Forming and managing the triangle relationships is the challenge of couples therapy

1. LECTURE 3. THE
THERAPEUTIC RELATIONSHIP
IN A COUPLE CONTEXT
COUPLE COUNSELLING SKILLS
KEVIN STANDISH

2. LEARNING OUTCOMES
1. How couple counselling differs from working with individual clients.
2. Building the Therapeutic Alliance in couples (Rait 2000)
3. Explore The Milan Principles (Brown 2010)
4. The Challenge of Creating Dialogical Space for Both Partners in Couple
Therapy (Rober 2015)
5. DEVELOPING THE WORKING ALLIANCE IN MARITAL THERAPY A
PSYCHODYNAMIC PERSPECTIVE (Patalano 1997; Scharff 2014;
Bagnini 2014)
6. Behavioral Couple Therapy: Building a Secure Base for Therapeutic
Integration (Gurman 2013)
7. Reflexivity and the use of self in the couple (GRANT & CRAWLEY 2001)

3. 1. HOW COUPLE COUNSELLING DIFFERS TO
WORKING WITH INDIVIDUAL CLIENTS.
C
1
Single client
therapist
model

4. WHO IS THE CLIENT: EACH PARTNER OR THE
COUPLE RELATIONSHIP?
•Moving from dyad to triad: the therapeutic triangle
Relating to them as a coup

5. PRESENTING ISSUES
•http://www.psychotherapy.net/video/emotionally-
focused-therapy-training
•3:30 min

6. FEEDBACK
•What did you see the therapist doing to ensure a
good therapeutic alliance is built?

7. 2. BUILDING THE THERAPEUTIC ALLIANCE
IN COUPLES (RAIT 2000)
https://www.youtube.com/watch?v=rgWnadSi91s
John Gottman: How to Build Trust 5min

8. FEEDBACK
•What can you do to help build trust in clients as a
couple in therapy?

9. THE THERAPEUTIC ALLIANCE COUPLES DIFFERS
FROM INDIVIDUALS IN THAT THE THERAPIST HAS
TO MAINTAIN MULTIPLE ALLIANCES
SIMULTANEOUSLY
• 5 important dimensions of the therapeutic alliance that apply
to the couples context:
1. The patient’s affective bond with the therapist,
2. the patient’s capacity to work effectively in therapy,
3. the therapist’s empathic understanding and involvement,
4. the agreement of patient and therapist on the tasks and
goals of therapy.
5. The couples capacity to mutually invest in, and collaborate
on, the therapy

10. MAINTAIN MULTIPLE ALLIANCES
SIMULTANEOUSLY
•Because there are multiple participants in couples,
simply meeting with a couple can be challenging,
especially for the beginning therapist.
•Couples sessions tend to be noisier and more
openly conflictual than the individual psychotherapy.
•Difficulties inmanaging the multi- sourced
therapeutic conversation,
•

11. MAINTAIN MULTIPLE ALLIANCES
SIMULTANEOUSLY
•recognizes that not every partner comes to treatment
with equal motivation, similar goals, or agreed-upon
beliefs about how to change.
•Couples therapy is conducted with individuals who are
to some degree, involuntary clients.
•As a result, many couple therapy approaches have paid
extensive attention to the beginning phase of treatment,
especially given the higher rates of premature
termination reported than in individual treatment

12. MAINTAIN MULTIPLE ALLIANCES
SIMULTANEOUSLY
• The therapist’s alliance with one or two family members
inevitably affects the alliance with other family members in a
circular, reciprocal fashion, no single dyadic or triangular
alliance can be considered in isolation.
• In couples the therapist needs to develop different levels of
alliance, including an alliance with each individual partner and
the couple as a whole.
• The couples therapist must be skilled at developing and
maintaining a functional therapeutic milieu that continually
balances the therapist’s relationship with each partner, as well
as the couple as a whole

13. THEY MUST ADOPT A CONCEPTUAL FRAMEWORK
THAT ACCOUNTS FOR INTERACTIONS IN
TRIANGLES AND HOW DIFFERENT MODELS PLACE
THE THERAPIST IN DIFFERENT POSITIONS
•dyadic exchanges are viewed within the context of
triangular relationships.
•Knowledge of triangles provides the therapist with a
way to think beyond the symmetrical and
complementary exchanges that characterize dyadic
interactions to three-person interactions.

14. INTERACTIONS IN TRIANGLES
•While a two person system may be stable as long as
it is calm, the dyad will immediately involve “the
most vulnerable other person to become a triangle”
when anxiety increases (Bowen, 1976, p. 76).
•If the emerging tension becomes too great for the
threesome, the system then can be expected to
engage others in a series of interlocking triangles

16. INTERACTIONS IN TRIANGLES
•Haley (1976) has asserted that the therapist needs
to include himself or herself in the description of the
couple:
• “When doing therapy with a couple, it is best for the
therapist to consider that whatever the partners do in
relation to each other is also in relation to the
therapist.”
•Thinking in terms of triangles carries important
implications for therapeutic practice.

17. INTERACTIONS IN TRIANGLES
•Unlike the therapist in individual psychotherapy,
the couple’s therapist must be able to join and
manage skillfully an alliance with each member of
the couple, as well as the couple as a unit.
•The therapist needs to be able to move freely
back and forth between members of the couple,
always attending to invitations to join one against
the other.

18. DIFFICULTIES IN THE THERAPEUTIC
ALLIANCE
• Whatever the therapist’s model of treatment, understanding of
the couple’s patterns, as well as his or her own participation in
them, problems in the therapeutic alliance do arise.
• While these impasses can be both frustrating and
demoralizing, they also represent a potential learning
opportunity for clinician and couple alike.
• the therapeutic impasse in couple therapy is a deterioration in
the therapeutic relationship in which the therapeutic
experience has lost its emotional energy.

19. DIFFICULTIES IN THE THERAPEUTIC
ALLIANCE
•they also provide the therapist and patient with
“indispensable information” and the opportunity for
genuine, corrective learning.
•According to Whitaker (1968), the responsibility to
prevent or terminate an impasse lies with the
therapist.

20. DIFFICULTIES IN THE THERAPEUTIC
ALLIANCE
•couple therapists,
regardless of
theoretical
orientation, may seek
to protect themselves
through:
•over-involvement,
• increasing isolation,
•or overreliance on
• Indications that the therapist is experiencing
a therapeutic impasse include:
• insufficient joining,
• lack of therapeutic intensity,
• lack of pacing,
• inability to challenge the system,
• diffusing conflict,
• being “ahead” of the couple,
• over identifying with one partner member,
• taking too central and directive a position

21. DIFFICULTIES IN THE THERAPEUTIC
ALLIANCE
•In each case, the fit between the therapist and
family’s goals, style, and preferences contribute to
the quality of the therapeutic alliance.
•While ruptures in the therapeutic alliance can
present a serious barrier to therapeutic progress,

22. THERAPEUTIC ALLIANCE AND PROGRESS IN
COUPLE
THERAPY: MULTIPLE PERSPECTIVES
(GLEBOVA 2011)
• There was very little change in alliance over the early sessions of
therapy, and
• changes in alliance did not always account for changes in
relationship satisfaction.
• Husbands’ perceptions of satisfaction and alliance seem to play
an important role in the dynamics of the therapeutic process.
• Findings suggest a reciprocal relationship between perceptions
of alliance and
• progress in therapy when combining perceptions of therapists
and couple clients.

23. 3. EXPLORE THE MILAN
PRINCIPLES (BROWN 2010)
THE MILAN PRINCIPLES OF HYPOTHESISING CIRCULARITY AND
NEUTRALITY
IN DIALOGICAL FAMILY THERAPY: EXTINCTION; EVOLUTION;
EVICTION... OR EMERGENCE?

24. COPYRIGHT © ALLYN & BACON 2003
CIRCULAR CAUSALITY: KEY
CONCEPT UNDERLYING SYSTEMIC
THERAPY
We mutually influence each other
via–
• Patterns of Interaction
• Family members’ characteristic
ways of behaving.
• Centrality of Communication
• Patterns of interaction expressed
are both verbal and nonverbal.
• “One cannot not communicate.”

25. CIRCULAR CAUSALITY
• Circular causality refers
to the fact that in family
systems, each family
member’s behavior is
caused by and causes
the other family
members’ behaviors.
They are each
impacting the other, in
a circular manner.

26. CIRCULAR CAUSALITY
• The distancer-pursuer and overfunctioner-underfunctioner are
just two examples of the sorts of circular patterns that can
develop in families. There are many other possibilities.
• A good clue to a “circular” pattern is when people tend to
respond in predictable ways to each other, and their
responses may become more extreme or even “stubborn”
over time.

27. CIRCULAR CAUSALITY:
DISTANCER-PURSUER

28. MILAN SYSTEMIC FAMILY THERAPY
KEY CONCEPTS
1.Hypothesizing
2.Circular questioning
3.Neutrality

29. 1. HYPOTHESIZING
• Systemic hypothesizing is the Milan therapist’s way of confirming or
disconfirming necessary information regarding how the family
functions and how the therapist conceptualizes their functioning.
• Hypothesizing begins with the initial telephone call from the family.
• Prior to the first session, the Milan team exhausts all possible
hypotheses about the family’s symptoms and functioning based on
the telephone conversation.

30. HYPOTHESIZING
• reflecting team members inform the therapist halfway through the
session of the new developed hypothesis.
• A new therapeutic direction may develop based on the consensus
of the reflecting team
• As the session comes to a close, the team arrives at a final neutral
hypothesis : the most systemic and powerful hypothesis for the
family.
• The final hypothesis not ascribe blame to any single family
member; often results in a prescription or ritual developed by the
reflecting team.
• Later, after the family leaves, the reflecting team and therapist
discuss how the family reacted to the intervention and plan for the
next session.
• In some cases, a therapeutic letter is written

31. CIRCULAR QUESTIONING
• Circular questioning is an interviewing method
used to gain descriptive assessments and deliver
interventions through questioning of the family
members
• Circular questioning is to expand the family’s
beliefs beyond the meanings that they currently
hold.
• This is often done by asking questions to
individuals that probe how others view the
situation.

32. CIRCULAR QUESTIONING
• Meaning formulation is an important component of this
approach to develop context. “Without context, there is no
meaning” (Campbell, 2003, p. 19).
• to examine their belief systems and the Meanings that they
attached to their behaviours.
• based on inquiries about the differences within the
relationships of family members and their perceptions

33. CIRCULAR QUESTIONING
• The therapist continually searches for patterns, feedback loops,
differences in beliefs among family members (called openings),
and the covert rules that support family interactions.
• openings allow a place during the session to begin questioning, ,
and exploring differences
• Circular questioning is an attempt for the therapist to see each
person’s point of view. This later changed to curiosity (Cecchin
1987)
• What is the symptom that the patient presents? What is it there
for? What function might it serve?
• What is the context of the symptom, i.e. what is happening
when the symptom occurs?
• Why now? Why this symptom? Who can make it better, who
can make it worse?
• Who is affected by the symptom? How? How does the
symptom affect the family and how does the family deal with it?

35. NEUTRALITY/CURIOSITY
• neutrality was that if every family member were asked at the end
of a session, ‘Whose side was the therapist on during the
session?’ they would all say, ‘My side’”
• neutrality has been misunderstood and challenged as implying
cold or aloof (Cecchin, 1987)
• A curious therapist allows all family members a voice
• Therefore, adhering to neutrality, the curious therapist is more
likely to be open to numerous hypotheses about the system and
invite the family members to explore those hypotheses, increasing
the number of options for change

36. THE MILAN PRINCIPLES (BROWN 2010)
• The primary aim of the three Milan principles of hypothesising, circularity
and neutrality
• was to proffer an effective methodology for interviewing families,
• with a secondary aim of casting off the stereotypical personal therapist
qualities such as intuition, charisma and concern
• The relevance of the three principles to the therapeutic process, the
therapeutic role and the therapeutic relationship is considered.
• seeks to conceptualise a vague 'knowing' that there is continual learning
and growth in grappling with the tensions in this field, in remaining ever
curious, in asking the questions ...

37. JOIN THE COUPLE SYSTEM
•The therapist engages the couple and becomes
empathically and emotionally connected to each
person
•Partners must experience the therapist empathy and
support for each of them individually and as a couple
if they working alliance is to be established

38. JOIN THE COUPLE SYSTEM
•A holding environment and blame free context for
the therapeutic work must be established with an
atmosphere of safety prevailing to allow risk taking
an exploration of vulnerabilities
•Joining with the couple involves collaborating with
them

39. JOIN THE COUPLE SYSTEM
•The therapist must be an active participant, structuring
and guiding the work while at the same time, conveying
the belief that the couple possess the power, strength
and resources to facilitate change
•Adequate and continuous joining is the glue that holds a
couple and therapist together

41. 4. THE CHALLENGE OF CREATING
DIALOGICAL SPACE FOR BOTH PARTNERS
IN COUPLE THERAPY (ROBER 2015)

42. THE CHALLENGE OF CREATING DIALOGICAL
SPACE
FOR BOTH PARTNERS IN COUPLE THERAPY
(ROBER 2015)• Dialogue in marital and family therapy (MFT) is by definition a multi-
actor dialogue the conversation is often tension filled and can have
dramatic real life consequences for family members
• the therapeutic relationship and the concept of not knowing
• marital and family therapist cannot escape the uncomfortable position
of being responsible to find ways to actively contribute to a helpful
dialogue with clients;
• a dialogue that is not a natural given, but rather a project that needs
the therapist’s constant consideration and care

43. CONCEPT OF NOT KNOWING
• Described as a general attitude in which the therapist’s
actions communicate a genuine curiosity
• In order to really listen to the client’s story, and to really
understand what the client means, the therapist needs to
be not knowing in the sense that he/she has to suspend
his/her own assumptions and preconceptions, and be
open to what the client wants to convey.
• The therapist is not the expert, but rather the client is
seen as such.
• HOWEVER The notion of the client as an expert does not
deny that a therapist has expertise!

44. KEY POINTS CREATING DIALOGICAL SPACE FOR
BOTH PARTNERS
1. The therapeutic relationship in a multi-actor setting is complex.
2. Free and spontaneous dialogue, in which mutual understanding and
intimacy can grow, is the exception rather than the rule as tension is at the
core of dialogue.
3. As a therapist who adopts a receptive stance too early in the first marital
therapy session can reinforce an already existing imbalance in the couple,
the therapist cannot escape the uncomfortable position of having the
responsibility to find ways to actively contribute to a helpful dialogue with
the clients.
4. A couple therapist needs to find a way to transform the antagonism in the
relationship into an agonism, in which tension and conflict are accepted
and talked about, and in which the partner can sometimes be seen as an
opponent or an adversary, but never as an enemy.

45. 5. DEVELOPING THE WORKING
ALLIANCE IN MARITAL
THERAPY A PSYCHODYNAMIC
PERSPECTIVE (PATALANO
1997; SCHARFF 2014; BAGNINI
2014)

46. DEVELOPING THE WORKING ALLIANCE IN MARITAL THERAPY; A
PSYCHODYNAMIC PERSPECTIVE (PATALANO 1997)
• A good working alliance in marital therapy is one in which
the partners are actively collaborating with their therapist to
work through conflicts.
• The therapist begins to develop the alliance by setting the
frame of therapy and helping the couple understand the
guidelines of treatment.
• The partners gradually identify with and emulate the
therapist's working style and use of self as a reflective
instrument.

47. ESTABLISHING A THERAPEUTIC
RELATIONSHIP IN ANALYTIC COUPLE
THERAPY (SCHARFF 2014)
• The therapist approaches the couple, not as two individuals
meeting the therapist, but as a couple.
• The patient is the couple relationship, not the two spouses who
comprise it.
• To deal with the couple, the therapist must enter a couple state of
mind as she addresses the task of the first interview and hopes to
move beyond assessment into couple therapy.

48. THE TRIANGULAR FIELD OF COUPLE
CONTAINMENT
(BAGNINI 2014)
• search for clinical ideas that reveal the unconscious
pathological matrix of couple relating (projections and
introjections; transference and countertransference)
• and provide therapeutic guidelines for ameliorating their
destructive hold on couple life
• Containment of the couple’s primitive defences and
anxieties is essential to establishing a safe working
alliance,
• but containment and its rupture reveals how therapists get

49. 6. BEHAVIORAL COUPLE THERAPY:
BUILDING A SECURE BASE FOR
THERAPEUTIC INTEGRATION (GURMAN
2013)
HTTPS://WWW.PSYCHOTHERAPY.NET/VIDEO/BEHAVI
ORAL-COUPLES-THERAPY-VIDEO
4 MIN

50. FEEDBACK
•Reflections on therapist approach?

51. BEHAVIORAL COUPLE THERAPY: BUILDING A
SECURE BASE
FOR THERAPEUTIC INTEGRATION (GURMAN2013)
• Integrative behavioral couple therapy (IBCT), the most visible and
influential of the several BCT approaches, is examined, with
particular attention to its functional–contextual base and the nature
and role of functional analysis in clinical case conceptualization.
• It is argued that continuing enhancement and refinement of IBCT as
an integrative therapeutic method will require greater flexibility in the
techniques that are used and increased
• attention to the self of the IBCT therapist.

52. ENGAGING MEN IN COUPLES' THERAPY
• https://www.youtube.com/watch?v=nP0N0UIkPEY
• 2min21

53. 7. REFLEXIVITY AND THE USE OF SELF IN
THE COUPLE THERAPY(GRANT & CRAWLEY
2001)

54. REFLEXIVITY AND THE USE OF SELF.
•The loss of reflective space.
• Countertransference and reactions
•Alliance with one partner versus the
other partner

55. THE SELF IN THE COUPLE RELATIONSHIP:
PART 1
JAN GRANT AND JIM CRAWLEY (2001)
•the importance of the ‘goodenough’ development
of the core self in the couple relationship
•It argues that difficulties in the development of the
self lie behind a significant number of troubled
couple relationships.
•individual therapy, by assisting in the development
of a more cohesive sense of self in the individual,
inevitably has an impact on the individual’s

56. THE SELF IN THE COUPLE RELATIONSHIP:
PART 2
JIM CRAWLEY AND JAN GRANT (2001)
•focuses on the significance of ‘the self’ for couples
therapy,
•argues that couples therapy may sometimes need to
include therapeutic work with one partner to
facilitate change in the relationship.
•Conceptualization of the couple relationship as ‘a
transitional space’ is central.
•Links to the idea of “containment” in couples

57. SUMMARY
1. Couple counselling differs from working with individual clients. It
involves working with triangles of relationships.
2. Building the Therapeutic Alliance in couples involves joining with
both individuals who make up the couple as well as the couple as a
unit
3. Systemic principles inform the feedback loops and the circularity of
interactions.
4. It is important to create Dialogical Space for Both Partners
5. Your therapeutic approach will determine the kind of working
alliance you develop
6. Reflexivity and the use of self in the couple is vital to understanding

58. SUE JOHNSON EMOTIONALLY FOCUSED COUPLES
THERAPY (EFT) IN ACTION VIDEO
• https://www.youtube.com/watch?v=xaHms5z-
yuM&ebc=ANyPxKrrw1smza8vU0370VX2xcOrvc1pXijShxyXOMv
n1AmFs0vBUFpxYqDWaXF0Xgj8qhStZkNP
• 3:49 min

59. CORE READINGS

60. EXTRA READINGS