10. Using Concepts in Therapy - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Down the Relationship Rabbit Hole, Assessment and Strategy for Therapy
Chapter 10: USING CONCEPTS IN THERAPY


Every assessment tool or process can be explicitly utilized to direct treatment.  The therapist may use these concepts, the 4 C's and the 3 D's in any manner that seems appropriate in therapy.  The therapist may find it useful to introduce this as an assessment tool in therapy with an individual, the couple, or a family.  As a teaching and therapeutic tool, it both help frame the individual, couple, or family's devolved relationship and begins to direct them to a rebuilding process.  Each individual's devolved relationship with another or others may have significant cultural aspects to consider.  The therapist should check the tolerance level for any person to remain stuck in one of these stages.  In some families-of-origin or cultures, it is not permissible to go beyond the first two stages or first three stages.  Actually criticizing, much less expressing open contempt at the other person may be unacceptable, especially a patriarchal authority figure or parent.  The individual with lesser power or status may be expected to avoid verbalizing and to stuff such feelings.  Or, open expression may be permissible from the father, but not from the wife or children.  A highly male dominated autocratic society may not allow for the wife or children to criticize any males including the elder patriarch in the multi-generational family.  In situations where divorce is not an option because of social or religious standards, the couple can get stuck in earlier stages of devolution such as contempt, defensiveness, or quite often, emotional disconnection.  The couple that is stuck in emotional disconnection may not always be seeking to greater romantic intimacy.  The couple may not feel it is possible to reconnect emotionally, and thus will have fundamentally different goals in therapy than a mainstream (and romantic couples therapist!).  Families may have similar dynamics and limitations for change.  The therapist needs to be aware of his or her expectations for an intimate relationship or marriage, especially if they are romantically based.  Whereas other couples or families may enlist the therapist to gain emotional reconnection and a more fulfilling relationship, an emotionally disconnected couple or family may be seeking a functional arrangement.  In other words, the goals are to reduce conflict, increase collaboration, and to make the relationship bearable.  In cultures without a strong tradition of romance-based marriages, marriage or the family is more of a business arrangement.  If the marriage or couples relationship or the family is such a functional relationship, then the issues that need to be facilitated are more practical contracts such as money and division of labor and responsibilities as opposed to emotional connectedness.  The therapy becomes more a renegotiation of the business arrangement.  And the therapist's role is not of an intimacy facilitator.  Use of the concepts or of this assessment tool may need to be adapted when the goals are more functional than intimacy oriented.  The assessment tool and concepts are designed primarily for couples or relationships with members that still wish to regain lost intimacy.
  
The devolution model of relationship is particularly useful when the couple or family has started to make or has made one of the two key transitions: from criticizing to contempt, or from defensiveness to disconnection.  It also is instructive for an individual who is looking at his or her relationship with some important person (intimate, professional, social, and so one) who may not be in the therapy.  The tool helps the individual, couple, or family see what has happened, is happening, and what is at stake.  At the same time, it directs the individual, couple, or family to what is required to grow and change and why it would be challenging.  The therapist can present this tool in the first session as an initial assessment tool.  The therapist can say, "I need to find out where you (or each of you) are in the relationship.  I'm going to tell you about seven stages, four C's and three D's.  After I describe them, I want you to each identify which stage you are at.   You might be in a stage or between stages."  After describing all seven stages, the therapist asks the individual or each person present in turn, which stage he or she is in.  Virtually, no one ever says that he or she is one of the first three stages: comment, complain, or criticize.  An individual, partner, or family member in the first three stages is having some communication problems but the relationship has not suffered emotional injuries.  The relationship is not at risk and coming to therapy is largely irrelevant.  A communication video, a couple's retreat, or a relationship book would probably suffice to handle any minor issues.  Once in a while, an individual, one or both partners, or the family have just ventured from the communication difficulties of the first three stages into the injuring stage of contempt.  In this all too rare scenario, the individual, one or both partners, or the family as a whole are so horrified that hurting one another has entered into the relationship, that therapy is initiated immediately.  And, not surprisingly therapy can be relatively simple and positive results can occur in relatively few sessions.  Communication training or therapy is effective since the individual, both partners, or family members are still able hold the five foundations to relationship: trust, vulnerability, express well, have empathy, and are heavily invested.  Unfortunately, many individuals, couples, or families do not quickly address the beginning of contempt in the relationship.  Instead, they stay in the contempt stage for years and decades, with ever debilitating pain before (if ever) opting for therapy.  The contempt and the injuries calcify and cripple the relationship.

One of the inherent problems, particularly in couple therapy is whether both partners are at the same stage.  If both persons are in the same stage of devolution, no matter how advanced, therapy is simpler in a manner.  Therapy directed at progressing from the common stage will be relevant to both persons.  When at the same stage in the process of devolution, they have similar issues, are doing the same things.  As a result, the therapist can use primarily one approach to facilitate, teach, and work with them together.  When they are in different stages however, the therapist finds him or herself managing a dual process!  Isakson, et al, (2006) discussed greater positive outcomes in couple therapy when partners started therapy with "similar levels of disturbance."  "However, if the female reported clinical levels of disturbance at intake but her partner did not, outcome for the female was especially poor in contrast to outcomes for females receiving individual therapy.  Clinically disturbed males showed significant gains in treatment even when their partners were not disturbed" (page 313).  Isakson's findings imply a culturally important distinction for at least some men that require further examination.  Men may benefit from the opportunity to address issues be in therapy because they are not otherwise addressed.  The therapist may hypothesize that with men's greater cultural reticence about discussing or revealing distress causes them to benefit with treatment once they are in therapy or invested in therapy.  Whereas, women who reported greater disturbance were steeped in the distress despite having already processed it with girlfriends, sisters, moms, and the nice pedicurist!  Other potentially relevant gender influences may include the lesser power and control of females in society to activate change having led to more enduring and deeper frustration in the relationship versus a more oblivious male partner.  In family therapy or in reference to issues with family dynamics, a child or adolescent may have inherent developmental power inequities or an adult may have historical family standards that inhibit if not prohibit certain communications.

Regardless of such qualifications, differences in stages of relationship devolution require the therapist to manage a cross-cultural process in dealing within another cross-cultural process (individuals from different cultures)... within still other cross-cultural processes (class, age, gender, and so forth)!  Getting the members in the relationship to the same stage may be comparable to finding a common culture shared by a pair of partners.  This could be the initial treatment goal. Often the less devolved partner will be surprised that his or her partner is in a more devolved stage.   For example, I have had many experiences with couples where one partner will report being in the contempt stage and moving toward becoming defensive, and then be shocked to find that the other partner identifies as being emotionally disconnected.  Therapy will be significantly more difficult as a result.  If the partners are at mismatched stages of devolution, the direction of therapy is to try to move the more devolved partner (in the disconnected stage) into the same stage as the other.  Attempting to move the less devolved partner (in the contempt-defensive transition) into an even more evolved- that is, healthier stage will not be productive or practical.  Since the relationship depends on mutual and reciprocal behavior, the lack of mutuality and reciprocality from the more devolved partner effectively blocks the less devolved (healthier) partner from risking greater trust and further vulnerability.  Becoming more evolved won't make sense yet to the less devolved partner since that would increase the difference between the partners.  An emotionally disconnected partner is withholding investment of his or her feelings in the relationship, which would make the other partner's greater investment foolish.  Getting the more devolved partner to evolve back to match the other partner's stage allows the less devolved partner to risk further experiences and time in the relationship.    The therapist may verbalize these issues and the direction of therapy to both partners.  The less devolved partner in particular, may need to be warned that the therapy may focus on the more devolved client for the time being.  Isakson, et al feel may be making a similar point when they assert that the gender differences in low versus high disturbance may be so significant that the structure of therapy may need to be adjusted.

"The interaction effect suggested that when clinically disturbed males are seen in couple therapy the degree of disturbance experienced by their wife had little relationship to the gains they made in treatment. Male patients seemed to benefit in couple and individual therapy, albeit more rapidly when seen with their partner. In contrast, when a female entered couple therapy in the clinical range and her male partner did not, she had a poor outcome relative to married females seen in individual therapy and females seen in couple treatment when both partners were equally disturbed… Were these findings replicated it would make sense to assess the level of functioning of both members of a couple before initiating treatment and refer females to individual therapy if their partner is not also scoring within clinical levels of disturbance. In this regard discrepant level of disturbance would be considered a contraindication for couple treatment. At the very least, females who enter couple treatment with a non-distressed partner should have their treatment response carefully monitored so that the clinician could intervene in a timely fashion in the case of a poor treatment response"(page 319).

While the gender values may be a relatively relevant difference, the therapist should duly note any difference in the relationship levels of the partners.  The therapist should work to equalize the levels- that is, facilitate getting both persons to the same level , especially if as Isakson, et al imply if the more disturbed client is the female in a heterosexual couple.  In same sex couples, the therapist may need to make a more careful and nuanced assessment of the individual styles of each partner beyond gender stereotypes when they are at different relationship levels to see if male or female attitudes or behaviors are relevant.  Gottman says, "…it wasn't that we should admonish couples not to fight but that we should admonish them to be able to repair it and recover from it." The assessment tool and theory is presented as a progressive devolution from benign to problematic to toxic stages- a progressively more unhealthy relationship.  It can also be interpreted to be a treatment tool for developing relationship and therapeutic goals to repair and recover.  By reversing the stages, a model is revealed for a progression- a positive evolution from toxic to problematic to benign and ultimately, healthy relationships.  Progressing in reverse from a devolved relationship (or forward toward a healthier relationship) occurs with working positively on the principles of each stage.  These define the goals for evolution of the relationship.  Starting with the last stage of devolution, a progressive goal for each stage becomes evident.  The therapist, for each stage should facilitate an individual such as a partner or family member and/or the couple or family moving toward what is discussed in the next chapter.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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