Introduction

Couple distress and separation/divorce are associated with anxiety, depression, substance abuse, and health problems in adults (Heene et al. 2007; Kubricht et al. 2017; Rehman et al. 2008), and psychological, behavioral, and academic problems in children (e.g., Cummings and Davies 1994; Fishman and Meyers 2000; Lansford et al. 2006). Research of the effectiveness of couples counseling has demonstrated clear benefits (e.g., Lebow et al. 2012; Stratton et al. 2015); yet despite a divorce rate between 40 and 50%in the US (e.g., Copen et al. 2012), relatively few couples initiate counseling (Albrecht et al. 1983; Johnson et al. 2002). The psychotherapy help-seeking literature has been growing in recent decades (e.g., Corrigan 2004). However, research in this area is focused almost exclusively on individual help-seeking, not couples help-seeking. Only a handful of peer-reviewed clinical studies have been conducted on the process of couples who sought counseling (e.g., Doss et al. 2003, 2009; Fleming and Córdova 2012).

Couples Help-Seeking Literature

The small body of research on conjoint relational help-seeking suggests that couples’ processes of help-seeking differ from individual help-seeking, perhaps most importantly, by the fact that both partners must agree to seek help together. In one early study of help-seeking, Wolcott (1986) found that over 70% of the couples who separated without seeking professional help reported that their spouse was unwilling or that it was too late for counseling to help. Gurman and Burton (2014) found that many clients with relational problems settle on individual therapy, often as a result of a partner’s refusal to seek couple therapy. Another obstacle confronting couples seeking conjoint treatment is that men and women often disagree on appropriate topics for counseling (Bringle and Byers 1997) and many couples feel that relationship problems should be kept private and/or addressed with spiritual leaders (Bringle and Byers 1997; Vaterlaus et al. 2015).

In one of the few studies of couple help-seeking, Doss et al. (2004, p. 612) found that partners possessed “strikingly low agreement” on the reasons for coming to counseling. Boisvert et al., (2011) found that couples often enter therapy with different “therapeutic mandates.” For example, couples may enter therapy with the intent to alleviate distress, with hope to reduce the negative impact of separation, or with ambivalence. Recent research has indicated that couples who enter therapy with “mixed-agendas” or “commitment uncertainty” (Doherty et al. 2015; Owen et al. 2012) are more likely to end the relationship following the conclusion of therapy. In addition, outcome studies have found that the more ambivalent couples are about therapy, the less likely they will report feeling satisfied about the relationship at the end of treatment and the more likely couples are to terminate counseling early (Mondor et al. 2013). Little research has examined how individual attitudes or couple patterns contribute to couples presenting for therapy with mixed-agendas.

Gender Differences in Help Seeking

Research suggests gender is an important consideration in relational help-seeking (Doss et al. 2003; Fleming and Córdova 2012). Specifically, men appear to be slower to seek help for distress related to intimate relationships. Doss et al. (2003) found that in 67–73% of couples (N = 147 couples), wives were the first to recognize a problem in the relationship, consider treatment, and seek treatment. This aligns with previous research that describes wives as the relationship “barometer” (Faulkner et al. 2005) and more sensitive to the “absence of positives” (Carroll et al. 2006, p. 1026) in a relationship. However, some evidence suggests that while women may complete the help-seeking steps first, when arriving for treatment, men and women are “equally cognizant and emotionally aware” of problems inherent in relationship adjustment (Moynehan and Adams 2007, p. 49). Fleming and Córdova (2012) found evidence that heterosexual men are not motivated to seek professional help as a result of their own relationship distress; however, they are motivated by their female partners’ distress. Therefore women may hold a unique position of power in the help-seeking decision-making process; however, more research is needed. Gender role socialization offers one way to think about male reluctance to seek professional help. Prior research has demonstrated that adherence to traditional Western norms of masculinity is negatively associated with help-seeking for individual counseling (e.g. Addis and Mahalik 2003; Hammer et al. 2013) and initial evidence has suggested that specific aspects of traditional masculinity are also negatively associated with relational help-seeking (Parnell & Hammer, In Press).

Relational Factors in Help-Seeking

Researchers have suggested that couples may go through the same stages of change as individuals (Prochaska et al. 1992; Doss et al. 2003). There are likely more complex interactions for couples as they advance through the stages. For example, a female partner with more positive attitudes towards counseling may be frustrated by her husband’s disagreement on the need for professional help. A male partner with more negative attitudes towards counseling and who does not recognize a need for help, may be equally frustrated by his partner’s encouragement. Partner disagreement on the need for therapy may be conceptualized within the demand–withdrawal pattern.

The demand—withdraw pattern of relational conflict, in which one partner demands change and emotional closeness, while the other avoids or disengages, is negatively associated with relationship satisfaction and positively associated with relationship termination (Christensen and Heavey 1990; Gottman 1993; Shi 2003). Both men and women engage in withdrawal behavior depending on the topic of conflict (Christensen and Heavey 1990) with the partner most interested in maintaining the status quo utilizing withdrawal behaviors (Epstein and Baucom 2002). In some contexts, withdrawal may be a healthy choice (Gottman 1993). However, when distancing behaviors become hostile and demeaning, relationship satisfaction decreases (Roberts 2000). Poor problem solving skills, difficulties with emotional regulation, and intense arguments have also been associated with relationship aggression, and situational couple violence (Lechtenberg et al. 2015; Leone et al. 2007; O’Leary 2008) which is an all too common phenomenon among distressed couples (Simpson et al. 2007; Stith et al. 2011). To date, little research has explored how patterns of conflict influence relationship help-seeking.

Purpose of the Current Study

In comparison to individuals, couples face a unique set of challenges when seeking conjoint therapy (Doss et al. 2003; Fleming and Córdova 2012) and relatively few couples overcome them to seek therapeutic treatment (Albrecht et al. 1983; Johnson et al. 2002; Wolcott 1986). Despite this, little is known about the help-seeking process of couples who are currently in distress. The present study was designed to identify individual perceptions and relationship patterns that influence couple help-seeking. The following research questions were developed to guide this study: (1) How do individual conceptualizations of the need for therapy affect conjoint help-seeking? (2) What interpersonal interactions and/or conflict patterns influence the decision to seek conjoint therapy?

Method

Sample

Participants were seven heterosexual couples (seven men and seven women) who sought couples counseling. The average length of the relationship was 6.21 years, with a range of 2.5–10 years. Eleven of the participants identified as White (79%), two identify as Black (14%), and one identified as Latina (7%). On average, participants were 31.14 years old, with ages ranging from 22 to 65 years of age. All participants lived in a large Midwest city.

Procedures

The Institutional Review Board approved the study and procedures. Couples were recruited through local clinics. Individuals who expressed interest in participating contacted the researcher for additional information. After consent was obtained from both partners, participants were interviewed separately to help both partners feel comfortable sharing freely without holding back or altering information. In addition, both partners’ accounts were compared for consistency (Beitin 2008). The individual members of each couple met with the interviewer for 30–60 min prior to their first therapy session to discuss their help-seeking processes. Interviews followed a semi-structured format and researchers covered the entire protocol with each individual, allowing some room for probing and clarifying questions. Interview questions addressed attitudes about couple therapy (What are your thoughts/feelings about therapy?); reasons for seeking help (What caused you to come to therapy at this time?); obstacles to therapy (What delayed you from coming to therapy?); and roles of partners (Who proposed couple therapy? What was your reaction?). Each interview was recorded and transcribed verbatim. The interview focused on understanding the couple’s perspectives and attitudes about the experience of coming to counseling.

Qualitative Analysis

A qualitative multiple-case study design was selected for this exploratory study. The case study approach to social sciences has clear strengths and limitations. Case studies offer the ability to explore complex social phenomena by allowing “investigators to retain the holistic and meaningful characteristics of real-life events” (Yin 2009, p. 4). The case study approach uses multiple sources of evidence to “converge in a triangulating fashion” upon contextually rich phenomenon (Yin 2009, p. 2). Interviewing both partners separately allowed the research team to compare people with different points of view to facilitate a rich and well developed understanding of help-seeking. Since the case study approach does not rely upon the experimental method, the ability to generalize results to other cases or to infer cause is limited.

The multiple-case study approach depends upon replication logic for external validity (Kazdin 1981). Replication logic implies that each case study is considered a single experiment. Analyzing multiple cases affords cross-experiment design and logic. There are no precise rules for setting criteria in identifying similar or contrasting patterns between cases, and consequently researchers look for patterns that are sufficiently similar as to be obvious (Yin 2009).

Following the transcription process, two researchers separately read and coded the text relevant to the help-seeking process. To increase consistency the research team then cross-checked codes for inter-coder agreement: the two independent coders compared their codes and shared the comparisons with an auditor. The auditor met regularly for consultation and feedback on each step of analysis. In line with analysis of multiple case design studies, the transcripts were analyzed at two levels, within each case (between partners) and across the cases (between couples; Stake 1995; Yin 2009). Steps in the analysis included (a) preliminary exploration by reading the transcripts and writing memos; (b) coding the data by dividing and labeling the text; (c) checking the codes through inter-coder agreement; (d) grouping similar codes together to form themes; (e) connecting and interrelating themes; and (f) cross-case thematic analysis. Validity of the findings was confirmed by member checking, inter-coder agreement, rich and thick descriptions of the cases, and reviewing and resolving disconfirming evidence (Stake 1995; Yin 2009).

Results

Individual Conceptualization of the Need for Therapy

Members of each couple were interviewed to identify how each individual conceptualized the need for therapy. The cross-case themes identified were: (a) proposing couple therapy, (b) stigma, and, (c) barriers to counseling.

Proposing Couple Therapy

In the majority of the couples interviewed (N = 5), the female partner initiated counseling, and in all seven cases it was the female who called for an appointment. John in Couple 3 said, “My wife decided to come to couples therapy because we aren’t doing so well. We just feel like we have some things to work on if we would like to stay together.” In the other two cases, the male partner, who was originally against counseling, reintroduced couples counseling as an option when the relationship had hit a new low. Molly in Couple 1 said, “He has always known that it’s what I wanted to do, so this time he was the one that presented that to me and I was willing to go.” The females in this sample were the first to conclude that professional help would be beneficial however their partners’ were slow to agree.

Stigma

Five of the male partners alluded to the idea that coming to couples counseling would be an admission that the relationship had failed. Gregg in Couple 5 shared, “That was a big thing, I don’t know, I didn’t want to admit to myself or to anybody that we are weak and need to do this.” Damian in Couple 4 offered, “To me it’s (coming to counseling) a sense of failure almost.” Later he described how he came to see the need for counseling as the severity of their problems increased. “I don’t know how to say it, if you think you are going to lose that (the relationship) you have more incentive to make a bigger effort.” These men expressed concern that parents, siblings, and friends would judge them for needing counseling. Fear of this shame seemed to be a motivation to deny that their relationship was in jeopardy. In addition to concern over what others might think, some of the male participants did not want to admit to themselves that there was a problem.

Barriers to Counseling

Some partners reported their reluctance about counseling was because they did not know what to expect. Multiple partners mentioned busy-ness and financial reasons as obstacles to coming to counseling. Couples 3 and 7 reported that they did not know where to look for a counselor and that they called several different places and started to feel frustrated. Two partners reported that they did not seek counseling earlier because they believed their problems were so big counseling could not help them. In contrast, other partners stated that they believed they could resolve the issues without help; essentially that their problems were not “big enough” to require counseling. Couples 3, 4, and 5 explained that they did not seek counseling earlier because they thought their relationship was too new (5 years or less) and that couples should not need counseling that early in a relationship. Help-seeking was delayed by concrete barriers (i.e. lack of knowledge, finances, and scheduling) as well social norms regarding what problems are appropriate for professional services.

The Role of Interpersonal Patterns on Help-Seeking

Members of each couple were interviewed to identify how interpersonal interactions or conflict patterns influence the decision to seek conjoint therapy. The cross-case themes identified were: (a) blame and responsibility, (b) anger and withdrawal, (c) increased distress, and (d) strengths.

Blame and Responsibility

Blaming others versus taking responsibility emerged as a significant theme across each of the cases and it appeared to be an important factor in how couples generated options. In five of the couples at least one individual took no responsibility and/or blamed the relationship problems on their partners. Mike in Couple 1 said, “It’s always about something that she’s not getting or wants or something that I didn’t do or a jealousy factor. It’s always that, it’s never anything other than those three things.” Ryan in Couple 2 stated, “I don’t totally understand why I need counseling because she is the one with the issues of the betrayal, so I don’t know.” When individuals blamed their partners, they did not conceptualize the problem as a “couple problem” meriting couple’s therapy, but as a personal problem located within their partner. Issues were identified as a his or her problem, rather than a we problem—thus delaying help-seeking.

Anger and Withdrawal

Most couples (N = 6) shared the negative effects of aggression or withdrawal. Mike in Couple 1 stated, “It’s hard to talk about our differences without getting into it. I say a lot of things that I don’t mean at the time in anger.” Partners reported “terrible name calling,” and yelling. Five couples reported incidents of violence during the course of their relationship (including perpetrators who were both male partners and female partners). Brittany in Couple 4 said, “I hit my partner and I hated myself for that. I swore that would never ever happen, I could not fathom that it happened with him.” All of the couples stated that the interpersonal violence had stopped before the time of the interviews. Across these cases, aggression affected the interpersonal dynamic in a way that delayed the help-seeking process. Four female partners shared that their partners tended to minimize issues that they felt were important. When male partners minimized or trivialized their female partners’ concerns, the conflict was entrenched, and female partners indicated that this was when they began considering separation.

Increased Distress

All of the couples spoke about specific recurring conflicts that intensified over time. Molly in Couple 1 explained how a problem takes on new meaning over the course of a relationship,

There’s been stuff, but you know in the beginning you probably don’t care as much as you do now, you aren’t as invested in it. So, in the beginning it was probably just like, “whatever,” I didn’t really care, and it kept going on and then it was to a point where we were in deep and now it’s like ok, this is a problem.

For most of the couples it took agreement from both partners that (a) the conflict was not going to be resolved without outside help, and (b) their problems posed a danger to the life of the relationship. Christian in Couple 7 said it this way, “It got to a point 2–3 weeks ago where everything was hitting the fan. We should probably do counseling or this isn’t going to work.” Five female partners stated that they hoped counseling would help them to decide whether to stay together or dissolve the relationship. No males brought up the possibility of terminating the relationship. Michelle in Couple 2 said, “I just don’t want to spend another 5 years with someone and find out that I was just wasting my time, like, it’s like I just have to know now.” For the couples in this sample the women recognized a need for therapy much earlier than their male partners. As relationship distress increased, men also began to recognize a need for help. Unfortunately, at the point of the both agreeing to seek help, some of the female partners’ dissatisfaction had reached a high enough level that they were now considering separation.

Strengths

In addition to discussing problems and conflict, most couples reported seeking counseling as a result of strengths that exist in the relationship. Michelle in Couple 2 shared, “I 100 percent love him and want to work things out.” Both partners in Couple 3 shared that their love for each other was a major motivation towards seeking counseling. John in Couple 3 stated that one of the areas he would like to grow in through counseling is learning how to demonstrate his love and affection for his wife. While acknowledging some of the challenges they face, Eric in Couple 6 stated, “We really do have a strong and loving, generally healthy relationship.” Across all the Couple cases, the expression of positive emotion for each other seemed to be accompanied by more hope for counseling and less blaming language, as well as taking more responsibility. Interestingly, multiple couples made the observation that they experienced an immediate positive change after deciding to seek counseling, before even attending their first session. John in Couple 3 said, “We’ve been talking a lot more since we decided that therapy was a good idea.”

Discussion

The overall purpose of this investigation was to expand the literature on couple help-seeking. The present study used a multiple-case study approach to explore the process partners go through when deciding to seek couples counseling. Overall, our findings identified the following patterns in couple help-seeking: (1) female partners more frequently proposed couple therapy, (2) males’ stigmatized view of couples counseling often led to withdrawal behavior when their partners suggest help-seeking; (3) as distress increased, male partners cost-benefit analysis shifted and counseling was reconsidered; (4) the perception of blaming and aggressive behaviors appeared to delay the help-seeking process and push the injured partners further towards separation; and (5) couples may be influenced by socially constructed norms that dictate how severe a problem should be or what length of time a couple should be together before seeking profession help.

Prior to seeking treatment, some couples in our study considered their problems too big for counseling whereas others thought their problems were not large or important enough to seek help. Some believed that they should not need professional help early in their relationships. Taken together, these findings suggest that couples may be operating under a social norms that relationships should not seek help in certain situations. Consequently, instead of receiving counseling early after the onset of the conflict, the problem severity seemingly increased for the couples of our sample to a point of desperation. Couples came to counseling after reaching the conclusion that the problem no longer was solvable on their own. Regardless of the level of distress, gender appeared to be a significant factor in help-initiating and help-seeking behaviors.

Gender and Help-Seeking

The most clear-cut finding revealed in the study was that female partners were the ones to initiate discussions about seeking couple counseling and then take steps to pursue treatment (Doss et al. 2003). In contrast, couples reported that male partners viewed help-seeking as a weakness or failure; thus, indicating couple help-seeking is stigmatized. For some of the male partners, the reluctance to disclose to family members, friends, or the counselor that the relationship was distressed was a significant obstacle to initiating treatment. Some of the men in the current study reported thinking through a cost-benefit analysis and described that they were initially more willing to endure their pattern of conflict than face a perception of weakness, failure, or loss of control (Vogel et al. 2006).

The participants also revealed that when female partners first proposed couple therapy their concerns were first ignored or minimized by their male partners. Delay in addressing problems led to more engrained difficulties in which both partners eventually felt hopeless to solve the problems on their own. For the reluctant men in this sample, as time passed and the relationship distress increased, the cost-benefit analysis apparently changed. Finances, cultural norms, and stigma no longer outweighed the desired benefit that counseling might, at best, improve the relationship, or at least, appease their partner. Two men reintroduced couple counseling as a possibility. The length of time it took for men to reintroduce or accept counseling as an option appeared related to the amount of hope for counseling and use of positive emotion in the interviews.

How long it takes couples to come to a consensus on counseling may relate to why couples enter therapy with different “therapeutic mandates” (Boisvert et al. 2011). When one partner feels that there is a problem in the relationship and proposes counseling but the other partner disagreed and resisted change, dissonance between their perspectives regarding the health and needs of their relationship seemed to grow. One or both partners then developed “commitment uncertainty,” (Owen et al. 2012) with one partner wanting to heal the conflict while the other partner, who had been advocating for change and counseling long before, was considering separation. This in turn may offer insight into why couples with at least one partner who enters therapy with the goal of clarifying the relationship are more likely to be separated 6 months after treatment (Owen et al. 2012). This highlights the benefit of helping couples choose counseling sooner rather than later (Doherty et al. 2015).

Demand–Withdrawal Patterns

The way couples conceptualized conflict patterns also affected the help-seeking process. When partners engaged in blaming and fault-finding there was less consensus that couples counseling was necessary or would be beneficial. This pattern of minimizing and blame tended to contribute to a mindset that the issue was really not our problem but his or her problem. This way of communicating fits within the demand–withdrawal pattern (e.g., Christensen and Heavey 1990) in which one partner demands and pursues the other for relationship change, while the other partner withdrawals. Epstein and Baucom (2002) explained that the partner most interested in maintaining the status quo will utilize withdrawal-type behaviors. In the present study, men withdrew when the topic of conversation was couples counseling.

When women recommended couples counseling, some male partners reported perceiving this as a personal criticism and responded by minimizing the female’s concerns, often using behavior that has been termed “angry withdrawal” (e.g., Roberts 2000). Angry withdrawal is different from conflict avoidance behaviors which may be a functional adaption (Gottman 1993); “angry withdrawal communicates anger, hostility, rejection, or a combination thereof” (Roberts 2000, p. 696). Angry withdrawal encourages conflict and a pattern of blaming, thus preventing a collaborative approach and the interpretation of problems as our problems. Angry withdrawal delays recognizing joint counseling as an appropriate solution after problem onset.

Most of the couples commented on how name-calling, yelling, and other demeaning and aggressive behaviors contributed to poor relationship satisfaction. This coincides with a longitudinal study by Doss et al. (2009) that found self-reported negative communication was related to the increased probability of attending couple counseling in the following year. Consequently, negative communication can prompt couples to seek help, but for most of the distressed couples in this sample, it did so only after the intensity of the conflict had convinced both partners that the situation was dire. Female partners shared that when aggressive behaviors took place it was more difficult to visualize a future together and they were less inclined to work on the relationship and more likely to consider separation.

Interpersonal Violence

Non-violent expressions of aggression can have devastating psychological and relationship consequences (e.g., Kar and O’Leary 2013). Moreover, in the present study, five out of seven cases in this study reported incidents of physical violence during the history of their relationship. This suggests a real need for counselors to be trained and ready to work on this significant issue (Epstein et al. 2015). Even if physical violence has not occurred recently in the relationship, the fact that it was brought up without the researchers specifically inquiring about it in the interviews suggests that past violence continues to impact relationship functioning long after its occurrence. Preliminary research has suggested that the type of violence, as well as individual, relational, and contextual factors influence help-seeking for intimate partner violence (Leone et al. 2007; Simpson et al. 2007).

Conjoint treatment of couples with a history of violence remains controversial. For couples experiencing severe violence conjoint therapy is contraindicated and referrals for individual treatment are recommended. However, growing evidence suggests that with careful screening couples therapy can be effective and safe for couples experiencing less severe forms of aggression to directly address the negative relational patterns and reduce or eliminate violence (Epstein et al. 2015; Lechtenber et al. 2015; Stith et al. 2011). It has been recommended that clinicians utilize both verbal interviews and valid self-report measures to carefully assess the severity and frequency of violence, psychological aggression, and substance abuse before conducting conjoint couple’s therapy with partners who report domestic violence. Ongoing risk assessment is a critical component during treatment (see Epstein et al. 2015; Stith et al. 2012).

Limitations and Future Directions

Generalizability in case study approaches is limited. Based on the small number of participants interviewed and the exploratory nature of the study, more research is needed before any conclusions can be drawn about whether or not the themes presented are representative of men and women in relationships. In particular, the sample of this study was composed primarily of White couples. Research on marital therapy and marriage education programs, and couple help-seeking have predominately been conducted with White, heterosexual, upper middle class, and college educated samples (Doss et al. 2004, 2009; Lebow et al. 2012). More culturally and demographically diverse samples are urgently needed (Davey and Watson 2008). Despite these identified limitations, this study provides an initial examination of the processes that couples undergo when deciding to seek therapeutic help and can help direct future studies.

Future research should utilize both qualitative and quantitative methodologies to explore men’s socially constructed attitudes towards relationships, and relationship help-seeking. Future studies should also examine how intimate partner violence affects couple help-seeking. Our study and previous research has shown that women are the first to recognize relationship problems, and the first to contact professionals for help. It is less clear how women’s unique sensitivity and influence motivate some couples to seek counseling with the intent to alleviate distress and others to seek separation. In addition, how does this influence couples who do present for counseling as opposed to the majority of couples in distress who do not seek counseling? Future research could also explore how the length of time it takes to establish consensus on seeking professional help and the nature and tone of the dialogue affects treatment seeking, goals for treatment, and treatment processes and outcomes. Intervention studies could be aimed at helping partners learn to propose couple therapy in a strength-based way—to minimizing blame and mitigate the sense that therapy indicates a relationship failure.