Clinical Social Work Journal Vol. 18, No. 2, Summer 1990

COUPLES THERAPY: INTEGRATING THE PSYCHOANALYTIC AND SYSTEMS VIEWPOINTS Paula Belsey, M.S.S.W.

ABSTRACT: This paper will discuss the treatment of couples based on an integration of analytic and systemic ways of regarding the couple in conflict. The author uses a combination of empathy and coaching of each partner, both oriented to validating each partner's integrity, and helping each to reflect on his or her own part in continuing the struggle. The goal of such treatment is to help them represent themselves by taking responsibility for themselves in differing from each other, in ways that respect themselves and each other. The premise is that partners in a struggling relationship have issues within their individual functioning that are continuing to defy their expressed intention of having a satisfying relationship. Their individual issues have contributed to their selection of each other as mates and, together, they have developed the ways of relating that are so problematical. We understand that the conflict and its effect within the couples' system is sufficiently meaningful to each partner to necessitate and justify the repetitive behavior.

In approaching an understanding of the psychodynamics of each partner's structure, this author has been aware of the congruence between concepts of Murray Bowen, a guiding figure in family therapy, and those of psychoanalytic writers, in particular, Meissner (1978), Nadelson (1978), and Kohut (1971, 1977). Bowen (1966) speaks of the degree to which individuals are "differentiated" from their families of origin, and describes couples as selecting each other at corresponding levels of differentiation from the "family ego mass" (p. 355). With his focus on c o n s t r u c t i o n of a t h e o r y of f a m i l y t h e r a p y , B o w e n d e v i s e d a

Special acknowledgement and appreciation is given to Joseph Palombo, MA, and Roberta Apfel, MD, for their critical review and constructive comments which helped develop this manuscript. 167

9 1990 Human Sciences Press

168

CLINICAL SOCIAL W O R K J O U R N A L

"differentiation of self scale" from 0 to 100, in an attempt to conceptualize all human functioning on the same continuum (p. 366). He referred to the lowest part of the scale in which "so much of life energy goes into maintaining the relationship system about t h e m , . , that there is no life energy for anything else." The highest part of the scale is for "principleoriented, goal-directed people who have many of the qualities that are called 'inner directed'." The present writer has used as a "rule of thumb" Bowen's implied notion that couples, in selecting each other, find a mate at a corresponding level of the scale. This is illustrated when we see couples in which one partner can apparently function so well, while the other is a symptom-bearer. We can understand that these partners have needs of each other, some of which reflect a particular set of pre-oedipal attachment problems. In self-object terms, this can also be described as their having self-object needs of a corresponding nature. For example, they can use avoidance defenses such as denial and projection in their ways of regarding each other, so that the well-functioning partner needs to cling to, and simultaneously look down upon, the symptomatic one, in denying his/her own capacity for equivalent contempt, despair, fear and other such feeling and thought issues. The symptomatic partner may consider him-/herself incapable of corresponding competence, and admire it, while also having, for example, contempt for, and shame of, the partner. In Bowen's terms the apparent functional-disfunctional balance can be seen as two sides of a triangle, with a third needed to provide stability. Referring to the concept of triangles, Bowen (478, 479) states "A triangle in a state of calm consists of a comfortable twosome and an outsider. As tension mounts in a two-person system, it is usual for one (partner) to be more uncomfortable than the other, and for the uncomfortable one to "triangle in" a third p e r s o n . . . when the triangle is in a state of tension, the outside position is the preferred position, in a posture that says 'You two fight and leave me out of it'." The Bowen concept of corresponding levels of differentiation from family of origin, can be particularly useful in understanding the avoided issues that the couple Can experience as being non-negotiable in ordinary circumstances. This author has found that the concept holds equally for any couples who choose each other, regardless of their legal status or gender. Bowen's concepts fit well with psychoanalytic authors such as William Meissner (1978). In "The Conceptualization of Marriage and Family Dynamics from a Psychoanalytic Perspective," he elaborates the way in which the individual's unconscious needs and conflicts, as well as ego functioning, worked together in his or her making life choices of whom, and how to love in a committed context. "The successful negotiation of separation and individuation leads to a progressively more differenti-

169

PAULA BELSEY

ated and integrated sense of self. Where the individuation remains fragile and susceptible to regressive pulls, the new relationship will involve residues of old attachments . . . . In some marriages, neither partner gives in and the result is a constantly conflictual relationship. The susceptibility they feel to the unexpressed feelings in each other prevents true sharing of feeling. The greater the lack of differentiation of the partners, the greater tendency to react to each other with hurt and despair" (pp. 32, 48). This author uses the above concepts, together with the understanding that the couple can be seen as a systemic entity in which behavior by one partner directly influences, as well as results from, the actions and expressions of the mate. Some authors have described this in terms of a ready made transference relationship between the partners. Nadelson (1978) describes psychoanalytically-oriented couple's treatment, in which she works with the partners' feelings toward each other, and toward her. With the development of self-psychology, and Kohut's exposition of self-object needs, and empathic therapy, there have been efforts to use these understandings in dealing with marital conflict. In a presentation before the Illinois Society for Clinical Social Work in 1975 (printed in 1980), Celia F. Rice stated, " . . . such narcissistic transference relations ~ p s . . , characterize many disturbed marriages; whereas the diagnostic signs of a narcissistic disorder in an individual patient emerge only gradually in his transference to his therapist, they are much more apparent in couples who present themselves with ready-made narcissistic transferences to each other (pp. 264, 266, 268). She describes a case in which the wife had "lost faith in her husband" and he "had lost faith in his own dreams." In a couple which she describes as "more primitive," s h ~ made an initial interpretation that "they both needed each other to live, but were afraid to trust each other with their survival." More recently, the Clinical Social Work Journal (1985) contained Marian Solomon's article, "Treatment of Narcissistic and Borderline Disorders in Marital Therapy: Suggestions Toward an Enhanced Therapeutic Approach." Solomon quotes Kohut's (1978) "I have no hesitation in claiming that there is no mature love in which the love object is not also a self object, or, to put this depth psychological formulation into a psychosocial context, there is no love relationship without mutual self esteem enhancing, mirroring, and idealization" (p. 141). Solomon's article deals with complementary patterns of pathology that characterize "narcissistic" or "borderline disorders," This author works to evaluate partners in terms of their thoughts and feeling states rather than in terms of diagnostic categories, finding that therapeutic empathy is appropriate in a wide range of diagnostic considerations. The use of psychodynamic evaluation combined with

170

CLINICAL SOCIAL WORK J O U R N A L

systems concepts allows the therapist in working with a given couple, to choose which problems to approach, and which to leave untouched at a given moment in the process of therapy. The therapist needs to be aware of his or her own counter-transference feelings and reactions, in relation to each of the partners. It is particularly helpful to be even-handed in dealing with the partners and to avoid implying that "sickness" in one is the reason for the couples' difficulty. Symptomatic partners, being whole people, influence and are reciprocally influenced by the partner's behavior and attitude to them. It is therefore particularly significant to reframe issues in terms of normalizing the nature of the symptomatic partner as being a full participant in the couple's problems. Needless to say, a symptomatic partner may, after the couples' therapy, want to consider individual treatment, but the therapy must be even-handed enough to avoid seeing the pathology as being almost a participant of its own in the relationship, instead of the pathology being a part of one of the partners. Systems concepts are particularly useful in cases where the divisive issues center around the involvement of one or more other family members. These m a y be in-laws, children, or even an intensely involved family friend. We can understand that this involvement is needed by the partner or partners to deal with issues that are non-negotiable between them at this time. As clinicians, we are likely to be familiar with cases in which an extra-marital romance expresses for the partner a self- and other experience that is not part of the existing relationship. For example, there can be a self-picture of being an engaging, romantic figure, while avoiding the fact of needing another attachment in fulfilling the dependency and status needs. (Again, discussion of "extra-marital," relates as well to homosexual partnerships.) It is our task in some such situations, where our help is sought to understand what, within the individual psychodynamics and the nature of the couples' system, necessitates the maintenance of this split. I want to discuss a five-session marital treatment in which the partners were relatively well functioning individuals with essentially neurotic character structures, who responded well to my empathy with each of them, and to systems oriented interpretation and teaching. Steve and Jill, in their late 20s, were parents of two children under three. When they sought therapy, Jill was very angry with Steve for his always siding with his mother, who was critical of her. They arrived in my office following a Christmas when Steve's mother, having changed the hour of Christmas dinner on short notice, had openly criticized Jill for being inflexible about coming with the children to the family festivities. Exploration revealed that Steve, an auto salesman, was the oldest of three sons, and that his father had died during the previous year after a three-month illness. Steve, a former college basketball player, had grown up knowing that his mother, with her temper, had to be

171 PAULA BELSEY

"humored." Jill, a nurse, was working part-time in her nursing profession, and was angry with Steve for not defending her against his mother's attacks. These issues had surfaced at Thanksgiving and at Christmas when Steve's brothers and their wives made changes in the days and times they could assemble at Steve's mother's house to celebrate the holiday. Steve's mother had expressed criticism of Jill's wanting the children to be rested and fed before the three-hour drive to the gatherings. Jill felt it was unfair of her mother-in-law to change the schedule on short notice, and to expect them all to arrive in a festive mood. She had told Steve at Christmas that her parents were being overlooked, and that this was the last Christmas she would go to his mother's house, if he didn't take her part and defend her in response to his mother's demands and criticisms. She was bitterly resentful, too, at how much time Steve also spent on the phone with his mother in the evenings. Jill berated him angrily and, in the first session, cried, ashamed of her "temper." A brief history revealed that, as the eldest daughter, she had had much responsibility for her younger siblings and was the target of criticism by her mother, who accused her of irresponsibility for not taking seriously these tasks. My initial assessment was that Steve and Jill each wanted to do well in the marriage, and had tender feelings for each other. I hypothesized that they each had internalized conflicts, with Steve being self reproachful at net pleasing Jill, but acted out his negative feelings toward her by justifying and acceding to his mother's attacks on Jill. I hypothesized that Jill was, in attacking, placing herself in a position that justified Steve's behavior in his own mind, and was eroding her own chance of getting the support she said she wanted. I responded to how she felt let down by Steve, and her own being flooded with feelings of anger and guilt. I thought it could be helpful to Jill to set a limit on her angry outbursts, and to help her use her cognitive ability to think about what she wanted from Steve, and her impact on him. in making this decision, I was aware that Jill had some depressive aspects, and that I would watch how the couple's treatment progressed in deciding, in this short-term treatment, how much to focus on her anger. I believed that Steve could benefit from being able to express his feelings in this situation and for both of them to be able to see their part in the system to which they were contributing: Steve's involvement with his mother resulting in escalation of Jill's attacks, and Jill's attacks sending Steve back to his mother. I asked Steve if he felt pulled between his mother and wife, and as if he coutdn,t make the choice Jill was asking. He acknowledged this, and I asked Jill what she thought about the spot Steve was in. She didn't have much sympathy for him; he had none for her. I wondered if she wanted to punish Steve in berating him and wondered, too, if this left her out on a limb. A flood of tears accompanied her acknowledgement. Jill angrily said that she was set up to fail, that Steve couldn't see how she needed his attention and participation. Though compassionate with Jill's predicament, I was aware of my own irritation with the chronically self-defeating behavior, and was pleased that she used the opportunity to enunciate what she was needing, albeit angrily. Steve said he hadn't been aware that Jill was feeling so unsupported. He hadn't meant it to be that way. I asked Steve if it made him feel like a good son and good person to be attentive to his mother. He acknowledged this, and said she needs "a lot of help, can't figure out her taxes and always needs advice about her car." We learned together that his mother is openly attacking if she doesn't get her way. Steve's father had always yielded to her. Steve saw himself as dealing with her in the same way. I wondered if Steve felt, in some ways, that his conciliatory manner was superior to his mother's

172 CLINICAL SOCIAL WORK, JOURNAL

open anger and neediness. He acknowledged this, and I commented that he might then feel the same way about Jill's anger and resent her emotionality. He responded with some relief, and an element of embarrassment. In the second session, Jill talked about her mother-in-law's arbitrariness and her controlling, demanding behavior. Steve agreed, and they talked about how terrible Steve's father's illness had been during his last week of hospitalization. When it was apparent he was going to die, Stove's mother didn't want anyone to talk to Father about his approaching death. She stayed by his bedside, monitoring the children's visits with him. Jill cried and said it had been really difficult for her: Steve's father had been such a good man and she had wanted to tell him how much she cared about him and to say "good-bye." Steve said this was true for him, and they both talked about his father and cried together about his death, expressing anger and frustration about the surrounding circumstances. They were visibly sad, and I observed to myself how much Jill fulfilled for Steve the self-object function of expressing some of his anger toward his mother; in her angry deprecation of her mother-in-law's demands, she remained distant from Steve and his conflict and provided for him a displaced target. In the three sessions that followed, I asked Steve to consider whether his mother could get answers to her questions elsewhere, and we talked about how he might feel guilty for looking down on his mother and therefore compelled himself to provide her with answers. He said he never thought about that, and he guessed that was something he was doing. This was consistent with Bowen's concept in the sense that, instead of Steve's effort to please his mother and keep Jill as the "outsider," the work was directed to bringing greater satisfaction in the couple relationship, leaving Steve's mother more in the "outsider" position. Clearly, it will require on-going efforts by each partner to bring about some change. I asked how he would feel about setting limits with his mother, and Jill commented on how Steve was able to do that with the children. She said t h a t Steve was a very good father and Steve later recounted an incident in which he had said "no" to his mother. Jill was visibly pleased, and I asked her if Steve had known at the time that she was pleased. They agreed that that was something Jill didn't do spontaneously, and I asked her to let Steve know when she was pleased with something he had done. Steve was visibly pleased, and I asked him how accustomed he was to expressing appreciation of Jill. This wasn't something they were accustomed to doing with each other. In the fourth session, Jill poured out how unwelcome she had felt in Steve's family. She had become pregnant while they were dating, and Steve felt they should get married. Jill hadn't wanted him to give up the possibility of a career in basketball, but Steve had been insistent. He had brought Jill to meet his parents, and to tell them of their plans to marry. Jill said that Steve's father was cordial, even warm, but his mother wouldn't commit herself. She stayed aloof, and Jill felt her disapproval. She felt it would never be possible to please her mother-in-law. How right she had been, she cried. I asked Steve if he could feel how unwelcome Jill had felt, and how the subsequent developments had appeared to confirm her fear. Steve said he hadn't had a similar feeling in his life, but said he felt bad that he hadn't been sensitive to Jill's feeling in the time before their marriage. For him, it had meant giving up the hope of a career in basketball. He said that, thinking about it, he really wasn't skilled enough. He spoke of the competitiveness of the field, and how he could never have made a living at the game. I asked him what the team was like for him, wondering if he had felt supported, and like a good guy. It had been a great feeling, he said, to play well and feel he was doing well. I contrasted this to how criticized he was feeling, in the conflict with Jill and how

173 PAULA BELSEY

much he had felt himself to be at a loss. We talked about the good feeling provided by the team support, and how that was something he missed, and that he and Jill could do for each other. Jill talked of how her parents were closer together now than when the children were growing up. She cried as she said she never really learned how to value Steve as a husband and that, with the pulls of working part-time and caring for the family, as well as Steve's working late some evenings, they took little time for themselves together as a couple. In the last session, we talked about their need to nurture the relationship between them, that it needed to be a conscious effort, in the way they were able to nurture the children. We used the metaphor of Steve's team, to talk about the kind of work it took to learn to work together, and to communicate with each other about their ideas and respective "moves." Both acknowledged their wish to do well as marital partners and as parents, and each spoke of how lost they felt when they were concerned that the marriage wasn't doing well. We spoke of how they each could reproach themselves, and that they had some of those ways of making themselves do things, but that being critical of each other was not a way in which they could enhance their relationship, but would continue to drive them looking outside of their relationship for support and endorsement. This was a couple in which a short-term focus was most appropriate for financial reasons, (they were on a pre-paid medical care program, with five sessions authorized). These people, being young, and having essentially stable personalities, were able to benefit from an airing of some of their pain, and to build a greater closeness, based on understanding the impact of their behavior on each other. Their capacity to express sadness together seemed to imply a relatively good prognosis for them. I have used this illustration for the purpose of showing how the work can be on an empathic and compassionate level, and at the same time, be directed toward coaching and teaching in a nonjudgemental way. Interventions were directed to what, in the self experience, was focal in the conflict and was accessible to awareness. With couples who have been married longer, and particularly those with symptomatic children, I have found t h a t the partners' antagonisms to each other need a considerably longer period of work together in the realms of anger and distrust. It would be interesting to see some discussion of these issues in the clinical literature. Within the family therapy literature, several authors have focused on integrating psychoanalytic and systems concepts. Friedman and Peggy Papp involve the partners in dramatizations and other portrayals of each partner's fears and fantasies, in efforts to promote selfreflection in the partners. Feldman (1979) used partners' dream material, and teaches couples about their fears of intimacy. As recently as the J a n u a r y , 1989 issue of the "Journal of Marital and Family Therapy," there is a series of articles discussing the limitations of using directive strategies, with Samuel Slipp (1989), discussing the need for partners to have insight into their motives, in order to m a i n t a i n and build on strategically gained stances.

174

CLINICAL SOCIAL WORK JOURNAL

There is room for more dialogue on the use of systems concepts to complement existing methods of work with couples. For this author, the focus on a role that combines empathy and teaching, has been particularly suitable to many couples' treatment situations.

REFERENCES Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry, 7, #5, 355. Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson, New York. Feldman, L. B. (1979). Marital conflict & marital intimacy: An integrative psychodynamic-behavioral systemic model. Family Process, 18 (1), 69-79. Friedman, L. J. (1980). Integrating psychoanalytic object-relations understanding with family intervention in couples therapy. Family therapy combining psychodynamic and family systems approaches, Pearce and Friedman, editors. New York: Grune & Stratton. pp. 63-79. Kohut, H. (1977). Restoration of the self. New York: International Universities Press. Meissner, W. (1978). The conceptualization of marriage and family dynamics from a psychoanalytic perspective. Marriage and marital therapy, Bruner-Mazel, New York, pp. 32-38. Nadelson, C. (1978). Marital therapy from a psychoanalytic perspective. Op~ Cit. N.Y. 89-165. Rice, C. F. (1975). Marital treatment with narcissistic character disorders. Psychotherapy and training in clinical social work. Gardner Press, N.Y., (1980) 264, 266, 268. Slipp, S. A differing viewpoint for integrating psychodynamic & system approaches. Journal of Marital & Family Therapy, 15 (1), 13-16. Sotom~n, M. F. (1985). Treatment of narcissistic and borderline disorders in malital therapy: Snggestions toward an enhanced therapeutic approach. Clinical Social Work Journal, 13(2), 141-156.

P a u l a Belsey 030 S W R i d g e Drive P o r t l a n d OR 97219