by Michael Mesmer, MFT

Theoretical and Practical Orientation

This case study concerns Mary & Mark, a recently married couple who sought help in stopping violence and abuse and reducing anger in their relationship. Mary had been arrested and convicted in the spring of 2006 for attacking her husband during an argument and was newly enrolled in a batterers’ treatment program in Marin County, California when I first met her and Mark in June of that year. They attended 11 one-hour sessions of couples’ therapy over 6 months, ending in January, 2007.

I am a Marriage & Family Therapist (MFT) and have been licensed in California (MFC 36859) since June of 2000. I have a private psychotherapy practice in San Rafael, California, where I work with adults, teens and children in individual, couples and family therapy. Among a diverse population of clients seen in short- as well as long-term therapy, I have provided treatment for several women who were concerned about their own anger and violence in their relationships as well as about, in some cases, the abusiveness of their partners or family members. I have also worked with several individual male adults and teens as well as many heterosexual couples in which the focus was on the man’s anger, as well as with a transsexual (male transitioning to female) who participated in sadomasochistic and violent sexual activities with several male partners. Mary and Mark were the first couple I have worked with in which the female partner had been identified by law enforcement as the batterer and the male as the victim in a domestic violence case.

I am also co-founder and co-director of Building Better Families, Inc. (BBF), a provider of batterers’ treatment groups certified by the Marin County Probation Department since 2003. BBF clients include both court-ordered and voluntary clients working on ending family and other forms of violence in their lives as well as managing their anger better. To-date, BBF groups have served over 160 male clients; female and teen groups are forming as this is written. Since BBF’s founding, I have led at least one group and sometimes two or three each week for two-hour sessions with as many as ten group members or as few as two. (Mary attended another provider’s program during the months I provided couples’ therapy to her and Mark.)

BBF promotes respect and responsibility as essential elements of healthy relationships and, through lectures, meditation, group exercises and individual check-ins and storytelling, provides its clients with tools and techniques to behave more respectfully and responsibly towards themselves and others. Responsibility is presented as empowering rather than burdensome and a point of view that can be considered (“How am I responsible, if at all?”) in any situation but particularly those in which we feel victimized by external events or others.

I understand psychotherapy to be a process by which one person helps another to help his or herself. My approach is eclectic, varies by client, and reflects my training and interest in a wide range of sometimes disparate psychotherapeutic approaches, including the expressive arts (including music, art, and movement therapy); crisis intervention; holistic health and the unity of mind, body and spirit (see Various, 2007); Grief therapy; 12-step and other self-help methods of healing addictive and self-destructive behaviors; meditation, guided visualization, and auto-suggestion (such as affirmations); Narrative therapy (see especially White & Epston, 1990); and Hakomi therapy, a body-oriented approach to working with trauma and other concerns (described in detail in Kurtz, 1990).

In particular, my work with both male and female perpetrators of abuse or violence has been strongly influenced by Alan Jenkins’ fascinating book, Invitations to Responsibility (Jenkins, 1990). Jenkins describes an approach to working with men who have been violent or sexually abusive that begins by modeling respect and by adopting a constraint model instead of a causal model in attempting to understand how these clients came to behave as they did and, more importantly, how to engage clients in discovering more respectful and personally rewarding ways of relating to others. In a manner reminiscent of the stance taken by therapists when conducting Motivational Interviewing (Miller & Rollnick, 2002), Jenkins addresses his clients in a disarming fashion, inviting them to wonder with him what keeps them from behaving respectfully and non-violently towards others rather than what causes them to do so. In his view, promoting responsibility is more difficult within a causal model of behavior ~ both the client and others in his (or her) life can use causes as excuses instead of recognizing one’s responsibility for one’s own behavior. Constraints, however, are more easily resisted by both client and therapist in promoting non-violent relationships and in encouraging clients to act more responsibly.

As someone who understands because of personal and professional experience that people of any gender (whether male, female, hermaphroditic or transgender) can behave violently or abusively towards others, I have been less interested in patriarchal theories of the origins of domestic violence and more in theories and therapies that lend themselves to a pan-gender model of violence in relationships. Attachment theory is one that offers a different view of the possible genesis of violence due to childhood trauma in men and women. Sonkin provides a good introduction to its potential in psychotherapy in general (Sonkin, 2005) and in responding to domestic violence in particular (Sonkin & Dutton, 2003), the latter albeit with a male-perpetrator focus.

Although often founded in real experiences, the historical and cultural significance of male-perpetrated violence and abuse that have informed much of the work to date in the field of family violence have proved unhelpful to me in the face of actual situations brought to my attention in the course of my work with various clients. The practical problem of treating both male and female perpetrators has led many practitioners, including myself, to recognize the universal challenges that face people of all genders in mastering the self-soothing and self-assessment practices so helpful in living respectfully and non-violently with others.

These are aspects of the theoretical background behind the interventions I employed during my work with Mary and Mark. It should be noted here that I use the terms “batterer” and “victim” to mean a person so identified by law enforcement and others but with the understanding that neither label is of much help to clients and clinicians seeking not only to understand the clients’ anger and violence but to manage the former and end the latter. I also view the distinction between court-ordered and voluntary clients to be a false one: all clients freely choose to participate to the extent and in the manner that they do, whether in a group or in life. Probation and its requirements are chosen by each probationer instead of other available options, such as a trial of unpredictable length and expense with an unpredictable outcome or an unpredictable sentence including time in jail. In this way, all clients are voluntary, though some are more aware of it than others.

Mary called me initially to ask if BBF had any women’s groups available (we did not) as she was “required by Probation to attend a 52-week program” after being convicted of assaulting her husband during an argument. I referred her to another provider in the county (where she subsequently enrolled). She also told me on the phone that she and her husband were seeking “couples counseling” to help them “learn how to communicate better”. I cautioned her that therapy was not appropriate for all couples, especially when violence was a concern, but agreed to meet with her and her husband to find out if I could or should work with them.

At our first session, Mary and Mark identified themselves as “white”, “Catholic” (her) and “¼ Jewish” (him). They had been married only 6 months earlier after a long-distance courtship of several years; her parents lived “back in Wyoming” and were Christian Scientists while his lived somewhere in the Bay area. Both gave their age as 29, with Mark the younger by just 6 weeks. Mary seemed to be about 5’ 3” tall, with broad hips and thighs (that she described as evidence she was overweight), but a small head and delicate shoulders, giving an overall impression of being “bottom heavy”. From her physicality and firm voice, I immediately got a sense of Mary’s strength and ability to assert her needs and views. Mark, on the other hand, may have been about the same height or a few inches taller than Mary but presented as of smaller stature due to the way he hunched over whether moving or sitting. Although he had a full head and beard of dark hair, he was slight of build and spoke in a quiet voice that was sometimes hard to hear in the room. Mark held Mary’s hand or reached out to touch her hand frequently during the session (as well as in future ones), and they kissed frequently (albeit chastely), especially after one of them had spoken of something distressing or disturbing to one of them. Mark was invariably polite and soft-spoken even when, during later sessions, discussing anger or fear (either his own towards Mary or his work, or hers towards her jobs or him). Mary, on the other hand, would become loud, even strident, and sometimes verbally attacking towards Mark or others when agitated or upset in our meetings.

Mary self-identified as a “part-time baby-sitter and home-care provider” with a B.A. Mark spoke a little about his work as a manager for a San Francisco Bay Area company; he held a Masters of Science degree and was concerned about a recent take-over of his employer. Their financial situation was “tenuous” and Mary was looking to increase her income. Mary wore glasses; Mark did not. Neither was in individual or other counseling, besides the 52-week program Mary had begun two days before our first meeting. Both reported moderate diets but little structured exercise, although Mary got “out and about” on her part-time jobs more than Mark did. Neither felt they were very spiritual.

Both Mary and Mark spoke at length about Mary’s anger and violence in their marriage. Taking turns, each described their arguments as primarily about Mary wanting something that Mark either couldn’t or wouldn’t give her. An example they gave me that we focused on during later sessions was that Mary wanted Mark to stay awake at night or, as an alternative, to fall asleep on the living room couch rather than “all the way” in the bedroom while she worked at the dining room table, until she was ready to fall asleep, even though he felt he needed more sleep and had to get up earlier than she did in the morning.

Mary described her arrest somewhat briefly although she acknowledged straightforwardly that she had scratched Mark’s face during their argument. (A neighbor’s call to 911 on the day of Mary’s arrest reported “loud yelling”.) But she became agitated when I pressed for more details. Mary again emphasized that, “we’re here to work on both of us,” and she worried that I might be prejudiced against her because she had been identified as a batterer and because I was a man like Mark and therefore more likely to bond with him. Mark described himself as “more passive” than Mary and wondered if he was somehow “enabling” Mary’s anger and violence by failing to be, perhaps, more patient or cooperative with her agendas or needs.

SESSION ONE:

Before learning this information from Mary and Mark, I began our first session, as with all clients, by discussing confidentiality, including my responsibilities regarding child and elder abuse reporting and the limits these imposed on the privacy of our meetings. Knowing that Mary had been violent towards Mark, I emphasized the importance of safety limits to confidentiality, especially regarding “danger to self or others” and briefly discussed Mark’s safety plan with him (he had money, a car, a cell phone, friends and neighbors close by), while Mary listened and became somewhat agitated. (At one point she commented, “I hope this isn’t going to be just about my anger”.) I also described my policy of not holding secrets from either party in couples therapy should information arise during conversations or meetings with one of them. Notwithstanding, I encouraged both of them to feel free to call me on my cell phone, reminded them of 911 and gave them the Marin County Psychiatric Crisis Center phone number (415-499-6666) as well as the 24-hour volunteer-staffed hotline number in San Rafael (415-499-1100).

Also knowing that Mary was enrolled in a batterers’ treatment program operated by someone I attended meetings with at the Marin County Probation Department every other month, I took time to explore whether or not Mary thought it might be helpful for me to be able to acknowledge her status as a client of mine in any contact with the program provider and to perhaps consult with him regarding Mary’s progress in their program. Mark agreed, saying “We’re here to work on our relationship, not Mary.” Mary, however, declined and I thus had no contact with her program provider regarding her participation in batterers’ treatment groups.

In our first session I discussed with Mary and Mark the problem that can arise in couples therapy when a therapist, being neutral and seeking to help all parties make changes that contribute to reaching their collective goals, inadvertently endangers one or both parties by inattention to the dynamics of a violent or abusive relationship. We agreed that, in this regard, I should remain mindful of ways in which I might be inadvertently blaming the recipient of abuse or violence rather than the perpetrator, however these roles were acted out by Mary and Mark, and that either of them could bring up this topic at any time, either in sessions or by calling me.

I proposed a hierarchy for us to adopt in our work, beginning with “Safety First”, for Mark and Mary (as well as neighbors, police, and others affected by the anger and violence in their relationship). This meant that anyone ~ Mary, Mark or I ~ could call 911 or anyone else we thought would be helpful in insuring everyone’s safety. This was followed closely by establishing “personal-truth telling” as the standard for statements made in therapy as well as at home; i.e., using “I-statements” whenever possible and relative language rather than absolutes, particularly when describing the other (as in “it felt cruel to me” rather than “it was cruel” or “sometimes you…” rather than “you always…”).

Considering that Mary already took some responsibility for her violence and had enrolled in a weekly batterers’ treatment program; was being supervised by Marin County Probation (which I knew would include, from previous work with BBF clients on probation, phone calls and personal meetings with the victim and other family members and neighbors, random house calls, and regular meetings with the probationer); and showed remorse and some empathy for her husband, I was willing to work with Mary and Mark. Their positive, forward-looking statements indicated that an ongoing conversation leading to positive change could be established, although only time would tell.

I should note that my interest towards their stated intentions was not whether they were believable or not (they were) but whether they could be used as benchmarks against which their future behaviors could be compared. I have found this to be a highly motivating practice for many clients who want to improve themselves and their relationships but find themselves feeling constrained by personal histories, cultural patterning, and the (usually negatively told) story of their family at the beginning of therapy.

We ended the first session by agreeing on a goal for treatment: help Mary and Mark communicate with each other about their differences in non-violent and more respectful ways. In practical terms, this would look like Mark being more assertive and Mary using less abusive and less violent ways of expressing her anger. I asked if anyone thought that Mark needed help with expressing anger nonviolently or Mary with speaking out more loudly ~ none of us did.

Privately, I also held an additional goal for Mary and Mark ~ I hoped that each could learn to take better care of themselves on their own, given Mary had already shown an unhealthy dependence on Mark for meeting her needs and that Mark felt that this was appropriate in some ways.

From the standpoint of attachment theory, Mary could be viewed as having a disorganized attachment style with extreme ambivalent features. She became highly agitated or angry, even violent, on occasions of unstructured or spontaneous separation from Mark ~ in fact, her arrest followed an argument about whether Mark ought to go to the store for milk even though Mary wanted him to stay with her. She had trouble caring for herself while alone for long periods of time. Yet, instead of welcoming Mark when he was available to be with her, Mary often attacked him verbally regarding their times apart. “Why did you take so long to come home?” was a common question, according to Mark, that Mary asked him upon arriving home at night. Mark could be viewed as having an avoidant attachment style in that he was happier apart from Mary in some ways than he could be when he was with her. Of course, Mark’s tendencies to isolate from Mary were in some respects a response to her excessive need for his company, which in turn was exacerbated by his isolating behaviors (such as going to sleep early).

I sent them home each with a copy of a handout I have adapted and successfully used with couples as well as anger management and domestic violence group clients, included here as Appendix A (Scotberg, 2002). This set of standards for healthy relationships was intended to further several treatment goals: the opening formula offers a clear alternative to the codependency apparent in Mary’s need for Mark to be there for her and to comply with even unreasonable requests as well as Mark’s fears of upsetting Mary versus taking more responsibility for getting what he needed from Mary, especially nonviolent and respectful behavior towards him. The list of “behaviors that interfere with a good relationship” on the handout provided a way to further assess the level of violence or abuse in the relationship, as well as naming it for the couple, in particular for Mark. And the “responsibilities of a good relationship” made clear at the beginning of our work together that I, as a therapist, was promoting relationships with balance and respect for all participants ~ this would give Mark and Mary more information on which to base their decision to return to work with me, as well as give them an opening to raise a different set of standards in response if they wished.

SESSION TWO:

They returned six days later. (Due to work schedules for the couple and myself, our appointments all began between 7 and 7:45pm. This became a factor as we began to focus on sleep concerns in later sessions.) Mary began by asking if confidentiality in our sessions would be threatened if she spoke of behavior that violated the terms of her probation. Although I said that I could not break confidentiality for past behavior, I asked her to consider whether she would rather be honest here in our sessions and with her husband, her Probation officer, and others in her life or would she like to be someone who lied or hid parts of her life from us. She admitted to a preference for honesty, and Mark agreed honesty was what he preferred as well. But I also made it safe for Mary to withhold information in treatment if she felt it was not in her own best interest by asking both her and Mark if that was important for either of them; they said it was. In the process, Mark acknowledged, “Sometimes I might be too willing to give in when Mary gets upset.” Mary enthusiastically agreed and said she wanted Mark to be more honest with her.

This conversation was part of my ongoing efforts to help Mary and Mark establish clear goals and standards, even ones they might not be ready to actualize. Rather than focus exclusively on Mary’s violence or other problems in their marriage, I think it can be very helpful to engage clients in positive, forward-looking conversations, using questions like, “Five years from now when your life is working again, what about yourself now will you look back on as having contributed to your healing?” I continued in the same vein by revisiting the previous week’s handout and asking them if they had questions or comments or perhaps disagreed with anything on the table or found something important to be missing.

It was also important to continue practicing with the couple the naming of abusive or violent behavior. So we discussed which behaviors were common among them from the list of “behaviors that interfere.” Mary acknowledged engaging in most of the top half ~ including physical and emotional violence, threatening words and actions, abusive anger ~ whereas they both agreed that Mark tended to block and withhold.

I finished this second session by giving them a handout on “Structured Time-Outs” we use in the BBF program (Appendix B) and saying that it was an important tool to learn if they wanted to realize some of the relationship goals we had been discussing. We reviewed the main points and Mary and Mark agreed that, in the coming week, they would each practice using time-outs as a way to soothe themselves and not to control the other.

SESSION THREE:

Our third session was a full one (we went over by 15 minutes) in which we continued to introduce many of the primary concepts I think are essential to reducing anger and ending violence in relationships. First, Mark and Mary each spoke with a lot of energy about their experimenting with time-outs. Mary found it particularly distressing when Mark took a time-out for more than 15 minutes; she had worries he might not return, wondered how upset or hurt he was, and berated herself for “being bad” again. Conversely, Mary found it somewhat distressing to take a time-out because she became focused on being alone and didn’t feel calmed or relaxed; she did acknowledge, though, that she, too, was only staying away for 15 minutes or so. I reemphasized the biological factors, including dropping adrenalin levels in our blood stream and returning blood flow to the cerebrum, that suggested longer durations for one’s (successful) time-outs. To reduce their anxiety, I suggested they try doing time-outs literally as a practice, i.e. taken during a time of harmony between them rather than stress or upset. And, not wanting to struggle with Mary’s defenses (evidenced in the limited tolerance she had for separation from Mark at times of disagreement), I suggested they do the time-outs for only 5 minutes; this, I explained, would be permissible in a practice time-out, since they would be doing them when they were feeling calm and okay about their situation at the moment.

Next, I initiated a discussion with an accompanying handout (Appendix C) about the differences between passive, passive-aggressive, aggressive and assertive communication styles and asked Mark and Mary to identify their own predominant styles, or combination thereof. Mary spoke out immediately. “Oh, I’m the aggressive one, no doubt.” Mark said quietly, “I guess I’m more passive but I don’t want to admit that, somehow…” Mary leaned over, said, “Awww”, and she and Mark kissed quickly.

Mark had reported and exhibited with me fear of Mary’s reactions to his feelings, especially anger or disappointment; Mary could become “hurt” (her word) if Mark thought badly of her and he acknowledged his tendency to “let things go”, meaning he would overlook minor transgressions of Mary’s because he didn’t want to face her disappointment. Could it be that some of Mary’s aggressiveness was related to efforts on her part to get more information from Mark about his feelings? This was still controlling behavior, of course, and no excuse, but it could indicate that, while working to reduce codependency by helping Mark to be more assertive, we might also help support empathic behavior between Mary and Mark that could become the new norm for them and help eliminate Mary’s violent behavior.

We finished by setting up their next “homework assignment”, as they had begun to call it despite my repeated assurances that these were suggestions. (The label may have signified something reassuring for them, or they may have been making clearer that they still felt apart from me.) I had in mind for Mary and Mark an exercise I first learned as a participant in the Insight “Awakening Heart” seminar I attended over 20 years ago (see www.insightseminars.org). In this exercise, each person takes turns telling the other something he or she dislikes or wants to change about the other; the recipient responds with a spoken, formulaic answer: “Thank you for caring enough to share that.” Then they take turns sharing something positive about the other; the structured response is: “I know.” This exercise potentially gives the participants practice in unapologetically accepting praise (which can deflect or undermine it) and in more calmly accepting criticism. I was curious if Mary and Mark would be willing or able to practice it at home.

I then presented a short description of the “cycle of violence”, which I described as a pattern occurring in many relationships wherein a “honeymoon” period of bliss is followed by a period of increasing stress, with disagreements and confrontations escalating in seriousness, ending with an abusive or violent explosion of anger and consequent separation, cooling down, and a resumption of the honeymoon phase. How can one intervene, given this pattern? We usually don’t want to “rock the boat” during the “honeymoon cruise”, nor do the initial or even medium-level upsets of the tension-building phase seem to warrant any comment ~ they’re “minor”, after all. And the explosion, once it occurs, is usually unstoppable and few people can listen or think during these confrontations. The answer, I suggested, was to intervene all along the way. The honeymoon phase presented an ideal time to raise difficult concerns; it’s a time when we’re most connected, probably calmest and most secure, and most likely to be able to listen and respond appropriately. During the tension-building phase, we should indeed mention, albeit respectfully and productively, many of the “minor” upsets of the day, the better and sooner to resolve them before they “get out of hand”. Finally, there is a way to intervene in the explosion ~ take a structured time-out as soon as we realize we’re involved, either as perpetrator or victim or both, in an abusive or violent interaction.

Both Mary and Mark expressed interest in “trying all of this at home”. We agreed to meet in two weeks because of scheduling issues.

SESSION FOUR:

Mary and Mark began by speaking at length about the progress they’ve seen at home between them. They had whole-heartedly taken to the “practice” timeouts and found that, by doing that every evening, they had reduced their conflicts and increased their sense of connection. (They held hands on the couch and sat closely together during most of the session.) They also felt that this had also contributed to an improvement in their ability to discuss problems, their initial treatment goal. I cautioned, as I often do when clients report early successes in therapy, “Progress can sometimes look like ‘two steps forward, one or two steps back’.” (I learned a while ago that, besides helping to avoid unrealistic expectations in clients, this statement invites a restatement by the client of the progress. It is always better for the client to be dragging us along the path to health than the other way around.)

They also said they had practiced the “praise and criticism” exercise and that they had seen how they could use this as well to improve their ability to communicate about disagreements. I wondered silently if a physicalization of their patterns of struggle or control could be helpful, perhaps to me as an assessment tool but preferably for them as an externalization and demonstration as well. So I suggested that we try an exercise together right there in the room instead of sending them home to try it. As always, I described the exercise first and emphasized that they could “take it or leave it” after hearing what was involved. I also emphasized that I thought it might be helpful for at least one of us.

This exercise was introduced to me as part of the “comprehensive” training in Hakomi Therapy I completed in 1998. (See www.hakomiistitute.com for more information.) A power and control exercise, it works like this: two people each take the part of “leader” and “follower” during three separate but related experiments. In all three experiments, the leader and follower begin by standing a little more than arm’s length apart facing each other. The leader holds his or her hand palm up at arm’s length extended in front and six inches or so from the follower’s face. The leader can but is not required to move their hand anywhere in the room, as long as he or she complies with two firm rules: the hand can only be moved at a pace slow enough to allow the follower time to move with the hand; and the leader must safeguard the follower at all times, i.e. not lead him or her into any dangerous situations. The follower must try to keep his or her face at the same six-inch distance from the leader’s hand throughout the experiment until told that time is up (about a minute). In the second experiment, the parties switch roles so that the follower is now the leader and vice versa. In the third experiment, both parties hold their hands out in front of the other’s face; both parties are the leader and the follower together. They must learn how to move, if they choose, while they compete or cooperate, depending on whether they struggle with their apparently conflicting roles or whether they discover ways to minimize conflict. I have seen this exercise used successfully (and have participated myself several times, as a therapist/student and in my own marriage counseling). It usually brings out either sadistic or otherwise controlling behaviors, sometimes from both participants, for all to see. It can also be a fun exercise during which people often giggle or laugh.

We took some time to outline and agree on the rules and then took about five minutes to run through each portion of the exercise. What appeared to me to happen was that they barely moved at all, standing almost motionless regardless of who was leader or follower. Each spoke afterwards about not wanting to challenge or upset the other. There was very little energy and neither demonstrated much in the way of controlling or sadistic behavior. The results were different than I expected and Mary and Mark later said they felt they didn’t get much from it.

SESSION FIVE:

After the previous week’s experiment, I thought it might be more helpful for me to shift to a more receptive and listening stance instead of the more directive and active stance I had employed to-date. As I often do, I engaged them at first in a review of last session for a few minutes (in which they reiterated their “ho-hum” experience in the exercise we’d tried). But for much of the session I listened to them speak about their experiences since our last meeting (again, two weeks earlier).

Each talked together and separately about several incidents in which Mary got upset but handled it by taking a “real” timeout (albeit for only 20 minutes). She found she could sit in her car outside their home with the radio playing soothing music and calm herself down. They both also spoke at length about ways in which Mark was “speaking up a little more” about feeling hurt or attacked by Mary’s words and anger.

They also spoke again of an ongoing problem for them that they’d mentioned early on ~ Mary didn’t want Mark to go to sleep in the bedroom while she was still awake in the living room, even though this is about ten feet away or when the bedroom door is left open. Mary spoke at length about how angry she got that Mark wouldn’t give her this “little bit” of support when she “needed it”. Mark said “it really wasn’t a problem” for him to sleep on the couch while Mary worked at the dining room table, their current compromise on the issue. When Mary was ready to go to bed, she’d wake Mark (gently, both reported) and they’d go to bed for the night. This practice had meant that Mark often felt he was not getting enough “quality” sleep because he was awakened after a few hours and because he worried all evening as this arrangement’s time approached whether Mary would get upset again. We ended the session agreeing that this recurring situation would be our focus next week.

Towards the end of the session, Mary said they’d be away for several weeks in August; the next appointment we could arrange was a month later. I noted that this meant a longer time between sessions than previously taken and wondered whether it might mean that they were concerned about our sessions in some way. Mark admitted that money had become a problem for them and that he felt the sessions were helpful but got “a little stressed” about paying for them, given his uncertainties about his job and their finances. I saw immediately a way in which I could be “punishing the victim” if I pressed for more sessions. Considering their overall progress and this particular scheduling issue, it seemed best to make the appointment when we could and not make too big of an issue about it at the moment.

SESSION SIX:

We reviewed their previous month of travel (to see her parents in Wyoming) and then shifted to a more detailed discussion of the sleeping issue. I engaged them in a conversation about the exact ways in which this problem manifested, including questions such as “What time and in what room?”, “Who speaks first and what is said?” and “How do you feel, Mark, and you, Mary, when that happens?” Then I asked them whether this happened every night and if not, why not? Not so surprisingly, there were occasions when (a) Mary went to bed at the same time as Mark wanted to; (b) Mark didn’t want or need to go to bed any earlier than Mary; or (c) Mary “didn’t mind” if Mark slept in the bedroom (usually because she would read in bed beside him). We then spent a fair amount of time wondering about what miht contribute to these exceptions to the rule and how they might be able to “encourage” more of them. I imagined that, by pointing out exceptions to their problem-focused story of their evenings together, I might enable them to develop some hopefulness about solving their problem. And, at first, this seemed to have occurred. Both Mark and Mary spoke in the session about how “it’s not all bad” and “we don’t always argue about this”. But another scheduling issue due to the approaching Labor Day holiday (and their finances) led to scheduling our next appointment four weeks away.

SESSION SEVEN:

Mary and Mark arrived visibly uncomfortable about being there and soon revealed their reason: they had had a “relapse”, in other words, a big fight, just last week, when Mark had tried to take a “practice” time-out (a now regular practice in their home) by sitting at the computer to play video games. The difference for Mary seemed to be that, when he sat outside or took a walk, she “knew he was working on their relationship” but felt the opposite when he sat at the computer. She argued that, since he had other options, he shouldn’t use one that upset her. We spent the next 30 minutes discussing options for how Mary could soothe herself when she got upset at Mark, as well as acknowledging that Mark seemed to be more willing to risk upsetting Mary if he felt he was taking care of himself (“Thanks a lot!”, Mary complained.)

I was concerned that our month-long break had contributed to their problems rather than relieving them. But then they gave me reason to adopt a more positive attitude about their prognosis. Mary surprised me by saying that their “sleep problem” had improved. Mark had slept in the bedroom, with the door open, while she watched television in the living room. Also, Mark was able to sleep with “much less anxiety” about how Mary was feeling. For her part, Mary said she thought about how she could calm down in a timeout and tried to “feel the same way”. We agreed to meet in three weeks.

SESSION EIGHT:

This session began with an extended description by Mary and Mark of the several ways they have been working on the “sleep problem” and seeing some progress in their goal of communicating about their differences more respectfully. But then Mary again surprised me by saying that she had noticed how upset she got if, when she was taking a time-out, Mark was sitting at the computer. Somehow, she felt this was “abandoning her” and that he should be “sharing my experience if he loved me”.

This led to a discussion of independence, interdependence and codependence. I likened the latter to a model of relationship in which each of two people is leaning on the other, making in effect an A-frame; neither party can move away without the other falling, and lifting the fallen one up from flat on the ground could be difficult. Independence is when neither person leans on the other but stands on his or her own two feet; in this scenario, either can move as far or as close to the other without causing anyone to fall. Interdependence is when two independent people choose to associate for mutual support while standing and moving on their own. Moreover, as a self-supporting person, one can better stop the other’s fall, catch them part-way to the ground and help them stand again much more easily than lifting them completely up. We ended there.

SESSION NINE:

Meeting again 3 weeks later, Mary spoke in this session about her batterers’ treatment groups for the first time since we began working. She had some resentments about the group leader and we spent some time discussing among us how Mary could (a) soothe herself and (b) communicate. (See Appendix A: “Self-soothe. Self-assess. Self-report. Self-soothe.”) For the first time we discussed explicitly the self-assessment skills needed to take a time-out before getting too upset. But Mark changed our focus by speaking about their respective families and their effects on his relationship with Mary. He felt that his own family, though living close by in the Bay area, were not nurturing of Mary and that she was mostly alone here in California where he had wanted them to move the year before. Mary started crying, saying she did feel lonely but that she wanted her marriage with Mark to be the one that replaced all others. This admission was followed by much hand-holding and quick kissing between them as Mark seemed to comfort her. Mark led the discussion to his family again, speaking about their religious beliefs and how they grated on Mary. We ended inconclusively.

SESSION TEN:

This session occurred a month later, after Thanksgiving had come and gone, and much of the session was taken up by a discussion of Mark and Mary’s experiences visiting Mark’s parents for the holiday. Mary felt that Mark’s parents were cold towards her while Mark differed, seeing them as “still getting to know you”. In the process, it was mentioned that Mark’s household had been “calm and quiet” in his memory of growing up while Mary’s family was large (four siblings), loud and boisterous (a farming family), and somewhat overwhelming for her. I noted the differences and wondered aloud if either one saw how their families could have contributed to their expectations and standards about marriage. Mark said he thought that he had problems dealing with Mary’s anger because it was so “foreign” to him. Mary said she felt that Mark was too easily disappointed in her because of that.

Before we could explore family-of-origin issues further, though, they spoke about recent “challenges” that Mark felt had arisen regarding Mary’s anger; he wanted to be able to go to the computer without Mary getting upset and she still felt this was disrespectful. I noticed, though, that the tenor of their story had changed. Although Mary still got upset, she was self-soothing in almost all the incidents they discussed by taking a time-out or using some other technique we had discussed or learned in her group meetings. They discussed as well several ways in which they felt they had worked on their “sleep problem”. I ended the session feeling that they were making progress.

SESSION ELEVEN:

This proved to be our last session, although it began like many others. We had last met a month before; during the intervening weeks, Christmas, Hanukah and New Year’s Day had come and gone, as well as, perhaps more significantly, Mary and Mark’s first wedding anniversary (December 31st). They spoke for several minutes about the fact that, much more often than before, Mark slept in the bedroom when he felt tired and Mary either joined him or stayed up doing whatever she was doing (watching television, reading, and so on). They had also reached a provisional compromise regarding Mark’s use of the computer, a ritual in which Mark notified Mary several hours ahead of time when he planned to be using the computer and Mary could thereby “get ready” through self-talk and other self-soothing tools we had discussed.

I then introduced to them a meditation exercise for us to do together in this session or next in which one “scans” one’s body by directing our attention to each part of the body beginning with the soles of our feet and ending at the top of our head after observing briefly everything in between. I offered it as a self-soothing as well as a self-study tool, but Mark cut me short in my description by saying, somewhat haltingly, that he and Mary wanted to “take a break from couples counseling for a while”.
I was completely surprised. I asked if this meant we would not meet again ever or if they wanted to suspend meeting for a fixed period of time and then resume. Mary and Mark held hands throughout this part of our session and kept looking at each other, as if for reassurance.

Mark said, “Money is part of it…but…I think we should…we should be able to work on this on our own.”

I asked if he could explain further what his concern was.

“I’m worried…that we’re not going to know how to do this…on our own if we…don’t take a break.”

“So you’re worried, if I understand you correctly,” I said, “that you won’t learn how to practice the things you’ve learned or treat each other respectfully if you don’t have the ‘crutch’ of therapy, is that it?”

Mary nodded vigorously and agreed. Mark interrupted her, though, to say, “I want to know that we have learned something we will know in ourselves without you reminding us.”

We had only a few minutes left in our session. I suggested we meet for one last session in which we could use the full amount of time to review and in several other ways maximize their benefit from the work they’d done. Mark replied, “We’ll think about it and call you.” I then spent a minute or two, suspecting this might be my last chance, to remind them of the number of sessions and calendar time they had spent working with me and what I remembered they had worked on. I asked if they felt they had benefited ~ they immediately agreed and, for a moment, it felt again that we were in the middle of our work rather than at the end. Mary spoke for several minutes (we ran over again) about how her weekly groups and our now monthly couples therapy had made a significant improvement in her feelings of hopefulness for their relationship. Mark spoke about the growth he’d seen in Mary’s ability to calm herself when angry and Mary responded by speaking of Mark’s increased assertiveness at home. We ended with mention of a possible phone call the following week to discuss a final session, but the message I left for them was not returned.

Assessing their Treatment

Given that, during our work in couples therapy, Mary attended a weekly batterers’ treatment program, it is hard to know, perhaps more than with other couples I have treated, how much our sessions contributed to Mark and Mary’s progress. The abbreviated termination process we engaged in did not provide as much time for acknowledging their successes and pointing towards future issues as I would have liked; I prefer at least two sessions for summing up and cleaning up any loose ends, if necessary.

Despite this and other problems that arose in the course of treatment, I see several ways in which Mary and Mark grew more respectful and responsible with each other during the time I knew them. Mary no longer exploded into anger after badgering Mark about some concern or other of hers ~ instead, she was now more likely to take a time-out or retreat from angry communications into more cooperative and empathetic conversation. Mark was more likely to assert his needs even if Mary might get angry, and he had shown himself more able to stand his ground in disagreements in the face of Mary’s distress, as when he went to sleep sooner in the evening without worrying as much about Mary’s reaction.

But we had only begun to scratch the surface of their respective family-of-origin issues, nor had I had much success in trying to direct our discussions towards a consideration of individual therapy for Mary and Mark. Mary exhibited attachment disturbances in her clinging and dependent behaviors, and Mark’s story of “no anger in my family growing up” left me wondering whether that could be entirely accurate, given the passive-aggressiveness shown when Mark played computer games to avoid resolving issues with Mary.

Perhaps the changing schedule of our sessions made it difficult to realize more results. We met initially once a week for three sessions. Significant progress was reported by the third session; we changed to a biweekly schedule for a month. After more progress was shown by the 5th session (at the end of July), we met thereafter once a month until terminating therapy after the 11th session. It seemed at each juncture that the increasing gaps in our schedule were preceded by signs that Mark and Mary were benefiting.

It may also be that our shift to a more talk-oriented approach was not as helpful as I imagined it would be. Although they reported progress even in the last session, Mary was still prone to strong feelings of abandonment and Mark was, by his own admission, still learning how to assert himself with her. It may be that more skills instruction and additional psychoeducation would have engaged the couple in their treatment for a longer period of time.

In conclusion, it seems that Mary and Mark benefited somewhat from the combination of couples therapy and batterers’ treatment groups. One can imagine that the contributions commonly found in the latter ~ requiring accountability and promoting responsibility and empathy ~ were impacting Mary positively and perhaps Mark as well. Their apparent ability to use didactic interventions to improve their relationship suggests that further work in that modality could have provided additional benefit.

References

Jenkins, A. (1990). Invitations to Responsibility: the therapeutic engagement of men who are violent & abusive. Adelaide: Dulwich Press.

Kurtz, R. (1990). Body-Centered Psychotherapy: The Hakomi Method. Mendocino: LifeRhythm.

Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing (2nd. Ed.). New York: Guilford Press.

Scotberg, Susan “Kass”. (2002) “The Goals of a Good Relationship”. Mill Valley: Private Practice.

Sonkin, D. (2005). “Attachment Theory and Psychotherapy”. In The Therapist, January/February 2005 issue. San Diego: California Association of Marriage & Family Therapy.

Sonkin, D. & Dutton, D. (2003). “ Treating Assaultive Men from an Attachment Perspective”, in Dutton, D. & Sonkin, D. (eds). Intimate Violence: Contemporary Treatment Innovations. New York: Haworth Publishing.

White, M. & Epston, D. (1990). Narrative Means to Therapeutic Ends. New York: W. W. Norton & Company.

Various (2007). “Holistic health”, subject topic on Wikipedia: The Free Encyclopedia (http://en.wikipedia.org/wiki/Holistic_health). St. Petersburg: The Wikimedia Foundation, Inc.