Specific techniques in behaviouralsystems couple therapy

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Reciprocity negotiation

Within the alternative levels of intervention hierarchy, reciprocity negotiation is at the lowest level, relating closely to the goals that the couple themselves have set, and depending on a fairly co-operative attitude on both sides. The partners state their complaints in everyday terms, and the task of the therapist is then to help them to achieve a compromise by each doing what the other partner wants in a reciprocal way.

Reciprocity negotiation is partly based on operant conditioning and partly on the social exchange theory of Thibault and Kelley. (29 The assumption is that satisfaction in marriage and other intimate relationships is based on a relatively equal and high level of input by each partner of positive (i.e. acceptable) behaviour and a relatively low input of negative or unacceptable behaviour. Problematic marriages have a low level of these mutually rewarding behaviours on both sides, or may have a gross imbalance in the input from the two different partners. Instead of exchanging positive behaviour, the partners may use coercive methods to try and force the other to stop doing those things of which they disapprove.

The remedy proposed by behavioural marital therapy is that each partner should state their complaints, but that these complaints should then be translated into wishes for an alternative way of behaving which is more acceptable, and, as a second stage, into tasks. It is very useful to concentrate on practical, domestic issues for these tasks, as these are easily grasped, frequently repeated, and more likely to be remembered than more abstract tasks. In principle the tasks for each partner should be linked and reciprocal, but if this is not possible a 'bank account' approach can be used in which each partner builds up a fund of good behaviour and they work out at the end of a period of time whether it has been mutually acceptable. In moving from complaints to tasks one also moves from past to future, and this is one of the most characteristic features of reciprocity negotiation. The therapist is thus more interested in what will happen next week than in what happened last week or last year.

The way that reciprocity negotiation is used in behavioural- systems couple therapy is a little different from its use in behavioural marital therapy. We will usually have the couple in a decentred position while negotiating, and feel that this helps the process both to be effective, and to translate more successfully to their home setting. We also use it quite briefly at different stages of therapy, rather than as the mainstay of therapy throughout.

The tasks should be specific, positive, repeatable, practicable, and acceptable to both partners. They should also be concerned with everyday activities, rather than once-only events such as arranging an overseas holiday. Sometimes sexual problems can be brought in to the negotiation, as in the following case.

Case Study Emma and Frank came to therapy with a complaint from Emma that Frank was cold and distant towards her. 'He never cuddles me, he can only snap at me and tell me that the house is untidy. The only time he is ever kind to me is when he is drunk, and then he wants to make love to me. I can't stand him when he is drunk.'

The therapist asked her if there was anything she wanted him to change, and she suggested that he might cuddle her when he was sober, and not necessarily expect sex to follow immediately. She said, however, that she did not expect him to be able to do this. He was asked to try approaching her in the desired way twice a week, without the expectation of sex.

He challenged her that she would not reciprocate if he approached her in this way, and his challenge was translated into a task for her to accept his affection. The couple were able to use this exchange of tasks, and both their emotional and their sexual relationship improved.

Reciprocity negotiation is a well-tried and effective method of couple therapy in those who accept that they have marital problems. But it is also, in our setting, a way of assessing whether the couple are ready for this sort of intervention; if not, they can be offered a more systemic input until they are more ready to negotiate.

Communication training

The second strategy in the alternative levels of intervention hierarchy is training in communication. This too is part of the behavioural marital therapy spectrum, but not so exclusively, because work on communication is part of most types of couple therapy. The characteristic feature of the form of communication training used in our setting, however, is that it aims for efficient and clear communication, with positive and constructive requests rather than complaints. Other forms of communication training(21) emphasize other skills such as empathy, reflective listening, and supportive comments. In the present form of communication training these are also issues to be considered, but the main emphasis is on issues such as reducing misunderstandings, ensuring that both partners have an equal say, and helping them both to speak from the 'I' position.

Problems encountered in couple therapy amenable to communication training include:

• inability to express emotion

• failing to listen

• monologues with no break for feedback

• one partner the spokesperson and the other silent

• mind-reading (i.e. A knowing better than B what is in B's mind)

• sting in the tail (a positive comment followed by a criticism)

• wandering off the topic

• continual criticism.

In carrying out communication training the therapist first decentres him- or herself, and asks the couple to converse about a relevant topic. When a problem of communication arises the therapist acts as a 'director' and asks them to discuss the topic in another way. If the problem observed is one of lack of empathy, this may include asking one partner to attend to the emotional state of the other, and perhaps to feed back his or her understanding. If it is of inability to express emotion, the therapist may try to intensify the interaction, pointing out the way in which they are holding back their emotions, and encouraging more expressiveness.

The next three problems are connected: failing to listen, talking in monologues, and the 'spokesperson' problem. Remedies can be decentring, encouraging each partner to speak for him- or herself, stopping the talkative partner (perhaps by asking them to listen to what the other partner has to say), and cutting any monologues short by asking for feedback from the other partner. In dealing with mind-reading one may have to be quite diplomatic, because the process is rather similar to psychotherapeutic interpretation, and some partners may feel that this is a legitimate way of giving insight; however, it should be tactfully blocked, usually by asking the recipient partner to say whether that is what he or she really thinks.

The 'sting in the tail' is dealt with usually by simply pointing it out, but in some cases it can be neutralized by asking the speaker to restate the idea the opposite way round with the 'sting' first. An example of this is given by a man who said 'I realize you were hurt by what I did, but I had no intention to harm you (i.e. you are being oversensitive)'. He was asked to rephrase it as 'I had no intention to harm you, but I realize that you must have been hurt', and his wife found this much more acceptable, because she could respond to the more positive part of the comment.

The problems of wandering off the topic and continuous criticism are often rather intractable, and it is helpful to remember the advice of Minuchin (12> not to try to restructure the interaction before one has a good working therapeutic relationship with the couple. One way, however, of keeping them to task is to bring them back frequently to the problem first presented, and ask whether they can concentrate on solving it. In the case of mutual criticism, one way of coping is to slow down the interaction so that each partner speaks only after a break for the therapist to reframe what has just been said.

As with reciprocity negotiation, communication training is used not as a self-contained therapy in itself, but rather as part of a menu of techniques to be chosen according to the problem presented or observed at the time.

Structural moves in session

The main interventions under this heading are raising arguments in the session, reversed role play, and 'sculpting'.

There are many couples in which there is a reluctance to enter any sort of conflict. They avoid differences of opinion, and pretend that there is agreement on almost every issue. The more dominant partner, usually more at ease verbally, effortlessly takes the spokesperson role. The other partner is either silent much of the time or spends much effort placating the other in order to reduce conflict.

One strategy with such couples is to ask them to argue (or, to put it more acceptably, to have a heated discussion) about a fairly trivial topic. One example might be whether the toilet seat should be left up or down after it has been used. It must be a genuine difference of opinion, and not simply one manufactured for the purpose, but it is important that it should be of a trivial nature, as otherwise the couple may feel inhibited about discussing it.

The therapist then asks them to discuss the issue without inhibition, and particularly encourages the more submissive partner to participate with enthusiasm. It may be necessary to ask him or her to speak louder, or to ask the other partner to listen more carefully to what the quiet partner has said, but the therapist should not take sides as such. What is being dealt with is not the issue itself, but the process of arguing. The outcome does not matter, except that the submissive partner should not be allowed to 'get away with' their usual tactic of giving in for the sake of peace. The couple may 'agree to differ' or the submissive partner may have a better than usual hearing, and even win the argument.

This intervention is particularly useful for those couples where there is a degree of depression in the quieter partner, or where the quieter partner is very reluctant to be involved sexually, and is blaming him- or herself.

Another intervention in session which can have an impact on the interaction is the 'reversed role play'. Here the couple are asked to discuss a particular issue, but they are asked to act as if they were the other partner, even perhaps changing chairs for the purpose. The exercise is useful for some couples who have difficulty understanding each other's point of view, and may promote better mutual understanding.

A third intervention in session is the use of 'sculpting', in which the partners position themselves wordlessly in a kind of tableau to express some aspects of the relationship. For example, a wife who feels herself excluded from her husband's life may place him looking away from her, while her husband might place the two arm-in-arm and facing the same way. Neither position would represent the objective truth, but each would gain some understanding of the views of the other. The different views could also be the subject for discussion in session or during 'homework'. As with reversed role play, sculpting, with the accompanying 'experiential' insight, can be useful in those couples where there is little understanding of the other's point of view.

Timetables and tasks

These are perhaps the most frequently used of our interventions. They are always given as part of the 'homework' at the end of the session, and may be of a behavioural nature (see above) or more systemic. Systems tasks are usually used for behaviour which is thought of as being out of control. Thus, they may be used in a couple where there is a jealous partner: this partner would be asked to raise his or her doubts about the other's fidelity, but only at a specified time each day and for a limited period (e.g. half an hour). If the topic comes up at any other time, they are asked to postpone any discussion till the appointed time. This can be frustrating for the jealous partner, although he or she will perhaps be reassured that the other will give the topic his or her full attention at the set time: but for the other partner it can come as a great relief that the issue of jealousy is at last under some sort of control, even in this simple form.

A timetabled task may be used in other situations, for example when one partner has a series of complaints which the other is rejecting. The couple can again be asked to discuss the issue only at certain times and for a limited duration. The advantage of a timetable under these circumstances is that the therapist does not have to face the issue of avoiding taking sides in the content of the argument, but simply asks that the couple raise their legitimate complaints at home at an appropriate but limited time.

Another frequently used timetable is the 'talk' timetable, in which a couple who do not communicate very often are asked to set a time each day or evening hen they can get together for a discussion about the day's events. In cases where there are difficulties with empathy it may be useful in addition to ask each partner at the daily talk session to repeat back what the other one has said to reassure the other that they have understood what is meant.

One situation which responds particularly well to timetabling is where the male partner is very keen on sex and the female (while not having a sexual dysfunction as such) is much less enthusiastic. Here the couple are encouraged to reach a compromise on the agreed frequency at which sexual relations might occur, and then they agree on a suitable timetable. The day of the week has to be fixed, since if this is not done the usual arguments will ensue as to whether sex should take place that night, and they are also asked to make the chosen night something special, with perhaps a dinner and the telephone disconnected. If, however, the enthusiastic partner suggests sex on another night, the other can simply remind him that it has been arranged and that they should stick to the arrangement. This remedy may seem somewhat crude, and it is often simply a temporary measure. However, it can be said to have virtually saved some relationships, because it takes the heat out of the sexual conflict which could otherwise lead to divorce, and its use can open up the discussions in subsequent sessions to include non-sexual topics which would otherwise be pushed out by the sexual issue.

It should be mentioned here that many relationship problems have a sexual and a general dimension. When the sexual difficulty is motivational rather than dysfunctional, it is often most productive to deal with it in couple relationship therapy either alone or in combination with psychosexual therapy. In such a case it is quite appropriate to suggest techniques such as the Masters and Johnson 'sensate focusing' (22> in addition to the couple therapy approaches already mentioned.

Paradoxical interventions

Paradox is always an option in couple therapy (Fig 1) when other methods are ineffective or where the couple relationship seems so rigid that no other intervention can be used. The rationale for paradox is somewhat obscure, and depends on a systemic hypothesis which states that the homeostatic forces in the system may be so strong that no straightforward intervention will alter it. All systems tend towards a resistance to change, but in some the resistance is maintained by powerful forces which themselves seem to be informed by extreme anxiety/1.:4 In these couples or families the only intervention likely to succeed in changing the system is one which prohibits change, but for unacceptable reasons. Although the above explanation is somewhat unsatisfactory, paradox remains in practice a technique which can unlock an otherwise stuck relationship and get the couple back on course for continued therapy.

Paradox is always applied with care and in a sympathetic manner. A common form is to 'prescribe the symptom', that is to advise the couple that it is best 'for the time being' to persist with both the behaviour complained of and the reciprocal behaviour in the other partner. The reason given for this conclusion is a plausible, but challenging and perhaps unacceptable, explanation based on systemic understanding of the relationship.

In using paradox the therapist should think in four stages. First, there should be a positive connotation of the 'symptom' and the reciprocal behaviour. Secondly, there should be a rehearsal of why they are at present helpful for the couple. Thirdly, a statement should be made of the hypothesized feared consequences if the behaviours were to stop. Fourthly, the symptom and the reciprocal behaviour should be prescribed. A case example may make this process a little clearer.

Case Study A couple who presented with depression in the wife (Edna) and a rather overprotective attitude on the husband, George's, side were in therapy for some weeks without much progress. Following a session in which the therapist asked many questions of both of them about the circumstances and consequences of the depressive episodes, the paradox was presented as follows. 'This depression seems in some ways to be quite good for you as a couple, because it helps Edna to help George by giving him a role in life as her protector. If the depression were to disappear it might be difficult for you both to continue your peaceful relationship, because the differences between your views and ideals would become very clear and you might argue all the time. So for the time being it is better for Edna to remain depressed and for George to be her spokesman and protector'.

This intervention led to quite an outburst from the wife, who up to that time had always been very quiet, and she began to talk of some of the differences of opinion that they had actually had. The husband looked rather disconcerted, and questioned the therapist's reasoning. In the next two sessions the couple reversed their imbalance to some extent, the wife became more assertive than the husband, and her depression became less severe.

The paradox can thus be a powerful mechanism for change, but it must be used with some caution, since an instruction given paradoxically may be taken literally. So it would be inappropriate to include in a paradox any instructions to break the law, to harm oneself or others, or to act irresponsibly. If given as recommended, however, the paradox can unlock a 'stuck' system and put the couple on the road to change and improvement.

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