Couple therapy: a therapist's manual

1. The programme at a glance

Indication. Lasting couple distress in two adult partners, of any sex and any orientation, who both wish to work on their relationship or at least to decide its future, and in whom the individual interviews have shown neither coercive control, nor fear of one for the other, nor violence that rules out joint work (section 9).

Reference model. The behavioural couple therapies: the traditional form, centred on change — positive exchanges, communication, problem solving — and the integrative form described by Jacobson and Christensen, which adds to it the acceptance of the differences that will not change. The protocol borrows from cognitive behavioural couple therapy the work on attributions and expectations (section 4), and from emotionally focused therapy (section 12) the attention paid to the emotions that hide beneath the cycle of arguments.

Format. Eighteen sessions of 60 to 75 minutes, joint except for the two individual interviews; the first and the fourth last 90 minutes. Weekly up to session 12, then fortnightly: five to six months in all. Two booster sessions, at one month and at three months.

Mechanism targeted. Not to make disagreements disappear, but to obtain three changes: to interrupt the cycle that turns every disagreement into a confrontation or a withdrawal (section 5), to increase what each one does for the other, and to make the differences that will remain be experienced as differences rather than as attacks.

Session	Focus	Session output
1	The first meeting, all three together	What each one is asking for, framework and rule on secrets set out
2	Individual interview: first partner	Safety assessed alone, commitment, health
3	Individual interview: second partner	Safety assessed alone, commitment, health
4	The shared formulation	Formulation recognised by both, treatment decision
5	The cycle of arguments	Cycle drawn and named, time-out agreed
6	What each one can change	Three gestures chosen by each, one ritual
7	What lies underneath	One sensitivity of each, said and heard
8	Looking at the problem together	One incident described by both, without blame
9	Speaking and listening	One difficult conversation held in session
10	Starting differently, repairing	One repair made and accepted
11	Solving a problem together	A written agreement, on trial
12	The mid-point review	Measures repeated, next steps decided
13	The subjects that keep coming back	An arrangement on the hottest subject
14	The wounds that do not pass	One wound told and acknowledged
15	Staying or separating	An explicit decision, or a dated deadline
16	Being parents together	Co-parenting rules written down
17	The couple leads the session	A conversation conducted without you
18	Review and relapse prevention	Written plan, measures repeated

What the couple takes away. Nine printable worksheets, listed in section 44: our starting point, our cycle and the time-out, what makes us different, what each one does for the other, speaking and listening, solving a problem together, deciding and staying parents, our plan for what comes next — and a safety worksheet, given to each of the two, alone.

What distinguishes this programme from the other manuals on this site. Three things. The patient is not a person but a relationship, and the therapist never says who is right. Section 9 on violence and coercive control, which can suspend the joint work before it even begins. And the refusal to make keeping the couple together the criterion of success: sessions 15 and 16 deal with the decision and with separation, because some of these couples will separate, and because the way they do it counts, in particular for their children.

2. Before you begin

The four preliminary decisions

Is there violence, control or fear? That is section 9, and it is the only question that can stop the programme. It is never asked in front of the other partner.

Are the two partners coming for the same thing? One wants to save the couple, the other is already half gone: that is common, and it is not treated by an ordinary couple therapy. Section 38.

Is there an individual disorder that comes first? A severe depression, a current suicide risk, active alcohol or drug use, a manic or psychotic episode. Section 8.

Is there a secret that distorts the work? An affair under way, a decision to leave already taken, a hidden debt. The rule on secrets is announced before the individual interviews, never after. Section 15.

What this programme does not treat

It does not treat a controlling relationship, which this manual also calls coercive control. Couple therapy is contraindicated there. Section 9 says what is done instead, and the programme Coercive control: recognising it and getting free may be indicated for the person concerned, with the precautions it describes.

It does not treat an individual disorder on its own. It may complement the treatment of one.

It does not treat an established sexual disorder. Sexuality is addressed as a couple subject in session 13; a sexual dysfunction calls for a specialist assessment.

It replaces neither family mediation nor a lawyer. When a couple separates, the therapist helps them decide and separate without doing damage; he settles neither the property nor where the children will live, and he writes no statement that takes sides. Section 39.

How to use it

Read the whole of it before the first session, in particular sections 6, 9, 15, 35 and 36: the model, violence and coercive control, the frame, the formulation, and acceptance. Those are the five places where the treatment turns.

Each session is described along the same framework: the aim, the course in steps, what you say, the common errors, and the criterion for moving on.

Three warnings specific to this reason for consulting.

Violence is not disclosed spontaneously. Among couples who consult, questionnaires and clinical interviews reveal it in more than 60 %, but fewer than 10 % report it themselves as a problem (Ehrensaft and Vivian, 1996). It appears only if it is looked for, through precise questions, and with each partner alone. Section 9.

Each one expects a verdict from you. Giving it, even once, even under your breath, makes one of the two lose. Section 15.

And the session can become the argument. An escalation replayed in front of you is not useful material: it is one more argument, with a witness. You interrupt it.

3. Five situations not to be confused

Five situations present with the same request — "we can't talk to each other any more" — and they do not call for the same conduct.

1. Couple distress

What you observe. Arguments that keep returning to the same subjects, or on the contrary avoidance and distance; reproaches, the feeling of no longer counting, the impression of living as flatmates; satisfaction that is crumbling in one or in both.

What points to it. Each one can say no, see those close to them, have the use of their own money, and speak in session without fearing what will follow. Neither is afraid of the other.

What this implies. This is the programme described here.

2. Conflict that spills over

What you observe. Arguments that rise as far as physical acts — pushing, throwing an object, blocking a door — often on both sides, without a general domination of one over the other.

What points to it. The acts occur at the peak of the escalation, are not accompanied by control over the other's life, and nobody lives in fear between the arguments. This is what the sociologist Michael Johnson called situational couple violence (M. P. Johnson, 2008).

What this implies. Joint work remains possible, under strict conditions: non-violence set as a condition, a safety plan, regular individual checking. Section 9.

3. Coercive control

What you observe. A set of repeated behaviours — surveillance, isolation, control of money, denigration, threats, sexual coercion — with or without blows. One person who watches the other's mood before speaking.

What points to it. Fear and the loss of freedom. The couple may present with a "communication problem", and it is sometimes the controlled person who asks for the therapy, because she hopes for a place where the other will change.

What this implies. No couple therapy. Section 9.

4. An individual disorder that is expressed within the couple

What you observe. A depression that makes someone irritable and paints everything black, alcohol use, an attention deficit hyperactivity disorder that makes one the "parent" of the other, post-traumatic stress, an invasive jealousy — and, more rarely, a delusional jealousy.

What points to it. The difficulties began or worsened with the disorder, and they are found outside the couple too.

What this implies. The disorder is treated individually; couple therapy comes as a complement, sometimes in parallel. Section 8. A delusional jealousy calls for a psychiatric opinion and an assessment of danger, not for couple therapy. For an invasive jealousy that is not delusional, the manual Morbid jealousy: a therapist's manual describes an individual protocol of twelve sessions, with one meeting with the partner alone and one optional joint session, which puts safety first.

5. A decision already taken

What you observe. One of the two comes "so that the other won't be alone" when he leaves, or so as to be able to say that he tried everything. He does not do the exercises and never speaks of the future.

What points to it. What is said in the individual interview: "I have already gone", "there is somebody else", "I just want this to go well".

What this implies. Not a couple therapy, but a decision-making piece of work or support through a separation. Sections 38 and 39.

The three sorting questions

"What does each of you hope for from this work?" Asked with both present, it brings out the differences of plan.

"Does it ever happen that you are afraid of your partner?" Asked alone, never in front of the other. It isolates situation 3.

"Where are you yourself with your wish to continue?" Asked alone, it brings out situation 5.

4. The dimensions of couple distress

What can be seen: the behaviours

Escalation. Each one answers the attack with a slightly stronger attack, and the argument leaves its original subject.

Demand and withdrawal. One asks, criticises, insists; the other avoids, defends himself, falls silent or goes away. Each movement feeds the other. The work of Christensen and Heavey (1990) shows that the position depends in part on who wants the change: each one tends to pursue when it is he who is asking, and to withdraw when it is the other. The roles are therefore not only character traits.

Mutual avoidance. The subjects that cause trouble are no longer raised; the peace is preserved and the resentments pile up.

Disengagement. No more arguments, no more plans, two parallel lives. It is often the latest and the most deceptive stage: calm is not a good sign there.

The corrosive attitudes. Gottman's observations of couples in conflict (1994) associated four attitudes with separation: criticism aimed at the person, contempt, defensiveness and the withdrawal that closes the discussion.

What is thought: attributions and expectations

The partner in distress attributes the other's negative behaviours to lasting and intentional causes — "he does it on purpose", "she doesn't care" — and his positive behaviours to passing or self-interested ones. Memory becomes selective. Implicit norms — "if you loved me, you would know" — turn every departure from them into proof. These processes are at the heart of cognitive behavioural couple therapy (Epstein and Baucom, 2002).

What is felt

Anger, resentment, sadness, loneliness within the couple, the feeling of not counting, the fear of being abandoned or on the contrary invaded, shame, and sometimes apathy. Beneath the anger of the one who pursues, one often finds the fear of not counting; beneath the other's withdrawal, often the fear of getting it wrong or of being overwhelmed.

What fades away

The pleasant moments, tenderness, sexuality, interest in the other's life, humour. This is the reserve a couple draws on when things are going badly; empty, it turns the slightest remark into an attack.

What touches each of them

In a general population survey, couple distress was associated with anxiety disorders, mood disorders and alcohol-related disorders (Whisman, 2007). A cross-sectional study does not tell the direction of the link, and in clinical practice it goes both ways. But that is enough to make an individual assessment of each partner compulsory.

5. What maintains the distress

The cycle

Each behaviour of one is the trigger for the behaviour of the other. The one who pursues does so because the other withdraws; the one who withdraws does so because the other pursues. Each one sees his own behaviour as a response, and the other's as the cause. The cycle is stable because each one has a good reason to do what he does.

The trap of wanting to change the other

Couples most often arrive after years of efforts to get the other to change. These efforts — reproaches, insistence, conditions, sulking — have a paradoxical effect: they harden the other's position, who defends himself, and they deepen the very difference they were meant to reduce. The integrative literature describes this polarisation, and the sense of being trapped that goes with it (Jacobson and Christensen, 1996; Christensen et al., 2020).

The attributions that turn every gesture into proof

Once the idea has settled that the other is selfish or indifferent, positive gestures no longer count and negative ones confirm everything. A real change in one may go unnoticed for weeks.

The erosion of reinforcement

Pleasant exchanges decrease, unpleasant ones increase, and the relationship ceases to be a source of pleasure and becomes a source of cost. This is the historical starting point of behavioural couple therapy (Jacobson and Margolin, 1979).

The stress that comes from elsewhere

Work, money, young children, illness, bereavement, moving house: external stress spills into the relationship, makes each one more irritable and less attentive, and makes intolerable differences that were tolerated until then.

Perpetual problems treated as soluble ones

Many lasting disagreements come from stable differences of personality or of need — closeness and distance, order and disorder, spending and saving. Treating them as though they could be settled once and for all produces a repeated failure, and each failure worsens the cycle.

The complete circle

A real difference touches a sensitivity. The sensitivity produces a reaction. The reaction triggers the other's. Each one's efforts to change the other widen the gap between them. The hostile attributions set hard. External stress speeds the whole thing up. And the reserve of positive moments empties.

This is the diagram you give back in session 4.

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