almost certainly hurt, a lack of feeling safe with him, and a sense of abandonment and loneliness. Even though she had had individual therapy, in talking to her individual therapist it was clear that she hadn’t been helped to become aware of these more vulnerable and more basic affect states. She accused me of siding with her husband and, after some months of treatment, decided that they weren’t getting anywhere and they discontinued.
In retrospect, I see that she was correct in her negative assessment of the therapy. I also realized that my framing of the difficulties in the relationship and my negative reactions to her had a lot to do with my own history with a very angry, blaming mother and a rather passive, placating father. It would, of course, have taken quite a bit of time and her feeling safe with me for her to begin to admit to the more vulnerable feelings behind her anger towards her husband. But, if I had been able to help her feel safe, and she had begun to express these feelings, her husband might have been better able to be empathic towards her. Positive interactions might even have helped him develop better self esteem and perhaps a more assertive attitude in his profession.
It can be very difficult for a therapist even to recognize his or her countertransference reactions in couples therapy. I was certainly unaware of my reactions at the time. But in order to be effective with a wide variety of couples, it is necessary to become aware of these countertransference reactions and to work through them. Here are some methods I now attempt to use in my work with couples that help me with my own, inevitable countertransference reactions.
1. I try to be very curious about each person and to know something about the families they grew up in. In the first session, I get some past history, particularly what the person’s childhood was like. This involves exploring their relationship with each parent and any siblings they grew up with; and the relationship between the parents. I find that when I know something about the beliefs, organizing principles and attachment styles they developed during their formative years, I have more awareness about the underlying reasons for the couple difficulties. Knowing what they’ve been through also helps me to be more empathic and to ameliorate any negative feelings I might have towards them.
2. A very common pattern I see in couples is that one person is seemingly logical, reasonable and more mature; the other immature, narcissistic and volatile. At one point in my career I tended to feel frustrated with the “immature” partner and silently used terms like “borderline,” “narcissistic,” or “hysteroid” to characterize him or her. I have since learned that, often without being aware of it, it’s the very lack of emotion in the seemingly more mature partner that is so upsetting to the more emotional one. I now point to the defensive nature of the “rational” one, help him or her to become more aware of and more expressive of emotion. This often helps the other party to feel a great sense of relief and better understood.
3.. I regard as a danger signal any negative reactions I am having toward one person and sympathy toward the other, and try to explore the reason for my countransference reactions. If I can’t figure it out, then I get some consultation from another therapist whom I trust.
4.. I notice and comment, at the appropriate time, on the power dynamics between the couple. This can take many forms: if one spouse, usually the husband, is earning most or all of the family money, the other spouse can feel weaker, less entitled and inferior. Of course, it is often the case that the one who earns more money sees himself or herself as more powerful and more entitled to dominate the spouse. If so, tI need to help that spouse articulate this attitude and to help the other person realize what this does to him or her and how it’s ultimately destructive to the relationship. Another common power dynamic is when one person is more verbal, more articulate, and has a larger emotional vocabulary and better able to argue his or her case. The result is that the other can feel a lot weaker and vulnerable and makes himself or herself safe by withdrawing. This of course is very frustrating to the more verbally powerful person and was the case with the couple I discussed earlier.
5.. In accord with #4 above, I focus a great deal on safety issues. When one person is articulate and assertive, and the other is quiet and withdrawn, it is practically always the case that the latter person is scared, feels inferior and ashamed, and withdraws because that makes him or her feel safer. If the therapist becomes frustrated with the silent, withdrawn partner, that only increases the need to withdraw and the therapy itself becomes unsafe. Out of a sense of shame or even unawareness, that person may continue the treatment, but with little progress.
6. I make certain that each party is heard. If one person is more articulate about his or her pain, it can be easy for the therapist to neglect the other party. If the other has the view of being the healthier one, not needing as much attention, he or she can end up not getting what he or she needs from the therapy. It can in itself be an indication of a dysfunctional dynamic in the relationship. So the therapist needs to be certain that each person be given approximately equal time, even if one person doesn’t feel the need for it. It doesn’t have to be done in each session, but over time each party needs to speak his or her mind.
7. Finally, I have to guard against the intention of keeping the couple together when one person decides to end the relationship. I made the mistake in the past that, when one person made that decision but wanted to continue the therapy in order to make the ending as painless as possible, of expressing my sadness about this outcome. In two cases the person who decided to part but decided not to continue treatment with me, felt that I was prejudiced against them. I really wasn’t, but realized later on that they probably felt guilty about ending the relationship because the other person was very hurt, and needed me to help them express their guilt and recognize their courage in still going ahead with the divorce.