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In This Chapter:
Systems
Five Models of Marital Therapy
Group Therapy
Chapter 15: Beyond the Individual: Systems Couples and Groups
The Impact of the Family Therapy Movement
Because traditional therapies have had such a heavy individual bias, it seems right to pay specific attention to family therapy and systems theory. These more recent additions to our understanding gained respect during the sixties, and were more "movements" than systems of therapy. By this time, however, the wisdom they have gathered has crept into the way individual therapy is practiced, as well as opening the way to group, couple and family work as alternative approaches. What follow are a few of the most practically useful ideas derived from this rich tradition.
Systems Theory: Homeostasis
Systems theory says that systems resist change. This is tremendously useful in understanding how the family may unwittingly sabotage your patient's efforts to grow. It is not from malevolence, but can be seen simply as a manifestation of how families work. Another consequence is that families and groups, even "open" ones tend to put up some resistance to arrivals and departures.
Fluid Boundaries and Roles
The study of systems shows that groups need specific members to fulfill certain roles, but the assignment can easily shift to another individual. The system may depend on one member to be the "scapegoat," but if that member leaves the group, then another will be assigned to the role. This is not unlike dogs, where the role of the alpha male can be passed on. Of course, the system's need for a member to fulfill a role may work against the goals of that member's individual therapy. It is very helpful to include this in your analysis of the energy dynamics of the therapy.
Open and Closed Systems
Cults represent the extreme of closed systems, rigid, require extreme sacrifice to join and hard to leave, controlling and destructive. Understanding these characteristics helps in making sense of lesser variations like families and couples where one member is excessively controlling. The system takes care of a needs for closeness and identity, but undermines individual autonomy, and is often the product of a narcissistic or insecure person's unhealthy externalized coping. Open systems have room for individual differences, coming and going, and new ideas. They generally strengthen and enhance personal autonomy.
Marital Therapy
Couples most often make their own decision to seek treatment. You may also feel that there are issues that can be helped with one of the approaches outlined below. At the extreme, divorce is an enormously costly "remedy," so much so that I like to compare it with amputation, something you would not think of doing unless it were clearly necessary.
Five Models for Marital Therapy
Over the years each of these models has had some popularity. Each offers useful insights and can be brought into the couple therapy when it is helpful. In recent years, Harville Hendrix has popularized "Imago" therapy, based on the concept of transference. Just as transference problems are the most common and powerful causes for the failure of therapies, they are also the greatest source of marital discord.
Communication: [ Buzzwords: "Hidden agenda," "mixed messages" ]The problem is seen as one of "mixed messages" being poorly communicated, and the treatment is to help the couple say directly what they "really want" from each other.
Negotiation: [ Buzzwords: "Contract," "needs" ]This model focuses on marriage as an arrangement, a sort of contract between two people. The treatment seeks to help the couple re-negotiate in a more effective way so as to meet their needs more effectively. A good contract is one that gives each member more than they would have without it, and is seen by both as "fair."
Boundaries: [ Buzzwords: "'I' statements" "I need some space" "enmeshment" ] Mutual respect for boundaries dictates ways of communicating. See ground rules for interaction in the last section of this chapter.
Systems Theory : [ Buzzwords: "Homeostasis," "Open; closed" "dynamic equilibrium" ] This model sees the couple as a system whose aim is to maintain the status quo, if necessary using triangular relationships, such as with a dysfunctional child.
Transference : [ Buzzword: "Imago" ]Marital trouble is seen as a product of distortions of each other based on early experience with parental figures which interfere with healthy marriage. After a "honeymoon" period, couples' "imagos" begin to distort their perceptions of each other and cause intense, repetitive conflicts. Just as with transference in individual therapy, the key to understanding and resolving these conflicts is to focus on each person's imagined perception of the other's underlying motivation.
Basic Requirements for Marital Therapy
Approximately Equal Health: When one member of a couple exhibits significantly greater pathology, marital therapy may amount to individual therapy with a witness and this can be painful. Usually individual therapy is a better approach.
No Affairs or Addictions: The presence of a triangular relationship means that whatever tension generated in the couple sessions will be relieved through the outside relationship, whether it is with a person or a substance. Couple therapy will not work. Individual meetings at the beginning of treatment will provide a place where you can ask about outside relationships. Also, if treatment is not working and the reason is not clear, consideration should be given to the possibility of a secret affair or addiction.
Therapist Seen as Neutral: If for some reason, one member of the couple does not see the therapist as a neutral party, then problems of trust will emerge and will be difficult to overcome. A deep therapeutic relationship with one member of the couple usually makes such neutrality impossible. This is a time to refer out.
Some Major Resistances Encountered
The "Riteous" Model: As long as "how it is supposed to be" is the standard for behavior within the marriage, the couple will remain stuck. The spouse who is chronically "wrong" would have reformed long ago if there weren't a good reason for the his or her behavior, but the "right way" doesn't leave room for a real explanation, only excuses. In our culture, a functional marriage is a freeform contract between two people that is acceptable as long as it gives back to each at least as much as he or she puts in.
The "I Can't Leave" resistance: One or both spouse's value systems demand that they stay in the marriage no matter what. When duty overrides happiness, it becomes essentially impossible to work out a relationship that is fulfilling to both parties. Resentment becomes intractable. For growth to take place in a marriage, both parties must feel that being together is a choice. If not, one or both parties fall into a victim role. "What can I say, I have no choice but to go along with what he wants."
Projective Identification : Both parties participate in a process by which one partner's unacceptable personality traits are projected on to the other, and the recipient accepts the role. This leads to the projector taking a smug, self-righteous position. "As soon as she gets over her timidity, then we can think about enjoying life together."
Spouse as Parent: Sometimes one partner, usually the man begins to realize the level of his early deprivation, and begins to wish for someone to make up for the shortfall. It is important to remember that healthy people do not want a child for a spouse, as much as the other partner may want and need it. The solution is for the one who wishes for the parenting to take the quest to healthy places (i.e. individual therapy) and to grieve for the part that cannot be fulfilled.
Triangulation: Family therapists supply us with this concept in which a third party becomes the focus of discussion as a means for the couple to avoid grappling with their own tensions..
Couple Sessions in Individual Therapy
Sometimes you may consider having a joint session. The advantage is that you may gain a chance to form an independent sense of the spouse and find out things you did not know before. The disadvantage is that your going outside the patient for information is somewhat undermining to the vital communication link you have established with the patient. Weighing these two considerations will generally tell whether a joint session will be positive. There are two situations where the need for objective information usually wins: Substance abuse and bipolar disorders. In both conditions, the patient's objectivity is so often flawed that at least one session in the presence of the spouse is usually helpful.
Group Therapy
The subject of group and family therapy is beyond the scope of this course, but it is worth pointing out that group has a special ability to bring out transference and neutralize defenses. Transference and countertransference may coincide in such a way that infantile needs and wishes remain hidden. Group interaction is so complex, and group members bring so many different sets of "blind spots," that the chances of having communal blindness are considerably reduced. Also, peers may be better at confrontation, since it is not so easy to dismiss the wisdom of multiple voices. This is the primary reason why group is often the preferred modality for substance abuse treatment.