Let’s view the Treatment Process Up Close

Introduction

Miguel and Luisa both served in the Navy during the Gulf War, but met after their time in the service. Miguel liked that Luisa was kind and “no-nonsense”. Luisa thought Miguel was exciting—he liked to “live for today”. However, their courtship was rocky. After dating for a year, Miguel had a brief affair. Luisa was hurt and broke up with Miguel. Miguel expressed remorse and, after several months, they moved in together. Although, Luisa wasn’t really sure she could really trust him again. Miguel felt frustrated—he hoped they could put the past behind them.

During an appointment with his primary care doc, Miguel mentioned he and Luisa were having a rough time. Miguel’s doctor recommended they consider a new couples therapy, called “Integrative Behavioral Couples Therapy” (IBCT). Miguel checked it out further at TreatmentWorksForVets.org, and showed the website to Luisa. They both liked that the therapy focused on the core reasons behind relationship problems and that it has helped many Vets. They agreed to try it out.

Sessions 1-3 (Assessment)

Miguel and Luisa met with Kevin, a social worker at the VA with expertise in IBCT. Kevin told them about the treatment and what to expect. He said the first few sessions would focus on learning more about their relationship. Then, in the fourth session, he would provide them with feedback and they could then decide together if they wished to continue to the Active Treatment phase. Miguel and Luisa liked the idea of learning more about their relationship and only having to agree to four sessions in the beginning.

Kevin asked Luisa and Miguel questions about their relationship—what first attracted them to each other first, their early history, what’s gone well, and what have they been struggling with. During the first session, Kevin collected this information by meeting with Miguel and Luisa together. And he gave them a few questionnaires on their relationship to complete on their own after session. Then, in Sessions 2 and 3, Kevin met with Miguel and Luisa separately to get their own perspectives on the relationship and to learn more about their personal histories.

Session 4 (Feedback)

During the fourth meeting, Kevin provided Miguel and Luisa with feedback on key factors affecting their relationship, using the “DEEP” understanding framework. This explains relationship problems based on:

Differences between partners
Emotional sensitivities or styles of each partner
External stresses (e.g., financial debt, job loss, parenting)
Patterns of communication used to resolve problems due to differences or stress

Kevin used the DEEP to help explain one of the primary issues they had identified—trust. He pointed out that though they cared for each other, the differences that brought them together (e.g., Miguel was outgoing and lively, Luisa was responsible and serious) now seemed to be areas driving them apart.

Kevin also explained that part of the problem was that they had different ways of dealing with disagreements—Miguel withdrew and Luisa kept repeating her concerns because she felt alone and unheard. Kevin said Miguel and Luisa had very different ideas of how to understand and come to terms with Miguel’s brief affair. He hoped to help them with that because they both seemed to deeply care about each other. Miguel was relieved not to be labeled “the bad guy”. Kevin said he believed that Luisa and Miguel were good candidates for IBCT. He suggested that they consider starting with four sessions. Then, they could see it is helping and if they wished to continue further. Luisa and Miguel liked this approach and agreed to go forward.

Sessions 5-8 (Active Treatment Phase)

Focusing on real-life situations, Kevin helped Luisa and Miguel better understand each other and their disagreements, as well as patterns of interactions around disagreements. In the seventh session, Miguel and Luisa described a bad argument they had after Miguel had come home from work a couple hours late and hadn’t called Luisa. Miguel said he had needed to finish a big work assignment and then stopped for a drink with a colleague to decompress. It was very innocent in his view. But, Luisa had become furious. With Kevin’s guidance, Luisa was able to say that she had thought he was with another woman—and all that was in her mind was her mother wondering and worrying about her father who was not around and with other women when Luisa was young. She didn’t want a life like that. It made her feel so small. So when Miguel came home, she needed to let Miguel know how upset she was.

Beneath the anger, Kevin helped Luisa tell Miguel that she felt hurt when he hadn’t called her, and that his earlier affair had “broken” her heart. Miguel was surprised that, over two years later, Luisa immediately thought he had gone out on her after being a little late. He took Luisa’s hand and stroked it. Kevin helped Miguel tell Luisa he loved her but that needing to report home made him feel controlled like he felt in his parents’ home. He also thought if he called, Luisa would go on about how hard things were at the house and with the kids, so he avoided it. Luisa said she never meant for Miguel to feel like she was trying to control him, but could see how her anger was getting in the way. Miguel said he didn’t realize she would think he was being unfaithful, as he’s been trying to be totally devoted. Miguel also willingly listened as Kevin prompted Luisa to describe how the affair had hurt her, and how her father’s affairs may have primed her to expect the worse from Miguel. Sharing their feelings helped Miguel and Luisa understand and start to feel closer to each other. Kevin helped identify the familiar interaction pattern—Luisa being critical and Miguel withdrawing.

Sessions 9-16 (Active Treatment Phase Continued)

Miguel and Luisa found that treatment was helping them to better understand each other and their interactions. As a result, they noticed that the tension at home had gone down, though they they still needed some work. They opted to continue for two more rounds of 4 sessions. During the next several sessions, Kevin helped Luisa and Miguel continue to increase their emotional understanding of each other’s behaviors. As this grew, Luisa finally felt able to relax a bit into the relationship and trust Miguel more. This prompted Miguel to want to “rise to the occasion” and take more responsibility around the house and with the kids.

Kevin also taught Miguel and Luisa strategies to help them communicate better and limit their approach-avoidance tendencies. Miguel noticed that as they focused more on communicating how things make them feel, rather than criticizing or blaming, he was less likely to have the feeling of being controlled. And Luisa said that as Miguel started to use listening skills they practiced in session, she felt better understood and more important to him. Miguel also made a point of trying to do something nice for Luisa each week. As Luisa felt more comfortable and confident, she was more laid back, and the intimacy in the relationship improved. Miguel and Luisa ended treatment after their 16th session. They felt they had made good progress and had new attitudes and tools to continue to address challenges that come up. Six months later, they were still fighting less and feeling more connected and committed to each other. And they had even set a wedding date!