From Couple Therapy 1.0 to a Comprehensive Model: A Roadmap for Sequencing and Integrating Systemic, Psychodynamic, and Behavioral Approaches in Couple Therapy

• Date: 01 September 2017
• DOI: http://doi.org/10.1111/famp.12300
• Author: Arthur C. Nielsen
• Published date: 01 September 2017

From Couple Therapy 1.0 to a Comprehensive

Model: A Roadmap for Sequencing and Integrating

Systemic, Psychodynamic, and Behavioral

Approaches in Couple Therapy

ARTHUR C. NIELSEN*

,†,‡

Couple therapy is a complex undertaking that proceeds best by integrating various

schools of thought. Grounded in an in-depth review of the clinical and research literature,

and drawing on the author’s 40-plus years of experience, this paper presents a comprehen-

sive, flexible, and user-friendly roadmap for conducting couple therapy. It begins by

describing “Couple Therapy 1.0,” the basic conjoint couple therapy format in which part-

ners talk to each other with the help of the therapist. After noting the limitations of this

model, the paper introduces upgrades derived from systemic, psychodynamic, and behav-

ioral/educational approaches, and shows how to combine and sequence them. The most

important upgrade is the early focus on the couple’s negative interaction cycle, which

causes them pain and impedes their ability to address it. Using a clinical case example, the

paper shows how all three approaches can improve couple process as a prerequisite for bet-

ter problem solving. Additional modules and sequencing choice points are also discussed,

including discernment counseling and encouraging positive couple experiences.

Keywords: Couple Therapy; Psychodynamic Couple Therapy; Beha vioral Couple Therapy;

Integrative Couple Therapy

Fam Proc 56:540–557, 2017

THE CHALLENGES OF COUPLE THERAPY

Couple therapy is difficult!It is complex because therapists must deal with two clients,

often at war with each other, with differing psychologies, histories, agendas, and com-

mitment to therapy. It is emotionally demanding because it evokes intense emotions. The

subject matter is challenging, including material topics like money, sex, and childrearing,

and abstract ones like power, commitment, and love. Finally, it is difficult because there

are many approaches to doing it, but a paucity of guidance in how to choose among them.

Each of the current, name-branded forms of couple therapy—Psychodynamic, Emotion-

Focused, Emotionally Focused, Object Relations, Self Psychological, Narrative, Bowenian,

Strategic, Behavioral, Cognitive–Behavioral, Integrative Behavioral, and Integrative

Problem-Centered Metaframeworks—has much to offer. However, with so many choices

available, therapists may cling for dear life to one theory or toss them all and go with the

flow, two frequent errors observed by Weeks, Odell, and Methven (2005).

*Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University,

Chicago, IL.

†

The Chicago Institute for Psychoanalysis, Chicago, IL.

‡

The Family Institute at Northwestern University, Evanston, IL.

Correspondence concerning this article should be addressed to Arthur C. Nielsen 333 E. Ontario St., Ste.

4209B, Chicago, IL 60611. E-mail: arthur@arthurnielsenmd.com

540

Family Process, Vol. 56, No. 3, 2017 ©2017 Family Process Institute

doi: 10.1111/famp.12300

Integrating therapeutic approaches provides the advantages of integrating vocabularies

(Lebow, 2014); giving common factors their due (Sprenkle, Davis, & Lebow, 2009); flexibly

meeting client expectations (Friedlander, Escudero, & Heatherington, 2006); and (most

importantly) providing more tools for working with diverse clients and complex, multide-

termined problems (Breunlin, Pinsof, Russell, & Lebow, 2011; Fraenkel, 2009).

This paper offers guidance concerning how to choose, sequence, and integrate tried-

and-true therapeutic interventions within a comprehensive model. It is the outcome of my

40-plus years of treating couples, supervising students, observing other therapists, and

studying the clinical and research literature. My goal is to provide a roadmap that empha-

sizes fundamentals and critical choice points. I say relatively little here about specific

interventions or the challenges of intimate relationships, although both inform therapeu-

tic choices (Nielsen, 2016).

My personal synthesis builds on, and substantially overlaps, the work of others who have

presented integrative models for couple therapy (especially Berman, Lief, & Williams,

1981; Breunlin et al., 2011; Christensen, 2010; Fraenkel, 2009; Gurman, 2013, Lebow,

2006; Pinsof, 1995; Pinsof, Breunlin, Russell, & Lebow, 2011; Scheinkman, 2008; Scheink-

man & Fishbane, 2004; Segraves, 1982; Snyder & Mitchell, 2008; Wachtel, 2017). After pre-

senting my own model, I will make some comparisons with these other integra tive models.

THE INTIMIDATOR AND THE NOVELIST: A PROTOTYPICAL CASE

Tom, a 35-year-old retired professional football player, and Jennifer, a 33-year-old nov-

elist, presented with the manifest conflict of deciding whether to move to another city.

There were clear pluses and minuses to relocating that they had “discussed” endles sly—

he, using what he considered logical arguments, and she, becoming exasperated and shut-

ting down. Jennifer remained unwilling to consider Tom’s arguments, as she felt that her

needs, though somewhat unclear even to herself, were not being considered. Both were

despondent, not only about the deadlocked decision, but about their sex life, which had

almost ceased, and about the viability of their 6-year marriage.

COUPLE THERAPY 1.0

Just Talk to Each Other

Had I seen Tom and Jennifer when I began doing couple therapy as a psychiatric resi-

dent in 1975, I would have suggested they meet with me to talk to each other while I

watched and tried to mediate. I call this relatively unstructured, here-and-now, talk-to-

each-other model Couple Therapy 1.0. It is the Model T of couple therapy and still provides

the scaffolding for my work. It makes intuitive sense because, like Tom and Jennifer, vir-

tually all couples coming for couple therapy complain of a breakdown in communication.

As with many forms of instruction—music, sports, or dance—the model assumes that talk-

ing about how a person interacts (or plays) is insufficient for revealing what is going on.

Rather, the therapist (or teacher or pro) must observe the client in action.

The format of conjoint meetings to deal with marital problems was uncommon until the

1960s, although “marriage counseling” began in the 1920s (Gurman & Fraenkel, 2002).

Couple Therapy 1.0 builds on simple couple counseling by adding here-and-now interac-

tions between the partners. It is distinguished from the upgraded forms I will describe

later by the absence of sophisticated methods for attending to and improving the interper-

sonal couple process. I chose to make this conjoint, talk-to-each-other model the basic 1.0

version (rather than the earlier couple counseling version or a later systemically informed

version) for two reasons: first, because many untrained counselors (peer or religiou s) and

Fam. Proc., Vol. 56, September, 2017

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