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This paper focuses on the location of illness and pathology in couples suffering from substantial disturbance and discusses some of the issues facing clinicians when working with these challenging couples.
There is a debate at present about the kind of patients that I am referring to. In the psychoanalytic papers that most of us are familiar with, these patients are classified as “borderline”, and more recently the term “personality disorder” has come into use to describe them. Perhaps an initial diagnostic discussion might be helpful here, so I will quote from the Department of Health's guidance document of 2003, “Personality disorder: no longer a diagnosis of exclusion”.
Health professionals have not always agreed how best to identify personality disorders, but the World Health Organisation has produced a useful definition. The International Classification of Mental and Behavioural Disorders (ICD-10: WHO, ), defines a personality disorder as: “a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption.” (DoH, 2003, p. 9)
Whatever medical terms we use to identify these patients, I hope that the description I give of these couples will feel sufficiently familiar to clinicians to discuss the working issues they present.
During the progress of a couple therapy, it is usual for our sense of where the problem lies within the couple to move around. It is as though our mind is like a camera lens, moving around different vantage points. First we identify and empathise with what one partner says. Seconds later, the lens is pointing a different way and we see another picture. These different points of view that occur inside us over and over again are only manageable because of the fundamental stance of a couple psychotherapist.