Ellen F. Wachtel, Ph.D, JD, is the author of “The Heart of Couple Therapy : Knowing What to Do and How to Do It” and a clinical psychologist in private practice in New York City. Dr. Wachtel is an adjunct faculty member at the Ackerman Institute for the Family.
Your book, “The Heart of Couple Therapy: Knowing What To Do And How To Do It,” presents an integrative approach to couple therapy. Which therapeutic traditions have you incorporated and who in the field has influenced your approach?
I first started integrating various approaches when doing family therapy with parents and young
children (see my 1994 book, “Treating Troubled Children and Their Families”). At that time, the integration consisted largely of introducing psychodynamic and cognitive-behavioral understanding and interventions into a family systems foundation.
Initially, in my work with couples, I integrated an understanding of each individual’s psychodynamic issues into what was primarily a solution-focused approach. I used the genogram not only to understand the transmission of family patterns across generations but also as a window into each person’s psyche, world-view, and both conscious and pre-conscious schemas and wishes.
Over time, my work with couples expanded to include the emotion-focused work of Les Greenberg and Sue Johnson; the focus on vulnerability cycles as described by Michele Scheinkman and Mona Fishbane; and the more direct work on sexuality described by Ester Perel and Suzanne Iasenza.
What are some of the most difficult things that clinicians who do couple therapy tend to struggle with, and how did you aim to address these things with your book?
Working with couples can be highly gratifying but not infrequently, good sessions, in which the couple seems to “get” the unproductive cycles in which they engage, do not lead to enduring change. Both the couple and the therapist can feel stuck and demoralized by how entrenched these patterns can be, despite the couple’s good will, insight and desire to change.
My book describes numerous methods designed to help motivate each individual to expand his or her sense of self and to combat the all too common feeling that “this is just the way I am.”
The book demonstrates how consistent attention to the couples’ strengths, the noticing of steps in the right direction (for example, being more emotionally open in a session) and the generous use of positive feedback helps combat despair and brings out the best in each partner.
Another common difficulty in couple therapy is that the sessions devolve into mutual complaints and counter accusations, leaving the couple feeling as bad or even worse than when they first arrived at the meeting. Therapists must learn how to change the focus from complaints to longings.
Rather than blaming one’s partner, each person is encouraged to search inside himself and change his or her role in problematic interactions. Right from the beginning of the work, I encourage self-examination and humility by asking each person, “what do you know about yourself that makes you not the easiest person in the world to live with?”
In the introduction to your book, you talk about the ever-evolving method of integrative couple therapy that you’ve developed through years of practice. What advice would you give about developing an integrative approach to a newer clinician who is interested in incorporating a range of methods and techniques into their practice?
Therapists need to have a large repertoire of methods since each couple is unique and the particular form of integration will vary from couple to couple. So for instance, one couple may need to work on connecting at a deeper level emotionally, while another’s difficulties may be primarily based on a lack of know-how in regard to resolving conflicts.
Both beginning and experienced therapists should take workshops and read books on a variety of approaches so they have the tools to innovate and design a form of integration that not only works for the couple, but feels natural and organic to the therapist.
One particularly useful place to learn a variety of ways of working and how to integrate them is at the annual meetings of The Society for Psychotherapy Integration. Although the particular integration will vary both from couple to couple and therapist to therapist, the aim with all couples is to help them relate to one another in a “brainstorming,” non-adversarial manner so that they can not only resolve conflicts but also try to gratify each other’s longings.
The therapeutic relationship is an interesting aspect of couple therapy; it is an equally important factor in achieving positive outcomes, but it must be approached differently with a couple. What are some of the key points for establishing this alliance in couple therapy that are different from how it’s approached in individual therapy?
Often, in individual therapy we initially form a therapeutic alliance by empathizing with what the patient is feeling. In couple therapy, we must be careful not to appear to be siding with one person. Too much expression of empathy for one person can feel like a rebuke to the other.
Rather, we can express empathy and understanding for what they, as a couple are going through. The doubts, the anguish of feeling disconnected, the stress of horrible fights, the fear of the future are but a few of the many emotions that couples share and that can be empathized with and perhaps even normalized.
But even more important than that is helping the couple feel valued for how they are as a couple despite the difficulties that have brought them to your office. Giving feedback about some of the positives about the couple so that the couple feels that you like them and see their strengths as well as their problems is a crucial aspect of forming a therapeutic alliance.
So, for instance, perhaps despite their difficulties they respect each other as parents, or they have warm relationships with family and friends or they have a shared sense of humor which peeks through even when discussing their difficulties or they work well together on projects.
It is almost always possible to find something that goes well in their relationship, and by making note of that the therapist not only builds a therapeutic alliance, but helps them feel a bit less despairing about their relationship.
Your book emphasizes a strengths-based approach to couple therapy. For therapists who have been trained in psychodynamic approaches, how might this challenge them to do things differently to what they are accustomed?
One of the challenges for psychodynamically-oriented individual therapists when they do couple therapy is that therapists originally trained in psychodynamic approaches are often prone to notice emotional damage, impairment and unconscious issues that play a role in the couple’s difficulties.
Frequently these perceptions are accurate and important. But just how they are taken into account in the work and how they are balanced with perceptions of the equally crucial strengths on which change must be grounded, is often the critical difference between successful and unsuccessful couple therapy.
At the heart of this book is a detailed examination of the myriad of choice points therapists encounter in every session and the consequences of pursuing—or not pursuing—any particular line of inquiry. My hope is that this book will help therapists learn to notice and work with strengths, rather than responding first to deficits.