Keywords

Joint Decision-Making and Couple Psychotherapy

Over recent decades, the notion of shared decision-making has gained increasing popularity in healthcare provision. Within the field of mental health, actively engaging clients in decisions about their care is advocated in terms of both its clinical utility and on ethical grounds (Slade, 2017). In this chapter, we explore joint meaning-making as a specific type of joint decision-making, taking place in couple therapy. We illuminate the verbal and affective interactional processes that underlie the joint creation of meaning, which we argue is an important and often implicitly actualized aspect of the therapeutic process.

Over the least 20 years, and influenced by social constructionism, the literature on couple and family therapy approaches human systems as linguistic systems that are organized by characteristic communicative markers (Anderson & Goolishian, 1988). Accordingly, psychological problems are conceptualized as created, maintained, and dissolved in and through language and social interaction. In this framework, psychotherapy is approached as a semantic process, which entails the reconstruction of meanings (especially meanings about the problem) and the reformulation of the clients’ subjectivity, reflected in changes in self-narratives and in subject positioning. A key aim of psychotherapy talk is for clients to reconstruct their life narratives in ways that are increasingly complex, emotionally salient, inclusive of experience, polyphonic and flexible (Avdi & Georgaca, 2007).

Within this framework, problem constructions are considered to be key to the practice of psychotherapy; through therapy talk, clients’ concerns are recast into the language of therapy and thus rendered understandable within the therapy discourse and treatable through its practices. Problem constructions are not neutral as they entail issues of accountability, blame, as well as positioning and ideology (Avdi, 2015). Problem constructions implicate a cause, ascribe responsibility and imply solutions (Buttny, 2004), and as such, are relevant to processes of decision-making. Furthermore, negotiations around problem constructions are an ongoing process in psychotherapy, as clients and therapists attempt to create a joint understanding of the clients’ difficulties and ways to address these.

In couple therapy, more specifically, problem constructions often involve negotiations around clienthood, that is discussions about who has the problem and who should change; these discussions are often affectively charged, and problem constructions are often contested in couple therapy (Wahlström, 2012). Partners may disagree about the causes, nature, and solutions to their difficulties; moreover, blame is a common dynamic in many distressed couples that seek help. On the other hand, couples may share a way of making sense of their difficulties, but this may be implicated in pathologizing or limiting one or both partners’ well-being. As such, examining the processes through which couple therapists navigate through the complex, and often affectively charged, processes of negotiating shared meanings about the couple’s distress can contribute to a better understanding of the process of couple therapy.

The Joint Creation of Meaning and Therapeutic Interaction

Several authors have argued that the establishment of a respectful and responsive conversational context, in which clients can begin to reconstruct their life narratives, is crucial for the process of therapy (Avdi & Georgaca, 2019; Smoliak & Strong, 2019). In this sense, therapy depends on the creation of “dialogical space” (Rober, 2005), which allows emotional expression, the generation of not-yet said meanings, the articulation of voices that have hitherto been silenced or excluded, and the re-organization of the clients’ position repertoire (Anderson, 2012; Seikkula, 2011).

Within contemporary collaborative and dialogical approaches to couple therapy, the therapist’s receptive and responsive attitude toward the clients’ storytelling is considered to be a key therapeutic task that is crucial for the reconstruction of the clients’ problem. Several related notions have been articulated to describe the therapists’ attitude, such as adopting a “not knowing” stance (Anderson & Goolishian, 1988), participating in dialogue (Seikkula, 2011), exhibiting tolerance of uncertainty (Seikkula & Olson, 2003) and being relationally responsive (Anderson, 2012). These concepts have been debated on both theoretical and practical grounds (e.g., Guilfoyle, 2003) but they remain key principles in couple therapy practice.

In line with this, there is strong evidence that aspects of the therapeutic interactions that are associated with responsive action on the part of the therapist are crucial for the outcome of psychotherapy (Norcross, 2011). A key concept relevant to conceptualizing responsiveness and collaboration in the client-therapist relationship is the therapeutic alliance. The therapeutic alliance is a pan-theoretical concept that reflects the collaborative aspects of the therapeutic relationship and is seen to consist of (a) a strong emotional bond characterized by trust and (b) agreement and collaboration on the goals and the tasks of therapy (Bordin, 1979). There is strong evidence that the quality of the therapeutic alliance is predictive of outcomes in both individual and family therapy (Friedlander, Escudero, & Heatherington, 2006; Horvarth & Bedi, 2002). Similarly, in the field of shared decision-making in mental health, the establishment of a strong alliance has been described by both professionals and service users as fundamental for its implementation (Eliacin, Salyers, Kukla, & Matthias, 2015). In conjoint treatments, several competing factors affect the formation of the alliance (e.g., power dynamics and conflict in the couple, trust, loyalty, and secrets) and these render its establishment difficult (Friedlander, Escudero, Heatherington, & Diamond, 2011). In couple therapy, the alliance comprises of a web of closely interlinked, complex relationships between participants and the various subsystems thus formed (Horvarth, del Re, Flückiger, & Symonds, 2011).

Recent research has addressed in detail the interactional processes through which the therapeutic alliance is formed, maintained, challenged, and restored within sessions (Safran & Muran, 2000). Conversation-analytic research has examined aspects of the alliance in terms of alignment and affiliation. Collaboration with regard to the goals and tasks of therapy has been studied through the notion of alignment, which entails cooperative actions that facilitate a conversational sequence or activity, such as accepting and following the sequence of conversation and joint meaning-making (Muntigl & Horvarth, 2016; Sutherland & Strong, 2011). Affiliation, that is, actions that display agreement, sharedness, solidarity, understanding, and empathy (Lindstrom & Sorjonen, 2013), has been associated with the emotional bond aspect of the alliance. A key aspect of affiliation entails the listener joining in the other’s emotional stance and, as such, is associated with concepts such as empathic attunement, rapport, reciprocity, engagement, and interpersonal sensitivity. In conversation, affiliation is actualized through both verbal and nonverbal means, such as continuers or minimal responses (e.g., “uh huh,” “yeah,” “yes”) (Fitzgerald, & Leudar, 2010), repairs (Mondada, 2011), smiling, head nods (Stivers, 2008), prosody (Kykyri et al., 2017; Weiste & Peräkylä, 2014), as well as affiliative facial expressions (Chovil, 1991; Peräkylä & Ruusuvuori, 2012). In psychotherapy process research, attending to the role of nonverbal displays is arguably crucial, given that therapy entails affectively charged processes of personal narration, problem construction and identity work.

Research Questions

In this chapter, we explore the interactional processes that underlie the joint creation of new meanings, between all participants, in the context of a systemic couple therapy. We use one interactive event from a couple therapy session to examine the following research questions:

  • How is the problem jointly (re)constructed in couple therapy?

  • How does the therapist affectively respond to the clients’ narratives in order to facilitate a joint understanding of their difficulties?

Data and Method

The research material used in this chapter was drawn from one session of couple therapy, conducted in a Family Therapy Department in Greece in the context of a wider research project (Avdi & Seikkula, 2019; Seikkula, Karvonen, Kykyri, Kaartinen, & Penttonen, 2015). The service provides couple and family therapy to the community; treatment follows systemic principles with the added use of reflective conversations (Andersen, 1987). In practice, sessions take place every three to four weeks between a primary therapist and the couple. A second therapist watches the session behind a one-way mirror and joins a conversation toward the end of each session. For the purposes of the research project, all sessions were video-recorded with four cameras, in split-screen mode. Following a naturalistic design, no changes were made in the way therapy was practiced. Couples were informed about the study by a graduate researcher and participated on a voluntary basis. Ethical approval was granted by the Family Therapy Department’s Scientific Board.

Two experienced, female systemic family therapists in their fifties participated in the therapy discussed in this chapter. The therapy concerned Costas and Demetra, a white heterosexual couple in their mid-thirties. The therapy consisted of 15 sessions, spanning 14 months. The couple came to therapy because of increasing tension in their relationship, following the birth of their baby 10 months earlier. At the end of treatment, the couple reported improvement both in their personal lives and their relationship.

The research material used in this chapter consists of the video and transcript of the third session. We decided to focus on an early session, as creating a shared understanding of the problem is a key task during this stage of therapy. Furthermore, the extent of the clients’ active participation in therapy is negotiated at the early stages of therapy. As such, achieving jointly constructed meanings, particularly in early sessions, is crucial for the work of therapy (Horvarth & Bedi, 2002; Knobloch-Fedders, Pinsof, & Mann, 2005).

This session was selected for analysis as it was shown to be primarily dialogical, that is to entail conversations characterized by responsiveness and mutual inquiry (Seikkula, Rober, & Laitila, 2012). The session was transcribed verbatim, following conventional conversation-analytic transcription notation, including key nonverbal displays. However, due to the nature of the analysis, which necessitates longer stretches of talk, speakers’ turns, rather than lines, are numbered sequentially. Nonverbal displays of affiliation are marked in the transcript, following the respective turns. The extracts were examined using discourse analysis (Georgaca & Avdi, 2011) informed by conversation-analytic tools.

More specifically, in terms of discourse use the primary focus of the analysis was on problem constructions and their development through the session. Furthermore, we examined the speakers’ responsiveness to each other’s meanings with a focus on affect mirroring and displays of affiliation and empathy, as well as nonverbal displays of tension. These different modes of interaction were combined to provide a detailed description of the process of joint meaning-making in the session.

Affective and Semantic Aspects of Joint Meaning-Making in Couple Therapy

The session discussed in this chapter is used to illustrate a therapeutic conversation in which the problem is gradually jointly reconstructed, as the couple begin to elaborate on painful and delicate issues in their relationship. The therapist’s stance is characterized by responsiveness to meanings that are yet not fully articulated and by affect mirroring. This way of working was typical in this therapy as a whole, and the extract analyzed illustrates several of the ways in which the therapist contributes to the creation of new meanings. Although the specifics of the meanings created are particular to this couple, the process of joint meaning-making described is arguably a key process in couple therapy. In line with dialogical principles, joint meaning-making has been shown to rely primarily on processes that elicit narrative elaboration, whereby not-yet articulated experiences come to be narrated and gradually assimilated into the clients’ self-narratives, and processes that promote emotional expression.

Before turning to the extract, we outline the main problem constructions in this couple therapy and the way they develop through time. At the start of therapy, the clients construct the problem in terms of disagreements over sharing household responsibilities: Costas is not sufficiently engaged in their household, which Demetra finds frustrating. This issue is quickly resolved and the difficulties that Demetra experiences in her role as mother become the primary focus of several sessions. In this session, the narrative of the couple’s difficulties gradually expands and Demetra begins to describe how she has felt depressed, trapped, and bored with her life, since the birth of their baby. She describes her baby as a “parasite” that makes constant demands on her, and reports having frequent bursts of anger, often aimed at her baby, which are followed by intense guilt. These issues are painful, delicate, and implicate troubled positioning with respect to motherhood. In the analysis that follows, we have illustrated how the delicate issue of Demetra’s sadness and hopelessness is gradually introduced into the conversation, thus contributing to joint construction of new meanings for the couple’s difficult experiences. We argue that the therapist’s responsive stance facilitates the narration for experiences that are as yet unstoried.

The extract discussed is from the beginning of the third session, where Demetra’s sadness and sense of feeling trapped is first brought into the conversation. The session starts with the couple reporting improvement; Costas is more engaged in the home and tension has subsided. Demetra introduces her sense of being “bored” with her life and their relationship, a description that Costas downplays. Just before Extract 1, Costas states that things have improved in their relationship and that if they “try a little harder, the next steps will follow.” The extract starts with the therapist inviting Costas to elaborate on this.

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At the start of the extract, the therapist invites Costas to elaborate on the meaning of his expression “the next steps will follow.” Therapists often use the clients’ personal language, joining in their “idiolect” (Holmes, 2009). This is an element of therapist responsiveness which helps create joint understanding and establish a personal relationship (Wahlström, 2019). In terms of meaning construction, preceding Extract 1, Demetra introduced her sense of feeling “bored” with their relationship, a problem description that Costas does not take up. Instead, he focuses on positive changes and downplays any reference to the couple’s difficulties. Considering this, Costas’ rather vague statement (“the next steps will follow”) can be seen as an attempt to shift the conversation away from what seems to be a difficult issue for them. In line with this hypothesis, following the therapist’s question, Demetra displays nonverbal markers of tension (turn 02) and Costas hesitates before addressing Demetra, which he does while looking at the floor (turn 03). These nonverbal displays mark the topic of the couple’s relationship as delicate. Such tensions around expressing one’s experience in the presence of one’s intimate partner and the associated anxiety about what one’s partner may choose to disclose are quite common in couple therapy (Friedlander et al., 2006), and may restrict what each client chooses to discuss. This may exclude important aspects of lived experience for one or both partners, with adverse implications for shared meaning-making.

In response to the therapist’s invitation (turn 01) Costas expresses, with hesitation, his wish to take Demetra out for a drink (turn 02). A brief exchange follows, in which Demetra rejects Costas’ invitation by appealing to facts with increasing emphasis (turns 04, 06, and 08). Through these turns, Demetra speaks in an increasingly assertive tone and lists in vivid detail the reasons why they cannot go to a bar (turn 08). Vivid descriptions and lists are considered to be rhetorical strategies of factualization that render an account credible and thus difficult to dispute (Edwards & Potter, 1992). On his part, Costas displays affiliation (smiles), speaks in an apologetic and conciliatory tone and appeals to his feelings (turns 05 and 07). Furthermore, during Demetra’s last turn (turn 08) Costas exactly mirrors Demetra’s movements. This is an example of non-conscious mimicry, a common aspect of human interaction that has been associated with affiliation and affective sharing (Chartrand & van Baaren, 2009). We could speculate that one aspect of the couple’s (presumably habitual) complementary conflict style is enacted in this brief exchange: Costas makes an affiliation attempt, Demetra rejects it with irritation, Costas displays further affiliation, and so on. The therapist allows the couple’s interaction to take place and observes it, while displaying several back-channel signs of attentiveness, such as smiling, gaze, and facial expression. She intervenes only when the interaction has been completed.

In sum, in Extract 1, the therapist’s question invites elaboration on the couple’s relationship, which is associated with tension for both partners. Following from this invitation to elaborate, difficulties in the couple’s relationship are not only narrated but also displayed; this allows for deepened exploration, as will be seen in the extracts that follow.

Next, the therapist focuses on Demetra’s lack of interest in the couple’s joint life, thus inviting further elaboration on this difficult topic, as illustrated in Extract 2.

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In turn 13 the therapist addresses Demetra and thus affects the course of the conversation by marking her response as relevant to the problem construction. Therapists often manage turn-taking to focus selectively on specific issues or interrupt problematic interactional patterns. In this case, the therapist addresses Demetra with a reformulation, which selectively focuses on specific aspects of what has been said by the previous speaker and in this way changes it, while seemingly accepting it. Reformulations are routinely used to promote therapeutic work (Antaki, 2008; Buttny, 2004; Davis, 1986; Weiste & Peräkylä, 2013). In this instance, the therapist positively reframes Demetra’s rejection of Costas’ invitation, as her wanting to spend time with him at home. Positive reframing is a key rhetorical practice in family therapy and an alliance-building strategy (Friedlander et al., 2006). She introduces this reformulation tentatively, with a hedge expression (“if I understand”), thus inviting collaboration. Over the next couple of turns, the therapist builds on her reformulation (turn 16) while Demetra resists it, by repeating “I don’t know” (turns 14 and 17). Demetra does not express her disagreement directly but rather withdraws from the conversation, a non-preferred response in therapy talk. Clients’ minimal responses to the therapists’ interventions are considered to be markers of withdrawal ruptures (Eubanks, Muran, & Safran, 2015) that reflect troubled collaboration.

Next, the therapist changes track and challenges Demetra’s lack of response more directly (turns 18 and 20); her intervention concludes with “I don’t know what you want.” With this latter statement, the therapist shifts the focus of conversation to the here-and-now, using Demetra’s own words again. This is an example of metacommunication, one of the strategies therapists use to repair alliance ruptures (Eubanks et al., 2015). Through this intervention, the therapist illuminates the troubled collaboration between herself and Demetra and renders it relevant to their conversation. Importantly, there is a marked change toward negative affect in the therapist’s facial expression in turn 20, as she reflects in an exaggerated manner Demetra’s affective state. Successful affect mirroring has been shown to consist of affective displays that are contingent on the original expression but marked; that is, different in intensity (Holmes, 2009). Therapists often exaggerate the affective display of clients, thus encouraging the expression of emotion with increased salience and depth. During this exchange, Costas joins in, in a quiet voice that overlaps with the therapist’s turns (turns 15 and 19) but does not interrupt them, and in fact aligns with them.

However, the therapist’s attempt to repair the alliance with Demetra and explore her experience is met with further resistance, as she withdraws further: Demetra does not respond to the therapist’s invitation, makes a “shrug face,” turns to Costas and laughs in a conspiratorial manner (turn 21), presumably in an attempt to shift focus. Costas displays signs of both tension and affiliation (turn 21), before taking the floor and introducing a new issue, as discussed in Extract 3.

The above exchange is quite complex with respect to the therapy process; the therapist works at maintaining an alliance with both partners through different modalities of communication. On a semantic level, the therapist’s turns (13, 16, 18, and 20) align with Costas’ account that the problem is associated with Demetra’s lack of interest. At the same time, the therapist affiliates with Demetra on a nonverbal level, through mirroring her affect and on a verbal level through addressing the difficulties in their current interaction (turn 20). In this way, the therapist maintains the therapeutic alliance with Costas (as she aligns with his problem description) and at the same time, attempts to repair the alliance with Demetra (through metacommunication and affect mirroring). In other words, the therapist joins in with both partners through different modalities.

The interaction that follows (Extract 3) is important in terms of joint meaning-making. Costas introduces a difficult topic for the couple, their sex life, and the interaction culminates in the expression of strong affect. The problem construction expands and becomes more inclusive of lived experience, strong emotions are expressed, and thus aspects of the couple’s experience that had been hitherto excluded, enter the conversation.

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At the start of the extract, Costas takes the initiative to introduce another delicate issue, the couple’s sexual relationship (turn 22). It seems that the therapist’s responsiveness in the previous turn contributed to the establishment of safety, which in turn facilitated this difficult conversation to take place. The therapist marks this as important with an emphatic continuer (turn 23). In response, Demetra states that she is “bored” with sex and displays signs of tension (turn 24); boredom is a rather vague emotion, often used to disguise more intense negative affect. Costas persists in talking about sex, in a light-hearted, humorous way (turns 25 and 27) and initially Demetra joins in his light tone and laughs (turn 26). However, her expression soon shifts to negative affect as she repeats, more emphatically, that she is bored (turn 28). Costas, presumably sensitive to Demetra’s distress, quickly aligns with her, affirming that he understands her feelings and smiles (turn 29). This responsive move on Costas’ part facilitates emotional expression and Demetra begins to talk about how difficult she finds sex and how tired she feels (turn 30). In terms of problem construction, this is an important development; the initially rather vague affective state of being bored becomes one of struggling, finding things difficult and feeling tired. Similarly, in terms of affect, diffuse tension is replaced by the expression of sadness. These shifts reflect a process whereby the couple’s narratives about their difficulties become richer, more inclusive, and emotionally salient, in line with the aims of psychotherapy.

In terms of meaning-making, it is interesting to note the differing responses by Costas and the therapist to Demetra crying. Faced with Demetra’s tears Costas smiles, presumably in an effort to cheer her up. On the other hand, the therapist’s facial expression changes drastically from smiling to negative affect, mirroring Demetra’s sadness (turn 31), and then she asks gently, in a soft, soothing voice, repeating Demetra’s exact wording “you feel tired?” (turn 32). The use of soft prosody and low vocal tone is a conversational tool that conveys affiliation and affect attunement that can promote the process of change in therapy (Kykyri et al., 2017; Weiste & Peräkylä, 2014). Furthermore, from a clinical perspective, turn 33 illustrates therapeutic change on a nonverbal level, as the therapist’s responsive focus on Demetra’s feelings of sadness (turn 32) disrupts a presumably habitual interactional pattern in the couple, which functions to exclude sadness from being expressed. Interestingly, Costas’ facial expression also changes to negative affect, following the therapist’s intervention. When Demetra’s crying subsides (end of turn 33), Costas makes another affiliative opening (turn 34) but Demetra withdraws (turn 35). Instead, the therapist focuses on Demetra’s affective experience (turn 36); she says, “you want to cry,” in a low quiet voice and a sad facial expression, an invitation that deepens Demetra’s affective expression. Following this interaction, and when her crying eventually subsides, Demetra begins to express her sadness, helplessness, and sense of despair (turn 38), topics which are further elaborated on in the remaining session.

In sum, in the interaction described above, the couple’s problem construction expands to include Demetra’s affectively charged struggles with motherhood, her depression and sense of helplessness, as well as Costas’ frustration and guilt in managing these strong feelings. The therapist contributes to these shifts primarily through empathic responsiveness and affect mirroring. The interaction described is an example of a process of joint meaning-making, whereby painful experiences for the couple begin to be expressed and a dialogical space is created in which new meanings regarding the couple’s life can gradually develop.

Conclusions

In this chapter, we illustrated some of the interactional processes involved in joint meaning-making in the context of couple therapy. We presented in detail an interactive event, which illustrates the therapist’s agenda and practices of promoting emotional expression and joint narrative elaboration of delicate issues in the couple’s life. Although our analysis focused on only one brief interactive episode, we propose that circumscribed events can activate processes of dramatic change, in line with the tenets of dynamic systems theory (Salvatore, Tschacher, Gelo, & Koch, 2015).

In line with the principles of collaborative and dialogical approaches to couple therapy, a key aim of therapy is to create a dialogical space that allows the narration of aspects of experience that are as yet unstoried, and thus to facilitate the expansion and reconstruction of the couple’s difficulties and self-narratives. Analysis of the session as a whole and as illustrated in the extracts presented, highlighted the therapist’s affective responsiveness to the clients’ storytelling as key aspects of this process. The therapist’s verbal interventions were minimal, as she used primarily continuers, repairs (often repeating the clients’ exact words) and, less frequently, reformulations. In other words, most of the therapist’s utterances were oriented toward establishing intersubjective understanding rather than directly shifting meaning. Although subtle, these interventions powerfully affected the unfolding conversation toward the creation of new, shared meanings. In other words, the therapist was active in creating the conditions for dialogue and jointly created meanings, primarily through responsiveness and affect mirroring. As a result, difficult feelings began to be expressed and the clients’ narratives became richer, more complex and more emotionally salient.

Previous discursive research has highlighted the more active rhetorical strategies that family therapists use to challenge, deconstruct, expand, and reverse problem-saturated accounts and to promote positive, solution-focused and relational descriptions of the family’s difficulties (e.g., Avdi & Georgaca, 2007; Smoliak & Strong, 2019). There is evidence that therapists use strategies such as direct questions, information-eliciting tellings and reformulations to elicit client narration (Buttny, 2004; Davis, 1986). In this case, however, the primary way in which the therapist contributed to narrative elaboration was through affiliation and affective responsiveness. This finding complements previous research and highlights the importance of studying nonverbal displays alongside language use when studying psychotherapy process.

This study focused on a good outcome case and a session characterized by collaboration; it would be interesting to extend this inquiry by studying so-called “monological” clinical interventions, i.e., conversations during which joint meaning-making is compromised, in order to deepen our understanding of the challenges implicated in this endeavor and to explore possible solutions to these.

The findings of this small-scale study have implications for psychotherapy theory, practice and research. More specifically, the findings highlight the importance for the therapy process of establishing a shared semantic framework, promoting collaboration, and establishing a therapeutic alliance. Moreover, the importance of a relationally responsive stance on the part of the therapist for fostering the creation of a healing conversation is underscored. Furthermore, the analysis illustrates that joint meaning-making in therapy is not always given, as clients often “resist” invitation to explore difficult feelings and experiences. Therapists need to work actively toward establishing alliance and collaboration and to creating conditions of safety where clients can risk exploring painful experiences.