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In this chapter, we present the case that will be studied from different angles in this book. We introduce the couple , the context in which the therapy took place and give an overview—session by session—of what happened in the therapy. Throughout the book, the process of therapy will be the background for the different analyses, but only in this chapter the whole development in the four sessions is described. In that way, we try to avoid needless repetitions in the chapters to come. Of course, summarizing a therapeutic process is already an intervention that alters the complexity of what actually happened, as some aspects of the therapy are highlighted while others are not mentioned. So it may already involve a perspective on what is more and what is less important. Still we tried to condense the therapy following central thematic lines in such a way that the reader is familiar with the whole process.

The Couple and the Context

VictoriaFootnote 1 is a Scandinavian woman aged 25. She contacted the psychotherapy clinic asking help for her and for her partner Alfonso.Footnote 2 Alfonso is a Mediterranean man of 21, who came to the country of Victoria for his studies. They have been living together for 3 years.

The couple therapy took place in a psychotherapy clinic in Victoria’s hometown. In this clinic, it is a custom that the clients are asked for written consent for research, as happened also in this case. The sessions were conducted in English (not the first language for any of the participants). There were two therapists present: T1 is an experienced male systemic therapist and T2 (not present in the first session), a younger female trainee in family therapy. A total of four sessions were conducted in a period of 3 months; the interval between the sessions was around 3 weeks.

The sessions were videotaped; the couple gave informed consent to participating in research. The videotapes of the sessions were transcribed. These transcripts were the main data the authors have been working on.Footnote 3 During meetings in Belgium (2009), Finland (2011, 2013), Greece (2011), and UK (2012), brief passages of the videotapes were watched by all researchers, so as to give them some sense of the emotional atmosphere of the sessions.

Alliance and Outcome

As it is regular practice in this psychotherapy clinic at the end of every session, the Session Rating Scale (SRS) was completed in order to assess the therapeutic alliance in the meeting (Duncan et al., 2003; Miller, Duncan, Brown, Sparks, & Claud, 2003). Starting from the beginning of the second session, both partners completed further the Outcome Rating Scale (ORS) to evaluate the therapeutic change.

If we want to get a sense of the progress made during therapy in terms of outcome, we have to focus on the ORS scores. The ORS having 25 points altogether from the four subscales is thought to present a life situation without urgent need for change and if the score is below 25, there seems to be need for change. At the start of the therapy, Victoria scored 19 on the ORS, while Alfonso scored 23. In the course of the therapy, Victoria’s ORS scores improved from 19 to 37 and Alfonso’s from 23 to 32. So the ORS scores seemed to suggest an important improvement for both. Interestingly, for both partners, the most notable change in the ORS scores occurred between the second and the third session (from 23 to 29 for Alfonso; from 19 to 31 for Victoria).

In SRS , out of total 40 points, an optimal evaluation of the session means rating above 36. Victoria’s SRS ratings were 36 after every session indicating an optimal evaluation of the alliance. Alfonso’s SRS ratings changed from 31 to 33, which are nearly optimal. So both partners experienced the therapeutic alliance as very positive throughout the therapy.

Concluding both the SRS and ORS ratings, it can be noted that the therapy seemed to be helpful for the couple in a therapy process, in which they felt a good working alliance.

The Therapy

When contacting the psychotherapy clinic, Victoria had said the reason for asking for help was Alfonso’s difficulties in speaking with her of almost any issues in their lives.

In the first session, Victoria explains that she had been depressed for 2 years (following an individual treatment), that she is a lot better now (turn 8), but what happened left scars on their relationship (t10). Alfonso was concerned that he might not have the patience to listen that he used to have anymore (t14), and whenever Victoria wants to talk or asks “is something wrong?” (t38) the tension in the couple rises. Alfonso seems to fear that she might get depressed again, and that he would not be able to be caring like he was the first time (t63). Alfonso thought that maybe he used up a lot of energy supporting Victoria and maybe he needs a rest now (t74). Victoria summarized the problem as “…we can’t talk anymore…” (t84). This was difficult because, as Victoria said (t80), “… if there is anything that bothers me I need to share it, I need to talk about it…” That is why they need someone to help them (t82). The therapist explored the difficult situations they were referring to and their cultural differences as well as Alfonso’s recent trip to his family in his native country (t129). Victoria explained that it was during a visit to Alfonso’s family 2 years ago that she started feeling depressed. So a few months ago, Alfonso went to visit his family again, but Victoria stayed at home, feeling very lonely, however (t137): “I feel no-one while he’s there,” she says (t139). She expected Alfonso to textmail her during the day, but Alfonso said he was too busy meeting friends and family during the daytime, but he sent a message every evening (t140). This is something Victoria did not understand (t143): “…that’s what makes me feel that I’m not your girlfriend” (t145). She explained that she needs some proof that he sometimes thinks of her (t174). When she does not get such proof she feels rejected (t190). They talked about their studies and the history of their relationship up until their trip together to Alfonso’s home country. It became clear that Victoria did not feel at ease with Alfonso’s family at all: “your family is like the Bold and the Beautiful for me, I’m like trash…” (t331) and that Alfonso’ mother “hates me because I stole her son…” (t342). Victoria only feels at ease with Alfonso’s brother, who is also the only family member who speaks English. Alfonso translates for her in her contacts with his family.

Almost at the end of the session, the therapist asked about their expectation of the therapy. Victoria referred to a “communication problem” (t390), and Alfonso said that he needed to be able to talk and hoped that Victoria would understand him better. Then the therapist and the couple spoke about the practicalities of their next meetings. At the end of the first session, the therapist gave them a small assignment by asking what they would like to do differently to each other to have a small but visible step towards a better relationship. Victoria asked Alfonso to show some closeness when they have some time together (t462). Alfonso asked Victoria to understand that when he is going some place he is still thinking of her (t476). Then the therapist proposed that Victoria and Alfonso make these small steps in the good direction before their next session (t518).

They came late to the second session. When one of the therapists went to meet them in the waiting room, he saw that they were quarrelling and Alfonso had to convince Victoria to come into the office. When they sat down in their chairs, the ORS was filled out. Then the therapist asked Alfonso how the past week had been for him, he said that it had been “all kind of OK.” Victoria replied that she felt different. The therapist invited her to say some more about it, and Victoria explained that she did not want to come to the session. She said that she had been working too much and that she was tired and felt sad. When asked about it, she replied: “…like now, when we were coming here, we were talking about the last things that you made us do last time, that we have to make a wish for the other one, and I am sad because I think that it didn’t work…” (t33). Alfonso disagreed with her in a comment that was difficult to follow, because he started sentences but did not finish them.

After introducing the co-therapist, therapist 1 tried to continue discussing what Alfonso had meant, but Alfonso could not give a clear expression to his thoughts. Victoria started to talk about her long 15 hours’ working days and said that she was never home at the same time as Alfonso. While speaking about her workload she said: “I am asking that I am the most important thing in his life … I don’t want to be in a relationship where I am not the first one” (t74). She gave some examples of what she meant: “Some text message, or some small surprise … or maybe that he has hovered … (t87)” Alfonso replied that he was committed but that Victoria did not recognize it: “I feel that I do things for us and for our relationship. I don’t understand how you don’t see that.” (t99) When the male therapist asked about the assignment that he had given to them at the end of the previous session, they both said that, as such, it had been a good task. For the most part of the end of the session, they wanted to speak of Alfonso’s upcoming trip to his home country.

At a certain moment, Alfonso referred to an issue he had with his parents: “there’s some kind of, some kind of problem that I have with them, so maybe if I could maybe solve that kind of thing then maybe I could also, this would be also easier that you [to V] could come there, but I feel (…) it’s that’s just the way I feel about them somehow, I just feel too forced to, now to just change that, it feels something not natural …” (t409) He explained that when he visits his family, his mother would want him to be with her all the time, and that probably when Victoria was around she felt jealous of her (t499). By the end of the session, Victoria and Alfonso seemed to agree that for the time being their idea of Victoria not visiting Alfonso’s family was a good solution (t513).

At the outset of the third session, Victoria said that she has started working less (t14), and that they had more time to see each other (t16). It was “a good period” (t24), Alfonso added. Victoria and Alfonso recounted that during Alfonso’s visit to his home country, he maintained regular contact with Victoria. She experienced this increased sensitivity to her as an expression of a shift in his loyalty and commitment to her. There had been a fight about Alfonso going to a concert in a neighboring country before he went to his home country to visit his family, without talking to Victoria about it (t37). But in the end it was no big deal to Victoria, as when Alfonso came back she could see that he had missed her (t71). After the therapist asked them how they wanted to use the time (t81), they reassured the therapist that things were fine (t81) but then returned to their misunderstandings and their fighting. Both agreed that it often started with Alfonso’s reaction to a simple question of Victoria’s. According to Victoria, it is a very big problem for them (t129): “He doesn’t trust me at all,” Victoria stated (t131). Alfonso explained that his problematic reaction to a question of Victoria’s happened when he had to explain something to her or prove something (t143). For Victoria, it sounded as if she was not allowed to talk about things and as if she did not have the right to feel sad (t148). Alfonso emphasized that it was important for him that Victoria would understand that he couldn’t control his reaction to her question: “I …can’t control it, and … I … don’t want to have this kind of reaction, but it is just how it is, I don’t control it….” (t164) The therapists explored a possible link of Alfonso’s reactions with his childhood and his experience of being hit by his mother (t262). The cultural difference between a Scandinavian and a Mediterranean culture was discussed in terms of emotional reactions (t278). Then Victoria explained that when Alfonso reacted in this problematic way, she started crying (t310). After this overview of exploring their circle of interactions, both partners agreed that they now had found a better way to deal with their troublesome communication: “At first we tried to talk about it, but then we realized that it’s not any use,” Victoria explained (t346). They have learned that it doesn’t do any good to try to solve it by talking (t348), and they decided to take some time and keep some distance instead and let things settle on their own: “…when we see that it’s like that, we don’t talk to each other and we left things calm down… before we were just trying over and over, to solve the thing, that was just worse…” Alfonso explained (t354). He added that when they come back together after such a tense situation they start hugging (t376). Asked by the therapist who takes the initiative, Alfonso said: “I think it is always me” (t378). In a final reflection together the therapists highlighted that Victoria and Alfonso seemed to have found new ways of being together that are more constructive (t405).

The fourth session was brief. It started with the therapist asking “How is your life today?” (t1). Victoria replied “It’s fine” (t2) and Alfonso agreed (t3). They both said it had been a good period (t12–13) because they didn’t have their usual fights (t15). “How did you make it possible … not having fights?” the therapist inquired (t26). “We have more time together,” Victoria first replied (t28), but on second thought they didn’t know how they had done it. The therapist inquired if Victoria changed her way of questioning Alfonso (t49), and Alfonso said it was the same (t52), but that there were fewer fights (t59). Victoria then said that she had been able to take things less seriously (t70): “…for example, if I get this bad feeling nowadays it’s easier for me to let go…” (t74). Alfonso backed her up by saying that he had noticed that (t75). Victoria explained that she had been thinking a lot and that she realized that she had these issues with trust and now she forces herself to believe Alfonso’s words of commitment in spite of the inner voice that says “don’t believe anything you hear” (t83). She emphasized several times that this is a struggle for her: “I know I will never be completely normal” she said (t93). Referring to the fact that there had been no fights in the last weeks the therapist addressed the couple and asked: “…is it the right or the wrong conclusion that you have …learned…to do something different, together?” (t111–113). They both agreed, but Victoria emphasized that it is never easy to learn (t117). She further said that they had learned to listen to each other (t121), and Alfonso added that they had learned to deal with the threat of an escalation by saying “OK, let’s just now stop” (t122). The therapist then asked about possible challenges for them in the future. One challenge they mentioned is that they are going to move in 2 days (t141–160). Another challenge would be Alfonso’s next trip to his home country, which was scheduled for 5 weeks later in the Christmas season. Alfonso concluded that he was confident that—like his previous trip a month earlier—all would go smoothly (t162). Victoria replied that for her it was weird to spend Christmas in different places, but that she was not ready yet to go with Alfonso to his home country (t169). Then they turned again to talk about moving and about the different views they have concerning their home. Rounding up the session, the therapist then asked if the couple now had an answer to the question they came in with (t235). “Yeah, I think we are getting better, yeah,” Victoria replied (t238). “Yes,” Alfonso agreed (t239). They decided to end the session there and not to have any more therapy sessions.