The Gottmans' Call to Make Couples Therapy More Effective

Since the days of Freud, perhaps no movement has arrived on the therapy scene with the force and freshness of general systems theory. In the 1950s and 1960s, it announced an entirely new way of understanding how psyches are shaped, wounded, and healed, not merely within our skulls, but in the vast, humming spaces of our environment, in social interaction. The revolution picked up speed and became an international movement following the 1968 publication of a book titled General System Theory by German biologist Ludwig von Bertalanffy.

The concepts of feedback, homeostasis, and a holistic view of a system captured the imagination of many psychotherapy pioneers, including Salvador Minuchin, Murray Bowen, Jay Haley, and Virginia Satir, and became firmly established in the training of every marriage and family therapist. Nevertheless, despite all the intellectual excitement, the hard truth is that, so far, the systems revolution hasn’t led to very effective ways of doing therapy.

Fortunately, a second revolution is quietly taking shape—a new wave of systems theory and therapy—that marries the wisdom of clinical intuition with the rigors of scientific inquiry. With more precision and accuracy, we can now begin to answer two key questions about relationships: what causes trouble between people and what helps them not merely survive together, but actually rekindle love and delight?

While most couples and family therapies over the past half-century have been short on scientific investigation and data, some research has now been conducted. What can we conclude from it? To explain the basic findings of these studies, we first need to get a bit technical and explain a unit called the standard deviation. Remember that bell-shaped curve you studied when you read about intelligence testing? You probably learned that the average IQ is 100, and that the standard deviation is 15. That means that a solid majority of people have IQs between 85 and 115—that is, within one standard deviation on either side of 100.

Now on to effect size, or how many standard deviations our intervention moves an untreated control group. In the 1968 science-fiction movie Charly, starring Cliff Robertson, Charly was a mentally disabled adult who underwent an operation that temporarily changed him into a very smart person. Charly’s IQ shot up from about 70 to 115, a change of 45 IQ points. That translates to an effect size of 45 divided by 15, which equals 3.0. That’s highly significant. An effect size of 1.0, which would’ve increased Charly’s intelligence just one standard deviation, would’ve boosted Charly’s IQ from 70 to 85. That’s some gain, and yes, it’s significant, but it’s not very meaningful—and it probably wouldn’t have led to a feature movie.

In general, of course, we want large effect sizes in our practice, and we want clinically meaningful effects. Here’s an example to make the concept of effect size clearer. In 2002, Donald Taylor and colleagues found probably one of the biggest effect sizes in medicine: the effects of exercising and quitting smoking. It turns out that doing those two things can increase a person’s lifespan by about 16 years, which is meaningful, without question! What’s the effect size here? About 2.0, because in lifespan, the standard deviation is about eight years.

Now let’s look at effect sizes for the systems-oriented couples and family therapies for which we have data. It’s not pretty. According to William Pinsof and Lyman Wynne’s exhaustive review of all the couple and family therapy studies, couple and family therapies have an average effect size of 0.5. What does this mean for real-life couples? The most effective therapies we have can take a couple that isn’t too unhappy to begin with and help make them a little bit happier. We can nudge them from mildly distressed to nondistressed. But in most cases, we can’t help them develop a great relationship, or even a very good one.

Identifying the Set Point

In part, the problem of small effect sizes is bound up with the old general systems theory itself, which promulgates a set of concepts in couples and family therapy that have essentially eluded definition and remained imprecise metaphors. In other words, concepts like feedback, homeostasis, first-order change, second-order change, self-organization, and so on were useless in research because they couldn’t be precisely measured. They were also useless to the working therapist because they didn’t lead to specific and powerful therapeutic techniques.

Let’s start with homeostasis, a biological concept introduced in 1932 by physiologist Walter Cannon. The metaphor here is a thermostat in a room, which has a set-point temperature, and continually makes adjustments as the actual room temperature deviates from that set point. It’s a great metaphor, but in biology there’s always a specific, measurable set point that’s being regulated. An everyday example is the body’s regulation of blood pressure. In biology, that kind of precision about the set-point variable leads to the identification of mechanisms that explain how and why the regulation takes place, and what regulates health versus illness.

Herein lies a strategy for building a more effective couples and family therapy. First, find a valid and reliable homeostatic set-point variable, and describe the healthy and unhealthy set points. For example, we might identify a critical number of hostile messages a couple launches at one another in a conflict discussion; 2 in 15 minutes might be okay, but 15 might exceed a healthy set point. Then, we could try to identify the mechanisms that regulate that set point, showing us the kind of therapy that’s likely to be effective.

In our own research, the two of us started this way, by asking, “What variable gets regulated in a couple or family system? What’s a healthy relationship, and what’s an unhealthy one?” When Robert Levenson and John began doing longitudinal studies of couples in the 1970s at Indiana University, a simple answer emerged. They discovered that one homeostatic variable in a couple’s relationship was the ratio of positive-to-negative emotions expressed during a conflict interaction, as detected by trained observers. What’s a healthy couple’s set point? During conflict interactions, a positive-to-negative affect ratio of 5 to 1 or higher is healthy. That’s the average ratio in stable, happy couples. What’s an unhealthy couple set point? If the positive-to-negative emotions during conflict encounters is 1-to-1 or less, that’s unhealthy, and indicates a couple teetering on the edge of divorce.

Searching for the Mechanism

In our observational study of repair in our Love Lab—an apartment laboratory equipped with computers, video cameras, physiological sensors, and other equipment—in which we studied interactions between 30 couples for three years, we found that every conflict discussion is characterized by many repair attempts. Some attempts fail, while others succeed. We discovered that couples who successfully repair can exit the negative-affect state early in the conversation, before it becomes too negative and hurtful. Effective repairs are emotional, vulnerable, and foster understanding and validation. We found that the two most powerful repair approaches were beginning the conversation gently and taking responsibility for even a part of the problem. Couples were then likelier to avoid the attack-defend mode and move instead into a collaborative mode.

In our research with newlyweds in our apartment laboratory, we discovered a subtle process as partners moved about the lab and we followed them with three cameras. Frequently, one person would request something from a partner, which we called a “bid.” For example, the first camera would record a wife going to the window and saying, “Oh, it’s so pretty out there. There’s a beautiful boat.” The second camera would focus on the husband. When he responded, even minimally, by saying, “Oh, yeah, it is,” we coded that as “turning toward” the bid. When the partner made no response, we coded it as “turning away.” We discovered that the 17 couples who divorced six years after their wedding had turned toward their partner’s bids an average of 33 percent of the time, while the 113 still-married couples had done so a whopping 86 percent of the time. When they turned toward their partner’s bids at a high rate, repair attempts during conflict were more successful.

In the observational study of the conflict interactions of 130 newlywed couples, we discovered that the reason why unhappy couples get stuck in this negative absorbing state is the failure of repair attempts. We’ve all worked with couples who enter our office hopelessly mired in this negative emotion bog. Research reveals that what lies at the heart of unhappy couple relationships can best be thought of not as some quality inherent in the partners, but as a failure to repair the inevitable conflicts and disjunctions that occur in any couple.

Creating a Safe Haven

Part of building trust—what couples researcher Susan Johnson calls a safe haven—is the ability to stay physiologically calm, and to help one’s partner stay calm, even in the face of conflict. In their very first Love Lab study, Robert Levenson and John discovered that couples whose relationships deteriorated over three years were those who became “diffusely physiologically activated” during conflict. That means that their hearts beat faster, their blood flowed faster, they sweat more from the eccrine glands in their palms, and they jiggled around in their seats more than couples whose relationships were happy, or became happier, over time.

Why does all of this matter? Because when a person’s heart rate is above 100 beats a minute, or their oxygen is below 95 percent, they can’t listen very well. They can’t empathize. They lose access to their sense of humor. They’re secreting two major stress hormones: adrenaline and cortisol. At home, this can mean escalating arguments between partners, with one agitated person shouting over the other, hearing nothing of their partner’s needs. In the consulting room, it can mean stalled progress. For instance, if the therapist asks one partner to summarize and validate what the other partner has just said, they can’t do it well if they’re physiologically aroused, or physiologically flooded.

But how is a therapist supposed to know if a client is flooded? Our experience shows that clinical intuition isn’t a reliable way of determining that. Instead, we’ve developed and tested direct ways of measuring physiological arousal with inexpensive and reliable pulse oximeters, an instrument that measures heart rate and the blood oxygen level. Pulse oximeters fit comfortably on a person’s index finger and can ring an alarm when the heart rate exceeds 100 beats a minute, or goes less than 95 percent oxygen concentration in the blood. We’ve concluded that’s the only way a therapist can know if a client is physiologically flooded.

Then, we use biofeedback to build self-soothing ability using Heart Math’s emwave device. The emwave is a simple biofeedback device that builds physiological resilience; our clients use an ear clip and learn to turn a light from red to green. With regular use, a client who gets physiologically flooded can learn to increase a neurological dimension of self-soothing called vagal tone. These very good pulse oximeters currently cost around US $15. The Heart Math’s emwave device currently sells for under $100.

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So if therapists can help clients build calm, trust, and commitment with their partners, will their intimate relationship measurably improve? If our proposed new general systems theory and therapy are effective, they ought to be able to create effect sizes bigger than the typical 0.5. So far, we’ve completed five outcome studies, with two more underway. Our effect sizes vary between 1.0 and 4.0, so we’re on the right track.

We realize that five studies is only a beginning. Much more research will be needed to provide firmer scientific evidence, but we believe we’ve identified the quantifiable variables that will lead to more truly empirically based treatment methods in the future. And we believe that our field should no longer be satisfied with therapies that produce weak effects. Looking ahead, we need to develop a therapy that can take an ailing relationship and help a couple create a happy and lasting relationship, not just one that’s slightly less miserable.

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This blog is excerpted from "The Science of Togetherness," by John and Julie Gottman. The full version is available in the September/October 2017 issue, The Future of Couplehood: Esther Perel is Expanding the Conversation.
 
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