Tools for Working with Spanish-Speaking Latino Couples

Abstract

This chapter provides a treatment outline and handouts for therapists working with distressed couples. The treatment consists of seven modules that occur over 12–18, 1 h sessions. The outlines described in this chapter were informed by key principles from evidence-based treatments for couples. Module 1 covers the intake and assessment sessions, in which the goals are to build rapport and provide feedback to the couple. In Module 2, couples are taught communication skills (e.g., speaker/listener roles), and they also practice these skills with a low-conflict issue. In Module 3, couples work through gaining a deeper understanding of one or two moderate-/high-conflict issues. Module 4 addresses how couples can identify triggers for their arguments and also reviews how to use a time-out strategy. In Module 5, couples learn problem-solving skills, and couples apply these skills to a specific problem. Module 6 focuses on increasing intimacy, through completing fun activities together and changing behaviors. Finally, Module 7 addresses termination issues and how to plan for life after therapy. When relevant, the modules include handouts to be used in session, as well as homework handouts that couples complete at home to further practice the learned skills.

Appendices

Module 1: Establishing Rapport and Setting Goals

Recommended Length: One to Two Sessions

Goals of module: Module 1 has several goals. As with any other kind of therapy, a primary goal for the first couple of sessions is to help those seeking intervention feel comfortable with the therapist and the process of therapy. A second goal is to clarify the reasons for seeking therapy and to set goals. A third goal is to motivate the couple and give them hope that therapy can be effective.

Couples’ responses to the handouts for Module 1 also will help the therapist better understand the couples’ needs. Total scores lower than 13.5 on the Couple Satisfaction Inventory (CS) (Handout 1b) indicate significant couple distress. Lower scores on the CSI likely suggest that therapy will take longer than higher scores. Responses to the CSI also are helpful to the therapist in monitoring couple progress over time. The Dyadic Adjustment Scale (DAS) also provides information on level of couple distress, but in addition, it also provides information about specific sources of distress.

Session #1 Outline

Have the couple complete (1) Intake Form (Handout 1a), (2) Couple Satisfaction Inventory (CSI) (Handout 1b), and (3) Dyadic Adjustment Scale (DAS) (Handout 1c).

Spend some time getting to know the couple and building rapport:

• What do they do? How did they meet? How long have they been together?

Goal setting:

• How did they decide to seek therapy?

• What are their goals and expectations for therapy?

• Discuss responses on the Intake Form (Handout 1a) when relevant.

Help motivate the couple:

• All couples will experience difficulty at one point or another. The key to a healthy relationship is how each couple deals with the problems they encounter.

• The cognitive-behavioral approach to couple therapy is backed by decades of research and literally hundreds of studies. The basic premise is that communication difficulties are one of the main factors that contribute to the distress couple experience, and there are proven ways to help couples improve how they talk to each other and solve problems. This will help reduce conflict as well as build intimacy. It is important for the couple to believe that it is possible to improve and strengthen their relationship.

Session #2 Outline

• Not all couples will need a second session for Module 1, but many will, especially more distressed couples. Session 2 is essentially an extension of Session 1.

• A common use of this session will be to have further discussion about specific goals for therapy and review problematic areas identified on the DAS.

Therapist Guide to the CSI and the DAS

It is recommended that therapists assess the level of marital distress in the couple before starting an intervention. This will inform the therapist about how serious the marital problems are, and measurement tools also are important for monitoring the effectiveness of therapy. Both the Couple Satisfaction Index (CSI : Funk & Rogge, 2007) and the DAS accomplish this goal, though each one is useful in its own way. The CSI items assess global satisfaction with the relationship and are rated on Likert scales ranging from 0 to 6 or 0 to 5, with total scores ranging from 0 to 21. The cutoff score for marital distress is 13.5. The four-item version of the CSI has demonstrated good convergent and construct validity. Given its short length, the four-item version of the CSI is a commonly used measure to assess couple distress and also to monitor couple progress over time.

The DAS also measures couple distress, but it is longer and more detailed and provides a greater amount of information. Although it does contain several subscales, more commonly, only the total score is used in assessing couple distress. A cutoff of 100 has been determined to differentiate distressed from non-distressed couples on the Spanish version of the DAS (Cano-Prous, Marin-Lanas, Moya-Querejeta, Beunza-Nuin, Lahortiga-Ramos, & Garcia-Granero, 2014). In this chapter, the DAS is used primarily as a tool for therapists to better evaluate specific sources of stress or disagreement in couples’ relationships.

Module #2: Teach and Practice Communication Skills

Recommended Length: Two Sessions

Goals of module: In these sessions, you guide the couple on learning listener and speaker skills. These skills are useful when understanding and defining relationship problems. They help to structure conversations in a way that allows for both partners to share their piece of the argument, while also feeling understood by his/her partner. In these sessions, you will also have the couple discuss and rate their top problems. This will help the couple in selecting topics to use for practicing the listener and speaker skills. These skills are initially practiced over two sessions and will continue to be emphasized and practiced throughout therapy.

Session Outline #1

• Provide couple with Handouts 2a and 2b and review these with the couple:

  • This worksheet provides information on what the “listener” and “speaker” roles entail. Go through the worksheet and describe both roles to the couple.

  • You don’t need to walk through all of the practice examples in session, and instead couples can complete these at home.

• After reviewing the listener and speaker roles, ask the couple to think of a problem in their relationship that they tend to argue about, but not have heated discussions about. The problem also needs to be something that they are both willing to talk about. You want this first conversation to go smoothly, and picking a topic that is too heated/difficult may set the couple up for more disagreements. The couple will be ranking their top problems for homework, and this first discussion is meant to be a conversation that is low-level conflict (i.e., the 1–3 range).

  • Possible topics:

    • Division of chores/housework

    • Finances

    • In-laws

• Your role here is to make sure that the couple is following the “rules” of the listener and speaker roles. For example, if the listener interrupts the speaker, let the listener know that they will have time to share their view when they are in the speaker role.

• Homework: Assign the couple Handout 2c (top problems) for homework and ask them to first individually rate issues in their relationship and then come together to fill out the six problems (Handout 2d) they will discuss in sessions using the listener and speaker roles.

Session Outline #2

• Homework review: Go over Handout 2d with the couple and discuss how the conversation went when they were picking their top problems.

• Practice the listener and speaker skills through two conversations in session that are more difficult topics than previously practiced. One conversation should start with a “moderate” conflict topic from Handout 2d and the second conversation should be a “high” conflict topic.

• If couples are struggling with the listener and speaker roles, therapists can mention that these skills may feel unnatural and that it can take a while for them to become natural. Also, emphasize that this technique is not one that needs to be used multiple times per day, but instead one that should be used for difficult conversations that may escalate into hostility and anger.

• Due to normative cultural differences in emotional expression, not all types of conflict will have the same impact on couples. Understanding how these differences present in therapy will be important to the therapist.

It is important for therapists to understand cultural differences in communication, and it may not be necessary to remedy the conflict that a couple is experiencing, unless it is hostile. Be sure to check in with couples to get a better understanding of what type of conflict is normative in their relationship and whether both individuals are negatively impacted by it.

Communication: Listener Skills

Communication: Speaker Skills (Using “I” Statements)

Module #3: Deeper Understanding of Issues

Recommended Length: Two to Three Sessions

Goals of module: In these sessions, you guide the couple as they try to more fully understand one or two of their main issues. These sessions are meant to build intimacy as couples work on understanding, but not solving their problems. Through using the listener and speaker roles, couples will continue to deepen their understanding of their partner’s perspective. Your role as a therapist is integral in these sessions, as you encourage couples to dig deeper into their issues without trying to solve the problem.

Session 1 Outline

• Describe the process of polarization to the couple and provide them with Handout 3a. Have them discuss an example of how this process has occurred in their relationship:

  • Polarization is a natural process in which partners’ differences become more extreme over time. For example, one partner may seek to be closer, while the other partner wants more space. By one partner pushing for more closeness, the other partner wants more space and distances further. This process continues after conflict and the couple becomes polarized.

• Next, provide the couple with Handout 3b:

  • Describe that in this session, the couple will be taking a deeper look into a moderate- or high-conflict issue from Handout 2d. They should have already been able to work through low-conflict issues in previous sessions.

  • Go over the worksheet and the various factors that could potentially relate to couples’ problems:

    • These differences are not “defects” but instead are part of how people are naturally different from each other and have had different experiences.

  • Ask the couple to fill out Problem #1 in session and save the second for homework.

• After the couple fills out some factors related to Problem #1, ask which partner would like to share first. Have this partner use the speaker skills:

  • Stay with this partner after he/she shares and ask questions geared at building intimacy (e.g., “What was it like to share with your partner?”). Use the partner’s own words as you ask additional questions.

  • Allow the other partner to respond and also share their understanding. A way to continue to build intimacy is to ask this partner: “How did it feel to have your partner open up to you?” or “How did it feel when your partner said X [something that was not blaming]?”

• The goal of these questions is to get beyond the content of what the couple shared, and instead tap into the emotions they felt during the conversation. If they are not sharing emotions, you can ask questions targeted toward that (e.g., “What did you feel when [partner] said that?”).

• Homework: Ask the couple to fill out the second problem on Handout 3b and have a conversation regarding the factors impacting this problem. Ask them to use listener and speaker skills. These factors and the discussion will be covered in the next session.

Sessions 2+ Outline

• Homework review: Go over Problem #2 on Handout 3b and ask them how their conversation went. If they did not complete the homework, start the session by having them do this.

• Spend session 2 (and potentially more depending on the couple) on continuing to build intimacy. The goal here is to remove blaming language that the couple uses and instead focus on the factors (from Handout 3b) that are related to their problems.

• Couples are ready to move onto Module 4 when you feel like they have gained more acceptance of their partner. This can be demonstrated through tone of voice, using non-blaming language, physical gestures, etc.

Note: Be sure to jump in if the couple starts to use blaming language and a negative tone of voice or tries to problem solve. Problem-solving occurs in a separate module, and the purpose in these sessions is to better understand that these problems aren’t necessarily to blame on someone, but that these differences are natural and have become worse over time.

Module #4: Argument Triggers and How to Control Them

Recommended Length: One to Two Sessions

Goal of module: The overarching goal for this module is how to help couples identify cues for arguments and to help them practice argument-control strategies. For most couples, one session is likely to be sufficient before proceeding to problem-solving in Module 5. However, if the time-out sequence does not go well when practiced at home, some couples may benefit from a second session for further review of the steps involved.

Session Outline

• Step 1: Help the partners identify cues that an argument is impending. See also Handout 4a:

  • What are the behaviors that they notice occur prior to an argument?

  • What are the thoughts that they notice occur prior to an argument?

  • What are the feelings that they notice occur prior to an argument?

  • What are the bodily sensations that they notice occur prior to an argument?

• Step 2: Partners agree to cool off when one of the triggers occurs – teach the couple how to take a brief time-out (see Handout #4b).

  • After each partner is able to identify for themselves the behaviors, thoughts, feelings, or bodily sensations that are signs of an impending argument, they each can be asked to make a contract that they will take some sort of action to cool off before the discussion escalates further.

  • Examples of actions that members of the couple could agree to take include:

    • Pause the conversation

    • Take time to calm themselves down

    • Take time to think about ways in which they are contributing to the problem

• Step 3: Help the partners identify times that are conducive to discussing and/or solving problems (after children have gone to bed, before children get up in the morning, a weekend morning) and also times that are not conducive (e.g., the moment one partner returns from work, in the middle of preparing dinner, while helping children with homework).

• Step 4: Partners need to identify a time to return to the discussion. The general recommendation is for this to happen within an hour or two, but no more than 24 h later. Optimally, time-outs or brief pauses in an escalating argument help the members of the couple calm down sufficiently so that they can come back and have a productive discussion. Time-outs, however, should not be overused or used to avoid a topic or to block a difficult but productive discussion.

• Step 5: As needed, the members of the couple can sign a contract which would specifically outline the steps they will take during a time-out (see Handout 4c).

• Homework: Practice the time-out steps at home.

How and When to Take a Time-Out

A time-out is a good idea when you and your partner are becoming argumentative, insulting, or aggressive:

• Partners should identify in advance the warning signs that a time-out makes sense, and they also should agree upon what kind of verbal or visual signal is going to be used to call for a time-out.

• Either partner can call for a time-out.

• The partner that calls for the time-out must agree to a set a time to return to the discussion (preferably, within no more than 24 h).

• Each partner should separately engage in an activity that is relaxing:

  • Examples: going for a walk, reading a book, listening to music

• Complete Handout 4c (“Time-Out Agreement”) which outlines what each person agrees to do to help themselves calm down. The goal is to prepare oneself to return to the discussion.

• At the designated time, when both partners are calmed down, partners return to the discussion.

• Time-outs should be used only when truly needed and not overused.

Module #5: Problem-Solving Skills

Recommended Length: Two to Three Sessions

Goals of module: In this session, you teach the couple problem-solving skills and describe the steps to take in problem-solving. Not all problems can or need to be solved, and sometimes a partner wants to vent opposed to solving a problem. In sessions, you will work with the couple through a specific problem that they would like to apply the problem-solving steps to.

Session Outline

• Homework review: Discuss how the use of the time-out strategy worked at home.

• Describe the rationale behind problem-solving. It is important to inform couples that not all problems need to be solved. These steps for problem-solving are for mutual problems that the couple wants to work through. Problem-solving should not occur in the heat of the moment, and instead it is helpful for couples to set aside a time to have problem-solving discussions (e.g., on Wednesday after the kids go to bed). Problem-solving conversations are structured, and it is helpful for couples to have a notepad where they can write down elements of their discussion.

• Let the couple know that not all problems can be solved. These include problems that are not under voluntary control, such as directly influencing a partner’s level of trust or influencing a partner’s sexual desire. Other problems that are not a good fit for problem-solving include ones where there are only two possible solutions (e.g., whether or not to have a child).

• There are also problems that don’t need to be solved. Sometimes a partner only wants to vent about a specific issue (e.g., problems with a co-worker), and it is important to use listener skills in that moment, opposed to suggesting solutions to your partner.

• Describe the steps of problem-solving and provide couple with Handout 4. As you are describing the steps of problem-solving, engage the couple in working through these steps in the session:

  • 1. Discuss and define the problem:

    • Have the couple use the listener and speaker roles to discuss the problem.

    • The problem must be mutually agreed upon.

    • The problem should be specific.

    • The problem should not be labeled in a blaming way.

    • Try to include a positive in the problem (e.g., I like it when you hold me when we watch movies, but I feel rejected when you aren’t as affectionate during other times of the day).

    • Have the couple set an agenda of what specific problem they will discuss, and tell the couple how they should only attempt to resolve a single problem in a problem-solving session.

  • 2. Brainstorm possible solutions (using Handout 4):

    • Have the couple generate solutions on their own first.

    • These solutions should include a wide variety of ideas – have couples think outside the box.

    • Partners should not criticize each other’s solutions.

  • 3. Agree on a solution

    • The couple should be able to answer “yes” to the following: “If we were to adopt this solution, would it help to resolve our problem?” If the answer is “yes,” have the couple discuss the pros and cons of each feasible solution and list their agreed-upon solutions on Handout 4.

    • The final agreed-upon solution that they will try first should be a compromise that is very specific.

    • Once the couple agrees on the solution, they should pick how long they are going to try out that specific solution (see Handout 4).

    • The couple should schedule a follow-up for when they will check in on how the agreed-upon solution is working. This should be in approximately 1 week.

    • If the first solution they try out doesn’t work, they should try out another solution from their list and follow up with that solution.

• Homework: Ask the couple to implement their solution and be ready to discuss it at the next session.

• Have the couple repeat these steps in additional sessions. Some couples, especially distressed ones, may need to work on problem-solving more than others.

Module #6: Building Caring and Intimacy Behavior

Recommended Length: Two Sessions

Goals of module: In these sessions, you guide the couple on building intimacy through caring acts. This part of the treatment is meant to engage the couple in behavioral strategies. Relationships are sustained through continued efforts by each partner, and these sessions provide strategies on how to engage in caring behaviors. When partners continue to engage in these behaviors over time, this can help to prevent relationships from becoming negative and hostile.

Session Outline #1

• Ask each partner to share how they think fun and friendship is going in their relationship. Most couples will likely benefit from continuing to use the listener and speaker roles to navigate this discussion.

• Provide couples with Handout 6a and ask them to generate a list of ideas together for what they can do for fun. Discuss this with the couple and make sure their ideas are specific.

• Next, provide couple with Handout 6b and ask the couple to spend a few minutes thinking of two to three ideas of what each partner can do for the other partner.

• To ensure that each partner has selected behaviors that are doable and appropriate, give feedback to each partner about the two to three ideas. This occurs while the other partner is still in the room; however, other partner should not be an active part of the discussion and should only listen. Explicitly explain this to the couple. It may be hard for each partner to not chime in regarding whether he/she likes the partner’s idea. The goal is to have little to no input from the other partner and let each partner take initiative on his/her own.

  • Make sure the ideas are specific.

    • Example: If one partner writes “be romantic,” it is the therapist’s job to transform that into an operational, concrete behavior that can be easily executed (i.e., go on a walk with [partner] and hold her hand).

  • If the other partner is unable to stay silent during this time, it may be a sign that the couple is not ready to complete this assignment yet, and that more understanding/acceptance work needs to be completed.

  • Describe to the couple that this can be an “experiment,” during which they try to implement one caring behavior each day.

• Homework: Have the couple fill out the rest of Handout 6b and also implement one or more of the behaviors daily. It can be the same behavior each day or a different one each day; it is up to the couple. Also, instruct the couple to not share their lists with each other or tell each other which items they have chosen from the list. One of the reasons they don’t share with each other is so that these tasks can become more natural, instead of something artificial that is prescribed by the therapist. Instruct the couple to be ready to report back next session on how the “experiment” went. Finally, have the couple complete one activity over the week from Handout 6a and have them specifically tell you which activity they intend to complete. They can change their mind and complete a different activity, but it is important for them to commit to completing at least one activity together.

Session Outline #2

• Homework review: Go over Handout 6b with the couple. Start with the partner that went second in the first session.

• You can generally tell right off the bat whether this assignment was a success or not. For those who it was successful, ask more about which tasks were attempted, successful, noticed by the recipient, etc. There may also be some tasks that take up too much time or are too difficult and need to be taken off the list.

• In this session, the recipient has the opportunity to ask for additional items to be added to the list. This does not mean that the giver needs to oblige and perform these tasks.

• If the assignment did not work, problem solve around why the task did not work out. Was it related to each partner not completing daily tasks, or was the list not tailored to what the recipient wanted? Discuss this with the couple if there were any problems with the task. Also, be mindful of using listener and speaker roles in this session, as needed.

• Describe to the couple that they should continue to choose one item from their Fun and Friendship list weekly and implement tasks from their Behavior Change sheet daily.

Module # 7: Ending Therapy and Planning for the Future

Goal of module: Ideally, couples’ therapy ends when the goals that have been mutually agreed upon are achieved or the problems that brought the couple to therapy have been resolved. Below are some general guidelines for therapists as couples’ therapy comes to a close.

• Remind the couple of the approaching ending of the sessions that remain. This should be done at least two to three sessions prior to the final one.

• It is helpful to review the progress that the couple has made during the therapy sessions. It is not uncommon for couples to forget the advances that they have made or to fail to give themselves credit for their accomplishments.

• Check in with the couple about what they have learned and what they intend to do with what they have learned after they leave therapy. What did they find helpful about the therapy sessions?

• Review the tools and skills that the couple has acquired through couples’ therapy. This will help solidify the gains the couple has made and also give them a sense of confidence and self-sufficiency going forward as they leave therapy and will have to handle problems on their own.

Treatment plan
Module	Session plan/goals	Worksheet
1 - Identify goals for therapy: rapport building; review of intake information; identify weaknesses in communication skills	Session 1: review reasons for why coming to therapy now; history of relationship; goals the couple hope to accomplish Sessions 2–3: the couple is observed trying to talk about a significant problem in their relationship; therapist notes strengths and weaknesses and provides this feedback to the couple	Intake Form (1a); Couple Satisfaction Inventory (1b); Dyadic Adjustment Scale (1c)
2 - Introduction to speaker-Listener skills: teach and practice communication skills	Sessions 1–2: teach appropriate speaker and listener skills (e.g., “I” statements; supportive listening); practice speaker-listener exercises Sessions 3–4: practice speaker-listener skills: The couple tries to discuss low-conflict issue to practice communication skills	Listener skills (2a); speaker skills (2b); top problems (2c and 2d)
3 – Deeper understanding of issues	Help couples more fully understand the context and contributing factors to top problems	Polarization handout (3a); developing a deeper understanding (3b)
4 - Argument triggers: identify triggers for arguments and practice communication and problem-solving skills	Help the partners identify cues that an argument is impending; identify times and conditions that are conducive to problem-solving; review how to take a time-out	Triggers (4a); time-out (4b); contract for time-out (4c)
5 - Problem-solving skills: teach and practice problem-solving skills	Sessions 1–2: teach and practice problem-solving steps and apply to a low-conflict couple problem Sessions 3–4: the couple tries to discuss conflict topic of moderate intensity, using the speaker-listener task, brainstorming, and plan selection	Problem-solving (5)
6 - Caring and intimacy-building behavior	Session 1: have the couple discuss what they can do for fun; generate Behavior Change lists for what each partner can change for the other partner Session 2: review how behavior change went; revise Behavior Change lists	Fun and Friendship (6a); Behavior Change (6b)
7 - Planning for the future and ending therapy	Help the couple in maintaining their gains after therapy