Helping individuals with mental health issues can be quite challenging. It can take several years of training and experience to begin feeling competent to help individual clients across a range of presenting issues. Yet, even after we feel competent to help individuals, when faced with couples in high conflict and distress, we can feel like novices all over again. I remember my early days of doing couples therapy, and one very challenging couple, Jack and Mary (not their real names).
Jack had made an appointment with the receptionist just the day before without any explanation as to their situation. As we began, Jack explained that he had admitted to Mary three days ago about his 11-month old affair, and that she, in response, wanted him to leave the house. It was a crisis situation. Despite having had over 300 hours of face-to-face supervised clinical contact through my master’s internships and having attended a weeklong externship on Emotionally-Focused Couples Therapy with Susan Johnson, I still felt nervous and ill prepared as I sat before the couple.
Mary, silver-haired and petite in her forties, sat in the far corner of the sofa seething with anger. Her cold, penetrating eyes and stiff silence seemed to cast a death-shadow over Jack’s guilt-injected muscular frame. Yet, he was relentless, doing everything he could to shake her from the spell that had fallen upon her to find some vestige of loving warmth and forgiveness. Dragging Mary in to see me was Jack’s last desperate attempt. I mustered up every counselling skill within me to listen to them as empathically and as non-judgmentally as I could, and I uttered prayers under my breath trying not to reveal my growing sense of ineptness.
As the session progressed, there seemed to be no movement. Jack had ended the affair several months prior and wanted desperately to save the marriage. Mary, however, remained unmoved, insisting that Jack leave the house. With three young children at home, she wanted to have some space to compose herself and continue to care for the children while she decided whether to stay in the marriage. Jack feared that if he left the house, knowing how decisive Mary could be, there would be no recourse for redemption. As a marriage-friendly therapist, my stance was clear: save the marriage if at all possible. But Mary’s position was uncompromising: Jack had the affair; he had to leave the house. As the therapy hour came towards an end, Jack and Mary’s stalemate required an intervention from me. If I supported Jack’s position, I would lose Mary; if I supported Mary, I would lose Jack. I agonized over how to salvage the situation and end the session well.
Working with couples may be challenging-especially for the uninitiated-but it can be extremely fulfilling. Certainly, not every case is as challenging as the case presented above. When we help a marriage overcome its relationship distress, we also partake in the rekindling of love that exemplifies the sacred bond God intended to have with humanity (Rev.19:7-8). But how do we begin? How do we make sense of the potentially messy drama of helping couples in conflict? In the rest of this article, I will sketch out a conceptual framework to help think through and strategize about how to help couples. Interspersed within the framework will be some examples and illustrations of important points to consider when working with couples.
A conceptual framework abstracts and clarifies the logic underlying a phenomenon, in this case, working with couples. Like a map, it can help practitioners navigate the terrains of their work with couples more effectively. I have found that conceptualizing couples’ work according to modes and systems of intervention to be extremely helpful. Modes refer to the types of intervention carried out with couples and reflect the therapist’s levels of functional involvement in helping couples move through change. Systems refer to the interdependent parts of a marriage-individual, interactional, and intergenerational-that are targeted in the interventions. If modes of intervention can be understood as how we help, then systems of intervention can be understood as who (and which relationships) we help.
Modes of Intervention
Broadly, we can categorize couples work into four modes: psychoeducation; counseling; therapy; and management.
Psychoeducation involves the lowest level of functional involvement in the practitioner. In this mode, we teach or impart knowledge to couples, typically covering topics such as a theology of marriage, conflict resolution approaches, and ideas on how to increase intimacy. Psychoeducation can include simple questionnaires to orient couples towards understanding themselves and their partners better, and under more experienced practitioners, may have an experiential component such as having couples practice communication skills during the class. Psychoeducation does not require that the practitioner have intimate knowledge of the background of the couple nor be licensed as a counsellor. So long as one can teach effectively, one can provide psychoeducation. Such courses can be offered to many couples simultaneously in a group setting and would work well in Sunday school classes, with couples attending separately or together. Thus, psychoeducation is an affordable means of low-level intervention, most appropriately used as a prevention tool. Premarital counselling for instance often has a strong psychoeducational component, and can work well as a method of prevention.
Care needs to be taken when offering psychoeducation to couples with high levels of conflict, as exposure to relationship topics can open up areas of discontent and exacerbate a couple’s sense of distress. A highly distressed couple may even become disruptive to the class, leaving an inexperienced practitioner flustered and disoriented. To avoid causing distress or having disruptions, screen out highly conflicted couples and offer them private counselling before letting them attend the program, or offer the class with an experienced counsellor as a co-presenter.
Given its lower level of practitioner involvement in client change, psychoeducation alone will tend to be insufficient for couples with more complex dysfunctional dynamics.
The next mode of intervention, counselling, refers to a level of involvement where the practitioner or provider helps clients to achieve their self-defined goals drawing on the resources the clients already possess. The goal could be to arrive at a decision or to solve a problem, such as a conflict over how to manage and organize family finances. The practitioner provides emotional and informational (i.e. psychoeducational) support, reflects and clarifies the clients’ steps in problem solving, and reinforces positive steps made. It is best done in a quiet, private setting as counselling could open up personal and emotional issues that require a safe place to process. Intervention at this level typically requires some level of training in the practitioner, particularly, basic counselling skills, foundational theories of counselling, and an understanding of couple and family dynamics. Most normal functioning couples with content-oriented difficulties (e.g. parenting challenges, work-life balance issues, or difficulties adjusting to life-cycle transitions such as births and deaths) will benefit from this mid-level intervention. Typically, couples who need this level of intervention will tend be willing to engage in the counselling process as the issues tend to be less shaming, with less taboo. Couples with more serious family-of-origin dysfunctions, individual psychopathology, or more problematic patterns of interaction will need a third mode of intervention, therapy.
Couples intervention at the therapy level requires expertise knowledge and skill. Typically, the therapist assists the partners to experience healing in both intrapsychic (within an individual) and interactional (between a couple) dysfunctions. Depending on the presenting issue, therapy interventions can also include other family members. The goal of therapy is to enable clients to achieve tasks that they were not able to perform in the past by helping to create conditions where clients develop new resources.(More details on couples therapy will be discussed in Systems of Intervention.)
Mental health practitioners with little training or experience in couples therapy will typically find this level of intervention to be beyond their ability to carry out. I have heard of practitioners blaming a couple or a partner as being uncooperative or problematic, and beyond help. Often, these practitioners are well-meaning helpers who are unaware that professional marriage and family therapists are trained and have the skills to help these highly distressed relationships. Practitioners and professionals alike with little experience in working with couples would do well to recognize their limitations and either receive more training in couples therapy or refer more complex cases to competent marriage and family therapists.
In the United States, marriage and family therapists are required to have at least a master’s degree in mental health with relevant coursework plus typically two years of supervised clinical experience culminating in an average of 1000 face-to-face clinical contact hours (500 of which need to be with couples or families). In addition, they have to pass a national written exam and an oral exam (in most states) with their state licensing board before they can become licensed. In spite of the rigorous training, the ethics of marriage and family therapy require licensed professionals to continue to learn by collecting continuing education credits and to seek consultation when feeling stuck with clients or to refer them to more competent mental health professionals. Take me for example.
In the last six months, I have consulted with many specialist professionals and practitioners to help with my client cases. These have included an American clinical social worker and an American marriage and family therapist with expertise in borderline personality disorder and dissociative identity disorder; a local female counselling psychologist to reflect on gender issues with a female client; two local clinical psychologists for diagnostic questions; a local drug and alcohol addictions counsellor for advice on a relapse case; a Singaporean provider specializing in working with adults with Asperger’s syndrome; a psychiatrist to provide psychopharmacological intervention for a client; two local inner healing prayer ministers concerning the spiritual dimensions of trauma; and more. It is my ethical duty to obtain the consultation and resources to help my clients as best as I can, including paying money to receive the necessary consultation.
The fourth mode of intervention, management, pertains to a helper’s active manipulation of the couple system for the ultimate benefit of the client, the family, or the larger community. It requires the highest level of functional involvement in the practitioner, and is best done with multiple providers. Cases such as domestic violence, substance addiction, and the sexual or physical abuse of children may require management as an intervention. Often, the aim is to intervene for a temporary duration until such a time when the individual, couple or family system can return to a healthier level of functioning that they are able to benefit from therapy. In crisis situations, I often find myself operating in a management mode where I take an active role in ascribing what ought to take place for the couple, including hospitalization when necessary.
Although management as a mode of intervention requires the highest level of involvement by a practitioner, it does not necessarily require specialized training when done in collaboration with a professional. Church ministers in particular can play a helpful role, especially when the clients are members of their congregation. For instance, the church leader can help to monitor instances of domestic violence, or the church community can provide shelter for the children of troubled parents, while a professional helps the clients to gradually heal from their dysfunctions.
Collaborating Across Modes
Different presenting problems require different modes of intervention and levels of functional involvement from the practitioner. Needless to say, a helper will be most effective when he or she can operate across all levels of intervention. But not everyone has the time or resources to be trained as a marriage therapist. Some of us can specialize as relationship educators or receive basic training to do couples counselling with less distressed couples. Others can provide prayer or a loving community to embrace a hurting couple. It makes sense to work collaboratively with other providers to manage the different modes and levels of intervention to increase our ability to help couples.
Systems of Intervention
Family systems theory is one of the foundational theories guiding the development of marriage and family therapy. Typically, a marital couple is made up of two individuals, the relationship between them, and any other family members. Thus, an integrative approach to working with couples considers intervention at three systems simultaneously: (a) individual; (b) interactional; and (c) intergenerational. The individual system refers to the biological, psychological, and spiritual systems within an individual (i.e. the husband or the wife); the interactional system refers to the relationship between the partners (i.e. the marriage); and the intergenerational system refers to the families-of-origin (parents and siblings of the couple) as well as the family-of-procreation (the children of the couple).
Targeting One System
When a couple presents with only relationship difficulties between them and nothing else of concern, working with interactional system (i.e. the couple’s relationship) alone can be sufficient for healing. For example, a husband has taken on greater responsibilities at work while the wife struggles as a stay-at-home mom, leading to conflicts that did not exist prior to their having children or career changes. For such a case, if there is no further individual mental health or family relationship concerns, a mid-level intervention such as counselling with psychoeducation (e.g. couples communication and problem solving skills)can provide the couple with the needed resources to overcome their challenges. If a mid-level intervention does not work, then the couple may need to engage in more intense couples therapy with a skilled marriage therapist to overcome their dysfunctional pattern. If that remains ineffective, there may be a need to include intervention targeted at the individual or intergenerational systems.
Targeting Multiple Systems
The more a couple presents with unresolved individual childhood issues such as abuse or neglect, the more likely couples therapy will need to include multiple systems-individual and even intergenerational. For example, a woman with a history of sexual abuse married to a man with anger issues from childhood will likely require not only couples therapy but also individual therapy to address the wife’s past trauma and the husband’s childhood emotional wounds. If there are children involved, family therapy combined with psychoeducation on parenting may also be beneficial.
Care needs to be taken at this point to ascertain our role as a therapist to the individual or the relationship. Holding both roles at the same time can result in an ethical dilemma. For instance, Linda, a therapist working with a couple decides to also see the wife alone. After several sessions with the wife, the wife decides to leave the husband and wants Linda’s support in doing so. When the husband finds out, he blames Linda for the change in his wife’s attitude and insists that Linda’s role was to help save their marriage, not destroy it. In a more litigious society, the husband could very well sue Linda for a breach in ethics, and even report her to the ethics board for investigation of malpractice.
One way to avoid this ethical dilemma is for us to clearly identify our role as either the therapist to the relationship or to the individual, and then to unambiguously communicate this with our clients with both of them present. Typically, when there is a strong likelihood of a conflict of interest, I prefer to collaborate with other professionals, referring one or both spouses to see an individual therapist. I will ask the clients to sign an inform consent for the release of confidential information so that my collaborating therapist(s) and I can discuss their case and strategize ways to help them heal as individuals and in their relationship.
The Joy of Working with Couples
The joy of seeing a couple rekindle their love for each other greatly outweighs the challenges and drama that can take place through the helping process. Sometimes, it is impossible to save a marriage. But with good training and supervision, our skills increase and we become better at handling even the toughest moments in therapy. Remember Jack and Mary at the beginning of this article?
Towards the end of the session, Jack and Mary sat before me in a deadlock. I had to make a move. As if inspired by heaven, it suddenly dawned on me to ask Mary, “if Jack left the house, when could he return again?” Mary replied, two or three days. “So he could come home after,” I emphasized. She nodded, indicating that she really just needed space to think and to remain composed for the children. I went on, “if Jack left the house believing that he might lose the marriage but he left for you, would this show you just how important you are to him?” Mary frowned but said nothing. I reiterated the question to emphasize the attachment bond, “if he left for you, would it convince you that he really does love you, and that he is really sorry?” Mary pondered. I turned to Jack, “Mary said you can come back after two or three days. Can you take her at her word?” He shook his head. Then, moving into a management mode to their deadlocked crisis, I suggested to Jack that he leave the house so that Mary could have some space to recover, and to return home after two days. Jack slumped his head and shoulders. Completely dejected, he stood up to leave. I stood up with him and suggested that we have a follow-up appointment next week. He shook his head hopelessly and proceeded to walk out. Suddenly, from the sofa, Mary said, “I will take the appointment and I will be here.” Jack paused and looked at Mary. Then Mary stood up, and they both walked out together.
The couple came back the next week and continued therapy over seven months. In their last session, Jack beamed a huge smile and placed his arm around Mary as she said, “our relationship is now stronger than ever before. Thank you.” In return, I gave them the credit for the courage and hard work in saving their marriage, and I thanked them for the privilege and honour of being invited to walk intimately with them through the most difficult moments of their marriage.
My late professor at the University of Minnesota, Dr. James W. Maddock, conceived of the idea of Modes of Intervention, which I have adapted here. Systems of Intervention is adapted from Gerald Weeks’ Intersystem Model. For a helpful introductory resource to couple’s therapy, consider Weeks and Treat (2001) Couples in Treatment: Techniques and Approaches for Effective Practice, 2nd edition, New York: Brunner-Routledge.
Johnben Loy, PhD, LMFT, is the founder and clinical director of Rekindle International Marriage and Family Therapy Center in Kuala Lumpur. He is a Licensed Marriage and Family Therapy in Minnesota USA, a Clinical Member of the American Association for Marriage and Family Therapy, and an AAMFT Approved Supervisor. His academic qualifications include a Master of Business Administration (Cambridge University, England), a Master of Theological Studies specializing in Counselling (Tyndale Seminary, Canada), and a Ph.D. in Family Social Science specializing in Marriage and Family Therapy (University of Minnesota, USA).