Susan Heitler on Couples Therapy

At work, you know for the most part who has power and what the expected roles are. At home, that needs to be negotiated. So, in families where everything becomes an issue, there are often underlying issues about how much power do I have, how much am I listened to? Or does he love me? Does she really care about me? We know that the more emotional intensity there is, the more likely people will regress in their collaborative dialogue skills.

Living well as a couple means living with an excellent skill set - a skill set for dealing with conflicts, for dialoguing and sharing information effectively, for relaxing and enjoying life, and also skills for emotional self regulation. So, instead of getting agitated and angry, people stay calm and are able to use their skill sets to deal with difficult issues.

I like to tell my patients I work on flow. A good analogy is traffic flow. Cars crash if the traffic is flowing too fast which is the equivalent to too much emotional intensity. Cars also crash if people don't follow simple traffic rules and guidelines.

What I hear over and over again is, "I wish someone had taught us these skills when we first got married. All those years and all that dreadful modeling we have done for our children wouldn't have happened. All those years of suffering, all those years of portraying how to make each other miserable wouldn't have happened if we had just known how to interact more maturely, more effectively."

Now does everybody do better? The reality is some people would rather stay how they are. My approach is a kind of a coaching approach to therapy and just like some people will prefer to stay beginners on the tennis court, some people aren't interested in learning in their marriages.

If there are conflicts between two people who have the cognitive flexibility to really listen to each other and work together till they can come out with win-win solutions, then those conflicts can be resolved. Of course, I would say that we all know some people aren't willing to learn the skills of win-win conflict resolution, but that is the exception. For example, I get conflicts about whether to have children or how many children to have. I have had a number of those cases in my practice and they have always come up with excellent win-win solutions. You would think either we are going to have a baby or not have a baby and that should be a zero-sum game, right? Wrong! It's how you decide to have a baby or if you decide not to have a baby. So even that is quite amenable to a win-win conflict resolution.

I am thinking of one poignant couple, for instance, where she was rather a brittle person who felt very much of a New Englander. Now, myself coming from New England, I can identify with that. She grew up in an old small subculture there and she felt safe there, she felt she belonged. Unfortunately, her husband, a lovely fellow who had been very successful in business, went through 3 or 4 years where he was unemployed. It was terrifying for him since he wanted to support his family. Finally, he got a job in the Southwest and she tried to move with him but just couldn't do it. She wasn't able or willing to make new friends. She strongly missed being away from her parents and felt they needed her since she was the only child. It was multi-dimensional and a very difficult issue to find a middle ground on.

Now, remember conflict can be at a shared decision making or conflict resolution level. Shared decision making is what we call the process if it's going smoothly. We call it conflict resolution if the couple is getting oppositional. In this case, they were going beyond oppositional to desperate because they each felt so strongly wedded to their own concerns and unable to embrace it in a broader way to take into account the concerns of their partner.

If a couple is accustomed to arguing, that means a lot of intervention. Intervention not just after they have argued but lots of setting them out to do it right. So, for instance, one person starts to says something... I can see the "b" of the word "but" forming on their mouth so I would interrupt them right there and offer alternatives.

I am referring particularly to what I call crossovers when people are labeling others or speaking for the other person versus people speaking for themselves. Are they listening to take in information or they are listening like a hockey goalie to bat it away? Did they digest what the other person said out loud or do they just move on to their own thought? So there can be a perfectly civil collaborative tone but each person ignores what the other says rather than what I call breathing the dialogue. The couple needs to have a positive experience versus just repeating what goes on at home.

Also, many people don't know how to ask good questions. In other words, the alternative to you-messages is not just I-messages, it's good questions. Good questions almost always begin with "What?" or "How?" and many people don't know how to ask those questions. Lastly, many couples lock into a tug-of-war over "I want X," - "No, I want Y." Many people don't know how to switch levels to the underlying concerns that fuel such tensions.

So I used my anger in service of the work by allowing myself to feel my own anger and express my experience with her parents... that this girl evoked that response in me and does so with others as well, but the parents continued to enable this oppositional behavior. I essentially told them they needed to address it, talk quietly with her about this, and help her learn skills so she would not continue to be provocative in that way. But I showed them how anger could be used well instead of just going head-to-head with her.

Now, at the same time, there are couples that the research would certainly say they ought to get divorced. If couples are fighting a lot, the research is unambiguous that it's better for the children for them to disengage; a climate of war in the house is not conducive to child rearing. Medved and Quayle partnered on a fine book called The Case Against Divorce where they outline 9 factors where divorce is indicated.

It is very important that a therapist have a policy and state it clearly in the first session. The prevailing policy seems to be that there are no secrets: if you tell me something in session, I have the option of disclosing it to the other.

After laying out the foundation of confidentiality, I turn to each of them and say, "When I work with either of you alone, the confidentiality that I am bound by limits keep me from saying to your spouse what we have talked about. Each of you can trust in that privacy." Then I explain that they are free to speak with each about their own therapy or to play the session tape because I audiotape every session and give them the tape so they can listen to it. I am the only one that's bound by confidentiality. The tape, by the way, radically increases a therapist's effectiveness since patients benefit greatly from listening to the session.