On marriage: Evolution of a conjoint therapy approach
Issue: BCMJ,
vol. 45 , No. 1 , January February 2003 ,
Pages 20-24 Clinical Articles
This article summarizes the author’s gradual development of a theoretical approach to conjoint therapy of couples in major conflict. A significant help in the evolution of an effective way of treating dysfunctional couples was the realization that “a good theory is the most practical thing,” and the theoretical basis the author has found most effective is outlined in this paper. The approach offered is a method of understanding what is really going on in a conflicted relationship.
Couples in conflict often have views about their spouse that are both negative and inaccurate. Here is an approach that family physicians can use in the office setting to help heal this most significant of adult relationships.
I have been seeing couples in conflict for nearly half a century. For the initial 9 years of this period I was a family practitioner in Quesnel and North Vancouver, and, having had no training in medical school about marriage, I was totally unprepared for the situations I encountered. I had a vague awareness that a lot of the physical symptoms that patients presented were related in a general way to unhappiness and that most of this somehow related to unsatisfactory relationships. I had no theoretical basis, however, to proceed beyond these ill-defined perceptions.
In the early 1960s I decided on a career in psychiatry. As in medical school, there was a dearth of interest in marriage and its vicissitudes. In view of the obvious serious impact of marital conflict on the lives of men, women, and their children, it didn’t make sense to me that this most significant of adult relationships, the very nucleus of society, should receive such short shrift from the medical profession generally and psychiatry in particular.
Once I was a psychiatrist and a junior faculty member I developed a small private practice. Most of my patients were women (who are more likely than men to seek treatment) and many of their complaints related to unsatisfactory relationships. These women fell into two groups: those who felt they were married to a prince and wanted my assistance in helping them to measure up to their partner, and those who were convinced they had got involved with the biggest turkey west of Prince Edward Island and hoped I could help them cope with these hopeless mates.
I decided to incorporate the partners, if both were agreeable, into the sessions, and a powerful and educational experience ensued. The princes and the turkeys turned out to be simply human, and did not resemble their advance billing. It was then that I began to understand the transactional nature of marriage, and my patients were a major help to me as I worked to understand the complexities of relationships. In the 1970s my learning was greatly assisted by the arrival of Ferdinand and Jirina Knobloch in the UBC Department of Psychiatry. More than anyone else I had encountered, these brilliant psychotherapy practitioners and researchers understood the value of a workable theory. In the introduction to their book Integrated Psychotherapy,[1] they state “We believe, as does Kurt Lewin, that good theory is the most practical thing.”
In 1978 I came across a seminal article by Segraves[2] that provided a theoretical basis for marital pathology. His model is testable, unites various partial theories into a common conceptual framework, relates individual psychopathology to interactional difficulties, and is clinically relevant. The Segraves theoretical model is as follows:
- Because of the complexity and quantity of interpersonal stimuli and the limited information-processing capacity of the human nervous system, people develop cognitive schemas or templates to organize their interpersonal perceptions. These schemas influence the manner in which new information about people is perceived and assimilated.
- It is hypothesized that in marital discord both spouses have schemas for the perception of the mate that are both negative and markedly discrepant with the mate’s real personality. Clinically, this will be observed as a fixed misperception of the mate’s character.
- It is hypothesized that these schemas or tendencies toward misperceptions were learned from previous intimate experiences. The most powerful influences in the creation of these schemas are childhood experiences with one’s parents, although they may be modified, for better or for worse, by later life experiences. A man, for example, who was raised with a domineering and intrusive mother will have developed a distorted cognitive schema for women. He will have a tendency to perceive all women, especially in emotionally significant relationships, as wanting to control and envelop him, which in the majority of cases is a gross misrepresentation of the intent.
- In cases of chronic marital discord, the person has difficulty observing the differences between the reality of the present partner and the images or cognitive schemas for the opposite sex.
- These distorted perceptions contribute to interactional sequences that maintain these distortions. A man who has developed a cognitive schema of women as manipulative may attempt to reduce this threat by being very controlling. That is, if he can control the relationship in all its aspects, he can reduce the danger of being manipulated. His spouse may respond to this attempt by fighting back, often in indirect ways, and thereby confirm her husband’s perception of women being manipulative. In mate selection, there is a strong tendency for dysfunctional individuals to unconsciously select a partner who complements their own pathology.
- Repetitive observation of spouse behavior discrepant with the cognitive schema for the spouse will result in a change in the person’s cognitive schema for the opposite sex. If, for example, our husband with the cognitive schema for women as domineering and intrusive is fortunate enough to marry a woman with healthy self-esteem and self-confidence, she will not fall into the transactional trap, and his cognitive schema will alter in a positive direction.
- As this framework implies that perception of the spouse is partially a function of the actual behavior of the spouse and partially a function of the distorted cognitive schema, the degree of influence of the latter on perception is a function of the ambiguity of the perceived situation. This implies that the use of clear and explicit communication patterns between spouses should minimize the amount of distortion possible.
If one bears in mind that distorted interpersonal perceptions are more fully elicited in emotionally meaningful, dependent relationships, then a typical scenario for difficulties in establishing and maintaining a mutually satisfactory relationship would be a person with an unhappy childhood relationship with one or both parents who, as a consequence, develops a cognitive schema that powerfully influences his or her perception of the partner in an emotionally dependent relationship so that he or she sees the partner not as the partner really is, but in a distorted way based on earlier unsatisfactory experiences. These distortions are reinforced because the person’s behavior elicits negative responses from the spouse.
As the years go by, the love and passion the partners had for each other dissipates gradually as the discord continues. Where once an out-of-control gas well flamed, there may now be only a flicker of interest in the other person. Motivation to retain the marriage is of paramount importance,[3] and if both partners are motivated, even couples with severely impaired capacities for intimacy tend to do well.
The conscious wish of each individual is to be a good partner. These good intentions are placed in jeopardy by unconscious forces arising from unhappy life experiences, but there are no villains in couples in conflict. This explains the mutual destructive hostility that exists in these marriages, as both partners are aware of how hard they try, and how hurt and angry they are when their needs are not met.
Because couples in conflict relate to each other in distorted schemas, they don’t know each other, and it can be very heartwarming to see a couple become acquainted with each other after years of estrangement.
A depressive illness in one or both of the partners is a common finding with couples in conflict. Myers has a good chapter on this issue.[4] Whether this mood disorder arises from the marital situation or occurs on its own, it must be diagnosed. Depression that occurs independently is often difficult to diagnose because the depressive symptomatology has become interwoven with the marital pathology. The depression will, in some instances, respond to conjoint therapy and some patients will require medication. I use the patient’s rating of his or her mood on a 1 to 10 point scale averaged over the preceding week. The Beck Depression Inventory is a useful adjunct.[5]
A model for an initial interview is summarized in Table 1.[6] You can take a family history on subsequent visits, looking particularly at whether they felt they were loved as children and what parental role model they were exposed to. The couples should be seen as couples, and if they argue openly in the office, let them know kindly that they can do this at home. Many less serious cases will respond to your interest and caring, the opportunity to ventilate, and an explanation they can relate to.
Couple conflict is a complex area, and the hallmark of the real professional is being able to say “I don’t know.” Resist the tendency to take sides, do an evaluation of both partners for depressive illness, and always arrange for another appointment. If you feel over your head, refer them.
Competing interests
None declared.
Table 1. The initial conjoint marriage therapy interview.
| Question | Comment |
|
1. (To each in turn:) What is your age and occupation? 2. How long have you been married? Did you live common-law prior to marriage? How long was the courtship? 3. (To each in turn:) Have you been married before? For how long? Did you have children? If so, what are their names and ages? Who do they live with? What kind of relationship do you have with each child? 4. Where do you live? Is it a house or an apartment? Do you own or rent? 5. (To both, if there are children:) What are your children’s names and ages? How is their physical and mental health? |
In response to the initial pleasantry, is there any evidence of a sense of humor, a very important quality in terms of prognosis? Who takes the initiative? How does the other partner respond to this? Do they disagree with each other over, for example, the duration of the courtship, one insisting it was a year, the other 13 months? If one or both partners have been married previously, the therapist will have gained some appreciation of the significance of these former spouses and the children to each of the partners. Asking about the children reveals whether they are a conflict-free area where both parents are in agreement on child-rearing, or whether one or more of the children have become pawns in the marital conflict. These initial five question areas permit the therapist to get to know something about the couple and allow them to assure themselves that they have a place in the world—a home, an occupation, children—which is helpful when they are on unfamiliar territory engaged in an unknown and very anxiety-provoking experience. |
| 6. Whose idea was it to come for conjoint therapy, and when did you first seriously consider it? | This is a very useful time to make a direct inquiry about motivation by asking how each partner feels about undertaking conjoint therapy. The motivation of each partner is a central issue, and is a curiously neglected area in the literature. As I have noted elsewhere, “While one or both members of the dyad may have ‘low’ motivation for working toward a happier and more functional marriage, they may have, in fact, very powerful alternate motivations for seeing a therapist….When the lack of congruence between the goals of the therapist and one or both marital partners goes unrecognized, effective therapy may be seriously prejudiced” (see Table 2 ). |
| 7. Have you, as a couple, had previous marital therapy? Who with, and when? How often were the visits, and how long were the sessions? (To each:) What is your perception of the outcome? |
Surprisingly often, one will give a positive report of the outcome, the other a very negative review, indicating a probable failure on the part of the therapist to have established a symmetrical relationship with the couple. Some support for this perception is given by the fact that commonly these previous interventions have been individual visits for both, usually more for the wife, and most commonly they have only been seen conjointly on one or two occasions. |
| 8. (To each:) As briefly as possible, what do you see as the problem in your relationship? How long has it been a problem? | Many couples will agree about the approximate duration of their conflict, but wide divergences are not uncommon. An extreme example of this is where the wife says there has been a major marital problem for 10 years, and the husband flatly denies that from his perspective there is any problem whatsoever. Asking for a brief statement of the problem is helpful in determining the degree to which each partner is prepared to take some share of the responsibility for their unhappy marriage. This ranges from the unrealistic (and narcissistic) acceptance of 100% of the responsibility by one partner, to a complete denial of any responsibility by one or both partners, and attributing the blame entirely to the spouse. |
| 9. (To each:) What do you hope to get out of therapy? | This helps to clarify each individual’s goals and provides an opportunity to assess the congruence of their expectations. |
| 10. (To each:) What thoughts have you had about separation? | The answers can be a rich lode of information, not only about the partner’s previous and current impulses to separate, hence constituting another monitor on their motivation, but also about their reasons for not wanting to separate. Themes of love and commitment may easily emerge here or, conversely, their absence, and concerns may be expressed that have less to do with the relationship and more to do with the partners’ apprehension over the practical and emotional consequences of separation and divorce. Another value of this question is to allay anxiety. A common fear of people contemplating conjoint therapy is that the process will end in divorce. Raising the issue directly and early is, in my experience, helpful. |
|
11. (A sequence, to each:) What is the “good news” about your partner? What behaviors of yours distress your partner? |
I am not particularly happy with this expression but one needs to affectively sanction the expression of negative thoughts and feelings. This provides an opportunity to focus on and assess the assets of the marriage. On rare occasions, in marriages in extremis, there is a paucity of good news or what is given is invalidated by the manner in which it is presented. This usually has motivational and prognostic implications. This question accomplishes a number of things. First, it is an indication of the person’s degree of comfort with hostile feelings. Second, it allows people to openly acknowledge that they are aware of the specific behaviors that antagonize their spouse and in so doing, take responsibility for what they do. Finally, this question introduces or reinforces the fact that the couple are at war—full scale war—and it is remarkably salutary, in my experience, to point that out to them. |
Table 2. Alternate motivations encountered in conjoint therapy.
|
We (I) have tried everything; now we can separate. I’ll get you, you bastard. You look after her (him). Marital therapy as a career. |
Obviously, I’m the innocent party. Taking the heat off. Let’s get out without fighting. |
References
1. Knobloch F, Knobloch J. Integrated Psychotherapy. New York, NY: Jason Aronson, Inc.1979:XIX.
2. Segraves RT. Conjoint marital therapy: A cognitive behavioural model. Arch Gen Psychiatry 1978;35:450-455. PubMed Abstract
3. Miles JE. Motivation in conjoint therapy. J Sex Marital Ther 1980;6:205-213.PubMed Abstract
4. Myers M. How’s Your Marriage? A Book for Men and Women. Washington, DC: American Psychiatric Press Inc. 1998:97-110.
5. Beck AT, Steer RA, Brown GK. Beck Depression Inventory—II. San Antonio, TX: The Psychological Corporation, 1996.
6. Miles JE. The initial interview in conjoint therapy. In: Marital Therapy in Psychiatric Practice: An Overview. Frelich LF, Waring EM (eds). New York, NY: Brunner/Mazel. 1987:30-55.
James E. Miles, MD, FRCPC
Dr Miles is professor emeritus in the Department of Psychiatry at the University of British Columbia and is in private practice in North Vancouver.