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Fam Proc 2:25-33, 1963

Psychotherapy of Marital Couples

EDWARD J. CARROLL, M.D. C. GLENN CAMBOR, M.D. JAY V. LEOPOLD, M.D. MILES D. MILLER, M.D. WALTER J. REIS, M.D., PH.D.a
aDr. Carroll, who served as supervisor of the continuous case seminar on which this paper is based, is Associate Professor of Psychiatry at the University of Pittsburgh. Dr. Cambor is Clinical Instructor at the same institution. Dr. Leopold is on the staff of the San Francisco Child Psychiatric Clinic. Dr. Miller is a Captain in the U.S. Army stationed at Walter Read Hospital, Washington, D.C. Dr. Reis is Clinical Instructor in Psychiatry at the University of Pittsburgh.

Increasing experimentation in recent years with psychotherapeutic techniques which differ from standard one-to-one relationships (1, 2, 3, 4) has led to techniques of family therapy. Defined as psychotherapy of two or more members of the same family unit at the same time and place by one therapist, family therapy has as its central idea the application of group therapy to the natural group rather than to the artificial group. It is well known that individual therapy not infrequently results in failure, stalemate, or very slow progress, and some investigators question whether the problems in these cases don't transcend the individual because they are an inseparable part of the group in which the individual is involved. This paper is a discussion of some factors in family therapy and presents two cases in which the technique of psychotherapy of marital couples was used.

COMMON OBJECTIONS
We were not unaware of the difficulties in, and the objections to, group therapy in general and family therapy in particular. However, in our experience many of those so-called defects were, from another point of view, the very virtues of group and family therapy. Some critics have suggested that it is hard enough to understand the interaction in a two person system and nearly impossible to disentangle multiple communication problems. However, frequently the addition of other family members tends to clarify the nature of the interaction and to reduce distortion. In these instances, the true character of the marital partners and their relationship becomes much more clear, usually surprising the therapist who felt that he knew his patient well from individual interviews. Specifically, the projections of paranoid patients become much more apparent and can be dealt with in situ. Also, the other members of the group act as observers and "therapists" too, increasing the amount of behavior the therapist observes. Objection has been raised that the dilution of the transference reduces the therapeutic leverage. To this the proponents of group or family therapy have replied that "therapy for therapy's sake" becomes less gratifying to the patient and thereby facilitates progress. Furthermore, although traditional transference is less intense, the level of emotional intensity in the interview is often greater, and its focus is shifting rather than centered upon the therapist as in individual therapy. A specific merit is the fact that whereas in long term intensive therapy termination is a problem, in this technique the transference is diluted and permits an easier separation. Another disadvantage of family therapy felt by some is that there is a reduced control over the therapeutic process by the therapist. However, the members of the group apply controls to each other directly as well as through the family as a unit. For example, in family therapy there is less direct control over the therapeutic process, but this is offset by the advantage gained when one person is recalcitrant or difficult and other members come to the aid of the therapist by putting pressure on the recalcitrant individual. Regardless of the relative merits of family therapy, the fact remains that many therapists do not feel comfortable in the role of group therapist. Some therapists preclude this type of treatment because of the anticipated lack of a close, intimate, exclusive relationship with the patient. Yet there can be an intense and rewarding relationship for the therapist in family therapy. While the points discussed above apply to group therapy in general as well as to therapy of family groups, some special criticisms have been raised against family therapy: 1. In Western European culture the family is regarded as sacred. Often there is the implication that the family is only held together by observing an internal conspiracy of secrecy with regard to certain "unholy" aspects of the family. Upon examination, however, many of the "secrets" are found to be actually known to all members of the family, even the children,

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and ventilating these secrets relieves everyone of the tension of avoiding taboo areas. 2. The therapy may become jeopardized and the therapist threatened if the husband and wife "gang up" on the therapist. 3. It is claimed that it is equally difficult to manage the attempt of the couple to force the role of judge and arbiter on the therapist. In this connection, the therapist may become involved in the question of whether the marriage should be preserved. 4. Related to this problem is the conspiracy of acting out by which the marital partners defend against this form of therapy. 5. If patients have been in individual treatment, they may try to force the therapist to allow them to return to their "beloved" individual treatment where dependency gratifications are more abundant. 6. One danger of family therapy which the therapist must appraise is whether he dares to disturb a modus vivendi, though neurotic, if he is not certain what the alternative will be. For example, the sicker member may be helped at the expense of an apparently better adjusted member who may begin to display pathology. Therefore, the therapist must decide if he is justified in disrupting an unhealthy balance if there is little to gain in a changed relationship. Family therapy might break down the apparently healthy compensatory adjustment of another member, and this type of intervention might therefore be unwarranted. 7. It is sometimes difficult to enlist the cooperation of other family members to the point where they will participate in treatment. In practice it has been our experience that while these problems must be considered they usually do not prove to be contraindications to family therapy. A discussion of the advantages and disadvantages of family therapy would not be complete without a consideration of the economic realities of many patients. In many instances, regardless of its merits individual therapy is not economically feasible for more than one member of a family. Family therapy is often a reasonable way to spread the benefits even if diluted, which is not necessarily the case. Likewise, from the point of view of psychiatric manpower, family therapy makes it possible to share psychiatric skills with more patients. In attempting to determine which cases might be better treated by family therapy, the following rules of thumb might be applied: 1. Individual therapy should be recommended when a conflict has been largely intrapsychic, of long standing, and where social relationships have not been severely handicapped. 2. Family therapy, on the other hand, should be recommended where the individual's discomfort occurs predominantly in his intimate relationships, where there appears to be a reciprocal pathological interaction between family members, and where the personal unhappiness outweighs the symptomatic distress.

TWO CASES
The family treatment to be discussed here will be confined to the basic group of husband and wife. In this series of six cases, family therapy was adopted after prolonged individual therapy had wholly or partially failed. The variation of technique applied in our cases consisted of bringing in the marital partner of the patient after weekly individual therapy had been in progress for some time. Most of the couples were seen together on a once-a-week basis. This study has been limited to a period of one year. Of the six cases seen, four made significant gains, while the other two were unimproved. Brief summaries of two of these cases follow.

Case One
The Patient A was a 48 year old, white housewife, who was hospitalized in 1956 with a diagnosis of paranoid schizophrenia. The patient was hospitalized twice before in 1954, receiving electro-convulsive therapy with transient improvement. Her symptom picture was rather diffuse, with a generalized phobic approach to life. The patient suffered from feelings of depersonalization, fear of insanity, anxiety, headaches, loss of balance, nausea, insomnia and colitis. She had become progressively agitated, preoccupied with morbid thoughts, depressed and finally actively critical of people about her. She is the youngest of two children, having a brother four years her senior who is a brilliant scientist towards whom she has always felt inferior. The patient's mother committed suicide by shooting herself when the patient was 27. She had been described as being a very moody individual given to violent tantrums and spells of depression. The father remarried shortly after his wife's death, but this wife had to be committed to a state hospital shortly thereafter where she died. The patient feels that she had a very unhappy life from the beginning, being continually upset by her mother's moods. She was not permitted the usual contacts and could not bring her girl friends to the home. The patient was an excellent student both in high school and college. She met her husband in college and marriage was the result of pregnancy. However, husband and patient had planned to marry eventually. After marriage, the patient immediately insisted on an abortion because she did not

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want the baby. She has always been fearful of being pregnant, and her later pregnancy, her one child, now a boy 14, was an accident. The patient was transferred to the present therapist in July, 1956 and was seen two hours weekly until November, 1956 when she was placed on outpatient status because it was felt that she had received maximum benefit from hospitalization. The patient objected strenuously to her discharge and tried to prove her need for further hospitalization by increased severity of her symptoms and anger. From November, 1956 until September, 1958 she was seen as an outpatient twice weekly and later once weekly. She made definite but slow progress, fighting against every step forward like she had fought against her discharge. She changed from a patient who never showed any emotion to one who expressed many feelings in these interviews, though predominantly hostile. Since it was felt that the husband's passive-aggressive behavior was making it difficult for patient to progress, arrangements were made for the husband to be seen by a social worker and when this did not work out, by a psychiatrist. The contact with the psychiatrist was terminated after ten interviews when the husband suffered a severe injury in an accident which definitely had psychogenic roots, and he required a prolonged period of convalescence. In December, 1957 the patient finally, grudgingly and with many reservations, agreed to get a job which seemed, at the time, important both therapeutically as well as realistically, since the husband's ability to return to work in the foreseeable future seemed questionable. She had a marked increase in symptoms, especially her diarrhea, but performed well as a secretary in spite of these symptoms and her dire predictions. In July, 1958 the therapist became convinced that he could not help the patient much further except along the lines of maintenance therapy unless the husband was able to change his blatantly passive-aggressive behavior. Since previous attempts to help the husband separately through a social worker and a psychiatrist had failed, the therapist suggested that he see the couple together. It was also hoped that this arrangement would facilitate termination of therapy, which would otherwise be difficult due to the archaic character of the transference. After many delays the patient agreed to this with reservations. As a preliminary start the therapist saw the husband a few times alone. The couple was seen once a week from September, 1958 until February, 1959 when the frequency was reduced to once very other week. It was later planned to see the couple once a month in preparation for termination of therapy. Since the patient insisted that she also would want to see the therapist alone, the couple was interviewed together for 45 minutes, and in alternate sessions each of the spouses was seen 15 minutes alone afterward. In joint therapy after the initial skirmishes, there were wild verbal fights between the marital partners in front of the therapist. On these occasions the therapist encouraged the spouses to look at their emotional needs underlying the angry outbursts. Gradually, the relationship between the husband and wife improved and there was a progressive change from a family in which the wife was an invalid to a family which interacted in a more normal fashion. In their neurotic relationship the wife's reward was to be taken care of as an invalid. On the other hand, the husband's reward was the right to assume the role of the long-suffering husband of a mentally ill wife, i.e., he had her to blame for his passivity. During the course of joint therapy it became apparent to each of them that her role was gratifying in terms of her passive dependency while the husband's role was gratifying to him through the projection of his inadequacy onto his sick wife. Significant changes occurred as the husband relinquished his passive-aggressive role and tended to act in a more masculine fashion, and also as the patient's paranoid ideations became more demonstrable and treatable in this family setting. The social interaction between the couple improved; there is much greater ease in living for each of them, with less disturbance by the periodic recurrence of the patient's symptoms than before. As the patient turned to her husband rather than the therapist for emotional gratification the transference with the therapist became diluted. In addition, it was evident that the son received a great deal of benefit vicariously from his parents' therapy. It is quite apparent that patient's emotional difficulties have not disappeared, though they are reduced in intensity. But it seems that the angry outbursts are less disturbing to the family interaction and for this reason permit an even earlier return to more normal family living.

Case Two
Patient B was a 29 year old married white Catholic male technician, father of a four year old daughter, who was referred to the clinic by his family physician because of feelings of anxiety and depression associated with stomach pains, headaches and impotence. The family physician had tried Thorazine, Belladonna and hypnotherapy without success. Patient presented a life long history of severe emotional instability with disproportionate emotional outbursts, even when confronted with minor frustrations. The father was described as cruel, punitive, paranoid and excessively demanding of the patient, while the mother was described as bitter and resentful of her role as a wife and mother and quite manipulative of her children through her attitude of long-suffering martyrdom. The patient had always felt jealous and angry toward the only sibling, a younger sister. He felt she had manipulated the parents to treat her non-critically and as the favorite by means of controlling them and extracting their sympathy through several chronic illnesses during childhood. When the patient was 14, the father was killed in a violent accident, and shortly thereafter the patient began a prolonged period of rebellious, defiant, acting-out behavior. His

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marriage at age 24 was characterized by repeated arguments and fights in which the couple were overly critical of each other's behavior, and during which the patient became progressively impotent and his wife frigid in their sexual relationship. On several occasions the patient lost control during these arguments and became violently destructive and aggressive. In the course of 50 hours of individual therapy the patient's somatic complaints decreased while his acting out behavior, especially toward the marital partner increased. He threatened suicide and homicide on several occasions, complaining primarily about frustrated dependency needs, and otherwise often seemed like a small boy in a temper tantrum. At this point in individual therapy, the consensus of opinion at a staff conference was that individual therapy could not be successful unless the patient was hospitalized in order to control his acting out. However, because hopsitalization was not acceptable to the patient nor economically feasible, joint therapy was begun. It immediately became apparent in joint therapy that there was a "mutual conspiracy" to maintain the status quo of the neurotic relationship. Each attempted to help the other maintain his neurotic role which was to protect each from an awareness of the other's acting in a specific neurotic way, because only then could each avoid the "frightening" truth about himself and thereby justify a continuation of his own neurotic behavior. At this point the therapist decided that one therapeutic goal would be to break through the neurotic interaction in order to help them achieve a more gratifying mutuality. As they were able to make their own fears conscious in the presence of the other, there was apparently less left to be projected, and this was particularly true of their feelings of inadequacy. The wife was unhappy because the patient could not give her attention, whereas he stressed his fears of developing a closer relationship to his wife and kept showing how she repeatedly attacked him whenever he became more closely involved with her. Each became able to verbalize his own hatred and see that it wasn't as destructive as he had fantasied. Gradually, their goal in therapy changed from one of trying to conceal the dynamics to one of trying to understand the dynamics of their relationship. This decreased the mutual neurotic provocation considerably. After 40 hours of joint therapy, their relationship had become one in which there was a more comfortable interaction, and each plans to continue with an individual therapist. At this time it was the therapist's impression that the gratification derived from the neurotic interaction had been greatly decreased so that individual therapy seemed promising. Family therapy as one psychotherapeutic technique is often very helpful in clarifying the dynamics of the individuals involved and serves to make these dynamics clearly evident to the therapist and to the family members. It tends to reduce the family unhappiness and dissension that have been involved in preserving secrecy around the motives for the neurotic family behavior and results in more harmonious living. It may not produce a "cure" of symptoms, but it will reduce the disturbing family reactions to the symptoms. Further experimentation with these techniques is warranted.

REFERENCES
1. 2. 3. 4. Ackerman, N. W., The Psychodynamics of Family Life, New York, Basic Books, 1958. Bower, M., "Psychotherapy of the Family as a Unit," presentation to Workshop #31 of the American Orthopsychiatric Association Meeting in New York, March 7, 1959. Eisenstein, V. W., Neurotic Interaction in Marriage, New York, Basic Books, 1956. Midelfort, C. F., The Family in Psychotherapy, New York, McGraw Hill, 1957.