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Rose Medical Center
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Denver, CO 80220
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Treating High-Conflict Couples

Susan Heitler, Ph.D.

University of Denver, School of Professional Psychology

1. Define conflict levels Conflict may be expressed in anxious tension, depression, disengagement (for fear of fights), and passive-aggressive or addictive behavior, as well as in overt anger, deprecating or demanding words and tone of voice or, in the extreme, physical violence. High conflict refers to the frequency with which a couple locks into oppositional stances and also to the intensity of anger expressed in disagreements.

2. Obtain requisite therapist skills. In addition to traditional therapy skills, a high conflict couple psychotherapist, like a professional mediator, needs referee skills for insuring that the couple=s dialogue stays safe plus expert knowledge of the steps of conflict resolution.

3. Arrange the therapy room for symmetry and interaction. Place the three chairs in an equilateral triangle. Rollers on the therapist=s chair are preferable so that the therapist can roll closer to the couple or to one or the other partners for interventions, and roll back when the couple=s dialogue flows cooperatively. Do not seat the couple side by side on a sofa as this arrangement encourages the couple to talk to the therapist rather than to each other.

4. Obtain a three-fold diagnostic picture. Include:

X  A history of each individual=s symptoms and any personality disorder. Accelerate this assessment by having each partner fill out a symptom checklist before beginning treatment. If the symptom checklist or your interview questions suggest anger outbursts, obtain detailed individual reports of exactly what has happened, bearing in mind the tendency to minimize and deny rages, emotional abuse, and physical violence (Holtzworth-Munroe et al., 1995).

X  A laundry list of conflicts about which the couple fights and

X  An initial assessment of communication and conflict resolution skills and deficits.

This three-fold diagnostic work-up organizes diagnostic information to correspond to the three main strands of treatment: Eliminate symptoms (excessive anger, depression, etc). Resolve each conflict on the laundry list, and in the process of resolving the conflicts, gain understanding of the central problematic relationships of childhood and their re-enactments in the marriage (Lewis, J., 1997). Build skills so the partners learn to resolve conflicts without angry fighting.

5. Note contraindications for couple therapy.

X  Unwillingness to agree that verbal and physical violence are out-of-bounds, at home and in the therapy session.

X  Poor impulse control, or other signs that therapy may be unsafe.

X  Reprisals for talking openly about concerns in the sessions.

X A paranoid-like blaming stance with a rigidly-held set of beliefs about the other (a fixed ideational system), ego-syntonic controlling behavior, and projection.

If these symptoms can be addressed with individual treatment and/or medication, subsequent couple treatment may be productive. Also, individual therapy for the healthier partner often can help him/her to cope more effectively with the spouse.

6 Audiotape the treatment sessions. Listening to the tape can be assigned as homework to accelerate and consolidate learning. Taping is contraindicated, however, if potential court involvement could result in the tapes being used as evidence detrimental to either participant.

7. Insure safety. Early in treatment teach disengagement/reengagement routines to prevent hurtful fights. See Time Out Routines for Emotional Safety at Home. Practice these routines in the session. Inquire intermittently about the couple=s experiences with their exit routines to insure their plan is fully effective.

8. Intervene immediately if anger escalates in a session. Redirect the outburst to you, away from the spouse, by engaging the angry person in dialogue. If the angry partner continues to escalate, stand between the two spouses and/or ask the receiving spouse to step out for a few moments. Simplifying the situation by having one partner leave enables tempers to deescalate and calm to return. If an angry spouse threatens to leave the session, agree, inviting him/her to return when s/he feels calmer. Thank him/her for demonstrating self-awareness and self-control.

After an angry outburst, reiterate the angry person=s underlying concerns in a quiet voice so that dialogue resumes in a calm mode and the angry person knows s/he is being heard. Detoxify the incident by reframing the contents of the outburst in non-blaming language and by discussing any hurt feelings that may have resulted from the outburst.

9. Initiate a collaborative set. Create a shared perspective on the part of each spouse that they are mutually responsible for the problems in the relationship, and that they both need to change themselves in the relationship is going to improve (Christensen et al., 1995). To transition from conflict to cooperation, develop face-saving explanations for the conflicts:

X  Define the last comfortable phase of marriage, and then identify external or developmental stresses that may subsequently have overloaded the system (e.g., arrival of children, illness, financial setbacks).

X   Explain the role of insufficient communication and conflict resolution skills.

X  Identify conflict resolution models in each spouse=s family of origin. Explain that you speak French if your parents spoke French, and that you are likely to argue if you grew up in a household where adults fought about differences. Alleviate parent-blaming by looking compassionately at parents= family of origin histories.

10. Begin by setting agendas. In the initial session, ask what each spouse wants to accomplish overall from therapy. Begin each subsequent session by asking what each spouse wants to focus on in that session. e.g., skills, a difficult feeling or issue, an argument from the prior week.

Close sessions by summarizing progress on each agenda item. Connect side issues to the focal concerns. In general, in a 45-50 minute session, one main conflict can be brought to resolution and one main skill improved.

11. Address symptoms immediately. Symptoms that disrupt personal or couple functioning need to be addressed early in treatment, particularly if they pose safety concerns and/or interfere with treatment. If violence is involved, immediate steps must be taken to remove guns from the home, to assure the woman escape options, to address impacts of alcohol and drugs on safety, to teach the husband ways of stopping himself when he begins to anger, to insure that both understand the high danger of even Aminor@ violence (e.g., a minor push can cause a major head injury), and to implement a temporary separation if violence risk is high. Firmly adopt the stance that no violent acts are acceptable (Holtzworth-Munroe et al., 1995).

12. Explain that a symptom is a solution, or a by-product of a solution, to a conflict (Heitler, 1993):

Anger may serve as a means of coercion in couples who settle their differences by means of dominant-submissive, winner-loser, strategies. Anger expresses frustration when stances have polarized and defensiveness has replaced listening. Anger energizes increased voice volumes in order to be heard or to have one=s viewpoint prevail. It also may serve to prevent discussion of hidden behavior (e.g., gambling, an affair, drugs).

Other symptoms commonly occur in high conflict couples. Anxiety arises when conflicts hover unaddressed. Depression is the by-product of dominant-submissive conflict resolution, that is, of submitting to the preferences or will of the other. Addictive and obsessive-compulsive disorders (including eating disorders and hypochondria) indicate attempts to escape from conflicts by means of distraction.

Symptoms generally can be removed by readdressing conflicts with healthier dialogue patterns. Augmenting the couple treatment format with individual therapy sessions and/or additional symptom removal treatment strategies (e.g., medications) may be necessary. Wherever possible, one therapist for the full system is preferable to having different therapists for the individual and the couple work (two therapists will tend to pull the couple apart). On the other hand, it is vital to utilize referrals for additional specialized treatments such as medication or treatment for substance abuse.

13. Teach about anger. Explain that when we are angry, we may feel like we are Aseeing red.@ Rather than attacking when we see red, as if we are bulls, we can interpret the red as a stop sign. Anger tells us to stop, look to identify the difficulty, listen to our and to our partner=s concerns, and then choose a safe route for continuing. Angry feelings enable us to identify problems; angry actions, however, seldom effectively ameliorate problems.

14. Resolve current disputes. Once flagrant symptoms have been sufficiently calmed, guide conflicts through the three stages of conflict resolution:

X  Express initial positions. Be sure that both spouses speak up and both listen to the other.

X  Explore underlying concerns. Be sure both spouses talk about their own thoughts and feelings, not about their partner=s, and that both listen to absorb, not to criticize.

X  Design a mutually satisfying plan of action, a solution set responsive to all the concerns of both spouses (Heitler, 1992).

15. Utilize the four S=s that are essential in conflict resolution (Heitler, 1997):

X  Specifics lead to resolution; generalities breed misunderstandings.

X  Short segments means that for conflicts to move toward resolution, participants need to speak a paragraph at a time, not multiple pages. Lengthy monologues lose data and drain energy from dialogue. For spouses who ramble, suggest a three-sentence rule.

X  Symmetry of air time gives a sense of fairness and equal power.

X  Summaries consolidate understanding and propel conflict resolution forward.

16. Have spouses talk with each other, not through you. High conflict couples need to learn to talk with each other when they have differences. To redirect comments when the partners are speaking to you instead of with each other, look at the listener rather than the speaker, or use a hand or head gesture to indicate that the partners are to talk each other. On the other hand, however, funneling the dialogue through you can be a way to de-escalate tensions when anger is escalating. Similarly, when a couple=s dialogue skills are poor or when you are running out of time in a session, having the spouses speak to you may speed up the conflict resolution process.

17. Identify core concerns. Hot spots in a dialogue indicate strongly felt concerns. As you discuss conflicts, certain underlying concerns will surface repeatedly, raising strong feelings each time. Luborsky et al (1986) call these transference issues–such as AI don=t want to be controlled,@ or APeople disappoint me by not doing what they should,@– core conflictual themes. I call them core concerns.

Note where spouses= core concerns dovetail, repeatedly reengaging the other=s central concerns in what Wachtel (1993) calls vicious cycles. For instance, her thought AI can=t seem to please him@ and resultant depressive withdrawal may interact with his AI never get the affection I want@ and angry complaining stance. Her depressive withdrawal triggers his anger; his angry complaints trigger her withdrawal. Establish new solutions for these concerns, replacing negative cycles with positive ones. (e.g., she greets him warmly when he comes home from work; he expresses appreciation for her dinner).

18. Depth dive to access family of origin roots of core concerns. As Norcross (1986) explains, deeper concerns are less accessible to conscious thought, and generally arise from historically earlier life experiences. See the accompanying protocol for the steps involved in a depth dive visualization (Heitler, 1995). During a depth dive, the non-diving spouse listens, holding his/her comments for the discussion after the depth dive.

19. Allow only healthy communication.

X  Prevent poor skills by prompting spouses before they speak. For example, to prompt effective listening, suggest, AWhat makes sense to you in what your spouse just said?@

X  If you did not succeed with prevention, rectify skill errors by inviting a re-do.

X  Alternatively, serve as translator, converting provocative comments into better form. For instance, after an accusatory AYou don=t do your part in keeping up the house,@ pull your chair next to the speaker and reiterate for him/her, AI feel like I=m doing more than my share.@

X  Repeat frequently simple iterations of basic communication rules, e.g., AYou can talk about yourself or ask about the other; it=s out of bounds to talk about the other.@

AWhat=s right, what makes sense, what=s useful in what your partner is saying?@

20. Coach communication skills. Design practice exercises to consolidate the essential skills:

X Insightful self-expression. Good spousal communicating involves expressing one=s own concerns and feelings instead of criticizing the other. Explain the difference between selfexpression and Acrossovers@ (my term for crossing the boundary between self and other by talking about what you think the other is thinking or feeling or telling them what to do). Practice self-expressive when-you=s (AWhen you left early, I felt rejected.@). Emphasize that the subject of a when-you is the pronoun I.

X  Digestive listening. Instead of listening like an adversary for what=s wrong with what the other is saying, cooperative partners listen to learn, to sponge in what makes sense in what their partner says. ABut . .@ indicates that the prior comments are being deleted, not digested.

X  Bilateral listening. Hearing both self and other so that both partners= viewpoints count. Bilateral listening contrasts with either/or thinking and the belief that if one person is right the other is wrong.

21. Convert blame after upsets to apologies and learning. Teach the couple to piece together the puzzle of what happened, with each spouse describing his/her own feelings, thoughts, actions, and mistakes. Attribute the problem to a Amis-@, e.g., a misunderstanding, mistake, miscommunication. Guide apologies, with each spouse owning his part in the difficulties. Conclude with each having learned something that will help to prevent future similar upsets.

5. Terminate therapy when the symptoms have been ameliorated, the conflicts resolved, and dialogue is consistently cooperative.

Time Out Routines for Emotional Safety at Home

Initiate time outs when either of you

X  Feels too upset or negative to talk constructively.

X  Senses that the other is getting too emotional to dialogue constructively.

To initiate a time out

X  Use a non-verbal signal, such as sports signals.

X  Go to separate spaces immediately, without any further discussion.

X  Self-soothe, by doing something pleasant.

X  Write in a journal if it feels helpful, but write primarily about yourself, not your partner.

To reengage

X  Wait until you both have regained normal humor.

X  Reengage first in normal activity before you attempt to talk again about a difficult subject.

X  If a difficult subject again provokes unconstructive discussion, save it for therapy.

Exit rules

X  No door slamming or parting comments.

X  NEVER block the other from leaving, or pursue the other when they need to disengage.

X  As soon as the going gets even a little bit hot, keep cool and exit. Prevention is preferable to destruction.

Protocol for Depth Dive Technique

for Exploring and Loosening Transference Reactions

I. Point of entry

X  When one partner shows a strong emotion or excessive response suggestive of a transference reaction or core concern

X  Instruct him/her to close eyes and focus on the feeling.

II. The dive

X  Say, AAs you focus on that feeling, allow a similar scene from your past to emerge, a scene in which you felt a similar feeling. Notice who you see, what they are doing, and how you responded then.@

X  Ask, AWhat elements feel to you the same as in the present situation?@

X  Ask, AAnd what in the present situation is different?@ And then, ASeeing these differences, what new options exist for you now?@

III. Debriefing

X  Have patient open eyes, and digest aloud the experience.

X  Clarify that the emotional response made sense in its originating circumstance. Since the present has elements in common with the original circumstance it is understandable that the response was similar.

X  Begin to experiment with the new response options available now that the patient understands the ways in which the present situation differs from the past.

Key Words

anger

conflict

blame

communication

dialogue

marriage

couple

conflict resolution

bilateral listening

depth dive

skills

coaching

listening

References and Readings

Christensen, A., Jacobson, N.S., & Babcock, J. (1995). Integrative behavioral couple therapy. In N.S. Jacobson & A.S. Gurman (Eds.), Clinical handbook of couple therapy (pp.31-64). New York: Guilford.

Heitler, S. (1992). Working with couples in conflict (audiotape). New York: Norton.

Heitler, S. (1993). From conflict to resolution. New York: Norton.

Heitler, S. (1995). The angry couple: Conflict-focused treatment (video) In video series, L. Schein (Ed.) Assessment and treatment of psychological disorders. New York: Newbridge.

Heitler, S. (1997). The power of two. Oakland, CA: New Harbinger.

Holtzworth-Munroe, A., Beatty, S.B., & Anglin, K. (1995) The assessment and treatment of marital violence: An introduction for the marital therapist. In N.S. Jacobson & A.S. Gurman, Clinical handbook of couple therapy (pp. 317-339). New York: Guilford.

Lewis, J.M. (1997). Marriage as a search for healing. New York: Brunner Mazel.

Luborsky, L., Crits-Christoph, P. & Mellon, J. (1986). Advent of objective measures of the transference concept. Journal of Consulting and Clinical Psychology, 54, 39-47.

Norcross, J. (1986). In J.O. Prochaska (Ed.), Integrative dimensions for psychotherapy. International Journal of Eclectic Psychotherapy, 5, 256-274.

Wachtel, P. (1993) Therapeutic communication. New York: Guilford.

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