A COUPLE IS THE MOST POWERFUL UNIT ON OUR PLANET
Couples Group Psychotherapy: A Quarter of a Century Retrospective
Judith Coché, Ph.D., A.B.P.P., C.G.P.*
The Handbook of Group Psychotherapy. J. Kleinberg, ed. Wiley Science Press, 2012.
This chapter reviewsthe history, theory, and research behind couples group psychotherapy as a unique treatment modality created from family psychotherapy and group psychotherapy. It highlights recent integrations including psychoeducation, positive psychology and neurobiology, and presents multiple case examples for the practicing clinician. Finally, the author predicts solid growth for couples group psychotherapy, as an efficient and effective model of treatment for individuals who are coupled.
A COUPLE IS THE MOST POWERFUL UNIT ON OUR PLANET
How fortunate is the mental health professional who is fascinated daily by the interpersonal puzzles put before him in clinical practice. She will be amply rewarded for the deep investment in the clinical skills it takes a lifetime to learn. Just as no two individuals are alike, no two couples are alike. Therein lies the unending fascination with the dynamics of interpersonal space, which engages both the intellect and the senses of every clinician who undertakes couples group psychotherapy. Tragic marriages are compelling in the human drama they create for the clinician. As complex as it is to learn the specialty areas of couples psychotherapy, family psychotherapy, and group psychotherapy, the rewards of doing so make the task worthwhile.
In the last quarter of a century since the first publication of Couples Group Psychotherapyin 1990, the field has begun to come into its own. Although relatively few clinicians undertake the difficulties of learning the model, couples now request couples group psychotherapy and clinicians regularly ask to be trained in it. This chapter helps the graduate student and practicing clinician learn to use couples group psychotherapy.
This chapter briefly addresses topics found at greater length in Couples Group Psychotherapy, Second Edition(Coché, 2010). It introduces the clinician to the theoretical foundations, the structure of couples group psychotherapy, the treatment strategies, selected professional and ethical issues, a capsule of evidence-based practice, and brief future directions of couples group psychotherapy.
WHAT IS COUPLES GROUP PSYCHOTHERAPY?
Couples group psychotherapy is a treatment modality founded on integration of principles from the field of group dynamics and family therapy. A small-group structure is used to promote healing and growth for married or unmarried heterosexual or homosexual couples. Conceptual origins in systems theory are drawn from the worlds of biology (von Bertalanffy, 1968) and social psychology (Lewin, 1951); clinical application in mental health services are drawn from two usually separated but not incompatible sectors: family and couples therapy and group psychotherapy, and form a unique treatment modality which treats each individual and the couple as a unit through a psychotherapy group format. Additional expertise comes from individual psychotherapy and is modified to apply to work with couples.
THE THEORETICAL FOUNDATIONS FOR COUPLES GROUP PSYCHOTHERAPY
A brief overview of treatment skills with intimate partners precedes a discussion of theoretical foundations for couples group psychotherapy.
TREATMENT SKILLS WITH INTIMATE PARTNERS
Key concepts from philosophy and couples therapy include an existential foundation for the process of change and an intergenerational frame for couples work.
Couples therapy is a relatively new treatment modality. James A. Peterson (1968) stated that couples therapy was established as late as 1942. Defining terms became an early focus, crystallizing disagreements: conjoint marital therapy, family therapy, multi family therapy, marriage counseling, marriage therapy, couples therapy, group counseling, group therapy, and network therapy meant different things to different professionals and, to some extent, still do, making communication in the field difficult. Lacking standardization of terms, the field has splintered into cognitive therapy, marriage encounter, psychodynamic therapy, psychoeducational approaches, counseling with couples…the terms are too numerous and inexact to mention. Enthusiasm and dedication is more frequent than cognitive clarity and solid research.
Early references to couples group therapy began to appear in 1960 when C. van Emde Boas (1962) worked with a group for couples. E. Leichter (1962) also recommended couples groups for couples with problems of separation and individuation, Murray Bowen's (1971) early work with multiple-family groups was influential in James Framo's (1982) model in 1973 for couples groups. Although articles on the marital treatment of couples in groups have been appearing for three decades, the field is still in its infancy in terms of research and more frequently is referred to as “couples counseling”, a term that is rarely operationally defined.
An existential foundation provides a philosophical stance for the process of behavioral and interpersonal change in the Coché model. Through clinical interventions that strengthen the use of self, Coché teaches couples basic attitudes toward being in the world. Three existential principles underlie the work:
1. Clients seek to be more of a person in an intimate context than they have been able to achieve. Carl Whitaker and David Keith (1981) stated that the goals of psychotherapy should be to establish a sense of belonging, to provide the freedom for persons to individuate, and to increase personal and systemic creativity. The obstacles that patients construct against desired intimacy create a dysfunctional level of stability within the personality structure, blocking growth in the desired direction. Learning to be more of a person means freeing up new levels of energy and creativity by overcoming some of the obstacles constructed by oneself and by one's family. Personal and interpersonal meaning increases, and the members of a couple need no longer return to the early frustrating Modus Operandi.
2. Adult intimacy involves taking responsibility for one's actions. Intimacy is at its best for adults when the partners are able to take responsibility for their own thoughts, feelings, and behavior in relation to the other person, Therefore, adult intimacy is best achieved when partners are skillful and careful in their communication with one another. One must respect personal boundaries in order to be close to someone else. Additionally, this model of successful intimacy is skill based: it necessitates learning how to experience emotions, communicate feelings, listen to the thoughts and the feelings of another person, and negotiate conflict in a respectful manner.
3. Living life fully and responsibly entails making life choices. No matter what happens in life, each person is faced with continual choices. Barring natural disasters, adults get to choose whether to have and raise children and how to feed and care for their bodies and intellects. Living life fully requires that people own their choices: they are entitled to fully enjoy life’s pleasures and to learn from their mistakes. In the Coché model, blame is superfluous: the emphasis is on positive and constructive cognitive and dynamic handling of human concerns. Coché assumes that people make unconscious choices based on hidden conflicts that echo the legacy of an early family pain. For Coché, the therapist often magnifies the existential theme for a couple struggling with what seems to be an everyday problem. Drawing attention to the larger existential issue often opens new ways to unstick the everyday dilemma. A clinical example illustrates:
Jean and Donald married despite concerns about their competitive families. Donald is American, of Italian heritage, and Jean is Australian. Both families wanted the couple in their home country and competed for the affection of grandchildren. After Jean's completion of graduate training, the couple settled in the United States where Jean was quite unhappy. Life did not mean very much to her in a society in which she saw as highly materialistic: she deeply preferred the more laid back culture of her native outback Australia. Her longing produced a haunting internal battle for emotional survival, and Jean finally sought treatment for depression.
As treatment for both Jean and the couple progressed, they began to explore the reasons for marrying the other. Jean, raised in a highly self-contained British family culture, thought that Donald’s high-spirited Italian family often acted in bad taste and she had no interest in learning to fit into their customs. Because Donald was more flexible and quite excited about the freedom that Australia offered, the couple thought through their lives and moved with their two sons to Australia where they remain. They love living near the ocean, they love the freedom of the country, and they find great meaning together raising their family in this society. As soon as they were able to agree on what would mean the most, they successfully overcame the daunting task of creating a meaningful culture for themselves and their children.
An Intergenerational Frame for Couples Work
Regardless of the theoretical map of the clinician, be it psychodynamic or cognitive-behavioral, clinicians need to help couples relearn dysfunctional interpersonal patterns. Couples therapy relies on cognitive interventions which stress the ability to master improved levels of interpersonal functioning, and on therapy that stresses the primacy of attachment in human bonding. Coché (2010) varies the old adage, “those who understand family history are not doomed to repeat it,” emphasizing retraining interpersonal dynamics as the foundation of working though dysfunctional patterns from family of origin. For example, Whitten et al., (2008) found that adolescents who experienced more hostilities in their families of origin were more likely 17 years later to show hostility during marital conflict resolution.
Tom found it near to impossible to be tolerant of Karen’s pension for bringing home “cute” objects. As far as he was concerned there was a place for everything and everything ought to be in its place…except his papers. As an academician, Tom believed his papers deserved to be wherever he wanted them, especially on the granite kitchen counter between the sink and the designer gas oven. Years of discussion proved fruitless until Tom reflected on his own family history: as a boy his only close moments were with his father when he followed his father around as “dad repaired one thing or another in the house.” Tom reflected that dad’s tools were everywhere and that when his mother tried to clean up his tools his father would bellow that “the place for a man’s tools is anywhere he wants to put them!” Once Tom got in touch with the meaning this behavior had in his family he and Karen were able to reach a more reasonable agreement about the place of objects in their lives.
THEORETICAL CONSTRUCTS IN COUPLES GROUP PSYCHOTHERAPY
Due to “turf” issues produced by competition for the same research and client dollars, there are few acknowledged similarities between the many theoretical bases of clinicians who practice couples group psychotherapy. Some groups are primarily support groups. Others are therapy groups which do not rely on group dynamics. The Coché groups rely on a foundation of group dynamics for therapeutic power. But all couples group therapy depends on the assumption that both couples and groups form a system and that treatment interventions need to be based on understanding and shifting interactive patterns.
The Coché model integrates group psychotherapy techniques and marital therapy. Theoretical and conceptual foundations from the fields of individual personality development, existential psychotherapy, family systems theory, and group psychotherapy theory form the basis of the model.
Clinicians need prior knowledge and training in both group psychotherapy and psychotherapy with couples and families. Group leaders must conceptualize client change through the psychotherapy process in contextual terms. Human change occurs within an interpersonal context and can, therefore, happen most efficiently when the psychotherapy process is conducted with awareness of the power of the interpersonal arena. As Harry Stack Sullivan (1953) stated, “it takes people to make people sick and people to make people well.” Further, a group sometimes operates like a family, and a family has the properties of a small group. Both are greater than the sum of their parts, and the subsystems of each can be fully understood only through a knowledge of the working of the whole (Spitz, 1979).
A key concept in the Coché model is the principle of isomorphism, a concept well-known to systems theorists. The principle states that similar structures and processes occur on several levels in related systems. Accordingly, a troublesome issue can manifest itself, with some variations, on an individual level (that is, within a member of a couple), on a couples level (between members of a couple), on a subgroup level (for all men or for all victims of abuse), and on a group level (for each group member). Applying that principle to a couples group enables the therapist to think on several levels simultaneously, to respond with flexibility to the challenges of the group, and to unravel otherwise bewildering shifts in levels. For example, the activity of a group can take place on any one of four levels at any time and on a combination of more than one level simultaneously. A brief description of each level follows.
Personal level. At the personal level the group concentrates intensively on one member. At times, couples group therapy looks like individual therapy in the presence of others. This therapy model is often intervention of choice because it has a very powerful effect on a person.
Couples level. At the couples level a group spends time on the dynamics of one particular couple.
Interpersonal level. At the interpersonal level the activity of the group is directed to interpersonal relationships between members or couples in the group, a subgroup level of attention. The members learn that others are struggling with similar issues and discover that they can be helpful to each other by sharing similar struggles, and their attempted solutions with others. Many of Irvin Yalom's (1985) curative factors, such as universality and altruism, come to full therapeutic power at the interpersonal therapeutic level. At times, the mere discovery of similarities is healing; at other times, only an extensive working with group member experiences can bring about therapeutic change.
Group-as-a-whole level. At the group-as-a-whole level interventions are aimed at each member of the group simultaneously. The leader makes a statement that applies to everyone, such as “the group is annoyed.” Directional shifts, group decisions, norm enforcement, and explorations of participants' roles in the group— all are topics of discussion that fall into the group-as-a-whole category (Agazarian & Peters, 1981). To be a successful working group, the group has to work out problems in its own dynamics. Kurt Lewin (1951) provided seminal thinking on the centrality of context in promoting human change. Group-as-a-whole work enables the group to progress developmentally from dependence on the leader through cohesiveness to interdependence between members. Members can gain therapeutic benefits in a group that has gained some mastery over its dynamics.
Rebecca annoyed her husband Michael because she stashed sweets and snuck drinks when she thought he was not looking. New to a couples group, Rebecca tried to avoid discussing her cravings in public. However, Rebecca craved more than chocolate and vodka. She craved intimacy, she craved being needed, and she craved sexual satisfaction. Working in the couples group, Doctors Judith Coché and Juliette Galbraith used the metaphor of craving blue cotton candy at a carnival when what was really needed was a substantial dinner. The leaders encouraged the group to discuss how “you can never get enough of what you really don’t want” as a way of inviting Rebecca to discuss her severe deprivation in the marriage. Group members related through their own experiences with smoking, drinking, and binge eating. By beginning to talk about the metaphor of craving sweets to fulfill human longing, the leaders were able to impact the group-as-a-whole as well as each individual member.
STRUCTURING COUPLES GROUP PSYCHOTHERAPY
Creating a Setting for Couples Group Therapy
Professional office space reflects the taste and values of the clinicians who work within the space. Although couples group psychotherapy can be led in institutional settings just as successfully as in independent practice settings, certain characteristics need to be considered for the space to be appropriate for professional treatment. Three qualities that enhance couples group psychotherapy settings are an atmosphere of personal reflection, a comfortable setting within which to work, and a crisply professional handling of clients.
An Atmosphere of Personal Reflection
An atmosphere of personal reflection is often evident in a psychotherapy environment. Comfortable furniture, non-intrusive background music or white noise machines, reflective reading material, fresh bottles of water, form the ingredients with which one builds an atmosphere for personal and interpersonal reflection for clients. This attitude must be communicated through appropriate attire and demeanor for professional staff in order for it to trickle down to the clients who choose to invest in increased well-being. At the Coché Center for example, staff wears casual but neat attire and speaks with modulated voices. Background music is soft and non-intrusive. Paintings on the walls create a place for thinking and planning. The space beckons towards the activity done within it.
A Comfortable Setting
Whether chairs or in a circle or couches are in a square, couples tend to sit together in couples group psychotherapy sp it is valuable to set up the room so that couples are able to sit independent of each other but near each other. Since the group meets for an extended period of time, comfort and special health needs, such as back problems and inability to sit still, also need to be considered. A couples group begins to think about the treatment room as “theirs” as if it belongs to their group alone. The group will negotiate how warm they want the room or cold and often will have opinions about furnishings and wall hangings. As the group becomes more cohesive, members claim their spaces and make it part of their treatment. They literally and figuratively take the space home with them.
Professional Handling of Clients
The structure of psychotherapy creates a foundation for interpersonal change. When therapists handle clients in a respectful manner it models respectful behavior and enables clients to handle each other in a respectful manner. Professional handling of clients requires respect for individual difference between clients, patience with the whims and individualities that clients bring to the treatment situation, and an eye for detail which fosters follow through on every level of practice.
Ken and Kandy had great trouble making ends meet. Despite two professional incomes their collections of animals, farm equipment, and motorcycles made it impossible for them to stay on top of their financial obligations for couples group psychotherapy. Lagging far behind the other couples in terms of payment, it was necessary to issue constant reminders in order to keep the payment nearly up to date. The professional staff was very careful to maintain fairness and dignity in dealing with Ken and Kandy in so doing the staff helped them reconsider their budget as a way of handling their financial needs more responsibly. Had impatience crept into their voices, Ken and Kandy’s defensiveness could have both slowed down treatment and decreased their sense of well-being.
Structuring an Effective Treatment Package
In order to structure an effective treatment package it is necessary to decide if one is going to do a closed or open group, one must plan the length of the sessions, one must set goals and do progress reports, and one must consider whether to require out of group psychotherapy. Finally, a decision about single or co-leadership needs to be reached. Each concern will be addressed briefly.
Closed or Open Group Therapy? The Coché Center has chosen groups which begin and end at the same time. Couples who sign up with the group agree to stay with it for the full duration which is usually 11 months. Closed-ended groups have a better chance to experience stages of group development together and form a tightly-knit working group. Just as a marriage is a closed contract, presumably for the lifetime of the members, a closed model of group psychotherapy provides a very powerful instrument of change. However, many clinicians prefer to run open groups in which members enter and leave as seems best for them and the group. Either approach can be viable.
Group size. A number of authors write that the optimal group size is three to five couples in a group. Smaller groups do not maximize the power of group dynamics factors, such as rotes and norms (Coché & Coché, 1990).
Length and Frequency of Sessions.Clinicians vary in their preferred length and frequency for group meetings. At the Coché Center sessions began in 1985 with a duration of 2 and a half hours twice monthly. After a decade of this approach, it became evident that it was more convenient and more powerful to meet less frequently for longer periods of time and the current model of 6 hour monthly meetings became operative. Groups of four couples meet with one or two leaders for six hours monthly, usually on a weekend. This format allows members to fully invest in their treatment. It also functions to give all members sufficient working time so that crucial issues cannot be avoided in the group. Members who travel from a distance would be unable to attend a group that met more frequently that once a month so this model has proven to be very powerful and efficient for relatively high functioning couples.
Although actual time varies, it is crucial is to adapt the frequency and length of the sessions to the needs of the members. In an institutional setting for example, where clients would find it hard to concentrate for a longer period of time, greater frequency and shorter duration of sessions would be necessary. Clinical success requires a match between the needs served and the clinical structures built.
A number of factors are important in member selection and group composition. Most authors agree that motivation for change is of paramount importance, especially in relation to the couple's commitment to their own relationship. The couple's willingness to stick, it out and work to resolve their difficulties is considered a necessary but not sufficient factor. Erich Coché and Judith Coché (1990) required an intimate relationship of at least three years duration; the desire to improve the marriage; ongoing and previous individual, couples, or family psychotherapy; an interest in learning from and participating with other adults.
Couples group psychotherapy is not for everyone. It is, for example, inappropriate for couples seriously contemplating divorce. With the use of stringent and careful screening and selection, most complications and limitations can be minimized.
Heterogeneity and Homogeneity
Couples groups are heterogeneous in relation to the members’ ages, diagnoses, and severity of marital problem. Couples groups can include people as old as 75 and as young as 25, A large age range prompts therapeutically useful transferences (Coché, 2010): for example, younger couples get into various aging-parent issues with the elderly members. Coché prefers groups that vary in their severity of the marital problems or individual diagnoses. Although one borderline patient in a group is difficult, two borderline patients work fairly well. The groups do not work well for members of average of below-average intelligence, nor do they work well for members who are psychotic or who have multiple personality disorders. The groups do work well for adults with learning disabilities.
Many couples are relatively high-functioning but need couples group therapy to refresh and revitalize a marriage that has gone stale. Some couples believe that their marriages are fundamentally solid but that the spark has gone out of the relationship: they choose group therapy to enhance and revitalize the marital foundation. Other members are going through a series of chronic crises and look at the group as their last hope. Many have been to marriage therapy before but found the experience disappointing. Having both types of couples in the group is encouraging. Those with the serious problems find much to learn from the others: those with stale marriages are relieved to learn that they are not as bad off as their peers in the group or as they had thought.
Such diversity offers group members concrete proof of the scope of marital function and dysfunction. The wide range of both positive and negative experiences of each couple creates a vast wealth of information at the disposal of each group member for use in making decisions or trying out new strategies for relationship improvement. Most rapid progress comes when group members are similar in intellectual and cognitive levels of functioning but who use different cognitive styles. Cognitively, the members are average or above average in intellectual functioning and have a variety of ways of organizing, their experiences to form their own definitions of interpersonal reality. Some members are gifted in warm, nurturing ways of thinking about others: others may be cool and distant yet insightful and incisive; some members are concrete and matter-of-fact: others are facile in thinking psychodynamically, systemically, or metaphorically. Some are remarkably articulate: others have great difficulty in knowing or expressing how they feel. Most members appreciate humor and enjoy the laughter that is central to the fluidity of group functioning.
Peggy Papp (1976) advocated separate groups for husbands and wives because of the element of surprise, intrigue, and curiosity that occurs when each partner has a same-gender group. She believed that such groups can expedite change and mollify the hopelessness that can accompany marital difficulties and can improve the work done when the groups eventually meet as a whole. Coché (Coché & Coché, 1990) finds that an individual group for one or each of the couples may enhance the overall therapy at modest price while intensifying therapeutic impact of the changes.
Many therapists advocate the use of co therapists in the conjoint or group treatment of couples. Besides the advantages to both therapists of convenience and sharing the work load, clinical lore claims that male-female cotherapy teams increase the likelihood and the quality of transference, ease identification, reduces therapist bias and dropout rates, and improves motivation, sensitivity, and efficacy. Unfortunately, few studies address the veracity of such cotherapy advantages. Nonetheless, the model is unparalleled for therapist support and training.
H. Gill and J. Temperly, E., and R. Lloyd and I. Paulson (1972) have found the use of cotherapists to be effective in working with couples presenting a variety of problems. Experienced co therapists further argue that the usefulness and the ultimate success of cotherapy depend on the working relationship between the two therapists involved and should not be tried unless a sound relationship exists. The co therapists may have different therapeutic styles, but they must agree on their basic therapeutic theoretical frame. Considerable differences in the theory of what is helpful to people in a group could severely undermine the efficacy of the therapy (Hellwig & Memmott, 1974). On a therapeutic level, the leaders provide a valuable complement to each other, if one of them either overlooks or exaggerates the importance of a particular issue at hand, the other can provide balance, bring in an additional point of view, and prevent potential iatrogenic problems. J. Scott Rutan and Walter N. Stone (1984) listed a variety of advantages of co leadership but also pointed out its drawbacks, citing a number of authors who noted that the complexities of the relationship between the co-leaders may detract from the power of the group.
If the leaders are of different genders, it is a further advantage to the group (Kluge, 1974), Members of heterosexual couples have the opportunity to project their own feelings toward the opposite sex onto one of the leaders and work out those feelings in the transference (Cooper, 1976).
Group Organization and Functioning
Pretraining. Most pretraining programs consist of brief informative sessions which function to define the therapist's role: teach group skills; and describe the session format, confidentiality, goals, the group purpose, contracting, and other general group policies. In William Piper's (1979) initial review of orientation techniques, he concluded that controlled studies show only "weak positive data in favor of pretraining for process and outcome data." In a later study, Piper (1981) found that cognitive-experiential approaches to pretraining have strong positive effects on attendance and dropout rates and mildly positive outcome effects, the weak outcome effects found are probably a result of (1) the large time span between the pretraining period and the outcome measures and (2) the less structured training methods used in early studies.
Phases of group development. For the purposes of simplicity, this chapter suggests that five stages are involved in the development of a group. Each will be reviewed briefly:
Joining. In the first stage of a group, the characteristics include fear of acceptance by group members, anxiety over the wisdom of joining a group, and social politeness. A group often depends on its leaders, and the members fear too much self-disclosure.
A newly formed couples group was asked to read the group policies before meeting for the first time. Although a couple of members read ahead, most members did not read what was assigned to them. Instead, the group nervously asked a lot of questions and found details which occupied a lot of their clinical time. When the leader asked them to talk about how they felt about being in the group, they admitted they were too nervous to read the material ahead of time and were more comfortable once they were there. They went on to say they wanted the leader to explain the policies about the group so that they could be sure and understand. The leader acknowledged that the group was feeling dependent and this was understandable given their anxiety about beginning a therapy experience with people they had never met.
Beginning working phase. In the beginning working phase, the members begin to work on marital problems. One of the hallmarks of the stage is what may be called moving from couple identify to personal identity. The members, who at first were merely seen by the others in the group as partners in a couple, begin to emerge as individuals with their own styles and their own problems.
Crisis. At the end of the second stage, the group often goes into a crisis. What often begins in stage two as dissatisfaction with leaders, format, money or other group variables can turn into a real battle. The onset is usually sudden. One couple may come into a session and threaten the group with dropping out if the evasiveness does not stop. Or a member suddenly loses his or her temper and noisily attacks the leaders or another member.
Intensive working phase. Once the crisis has been overcome, the group members tacitly agree on a comfortable level of self-disclosure, which creates an atmosphere in which therapeutic work can be done. The group enters its second working phase, at that stage the group is cohesive: the members express genuine liking and affection for each other.
A group of three couples began their work as soon as the clock indicated start time. They immediately divided the time between them ensuring that each couple got at least one hour to do work. With no help from the leader they decide the couple who has having the most pressing problems ought to go first. This couple described the devastation that occurred when the husband had been let go from his job and the group wrestled with them problem with very little leader intervention. The group occasionally turned to the leader to ask for additional descriptive material based on her knowledge of the situation but did not rely on her leadership in order to work in the group. Although it might look to a naïve observer as though the leader was not necessary, the group appreciated her skill in letting the group do its own work, intervening only when necessary.
Termination. About two months before the last meeting, one of the leaders reminds the group that it will end in eight weeks. During the termination phase, reconstructing becomes a major issue. Couples decide if they want to end their membership or join again for another year. They ask for feedback from the rest of the group and report to the group on their progress during the group year. Much of that progress is clearly visible to the group. An atmosphere of sadness about ending the remarkable experience of their group is mixed with the pride and the team spirit that come from hard work.
As the contract came to a close for a group that had worked together for 22 months, members began to evaluate the importance that the group held for them. A summary of these comments, drawn from Coché (2010) indicates the power of the experience:
· “I am more secure as an individual and as part of a team together”
· “My partner is helping me grow by communicating more of his feelings and sticking to his positions”
· “We are more responsible and more considerate of each other”
· “There is a happier home life for all”
Assessment Forms the Foundation for Treatment Planning
Assessment consists of deciding how to handle an initial contact, providing a structure for the initial consultation, deciding whether to do in-depth psychological testing or psychiatric consults. Each will be dealt with briefly.
Responding to Initial Contacts.When clients initially contact a professional for assistance they are understandably uneasy and worried. Since every contact with a client is potentially therapeutically helpful or harmful, therapists need to be both friendly and professional at all times. A quick return call to say “hello” and answer inevitable questions of cost, treatment philosophy, and other concerns sets the tone for a respectful interchange between client and professional. These initial phone calls turn out to be crucially important in allowing clients to relate to a professional with ease.
Structuring an Initial Couples Consultation. A 90-minute independent consultation is the beginning for all client contact at the Coché Center (Coché, 2010). The purpose of this initial consult is to determine whether or not there is a match between what the client is requesting and what the clinician can provide. If this match is not present at this initial consultation, there is follow through with client referral to an appropriate source for help. Most frequently, however, the consultation becomes the first appointment. The goal of the initial consultation is to assess the strengths and weaknesses as the couple sees them. This is done by encouraging each partner to think about why they chose their partner and what they enjoy about them. Framing the initial consultation within a positive psychological viewpoint often gives the couple hope that progress can be made with their more difficult concerns. The latter part of the consultation looks at the troubles the couple is having and the goals they have for themselves in the treatment process. In sum, an initial consult looks at what works in this relationship and what needs to be improved. Finally, it encourages the partners to think about if and how they want to move forward with treatment.
In-Depth Psychological Testing and Psychiatric Assessment. It is up to the clinician to determine whether or not in depth testing and psychiatric assessment seems important. If a clinician spends over an hour and a half with a couple but is still left with more questions than answers, further assessment is wise. In an initial consultation a clinician can begin to gather critical background information to develop sound treatment plan and take a developmental history for each member of the couple. For in depth assessment, advanced personality testing can be of particular value when there are diagnostic concerns. Finally, if there is a history of psychiatric consultation or a question about whether medication is necessary, it is incumbent about the clinician to require medical consultation with a psychiatrist in order to move treatment planning forward.
TREATMENT STRATEGIES FOR COUPLES GROUP PSYCHOTHERAPY: A GUIDE FOR CLINICIANS
Couples group psychotherapy has benefited from recent developments with foundations in evidence-based practice. This brief overview considers key concepts in member self-disclosure; helping client’s set therapy goals, and additional psychotherapy outside of the group. A brief consideration of the handling predictable problems and clinical emergencies in groups follows. Finally, it considers current paradigms from relational psychoanalysis, positive psychology, non-verbal dimensions, and attachment theory.
Research during the past two decades has indicated numerous positive therapeutic effects for members of psychotherapy groups. One of the benefits in psychotherapy within a group involves the willingness of members to self-disclose (Coché, 1983). There are two kinds of self disclosure in groups: in one, members tell the group about their life situations, backgrounds, and marriages In the second, members reveal their dynamics by their behavior in the group in the here and now. Both are invaluable in promoting therapeutic power. It is wise for leader to teach members effective self-disclosure methods, which are known to increase group cohesiveness.
Therapy Goals and Progress Reports
Therapy goals vary from group to group, couple to couple, and member to member. Typical goals are to enable each couple to break their dysfunctional patterns, learn to be successfully intimate, and make informed choices about their future together. Therefore, the treatment goals focus on improved communication skills, heightened awareness and openness, increased flexibility in intimacy, sexuality, problem solving, clarification of role ambiguities and conflicts, improvement of the couple's maladaptive defense styles, increasing awareness of intergenerational issues, and the induction of circular thinking.
Angie was certain that her husband Sam was verbally abusive to her and her children but Sam disagreed vehemently. Sam said that it was his birthright to say what was on his mind and he was proud to grow up in a family that knew how to talk about “stuff.” Because Angie was not able to have a therapy goal that included changing her partner, she was forced to look inward in order to set a goal for her own work. After a lot of thought, Angie decided that her goal for her work in the upcoming year was to “understand what I do to provoke treatment of me that I find hard to manage.” Additionally, Angie decided that she wanted to learn to manage her own anger better. In this way, Angie’s goal did not revolve around changing her husband; instead it concentrated on work that she was able to achieve. In the course of the year Angie met her goals and reported this in her progress reports.
In order to assess progress, a key part of the group’s work is to take time near the end of the group to do written progress reports. In these progress reports each member outlines the changes they have seen for themselves and outlines whether or not they think it is wise to return. Couples share these progress reports with one another after which feedback is given from the members of the group to each couple about changes seen and the wisdom of returning for another contract period. These frank discussions rely on the power of group dynamics. The group is truly a hall of mirrors when it comes to giving members feedback about what other members have seen in terms of clinical progress. This phase of the group devoted to evaluating progress for each member is crucial in helping members see their own change realistically and for convincing couples to return for deep work in the next contract period.
Out-of-Group Psychotherapy Work
Working with a therapist in individual, couples, or family sessions at least once every three weeks is a necessary part of the treatment package for the Coché model (Coché, 2010). Concurrent psychotherapy is necessary, because the group moves quickly. It is impossible to contain all the issues for each member and for each couple through group interaction alone.
Concurrent treatment modalities are often used to maximize therapeutic effectiveness or to deal with special problems that arise within a couple. Popular formats are individual psychotherapy with one or both members of a dyad, couples therapy, family therapy consultations with the families of origin or the couple's children, and workshops. Henry Greenbaum (1983) advocated a combination of individual, couples, and group therapy because he believed that the combination intensifies the therapeutic process, decreases resistance, and minimizes interpersonal distortions. Conversely, Florence Kaslow (1981) argued against the concurrent use of treatment modalities. She asserted that group therapy alone is critical in maintaining a sense of group belonging and integrity confidentiality and for making sure that, the values of group therapy for each couple are maximized.More recent approaches are mentioned in the next section of this chapter.
How Does One Facilitate Psychotherapeutic Change Within a Couples Group Setting?
Two facets of facilitating change within a couples group setting are worthy of brief clinical attention. First, group leaders need comfort with handling predictable problems and clinical emergencies in ongoing groups. The second involves choices of treatment paradigms for maximal therapeutic progress. In addition to recent developments in relational psychoanalytic thinking and cognitive-behavioral approaches to psychotherapy, particular mention is devoted to the impact of positive psychology on psychotherapeutic change, the nodal work on attachment theory in couples group psychotherapy, and the foundation work in the technology of neuropsychological and non-verbal aspects to couples group psychotherapy. Each will be briefly considered.
Group Leadership Variables in Couples Group Psychotherapy
Assuming that leaders are aware of group dynamics principles in basic leadership styles, leaders need to be able to handle predictable problems and clinical emergencies as they crop up in groups.
Handling Predictable Problems in Ongoing Groups. Predictable problems in couples groups include absences, lateness’s, and finances. All three areas are handled with clinical follow through, eye for detail, and perseverance. A leader needs to be able to set the norm that absences are serious undertakings. For example, at the Coché Center groups are paid for whether the member attends or not. This makes the statement that the place for the member is held in the group whether or not the member is present. Member absences are discussed in detailed and members are expected to attend.
In similar fashion, leaders state clearly that “the group starts on time and ends on time.” Because members travel great distances to reach their destination, lateness is not tolerated in a psychotherapy group. Routine lateness is handled in a clinical manner and is taken as an indication of interpersonal patterns. Most frequently the way in which a couple handles lateness and absence is indicative of the way they handle each other and their children. Likewise, the expectation is that members will pay promptly for group therapy at the beginning of the month for the group to come (Coché & Coché, 1990; Coché, 2010). It often happens that those members who have trouble meeting their financial obligations to the group, also have trouble meeting their financial obligations in the community. A discussion of absence, lateness, and finances, as it impacts the group members, often reveals a deeper conflict around honesty, accountability, and personality responsibility as it exists inside the members. A group discussion around these seemingly superficial parts of group therapy are often the beginning of an important change mechanism.
Angie and Sam often entered the group bickering about why it took Angie so long to get into the car before she left the house. The couple often commented that they had argued on their 45 minute drive to group therapy why Angie was late and why Sam had so much trouble paying the family bills on time, including the fee for monthly group therapy. Arriving late and disheveled, the couple monopolized group time through their own disorganization. Sensing the group’s frustrations, Dr. Coché invited the members to discuss their reactions to the pattern of lateness. By listening to the reactions their behaviors stimulated in valued group members, Angie was able to alter her own behaviors so she started earlier and avoided being late. In like fashion, Sam began to to pay his monthly therapy fee on time when he realized other group members were going out of their way to do so. In this way, routine administrative concerns can be handled clinical in a way that is beneficial to the clients and to the psychotherapy practice.
Handling Clinical Emergencies. All groups have clinical emergencies although these vary from group to group. Breaking group policies constitutes an emergency in most group settings. In this case, leaders deal with the dynamics by inviting the group to process the way they handled group policies. This level of here-and-now work in which members speak about their emotional reactions, as well as their intellectual analyses of the concern at hand, allows members reach conclusions together which can dissolve a stalemate in the group.
Clinical Paradigms in Treating Couples in Groups
Psychoanalytic practice has begun to embrace relational perspectives and cognitive psychotherapy continues to be clinically viable and powerful in treating couples. Additionally, however, three contemporary paradigms deserve mention: new energies from the educational imperative provided by positive psychology, integrating non-verbal dimensions into couples group psychotherapy, and enabling progress in primary human attachments.
Relational Psychoanalytic Concepts in Practice.Long considered the epitome of attention to individual psychodynamics, recent psychoanalytic trends have begun to concentrate on the dynamics of interpersonal engagements. Enactments (Frank 2002; Ginot, 2007), are interpersonal manifestations of disassociated relational styles. Unconsciously triggered between two people, these internalized relational patterns can be changed by experiences both inside and outside the therapeutic setting. By making automatic and unconscious patterns conscious, therapists attempt to repair and enhance chronically dysfunctional life patterns. This attention to the interpersonal dimension is a welcome addition to the traditional focus on impact of earlier learning.
The Educational Imperative from Positive Psychology.Over the past decade positive psychology has provided legitimacy for the desire to enjoy one’s life fully and strive towards optimal functioning. Positive psychology does not pretend to ignore psychopathology. Instead it uses cognitive restructuring as a way to open their minds and their hearts to greater happiness. Seligman (2002) emphasizes that the goal for psychological treatment is not merely to remove the dysfunctions and roadblocks that create unhappiness and suffering, but to enable fulfilled and satisfying lives and relationships. Positive psychology stresses the importance of positive emotions and positive interaction styles to support coupled relationships. Gable, Reis, Downey (2003) have demonstrated that responding actively and constructively to a partner enhances satisfaction within coupling. Success begets success. As Gottman (1994) found, couples minimally need a 5:1 ratio of positive to negative behaviors such as compassion, forgiveness, and gratitude. For a couple to achieve happiness they need to go beyond repairing dysfunctionality and learn the assumptions and behaviors involved in choosing happiness as a lifestyle. Recent research is beginning to provide solid guidelines for this relation set (Gable, Reis, Impett, & Asher, 2004).
Integrating Non-Verbal Dimensions into Couples Group Psychotherapy.As Coché and Gillihan found in their recent review of non-verbal communication in coupling (Coché, 2010) the bulk of couples’ communication has always been non-verbal. Siegel (2006) stresses the necessity to promote neural integration into therapy suggesting, that the clinician focus on attunement as the heart of therapeutic change. In similar fashion, Johnson and Greenberg (1994) concluded that emotion is central in all forms of interaction. For example, Walter et al. (2008) point out that the sexual response involves four distinct components (cognitive, motivational, autonomic, and emotional). The nature of human attachment requires nonverbal dimensions of sensuality and sexuality in order to sustain human loving.
Enabling Therapeutic Progress in Primary Human Attachments. As Konner (2004) states, attachment is “one of the most important determinants of human well-being.” Current research suggests that psychodynamic processes underlying romantic attachment are similar to those underlying parent-infant attachment. Recent research points to the key role of the reward system in the development of human attachment. Specific focus on the centrality of sensory awareness by Damasio (1999) and others, points the way to deepening levels of intimacy by increasing positive human bonding through movement, massage, and non-verbal communication.
Arthur and Jane were locked into a marriage of over 30 years because both refused to divorce. The marriage felt like a terminal sentence for boredom and frustration. They described themselves as “totally unconnected” but the leader was able to help them understand that they were deeply bonded to one another through withdrawal and silent anger. The couple came to understand that the work of the therapy would be to transform the nature of their bonding so that it felt comfortable and safe for each member. Although that sounded like an unbelievable goal to them, they were only too happy to dream about the day that life would be better. Through the work of the group they were able to understand that they had learned a method of human bonding which had existed in both families of origin. Using insight, cognitive psychotherapy, and the experience of the group itself, Arthur and Jane successfully improved their relationship to a level of deep satisfaction.
PROFESSIONAL AND ETHICAL DIMENSIONS OF COUPLES GROUP PSYCHOTHERAPY
Three professional and ethical dimensions stand out in reviewing clinical work with couples and groups.
1. Confidentiality.Confidentiality is the most important policy in psychotherapy. A group cannot function unless a group trusts one another (Davis & Meara, 1982). Confidentiality is complex when couples spend 6 hours a month together. The centrality of confidentiality in the psychotherapeutic process is magnified by couples who come from the same residential community and do psychotherapy together. In small towns it is highly likely that one will be invited to be in a group with one’s neighbor, for example. However, even in a large city the boundaries of confidentiality are complex when members of the same academic community choose the same psychotherapist. Likewise, the restriction against social contact outside of the group is complex. Written policies help by delineating clear guidelines. For example, Coché (2010) provides a written contract around confidentiality which states “that all information discussed at all group psychotherapy meetings is to remain in the room.” This policy is enforced through continued discussion whenever there is danger of breaking the confidentiality.
When a therapist works in an individual setting as well as a group setting with the same client, the therapist needs to be careful about information carried from an individual meeting into a group. Professionalism and good judgment provide standards of excellence. The consent of the group member is always obtained before revealing confidential information.
2. Handing the Financial Commitment. Coché (2010) finds that the most desirable approach to handling fees is direct and firm. She suggests that clinicians might offer clients in financial need a financial need-based scholarship supports needed work. She further suggests that payment be collected at the first of each month for the group meeting to come. Finally, she suggests that payment concerns be part of the clinical life of the group when it becomes obvious that couples find it impossible to handle their own finances appropriately. Often a couple who is having trouble paying their group fee is having financial trouble in their lives. Her recommendation is to deal with finances as any business person might. Her experience is that this approach is highly successful and models appropriate financial accountability for the members of the group.
3. Is Marriage and Family Therapy Ethical and Effective?Many psychotherapists trained in individual psychotherapy believe it is unprofessional and even bordering on unethical to work with two members of a couple. Resolving this concern in the context of couples group psychotherapy provides an ethical and professional challenge. Inspection of the website for the American Association for Marriage and Family Therapy (www.aamft.org) provides substantial documentation for an approach which includes the treatment of the individual in the context of their family. Marriage and family therapy has had the benefit of 60 years of theory and research as the underpinning for clinical treatment. An extensive set of ethical guidelines are available on the website.
In addition to the theoretical and research foundation for marriage and family therapy as a treatment of choice, marriage and family therapists have pressed for mandatory licensure in all 50 states. As a result of their dedication to high standards and credentialing, the federal government considers marriage and family therapy a legitimate treatment for those individuals who are part of the military. In summary, marriage and family therapy as a treatment modality, has been validated through theory, research, high standards in clinical practice, ethical guidelines and recognition by policy makers.
The special challenge of couples group psychotherapy. As with any treatment modality responsible leadership requires an honest assessment of potential roadblocks and ethical concerns. Three thorny dilemmas come to mind in relation to couples group psychotherapy. A brief discussion follows:
1. “Who’s side are you on?” Although couples group psychotherapists are trained to keep the welfare of the unit of the couple and family there is often misunderstanding on the part of the clients who find it hard to understand that anyone could be trained to be dedicated to the welfare of all members of the family simultaneously. For example, an attorney trained primarily in the representation of one client, often challenges the assumption that a leader will keep the welfare of both people in mind. Often the feedback from other group members helps skeptics begin to see that it is not only possible, but useful to engage in psychotherapy which concerns itself with the welfare of everyone.
2. “But what if we need to break up during a group?” Often the very couples who need couples group psychotherapy the most are those near divorce. Because it is necessary to construct a group with the welfare of all members in mind, it is not responsible to invite couples into a group if it is likely that they will divorce during the period of the group contract. This frequently feels disloyal to those couples who believe that they should be able to join the group and leave it if they have to divorce. It is the job of the leader of the group to explain to them that just as a family needs to look out for the welfare of all members at all the time. A couples group needs to be a viable treatment modality for all members during the duration of the contract. Explained in this way, couples frequently accept the limitations placed by the leader on their membership.
3. “This is really hard to lead.” Frequently colleagues are excited by the power of the treatment they see as they come to know couples group psychotherapy trained in either couples or group therapy but not both, these clinicians want to start doing couples group therapy without adequate training in both modalities. Because they see the model as demanding of their time and energy, they find it difficult to create the time needed to learn the model before practicing it. Often these leaders find the model very hard to use and give up. Instead, when potential couples group therapy leaders invest in learning the various facets of leading couples in groups, they enjoy a growing fascination with the model and with their own career.
Supervision and Training in Couples Group Psychotherapy
As Coché and Coché started in their training tape for colleagues (Coché, E. & Coché, J., 1990) couples group psychotherapy is a unique combination of two separate but related fields. For best practice couples group psychotherapy, the clinician requires advanced training in both couples psychotherapy and group psychotherapy. Although the years of training may seem burdensome, the result of investing in the development of expertise in individual therapy, couples therapy, and group therapy creates a fertile and challenging career path in which boredom is never of concern.
For training in couples therapy, clinicians have major resources from the American Association of Marriage and Family Therapy, and the American Family Therapy Association. Additionally, each professional organization has its own training process.
For training in group psychotherapy the American Group Psychotherapy Association provides excellence in academic, clinical, and research dimensions for training in all kinds of therapy groups including couples groups. Couples groups have been in existence for over 25 years. Ample opportunity for training exists, in person and online.
It is assumed that any clinician undertaking couples group psychotherapy will have substantial training in individual psychotherapy because couples and groups are comprised of individuals. Best practice clinical work rests on a dual foundation of depth psychotherapy and cognitive/behavioral interventions. Practitioners need expertise in both dimensions if they are to work with individuals on long-lasting behavioral changes at the same time they tackle issues of personality organization.
In sum, training and supervision in couples group psychotherapy is actually an amalgam that begins with training in individual psychotherapy, then moves to training in both couples and group psychotherapy. Finally, clinicians interested in couples group psychotherapy integrate all dimensions into the very powerful and dynamic model of couples group psychotherapy (Coché, 2010).
EVIDENCE-BASED PRACTICE IN COUPLES GROUP PSYCHOTHERAPY
A couples group creates a microcosm of a marital community in which couples show their interactive style. The intensity of relating to the same group members for over 50 hours in a calendar year creates a hall of mirrors in which one cannot help but see one’s own behavior.
A sizable body of research informs that both couples and group psychotherapy are effective treatment modalities (Coché, 2010). Couples psychotherapy has been used to treat anxiety disorders (Monson, Schnurr, Stevens, & Guthrie, 2004), mood disorders (Barbato and D’Avanzo, 2008), substance abuse (Powers, Vadal, & Emmelkamp, 2008), and relationship satisfaction (Shadish and Baldwin, 2003). Research tells us that couples psychotherapy is better than no therapy for about 80% of individuals receiving it (Snyder et al., 2006).
Likewise, group psychotherapy has been shown to be quite effective in treating a vast array of presenting problems (DeRubeis & Crits-Christoph, 1998). Therefore, it is no surprise that, despite little research on couples group psychotherapy, couples group psychotherapy has been used to deliver treatment for partner illnesses including alcoholism, drug use, HIV, breast cancer, borderline personality disorder, partner abuse, and sexual deviance. These studies consistently show the effectiveness of couples group psychotherapy (Coché, 2010).
Couples have reported that a cohesive group is helpful to them. Perceived as less helpful were structured exercises. This finding is especially surprising because these same couples requested more structured interventions (McCarthy and Coché, 2006). The authors suspect that different patients with varied cognitive styles experience the interventions uniquely and that seemingly contradictory data may, in fact, be due to different subgroups responding consistently within their own experiences. For example, some couples need and respond well to structure; other couples grow more quickly through a group that deals primarily in the here and now.
The interpersonal aspects of the group are the most important factors-honesty, trust, helping, and being in a group. The structure imposed by the therapists, important though it may be to the overall functioning of the group, is not paramount in the minds of the participants.
Evidence-Based Practice at the Coché Center.Assessments made at the beginning of a group often form the basis for later evaluations of a couple’s progress (E. Coché, 1983). Adopting the attitude that modest research goals can be used to address key questions, Coché, Hunt, & McCarthy, designed a small study to address the effectiveness of the groups in assessing desired change. Coché et al. used the Group Climate Questionnaire, the Millon Index of Personality Styles, and the Marital Assessment Inventory and the Dyadic Adjustment Scale to address how couples had changed. Couples reported that each partner had changed as well as the couple as a whole. For example, in 2009, couples stated “We are most responsible and considerate of each other” and “we have a new model for living life.” (Coché, 2010). The team concluded that many aspects of the relationship improved as response to treatment. For example, one woman said “I feel as though my husband, for the first time in 16 years, actually desires my company, and that is awesome” (Coché, 2010). McCarthy (McCarthy and Coché, 2008) suggested that clinicians need to move forward with evidence-based practice as a way of improving our understanding of clinical work. He further suggested that evidence-based practice need not be expensive, cumbersome, or esoteric and reported that practice research could be accomplished with a simple spreadsheet.
COUPLES GROUP PSYCHOTHERAPY: THE NEXT QUARTER OF A CENTURY
Couples group psychotherapy provides both cognitive and experiential learning for couples. This multilevel learning guarantees that individuals will learn to experience themselves differently by being a member of a group for couples. In the next quarter of a century, one might predict that economic necessity will combine with increased interest in optimal mental health, to create an ideal environment for the expansion of couples groups as a clinical modality. Because of the complex training in the field (see section on training and supervision) many clinicians who might enjoy working with couples and groups have been shy about getting needed training. In 2009, the American Group Psychotherapy Association began to offer telecourses in couples work and couples group work which allowed a clinical community to form, in which training in couples work and couples group work were available through teleconferencing. These technical advances combined with the pressure for clinicians to treat mental health disorders quickly and efficiently suggests that couples group psychotherapy may expand in a few key directions in the next 25 years. Three directions are briefly mentioned.
1. Monthly Couples Groups.Despite the earlier popularity of a weekly couples group, Coché and others have found that meeting monthly for up to 6 hours at a time provides a powerful clinical setting guaranteed to promote personal and interpersonal change. The ability to vary the frequency and duration of the group is a distinct advantage (Coché et al., 2006).
2. Theoretical Advances in Couples Group Psychotherapy. Recent work in rational psychoanalytic psychotherapy provides tremendous encouragement for psychodynamically trained clinicians. For example, the notion of enactments – interpersonal manifestations of dissociated interpersonal styles – find support in both attachment studies and neuroscientific research (Frank, 2002; Ginot, 2007). While psychoanalytic thinking was moving forward, positive psychology quietly began to legitimize happiness as a goal for human existence for the first time in the history of clinical practice. In 2002, Martin Seligman had the courage to state that happiness is not only a legitimate goal in psychotherapy, but necessary for the welfare of individuals and couples. As this article goes to press, the field of positive psychology is beginning to do solid research on the variables that contribute to individual well-being and human thriving. It cannot be long before happiness in couples becomes a legitimate area for theory and research. Further, psychotherapists are able to internalize theory and research in order to select therapeutic interventions from the fields of psychodynamic psychotherapy, cognitive-behavioral psychotherapy, and positive psychology. This creates a promising future for theory and practice in couples group psychotherapy.
3. Neurobiology is a Reality to be dealt With in Psychotherapy.The beginning decade of the 21stcentury saw an explosion in theory and research demonstrating the centrality of neurobiology in the functioning of couples. As early as 1997, Dan Goleman reported the importance of emotional intelligence. Building on earlier work, Dan Siegel (2006) created the concept of the mindful brain. Siegel integrated meditation with brain research and challenged clinicians to recognize that talk is only a small part of human change. In Gillihan’s review of the neurobiological research on coupling (Coché, 2010) he drew the conclusion that the integration of sensuality, sexuality, attachment, and nonverbal communication form a foundation of relearning sensory awareness as a part of couples group psychotherapy. Coché and Slowinski began to treat sexual dysfunction in a couples group in 2002 (Coché et al., 2006) and Coché began to integrate nonverbal communication, dance, and other forms of non-traditional movement into couples work, so that couples could learn to move together more smoothly. In the final analysis it is the relearning of dysfunctional neuropsychological pathways that contributes to the most powerful change for couples.
Couples Group Psychotherapy has travelled light years since Coché began to develop her model in the late 1980s. Originally considered a “quirky” little modality that few understood and fewer practiced, couples group psychotherapy has become a treatment of choice for many couples who seek therapists able to practice it. Both efficient and effective, the modality is founded on principles of ethical and professional practice, integrative theory and clinical work, and solid evidence-based practice. Despite the requirement of complex training, at the writing of this chapter, the popularity of the modality is mushrooming as clinicians recognize that couples psychotherapy and group psychotherapy can lead to efficient and effective change. One might predict that as this field continues to mature, more and more couples will benefit from it.
Agazarian, Y., & Peters, R. (1981). The Visible and Invisible Group: Two Perspectives on Group Psychotherapy and Group Process. London: Routledge & Kegan Paul.
Barbato, A., & D’Avanzo, B. (2008). Efficacy of couple therapy as a treatment for depression: A meta-analysis. Psychiatric Quarterly, 79, 121-132.
Buber, M. (1958). I and thau, 2ndedition. New York, NY: Scribner’s.
Bugental, J.F.T. (1981). The search for authenticity: An existential analytic approach to psychotherapy. New York, NY: Irvington.
Coché, E. (1983). Change measures and clinical practice in group psychotherapy. In R. R. Dies & K. R. MacKenzie (Eds.). Advances in Group Psychotherapy (pp.79-99). New York, NY: International Universities Press.
Coché, J. (1995). Group therapy with couples. In N. S. Jacobson & A. S. Gurman (Eds.).Clinical Handbook of Marital Therapy (pp. 197-211).New York, NY: Guilford.
Coché, J. (2010). Couples group psychotherapy: A clinical treatment model, 2ndedition. New York: Taylor and Francis.
Coché, J. & Coché, E. (1990). Couples group psychotherapy: A clinical practice model. New York, NY: Brunner/Muzzel.
Coché, J. M., Slowinski, J., McCarthy, K. S., & Galbraith, J. (2006). Couples Group Psychotherapy for Sexuality and Intimacy: Intensive Treatment for Lifelong Change. Group, 30,25-39.
Cooper, L. (1976). Co-therapy relationships in groups. Small Group Behavior, 7, 473-498.
Damasio, A. (1999). The Feeling of What Happens: Body and Emotion in the Making of Consciousness. San Diego, CA: Harcourt.
Davis, K. L., & Meara, N. M. (1982). So you think it is a secret. Journal for Specialists in Group Work, 7, 149-153.
DeRubeis, R. J., & Crits-Cristoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal ofConsulting and Clinical Psychology, 66, 37-52.
Framo, I. L. (1982). Explorations in Marital and Family Therapy. New York, NY: Springer.
Frank, K. A. (2002). The “ins and outs” of enactment: A relational bridge for psychotherapy integration. Journal of Psychotherapy Integration, 12, 267-286.
Gable, S., Reis, H., & Downey, G. (2003). He said, she said: A quasi-signal detection analysis of daily interactions between close relationship partners. Psychological Science, 14, 100-115.
Gill H., & Temperly, J. (1974). Time limited marital treatment in a foursome. British Journal of Medicine Psychology, 47, 153-161.
Ginot, E. (2007). Intersubjectivity and neuroscience: Understanding enactments and their therapeutic significance within emerging paradigms. Psychoanalytic Psychology, 24, 317-332.
Goleman, D. (1997). Emotional intelligence:Why it can matter more than IQ. New York, NY: Bantam.
Gottman, J. M. (1994). What predicts divorce: The relationship between marital processes and marital outcomes. Hillsdale, NJ: Lawrence Erlbaum Associates.
Greenbaum, H. (1983). On the nature of marriage and marriage therapy. Journal of the American Academy of Psychoanalysis, 11, 283-297.
Hellwig, K. & Memmott, R. J. (1974). Co-therapy: The balancing act. Small Group Behavior, 5, 175-181.
Johnson, S. M. (2005). Attachment Processes in Couple and Family Therapy. New York, NY: The Guilford Press.
Johnson, S. M. & Greenberg, L. S. (1994). The heart of the matter: Perspective on emotion in marital therapy. New York, NY: Brunner Mazel.
Kaslow, F. (1981). Group therapy with couples in conflict: Is more better? Psychotherapy: Theory, Research, and Practice, 18, 516-524.
Kluge, P. (1974). Group Psychotherapy for married couples. Psychotherapy and Medizinische Psychologies, 24, 132-137.
Konner, M. (2004). The ties that bind: Attachment: The nature of the bonds between humans are becoming accessible to scientific investigation. Nature, 429, 705.
Leichter, E. (1962). Group psychotherapy of married couples group: Some characteristic treatment dynamics. International Journal of Group Psychotherapy, 12, 154-163.
Lewin, K. (1951). Field theory in social science: Selected theatrical papers.Chicago, IL: University of Chicago Press.
Lloyd, R. & Paulson, I. (1972). Projective identification in the marital relationship as a resistance in psychotherapy. Archives of General Psychiatry, 27, 410-413.
McCarthy, K. S. & Coché, J. M. (2008). Making an evidence base from practice: Good intentions, complications, and recommendations for group psychotherapists.Paper presented at the annual meeting for the American Group Psychotherapy Association, Washington, DC.
Monson, C. M., Schnurr, P. P., Stevens, S. P., & Guthrie, K. A. (2004). Cognitive-behavioral couple’s treatment for posttraumatic stress disorder: Initial findings. Journal of Traumatic Stress, 17, 341-344.
Peterson, J. A. (1968). Marriage and family counseling: Perspective and prospect.New York: Association Press.
Piper, W., Debbane, E. G., Garant, J., Bienvenu, J. (1979). Pretraining for group psychotherapy: A cognitive-experiential approach. Archives of General Psychiatry, 36, 1250-1256.
Piper, W. (1981). Selecting suitable patients: Pretraining for group therapy as a method of patient selection. Small Group Behavior, 12, 459-475.
Powers, M. B., Vedel, E., & Emmelkamp, P. M. G. (2008). Behavioral couples therapy for alcohol drug use disorders: A meta-analysis. Clinical Psychology Review, 28, 952-962.
Rutan, J. S., & Stone, W. N. (1984). Psychodynamic group psychotherapy.New York, NY: Macmillan.
Seligman, M.E.P. (2002). Authentic Happiness. New York, NY: Free Press.
Shadish, W. R., & Baldwin, S. A. (2003). Meta-analysis of MFT interventions. Journal of Marital and Family Therapy, 29, 547-570.
Siegel, D.J. (2006) Toward an interpersonal neurobiology of psychotherapy. Paper presented at the American Group Psychotherapy Association Annual Meeting, Austin, TX, March 8, 2006.
Snyder, D. K., Castellani, A. M., & Whisman, M. A. (2006). Current status and future directions in
couple therapy. Annual Review of Psychology, 57, 317-344.
Spitz, H. I. (1979). Group approaches in treating marital problems. Psychiatric Annuals, 9, 318-337.
van Emde Boas, C. (1962). Intensive group psychotherapy with married couples. International Journal
of Group Psychotherapy, 12, 142-153.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: Routledge.
von Bertalanffy, L. (1968). General systems theory: Foundations, development, and applications. New York, NY: Braziller.
Walter, M., Bermpohl, F., Mouras, H., Schiltz, K., Tempelmann, C., Rotte, M., et al. (2008). Distinguishing specific sexual and general emotional effects in fMRI: Subcortical and cortical arousal during erotic picture viewing. Neuroimage, 40, 1482-1494.
Whitaker, C. A., &, Keith, D. V. (1981). Symbolic-experiential family therapy. In A. Gurman & D.
Kniskern (Eds.). Handbook of family therapy (pp. 187-225).New York, NY: Brunner/Mazel.
Whitton, S. W., Waldinger, R. J., Schulz, M. S., Allen, J. P., Crowell, J. A., & Hauser, S. T. (2008). Prospective associations from family-of-origin interactions to adult marital interactions and relationship adjustment. Journal of Family Psychology, 22, 274-286.
Wolf, T. J. (1987). Group psychotherapy for bisexual men and their wives. Journal of Homosexuality, 14, 191-199.
Yalom, I. D. (1985). The theory and practice of group psychotherapy, 3rdedition.New York, NY: Basic Books.
Author Note: *This book chapter was prepared with the assistance of Stephen Schueller, M.A., who assisted in formatting and conceptualization of the relationship between positive psychology and coupling. Stephen can be reached at firstname.lastname@example.org.