Couple Therapy

1. Couple and Family Therapy
Demetrios Peratsakis, LPC; December 2015

2. Family Systems Therapy
“Seeing” is the insight that occurs when the therapist transcends their singular perspective and views
the individual and the family as inseparable, interdependent systems occurring within the same space and time… --dperatsakis
Note: How to Develop Super-Vision
1. Look from a System’s Perspective
2. Look at the Purpose of the Problem Behavior (how is it empowered; how is it connected to the tasks of life)
3. Look at how and where the system resonates for the clinician

3.  Power (Hierarchy; Decision Making)
 Boundaries (closeness/distance; independence) and Intimacy (trust)
 Conflict (Cooperation, Problem-resolution)
 Coalitions (ie Triangle)
 Roles
 Rules
 Complementarities and Differences
 Similarities
 Myths
 Patterns of Communication
 Effective Parenting
 Warmth (Nurturing, Boundaries)
 Control

4. 1. Inflexible response to maturational (developmental) and environmental
challenges leads to conflict avoidance through enmeshment or disengagement
(Goldilocks Rule on Emotional Distance: Too Much vs Too Little)
2. Disengagement and Enmeshment tend to be compensatory (“I’m close here to
make up for being distant elsewhere”)
3. Patterns of Disengagement or Enmeshment lead to Cross-generational
Coalitions (triangulation/triangular structures)

5. 1. Families are comprised of individuals in trust relationships acting alone and in concert to accomplish
and obtain their individual and collective purposes and needs.
• Basic Needs
1) Bio-physiological and Safety needs - food, drink, shelter/warmth and protection from the elements, safety and
security/freedom from fears;
2) Love and belongingness needs - friendship, intimacy, affection and love, sex; and
3) Esteem needs and Self-Actualization needs - achievement, mastery, independence, status, dominance, prestige, self-respect,
respect from others; realizing personal potential, self-fulfillment, seeking personal growth and peak experiences
• Life Tasks include those larger processes that the family, as a group, must accomplish (Life-cycle Tasks) and that each
individual must master (Developmental Tasks) and reconcile (Adler Life Tasks/Existential Anxiety)
2. Families have organized operational structures that include sub-systems, roles and interactional
patterns that aide the group and its individuals in achieving these outcomes and define the manner in
which interaction occurs around tasks functions and responsibilities.
These are partly universal (cultural) and partly idiosyncratic (intergenerational): information (rules and myths) on how to
accomplish tasks and assume responsibility; how gender, roles, and functions are defined; how power and emotion is expressed;
how loyalty, intimacy and trust are conveyed; and so on.
Core Structural-Strategic Family Therapy Tenets
Demetrios N Peratsakis, LPC 5

6. 3. Elements of the Family Organization include:
• Power: the ability to influence the outcome of events
• Hierarchy: established levels of authority and responsibility (executive subsystem at the top)
• Roles: established assignments for performing specific functions and tasks
• Subsystems: subgroupings within the family based on age (or generation), gender and interest (or function); ie.
parenting, spousal; sibling
• Boundaries: invisible barriers that regulate contact between members and regulate the flow of information in and out of
the system. Structural therapists use a “Goldilocks” approach to seeking moderation.
 Diffuse, too weak, too open, or “enmeshed”; mapped as
 Rigid, too fortified, too closed, or “disengaged”; mapped as
 Appropriate boundaries retain a healthy balance; mapped as
◦ boundaries are reciprocal
 That means that a weak boundary (enmeshment) in one relationship usually means that the same person is
disengaged from someone else.
 Example is wife who is enmeshed with child and disengaged from husband. Mapped as M F
C
 Example is father who is very close and enmeshed with older son who hunts with him, and disengaged
with daughter who is quietly depressed and cutting herself. Mapped as F
S D
4. The executive sub-system (no matter the configuration) is the recognized authority responsible for the decision-
making and problem-solving capability of the family. It’s core responsibility is to effectively manage stress and
negotiate conflict as individual members and the group adapts to change.
Demetrios N Peratsakis, LPC 6

7. Problem Origination/Symptom Development
5. Problems occur when the executive subsystem is ineffective at fulfilling its function, typically due to
1. a power-play between its members;
2. dysfunction within one of its members; or
3. incapacity due to trauma, disaster or catastrophe
6. This typically occurs at the confluence of vertical and horizontal stressors
• Vertical stressors are emotional norms and rules transmitted across generations. Examples are family secrets, attitudes,
taboos, labels, legacies, myths, loaded issues.
• Horizontal stressors refer to predictable (developmental crises) and unpredictable current events (life threatening illness,
divorce, etc).
7. Under duress the family intensifies its excessive rigidity around a key interactional pattern, rule or
role (structures) thereby developing a recurring or nodal problem (Symptom)
In essence, the family becomes insufficiently flexible to adapt to change, mend trauma or respond to maturational (or
developmental) and environmental challenges intensifying its stress and conflict.
8. The family adapts measures in response to the intense or prolonged conflict that exacerbate the
problem:
a. conflict avoidance through disengagement or enmeshment
1. Disengagement and enmeshment tend to be compensatory (I’m close here to make up for my distance elsewhere.)
2. This leads to what is called the cross-generational coalition, which is a triangular structure
b. power-struggles, marked by improper alignments, such as collusions, coalitions, alliances and triangulations
c. emotional cut-offs, disavowing contact with key members or supports
d. failure or dysfunction in one or more of its members
Demetrios N Peratsakis, LPC 7

8. 9. Therapeutic Goals: Intervention to transform the structure (restructuring)
• Join family: assume position of leadership
o Important to join with angry and powerful family members
o Important to build an alliance with every family member
o Important to respect hierarchy
 Help the Couple or Executive Subsystem form a healthy (Spousal/Parental) Subsystem:
1. Must develop complementary patterns of mutual support, or accommodation (compromise)
2. Must develop a boundary that separates couple from children, parents, in-laws and outsiders. May need to
reconcile family-of-origin issues and concerns.
3. Must claim authority in a hierarchical structure. Partners must be equal and may need to address how each
expresses power or controls the outcome of decisions.
4. Must learn to problem-solve in order to effectively navigate conflict
5. Must reconcile Life-cycle Task processes:
 Readiness to move from Couple to Family
 Decision about Parenthood
 Contending with pregnancy or birth-related concerns, such as difficulty conceiving or pregnancy complications
 Integrating the child while negotiating space with in-laws, etc.
 Child-care arrangements , separations and concerns
 Child-rearing –resolving differences and adopting parenting styles that are balanced and complimentary
 Agreeing on family goals and aspirations
 Reconcile Power: hierarchy and age appropriateness; responsibility matched with authority; disengage power-plays,
alliances, collusions and triangles
 Balance Boundaries: Boundaries must be balanced; strengthened in enmeshed relationships and weakened (or
opened up) in disengaged ones. Clarify Roles and Rules: Who is to do what and when and how? Matching
authority match responsibility.
 Help Family Comfort and Care: Members support one another’s growth and encourage affection, tenderness and
mutual support.
Demetrios N Peratsakis, LPC 8

9. 10. Structural (Strategic) Therapeutic Interventions
1. Working with Interaction by inquiring into the family’s view of the problem, and tracking the
sequences of behaviors that they use to explain it.
2. Mapping underlying structure in ways that capture the interrelationship of members -- A structural map
is essential!)
1. Family structure is manifest only with members interact
2. By asking everyone for a description of the problem, the therapist increases the chances for
observing and restructuring family dynamics.
3. Highlighting and modifying interactions
1. Spontaneous behavior sequences (interrupt, re-play, highlight/embellish)
2. Enactments (directives and tasks) -- directed by therapist
4. Restructuring
1. Use of reframing to illuminate family structure
2. Use of circular perspectives, e.g. helping each other change
3. Boundary setting
4. Unbalancing (briefly taking sides)
5. Challenging unproductive assumptions
6. Use of intensity to bring about change
7. Shaping competency
8. Not doing the family’s work for them (refusing to answer questions, or to step in and take charge
when it’s important for the family members to do so.
5. Homework
1. Should be to increase contact between disengaged parties
2. To reinforce boundaries between individuals and subsystems that have been enmeshed
3. Should be something that is not too ambitious
4. Caution family members to expect setbacks in order to prepare them for a realistic future.
Demetrios N Peratsakis, LPC 9

10. Simple Genogram of a Blended Family
Presenting Problem: Don took Ben (17 yo) on a drinking spree; when stopped, police found two open
bottles and a bag of pot in the car. Step-dad wants Don to leave the house; mom (Katal) claims that Don is
depressed and upset about the anniversary of his father’s death
Assignment:
1. What Questions jump out at you? Form some initial hypothesis that should be tested.
2. Who should participate in session and why?
3. List some of the more significant issues that may be concerns
Reminder:
1. Always track who participates in the problem and how
2. Look for themes and patterns, such as roles, boundaries and conflicts
3. Examine cut-offs
Drug Use;
Depression;
Attempted
suicide;
multiple
hospitalizations
Alcoholism;
Depression;
Suicide
22 yo
Drug Use
Bad Temper
Recent crime: petty
theft; assault
D.= Overdose
Alcoholism
Domestic Violence
Local Pastor; got
custody of
children while
mom is in rehab
16 yo; straight
“A” student;
model child

11. 1. Use of Boundary Mapping: problems may be the by-products of inappropriate boundaries
(emotionality); manipulate boundaries with tasks that push to its opposite extreme.
Ie.
M F task M F
.….…… ______ ______..............
Kids ‘push’ to opposite Kids
Key: ……………….………_ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _____________________
Enmeshed Clear Boundaries Disengaged
(Inappropriately diffuse boundaries (Normal Range) (Inappropriately tight boundaries)
◦ Mark boundaries between partners, subsystems, or entire groups; examine skewed
boundaries
◦ Give directives and assign tasks that push individuals with diffuse boundaries closer,
enmeshed further apart. Firm up individual or relational identities and point to disparities
or similarities
◦ Partner enmeshed persons with others in and members outside the nucleus; partner
peripheral persons through teamwork, alliances and collusions
Sample Mapping Directives for Nudging Boundaries
Problem Boundary Pattern: Dad is very peripheral; Mom is over-enmeshed with Daughter and Son:
M F Note: “Risk” comparison for three simple options for testing boundaries
……… ______
Kids (D and S) M F
………………
D S
“The Girls versus the Boys” (relatively “safe” task;
keeps mom attached)

12. 1. Join the executive subsystem as a coach or mentor, build an alliance with each member and accommodate to the
family’s temperature and style:
1. Determine the source of power and who can mobilize the family to action
2. Immediately challenge assumptions about the Identified Patient (and Presenting Problem)
3. Examine the Presenting Problem and what interactional pattern supports it; examine the purpose of the symptom to the family
4. Continually check reactions and comfort with tasks, directives and challenges to the symptom or presenting problem
5. Continually reaffirm family’s power: take one-down and re-frame progress as family’s love and commitment to each other
6. Create intimacy through use of self and personal history, family bragging, praise, celebrations and story-telling
7. Continually validate privilege of working with family, their acceptance and their permission to share pain, secrets and shames
2. Build the executive subsystem: work with the couple as parents and address power-plays, old betrayals and trust issues, personal
dysfunctions with relational components, family-of-origin problems, in-law/friend interferences; help members practice expressions of
mutual support and tenderness
3. Get parents to parent
4. Make kids age appropriate: throw kids out of spousal alliances; match authority, responsibilities and benefits by age; promote (or
demote) older teens and young adults with “parental” responsibilities
5. Get parents to address individuation issues with teens and young adults
6. Challenge power inequities:
1. dis-engage and redirect power-plays toward common purpose task or problem
2. Ensure that functions are clarified, roles are assigned and that authority (power) matches responsibility
3. Bridge disengaged members and cut-offs and create breathing room and independence for enmeshed members; interrupt/block
inappropriate communications and direct proper exchanges
7. Address hurt and betrayal and trauma and trust issues as major barriers to effective governance and growth
8. Examine ghosts: confront family myths, cut-offs, or other legacy issues that interfere or serve as road-blocks to effective problem-
solving or growth. Do this verbally, through imagery and through empty-chair techniques.
9. Force enactment: encourage in-session practice of new behavior patterns and new forms of expression; assign related homework,
continually reaffirming that behavior rehearsal is critical to solidify new ways of being.
10. Have fun and get the family to laugh!
Demetrios N Peratsakis, LPC 12

14.  Systems Thinking
 Family of Origin (Genogram)
 Developmental Tasks/Stages of the Family Life Cycle
 Couples
 Marital Discord/Couple Therapy
 Typical Presenting Problems
 Divorce
 Post-Divorce
 Remarried Family Formation

15. 15

17. Ideas on the purpose and function of being a couple vary widely, with most viewing the social and sexual pair-bonding as a vehicle for
the purpose of procreation. At minimum, it is an agreement (contract) between individuals for mutual trust and support that includes an
avenue for the expression of sexual and emotional intimacy not socially acceptable in other relationships.
The quality of the relationship is a product of the individuals’ ability to demonstrate three (3) skills, each dependent on the rest:
1. to demonstrate mutual trust, loyalty and support, including tenderness, affection and love
2. to work toward goals, joint achievements and plans, and
3. to effectively problem solve the myriad of challenges and conflicts that arise as a natural consequence of change.
In it’s simplest terms, the job of the therapist is to challenge the couple into prioritizing a single goal or problem and then assisting
them in working toward its end, trusting that all clinical issues of relevance, both personal and relational, will surface along the way.
Therapy is continuously shaped, and its progress impeded, by three (3) principle factors, each intimate to defining the
individual’s personal sense of Power and, thereby, the couple’s collective ability to successfully negotiate matters of conflict:
1. unresolved matters from the family of origin (“ghosts”);
2. unresolved trauma; and
3. personal progress in reconciling one’s individual tasks of life: work, social interest, love, self-development, and spirituality.
As therapy gets underway, the couple should be advised to postpone any final decision about their relationship until a later time. If
practicable, this should include not actively engaging in any unilateral decisions or actions that could pose a peril, such as seeking
legal counsel, separating or relocating. Given the challenges above, the work will necessarily include assisting the couple with their
decision-making and problem-solving skills; re-instilling trust and working through hurt, betrayal and personal trauma; and exploring
each partner’s family legacy and how it shapes their actions, attitudes and experience with the expression of power:
1. power (decision making; problem-resolution; planning)
2. intimacy (joint accomplishment; affection; trust and loyalty; commitment; friendship; sex)
3. conflict mediation (cooperation; problem-resolution)
17

18. 18

19.  Sound relationship but block in communication or cooperation
 Pattern of bickering and fighting; great hurt or betrayal; lack of trust
 Mutual caring but lack of passion and “zing”
 Complaint about Family of Origin or In-laws (triangulation; intrusion; immaturity in partner)
 Re-marriage/Blended family problems
 Sexual dysfunction
 Dysfunction in One Partner (ie. depression, phobias)
 Special Issues
◦ Extra-marital Relations
◦ Alcoholism/Drug Abuse
◦ Incarceration
◦ Incest
◦ Sexual Abuse/Violence
Special Contracts: treating unmarried couples; lesbian or gay male couples; or co-habitating
couples serving as custodial parents

20. A. Stable Unsatisfactory Situation
Unresolved conflicts and power-plays result in chronic fatigue and tension:
1. Individual Symptoms (ie. depression, drug abuse, phobias, failure) or
2. Symptomatic Interactions (abuse, bickering/apathy, sexual dysfunction)
B. Marital Crisis
1. “Trigger event” (ie. death in family, job change)
2. Precipitating event (ie. Extra-marital affair

21. Demetrios Peratsakis, LPC 21
A. Crisis Event Typically, the reason for seeking treatment is clear, such as when a crisis erupts in the individual or couple’s life
“triggered” by some precipitating event such as a death in family or job change.
1. It may come through the disclosure or discovery of a major breach of the couple contract: an affair; incest; desire for separation or divorce; desire
to change gender or sexual orientation; incarceration; or a unilateral decision that results in a major change in couple’s finances or life-style, ie.
pregnancy; permitting in-law or friend to move in; new job requiring relocation.
 Therapist’s Job: a) stabilize the crisis and implement an immediate, short-term plan of action; b) implement supports by the partner; consider
ancillary counseling (individual, group or family); c) push off final decisions about the fate of the relationship, if possible. If not, consider a
“structured separation”, then determine interest in repair of the relationship or separation.
2. Trauma or life-changing event may befall one partner: rape; victim of a crime; death of a loved one; job loss; major illness or health related loss
 Therapist’s Job: first stabilize the crisis and implement an immediate, short-term plan of action. Then determine interest in repair of the relationship
B. Stable Unsatisfactory Situation In a “stable unsatisfying” relationship however, the couple has accommodated to change, albeit in
an unhealthy or dissatisfying way. The imperative for change may be less defined and pose a challenge to deduce, including by the partners:
1. Has an illness or symptom worsened or become manifest in a more vulnerable member, such as a child?
2. Has pressure been brought to the couple from the outside, such as by the school, the court or by one’s job?
3. Has an underlying “secret”, such as incest or spousal abuse , been finally discovered or revealed?
4. Has some major shift alignments occurred such as the birth of a child or a teenager beginning the process of leaving home?
5. Is there a surreptitious plan by one of the partners to escape the relationship?
Unresolved conflicts and power-plays result in chronic fatigue and tension, either as Individual Symptoms (ie. depression, drug abuse, phobias,
failure) or Symptomatic Interactions (abuse, bickering/apathy, sexual dysfunction). Typical Presenting Problems include
◦ Sound relationship but block in communication or cooperation
◦ Pattern of bickering and fighting or lack of trust due to great hurt or betrayal/Mutual caring but lack of passion and “zing”
◦ Re-marriage or blended family problems/Complaint about Family of Origin or In-laws (triangulation; intrusion; immaturity in partner)
◦ Sexual dysfunction
◦ Dysfunction in One Partner (ie. depression, phobias)
 Therapist’s Job: a) explore what has changed (“Why now?”) b) push the dead-lock and disengage and re-direct the power-play; alternatively create
a crisis c) push off final decisions about the fate of the relationship, but force an “interim” direction toward repair or separation.

22. Conflict is always about Power, influence and control within the relationship system:
 Tend to occur around issues of money, work, sex, children, chores, and “in-laws”. Determines style of communication and how
love, caring, anger, and other emotions are expressed and understood
 Determines style of decision-making and problem-solving;
 Defines level of trust for meeting or not meeting needs;
 Establishes rules for interdependence and independence and for distance and closeness between members (attachment/mutual
accommodation; affection/expressing and experiencing love)
 Defines roles, or positions, taken or assigned: reciprocal, interactive patterns of behavior (typically from the Family of Origin,
thereby possessing an intergenerational quality) that the individual is expected to maintain. They are relatively enduring
(permanent) and acquire “moral character” and have ‘status’, thereby determining placement on the power hierarchy.
Chronic conflict is a stalemate, a power-play that breeds tension and duress: “When anxiety increases and remains
chronic for a certain period, the organism develops tension, within itself or in the relationship system; the tension may result in
physiological symptoms, emotional dysfunction, social illness or social misbehavior” (Bowen).
Faulty remedies ingrain the stalemate and result in feelings of hopelessness:
 Failed Remedies: previous counseling, mediation, consultation with attorney, legal separations
 Power-less Power: One partner becomes dysfunctional, fails or becomes the Identified Patient (I.P.)
 Equal but Separate: solo activities, hobbies or individual interests; mutual or solo acts of defiance, selfishness, or betrayal
 Combat: fighting, forcing, hurting, beating, withholding, stealing, etc. often involving outside groups (triangulation) such as the
police, the courts or spouse abuse programs/shelters
 Alliances, Coalitions, Collusions and Triangles/Triangulation: patterns of adding power or deflecting anxiety through the
inclusion of a third-party, such as friends, family, children or extra-marital affairs or relationships
22

23.  Begin here or here 
1. Tell me about your relationship and how it began?
2. What brings you to see me? or What do you see as the pain in the relationship/marriage? (Symptom)
3. What happens when this problem occurs? (Underlying Dysfunctional Interaction/Pattern)*
* Note how the unresolved conflict manifests itself. How does the Power-play play-out?
Descriptors & History (collected as presented or needed
over the first few sessions)
1. Partners: Brief description of partners/partnership, including names; ages/DOBs;
occupations/work histories; educational background; race, religion and cultural factors; Family of
Origin 3-generation data; physical appearances; history of relationship, including children,
previous “marriages”, separations, “divorces”, etc. ;illnesses/medical conditions;
income/finances; resources, including transportation, home ownership/rental arrangements; major
family cut-offs
2. History: Brief history of relationship including onset and chronology of couple events;
family of origin, extended family and partner’s family; friends and other sources of stress and
support; re-locations, neighborhood/landlord issues
3. Process: Explore what happens with differences, problems and conflicts; inquire as to how
the couple make decisions, who participates and how; explore issues of attraction and mate
selection, parenting styles, individual and couple ways of dealing with anger, grief and so on.
Joining and agreement to work toward separation or repair of the relationship
23

24. Couple counseling is nothing more than getting two people to work effectively together as a team. Hurt and
betrayal must be mended and success in some joint achievement experienced.
1. Disengage and re-direct the inherent power-play
◦ Obtain commitment to work as a team (push off final decisions about the fate of the relationship)
◦ Implement a truce and exchange “acts of good faith”
◦ Turn the dyad’s energies toward a common purpose, goal or problem
2. Effective Teamwork
◦ Obstacles to effective team-work
 Power-plays: over-powering (bullying) or under-powering to get one’s way or ends met
 Traumatizing: wounding the partner or self-mutilation; picking the scabs off trauma
 Alliances, Coalitions, Collusions, Triangulation
◦ Supports to effective team-work
 Conflict-resolution skills: planning for outcome, decision-making, problem-solving
 Forgiveness/Repairing Trust: tenderness, affection, appreciation and respect
 Experiencing success working as a team
24

25. 1. Sets appointment, cancels/no-shows; sets appointment, cancels/no-shows
2. Spouse/Partner sets appointment, partner refuses to attend
3. One sets appointment, then sabotages their partner’s participation
4. Both attend, one sees a problem, one does not
5. Both attend, both agree that one partner is the problem (identified patient/I.P.)
6. Both attend, agenda moves to Individual Counseling (I/C) or child focus (F/C)
7. Both attend, one begins to No-show (leaving therapist with partner/spouse)
8. Both attend, one drops a “bomb” (ie. sexual affair, drug abuse, major illness)
9. Both attend, one discloses their desire to separate or divorce
10. Both attend, one or both unclear on commitment (separate or remaining together)
11. Both attend, one or both continually triangulate the therapist
12. Both attend, the agenda and goal of therapy continually changes or vacillates
25