THE

AMERICAN

Marital

Therapy

BY

\I.

ELLE\

BER\1

from %\,

\I.I).,

JOURNAL

a Psychiatric A\I)

II ROLt)

OF

Perspective: I.

LIEF.

AMONG THE PROLiFERATING forms of psychiatric therapy in the last decade, marital and dyadic therapy have assumed an ever-increasing importance. Marital problems of patients have always been a significant consideration for psychiatrists and psychotherapists. A survey by Sager and associates (1) demonstrated that 50 percent of the patients requesting psychotherapy did so largely because of marital difficulties, and another 25 percent had problems related to marriage. According to Gurin and associates (2), among the reasons why people seek help for emotional problems, marital concerns rank first, followed by other family problems. Nevertheless, until the

paper

was

written

at the invitation

of the

An Overview

\I.1).

The authors describe various methods ofmarital therapy in use today. A/though absence ofa unifying conceptual scheme in thepast has hampereddevelopments in this field, the increasing ackno wledgment by psychiatrists of the important effect ofthe environmental system on thoughts. feelings, and behavior hasfacilitated a therapeutic approach stressing not only a person ‘s intrapsychic conflicts but current environmental, family, and spouse-related phenomena. The authors discuss three dimensions of marital psychodynamics-power, intimacy, and marital boundary setting-and relate them to the marital life cycle and to four classifications of the marital relationship: 1) rules for defining power, 2) parental stage, 3) level of intimacy, and 4)personality style and psychiatric terminology. The paper includes a brief discussion of therapy techniques, sex counseling, the use of cotherapists, the future of marriage, and alternative lifestyles.

This

PSYCHIATRY

Editor.

Dr. Berman is Assistant Professor and Dr. Lief is Professor, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pa.; they are also with the Department’s Division of Family Study, where Dr. Berman is Chief of Counseling Services and Dr. Lief is Director. Address reprint requests to Dr. Berman, Division of Family Study, 4025 Chestnut St., Room 210, Philadelphia, Pa. 19104.

middle of the last decade few psychiatrists specialized in marital therapy (3), and little training in marital therapy was available to psychiatric residents (4).

RESISTANCE

OF

PSYCHIATRISTS

TO

MARITAL

TH E RAPY

The one-to-one doctor-and-patient model of therapy is ingrained in medical-student teaching. In psychiatry this perspective has been augmented by the psychoanalytic dictum that the relationship between the doctor and the patient will be attenuated and the transference diluted if the therapist sees other family members. In addition, psychoanalysis and psychodynamic psychotherapy (at least in the past) tended to emphasize intrapsychic rather than interpersonal problems, so that many therapists felt incompetent and uncomfortable in dealing with more than one patient at a time. Although the more eclectic training programs have recognized that systems or transactional issues are valid areas of therapeutic exploration, they have usually emphasized one-to-one treatment and the use of transference phenomena as a means of effecting change in the dyad. The therapist, therefore, may avoid dyadic couples’ therapy even when he feels that such techniques might be indicated. In addition, many psychiatrists felt that their professional status might be threatened because of the insufficient status assigned to the field of marriage counseling, a field that comprises practitioners from a variety of disciplines with different perspectives and methods of treatment (5-7). The absence of a unifying conceptual scheme and the complexities and difficulties of developing a suitable diagnostic classification also inhibited psychiatrists who otherwise might have been led into the field. At the present time there is enough information on new concepts dealing with possible conceptual schemes and diagnostic classifications to warrant reconsideration. This paper will tie together the multiple models of dyadic therapy that form the framework for the therapeutic intervention and will, in addition, discuss methods of marital therapy.

AmfPsychiairy

132.6,June

1975

583

MARITAL

THERAPY

DEFINITIONS MARITAl.

OF

MARRIAGE

COUNSELING

ANE)

THERAPY

Even if the terms “marriage counseling” and “marital therapy” (8) often have been used interchangeably, it is important to assess their differences and similarities. Marriage counseling has traditionally included a broad range of activities, from giving advice about financial affairs or how to deal with in-laws to a sophisticated analysis of the transactional processes between the husband and wife. We define marital therapy to include all of these counseling activities and, in addition, the use of unconscious processes such as those manifested in symptom formation, dreams, fantasies, and slips of the tongue, together with a more thorough consideration of individual psychopathology. In marital therapy the therapist brings to bear his full range of skills, depending on his knowledge of individual and transactional psychodynamics, making use of transference manifestations as well as unconscious factors (internal conflicts and defenses) in making his appraisal and choosing his therapeutic interventions. Marital therapy may include behavioral techniques that make little or no use of unconscious processes but take into account the subtleties and nuances of the transactions between the spouses. In contrast to individual psychotherapy, which emphasizes intrapsychic factors, marital therapy focuses primarily on interpersonal relationships. The psychiatrist who is trained in both individual and marital psychotherapy is in a particularly advantageous position, for he has the capacity to shift between intrapsychic and interpersonal factors-a skill that those trained in only one of these modalities lack. The interrelationships between intrapsychic and interpersonal factors are the heart of marital therapy. Confusion about marital therapy exists because many professionals who practice it do not take cognizance of unconscious or transference issues and are not always concerned with matters of diagnosis and individual dynamics. There are others who do not simply disregard these issues-they claim that consideration of individual dynamics, even pathology, and diagnosis interferes with the effective treatment of a marital couple.

EMERGING

TRENDS

Despite its diverse background, marriage counseling seems to be developing a growing professional organization and identity as a separate discipline (9-16). The American Association of Marriage and Family Counselors has doubled its membership in the last 5 years. The total literature devoted to marital therapy has also doubled in the last few years (17, 18), indicating a sharply increasing interest among professionals in this field. Special journals such as The Journal of Marriage and the Family, The Family Coordinator, and Family Process, as well as two new ones, The Journal of Marital and Sexual Therapy and The Journal of Marriage and Family Counseling, also indicate the growth of the field. 584

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Psychiatry

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Training in marital therapy in medical schools has also noticeably increased. Martin and Lief(4) have reported that 50 percent of the medical schools in the United States include marital therapy in the training of psychiatnc residents. Thus the “illegitimate child” of a multidisciplinary union not only is growing rapidly but is achieving legitimacy through professional organizations and new journals, by increasing numbers of research reports and practitioners, and by the stepped-up training of psychiatric residents. Despite these trends, however, training in marital therapy is still inadequate, and only a few centers in the United States provide adequate formal, supervised clinical experience.

CONCEPTUAL

SCHEMES

IN

THERAPY

Although there is still much confusion over conceptual schemes in marital therapy, one factor is achieving wider recognition, namely, the effect of the environmental system on thoughts, feelings, and behavior(19). As increasingly successful techniques have developed involving symptom removal by changing the transactional system, it has become apparent that behavior is motivated not only by underlying intrapsychic conflicts but by feelings and attitudes involving the dyad as well as the family and the environment (20-25). Therefore, marital therapy must be related not only to a person’s intrapsychic conflicts but, more importantly, to current environmental, family, and spouse-related phenomena. Conceptual schemes for dyadic relationships are clearly in their infancy. Over the last 30 years many clinicians, from Sullivan (26) and Spiegel (27) to Minuchin (28), have attempted to describe the complicated framework of interpersonal patterns of communication. But there has been no system that satisfactorily explains the multiple variables and complicated processes involved, at least in operational terms. Three of the most helpful approaches (29) have centered on the following factors: 1. How we communicate: the rules or formal aspects of communication most eloquently described by systems and communications analysis. 2. What we communicate: primarily issues of role expectations and behavior based on social-psychological concepts. 3. Why we communicate: motivational factors based on the more traditional psychodynamic approaches to internal conflict usually related to early childhood experiences and learning. A prominent problem in marital therapy has been to distinguish severe characterological pathology, for which the best treatment is long-term psychotherapy (30), from behavior determined by pathological transactions, which is modifiable by changes in the transactional system. In this respect a systems-behavioral approach is particularly helpful because it gives clues as to what in the current environmental system may give rise to dysfunctional or disturbed behavior. We have linked the systems and behavioral approaches because both concentrate on observable behavior and

ELLEN

rules of current communication (3 1-34), without immediate recourse to a historical “why” (always mindful of the potential understanding provided by the ontogenetic method, e.g., the similarity of spouseand parent-related behavior). Behavior therapy describes the rules by which certain behaviors can be learned, reinforced, or extinguished, regardless of the original reason for the behavior (35-38). It provides a theoretical basis for the commonsense knowledge that even simple behavioral changes can sometimes evoke major alterations in the behavior and feelings of the spouse or children, thus substantiating the findings of social psychologists that behavioral changes usually precede attitudinal ones. Systems theory aids our perspective with the postulate that in any system, the whole is not simply the sum of its parts but an integrated entity (39). The parts of the systern are so interrelated that a change in one causes changes in all. Thus the relationships are not simply linear but, by means of feedback loops, circular and continuous with no beginning or end. In the process of being a positive or negative reinforcer, the person producing change is himself changed. Although further discussion of this complicated subject is beyond the scope of this paper, we have found that many of the postulates of systems theory are helpful (4043). Conceptually, the marital dyad is an open system that is in (easy or uneasy) equilibrium with its environment. Once children enter the picture, the system enlarges. Minuchin (28) has described the enlarged system particularly well within the context of structural family therapy. As marital-change agents, however, we often find it useful to separate the marital dyad from the family system, recognizing and dealing with the other elements in the system when necessary.

MARITAL

PSYCHODYNAMICS

Marital or dyadic relationships involve three critical dimensions that are similar to those explicated for group process, as follows: I. Power Who is in charge? (It is commonplace now to point out how often the submissive, weak, or sick partner exerts control and power over the “dominant,” decision-making spouse.) 2. Intimacy: How near, how far? (The vacillations in emotional and geographic distance, as partners struggle with their need for and fear of closeness, are significant data for the marital therapist. Coming close and separating again and again is a dialectical feature of life, which became the cornerstone of Rank’s theories [44].) 3. Inclusion-exclusion: Who else is considered to be part of the marital system? (This applies not only to inlaws or the extended family but to friends, careers, recreational and social activities, and even pets.) All relationships must in some way come to terms with these issues. The ways in which these fundamental human questions are solved depend on intrapsychic processes and marital style (see the section on Systems of Marital

M.

BERMAN

AND

HAROLD

I.

LIEF

Classification and Diagnosis). In healthy relationships the solutions are not static but instead are in continuous flux, depending on the stage and needs of the couple. Dysfunctional couples tend to erect more static and rigid solutions. The dynamic forces in the marriage result from each spouse’s need to achieve his/her expectations (certain levels of power, intimacy, and boundary setting), offset and opposed by the need to compromise or submerge these desires in order to enable the partner to attain his/ her expectations. The balance between the struggle for autonomous self-fulfillment and the need to please the partner or aid the relationship whenever these are opposing or uncomplementary forces is not only the heart of the marriage but the core of marital therapy. Because one’s own needs and desires are often contradictory, internal conflict is inevitable. The complexity of the interpersonal situation is augmented by the presence of internal conflict in one of the spouses. Internal conflict leads to the sending out of conflicting messages or ambiguous and confusing role behavior, hence the need for attention to patterns ofcommunication in mantal therapy (12, pp. 3-20). In order to effect change, the individual and internal conflicts ofeach partner must also be carefully examined. In the end, in some marriages fundamental changes in behavior depend on a change in the individual personality structure of one or both of the partners involved. However, until the structure - the what and how-of communication is carefully appraised and classified, the adequate separation and exploration of intrapsychic processes are almost impossible.

THE

MARITAL

I.IFE

CYCLE

Individual and marital development are inexorably entwined. The marital life cycle is best examined in light of the recent research on adult development by Levinson and coworkers (45) and by Gould (46). which builds on Erikson’s theories of psychosocial development (47); these authors have developed a series of normative stages in the adult life cycle. In table I we have attempted to relate the marital life cycle to individual developmental tasks and stages, as set forth principally by Levinson and associates (45). Butler (48), Neugarten and Datan (49), and Lidz (50) have also done work in this area. The individual and the marital life cycles can be divided into seven stages, as indicated in table 1. Any such graphic description of complicated life events is bound to be schematic and simplistic. Space limitations preclude a more thorough analysis; we plan to publish this material separately. We feel, however, that it is crucial to recognize that critical stages in the marriage are intimately related to critical stages in the individual life cycle. Issues that appear to be either purely individual or purely dyadIc are often actually the result of a complicated interaction between marital and individual crisis points (especially at ages 30 and 40). The three dimensions of potential conflict chosen were described in the section on Marital Psychodynamics. Al-

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MARITAL

THERAPY

TABLE

I

Individual

and Mania!

Stages of Development

Stage 1 (18-21 years)

Stage 2 (22-28 years)

Stage 3 (29-31 years)

Individual stage

Pulling

Provisional adulthood

Transition age 30

Individual task

Developing autonomy

Developing intimacy and occupational identification; “getting into the adult world”

Deciding about commitment to work and marriage

Shift from family oforigin to new commitment

Provisional marital mitment

Commitment crisis; restlessness

Item

Marital

task

up roots

corn-

at

Stage 4 (32-39 years)

Stage 5 (40-42 years)

(43

Settling

Mid-life transition

Middle hood

Deepening commitments; pursuing more long-range goals

Searching for “fit” between aspirations and environment

Restahiliting reordering priorities

Productivity: children. work, friends, and marriage

Summing up: success and failure are evaluated and future goals sought

Resolving conIlicts and stabiliting the marriage for the long haul

down

Stage 6 59 years)

Stage 7 (60 years and over)

adult-

Older

and

age

Dealing effectivelv with aging. illness, and death while retaining Lest or life

Supporting and enhancing each other’s struggle for productivity and fulfillment in face of the threats

of aging

Marital conflict

Original family ties conflict with adaptation

Uncertainty about choice ofmarital partner; stress over parenthood

Doubts about choice come into sharp conflict: rates ofgrowth may diverge if spouse has not successfully negotiated stage 2 because of parental obligations

Husband and wife have different and conflicting ways of achieving productivity

Husband and wife perceive “success” diiferently: conflict between individual success and remaining in the marriage

Conflicting rates and directions ofemotional growth: concerns about losing youthfulness may lead to depression and! or acting out

Conflicts are generated by rekindled fears of desertion, loneliness. and sexual failure

Intimacy

Fragile

Deepening ambivalent intimacy

Increasing distance while partners make up their minds about each other

Marked increase in intimacy in “good” marriages: gradual distancing in “bad” marri-

Tenuous macy tasies others

Intimacy is threatened b aging and b boredom visi-vis a secure and stable relationship: de-

Struggle to maintam intimacy in the face of eventual separation: in most marriages this dimension

intimacy

but

intias fanabout increase

ages

Power

Testing

of power

Establishment patterns conflict tion

Marital boundaries

Conflicts in-laws

over

of of resolu-

Friends and potential lovers; work versus

family

Sharp vying for power and dominance

Temporary ruptions eluding marital

586

Levinson

Am

and associates

(45).

I Psychiatry

132:6, June

1975

of pat-

terns of dccision making and dominance

disinextrasex or

reactive “fortress building”

From

Establishment definite

parture children increase

Nuclear closes aries

family bound-

Power in outside world is tested vis-#{224}-vispower in the marriage

Disruption due to reevaluation: drive versus lization

restabi-

of may or de-

crease

intimacy

Conflicts increase

often when

achieves a stable plateau

Survival fears stir up needs for

children leave, and security appears threatened Boundaries usually except such

control and dominance

are infixed crises

Loss of family and friends leads closing in of to

as illness,

death, job change, and sudden shift role relationships

boundaries:

in

physical environment is crucial in maintaming ties with the outside world

ELLEN

though the chart is primarily drawn to describe people who marry in their 20s, it describes to some extent the stages that all married people go through.

SYSTEMS

OF

MARITAL.

CLASSIFICATION

Marital therapists do not yet have a systematic and formally agreed-upon classification of marriage relationships. No one has yet formulated a diagnostic scheme covering all measures. A review of the current systems of classification, however, permits us to look at a number of ways of considering and examining the marital pair. Three of the following classifications are based on the critical dimensions described earlier in this paper, namely, power, intimacy, and marital boundary setting. The fourth classification is based on personality styles familian to psychiatrists. I. Based

on R ules Jbr

Defining

Po wer

This classification has been proposed by Lederer and Jackson (22). I The symmetrical relationship. This is a relationship between two people with the same types ofbehavior; both are expected to give and both to receive; both give orders and both take them. This type of relationship minimizes differences between the two people. Partners are seen as having essentially not only equal but similar role definitions and thus they tend to mirror each other’s behavior. Problems tend to stem from competition. 2. The complementart’ relationship. Two people cxchange different types of behavior. In marriage this type of relationship is most often described as traditional. One member is seen as “one-up” and one member as “onedown,” e.g., helper and helpee. This type of relationship maximizes differences, and each member exchanges dissimilar but need-fulfilling behavior evoked by the other. It tends to be less competitive than other types of relationships and is often highly workable, especially when the “helpee” has some areas to be in charge of. It angers many people because of the implication that the “onedown” person is bad and somewhat inferior. 3. The parallel relationship. The spouses alternate between symmetrical and complementary relationships in response to the changing situations. They may be supportive and competitive without fear. According to Ledencr and Jackson (22), this is “the most desirabe relationship for our egalitarian culture.” .

Classification

AND

HAROlD

I.

11FF

3.’ By

Level

of intimacy

This

DIAGNOSIS

Classification

BERMAN

dyad. Pollak’s classification includes the following stages: 1) before child rearing, 2) early child rearing, 3) latency and adolescent children, and 4) after the children leave (the “empty nest”). Classification

ANt)

M.

2.’ By Parental

Stage

This classification is a dimension of inclusion-exclusion, or boundary setting, best described by Pollak (51). In today’s nuclear family, the inclusion of children tends to produce the principal disruption to the marital dyad. There is, of course, no question that other groups such as relatives and friends infringe on the couple, but not with such force as children do. The period of child raising tends to be crucial in terms of difficulties for the

often-quoted system was proposed by Cuber and Harroff (52). 1. The conflict-habituated marriage. This marriage is characterized by severe controls, tension, and conflict. Unpleasant as the relationship is, the partners are held together by a fear of aloneness and by the pseudomasteny ofcontrolling while angering their partner. 2. The devitalized marriage. This marriage is characterized by in frequent expressions of dissatisfaction, probably because ofseparate activities and interests. This type of interaction is characterized by numbness and apathy and is overtly conflict free but devoid of zest. There is an occasional sharing of companionship, but otherwise the relationship is held together principally by legal and moral bonds and children. 3 The passive-congenial marriage. Th is ma rniage is “pleasant” and feels comfortably adequate to both partners. There is a sharing of interests but a somewhat uninvolved type of interaction. The principal social supports come from outside the marriage, and interests are with other people. The partners tend to feel that “everyone’s marriage is like that,” and they derive some genuine feeling of support from the structure of the relationship. 4. The vital relationship. This relationship is exciting and rewarding and is highly important to both partners in at least one area, such as child rearing or work. The partners work together in an enthusiastic manner. The mdividual partner is seen as indispensable to the pleasure of the activity. This marriage can contain some overt conflict, but it is basically a crucial, emotionally rewarding tie as well as a stabilizing force. 5. The total marriage. In terms of level of involvement, this type of marriage is similar to the vital marriage except that it is more multifaceted. All reinforcing activities are shared, and the partner is seen as indispensable, whatever the activity. This type of relationship is rare but possible; however, it is particularly precarious because of its multifaceted nature, which can lead to power conflicts. .

Classification

4.’ By

Personality

Style

and

P.cychiatric

Terminology Several groups have independently tem (9, pp. 303-312; 53). For another chodynamic level of interaction, (54);

work

Stevens’ 1.

for

work The

a general

(14,

pp.

discussion

proposed variant

see refer

his

feelings

obsessive-compulsive

man

who

and

who

ArnJ

has

Dicks

and

the

hys-

139-154). husband

and

as a condemanding woman.” dependent,

wife.

obsessive

sys-

a psy-

Mittelmann’s to

This dyad has also been described flict between the detached husband and the wife, on the “‘cold-sick’ man and the love-sick Basically, this pattern involves a somewhat terical

this at

particular

is often

P.s schiatrv

difficulty

seen

as

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the

strong,

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silent

587

MARITAL

THERAPY

type. This type of man, who is overly concerned with “doing the right thing,” often picks a woman who is the stereotype of femininity in our culture. She appears to be passive and somewhat seductive and has a marked tendency toward dramatic self-presentation-in psychiatric terminology, a hysteric. At first she brings great excitement into her husband’s life because she expresses and evokes in him feelings that he has never felt before. The release of his feelings excites him, and this enhances his pleasurable appreciation of hen. Taking care of her adds to his feelings of importance. On her part, the wife is looking for a good parent, someone who will give hen a sense of stability and security. If the couple begins to experience stress after the penod of romance is over, the husband will regard his wife’s more intuitive emotional nature and her analogical form of thinking as highly unpleasant and disorganized, and his wife will find his reactive emotional distance highly unpleasant. As she increases hen nagging demands and he increases his detachment, each blames the other, whereas it is the transactional system that is really at fault. The relationship tends to be a parent-child interaction and may degenerate from the good parent with the good child to the distant parent with an angry child. Of the three major dimensions of marital interaction, conflicts over intimacy become the central focus. 2. The passive-dependent husband and the dominant wife. In these relationships the husband is originally attracted to a self-reliant woman in order to incorporate hen strength. Because of his lack of self-assertion he feels inadequate; in addition, he may be alcoholic on obese. He handles his doubts about his masculinity by choosing a woman who will take care of him. He usually picks a woman who has severe conflicts oven her feminine role and is highly uncomfortable in a dependent position and therefore chooses a man whom she can control. If this relationship becomes conflict laden, it will be due to the husband’s increasing passive-aggressive behavior and depnession, a reaction to the wife’s attempts at overcontrol. Hen inability to control and dominate him and the frustnation of her own unconscious dependency needs may lead her to become angry and hostile. Power is the central theme in this transactional system. 3. The paranoid husband and the depression-prone wife. This relationship often has significant sadomasochistic elements. The husband, a jealous, suspicious, hostile, and angry man with concerns about his masculinity and a fear of ego disintegration, may pick a woman who has low self-esteem and readily accepts blame. Convinced because of hen own poor self-esteem that she cannot do any better, she becomes his wife. Her pathologic low selfesteem can often be traced to rejecting attitudes by excessively critical parents. She may pick a husband who is a psychological replica of her more rejecting parent and from him seek the approval that was unobtainable from the idealized and unreachable parent. These marriages are particularly stormy because both partners have inadequate coping and defense mechanisms and vulnerably low self-esteem. Conflicts are almost always multidimensional.

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4. The depression-prone husband and the paranoid wife. This relationship is the reverse of type 3. A woman who is suspicious and jealous marries a man who tends to be depressed and distraught. In addition to the masochistic elements in the husband’s personality that permit the continuation of the painful relationship, the wife’s suspicious and hostile nature gives the man an excuse for not moving out into the outside world, which is seen as threatening. His passive depression allows her to maintam hen suspicious and angry behavior without having to cope with a controlling partner. Conflicts often center around the issue of enlarging the marital boundaries to include others. 5. The oral-dependent relationship. Both members of the relationship are passive, dependent, immature, and nivalrous. They both have an intense longing for affection and feel that they are giving more than they are getting. Relationships of this type are particularly stormy, although occasionally the partners may be able to take cane of each other. Both exhibit temper tantrums and a desire for childish gratifications. Neither one can exhibit interest in the well-being of the other. In this type of relationship, conflicts may center around any of the major themes of marital interaction. 6. The neurotic wife and the omnipotent husband. In this relationship the woman is helpless and chronically ill and expects hen mate to be omnipotent and relieve her suffering. She expresses unconscious resentment through depression and an exacerbation of symptoms. The husband stays in the marriage because of I ) his desire to help, and 2) his extreme sense of inadequacy. He is strengthened by the idea of helping a person who is weaken than he is, but his continual failure at this results in a loss ofconfidence. Power is the primary area of conflict. Comment It is important to recognize that these marital styles do not always result in severe conflict and divorce. These couples find each other because of some kind of neurotic balance, and if the couple is moderately flexible and has recourse at times to other patterns of behavior, the marniage can go rather well. This is particularly true of the obsessive-compulsive h usband and the hysterical wife when the husband is able to accept his wife’s rather charming personality and live with her disorganization. Problems arise only when the cost of keeping the system going is too high (for example, when one spouse’s depression results in hospitalization and in the reactive wish of the partner to get out of the relationship); when one spouse changes, thereby upsetting the system; on when one partner is not willing to live by the “rules,” although the two had married in the expectation that they would.

METHODS Types

OF THERAPY

of Marital

Therapy

Almost all marital therapies can be placed into lowing six categories: individual, collaborative, current, conjoint, combined, and group therapy.

the folcon-

ElLEN

individual marital therapy. Only one of the two pantners is in treatment. This therapy differs from individual psychotherapy in that the focus is on the marriage relationship, even though the format is similar to that used in individual psychotherapy. Individual marital psychotherapy may be psychoanalytically, behaviorally, or interpersonally oriented. Common to all of these approaches is the therapist’s attempt to get the patient to make modifications in his on hen behavior in the dyadic relationship and to react appropriately to changes in the partner. A second but usually subsidiary goal is to enable the patient to more adequately cope with the problems encountered in the marriage. Collaborative marital therap. Both spouses are seen individually by different therapists who meet regularly to exchange their impressions and treatment plans (55). The usefulness of this technique is limited by the difficulties in arranging for frequent meetings of busy therapists and the additional costs to the patients (who have to pay for the time spent in collaboration), as well as by the greater advantages of conjoint marital therapy. It is still of some value, however, particularly in specialized marital thenapy clinics where partners who refuse to work together are seen separately. It is most useful in the treatment of couples in the process of separation or divorce, when the spouses’ mutual hostility might be increased rather than diminished during conjoint sessions. Concurrent marital therapy. Both spouses are seen individually by the same therapist (56). In the history of marriage counseling, this was the most frequently used technique until the mid-l9bOs, when conjoint therapy became the vogue. The concurrent psychoanalysis ofa manital pair was pioneered in the late 1940s by Mittelmann (57), who braved the scorn of his analytic colleagues who were unalterably opposed to even a single interview of a family member. One of the obvious advantages of this type of therapy lies in the screening of perceptual distortions. It is easier for just one therapist to sift out the distortions, and this technique avoids the possibility of each therapist identifying with his own patient and the consequent additional distortions this may create. If the therapist wishes to develop and make use of a transference neurosis, this is a fan more effective technique than conjoint marital therapy, in which transference elements tend to be more muted. Concurrent marital therapy is also used effectively in cases where one partner markedly dominates the other, thus preventing the partner from having equal time or an equal share of the therapist’s attention. Problems include the ne-creation of the triangular sibling rivalry situation, issues of privacy and privileged communication, and lack of opportunity to observe the dyadic function. Conjoint and combined marital therapy. In conjoint marital therapy the couple is seen together most of the time by one on more therapists (58-61). This has become the dominant mode of marital therapy; approximately 80 percent of all marital therapy is conducted by the conjoint method. If the partners are seen together it is difficult for one partner to assign the blame and to continue

M.

BERMAN

ANI)

HAROlD

I.

1.1FF

to scapegoat the other, making that partner the “sick one.” With both partners present, the focus is inevitably on the relationship. One problem in conjoint marital therapy is that there is no opportunity for private exploration, and since in many marriages there are some kinds of private information that the partners will never reveal, the therapy remains at the behavioral level. In combined marital therapy there is a combination of concurrent and conjoint marital therapy. Concurrent therapy may be augmented by seeing the couple conjointly on a regular or a sporadic basis, depending on the need. This facilitates communication and the feedback of perceptions and feelings, thus enabling the therapist to reduce perceptual distortion and to increase effective communication. Most psychiatrists use the combined method because it provides maximum information about interpersonal behavior and intrapsychic feelings and attitudes. The problem with this type of therapy is that occasionally the focus of treatment is obscured as the thenapist tries to shift from the needs ofeach individual to the transactional aspects of the marriage. With both combined and conjoint marital therapy, feelings, attitudes, and behavior are displayed in the here and now, thus permitting a more thorough appraisal and evaluation by the therapist. One does not have to wait for feedback; it occurs, even if not immediately, within the session. The data then bec’ome more objective because they can be witnessed directly, without the extrapolation required in tIie historical analysis of the relationship. Ventilation of feelings with catharsis is inevitable. It is difficult for either partner to maintain emotional detachment for very long, since confrontation by the partner on the therapist undermines this defense. Patterns of cornmunication are directly observable and modifIable. Communication skills can be taught directly, and much of marital therapy is directed toward this goal. Behavior therapy. In addition to the use of insight, the therapist may employ techniques of behavioral therapy (operant conditioning, contingency reinforcement, cognitive restructuring, etc.).that are aimed at reinforcing suitable behaviors. The partner can be used as a cotherapist in these behavioral modifications. (Charting behavioral responses and noting their changes over time is an aid in these efforts.) When persuasion is used directly or indirectly, the partner can also be a cotherapist. An additional advantage is that the partners may engage in behavional rehearsals of new “tasks.” They can practice their new “strokes” of behavioral technique in the therapist’s office before trying them out at home. A frequent technique used to advantage in this regard is role playing, on reverse role playing, in which the partner either plays himself in a hypothetical situation or takes on the role of his partner. Many therapists, notably Hollender (62), have voiced concern about moving back and forth between a maritaland individual-oriented therapy method. Their questions center on the inadvisability of changing the therapeutic focus, the possibility of confusing goals, and a “scattergun” approach. We have found that both individual therapy concurrent with marital therapy and the therapist’s

Am

J Psvehiairt

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willingness to shift focus between individual and dyadic therapy as the treatment evolves are valid methods of procedure. As long as the change in method of therapy is discussed with the patients and agreed upon beforehand, the patients generally respond well and with a minimum of confusion. There is precedent for this approach in othen “combination therapies” that are frequently used today, such as group plus individual treatment and insight-oriented therapy plus medication. Other

Therapeutic

Methods

In recent years specialized techniques have been developed using videotaped playback as an important aid to marital behavioral changes (63-65). Increased use is also being made of group therapy for marital partners (6670). There are some who claim that group therapy is the treatment of choice for couples. This is particularly true of couples who are attempting to manage transactional crises that require role modifications for effecting appnopniate adaptation to changing life circumstances. It should be remembered that even when the therapist is working with only one dyad, it is a form of group therapy. As Dicks and Stevens (14, pp. 139-154) stated, “It is group psychology for the smallest numerical group.” The Place

ofthe

New

Sex

Therapy

in Marital

Therapy

The behavioral techniques for the treatment of sexual dysfunction, first described by Masters and Johnson (71) and modified by Kaplan (72), have given major impetus to the treatment of sexual dysfunction in the marital dyad. The high rate of success of conjoint behavioral techniques indicates that although individual therapy methods for curing sexual dysfunction are sometimes necessary, neglecting couples’ interactional problems means the loss of crucial vectors in undoing maladaptive mechanisms that have either initiated or maintained the dysfunction. However, those beginning to employ behavioral techniques tend to use them mechanically in a nondiscriminatory fashion without regard for the basic pninciples of marital therapy. In fact, these behavioral techniques-operant conditioning, contractual contingencies, and task assignments-should be regarded as an elegant form of desensitization and behavioral modification (73), with their success subject to all of the vicissitudes of the marital system. The successful use of these techniques depends on a basic understanding of the couple’s dynamics and resistances. Sex therapy cannot be conducted separately from an examination of the couple’s communication pattern and their wishes for and fears of intimacy and power. The best available description of how these techniques can be integrated with marital and individual psychodynamics can be found in Kaplan’s The New Sex Therapy (72). Dual

Sex

Therapy

Ever since Masters and Johnson (71) described the advantages of using two sex therapists in the treatment of sexual problems, psychiatrists have shown a great deal of interest in the possible uses of this approach. Masters and 590

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Johnson stressed the ability of the dual sex team to decrease opposite-sex transference manifestations, as well as the use of patient support by the same-sex eotherapist. Other researchers, including Bruni (74), have found that the dual sex cotherapist’s interventions support; interpretation of feelings; and explanations of transference, behavior, marital interactions, confrontations, etc. can be carried out without the sex-linked limitations imposed by the Masters and Johnson plan. The modeling of behavior or suggestion of a new perspective can he done by the therapist of the same or opposite sex. Many of the advantages of the dual sex team in sex therapy are present in the treatment of couples who have other types of marital dysfunction. This approach does not have to be restricted to the treatment of sexual disorders or dysfunctions. One therapist can aid the other by augmenting interventions, adding additional insights or emotional supports, and correcting “off-target” interventions. The opportunity to check one’s perceptions and understanding with the cotherapist is as important here as it is in group therapy. As in group therapy, effective teamwork depends on the capacity to pick up cues from the other therapist as well as from the patients and to interact with the cothenapist to strengthen, modify, or redirect responses of the therapist-partner. Confrontations often have much more impact in this method oftneatment than in the usual form of treatment with one therapist. Cotherapists often describe the “fun,” even the exhilaration, of a successful session in which female and male therapists have worked together effectively. The special elements of treatment when the dual sex team is a husband-and-wife pair have been described by Bellville, Raths, and Bellville (75). The main disadvantage of using cotherapists is the increased cost due to the large amount of therapist time involved in treatment and its coordination. In addition to the cost of two therapists, which has to be passed on to the patients, ineffective teamwork due to poor communication, competition, countentransfenence reactions, etc., may more than outweigh the advantages of the dual sex therapy model.

DIVORCE

ANI)

THE

FUTURE

OF

MARRIAGE

American psychiatrists and marriage counselors have become increasingly involved in two complex and related social-psychological phenomena: the rising divorce rate and the search for alternative lifestyles. The central philosophical question surrounding the controversy has been whether these phenomena stem from new sets of social and marital stresses common to the late 20th century or whether they are simply new solutions to old problems (76). At any nate, therapists are increasingly being asked to take sides regarding the appropriateness of divorce or new lifestyles, while continuing to treat the battle scanned (77). In our opinion, both the rising divorce and remarriage rates and the increase in new marriage styles apd fashions (“swinging,” open contracts, group marriage) are social

ELLEN

rather than psychopathological phenomena and are pnincipally a reaction to the increased expectations and demands for happiness, autonomy, and experience collection common to the 1960s. In fact, it may turn out that these are essentially fads and are already past their peak. Some researchers (78, 79), however, see the rise in open contracts and serial monogamy as essentially normal and potentially healthy responses to longer lives and more Unban lifestyles. They predict an increase in the quantity and quality ofsuch new experiments. We still are faced, however, with numerous patients entening our offices, most of whom are alone, uncertain and anxious about whether to divorce, depressed after a recent divorce, on debating the need for “more experience of life.” Their complaints may be voiced in terms of blaming their spouses or their need to reevaluate their lives and find new stimulation. Aids

to Therapy

We have found the following concepts particularly helpful as an aid to therapy. 1. We have learned that almost never, under any cmcumstances, can a therapist accurately predict the personality on behavior of the other spouse solely from his partner’s report. Reality pressures tend to be either much milder or much more overwhelming when described by the spouse. We have therefore insisted under all possible circumstances that the partner come in for at least a brief meeting. 2. The issue ofthe therapist’s role in decision making is sometimes complicated and delicate. Both in conflict over divorce and over altered lifestyles, the usual method is to help the partners lay out the alternatives and choose among them. On the other hand, when the evidence of permanent dysfunction seems overwhelming, we have occasionally deliberately supported a trial separation. It is notable that although we seldom give advice, it is even more seldom that our patients take and act upon it. 3. When the partners have different commitments to their marriage (and consequently to marital therapy), marital therapy may have to be suspended. Ifone spouse is only partly committed to the marriage, or if one or both of the spouses want to end the marriage, standard marital counseling is simply not possible. The focus must be on the couple’s decision about whether to stay in the marriage. If one member wants to abandon the marriage, we can offer only separation counseling. Some couples, however, will remain indecisive for many months, and the therapist must deal with the problems and the questions created by their indecisiveness. 4. Regardless of how bad the marriage is for both spouses, most divorced single people find that living alone is excruciatingly painful. Many divorced people face a period of depression that lasts from a few months to as long as a year. We must accept the existential fact that for many long-married couples, there simply are no painless decisions. Remaining in the marriage is painful, but living alone is more painful, and other options may well be closed to them. 5. Alternative lifestyles, particularly group marriages,

M.

BERMAN

AND

LIAROLI)

1.

11FF

are harder to maintain than monogamous relationships and require more flexibility and maturity than living alone. 6. We have found that in many cases, separating and divorcing partners learn to handle their problems better in group therapy than in individual therapy. The focus in the initial postsepanation period must be on support and a new lifestyle. Most people are in no shape to really examine the conflicts that brought them to the point of separation. Groups provide much more direct support and, if the group is well led, do not increase the bitterness felt by the separating or divorced person. Comment In summary, we feel that alternative living arrangements and serial monogamy will be the continued choice of some people. In general, however, most people in our culture seem to prefer a monogamous lifestyle with some element of long-term security. Marriage as an institution is therefore likely to survive, although it will feature more emphasis on equal nights for women (52), less of a sense of ownership or possession of the spouse, and hence some decrease in sexual jealousy. The human-potential movement and the development of community programs for marital enrichment speak to the need of vast numbers of people to find greater individual fulfillment in the context ofa growing, developing, and vital partnership.

REFERENCES I . Sager CJ, Gundlach R, Kremer M, et al: The married in treatment. Arch Gen Psychiatry 19:205-217, 1968 2. Gurin G, Veroffi, Feld 5: Americans View Their Mental Health: A Nationwide Interview Survey. Joint Commission on Mental Illness and Health Monograph Series4. New York, Basic Books, 1960 3. Laidlaw RW: The psychiatrist as marriage counselor, in Readings in Marriage Counseling. Edited by Vincent CE. New York, Thomas Y Crowell Co. 1957, pp 2 61 4. Martin PA, Lief HI: Resistances to innovations in psychiatric training as exemplified by marital therapy, in Psychiatry: Education and Image. Edited by Usdin G. New York, Brunner/Mazel, 1973, pp 132 ISO 5. M udd E: I mpact of the development of marriage counseling on traditional and related professions, in Marriage and Family Counseling: Perspective and Prospect. Edited by Peterson iA New York, Association Press, 1968, pp 71 188 Nichols WC Jr The field of marriage counseling: a brief review. Family Coordinator 22:3 10, 1973 7. Manus GL: Marriage counseling: a technique in search ofa theory. Journal of Marriage and the Family 28:449 453. 1966 8. Lid HI: Sexual counseling, in Gynecology and Obstetrics: The Health Care ofWomen. Edited by Romney 5, Gray M, Little B, et al. New York, McGraw-Hill Book Co (in press) 9. Ard BN, Ard CC (cds): Handbook of Marriage Counseling. Palo Alto, Calif. Science & Behavior Books, 1969 10. Dicks HJ: Marital Tensions. New York, Basic Books, 1967 II. Greene BL: A Clinical Approach to Marital Problems. Springfield, Ill, Charles C Thomas, 1970 12. Rosenbaum 5, Alger I (eds): The Marriage Relationship. New York, Basic Books, 1968 13. Klemer RH (ed): Counseling in Marital and Sexual Problems. Baltimore, Williams& Wilkins Co. 965 4. Abse DW, Nash EM, Louden LMR (eds): Marital and Sexual Counseling in Medical Practice, 2nd ed. New York, Harper & Row, 1974 IS. Alger I: Marriage and mental problems, in American Handbook of 6.

Am

J Psychiatry

132:6,

June

/975

591

MARITAL

16. 17. 18.

19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

30.

31. 32. 33.

34. 35. 36.

37. 38.

THERAPY

Psychiatry, 2nd ed, vol 1. Edited by Arieti S. New York, Basic Books, I 974, pp 446466 Araoz D: The marriage and family counseling profession. Journal of Family Counseling I (2):4 10, 1973 Gurman AS: Marital therapy: emerging trends in research and practice. Family Process 12:45 54. 1973 Olson DG: Marital and family therapy: integrative review and entique. Journal of Marriage and the Family 32:501 -538, 1970 Bakker CB, Bakker R: No Trespassing: Explorations in Human Territoriality. San Francisco, Chandler & Sharp, 1973 Ackerman NW: The Psychodynamics of Family Life. New York, Basic Books, 1958 Ackerman NW: Treating the Troubled Family. New York, Basic Books, 1966 Lederer W, Jackson DD: The Mirages of Marriage. New York, WW Norton & Co. 1968 Sager U. Kaplan HS (eds): Progress in Group and Family Thenapy. New York, Brunner/Mazel, 1972 Haley J: Strategies of Psychotherapy. New York, Grune & Stratton. 1963 Haley J (ed): Changing Families A Family Therapy Reader. New York, Grune & Stratton, 1971 Sullivan HS: The Interpersonal Theory of Psychiatry. New York, WW Norton & Co. 1953 Spiegel JP: Transitions: The Interplay Between Individual, Family and Society. New York, Science House, 1971 Minuchin 5: Families and Family Therapy. Cambridge, Mass, Harvard University Press, 1974 Watzlawick P, Beavin JH, Jackson DD: Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies, and Paradoxes. New York, WW Norton & Co. 1967 Levitt H, Baker R: Relative psychopathology of marital partners. Family Process 8:33-42, 1969 Bolte GL: A communications approach to marital counseling. FamilyCoordinator 19:3240, 1970 Hunvitz N: Interaction hypotheses in marriage counseling. Family Coordinator 19:64-75, 1970 Kotler SL: Role theory in marriage counseling. Sociology and Social Research 52:5062, 1967 Mangus AR: Role theory in marriage counseling. Social Forces 35:200-209, 1957 Liberman R: Behavioral approaches to family and couple therapy. Am J Orthopsychiatry 40: 106-I 18, 1970 Goldstein MK: Interactive accelerators, in Behavioral Counseling Methods. Edited by Krumboltz J, Thorenson R. Stanford, Calif. Stanford University Press (in press) Knox D: Marriage Happiness: A Behavioral Approach to Counseling. Champaign. Ill, Research Press. 1971 Lazarus AA: Behavior Therapy and Beyond. New York, McGraw-

49.

50. SI.

52. 53. 54.

55.

1963 56.

57. 58. 59. 60.

Bertalanify L: General system theory and psychiatry, in Amencan Handbook of Psychiatry, 2nd ed, vol 1. Edited by Anieti S. New York, Basic Books, 1974, pp 1095-I 117 40. Gninker RR: Toward a Unified Theory of Human Behavior, 2nd ed New York, Basic Books, 1967 41. Kuhn TS: The Structure ofScientific Revolutions, 2nd ed. Chicago, University ofChicago Press, 1970 42. Meir A: General system theory: developments and perspectives for medicine and psychiatry. Arch Gen Psychiatry 21:302-310, 1969 43. Kluckhohn F, Spiegel JP: Treatment of Families in Conflict: The Clinical Study of Family Process. New York, Science House, 1970 44. Rank 0: The Trauma of Birth. New York, Basic Books, 1952 45. Levinson DJ, Darrow CM, Klein EB, et al: The psychosocial development of men in early adulthood and the mid-life transition, in Life History Research in Psychopathology, vol 3. Edited by Ricks DF, Thomas A, Roff M. Minneapolis, University of Minnesota Press, 1974. pp 243258 46. Gould RL: The phases of adult life: a study in developmental psychology. AmJ Psychiatry 129:521-531, 1972 47. Enikson F: Identity, Youth, and Crisis. New York, WW Norton & Co. 1968 48. Butler RN: Toward a psychiatry of the life cycle. Psychiatric Research Reports of the American Psychiatric Association 23:233-248, 1968

592

A mJ

P.sychiatrv

/32.6, June

/975

Solomon AP, Greene BL: Marital disharmony: concurrent therapy of husband and wife by the same psychiatrist. Dis Nenv Syst 24:2 I 28, 1963 Mittelmann B: The concurrent analysis of marital couples. PsychoanalQ 17:182-197, 1948 Leslie GR: Conjoint therapy in marriage counseling. Journal of Marriage and the Family 26:65-71, 1964 Sager CJ: Transference in conjoint treatment of married couples.

ArchGen

Psychiatry

16:185-193,

Fitzgerald follow-up

RO: study.

marital psychotherapy: an outcome Process 8:260-271, 1969 marital therapy, in The Psychotherapies Edited by Greene BL. New York, Free

61. Satin

62.

63. 64.

65.

66.

68.

69. 70. 71. 72. 73. 74. 75.

76. 77.

VM:

Conjoint Family

Conjoint

1967

Marital Disharmony. 1965, pp 121-133 Hollender MH: Selection rent Psychiatric Therapies, York, Grune & Stratton,

of Press,

Group

Psychothen

12:142-153,

1962

Leichter E: Group psychotherapy of married couples’ groupssome characteristic treatment dynamics. lnt J Group Psychother 12:154-163, 1962 Blinder MG, Kirschenbaum M: The technique of married couple group therapy. Arch Gen Psychiatry 17:44 52, 1967 Gottlieb A, Pattison EM: Married couples group psychotherapy. ArchGen Psychiatry 14:143-152, 1966 Framo JL: Marriage therapy in a couples group. Semin Psychiatry 5:207-217, 1973 Masters WH, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown and Co. 1970 Kaplan HS: The New Sex Therapy. New York, Brunner/Mazel, 1974 Annon JS: The Behavioral Treatment of Sexual Problems. Honolulu, Kapiolani Health Services, 1974 Bruni E: Psychotherapists as sex therapists. Psychotherapy: Theory, Research and Practice I 1:277-281, 1974 Bellville TP, Raths ON, Bellville CJ: Conjoint marriage therapy with a husband and wife team. Am J Orthopsychiatry 39:473-483,

1969 Hunt MM: The World of the Formerly Married. New York, McGraw-Hill Book Co, 1966 Gardner RA: Psychological aspects of divorce, in The American Handbook

York,

of Psychiatry,

Smith Sexual 1974

Basic

2nd

ed,

vol

1974, pp 496-512 78. Comfort A: Sexuality in a Zero Growth the Center for the Study of Democratic bara, Calif. CSDI, 1972 79.

and

of therapy for marital problems, in Curvol I I. Edited by Masserman JH. New 1971, pp 119-128 Alger I, Hogan P: The use ofvideotape recordings in conjoint mantal therapy. Am J Psychiatry 123:1425-1430, 1967 Alger I, Hogan P: Enduring effects of videotape playback expenience on marital and family relationships. Am J Orthopsychiatry 39:86 96, 1969 Bergen MM: Videotape Techniques in Psychiatric Training and Treatment. New York, Brunner/Mazel, 1969 Boas LVE: Intensive group psychotherapy with married couples.

IntJ 67.

Hill Book Co. 1971 39. von

Neugarten BL, Datan N: The middle years, in American Handbook of Psychiatry, 2nd ed, vol 1. Edited by Anieti S. New York, Basic Books, 1974, pp 592-608 LidzT: The Person. New York, Basic Books, 1968 Pollak 0: Sociological and psychoanalytic concepts in family diagnosis, in The Psychotherapies of Marital Disharmony. Edited by Greene BL. New York, Free Press, 1965, pp 15-26 Cuber JF, 1-larroff PB: Sex and the Significant Americans. Baltimore, Penguin Books, 1966, pp 43-65 Jacobs L: Sexuaj problems and personalities in four types of marniage. Medical Aspects of Human Sexuality 8: 160- 178, 1974 Mittelmann B: Analysis of reciprocal neurotic patterns in family relationships, in Neurotic Interaction in Marriage. Edited by Eisenstein VW. New York, Basic Books, 1956, pp 81-100 Martin PA, Bird HW: An approach to the psychotherapy of marniage partners: the stereoscopic technique. Psychiatry 16:123-127,

1. Edited

by

Anieti

S. New

Books,

JR. Smith Alterations

LG

Society. A Report Institutions. Santa

from Bar-

(eds): Beyond Monogamy: Recent Studies of in Marriage. Baltimore, Johns Hopkins Press,