AmJ Psychiatry155:5, May1998

Special Article
JERRY M. LEWIS INTERPERSONAL RELATIONSHIPS
For Better or Worse:
Interpersonal Relationships and Individual Outcome
Jerry M. Lewis, M.D.
At a time of strong biological emphasis in psychiatry, it is important to emphasize that
relationships with important others may play a crucial role in individual outcome. Psychoana-
lytic theories in the form of object relations, self psychology, and relational psychoanalysis
reflect this emphasis, and at a broader level, the interpersonal school of psychiatry focuses
selectively on the role of relationships in health and illness. Ten central premises of the inter-
personal school are presented, followed by brief, selective reviews of three bodies of empirical
data: studies of well-functioning marriages and families, the role of adult relationships in
undoing the adult consequences of destructive childhood experiences, and the relationship of
marital variables to the onset and course of depressive disorders. Clinical experience and
research findings suggest that clinicians treating couples and families may be helpful by using
techniques designed to both increase the intensity of affective bonds and repair the inevitable
disruptions of those bonds. I t is also noted that recent psychophysiologic studies suggest that
derivatives of intense affective bonds and their disruptions, in the form of confiding and con-
flict, may influence both vascular reactivity and cellular immune competence. These studies
suggest that for better or worse may have physiologic as well as psychological implications.
(Am J Psychiatry 1998; 155:582589)
I
n these days of bi ologi cal reductionism, with its
brain disease metaphor and emphases on descriptive
diagnoses and psychotropic medications, it is easy to
forget that life is lived in relationships, and the quality
of those relationships has much to do with how life
turns out. Curiously, the minimization of relationships
has occurred despite an increasing emphasis on rela-
tionships in major theories of growth and development,
including psychoanalysis, attachment theory, and cog-
nitive approaches to psychotherapy. At the broadest
level, the interpersonal approach to psychiatry focuses
on the interplay between psychopathology and the in-
dividuals relationships with significant others. At its
center this perspective holds that relational structures
the more or l ess enduring patterns of interaction
either facilitate or impede the continued maturation of
the participants. It is important to note that the rela-
tionship between an individual and his or her relational
system is not linear; rather, individual characteristics
influence system properties, and these properties shape
individual characteristics.
Although this presentation focuses on marital relation-
ships and their impact on the participants, it is my belief
that what has been learned applies equally well to all cen-
tral adult relationships, including enduring heterosexual
and homosexual alliances, deep friendships, and other
dyadic relationships that form lifes crucial context. The
current status of the interpersonal perspective is illus-
trated with the use of selected data from three sources:
the Timberlawn studies of well-functioning marriages
and families, data supporting the idea of healing mar-
riages, and information regarding the role of marital fac-
tors in the onset and course of depressive syndromes. Be-
fore turning to these areas, however, I will describe a
small group of basic relationship concepts. These con-
cepts are derived from the literature (17) and my re-
search and clinical work with marital couples.
BASIC RELATIONSHIP CONCEPTS
1. Attachment. Each individual seeks a central relation-
ship in which to find security, satisfaction, and meaning.
Presented as the Benjamin Rush Award Lecture at the 150th annual
meeting of the American Psychiatric Association, San Diego, May 17
22, 1997. Received July 7, 1997; revision received Sept. 29, 1997;
accepted Oct. 17, 1997. From the Timberlawn Research Foundation.
Address reprint requests to Dr. Lewis, Timberlawn Research Foun-
dation, P.O. Box 270789, Dallas, TX 75227.
582 Am J Psychiatry 155:5, May 1998
2. Connection and separation. Each i ndi vi dual
brings to the central relationship a greater or lesser pro-
clivity for both connection (closeness, intimacy) and
separateness (independence, autonomy), the strengths
of which are determined by the complex interaction of
biological, developmental, psychodynamic, social, and
cultural variables.
3. Negotiation. The early stages of relationship forma-
tion involve a complex negotiation between the partners
of the balance of connection and separateness that is to
prevail in the relationship and that cannot be predicted
solely on the basis of each individuals characteristics.
4. Unconscious fears. Because for many individuals
unconscious fears of connection, separateness, or both
that arise from childhood experiences play an impor-
tant role in the negotiation, each individual attempts to
achieve a relationship balance that provides both maxi-
mum satisfaction and freedom from fear.
5. Power. In the negoti ati on of the rel ati onshi p
structure, including, centrally, the balance of connec-
tion and separateness, each individual attempts to influ-
ence the other to accept a balance congruent with his or
her proclivities and fears.
6. Maintenance of balance. Once established, the
bal ance i s mai ntai ned by day-to-day i nteracti ons
around issues such as space (actual and metaphorical),
affection, work, relationships with extended families,
parenting responsibilities, and other everyday issues.
These interactions become patterned and usually oper-
ate out of awareness.
7. Changes in the balance. Although the balance is
more or less enduring, changes may occur as a conse-
quence of normative challenges (e.g., parenthood) and
stress (e.g., loss of a child). Changes in the balance re-
sult from either relatively conflict-free negotiation or
crisis and conflict.
8. Health-facilitating balances. Although any balance
of connection and separateness may be relatively satisfac-
tory to both participants, certain balances facilitate the
continued and healthy development of the participants.
9. The optimal balance. Although contextual factors
(e.g., poverty, chronic illness) may limit that which is pos-
sible, health-facilitating systems are usually characterized
by high levels of both connection and separateness.
10. Values. A systems characteristic interactions re-
flect underlying shared beliefs about the nature of hu-
mankind (e.g., how dangerous it is to be close to others)
and other existential concerns (e.g., whether the world
is orderly or capricious). The systems characteristic in-
teractions also memorialize the underlying shared be-
liefs. Cultural factors often influence the values that
predominate in a marital or family system.
THE TIMBERLAWN STUDIES
For 30 years my colleagues and I have reported find-
ings from three different studies, two of which were
cross-sectional and descriptive and one of which was
longitudinal (814). Basing our work on the value judg-
ment that the cardinal tasks of the family are the facili-
tation of the continuing maturation of the spouses and
the provision of an emotional climate conducive to the
healthy development of the children, three groups, con-
sisting of 128 individuals, were studied. Two of the
groups, a middle-class Caucasian and a lower-income
African American, contained adolescent children. The
thi rd group invol ved young, predominately middle-
class couples expecting their first child at the start of the
study. Multiple observational and self-report measures
were used at the level of the individual, the couple, and
the family in all three study groups.
For the purposes of this presentation, the focus is on
the characteristics of the parents marital relationship
that facilitated healthy development of all family mem-
bers. Despite the absence of overt psychiatric distur-
bances in the participants, the groups contained many
couples and families who had overtly dysfunctional re-
lational structures. Reasonably healthy people can con-
struct very dysfunctional relationships.
First, it is clear that the marital relational structure
formed the template for the family system. Although on
the surface some coupl es may l ook ei ther better or
worse with the children present, independent ratings of
marital and family videotapes are highly correlated.
Another within-group difference concerns what can
be called style. Some competent couples have a charged,
passionate bond, and others present a more even and
bland exterior. For some, a vibrant sexuality is present,
while for others, the sexual relationship is more periph-
eral. Some competent couples share a strong emphasis
on career; for others, careers are valued not for them-
selves as much as for what marital and family benefits
they provide. Religion is another difference. For some,
neither beliefs nor practices are important, while for
others, religion provides an important foundation for
the marital relationship.
These and other differences are unrelated to the com-
petence of the marital relationship in facilitating the
maturation of the spouses and the healthy development
of the children. What, then, is common to couples who
so often seem very different in style? Characteristics of
well-functioning marriages include the following.
1. Power is shared. It is clear that in the basic process
of defining the relationship structure, including how
much of what types of connection and separateness are
to prevail, both partners have had significant influence.
Many couples come to a relatively equal sharing of
power after considerable trial and error in which each
tries to get his or her definition of the relationship ac-
cepted. The complex negotiations occur around everyday
issues such as money, sexuality, families of origin, and
the like, but imbedded in these everyday matters is the
more fundamental issue of how connected (in agreement)
and how separate (different) the spouses are to be.
2. There are high levels of both connection and sepa-
rateness. Competent marriages encourage both con-
necti on and separateness. The spouses are strongl y
committed to each other (no other relationship is as im-
portant), demonstrate high levels of closeness (sharing
JERRY M. LEWIS
Am J Psychiatry 155:5, May 1998 583
values and interests), and may communicate at the in-
timate level (the reciprocal sharing of vulnerabilities).
They also demonstrate high levels of separateness (firm
self-identities, autonomy, and the capacity for genera-
tive solitude).
3. Respect for subjective reality is prominent. The abil-
ity to accept and respect each others opinions and feel-
ings results, in part, from shared power. One is better
able to share openly and to both listen carefully and re-
spond respectfully to the experiences of an equal. Differ-
ences are not usually the source of power struggles and
conflict in well-functioning marriages; rather, they are
often valued. There is no preoccupation with the truth
unless such is called for by the context ( Our car is stalled
on the railroad tracks! Is the train coming? )
4. Affects are openly expressed. The unspoken rules
that govern who can express which feelings under what
circumstances are very liberal. Perhaps, again, in re-
sponse to the shared power and respect for subjective
reality, a wide range of feelings are freely expressed.
The mood of the relationship is affectionate and opti-
mistic under usual circumstances. Empathy is found
more frequently than it is in less competent couples.
5. Problem solving is highly developed. Once again,
equal power and respect for differences sets the stage for
effective problem solving. Competent couples explore
problems thoroughly, use outside experts and data when
such are needed, and show the ability both to negotiate
and to reach compromises. In laboratory problem-solv-
ing exercises these couples are not only effective in the
sense of reaching closure (unlike many less competent
couples) but are seen as clearly working together.
6. Conflict, although inevitable, is not chronic and
infrequently escalates. Chronic conflict often focuses on
a particular topic or topics, but it is frequently related
to the failure of the partners to agree on a basic defini-
tion of their relationship. In competent marriages the
basic definition of the relationship is acceptable to both
partners. When conflicts do occur they often involve
those situations in which one partner is not emotionally
available to the other. The couples usual mechanisms
of repair fail, and conflict ensues. In competent mar-
riages escalation (increased affective intensity) and gen-
eralization (broadening the scope of the initial conflict)
may occur, but at a lower frequency than in less com-
petent couples.
These six features of competent marriages can be un-
derstood as the foundation of a relational structure that
facilitates emotional maturation and healing. Both the
strength of the connection and the ability to repair it
after the inevitable periods of lack of synchrony, in
combination wi th the encouragement of autonomy,
play crucial health-inducing roles. To be healthy means
to be able both to connect and to stand alone.
HEALING MARRIAGES
Many years ago and before our studies of well-func-
tioning marriages and families had started, my atten-
tion was called to the possible healing impact of new
connections by spending a day with each of 35 former
intravenous drug users who had stopped using drugs
without formal treatment. My motivation for this pro-
ject was the question of how persons are able to emerge
from an addiction that is notoriously difficult to treat.
When asked how they had done so, most of the former
addicts talked about hitting bottom or used other
metaphors of despair. When asked, however, to de-
scribe what was going on in their lives before and dur-
ing the period of giving up intravenous drugs, each sub-
ject described a new and intense connection to either a
person or a bel i ef system (usual l y rel i gi ous). What
seemed important about their descriptions was the in-
tensity of the new connections.
As a result of this experience with these young men
and women, my interest in the ability of some adult
relationships to transform the lives of some individuals
increased. At this point involvement with research vol-
unteer couples and families revealed that, for some,
there was a history of chil dhood abuse, neglect, or
abandonmentmuch the same as is usually found in
clinical samplesbut in these spouses there was clear
evidence of competent marriages and healthy individual
functi oni ng. The i ntervi ew data suggested that the
marital relationship had been an experience of individ-
ual transformation, a healing process.
In couples therapy it was useful to understand marital
dysfunction as failed healing (15). It was usually possible
to identify a central problematic relationship of child-
hood that was either being vigorously defended against
or being reenacted in the marriage. The issue can be
framed as why some people repeat the pattern of the past
(why transference prevails or, in Ackermans evocative
words, why love is the language of scars ) (16, p. 79),
whereas others work through the internalized childhood
relationship and experience a healing process.
These experiences with research and clinical samples
led to a literature review and a growing list of studies
suggesting healing marriages. I describe below a few
representative studies.
Quinton et al. (17) reported on 94 women who had
been raised in institutions and a control group of 51
women who had been raised by their parents. The in-
stitution-raised girls had been given up by their parents
because of their behavioral difficulties. In young adult-
hood these women had a greater prevalence of both
poor psychological functioning and parenting difficul-
ties. About one-fourth of the institution-raised women
had good outcomes that were associated with entering
stable marriages with healthy, supportive men. The
authors noted that the women with stable marriages
and better outcomes did not have fewer or less serious
adolescent problems, and that the mechanisms underly-
ing healing marriages are unknown.
Women who were abused as children are more likely
to abuse their own children. An emotionally supportive
rel ati onshi p wi th a husband or boyfri end has been
shown to protect such women from abusing their chil-
dren (18, 19).
INTERPERSONAL RELATIONSHIPS
584 Am J Psychiatry 155:5, May 1998
Some of the delinquent boys studied by the Gluecks
in the 1940s turned out well in adult life (20). The two
processes that reversed the delinquent life trajectory
were a steady job with an employer who valued them
and a strong, stable marriage.
The Berkeley Guidance Study followed four genera-
tions of subjects. Caspi and Elder (21) described the in-
terplay of individual problems, marital dynamics, and
parenting skills in the generational production of psy-
chopathology. Women who had demonstrated prob-
lems with anger and inadequate behavioral controls as
children were likely to marry passive men and to mani-
fest continuing problems as adults. They were described
by thei r children as mean and ill-tempered. If such
women, however, married more assertive men, they did
not continue to manifest behavioral problems in adult-
hood and were not described negatively by their chil-
dren. Once again, the authors indicated that although
marriage can be a corrective experience, its mode of op-
eration is not known.
Paris and Braverman (22) presented qualitative data
about marriages that appear to interrupt the course of
borderline pathology in young women. Older, caretak-
ing spouses who provi de an accepting envi ronment
may reverse the course of mild to moderate borderline
pathology.
There is also evidence that women who describe inse-
cure attachments with their mothers during childhood
(a predictor of insecure attachments with their own in-
fants) may enter into secure attachments with their in-
fants if they have experienced a corrective attachment
experience in marriage or psychotherapy (23).
These and other studies demonstrating discontinuity
in development have been examined (24, 25), with the
concl usi on that correcti ve emotional experi ences
with spouses, teachers, and therapists provide the most
common mechanisms for healing. Thus, it is believed
that although we have evidence that adult relationships
transform lives, we know little about how such healing
rel ati onshi ps come about and what their dynamics
might be. At the descriptive level, it appears that some
such relationships may be brought about through the
mechanisms of emotional support and affirmation (em-
pathy, warmth, and genuineness) and others through
provi di ng a speci fi c rel ati onshi p i ngredi ent that i s
needed (asserti veness rather than passivity). At this
stage of our knowl edge, however, we do not know
whether the crucial factors are to be found in the per-
sonalities of the individuals or their partners, the struc-
ture of the transforming relationships, or both. Con-
temporary psychoanal yti c theory suggests that we
might well focus on higher-order internalization proc-
esses. Blatt and Behrends (26), for example, suggested
that growth resulting from psychoanalytic treatment
involves the same processes as normal development,
and they focused on the establishment of a strong affec-
tive bond and repair of its disruptions as the necessary
precursors of internalization in both situations.
A final comment about the dynamics of healing rela-
tionships: it seems likely that whatever the crucial dy-
namics turn out to be, they must be understood as pow-
erful enough to block the strong inclination to repeat
the ubiquitous presence of transference.
MARITAL RELATIONSHIPS AND DEPRESSION
Although Vaillant (27) has written that in the longi-
tudinal study of mens lives, a stable marriage is syn-
onymous with freedom from all serious individual psy-
chopathol ogy, here the focus wi l l be onl y on the
relationship of marriage and depression. This is because
there are more data that assist in a beginning clarifica-
tion of this complex interface.
From a clinical perspective, couples are seen when a
depressed spouse fails to respond to antidepressants
and individual psychotherapy, and the referring clini-
cian suspects that there is a connection between the re-
fractoriness to treatment and the patients marriage.
Several types of relational structures are commonly
seen. In my experience the most common is a dominant-
submissive marriage in which the depressed patient has
played the less powerful role. He or she (more usually,
she) compl ai ns about the spouses control l i ngness,
emotional inaccessibility, and lack of investment in the
marriage. The depressive symptoms can be understood
as attempts, usually unconscious, to change the rela-
tional structure. They may reflect one or several themes.
Depressive symptoms may be a plea for help, an at-
tempt to redress the power imbalance, or a vengeful ef-
fort to punish.
A second type of relational structure involves the very
distant marriage. Neither spouse is particularly domi-
nant; rather, each participated in the negotiation of a
relationship involving high separateness and little close-
ness and intimacy. Often, the onset of the depressed
spouses symptoms follows the loss of a relationship
with a child, parent, or friend that provided her (or him)
with closeness and intimacy. The unconscious messages
carried by the symptoms may also involve needs for
closeness, power, and vengeance.
A third marital relational structure often seen in the
marriages of depressed individuals is chronic conflict.
The couple has never been able to agree on a definition
of their relationship, and the depressive symptoms are
understood as another set of unconscious tactics in the
chronic struggle to define the relationship.
In all three types of marital relational structures, the
core conflict involves the struggle to define (or redefine)
the basi c structure of the marriage, particularly the
amount and quality of closeness and intimacy. It needs
to be emphasized, however, that these relational vari-
ables should not be considered the only factors involved
in the etiology of the depression. Frequently, there is
evidence for both family loading for depression and in-
dividual personality characteristics that predispose to
depression. There is also nothing about the three rela-
tional structures that is specific to depression. The same
patterns are found i n coupl es referred because one
spouse is resistant to treatment for alcohol abuse, pho-
JERRY M. LEWIS
Am J Psychiatry 155:5, May 1998 585
bic symptoms, or other individual syndromes. A brief
clinical vignette may give a better sense of some of the
issues involved at the interface of depressive syndromes
and relational structures.
Mr. A was a successful attorney, married, with three young
children. His chronic depression had not yielded to any anti-
depressant, and although he was capable of working, he was
plagued with severe insomnia and other vegetative symptoms.
His childhood had been filled with abuse and neglect. His
salvation was his intelligence, and the scholarships he won
allowed him to leave home and complete college and law
school.
There was a strong family loading for depression. From a
psychodynamic perspective, his psychopathology seemed to
be rel ated to i ntense and fri ghteni ng dependent stri vi ngs
associated with problems of trust. His underlying sadness was
thinly disguised by rage. Although many of his defenses were
obsessive-compulsive in nature, there was also manifest evi-
dence of more immature defenses in the form of denial, pro-
jection, and somatization.
His wife was a doctoral-level scientist. Although loving him
and their children, she was by nature a solitary, almost schiz-
oid woman. Their relationship was characterized by high lev-
els of separateness. They shared few interests, each had differ-
ent social networks, and psychological intimacy was entirely
absent.
In initial interviews Mr. A focused mostly on his depressive
symptoms, but then he came to talk more and more about his
marital dissatisfaction. He described accurately his wifes re-
moteness but was without awareness of his role in angrily
keeping her at some distance. Joint interviews quickly revealed
their characteristic interactional pattern, a ballet of avoidance
of closeness.
The central issues in treatment planning were understood
as the failure of his symptoms to respond to antidepressants
prescribed at numerous academic centers and the difficulties
anticipated in an individual psychotherapeutic approach (geo-
graphical distance, the need for frequent sessions, the likeli-
hood of suicidal crises, and his rigid and brittle defenses). Mr.
A and his wife were treated with couples therapy and seen
once a month (double- and triple-length sessions) for 3 years.
When told that her emotional remoteness was a part of the
problem and that she had to be part of the solution, Mrs. A
entered couples therapy with a helpful commitment, often
shoring up her husbands flagging motivation. She was par-
ticularly impressed by the audiotapes that they made for me
of discussion tasks, which revealed her difficulties in identify-
ing and responding helpfully to his affective messages.
Progress was slow, but as the couple became better able to
explore each others subjective reality, Mr. As symptoms
abated. He needed occasional individual sessions focusing on
the management of his anger, particularly as it emerged in
professional contexts. The couple continued to be seen at re-
duced frequency, and the focus remained on their attempts to
develop a stronger base of intimate communication skills.
When the focus is turned from clinical to research
observations, there is much that is congruent with the
cl i ni cal observati ons as previ ousl y outl i ned. I wi l l
briefly describe several representative studies. Although
most of these studies showed the adverse influence of
diminished marital quality on the course of depression,
several reported the buffering effect of a close, confid-
ing relationship on the onset of depression. Thus, some
studies showed that women or men at high risk for de-
pression are less apt to develop depression if they par-
ticipate in a supportive, confidential relationship (28,
29). In a similar vein, women who had lost their moth-
ers in childhood were less likely to show elevated levels
of state or trait depression if they received high levels of
affecti on from thei r husbands (30). Wei ssman (31)
documented a 25-fold increased risk of depression in
both men and women who reported unhappy mar-
riages, and Barnett and Gotlib (32) concluded on the
basis of their extensive review that marital distress is
both a consequence and an antecedent of depression.
A negative course of both depression and bipolar dis-
order has been associated with high marital expressed
emotion (hostile, critical comments by the spouse) (33,
34). Long-term marital conflict was found to be one of
a small group of variables associated with treatment-re-
fractory depression (35). A rare prospective study of
women wi th major depressi on demonstrated that
womens reports of high levels of spousal support or
high levels of marital conflict were the strongest pre-
treatment predictors, respectively, of positive or nega-
tive outcome of treatment (36).
Waring and colleagues (37) reported qualitative data
suggesting that it is the presence or absence of intimacy
in a marriage that is crucial in determining the severity
of depressive symptoms.
NARROWING THE FOCUS
After the review of representative studies that suggest
the i mpact of rel ati onal system characteri sti cs on
healthy individual development, the evidence for the
healing impact of some adult relationships, and the role
of marital factors in depressive syndromes, the question
about crucial relationship processes can be asked. I sug-
gest that a promising focus for future exploration is the
factors that lead to the establishment of strong affective
bonds and the clarification of the processes of repair
when such bonds are temporarily dissolved.
Affective Bonds, I ntimacy, and Empathy
In The Stone Diaries Carol Shields (38) writes that
our lives are our life stories, and we need important
others to listen to them ( Life is an endless recruitment
of witnesses ) (p. 36). Toni Morrison (39) has Sixto
explain in Beloved that he spends his weekend walking
to see the Thirty Mile Woman because she is a friend
of his mind, a person who helps him better understand
what he thinks. These modern novelists speak to the
importance of having someone who listens to our expe-
riences and helps us to sort them out. To be able to enter
into such a relationship usually requires the develop-
ment of an affective bond. The prerequisites include a
genuine and reciprocal liking for each other, mutual re-
spect, and a two-way valuing and affirmation.
It can be argued that intimacy, the reciprocal sharing
of vulnerabilities, is the hallmark of the strongest affec-
INTERPERSONAL RELATIONSHIPS
586 Am J Psychiatry 155:5, May 1998
tive bonds. Its presence in a relationship grows out of
repetitive conversations in which the following charac-
teristics are found. 1) One partner discloses an emotion-
ally charged experience with self, the other partner, or
an outsider. 2) The other partner reacts by listening
carefully and assisting in the exploration of the experi-
ence. He or she often responds empathically to the feel-
ings expressed and does not change the subject, direct
the conversation, impose meanings, give advice, or pass
judgment. Rather, he or she attempts to understand
and/or immerse himself or herself in the partners sub-
jecti ve real ity. 3) Such conversations often result in
greater sel f-expl orati on and self-understandi ng and
feelings of intense closeness. The participation of both
partners may lead to what Weingarten (40, 41) has
called the co-creation of meaning.
Most often, the experience being disclosed involves
feeli ngs of vulnerability. The speaker must take the
chance of being hurt by the listeners response. Thus,
some level of trust is essential, except in intimacy with
strangers with whom one anticipates no further contact
and, as a consequence, little likelihood of being hurt.
My understanding of an individuals empathic ability
and its biological, developmental, and social antece-
dents has been described in some detail in other publi-
cations (4244). The ability to accurately recognize and
respond to anothers feelings and, at times, to share
those feel i ngs i s understood as movement i nto the
others subjecti ve reality. Empathy, however, is not
without its dangers, since for some it provokes under-
lying fears of engulfment. Havens (45, 46) has taught
us that there is a language of empathy just as there is a
language of distance and objectivity. Indeed, he sug-
gests that in our choice of language we regulate the
metaphorical distance between us and others. Anderson
(47) has written of collaborative language and the im-
portance of the avoidance of premature conclusions.
During the last few decades, instructional techniques
from my semi nars wi th begi nni ng psychotherapi sts
have been i ncorporated into my work with couples
(15). As the brief clinical vignette indicates, my experi-
ences with beginning therapists and couples in therapy
suggest that most persons empathic abilities can be en-
hanced. In those instances (with couples) in which the
treatment fails, it is usually because of my inability to
intervene successfully in the intense blaming-projecting
process, a prerequisite for learning how to have inti-
mate conversations.
Even under the best of circumstances, partners often
fail to be empathic, and the conversation produces dis-
appointment, distance, and lack of synchrony. There
are no data that inform us about how often a spouse or
therapist needs to respond empathically for the rela-
tionship to be successful. In one study of normal moth-
ers, however, it was reported that a 30% empathic suc-
cess rate was usual (48). It would be interesting to know
whether a similar rate of empathic responding is asso-
ciated with competent marriages and successful psycho-
therapy. Regardless of what the needed frequency of
empathic responses may turn out to be, it is clear that
couples must deal with empathic failures, and that the
processes of repair are important in the establishment
of an intimate relationship.
Repair or Conflict
There are a number of factors that influence whether
repair or conflict follows an empathic failure. Although
the failure can best be understood as interactional (i.e.,
i nvol ving both participants), some factors are more
closely associated with one or the other participant. To
begin with, the nature of the disclosed experience itself
has an important influence on the outcome of the inter-
action. Experiences with and feelings about oneself or
an outsider are easier to respond to empathically than
are feelings about the listener. In the latter instance
there is an increased likelihood of a defensive, distanc-
ing response. In teaching beginning therapists and cou-
ples, it is important to begin the learning process with
feelings that are not directed at the listener. After the
participants have learned something of the pragmatics
of intimate conversations, we can then turn to feelings
they have about each other with a lesser likelihood of
failure.
Another factor involves the context in which the con-
versation occurs. More often than not, it is the partner
who wishes to share the experience who selects the time
and place. If inappropriate contexts are repetitively se-
lected, there often are unconscious factors at work. In
couples therapy an agreed-upon time and place charac-
terized by privacy and an absence of distractions, when
both partners are emotionally available to focus on the
task, is important.
Although the storyteller is often the initiator of the
interaction, the listener may take the first step by re-
sponding to or asking about the affective component of
the experience. How do you feel about that? is often
a response that signals the listeners availability to ex-
plore the storytellers experience at the level of feelings.
Thus, the failure of the interaction to move toward the
intimate conversational level is understood as a shared
failure.
The clarity with which the experience is related also
is an important factor in determining the outcome. In
enduring relationships partners may come to know that
one or both introduce painful experiences indirectly
and with much tentativeness and, as a result, they do
not seize the initial story as necessarily the one that
needs exploration. The real story is often the result
of the interaction itself; it evolves out of the conversa-
tion rather than existing in final form before the con-
versation begins.
Another factor involves how readily available the sto-
rytellers feelings of vulnerability may be. Often, the
hurt or fear is hidden behind anger. Some individuals
appear relatively fixated at the angry level, while others
are much more in touch with the underlying hurt or
fear. The responses of the listener may be crucial; denial
(of the hurt or fear) often requires the assistance of a
compliant other. In work with couples it is often neces-
JERRY M. LEWIS
Am J Psychiatry 155:5, May 1998 587
sary to take the l ead i n earl y sessi ons i n hel pi ng the
storyteller move to the level of vulnerability. Indeed,
this approach is the major intervention used in the at-
tempt to moderate conflict between the partners and to
stop the blaming-projecting process.
Most of the experiences we wish to share involve re-
lationships with self, partner, or an outsider. In some
couples there is the gradual recognition of central pain-
ful rel ati onshi p patterns. Such central rel ati onshi p
themes have been the focus of empirical research into
essenti al processes of psychotherapy and, more re-
cently, with nonclinical populations (49, 50). It appears
that there may be a finite number of such themes, per-
haps a dozen or so. In couples therapy it is often useful
to help each partner become aware of his or her central
relationship pattern and that of the other partner.
There is a tendency for the processes of either repair
or conflict to become patterned. Couples who seek ther-
apy often present with a pattern of conflict that can be
understood as emanating from failed efforts both to
connect with each other and to repair the disconnec-
tions. Generalization and escalation of the conflict are
common. Such couples need to learn conflict manage-
ment mechanisms, including techniques to prevent es-
calation. These can be taught in the marital therapists
office and may generalize to the real world. When they
do not, and couples continue to live a life of conflict, it
is safe to assume that one or, usually, both spouses may
have underlying fears of closeness and intimacy, and
explorations of this possibility are required. If this part
of couples therapy does not succeed, individual therapy
may be in order.
In recent years the importance of the establishment of
a strong affective bond and the successful repair of its
inevitable breakdowns has received empirical support
from studies of marital interactions in which physi-
ologic markers have been used as outcome measures
(5154). The studies focus on two relationship proc-
esses, confiding and conflict, that are closely related to
the establishment of a strong affective bond (confiding)
and the failure to repair its disruption (conflict). Taken
as a whole, confiding and conflict have opposite effects
on physical well-being. Confiding has positive effects
on both hemodynamic and cellular immune function-
ing, whereas conflict has a negative impact on both.
CONCLUSIONS
Cl i ni cal observati ons and empiri cal research that
support the role of interpersonal relationships in nor-
mal development, in healing relationships, and in the
course of individual psychopathology have been briefly
described. The focus of this presentation has been on
those aspects of interpersonal relationships that can be
observed directly, that is, on the interactional rather
than the transferential. It seems increasingly clear that
relationships can be altered by changing the way people
talk to each other. It is possible to teach some couples
i nti mate communi cati on, wi th i ts emphasi s on em-
pathic processes and exploratory skills and the proc-
esses of repair of the all-too-frequent disconnections
that are a part of life with important others. Indeed, a
promising hypothesis for the development of a superor-
dinate science of interpersonal relationships might well
focus on the evidence that the repair of disrupted bonds
is a common thread in successful infant-mother interac-
tions, healthy marriages, and effective psychotherapy.
Finally, the data presented in this article point to the
need for a greater emphasis on relationship in our sys-
tem of diagnostic classification.
In closing, here is the way in which the depressed at-
torney and his scientist wife ended our last session. He
said that they did not wish to schedule any further regu-
lar appointments but preferred to move to an as-needed
format. Im feeling so much better, he said, and our
relationship is so different. Yes, his wife added,
were more connected and each of us is less alone.
You may not need a therapist so much, he concluded,
if you talk with each other sometimes like you do in
therapykind of explore things. You become, well,
sort of each others therapist.
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