[Paleopsych] NYT: Married With Problems? Therapy May Not Help

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Health > Mental Health & Behavior > Married With Problems? Therapy May Not Help
http://www.nytimes.com/2005/04/19/health/psychology/19coup.html
    By SUSAN GILBERT

    Each year, hundreds of thousands of couples go into counseling in an
    effort to save their troubled relationships.

    But does marital therapy work? Not nearly as well as it should,
    researchers say. Two years after ending counseling, studies find, 25
    percent of couples are worse off than they were when they started, and
    after four years, up to 38 percent are divorced.

    Many of the counseling strategies used today, like teaching people to
    listen and communicate better and to behave in more positive ways, can
    help couples for up to a year, say social scientists who have analyzed
    the effectiveness of different treatments. But they are insufficient
    to get couples through the squalls of conflict that inevitably recur
    in the long term.

    At the same time, experts say, many therapists lack the skills to work
    with couples who are in serious trouble.

    Unable to help angry couples get to the root of their conflict and
    forge a resolution, these therapists do one of two things: they either
    let the partners take turns talking week after week, with no end to
    the therapy in sight, or they give up on the couple and, in effect,
    steer them to divorce.

    "Couples therapy can do more harm than good when the therapist doesn't
    know how to help a couple," said Dr. Susan M. Johnson, professor of
    psychology at the University of Ottawa and director of the Ottawa
    Couple and Family Institute.

    One couple, in Boonton, N.J., saw two marriage counselors over 13
    years.

    "One therapist hurt our marriage and actually a caused our
    separation," said the husband, Jim, who did not want his last name
    used out of concerns for his privacy.

    "She told my wife, 'You don't have to put up with that,' " referring
    to his battle with alcoholism, he said.

    To be sure, many couples credit counseling with strengthening their
    marriages. And therapists say that they could save more marriages if
    couples started therapy before their relationships were in critical
    condition.

    "Couples wait an average of six years of being unhappy with their
    relationship before getting help," said Dr. John Gottman, emeritus
    professor of psychology at the University of Washington and executive
    director of the Relationship Research Institute in Seattle. "We help
    the very distressed couples less than the moderately distressed
    couples."

    In the last few years, efforts to find ways to save more marriages and
    other long-term relationships have increased.

    With an experimental approach called integrative behavioral couples
    therapy, for example, 67 percent of couples significantly improved
    their relationships for two years, according to a study reported in
    November to the Association for the Advancement of Behavior Therapy.

    Instead of teaching couples how to avoid or solve arguments, as
    traditional counseling techniques do, the integrative therapy aims to
    make arguments less hurtful by helping partners accept their
    differences. It is based on a recent finding that it is not whether a
    couple fights but how they fight that can destroy a relationship.

    Especially encouraging, all of the couples in the study were at high
    risk of divorce. "Many had been couples therapy failures," said Dr.
    Andrew Christensen, a professor of clinical psychology at the
    University of California, Los Angeles and the lead author of the
    study.

    But some experts who were trained as couples therapists have now
    become so disillusioned that they question the value of couples
    therapy in any form. They say that couples are better off taking
    marriage education courses - practical workshops that teach couples
    how to get along and that do not ask them to bare their souls or air
    their problems to a third party.

    Two large nationwide marriage education programs, Practical
    Application of Intimate Relationship Skills and the Prevention and
    Relationship Enhancement Program, offer such workshops.

    "When I was a practicing therapist, I was like a judge listening to
    each partner tell why the other was ruining the marriage," said Diane
    Sollee, a former couples therapist who founded Smartmarriages, a
    clearinghouse of marriage education programs. "There was a lot of
    crying. Marriage education classes are more empowering."

    Developed several decades ago mainly to prevent marital problems in
    newlyweds or engaged couples, marriage education programs are now
    attracting couples who have not been helped by couples therapy but who
    want to try one last thing before deciding to divorce.

    How effective these programs are is unclear.

    Some studies indicate that couples who take marriage education classes
    have a lower divorce rate than couples who do not take the classes.

    But Dr. Gottman, who uses marriage education workshops and couples
    therapy, has found that workshops alone are insufficient for 20
    percent to 30 percent of couples in his research. These couples have
    problems - like a history of infidelity or depression - that can be
    addressed only in therapy, he said.

    Couples therapy, also called marriage counseling and marriage therapy,
    refers to a number of psychotherapy techniques that aim to help
    couples understand and overcome conflicts in their relationship.

    It is conducted by psychologists, psychiatrists and social workers, as
    well as by marriage and family therapists.

    Three types of couples therapy have been found to improve people's
    satisfaction with their marriage for at least a year after the
    treatment ends.

    The oldest approach, developed more than 20 years ago but still widely
    used, is behavioral marital therapy, in which partners learn to be
    nicer to each other, communicate better and improve their
    conflict-resolution skills.

    Another, called insight-oriented marital therapy, combines behavioral
    therapy with techniques for understanding the power struggles, defense
    mechanisms and other negative behaviors that cause strife in a
    relationship.

    With each method, about half of couples improve initially, but many of
    them relapse after a year.

    A relatively new approach that studies have found highly effective is
    called emotionally focused therapy, with 70 to 73 percent of couples
    reaching recovery - the point where their satisfaction with their
    relationship is within normal limits - for up to two years, the length
    of the studies.

    Dr. Johnson, who helped develop emotionally focused therapy in the
    1990's, said that it enabled couples to identify and break free of the
    destructive emotional cycles that they fell into.

    "A classic one is that one person criticizes, the other withdraws,"
    she said. "The more I push, the more you withdraw. We talk about how
    both partners are victims of these cycles."

    As the partners reveal their feelings during these cycles, they build
    trust and strengthen their connection to each other, she said.

    Surprisingly, Dr. Johnson said, until emotionally focused therapy came
    along, therapists were so intent on getting couples to make contracts
    to change their behavior that they did not delve into the emotional
    underpinnings of a relationship.

    "It was like leaving chicken out of chicken soup," she said.

    Dr. Johnson's latest research, completed in January, included 24 of
    the most at-risk couples, people who were unable to reconcile because
    their trust in each other had been shattered by extramarital affairs
    and other serious injuries to their relationship.

    "These injuries are like a torpedo," she said. "They take a marriage
    down."

    The study found that after 8 to 12 sessions, a majority of the couples
    had healed their injuries and rebuilt their trust.

    Most important, these gains lasted for three years. "It's very
    satisfying to know that we can make a difference with these couples
    and that it sticks," Dr. Johnson said.

    Alice, a library program coordinator in Honesdale, Pa., credits her
    couples therapy, which focused on emotional issues, with getting her
    and her husband to reunite after a yearlong separation.

    "The marriage counselor brought us back together," she said.

    Alice, who did not want her last name used out of privacy concerns,
    said an important catalyst for their reunion was the therapist's
    asking each to think about the ways that the other person wanted to
    feel appreciated and loved. Gradually, she said, she has come to see
    that her husband's needs were different from her own.

    "Going back to this exercise is one thing that has gotten us through
    hard times," she said.

    Researchers have begun to identify which qualities in a couple make
    for a lasting relationship. The findings challenge some common
    assumptions - that couples who fight a lot are beyond help, for
    example.

    Over more than two decades of videotaping and analyzing the behavior
    of happy and unhappy couples, Dr. Gottman has found that all couples
    fight and that most fights are never resolved. What is different
    between happy and unhappy couples is the way they fight.

    The happy couples punctuate their arguments with positive
    interactions, he said, like interjecting humor or smiling in fond
    recognition of a partner's foibles. The unhappy couples have corrosive
    arguments, characterized by criticism, defensiveness and other
    negative words and gestures.

    Of course, even the happiest of couples can get nasty sometimes. But
    Dr. Gottman has found that as long as the ratio of positive to
    negative interactions remains at least five to one, the relationship
    is sturdy. When the ratio dips below that, he says, he can predict
    with 94 percent accuracy that a couple will divorce.

    Dr. Gottman says that couples therapists can use this information to
    help keep couples together. "You can't just teach a couple to avoid
    conflict," he said. "You have to build friendship and intimacy into
    the relationship. If you don't, the relationship gets crusty and
    mean."

    But not all marriages are salvageable, therapists say. "Some people
    are fundamentally mismatched, and they can't benefit from therapy,"
    Dr. Gottman said.

    Others - beyond the scope of couples therapy or marriage education
    programs - are people with personality disorders and relationships
    marred by violence and intimidation.

    "We have nothing to offer them," he said.

    Couples therapy is designed to be relatively short term: 26 weeks or
    less.

    "The vast majority of my patients do better after 5 to 10 sessions and
    are satisfied. The cycle of blaming is interrupted," said Dr. John W.
    Jacobs, a psychiatrist in New York and author of the 2004 book "All
    You Need Is Love and Other Lies About Marriage."

    But even when a therapist loses hope in a couple's future, the couple
    may not give up. Many couples, determined to avoid becoming yet
    another divorce statistic, keep searching for new therapists or
    programs to help them stay together.

    After two rounds of couples therapy and one separation, Jim, of
    Boonton, and his wife, Valerie, decided to try Retrouvaille, a program
    of intensive weekend workshops and follow-up seminars affiliated with
    the Roman Catholic Church and geared to couples who are on the verge
    of divorce or separation.

    "There are talks on various subjects, like disillusionment,
    forgiveness and the sacrament of marriage, and then you write about
    them," Jim said. "The big focus is on feelings. You end up feeling
    what your partner feels."

    Another advantage for Jim is that Retrouvaille did not have the stigma
    of therapy.

    "Regular people get up and tell their stories about infidelity,
    overspending and other problems," he said. "There's comfort in
    numbers. It takes away some of the embarrassment and shame."

    Six years after their Retrouvaille weekend, Jim and Valerie now lead
    Retrouvaille sessions, symbols of hope to couples on the edge. But
    they still struggle with their own marriage.

    "We both realize that our marriage is something that needs to be
    worked on," Jim said. "But we're committed to staying together."