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archives of psychiatry and psychotherapy 2011 3 57 64 marital therapy couples therapy indications and contraindications magorzata wolska summary the author basing on literature and her own experiences in conducting ...

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                          Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64
                                                    Marital Therapy/Couples Therapy: Indications and 
                                                    Contraindications
                                                    Małgorzata Wolska
                                                    Summary
                                                    The author, basing on literature and her own experiences in conducting marital/couples, presents the in-
                                                    dications and contraindications for this form of therapy for both recipients of the therapy and therapists. 
                                                    Insufficient motivation to change relationships and behaviours, the threat of divorce, violence, deep emo-
                                                    tional and/or psychological disturbances in one or both spouses, the engagement of one of the partners 
                                                    in a relationship outside of marriage are some of the contraindications to therapy, as referred to in the ar-
                                                    ticle. What is being elaborated on are also correct approach and characteristics of marital therapist as 
                                                    well as contraindications to conduct this form of therapy. The author proposes a scheme of work with mar-
                                                    riage/couple in crisis: preliminary consultations as the basis for the therapeutic contract or relegating part-
                                                    ners to other specialists.
                                                    marital /couples therapy / indications to the therapy
                          INTRODUCTORy REMARKS                                                      the relationship on one hand, and on the oth-
                             Working with married couples/pairs in a se-                            er they tend to shift the blame for the crisis on 
                          vere crisis, which threatens the stability of their                       the partner and at the same time expect that the 
                          relationship, is a big challenge for therapists pri-                      therapist will help them by taking the role of an 
                          marily for the reason that arguing partners, both                         ally, solicitor, advocate or judge. To unravel the 
                          at the same time experiencing a sense of injustice                        complex marriage games and to reach sources of 
                          and grief, give the impression that they are not                          conflict between partners is a burdensome task 
                          interested in undertaking any kind of interven-                           for the therapist, requiring sustained attention, 
                          tion that could elicit actions bringing them relief                       concentration, keeping watch over the neutrali-
                          and improving relations. A woman and a man                                ty and making sure not to follow the therapeutic 
                          experiencing a crisis in their relationship fear                          work in his/her own convictions regarding the 
                          abandonment and undertake many desperate                                  role of women and men in a relationship.
                          and unsuccessful attempts to save and improve                                Psychologists involved in marital/couples 
                                                                                                    therapy probably would feel inclined to agree 
                          Małgorzata Wolska: Jagiellonian University, Medical College, Depart-      with the fact that this is one of the most diffi-
                          ment of Child and Adolescent Psychiatry, 21a Kopernika Str., Kraków,      cult forms of therapy mainly because the risk of 
                          Poland. Correspondence address: Małgorzata Wolska, Jagiellonian           losing the distance and neutrality is higher than 
                          University, Medical College, Department of Child and Adolescent Psy-      in other therapeutic situations and the counter-
                          chiatry, 21a Kopernika Str., Kraków, Poland. 
                          E-mail:  malgo.wolska@gmail.com                                           transferential reaction on their behalf may ap-
                          The article is an extension of a paper delivered at the conference        pear. Frustrations caused by more often than 
                          Marital Therapy; Couples Therapy organised by the Family Therapy          not enormous difficulties in obtaining a positive 
                          Section of the Polish Psychiatric Association, held in Kraków on          change in the relationship of quarrelling part-
                          21–22 April 2007.                                                         ners induce the therapist to answer some fun-
                          This article has not been aided by any grant.                             damental questions:
                   58	                                          Małgorzata	Wolska
                   •		Was	the	proposed	treatment	not	too	fast	in	           what they also need is a therapy including the 
                      reference to the vague, uncertain or low mo-          realm of feelings? This therapy would be use-
                      tivation to maintain the relationship and sing        ful with abandoning the fight between a cou-
                      up for the therapy?                                   ple, regaining the confidence, allowing them-
                   •		Was	the	pace	of	change	proposed	by	the	ther-          selves to split piecefully and thus reaching the 
                      apist adjusted to the needs and capacities of         agreement on cases they are still forced to share. 
                      the spouses/partners?                                 However, such treatments are not always possi-
                   •		Was	the	therapist	not	too	passive	or	too	im-          ble in a situation of strong tension, fighting and 
                      posing?                                               blame-game, as demonstrated by the experience 
                   •		Did	not	the	therapist	take	too	much	responsi-         of therapists conducting family/marriage ther-
                      bility for the relationship between the two un-       apies mandated by court order [1]. Taking this 
                      dertaking therapy?                                    under consideration, marital/couples therapies 
                     Before proposing to marriage/couple an in-             are proposed only to pairs who declare their de-
                   volvement in the therapy, the therapist should           sire to maintain the relationship.
                   know what to propose, which means to know                  The main objectives of marital/couples thera-
                   the couples expectations, to determine the               py can be defined as:
                   strength of their relationship, the risk of collaps-     •		a	support	of	marriage/couple	in	identifying	
                   ing degree, the motivation to stay together and             sources of conflict;
                   motivation to engage in conducting of positive           •		a	help	to	each	partner	in	determining	their	
                   changes. He/she should meet the needs of each               own participation in the conflict;
                   partner, the possibility of their implementation         •		a	help	in	realisation	of	the	mutual	expecta-
                   as well as ability to fulfil expectations of a part-        tions;
                   ner. Precise determination of the therapy aim            •		a	help	in	defining	the	rules	of	functioning	of	a	
                   adjusted to the couple’s expectations, needs and            relationship, fulfilling roles, defining the lim-
                   emotional/intellectual capabilities of both part-           its of internal boundaries (individual) and ex-
                   ners are important factors for positive changes             ternal boundaries (separating the relationship 
                   in therapy. Extremely important is also the divi-           from the rest of the world);
                   sion of responsibilities: the therapist is respon-       •		an	improvement	in	mutual	verbal	communi-
                   sible for the conduct of therapy, the therapist to-         cation (to avoid further misunderstandings) 
                   gether with both partners share responsibility              and nonverbal communication (to make it 
                   for achieving goals, but the partners themselves            easier and more clearly to express feelings);
                   take responsibility for their relationship, that is,     •		an	assistance	in	constructive	conflict	resolu-
                   whether to continue it or to end.                           tion;
                                                                            •		a	help	in	deciding	whether	to	continue	the	re-
                   DEFINITION AND GOAlS OF MARITAl/COUPlES                     lationship or to part (note: the responsibili-
                   THERAPy                                                     ty for this decision lies exclusively within the 
                                                                               spouses/partners).
                     Generally speaking the marriage/couples ther-            Couples who seek therapy because of dif-
                   apy is a help for the partners remaining in a dif-       ficulties with mutual coexistence, more often 
                   ficult, conflicting and critical relation prevent-       not only expect to improve relations and re-ap-
                   ing from obtaining closer intimacy and greater           proximation but the confirmation that the fault 
                   satisfaction in being together. So, instead of pro-      lies with the other partner. Each partner is con-
                   posing a married couple in the middle of a di-           vinced that he did everything that was possible 
                   vorce a marriage therapy, the therapist should           for the relationship to be good, and now is try-
                   undertake a divorce mediation suggesting rath-           ing to shift responsibility for the problems on a 
                   er the new organisation of life than staying in a        spouse placing the therapist at his side in a posi-
                   realm of feelings. But here there emerges a ques-        tion of an ally in the fight with a husband/wife. 
                   tion: whether divorcing marriage which is still          Eric-Emmanuel Schmitt [2] in his Little Marital 
                   in the phase of combat (but which cannot yet             Crimes writes that a relationship is as home to 
                   be separated) only need divorce mediation or             which the keys are in the hands of people. The 
                                                                       Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64
                                       Marital Therapy / Couples Therapy: Indications and Contraindications                 59
                    therapist cannot assess or advise whether the re-      naires and surveys typically used at the stage of 
                    lationship should be continued or whether the          initial contact with the married couple by ther-
                    partners should part. He/she can only help the         apists working in the cognitive approach. Not 
                    spouses/partners to find the right ‘set of keys’ -     only each spouse completes the questionnaire 
                    if both are interested in finding them.                separately, but it is also followed by reviewing 
                                                                           the questionnaires by the therapist and conduct-
                    CONTRAINDICATIONS TO CONDUCT                           ing individual talks with both partners [7]. Un-
                    MARITAl/COUPlES THERAPy                                der such conditions, surely it is easier to reach 
                                                                           things that are, for various reasons, deeply hid-
                      There are several specific situations in which       den. But on the other hand, the question arises 
                    we cannot propose to take care of marriage/cou-        what to do if, for example, one of the spouses 
                    ples therapy even when we are convinced that           reveals that he/she has betrayed the partner at 
                    the partners are really into it. Therapists dealing    the same time asking the therapist to kept it as 
                    with problems of marriage/couple in crisis are in      a secret. Of course, the therapist cannot disclose 
                    agreement that the therapy cannot be offered in        without permission any contents of the conver-
                    following situations:                                  sation but it will certainly be difficult for him/
                                                                           her to lead further therapy (if at all possible) in 
                    •		physical	violence	between	partners;                 a situation of inability to appeal to the relevant 
                    •		mental	illness	or	addiction	problems	of	one	        facts known only to him/her, that also hinder the 
                      (or both) partners;                                  achievement of positive emotional closeness of 
                    •		staying	(of	one	or	both	partners)	in	other	re-      the couple.
                      lationships and lack of motivation to give up          To the above-mentioned absolute contraindi-
                      one of them;                                         cations for marital/couples therapy one may add 
                    •		undertaking	(by	one	or	both	partners)	the	de-       a condition found in the literature of the subject 
                      cision of a divorce (regardless of whether they      [5, 6] that if the disclosure of a deep, long-lasting 
                      reported it to the court or not) [3, 4, 5, 6].       psychological conflict with only one of the part-
                      If during the initial consultations the therapist    ners appears, the decision of continuation the 
                    succeeds in discovering and diagnosing any of          common therapy should not be taken. Instead, 
                    above-mentioned problems, he/she can offer one         the proposition of individual therapy should be 
                    or both of the partners turning to the right peo-      introduced. Crane [3] recommends not to offer 
                    ple/institutions (eg. psychiatrist, mediator, rehab    therapy or hinder it in a situation where partners 
                    counselling, crisis intervention centre, etc.) as a    want to talk about their individual problems, 
                    means of help in solving the problem. There are        rather than focus on their relationship. Howev-
                    however some situations where the person ap-           er, it seems that one or several joint session after 
                    plying for therapy for some reason do not tell         unveiling an individual problem, is reasonable 
                    the therapist about the most difficult problems,       and could be used to motivate people with un-
                    such as the wife may be afraid that if she reveals     resolved psychological conflict to take individ-
                    how her husband beats her, he will later on took       ual psychotherapy, while considering together 
                    revenge on her, or one of the partners does not        whether the other partner also needs counsel-
                    wish to disclose that he/she remains in union          ling and, if so, what kind.
                    with other person because of the fear of losing          Here again, the therapist should act carefully 
                    benefits, disintegration of the original relation-     and thoughtfully, so as to focusing on individual 
                    ship or accusations of contributing to the crisis.     issues do not served spouses/partners as a con-
                    Therapist undertaking the work with marriage/          tinuation of fight over who is to blame for the 
                    /couple in crisis should be alert and attentive,       current status quo of the crisis (a person with a 
                    but not suspicious, and pay attention to different     revealed mental disturbance is more likely to be 
                    types of behaviour and specific words that may         exposed to accusations of the ‘healthier’ partner, 
                    indicate the existence of a secret. What might be      but it can also happen that the above-mentioned 
                    helpful in the diagnosis of the problem (crisis)       partner would be accused that his/her behaviour 
                    and type of relationship is a variety of question-     caused the state of the first one).
                    Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64
                  60	                                         Małgorzata	Wolska
                    Freeman [5] believes that therapy should be             Freeman [5] is an advocate of short-term mar-
                  suspended or terminated in a situation where            ital therapy which combines the cognitive and 
                  after passing the initial phase (for example af-        behavioural techniques as well as marital thera-
                  ter the third session) it is at a standstill, mean-     py with crisis intervention. According to her as-
                  ing the partners continue to work on each other         sumptions, as an indication for treatment she ac-
                  destructively, when they show no motivation to          cepts the visible signs of crisis in both spouses 
                  change the relationship, when they are not able         or one of them. These signs of crisis are: a sense 
                  to open in front of the therapist or they are too       of hopelessness, inadequacy, increased level of 
                  preoccupied to listen to each other, and contin-        anxiety, frustration and inability to deal effec-
                  ue efforts to destroy each other.                       tively with the situation. Like other therapists, 
                                                                          she attaches a great importance to the motiva-
                                                                          tion of both spouses, which is assessed on the 
                  INDICATIONS FOR MARITAl/COUPlES THERAPy                 basis of completing tasks and undertaking var-
                                                                          ious actions designed to alleviate existing ten-
                    After this long list of objections and contrain-      sions.
                  dications to take up and lead marriage/couples            Crane [3] believes that the therapy is possible 
                  therapy, there arises inevitable question: when         in the following situations:
                  and to which couples this kind of therapy can be        •		when	both	partners	are	trying	to	improve	re-
                  offered? In the literature on marital therapy on           lations between them by mastering commu-
                  the first place on the list of indications, the mo-        nication and effective problem solving;
                  tivation of both partners is placed, so it is up to     •		when	partners	with	negative	experiences	of	
                  them to make efforts to achieve positive chang-            failed relationships of their parents or their 
                  es to their mutual relations [3, 5, 6, 7, 8, 9]. Ther-     own previous relationships want to prevent 
                  apists working with marriages in the behav-                problems or to solve those that already exist;
                  ioural approach examine partners’ motivation            •		when	partners,	fearing	the	disintegration	of	
                  to change their conduct by giving them tasks to            the relationship, want to prevent the accumu-
                  accomplish in the time between sessions. Com-              lation of difficulties and to rebuild the bond;
                  pletion of these ‘home assignments’ would indi-         •		when	partners	want	to	make	an	attempt	to	
                  cate a good motivation to improve mutual rela-             reach an agreement before taking a final de-
                  tions but, unfortunately, it happens sometimes             cision about the divorce or separation;
                  that some people perform tasks in order to dis-         •		when	partners	have	already	committed	part-
                  miss the allegations of their partner about the            ing but wish to avoid tension or to find a so-
                  lack of commitment or a negative attitude, or              lution to the problems existing in their rela-
                  to have an argument to continue fighting with              tionship;
                  him/her, which can be expressed, for example, in        •		when	partners	want	to	undertake	therapy	as	a	
                  this way: ‘You care for nothing! You are not in-           form of support with other problems solving, 
                  volved! It is I who does everything to solve our           for example marital therapy is to be a part of 
                  problems and you just sit and wait for it!’, etc.          family therapy, conducted because of a prob-
                    Except good motivation and among other in-               lem of a child, who is about to appear.
                  dications for therapy, the behavioural therapists 
                  of marital/couples problems place the following 
                  types of problems:                                      THE INITIAl PHASE OF WORKING WITH  
                  •		overprotection	of	one	partner	coexisting	with	       MARRIAGE/COUPlE IN CRISIS: CONSUlTATION
                     emotional dependence of the other;
                  •		jealousy	combined	with	control,	suspicion	and	         In the first contact with a pair in crisis, when 
                     restriction of freedom;                              there is general confusion and tension, proceed-
                  •		the	dominance	of	a	partner	combined	with	the	        ing according to the indications and contraindi-
                     lowering of the value and self esteem of the         cations to therapy outlined above can help the 
                     other, passive partner;                              therapist in making the diagnosis of the crisis 
                  •		mutual	antagonism,	blaming	and	emotional	            and problems in relationships as well as in tar-
                     interdependence [6].                                 geting, defining purpose, scope and method of 
                                                                     Archives of Psychiatry and Psychotherapy, 2011; 3 : 57–64
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...Archives of psychiatry and psychotherapy marital therapy couples indications contraindications magorzata wolska summary the author basing on literature her own experiences in conducting presents dications for this form both recipients therapists insufficient motivation to change relationships behaviours threat divorce violence deep emo tional or psychological disturbances one spouses engagement partners a relationship outside marriage are some as referred ar ticle what is being elaborated also correct approach characteristics therapist well conduct proposes scheme work with mar riage couple crisis preliminary consultations basis therapeutic contract relegating part ners other specialists introductory remarks hand oth working married pairs se er they tend shift blame vere which threatens stability their partner at same time expect that big challenge pri will help them by taking role an marily reason arguing ally solicitor advocate judge unravel experiencing sense injustice complex games...

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