Couples in conflict

Liz Scott discusses how to manage couples with relationship conflicts

Couples who present with relationship conflicts and request support, advice or referral may be married, cohabiting or living separately. They may be heterosexual, gay or lesbian. There are few committed relationships experiencing serious difficulty without sexual problems, however, and these couples may initially present to their GP with sexual dysfunction. As many couples have difficulty in discussing sex, this leads to a 'no-go' area of poor communication, which intensifies as each partner feeds on resentments and assumptions. The sexual problem becomes a hook on which the couple hang their relationship problems.

Many of the difficult behaviours and acting out we observe in relationship conflicts are attempts to soothe internal pain and distress caused by emotional damage in earlier developmental stages. Just as the individual follows through from infancy, childhood, adolescence and adulthood, committed relationships go through developmental stages. Unresolved problems in early individual development often get re-enacted and recreated in adult relationships, and the GP is often the first person whom couples approach with their relationship conflicts or sexual difficulties.

Assessment and treatment

GPs may see a couple together for assessment before making an appropriate referral or offer them several sessions of brief therapy if the practitioner has sufficient time and experience. Any treatment aimed solely at the sexual problem may well have limited success if relationship conflicts are not addressed. For many couples, there is considerable shame and sense of failure experienced when seeking help for relationship breakdown or sexual problems. It is useful to bear in mind the importance of establishing a good rapport with both partners and of recognising how significant the personal relationship is in enabling change and learning. Even if one partner appears to be more affected or presents as the main problem contributor in the relationship, it is necessary to get the couple to see the problem as a shared one in order for the work to begin.

It is important to establish the purpose of therapy with the couple: do both partners have similar goals?

Is one partner putting the other under pressure to enter into treatment?:

• Are both partners prepared to work towards change?

• What are their expectations of treatment?

• Why me? It is critical that the couple has faith in the person they are to work with

A three stage model of counselling as set out by Egan and Nelson-Jones and adopted by Relate provides an excellent framework for working with couples with relationship conflicts: exploration, understanding, and action.

If the couple spend most of their time together in hostile verbal confrontation or one partner is bitter and withdrawn in resentful silence, the most useful way of helping them is to explore the resentments and see if they can unite to overcome their problems by negotiation and compromise. Work with the couple may involve use of the psychodynamic, cognitive, systemic or integrative models. The work could continue at home if behavioural tasks, acceptable to both partners, are set as homework.

Homework. The homework should not only reflect a continuation of work begun in the session but may, initially, need to be deliberately 'bland' in order for a couple locked in conflict to feel safe enough to use the exercise. A hostile couple presenting with a sexual problem, for example, may need to start with communication tasks and only move on to touching and sensate focus work when they are able to communicate more effectively and are beginning to negotiate reciprocity. Homework should encourage the couple in boundary keeping, finding time to play and have fun in addition to making time to talk to each other. The homework should also teach them to give each other space, as well as encourage mutual sharing of feelings. Although commitment to homework needs to be discussed and agreed upon by the couple, it is necessary to point out to them that if it has not been possible to complete the homework, the difficulties involved can be discussed in the next session.

If the couple are helped to discuss, within the treatment sessions, topics of disagreement and resentment without hostility and in a constructive manner, homework could initially encourage the couple to take responsibility for their own feelings by using the personal pronoun 'I' before feelings, rather than "You make me....". As homework needs to be carefully graded to the level of interaction of the couple, the exercise set out in Table 1 is useful for couples who are barely talking to one another:

It is sometimes appropriate to manage the couple as if they were preparing to separate or divorce, in order that the least destructive way forward can be negotiated, especially if children are involved in the breakdown of the family. Whereas couples will benefit from a few sessions with a responsive and empathic doctor or therapist, brief therapy is contraindicated in the following situations:

• Where one partner suffers from alcoholism, drug addiction or a severe personality or psychotic disorder

• If the couple is held together in a destructive enmeshed relationship, unable to reach out to each other

• Violence within the relationship threatens the survival of one partner and perhaps the children

Conclusion

An important part of the therapy is appropriate referral and a thorough knowledge of the community resources available. This article includes a list of organisations which supply addresses and telephone numbers of their local offices or lists of accredited therapists, on request (see more information box). With new pharmaceutical treatments becoming available to treat male impotence, it could be easy to treat the individual, restoring his erectile capacity without addressing conflicts and relationship issues. We need to continue to think, however, of the man as one partner in a couple relationship and be prepared to offer treatment which includes both a medical approach and sex and couple therapy where appropriate.

Liz Scott is a sex and relationship therapist in private practice, Sussex

References
Crowe R, Ridley J. Therapy with Couples: A behavioural-systems approach to marital and sexual problems. Blackwell, London 1990
Egan G. The skilled helper: A systematic approach to effective helping. Brookes/Cole, California 1990 Gilbert M, Shmukler D. Brief therapy with couples. Wiley, Chichester 1996 Hawton K. Sex therapy: A practical guide. Oxford University Press, Oxford 1985
Nelson-Jones R. You can help. Cassell, London 1983
Riley AJ, Athanasiadis L. Impotence and its non-surgical management. British J Clinical Practice. 1997; 51(2): 99-103