Inside a Case of Couple's Therapy

If anything in psychotherapy research has stood the test of time, it’s the importance of the working alliance (APA 2012). Bordin (1979) narrowed this concept down to three features: mutual goals, task relevance, and relational bonds. “Task relevance” means that all parties see how engaging in the tasks of treatment will lead to the goals. “Relational bonds” are not rapport or mutual validation; they are the kinds of bonds that emerge when people work together collaboratively.

A case formulation specifies the psychology that underlies a life problem and how the treatment will change that psychology. It is thus central to task relevance. Clients should not vaguely feel that their therapist will alleviate their pain. They should instead understand how the sessions will address problematic patterns of behavior.

Couples come for therapy for all sorts of reasons, ranging from parenting decisions to managing infidelity to arguing about money. Resulting therapies are analogous to brief treatment with individuals, addressing the problem directly. Often, however, these problems emerge or remain because the couple cannot stay on track with the relationship they both want. They may keep hurting, disappointing, or irritating each other. They want to act one way, but culture, family, and personality keep driving them into another way of relating to each other.

The case formulation, then, describes the relationship they want and the relationships they typically veer into. The variables include such things as how they talk to each other, the frequency and importance of sex, and their relational boundaries. The therapist helps them recognize their swerves and to remain on track. Before long, they learn to recognize these deviations themselves.

Agnes and Maria* wanted a healthy and loving connection between two independent people. Their model for this relationship was an older lesbian couple they both knew, affectionate successful professionals, whom we nicknamed “Double Star.” Their problems arose in patterns that we were able to identify. Agnes wanted more than emotional support; she wanted to be supported no matter what. We eventually labeled this as “You Poor Dear.” We noted together that Maria’s support became meaningless when it was guaranteed, and we also noted that Maria could not provide that kind of support without losing her sexual interest in Agnes.

On Maria’s side, she wanted life with Agnes to be an adventure, which sounds great, but in her case, it translated into impatience and intolerance if dinner was scheduled for the same time every day or if Agnes wanted to zone out in front of the television. Maria flirted with other women that sometimes seemed threatening to Agnes and thus made her dependent and needy. We named Maria’s hidden agenda “Thelma and Louise,” noting the disastrous end in that film to constantly insisting on adventure.

Agnes and Maria learned quickly to call each other out when they departed from the Double Star and headed into either You Poor Dear or Thelma and Louise. Then we used our time together to find ways for Agnes to express dependencies (like receiving a massage) and for Maria to express swashbuckling (like planning trips) that didn’t change the fundamental way they related to each other.

Notice how this approach to case formulation for couples embraces other approaches. For example, the couple may want to relate to each other like securely attached people and swerve into relating like insecurely attached people. The insights of emotionally-focused therapy would then be relevant. If you think of the couple relating to each other in their preferred manner as positive interactions and the offroad diversions as negative interactions, then the Gottman method becomes relevant.

This approach also works with individual clients, although most individual work benefits from putting life goals first and relational goals with the therapist second. In couple’s work, the couple’s relational goals are primary. Still, a case formulation in individual work can benefit from specifying what the therapy relationship should look like. (This has become contentious as increasing numbers of therapists think the therapy relationship should include cheerleading, soothing, and avoiding conflict.)

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“Transference” can then be described as the relationship the patient keeps trying to impose on the dyad, and “countertransference” is the departure from the therapeutic stance that the therapist keeps trying to impose, whether because of poor training, poor judgment, or personality patterns of their own.