Notes on Structure in Couple Therapy
Rob MacFadden
An understanding of structure and how it can assist your professional practice with couples is important. Structure can be used to anticipate, educate, prepare, plan, assess, implement and evaluation and many other things.
Structure can include frameworks, sets of expectations, boundaries, schedules, phases and many other things. It refers to the way in which something is organized or constituted.
Our life is filled with structure. As children we learn how to relate to structure and what to expect. Mealtimes, bath times, school times are examples of this. Indeed, time itself reflects a critical structure that we are tied to constantly. Know how to use time effectively is one of the most important skills social workers can have. Theoretical frameworks reflect attempts to structure concepts into a coherent wholes. Concepts are used like scaffolds used to construct theories.
Life is filled with overlapping and intersecting levels of structure. There are many benefits of structure; it can create order out of chaos. It can reduce our anxiety because we know what we will be facing- it can add predictability. Too much structure can reduce freedom and lead to inflexibility. It can make it difficult to individualize interventions and services. Think of situations that are highly structured. How do they make you feel? Think of situations that are highly unstructured, what are your reactions? If it depends, what are some factors that cause you to react in different ways?
Social workers have been aware of structure and the importance and use of structure for some time. Consider the structure that confronts a couple when they seek out help from a social agency.
Telephone contact, possibly a waiting list with a set of rules
Intake: longer session, forms to be filled out
Informed consent by the clients is critical : social workers need to provide information about what the service is about, costs, times, locations, contacting others, confidentiality with exceptions, benefits, risks, qualifications of staff, cancellation policies, nature of the intervention, what their roles would be, etc.. Couples sometimes see social workers as judges, psychiatrists, rescuers, or doctors who have a magic pill.
Important for the couple to have a realistic sense of what the therapy is about, what they will need to do, what to expect, in general, what you can do and can’t do, etc., This “congruence” is a factor in reducing the sizable drop-out rate after the first few sessions. Prepare the couple for possible events in therapy, including the “ups and downs” of progress, heightened emotionality at times, need to share and discuss openly
Frequency: how often meetings are held
Duration: how long sessions will last
Case closings: possibly follow-up
As part of building the therapeutic alliance, explore with the couple their understanding of how the problems formed and their theory of change. Find out what they expect you as a therapist to do and what they will be doing in therapy. Culture may an important determinant in how couples view problems. Some cultural groups may expect more structure and be very uncomfortable with too much ambiguity. Some cultures may expect you to be more of an expert, freely providing advice. Don’t assume anything. Take the position of an curious and respectful learner and find out about their perceptions and expectations. Also find out if they have ever experienced couple therapy or other types of therapy previously. If the couple has had previous experience, they will likely have many specific expectations about what you will be doing. One couple who had worked previously with a Gestalt therapist were visibly upset when I gathered a communications history from them. They had been taught that therapy had to maintain a complete focus on the present. Talking about the past was viewed as counterproductive. Preparing clients for what to expect in therapy has been described as a role induction process where mutual expectations are made clear and client-worker congruency is enhanced.
Physical structure: size of building, location, condition of interior, exterior, signage, waiting room (location, condition, size, privacy)
Therapy offices: size, condition, number of chairs and availability, position of the social worker’s desk
Question: In your agency, what messages about themselves does a couple receive from the time they call up to seek help from your agency to the time they see a social worker?
Interview Sessions
Number of sessions: beginning sessions, middle sessions, ending sessions
Sometimes limit to total number of sessions & may need to justify additional sessions
Duration: usually set time (e.g., 1 or 1.5 hrs)
Each session: beginning, middle and end of session.
Critical use of time. “Doorknob” phenomenon. Tendency for some partners to disclose something important as they have their hand on the doorknob to leave. Use time structure to avoid this. “We have about 15 minutes left, are there any issues you really wanted to address today that we haven’t discussed?” Knowing the range of time available and using it to focus attention, commitment, action. “We have only 3 sessions left”. Frequently you can recontract if appropriate, but working to a timeline can act to focus and energize and discourage dependency.
Common structure for sessions (varies with model & may not be relevant re: crises): e.g., greetings, homework, key issue (s), remaining issues, reviewing progress, planning for next week.
Can taper off couple sessions: First five sessions can be weekly, next three sessions every two weeks, last two sessions every four weeks. For couples who may be ambivalent, sometimes a practitioner will suggest two or three assessment sessions before the couple decides whether to continue. This allows the couple to “ease” into the therapy, control commitment and expenses and offers a chance to see whether they can relate to the social worker and whether they feel the therapy might work.
Early in social work’s history, much effort was directed towards the termination phase. It was assumed that in this phase, for many people there would be regression (e.g., problems that had be reduced would suddenly arise at the end), so the worker needed to be ready for this and prepare to end with a client appropriately. Perhaps because of our shorter time periods with couples, termination is not quite as significant? Would the nature of the therapeutic alliance be different with the shorter intervention durations of today?
Most therapy models have specific configurations re: structure. EFT has 9 steps. Many have an assessment, intervention and termination phase, acknowledging that the assessment phase spreads over into the intervention phase as well. Behavioural and cognitive-behavioural models make strong use of structure. This might include structured assessment tools, structured intervention with manuals in some cases, and homework. If homework is negotiated, always remember to review it unless there is some compelling reason. Not following up on your structure can weaken the therapeutic alliance.
How do the models that comprise your practice approach handle structure? What is unique to these models and what is shared across the models?
A contract, for instance, is a clear example of structure. Contracts can be verbal or written and usually incorporate a statement of goals, actions, timelines, and who is responsible for what. They are negotiated, reviewed, revised if necessary. Contracts can help to maintain focus, heighten commitment and accountability.
Many clients feel out of control and have problems understanding what is happening to them. They may feel they are going crazy or have no option but to break up with their partner. A model’s theoretical framework can provide an understanding for the couple and therapist in terms of why things are happening and what is influencing what. The structure of the model can help to reduce client anxiety and focus through identifying problems and prioritizing them and framing them as positives or goals. Identifying problems and goals itself can be an important first step.
Couple problems are frequently complex and the couple feel they have no alternatives. One of the most important things you can do is to free them up to consider the alternatives that they do have. It also can free you up as a therapist too. Believing you have only one or two options can make the situation more problematic.
For instance, a couple can stay together without counselling, can stay together with counselling, can separate, can separate and attend counselling. There are likely more alternatives. Opening these up frequently reduces the pressure immediately because the couple haven’t considered all the alternatives. It is sometimes useful when you read the brief problem statement before meeting the couple to imagine what alternatives there might be for a couple in this “situation”, with the strong caution that you have to be completely open to their actual situation and not prejudge what you think it to be.
Using an evaluative process such as a single system evaluation can provide additional structure and clarity. It requires some discussion of the problem with the client, mutual determination of goals, how the goals will be measured, and a plan to monitor change. Feedback about change and progress occurs regularly and it is clear the extent to which the clients have realized their goals.
Some questions: