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dissertation entitled

ELICITING THE VOICE OF THE CLIENT:
INFLUENCES ON CLIENT SATISFACTION WITH
INTEGRATIVE COUPLES’ THERAPY
A QUALITATIVE STUDY

presented by

Dahlia Brenda Berkovitz

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ELICITING THE VOICE OF THE CLIENT:
INFLUENCES 0N CLIENT SATISFACTION WITH INTEGRATIVE COUPLES’
THERAPY
A QUALITATIVE STUDY
By

Dahlia Brenda Berkovitz

A DISSERTATION

Submitted to Michigan State University
In partial fulfillment of the requirements
For the degree of

DOCTOR OF PHILOSOPHY
Department of Family and Child Ecology

2005

ABSTRACT
ELICITING THE VOICE OF THE CLIENT:
INFLUENCES ON CLIENT SATISFACTION WITH INTEGRATIVE COUPLES’
THERAPY
A QUALITATIVE STU DY
By
Dahlia Brenda Berkovitz
How individuals in couples’ therapy describe what influences their level of
satisfaction with Integrative Couples’ Therapy was examined through a case
study approach. Six couples in an intimate relationship participated in a conjoint
open-ended-questions interview and filled out a demographic questionnaire.
Data collection took place at the clinic where they attend or attended couples’
therapy with a Marriage and Family therapist who practices Integrative Couples’
Therapy. Participants were selected from two Marriage and Family clinics. The
therapists were interviewed about how they applied the integrative approach to
each participating couple and about their view on how each couple perceived the
therapeutic process. This study follows the theoretical stance of Human Ecology
theory (Bronfenbrener, 1979, 1989, 1993) and specifically Family Ecology
(Bubloz & Sontag, 1993), and Integrative Couples’ Therapy (Pinsof, 1983, 1994a,
1995; Lebow, 1984).
Human ecological, family, and clinical aspects interact and have an

influence on client’s level of satisfaction with treatment and outcome of couples in

Integrative Couples’ Therapy. The eco-systemic factors involve clients’ values

and beliefs, social support that is available for the couple, and the individual’s
perception of level of fairness of the therapist during treatment. The clinical
aspects involve the therapist’s characteristics, therapist’s use of Integrative
Couples’ Therapy, the therapist’s values and beliefs, and therapist’s fairness
toward both partners in treatment.

Data analysis involves description and examination of themes and
categories within each case (Similarities and differences in responses of each
partner), and across cases. Findings are presented in accordance with the
original research questions. More studies involving different therapeutic
approaches to couples therapy will be beneficial to increase the database
relating to client’s satisfaction with Integrative Couples’ Therapy, and possibly

rendering the therapeutic process more effective.

Dedicated with love to
my parents
Doris and Pesach Rosen
Mission accomplished

iv

ACKNOWLEDGMENTS

First, I would like to acknowledge the boundless support, patience,
encouragement and love with which my family has endowed me throughout this
arduous process. To my parents, Pesach and Doris, thank you for your never
falling faith in my ability to accomplish the goal I have set for myself, your
supportive words, and your wisdom that will guide me throughout my life. To my
children, Limor and Ron, you always expressed your pride in the task I have
chosen to take on, and you always stood by me. You enriched my life in
countless ways, and I love you so much. To my Sister Orit, and my borther
Nathan, and their families, thanks for believing in me.

I want to extend my gratitude to the faculty and staff in the Department of
Family and Child Ecology at Michigan State University for their guidance, and
patient counsel. I give special thanks to Dr. Esther Onaga, who without wavering
accepted the task, was always available to answer any question, and offered
insightful suggestions. You possess more than professionalism, you are truly a
mentor, and I look up to you. To Dr. Marsha Carolan, thank you for years of
unwearied instruction. You provided me with the foundation and understanding
of qualitative research and its application to Marriage and Family Therapy. You
always assured me that the end of this process is around the corner and showed
genuine delight when I got there. To Dr. Griffore, thank you for your profound
knowledge in Human Ecological and Family Ecological theories and your
substantial contribution to this dissertation. To Dr. Stollak, I thank you for your

insurmountable knowledge in couples’ therapy, your wonderful sense of humor,

your ability to turn a stressful situation into an enjoyable event, and for adding
new dimensions to my professional approach. I thank all of you for your high
professional standards. I learned from all of you.

I would like to thank all my wonderful friends who stood by me and
convinced me that there is a light at the end of the tunnel. Especially, I would like
to give gratitude to Francesca and Natasha, my friends and colleagues in the
Marriage and Family Therapy program, who went through the same grueling
experience, and were able to provide both professional insight and reassurance.
You are true lifelong friends, and I am grateful our paths crossed. This

experience would not have been the same without you.

Table of Contents

LIST OF FIGURES...

CHAPTER1
INTRODUCTION... .. .
Purpose and Significance of the StUdy
Theoretical Framework. ..
Human Ecology and Family Ecology Theory
Bronfenbrener’s Ecology of Human Development Applied to
Couples’ Therapy... . ..
Conceptual & Theoretical Map .. .. ..
Figure 1.1 A Conceptual & Theoretical Map
Research Questions... .....

CHAPTER 2
Review of Literature...
Integrative CoupleS’ Therapy
Human Ecology and Family EcoIogy Theory .
Client’s Satisfaction with Couples’ Therapy... ... ..
Summary...

CHAPTER 3
Methodology.

Dyadic ResearCh Methods
Case Study Methodology...
Procedures...
Researcher: Self as Instrument
Sample...
Data ColleCtion...
Table 3 1 Theory, reSearch & therapiSt interView questions
Table 3. 2 Theory, research & conjoint interview questions...
Data Analysis...

CHAPTER 4

FINDINGS... ..
Table 4.1: Demographrc CharacteristIcs of Particrpatrng
Couples... . .. .. ..
Content Analysis... .

Couple #1— Chris and Christina... .

Influences of Demographic FaCtors, CUItUraI and Family of
Origin on Couple’s Perception of Therapy... .
Own Values: Definition of a Healthy Intimate RelatIonshIp

vii

19

”n..... 19
26

27
4O

42
. .. 43

I... 46
47
...50

.52
54
56

.60

61
.. 62

.65

.66

Influences of Therapist’s Characteristics and Therapeutic

Milieu... .. 67
Helpful and Unhelprl Aspects of Therapy ... .. 69
Goals... . . 70
General Statement ...................................................... 71
Couple #2— Kyle and Karen... . . 72
Influences of Demographic Factors, CUltUral and Family of
Origin on Couple’ 3 Perception of Therapy... 73

Own Values: Definition of a Healthy Intimate Relatronshrp 74
Influences of Therapist’ 5 Characteristics and Therapeutic

Milieu... . 75
Helpful and Unhelprl Aspects of Therapy .... .. 76
Goals. .. 77
General Statement ...................................................... 80
Couple #3- Don and Donna... . .. . 81
Influences of Demographic Factors, mCUItUral and Family of
Origin on Couple’s Perception of Therapy.. .. 82

Own Values: Definition of a Healthy Intimate RelatIonshIp 83
Influences of Therapist’ s Characteristics and Therapeutic

Milieu... .. 84
Helpful and Unhelprl Aspects of Therapy .... .. 86
Goals... . 88
General Statement ...................................................... 89
Couple #4- Tim and Theresa... . 91
Influences of Demographic FaCtorS, CultUral and Family of
Origin on Couple’s Perception of Therapy... . 92

Own Values: Definition of a Healthy Intimate Relatronshrp 93
Influences of Therapist’ 5 Characteristics and Therapeutic

Milieu... .. 94
Helpful and Unhelpful Aspects of Therapy .... .. 96
Goals... . . . 97
General Statement ...................................................... 99
Couple #5— Ed and Edna... .. 100
Influences of Demographic Factors, CUItUral and Family of
Origin on Couple’ 3 Perception of Therapy. . .. 101

Own Values: Definition of a Healthy Intimate Relatronshrp 103
Influences of Therapist’ s Characteristics and Therapeutic

Milieu... . 103
Helpful and Unhelpful Aspects of Therapy .... .. 106
Goals... . 107
General Statement ...................................................... 109
Couple #6— Adam and Amanda... . 110
Influences of Demographic Factors, CUltUral and Family of
Origin on Couple’ s Perception of Therapy. .. . 111

Own Values: Definition of a Healthy Intimate RelatIonshIp .112

viii

Influences of Therapist’s Characteristics and Therapeutic
Milieu... .

Helpful and UunhelprI Aspects of Therapy

Goals...

General Statement ......................................................

Statements made by the therapIst of couples: #1, #2, #4,

and#6... .. .. .
Cross- Case AnaIySis...

Data Matrix...

Family of Origin on Couple’s Perception of Therapy...
Table 4. 3 Influences of Therapist Characteristics &
Therapeutic Milieu... .
Table 4 4 Themes of Helpful and Unhelpful Aspects of
Therapy.
Table 4. 5 Goals .

Table 4. 6 Couple’ s General Statements
Answers to Research Questions...

CHAPTER 5

151
152
.....152
.....154
Methodological Issues

Overview...

Key Findings .

Theoretical Foundation

Figure 5.1: A Revised Conceptual and Theoretical Map
Other Findings...

Limitations...
Recommendations for FUture Research

APPENDICES
Appendix A

Interview Outlines for Therapists’ Interviews... .... .

Appendix B

Interview Outlines for Conjoint Interviews... ..

AppendixC

Demographic Questionnaire...
AppendixD

Informed Consent
AppendixE

Informed Consent...................

ix

112
115
116
118

119
120
121

Table 4. 2 Influences of DemographIc factors, CUItUre and

.. .125

128

132
135

138
. 139

151

161

162
163
Clinical implications......................... .
Summary......................

163
166

169
173
177
178
181

183

List of Tables

Table 3.1 - Theory, research & therapist interview questions... ..

Table 3.2 -— Theory, research & conjoint interview questions...

Table 4.1 - Demographic Characteristics of Participating Couples... ..

Table 4.2 - Influences of Demographic factors, Culture and Family of
Origin on Couple’s Perception of Therapy

Table 4.3 - Influences of Therapist Characteristics & Therapeutic Milieu.

Table 4.4 — Themes of Helpful and Unhelpful Aspects of Therapy .........

Table 45-Goals

Table 4.6-Couples’ General Statements..........................................

....52

54

.61

125
128
132

135

138

List of Figures
Figure 1.1 -A Conceptual and Theoretical Map...... 16

Figure 5.1 — A Revised Conceptual and Theoretical Map... 154

xi

CHAPTER 1

Introduction

The field of couples’ therapy has been a part of psychotherapy practice as

early as 1930 (Gurman & Fraenkel, 2002). Presently, couples’ therapy gains
only secondary importance in the larger field of family therapy (Gurman &
F raenkel, 2002). Ackerman (1970) has identified treating marital discord as the
main method to bring about change in families. In spite of the secondary status
of couples’ therapy, marital and couple problems are issues most commonly
identified by clients (Rait, 1988) and treated by therapists (Doherty & Simmons,
1995, 1996; Whisman, Dixon, & Johnson 1997). Increased number of books,
workshops, and conferences relating to couples’ therapy in the last decade
indicate that only lately the practice of couples’ therapy has become common
practice. In terms of research, the field needs more studies evaluating
effectiveness of different family therapy approaches in achieving the desired
outcomes (Gurman & Fraenkel, 2002). This study utilizes an integrative
approach to couples’ therapy (Lebow, 1987 & Pinsof, 1995). The integrative
approach was selected for this study on the basis that it is a model that can
address a wide range of presenting problems. It integrates major theoretical
models and allows the therapist to tailor a treatment plan that fits the client’s
needs (Pinsof, 1995).

Additional scientific studies are needed to explore the phenomenon of

clients’ satisfaction with couples’ therapy. Allowing clients to express their

feelings and voice their opinions regarding their experience of couples’ therapy
can render the treatment more effective and lead to better outcomes for all
involved (Quinn, 1996). There are several eco-systemic components that need
to be considered as affecting client’s satisfaction with couples’ therapy. The
therapist’s background, professional values, personal values and beliefs
(Lazaloffy & Hardy, 2000; Markowitz, 1994), and the therapeutic model used are
all important factors influencing the direction of treatment. Likewise, each
partner’s background, values and beliefs are important eco-systemic factors.
Dynamics in families of origin of all individuals involved, in the proposed model,
may also affect the process of treatment (Lazaloffy & Hardy, 2000; Markowitz,
1994)

When treating couples, therapists also need to consider demographic
factors and social forces. There is a continuous and reciprocal interaction within
the different eco-system levels described above, and eliciting the client’s voice
will facilitate a better understanding of all the eco-systemic factors that are
specific to each individual case (Bubolz & Sontag, 1993).

Some research was conducted to investigate client’s satisfaction with
individual therapy, but only a few studies were geared towards client’s
satisfaction with couples’ therapy (Bowan & Fine, 2000; Christensen, Russell, &
Miller, 1998; Helmeke & Sprenkle, 2000). The phenomenon of investigating
client’s satisfaction with couples’ therapy lends itself to qualitative methods of
exploration, providing subjects with the opportunity to express their feelings and

views about their experience in the therapeutic process. Using a dyad as the unit

of analysis may complicate matters since partners may perceive the therapeutic
process in different ways. It is assumed that the way each partner
conceptualizes the problem will impact his/her experience and perception of the

therapeutic process.

Purpose and Significance of the Study

This study purports to explore how human ecological, specifically the
social/structural environment in family ecological aspects, and clinical aspects
influence client’s level of satisfaction with treatment of couples in couples’
therapy. This phenomenon lends itself to a qualitative exploration in which the
clients are given the opportunity via in-depth interviews to candidly describe their
experience and feelings about the therapeutic process and treatment outcomes.
The qualitative approach is suited to answer the questions raised regarding the
therapeutic experience since this subject is under researched, and because the
qualitative in—depth questions such as “how,” and “what.” Qualitative researchers
need to be well informed and highly involved with all data collection and analysis
process. The researcher is expected to have “intimate” knowledge of the data in
order to gain a profound understanding of the case under investigation (Helmeke
& Sprenkle, 2000).

Most studies addressing therapy concern the therapist’s perception about,
rather than the client’s experience with the therapeutic process (Laszloffy, 2000).
Understanding the social/structural environment of human and family ecological
systems, and clinical aspects as influencing the level of satisfaction of clients in

Integrative Couples’ Therapy and outcome of treatment, and the possible

differences of how each partner perceives the experience will allow therapists to
be attentive to the needs of each partner while attempting to work with them
collectively. Allowing each partner in couples’ therapy to recount his/her
experiences and express satisfaction or dissatisfaction with the therapeutic
process will add to a body of research that concentrates on the client’s
satisfaction with individual therapy. Unlike previous studies that considered an
individual in therapy as the unit of analysis, this study views the relationship
between the therapist and the couple in therapy as the unit of analysis. This unit
of analysis has its own rules, norms and looks at relational issues. Interviewing
the couple conjointly would allow for the emergence of new understanding of the
dynamics of couples’ therapy. And, interviewing the therapist regarding his/her
view of the therapeutic experience with each couple will help examine the level of
congruency between the client unit and the therapist.

It is hoped that this study will offer insight into understanding effective
clinical methods (i.e., transgenerational approach, behavioral therapy, solution-
focused approach), and will present therapists working with couples with new
helpful tools. Through the results of this research, therapists will have the
opportunity to examine what they do that is helpful or unhelpful in therapy, what
they need to avoid and what they can build on (Bowan & Fine, 2000), resulting in
a more effective therapeutic process. Additionally, if the couple benefits from the
therapeutic process, and gains positive changes in their relationship, there will be
a ripple effect on their close environment (i.e., children and other family

members) (Gunnan & Fraenkel, 2002).

Thus far, studies investigating client’s satisfaction with therapy were
geared toward individual therapy. This investigator found only one study
(Bowman & Fine, 2000) that specifically examined couples’ perceptions (i.e.,
“Client’s perception of couples’ therapy: helpful and unhelpful aspects”), and a
small number of studies that incorporated some aspects of client’s satisfaction in
couples’ therapy (Denton et. Al, 2000; Locke & McCoIIum, 2001; & William &
Simmons, 1996).

Treating a couple involves different dynamics than treating an individual.
A dyad involves personal interdependence and mutuality (Thompson & Walker,
1982). When dealing with a dyad it is necessary to include: conceptualization of
the problem from a relational perspective, individuals that represent a
relationship, measurements that can be applied to one or both members of the
dyad and to the relationship assessment, an interpersonal analysis examining
patterns between partners in a relationship, and interpretations and implication
depicted about the relationship between the individuals (Thompon & Walker,
1982). This study is unique and important as it deals with the complex feature of
investigating a dyad as opposed to an individual. Allowing the couple to
describe their unique experience of the therapeutic process and express their
satisfaction or dissatisfaction with the process may reduce the gaps between the
therapist and each partner and hopefully lead to the professional growth of the

therapist and hopefully, the personal growth of both partners.

Theoretical Framework

The main theoretical perspectives used for this study are the social
environments of Human Ecology Theory (Bronfenbrenner, 1979, 1989), Family
Ecology (Bubolz & Sontag, 1993), and Integrative Couples’ Therapy (Lebow,
1987; Pinsof, 1995). A conceptual and theoretical map is provided in Figure 1.1
depicting how the concepts of Human Ecology, Family Ecology, and clinical
aspects of therapy influence the level of satisfaction with the therapeutic
experience and with outcome of treatment of individuals in Integrative Couples’
therapy. Bi-directional arrows show the reciprocal interaction between the
human ecological environment, Family Ecology theory and clinical aspects of
therapy, providing the goodness of fit that will likely lead to satisfaction with the
therapeutic experience and with outcome of treatment. Viewing couples therapy
as part of an ecological system uncovers links and dynamics that explain the

influence among the different factors involved.

Human Ecology and Family Ecology Theory
This researcher discusses Human Ecology Theory (HET), using
Bronfenbrenner’s systems approach extensively, in order to provide an
explanation regarding the physical environment and the dynamics in and
between all the systems in which families exist. However, for the purpose of this
study, the main focus is on the social/structural environment, which is depicted in
the Family Ecology Theory (Bubolz & Sontang, 1993). According to Human

Ecology Theory (HET) humans engage in an ongoing reciprocal interaction in

different levels of the environment: the natural/physical environment, the human
built environment, and the social/structural environment (Bubolz & Sontang,
1993) (See Figure 1.1). Each environment also affects couples and couples
therapy. The natural/physical environment provides life-sustaining goods such
as food, water, air and the like. The human built environment provides shelter
and other made-up resources, which are necessary for the sake of safety.

Family Ecology Theory integrates human development and family
relationships in a family resource management framework. Bubloz and Sontag
(1993) propose similar ideas to Bronfenbrenner’s systems approach suggesting
that a family interacting with the environment is an ecosystem. The family is the
basic human system made up of subsystems.

Family theory is in line with the viewpoint of critical science, which looks at
knowledge as a source of education and emancipation, helping transform
oppressive social structures to bring about justice and freedom for families,
liberating individuals and groups from irrationalities. It employs hermeneutic
rationality focusing on inter-subjective understanding of one another and mutual
agreement on ethical issues, in spite of cultural differences, and understanding
intentions and reasons for behaviors (Bubloz & Sontag, 1993).

The social/structural environment is the most significant for the purpose of
this investigation. It is comprised of societal roles, norms, values, and beliefs
about couples and couples therapy. Each culture constructs its own norms,
values and beliefs, and each person may interpret cultural norms differently

(Lazaloffy & Hardy, 2000).

Components of General Systems Theory are applied to Family Ecology.
First, the structural components of the family involve physical structure, roles,
rules, gender, age, and the like. Specific patterns result from various
characteristics of individuals and families. Some factors influencing the structure
are structure of subsystems, ethnicity, cultural origin, developmental stages of
the individuals and the family, and socio—economic status (Griffore & Phenice,
2001 ). Also, needs, values, and goals of individuals and the family contribute to
the structure of the family. The internal structure of the family regulates the
relations within the family. The external structure involves interactions with
outside organizations and systems of the family (i.e., school, work, church)
(Griffore & Phenice, 2001).

Governing components of the family include: needs of individuals and the
family in order of survival and adaptation, and values. Ethnicity is a factor
influencing family values. It is noted that families in poverty have fewer
resources to assist them with a healthy development and individuals in these
families may be at risk for unhealthy values and behaviors. Goals of the family
are another governing component. Values and goals are the major motivating
force in families, and they may be different at different times (Griffore & Phenice,
2001)

Dynamic components involve energy and matter as they flow and
transform from one form to another leading to individual and family processes.
lnforrnation processing components suggest that perception is the process a

person uses to make sense of his/her experience (Griffore & Phenice, 2001).

These would be affected by individual’s goals, interests, abilities, environment,
the fit of the person perceptual state to his/her ability to take advantage of the
environment, and how the individual responds to this perception. Perception is
also influenced by social context and cultural settings (Gibson, 1997, as cited in
Griffore & Phenice, 2001).

lnterrelationship components relate to decision-making. It is the main
cybernetic control system aimed at achieving individual and family goals. They
involve rules and consideration of alternatives, reflecting individual and family
needs and values (Bubloz & Sontag, 1993). Decision-making helps maintain the
stability of the system, and allows for non-disruptive change and adaptation
(Griffore & Phenice, 2001).

Finally, life process components refer to family adaptation, involving the
process of different situations that are introduced into the family’s life. The family
is a complex organization in which the whole is composed of parts. There is a
constant need to coordinate actions of two or more persons in order to achieve
goals (Kuhn, 1974, as cited in Griffore & Phenice, 2001).

Approaching couples therapy without incorporating the human ecological,
and specifically social/structural environment of family ecological, lens will result
in a linear cause-and-effect view of relationships. The ongoing reciprocal
dynamics between persons and their environments, which are crucial to
understanding couples and their therapeutic experience, will be ignored without
consideration of the human ecological and family aspects. Using the Human

Ecology and Family Ecology approaches in couples therapy allows the therapist

to observe the interrelationships among the marital system, natural environment,
human constructed environment, and human behavioral setting. All these impact
the therapeutic process. The client unit in therapy, being an individual, a couple,
or a family, is seen as an adaptive system responding to different circumstances
in the environment, such as physical, biological, economic, structural, and
political factors (Bubolz, Eicher, & Sontag, 1979). It is assumed that a family will
have different resources available to it if living in a rural area as oppose to in an
urban setting. Having a large extended family in close proximity may provide a
social support system, whereas, being more isolated from extended family
members or other individuals may present some difficulties. If one or more family
members have a medical or mental challenge the others will be affected by it.
Religious and/or societal values may affect the way individuals interact with one
another and with their environment as well as how they view couples” therapy.
Socio-economic status may determine how many therapeutic sessions a couple
can attend. Political agendas may affect third party coverage of couples’ therapy
rendering it more or less accessible. Finally, the characteristics of each
individual must also be considered in the process of couples’ therapy.

Bronfenbrenner (1989) offered an ecological model consisting of different
systems. The microsystem consists of face-to-face interaction between
individuals. The mesosystem relates to the interaction between two or more
microsystems. The exosystem refers to a setting in which the individual may not
be directly actively involved, but has an influence on the individual. The

macrosystem is an overarching design encompassing the micro-, meso-, and

10

exosystmes’ features of a specific culture, subculture, and other larger social
context. Finally, the chronosystem is the influence over time such as life
transitions, family life cycle and the like.

Therapy is influenced contextually and environmentally. Various
interrelated factors, some obvious and some less obvious, affect the quality and
effectiveness of therapy. Being part of the eco-system milieu, couples therapy is
an active interaction likely to be described as being a helpful or not so helpful
experience depending on internal and external circumstances and the interaction
between them.

Systems consist of parts that interact in order to accomplish certain goals.
As couples therapists, Hiebert, Gillesphie, & Stahmann (1993) try to understand
these interacting parts and “modify the dysfunctional interchange of the system"
(Hiebert, Gillesphie, & Stahmann, 1993, p. 2). Additionally, these authors state
that therapists must pay attention to set patterns in the system: roles, rules,
traditions, as well as lived history and attempts at changing patterns that resulted

in the same dysfunctional interactions.

Bronfenbrenner’s Ecology of Human Development Applied to Couples’ therapy
According to Bronfenbrenner (1979) human development is seen as a
flowing process growing from the interaction between organism and the
environment. Persons operate within several interrelated levels in the
environment, oscillating from interaction between individuals (i.e., therapy with

couples or families) to remote social frameworks (i.e., social views on therapy

11

and couples’ therapy, social values regarding marriage and marital conflict). The
environmental factors may have a positive or negative impact on the process of
couples’ therapy, and the level of satisfaction with treatment of couples in
couples’ therapy.

The microsystem is the immediate environment of the individual involving
interaction between individuals and their ever-changing milieu. It is believed to
have an important influence since persons are part of different microsystems at
the same time (Bronfenbrenner, 1979). Some microsystems in which a couple in
therapy participate include family members who are affected directly by the
couple’s issues as well as indirectly by the benefits of therapy, friends who
provide support or on the other hand criticize the couple, church or other religious
clergy, and the therapist. In order for growth to take place it is necessary to have
a face-to-face interaction in the immediate milieu in which the individual lives
(Bronfenbrenner, 1993). Face-to-face interaction between the couple and the
microsystems mentioned above may increase emotional support for the couple
allowing for growth and resolution of conflicts.

The therapist may have a significant part in the couple’s growth. He or
she has the professional knowledge and understanding of couples’ dynamics and
also uses his/her own personality in the therapeutic process. It is necessary to
have dynamic interplay between individuals for change to take place. Family
theory addresses among other things which changes are necessary in order to
bring about improvement in human conditions and how professionals can help

(Bubolz & Sontag, 1993).

12

Mesosystems represent the connection and interaction that occur between
microsystems. Couples express their feelings regarding their conflicts in more
than one area (i.e., therapy, parents, children, friends, workplace). “Synergistic
effects created by the interaction of developmentally instigative or inhibitory
features and processes present in each setting” (Bronfenbrenner, 1993, p. 22).
Understanding the mesosystemic interactions and connections (i.e., how each
spouse interacts with his/her parents) helps the therapist and couple to develop
an effective treatment plan. The spouse’s microsystems may collide when
emotional injuries from the past are being projected onto present relationships.

Social support groups offer relief on a micro- and meso-systemic levels as
they allow individuals and families to meet their social and relational needs, and
safeguard them from undesirable effects of daily stressors (Garbarino, 1983;
Vaux, 1988). Social support is described as mediating structures (Wittaker,
1983) in which individuals and families receive and provide formal and informal
help from others. This kind of support is significant to a couple in times of crisis
when members from inside the family are unable to provide support.

Exosystem is the connection between more than one setting in which the
participating individuals are not directly involved (Bronfenbrenner, 1989). For
example, the process of therapy described in this study indirectly affects a child
whose parents engage in couples’ therapy.

The macrosystem affects all other systems. It involves social, cultural,
political, economic, and other global influences. Social norms and values affect

how individuals view marriage, divorce, and couples’ therapy. A person’s

l3

“directive belief systems” and the way he/she perceives an experience is affected
by his/her culture and have an effect on the person’s thoughts and behavior
(Bronfenbrenner & Morris, 1998, p. 1010). No specific literature was found that
relates to the macrosystem as it applies to couples’ therapy.

Chronosystem is a concept related to time and is part of the macrosystem
(Bronfenbrenner & Morris, 1998). It suggests that growth occurs over time in
both the individual and the environment. Human beings are viewed as a
functional whole, whose psychological development, including: cognitive,
affective, emotional, motivational, and social aspects interact with one another
(Bronfenbrenner & Morris, 1998). No specific literature was found that relates to

the Chronosystem as it applies to couples’ therapy.

Conceptual & Theoretical Map

The social environment of Human Ecology Theory provides an
understanding of the individuals in couples’ therapy in context of their systemic
interaction with their environment (Bronfenbrenner, 1979,1989), and the
social/structural environment of Family Ecology Theory provides an
understanding of individuals” value system while using Bronfenbrenner’s systems
approach (Bubloz & Sontag, 1993). Additionally, according to Bronfenbrenner
(1979) systems theory, bi-directional arrows show interaction between the
different layers of systems: Micro-, Macro-, Exso-, Meso-, and Chronosystem.

Also, according to Family Ecology Theory, bi-directional arrows show interaction

14

within three environments: natural/physical, human built, and social/cultural
environment (Bubloz & Sontage, 1993).

These different aspects add information regarding the most suitable fit
that will likely produce satisfaction with the therapeutic experience and with
outcome of treatment in couples’ therapy. ln-depth interviews provide a better

understanding of each case under investigation.

15

Most Suitable Fit

 

  
 
 
 

 

 

 
    

 

   

 

 

Chronosystem

Microsysterns

Figure 1.1 A Conceptual & Theoretical Map

 

 

 

 

Family Ecology Clinical Aspects
Theory ( F ET)
Interaction within 3 I I _
environments Therapist/Process
(Bubloz & Sontag,
1993) Use of Integrative
approach (Pinsof 1983.
Couples Natural/ Human built 199% ,995 & Lebow.
Values/beliefs ' °"Vi'°"‘- 1984.1987)
COUPE? Therapist’s Values
Perceptlon of Social/structural environment & beliefs
Fairness
Therapist’s
Outcome/Satisfaction Famess
Microsystem
Couple's system
Social Suppport
Mesosystems Human Ecology Theory
- - -4 ‘— (HET)

(Bronfenbrenner, 1979,
1 989)

 

Research Questions

The overarching questions of this study are:

Research Question # 1: How does the ecosystem (social environment) influence

client’s level of satisfaction with treatment of couples in couples’ therapy?
flResealch @estion # 1.1: What are the eco-systemic
(social/structural environment) influences on client’s level of satisfaction
with couples’ therapy and outcome of treatment?
S_ut);Reie_a_rch Question 1.2: How do values and beliefs of both partners
influence client’s level of satisfaction with couples’ therapy and outcome of
treatment?
§_L_ib-Res,e_a_rch Qgestion 1.3: How does their perception of fairness
influence level of satisfaction of clients with couples’ therapy and outcome
of treatment?

Research Question # 2: How does Integrative Couples’ therapy influence clients

level of satisfaction with couples’ therapy and outcome of treatment?
Su¢Rese§rch Question # 2.1: How do client’s demographic aspects
influence client’s level of satisfaction with couples’ therapy and outcome of

treatment?

Sub-Research Qgestion # _2._2: How does implementing the most suitably

fitted therapeutic or clinical process influence client’s level of satisfaction

with Integrative Couples’ Therapy and outcome of treatment?

17

MesearcLQfition # 2.3: How do therapist’s demographic
characteristics influence client’s level of satisfaction with Integrative
Couples’ Therapy and outcome of treatment?

§u_b-Researchfi0gestion 2.4: How does the Integrative approach to

couples’ therapy influence client’s level of satisfaction with couples’

therapy and outcome of treatment?

In order to attempt to address these research questions, it is important to
understand what is known about the influences on level of satisfaction of clients
in Integrative Couples’ therapy and how qualitative approach impacts the study of
client’s satisfaction with outcome of therapy. Additionally, it is important to
understand what is known about the complexities of studying a dyad as the unit
of analysis.

Chapter 2 reviews the literature related to client’s satisfaction with therapy.
Chapter 3 expands on the qualitative approach applied to this study, focusing on
case studies and in-depth-interviews. Chapter 4 will present the findings of the
study. Chapter 5 will discuss the findings, critique the research, and will offer

suggestions for future research and treatment of couples’ therapy.

18

CHAPTER 2

Review of Literature

The review of literature for this study covers three main areas: Integrative
Couples Therapy, influences of Human Ecology and Family Ecology on couples

in therapy, and client’s satisfaction with outcome of couples’ therapy.

Integrative Couples’ Therapy

The term “integrative” refers to the combination of aspects of different
schools of psychotherapy (Lebow, 1987). There is a wide scope of methods that
can be used under this approach and there is also a large diversity among
therapists practicing an integrative approach. Thus, a great deal of variability in
practices is expected within Integrative Couples’ Therapy.

The first attempt at integration of treatments incorporated psychoanalytic
and behavioral orientations within the context of an individual (Wachtel, 1977).
More recently, orientations such as structural, strategic, and psychoanalytic were
integrated within an individual context (Wachtel & Wachtel, 1986), and strategic,
behavioral, and psychoanalytic within the couple context (Gurman, 1981 ). Pinsof
(1983, 1994a) discusses the problem-centered model, which includes three
contexts and six orientations. The first context, family-community, relates to
extended family, nuclear family and immediate community. The second context,
couple, includes homosexual, sibling, premarital, heterosexual, or friendship

couple. The third context, individual, relates to a single person, and although

19

treatment can target the individual’s relationship with others it focuses primarily
on the individual’s perspective of these interpersonal relationships.

The six orientations include: Behavioral, Bio-behavioral, Experiential,
Family of Origin, Psychodynamic, and Self Psychology. The first three
orientations are contemporary and focus on the here and now. The assumption
is that presenting problems result from organizational, biological and
constrictions of meaning. The past is not considered as a focal factor in the
progression of change. Behavioral orientation targets interpersonal behaviors,
and it draws on the theory of social learning, problem-solving strategic therapy,
solution-focused, functional family therapy, and structural family therapy. These
theories ascribe the development and maintenance of psychological problems to
dysfunctional behavioral patterns that stem from a social organizational issue.
Intervention is geared toward finding alternative behaviors that will change the
organization of the client system. Behavioral approaches, although focused on
behavioral modification, integrate cognitive, experiential, and affect therapy
(Pinsoff, 1995).

The second orientation, biobehavioral, uses either behavioral or biological
approaches to modify biological constraints. This orientation draws on
conditioning and training, biofeedback, psychopharmacology, and
psychoeducation (Pinsoff, 1995).

Experiential orientation targets mainly the metaframework of meaning.
Metaframework focuses on the organization of the structures of the self. This

orientation draws on cognitive, narrative, emotionally focused, and interpersonal

20

communication (especially of feelings within intimate systems) therapies. All
these interventions focus on meaning and empathic communication (Pinsoff,
1995).

The last three orientations: family of origin, psychodynamic, and self-
psychology are historical orientations that look for meaning that stems from the
past that needs to be addressed in order to resolve the presenting problem. The
family-of-origin approach targets mainly transgenerational patterns of interaction
in the formation, maintenance, and resolution of the problems which clients
present in therapy. This orientation draws from contextual therapy, Bowen
systems theory, and direct family of origin. The last method involves direct
engagement of adult clients’ families of origin in therapy sessions. The
psychodynamic orientation focuses on object relations, or part of the psyche, and
how they maintain homeostasis. This orientation focuses primarily on the history
of the client in his/her nuclear family of origin and the influence it has on the
development of the client’s psychodynamics. Intervention targets analysis and
modification of defensive and symptom-maintaining mechanisms. This approach
uses the client-therapist relationship as a major tool for change as the therapist
becomes a transference object for the client. The six orientation, self-
psychology, focuses on the self-metaframework that aims at the organization of
the structures of the self. A more recent development in this area is the model of
the self as a self-organizing open system, which is consistent with family-system
theories (Kohut, 1971, 1977, 1984). Using this approach the therapist attempts

to mend the self-object transferences within the family systems. This model has

21

mostly been used to comprehend and treat narcissistic weakness in marriage
(Solomon, 1992).

The main components of the theoretical framework of problem-centered
therapy are: interactive constructivism, systems theory, and mutual causality.
Interactive constructivism asserts that “ there is an independent, objective reality
but that human beings can never know it objectively,” and the way they view the
world is inevitably subjective (Pinsof, 1995, p. 47). Systems theory stems from
general systems theory (Buckley, 1968), which states that human life is made of
hierarchically organized living systems (Pinsof, 1995). Mutual causality refers to
the idea of circular causality, which is an alternative to the linear approaches and
is congruent with systems theory and the notion of feedback (Pinsof, 1995).
Examining effectiveness of treatment requires looking at how the different
specific approaches to psychotherapy may be incorporated to maximize their
benefits and minimize their deficits. Additionally, it is useful to consider how
certain treatment methods can be integrated to maximize cost—effectiveness
(Pinsof, 1995). Some strength that is inherent in the integrative approach is its
inclusion of different elements from different theories: it allows the inclusion of a
larger range of human behavior, allows for more flexibility in treatment of different
units of clients, offers an opportunity for more acceptability and efficacy of care,
easily adapted to different client population, more easily customized by therapists
to fit their own personal style, they offer a large spectrum of interventions and
treatment techniques to deal with specific issues, can be easily improved with the

development of new techniques and research findings, and they present

22

exceptional benefits in training (Lebow, 1984). The integrative approach to
therapy may lack some theoretical focus, present some inconsistency in
formulation, attempt to set perfect goal in therapy that may result in perpetual
treatment, and have too much intricacy that may have harmful effects on the
therapeutic relationship and complicate the way intervention is structured.
Integrative approaches are more difficult to teach than other approaches (Lebow,
1984)

Lebow (1984) discusses guiding principles for clinicians to develop their
personal paradigm in using an integrative approach that will allow for best use of
their potential and avoid the drawbacks of integration. Principle #1 asserts that
an integrative approach “must have a clear and internally consistent theoretical
underpinning” (Lebow, 1984, p.3). Therapists using this approach need to have
a theoretical framework, know the purpose of therapy, where, how and level of
change that needs to occur, and what are the long and short-term goals of
treatment. Principle #2 states, “the theoretical formulation should lead to a
method of practice consistent with that formulation” (Lebow, 1984, p. 4).
Interventions must be purposeful and carefully tailored, and strategies must be
articulated. Principle #3 states “no single integrative theory is likely to emerge as
the theory of therapy nor will a perfect theory will emerge” (Lebow, 1984, p. 4).
Principle #4 points “scholastic approaches can be disassembled into a set of
building blocks of treatment; integrative therapists can create their own
combination of theory, strategy, and technique from these building blocks"

(Lebow, 1984, p. 5). Therapists can select some concepts from different schools

23

of thought and leave out others. Therapists differ from one another in how they
use integrative approaches. Principle #5 states, “Not all scholastic approaches
need be obvious. Integrative therapists can limit their use of the concepts of an
approach to the provision of an additional perspective on a strategy derived from
another model” (Lebow, 1984, p. 5). Principle #6 claims, theories, strategies,
and techniques may add in synchronous ways to greater power or have negative
interactions that reduce overall effectiveness” (Lebow, 1984, p. 6). The therapist
needs to plan carefully before adding a new intervention strategy, and monitor
early on how a new intervention impacts the therapeutic process. Principle #7
asserts “problems are manifested simultaneously on a number of levels” (Lebow,
1984, p. 6), Le, individual intrapsychic, family structure, biochemical, or
behavioral. Principle #8 argues, “in choosing intervention strategies, integrative
therapists must be aware of the importance of who is seen as well as what is
done” (Lebow, 1984, p. 6). Integrative therapists must have a schema of the
different modalities, and understand how treatment of one modality (individual)
may impact other contexts (family). Principle #9 states, “each of the formal
stages of treatment must be considered; the treatment plan should address each
stage” (Lebow, 1984, p. 7).

Principles #10 through #12 involve the role of the therapist. Principles
#10 claims, “technique is no substitute for therapeutic skills” (Lebow, 1984, p. 7).
The therapeutic relationship must be included in treatment. According to
psychotherapy research, the therapeutic relationship is one of the most important

factors in the effectiveness of treatment. This is also true in family therapy

24

(Pinsof & Catherall, 1986). “The therapist must create an environment that is
psychotherapeutic, i.e., that can be a vehicle for personal change. The personal
qualities of the therapist are vitally important in the pursuit of such an
environment” (Lebow, 1984, p. 8). The therapist needs to have the ability to feel
and be hopeful, empathic, assertive, confrontive, and focused (Lebow, 1984, p.
8). Principle #11 states, “the integrative therapist should be attuned to the
personal value implicit in theory and practice” (Lebow, 1984, p. 8). The therapist
needs to be aware of his/her own values and whether they affect the choice of
intervention. Principle #12 asserts, “the integrative therapist must also deal with
what it means to be an integrative therapist” (Lebow, 1984, p. 8). The therapist
must be able to adjust to the stresses that the integrative approach presents,
stay current with all the latest developments in the different schools of thought,
examine self in relation to the present status of his/her personal model, and be
able to handle the large number of choices that must be made continually.
Principles #13 through #15 deal with adapting the integrative model to
specific cases. “Principles #13: For each case, the therapist must choose among
the available explanations and interventions and select a strategy that will
maximize the accomplishment of the specific goals of the treatment... Principle
#14: In choosing a specific intervention strategy, the therapist also must consider
factors as its acceptability to the client and the resources available to serve this
particular case... Principle #15: In treating each case, the integrative therapist
must balance a coherence of approach and the flexibility to move to additional

modes of intervention” (Lebow, 1984, p. 9).

25

Principles #16 through #19 describe the building of an integrative model.
Principle #16 states, ”in moving to an integrative approach, the therapist should
begin with a delimited range of interventions” (Lebow, 1984, p. 9). The therapist
has to have a structure for practice that manages the complexity presented with
the integrative approach, but at the same time allows for future personal
development. Principle #17 asserts, “An integrative approach is not a static
entity but an evolving method” (Lebow, 1984, p. 10). It is a system open to new
ideas in which certain theoretical ideas and techniques may change over time
(Liddle, 1985). Principle #18 states, “Techniques should only be added to the
therapeutic annamentarium with care; requisite for experimentation with a
technique should be both a technical understanding of the procedures involved
and a theoretical understanding of the context within which it was created”
(Lebow, 1984, p. 10). The therapist must consider carefully each technique’s
suitability to the case that helshe wants to integrate into treatment. Finally,
Principle #19 states: “programs should more explicitly focus on training in
integrative concepts and intervention strategies and should shape a path toward

integration” (Lebow, 1984, p. 11).

Human Ecology and Family Ecology Theory
This researcher did not find any studies regarding the influence of Human
Ecology and Family Ecology aspects on the level of satisfaction with treatment of
couples in couples’ therapy and outcome of treatment. However, the principles

and ideas associated with Human Ecology and Family Ecology are salient to

26

outcomes of couples’ therapy. For example, the social environment is comprised
of societal roles, norms, values, and beliefs that among other areas pertain to
couples and couples’ therapy. Each culture constructs its own norms, values
and beliefs, and each person may interpret cultural norms differently (Lazaloffy &
Hardy, 2000). How individuals or systems interact with one another is relevant to
couples attending couples’ therapy interacting with the therapist and other
systems that may influence their level of satisfaction with treatment. The client
unit in therapy, being an individual, a couple, or a family, is seen as an adaptive
system responding to different circumstances in the environment (Bubloz, Eicher,

& Sontag, 1979).

Client’s satisfaction with couples’ therapy

Literature addressing client’s satisfaction with couples’ therapy is limited.
Most studies done in this area investigate individual satisfaction with therapy.
Although not specifically aimed at couples’ therapy, William and Simmons (1996)
survey can be used with couples. The authors conducted their survey at the
Family Social Science Department of the University of Minnesota in the summer
of 1994. Clinical members of the department filled out this survey to provide
detailed information regarding clinical practices of AAMFT clinical members
throughout the United States. One of the eight questions in the survey
specifically addressed “How satisfied are their clients” (William & Simmons, p. 9,
1996). Fifteen states representing all geographic regions of the United States,

from states that do and do not regulate family therapists participated in the

27

survey. Clinical members of AAMFT in each state received a letter explaining
the challenges facing the MFT profession. Random sample of 1716 clinical
members was drawn from the 15 states, and the final number of responses by
therapist used for this survey reached 526. Outcomes for level of clients’
satisfaction yielded: “97.4% of all clients reported themselves generally satisfied,
in an overall sense, with the services they received. In 98.1% of the cases,
clients rated the services as good or excellent” (William & Simmons, p. 4, 1996).
Additionally, 97.1% of the clients reported that they received the help they
wanted, 91.2% were satisfied with the amount of help they got, 93% reported that
their needs have been met, 98% of the clients indicated that the services they got
from MFT therapists benefited them in terms of handling problems more
effectively. Moreover, 94.3% of the clients stated that they would seek therapy
with the same therapist in the future if they had problems, and 96.9% stated that
they would recommend their therapist to others.

Another study geared to measure individual client’s satisfaction with
therapy is that of Locke and McCollum (2001) who conducted a qualitative study
at a university based clinic. The authors assessed clients’ perception of, and
satisfaction with live supervision, as well as clients’ level of satisfaction with
therapy. The relationship between the two was then examined. The study was
not geared specifically to couples’ therapy; however, it would be interesting to
apply the questionnaires to couples in therapy. One hundred and eight
participating clients provided at least partially completed surveys. Information

was kept confidential from participating therapists. Two self-reports were used to

28

examine clients” satisfaction with the therapeutic experience and with live
supervision. Client Satisfaction Questionnaire—8 (CSQ-B) was used to assess
clients’ satisfaction with the therapeutic experience. This Likert scale includes
eight question to be rated from “1” to “4” - low to high. An example of these
questions is: “How would you rate the quality of the services you received,” and
“To what extent has our program met your needs” (Locke & McCoIIum, 2001, p.
131 ). The scores on the CSQ-8 showed that clients were generally satisfied with
their experience in therapy. Average satisfaction score was 28.4 when scores on
the CSQ-8 ranged from 8 to 32, and higher scores indicated high level of
satisfaction (Locke & McCoIIum, 2001).

Denton, Burleson, Clark, Rodriguez, and Hobbs (2000) conducted a study
in which they compared couples that received Emotion-Focused Therapy (EFT)
with couples on a waiting list. One of the aspects addressed in the study was
clients’ satisfaction with the therapeutic process. Couples participating in the
study were referred by clinicians or responded to local newspaper
advertisements. The couples had to meet certain criteria; they had to be
married, living together, and experiencing problems in their marriage. Clients
were selected randomly to be in the treatment group or on the waiting list for the
eight weeks of therapy. Cases of presence of physical or emotional abuse,
substance abuse issues, and primarily sexual problems were excluded from the
study. The Dyadic Adjustment Scale (DAS) was used to determine if at least one
of the spouses had a certain level of distress. Therapy was free of charge,

conducted in a room with a one-way-mirror, video camera, microphone, and an

29

intercom phone system. Generally, sessions were held weekly. Supervision
sessions were provided to the therapists, and 10 minutes before conclusion of
each session the therapist took a break to consult with the supervisor (Denton,
Burleson, Clark, Rodriguez, & Hobbs, 2000). To examine client’s satisfaction
with therapy clients completed the Purdue Family Therapy Satisfaction Scale
(PFTSS; Paddock, 1990), and the Client Satisfaction Questionnaire (CSQ;
Nguyen, Attkisson, & Stegner, 1983). Thirteen couples assigned to the treatment
group and nine couples assigned to the waiting list completed the study.
Average age of participants was 36 ranging from 23 to 59 years. Participants
rated themselves as slightly to moderately religious, indicated they had been
married 1.2 times (1 -3), had been divorced .2 times (0-2), average number of
years married 10.5 (1-36), reported annual income between $30,000 to 49,999,
and had an average of one child living at home (0-2) (Denton, Burleson, Clark,
Rodriguez, & Hobbs, 2000). The two groups were similar on the demographic
variables and assessment of martial satisfaction. Participating therapists
included eight residents in psychiatry who agreed to participate in return for
clinical supervision; six females and two males, seven Caucasians and one
Asian, who were at least in their second year of residency training. None had
prior experience in couples’ therapy. The therapist received EFT training
(Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000).

The CSQ is an eight-items self-report measure assessing client
satisfaction with therapy experience. Clients rate items with one of four answers

that vary according to the question. The measure shows evidence of validity and

30

reliability (Attkisson & Zwick, 1982). PFTSS is an 18-item, 5-point Likert scale.
In this study, four of the items were reworded to reflect couples rather than
families (Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000). Outcomes
showed that gender of clients or initial group to which clients were assigned were
not a factor in client’s satisfaction. Likewise, age, number of years of marriage,
and cognitive complexity were not found to be related to client’s satisfaction.
Level of education and income were inversely related to level of client’s
satisfaction. Two open-ended questions were added to the CSQ: 1) ”The thing I
like best about the center is,” and 2) ”If I could change one thing about the
center, it would be.” Forty-three clients responded to the open-ended questions.
Comments to the questions were categorized. Participants provided positive
comments relating to the EFT program regarding the therapist role as a facilitator
of discussion. They suggested that the therapist allowed discussion of feelings in
front of the other spouse, facilitated understanding of each spouse by the other
regarding where the other spouse stands, making the experience comfortable,
providing guiding questions, allowing the client to think, feel, and express
himself/herself while the therapist acted only to stimulate conversations,
encourage communication, pointing out things, and letting the client find
solutions. The major category of comments was positive statements about
therapists being caring and concerned, and there were no negative statements
about therapists. Some of the positive comments related to aspects of couples
therapy, which are more general and not unique to EFT (Denton, Burleson,

Clark, Rodriguez, & Hobbs, 2000). Some participants, who asked for change in

31

therapy, suggested that the therapist should take a more directive role in helping
them solve their problem, and some indicated they wanted more homework
assignments. One participant thought it was not helpful to focus on present
experiences and that working on revealing the sources of the problems would be
more beneficial. Yet, another participant wanted more “guidance” on how to
continue after the end of treatment. Most comments about having a team were
positive. Some participants stated they were uncomfortable with the one-way
mirror (Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000).

The one study found for the purpose of this review that deals specifically
with client’s perception of couples” therapy is Bowman and Fine’s (2000) study of
“Client perceptions of couples’ therapy: Helpful and unhelpful aspects.” This
study addressed the following issues: clients’ perception of helpful and unhelpful
experiences in therapy, therapist’s activities perceived by clients as helpful or
unhelpful, client’s perception of impact of helpful and unhelpful aspects of
therapy, and finally similarities of individual’s perceptions within couples of what
is helpful and unhelpful. This qualitative study used discovery methodology
attempting to add to the existing literature and develop ideas based on client’s
perceptions of his/her therapeutic experience. The opportunistic sample of five
heterosexual couples from South Ontario was selected from couple clients
receiving therapy at a university-based couple and family therapy clinic. Four of
the couples were attending conjoint therapy at the above clinic at the time of the
research interviews. The last couple completed the therapeutic process eight

days before interviews started. Couples completed between five and 40

32

sessions averaging 20 sessions. All participants were white. They were either
married or cohabiting couples. Length of time together was between 5.5 and 10
years. Researchers and therapists were all in their second year of a Master’s
level Marriage and Family Therapy program, and training as therapists (Bowman
& Fine, 2000). Approximately 1.5 to 3 hours of face-to-face interviews with both
partners were conducted within eight days of a therapy session. Interviews were
semi-structured, and followed the research questions. In order to minimize the
researcher’s influence on the participants, couples were asked to elaborate
and/or clarify their responses.

Interviews were transcribed and coded separately, and were then
compared for emerging themes across all interviews. Interviews were then re-
examined, and codes were revised. Throughout the coding process, the
researcher noted thoughts and relevant literature. To increase the credibility of
the findings, participants were given a detailed summary of the codes and
highlighted segments of the interviews to check and revise them. Additionally,
the second author and other colleagues were consulted throughout the coding
process.

The findings of this study demonstrated that the therapeutic atmosphere
was the single most contributing factor in the self-reported helpful aspects of
therapy. Trust in the therapist was one subcategory of this factor, which involved
the following constructs: validation, support and being nonjudgmental, genuine
interest and caring by the therapist, and willingness of the therapist to share

his/her perceptions. Other subcategories of therapeutic atmosphere were safety

33

in session structure, rules, and closure. Additional factors included the client’s
decisions to devise their own solutions, the ability of clients to determine the
focus of each session, the freedom to reject a specific approach or idea, and the
absence of pressure to answer in a certain way in order to accomplish certain
goals. Another element contributing to the therapeutic atmosphere was the
equal treatment of both partners by the therapist, where both feel heard and
acknowledged, and where the therapist is able to refocus the session. Finally,
the last subcategory described is therapy context as being a special time to
concentrate on relationship. The other factor of helpful aspects of therapy is
ideas and information. This includes the subcategory of arriving at a new
understanding regarding the relationship, which involves the partners gaining
more understanding about, and a different view of each other as well as
understanding underlying issues. It also involves gaining more knowledge about
couples’ communication and interactions. Another subcategory is seeing the Self
in a new light, gaining new ideas about gender, and making a connection
between one session and the next.

Therapeutic atmosphere, under unhelpful aspects of therapy, includes
unequal treatment of each partner by the therapist, interrupting clients when they
want to talk, using the term “therapy”, and short sessions lasting only one hour.
For ideas and information under the unhelpful aspects of therapy there was only
one subcategory, which refers to the issues discussed in therapy not being

applied to client’s real life.

34

The authors state that many of the themes and findings in their study are
congruent with previous studies. However, they point out to an important theme
that they did not find in previous literature, which deals with client’s perception of
“safety in session structure”. Bowman and Fine (2000) also found that there
were insignificant gender differences in how partners perceived therapy, and
there was very little disagreement between partners regarding what was helpful
in therapy.

The studies reviewed in the aforementioned literature demonstrate a
number of methodology strengths and limitations pertaining to sample selection,
data collection, and analysis. The semi-structure of face-to—face interviews
allows interviewers to focus on the research questions. By only asking for
elaboration and clarification of the responses the level of influence of the
interviewer on the participant is reduced. It also allows for more exploration and
in-depth understanding of the client’s experience. Examination and re-
examination of codes and revising them helps the reduction process of
categorization and getting closer to the core essence of the data. Conducting
individual and conjoint interviews with participants is one way of triangulating
data. Carrying out semi-structured face-to-face interviews and using separate
coding system with participants' review of a detailed summary of the codes, and
highlighted segments of the interview reduces the degree to which the
researcher might impose his/her own bias on the interpretation of data, adding

more credibility to the findings. Finally, consulting with others throughout the

35

coding process allows more perspectives to be included, thus, reducing
subjectivity of the researcher, and providing a more precise set of categories.
Bowan and Fine’s (2000) study highlights a number of limitations inherent
in couples’ qualitative research on satisfaction with couple’s therapy. The study
employed a small homogeneous sample, thus, reducing the ability to make
inferences beyond this population. There is extreme variability in number of
therapeutic sessions that the couples received ranging from five to 40. It may be
possible that the number of sessions received affects how the participants
perceive the therapeutic experience, however, the study failed to examine this
issue. The therapists involved in this study were second year, Master’s level
students, in a Marriage and Family Therapy program, training as therapists. This
leads to believe that their experience as therapists was limited. The question is
whether it is possible that therapists in training are more careful with the way they
treat clients, perhaps trying to please them. However, an inexperienced therapist
may have difficulty with treating both partners equally, which would lead to the
opposite of this study’s findings resulting in dissatisfaction of the participants with
the therapeutic experience. Additionally, the therapists and researchers training
focused on social constructionist, narrative, feminist, and solution-focused
models. The researchers point out that participants closely associated positive
aspects of therapy with ideas related to the social constructionist approach.
Participants identified only a few unhelpful aspects in their therapeutic
experience under study. This could be a result of the fact that clients agreeing to

participate in a study that involves therapy may already have a positive outlook

36

on therapy. Furthermore, it is also possible that being involved in a study
following therapy, participants may feel uncomfortable criticizing their therapists.
Finally, interviewing the partners together may have produced false findings
about the actual perception of each individual of the therapeutic experience.
There is no indication if in fact each partner was influenced by the other’s view
and how this was captured in the interview setting, nor was it mentioned how the
interviewer controlled for this factor.

Pasley, Rhoden, Visher, and Visher’s (1996) studied helpful and unhelpful
aspects of couples’ therapy. Helpful aspects of therapy were found to be related
to affective support, clarification of issues, and to the therapeutic process and
structure. Unhelpful aspects of therapy were found to be related to therapist’s
lack of training, skills, knowledge of a specific subject related to the presenting
problem, and skills that stimulate trust and empathy. Additionally, negative
outcomes in therapy were related to therapy being too simplistic, not practical,
problems not being identified, goals not being set, and issues not being resolved
(Pasley, Rhoden, Visher, & Visher, 1996).

Quinn’s (1996) study of clients’ view of their experience with therapy
identified three domains of meaning while conducting interviews with clients after
therapy ended: affirmation, discovery, and congruence. Letting the client provide
feedback regarding the therapeutic process provides an understanding of the
impact that treatment has on human behavioral change, an acceptance of the
client’s rights and awareness of his/her expectations regarding appropriate and

ethical treatment, and a sincere consideration and full recognition for the

37

influence the client’s perception has on the process and outcome of therapy
(Quinn, 1996). Through client’s feedback the meaning of problems can be
revised. This idea challenges the way the therapist normally thinks about
intervention. It requires the therapist to be open minded and flexible about
treatment. Without the client’s feedback, gaps in the way the therapist and client
view the problem, solution, personal traits, family members and other therapy
related issues could lead to a disharrnonious treatment plan (Quinn, 1996).

In his qualitative study, Quinn (1996) intended to provide therapists with
an opportunity to hear through clients’ descriptions how they perceive therapy
without having the therapists impose their conceptual limitations. Therapists
participating in the study were doctoral candidates in a Marriage and Family
Therapy accredited program by the American Association for Marriage and
Family Therapy (AAMFT). Interviewers were research associates, and
interviews lasted between one and several hours. The interviewers had some
therapy training, but were not involved in any way with participating clients.
Fourteen client systems were chosen from the log of recently closed cases in the
clinic of the MFT program. They were interviewed in their homes to allow more
interactional space. Five interviews were conducted with single informants, three
of whom were in individual therapy and two in group therapy; another five were
couples; and four were families. Interviews were audio taped and transcribed.
Transcripts were then analyzed for patterns and themes that were then
conceptualized as domains of meaning. Analyses were done by the author and

another two research assistants. Consensus was reached regarding three

38

categories. The first category, Affirmation, relates to clients wanting to know that
their therapists are humans and live in the same world as they do. They want to
feel some sort of social connectedness to being human and to be validated with
their assets and limitations. Key phrases used by clients/informants for this
category include: “we count, being comfortable, being able to stay with me,
extending herself, drawing me into her life” (Quinn, 1996, p. 79), and others. The
second category, Discovery, represents the clients’ experience of gaining insight
or knowledge. Clients gave the sense that an important component of therapy
was the unique conversation that provided them with a new way of looking at
their problem. Discovery becomes possible when client’s needs of belonging,
freedom, power, and enjoyment of living were being met. Key phrases used by
clients/informants to create this category include: “the light going off, not
clamming up, throwing questions right back to us, asking a question I never
considered” (Quinn, 1996, p.85), and others. The third category discusses
congruence between the client and therapist. From client accounts it became
evident that therapists must have “flexibility in their influential posture” (Quinn,
1996, p. 86). Clients have an idea about therapy from previous experiences,
from other sources of information, as well as from their background. In order for
treatment to be effective, there must be congruence between client’s
expectations of treatment and the therapist’s delivery of those services. Key
phrases in this category include: “connecting what was happening, keeping me in
a balance, pinpointing the problem, knowing where I need to go, putting myself

through this little session in my mind, building up the talk, and someone who can

39

help you in that area” (Quinn, 1996, p. 90). Quinn states that eliciting the client’s
voice is beneficial because it allows therapists to explore the dimensions of
therapeutic processes within their own therapeutic setting and it provides clients
with an opportunity “to be positively changed by the experience” (Quinn, 1996, p.
91).

It is assumed that using open-ended unstructured questions in interviews
allows individuals to express themselves (Bowman & Fine, 2000). Qualitative
research allows both, the therapist and the client, to explore how the client came
to seek therapy, and creates a milieu for creativity and expression through
reflective conversations (Hoffman-Hennesy & Davis, 1993). Open-ended,
collaborative research allows examining with clients over time and periodically
how they are experiencing their process, and talking about the process.
Andersen’s (1993) approach of “hermeneutics” to therapy asks clients about their
therapeutic experience, specifically how they came to seek treatment, how they
feel about being in treatment, and how they plan to direct sessions. He asserts
that when clients express themselves they establish a sense of ‘self.’ Clients
have unique experiences that may or may not be shared by their therapists, thus
using open-ended questions allows for more genuine conversations and

collaboration (Anderson & Goolishian, 1988; Goolishian & Anderson, 1987).

Summary
This researcher attempted to explore what factors influence the level of

satisfaction of couples in Integrative Couples’ Therapy, how they perceive the

40

therapist, helpful and unhelpful aspects of therapy, and how satisfied or
dissatisfied each partner is with the therapeutic experience and outcomes. The
researcher used the integrative approach to couples’ therapy, and discussed
aspects of Human Ecology and Family Ecology that influence the level of
satisfaction of couples in couples’ therapy.

The reviewed literature for this study describes the concept of couples’
therapy and client’s satisfaction with this form of therapy. The literature covered
clients describing their experience in couples’ therapy and what they found to be

helpful and unhelpful aspects of the therapeutic experience.

41

CHAPTER 3

Methodology

This qualitative study explores human and family ecological aspects, and
clinical aspects that influence clients’ level of satisfaction with Integrative
Couples’ Therapy and outcome of treatment. The qualitative approach was
chosen for this study because it provides rich descriptions of and explanations to
the flow of events in a contextual setting (Miles and Huberrnan, 1994), and it
accounts for the voices of participants and therefore is more representative of
them. Qualitative approaches assume that it is necessary for researchers to
know empathetically and subjectively the perspectives of the participants (Linclon
& Guba, 1985; Patton, 1980; Rist, 1977; Smith, 1983; Wilson, 1977, as cited in
Jacob, 1988). Qualitative research is said to be an interactive and
transformational process involving a close interaction with the researcher,
participants, and the data. The researcher’s background, gender, social class,
values, and ethnicity all impact the way helshe interprets data (Sword, 1999).

Using qualitative methods allows the proper representation of human
diversity, involves the researcher as a person, and establishes a relationship
between the researcher and the participants (Avis & Turner, 1996). The
participants are active members in the process of data collection and are
considered to be the experts of their own experience, and command respect for
that (Daly, 1992). Using a family or a couple as the unit of analysis is suitable to

qualitative research methods (Daly, 1992).

42

Dyadic Research Methods

Dyadic research methods, using a couple or several family members, are
suitable for qualitative research methods (Daly, 1992). Research with a dyad as
the unit of analysis is a relatively new phenomenon in which the researcher is
interested in studying the interactive properties in relationships. Consequently,
the researcher must remain focused on the relationship throughout the research
process and be aware of the conceptual assumptions that support dyadic
research (Thompson & Walker, 1982). A dyad includes two individuals in an
intimate and direct relationship over time, in which personal interdependence and
mutuality are at the heart of its attributes (Thompson & Walker, 1982). Dyadic
research must include: conceptualization of the problem from a relational
perspective, participants that represent a relationship, measurements that can be
applied to one or both members of the dyad and to relationship assessment, an
interpersonal analysis examining patterns between partners and relationships,
and interpretations and implications depicted about the relationship between the
individuals (Thompson & Walker, 1982).

This study employs the above criteria for dyadic research by utilizing
partners in intimate relationships for at least three years, open—ended questions
in in-depth conjoint interviews with both partners, and separate in-depth
interviews with the therapists who provide or provided couples’ therapy to the
selected couples, and by using a systemic viewpoint to analyze the outcomes.

Whereas research involving individuals as the unit of analysis focuses on

the individual’s values, beliefs and opinions, studying dyads adds the dimension

43

of relational norms, rules, power differences, and interdependence between
members (Thompson & Walker, 1982). In dyadic research the researcher may
gather information from one or both individuals. In this study data was gathered

conjointly.

Case Study methodology

Case study approach focuses on the development of an in-depth analysis
of a single or multiple case(s) (Crowell, 1998). Case studies have been
important in the development of humanistic and transpersonal clinical models
(White, 1972; Rogers, 1942; Lukoff, 1996; May, 1972, as cited in Edwards, D. J.
A., (1998). Data is collected for case studies from a variety of sources including:
documents, archival records, interviews, observations, and physical artifacts.
Using this method the research can be conceptualized in distinct phases:
descriptive phase, theory development phase, and theory-testing phase
(Eckstein, 1975; Giorgi, 1986b, as cited in Edwards, D. J. A., 1998). The
descriptive phase is further divided into subscales of exploratory-descriptive work
and focused-descriptive work. The theory development phase includes
grounded theory building and hermeneutic work. The theory-testing phase
includes testing propositions within grounded theory and meta-theoretical
deconstruction, using material from cases to reveal hidden assumptions, which
then provides a base for the body of psychological theory (Edwards, D. J. A.,
1998). Case studies require in-depth data collection, a small number of cases

that are purposefully chosen, and a clear demarcation of time and space

44

boundaries relating to the phenomenon being studied (Creswell, 1998; Moon &
Trepper, 1996).

Gathering data from a variety of sources strengthens the confidence in the
collected information, and increases the level of trustworthiness (reliability). It is
suggested that some ways to increase trustworhtiness include: persistent
observation, using research procedures, and using multiple observers (Miles &
Huberman, 1994; Moon & Trepper, 1996). To assure validity in case studies the
researcher may use the following methods: observation in the natural
environment, triangulation of data collection and sources, extended involvement
in the setting, and discussion of burgeoning concepts in the case with co-workers
(Moon & Trepper, 1996).

To assure trustworthiness in this study, the researcher 1) employed
persistent observation via listening repeatedly to audio tapes of the interviews,
and transcription; 2) followed research procedures relating to interviewing; 3)
observed and interviewed couples in the therapist’s office; 4) collected data via
in-depth interviews, observation during the interviews; 5) used direct quotes from
the interviews when reporting findings; 6) minimized researcher’s biases via
consultation with research advisor and coworkers; and 7) used a co-rater to

analyze and decode data.

45

Procedures
Researcher: Self as Instrument
The researcher’s use of self in qualitative studies is instrumental
(Creswell, 1998). This researcher developed in the last six years a clinical
caseload consisting mainly of couples and families in distress, and became
interested in exploring clients’ satisfaction with couples’ therapy. It became
evident that treating a dyad or a larger client unit requires a different approach
than treating an individual. Treating an individual entails interaction between the
therapist and one individual present in the session; working with couples and
families involves complex dynamics within the client unit, between different
members of the client unit and the therapist, and between the entire client unit
and the therapist. The therapist is required to be attuned to all members and
their interaction with each other. Helshe has to master the ability to join with
each individual without creating a situation where any of the individuals feels
excluded. With couples, or families, the treatment goals relate to the relationship
between the individuals that compose the client system. Treating a couple is
complicated because the therapist has to consider the needs and expectations of
each individual as well as the needs of the relationship, has to assure that helshe
doesn’t side with one partner and excludes the other, and has to assure that the
goals of the relationship are being addressed.
Fascinated by the complexity of this delicate balance in couples’ therapy,
this researcher embarked on the task of reviewing existing literature dealing with

clients’ perception of couples’ therapy. It became evident that only limited

46

research had been done in this area. Wishing to help other therapists who work
with couples and to increase the effectiveness of couples’ therapy and render it
more beneficial for the clients, this researcher decided to further explore this
phenomenon and the level of satisfaction of clients with the therapeutic
experience and treatment outcome via in-depth interviews with couples who are
currently attending, or attended in the past conjoint couples’ therapy to work on

their relational issues.

Sample

The purposeful sample for this study included six couples, five of whom
are currently engaged in couples’ therapy and one couple was in couples’
therapy one and one half years prior to this study, with the selected therapists.
The sampling procedure was aimed at being sufficient to reach saturation of
crosscurrent themes and meaning among the individuals’ description of their
experience of couples’ therapy and the treatment outcome (Marshall & Rossman,
1995). When these themes started recurring, or reached saturation, the sample
was considered sufficient (Denzin, 1994; Newfield, Sells, Smith, Newfield, and
Newfield, 1996). All materials relating to the participants including audiotapes,
transcribed interviews, field notes, demographic questionnaires, and all other
materials were secured in a locked file cabinet. Raw data with identifying
information of participants is available only to the researcher. Instead of using

individuals’ names, each couple was assigned a pseudonym. Participants were

47

informed of procedures that were taken to assure confidentiality of the data they
shared with the researcher.

The six couples selected for this study met the following requirements:
couples who were married or have been together for at least three years at the
time of the study, not filed for divorce, and not involved with another therapist
other than the couple’s therapist. Couples where domestic violence was an
issue or where substance abuse was a present issue were excluded from this
study.

This researcher contacted via telephone several MFT therapists listed on
the on-line AAMFT therapist locator. The researcher explained the purpose of
the call and described the study she is conducting, questioned them whether
they considered themselves as providing Integrative Couples’ Therapy, and
inquired whether they had couples on their caseload that answer the criteria for
this study. She then sent to therapists who confirmed their integrative practice
with couples and who expressed their willingness to participate the abstract of
this study, the Interview Guide for Conjoint Interviews (see Appendix 8),
Demographic Questionnaire for participating couples (see Appendix C), Informed
Consent for participating individuals (see Appendix D), and Informed Consent for
participating therapists (see Appendix E). The information included issues
related to confidentiality of potential participants. Only two out of twelve
therapists chose to continue with the study. The two therapists are licensed in
Marriage and Family Therapy. Both have their master’s degree in Social Work.

Both therapists are Caucasian. One is a female and the other is a male therapist.

48

The female therapist, who is trained in MFT, has 20 years of experience
providing therapy, and the male therapist has 28 years of experience in Marriage
and Family Therapy. He also has been teaching this subject at Wayne State
University for the last 14 years, and is an approved MFT supervisor. Both
practice in the Detroit Metro area in Michigan.

The selected therapists discussed with their selected clients this study
and provided willing couples with the Informed Consent and the Demographic
Questionnaire. The therapists coordinated with the selected couples and the
researcher a time for the interview. Interviews with therapists were conducted
prior to interview with the respective clients (see Appendix A).

A pilot study was conducted with one of the couples who was willing to
participate in this study before the actual study took place. This allowed the
researcher to verify that audio equipment works properly, that the interview
questions are clear, and to promote a comfortable and safe setting to share
beneficial information relating to this study. Based on feedback from the pilot
study, one interview questions was removed. The pilot study lasted one and one
half hour. The same protocol and procedures that applied to the main study
were applied to the pilot study.

Participants in this study completed and signed an informed-consent form.
They were informed of their right to discontinue their participation at any time
during the study, that being part of this study would not interfere with services
they were receiving from their therapist, and that their therapist had no access to

information shared by them for the purpose of this study. Additionally, it was

49

clarified to all participants that participation in the study was completely voluntary.
Finally, as a token of appreciation for participating in the study, each couple
received a copy of a book on marriage: Gottman, J. M. & Silver, N. (1999). IE
seven Qrincigles for making marriage work. New York, New York: Three Rivers
Press.
Data Collection

Data collection for this cross-sectional study was done at the clinical office
of the therapist who provided services to the particular couples. Each partner
completed a demographic questionnaire. Interviews with the therapists were
conducted prior to interviews with the clients. Conjoint interviews took place
either before or after the couple’s therapeutic session in the five cases of the
couples that were still in treatment at the time of the interview, not prior to the
sixth session. All interviews were comprised of open-ended questions. The
therapists’ interviews can be found in Appendix A. Conjoint interviews are in
Appendix B, and partners’ demographic questionnaires are in Appendix C.
Partners’ interaction was closely observed by the researcher at the time of the
conjoint interviews in order to obtain information regarding possible influence
they may have had on one another concerning their perception of the therapeutic
experience. Conducting combined interviews allowed the researcher to examine
how both partners perceived the same experience. This researcher also
employed persistent observation via listening repeatedly to audiotapes of the

interview, and transcription. Additionally, when reporting findings, the researcher

50

used direct quotes from the interviews. The researcher also consulted with a co-

rater to reach consensus regarding the emerging themes and categories.

51

Table 3.1

What influences client’s level of satisfaction with Integrative Couples’
Therapy (ICT)?
Therapist Interview

 

For each couple the therapist will be asked the following questions:

Research
Question

 

Human Ecology

How does the eco-system

Demographic questionnaire: point out

 

(Bronfenbrenner, influence client's satisfaction things that may influence this couple.
1979, 19890 with couples’ therapy 8: What is the relationship between
outcome of treatment: demographic characteristics (i.e.
What are the coo-systemic cultural/ethnic background) &
influences on client’s level of satisfaction with therapeutic
satisfaction with couples’ experience?
therapy & outcome of What do you know about how this
treatment? couple's culture or ethnic group views
couples' therapy?
Probe: Is it accepted? Encouraged?
Looked down on?
From what they shared with you, how
do their families (relatives, or children)
view couples’ therapy?
Probe: Are they encouraging? Are they
against it? Are they supportive of their
decision to seek couples’ therapy? In
what way are they supportive:
emotional? Financial? Providing
childcare?
Family Ecology How do your values and How do you define a healthy intimate
(Bubloz 8. Sontag, beliefs influence the relationship?
1993 therapeutic process? Probe: Couples that spend a lot of time

together? Apart? How are decisions
made? Does it involve sexual intimacy?
How?

 

How does their perception of
fairness influence the couple in
therapy?

How do you feel regarding treating each
partner fairiy during the therapeutic
session?

Probe: Do you feel that you took sides?
How or how not?

 

 

Clinical approach

ICT (Pinsoff, 1983,

1 994a, 1 995;
Lebow, 1984,
1987)

 

How does ICT influence
client's level of satisfaction with
couples‘ therapy & outcome of
treatment?

How do client's aspects
influence client‘s level of
satisfaction with couples’
therapy & outcome of
treatment?

 

 

Same question as in the section related
to Human Ecology

 

 

52

 

Table 3.1. cont.

 

Theory

Research
Question ' '

' ~ 'r:.' Q

 

How does the therapeutic 0
clinical process' goodness of fit
influence client’s level of
satisfaction with couples‘
therapy & outcome of
treatment?

What aspects of therapy do you think
the couple found to be helpful or
unhelpful? Why or why not?

What aspects of therapy did you find to
be helpful or unhelpful? Why or why
not?

 

What was this specific couple hoping to
accomplish?

What were their goals in coming to
therapy as a couple?

What were their goals in coming to
therapy as individuals?

Do you feel they’ve accomplished any
of their goals? Why or why not?
Overall, scale 1-10, "1" - “not
accomplished,” “10' — “completely
accomplished,‘ how close do you feel
they are to accomplishing their goals?
How were these goals decided on?
(e.g., alone, tougher with spouse, by the
therapist, or both)?

 

How do therapist's aspects
influence client’s level of
satisfaction with ICT &
outcome of treatment?

What are your values and beliefs
regarding couples’ therapy?
What, if any, biases do you have
regarding gender, religion, ethnic
grou s, or an other?

 

 

 

How does the Integrative
approach to couples' therapy
influence client’s level of
satisfaction with couples’
therapy & outcome of
treatment?

 

Do you feel that you were flexible in
meeting the couple's needs?

Do you feel that the interventions used
by you were appropriate most of the
time?

How do you feel about your style fitting
with who the partners are and with their
style?

Do you feel you addressed the
presenting problem in a way that was

 

comfortable for the gnners? How?

 

Table 3.1 Theory, research & therapist interview Questions

53

Table 3.2

What influences client's level of satisfaction with Integrative Couples’ Therapy

Conjoint Interview

The couple will be asked the following questions:

 

Theory

Research
Question

 

Human Ecology

How does the eco-system

Demographic questionnaire:

 

(Bronfenbrenner, influence client‘s level of What is the relationship between
1979, 19890 satisfaction with couples‘ demographic characteristics (i.e.
therapy 8. outcome of cultural/ethnic background) &
treatment? satisfaction with therapeutic
What are the eco-systemic experience?
influences on client‘s Tell me how your culture or ethnic group
satisfaction with couples' views couples‘ therapy?
therapy 8. outcome of Probe: Is it accepted? Encouraged?
treatment? Looked down on?
How does your family (relatives. or
children) view couples’ therapy?
Probe: Are they encouraging? Are they
against it? Are they supportive of your
decision to seek couples’ therapy? In
what way are they supportive:
emotional? Financial? Providing
childcare?
Family Ecology How do your values and How do you define a healthy intimate
(Bubloz 8 Sontag, beliefs influence the relationship?
1993 therapeutic process? Probe: Do you spend a lot of time

together? Apart? How are decisions
made? Does it involve sexual intimacy?
How?

 

How does their perception of
fairness influence the couple in
therapy?

How do you feel you were treated fairiy
during the therapeutic session?

Probe: Do you feel that the therapist
took sides?

Do you feel that the therapist blamed
you or your partner unfairty’? Why or
why not?

 

 

Clinical approach

ICT (Pinsoff, 1983,

1994a, 1995;
Lebow, 1934,
1987)

 

How does ICT influence
client's level of satisfaction with
couples' therapy 8. outcome of
treatment?

How do client's aspects
influence client’s level of
satisfaction with couples'
therapy 8. outcome of
treatment?

 

Same question as in the section related
to Human Ecology

 

54

 

Table 3.2, cont.

 

Theory

Research
Question

Imervieruaion .

 

How does the therapeutic or
clinical process' goodness of fit
influence client’s level of
satisfaction with couples’
therapy 8. outcome of
treatment?

What aspects of therapy did you find to
be helpful or unhelpful? Why or why
not?

What did the therapist do that was
helpful

What did the therapist do that was
unhelpful?

What aspects of therapy would you
have liked to see happen more often?
What aspects of therapy would you
have liked to see happen less often?
What were you hoping to accomplish?
What were your goals in coming to
therapy as a couple? List the top 3 with
the most important goal first.

What were your goals in coming to
therapy as individuals? List the top 3
with the most important goal first.

Do you feel you accomplished any of
your goals? Why or why not?

Overall, scale 1-10, '1' — “not
accomplished,‘ '10' — “completely
accomplished,‘ how close do you feel
you are to accomplishing your goals?
How were these goals decided on?
(e.g., alone, tougher with spouse, by the
there ist, or both ?

 

How do therapist's aspects
influence client's level of
satisfaction with ICT 8.
outcome of treatment?

Do you feel y0ur therapist has any
biases regarding gender, religion, ethnic
groups, or any others?

 

 

 

How does the Integrative
approach to couples’ therapy
influence client's level of
satisfaction with couples'
therapy 8. outcome of
treatment?

 

Do you feel that the therapist was
flexible in meeting your needs? HOW?
Do you feel understood by the
therapist?

Do you feel that the interventions used
by the therapist were appropriate most
of the time?

How do you feel about the therapist's
style fitting your 8. your partner's style?
Do you feel that your therapist
addressed the presenting problem in a
comfortable way?

 

Table 3.2 Theou, research 8. conjoint interview Questions

55

 

Data Analysis

Data analysis involved several steps and was done manually, without
utilizing qualitative data analysis software. First, this researcher transcribed the
interview audiotapes verbatim. Then, transcripts were edited to remove inaudible
parts. Notes taken at the time of the interview were reviewed, analyzed, and
served as observational information. Demographic data was arranged in a table
to compare at a glance important information related to the different couples and
individuals in each partnership (Table 4.1).

Subsequently, the transcripts were analyzed. Repeated reviews of the
transcripts and notes taken during the interviews resulted in the emergence of
themes and categories within each case. Initial codes for the transcripts
consisted of influences of: demographic factors (i.e., education, SES), cultural
values, family of origin’s view of therapy, individual values, individual’s perception
of the therapist’s characteristics and therapeutic atmosphere, helpful and
unhelpful aspects of therapy therapist’s values. In addition therapeutic goals,
setting goals, and goal attainment were examined. Further analysis and
discussion of themes and categories with the co-rater led to some changes in the
initial codes. For example, Demographic, Cultural and Family of Origin
Influences were grouped together (see Table 4.2), and now include the themes:
(1) Level of education and income; (2) Presence of children; (3)

Transgenerational experience with family of origin; and (4) Previous counseling.

56

The final list of codes and themes included:

1. Influences of Demographic Factors, Cultural and Family of Origin
on Couple’s Perception of Therapy (see Table 4.2).
Themes: (1) Level of education and income

(2) Presence of children
(3) Transgenerational experience with family of origin.
(4) Previous counseling

2. Influences of Therapist’s Characteristics and Therapeutic Milieu on

Couple’s Perception of Therapy (see Table 4.3).
Themes: (1) Fairness
(2) Free of biases
(3) Relaxed demeanor/laid back
(4) Partners being treated equally
(5) Addresses the problem in a comfortable way:
safe to talk, non-judgmental, non-threatening
3. Aspects of Therapy (see Table 4.3).
Themes for Helpful Aspects of therapy:

(1) Active listening
(2) Communication skills
(3) Solution oriented
(4) Homework assignments

Themes for Unhelpful Aspects of therapy:

57

(1) Lack of structure
(2) Lack of direction
(3) Lack of specificity
(4) Lack of assertiveness
4. Therapeutic Goals
Themes for Relational Goals:
(1) Avoid divorce
(2) Improve communication
(3) Improve intimacy
Themes for Individual Goals:
(1) Emotional regulation
(2) Intimate behavior
Themes for Setting Goals:
(1) Partners together
(2) Partners with therapist
(3) Individually
(4) Implicit goals/not discussed
Themes for Goal Attainment:
(1) Attained
(2) Progressing
(3) Score
The codes and sub-codes were used to analyze each case. The six

cases are each narrated in Chapter 4. Reliability of the stories of each couple is

58

assured via direct quotes that are incorporated into the observations and
analysis. Data was examined within cases and across cases. The findings will
be presented in accordance with the original research questions in Chapter 4.

This researcher is a 50-year-old white, female who moved to the United
States from Israel 17 years ago. Being privileged and from a different culture
may present a certain level of bias on her part. However, she is aware of this
possibility and practiced extra caution in order not to allow this bias to interfere
with the process of this study.

Another bias of this researcher may relate to the fact that she is a couples’
therapist and believes in the benefits of couples’ therapy. Hence, she is more
prone to elicit a more positive type of feedback from participants in this study. To
assure controlling the tendency to hear the positive aspects and put less
emphasis on the negative ones, this researcher used: a co-rater to analyze all
interviews, peer consultation and peer supervision, and debriefed with members

of the research committee.

59

CHAPTER 4
Findings

This qualitative study explored how individuals in couples’ therapy
described what influences their level of satisfaction with their therapeutic
experience and outcome from Integrative Couples’ Therapy. In-depth interviews,
observations, and analysis of demographic questionnaires from the six
participating couples provided data on the factors that influenced their level of
satisfaction with their therapeutic experiences and outcomes from the treatment.

Demographic data on the couples is presented in Table 4.1. Then, a
narrative of a within-case analysis of the findings of the six couples and the
response of the related therapist will be provided for each case. This will allow
the presentation of similarities and differences between the therapist and the
couple. Finally, this researcher will provide the cross-case analysis showing
similarities and differences among the cases.

Information gathered from the demographic questionnaires, interviews,
and field notes taken at the time of the interviews were analyzed.
The data gathered from the demographic questionnaire was entered into a table
form (Figure 4.1), summarizing the demographic characteristics of participants.
Observation of the couples’ interaction and their use of body language provided
important information regarding congruency with the content of the verbal
responses. (i.e., discussing different topics comfortably, seeking approval from

one another, reaching out to one another, facing away from one another).

60

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61

Content Analysis

The following analyses are a product of in-depth interviews, written
questionnaires, and observations of the couples at the time of the interviews.
When reporting the outcomes of this study, this researcher, whenever feasible,
used direct quotes from the participants. The researcher did not impose her
personal values on the couples’ reports. Personal statements by the researcher
were kept for the cross-case analysis segment.

Figure 4.1 portrays a summary of the information gathered from the
demographic questionnaires. To protect the identity of the participants the
researcher used pseudonyms with the same letter (i.e. Couple #1 - Chris,
Christina) with numbers to link the couple with the information. Couples’
pseudonyms are found at the top of Figure 4.1, and demographic information is
in the rows below it. This format provides comparison within and across —cases
demographic information of the couples. Analyses of all cases are given in a
narrative form that is identical for each couple. This allows the presentation of
consistent findings and comparisons. Each analysis includes an introduction,
description of the individuals’ background, description of the relationship, the
application of the thematic sub-categories which emerged from the researcher
and co-rater rating the categories separately, comparing for similar themes and
finally arriving at a consensus. For the most part, 95% of the time, this
researcher and the co-rater came up with similar themes. The themes were
consistently applied to each narrative and are also shown in a table form. They

include the following categories, sub-categories and themes: (1) Influences of

62

Demographic factors. Cultural and Family of Qrigin Ffiapctors on Couple’s
Perception of Therapy, which is broken down into the following themes: level of
education and income, presence of children, transgenerational experiences with
family of origin, and previous counseling (see Table 4.2); (2) memes of
Thegpist’s Characteristics and Therapeutic Milieu, which includes the following
themes: Fairness, being free of biases, relaxed demeanor/laid back, partners
being treated equally, addressing the problem in a comfortable way: safe to talk,
non-jusgmental, non-threatening (see Table 4.3); (3) Helpful a_nd Unhelflgl
Aspects of Therapy divided into sub-categories: Helpful Aspects with the
following themes: active listening, communication skills, solution oriented, and
homework assignments, (see Table 4.4), and Unhelpful Aspects including the
following themes: lack of structure, lack of direction, lack of specificity, lack of
assertiveness (see Table 4.4); (4) Therapeutic Goals divided into: relational
goals, individual goals, setting goals, and goal attainment. Relational Goals
include the following themes: avoid divorce, improve communication, and
improve intimacy. Individual Goals include: emotional regulation and intimate
behavior. Setting goals include: partners deciding together, partners and
therapist decide together, individually, and implicit goals/not discussed. Finally.
Goal Attainment includes: attainment, progressing, and score (see Table 4.5).
The format for all the Tables is similar providing the couple’s number and
names in the two left columns, Categories and themes in the top row, and direct
quotes from couples’ and therapists’ narratives in the rows below it. This format

provides an easy way to compare within case and cross-case data.

63

Couples’ statements offering their insights to beginner couples’ therapists’
to inform them about helpful and unhelpful aspects of therapy is also provided in
a table form and uses direct quotes from the couples (see Table 4.6). As
consumers, these couples may be the best source of insightful information to
therapists. They indirectly tell the therapist what they need. A summary of
partners’ definition of a healthy intimate relationship is also provided.

Finally, the cross-case analysis of the data gathered is provided in the
form of answers to the original research questions. As presented in Chapter 1,
Research Question #1 relating to Family Ecology is answered in the couples’ and
therapists’ narratives, and in Tables: 4.1 and 4.2. Research Question #2 is
answered in the couples’ and therapists’ narratives, and in Tables: 4.3, 4.4, 4.5,

and 4.6.

64

Couple #1 — Chris and Christina

Chris and Christina are both 40 years old. The couple has been living
together for the last five years in an urban area. Chris is African American and
Christina is Caucasian and was born in Poland. They state that they do not have
any children. Both report no specific religion. He has a bachelor’s degree and
she is holding a PhD. Both work full-time and the household’s annual income is
over $50,000. This couple attended six therapeutic sessions at the time of the
interview, and both indicated being in couples’ therapy previously.

At the time of the interview, Chris and Christina seemed to have some
tension between them, even though there was a large comfortable couch in the
office they set on different chairs separate from each other. They were pretty
guarded with their answers and their body language communicated a lack of
ease. They did not smile once during the entire interview, and the interview did
not seem to flow with ease. The tension between the couple dominated the
interview.

The therapist of this couple described how he used the integrative
approach with this couple by initially focusing on problem solving and crisis
intervention and gradually focusing more in-depth on issues including emotional

closeness and family of origin issues.

65

Influences of Demographic Factors, Cultural and Family of Origin on Couple '3
Perception of Therapy

Cultural view did not seem to play a role in Chris and Christina’s decision
to seek therapy or how they view it, perhaps because of their level of education.
It appears that in their cultural background and families of origin individuals
utilized church clergy for counseling. Christina stated that in her culture “The
priest would be the couples’ therapist,” and Chris stated, “mom has seen the
local priest [for counseling] and “[my] siblings have not been [to therapy].” Also,
Chris stated, “AA people are still attached to church.”

The therapist of this couple felt they were “a highly educated couple who
seemed open to being involved in psychotherapy... For male partner, who is
African American, generally couples’ therapy is not encouraged.” And with
relation to how their families of origin viewed it he was “not aware of either any

support or discouragement.”

Own values: definition of a healthy intimate relationship

There seems to be some differences between Chris and Christina with
regards to their view of communication and time spent together in an intimate
relationship. Chris suggested, “In an intimate relationship communication is
different [than in just any relationship], more difficult " Christina stated,
“Communication [in an intimate relationship] should be easier.” Chris added, “at
a time of conflict [in an intimate relationship] you might get hurt.” Christina and

Chris differ in respect to spending time together in an intimate relationship. She

66

believes that individuals in an intimate relationship “need a balance of time
together and space,” whereas Chris believes that they need to “spend more time
together.” The couple was not clear about how they formed their ideas about
intimate relationships. The therapist reported different views of this couple; “the
female partner pushes for more together time; male partner pushes for more
alone time. They see decisions being made in a joint manner. For both, a
healthy relationship includes sexual intimacy.” how he perceived this couple to
define an intimate relationship “as a mutual partnership that can solve problems

and where there is emotional and sexual intimacy."

Influences of Therapist Characteristics and Therapeutic Milieu

The couple did not elaborate on this matter. However, they did agree that
the therapist was fair. Christina stated briefly, “Evenhanded’ and Chris said, “Not
taking sides, very good in this regard.” Both Chris and Christina felt that their
therapist did not have any biases. Both felt that he showed flexibility in meeting
their needs, which was helpful for the therapeutic process and atmosphere.
Although the partners have a positive perception of their therapist’s
characteristics as they relate to the therapeutic process, they only attended six
sessions at the time of the interview and are not yet (at least at this point)
satisfied with the outcome. They are unable yet to make any connection
between the therapeutic process and outcome of treatment. They realize that the
short period they have been in therapy could be a reason for not being where

they want to be. Both agreed that, for the most part, they felt understood by their

67

therapist. Christina stated, “He’s in the process of understanding, hasn’t learned
yet, so doesn’t completely understand because haven’t been here so many
times.” Chris asserted, “He cuts me off sometimes too quickly. He’s good at
picking up on body language. He stops me actually because he got the idea.”
Chris feels that the therapist has good insight in his case. Both agree that their
therapist intervened appropriately most of the time, and Chris likes the
communication directives that help him change the way he communicates. “He’s
pointing out things, gives a lot of directives regarding how to listen and how to
talk.” Christina and Chris felt comfortable with the therapist’s style; Christina
described him as “very adaptive and non-threatening,” which contributes to a
safe therapeutic atmosphere. Chris stated, “[he] has control of the session; he
manages time and talks well.” Both also agreed that the therapist addressed the
presenting problem in a comfortable way; Christina said, “He is non-judgmental,”
and Chris added, “He addressed the presenting problem in a comfortable
way... He’s non-threatening. Sessions have a free-form style. He doesn’t dictate
what should be talked about. He doesn’t come with an agenda.”

The therapist stated he addressed the problem in a comfortable way,
supported Christina on the issues of Chris’ affair, “but was able to help the couple
see that there were relational issues that contributed to the affair and that they

both needed to work on change.”

68

Helpful and unhelpful aspects of therapy

Christina and Chris both had a different view on what was helpful
for each one of them in therapy. The therapist provided a good, safe therapeutic
atmosphere. Christina felt that being able to express herself about different
things in the therapeutic setting was beneficial; “it was helpful to talk about
different issues in a safe setting with a mediator.” Chris, on the other hand, liked
getting the tools to use in the relationship; “concrete solutions and tools, helping
to communicate better.” Christina was not able to identify any unhelpful aspects
of therapy, but Chris stated, “As a couple [as oppose to an individual in therapy]
we tend to repeat the same things over and over.” Both however, agreed that
they could use more homework assignments and tools in therapy. Christina
asserted, “do more exercises, and homework assignments, do more and use
them on our own at home, so at some point they become second nature,
implement them as tools in our relationship.” Chris stated, ”Need more tools and
concrete communication exercises.” Both wanted the sessions to be less
negatively charged; Christina said, ”Therapist can actually be more helpful by
seeing the negative at the session.” Chris said, “We still slip to negative
communication at the session. The session itself should be used to control
communication.” The therapist felt that the couple viewed as helpful aspects of
therapy “communication training and problem solving, re—establishing trust in the
relationship, and increasing emotional closeness.” The therapist added another
aspect that he thought was helpful, “working on forgiveness in order to recover

from the affair.”

69

Goals

The couple came to therapy because of an affair that Chris had had, and
because there were problems in the relationship prior to it. They both decided to
seek therapy together. Christina stated, “The relationship broke up because of
the affair, but had problems before. Communication got worse, fights got worse,”
and Chris reiterated, “Our relationship was falling apart, we wanted to stabilize
the relationship. I had an affair. We decided to come together [to therapy].”
Coming to couples’ therapy, Christina’s relational goals were “get some
understanding why we can’t get along together. Why we got to where we did
after five years, and to be able to communicate more effectively.” Likewise Chris’
relational goals were: “to be able to talk with one another, and to get an
understanding of why we’re at the point we’re at.”

On the individual level, Chris goals were “try to salvage some kind of
friendship. Learn to be civil to each other. Just basic stuff.” Christina’s goals
were to “have a discussion of the affair, why it took place. Eventually,
acceptance of what happened. And what he said [salvage the friendship and be
more civil to one another. ]” Both believe that they are not there yet as Christina
stated, “We are not exactly where it was at the beginning [of the relationship],”
and Chris asserted, “we are working toward it.” On a scale of 1-10, “1”-“not
accomplished” “10” “completely accomplished,” both agreed that they are at “3.”
There was no formal procedure for defining their goals. Christina suggested,

“The goals were kind of implicit since we decided to come to couple’s therapy

and work on problems and solutions,” and Chris stated, “We didn’t formally talk

70

about goals. He [therapist] would listen, pick out of what we were saying and
would say, “work on this.” He’s insightful and able to focus on things we need to
work on.” This couple is still in a beginning stage of therapy, there is still a lot of
emotional pain and confusion and it almost felt they were relieved to have their
therapist guide and helping them materialize their goals in therapy. The
therapist’s view of this couple’s goals was: relational goals “restore trust and
closeness,” individual goal for Christina: “increase couple time and emotional
closeness,” and for Chris “decrease intensity of conflicts.” The therapist scored
the progress for this couple at “8.” According to the therapist, the therapeutic

goals were decided by “both, [couple and therapist].”

General Statement

To the question, “We hope this will educate future generations of
therapists. If you were to communicate the idea of helpful and unhelpful aspects
of couples’ therapy to a beginner therapist what would you, as a consumer,
advise him/her to do? The couple answered as follows:
Christina suggested, “Don’t take sides, listen, offer solutions based on other

research of working with couples,” and Chris said, “Be non-judgmental.”

71

Couple #2 — Kyle 8. Karen

Kyle and Karen are 38 and 39 years old. They have been in a
relationship for 8 years and married for 6. This is the first marriage for Kyle and
the second marriage for Karen. The couple has no children from previous
relationships. They have 2 sons ages 5 and 1. They live in a suburban area.
Both are Caucasian and were born in the United States of America. Both report
being Christian. Both completed high school. The husband is the provider and
the wife is a stay-at-home mom. The household’s annual income is between
$40,000 and 49,999. This couple attended couples’ therapy on an every other
week basis for two years and terminated two years ago when the younger son
was born. The wife indicated that she had taken a parenting workshop in the
past

At the time of the interview, Karen seemed to be somewhat resentful of
her husband, portraying it more by her body language than verbally. Though
they were sitting on the same couch, they were sitting at different ends of it, and
every time Kyle tried to pull closer to Karen she would pull away and brush him
off. However, both were at ease during the interview, they provided information
willingly, were talkative, smiled, and sometimes even laughed. There was a
sense of caring between them; Karen stated she loves Kyle, but was adamant
about maintaining certain boundaries in order to protect herself from being
emotionally hurt by him. He was remorseful and tried to gain her empathy by
trying to make eye contact and looking at her with begging eyes, touching her

arm, and saying he loved her. Kyle also tried to ease Karen’s resentment by

72

joking and telling her that he could see she was not able to stop herself from
laughing.

The therapist of this couple described how he used the integrative
approach with this couple as follows: “Focused initially on present day issues and

gradually focused more on historical issues and family of origin issues.”

Influences of Demographic Factors, Cultural view and Family of Origin on
Couple ’3 Perception of Therapy

lt terms of demographic factors, they did not seem to apply to this couple
and have any influence on how they perceived their therapeutic experience.
Karen stated, “There is no relation” between their economic status, level of
education, or any of the other demographic factors and how they perceived the
therapeutic experience. Kyle stated, “I guess not” [no relation between the two].
The cultural view of therapy also did not seem to play a role in the couple’s
decision to seek therapy or how they view it. Karen stated “I’m a mutt: German,
French, Irish, and English.” As far as Karen’s cultural background is considered
“there was never an issue about us attending couples’ therapy.” Her mother was
aware of the fact but did not know the specific issue for which they sought out
therapy. Karen stated: “my mom thinks it’s a good idea [going to counseling],
and so does my dad, but he doesn’t know about this [them attending couples’
therapy in the past].” Kyle stated that his cultural background is “Polish and lrish”
and “I don’t know how they look at marriage counseling.” He also stated about

his family’s view, “mom did go to counseling, but no one ever talked about

73

marriage counseling.” According to Karen, Kyle’s brother “doesn’t care if they
even stayed together or not,” and Kyle confirmed it to be true by nodding his
head. Karen stressed the fact that the children were an important factor in her
decision; “I have two children what am I going to do?”

The therapist of this couple did not perceive their demographic factors to
be of any influence, as he stated, “Does not appear to be.” With relation to
cultural view, he stated that it is not encouraged ”especially for male partner,
generally looked down upon,” but he was “not aware of either any support or

discouragement” in their case as far as their family was considered.

Own values: definition of a healthy intimate relationship

It seemed easier for Karen, who was more certain about her answer, to
define a healthy intimate relationship saying “It’s [he’s] supposed to be your best
friend, talk about everything, support one another, show affection, doing for one
another without being told, show love: sharing, experiencing, surprising one
another, rubbing each other’s back, knowing what the other needs. Kyle stated
that he “had no thought about it in the past,” and that a healthy intimate
relationship is about “showing feelings, doing things for each other.” Then he
admitted, “I guess I don’t do a lot of it [showing feelings and doing things]. I don’t
do enough things that show I care about her. Trust [being part of the definition],
but it’s difficult sometimes.” It is clear from their statements that Karen had given
the matter some thought, perhaps based on her past experience in her first

marriage, whereas, Kyle was to some degree unaware about what an intimate

74

relationship is all about, and was looking to her for some insight. It is not clear
whether their views and beliefs, or lack of, were influenced by they views and
behaviors in their families of origin. The therapist added how he perceived this
couple to define an intimate relationship “As one where there is time spent

together, there is joint decision making, and there is sexual intimacy.”

Influences of Therapist Characteristics and Therapeutic Milieu

Both Kyle and Karen agreed that their therapist was “non-judgmental.”
She stated, “he understood more [than she did] where Kyle was coming from
because he’s a man, and he tried to bring it to my attention so I can be more
understanding.” Kyle stated ”for the most part [he felt understood], maybe
sometimes he [therapist] might have taken sides with her [wife].” Both agreed
that the therapist showed no biases. Karen stated, “ I don’t see any looking
down on because of the situation. He brought the men issue like pointing out
that I’m nagging. Brought the men’s point of view, but without disregarding my
point of view.” Kyle confirmed about whether their therapist had any biases by
saying “Not really.” They also agreed that their therapist was flexible at meeting
their needs, especially by accommodating them with the time for sessions, and
location. Additionally, Kyle and Karen felt understood for the most part, and
Karen felt that he might have not understood that her pregnancy would not have
gotten in the way “All except for the pregnancy when he [therapist] decided to

terminate.”

75

Both, Kyle and Karen liked their therapist’s style as Karen stated, “I liked
that he wasn’t stiff and was laid back,” and Kyle confirmed. The couple agreed
that the therapist addressed the problem in a comfortable way, but Kyle just felt
uncomfortable because he personally felt uncomfortable as a result of the reason
they came in to therapy. Karen explained that she came in so angry and in need
to let it all out that she did not care about letting the secrets out “when we first
came to see him I lost it. I was fuming and was a rambling fool and my thoughts
were “help me” and I didn’t care who was around. It was comfortable.”

Both partners had a positive perception of their therapist’s characteristics
relating to the therapeutic process. Karen was not pleased with the therapist
deciding to terminate after two years of treatment because she felt they were not
ready yet. Other than this issue they were satisfied with the process and the
therapeutic milieu. The therapist felt that he addressed the problem in a
comfortable way, as he stated he generally allowed the male partner to focus on

his presenting problem as he saw how it negatively influenced the marriage.

Helpful and unhelpful aspects of therapy

Kyle and Karen had different ideas about what was helpful in therapy.
Karen expressed her satisfaction with Ieaming how to communicate effectively
was “very helpful, I do feel that today we can communicate better.” But, she felt
that the reason that brought them in to couples’ therapy was overlooked “the
initial reason why we came was pushed aside” whereas Kyle felt satisfied with

how the issue was dealt with and considered it to be a helpful aspect of therapy

76

“bringing the situation to the front made me realize I did something wrong.”
Neither one of them had anything specific to say about unhelpful aspects of
therapy. She felt they could have benefited more if the frequency of therapy
would have been once a week instead of every other week “I would have liked to
see him more often, once a week, not every other week.” And, he stated, “I
would have liked to have more homework to try and work at home.”

With regards to helpful and unhelpful aspects of therapy, this therapist felt
that the couple liked working on communication training, increasing couple time,
working on husband’s personal problem. In addition, he suggested that they also

benefited from working on “better understanding between partners.”

Goals

Karen wanted to gain trust back and understand why her husband
betrayed her trust “I wanted him [therapist] to fix the broken trust and tell us why.”
She felt that they improved their communication skills, “and through the time the
communication was bringing it [trust] back up. I gained a little more trust through
the communication opening.” To some degree the goals were attained.
However, the relationship “wasn’t completely healed.” Kyle repeated some of
what Karen said suggesting “I guess we came to find out why I do the things I do
and make our relations better since I didn’t do communication at all.” It seems
that Kyle who felt they came to therapy because of his wrongdoing had to
maintain the same goals as Karen did. From the couples answers it seems that

there was not a structured procedure for setting the therapeutic goals. It

77

appeared that the therapist decided to work with them on their communication
skills and then allowed them to bring up the topics that were an issue in the
relationship. This appears to be welcomed by the couple since they recognized
their need to improve their communication skills. Karen stated, “I don’t think we
discussed goals. He said he’d work with us on our communication and that’s
where we’d start.” Kyle agreed stating, “For the most part I feel the same.”

Both, Kyle and Karen seemed to want the relationship to work out. Karen
stated, she “wanted the marriage to be saved” and felt that “knowing why” and
“Having trust in my husband” was important in order to save the relationship.
Kyle’s goals for the relationship were to “work on the trust thing, loss of trust
issue and the situation of seeking someone else. Try to enjoy her company
more.” The same theme emerged in the individuals’ therapeutic goals where
Karen asserted her goal was “getting through my anger, gaining trust. I was
ready to move on. Wanted to know for myself is it worth it or not, because I was
getting my resources to move on.” And, Kyle reiterated his goal “trust, tell the
truth instead of what I did [lying].”

With respect to attaining goals it seems that Kyle and Karen felt they were
making progress. Karen suggested that at the time of therapy [ended one and
one half years ago] she felt that there was some progress toward the goals, her
anger decreased, her trust in Kyle increased, and their communication skills
improved. However, she did not find out the reason for Kyle’s behavior; “At the
time the anger had subsided through therapy and trust was building up. “The

therapist said I [Karen] will never find out why and I wanted to know if it was a

78

self-esteem or rejection issues, so if I can see it coming back again I can deal
with it. I felt good in therapy.” But, things deteriorated with time after therapy
was terminated, and both Kyle and Karen agreed that the goals were not fully
accomplished as Karen stated, “I feel we stopped before I was ready to stop. I
felt that he [therapist] decided to stop seeing us because I was pregnant” and
Kyle suggested “I guess not [accomplished goals] because we still have the trust
issue and stuff like that.” The couple had similar responses, scoring progress in
therapy (“1” being “not accomplished” and “10” being “completely
accomplished”) Karen scored their progress “56” and Kyle scored “."6 It
appears that at the time of termination the couple was content with the progress.
However, Karen seemed to be somewhat frustrated because she did not find out
the reason for her husband’s behavior, and because she did not feel ready to
terminate treatment. Considering the fact that at the time of the interview they
were one and one half year past termination of treatment and the fact that they
nevertheless scored “56” and “6” on the scale of attaining their goals, it appears
that the outcome of therapy had a lasting effect on them.

The therapist stated that, as a couple the goals were to “improve
communication, increase couple time, and improve parenting.” Kyle’s individual
goal was to “improve parenting, and” address the problem for which he came to
therapy, and Karen’s goal was to “feel Ies depressed.” The therapist felt that the
“relationship generally improved, terminated treatment,” and he scored the

progress for this couple “7.”

79

General Statement

To the question, “We hope this will educate future generations of
therapists. If you were to communicate the idea of helpful and unhelpful aspects
of couples’ therapy to a beginner therapist what would you, as a consumer,
advise him/her to do? The couple answered as follows:
Karen “Don’t take sides, got to walk the fence, be laid back.”

Kyle “Be honest. Talk as you are talking to a person not to a doctor.”

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Couple #3 - Don & Donna

Don and Donna are both 51 years old. They have been in a relationship
for 32 years and married for 28. They have three sons, the two oldest are 25 and
21 years old and both live out of state, their younger son is 15 years old and
resides with his parents in a suburban area. Both are Caucasian and were born
in the United States of America. Both report being of the Jewish faith. Donna
has a Master’s degree and Don has a Bachelor’s degree. She has a full-time
job, and he reports working part-time from the home. The household annual
income is between $40,000 and 49,999. At the time of the interview, this couple
attended 10 sessions of couples’ therapy, and is currently continuing their
conjoint therapy. At the time of the interview, both seemed to be willing to
discuss their experience and expressed their satisfaction with the therapist and
the therapeutic process. Both avoided making negative statements about each
other, and instead were smiling at one another and reveling at the wonderful
family that they have together. Though they were sitting on the same couch,
they were sitting at the different ends of it, turned toward each other and making
eye contact with one another and with the interviewer. Don seemed to be at ease
during the interview; his posture and demeanor were relaxed, he smiled a lot,
and took time to think about the different items before he answered. Donna
seemed slightly more guarded and constricted in her posture some of the time.

The therapist of this couple described how she used the integrative
approach with this couple as follows: “Addressed present relational issues,

worked on communiwtion skills, explored dynamics in family of origin, and

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explored past emotional injuries.” Her personal values and beliefs regarding
couples’ therapy are: “Many times issues can be traced back to dynamics in
family of origin and how each individual internalizes things. I also believe that if

the partners are open minded and want to resolve their issues they can.”

Influences of Demographic Factors, Cultural and Family of Origin on Couple’s
Perception of Therapy

During this interview, Donna seemed to be a little apprehensive about
seeking out therapy; “For me it took a lot because I’m a little anxious about
therapy, but it turned out to be very good, there’s nothing wrong with it,” and as it
came out later in the interview, it was because of her personal experience in her
family of origin. In spite of her fears she sought out counseling and as she
described later in the interview she was satisfied with her experience. In terms of
being of the Jewish faith, both had similar thoughts about how it is viewed by
people in this faith; Don stated, “Being of Jewish background makes us more
willing to seek out therapy.” Donna added, “It terms of being Jewish and having
the education and occupation l have makes therapy a positive thing.” As far as
the way their families view therapy the couple reported different views; Donna
described, “Our 3 children, I believe they’re very happy that we are in counseling
because there’s nothing worse for them than seeing their parents facing a
divorce. It must be reassuring to them that we are working on issues. I don’t talk
to my parents much about it. I’m sure they would support me with this. There’s

nothing wrong with this.” Don stated, ”My parents were the old school. Marriage

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counseling was not a consideration; you take care of the problem, what you don’t
resolve you ignore. That’s how they deal with it. The kids, they realize that us
being in counseling is helpful. lt’s reassuring for them.” The negative attitude in
Don’s family of origin did not seem to influence his decision to seek counseling;
“Anything is better than divorce and you should try everything to fix the marriage.
Sometimes it takes an outside person to make you realize you have a problem,
and taking care of it while it’s still manageable is better.” Don’s personal values
seem to have had a positive influence on him seeking out counseling.

The therapist in this case did feel that “individuals from of the Jewish faith
are pretty open-minded about therapy, and though it seems to be true for Don,
Donna had her own personal issues and perceptions that had some impact on
how she opened up in therapy. For her it took a little longer to feel comfortable to
discuss issues. I know she discussed it with her children and feels that they are
ok with it because it means that their parents are trying to resolve issues without

resorting to divorce.”

Own values: definition of a healthy intimate relationship

Don and Donna have similar ideas about what an intimate relationship is
all about, and it seemed that Don was coming to a clearer understanding as he
was describing it. Donna asserted, “Friendship. There are other aspects, but
without friendship it can’t work. And you need to have some communication
going on between you, not just being together. Having some things in common

other than your children.” Then Don stated, “I look at the larger picture.

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Everything she said is important. The bottom line is that it’s better to be together.
Friendship, intimacy, ability to understand and fulfill needs and desires.
Spending more time together.”

The therapist stated, “I heard Donna say many times that she wants him
to be her friend, to be able to spend fun time with him without the children being
around. Donna also mentioned that her siblings have the kind of relationship she
would like to have with Don, they have fun together and share thoughts with one
another. I am not so clear about how he views intimate relationships, it is quite
obvious that he likes to spend time by himself.” It seems like Donna, to some
level, is basing her ideas about intimate relationships on what she observes with

her siblings. It is not clear if she did the same with her parents.

Influences of Therapist Characteristics and Therapeutic Milieu

Both Don and Donna expressed their high regard to the therapist which
was likely to influence how they view the therapeutic experience; Donna stated,
“The therapist is great. One of the things I’ve really like about this is when we go
home from a session and we say “lets have a conversation like we had in
session.” The therapist is supportive of US [the couple].” Don confirmed, “Very
neutral overall, and careful about not taking sides.” The therapist asserted, “I
always try my best not to take sides and to treat partners fairly, and I believe this
is the case with this couple.”

Both, Donna and Don did not see any biased tendencies in their therapist;

Donna stated, “i don’t think the therapist has any biases. I think the therapist

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treats us equally, working on bringing us together.” Don confirmed, “No biases.
The therapist is very objective, that’s very reassuring, she always encourages us
to do our own little reality checking.” The therapist stated, “I’d like to believe I
don’t have any biases.” Both, Don and Donna felt that their therapist was flexible
in meeting their needs; Donna stated, “She is flexible about time, and with the
way she helped us think.” Both, Don and Donna reported feeling understood by
their therapist, as Don expressed his amazement about the therapist being able
to have such insight considering the fact that she does not know him that well;
“[She] doesn’t know everything about me.” They both felt that the intervention
was appropriate most of the time, and Don added, “Even when I didn’t
understand the purpose of a certain intervention, she made me aware of things,
and helped me put closure on them.” With regard to the therapist’s style Donna
stated, “[the therapist is] very objective and encourages us to work on the
relationship.” Don also said he thought the therapist’s style fit his own “Yes, very
laid back, relaxed, “trying to help” kind of attitude, low key, Very compatible with
my personality.” The therapist stated, “I feel that all three of us to some degree
are pretty laid back.”

It appears that the therapist was able to deal with Don and Donna
effectively, considering the fact that both have very different personalities and
style. She was able to provide a safe environment to Donna who was then able
to open up and express herself, and she was able to move Don out of his comfort
zone in order for him to become motivated to make some necessary changes.

Donna felt that the therapist addressed the presenting problem in a comfortable

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way since according to her she normally is shy and private about certain issues.
She stated, “I don’t like to open up to others and the therapist has been
instrumental in that respect.” On the other hand, Don stated, “I can’t have things
presented to me in a “nice” way because then I don’t feel I need to make any
changes.” The therapist was able to approach each one of them in the way that
fits their different individual styles and needs. The therapist stated, “In my
opinion, for the most part, I addressed the issues with this couple in a
comfortable manner. They are a little different from one another. He needs a
little push to get him a little more motivated and a reminder to get back on track,
and she needs to feel that this is a safe place to express herself.” It is obvious
that both partners expressed very positive feelings about their therapist’s
characteristics and the therapeutic atmosphere and process. At this point of their
therapy (having completed ten sessions), it is not clear yet how close they are to

and how satisfied they are with the outcome of treatment.

Helpful and unhelpful aspects of therapy

Don and Donna both reported benefiting from therapy. They seem to
benefit from communication skills and self-awareness. Don also seems to
respond well when he is taken out of his comfort zone by the therapist. Donna
reported aspects of therapy that were helpful, “to see him [Don] with the good
and the bad, the person I fell in love with. ...Communication skills; I try to listen
more,” and Don stated, “I always guess what others think and I learned to

restrain it. I am more aware of things.” Both, Don and Donna did not report any

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unhelpful aspects in their couples’ therapy sessions, and Don stated that even if
some things seemed to be unhelpful they really “served to increase my
awareness, pointing out things that are uncomfortable. You need to know the
things you are doing wrong in order to correct them.”

Don and Donna both expressed the need to work more on their
communication skills. Donna stated, “I would like to have more conversations in
our sessions and work on reality checking. Don is more intellectual and I’m more
emotional and it helps to listen and express ourselves.” Don stated, “Being able
to honestly speak what’s on your mind, and to discuss things that you normally
avoid. Actually, be clear bout what’s important to you. You can’t take things for
granted and make assumptions. The more you open up and the clearer you are
about your needs the more negotiation power you have.” The couple did not
report any aspects of therapy that need to happen less. Donna expressed her
need “to be less negative about things.”

The therapist had the notion that this couple learned from their families of
origin to walk on eggshells and not to confront or hurt anyone’s feelings. Thus,
allowing them to have a safe environment where it is acceptable to talk about
issues, and equipping them with communication skills was considered helpful in
this case. The therapist was not able to identify any aspects of therapy that were
unhelpful or that needed to happen less in sessions; “In their own families they
learned not to rock the boat and not to hurt anybody’s feelings, and they seem to
do the same with one another. So, I think they actually benefited from the fact

that this is a place where they are allowed to talk about things. I also think that

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practicing communication skills was helpful for them ...I don’t think there was

anything that was unhelpful or anything that needed to happen less.”

Goals
ln therapy Donna wanted to accomplish “Be intimate with my husband. I

want to be able to talk with him about things, be open with him. I can see some
positive changes since we started therapy. I definitely didn’t want to get a
divorce.” Don came to therapy hoping to “have a better relationship, more
rewarding and enjoyable, have more heart to heart conversations.” Donna’s
relational goals were: “Keep the marriage. Having more fun together.” Don’s
were: “Make it better and stronger.“ Don reported his individual goals in therapy,
“To get more satisfaction as an individual. Get validated in terms of self worth,
and be more contented.” Whereas Donna stated that she wanted ”To be more
intimate with him, do fun things together, talk to one another, and share with one
another.”

According to Donna the goals were decided on together. Contrary to her,
Don asserted that he “Never formally talked with her [Donna], did it myself. I set
my goals according to the situation.” They did not view the therapist as a side in
setting goals. As far as accomplishing the goals, both expressed their feelings
about therapy being a process. Donna stated, “The resentment level has gone
down... it’s a process and it’s getting better,” and Don asserted, “I’m in the

process, you want to be in the right direction.” They did differ when scoring their

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level of accomplishment of their goals; Donna scored “3,” and Don had a more
optimistic view scoring it “6.”

The therapist stated, “Donna was very clear about not wanting their
relationship to end up in a divorce and wanted to spend more fun time together
with Don... He seemed to want the relationship to be stronger, to be able to
overcome any crisis, but I believe he was leaning more toward his own needs
being met in the relationship, being validated. In terms of setting the goals, they
both wanted to save the relationship so it became the primary goal, but other
than that I think he had his own agenda, and he would bring up topics that were
completely unrelated to the reason they came to therapy. I had to redirect a lot.
They have some work to do. I would say they are at “3” or “4” on the scale.”

From the different statements made by Don, Donna, and their therapist, it
becomes clear that Don does things alone. He was assertive about deciding on
the therapeutic goals by himself, and his score of “6” is indicative of his sense of
progress. Donna’s score of “3” is more in line with the therapist’s score of
attainment of the therapeutic goals. It is not clear how the partners perceive
setting goals as having influence on their level of satisfaction with the therapeutic

process or outcomes.

General Statement

To the question, “We hope this will educate future generations of

therapists. If you were to communicate the idea of helpful and unhelpful aspects

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of couples’ therapy to a beginner therapist what would you, as a Consumer,
advise him/her to do? The couple answered as follows:

Don: “People are different and couples are different, and the therapist has to
tailor the treatment to fit each couple.”

Donna: “Agree with a lot of what Don said. Everyone is unique.”

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Couple #4 — Tim & Theresa

Tim and Theresa are 38 and 36 years old. They have been in this
relationship for 16 years and married for 14. They have 2 sons under 18 and
her older son who is over 18, from a previous marriage, who is living with them.
This is Tim’s first marriage and Theresa’s second marriage. The family lives in a
suburban area. Both partners are Caucasian and were born in the United States
of America. Both report being Christian. Chris completed high school, and
Theresa reported having less than a high school diploma. Tim is the main
provider, working a full-time job, and Theresa only works part-time. The
household’s annual income is between $30,000 and 39,999. At the time of this
interview, this couple attended six sessions of couples’ therapy on a weekly basis
and at this point is still attending. Both indicated that they also attended
individual therapy in the past.

At the time of the interview, Tim and Theresa set next to each other on the
same couch. They seemed amicable and comfortable with one another as they
turned to one another to make eye contact, smiled at each other, and made
affirming statements to one another. Theresa touched Tim’s arm several times
during the interview. Both seemed at ease during the interview. They provided
information willingly, were talkative, smiled, and sometimes even laughed. At
times, they were very concise with their answers.

The therapist of this couple described how he used the integrative

approach with this couple as follows: “Focused initially on present day issues and

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problem solving and eventually focused more on historical issues and family of

origin issues.”

Influences of Demographic Factors, Cultural and Family of Origin on Couple’s
Perception of Therapy

This couple differed in their view about education and their social
economic status and how they influence their acceptance of therapy and
perception of their therapeutic experience. Theresa stated, “I don’t see any
influence. I don’t think that my education, economic status, or any of that makes
a difference for me.” On the other hand Tim asserted, “I believe that the more
educated you are, and the more income you have, the more accepting of therapy
you will be.” Both felt the same about their cultural background not having any
influence on how they experienced couples’ therapy; Theresa stated, “There is
no view one way or the other, so there is no influence.” Tim stated, “I feel the
same as her. I am from a mixed culture.” Theresa and Tim’s families, both
support the idea of counseling. From the way they explained it to their children, it
appears that both have a positive outlook on counseling. Theresa explained,
“The children know that we are in therapy; I told them that we want to better our
relationship [spouses] and to better our relationship with them... Our kids
understand it, they know people have issues. I come from a dysfunctional family,
my father was an alcoholic and it created many problems in the family. My kids
saw all this. Our son, he’s 11, he use to... we had an argument and he was very

nervous when we fought. He was afraid that we’d get a divorce. He feels much

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more secure now, he understands that people do have arguments and they are
going to disagree, and it doesn’t mean that they want to divorce each other.
Therapy is a positive thing not negative. I tried counseling when l was younger,
about 12 or 13, on and off, all my life because my father was an alcoholic.” Tim
had also been in individual therapy as a teenager, and he states about his
parents, “they were pretty open minded about it.”

The therapist of this couple did not perceive their demographic factors to
be of any influence. He stated that he believes that in their culture couples’

therapy is “generally accepted.”

Own values: definition of a healthy intimate relationship

It is likely that Tim and Theresa are open minded about attending couples’
therapy as they both feel the same about intimate relationships; Tim asserts, “In
an intimate relationship both partners care about the other person as much as
you care about yourself. The other person’s happiness means a lot to you, as
important as your own.” Theresa added’ “Almost care m about the other
person. There is complete trust, faithfulness, and compassion.” The therapist
added how he perceived this couple to define an intimate relationship “as one
that allows for time spent together as well as individual time spent apart. Joint

decision making is important as well as sexual intimacy.”

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Influences of Therapist Characteristics and Therapeutic Milieu

Both Theresa and Tim felt that their therapist treated them fairly; Theresa
stated, “I feel that he [therapist] treats us fairly. I don’t like it when I’m wrong and
when he says I should do this or that. (Wife is smiling when she says that). He
addresses both of us and includes both of us. He is non-judgmental and doesn’t
point fingers, you can say anything that comes to your mind and it’s ok.”
Likewise, Tim stated, “He’s fair. Maybe he just points out things [when he tells
me what I need to do], brings them out for our attention. We have a referee. But
basically, you can say anything and be ok because he is not shocked by
anything. So it’s pretty comfortable, and he pretty much treats us equally.”

Both, Tim and Theresa agreed that their therapist did not show any
biases: Theresa stated, “I don’t think so at all, if he does he hides it well,” and
Tim confirmed her response. They also felt that he was flexible in meeting their
needs as Tim suggested, “We brought the kids one session and he said, “Oh
fine, that’s ok,”” and Theresa confirmed his response. Additionally, Theresa and
Tim agreed that they felt understood by the therapist; Theresa said, “I feel he
hears us and what we bring to the table,” and Tim stated that he felt the same.
The interventions used by the therapist were perceived as being appropriate
most of the time by both Theresa and Tim. Theresa stated, ”We learn how to say
things to one another, and how to do things in a different way. “ Tim stated, “he
helps us understand the difference between us, and he lets us come up with our

own solutions.” Regarding the therapist’s style fitting the couple’s style, Theresa

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liked that she is able to go in depth about the issues that are brought up in
sessions and Tim actually was less pleased with the laid back character of the
therapist; Theresa said, “I’m happy with him. I like going more in depth with
things, I like to talk more about certain things and he [husband] is more “I get the
point lets go on.” It took us a long time to get here and it will take more than 6
sessions to work on things, I hope not 14 years but you know, can’t be rushed
into anything.” Tim stated, ”I think he’s a little laid back, and I’m more aggressive
at fixing stuff. If there’s a job to be done it needs to be done.” Theresa and Tim
also felt that the therapist addressed the presenting problem in a comfortable
manner: Theresa stated’ “Yes, his wording, he doesn’t point a finger, instead he
asks “what if you’ve done this?” If someone would have come to me and said
you are wrong, I would not take it very well. [He is] non-judgmental.” Tim
confirmed “ Yes. I don’t think anything can shock him; he will not be knocked out
of his seat. I can tell him that I wore my wife’s undenrvear on the weekend and I
don’t think he will freak out or anything. We are comfortable with him.”

Although the partners for the most part have a positive perception of their
therapist’s characteristics as they relate to the therapeutic process, they only
attended six sessions at the time of the interview and have not yet (at least at this
point) reached their goals. They are unable yet to make any connection between
the therapeutic process and outcome of treatment. Theresa realizes that therapy
will take some time and Tim would like to see more immediate and direct

intervention and result. The therapist felt he addressed the presenting problem

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in a comfortable way, reframing it in an interpersonal context with a “non-blaming

position with each partner.”

Helpful and unhelpful aspects of therapy

Theresa and Tim felt that practicing communication skills was a helpful
aspect of therapy. Theresa described being challenged by the therapist to come
up with solutions to different situations as helpful; “He [therapist] asks us to come
up with a solution, if we could have handled things differently, use “I” messages,
“I feel” instead of “you," and Tim stated, “Getting stuff out in the open. We have
an hour once a week to just talk. lt forces us to have open communication once a
week.”

Both, Theresa and Tim agreed that the lack of structure in therapy was
somewhat unhelpful, as Tim suggested, ”I think he [therapist] can be more
specific. I think we are still in the “get to know you” sessions, and at this point I
think we can move forward. It’s a free form [session], and I need structure and
goals, and a time frame. Now is the time [to do all this].” Theresa confirmed, but
added, seemingly in an attempt to justify the free form sessions, ”Things come
up, you know, with three kids things happen so you talk about different things.”
When asked what aspects they would like to see happen more in therapy,
Theresa expressed her satisfaction with homework assignments: “He gives us
homework every week for the week,” and Tim once again stressed the need for
directness: “I would like to see him be direct with us; tell us what is wrong “what

do you think” and what to do.” Neither one of them felt strongly about aspects

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that need to happen less in sessions; Theresa smiled when she said “I don’t like
to be told what I’m doing wrong,” but also said, “I’m happy with the sessions and
how he lets us add on and go on.” Tim remained consistent with his line of
structure and directness saying, “Slowing us down, just could go faster. If he
was a little more assertive.”

With regards to helpful and unhelpful aspects of therapy, this therapist felt
that the couple found helpful working on “communication training, working on

emotional closeness and sexual intimacy - all improved the marriage.”

Goals

Both, Tim and Theresa wished to have a better relationship. Theresa
asserted, “[Did] not want to end up in a divorce court. Wanted to communicate
better, become intimate, improve our physical intimacy, improve our
psychological intimacy, to be equal, and become one.” Likewise, Tim wanted
“instead of being adversaries to be a team.” Theresa’s individual goals in
therapy were more involved than Tim’s, wanting to “Deal with my temper, with my
short fuse, everything is an emergency, lower my stress level, not to take
everything so personally, interact better with my husband and kids. Learn to
know myself; what makes you [me] tic.” Tim wanted to “Learn the tools of how to
be intimate.” As far as accomplishing the goals, both feel that they are working
on them and have some progress; Theresa stated, “There are good days and
there are bad days in terms of our behavior. Some days we can apply our tools

and some days we can’t. We are more conscious about it,” and Tim asserted, “I

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feel we are getting somewhere.” And, on a scale from 1-10, “1” being “not
accomplished” and “10” being “completely accomplished,” Theresa scored “4”
and Tim scored “5.” Theresa stated that they decided individually what their
goals should be, and Tim suggested that the therapist was still getting to know
them and learning about their personalities, “so we didn’t talk about goals yet.”
It appears that in spite of Tim’s need for directness he is willing to accept the fact
that they are only at the beginning of the process and is hopeful that things will
move on and that the therapist will set the goals. Theresa indicated earlier that
she likes the ability to talk about different issues more in depth. Both have their
ideas about their relational and individual goals in therapy. In spite of the early
stage of therapy they both indicated some progress toward their goals; Tim
scored “5” and Theresa “4.”

The therapist stated that the relational goals for this couple were:
“Increased emotional and sexual closeness.” Tim’s individual goal was
“decrease use of pornography,” and Theresa’s individual goal was to “stabilize
[her] mood.” The therapist feels that this couple made some progress “[the]
couple generally feels as if their relationship has improved, communication is
better, [there are] fewer conflicts.” The therapist scored the progress for this
couple “6.” According to the therapist, the therapeutic goals were decided by

“both, [couple and therapist].”

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General Statement

To the question, “We hope this will educate future generations of
therapists. If you were to communicate the idea of helpful and unhelpful aspects
of couples’ therapy to a beginner therapist what would you, as a consumer,
advise him/her to do? The couple answered as follows:
Theresa: “To a beginner therapist, don’t dismiss anything the couple says.
Tim: “I think school prepares you right, some people get it and some don’t.
Personalities don’t always mesh [therapist and client]. You need to find clients
with whom you mesh. You need to feel comfortable. Find the right therapist for

the right client. Do the best you can.

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Couple #5 — Ed & Edna

Ed and Edna are 46 and 42 years old. They have been in this relationship
for 18 years and married for 16 years. This is Ed’s second marriage and Edna’s
first. The couple has 2 sons 15 and 13 years old, both living at home. The family
lives in a suburban area. Both partners are Caucasian and were born in the
United States of America, and are both from Eastern European background.
Both report being Christian. Ed completed high school and got vocational
training. He works full-time. Edna reported having a high school diploma and a
few college courses. Ed is the main provider, and Edna only works part-time.
The household’s annual income is between $40,000 and 49,999. At the time of
this interview, this couple attended couples’ therapy for seven months on an
every other week basis and at this point they are getting ready to terminate their
therapy. Edna indicated that she also attended individual therapy in the past.

At the time of the interview, Ed and Edna set on the same couch a little
apart from each other. They seemed amicable and comfortable with one another
as they turned to one another to make eye contact, smiled at each other, and
Edna intervened several times when Ed was talking, trying to help him with his
response. Both seemed at ease during the interview, they provided information
willingly, were talkative, smiled, and sometimes even laughed. Ed got side
tracked several times but came back to the topic after a short while.

The therapist of this couple described how she used the integrative

approach with this couple as follows: “Addressed present relational issues,

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worked on communication skills, explored dynamics in family of origin, explored
past emotional injuries and worked with wife on setting boundaries effectively.”
Her personal values and beliefs regarding couples’ therapy are: “Many times
issues can be traced back to dynamics in family of origin and how each individual
internalizes things. I also believe that if the partners are open minded and want

to resolve their issues they can.”

Influences of Demographic Factors, Cultural and Family of Origin on Couple ’8
Perception of Therapy

The demographic, cultural, and family of origin factors do not seem to
have influenced this couple’s level of satisfaction with the therapeutic process or
outcomes. They are aware of these factors but set them aside for the purpose of
dealing effectively with the issues they are facing as a couple. Edna and Ed both
thought that the need to attend couples’ therapy. They prioritized over other
things regardless of their financial situation at the time. Edna stated, “Not having
money would not stand in the way of getting therapy because it was an important
issue that had to be dealt with.” Ed confirmed, ”Just like she said.” Being from
Eastern European background the couple felt that the generation before them
was very much against counseling, thinking it is a weakness. However, Ed and
Edna don’t feel that this is the case with their generation. Edna stated, “I think it
depends on the generation. Our parents and their generation were in denial
about any issues that they might have had. They felt it was a weakness to talk

about problems and going to therapy. I don’t have problems with it.” Ed

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confirmed. Their families were no exception to the rule of being from Eastern
European background. It was especially apparent in Edna’s family when a
traumatic event happened to one of the family members, and where counseling
could have been of valuable help, but was never considered. Nevertheless,
Edna has not been influenced by her culture and family to view therapy in a
negative light. On the contrary, she believes counseling to be very beneficial.
Edna remembers well the details of the incident and how the family dealt with it,
as she described, “When my brother went through a very traumatic incident, and
he needed counseling, my dad told him “you’ll be ok, don’t worry, it’s ok,” dad
was almost ashamed. It was more like he doesn’t need it, he’s strong, he can
deal with it, and it was not allowed to talk about it. My dad would say “why do
you want to talk to them, what do they know about you, how can they fix it better
than you can?” Edna also described how the family viewed the fact that one of
her uncles was in counseling when he was young, “He [uncle] had a serious
breakdown in his teenage years and he saw a therapist...they thought about him
that he was weak, a little crazy. It was considered a weakness to get help; you
should be able to solve your own problems. We don’t tell anyone in the family
about us being in therapy. I feel very good about counseling.” Ed admitted that
he had been reluctant about seeking therapy at the beginning and did not know
what to expect. In his family people do not talk about certain things and therapy
is downplayed “I had my own little issues with my father. Things are also [as in

Edna’s family] pushed aside and ignored. My father says about therapy that you

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need to be strong and take responsibility and not blame anyone for your
problems.”

The therapist stated, “In this case, some family members shy away from
therapy, but this didn’t seem to be a problem for Ed and Edna. Actually, it was
less of a problem for Edna than for Ed. He had to warm up to the idea, and after
he did he was completely fine with it.” In this case it also appears that the
presence of children at home was a motivating factor to seek out counseling.
The therapist added, “I know they [the couple] discussed several times their
children having to witness their arguments and they were concerned about how it

affected them.”

Own values: definition of a healthy intimate relationship

Ed and Edna have very similar description of a healthy intimate
relationship. According to Edna, “Intimacy is about being able to show, feel, and
share your deepest feelings with the person you love.” Ed stated, “Intimacy is
supposed to be about friendship, love, expressing yourself, being comfortable
with your partner, feel comfortable talking to your partner about anything.” The
therapist felt that for this couple an intimate relationship meant “closeness and

ability to share with one another.”
Influences of Therapist Characteristics and Therapeutic Milieu

Edna felt that the relationship was deteriorating and was determined to

seek therapy no matter how uncomfortable it might be. Ed was nervous about it,

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but realized the severity of the problem, and thus overcame his fears and
uncomfortable feelings. Edna described, “I felt I was holding inside things that
bothered me for too long, and I couldn’t do it anymore. When I first came to
therapy it felt like now I can take this load off, not have to walk on eggshells
anymore. I felt that the therapist was not looking down on us or judging us. She
listened to both of us equally, treated us fairly, and made some suggestions that
seemed fair.” Ed describes the experience, “I was concerned at the beginning
because I didn’t know the therapist, so I felt a little uncomfortable. But after a
short time it felt easier and more natural and was able to talk about things. The
therapist did not take sides at all, which made me feel more secure and relaxed.”
The therapist stated, “I normally do not take sides when I’m dealing with couples,
and I always try to treat everyone fairly. I believe I did it with this couple as well.”

Edna stated she did not think their therapist showed any biases and Ed
felt that her being a woman could have been a problem at the beginning because
of his thoughts that she would side more with his wife, and he stated, “At first, I
felt she might take her [wife’s] side, but she didn’t. She took my side, then took
my wife’s side, so it’s not like it became the two of them against me.” The
therapist stated, “I don’t believe I have any biases that would interfere with
therapy.” Both reported that their therapist was flexible in meeting their needs,
especially with relation to scheduling time for the appointments. All, Ed, Edna
and the therapist agreed that the interventions used by the therapist were

beneficial and appropriate most of the time.

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Ed and Edna have different styles and different personalities, and even
though Edna sometimes felt she would have wanted the therapist to intervene
more and be more direct with Ed, she realized that he needed the more laid back
style in order to benefit from therapy “Personally I don’t think he would have done
well with someone who is more direct and talks a lot. He needed someone softer
and calmer and more laid back, and she [therapist] is all that.” About herself
Edna stated, “I can adjust to any situation, or person, so even if I want a more
direct person, I can work with more laid back personality style.” Ed felt
comfortable with the therapist’s style, especially her “knowing how and when to
intervene, how to address certain issues without making you feel bad about
yourself. I feel understood.” The therapist did not describe any issues related to
personality differences; “I don’t know that we all have the same style, but it really
didn’t matter in the course of therapy, because there was openness, mutual
respect, and a maturity level on everybody’s part.”

Both, Ed and Edna agreed the presenting problem was addressed in a
comfortable way. Ed actually was a little emotional when he talked about this
and stated, “She [therapist] approached me without hurting my feelings...And
she knew exactly what to say to get to me and make me understand what I was
doing wrong and made me realize what I can do to make the situation better for
me and everyone around me, it made complete sense.” Edna confirmed. The
therapist felt “I didn’t do anything out of the ordinary to address the presenting

problem in a comfortable way, I just tried to remain non-judgmental, to listen to

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both of them, validate them when needed, and normalize their feelings. And, of
course, I intervened when necessary.”

This couple made very clear statements regarding the therapist’s
characteristics, and the therapeutic atmosphere indicating their satisfaction with
the therapeutic process. In spite of Ed’s reluctance and concerns about therapy,
he was able to maintain an open attitude about the process. In fact, both came

in with the understanding that they needed this to resolve their marital issues.

Helpful and unhelpful aspects of therapy

Both, Ed and Edna gained some insight into therapy and learned about
each other and about other people in their life. Ed also learned no to react and
listen more attentively. Edna reported helpful aspects to be as: “When she
[therapist] gave us input; tools to deal with the situations, useful input and view,
helped us understand why people say what they say and do what they do,
helped us understand each other and realize that we are not enemies and that
we each have our own baggage from our families and other situations and it has
nothing to do with the other person.” And, Ed stated, “She helped me to be
calmer, more aware, a better listener, and have more understanding about
different things. I learned to relate better to my wife. I don’t think we argue as
much, I think both of us listen more and don’t jump immediately at each other’s
throats. I think we know each other better.” Both of them thought there weren’t
any unhelpful aspects, and Ed even asserted, “We wouldn’t want to be here if

that was the case.”

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In terms of what they would have wanted to see happen more often in
therapy, both felt that the homework assignments were beneficial. Edna said,
“We need our weekly assignment and then discuss it in therapy. The practice
helps.” Ed liked the communication skills on which they worked at home, and
which forced him to “listen without interrupting.” There were no aspects that the
couple wanted to see happen less often.

In terms of helpful aspects of therapy, the therapist stated, “I believe
practicing communication skills was helpful for them, discussing issues related to
family of origin and how they affect the couple today, and probably setting
boundaries with others. I think that this is what they can continue working on. I
don’t know of any unhelpful aspects of therapy or those that need to happen

less.”

Goals

Ed and Edna felt that they had arrived at a point where they were not
communicating well, the relationship was stagnating and Edna was beginning to
have thoughts about leaving the marriage. They realized that they needed to
work on the issues between them. Ed said, “I wanted to get things taken care of,
we never sat down and talked about any of it. We couldn’t escape it any more.”
According to Edna, “l was at a point where l was not willing to compromise my
life any more, it was not good for anyone. I was practically ready to divorce him.
I was angry all the time, we were arguing and yelling in front of the kids, there

was no communication, or at least normal communication, between us. We

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didn’t understand each other, or maybe didn’t want to. Something had to
happen, and fast.” Both reported their relational goals in therapy to have better
communication skills; Edna stated, “We need to be able to listen to one another
without making assumptions or guessing what the other wants or feels. We stop
taking everything so personally and realize that sometimes him yelling is not
about something I actually did, maybe he just had a bad day, or he’s tired.” Ed
confirmed, “Communication and listening.” Their individual goals were different
from one another. Ed remained consistent with his need to be a better listener;
“listening better before you say anything,” and Edna wanted to learn how to set
boundaries with her family and not let them interfere with their life [Ed’s and hers
and the children’s], “quit worrying about what they think and say.”

They both reported progress toward their goals, and emphasized that it is
a process; Edna said, “I think it’s a working process,” and Ed also stated, “this is
a ladder and we are climbing up.” They both scored ”7” on the scale of 1-10“1”-
“not accomplished” “10” “completely accomplished.” Ed and Edna felt that even
though the therapist helped them with their goals, they were the ones who
actually decided on them, as stated by Edna, “She helped us together, but we
brought up the issues we wanted to work on,” and Ed confirmed.

The therapist stated, “the goals for this couple was to strengthen their
relationship, gain better communication skills, gain an understanding of how their
families of origin did business, and gain a better understanding of how this
impacts the way they interact with one another. I’m not certain they actually had

specific individual goals. They made very good progress toward their goals; as a

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matter of fact they are getting ready to terminate treatment. I would say they are
at “7” or an “8” on the scale, and basically, need maintenance.”

It appears that coming to therapy, both, Ed and Edna had clear goals.
Being able to get things out, being aware of their marital issues, and the
therapist’s help with respect to their goals and guidance with other things, all
contributed to their level of satisfaction with the therapeutic process and the

outcome of treatment.

General Statement

To the question, “We hope this will educate future generations of
therapists. If you were to communicate the idea of helpful and unhelpful aspects
of couples’ therapy to a beginner therapist what would you, as a consumer,
advise him/her to do? The couple answered as follows:
Edna: “Give each person the opportunity to say everything they have, so there is
nothing left unsaid and there is no misunderstanding about what they think and
feel about the relationship and other things that are going on, otherwise it’s not
going to work. It is not easy to come here so take advantage of the opportunity.”

Ed: “Be patient with your clients.”

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Couple 6- Adam and Amanda

Adam and Amanda are both in their early forties. They have been in a
relationship for 3 years and married for almost two. Adam’s teenage daughter,
from a previous relationship, moved in with the couple last summer. The couple
lives in a suburban area. Both are African American, born in the United States of
America. Both report being Christian. Adam reports having some college
education and Amanda reports having a master’s degree. Both work full-time
and report an annual household income of over $50,000. Adam and Amanda
report attending couples’ and family therapy in the past. The experience with
couples’ therapy started six months ago, and they have been attending every
week.

At the time of the interview both seemed very comfortable with one
another and with the interviewer. They were sitting on separate chairs next to
one anther (there was no couch in the office). Adam was very talkative, and was
joking between answers. Amanda was more serious than he was, but several
times laughed in reaction to his jokes. It was necessary to help them refocus,
especially Adam, several times during the interview. Both, Adam and Amanda,
provided information willingly.

The therapist of this couple described how he used the integrative
approach with this couple as follows: “Focused on here-and-now issues as well
as historical issues and family of origin issues. Also, focused on male’s

substance abuse problems.”

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Influences of Demographic Factors, Cultural and Family of Origin on Couple’s
Perception of Therapy:

Adam and Amanda felt very strongly about education and income level
having a direct influence on being open minded to seek out therapy and to
perceive it as helpful. Amanda stated, “Education and income are a factor,” and
Adam asserted, “Definitely with education level you get more open...the more
knowledge you have the more likely you are to go to therapy.” In the African
American culture Amanda stated, “In some families depending on the income
level and the education level, if it’s higher they are more willing, but then in other
cases I noticed that people who don’t have also go to therapy... so it just
depends on the situation, but I still think it matters.” Adam confirmed Amanda’s
statement.

The culture was not mentioned as a factor influencing this couple’s level of
satisfaction with the therapeutic process or outcome. Regarding the family of
origin Amanda stated, “My parents have been in therapy before and took my
sisters to therapy, they think it’s a positive thing...My sister knows about us being
in therapy and she also wants to come to see our therapist with her children...My
parents have in-home therapy now. Amanda also believes that in her line of work
therapy is considered a helpful factor as she stated, “research has shown that in
my field that I’m at therapy is a factor.” Similarly, Adam reports that members in
his family of origin have a positive outlook on therapy; “my parents too are open
minded about it.” He personally thinks that that “everyone can use it at one point

or another in their life.” Adam also discussed the religious aspect. He believes

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hat if he were more involved with the church he would actually have better tools
to deal with his issues “if I had more religion in my life my faith would help...We
don’t have enough of God in our relationship...my faith would carry me.” The
therapist stated that in the African American culture “couples’ therapy is generally

not encouraged.

Own values: definition of a healthy intimate relationship

Adam and Amanda had a little different twist on their definition of what is a
healthy intimate relationship. Amanda believes that in an intimate relationship
there is: “respect, loyalty, honesty, and the rest will follow, then love of course,
bringing people more together and religion.” Adam did not contradict what
Amanda said but put it in different words stating it is “I think it’s a feeling of
oneness, l breath in she breaths out, two people together like a melting situation;
sexually, mentally, physically, emotionally, everything, that would be my perfect
intimate relationship, and I don’t feel I have it, that’s why we are here.” Amanda
responded to Adam’s statement “for me, if we had all the things I talked about we
would be one.” The therapist added how he perceived this couple to define an
intimate relationship “as a mutual partnership that can solve problems and where

there is emotional and sexual intimacy.”
Influences of Therapist Characteristics and Therapeutic Milieu

Both Adam and Amanda have very positive things to say about their

therapist and they start with both saying “he’s a very good therapist...” and

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Amanda added, “He’s very objective...l like coming here...l don’t like to miss
sessions...l recommend him highly, I told other people about him.” Both agreed
that their therapist treats them in a fair manner. Amanda was the one who
stressed the need to seek therapy for their relational issues and wanted Adam to
be comfortable in therapy; “I wanted to make sure that he had a male therapist
so he would feel more comfortable and not be defensive about it.” At the
beginning she had concerns that the therapist would be on one side, but instead
she found out that “he’s fair and objective.” Adam said about “I think he’s real
fair, sometimes I think he’s a little soft core...he doesn’t take sides, listening to
both sides and being open.”

Amanda also emphasized that their therapist is “a good active listener, he
repeats back, and tries to make us see what we’re actually saying, and to realize
certain differences that we have, but see the connection and the bond that we
have are actually stronger than we think.”

With regards to therapist’s biases, Amanda stated “not for me.” Adam
confirmed her response but then added, ”We come from two different worlds...
there were times when I expressed myself with a lot of vulgar language and I
don’t use it to be tough or anything it’s just the way it comes out, and he made a
statement about it.” Amanda challenged Adam on this because she stated it also
bothered her. Adam however, would just ”like to be able to express myself in
therapy worrying about it, I don’t want to monitor myself in a therapy session... I
was raised on the streets... he [therapist] has style and class.” Both feel that

their therapist is flexible: Amanda stated, “He’s very versatile about how we do

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things, he doesn’t have a uniformed set about how we do things, there’s nothing
written in stone, whatever works for the situation... he is very flexible.” Adam
nodded his head to confirm Amanda’s statement. Amanda also felt understood
by the therapist stating, “He’s an active listener, he paraphrases, and makes me
think.” Adam felt understood most of the time, but he also stated, “there were
times when he totally understood me, but I have moments when no one
understands me, maybe it’s the way I express myself.” Amanda stated that
Adam tends to “get lost and goes on and on with stuff, he does it to me.”

With regards to how the couple perceived the interventions that their
therapist used, both Adam and Amanda responded affirmatively. Amanda
stated, “When we bicker he brings us back and refocuses us. We need a
referee,” and Adam added, ”I got a tunnel vision and I’m thinking that you should
understand, I’m so opinionated that I need to understand that just because my
way is cracked to the left yours can’t be to the right, there are many ways to cook
an egg. He keeps me focused.”

With respect to the therapist’s style fitting their own, Amanda said,
“Sometimes we become too dependent, we can take on something, but he
[Adam] tries to avoid it, and he starts stuff so he can avoid discussing issues.
“His [therapist] style is very good, because he’s very laid back and he’s
confrontive sometimes when he needs to be, sometimes we look at issues that l
othenrvise don’t want to look at, and he does it in non-threatening way.” Adam
said about the therapist’s style that “He has a lot of style, a lot of class, he is very

patient. He always brings you back to the center, it’s very helpful. It

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compliments what I need.” Amanda also stated that the therapist “addressed the
presenting problem in a comfortable way - non threatening way, and Adam
confirmed, “non threatening.” The therapist felt he addressed the presenting
problem in a comfortable way, but “it seemed that Adam sometimes felt there
was too much focus on his substance abuse and not enough focus on changes

that Amanda need to make.”

Helpful and unhelpful aspects of therapy

With regards to helpful aspects of therapy Amanda stated, “I don’t see
where it hasn’t been helpful. What I see helpful is that I get a sense of relief,
being able to talk to Adam and the therapist, and get their feedback about
everything, because a lot of times we hold back, things that we don’t want to
argue about, so we hold it for a week until we come to see him, it is a safe place.”
Adam described helpful aspects of therapy referring to their therapist, “open
minded and how he expresses himself, tells us look at the situation from a
different angle. Being able to get help, having someone to reveal my secrets to
and let it dies. Both felt it was a safe place.” Amanda actually would have liked
to come more frequently “I wish he was available more often, more hours.”
Adam wants to spend less time talking about the negative things they bring to the
sessions. He expressed his wish to be able to “leave therapy sessions and feel
the sense of oneness that we talked about earlier, be less negative and more
bonding.” Adam does mention one thing that is unhelpful about the therapeutic

process and that is “after sessions I am tired, I’m emotionally drained.” But, he

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realizes that this is part of the process. With regards to helpful and unhelpful
aspects of therapy, this therapist felt that the couple benefited from
“communication training and problem solving,” and he believes that Adam “felt
[as well as the therapist] too much time was spent on his substance abuse

problems.”

Goals

Amanda and Adam had the same goal coming to therapy. She clearly
stated that her purpose in coming to therapy was “not to get a divorce.” And
Adam confirmed. In the beginning, Adam said, “I was trying to pacify her and just
do what she wanted. I thought it was a waste of time and, I thought you need it
[wife]. I did it for her.” But things changed once they started the process, and
now he “looks forward to it because it’s a release, basically you have a referee,
and sometimes we need it, we can start off with a basic conversation and
somehow it evolves to yelling.” Amanda was trying to figure out in therapy
whether this relationship was “worth staying in.” She also” wanted to know if he
[husband] will stop using.” As to her individual goals Amanda stated, “[I] wanted
to see if I can get back a sense of self, since I’ve lost it since we’ve been
together.” Adam added about the relational goals that he was “trying to have a
better form of communication and understanding of our life, and how what I did
affects her.” As far as his individual goals Adams stated he wanted to “get a

method to stay clean and get a better insight about who I was when l was using

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and who I am without using, and the process of going back again and again, and
what were some of the reasons and steps I took before I went back and used.”

About goal attainment they both see there is progress. Adam feels he
accomplished some of his individual goals; he is now in recovery and stopped
using. He stated, “Some of the thing I’m still working on, it’s a process, I
understand now that the reason I relapsed was because I wanted to, I see the
patterns and know what I need to do to avoid it. I can change the behavior.”
Amanda stated, “There is some progress, it is a process.” Amanda added about
what she liked in therapy “The whole process of therapy, I believe in therapy. It
can work, and I do see some small steps that we’ve made.” And Adam stressed
the need to assume your own responsibility for the outcomes as he suggested,
“...You need to do the changes that need to be done.” On the scale of 1-10“1”-
“not accomplished” “10” “completely accomplished” Adam and Amanda have a
little difference between them. Adam scored “6” and Amanda scored “4.”

They both report that the goals were decided on individually because they
cannot talk about things without getting pulled into an argument. Adam believes
that “goals are being redefined on a daily basis, had a thought about divorce,
now we dealt with it and there is another goal... We have goals set in mind and
we actually work on it.”...” And Amanda stated, “decide individually and the
therapist would talk with us about it.”

The therapist stated that, as a couple the goals for Adam and Amanda
were to gain more closeness and argue less. The therapist also felt this couple

was making progress and stated that they were having “Somewhat less

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arguments,” and that they seem to be “more compatible.” With regards to
Adam’s individual goal the therapist said, “he reports he has not used in several
months.” The therapist scored the progress for this couple “5.” According to the

therapist, the therapeutic goals were decided by “both, [couple and therapist].”

General Statement

To the question, “We hope this will educate future generations of
therapists. If you were to communicate the idea of helpful and unhelpful aspects
of couples’ therapy to a beginner therapist what would you, as a consumer,
advise him/her to do? The couple answered as follows:
Adam: “Be patient and be caring about his clients, have a true concern and really
want to see them becoming successful and not only to be that way but to really
be able to communicate, and be able to verbally say and do what needs to be
done. And, you are better off if they’re married so they have their own
experience with what’s it like to be married.”
Amanda: “I agree about being caring, those kind of things do matter. Let it be
more than a job, be able to be empathic and understanding of each person’s

concerns and problems. Have experience.”

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Statements made by the therapist of couples: #1, #2, #4, and #6

The therapist of couples: #1, #2, #4, and #6 described his personal values
and belief regarding couples’ therapy is that problems are generally
interpersonally based, reciprocal, and are best worked on and resolved
interpersonally. The therapist also felt he treated each partner fairly and did not
take sides. As far as having any biases this therapist stated, “Men tend to be
less open and involved in the psycho therapeutic process.” He felt that his laid
back style fit with the style of all his couples. The therapist stated he was flexible
in meeting the partners’ needs, used appropriate interventions, and always
addressed the presenting problem in a comfortable way, framing the problem in
a relational manner. According to the therapist, the therapeutic goals for all of his
four couples were decided by the couple and the therapist. With regard to
influence of family of origin on his clients perceived the therapeutic experience,
this therapist reported that he was “not aware of either any support or

discouragement.”

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Cross-Case Analysis

The interviews of six participating couples in this study were described
earlier in this chapter. They illustrate how these couples perceived their
therapeutic experience and what were the contributing factors to their level of
satisfaction with the process and outcomes of couples’ therapy. The last Table
(see Table 4.6) provides couples’ suggestions to beginner couples’ therapists
about helpful and unhelpful aspects of therapy. Information from the two
participating therapists was also provided regarding each couple at the end of the
corresponding couple’s interview. The information will be examined with regard
to the original research questions.

Demographic characteristics of the six participating are shown in Table
4.1. Four of the couples were Caucasian, one couple was African American, and
one couple was mixed; the male partner being African American and the female
partner Caucasian born in Poland. The mixed couple is cohabiting, and is the
only couple that is not married. Four couples reported being Christian, one
couple reported being from the Jewish faith, and the cohabiting couple reported
being of no particular faith. The average length of being together was 10.33
years, ranging from three years to thirty-two. With respect to education, one
male did not report his education level, one female participant had less than a
high school diploma, five participants reported completing high school (3 males
and 2 females), two males reported having a bachelor degree, two females had a
master degree, and one female had a PhD. With respect to employment, eight

participants reported having full-time employment (5 males, 3 females), three

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reported working part-time (1 male, 2 females), and another female reported
being a stay-at-home mother. The average annual household income reported
was over $40,000, two couples reported an annual household income over
$50,000, two reported between $40,000 and 49,999, and two reported an annual
household income of $30,000 to 39,999. All, but the cohabiting couple who is not
married, have children. One couple has 2 toddlers, sons, one couple has two
adult children who do not live at home and one teenage son who resides with
them, another couple has two teenage sons who reside with them, one couple
has one adult son and two teenage sons who all live with the couple, and one
couple had a teenage daughter, who recently moved in with them, from the
husband’s previous relationship. Two couples reported attending six sessions of
couples’ therapy, one reported ten sessions, one reported 14 sessions, one
couple reported being in therapy for the last six months on a weekly basis, and
one couple who already terminated at the time of the interview reported having
two years of couples’ therapy every other week. All reported receiving some sort

of counseling in the past (i.e., individual, couples’, family, parenting workshops).

Data Matrix
The following Tables provide data in a form of direct quotes from the
individuals and the therapists relating to the different categories and themes that
were established for the purpose of this study. There was no particular order in
which the couples were organized in the templates. There are five Tables, four

of which specifically address the chosen categories and themes, and the last one

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provides direct quotes of the partners’ suggestions to beginner couples’
therapists about helpful and unhelpful aspects of therapy (see Table 4.6).

The column in Table 4.2 with quotes about demographic factors, cultural
aspects, and family of origin aspects that are believed to have influence on how
partners perceive the therapeutic process and its outcomes corresponds to the
first research question: “How does the eco-system influence client’s level of
satisfaction with treatment of couples in couples’ therapy and outcome of
treatment?” The couples describe the different demographic factors (i.e., level of
education and socio-economic status), cultural factors and family of origin and
how they influence their perception, acceptance, and experience of the
therapeutic process (see Table 4.2). The column in Table 4.3 with quotes of the
partners about the therapist’s characteristics and the therapeutic milieu, and the
columns in Table 4.4 of couples quotes about helpful and unhelpful aspects of
therapy, correspond to the second research question: “How does Integrative
Couples’ Therapy influence clients level of satisfaction with couples’ therapy and
outcome of treatment?” The couples describe characteristics of the therapist and
the therapeutic milieu that were perceived as desirable in terms of influencing
their level of satisfaction with the therapeutic process and outcome of treatment
(see Table 4.3). The couples describe in their own words what they perceived as
helpful and unhelpful aspects of therapy that may have influenced their level of
satisfaction with the therapeutic experience (see Table 4.4). Finally, the columns
in Table 4.5 with quotes from the couples regarding goals in therapy corresponds

to the first research question as it provides the partners values (i.e., staying in a

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marriage), and to the second research question as it also relates to dynamics in
therapy between the therapist and the couple (i.e., deciding on goals) (see Table
4.5). The description of couples’ definition of a healthy intimate relationship also
relates to the first research question as it presents the couples values and
beliefs.

As participants describe their cultural background and values held by their
families of origin, they mainly express how their parents valued or devalued
therapy, what were the expectations, and how it affected them. For example,
when Edna states that therapy became a priority in their lives, she explains that
she wanted to keep the marriage without compromising her own needs. She
was troubled by the fact that her relationship with Ed was affecting their children
negatively. By attending therapy she actually went against cultural traditions and
against her own family’s beliefs. Ed on the other hand, was caught in between
the old generation’s values and realizing that the relationship needed some
changes. He was a little reluctant at the beginning, but as things progressed in
therapy, he began to feel more comfortable and reported progress.

Moreover, participants reflect on the role of the therapist and the
therapeutic environment as being salient in their experience with therapy and
outcome of treatment. For example, Chris and Christina view their therapist as
being non-judgmental and treating them equally. Chris feels comfortable with the
therapist in spite of the fact that the couple initiated therapy because of his

outside affair. Christina describes the therapeutic milieu as a safe place to talk

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about different issues with the therapist being a mediator. In spite of the small

number of sessions (6) they report making some progress.

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Table 4.2
Influences of Demographic factors, Culture and Family of Origin on Couple’s
Perception of Therapy

 

Demographic. Cultural and Family of Origin Influences
Themes: (1) Level of education and income; (2) Presence of children; (3) Transgenerational
experiences with family of origin; (4) Previous individual counseling

 

Couple

Name

 

No. 1

Chris

”AA people are still attached to church”
Attended couples’ therapy in the past

 

Christina

“The priest is the Couple's therapist”
“Mom has seen the local priest”
“Siblings have not been [to therapy]"
Attended individual therapy in the past.

 

Therapist

They are 'a highly educated couple who seemed open to being involved in
psychotherapy...For male partner, who is African American, generally couples' therapy is not
encouraged.”

 

No. 2

Kyle

“I guess not [no relation between economic status, level of education, or any other such
factors”

“Mom did go to counseling, but no one ever talked about marriage counseling.”
Attended couples' therapy in the past

 

Karen

“There is no relation [between economic status, level of education, or any other such factors].
”I have 2 little children, what am I going to do?”

”There was never an issue [family or cultural] about us attending couples’ therapy...My Mom
thinks it's a good idea, and so does my dad, but he doesn't know about this.”

Attended couples' therapy and a parenting workshop in the past.

 

Therapist

Demographic factors “Does not appear to be [any influence].”
Cultural view ”especially for male partner, generally looked down upon.”
Family of origin ”Not aware of either any support or discouragement.”

 

No. 3

Don

”Being of Jewish background makes us more willing to seek out therapy.”

“The kids, they realize that us being in counseling is helpful. It’s reassuring for them...Anything
is better than divorce and you should try everything to fix the marriage.”

“My parents were the old school. Marriage counseling was not a consideration; you take care
oftheproblern,whatyoudon’tresolveyouignore.”

Reported some experience with ind'widual therapy.

 

Donna

‘InterrnofbeingJewishandhavingtheeduoationandoccupation I havemakestherapya
positive thing.”

“Our 3 children, believe they're very happy that we are in counseling because there's nothing
worseforthemthanseeingtheirparentsfacingadivoroe. ltmustbereassuringtothemthat
we are working on issues.”

“I don't talk to my parents much about it. I'm sure they would support me with this. There’s
nothing wrong with this.”

“Forrneittooka lotbecausel'malittleafraidoftherapy... ittumedouttobeagoodthing.”
Attended individual therapyin the Jest.

 

 

 

Therapist

 

“Individuals from the Jewish faith are pretty open minded about therapy.”

”I know she discussed it with her children and feels that they are ok with it because it means
that their parents are trying to resolve issues without resorting to divorce.”
‘Donmhadherownpersonalissuesamperceptbnsmathadsmieimpadmhwshe
opened up in therapy.”

 

125

 

Table 4.2, cont.

 

Demographic, Cultural and Family of Origin Influences
Themes: (1 ) Level of education and income; (2) Presence of children; (3) Transgenerational
experiences with family of origin: (4) Previous individual counseling

 

Couple Name

 

N0. 4 ‘I am from a mixed culture.” ”I feel the same as her.”

”I believe that the more educated you are, the more income you have, the more accepting of
therapy you will be.”

Parents: ”they were pretty open-minded about it.”

Attended individual therapy in the past.

Tim

 

Cultural influences: ”there is no view one way or the other, so there is no influence.”

“I don‘t think that my education, economic status, or any of that makes a difference for me.”
“The children know that we are in therapy; I told them that we want to better our relationship
and to better our relationship with them...0ur kids understand it.”

”Our son, he's 11 he ...was very nervous when we fought. He was afraid that we'd get a
divorce. He feels much more secure now, he understands that people do have arguments...
and it doesn't mean that they want to divorce each other.” ”Therapy is a positive thing...”

”I come from a dysfunctional family, my father was an alcoholic and it created many problems

 

 

g in the family. My kids saw all this.”
5 Attended individual and couples’ therapy in the past.
E .
In their culture couples’ therapy is ”generally accepted.”
.‘2 Family of origin ”Not aware of either any support or discouragement.”
t!
0
1:
5.
N05 Cultural background: Ed confirmed what Edna stated about their culture.

Confirmed what Edna said about money and seeking out therapy.

I had my own little issues with my father...Things are also [as in Edna's family] pushed aside
and ignored.”

“ My father says about therapy that you need to be strong and take responsibility and not
blame anyone for you problems.”

Attended couples‘ therapy in the past.

Ed

 

Cultural background: I think it depends on the generation. Our parents and their generation
were in denial about any issues that they might have had. They felt it was a weakness to talk
about problems and going to therapy. I don't have a problem with it

“Not having money would not stand in the way of getting therapy because it was an important
issue that needed to be dealt with.”

”When my brother went through a very traumatic incident, and he needed counseling, my dad
told him ”you'll be ok, don‘t worry, it’s ok, ” dad was almoa ashamed. It was more like he
doesn‘t need it, he’s strong, he can deal with it, and it was not allowed to talk about it.”

[My uncle] had a serious breakdown in his teenage years and he saw a therapist... they
thought about him that he was weak, a little crazy. It was considered a weakness to get
help...”

”We don‘t tell anyone in the family about us being in therapy. I feel very good about being in
therapy.”

Attended individual therapy in the past.

Edna

 

 

“I know they discussed in several sessions their children having to witness their arguments.”
”...Some family members shy away from therapy, but this didn’t seem to be a problem for Ed
and Edna. Actually, it was less of a problem for Edna than for Ed. He had to worm up to the
idea, and after he did he was completely fine with it.”

Therapist

 

 

 

126

 

Table 4.2. cont.

 

Demographic, Cultural and Family of Origin Influences
Themes: (1) Level of education and income; (2) Presence of children: (3) Transgenerational
experiences with family of origin; (4) Previous individual counseling

 

Couple Name

 

No.6 ”Definitely with education you get more open...The more knowledge you have the more likely
E you are to go to therapy.”
a “My parents too are open minded about it.”
'0 . - - n
< Personally, everyone can use rt at one pornt or another...

 

“Education and income area factor... In some [African American] families depending on the
income level and education level, if it’s higher they are more willing, but then...people who
don‘t have also go to therapy...”

 

 

a “My parents have been in therapy before and took my sisters, they think it’s a positive thing...”

2

E

<
In the African American culture ”couples' therapy is generally not encouraged.”
Family of origin ”Not aware of either any support or discouragement.”

E

Q

‘3

0

55

 

 

 

127

 

Table 4.3
Influences of Therapist Characteristics & Therapeutic Milieu

 

Couple

Name

Therapist Characterlsties Themes and
Therapeutic Milieu
(1) Fairness: (2) Free of biases: (3) Relaxed demeanor/laid back; (4)
Partners treated equally; (5) Addressed the problem in a comfortable way:
safe to talk, non-judgmental, non-threatening;

 

No. 1

Chris

”Not taking sides, very good in this regard.”

”has control over the session; he manages time and talks well.” "

”He's non-threatening, sessions have a free-fon'n style.”

”He doesn't dictate what should be talked about. He doesn‘t have an agenda.”

”He addressed presenting problem in a comfortable way.”

”He’s good at picking up on body language.”

”He cuts me off sometimes too quickly. He‘s good at picking up on body language. He stops me
actually because he's got an idea.”

”He's pointing out things, gives a lot of directives regarding how to listen and how to talk.”
Did the therapist show flexibility/i ”Yes”

Did the therapist intervene appryriately most of the time? ”Yes”

 

Christina

”He's in the process of understanding, hasn't learned yet. because haven’t been her so many
times.”

“He‘s nonjudgmental”

”Evenhanded”

”It was helpful to talk about different issues in a safe setting with a mediator.”

”He‘s very adaptive and non-threatening.”

Did the therapist show flexibility? ”Yes”

Did the therapist intervene appropriately most of the time? ”Yes”

 

Therapist

”Each partner was treated fairly. Did not take sides. Framed problem in a relational manner...”
Biases: ”Men tend to be less open and involved in the psycho-therapeutic process.”

Flexible, appropriate interventions.

Style: ”Being laid back seemed to fit with their [couple] style.”

Addressed the problem in a comfortable way. ”Yes, issues of affair - supported her, but was
able to help the couple see that there were relational issues...”

 

No. 2

Kyle

”Non-judgmental”

”Same” [as Karen - liked that the therapist was not stiff and laid back]

”I was a little uncomfortable because ] felt uncomfortable. [Because of my issue)”
Addressed the problem in a comfortable way.

”Maybe sometimes he might have taken sides with her.”

Did the therapist show flexibility/2 ”Yes”[with time and locations]

 

Karen

”ldon‘tseeanylookingdownonbecauseofthesituation.

Brought the man's point of view, but withom disregarding my point of view.”

”He understood more where Kyle was coming from because he's a man, and he tried to bring it
to my attention so I can be more understanding... It was comfortable.”

”Non-judgmental”

”I liked that he wasn‘t stiff and laid back.”

”I was fuming and was a rambling fool and my thoughts were ”help me” and I didn‘t care who
was around. It was comfortable.”

Did the therapist show flexibility/.7 ”Yes” [time and location]

For the most part, did you feel understood by your therapist? - ”All accept for the pregnancy
when he [therapist] decided to terminate.”

 

 

 

Therapist

 

Fairness: ”I tend to frame problems in reciprocal, interactive terms.”

Biases: ”Men tend to be less open and involved in the psycho-therapeutic process.”

Flexible, appropriate interventions.

Style: ”Being laid back seemed to fit with their [couple] style.”

Addressed the problem in a comfortable way: ”I generally allowed the male partner to focus on
his personal problem as he saw how it negatively influenced the marriage.”

 

128

 

Table 4.3, cont.

 

‘ Couple

Name

Therapist Charaderistics Themes and
Therapeutic Milieu
(1) Fairness; (2) Free of biases; (3) Relaxed demeanor/laid back; (4)
Partners treated equally: (5) Addressed the problem in a comfortable way:
safe to talk. non-judgmental, non-threatening;

 

No.3

Don

”Very neutral overall”

”Careful about not taking sides.”

Therapist‘s style: ”Very laid back, relaxed, ”trying to help” kind of attitude, low key, very
compatible with my personality.”
”The therapist is very objective, that’s very reassuring.”

Expressed his amazement with the therapist understanding him even though she ” doesn’t know
everything about me.”

”She made me aware of things, and helped me put closure on them.”

”The therapist is very objective, that's very reassuring, she always encourages us to do our
own little reality checking.”

”I can’t have things presented to me in a ”nice” way because then I don’t feel I need to make
any changes.”
Appropriate intervention - ”Even when I didn’t understand the purpose of a certain intervention,
she made me aware of things, and helped me put closure on them.”

 

Donna

”The therapist is supportive of US.”

”I think the therapist treats us equally, working on bringing us together.”

Therapist‘s style: ”Very objective, encourages us to look at the whole picture and work on the
relationship.”

”I don't like to open up to others and the therapist has been instrumental in that respect.”
”The therapist is great...really liked. . . have a conversation like we had in session.”

Felt understood? - ”Yes”

”She is flexible about time, and with the way she helped us think.”

 

Therapist

”I always try my best not to take sides and to treat partners fairly, and I believe this is the case
with this couple.”

”I feel that all three of us to some degree are pretty laid back.”

”I addressed the issues with this couple in a comfortable manner. They are a little different
fromoneanother. Heneedsalittlepushtogethimalittlemoremotivated andareminderto
getbackontrack,andsheneedstofeelthatthisisasafeplacetoexpressherself.”

 

No. 4

Tim

”He’s fair.

”Maybehejustpointsoutthings [whenhetellsmewhatlneedtodo], bringsthern to my
attention.”

”It's [therapy 8. the way the therapist addresses issues] pretty comfortable.”

”We have a referee.”

Addressed the problem in a comfortable way - ”Yes...He is non-judgmental and doesn‘t point
fingers, you can say anything that comes to your mind and it's ok... because he's not
shocked...”

”He pretty much treats us equally.”

”We brought the kids one session and he said, ”Oh fine, that's ok.”

Confirmed Theresa's response ”He hears us...".

Appropriate intervention” He helps us understand the difference between us, and he lets us
come up with our own solution.”

Therapist's style - ”I think he‘s a little laid back, and I’m more aggressive at fixing stuff. If there‘s
ajobtobedone it needstobedone.”

 

 

 

Theresa

 

”I feel that he treats us fairly

”He addresses both of us and includes both of us”

”I feel he hears us and what we bring to the table.”

Addressed the problem in a comfortable way) ”His wording... He is non-judgmental and doesn‘t
point fingers, you can say anything that comes to your mind and it's ok.”

Appropriate intervention - ”We learn how to say things to one another, and how to do things in a
different way.”

”He [husband] is more ”I get the point lets go on”

Therapist's style ”I like going more in depth with things, I like to talk more about certain things”
”It took us a long time to get there and it will tale more than 6 sessions to work on things.”

”he asks ”what if you've done this?”

Was the therapist flexible in meeting their needs ? ”Yes”

 

129

 

Table 4.3, cont.

 

Therapist Characteristics Themes and
Therapeutic Milieu
(1) Fairness: (2) Free of biases: (3) Relaxed demeanor/laid back; (4)
Partners treated equally: (5) Addressed the problem in a comfortable way:
Couple Name safe to talk. non-judgmental, non-threatening;

 

Fairness: ”Yes, I treat each partner fairly - I didn't take sides.”

Biases: Biases: ”Men tend to be less open and involved in the psycho-therapeutic process.”
Flexible, appropriate interventions.

Style: ”Being laid back seemed to fit with their [couple] style.”

Addressed the problem in a comfortable way. ”Yes, problems were refrarrred in an interpersonal
context and there was a non-blaming position with each partner.”

Therapist

 

N0. 5 ”The therapist did not take sides at all, which made me feel more secure and relaxed.”

”At first, I felt she might take her [wife‘s side, but she didn‘t. She took my side, then took my
wife's side, so it‘s not like it became the two of them against me.”

”I was concerned at the beginning because I didn’t know the therapist, so I felt a little
uncomfortable. ..After a short time it felt easier."

”Her [therapist] knowing how and when to intervene, how to address certain issues without
making you feel bad about yourself. I feel understood.”

Addressed the problem in a comfortable way - ”She [therapist] approached me without hurting
my feelings...And she knew exactly what to say to get to me and make me understand what I
was doing wrong and made me realize what I can do to make the situation better for me and
everyone around me, it made complete sense.”

Ed

 

”She listened to both of us equally, treated us fairly, and made some suggestions that seemed
fair.”
”Itfeltlikenowlcantakealoadoff...lfeltthatthetherapistwasnotlooldngdownonusor
judging us.”

”He [husband] needed someone softer and calmer and more laid back, and she [therapist] is all
that...l can adjusttoanysituation,orperson, soeveniflwantamoredirect person, I canwork
with more laid back personality style.”

Addressed the problem in a comfortable way - confirmed what Ed said

Edna

 

”I normally do not take sides when I'm dealing with couples, and I always try to treat everyone
fairly. I believe I did it with this couple as well.”

”There was openness, mutual respect, and a maturity level on everybody’s part.”

”I just tried to remain non-judgmental, to listen to both of them, validate them when needed, and
normalize their feelings. And, of course, I intervened when necessary.”

Therapist

 

NO. 6 ”I think he's real fair... He doesn't take sides, listening to both sides and being open.”

Biases: ”We come from two different worlds...there were times when I expressed myself with a
lot of vulgar language...and he made a statement about it...l was raised on the streets...he
[therapist] has style and class.”

Flexibility: confirmed with a nod of the head what Amanda said.

Felt understood: ”there were times when he totally understood me, but I have moments when no
one understands me, maybe it's the way I express myself.”

Appropriate interventions: ”He keeps me focused.”

Therapist's style: ”... He's very patient, he always brings you back to the center...compliments
what I need.”

”Non-threatening.”

Adam

 

 

”He’s fair and very objective.”

”A good active listener...and tries to make us see what we are actually saying...”

Biases: ”Not for me.”

F lexibrlity: ”He's very versatile about how we do things...whatever works for the situation.”
Felt understood: He‘s an active listener, he paraphrases...”

Appropriate interventions: ”When we bicker he brings us back and refocuses us...”
Therapist's style: ”He's style is very good, beca7use he's very laid back and he‘s confrontive
when he needs to be...”

”Non—threatening.”

Amanda

 

 

 

130

 

 

Table 4.3, cont.

 

Therapist Characteristics Themes and
Therapeutic Milieu
(1) Fairness: (2) Free of biases; (3) Relaxed demeanor/laid back; (4)
Partners treated equally: (5) Addressed the problem in a comfortable way:
Couple Name safe to talk. non-judgmental, non-threatening;

 

Fairness: ”...tried not to take sides.”

Biases: Biases: ”Men tend to be less open and involved in the psycho-therapeutic process.”
Flexible, appropriate interventions.

Style: ”Being laid back seemed to fit with their [couple] style.”

Addressed the problem in a comfortable way: ”It seemed that Adam sometimes felt there was

too much focus on his substance abuse and not enough focus on changes that Amanda needs
to make.”

Therapist

 

 

 

 

131

Table 4.4 Themes of Helpful and Unhelpful Aspects of Therapy

 

Couple

Name

Helpful Aspects of Therapy
Themes: (1) Active listening; (2)
Communication skills;

(3) Solution oriented;

(4) Homework assignments

Unhelpful Aspects of Therapy
Themes: (1) Lack of structure (2) Lack of
direction; (3) Lack of specificity; (4) Lack
of assertiveness

 

Chris

”Concrete solutions and tools, helping to
oornmunicate better”

(2)(4) Want” more tools and- concrete
communication exercises.

”As a couple we tend to repeat the same things over
and over..The session itself should be used to
control communication”

 

Christina

”To talk about different issues in a safe
setting with a mediator

”Therapist can actually be more helpful
by seeing the negative atthe session”
Want more ”exercises. .homework
assignments.”

 

Therapist

”Communication training and problem
solving, re-establishing trust' in the

ordertorecoverfromtheaffair.”

 

Ky Ie

”Bringing the situation to the forefront
made me realize I did something wrong”
Want more ”more homework to try and

 

Karen

work at .

”I do feel that today I can communicate
better.”
Want more: Frequency ”I would have
liked to see him more often, once a mk,
not every other week."

“The initial reason why we came was pushed aside.”

 

Therapls

”Communication tralring, increasing
husband

 

No. 3

Don

”laMaysguessirirhatothersthlnkandl
leamedtorestrainit.. Servedlo'ncrease
awafrerrem
Beirg‘WabletohorrewyspeakMrat'son
yourmind, anddiswssthingslhatyou
normalyavoid”

 

Donna

ToseelDon]wlththegoodandthebad,
thepersonlfell'nlove
with. .Communicatlonsklls; rrryroiaen

”lwouldiketohavemoreconvarsatlons
inoursessionsandworkonreallty
checking.”

 

 

 

Therapist

 

”Itl’rinktheyactuallybeneftedfromthe
factthatthisiaaplacewheretheyare
almdtotalkaboutthlngs.”
”lalsothlnkthatpracticlng
communicationsklllsweshelpful'

 

 

132

 

Table 4.4, cont.

 

Couple

Name

Helpful Aspects of Therapy
Themes: (1) Active listening; (2)
Communication skills:

(3) Solution oriented:

(4) Homework assignments

Unhelpful Aspects of Therapy
Themes: (1) Lack of structure (2) Lack of
direction: (3) Lack of specificity: (4) Lack
of assertiveness

 

Tim

”Getting stuff out in the open. We have
an houronceaweektojusttalk. Itforces
us to have open communication once a
week

It' s free form and I need structure and goals, and a
time frame. Now is the time

”I would like to see him be direct with us; tell us
whatiswrongu ...andwhattodo .ergofast

”I think he can be more specific. I think we are still in
the ”get to know you” sessions, and at this point we
can move forward.”

”If he was a little more assertive.”

 

Theresa

”l'mhappywiththesessionsandhowhe

”Heasksustocorneupwithasolution, if
wewould have handled things
differently.”

”He gives us homework everyweek for
theweek.

”Lack of structure” — confimied what fim said

 

Therapist

”Communication training, working on
emotional closenessand physical

 

Ed

”Shehelpedmetobecalmer,more
aware,abettaridener,andhavemore
'lleamadtorelatebettertomywife.”
”ldon‘tthinkweargueasmuch, lthink
bothofuslistenmoraanddon'tjump

 

Edna

 

”Shegaveusinput; loolstodealwilhthe
situations... useful'nputaid

view" .helpedusundarstandvmypeople
saywhatthayaayanddowhuthaydo,
helpedusmderstandeachothermd
realizethatirvearenotenemiesandthat
weeachhaveourownbaggagefrunour
farniliesandotherskuationsandithas

 

 

 

Therapist

 

”Discussinglssuesrelatedtofamllyof
originandhowtheyat'fectthecouple

Settingboundarieswlhothers.”

 

 

133

 

 

Table 4.4, cont.

 

 

Helpful Aspects of Therapy Unhelpful Aspects of Therapy
Themes: (1) Active listening; (2) Themes: (1) Lack of structure (2) Lack of
Couple Name Communication skills: direction: (3) Lack of specificity: (4) Lack
(3) Solution oriented; of assertiveness
(4) Homework assignments
No. 6 ”[Therapist‘s] open mindness... Look at ”After sessions I‘m tired, I'm emotionally drained.”
the situation from a different
angle...someone to reveal my secrets to
and let it die.”

Be able to ”leave therapy sessions and
feel the sense of oneness...be Ies
negative...more bonding.”

Adam

 

”Get a sense of relief...Being able to ”I don‘t see where it hasnt been helpful.”
talk...Get feedback...lt's a safe place.”

 

 

§ ”I wish he was available more often...”

(0

E

<

a ”Communication training and problem [Therapist] felt too much time was spent on his
a solving.” substance abuse problem.”

i

.C

'—

 

 

 

 

134

Table 4.5 Goals

 

 

 

 

 

 

 

 

 

Couple Name Relational Goals Individual Goals Setting Goals Goal
Themes: (1) Avoid Themes: (1) Themes: (1) Attainment
Divorce; (2) Improve 'Emotional Partners Themes: (1)
Communication: (3) Regulation; together. (2) Attained; (2)
Improve Intimacy (2) Intimate Behavior Partners with Progressing;

Therapist: (3) (3) Score
Individually;
(4) Implicit

No. I “Stabilize the relationship" ' Learn to be civil to each 'We didn't 'We are working
“Be able to talk to one other" formally talk toward it."
another...get an "Try to salvage some kind about goals .He Score “3'
understanding of why of friendshi [therapist] would
we'reatthepointwe‘reat' isten.pickoutof

what we WM
say ”wk on
Insightful and
.9 able to focus on
5 things we need to
work on.‘
“Get sorneunderstanding “...Bemorecifltoone ‘Werekindof "Wearenot
g why we can't get along another.‘ implicit.‘ exactly where it
79‘ t.ogether.'. “Discussion of the affair, was at the
5 'Be able to communicate why it took place " beginning.‘
more effectively' '...Salvage Score '3'
relationship'
_ “Restore trust and Chris': “Decrease intensrty 'Both [couple and Score: '8'
.3 closeness.” of conflicts.‘ therapistl"
I! Christina's: 'Increase
g couple time and emotional

N0. 2 'Staymarried' ‘Trust, tellthetruthinstead 'lguessnot
"Work on the trud of what I did." [attained].
thing... .andthesituationof becausewestill

someone else. Try have the trust
to enioy her compmy issue.“
0 more.“ Score '6'
I?
'Wantedthemaniageto 'Gettingthrmghmyanger ‘Atthellmethe
besaved...havingtrustin angerhad
my husband' "Wantedm‘ISt to know for subsided through
myselfisitmthitornot.‘ therapyandtrust
§ “Knrwving why.” was building up
Q said I will never
fhd om why '
Score '5-6‘
“Improve communication Kyle‘s: “Improve 'Both [couple and "Reldionshlp
increase couple time. parenting.‘ Address therapisf'] generally
improve parenting.“ personal problem that is improved,
affedhg the marriage. terminated
Karen's: “Feel less treetment.‘
is depressed.” Score: '7'
‘a
E
No_3 'Makeitbetterand 'Togetmoresatisfactron 'Neverformally ‘lminthe
stronger.“ as an individual. Get talied with her
i: validatedintermsofsell [Donna].didit wanttobeinthe
8 womanabemom myselflsetmy rightdirection.‘
' ' Score ‘6'
to the situation.‘

 

 

 

 

 

 

135

 

Table 4.5, cont.

 

 

 

 

 

 

 

 

 

Couple Name Relational Goals Individual Goals Setting Goals Goal
Themes: (1) Avoid Themes: (1) Themes: (1) Attainment
Divorce; (2) Improve "Emotional Partners Themes: (1)
Communication; (3) Regulation; together; (2) Attained; (2)
Improve Intimacy (2) Intimate Behavior Partners with Progressing;

Therapist; (3) (3) Score
Individually;
4 I ' '

N0. 3 “Make it better and "To get more satisfaction "Never formally “I'm in the
stronger." as an individual. Get talked with her process, you

c validated in terms of self [Donna], did it want to be in the

0° worth, and be more myself, I set my right direction."

content.” goals according Score "6"
to the situation."
“I definitelyce didn't want to “To be more intimate with Together with "The resentment
get a divor him Don level has gone
“Having more fun Do fun things down...it‘s a
tf‘ogether together process and it‘s

«I '...Talk to one another, getting better "

E and share with one Score '3"

0 another."

a
'Donnawasveryclear ‘Ibelievehewasleaning ‘Theyboth 'Theyhavesome
aboutnotvrantingtheir moretowadhisown wantedtosave worktodo.‘
relationship to end up in a needs being met' in the the relationship Score "3" or '4"
divorce relationship. being so i became the
“[Donna] wanted to spend validued. ' primary goal"
morefuntimetogetherwith ‘Ithinkhehad

E Don." his own agenda.

'0. 'He seemed to want the and he would

§ relationship to be stronger, bring up topics

,5 to be able to overcome any that were
crisis.“ completely

unrelated to the
reason the came
to ..

N0. 4 “Instead ofbeing ‘Learnthetoolsofhowto "metherapistis 'Therearegood
adversariest.obeateam beintimate' stillgettingto daysandthere

them 'so are bad days in
we didn‘t talk term of our
aboutgodsyet' behavior. ...We
are more
conscious about
it."

E Score 5'
'[Didlnctwanttoendupin ',Dealwithmytemperwith Decidedongoals '[llfeelweare
adivoroecourt." myshortfuse.everything onourown. getting
“Wantedtocommunicate isan emergency. lowermy '
better." stress level. not to take Score “4'
“Become intimate ‘ so

3 our physical Intimacy, 'lnteract betterwith my

9 improve our real husband and kids Learn

g intimacy, tobeequal,and tokmirrmyself;whu
become one." makes you tic."

“Increased emotiond and Tim's: "Decrease use of ‘Both [couple and '[T he] couple
semal closeness " .' therapist] generally feels as
Theresa's 'Stabilize [her] if their
relationship has

_ improved,

-3 communication is

g better.[ there are]

‘5 fewer conflicts.‘

Score: “6"

 

 

 

 

 

 

136

 

Table 4. 5, cont.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Couple Name Relational Goals Individual Goals Setting Goals Goal
Themes: ( 1) Avoid Themes: (1) Themes: (1) Attainment
Divorce; (2) Improve 'Emotional Partners Themes: (1)
Communication; (3) Regulation; together; (2) Attained; (2)
Improve Intimacy (2) Intimate Behavior Partners with Progressing;

Therapist; (3) (3) Score
Individually;
(4) Imgicii
NO. 5 “Communication, “Listening better before Confirmed what “This is a ladder
listening..." you say anything." Edna said and we are
climbing up."
1:! Score ”7'
m
'Iwasatapointwherel 'Quitworryingabcutwhat 'Shehelpedus 'lthinkit'sa
was not willing to they [family members] t , we working process."
compromise my life think and say... brought up the Score '7'
anymore. .we were Issues we
arguing and yelling In front wanted to work
thekids. .there was no on '
cornmunication...we didn't
understand each other."
”Listen to one another
without making
2 assumptions or guessing
3 what the other wants or
feels...“
“Strengthen their “They are getting
relationship“ ready to
E “Gain better laminate
g communication skills" treatment
IE “Gain an understanding of need
how their families of origin maintenance"
' businessmhow this Score'T'or'a'
m the WW they
mm with one

No. 6 Confirmednotwanting to ‘Geta nethodtostay 'Indlvidua'y’and Accomplished
getadivorce clean...whaweresomeof thenwllh hdividualgoels.
'Tryingtohaveabetter thereasonsandstepsl tt'Ierapist 'Someofthe

E formof ionand tookbeforelwentback thingsl'mstill
2 understanding... How what and used." working on."
I did affected her?" Score: '6‘
“Not get a divorce." '[Was “[I] wanted to see if I can “Individually and "Small steps"
g itlworthstayingim' getbackasenseofself..." then ' Scorez‘4'
a "Will [Adam] stop using?“ world talk with
E us."
or
Gain more closeness and Adam‘s goal: not use Dwided together "Having
argue lea somewhat less
% arguments...
8 more
Score: '5'

 

137

 

Table 4.6

Couple’s General Statements about Couple ’3 Therapy Experience to the

question” “We hope this will educate future generations of therapists. If you were

to communicate the idea of helpful and unhelpful aspects of couples’ therapy to a

beginner therapist what would you, as a consumer, advise him/her to do?”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Couple Name

No. 1 Chris “Be non-judgmental.”

Christina “Don’t take sides, listen, offer solutions based on others’ research
of working with couples."

No. 2 Kyle “Be honest. Talk as you are talking to a person not to a doctor.

Karen “Don‘t take sides, got to walk the fence, be laid back.”

No. 3 Don “People are different and couples are different, and the therapist
has to tailor the treatment to fit each couple.”

Donna “Agree with a lot of Don said. Everyone is unique.”

No. 4 Tim “I think school prepares you right, some people get it and some
don't. Personalities don't always mesh [therapist & client]. You need
to find clients with whom you mesh. You need to feel comfortable.
Find the right therapist for the right client. Do the best you can.“

Theresa “Don‘t dismiss anything the couple says.“

No. 5 Ed “Be patient with your clients.“

Edna “Give each person the opportunity to say everything they have, so
there is nothing left unsaid and there is no misunderstanding about
what they think and feel about the relationship and other things that
are going on, otherwise, it’s not going to work. It is not easy to
come here so take advantage of the opportunity.“

No.6 Adam “Be patient and be caring about his clients, have a true concern and
really want to see them becoming successful and not only be that
way but to really be able to communicate, and be able to verbally
say and do what needs to be done. And, you are better of if they're
married so they have their own experience.“

Amanda “I agree about being carrying, those kind of things do matter, let it

 

 

be more than a job, be able to be empathic and understanding of
each person’s concerns and problems. Have experience.

 

I38

 

Answers to Research Questions

Research Question #1: How does the eco-system influence client’s level

of satisfaction with couples’ therapy and with outcome of treatment?

Sub-Research Question #1. 1: What are the eco-systemic(sociaI/structural

environment) influences on client’s level of satisfaction with couples’

therapy and with outcomes of treatment? And, Sub-Research Question
£21: How do client’s demographic aspects influence client’s level of
satisfaction with couples’ therapy and outcome of treatment?

Two of the themes that emerged for this question seems to be a strong
indicator of having influence on participants’ perception of therapy and its
outcome. The first theme was common for five out of the six couples and it
relates to
. Presence of children: Unrelated to Integrative Couple’s Therapy or to

therapist’s characteristics, the presence of children at home seems to

have a significant influence on how willing parents are to seek couples’
therapy. There is a sense of parents not wanting to emotionally hurt their

children and allow the couple’s interaction to affect them negatively (i.e.,

arguing, fighting, maintaining distance). Thus, children in the household

present a motivating factor to seek out therapy. Five of the six couples
had children at home and at least one partner of each of those couples,
the wife in four of the cases, expressed their feelings about the
importance of couples’ therapy concerning the well being of the children.

Don in Couple #3 was the fifth participant who had commented on

139

children needing to be reassured that their parents are taking care of
issues between them. The couple that did not have children naturally did
not point this out to be a motivating factor in their decision to seek out

therapy.

The second strong theme that emerged and that was common for all six couples

is

Previous counseling experiences: All participants reported being in some
form of therapy in the past. This may be another aspect that may present
a contributing factor in helping participants be more accepting of the
therapeutic experience. Eight participants reported being in couples’
therapy in the past, two reported being in family therapy in the past, five
participants had individual counseling, and one mother attended a
parenting workshop. It is quite possible that having a previous therapeutic
experience removed the nervous anticipation of the unknown and made

the current process more familiar and thus, more easily acceptable.

The other emerging themes include:

Education and income level: This factor may have some influence on how
couples perceive their therapeutic experience. In two of the couples both
partners had a higher level of education. One of the couples the
cohabiting couple with no children reported a higher level of income. Don
and Donna (#3) were the other couple with a higher level of education for
both partners. Both partners reported feeling it was a helpful factor.

Amanda (#6) had a master’s degree and he had some college education.

140

Both stated that higher education and higher income level are important
factors. Tim (#4), who only had high school education, asserted that
higher levels of education and income are directly correlated to
acceptance of therapy. His wife did not see any correlation between the
two, as did the other two couples.

Transgenerational experience with family of origin: All couples were aware
of their parents’ view of therapy. Seven individuals reported their parents
as being supportive of therapy, and five reported parental disapproval of
marital therapy or any other type of therapy. All participants had a
positive attitude about marital therapy regardless of how their parents
viewed it. It is intriguing that values in the family of origin, in spite of
normally being a strong element in individuals’ earlier stages of life (at
least until age18), do not always necessarily seem to be claimed by the
next generation. As Edna (Couple #5) reminds us in her narrative “I think
it depends on the generation. Our parents and their generation were in
denial about any issues that they might have had.”

The therapists did not perceive the couples’ cultural background or family
of origin values to have significant influence on client’s perception of the

therapeutic experience.

grb-Reseamflresfion #142: How do values and beliefs of both partners

influence level of satisfaction with couples’ therapy and outcome of

treatment?

141

Direct quotes of partners’ definition of a healthy intimate relationship show
within-case similarities in four of the couples. The emerging themes in those
couples are: friendship, conversing and sharing with one another, love, care,
affection, trust, and other affectionate feelings. The couple that differed in their
definition of intimate relationship was the cohabiting couple. Chris and Christina
agreed that communication is part of the definition, however, the male partner
suggested that in an intimate relationship communication is more difficult, and
the female partner stated that communication in an intimate relationship should
be easier. It is possible that he was relating to the fact that in an intimate
relationship the interaction can take a more emotionally charged meaning. They
also differed on spending time together; he thought that in an intimate
relationship partners spend more time together, whereas, she asserted that there
is a need to balance time spent together and space between the partners.
Interestingly, their therapist perceived their need for time spent together as
reverse from what they reported; wife wants more time together and husband
needs more time alone. Partners in another couple had different definitions but
not contrasting; the wife described it as having respect, loyalty, love and caring,
and the husband thought of it as being one. The one couple that in comparison
to the others is in a more progressive stage of their therapy described their view
of an intimate relationship with words that indicate affectionate feelings and a
comfort level, and the wife also suggested that reciprocity is part of it. The
therapists had similar answers to the couples in most cases. In some cases the

therapist added to what he thought the couple’s definition was. For example, in

142

the case of Tim and Theresa, Tim stated, “In an intimate relationship both
partners care about the other person as much as you care about yourself,”
Theresa suggested “trust, faithfulness, and compassion,” and the therapist
added, “Time spent together as well as individual time apart, joint decision
making is important as well as sexual intimacy.” Even though the definitions are
not the same, they are not necessarily different either. They seem to emphasize
a different part of what could actually be a very similar definition. It is not
apparent that the participants’ personal view regarding intimate relationships is

indicative of any influence on their level of satisfaction with couples’ therapy.

Research Question #2: How does Integrative Couples’ Therapy influence
client’s level of satisfaction with couples’ therapy and with outcome of
treatment?

Sub-Research Question #1. 3: How does their perception of fairness of the

therapist (and other characteristics of the therapist) influence client’s level

of satisfaction with couples’ therapy and with outcome of treatment?

With respect to this question it was expected that therapists trained in
Marriage and Family would know how to approach a dyad in session and how to
deal with the complexities that a couple, as opposed to an individual, bring to
therapy. This study’s findings support this idea. All participants in this study
perceived their therapist as being fair. The therapists also felt that they treated

their clients in a fair manner and did not take sides. The theme in this case is:

143

o Therapist being fair and partners being treated equally: Partners perceived
the therapist as being fair, and not taking sides. They also perceived
therapist as treating them equally. The words and phrases they used to
describe this are: evenhandedly, being neutral, and being supportive of
us, and includes both of us. It is detrimental to the success of the
therapeutic experience; the therapist must treat the partners equally. If
the therapist were to favor one partner over the other, the one less favored
is likely to feel left out and develop resentment not only toward the
therapist, but also to the other partner and toward the entire therapeutic

process.

Sub-Research Question #2. 2: How does implementing the most suitably
fitted therapeutic or clinical process influence client’s level of satisfaction
with couples’ therapy and outcome of treatment?

Participants describing aspects of therapy that were helpful and unhelpful,
treatment goals, goal setting and goal attainment had the following points in
common:

0 Helpful aspects of therapy:

- Communication skills: Eight participants reported the practice of
communication skills to be helpful, describing having less
arguments and a better ability to listen and express themselves.
Another three partners (two of them are a couple) reported being

able to practice active listening with their partner in session and out

144

of session, and becoming aware of aspects related to partner and
self. Those who reported benefiting from communication skills and
active listening skills made repeated statements about it.

- Homework assignments: Five participants suggested that having
homework assignments for the week was helpful. It gave them time
to apply what they learned in sessions.

- Solution orientation and tools: Five participants either reported

- getting concrete solutions from the therapist, or tools (i.e.,

reality checking) or being challenged to come up with a solution,
found it to be a helpful aspect of therapy. Four of the above
participants were among the five that reported practicing
communication skills as helpful.

The above aspects could all be grouped into one as they all describe

concrete behaviors in therapy. Active listening is a component of

communication skills that are also used for homework assignments. All of
these are therapeutic tools utilized to construct a solution.

Unhelpful aspects of therapy: Five participants reported unhelpful

aspects of therapy. One reported her initial reason for coming to therapy

being “pushed aside.” This participant was hoping to gain an
understanding as to why her husband did what he did, and her need to
know was not satisfied. The other three participants thought there was not
enough structure in the sessions. These participants used phrases such

as “the session...should be used to control,” “lack of structure,” “need

145

structure and goals, a time frame, now is the time...be more direct...go
faster, be specific...more assertive.” Tim (#4) was the most adamant
about lack of structure and assertiveness being an unhelpful aspect of
therapy, and his wife, in spite of reporting being able to discuss ”in depth”
different issues and “add on“ when needed, confirmed her husband’s
statement. It is possible that due to the nature of therapy being a helpful
profession, individuals in therapy will have the tendency to think of their
therapist in positive terms, and choose not to see the unhelpful aspects of
it. The one participant who reported some dissatisfaction with lack of
structure in therapy seemed to have honestly believed that the therapist’s
and his personalities did not fit. In his general statement he suggests,
“You need to find clients with whom you mesh. You need to feel
comfortable... Find the right therapist for the right client.“ The husband in
Couple #6 stated as an unhelpful aspect the fact that after sessions he
was emotionally drained. The nature of this experience is such that it
does sometimes produce emotional exhaustion.

Sub-Research Question #2. 3: How do therapist’s demographic factors
influence the client’s level of satisfaction with couples’ therapy and
outcome of treatment?

Participants’ quotes in the narratives provided earlier in this chapter
indicate that only one of the partners perceived their therapist as having
biases. Adam (#6) indicated that the therapist and him were from a

different world, and that the therapist made a comment about him using

146

vulgar language. It is possible that the therapist was setting his own
boundaries in this case. The husband in Couple #5 was concerned that
the therapist, being a female, might take his wife’s side, but he then
reported that his concerns were put to rest. The one therapist in all four of
his cases stated that he did have a bias relating to men tending to be Ies
open and involved in the process of therapy. However, none of his clients
reported to notice this bias. The other therapist stated she did not feel she

had any biases that interfered with the process of therapy.

Sub-Research_Question #24: How does the Integrative approach to
couples’ therapy influence client’s level of satisfaction with couples’
therapy and with outcome of treatment?

The themes emerging for this research question and that were common to

most of the participants include:

Therapist being flexible in the way helshe handled sessions: Nine of the
participants confirmed that the therapist was flexible. For example,
“flexible about time,“ “We brought the kids one session...” And, flexible
about time of the sessions and sometimes location of the sessions. The
participants that did not indicate that their therapist was flexible in meeting
their needs also did not contrast it.

Participants feeling understood by the therapist: Ten participants stated
that they felt the therapist understood them. Some of the words and

phrases used by participants to support this theme include: “He’s good at

147

picking body language,” He understood...where he’s coming from,” “He
hears us... ,” and “I feel understood.“ The one male participant who did
not confirm or contrast this perception is the husband in Couple #2 who
also indicated that he felt uncomfortable, not because of anything that the
therapist did, but rather because of the issue that was brought up and that
had to deal directly with his actions that created a problem in the
marriage. His wife stated that she felt the therapist did understand her
husband, and for the most part understood her; except for when he
decided to terminate their treatment because she was pregnant.
Interventions by the therapist were appropriate most of the time: Eleven
participants indicated that the interventions by their therapist were
appropriate most of the time. The interventions were perceived to be
positive by the participants, and even when husband in Couple #1 stated
that the therapist cuts him off too soon sometimes, he immediately added
that it was because the therapist “got an idea” and therefore the
intervention was actually perceived as being effective. Some phrases
that describe this theme include: “he tried to bring it to my attention...”
“Helped me put closure...“ “Encouraged us to look at the whole picture...”
“Helps us understand the difference between us...“ and one suggested
that the therapist challenged them to come up with their own solution to
the issue they were presenting.

Therapist’s style fitting with client’s style: Seven participants felt that the

therapists’s style fit their own. Three participants liked that their therapist

148

was “laid back” and “not stiff.” The wife in Couple #5 agreed that their
therapist was laid back and felt that the therapist’s style actually fit better
her husband’s style as opposed to her own. However, although she
would like a more direct person she stated, “I can work with more laid
back personality.” The only one who actually seemed to have more
difficulty with the therapist’s laid back style was the husband in Couple #4,
whose answer was consistent with previous statements he had made
regarding wanting more structure in therapy. Other things that were
pointed out as therapist’s style fitting the client’s style include: “has control
over the session... manages time...” “Very adaptive,” “objective,”
supportive of us,” and going more in depth with things...” Finally,
Addressing the presenting problem in a comfortable way: All participants
agreed that their therapist addressed any issue that was brought up in
session in a comfortable way. They used words and phrases that include:
“He’s non-threatening,” Non-judgmental,” “I don’t see any looking down
on,” “Without disregarding my point of view,“ “It was comfortable,” “I don't
like to open up to others and the therapist has been instrumental in that
respect," “Doesn’t point fingers,“ and “You can say anything that comes to
your mind and it’s ok.” Some participants had a little more difficulty at the
beginning of their therapeutic process, but once they became more
familiar with their therapist they became more comfortable. Their initial

uncomfortable feeling was not related to the therapist’s actions. These

149

participants were Kyle (#2) and Ed (#5). Their responses are consistent
with their previous statements regarding their own uneasy feelings.

It is apparent that the therapist addressing the problem in a comfortable
way contributes to a safe therapeutic atmosphere and the therapies being
perceived as treating the couple in a fair way, are conducive to the
therapeutic experience and according to this study are found to be the two
strongest factors that influence the level of satisfaction with couples’

therapy.

150

CHAPTER 5
Discussion
Overview

This study aimed to explore how individuals in Integrative Couples’
Therapy perceive and describe their therapeutic experience and the factors
influencing their level of satisfaction with the therapeutic process and treatment
outcome. Couples’ level of education and income, values inherent in
participants’ cultural background as well as of their families of origin were
explored as possible correlates to satisfaction. Therapist’s characteristics and
therapeutic milieu were also examined to uncover possible influences on
participants’ level of satisfaction with the therapeutic experience.

Six couples who were in an intimate relationship for at least three years at
the time of the study, and who were either attending or attended at least six
session of couples’ therapy with a therapist trained in MFT, using an integrative
approach, participated in this qualitative case-study. Therapists were interviewed
about their utilization of an integrative approach with couples participating in this
study. Discussion of the findings includes the theoretical foundations of the study
with a revised conceptual map, and key findings. The remainder of this chapter
will address methodological issues, limitations of the study, implications for

couple therapists, and recommendations for future studies.

151

Key Findings
Theoretical Foundations

The researcher designed a demographic questionnaire and
craftedinterview questions, and analyzed participants’ narratives and therapists’
responses in accordance with the social environment element of Human
Ecological Theory (Bronfenbrenner, 1979, 1989), and, more specifically, Family
Ecology Theory (Bubolz & Sontag, 1993), and clinical aspects using Integrative
Couples’ Therapy (Lebow, 1987; Pinsof, 1995). Despite family of origin
perspectives about therapy, or cultural values, participants embraced a positive
view of therapy.

The original conceptual & theoretical map, described in Chapter 1 (Figure
1.1), portrays the above theories as having equal weight in the manner they
influence client’s satisfaction with Integrative Couples’ Therapy and outcome of
treatment. However, the findings of this case study do not demonstrate equal
significance of the different elements involved. Specifically, the influence of the
therapist’s characteristics, therapeutic approach, and the therapeutic milieu were
found to have more influence than the ecological systemic factors including:
cultural values, family of origin perspectives, and demographic characteristics
such as education and level of income. Key factors related to therapist’s
characteristics include: (1) clients’ perception of the therapist as being fair; (2)
therapist’s biases (3) partners being treated equally; and (4) therapist’s style the.
Factors related to the therapeutic approach were: (1) using appropriate

interventions; (2) therapist being flexible to meet the needs of the couple and

152

individuals; (3) addressing the presenting problem in a comfortable way and
providing a safe therapeutic environment where clients are able to express

themselves. The Conceptual & Theoretical map was revised to reflect the

findings.

153

 

Clinical Aspects
Therapist’s characteristics/Process

Use of Integrative Couples’ Therapy
Suitable Fit
Safe therapeutic Environment

Therapist's Fairness

 

 

 

 

Family Ecology
Theory (FET)
Social/structural
environment
(Bubloz & Sontag,
1993)

 

 
  
  
  

Client’s Level of
Satisfaction Couples '
With Integrative Coup,“ game's/beliefs
Therapy (Pinsof. 1983. 1994a, 1995; 0UP es
W. 1984.198?) - Perception of
& Outcome of Treatment Fairness

Human Ecology

Theory (Bronfenbrenner,
1 979, 1 989

 

 

 

 

Macrosvstem

 

 

 

Willingness to attend therapy

  

Being open~minded

i

Presence of children
Previous counseling
Education and income

 

  
 

Exosvstem

 

 

 

Chronosystem

 

 

 

 

Figure 5.1 A Revised Conceptual & Theoretical Map

154

The revised conceptual map (Figure 5.1) illustrates the findings relating to
clinical aspects having the strongest influence on client’s satisfaction with
Integrative Couples’ Therapy and outcome of treatment. For example, all
participants perceived the therapist to treat them in a fair way (sub-research
questions #1.3 & #21). The participating therapist also stated that they treated
partners in a fair way by not taking sides. It was expected that Marriage and
Family therapists who are familiar with the complexities related to treating a dyad
as opposed to an individual, would be more able to focus on relational aspects of
the dyad and treat the partners ‘evenhandedly‘. This suggests the importance of
maintaining a relational, balanced approach in treatment to be viewed as fair.

Eleven out of twelve participants perceived their therapist devoid of
biases. Adam, who indicated that his therapist seemed uncomfortable when he
used vulgar language, attributed this to the perception that the therapist and he
came from “different worlds.“ One therapist stated that she believed she was
free of biases that interfered with the therapeutic process. The interview with the
second therapist revealed that he tended to viewed men as being less involved in
the therapeutic process. Taken together, therapists’ biases and participants
perception affected how couples viewed their therapeutic experience.

Using an integrative approach for couple therapy appears to relate to client’s
level of satisfaction with the therapeutic experience and outcome of treatment.
For example, a majority of the individuals confirmed that the therapist was
flexible in meeting their needs, and reported feeling understood by the therapist,

which are core aspects of integrative approach. Furthermore, nearly all

155

participants perceived interventions by the therapist as being appropriate, most
of the time. Even though one individual stated that the therapist interrupts too
soon sometimes, he attributed this to the fact that the therapist had gained
insight into what he was trying to convey to him. Moreover, seven participants
felt that the therapist’s style fit his or her own way of relating. Three participants
liked that their therapist was “laid back.“ There appears to be a slight difference
amongst couples about this observation. It appeared that males in this sample
were more likely to prefer more direct, goal-oriented interventions instead of
relaxed, less focused practices. All participants agreed that their therapist
addressed issues that were brought up in sessions in a comfortable way. They
felt that their therapist was non-threatening, non—judgmental, provided a safe
environment to discuss any issue, and was instrumental in helping clients to
freely express themselves. Two participants reported initially being
uncomfortable because of their own uneasy feelings that were not related to the
therapist’s actions. However, once the process and therapist became more
familiar they reported feeling more comfortable.

It is apparent that the therapist addressing the problem in a comfortable
way contributed to a safe therapeutic atmosphere. The therapist being perceived
as treating the couple in a fair way, and as being free of biases are all conducive
to the therapeutic experience, and according to this study are found to be the

strongest factors that influence the level of satisfaction with couples’ therapy.

156

Other Findings

The key findings of this study suggesting that clinical aspects had the
strongest influence on client’s satisfaction with Integrative Couples’ Therapy were
discussed in detail earlier. Other findings of this study include helpful aspects of
therapy, and treatment goals, and gender related issues.

The findings of this study show that participants generally found concrete
behavioral techniques, such as active listening, communication training and
practice, homework assignments, and specific solutions to be helpful aspects in
therapy. Preparing homework assignments may be viewed as an indicator of the
client’s level of motivation to participate in the therapeutic process. Eight
participants reported communication skills to be a helpful instrument. They found
it to be helpful in decreasing the level of reactivity in arguments and increasing
their ability to listen and express themselves more effectively. Practicing active
listening in and out of session while becoming increasingly aware of feelings
related to themselves and their partner, couples not only improved their
interaction with one another, they also reported gaining insight and a better
understanding of one another. Children also appeared to benefit from these
newly acquired communication and listening skills. Participants reported
exposing their children to healthier interactions, which gave children the
reassurance of a stronger relationship.

Homework assignments were helpful in allowing the application of the
learned skill out of sessions. Other elements of integrative therapy included

receiving concrete solutions for problems or being challenged to generate a

157

solution. Unhelpful aspects of therapy were less significant than helpful aspects,
with less than half of the individuals reporting unhelpful aspects. For example,
Karen was dissatisfied with the fact that the therapist did not provide her with the
reason for Kyle’s behavior. Another aspect, reported by Adam as unhelpful, was
being emotionally drained after sessions. The nature of the therapeutic
experience is such that it does sometimes produce emotional exhaustion. Lack
of structure in therapy was the most reported (three participants) aspect under
this category. For example, Tim felt negatively about the lack of structure in
sessions and assertiveness on the part of the therapist. He would have liked to
see a faster progression in therapy, and more intervention in order to keep the
conversation on track. His wife, Theresa supported him on the one hand, but on
the other expressed her satisfaction with being able to discuss ”in depth“ different
issues. Tim seemed to have honestly believed that the therapist’s and his
personalities did not fit. It is apparent in the general statement Tim made for
beginner therapists where he suggested finding the right therapist for the right
client. It is possible that individuals in therapy would normally tend to think of
their therapist in positive terms, and choose not to see the unhelpful aspects of
therapy.

Therapeutic goals is another aspect relating to the clinical process and the
most suitably fitted therapeutic approach being a contributing factor to client’s
satisfaction with Integrative Couples’ Therapy. Nearly all partners reported not
wanting to divorce one another or the dissolution of the relationship, but wanting

to improve and strengthen the relationship. Some had similar relational and

158

individual goals. For example, Christina stated, for both individual and relational
goals, she wanted to gain understanding to why they were not getting along, and
gain the ability to communicate more effectively. In all cases it appears that
goals were not discussed formally, and that it was more of a fluid process, where
issues were brought up, processed, and tackled. Goal attainment did not
necessarily seem to be the most important factor influencing client’s satisfaction
with the therapeutic experience and with its outcome. All clients expressed
varying levels of satisfaction with the therapeutic process, and only one couple
was getting close to accomplishing the treatment goals. Most couples and
therapists, provided similar or very close, within case, scores for goal attainment.
The findings of this study show that all participants were content with the
progress they have made in therapy. Moving in the right direction and seeing
improvement are motivating forces for clients and therapists to continue their
course of action.

The influences of demographic factors, factors related to cultural values
and perception of therapy and family of origin views of therapy were found to be
less of an influence that initially theorized. It appears that the above factors,
have less influence on how likely clients are to seek therapy or value the
therapeutic experience. For example, all couples were aware of their parents’
view of therapy. Seven participants reported parental support, and five reported
parental disapproval of marital therapy or any other type of therapy. However, all
participants had a positive attitude about marital therapy regardless of their family

of origin views. This could be a result of the general sense of how society is

159

evolving, and the process of change from one generation to the next, as Edna
simply stated that their parents were from a different generation. The culture of
the individuals had even less significance. This could be a result of lack of
diversity in the sample.

Education and income was reported by some of the participants as a
factor influencing their level of acceptance of therapy and how they perceive the
therapeutic experience. Five of the participants, held either a bachelors,
masters, or a PhD. degree; another two had some college education. The
average income was over $40,000 ranging from $30,0005 to over $50,000.

The presence of children in the home and previous counseling experience
appeared to influence the motivation to seek therapy and accept therapy as a
viable solution. Five out of the six couples had children at home. Participants
expressed concern about the negative effect their conflictual interaction would
impose on their children (i.e., arguing, fighting, maintaining distance). For
example, Don and Donna commented on how children need to be reassured that
their parents are taking care of issues between them.

To summarize, findings of these case studies highlight the importance of
children in seeking treatment, as well as previous counseling experiences. The
last factor is likely to promote an open-minded attitude to counseling because
they have some sense of familiarity with the process of therapy and are more
likely to free of the possible anxiety that is associated with the unknown.

Gender difference in how partners perceived their therapeutic experience

was minimal in this study. There was very little disagreement between partners

160

about helpful aspects of therapy. It is possible that because partners were
interviewed together they influenced each other’s views. In future research

interview questions need to be more specific to address this issue suitably.

Methodological Issues

The thought of interviewing couples for a research project was an
invigorating one, as it offers a different angle on approaching couples than what
this researcher is accustomed to as a Marriage and Family therapist. Having the
interviewing skills acquired through many hours of conducting therapy with
couples, this research presented the challenge of embarking on a different
aspect of interviewing dyads. The researcher was preparing to interview
couples for the sole purpose of gathering information without the aspect of
providing the intervention. As it turned out, the interviews went smoothly;
couples shared information related to this study willingly, and eagerly provided
suggestions to beginning therapists. Several times during the interviews the
researcher had to remind herself to stay loyal to the task of data collection and
was able to fight the urge to intervene. The use of audiotapes allowed for a post
interview review and provided a repeated examination of the data with complete
focus on data analysis. It is recommend that other researchers, who are
therapists, and who intend to use interviews as their methodology take into
consideration the need to balance between being a qualitative researcher and a

therapist.

161

Limitation

There are some inherent limitations in this study. First and foremost, the
small sample of this study reduces the ability to make inferences beyond this
population. The intention was to interview between ten to twelve couples and
investigate them in great detail. The process of recruiting the couples was
arduous. MFT therapists were either reluctant to participate in the study or did
not have clients who fit the criteria on their caseload. This researcher then
settled for a sample that would reach a point of saturation and ended with six
couples for this study.

Participants were not representative of the diverse larger population in
terms of race, religion, socio-economic status, ethnicity, and different dwelling
areas. It is therefore, impossible to make generalizations to other couples who
do not have the same characteristics as do the participating couples in this study.
However, this is a qualitative study, and the intention was to gain as much details
as possible regarding each case. The face-to—face interviews with couples and
therapists provided the details needed for this study.

Another limitation was the variability in number of therapeutic sessions
that the couples received ranging from six sessions to over 40 sessions. Having
fewer sessions places some couples in a less advantageous position with
relation to their comfort level with the therapist and their progress in therapy. In
this study this did not seem to influence the level of satisfaction of participants

with the therapeutic experience.

162

Recommendation for Future Research

More research is needed to explore the phenomenon of what influences
client’s satisfaction with couples therapy and outcome of treatment. It would be
beneficial to have a more diverse sample. Couples need to be from different
ethnic groups, different socio-economic levels, different religions, and different
locals. This will allow to gain a better understanding of and a way to compare
how different individuals from different groups perceive the therapeutic
process.Future research should also assess expectations of therapy and the
relationship to satisfaction with couples’ therapy and outcome of treatment.
Utilizing the instrument used in this study, or a modified version of it when
employing it at certain points of the therapeutic progression could help therapist
understand their clients’ expectation, allowing therapists and clients to reach a
better level of comfort and appreciation where there will be room for creativity
and ability to tailor a more suitable treatment plan for each unique couple. It
would be especially interesting to use clients’ recommendations, as provided in
the general statements which participants made in this study, to inform beginner

therapists who intend to work with dyads or families.

Clinical Implications
The clinical implications of this study involve several points. The
overwhelming findings indicating the importance of the therapist’s characteristics
and the therapeutic milieu as influencing client’s level of satisfaction with the

therapeutic experience lead this researcher to consider the following as viable

163

pursuits. First, Marriage and Family therapist need to understand the intricate
nature of treating a dyad as the client unit. Marriage and Family Therapy
programs need to emphasis with students the complexity of treating a client
system that consists of more than one person, stressing the need to monitor the
therapeutic process and maintain balance between relational issues and
individual differences. Treating partners fairly and equally is an essential aspect
of the therapeutic process. If the therapist favors one partner over the other, the
less favored partner is likely to feel left out and develop resentment not only
toward the therapist, but also to the other partner and toward the entire
therapeutic process.

Secondly, MFT programs should introduce to students all family theories
and methods as part of the required curriculum. As part of supervisory
experience, students should be required to utilize different methods in order to
become more secure in implementing them as needed. Additionally, as part of
the supervisory requirements, future therapists should have a certain number of
hours of watching videotapes of seasoned marriage and family therapists
providing therapy to couples and families, use the one-way-mirror to watch
sessions with couples and families, and then discuss the dynamics. It is
essential that students attending an MFT program will have sufficient number of
clinical sessions with couples and families. By gaining practice while in
supervision, future therapist will become more comfortable and better equipped

to provide therapy upon completion of their program.

164

Using an integrative approach requires profound knowledge of the
different theoretical approaches and methods that are utilized by marriage and
family therapists. As suggested by Pinsoff, the integrative approach allows the
inclusion of a large range of human behavior, allows for more flexibility in
treatment of different units of clients, offers an opportunity for more acceptability
and efficacy of care, allows to tailor a unique treatment plan for each client, and
is more easily customized by therapists to fit their own personal style (1995).
Having mastery of the different theoretical approaches and methods provides
therapists with the freedom to address the important issues that the clients
present, and it also creates a comfort level for the therapist to shift from one
theory to another as the situation necessitates. As evident by the findings of this
study, the majority of participants confirmed that the therapist was flexible in
meeting their needs, reported feeling understood by their therapist, and nearly all
participants perceived the interventions to be appropriate most of the time. It is
therefore this researcher recommendation for clinicians and future clinicians to
utilize the integrative approach to couples’ therapy and to integrate clients’
expectations of therapy as a primary step. The therapist needs to recognize the
unique needs of and tailor the most suitable treatment plan for each couple.
Training students in different theories and methods will allow them to gain more
flexibility in shifting from one method to another when a specific case and
situation requires such practice. Considering client’s expectations may relate to

client’s level of satisfaction with the therapeutic experience.

165

Finally, it is vital to stress to students the need to become aware of and
examine regularly their own values, biases, and what triggers them. They need
to be able to set them aside during therapy and not impose them on their clients.
When therapists succumb to their own biases the therapeutic outcome cannot
serve the needs of the clients. The researcher’s final note to future marriage and
family therapists is to explore with clients about their expectations of the
therapeutic experience, and, at different points of therapy, how they perceive the
therapeutic process. Then, this information can be integrated into the treatment

plan.

Summary

This collective case study explored the factors influencing client’s
satisfaction with Integrative Couples” Therapy and outcome of treatment. It
intended to add to the limited literature on this topic. It is hoped that more
qualitative research will follow to explore further aspects of this phenomenon.

Although the range of this study was limited in sample size and diversity,
clinical aspects were found to be the strongest factors influencing client’s
satisfaction with Integrative Couples’ Therapy and outcome of treatment.
Clients’ perception of therapist’s fairness, being free of biases, being flexible in
meeting their needs, using appropriate interventions most of the time, and
addressing the problem in a comfortable way, all elements of the integrative
approach, were contributing factors to the therapeutic process and environment,

and to the resulting level of participant satisfaction.

166

Cultural views and family of origin views on therapy were not found to
have the same influence on participants. Participants embraced a positive
attitude about therapy in spite of how their families viewed it. Education and
income level were found to have some influence on participants, but not
significant enough to make generalizations to the larger population. Presence of
children in the home and previous counseling experience were also found to be
motivating forces in seeking therapy.

More research needs to be done in this area addressing a more diverse
population. Future research also needs to explore how expectations of therapy

influence client’s satisfaction with the therapeutic process.

167

APPENDICES

168

APENDIX A
Interview Guide for therapists’ interviews
Each therapist will be asked to describe specifically how they use an
integrative approach in their practice with couples.
The following questions will apply to each participating couple:
Research Quiestion # 1: How does the eco-system (social environment)
influence client’s level of satisfaction with treatment of couples in couples’
therapy?
fl-Research Question # 1.1: What are the eco-systemic (social/structural
environment) influences on client’s level of satisfaction with couples’ therapy and
outcome of treatment?
Demographic questionnaire: point out things that may influence this couple.
1. What is the relationship between demographic characteristics and
satisfaction with therapeutic experience?
2. What do you know about how this couple’s culture or ethnic group views
couples’ therapy?
Probe: Is it accepted? Encouraged? Looked down upon?
3. From what they shared with you, how do their families (relative, or
children) view couples’ therapy?
Probe: Are they encouraging? Are they against it? Are they supportive of
their decision to seek couples’ therapy? In what way are they supportive:

emotional? Financial? Provided childcare?

169

SAID-Research Question #12: How do values and beliefs of both partners
influence client’s level of satisfaction with couples’ therapy and outcome of
treatment?
1. How do they define a healthy intimate relationship?
Probe: Couples that spend a lot of time together? Apart? How are
decisions made? Does it involve sexual intimacy? How?
S_ub-Resegrch Question #13: How does their perception of fairness influence
client’s level of satisfaction with couples’ therapy and outcome of treatment?
1. Do you feel that you treated each partner fairly during the therapeutic

sessions?

Probe: Do you feel that you took sides? How or how not?

Research Question # 2: How does Integrative Couples’ Therapy influence client’s

level of satisfaction with couples’ therapy?

Sub-Research Question #21: How do client’s demographics influence his/her
level of satisfaction with couples’ therapy and outcome of treatment?

Same questions as in the section related to Human Ecology (social

environment).
fl-Research Qgestion #22: How does implementing the most suitably

fitted therapeutic or clinical process influence client’s level of satisfaction with

couples’ therapy and outcome of treatment?

1. What aspects of therapy do you think the couple found to be helpful or

unhelpful? Why or why not?

170

2. What aspects of therapy did you find to be helpful or unhelpful for this
specific couple? Why or why not?

3. What was this specific couple hoping to accomplish?

4. What were their goals coming to therapy as a couple?

5. What were their goals coming to therapy as an individual?

6. Do you feel they’ve accomplished any of their goals? Why or why not?

7. Overall, scale 1-10, “1”-“not accomplished” “10” “completely
accomplished,“ how close do you feel they are to accomplishing their
goals?

8. How were these goals decided on? (e.g., alone, together with spouse, by
the therapist, or both)?

Sub- Research Question #23: How do therapist’s demographics influence
client’s level of satisfaction with Integrative Couples’ Therapy and
outcome of treatment ?

1. What are your values and beliefs regarding couples’ therapy?

I"

What, if any, biases you have regarding gender, religion, ethnic groups, or
any others?

Sub-Research Question #251: How does the integrative approach to couples’
therapy influence client’s level of satisfaction with couples’ therapy and
outcome of treatment?

1. Do you feel that you were flexible in meeting the couple’s needs?

2. Do you feel that the interventions used by you were appropriate most

of the time?

171

3. How do you feel about your style fitting with who the partners are and with
their style?
4. Do you feel you addressed the presenting problem in a way that was

comfortable for the partners? How?

172

APENDIX B
Interview Guide for Conjoint Interviews
If the interviewee does not provide a complete answer to any one of the
open-ended inquiries, the interviewer will follow with a more specific question to
clarify what she means.
Research Quiestion # 1: How does the eco-system (social environment)
influence client’s level of satisfaction with treatment of couples in couples’
therapy?
Sib-Research Question # 1.1: What are the eco-systemic (social/structural
environment) influences on client’s level of satisfaction with couples’ therapy and
outcome of treatment?
Demographic questionnaire:
1. What is the relationship between demographic characteristics and
satisfaction with therapeutic experience?
2. Tell me how your culture or ethnic group views couples’ therapy?
Probe: Is it accepted? Encouraged? Looked down upon?
3. How does your family (relative, or children) view couples’ therapy?
Probe: Were they encouraging? Were they against it? Were they
supportive of your decision to seek couples’ therapy? In what way were

they supportive: emotional? Financial? Provided childcare?

Research Sub-Question 1.2: How do values and beliefs of both partners

173

influence client’s level of satisfaction with couple in couples’ therapy and
outcome of treatment?

1. How do you define a healthy intimate relationship?

Probe: Do you spend a lot of time together? Apart? How are decisions
made? Does it involve sexual intimacy? How?
Sub-Research Question 1.3: How does their perception of fairness influence
client’s level of satisfaction with couples’ therapy and outcome of treatment?
1. Do you feel you were treated fairly during the therapeutic Sessions?
Probe: Do you feel that the therapist took sides? Do you feel that the
therapist blamed you or your partner unfairly? Why or Why not?
Research Question # 2: How does Integrative Couples’ Therapy influence client’s
level of satisfaction with couples’ therapy?

Suu-Research Question #2. 1: How do client’s demographics influence his/her

level of satisfaction with couples’ therapy and outcome of treatment?

Same questions as in the section related to Human Ecology (social
environment).

Same questions as in the section related to Human Ecology.

S_ub-Research Question #22: How does implementing the most suitably
fitted therapeutic or clinical process influence client’s level of satisfaction with
couples’ therapy and outcome of treatment?

1. What aspects of therapy you found to be helpful or unhelpful? Why or why

not?

2. What aspect of therapy would you have asked to see happen more often?

174

3. What aspect of therapy would you have asked to see happen less often?

4. What were you hoping to accomplish?

5. What were your goals coming to therapy as a couple? List the top 3 with
the most important goal first.

6. What were your goals coming to therapy as an individual? List the top 3
with the most important goal first.

7. Do you feel you accomplished any of your goals? Why or why not?

8. Overall, scale 1-10, “1”-“not accomplished" “10” “completely
accomplished,” how close do you feel you are to accomplishing your
goals?

9. How were these goals decided on (e.g., alone, together with partner, by
the therapist, or both)?

Research Sub-Question #23: How do therapist’s demographics influence
client’s level of satisfaction with Integrative Couples’ Therapy and
outcome of treatment ?

1. Do you feel your therapist has any gender, religion, ethnic groups, or any
other biases? If yes, what impact do you feel it has on the therapeutic
process?

Research Sub-Question #24: How does the integrative approach to couples’

therapy influence client’s level of satisfaction with couples’ therapy and

outcome of treatment?

1. Do you feel that the therapist was flexible in meeting your needs?

2. Do you feel understood by the therapist?

175

3. Do you feel that the interventions used by the therapist were appropriate
most of the time?
4. How do you feel about the therapist’s style fitting with who you are, yours
and your partner’s style?
5. Do you feel that your therapist addressed the presenting problem in a

comfortable way? How?

General statement to the couple: We hope this will educate future generations of
therapists. If you were to communicate the idea of helpful and unhelpful aspects
of couples’ therapy to a beginner therapist what would you, as a consumer,

advise him/her to do?

176

APENDIX C
Demographic Questionnaire

Gender: M F
Age:

Living environment: ElRural El Urban DSuburban DOther

Marital status: [Married DNot married DWidow/er ClDivorced
[:lLiving-together

Race: DCaucasian DAfrican American DAsian American
[Native American EIHispanic ClOther

Religion: ElChristian DJewish DMuslim DOther

Education: ElLess than H.S. DCompleted H.S. Elln college
ClBachelor’s UMaster’s DPhD

Employment: ElUnreported [Full-time [Part-time DNILF

CIRetired
Household size:

Household annual income: D$0-9,999 El$10,000-19,999 D$20,000-
[329,999 El $30,000-39,999 D$40,000-49,999
D$50,000+

# of children in the household: _Under 5 _Under 10 _under 18

_over 18

How long have you been in the current relationship?
How many therapeutic sessions did you attend by now?
Please check all previous treatment or couple’s educational programs

El Individual therapy D Couple’s therapy [I Family therapy
C] Parenting workshop [:1 Premarital counseling

El Couples workshops or seminars

177

APPENDIX D
Eliciting the voice of the client: Influences on client satisfaction with
Integrative Couples’ Therapy
A qualitative study

Informed Consent

The purpose of this collective case study is to explore what factors
influence client’s satisfaction with couples’ therapy. We believe that some of
these factors may include values and beliefs held by you, your partner, and your
therapist, any social support that is available to you and your partner, and the
clinical approach used by the therapist. You are being asked to describe your
experience of couple therapy: your feelings, thoughts, and values regarding
couples’ therapy, and how they influence your experience. Prior to participating
in a conjoint interview (you and your partner), which will last approximately one to
one and one half hours, your therapist will be interviewed, and helshe will be
asked similar questions to those in the conjoint interview. Your therapist will not
have access to your responses in the interview with your partner.

. Your participation in this project is completely voluntary and can be
terminated at any time. You may choose to decline to answer certain
questions. If one partner decides to terminate his/her participation, the
couple unit will be released from further interviewing. You will not incur
any penalty as a result of the above.

0 All information obtained will be kept confidential and all written
documents will not use any identifying facts. Your privacy will be
protected to the maximum extent allowable by law.

You may address questions about the study to the researcher, Dahlia
Berkovitz, M.S.W., C.S.W., L.M.F.T. at (248)760-8550 at any time during the
process, or to Dr. Esther Onaga at the Family & Child Ecology Dept.
on 27 Kellogg Ctr, East Lansing MI 48824-1022, Tel. # 517-353-6617.

178

If you have any questions or concerns about your rights as a participant in this

study, or are displeased at any time with any aspect of this study, you may

contact anonymously, Peter Vasilenko, Ph.D., Chair of the University Committee
on Research Involving Human Subjects (UCRIHS) on 202 Olds Hall, East
Lansing, MI 48824 Tel. # (517)355-2180.

All interviews will be audio taped, unless participants specifically ask not
to be audio taped, and all tapes will be destroyed after this study is
complete. Transcripts of the interviews will be kept locked by the
researcher at all times.

Your therapist, who referred you to this study, will not be informed of the
content of the conjoint interview (you and your partner), and if you are
still receiving therapy from this therapist, the services will not be
affected by your participation, non-participation, or withdrawal from this
study.

In case of ambiguity regarding some of the information gathered during
the interview, the researcher will contact you via telephone (number
provided by you), within a week after the interview, to confirm the
information obtained at the interview, or to ask follow-up questions.

We do not anticipate any psychological or emotional distress as a result
of participation in this study, but you are encouraged to ask questions
about this study or your participation in it at any time.

To show our appreciation for your time and effort, we will offer you a
copy of a recently published book about couples’ therapy, entitled “The
Seven Principles for Making Marriage Work“ by John M. Gottman,
Ph.D., and Nan Silver. This token of appreciation will be given to you
even if you or your partner decides to discontinue participation mid way
through the study.

179

Your signature below indicates that you have read and voluntarily agreed to

the above statements. A copy of this document will be made available to you for
your records.

Signature of participant with consent to audiotape
Signature of participant without consent to audiotape
Name

Date

 

 

 

180

APPENDIX E
Eliciting the voice of the client: Influences on client satisfaction with
Integrative Couples’ Therapy
A qualitative study

Therapist
Informed Consent

The purpose of this collective case study is to explore what factors
influence client’s satisfaction with couples’ therapy. We believe that some of
these factors may include values and beliefs held by you and your individual
clients, any social support that is available to your clients, and the clinical
approach used by you. You are being asked to describe your clinical approach
and your thoughts of how your clients experience couple therapy with you: their
feelings, thoughts, and values regarding couples’ therapy, and how these
influence their experience. Prior to your clients participation in a conjoint
interview, which will last approximately one to one and one half hours, you will be
interviewed regarding to each specific couple. This interview will last
approximately one half hour. You will not have access to your clients’ responses
in the couple’s interview.

0 Your participation in this project is completely voluntary and can be
terminated by you at any time. You may choose to decline to answer
certain questions. You will not incur any penalty as a result of the
above.

. All information obtained will be kept confidential and all written
documents will not use any identifying facts. Your privacy will be
protected to the maximum extent allowable by law.

You may address questions about the study to the researcher, Dahlia

Berkovitz, M.S.W., C.S.W., L.M.F.T. at (248)760-8550 at any time during the
process, or to Dr. Esther Onaga at the Family & Child Ecology Dept.

on 27 Kellogg Ctr, East Lansing MI 48824-1022, Tel. # 517-353-6617.

If you have any questions or concerns about your rights as a participant in

181

this study, or are displeased at any time with any aspect of this study, you

may contact anonymously, Peter Vasilenko, Ph.D., Chair of the University
Committee on Research Involving Human Subjects (UCRIHS) on 202 Olds Hall,
East Lansing, MI 48824 Tel. # (517)355-2180.

0 All interviews will be audio taped, unless participants specifically ask not
to be audio taped, and all tapes will be destroyed after this study is
complete. Transcripts of the interviews will be kept locked by the
researcher at all times.

0 You will not be informed of the content of the conjoint interview of your
clients and if the couple is still receiving therapy from you, the services
will not be affected by your and their participation, non-participation, or
withdrawal from this study.

a In case of ambiguity regarding some of the information gathered during
the interview, the researcher will contact you via telephone (number
provided by you), within a week after the interview, to confirm the
information obtained at the interview, or to ask follow-up questions.

0 We do not anticipate any psychological or emotional distress as a result
of participation in this study, but you are encouraged to ask questions
about this study or your participation in it at any time.

Your signature below indicates that you have read and voluntarily agreed to
the above statements. A copy of this document will be made available to you for

your records.

Signature of participant with consent to audiotape

 

Signature of participant without consent to audiotape
Name
Date

 

 

182

REFERENCES

Ackerman, N. W. (1970). Family psychotherapy today. Family Process. 9,
123-126.

Andersen, T. (1993). See and Hear, and be seen and heard. In S. Friedman
(Ed), The new language of change: Constructive collaboration in
psychotherapy (pp. 303-322). New York: Guilford Press.

Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems:
Preliminary and evolving ideas about the implications for clinical theory. Family
Process. 27, 371-393.

Attkinson, C. C., & Zwigg, R. (1982). The client satisfaction questionnaire:
Psychometric properties and correlation with service utilization and
psychotherapy outcome. Evaluation and Program Planning. 5, 233-237.

Avis, J. M. & Turner, KJ. (1996). Feminist lenses in family therapy research:
Gender, politics, and science. In D. Sprenkle & S. Moon (Eds), Research
Methods in Family Therapy. New York: The Guilford Press.

Bowman, L., & Fine, M. (2000). Client perceptions of couples therapy: Helpful
and Unhelpful aspects. The American journal of Family Therapy 28(4),
295-31 0.

Bronfenbrenner, U. (1979). The Ecology of Human Development. Cambridge,
MA: Harvard University Press.

Bronfenbrenner, U. (1989). Ecological systems theory. In R. Vasta (Ed.),
Annalysis of Child Development, 6, 197-249. Greenwich, CT: JAI
Press.

Bronfenbrenner, U. (1993). The ecology of cognitive development: Research
models and fugitive findings. In R. H. Wozniak & K. W. Fischer (Eds),
Development in context: Acting and thinking in specific environments.
(pp. 3-44). Hillsdale, NJ: Erlbaum.

Bronfenbrenner, U. & Morris, P. A. (1998). The ecology of human developmental
processes. In W. Damon Series & R. M. Lerner (Eds),
Theoretical modes of human development. Vol. 1 of Handbook of child
psychology (5th ed., pp. 993-1028). New York: Wiley.

Bubolz, M. M., Eicher, J. B., & Sontag, M. S. (1979). The human ecosystem: A
model. Journal of Home Economics, 71(1), 28-31.

183

Bubolz, M. M. & Sontag, M. S. (1993). Human Ecology theory. In P. Boss, W.
Doherty, R. LaRossa, W. Schumm, & S. Steinmetz (Eds), Sourcebook of
Family Theories and Mehtods: A Contextual Approach. (pp. 419-448).

New York: Plenum Press.

Buckley, W. (1968). Modern systems research for the behavioral scientist.
Chicago: Alsine.

Christensen, A., Jacobson, N. S. & Babcock, J. C. (1995). Integrative behavioral
couple therapy. In N. S. Jacobson & A. S. Gurman (Eds), Clinical
Handbook of Couple Therapy, (pp. 31 -64). New York: The Guilford Press.

Christensen. A., Russell, C. S., & Miller, R. B. (1998). The process of change in
couples therapy: A qualitative investigation. Journal of Marital and Family
Therapy, Vol. 24, (2) 177-188.

Creswell, J. W. (1998). Qualitative inquiry and research design. Choosing
Among Five Traditions. Thousand Oaks: SAGE Publications, Inc.

Daly, K. (1992). The fit between qualitative research and characteristics of
families. In J. F. Gilfun, K. Daly, & G. Handel (Eds), Qualitative methods
in family research. Thousand Oaks: Sage Publications, Inc.

Denton, W. H., Burleson, B. R., Clark, T. E., Rodriguez, C. P., & Hobbs, B. V.
(2000). A randomized trial of emotion-focused therapy for couples in a
training clinic. Journal of Marital and Family Therapy. Vol. 26, 65-78.

Denzin, MK. (1994). The art and politics of interpretation. In N. K. Denzin &
Y. 8. Lincoln (Eds), Handbook of qualitative research (pp. 500-515).
Thousand Oaks, CA: Sage.

Doherty, W. J., & Simmons, D. S. (1996). Clinical practice patterns of marriage
and family therapists: A national survey of therapists and their clients.
Journal of Marital and Family Therapy. Vol. 22, 9-25.

Garbarino, J. (1983). Social support networks: Rxfor the helping professions. In
Wittaker, J. K. & Garbarino, J. (Eds). Social support networks: Informal
helping in the human services. New York: Aldine Publishing Co.

Goolishian, H., & Anderson, H. (1987). Language systems and therapy: An
evolving idea. Psychotherapy, 24(3S), 529-538.

Gottman, J. M., 8 Silver, N. ((1999). The seven principles for making marriage
work. New York: Three Rivers Press.

184

Gurman, A. (1981). Integrative therapy: Toward the development of an
interpersonal approach. In S. Budman (Eds), Forms of brief therapy.
New York: Guilford Press.

Gurman, A. S. & Fraenkel, P., (2002). The history of couples’ therapy: A
millennial review. Family Process. Vol. 41(2), 199-260.

Helmeke, K.B., & Sprenkle, D. H. (2000). Clients’ perception of pivotal moments
in couples therapy: A qualitative study of change in therapy. Journal of
Marital and Family Therapy, Vol. 26, (4).

Hiebert, W. J., Gillesphie, J. P., & Stahmann, R. F., (1993). Dynamic
Assessment in Couples’ therapy. New York, NY: Lexington Books.

Hoffman-Hennessy, L., & Davis, J. (1993). Tekka with feathers: Talking about
Talking (about suicide). In S. Friedman (Ed.), The new language of change:
Constructive collaboration in psychotherapy (pp. 323-344). New York:
Guilford Press.

Jacob, T. 8 Krahn, G. L. (1988). Marital interactions of alcoholic couples:
Comparison with depressed and nondistressed couples. Journal of
Consulting and Clinical Psychology. 56, 73-79.

Kohut, H. (1971). The Analysis of the Self. New York: International Universities
Press.

Kohut, H. (1977). The Restoration of the Self. New York: International
Universities Press.

Kohut, H. (1984). How Does Analysis Cure? Chicago: University of Chicago
Press.

Laszloffy, T. A. (2000). The implications of client satisfaction feedback for
beginning family therapists: back to the basics. Journal of Marital and
Family Therapy, Vol. 26, 391-397.

Lazaloffy, T. A., & Hardy, K. V. (2000). Uncommon strategies for a common
problem: Addressing racism in family therapy. Family Process, Vol. 39,
35-50.

Lebow, J. L. (1984). On the value of integrating approaches to family therapy.
Journal of Marital and Family Therapy, Vol. 10, 127-138.

Lebow, J. L. (1987). Developing a personal integration in family therapy:

Principles for model construction and practice. Journal of Marital and
Family Therapy, 13, 1-14.

185

Liddle, H. (1985). Five factors of failure in structural/strategic family therapy: A
contextual construction. In S. Coleman (Ed.), Failures in family therapy.
New York: Guilford.

Locke, L. D., & McCoIIum, E. E. (2001). Client’s views of live supervision and
satisfaction with therapy. Journal of Marital and Family Therapy. Vol. 27,
129-133.

Markowitz, L. M. (1994). The cross-currents of multiculturalism. The Family
Therapy Networker, Vol. 18, 27.

Marshall, C. & Rossman, GB. (1995). Designing Qualitative Research.
Thousand Oaks, CA: Sage.

Miles, M. B. & Huberman, A. M. (1994). Qualitative Data Analysis: An Expended
Sourcebook. Second Edition. Thousand Oaks: SAGE Publications, Inc.

Moon, S. M. & Trepper, T. S. (1996). Case study research. In D. Sprenkle & S.
Moon (Eds), Research methods in family therapy. New York: The
Guilford Press.

Newfield, N., Sells, S.P., Smith, T.E., Newfield, S., & Newfield, F. (1996).
Ethnographic research methods: Creating clinical science of the
humanitiews. In D. H. Sprenkle & S. M. Moon (Eds), Research methods
in family therapy. (pp. 25-63). New York: Guilford Press.

Nguyen, T. D., Attkinsson, C. C. & Stengner, B. L. (1983). Assessment of patient
satisfaction: Development and refinement of a service evaluation
questionnaire. Evaluation and Program Planning, 6, 299-314.

Paddock, G. B. (1990). The development of a client self-report instrument to
measure satisfaction with family therapy treatment. Unpublished doctoral
dissertation, Purdue University, West Lafayette, IN.

Pasley, K. Rhoden, L., Visher, E. B., & Visher, J. S. (1996). Successful
stepfamily therapy: Client’s perspectives. Journal of Marital and Family
Therapy, 22, 343-357.

Pinsof, W. (1983). Integrative problem-centered therapy: Toward the synthesis
of family and individual psychotherapies. Journal of Marital and Family
Therapy, 9, 19-35.

Pinsof, W. (1994a). An overview of integrative problem centered therapy.
Journal of Family Therapy, 16, 103-120.

186

Pinsof, W. & Catherall, D. (1986). The integrative psychotherapy alliance.
Journal of Marital and Family Theragy, 12, 137-152.

Pinsof, W. M. (1995). Integrative problem-centered therapy. New York: Basic
Books.

Quinn, W. H. (1996). The client speaks out: Three domains of meaning.
Journal of Family Psychotherapy. Vol. 7, (2), 71-73.

Quinn, W. H., Nagirreddy, C., Lawless, J., & Bagley, R. (1996). Utilizing clients’
voices in clinical supervision. The Supervision Bulletin. Vol. 9 (1 ), 4-8.

Simmons, D. S., & Doherty, W. J. (1995). Defending who we are and what we
do: Clinical practice patterns of marriage and family therapists in
Minnesota. Journal of Marital and Family Therapy, 21: 3-16.

Solomon, M. (1992). Narcissism and Intimacy: Love and Marriage in an Age of
Confusion. New York: Norton.

Sword, W. (1999). Pearls, pith, and provocation; Accounting for presence of self:
Reflections on doing qualitative research. Qualitative Health Research.
Vol. 9(2), 270-278.

Taylor, S. J., & Bogdan, R. (1984). Introduction to Qualitative Research
Methods: The search for meanings (2nd ed.). New York: John Wiley &
Sons.

Thompson, L. & Walker, A. J. (1982). The dyad as the unit of analysis:
Conceptual and methodological issues. Journal of Maniage and the
Family, 44, 889-900.

Vaux, A. (1988). Social Support: Theory, Research, and Intervention. New York:
Praeger.

Wachtel, P. L. (1977). Psychoanalysis and Behavior Therapy. New York: Basic
Books.

Wachtel, P. L., & Wachtel, E. F. (1986). Family Dynamics in Iindividual
Psychotherapy: A Guide to Clinical Strategies. New York: Guilford Press.

Whisman, M. A., Dixon, A. E., & Johnson, B. (1997). Therapists’ perspectives of
couple problems and treatment issues in couples’ therapy. Journal of
Family Psychology, 1 1, 361 -366.

William, J. D., & Simmons, D. S. (1996). Clinical practice of marriage and family
therapists: a national survey of therapists and their clients. Journal of

187

Marital and Family Therapy, 22, 9-25.
Wittaker, J. K. (1983). Mutual helping in human service practice. In Wittaker, J.

K. & Garbarino, J. (Eds), Social Support Networks: Informal Helping in
the Human Services. New York: Aldine Publishing Co.

188