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Couple Therapy for Depression
Competency Framework
September 2010
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IAPT Programme - Competency Framework for Interpersonal Psychotherapy (IPT)
Introduction
This document details the competences that staff delivering
Couple Therapy for Depression need to demonstrate to work
in IAPT services. The work to derive these competences was
commissioned by the Improving Access to Psychological
Therapies (IAPT) programme.
The updated NICE Guidelines for Depression (available at
www.nice.org.uk) indicate that these therapies can all be
effective treatments for depression, but not all therapies will
be effective for all patients. In November 2009, the IAPT
programme embraced this advice and committed to making
these therapies available in IAPT services.
The publication of the competency frameworks, for the
modalities additional to the previously published framework for
Cognitive Behavioural Therapy (CBT), is a key milestone for
the programme.
You can find out more about the Improving Access to
Psychological Therapies Programme and download all the
competency frameworks by visiting www.iapt.nhs.uk
While NICE recommends a range of interventions, based on a
wide-ranging evidence base, for the treatment of depression,
choice of therapy and treatment should be made at a local
level with the full involvement of the patient, supported by
good quality patient information.
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IAPT Programme - Competency Framework for Interpersonal Psychotherapy (IPT)
Couple Therapy for Depression
a)
to directly relieve the depressed feeling in the patient
seeing their relationship as constituting a third element that
has the potential to supplement or diminish the resources of
each partner.
Therapists need to have the ability to
understand couple relationships as self-regulating systems
while not losing sight of the individual impact on the system of
each partner’s constitutional and characteristic profile
(physical, psychological and relational). Therapists also need
to have the ability to understand couple conflict as resulting
from intrapsychic as well as interpersonal meanings, linking
individual perceptions and relationship ‘events’. In addressing
the complex strands of perspectives, actions and meanings
that constitute a couple’s experience, the therapist must be
able to act in a manner that assures both partners that their
position is recognised and respected, especially when that
position may be disagreed with.
b)
to work on the precipitating and maintaining elements
of the couple relationship that are known to have a
direct effect on the incidence of depression
Couple Therapy for Depression aims to improve the overall
quality of a couple’s relationship as poor relationship quality is
known to be a precipitating factor in depression.
Couple Therapy for Depression is a brief (20 session)
integrative treatment for depression for couples where there is
both relationship distress and depression in one or both
partners. It has been developed by identifying best practice in
a range of couple therapies as seen in random controlled
effectiveness trials. Taken together these represent good
clinical practice in the treatment of depression.
Couple Therapy for Depression is specifically designed to
address presenting symptoms of depression and for delivery
within the context of the IAPT programme. It is an add-on skill
to existing advanced competence in Couple Therapy.
Couple therapy has a dual aim:
The model focuses on the relational aspects of depression
and on factors that reduce stress and increase support within
the couple. These are broken down into
• Relieving stress and improving communication;
Managing feelings and changing behaviour
• Solving problems and promoting acceptance
• Revising perceptions.
The core of the model is the ability to implement couple
therapy in a balanced manner that keeps the focus on the
couple relationship without discounting the two individuals
who comprise it. This is sometimes referred to as seeing the
‘couple as patient’, and requires a perspective that takes full
account of how each partner acts on, and is acted on, by the
other. By focusing on the interaction between partners, and by
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Competency Map
applying their skills; to think not just about how to implement
their skills, but also why they are implementing them.
Why identify competences?
The IAPT programme involves delivering high quality
treatments, and this requires competent practitioners who are
able to offer effective interventions. Identifying individuals
with the right skills is important, but not straightforward.
Within the NHS, a wide range of professionals deliver
psychological therapies, but there is no single profession of
‘psychological therapist’. Most practitioners have a primary
professional qualification, but the extent of training in
psychological therapy varies between professions, as does
the extent to which individuals have acquired additional postqualification training. This makes it important to take a
different starting point, identifying what competences are
needed to deliver good-quality therapies, rather than simply
relying on job titles to indicate proficiency.
Beyond knowledge and skills, the therapist’s attitude and
stance to therapy are also critical – not just their attitude to the
relationship with the client, but also to the organisation in
which therapy is offered, and the many cultural contexts within
which the organisation is located (which includes a
professional and ethical context, as well as a societal one). All
of these need to be held in mind by the therapist, since all
have a bearing on the capacity to deliver a therapy that is
ethical, conforms to professional standards, and which is
appropriately adapted to the client’s needs and cultural
contexts.
The development of the competences needs to be seen in the
context of the development of National Occupational
Standards (NOS), which apply to all staff working in health
and social care. There are a number of NOS that describe
standards relevant to mental health workers, downloadable at
the Skills for Health website (www.skillsforhealth.org.uk).
---------------------------------A competent clinician brings together knowledge, skills and
attitudes. It is this combination that defines competence;
without the ability to integrate these areas, practice is likely to
be poor.
Clinicians need background knowledge relevant to their
practice, but it is the ability to draw on and apply this
knowledge in clinical situations that marks out competence.
Knowledge helps the practitioner understand the rationale for
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Competency Map Explained
The Competency Map
The competency map for each of the modalities organises the
competences into a number of domains and shows the
different activities which, taken together, constitute each
domain. Each activity is made up of a set of specific
competences. The maps show the ways in which the
activities fit together and need to be ‘assembled’ in order for
practice to be proficient. The descriptions below give details of
the competences associated with each of these activities.
Generic Therapeutic Competences
Generic competences are employed in all psychological
therapies, reflecting the fact that all psychological therapies,
share some common features. For example, therapists using
any accepted theoretical model would be expected to
demonstrate an ability to build a trusting relationship with their
clients, relating to them in a manner that is warm, encouraging
and accepting. They are often referred to as ‘common factors’.
Basic Competences
Basic competences establish the structure for therapy and
form the context and structure for the implementation of a
range of more specific techniques. This domain contains a
range of activities that are basic in the sense of being
fundamental areas of skill; they represent practices that
underpin the modality.
Specific applications
Even within the same therapeutic approach there can be
slightly different ways of assembling techniques into a
‘package’ of intervention. Where there is good research
evidence that these different ‘packages’ are effective it makes
sense to describe them, so that clinicians know how these
specific intervention are delivered.
Metacompetences
Metacompetences are common to all therapies, and broadly
reflect the ability to implement an intervention in a manner
which is flexible and responsive. They are overarching,
higher-order competences which practitioners need to use to
guide the implementation of therapy across all levels of the
model.
Competence Map Key:
- The competences in each of the framework maps are colour coded
under each of the headings above.
- The maps outline the competences under each heading and also group
some key competences, that are fundamental components in
demonstrating competence in that modality.
Specific Techniques
These competences are the core technical interventions
employed in the therapy. Not all of these would be employed
for any one individual, and different technical emphases would
be deployed for different problems.
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Couple Therapy for Depression (CTD)
Generic therapeutic
competences
Knowledge and understanding of
depression and mental health
problems
Knowledge of, and ability to operate
within, professional and ethical
guidelines
Knowledge of a model of therapy,
and the ability to understand and
employ the model in practice,
including the treatment of
depression
Knowledge/understanding
of the basic principles of
couple therapy
Knowledge of sexual
functioning in couples
Knowledge of depression
and the ways it manifests in
couples
Specific couple therapy
techniques
Ability to use techniques
that engage the couple
Ability to use techniques
that focus on relational
aspects of depression
Ability to use techniques
that reduce stress upon
and increase support within
the couple, for example
through:
Ability to engage client
Knowledge and experience
of working within a model
of couple therapy
Ability to foster and maintain a good
therapeutic alliance, and to grasp
the client’s perspective and ‘world
view’
Ability to assess the
suitability of couple
therapy for alleviating
depression
Ability to work with the emotional
content of sessions
Ability to identify and
manage risk
changing behaviour
Knowledge of and ability to
liaise with other services
promoting acceptance
Ability to manage endings
Ability to undertake generic
assessment (including relevant
history and identifying suitability for
intervention)
Ability to assess and manage risk of
self-harm
Ability to work with difference
(‘cultural competence’)
Ability to make use of supervision
Ability to use measures to guide
therapy and monitor outcomes
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Basic couple therapy
competences
improving
communication
coping with stress
Specific adaptations of
couple therapy for
Behavioural Couple
Therapy
Metacompetences
Generic metacompetences
Capacity to use clinical
judgement when
implementing therapy
Marital Therapy for
Depression (MTD) Beach
et al.., 1990.
Capacity to reflect critically
on the experience of
therapy
Conjoint Marital
Interpersonal
Psychotherapy (IPT-CM )
Rounsaville et al, 1986.
Coping Oriented Couple
Therapy (COCT)
Bodenmann, G & Widmer,
K., 2008.
Capacity to convey and
respond to interest, affect
and humour
Specific metacompetences
managing feelings
solving problems
Capacity to work reflexively
with complex relational
systems
Capacity to manage the
tension between competing
duties of care
revising perceptions
Capacity to work with
difference and uncertainty
Ability to establish and
convey the rationale for
couple therapy
Capacity to apply different
levels of therapeutic
response appropriately and
coherently
Ability to initiate couple
therapy
Ability to maintain and
develop a therapeutic
process with couples
Ability to end couple
therapy
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Generic Competences
Knowledge and understanding of depression and mental health
problems
•
During assessment and when carrying out interventions, an ability
to draw on knowledge of common mental health problems and
their presentation, particularly depression.
•
An ability to draw on knowledge of the factors associated with the
development and maintenance of mental health problems.
•
An ability to draw on knowledge of the usual pattern of symptoms
associated with mental health problems.
•
An ability to draw on knowledge of the ways in which mental
health problems can impact on functioning (eg maintaining
intimate, family and social relationships, or the capacity to
maintain employment and study).
•
An ability to draw on knowledge of the impact of impairments in
functioning on mental health.
•
An ability to draw on knowledge of mental health problems to
avoid escalating or compounding the client’s condition when their
behaviour leads to interpersonal difficulties which are directly
attributable to their mental health problem.
Knowledge of depression
•
An ability to draw on knowledge of the cluster of symptoms
associated with a diagnosis of depression:
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depressed mood most of the day
marked loss of interest or pleasure in daily activities
sleep problems
loss of appetite and significant loss of weight
fatigue/exhaustion
difficulties getting to sleep or excessive sleep
psychomotor agitation (feeling restless or agitated) or
psychomotor retardation (feeling slowed down)
feelings of worthlessness or excessive guilt
low self-confidence
difficulties in thinking/ concentrating and/or indecisiveness
recurrent thoughts of death, suicidal ideation, suicidal
intent (with or without a specific plan)
•
An ability to draw on knowledge:
• that a diagnosis of depression is based on the presence of a
subset of these symptoms
• that of these symptoms, depressed mood; loss of interest or
pleasure; and fatigue are central
• that symptoms need to be present consistently over time (e.g.
DSM-IV-TR criteria specify two weeks, ICD-10 criteria specify
one month)
•
An ability to draw on knowledge of the diagnostic criteria for all
mood disorders (including minor depression/dysthmic disorder and
bipolar disorder) and to be able to distinguish between these
presentations
•
An ability to draw on knowledge of the incidence and prevalence
of depression, and the conditions that are commonly comorbid
with depression
•
An ability to draw on knowledge of the patterns of remission and
relapse/ recurrence associated with depression
•
An ability to draw on knowledge of factors which are associated
with an increased vulnerability to depression e.g.:
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developmental risk factors (e.g. temperament)
quality of early experience with parents or significant others
quality of relationships with partner, family and significant
others
quality of current social relationships
social isolation
major adverse life-events (e.g. childhood abuse or neglect,
financial loss, unemployment, separation from a partner,
bereavement, retirement)
major life-transitions (e.g. becoming a parent)
acute and chronic physical illness (both in the client and in
significant others)
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•
•
•
• recognition of the limits of competence and taking action to
enhance practice through appropriate training/professional
development
An ability to draw on knowledge of the impact of depressive
symptoms on the client’s functioning (e.g. in interpersonal and
work domains), and the fact that difficulties in functioning can (in
turn) contribute to depressive symptoms
• protecting clients from actual or potential harm from
professional malpractice by colleagues by instituting action in
accordance with national and professional guidance
An ability to draw on knowledge of the evidence for the
effectiveness of psychological and psychopharmacological
interventions for depression, and their effectiveness in
combination
• maintaining appropriate standards of personal conduct for
self:
a) a capacity to recognise any potential problems in
relation to power and ‘dual relationships’ with clients, and
to desist absolutely from any abuses in these areas
An ability to draw on knowledge of the ways in which depression is
conceptualised within the model of therapy being adopted
b) recognising when personal impairment could influence
fitness to practice, and taking appropriate action (e.g.
seeking personal and professional support and/or
desisting from practice)
Knowledge of, and ability to operate within, professional and ethical
guidelines
Knowledge of guidelines
•
An ability to maintain awareness of national and local codes of
practice which apply to all staff involved in the delivery of
healthcare, as well as any codes of practice which apply to the
counsellor as a member of a specific profession.
•
An ability to take responsibility for maintaining awareness of
legislation relevant to areas of professional practice in which the
counsellor is engaged (specifically including the Mental Health
Act, Mental Capacity Act, Human Rights Act, Data Protection Act).
Knowledge of a model of therapy, and the ability to understand and
employ the model in practice, including the treatment of depression
•
An ability to draw on knowledge of factors common to all
therapeutic approaches:
•
supportive factors:
o
a positive working relationship between counsellor and
client characterised by warmth, respect, acceptance and
empathy, and trust
o
the active participation of the client
o
counsellor expertise
o
opportunities for the client to discuss matters of concern
and to express their feelings
Application of professional and ethical guidelines
• An ability to draw on knowledge of relevant codes of professional
and ethical conduct and practice in order to apply the general
principles embodied in these codes to each piece of work being
undertaken, in the areas of:
• obtaining informed consent for interventions from clients
• maintaining confidentiality, and knowing the conditions under
which confidentiality can be breached
• safeguarding the client’s interests when co-working with other
professionals as part of a team, including good practice
regarding inter-worker/ inter-professional communication
• competence to practice, and maintaining competent practice
through appropriate training/professional development
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•
Ability to engage client
learning factors:
o
advice
o
correctional emotional experience
o
feedback
o
exploration of internal frame of reference
o
changing expectations of personal effectiveness
o assimilation of problematic experiences
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While maintaining professional boundaries, an ability to show
appropriate levels of warmth, concern, confidence and
genuineness, matched to client need.
•
An ability to engender trust.
•
An ability to develop rapport.
•
An ability to adapt personal style so that it meshes with that of the
client.
•
An ability to recognise the importance of discussion and
expression of client’s emotional reactions.
•
An ability to adjust the level of in-session activity and structuring of
the session to the client’s needs.
•
An ability to convey an appropriate level of confidence and
competence.
•
An ability to avoid negative interpersonal behaviours (such as
impatience, aloofness, or insincerity).
action factors:
o
behavioural regulation
o
cognitive mastery
o
encouragement to face fears and to take risks
o
reality testing
o
experience of successful coping
An ability to draw on knowledge of the principles which
underlie the intervention being applied, using this to inform the
application of the specific techniques which characterise the
model.
An ability to draw on knowledge of the principles of the
intervention model in order to implement therapy in a manner
which is flexible and responsive to client need, but which also
ensures that all relevant components are included.
Ability to foster and maintain a good therapeutic alliance, and to
grasp the client’s perspective and world view’
Understanding the concept of the therapeutic alliance
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An ability to draw on knowledge that the therapeutic alliance is
usually seen as having three components:
•
the relationship or bond between counsellor and client
•
consensus between counsellor and client regarding the
techniques/methods employed in the therapy
•
consensus between counsellor and client regarding the goals
of therapy
An ability to draw on knowledge that all three components
contribute to the maintenance of the alliance.
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Capacity to develop the alliance
Knowledge of counsellor factors associated with the alliance
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An ability to draw on knowledge of counsellor factors which
increase the probability of forming a positive alliance:
•
being flexible and allowing the client to discuss issues
which are important to them
•
being respectful
•
being warm, friendly and affirming
•
being open
•
being alert and active
•
being able to show honesty through self-reflection
•
being trustworthy
•
An ability to listen to the client’s concerns in a manner which is
non-judgmental, supportive and sensitive, and which conveys a
comfortable attitude when the client describes their experience.
•
An ability to ensure that the client is clear about the rationale for
the intervention being offered.
•
An ability to gauge whether the client understands the rationale for
the intervention, has questions about it, or is skeptical about the
rationale, and to respond to these concerns openly and nondefensively in order to resolve any ambiguities.
•
An ability to help the client express any concerns or doubts they
have about the therapy and/or the counsellor, especially where
this relates to mistrust or skepticism.
•
An ability to help the client articulate their goals for the therapy,
and to gauge the degree of congruence in the aims of the client
and counsellor.
Knowledge of counsellor factors which reduce the probability of
forming a positive alliance:
•
being rigid
•
being critical
•
making inappropriate self-disclosure
•
being distant
•
being aloof
•
being distracted
•
making inappropriate use of silence
Capacity to grasp the client’s perspective and ‘world view’
•
An ability to apprehend the ways in which the client
characteristically understands themselves and the world around
them.
•
An ability to hold the client’s world view in mind throughout the
course of therapy and to convey this understanding through
interactions with the client, in a manner that allows the client to
correct any misapprehensions.
•
An ability to hold the client’s world view in mind, while retaining an
independent perspective and guarding against identification with
the client
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Ability to work with emotional content of session
Capacity to maintain the alliance
•
An ability to recognise when strains in the alliance threaten the
progress of therapy.
•
An ability to deploy appropriate interventions in response to
disagreements about tasks and goals:
•
an ability to check that the client is clear about the rationale for
treatment and to review this with them and/or clarify any
misunderstandings.
•
an ability to help clients understand the rationale for treatment
through using/drawing attention to concrete examples in the
session.
•
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An ability to facilitate the processing of emotions by the client – to
acknowledge and contain emotional levels that are too high (eg
anger, fear, despair) and contact emotions when levels are too low
(eg apathy, low motivation).
•
An ability to work effectively with emotional issues that interfere
with effective change (e.g. hostility, anxiety, excessive anger,
avoidance of strong affect).
•
An ability to help the client access differentiate and experience
his/her emotions in a way that facilitates change.
Ability to manage endings
•
An ability to signal the ending of the intervention at appropriate
points during the therapy (e.g. when agreeing the treatment
contract, and especially as the intervention draws to close) in a
way which acknowledges the potential importance of this transition
for the client.
•
An ability to help client discuss their feelings and thoughts about
endings and any anxieties about managing alone.
•
An ability to review the work undertaken together.
•
An ability to say goodbye.
an ability to judge when it is best to refocus on tasks and goals
which are seen as relevant or manageable by the client (rather
than explore factors which are giving rise to disagreement
over these factors).
An ability to deploy appropriate interventions in response to strains
in the bond between counsellor and client:
•
an ability for the counsellor to give and ask for feedback
about what is happening in the here-and-now interaction,
in a manner which invites exploration with the client.
•
an ability for the counsellor to acknowledge and accept
their responsibility for their contribution to any strains in
the alliance.
•
where the client recognises and acknowledges that the
alliance is under strain, an ability to help the client make
links between the rupture and their usual style of relating
to others.
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•
an ability to allow the client to assert any negative
feelings about the relationship between the counsellor
and themselves.
an ability to help the client explore any fears they have
about expressing negative feelings about the relationship
between the counsellor and themselves.
Ability to undertake a generic assessment (including relevant history
and identifying suitability for intervention)
•
An ability to obtain a general idea of the nature of the client’s
problem.
•
An ability to elicit information regarding psychological problems,
diagnosis, past history, present life situation, attitude about and
motivation for therapy.
•
An ability to gain an overview of the client’s current life situation,
specific stressors and social support.
•
An ability to assess the client’s coping mechanisms, stress
tolerance, and level of functioning.
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•
An ability to help the client identify/select target symptoms or
problems, and to identify which are the most distressing and which
the most amenable to intervention.
•
An ability to help the client translate vague/ abstract complaints
into more concrete and discrete problems.
•
An ability to assess and act on indicators of risk (of harm to self
or others and the ability to know when to seek advice from
others).
An ability to gauge the extent to which the client can think
about themselves psychologically (e.g. their capacity to reflect
on their circumstances or to be reasonably objective about
themselves).
An ability to gauge the client’s motivation for a psychological
intervention.
An ability to discuss treatment options with the client, making
sure that they are aware of the options available to them, and
helping them consider which of these options they wish to
follow.
An ability to identify when psychological treatment might not be
appropriate or the best option, and to discuss with the client
(e.g. the client’s difficulties are not primarily psychological, or
the client indicates that they do not wish to consider
psychological issues) or where the client indicates a clear
preference for an alternative approach to their problems (e.g. a
clear preference for medication rather than psychological
therapy).
•
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Ability to assess and manage risk of self-harm
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•
An ability to draw on knowledge of indicators of self–harm, and to
integrate research/actuarial evidence) with a structured clinical
assessment and the exercise of professional judgment in
appraising risk
•
An ability to draw on knowledge of the limitations of using risk
factors to predict self-harm:
• that risk factors identify high risk groups rather than
individuals
• that because suicide is a relatively rare event it is difficult to
predict at the level of the individual:
even where accurate systems of prediction are
employed these will incorrectly identify a substantial
number of individuals as possible suicides
that because most risk factors relate to long-term risk they
are less helpful in prediction in the short-term or immediate
clinical situation
o
•
•
An ability to draw on knowledge that individuals with a history of
prior suicide have a markedly elevated risk of self-harm
•
An ability to draw on knowledge of factors associated with an
elevated risk of self-harm that apply across the population:
• childhood adversity
• experience of a number of adverse life-events (including
sexual abuse)
• a family history of suicide
• a history of self-harm
• seriousness of previous episodes of self-harm
• previous hospitalisation
• mood disorders
• substance use disorder
• a diagnosis of personality disorder
• anxiety disorder (particularly PTSD)
• a psychotic disorder (e.g. a diagnosis of schizophrenia or
bipolar disorder)
• presence of chronic physical disorders
• bereavement or impending loss (where psychological
problems preceded the bereavement)
• relationship problems and relationship breakdown
• severe lack of social support
• socio-economic factors e.g.
o
people who are disadvantaged in socio-economic
terms
o
people who are single or divorced
o
people who are living alone
o
people who are single parents
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•
An ability to draw on knowledge that individuals with depression
have a significantly elevated lifetime risk of suicide
•
An ability to draw on knowledge that the risk of suicide is highest
relatively early in a depressive episode, and less likely during
periods of remission
•
An ability to draw on knowledge that hopelessness (negative
expectations of the future) may be a more important marker of
risk than the severity of depression
•
•
•
An ability to draw on knowledge that the combination of
depression, hopelessness and continuing suicidal intent
represents a marker of elevated risk
An ability to draw on knowledge that the risk of suicide is elevated
if the following factors are present, and the person:
• has a history of previous attempts
• used a violent method in their attempt
• left a suicide note
• is older (45 and over)
• is male
• is living alone
• is separated, widowed or divorced
• is unemployed
• is in poor physical health
•
An ability to assess the client’s strengths and resources by
asking them about:
• external resources (e.g. relationship with care services, self
help groups, local associations)
• supportive relationships (e.g. a partner or close friend who
they trust and can confide in)
• personal resources (e.g. ability to suggest ways of managing
their present difficulties)
• previous patterns of coping (i.e. how they coped with
potentially stressful events in the past)
An ability to undertake an assessment which aims
• to understand the social, psychological and motivational
factors specific to the act of self-harm
• to assess the degree of suicidal intent:
• to assess current suicidal intent and hopelessness
• to assess current mental health and social needs
•
An ability to convey a nonjudgmental and tolerant attitude when
discussing self-harm with the client
•
An ability, where required, to ask direct questions to clarify an
understanding of the attempt, and the extent of suicidal intent
•
An ability to work with the client to develop a detailed sequential
account of the period leading up to self-harm, in order to identify
the events which precipitated it
Assessing risk in individuals who have self-harmed
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An ability to draw on knowledge that the risk of suicide is
particularly elevated in the three months following attempted
suicide, and that this risk remains elevated in the longer-term.
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•
•
An ability to work with the client in order to assess the degree of
suicidal intent e.g.:
• whether the event was impulsive or planned
• whether the client was alone, whether someone was present
or within easy access, whether the client was likely to be
found soon after the attempt
• whether any steps were taken either to prevent or to ensure
discovery
• if alcohol or drugs were taken prior to or during the attempt,
and the intent and/or impact of taking these substances on
the attempt
• client’s expectations regarding the lethality of the drugs or
injury
• presence of a suicide note (including recorded and text
messages)
• the client’s efforts to obtain help after the event
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•
•
An ability to ensure that (so far as is possible) the client is
involved in decisions regarding any actions to be taken to
manage risk
•
An ability to draw up an appropriate plan of action which specifies
the ways in which risk will be managed, and is tailored to the
needs of the individual
•
Where there is a clear risk of repetition, an ability to draw up a
plan which is maintained over an extended period (e.g. 3 months)
and which includes:
An ability to ask about previous acts of self harm (including the
circumstances and the level of intent)
An ability to administer and interpret standardised measures for
assessing suicidality and hopelessness (e.g. Suicide Intent Scale,
Suicide Assessment Checklist, Beck Hopelessness Scale (etc))
Management of risk of self-harm
14
•
An ability to draw on knowledge of local and national protocols
(e.g. NICE 2004) for the management of self-harm, and an ability
to ensure that actions taken comply with these protocols
•
An ability to draw on knowledge of relevant legislation (e.g.
Mental Health Act, Mental Capacity Act) when considering
admission of a client who is considered to represent a significant
risk to themselves (but is not willing to receive treatment)
the management of actively suicidal clients who refuse
intervention
decisions regarding the involvement of relatives
•
•
•
•
•
Use of standardised scales to assess risk of self-harm
•
An ability to draw on knowledge that if a standardised risk
assessment scale is used to assess risk, this should be used only
to aid in the identification of people at high risk of repetition of
self-harm or suicide
•
An ability to identify and manage ethical issues in relation to risk
management e.g.:
frequent access to a therapist when needed
home treatment when necessary
telephone contact
outreach (which include active follow-up when appointments
are missed)
•
An ability to liaise with and refer to any relevant colleagues and
services who need to be involved in delivering the plan of action,
or who need to be aware of its content
•
Where plans for the management of risk are compatible with the
maintenance of the therapeutic contract, an ability to integrate the
management of risk with the current intervention
• an ability to make appropriate modifications to a treatment
contract in order to ensure that it includes elements focus on
the management of risk (e.g. a problem-solving orientation
focused on identifying potential crises and the strategies for
avoiding or resolving these)
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•
An ability to seek supervision and/or consult with colleagues in
relation to decisions regarding risk-management
•
Ability to maintain a record of assessments and plans for managing
risk
•
•
An ability to maintain a clear and detailed record of any
assessments and of decisions regarding plans for managing risk,
in line with local protocols for recording clinical information
An ability to communicate (verbally and in writing) with relevant
clinicians and services in order ensure that all individuals or
services involved in the management of risk are appropriately
informed
• an ability to draw on knowledge of the conditions under
which confidentiality can be breached in support of the
management of risk, and the national and profession-specific
guidance which addresses this issue
•
An ability to maintain an awareness of the potential significance
for practice of social and cultural difference across a range of
domains, but including:
• ethnicity
• culture
• class
• religion
• gender
• age
• disability
• sexual orientation
•
For all clients with whom the therapist works, an ability to draw
on knowledge of the relevance and potential impact of social and
cultural difference on the effectiveness and acceptability of an
intervention
•
Where clients from a specific minority culture or group are
regularly seen within a service, an ability to draw on knowledge
of that culture or area of difference
•
An ability to draw on knowledge of cultural issues which
commonly restrict or reduce access to interventions e.g.:
• language
• marginalisation
• mistrust of statutory services
• lack of knowledge about how to access services
• different cultural concepts, understanding and attitudes
about mental health which affect views about help-seeking,
treatment and care
• stigma, shame and/or fear associated with mental health
problems (which makes it likely that help-seeking is delayed
until/unless problems become more severe
Ability to work with difference (cultural competence)
Although it is common (and appropriate) to think about ‘difference’ in
relation to specific demographic groups, this may be a somewhat narrow
perspective. There are many ways in which both therapists and their
clients could be ‘different’, partly because some areas of difference will not
be immediately apparent, and also because it is the individual’s sense of
their difference that is important. On this basis almost any therapeutic
encounter requires the therapist to consider the issue of difference.
In what follows the term ‘culture’ is sometimes used generically, so (for
example) referring to an intervention as ‘culturally sensitive’ means that
the intervention is responsive to the demographic group to which it is
applied.
•
•
15
An ability to draw on knowledge that the term ‘difference’ refers to
the individualised impact of background, lifestyle, beliefs or
religious practices
An ability to draw on knowledge that the demographic groups
included in discussion of ‘difference’ are usually those who are
potentially subject to disadvantage and/or discrimination, and it is
this potential for disadvantage that makes it important to focus on
this area
An ability to draw on knowledge that clients will often be a
member of more than one “group” (for example, a gay man with
disabilities, or an older adult from a minority ethnic community),
and that as such, the implications of different combinations of
difference needs to be held in mind by therapists
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•
•
•
An ability for therapists of all cultural backgrounds to draw on an
awareness of their own group membership and values and how
these may influence their perceptions of the client, the client's
problem, and the therapy relationship
•
An ability to take an active interest in the cultural background of
clients, and hence to demonstrate a willingness to learn about
the client’s cultural perspective(s) and world view
•
An ability to work collaboratively with the client in order to
develop an understanding of their culture and world view, and
the implications of any culturally-specific customs or
expectations, for:
• the therapeutic relationship
• the ways in which problems are described and presented
by the client
o an ability to apply this knowledge in order to
identify and formulate problems, and
intervene in a manner that is culturally
sensitive, culturally consistent and relevant
o an ability to apply this knowledge in a manner
that is sensitive to the ways in which
individual clients interpret their own culture
(and hence recognises the risk of culturerelated stereotyping)
•
16
stigma or shame and/or fear associated with being
diagnosed with a mental health disorder
preferences for gaining support via community contacts/
contexts rather than through ‘conventional’ referral routes
(such as the GP)
An ability to take an active and explicit interest in the client’s
experience of difference:
• to help the client to discuss and reflect on their experience
of difference
• to identify whether and how this experience has shaped the
development and maintenance of the client’s presenting
problems
•
An ability to discuss with the client the ways in which individual
and family relationships are represented in their culture (e.g.
notions of the self, models of individuality and personal or
collective responsibility), and to consider the implications for
organisation and delivery of therapy
•
An ability to ensure that standardised assessments/ measures
are employed and interpreted in a manner which is culturallysensitive e.g.:
• if the measure is not available in the client’s first language,
an ability to take into account the implications of this when
interpreting results
• if a bespoke translation is attempted, an ability to crosscheck the translation to ensure that the meaning is not
inadvertently changed
• if standardisation data (norms) is not available for the
demographic group of which the client is a member, an
ability explicitly to reflect this issue in the interpretation of
results
•
An ability to draw on knowledge of the conceptual and empirical
research-base which informs thinking about the impact of cultural
competence on the efficacy of psychological interventions
•
Where there is evidence that social and cultural difference is
likely to impact on the accessibility of an intervention, an ability to
make appropriate adjustments to the therapy and/or the manner
in which therapy is delivered, with the aim of maximising its
potential benefit to the client
An ability to draw on knowledge that culturally-adapted
treatments should be judiciously applied, and are warranted:
• if evidence exists that a particular clinical problem
encountered by a client is influenced by membership of a
given community
• if there is evidence that clients from a given community
respond poorly to certain evidence-based approaches
•
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•
•
Where the therapist does not share the same language as
clients, an ability to identify appropriate strategies to ensure and
enable the client’s full participation in the therapy
• where an interpreter/advocate is employed, an ability to
draw on knowledge of the strategies which need to be in
place for an interpreter/advocate to work effectively and in
the interests of the client
Ability to make use of supervision
•
An ability to use feedback from the supervisor in order further to
develop the capacity for accurate self-appraisal.
Capacity for active learning
•
An ability to act on suggestions regarding relevant reading made
by the supervisor, and to incorporate this material into clinical
practice.
•
An ability to take the initiative in relation to learning, by identifying
relevant papers, or books, based on (but independent of)
supervisor suggestions, and to incorporate this material into
clinical practice.
An ability to hold in mind that a primary purpose of supervision
and learning is to enhance the quality of the treatment clients
receive.
An ability to work collaboratively with the supervisor
•
An ability to work with the supervisor in order to generate an
explicit agreement about the parameters of supervision (e.g.
setting an agenda, being clear about the respective roles of
supervisor and supervisee, the goals of supervision and any
contracts which specify these factors).
•
An ability to help the supervisor be aware of your current state
of competence and your training needs.
•
An ability to present an honest and open account of clinical
work undertaken.
•
An ability to discuss clinical work with the supervisor as an active
and engaged participant, without becoming passive or avoidant, or
defensive or aggressive.
•
An ability to present clinical material to the supervisor in a
focussed manner, selecting the most important and relevant
material.
Capacity for self-appraisal and reflection
•
An ability to reflect on the supervisor’s feedback and to apply
these reflections in future work.
•
An ability to be open and realistic about your capabilities and to
share this self-appraisal with the supervisor.
Capacity to use supervision to reflect on developing personal and
professional role
•
An ability to use supervision to discuss the personal impact of the
work, especially where this reflection is relevant to maintaining the
likely effectiveness of clinical work.
•
An ability to use supervision to reflect on the impact of clinical
work in relation to professional development.
Capacity to reflect on supervision quality
•
An ability to reflect on the quality of supervision as a whole,
and (in accordance with national and professional guidelines)
to seek advice from others where:
•
there is concern that supervision is below an acceptable
standard
•
where the supervisor’s recommendations deviate from
acceptable practice
•
where the supervisor’s actions breach national and
professional guidance (e.g. abuses of power and/or
attempts to create dual (sexual) relationships)
Ability to use measures to guide therapy and to monitor outcomes
17
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measured) and reliable (i.e. reasonably consistent with how
things actually are)
Knowledge of measures
•
Ability to integrate measures into the intervention
An ability to draw on knowledge of commonly used
questionnaires and rating scales used with people with
depression
•
An ability to use and to interpret relevant measures at appropriate
and regular points throughout the intervention, with the aim of
establishing both a baseline and indications of progress
•
An ability to share information gleaned from measures with the
client, with the aim of giving them feedback about progress
•
An ability to establish an appropriate schedule for the
administration of measures, avoiding over-testing, but also aiming
to collect data at more than one timepoint
Ability to interpret measures
•
•
An ability to draw on knowledge regarding the interpretation of
measures (e.g. basic principles of test construction, norms and
clinical cut-offs, reliability, validity, factors which could influence
(and potentially invalidate) test results)
An ability to be aware of the ways in which the reactivity of
measures and self-monitoring procedures can bias client report
Ability to help clients use self-monitoring procedures
Knowledge of self-monitoring
•
An ability to draw on knowledge of self-monitoring forms
developed for use in specific interventions (as published in
articles, textbooks and manuals)
•
An ability to draw on knowledge of the potential advantages of
using self-monitoring
• to gain a more accurate concurrent description of the
client’s state of mind (rather than relying on recall)
• to help adapt the intervention in relation to client progress
• to provide the client with feedback about their progress
•
•
18
An ability to draw on knowledge of the potential role of selfmonitoring:
• as a means of helping the client to become an active,
collaborative participant in their own therapy by identifying
and appraising how they react to events (in terms of their
own reactions, behaviours, feelings and cognitions))
An ability to draw on knowledge of measurement to ensure that
procedures for self-monitoring are relevant (i.e. related to the
question being asked), valid (measuring what is intended to be
•
An ability to construct individualised self-monitoring forms, or to
adapt ‘standard’ self-monitoring forms, in order to ensure that
monitoring is relevant to the client
•
An ability to work with the client to ensure that measures of the
targeted problem are meaningful to the client (i.e. are chosen to
reflect the client’s perceptions of the problem or issue)
•
An ability to ensure that self-monitoring includes targets which are
clearly defined and detailed, in order that they can be
monitored/recorded reliably
•
An ability to ensure that the client understands how to use selfmonitoring forms (usually by going through a worked example
during the session)
Ability to integrate self-monitoring into the intervention
• An ability to ensure that self-monitoring is integrated into the
therapy, ensuring that sessions include the opportunity for regular
and consistent review of self-monitoring forms
•
An ability to guide and to adapt the therapy in the light of
information from self-monitoring
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Basic Competences
Knowledge and understanding of the basic principles of couple
therapy
•
An ability to draw on knowledge and experience to establish and
maintain a balanced position in relation to the couple, in order to:
• focus attention on their relationship, rather than either
partner, as the means of achieving change;
• provide a framework for understanding and managing
presenting concerns.
•
An ability to draw on knowledge to understand the nature of the
commitment that underpins a couple’s relationship and
contributes to shaping its dynamics, including:
• the feelings the partners may have for each other, their
understanding of why they chose each other, and their
sense of being (or not being) a couple;
• the conscious and unconscious expectations, assumptions,
beliefs and standards they may share (or differ about) with
regard to their relationship;
• the role of external factors (such as religious affiliation,
ethnicity and other social grouping) on their choice of
partner and support for their partnership.
•
19
An ability to draw on knowledge to understand interpersonal
factors that contribute to shaping the dynamics of couple
relationships, for example, the effects of:
• potentially different understandings and levels of awareness
between partners about their roles, responsibilities and
expected behaviour;
• the degree of fit or misfit within the couple over such matters
as what constitutes a comfortable distance in their
relationship, or how feelings are managed;
• the degree of fit or misfit within the couple over the values,
beliefs and meanings each partner brings to interpreting
events occurring inside and outside their relationship;
• the degree to which each partner is aware of and
responsive to the other’s feelings, intentions and states of
mind, especially in stressful situations;
• their communication skills, including their capacity to give,
ask for and accept support from each other;
• the rigidity or flexibility with which partners interact together,
including their capacity to adapt and change over time.
•
An ability to draw on knowledge to understand developmental
factors that contribute to shaping the dynamics of couple
relationships, for example:
• the effects of family of origin, childhood and earlier
partnership experiences on each partner’s assumptions
about and expectations of their relationship;
• the restructuring of couple and family relationships
occasioned by predictable life events such as the birth of a
child;
• the restructuring of couple and family relationships
occasioned by unpredictable life events such as
unemployment, illness, or bereavement;
• the potential for past relationship conflicts, and ongoing
commitments resulting from them (such as parenting or
financial responsibilities), to affect the process of re-forming
family life with a new partner.
•
An ability to draw on knowledge to understand contextual factors
that contribute to shaping the dynamics of couple relationships,
for example:
• the influence of culture and ethnicity on each partner’s
assumptions about and expectations of their relationship;
• the potential for social constructions of gender to shape
assumptions about roles and responsibilities in the couple;
• the effects of socio-economic factors such as employment,
relocation, and redundancy on couple and family
relationships.
Knowledge of sexual functioning in couples
•
An ability to draw on knowledge of factors that may influence
sexual functioning, for example:
• physiological factors such as hormone levels, medication,
addictive substances, debilitating illness and ageing;
• psychological factors, such as:
• major current life stressors;
• past experiences of sexual inhibition or trauma (for
example, prohibitive sexual attitudes, ignorance, abuse);
• current relationship difficulties.
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and vulnerability to abuse.
•
An ability to draw on knowledge of the main sexual dysfunctions
in women and men and available psychosexual, pharmacological
and mechanical/surgical treatment options for:
erectile and ejaculatory/anorgasmic difficulties in men;
vaginismus, dysparaneuia and anorgasmia in women;
reduced sexual drive and desire in women and men.
Knowledge and experience of working within a model of couple
therapy
•
Knowledge of depression and the ways it manifests in couple
relationships
•
•
20
An ability to draw on knowledge about the clinical manifestations
of depression, including:
• biological symptoms of depression, such as loss of sleep,
appetite, weight and sex drive;
• psychological symptoms of depression, such as poor
concentration, sadness, low self esteem, guilt, reduced
coping capacities and suicidal thoughts.
An ability to draw on knowledge about non-organic factors that
might predispose towards, precipitate and maintain depression,
including the effects of:
• support, or lack of it, from partner, family and friends;
• the interaction between partners on symptomatic roles (for
example, a partner’s response to the depressed partner’s lack
of assertiveness, interest and competence, and the impact of
that response on the depressed partner);
• developmental factors, including a history of insecure
attachment, loss or abuse;
• life events, such as the birth of a baby (in potentially triggering
puerperal and postnatal depression), bereavement, and other
stressful occurrences (such as reversals in health, work or
financial security);
• social constructions of gender, which may increase
vulnerability for those (most often women) who are financially
dependent, vulnerable to abuse, emotionally expressive and
carrying undue caring responsibilities;
• social exclusion on minority groups (such as the disabled or,
in some cultures, those of homosexual orientation), which can
aggravate, sometimes punitively, stress that undermines selfconfidence and self-esteem, and increases social isolation
An ability to draw on knowledge and experience to be able to
work within a recognised model of couple therapy that is based
on:
• a coherent conceptual framework for understanding couple
relationships;
• an externally validated programme of couple therapy training
and supervised practice;
• evidence of efficacy.
Ability to assess the suitability of couple therapy for alleviating
depression.
•
An ability to create an environment that facilitates exploring the
couple’s relationship, for example by:
• providing a protected time and predictable setting for
meetings with both partners;
• conveying impartiality towards the partners and in relation to
outcomes;
• conveying interest in each partner, both as individuals and as
part of a couple;
• exploring each partner’s definitions of and perspectives on the
presenting problem in an even-handed way;
• demonstrating sensitivity towards the fear that the therapist
may favour one or other partner because of gender, race or
other differentiating factors;
• focusing on the couple relationship rather than on either of the
partners.
•
An ability to structure the assessment of the couple relationship,
for example by:
• providing information about the processes of assessment and
couple therapy;
• setting and maintaining boundaries relating to the time and
place of sessions;
• initiating an exploration of the relationship’s strengths,
problems and potential;
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•
•
An ability to screen for psychotic depression, bi-polar disorder or
other psychotic conditions, through:
• taking a mental health history of the depressed partner;
• ascertaining recent or current treatments received for
diagnosed conditions (including medication);
• gauging the depressed partner’s degree of contact with
reality;
• seeking expert advice for help in the screening process where
necessary.
•
An ability to establish the presence of relationship problems,
either preceding or concurrent with the partner’s depression, and
to assess how couple discord might contribute to causing and/or
maintaining the condition, including:
• the timing of the onset of depressive symptoms;
• the timing of the onset of any relationship problems;
• reactions of the non-depressed partner to depressive
symptoms, including whether s/he has experienced them too;
• the impact of depression on home life, including parenting
and work roles;
• levels of support and tolerance from significant others outside
the couple, both in terms of the acceptability of the condition
and perceived stigma.
•
21
setting clear ground rules for the assessment and any offer of
couple therapy.
An ability to assess the rigidity of the depressive symptom, and to
identify the main areas of relationship difficulties associated with
depression, for example:
• the depressed behaviour of one partner being directed
towards the other, but not towards other people;
• low levels of companionable time partners spend in each
other’s company;
• asymmetry within the partnership, for instance where the
depressed person constantly diminishes their value and selfregard in relation to their partner;
• the non-depressed partner expressing less hostility and
frustration than they might be feeling;
• the degree of rigidity with which the depressed partner might
be persisting in a comparatively limited and ‘disabled’ role
within the relationship.
•
An ability to formulate and test hypotheses about the functional
significance of depression, for example:
• as a means of securing help for the relationship, or of
coercing a partner into treatment;
• as a means of communicating about the emotional
significance of life events, asserting relationship rules,
punishing past misdemeanours, regulating distance, securing
care, or registering protest;
• as a means of discouraging any change in the partners’ roles
and relationships;
•
An ability to engage the couple in identifying and assessing
interpersonal factors that may contribute to depression and the
couple’s concerns, for example:
• communication patterns, such as repeated criticism and
complaint;
• interactive processes, such as cycles of withdrawal and
pursuit;
• affective cycles, such as the escalation of anger or
depression.
•
An ability to identify factors that maintain problematic patterns of
relating, for example:
• the contribution of each partner to the couple’s difficulties;
• the potential risks for each partner of not maintaining their
presenting concerns.
•
An ability to engage the couple in identifying and assessing
developmental factors that may contribute to the couple’s
concerns, for example by inviting:
• an account of each partner’s history of family and attachment
experiences;
• an account of each partner’s perspective on the history of
their relationship;
• a review of their presenting concerns within the meaningful
context of their relationship histories.
•
An ability to recognise and address individual needs that may
conflict with relationship goals, for example by:
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•
•
•
•
•
gauging each partner’s level of commitment to the
relationship and to couple therapy, including any differences
there may be between them;
identifying incapacitating individual conditions, such as acute
or chronic depression, and, if necessary, arranging for these
to be addressed alongside or independently of couple
therapy;
providing separate as well as conjoint assessment meetings,
ensuring these are conducted in ways that do not disturb the
couple’s trust in therapist impartiality.
An ability to engage partners in working with complex boundary
issues, for example:
• the disclosure to the therapist in an individual session of an
ongoing or past secret extra-marital sexual relationship.
Ability to liaise with other services
•
An ability to draw on knowledge about the salient network of
services and when to liaise with other service providrs, for
example:
• when statutory requirements need to be complied with (such
as child protection);
• when the risk of domestic violence is high;
• when there are major changes in the clinical picture (such as
a marked exacerbation of depressive symptoms).
•
An ability to make appropriate referrals.
Ability to establish and convey the rationale for couple therapy
An ability to identify factors in the couple’s presentation that are
amenable to change and the resources available to the couple to
achieve this, for example by:
• focusing on the strengths of their relationship;
• inviting the partners to identify challenges they have
successfully overcome together as a couple.
•
An ability to establish for each partner the rationale for focusing
on their relationship as a means of addressing depression and
their other presenting concerns, for example by demonstrating
how their:
• negative patterns of relating may create, maintain and
exacerbate these concerns;
• positive patterns of relating, either in the present or the past,
might be mobilized to alleviate them.
•
An ability to integrate different aspects of the assessment
experience when making dynamic formulations of the couple’s
relationship difficulties.
•
An ability to work with couples in achieving collaborative
formulations about, or understandings of, their problems, their
strengths and the therapy strategies that are appropriate to their
needs.
•
An ability to work collaboratively with the partners to draw up a
therapy plan with clear, specific and achievable goals to which
they can agree and subscribe.
•
An ability to agree with the couple a risk assessment and
management plan where this is needed, and to liaise with other
Ability to identify and manage risk
•
22
An ability to apply to couples knowledge about the risk of suicide,
self harm, domestic violence, and other violence towards/abuse
of vulnerable adults and children, including:
• their nature, impacts, prevalence, indicators, contexts and
socio-legal implications;
• theories about causative and risk factors.
•
An ability to work within the policies and protocols laid down by
Strategic Health Authorities with regard to such risks.
•
An ability to draw on knowledge of the above areas to establish:
• whether the couple relationship is an appropriate site for
addressing depression and the partners’ other presenting
concerns;
• what safeguards might need to be put in place before offering
therapy.
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practitioners to implement it.
•
An ability to frame interventions in ways that take account of
knowledge that:
• all close relationships contain personal incompatibilities that
may find expression in depressive symptoms and relationship
concerns;
• reactions to such symptoms and concerns can be as
problematic as the symptoms or concerns themselves;
• attempts to change depressive symptoms or relationship
concerns can consequently be a problem for couples as well
as a solution;
• accepting what cannot be changed may in itself constitute an
important change.
•
An ability to establish and maintain momentum for change within
the couple’s relationship, for example through remaining focused
on the relationship in the face of individual concerns.
•
An ability to motivate couples to read any manuals or self-help
guides that are associated with the therapy.
•
An ability to motivate and help couples to understand, complete
and evaluate between-sessions tasks that might be designed as
part of the therapy.
Ability to initiate couple therapy
•
An ability to engage both partners early on:
• in the knowledge that with depression comes easy
demoralisation and early abandonment of treatment;
• in avoiding precipitating the sense of failure or hopelessness
commonly present in depression, either within the depressed
partner or the couple;
• in supporting each other to collaborate together in addressing
sources of stress external to their relationship.
•
An ability to build and balance collaborative alliances between:
• the therapist and each partner;
• the therapist and the couple as a unit;
• the partners in their relationship with each other.
•
An ability to mediate between partners, for example by:
• avoiding taking sides or being drawn into an adjudicatory role;
• avoiding forming a coalition with either partner against the
other.
•
•
23
An ability to identify and work with differences between the
partners in exploring relationship difficulties, including being able
to:
• validate their different definitions, experiences and
perceptions of their problems;
• value the positive potential of these differences for the
relationship;
• explore possible meanings associated with these differences
for the partners and their relationship.
An ability to identify, understand and explore the emotional bonds
underlying the partners’ attachment to each other, including:
• strengths and vulnerabilities in their relationship;
• their respective responses to roles they assume in relation to
each other;
• the feelings each partner has for and generates in the other,
and how these are expressed.
Ability to maintain and develop a therapeutic process with couples.
•
An ability to structure the therapeutic process, for example by:
• scheduling sessions, maintaining time boundaries, staying on
task and avoiding being sidetracked;
• helping partners to formulate and prioritise their agendas for
change;
• holding in focus the negotiated goals of therapy;
• maintaining the therapeutic ‘conversation’ by:
• moving in and out of engagement with each partner;
• encouraging partners to speak directly to each other.
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•
•
•
•
•
An ability to manage the boundary of the couple therapy, in
relation to:
• any other therapy partners might be undergoing;
• out of session contact with either or both partners;
• behaviour within or outside therapy that might compromise
confidentiality or safety.
An ability to help couples learn about areas where they may have
insufficient knowledge or skills, for example by working with them
to create conditions in which they can be:
• taught;
• practised in and outside sessions;
• applied to other domains of their lives.
An ability to integrate the content of sessions into relationship
themes, using these to promote understanding in the couple, for
example by:
• identifying overarching themes that link specific conflicts (for
example, identifying the difficulty balancing the need for
intimacy and autonomy that runs through different arguments
between the partners);
• using themes to encourage the couple’s understanding of
their problems;
• providing a sense of hope through helping partners deepen
their understanding of their relationship.
•
An ability to review the progress of therapy, for example by
identifying what has been achieved, what remains to be achieved
and what cannot be achieved.
•
An ability to identify with the couple feelings associated with
ending, including the ways these can be expressed indirectly, for
example through:
• recurrences of presenting problems, or the emergence of new
difficulties within the partnership that call into question the
wisdom of ending;
• requests from the couple to end early or precipitately, which
may serve to avoid difficult feelings associated with ending.
•
An ability to prepare couples for the likelihood of a recurrence of
depressive symptoms and the need to plan for that eventuality,
for example by considering:
• extending therapeutic support through follow-up meetings;
• other possibilities of outside help.
•
An ability to liaise about the ending appropriately with
practitioners who made the referral for couple therapy, and to
refer on to other services where required and agreed.
An ability both to participate in and observe interactions in the
couple.
An ability to move between engaging each partner directly and
working with the relationship between them.
Ability to end couples therapy
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•
An ability to terminate therapy in a planned and considered
manner, including being open to revising a planned ending.
•
An ability to act with discretion and awareness that timescales are
different for different individuals, and that timetables can be
disrupted by events.
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Specific Competences
Ability to use techniques that engage the couple.
•
•
An ability to form and develop a collaborative alliance with each
partner and to enlist their support for relationship-focused
therapy, for example by:
• responding empathically in order to validate the experience of
each partner, especially their emotional experience;
• accepting and exploring each partner’s reservations about
engaging in couple therapy;
• gauging when and whether separate sessions are needed to
engage each partner in the therapy, or to overcome an
impasse;
An ability to form and develop an alliance with the couple as a
unit, for example by:
• reframing any presentation of individual problems in
relationship terms;
• focusing attention on shared as well as separate concerns;
• supporting the partners’ sense of themselves as being part of
a unit as well as two individuals.
•
An ability to promote a collaborative alliance between the partners
in the couple, for example by:
• using empathic questioning to help the partners explore and
reappraise their respective positions;
• encouraging the partners to address each other directly,
rather than the therapist being drawn into a role as mediator
or interpreter.
•
An ability to engender hope about the therapeutic process, for
example by:
• expecting neither too little nor too much about what can be
achieved and by when;
• engaging constructively with problematic issues;
• encouraging, recognising and reflecting back positive cycles
of interaction in the couple;
• reinforcing achievements by marking and celebrating positive
change.
•
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•
An ability to instigate therapeutic change, for example by:
• encouraging shared responsibility for the therapy by
•
•
•
constructing agendas collaboratively;
recapitulating and checking out key communications made
during sessions;
encouraging couples to describe events and episodes in
active rather than passive terms (for example, asking ‘how did
you make that happen?’ rather than ‘how did that happen?’);
creating openings for new relational experiences (for
example, through collaboratively setting homework
assignments);
being clear and sensitive about the rationale for any
homework assignment, and following up on how it is
experienced as well as whether it has been completed.
Ability to use techniques that focus on relational aspects of
depression
•
An ability to focus on and reduce negative cycles of influence
between depression and couple interactions, for example by:
• educating couples about potential links between depression
and stressful patterns of relating in the couple;
• gathering in broader aspects of the couple’s relationship and
focusing on these (for example, concentrating on their roles
as parents as well as partners);
• inviting the depressed partner to assume the caring role
normally occupied by her or his partner;
• asking the depressed partner to help her or his partner to
express feelings;
• supporting the depressed partner in being assertive;
• discouraging blaming and denigration;
• encouraging partners to maintain routines, surroundings and
relationships that provide them with a sense of familiarity and
security;
•
An ability to review interpersonal roles in the couple relationship,
especially with regard to care giving and care receiving, for
example by:
• using family life-space techniques (such as sculpting or
button/stone games) to enable partners to represent how
roles are divided between them, including any changes that
have taken place;
• encouraging each partner to depict graphically the amount of
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•
•
•
•
•
An ability to consult with the couple about their interaction, for
example by reflecting back observations about:
• recurring patterns of relating between the partners;
• ways in which each partner and the couple use their therapist;
• any relevance this might have to their relationship concerns.
•
An ability to generate and test hypotheses that explain depressive
symptoms through the relational contexts in which they occur, for
example by:
• offering thoughts about the possible functions of symptomatic
behaviour for each partner;
• highlighting the roles played by each partner and others in
creating and maintaining depressive symptoms, and exploring
possible reasons for these;
• describing interactive patterns that may maintain depressive
symptoms.
•
•
26
time and energy they believe they spend carrying out these
roles, including any changes that have taken place;
using genograms to investigate family-of-origin roles;
reviewing how roles were allocated in previous partnerships;
highlighting similarities and differences between each partner
in terms of their cultural expectations;
investigating how their audit of relationship roles compares
with what each partner expects and desires;
identifying areas where changes might be achieved.
An ability to challenge repetitive sequences, for example by:
• interrupting monologues, or cycles of accusation, rebuttal and
counter-accusation;
• exploring possible functions performed by such repetitive
sequences for each partner and the couple;
• suggesting alternative behaviours or ways of communicating.
An ability to offer possibilities for altering interactions, for example
by:
• tracking and reflecting back observations about patterns of
relating and their possible purposes for each partner and the
couple;
• replaying and highlighting key interactions so they can be:
• more directly be experienced in the session;
•
• made available for reflecting on in the therapy;
providing opportunities for each partner to imagine what they
think might happen if existing roles and relationship patterns
were to change;
Ability to use techniques that reduce stress upon and increase
support within the couple:
Improving communication
• An ability to teach listening skills, for example by:
• encouraging partners to listen actively (clarifying but not
debating what is being said) in a manner that supports and
validates the speaker;
• encouraging partners to summarise and reflect back what
they have heard, especially in relation to key issues voiced;
• discouraging either partner (or their therapist) from making
unfounded assumptions about communications.
•
An ability to teach disclosing skills, for example by:
• encouraging direct rather than ambiguous statements;
• encouraging the expression of appreciation, especially before
raising concerns;
• softening the way concerns are introduced and voiced;
• discouraging ending on a criticism when positive statements
are made;
• promoting ‘I’ statements (rather than ‘We’ or ‘You’ statements
that attribute meanings and intentions to others);
• encouraging concise, specific and relevant speech;
• encouraging expression of information about feelings as well
as reports of thoughts and experiences.
•
An ability to use exploratory techniques to aid communication, for
example by:
• using open-ended questioning;
• extending the issue being discussed;
• using silence while actively and supportively listening.
•
An ability to use explanatory techniques to aid communication, for
example by:
• clarifying what has been said;
• providing feedback about a communication;
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•
•
reconstructing the content of a message, especially where
contradictions may be embedded within it.
Coping with stress:
• An ability to help partners cope with their own and each other’s
stress, for example by:
• enhancing a sense of safety by encouraging each partner to
talk first about low-level stressors that are removed from
home before going on to talk about higher-level stressors that
may be closer to home;
• encouraging the speaking partner to identify what they might
find helpful in coping with the stress;
• enabling the listening partner to offer empathic support for the
speaker in disclosing what they are finding stressful, and any
specific needs they may have in order to cope with the stress;
• encouraging the speaking partner to provide empathic
feedback on their experience of being supported;
• repeating these sequences with the partners changing
speaker and listener roles;
• maintaining fairness and equity in the balance of speaker and
listener roles to ensure neither partner is privileged in either
role.
•
•
•
•
•
An ability to work with partners who amplify the expression of
emotion, for example by:
• bounding the expression of emotion within sessions;
• helping partners differentiate between their emotional states:
• as experienced in themselves;
• as observed by others;
• helping them to clarify when unexpressed emotional states
might underlie expressed emotion (for instance when
unexpressed fear underlies the expression of anger);
• promoting containment of upset in one domain of life to
prevent it infiltrating other domains;
• curtailing statements of contempt through opening up
explorations of its impact and underlying emotions;
• helping partners to establish useful boundaries around
emotional expression, for example through:
• scheduling mutually agreed times and places in which
to discuss feelings, especially those associated with
painful experiences, whether shared or separate;
• encouraging partners to accept the importance of other
relationships (such as friends and relatives) to provide
additional emotional support, and to reduce
unmanageable pressure on the relationship, while also:
• identifying and agreeing upon mutually acceptable
boundaries (such as, for example, mutually agreed
sexual or financial limits to other relationships).
•
An ability to work with mismatches between partners’ emotional
Managing feelings:
• An ability to encourage the expression and reformulation of
depressive affect, for example by:
• supporting the expression of depressed feelings, and the
partner’s reactions to depressed feelings, and encouraging
acceptance of them;
• exploring past and present experiences of loss that may
account for these feelings, which provide a framework for
acknowledging and understanding them;
• facilitating mourning.
•
27
An ability to work with partners who might minimise expressions
of emotion, for example by:
• normalising emotional experience;
• describing emotions in language that is both accessible and
meaningful to the couple;
• validating and promoting acceptance of both existing and
newly-experienced feelings of each partner;
using questions, hypotheses, and/or reflections that can
evoke emotions within the session in the service of then
making them intelligible to each partner;
using pacing and softening techniques to create safety in
evoking emotion;
heightening awareness of the link between physiological
arousal and emotional states (for example, by using biofeedback methods);
teaching individual self-soothing techniques;
• when possible, inviting and enabling partners to help
each other implement self-soothing techniques;
heightening emotions, in a controlled and safe way within the
session by repeating key phrases to intensify their impact.
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•
responses and meanings, for example by:
• building awareness between partners of:
• their different attitudes, histories and experiences with
expressing specific emotions;
• their different attitudes towards introspection, selfdisclosure and exploration of feelings;
• accepting and processing mismatches of emotional
expression and responsiveness;
• helping translate each partner’s respective meanings of the
other’s behaviours;
• helping the couple reach clearer shared understandings of
each other’s responses and meanings.
•
An ability to provide empathic support, for example by:
• tracking the emotions of each partner, as signalled within
sessions through verbal and non-verbal cues;
• tuning into and validating emotional experience, for example
by responding sensitively and robustly;
• focusing on patterns of relating that disrupt emotional
connection, and promoting their repair through reprocessing
sequences as experienced by each partner;
• reframing the emotional experiences of partners to make
them intelligible and acceptable to each other.
Changing behaviour:
• An ability to hold collaborative discussions to establish and assist
in achieving agreed upon and specific goals, including:
• helping couples identify and set their own goals for the
therapy;
• establishing the rules and procedures for achieving these
goals;
• when appropriate, contracting with either or both partners to
refrain from specific behaviour (for instance, behaviour that
has been agreed-upon as dangerous);
• exploring why behavioural agreements entered into by the
partners have worked or failed to work, and reviewing goals in
the light of this.
•
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An ability to instigate an increase in reciprocated positive
behaviour, for example by:
• noting such behaviour in the couple and:
•
•
•
•
•
focusing on increasing the frequency of
positive exchanges
• rather than on diminishing negative
exchanges;
helping each partner to generate a list of specific, positive,
non-controversial things they could do for the partner;
helping the partner to whom the list is directed to develop the
list;
conducting a staged approach in which:
• requests from partners are simple and clear,
• complaints from and about partners become wishes,
• specific, reciprocal, achievable changes are negotiated
and worked at together, and
• progress is monitored by all participants;
encouraging the reciprocation of positive behaviour.
An ability to instigate an increase in positive behaviour that does
not depend on reciprocation, for example by:
• enabling partners to identify and achieve specific changes
they want to make in themselves irrespective of whether their
partner reciprocates, including:
• changes of a broad nature, such as improving the
emotional climate of the relationship through being more
available to share time;
• changes with a specific focus, such as the manner in
which concerns are raised;
• encouraging partners to predict how changes in their own
behaviour might have a positively reinforcing effect upon their
partner:
• exploring how this prediction looks to the partner;
• exploring their own and their partner’s response to
initiating such change;
• identifying and articulating relationship themes and meanings
for each partner that lie behind specific behaviour.
Solving problems:
• An ability to create and nurture shared systems of meaning within
the couple as a prelude to addressing problems, for example by:
• encouraging partners to talk to each other about respective
hopes and fears they have about their relationship, especially
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•
•
29
when they feel upset or threatened;
establishing and noting, to underline their intentional nature,
the partners’ daily rituals of connecting with each other (over
meal times, shared activities and so on);
identifying ways, and noting their intentional nature, in which
partners already are supported by each other in their shared
roles (parenting, home maintenance and so on);
facilitating the emergence and recognition of a shared
relationship story:
• noting how it clarifies and sustains the values and
meanings the partners have in common.
•
An ability to help couples define problems in ways that can limit
complaint or criticism, for example by encouraging partners to:
• use specific examples when raising potentially contentious
issues;
• convey why the problem is important to them;
• include clear statements about how the problem makes them
feel.
•
An ability to provide a structured and stepped approach to
problem-focused discussions, for example by:
• separating the process of sharing thoughts and feelings from
discussions about the way in which decision-making and
problem-solving will proceed;
• developing communication skills before applying them to
problem-solving;
• starting with low conflict before proceeding to high conflict
issues;
• addressing one problem at a time;
• avoiding being sidetracked;
• discouraging disagreements when there is insufficient time to
address them.
•
An ability to enable partners to try out different approaches to
managing conflict, for example by:
• enacting arguments in the safety of the therapy session;
• interrupting enacted arguments to explore alternative
approaches;
• encouraging pretend or controlled arguments outside
sessions.
•
An ability to help couples find a solution to identified specific
problems through sequentially:
• defining problems;
• brainstorming potential positive alternatives to current
problematic behaviour;
• evaluating the pros and cons of those alternatives;
• negotiating alternatives;
• identifying the components of a contract;
• forming an explicit (when appropriate, written) contract.
Promoting acceptance:
• An ability to work with couples in ways that respect each partner’s
experience of depression, for example through:
• educating the couple about depression:
• naming and explaining the symptoms of depression,
• allowing depression to be viewed as an illness, and
thereby
• reducing feelings of guilt or blame associated with the
condition;
• accepting the couple’s reality of the depressed partner as
patient:
• especially in the early stages of therapy, and
• simultaneously helping the non-depressed partner play a
supportive role;
• accepting the reality of both partners’ depression when this is
the case, and the limitations on what each can do for the
other in the short term;
• engaging the supportive abilities of the non-depressed
partner, for example by involving him or her in:
• helping the depressed partner:
• prioritise tasks,
• undertake manageable social activities,
• be assertive;
• recognise dysphoric symptoms;
• seek out situations that can relieve such symptoms;
• evaluating and managing the patient’s depressive
symptoms, including the need for either social stimulus
and/or medication;
• relating to the depressed partner as ‘more than his or her
depression’, to help reduce the effects of depression.
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•
•
•
•
assisting the depressed partner to manage their condition
for themselves.
An ability to help partners empathically connect with each other
around their concerns by:
• eliciting vulnerable feelings from each partner that may
underlie their emotional reactions to their concerns;
• encouraging them to express and elaborate these feelings;
• conveying empathy and understanding for such feelings;
• helping each partner develop empathy for the other’s
reactions through modelling empathy toward both partners.
An ability to help the couple empathically connect with each other
in distancing themselves from their concerns, for example by
helping partners:
• step back from their concerns and take a descriptive rather
than evaluative stance towards it;
• describe the sequence of actions they take during
problematic encounters to:
• build awareness of the triggers that activate and escalate
their feelings;
• consider departures from their behaviour and what might
account for such variations;
• generate an agreed name for problematic repetitive
encounters to help them call ‘time out’.
An ability to help the couple develop tolerance of responses that
the problem can trigger, for example by:
• helping partners identify positive as well as negative functions
served by problematic behaviour;
• using desensitising techniques to reduce the impact of
problematic behaviour (such as practising arguments in
sessions).
Revising perceptions:
• An ability to observe and reflect back on observations of
seemingly distorted cognitive processing, for example through:
• marking selective inattention;
• encouraging partners to check out the validity of attributions
they make about each other;
• encouraging partners to check out the validity of perceived
30
•
(as compared with actual) criticism;
drawing attention to self-reinforcing problematic predictions
and assumptions.
•
An ability to reduce blame and stimulate curiosity in the partners
about their own and each other’s perceptions, for example
through:
• ‘circular’ questioning (questioning that highlights the
interactive nature of each partner’s behaviour on the other);
• ‘Socratic’ questioning (questioning that re-evaluates the logic
behind existing positions in order to create an alternative,
more functional logic);
• encouraging partners to ‘read’ what their partner is thinking
and feeling through:
• picking up verbal and non-verbal cues and messages;
• listening to feedback about the accuracy of these
readings;
• imagining the effects their behaviour and feelings have on
their partner, and to accept and reflect on feedback from their
partner about this.
•
An ability to use techniques that increase the partners’
understanding of their own and each other’s vulnerability to
cognitive distortion, for example by encouraging them to:
• identify recurring behaviour and feelings that might act as
flashpoints for each partner in their relationship;
• explore the contexts in which they arise;
• encourage reflection across relationship domains about
similar experiences and reactions.
•
An ability to engage the curiosity of partners about possible links
between their current relationship perceptions and past
developmental experiences, for example by:
• taking a thorough family and relationship history for each
partner, or facilitating this to emerge in the context of the
therapeutic process, that includes attachment patterns,
events and themes;
• using devices such as family genograms to identify crossgenerational family meanings, norms, and/or expectations,
especially with regard to relationship roles and scripts;
• allowing embedded roles, scripts, themes, and patterns that
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31
might contribute to distortions in the representation of
relationships to emerge and be worked with;
linking past attachment themes and problematic experiences
with current perceptions and predictions.
•
An ability to develop shared formulations of central relationship
themes, for example by:
• exploring the transference of representations of past
attachment patterns, roles and affects into current couple
and/or therapy relationships, and helping the couple
distinguish between past and present meanings and realities;
• exploring the therapist’s own emotional and behavioural
responses, both to each partner and to the couple itself:
• to identify affects and experiences that may reflect and
resonate with those of the couple;
• to make connections between the affective experiences of
each partner and their therapist to build understanding from
shared experience.
•
An ability to identify and make links between specific arguments
and central relationship themes, for example by highlighting:
• meanings, thoughts and feelings that accompany escalating
arguments;
• recurring tensions over the need for intimacy and autonomy;
• conflicts that are structured around issues of dominance and
submission;
• roles that rooted in gender or cultural expectations that might
be uncomfortable for one or other of the partners;
• past attachment experiences that might be creating anxieties
and fears.
•
An ability to reframe events, actions, feelings or interactions to
provide alternative, more positive and/or functional meanings to
those posited by one or both partners in order to change
perceptions of what is going on in the relationship, for example
by:
• reconceptualising a partner’s perceived negative motivations
as misguided or misfired attempts to be supported by and/or
supportive of the other;
• emphasising the desire of partners to enable rather than
disable each other.
•
An ability to apply developing formulations to achieve changes in
perception, for example by:
• working through past attachment difficulties, disappointments
and losses;
• making accessible and accepting feared
emotions/experiences, and encouraging new ways that
partners can be with each other;
• providing the context for a corrective emotional experience
that encourages each partner to feel secure with each other.
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Specific Adaptations
IBCT) about their problems and about their forthcoming
treatment.
Traditional behavioural couple therapy (TBCT)
Source: Jacobson, N. & Margolin, G. (1979) Marital therapy: Strategies
based on social learning and behavior exchange principles. New York:
Brunner/Mazel. Supplemented by Jacobson, N. S., & Christensen, A.
(1994). Traditional behavioral couple therapy manual. Unpublished
manuscript, University of Washington.
Couples were also given reading during the communication-training
segment of the therapy: Gottman, J. M., Notarius, C., Markman, H., &
Gonso, J. (1977) A couple's guide to communication. Champaign, IL:
Research Press.
Integrative behavioural couple therapy (IBCT)
Traditional TBCT relied for its effectiveness on the ability of couples to
accommodate and collaborate with each other. Aware that many couples
could not do this, and that conflict could have positive as well as negative
effects, Jacobson and Christensen developed the model to incorporate
‘acceptance’ as a central focus for couples with irreconcilable differences.
Source: Jacobson, N. & Christensen, A. (1998). Acceptance and change
in couple therapy: A therapist's guide to transforming relationships. New
York: Norton.
Couples were also asked to read Christensen, A. & Jacobson, N. (2000).
Reconcilable differences. New York: Guilford Press.
Components of TBCT and IBCT:
Ability to assess the couple’s difficulties
• An ability to draw on knowledge that the initial stages of both
TBCT and IBCT usually comprises four sessions of assessment
followed by feedback:
• an initial session (attended by both partners) to assess
presenting problems and obtain a brief relationship history
of the couple;
• two sessions (attended by each partner separately) to
assess presenting problems and obtain an individual history
from each partner;
• a joint session to obtain additional information, and to
provide the couple with feedback (appropriate to TBCT or
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Ability to give feedback to the couple (offer a rationale)
• An ability (for TBCT) to focus on feedback which emphasises the
strengths of the couple and delineates specific problem areas that
could be the target for later communication and problem-solving
efforts.
• An ability (for IBCT) to focus on broad themes in the conflicts
between partners rather than on particular problematic issues:
• an ability to formulate the couple's difficulties in terms of the
differences between them, in terms of:
• the understandable (though often ineffective or selfdefeating) actions that each has taken;
• the natural emotional reactions that each experiences.
• an ability to describe the couple’s realistic strengths;
• an ability to convey hope that examination may lead to a
greater understanding of each other's emotional reactions
and to a greater closeness.
TBCT
Knowledge
• An ability to draw on knowledge that TBCT aims to promote
positive change in couples through direct instruction and skill
training.
• An ability to draw on knowledge of the three primary treatment
strategies employed in TBCT (behavioural exchange,
communication training and problem-solving).
Behavioural exchange
• An ability to direct efforts to increase mutual, positive behavioural
exchange.
• An ability to help each partner to generate a list of specific,
positive, noncontroversial behaviours that they could do for the
partner;
• an ability to help the partner to whom the list is aimed to
develop this list.
• An ability to encourage each spouse to perform activities from the
list in an effort to increase mutual positive reinforcement.
Communication training
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An ability to teach partners both speaking and listening skills.
An ability to help partners develop their speaking skills (for
example, by focusing on “I” statements and teaching partners to
specify their emotions and behaviour (e.g. “I feel disappointed
when you come home late without calling” vs. “you are so selfish
and inconsiderate”).
An ability to help develop their listening skills (for example, by
learning to paraphrase or summarize the other's message).
•
•
An ability to help the couple employ a strategy of “empathic
joining” around the problem:
• an ability to elicit vulnerable feelings from each spouse that
may underlie their emotional reactions to the problem;
• an ability to encourage partners to express and elaborate
these feelings;
• an ability to communicate empathy for having these
understandable reactions;
• an ability , by adopting this stance toward both partners, to
help each partner develop empathy for the other’s reactions.
•
An ability to help the couple employ a strategy of “unified
detachment” from the problem:
• an ability to help the couple to step back from the problem
and take a descriptive rather than evaluative stance toward
the issue;
• an ability to help the couple engage the couple in an effort
to describe the sequence of actions they take during their
problematic pattern:
• to specify the triggers that activate and escalate their
emotions;
• to consider variations of their patterned behaviour and
what might account for these variations (e.g., a typical
struggle over their child was less intense because they
had felt close to each other earlier);
• to generate a name for their problematic pattern.
•
An ability to help the couple build tolerance to some of the
responses that the problem can trigger;
• an ability to engage the couple in an analysis of the positive
functions as well as the negative functions of their
differences and their problematic behavioural patterns;
• an ability to encourage the couple to deliberately engage in
Problem-solving skills
• An ability to help couples to:
• define problems;
• generate positive alternatives to current problem behaviour;
• evaluate the pros and cons of those alternatives;
• negotiate alternatives;
• implement and evaluate planned change.
IBCT
Knowledge
• An ability to draw on knowledge that IBCT is designed to enhance
TBCT by adding a focus on emotional acceptance.
• An ability to draw on knowledge that IBCT assumes:
• that all close relationships are characterised by some
genuine incompatibilities, and the reactions to problem
behaviour are often as problematic as the behaviour itself;
• that direct change efforts are often as much a problem for
couples as they are a solution.
• An ability to draw on knowledge that IBCT focuses more on the
emotional reactions of partners to the difficulties they encounter in
their relationships and less on the active solutions they can take
to resolve these difficulties;
• an ability to draw on knowledge that this stance is especially
relevant for what seem to be insoluble problems.
Application
• An ability to maintain a focus on salient incidents that:
• have occurred recently (e.g. an argument the previous
night);
• will soon occur (e.g. a forthcoming trip to stay with the family
of one partner);
• or are occurring in the session (e.g., one partner feels
33
invalidated by the other's reaction in the session).
An ability to employ three major strategies to promote emotional
acceptance:
• “empathic joining” around the problem;
• “unified detachment” from the problem;
• building tolerance to some of the responses that the
problem can trigger.
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•
•
•
•
•
the problem behaviour during the session or at home, so
that each partner can become more aware of the pattern
and take it less personally.
•
An ability to make use of the direct change efforts employed in
TBCT.
MARITAL THERAPY FOR DEPRESSION (MTD)
Source: Beach, S., Sandeen, E. & O’Leary, K. (1990) Depression in
marriage: A model for etiology and treatment. New York: Guilford.
MTD is a modification of TBCT, specifically adapted to treat depression.
Based on the ‘marital discord model’ of depression, which focuses on the
role of stress and social support in triggering and protecting against
depression, it aims to reduce stressful transactions in marriage and
enhance social support between the partners. Its effectiveness was
associated with ongoing marital problems that preceded depression, but
the need for supportive couple interventions in the absence of this
chronology was justified on the basis that depression restricted positive
interactions between partners even when there was no reported
relationship problem.
Knowledge:
• An ability to draw on knowledge that MTD aims to promote
positive change in couples through:
• administering the therapy in a structured manner;
• mediating the therapeutic alliance with both partners;
• re-educating the couple about depression and relationships;
• modelling approaches and skills;
• celebrating positive change.
•
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An ability to draw on knowledge about the marital discord model
of depression, in which marital discord:
• increases stress in the relationship, which can result in or
exacerbate depression;
• reduces support from the relationship, which can have similar
effects;
• is treated by the therapist working to reduce stress and
increase support from the couple’s relationship, and so
prevent or mitigate depression by:
•
promoting couple cohesion;
encouraging the acceptance of emotional expression;
increasing actual and perceived coping assistance;
supporting positive self-esteem;
increasing spousal dependability;
deepening intimacy and mutual confiding.
An ability to draw on knowledge of the main treatment strategies
used in TBCT:
• behavioural exchange;
• communication training;
• cognitive restructuring;
• problem-solving.
Application:
• An ability to draw on knowledge that assessment for MTD usually
comprises at least two sessions, where partners are seen
together and separately, to satisfy the following conditions:
• the risk of suicide or suicidal gestures is low;
• the depressed partner has received a thorough diagnostic
assessment and is not bi-polar;
• the presence of marital discord has been clearly established;
• marital discord appears to play an aetiological or maintaining
role in the depression;
• there are no hidden agendas that caution against the offer of
marital therapy (for example, low commitment, or the desire
for divorce).
•
An ability to draw on knowledge that MTD usually comprises
three phases over approximately 15 sessions:
• an initial phase that aims rapidly to eliminate major stressors
and enhance couple cohesion, caring and companionship;
• a mid-therapy phase that focuses on the ways partners
communicate, solve problems and interact on a day-to-day
basis;
• a concluding phase that prepares the couple for termination.
•
An ability to apply depression-specific knowledge and techniques,
for example:
• evaluating the role of the relationship in eliciting and/or
maintaining depression;
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•
•
•
•
•
•
•
seeing the couple together;
increasing awareness of each partner’s agency in relation to
the other;
combating negative self statements;
increasing positive events;
identifying relationship factors that increase or lessen
depression;
setting therapeutic contingencies at realistic levels (for
example, in relation to complying with homework).
An ability to apply behavioural, communication, cognitive and
problem-solving couple therapy techniques to the therapeutic
process.
Conjoint Marital Interpersonal Therapy (IPT-CM)
Source: Rounsaville, B., Weissman, M., Klerman, G. & Chevron, E. (1986)
Manual for conjoint marital interpersonal psychotherapy for depressed
patients with marital disputes (IPT-CM). Yale University School of
Medicine. Unpublished.
IPT-CM is a specific treatment for clinically depressed partners with marital
disputes. On the basis that an increase in couple discord is the most
commonly reported life stress preceding the onset of clinical depression,
and that an intimate, confiding relationship provides robust protection
against depression, the IPT-CM model engages couples in renegotiating
role expectations as a means of reducing symptoms and improving
interpersonal processes. The primary focus is on achieving sustained
change through helping couples gain a richer understanding of the
problem in their relationship.
Knowledge:
• An ability to draw on knowledge that IPT-CM aims to promote
positive change in couples through promoting understanding of
the interpersonal context of depression, specifically to:
• facilitate a reduction of depressive symptoms and remission
of acute depressive episodes;
• promote the renegotiation of role relations between the
partners.
•
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An ability to draw on knowledge about the IPT-CM model of
depression, in which marital disputes:
• provide an important aspect of the interpersonal context for
precipitating and maintaining depression;
• are understood as resulting from discordant role expectations
in the couple relationship;
• form the focus of therapeutic attention.
•
An ability to draw on knowledge of the main treatment strategies
used in IPT-CM:
• accepting depression as a clinical disorder;
• limiting set goals and timescales;
• encouraging an exploratory, patient-led process;
• promoting understanding within and between partners;
• focusing on the relationship between marital disputes and
depression.
Application:
• An ability to draw on knowledge that IPT-CM usually comprises
three phases over approximately 3-6 months of weekly sessions:
• an initial phase that aims to evaluate and manage depressive
symptoms by:
• evaluating the identified patient’s depression, including
the need for medication;
• educating the couple about depression and ways of
managing it;
• identifying marital disputes;
• explaining the rationale for the marital treatment;
• determining the relationship between depression and
marital disputes;
• performing an interpersonal inventory;
• setting the treatment contract;
• a middle phase that focuses on renegotiating marital roles by:
• structuring sessions through repeatedly tying new
material to central themes and targeted problem areas;
• identifying options for role change;
• facilitating communication and role renegotiation;
• a concluding phase that prepares the couple for termination
by:
• discussing termination explicitly;
• encouraging discussion about the loss of treatment;
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•
•
•
An ability to apply specific IPT-CM techniques to the therapeutic
process:
• conducting communication analyses;
• promoting acknowledgement and acceptance of affect;
• negotiating and structuring behaviour change;
• making interpretations (especially clarification);
• encouraging exploration.
Coping Oriented Couple Therapy (COCT)
Source: Bodenmann, G & Widmer, K. (2008) Coping-oriented couple
therapy. Fribourg: Institute for Family Research and Counselling,
University of Fribourg. Unpublished German edition. Developed from
Bodenmann, G. & Shantinath, S. (2004) The couples coping enhancement
training (CCET): A new approach to prevention of marital distress and
coping. Family Relations 53 (5): 477-484.
In addition to promoting better couple communication through teaching
speaking and listening techniques, COCT focuses on promoting improved
individual and couple coping skills through partners being helped to
communicate about and respond to their own and each other’s stress.
Knowledge:
• An ability to draw on knowledge that COCT aims to promote
positive change in couples through acquiring new adaptive
skills/behaviours and strengthening existing ones.
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•
•
fostering feelings of competence and accomplishment;
discussing future treatment needs.
•
An ability to draw on knowledge about the COCT stress model of
couple dissatisfaction, in which stressors external to the couple:
• reduce the time they spend together;
• erode communication and intimacy between partners;
• increase health problems, and consequently add to the
couple’s burdens;
• result in mutual alienation and increased stress from within
the relationship.
•
An ability to draw on knowledge of the main treatment strategies
used in COCT:
• improving individual stress management capabilities;
•
•
enhancing the ability to cope as a couple;
sensitising the couple to issues of mutual fairness, equity and
respect;
improving couple communication;
improving the couple’s problem-solving skills.
Application:
• An ability to draw on knowledge that COCT usually comprises up
to 20 hours of sequenced therapy sessions in which:
• an initial session focuses on:
• analysing the presenting problem;
• taking an oral history from each partner in the presence
of the other;
• a middle phase focuses in sequence on:
• reciprocity training and improving the repertoire of
positive experiences;
• communication training;
• problem-solving training;
• enhancing couple coping through partners expressing
their own stress and supporting each other in managing
their stress;
• learning to accept what cannot be changed;
• a concluding phase focuses on preparing the couple for
termination.
•
An ability to apply traditional and integrative behavioural couple
therapy techniques to the therapeutic process:
• reciprocity training;
• communication skills training;
• problem-solving training;
• stress management training;
• promoting emotional acceptance.
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Metacompetences
Generic metacompetences
Specific metacompetences
Capacity to use clinical judgement when implementing therapy.
Capacity to work reflexively within complex relational systems
Capacity to work with assessment and termination in ways that recognise
ambiguities contained in these processes as well as the needs of different
couples.
A capacity continuously and actively to monitor the system of therapeutic
alliances (i.e. therapist to each partner, therapist to couple, and partner to
partner), especially when they are threatened or out of balance, and to
reflect on and work with disruptions to the system as and when they occur.
Capacity to recognise and work with relevant clinical material that is not
directly, verbally or consciously acknowledged by the partners.
Capacity to approach each couple as unique, requiring a tailored approach
that attends to:
each partner’s specific personality, current circumstances and life
experiences;
those of their therapist;
the interaction between those participating in the therapeutic
process.
Capacity to reflect critically on the experience of therapy
Capacity to adapt and develop practice in the light of the experience of a
therapy, and the experience of other practitioners using similar and
different therapeutic models.
Capacity to recognise the limits of one’s abilities and knowledge, and to
learn from the experience of others (for example through supervision,
consultation and continuing professional development).
Capacity to convey and respond to interest, affect and humour
Capacity to draw on authentic responses to promote emotional
connection, for example by judging:
the function of humour in a session, and whether and how to respond
to it;
when it might be therapeutically useful to make a personal disclosure
and being able to do so appropriately, for instance to validate an
experience or cement an alliance.
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Capacity to manage the tension between competing duties of care
Capacity to manage conflicting confidentiality claims, for example the
disclosure of unprotected sex and/or HIV to an unknowing partner.
Capacity to work with difference and uncertainty
Capacity to work with the competing realities of partners:
validating both;
privileging neither;
and engaging with the potential function and meanings of difference.
Capacity to entertain feelings associated with not understanding and
knowing about aspects of the couple’s experience, without losing
confidence in what is known and understood, in order to:
encourage an attitude of curiosity in the couple for exploring their
experience;
avoid taking precipitate action in the face of anxiety;
resist internal and external pressures to share observations,
interpretations or hypotheses prematurely;
resist adhering to a single, fixed interpretation or hypothesis by being
open to the couple’s ideas and responses;
ensure, through collaborating in this way, that there is convincing
evidence;
assess whether sharing an interpretation or hypothesis is likely to be
helpful.
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Capacity to use different therapeutic approaches appropriately and
coherently.
A capacity to select from, integrate and move between different
therapeutic models and techniques to provide a coherent and appropriate
therapeutic response to the different and changing needs of couples, for
example by:
applying a graded model of intervention tailored to the nature and
severity of the couple’s areas of concern;
exploring behavioural contracting, communication and conflict
management skills in conjunction with more complex, in-depth work,
and determining the appropriate level on which to work;
drawing on other, more complex approaches, such as insight-oriented
ones, where the couple can both benefit from and work with a deeper
understanding of underlying developmental factors that may be
interfering with their relationship;
focusing on accepting limitations for the partnership set by factors
within, between and external to the partners as a means of increasing
relationship satisfaction.
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Acknowledgments
The work to devise the competences in this document was led
by:
•
•
•
39
Christopher Clulow
Susannah Abse
Nick Turner
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