When I began my psychiatric training at Yale in the early 1970s, my teachers really believed in the biopsychosocial model, in the irreducibility of biological, psychological, and social variables in accounting for human suffering. We sought to fit our treatments to the patient, rather than the other way around. After my residency and alongside psychoanalytic training, I learned “structural family therapy” at the Philadelphia Child Guidance Clinic, studied group dynamics in numerous “Group Relations Conferences in the Tavistock Tradition,” and devoted much of my professional life to the conjoint treatment of families and couples.
Just as medical and psychoanalytic concepts and experience shape my daily thought about pathology and treatment, so do the explanatory concepts of structure, process, culture, authority, task, and role—to name only a few social variables—facilitate my psychoanalytic work with individuals and my conjoint work with families. In this discussion, I use the two-person group of marriage to sketch some social systems concepts and interventions that, like antidepressants, can extend the therapeutic efficacy of the psychoanalyst.
When might a psychoanalyst recommend a marital consultation or therapy? Here are three typical scenarios.
The patient fills the hours with complaints about the spouse and no headway is being made in either the analysis or the marriage. Transference work seems blocked by pressing external problems, and it is unclear how much the external impasse is due to the spouse. Spouses may also appear to be opposing beneficial characterological changes (“I want my old wife back!”).
The patient has an important unresolved disagreement with a spouse (whether to have children, how to handle the ones they have, how to relate to in-laws, etc.) and the analysis has not moved things to resolution.
The patient is improving and is considering divorce, which is viewed as an adaptive improvement, but analyst and patient are unclear whether the spouse—usually someone with less therapy and possibly opposed to it—might be willing to attempt changes in order to maintain the marriage. (Analysts are advised to recall Gurman's research in the late 1970s, which documented the frequent destabilizing effect of individual therapy on marriages.)
What these scenarios have in common is the inability of analyst and patient to fully assess or ameliorate a specific marital impasse. Intervention with the absent spouse can often help.
So what might the analytically informed couples therapist do with such couples? As you can easily imagine, I assess individual psychological issues (defenses, wishes, object relations, etc.) and try to create a safe forum for understanding and mediation. Beyond this, what group-level concepts inform my work? Just as analysts focus on the here and now, I focus on the process through which the couple interact.
My default format is that couples choose a topic of concern and try to work it out between them. We then get to observe directly the reason they are in my office. Almost invariably, the patterned circular process (the “dance”) they use to talk with each other not only fails to make things better; it makes things worse. Each couple employs its own signature process, but in all variations, the initial problem is soon left behind as defensiveness escalates; empathic ability is lost; contempt isolation, and hopelessness fill the room; and the relationship itself becomes the central concern. John Gottman, perhaps the pre-eminent marital researcher, has found that such maladaptive process in newly-weds, independent of content is the best predictor of marital unhappiness and subsequent divorce. Consequently, the couple's maladaptive process usually becomes the focus of our work.
Since the maladaptive process generally escalates rapidly (systems theorists term this a “runaway”) marital therapists must make far more interventions per minute than in analysis—including sometimes calling “time outs” to halt the spiraling negativity. Often one must put one's own empathy and understanding between the warring partners.
Arthur C. Nielsen, M.D., is a faculty member of the Chicago Institute for Psychoanalysis, a Clinical Associate Professor of Psychiatry at Northwestern University Medical School, a faculty member at Northwestern's Family Institute, and a founding member of the Chicago Center for the Study of Groups and Organizations of the A. K. Rice Institute. He thanks his wife of twenty-three years for many insights into the rewards and difficulties of marriage. Full references are available from the author at .
Escalation of tension and deterioration in the process result from a combination of “mutually reinforcing transferences” (each partner's worst fears appear confirmed, as J. Zinner observed in 1989) and projective identification (each partner attempts to attribute and induce negative characteristics in the other, as noted by D. R. Catherall in 1992). These concepts powerfully link individual and group pathology. My ability to interrupt and interpret these developments has been perhaps my best predictor of success.
While interrupting and interpreting pathological process often works, sometimes couples fail to alter their process, and I continue to be needed to manage their conflicts. In such cases, I have found it useful to prescribe the “speaker-listener technique” as advocated and researched by Markman, Stanley, and Blumburg at the University of Denver (published in their book Fighting for Your Marriage). This amounts to a prosthetic structure allowing communication to proceed more safely. When this approach is successfully employed, the analytic therapist will frequently be pleased by the new levels of psychological depth and healing empathy that follow.
Many of the people I see in couples therapy are also in analysis. Our group of Chicago psychoanalyst–couples therapists carefully studied the complex systems of multiple therapists and patients that form when one or more member of a couple in marital therapy is also in analysis. When there were therapeutic impasses, we frequently found therapists working at cross-purposes, often unconsciously over-identified with their patients or the patients' spouses. Such situations usually resulted in therapeutic impasses. Communication between therapists almost invariably assisted both analysis and couples therapy.
After witnessing how many people unconsciously “marry their problems” or wait hopelessly too long before seeking help, I wanted to intervene earlier Working with couples therapists William Pinsof and Cheryl Rampage at Northwestern University's Family Institute, we designed and implemented “Marriage 101,” a for-credit academic course for undergraduates at Northwestern University. This course offers many opportunities for improved self-understanding (extensive journaling, interviews with students' parents, and experiential classroom exercises) as well as the usual academic fare and aims to prepare students for intimate relationships. Marriage 101 has been extremely popular, and research on its effectiveness is under way.