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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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