Warming Up to a Cold-Sick Spouse ROBERT L. BECK, M.A., C.S.W.* Houston, TX
This article explores the problems faced in working with the '>old-sick/love-sick" marital system. Particular attention is paid to the dynamics of these relationships and the vanety of cold-sick/love-sick partners seen in treatment. Utilizing case illustrations, treatment strategies for both the love-sick wife and the dificult to engage cold-sick husband are described. The paper emphasizes the importance of forming arl alliance with the husband while empathically responding to his wife's pleading, hurt, yet angry expressions of longing.
She: He never gives me what I need. He is so distant. He doesn't care. He falls asleep in the middle of an argument. He: If she would just get off my back. . . . All she does is complain, complain, complain. Such couples are frequently encountered in treatment. The husband is often aloof, distant, and seemingly not in tune with his spouse's needs and her longing for acknowledgment. The wife is angry, pleading, desperate, and never satisfied. Labeled variously as "cold sick and love sick,"'.2 the "hysterical wife,"3 and "obsessional husband,"? the "rational and childlike partnersn4and as players in the "hysterical marriage,"' these relationships pose a significant challenge to the clinician. Guerin et a1.,6 discuss the "pursuer and distancer styles" of interaction, which parallel those of the previously cited papers. They elaborate further by describing the "interactional sequence" in conflictual marriages that involves an increasingly tense series of interchanges resulting in a stalemate in which neither partner gets what he or she is seeking (pp. 46-47), In working with these couples, therapists face a formidable task involving both containment of the one partner's desperate pleading and angry outbursts and the other's seemingly cool retreat. This paper will explore the love-sicklcold-sick pattern of couples' interaction as it is described in the literature and as it appears clinically. Treatment interventions will be emphasized which address the cold-sick spouse-the partner who is usually the more difficult to engage. The love-sick partner will be given attention in light of this individual's potential for interfering with a therapist's attempts to form an alliance with the elusive cold-sick mate. Case *Assistant Professor, Department of Psychiatry, Baylor College of Medicine; Adjunct Associate Professor, Graduate School of Social Work, University of Houston. Marling address: Baylor College of Medicine, O n e Baylor Plaza, Houston, T X 77030. AMERICA& JOURNAL OF PSYCHOTHERAPY, VOI.XLV, NO. 2, April 1991
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examples will be offered to illustrate variations in love-sick/cold-sick relationships and treatment strategies will be described which address special problems in therapeutic intervention. THE LITERATURE
The Wife An early paper by Revitch7discusses ". . . the problem of conjugal paranoia," describing in effect, this hysterical relationship pattern in marriages. Martin2 describes this cold-sick (husband) love-sick (wife) relationship in detail. He sees the wife as anxious, deprived, blaming, and not at all aware of her role in the conflict. She views her mate as unable to love, and insists that the only solution is in getting him to change, but at the same time berating him for being unable to change at all. Martin views the wife as theatrical, lacking in self-esteem, "high strung," and "parasitic . . . with her husband as the host" (p. 19). In Martin's view, her dependency is masked by her dramatic outbursts and threats to leave him. Willij describes the "hysterical woman" who is unable ". . . to do anything alone, and finds no inner resources to give her security" (p. 436). Most of these authors focus their attention on the confused, angry wives. Yet, many wives are amenable to intervention and not locked in life-or-death struggles with their spouses. The husband's cool and aloof demeanor may make him the more difficult partner to engage. The Husband Dupont and Grunebaum's8 previously cited paper describes the husbands as "willing victims" to their partners and elaborate on their provocative distancing from the increasingly agitated and later out-of-control spouses. Martin and Bird' view these husbands as, at the one extreme, seeing the problem as entirely in their wives, and at the other, beginning to question their role in the marriage. Martin2 suggests that despite the husband's assets (competence, responsibility, and community respectability) he will have difficulty with intimacy, be cold and aloof, and be ". . . unable to show feelings of closeness, intimacy, anger or love" (p. 21). Willi's "hysterophile" husband is described much in the same way as is his (p. 442). Willi sees the husband passivity, and "inhibitions of all e~hibitionism"~ as provocative in his passivity and when his wife ultimately loses control, he moves in as a calming influence and "rescuer" (p. 442). Guerin and his co-authors6 illustrate the husband's "reactive position" as he "becomes quiet and withdrawn . . . in response to his wife's overflowing emotionality" (p. 130). Sager's4 "rational partner" is described as defending "himself against admitting emotions may influence his or her behavior" (p. 123). He uses "a reasoned, logical, well ordered" (p. 123) approach to interacting with his partner and will frequently stimulate his spouse's rage. The projective elements of the husband's behavior have been described by
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Zinnerg at length, and the wife is seen as acting out his rage, which he finds so unacceptable. He has long thwarted his wife's attempts to gain access to him and he will potentially present a similar problem for a therapist. These husbands are universally viewed as unconscious collaborators in their wives' increasing loss of control. They are seemingly able to relax in the marital environment they help to create as their spouses noisily but predictably fall apart emotionally. They know the pattern that evolves will follow the same course-one which results in the wife assuming the role of patient-volatile and out of control. They, in contrast, appear to be rational, calm, thoughtful, and on the side of reasoned negotiation. In reality, while they are in control, they are also constricted and maddeningly nonresponsive and noninteractive. It is crucial that the husband's attempts to defend against painful interaction be addressed if any gains are to be made. While clinical experience and the review of the literature suggests that the vast majority of cold-sickllove-sick relationships feature a cold-sick husband and love-sick wife, relationships with reverse roles are not unknown. Considering cultural and societal emphases on men as rational, and women as emotional and feeling-oriented, it is not surprising that the wife usually presents as love sick and the husband as cold sick.
The Couple The partners' decision to marry is often explained by each in the initial interviews: She: You know, I thought he would be good for me. I got kind of wild at times and he was so solid-he knew how to calm me down. He: She really needed someone to help her get a foothold. I was attracted to her spontaneity. It's easier for her to have fun and she didn't always get so fired up emotionally. This checks-and-balances relationship made logical sense-the partners were good for each other and complemented one another. One can hear the respective families giving their stamp of approval to such a union. Yet, the husband's need to maintain his distance and keep his emotions under wraps will ultimately grate on his exuberantly dependent wife. Her requests that he become involved in her emotional world will intensify and encourage him to increase his distance as her rage escalates. As she does not relent and becomes more dependent, the husband will withdraw deeper into his world of work and set the destructive cycle in motion. The conflict that emerges bears no resemblance to the intimacy each wants. In therapy, these couples appear to be locked in a demandlwithdrawal cycle and frequently divert themselves from closeness as they collide. ENGAGING THE PARTNERS
The Wife The cold-sick husband is often given short shrift in the literature and the vocal wife stands out in bold relief to his withdrawn style. She begs for attention and
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cannot be silenced long enough to be engaged. The wife must be attended to, but as she is usually desperate, she is not likely to bolt from therapy. She can form a speedy, though dependent therapeutic attachment if she is heard. On one level, she yearns for the attachment, and on another, she would not know what to d o with it if she had it. This neediness drives her to her demands, yet the intimacy she asks for would prove to be alien and uncomfortable if provided. For all but the most desperate love-sick partners, the wife can be assisted in delaying gratification, while a carefully nurtured alliance is formed with the husband. Attempts to reach the husband may be interpreted by the wife as an effort to get her what she wants. As she might feel excluded, it is vital that her importance in the process will be underscored. If an empathic connection is made with her, her painful longing is gently interpreted, and she is assured that she is deserving of a closer relationship with her husband, her demands may be defused. This would serve to demonstrate the therapy's potential. I n my view, the love-sick partner is a "surer thing" and more easily engaged. Her husband is so well defended and emotionally closed off that particular attention needs to be paid to his needs to achieve a productive outcome.
The Husband As indicated earlier, the husband has retreated, either to his work, his private thoughts, or another relationship. His distant style may mask intense longing similar to his wife's. He often presents as responsible, logical, wishing for peace, and wanting the marriage. His dependency is blurred by his seeming aloofness and "I can take you or leave you" posture. He gets little acknowledgment for what reaching out he attempts and is hurt by the minimal support he receives from her. I n therapy, he may look bewildered, uncomfortable, and embarrassed by his wife's vociferous accusations and complaints. He may look at the therapist as if to say "I really don't know what to d o with her." She will be exasperated by his helplessness, and reacts with more anger, usually sending him further into retreat. T o illustrate:
Sam, a driven, successful professional, presented with his equally driven and successful wife of two years after she threatened divorce. Judy's complaints centered on Sam's inattention to her emotions, his limited interest in sex, and his all-work and no-play ethic. She angrily dominated the session and repeatedly attacked her husband. He responded predictably-by further retreat, suppression of his anger, and passive-aggressive behavior. 1 nurtured the alliance with Judy by carefully listening to her complaints. I reassured her that I would make every effort to understand what was preventing Sam from giving her what she wanted. This resulted in Judy's calming down, but left Sam feeling that his wife would be forever making demands and he remained distant. I addressed the origins of
Warming Up to a Cold-Sick Spouse Sam's need to remove himself from strong emotional fields. He traced this to his relationship with his controlling and demanding mother from whom he emotionally distanced himself. Judy punctuated Sam's description of his relationship with his mother by blaming him for coming from a terrible family. I assured Judy that I understood her fears and helplessness. Judy looked on with some interest as I worked to penetrate her husband's cmotional barrier.
When the wife's demands are acknowledged, it may not be necessary to aggressively nurture her engagement. While many love-sick partners angrily attack their spouses in treatment, some present primarily with hurt, disappointment and controlled anger. A therapist is then able to turn the bulk of his or her attention to engaging the husband. T h e more easily managed cold-sickllove-sick couple is illustrated as follows:
Susan and Frank, married 16 years, with one son, presented for marital therapy to a female therapist. Frank immediately felt misunderstood, "ganged u p on," and dropped out of treatment. Alarmed at Susan's threats to leave, Frank found a male therapist-meand made an appointment for the two of them. In the first session Frank indicated that h e was a "black-and-white kind of person" for whom "two plus two always equals four." Susan described herself as romantic and emotional, and had been angry at Frank's distancing, his non-feeling sexual demands, his critical nature, and his preoccupation with work. Frank acknowledged that he would have difficulty changing, but wanted the marriage badly enough to d o whatever was necessary. Frank was all business in the first session and spoke with certainty about what he observed in the marriage. All the while he looked at me, and repeatedly sought acknowledgment by asking "do you know what I mean?" and "do you understand what I am saying?" My task was to develope a working alliance with each and was made somewhat easier by Susan's controlled love-sick style. I repeatedly demonstrated that I understood Frank's pain, while monitoring Susan's potential volatility. Susan was grateful that Frank had finally consented to participate in therapy, and watched the husband's interaction with me with great interest. Addressing most of my attention to Frank, while periodically acknowledging Susan's presence and concerns, an attempt was made to form an alliance with Frank. As Frank had previously retreated from couple's therapy, was suspicious of the process, and saw it as a forum for Susan's attacks o n him, it was imperative that I work aggressively with him in the early stages. My task was made easier by Frank's readiness for acknowledgement arid the fact that his pain was so near the surface. Judy, more disappointed than enraged, occasionally expressed muted demands, but was amenable to my work with her husband.
This couple was able to participate productively in this process because of Frank's emotional accessibility, Susan's self-control and my continued effort to balance the interview and not attend primarily to one partner or the other. Certainly, other factors may have influenced Frank's engagement, including the fact that he had selected a therapist of his choice and his fear that Judy might leave him.
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With some couples, a more disappointed wife and retreated husband will offer a more challenging task:
Ed and Joan, married less than one year, and both recovering alcoholics, had entered this disappointing marriage with themes of dependency, low self-esteem, unresolved family-of-origin issues, and anger at their respective former spouses. Joan immediately attempted to engage me in a dialogue about Ed's passivity, and inattention to her emotional needs. In the session, she was out of control while voicing her unwillingness to tolerate Ed's rage. Ed presented as controlled but angry, rolling his eyes periodically as Joan listed his infractions. He did not speak directly to her nor did he face her as she criticized him. Joan repeatedly interrupted his attempts to respond, and spoke angrily about how he had misrepresented himself, "lied to me, and uses me." This hostile-dependent relationship was one in which Joan-the love-sick spouseverbalized the mutually experienced rage, and Ed-the cold-sick partner-contained it. I made attempts to reach out to her though she who would angrily shift the focus by reiterating her complaints. Ed defended himself, and on two occasions threatened to leave the room if she continued. Joan wanted validation of her feelings and to be joined by me in her attacks on her husband. She was unable to connect with me and begrudgingly responded to my attempts to gather a developniental history.
I aimed to encourage Ed to identify his positive feelings about the relationship, and then indicate some desire to work on it, in the hope that it might mollify Judy long enough for the conjoint work to begin. I was successful in addressing Ed's hurt and he talked tearfully about his mother's withdrawal from him and the loss of his daughter to his ex-wife. Despite my attempts to help her understand what Ed was feeling, Joan criticized him for having expressed no such love or caring for her. My effort to help each understand the other's pain was not successful. As Ed had feared, Joan began to criticize him in the wake of his fleeting vulnerability. Ed and Joan's rage and disappointment were so great that there appeared to be little hope for building an alliance with either partner. Joan was too enraged to enter into a dialogue with Ed. Ed, potentially accessible and revealing occasional cracks in his armor, would have been "led to his slaughter" if he had been encouraged to expose himself to his demanding and punitive wife. Preliminary individual work was needed to address the difficulties each partner was having in getting needs met, hearing the other, and being heard.
As illustrated by the case of Ed and Joan, a therapist must move cautiously t o encourage the cold-sick partner to emerge from his shell in the presence of his spouse. No guarantee can be made that the love-sick partner will warmly embrace his new vulnerability as her anger might resurface when she again realizes how long she has waited for him. She may be frightened about his vulnerability and unable to tolerate his self-exposure. The husband, if pried open, may consider this opening up as a threat to his equilibrium and fear his spouse's rushing in aggressively.
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TREATMENT OPTIONS
Once the cold-sick husband's defenses have been unlocked and attended to, and the wife's needs are acknowledged, the treatment plan must be renegotiated. It is important to consider the husband's potential retreat at the slightest rejection or wounding. The wife must also be carefully considered, for if a therapist is overly alertive to her husband, she may believe she is being short changed. Finally, the husband must be protected from his wife's barbs so as to insure his safe entrance into the process. The task is a difficult one as the therapist moves back and forth between the roles of protector, supporter, and interpreter. A move toward strategic individual interviews might be considered to assist in the process of engagement and mutual accessibility to each other.'0," A balance must be maintained in which neither partner is left unattended for long and a conjoint structure may remain in place while an individual alliance is built with each partner. By empathizing with both partners' frustration in dealing with each other, the pressure is taken off the husband, and the wife is likely to feel less hopeless as the couple begins to communicate less chaotically. While the ongoing work might continue conjointly, the couple has been provided an opportunity to address their concerns and each has been heard. Stages of lntervention In working with these couples, a five-stage course is recommended that addresses the individual dynamics as well as the systemic properties of the relationship. Stages of Intervention 1 . Calming the love-sick partner through: a. Empathic connecting; b. Building a therapeutic alliance. 2 . Reaching out to the cold-sick partner through: a. Empathic connecting; b. Attempting to understand the meaning of this self-protective retreat. 3 . Teaching the partners that each may be utilizing different strategies to deal with similar feelings and desires. Initially, each partner is engaged individually in the conjoint sessions with limited attention paid to their interactional problems. While I may need to attend to the relationship, it is in order to bring some calm to the interaction while the individual alliance is being built. Once this is accomplished, the relationship is addressed by: 4. Interpreting each to the other in regard to: a. T h e nature of their particular needs and fears. b. Historical antecedents to the conflicts. The wife is often in obvious pain and longing for someone to attend to her
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needs. Once trust has been established, interpretations a r e m a d e as to t h e meaning of h e r longing for t h e husband. T h e wife is taught about h e r husband's fears a n d how his retreat is exacerbated by h e r demands, as well as a function of his own unfinished issues. T h e partners a r e asked, in effect, to n o t "take it so personally" by: 5. Redirecting t h e partners from blamingi4 to increased self-understanding by: a. Elaborating o n t h e growing awareness of t h e o t h e r partner's needs; b. Consistently underscoring t h e pain that has been uncovered i n each. Both partners' growing understanding of themselves a n d their spouses is encouraged. T h e couple may repeatedly r e t u r n to their accustomed style of relating-replete with projections, blaming, a n d anger-and they a r e reminded of t h e meaning of their behavior a n d t h e other's needs. T h e following case further illustrates my attempt to engage t h e cold-sick spouse i n marital treatment.
Jan expressed concerns about her sister's "exploiting" their mother. After a brief period, Jan was able to move out of this triangle, become more secure about her mother's affection for her and clearer about the projected elements of her concerns. In the course of this brief therapy it became evident that Jan was dissatisfied with her 13-year-marriage. Prior to termination ofthe short-term treatment, I suggested that at some point Jan and her husband might come in together to talk about their relationship. Jan could not imagine her husband agreeing to enter a therapist's office. Six months later, Jan returned to talk about a memory that had surfaced about her sister being sexually molested. While she again entered treatment based on concern for someone else, she soon addressed her anxieties about her relationship with her father, her anger at her mother for allowing this to happen, her concerns about the distance in her marriage and her preoccupation with another man. She described her unrelenting pursuit of her husband whom she saw as distant, aloof, depressed, and not accessible. I again suggested that she consider inviting her husband to a session. She once again indicated that there was no way he would agree. Yet, when a month later, she broached the subject with him, he agreed to join her. Steve was initially remote and acknowledged anxiety about seeing a therapist. In light of the preexisting alliance with Jan, I carefully attempted to engage the cautious and formal Steve. In her continuing individual sessions Jan told me that she was certain Steve could not be reached. She repeatedly expressed this concern in the couple's sessions by alluding to Steve's not wanting to be in therapy, and his "obvious" anxiety about participating. In a subsequent session, Steve denied each of his wife's assertions. While she acknowledged that the process was uncomfortable, he repeatedly assured his wife that he would do anything to keep the marriage. I attended to Jan's growing impatience with Steve and suggested that she possibly might be anxious about the outcome as well as uneasy about the prospect of relating in a new way with him. I assured Steve that I understood his discomfort with Jan's emotional outbursts and his uneasiness about most emotional interchanges. Steve re-
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sponded warmly to me and proceeded with greater ease. In a short time, a strong working alliance was established with Steve and he and his wife began to work on their marriage. In working with this couple, I initially built an alliance with Jan by calming her through empathic connecting (l-a) regarding the multitude of issues she presented. As an alliance was built (l-b),and she was generally responsive to my input, I was thus able to approach Steve by empathic connecting (2-a) and through exploration of his difficulties in the face of intense emotions (2-b). I then interpreted each to the other (4-a and 4-b) prior to encouraging them to examine their contribution to the conflict (5-a and 5-b). Given their mutual commitment to the relationship and emotional accessibility, the couple responded positively to this approach. Couples present in projecting pairs-they blame each other and in a manner that is often overwhelming and gives a therapist little opportunity for detached observation. They pull at a therapist, and as they engage in a pattern ofblaming, A therapist may be pulled toward joining triangling patterns may with one partner's criticism of the other or will subtly form an attachment to one partner's position. Given the intensity of the process, triangling in marital treatment is inevitable, and staying out of this process is a primary therapeutic task. Both partners will present compelling arguments as to how they have been wronged by the other, and they must be responded to with interventions that break through the defenses that maintain the unhealthy equilibrium.14 Treating the love-sickicold-sick partnership requires an understanding of the dynamics of the relationship as well as a grasp of specific strategies for intervention. Working with these couples tests therapists' mettle as they must, on the one hand, be able to identify each partner's needs and on the other, develop an empathic connection with each. The treatment process requires an initial awareness of the nature of these relationships and their fight-flight pattern. SUMMARY
This paper has examined the cold-sick/love-sick pattern of a couple's interaction and presented a schema for intervening with the less accessible, but pivotal partner-usually the husband. The importance of carefully attending to the wife's needs, expectations, wishes, and frustrations has been understood. She is not to be considered an ace-in-the-hole. Acknowledging her needs, while gently urging her husband out of his protective covering will enhance a therapist's ability to enter the relationship system. The love-sick spouse need not frighten off a therapist, and if her rage is reframed as a desperate cry for help, she may be more approachable. While difficult to engage, the cold-sick partner can be reached if his discomfort is acknowledged and his defenses initially honored. With carefully plotted and sensitive attempts to form an alliance with each partner, these couples can be engaged in successful treatment.
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REFERENCES 1. Martin, P. A., and Bird, H. W. A Marriage Pattern: the 'Lovesick' Wife and the 'Cold Sick' Husband. Psychiatry, 22:246-49, 1959. 2. Martin, P. A. A Marital Therapy Manual. BrunnerIMazel, New York, 1976. 3. Barnett, J. Narcissism and Dependency in the Obsessional-Hysterical Marriage. Family Process, 10:75-83, 1971. 4. Sager, C. J. Mamiage Contracts and Couple Therapy. BrunnerIMazel, New York, 1976. 5. Willi, J. The Hysterical Marriage. In Contemporary Mamage: Structure, Dynamics, and Therapy. Little, Brown & Co., Boston, 1976, pp. 435-56. 6. Guerin, P. J., Fay, L. F., Burden, S. L., and Kautto, J. G. The Evaluation and Treatment of Marital Conflict. Basic Books, New York, 1987. 7. Revitch, E. The Problem of Conjugal Paranoia. journal of Diseases of the N m o u s System, 15:271-77, 1954. 8. Dupont, R. L., and Grunebaum, H. Willing Victims: the husbands of Paranoid Women. Psychiatry, 125:151-59, 1968. 9. Zinner, J. The Implications of Projective Identification for Marital Interaction. Contemporary Marriage: Structure, Dynamics, and Therapy, 19:293-308, 1976. 10. Kugel, L. Combining individual and conjoint sessions in marital therapy. Hosp. Community Psychiatry, 25:795-98, 1974. 11. Beck, R. L. The Individual Interview in Couple's Treatment. journal of Family Therapy, 2:23141, 1989. 12. Bowen, M. Family Therapy in Clinical Practice. Jason Aronson, New York, 1978. 13. Aylmer, R. C. Bowen Family Systems Marital Therapy. In Clinical Handbook of Marital Therapy. The Guilford Press, New York, 1986, pp. 107-48. 14. Beck, R. L. Redirecting Blaming in Marital Psychotherapy. Clinical Social Work Journal, 15:148-58. 1987.
This article explores the problems faced in working with the '>old-sick/love-sick" marital system. Particular attention is paid to the dynamics of these relationships and the vanety of cold-sick/love-sick partners seen in treatment. Utilizing case illustrations, treatment strategies for both the love-sick wife and the dificult to engage cold-sick husband are described. The paper emphasizes the importance of forming arl alliance with the husband while empathically responding to his wife's pleading, hurt, yet angry expressions of longing.
She: He never gives me what I need. He is so distant. He doesn't care. He falls asleep in the middle of an argument. He: If she would just get off my back. . . . All she does is complain, complain, complain. Such couples are frequently encountered in treatment. The husband is often aloof, distant, and seemingly not in tune with his spouse's needs and her longing for acknowledgment. The wife is angry, pleading, desperate, and never satisfied. Labeled variously as "cold sick and love sick,"'.2 the "hysterical wife,"3 and "obsessional husband,"? the "rational and childlike partnersn4and as players in the "hysterical marriage,"' these relationships pose a significant challenge to the clinician. Guerin et a1.,6 discuss the "pursuer and distancer styles" of interaction, which parallel those of the previously cited papers. They elaborate further by describing the "interactional sequence" in conflictual marriages that involves an increasingly tense series of interchanges resulting in a stalemate in which neither partner gets what he or she is seeking (pp. 46-47), In working with these couples, therapists face a formidable task involving both containment of the one partner's desperate pleading and angry outbursts and the other's seemingly cool retreat. This paper will explore the love-sicklcold-sick pattern of couples' interaction as it is described in the literature and as it appears clinically. Treatment interventions will be emphasized which address the cold-sick spouse-the partner who is usually the more difficult to engage. The love-sick partner will be given attention in light of this individual's potential for interfering with a therapist's attempts to form an alliance with the elusive cold-sick mate. Case *Assistant Professor, Department of Psychiatry, Baylor College of Medicine; Adjunct Associate Professor, Graduate School of Social Work, University of Houston. Marling address: Baylor College of Medicine, O n e Baylor Plaza, Houston, T X 77030. AMERICA& JOURNAL OF PSYCHOTHERAPY, VOI.XLV, NO. 2, April 1991
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examples will be offered to illustrate variations in love-sick/cold-sick relationships and treatment strategies will be described which address special problems in therapeutic intervention. THE LITERATURE
The Wife An early paper by Revitch7discusses ". . . the problem of conjugal paranoia," describing in effect, this hysterical relationship pattern in marriages. Martin2 describes this cold-sick (husband) love-sick (wife) relationship in detail. He sees the wife as anxious, deprived, blaming, and not at all aware of her role in the conflict. She views her mate as unable to love, and insists that the only solution is in getting him to change, but at the same time berating him for being unable to change at all. Martin views the wife as theatrical, lacking in self-esteem, "high strung," and "parasitic . . . with her husband as the host" (p. 19). In Martin's view, her dependency is masked by her dramatic outbursts and threats to leave him. Willij describes the "hysterical woman" who is unable ". . . to do anything alone, and finds no inner resources to give her security" (p. 436). Most of these authors focus their attention on the confused, angry wives. Yet, many wives are amenable to intervention and not locked in life-or-death struggles with their spouses. The husband's cool and aloof demeanor may make him the more difficult partner to engage. The Husband Dupont and Grunebaum's8 previously cited paper describes the husbands as "willing victims" to their partners and elaborate on their provocative distancing from the increasingly agitated and later out-of-control spouses. Martin and Bird' view these husbands as, at the one extreme, seeing the problem as entirely in their wives, and at the other, beginning to question their role in the marriage. Martin2 suggests that despite the husband's assets (competence, responsibility, and community respectability) he will have difficulty with intimacy, be cold and aloof, and be ". . . unable to show feelings of closeness, intimacy, anger or love" (p. 21). Willi's "hysterophile" husband is described much in the same way as is his (p. 442). Willi sees the husband passivity, and "inhibitions of all e~hibitionism"~ as provocative in his passivity and when his wife ultimately loses control, he moves in as a calming influence and "rescuer" (p. 442). Guerin and his co-authors6 illustrate the husband's "reactive position" as he "becomes quiet and withdrawn . . . in response to his wife's overflowing emotionality" (p. 130). Sager's4 "rational partner" is described as defending "himself against admitting emotions may influence his or her behavior" (p. 123). He uses "a reasoned, logical, well ordered" (p. 123) approach to interacting with his partner and will frequently stimulate his spouse's rage. The projective elements of the husband's behavior have been described by
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Zinnerg at length, and the wife is seen as acting out his rage, which he finds so unacceptable. He has long thwarted his wife's attempts to gain access to him and he will potentially present a similar problem for a therapist. These husbands are universally viewed as unconscious collaborators in their wives' increasing loss of control. They are seemingly able to relax in the marital environment they help to create as their spouses noisily but predictably fall apart emotionally. They know the pattern that evolves will follow the same course-one which results in the wife assuming the role of patient-volatile and out of control. They, in contrast, appear to be rational, calm, thoughtful, and on the side of reasoned negotiation. In reality, while they are in control, they are also constricted and maddeningly nonresponsive and noninteractive. It is crucial that the husband's attempts to defend against painful interaction be addressed if any gains are to be made. While clinical experience and the review of the literature suggests that the vast majority of cold-sickllove-sick relationships feature a cold-sick husband and love-sick wife, relationships with reverse roles are not unknown. Considering cultural and societal emphases on men as rational, and women as emotional and feeling-oriented, it is not surprising that the wife usually presents as love sick and the husband as cold sick.
The Couple The partners' decision to marry is often explained by each in the initial interviews: She: You know, I thought he would be good for me. I got kind of wild at times and he was so solid-he knew how to calm me down. He: She really needed someone to help her get a foothold. I was attracted to her spontaneity. It's easier for her to have fun and she didn't always get so fired up emotionally. This checks-and-balances relationship made logical sense-the partners were good for each other and complemented one another. One can hear the respective families giving their stamp of approval to such a union. Yet, the husband's need to maintain his distance and keep his emotions under wraps will ultimately grate on his exuberantly dependent wife. Her requests that he become involved in her emotional world will intensify and encourage him to increase his distance as her rage escalates. As she does not relent and becomes more dependent, the husband will withdraw deeper into his world of work and set the destructive cycle in motion. The conflict that emerges bears no resemblance to the intimacy each wants. In therapy, these couples appear to be locked in a demandlwithdrawal cycle and frequently divert themselves from closeness as they collide. ENGAGING THE PARTNERS
The Wife The cold-sick husband is often given short shrift in the literature and the vocal wife stands out in bold relief to his withdrawn style. She begs for attention and
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cannot be silenced long enough to be engaged. The wife must be attended to, but as she is usually desperate, she is not likely to bolt from therapy. She can form a speedy, though dependent therapeutic attachment if she is heard. On one level, she yearns for the attachment, and on another, she would not know what to d o with it if she had it. This neediness drives her to her demands, yet the intimacy she asks for would prove to be alien and uncomfortable if provided. For all but the most desperate love-sick partners, the wife can be assisted in delaying gratification, while a carefully nurtured alliance is formed with the husband. Attempts to reach the husband may be interpreted by the wife as an effort to get her what she wants. As she might feel excluded, it is vital that her importance in the process will be underscored. If an empathic connection is made with her, her painful longing is gently interpreted, and she is assured that she is deserving of a closer relationship with her husband, her demands may be defused. This would serve to demonstrate the therapy's potential. I n my view, the love-sick partner is a "surer thing" and more easily engaged. Her husband is so well defended and emotionally closed off that particular attention needs to be paid to his needs to achieve a productive outcome.
The Husband As indicated earlier, the husband has retreated, either to his work, his private thoughts, or another relationship. His distant style may mask intense longing similar to his wife's. He often presents as responsible, logical, wishing for peace, and wanting the marriage. His dependency is blurred by his seeming aloofness and "I can take you or leave you" posture. He gets little acknowledgment for what reaching out he attempts and is hurt by the minimal support he receives from her. I n therapy, he may look bewildered, uncomfortable, and embarrassed by his wife's vociferous accusations and complaints. He may look at the therapist as if to say "I really don't know what to d o with her." She will be exasperated by his helplessness, and reacts with more anger, usually sending him further into retreat. T o illustrate:
Sam, a driven, successful professional, presented with his equally driven and successful wife of two years after she threatened divorce. Judy's complaints centered on Sam's inattention to her emotions, his limited interest in sex, and his all-work and no-play ethic. She angrily dominated the session and repeatedly attacked her husband. He responded predictably-by further retreat, suppression of his anger, and passive-aggressive behavior. 1 nurtured the alliance with Judy by carefully listening to her complaints. I reassured her that I would make every effort to understand what was preventing Sam from giving her what she wanted. This resulted in Judy's calming down, but left Sam feeling that his wife would be forever making demands and he remained distant. I addressed the origins of
Warming Up to a Cold-Sick Spouse Sam's need to remove himself from strong emotional fields. He traced this to his relationship with his controlling and demanding mother from whom he emotionally distanced himself. Judy punctuated Sam's description of his relationship with his mother by blaming him for coming from a terrible family. I assured Judy that I understood her fears and helplessness. Judy looked on with some interest as I worked to penetrate her husband's cmotional barrier.
When the wife's demands are acknowledged, it may not be necessary to aggressively nurture her engagement. While many love-sick partners angrily attack their spouses in treatment, some present primarily with hurt, disappointment and controlled anger. A therapist is then able to turn the bulk of his or her attention to engaging the husband. T h e more easily managed cold-sickllove-sick couple is illustrated as follows:
Susan and Frank, married 16 years, with one son, presented for marital therapy to a female therapist. Frank immediately felt misunderstood, "ganged u p on," and dropped out of treatment. Alarmed at Susan's threats to leave, Frank found a male therapist-meand made an appointment for the two of them. In the first session Frank indicated that h e was a "black-and-white kind of person" for whom "two plus two always equals four." Susan described herself as romantic and emotional, and had been angry at Frank's distancing, his non-feeling sexual demands, his critical nature, and his preoccupation with work. Frank acknowledged that he would have difficulty changing, but wanted the marriage badly enough to d o whatever was necessary. Frank was all business in the first session and spoke with certainty about what he observed in the marriage. All the while he looked at me, and repeatedly sought acknowledgment by asking "do you know what I mean?" and "do you understand what I am saying?" My task was to develope a working alliance with each and was made somewhat easier by Susan's controlled love-sick style. I repeatedly demonstrated that I understood Frank's pain, while monitoring Susan's potential volatility. Susan was grateful that Frank had finally consented to participate in therapy, and watched the husband's interaction with me with great interest. Addressing most of my attention to Frank, while periodically acknowledging Susan's presence and concerns, an attempt was made to form an alliance with Frank. As Frank had previously retreated from couple's therapy, was suspicious of the process, and saw it as a forum for Susan's attacks o n him, it was imperative that I work aggressively with him in the early stages. My task was made easier by Frank's readiness for acknowledgement arid the fact that his pain was so near the surface. Judy, more disappointed than enraged, occasionally expressed muted demands, but was amenable to my work with her husband.
This couple was able to participate productively in this process because of Frank's emotional accessibility, Susan's self-control and my continued effort to balance the interview and not attend primarily to one partner or the other. Certainly, other factors may have influenced Frank's engagement, including the fact that he had selected a therapist of his choice and his fear that Judy might leave him.
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With some couples, a more disappointed wife and retreated husband will offer a more challenging task:
Ed and Joan, married less than one year, and both recovering alcoholics, had entered this disappointing marriage with themes of dependency, low self-esteem, unresolved family-of-origin issues, and anger at their respective former spouses. Joan immediately attempted to engage me in a dialogue about Ed's passivity, and inattention to her emotional needs. In the session, she was out of control while voicing her unwillingness to tolerate Ed's rage. Ed presented as controlled but angry, rolling his eyes periodically as Joan listed his infractions. He did not speak directly to her nor did he face her as she criticized him. Joan repeatedly interrupted his attempts to respond, and spoke angrily about how he had misrepresented himself, "lied to me, and uses me." This hostile-dependent relationship was one in which Joan-the love-sick spouseverbalized the mutually experienced rage, and Ed-the cold-sick partner-contained it. I made attempts to reach out to her though she who would angrily shift the focus by reiterating her complaints. Ed defended himself, and on two occasions threatened to leave the room if she continued. Joan wanted validation of her feelings and to be joined by me in her attacks on her husband. She was unable to connect with me and begrudgingly responded to my attempts to gather a developniental history.
I aimed to encourage Ed to identify his positive feelings about the relationship, and then indicate some desire to work on it, in the hope that it might mollify Judy long enough for the conjoint work to begin. I was successful in addressing Ed's hurt and he talked tearfully about his mother's withdrawal from him and the loss of his daughter to his ex-wife. Despite my attempts to help her understand what Ed was feeling, Joan criticized him for having expressed no such love or caring for her. My effort to help each understand the other's pain was not successful. As Ed had feared, Joan began to criticize him in the wake of his fleeting vulnerability. Ed and Joan's rage and disappointment were so great that there appeared to be little hope for building an alliance with either partner. Joan was too enraged to enter into a dialogue with Ed. Ed, potentially accessible and revealing occasional cracks in his armor, would have been "led to his slaughter" if he had been encouraged to expose himself to his demanding and punitive wife. Preliminary individual work was needed to address the difficulties each partner was having in getting needs met, hearing the other, and being heard.
As illustrated by the case of Ed and Joan, a therapist must move cautiously t o encourage the cold-sick partner to emerge from his shell in the presence of his spouse. No guarantee can be made that the love-sick partner will warmly embrace his new vulnerability as her anger might resurface when she again realizes how long she has waited for him. She may be frightened about his vulnerability and unable to tolerate his self-exposure. The husband, if pried open, may consider this opening up as a threat to his equilibrium and fear his spouse's rushing in aggressively.
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TREATMENT OPTIONS
Once the cold-sick husband's defenses have been unlocked and attended to, and the wife's needs are acknowledged, the treatment plan must be renegotiated. It is important to consider the husband's potential retreat at the slightest rejection or wounding. The wife must also be carefully considered, for if a therapist is overly alertive to her husband, she may believe she is being short changed. Finally, the husband must be protected from his wife's barbs so as to insure his safe entrance into the process. The task is a difficult one as the therapist moves back and forth between the roles of protector, supporter, and interpreter. A move toward strategic individual interviews might be considered to assist in the process of engagement and mutual accessibility to each other.'0," A balance must be maintained in which neither partner is left unattended for long and a conjoint structure may remain in place while an individual alliance is built with each partner. By empathizing with both partners' frustration in dealing with each other, the pressure is taken off the husband, and the wife is likely to feel less hopeless as the couple begins to communicate less chaotically. While the ongoing work might continue conjointly, the couple has been provided an opportunity to address their concerns and each has been heard. Stages of lntervention In working with these couples, a five-stage course is recommended that addresses the individual dynamics as well as the systemic properties of the relationship. Stages of Intervention 1 . Calming the love-sick partner through: a. Empathic connecting; b. Building a therapeutic alliance. 2 . Reaching out to the cold-sick partner through: a. Empathic connecting; b. Attempting to understand the meaning of this self-protective retreat. 3 . Teaching the partners that each may be utilizing different strategies to deal with similar feelings and desires. Initially, each partner is engaged individually in the conjoint sessions with limited attention paid to their interactional problems. While I may need to attend to the relationship, it is in order to bring some calm to the interaction while the individual alliance is being built. Once this is accomplished, the relationship is addressed by: 4. Interpreting each to the other in regard to: a. T h e nature of their particular needs and fears. b. Historical antecedents to the conflicts. The wife is often in obvious pain and longing for someone to attend to her
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needs. Once trust has been established, interpretations a r e m a d e as to t h e meaning of h e r longing for t h e husband. T h e wife is taught about h e r husband's fears a n d how his retreat is exacerbated by h e r demands, as well as a function of his own unfinished issues. T h e partners a r e asked, in effect, to n o t "take it so personally" by: 5. Redirecting t h e partners from blamingi4 to increased self-understanding by: a. Elaborating o n t h e growing awareness of t h e o t h e r partner's needs; b. Consistently underscoring t h e pain that has been uncovered i n each. Both partners' growing understanding of themselves a n d their spouses is encouraged. T h e couple may repeatedly r e t u r n to their accustomed style of relating-replete with projections, blaming, a n d anger-and they a r e reminded of t h e meaning of their behavior a n d t h e other's needs. T h e following case further illustrates my attempt to engage t h e cold-sick spouse i n marital treatment.
Jan expressed concerns about her sister's "exploiting" their mother. After a brief period, Jan was able to move out of this triangle, become more secure about her mother's affection for her and clearer about the projected elements of her concerns. In the course of this brief therapy it became evident that Jan was dissatisfied with her 13-year-marriage. Prior to termination ofthe short-term treatment, I suggested that at some point Jan and her husband might come in together to talk about their relationship. Jan could not imagine her husband agreeing to enter a therapist's office. Six months later, Jan returned to talk about a memory that had surfaced about her sister being sexually molested. While she again entered treatment based on concern for someone else, she soon addressed her anxieties about her relationship with her father, her anger at her mother for allowing this to happen, her concerns about the distance in her marriage and her preoccupation with another man. She described her unrelenting pursuit of her husband whom she saw as distant, aloof, depressed, and not accessible. I again suggested that she consider inviting her husband to a session. She once again indicated that there was no way he would agree. Yet, when a month later, she broached the subject with him, he agreed to join her. Steve was initially remote and acknowledged anxiety about seeing a therapist. In light of the preexisting alliance with Jan, I carefully attempted to engage the cautious and formal Steve. In her continuing individual sessions Jan told me that she was certain Steve could not be reached. She repeatedly expressed this concern in the couple's sessions by alluding to Steve's not wanting to be in therapy, and his "obvious" anxiety about participating. In a subsequent session, Steve denied each of his wife's assertions. While she acknowledged that the process was uncomfortable, he repeatedly assured his wife that he would do anything to keep the marriage. I attended to Jan's growing impatience with Steve and suggested that she possibly might be anxious about the outcome as well as uneasy about the prospect of relating in a new way with him. I assured Steve that I understood his discomfort with Jan's emotional outbursts and his uneasiness about most emotional interchanges. Steve re-
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sponded warmly to me and proceeded with greater ease. In a short time, a strong working alliance was established with Steve and he and his wife began to work on their marriage. In working with this couple, I initially built an alliance with Jan by calming her through empathic connecting (l-a) regarding the multitude of issues she presented. As an alliance was built (l-b),and she was generally responsive to my input, I was thus able to approach Steve by empathic connecting (2-a) and through exploration of his difficulties in the face of intense emotions (2-b). I then interpreted each to the other (4-a and 4-b) prior to encouraging them to examine their contribution to the conflict (5-a and 5-b). Given their mutual commitment to the relationship and emotional accessibility, the couple responded positively to this approach. Couples present in projecting pairs-they blame each other and in a manner that is often overwhelming and gives a therapist little opportunity for detached observation. They pull at a therapist, and as they engage in a pattern ofblaming, A therapist may be pulled toward joining triangling patterns may with one partner's criticism of the other or will subtly form an attachment to one partner's position. Given the intensity of the process, triangling in marital treatment is inevitable, and staying out of this process is a primary therapeutic task. Both partners will present compelling arguments as to how they have been wronged by the other, and they must be responded to with interventions that break through the defenses that maintain the unhealthy equilibrium.14 Treating the love-sickicold-sick partnership requires an understanding of the dynamics of the relationship as well as a grasp of specific strategies for intervention. Working with these couples tests therapists' mettle as they must, on the one hand, be able to identify each partner's needs and on the other, develop an empathic connection with each. The treatment process requires an initial awareness of the nature of these relationships and their fight-flight pattern. SUMMARY
This paper has examined the cold-sick/love-sick pattern of a couple's interaction and presented a schema for intervening with the less accessible, but pivotal partner-usually the husband. The importance of carefully attending to the wife's needs, expectations, wishes, and frustrations has been understood. She is not to be considered an ace-in-the-hole. Acknowledging her needs, while gently urging her husband out of his protective covering will enhance a therapist's ability to enter the relationship system. The love-sick spouse need not frighten off a therapist, and if her rage is reframed as a desperate cry for help, she may be more approachable. While difficult to engage, the cold-sick partner can be reached if his discomfort is acknowledged and his defenses initially honored. With carefully plotted and sensitive attempts to form an alliance with each partner, these couples can be engaged in successful treatment.
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