Conjoint Marital Therapy A
Cognitive Robert
Behavioral Model
Taylor Segraves, MD,
PhD
\s=b\ This article presents an integrated cognitive-behavioral model for conjoint therapy of chronic marital discord. The model is based on eight empirically testable hypotheses that are clinically relevant and integrate contributions from general systems theory, behavioral marital therapy, and psychoanalysis.
Disproof of cognitive schemas for the perception of the opposite (transference reactions) is hypothesized to be a common therapeutic mechanism in the dissimilar models of marital therapy. (Arch Gen Psychiatry 35:450-455, 1978)
wealth of evidence indicates the existence of important between marriage and psychiatric difficulties and the need for eclectic psychiatrists to gain skills in the field of marital therapy. An association between single and divorced marital status, psychological maladjustment, and psychiatric morbidity has been noted.1 Ovenstone2 and Kreitman et al3 reported evidence suggesting the role of marital interaction in eliciting individual neurotic behavior. The degree to which marital discord and separation are judged to be major life stresses,4 the frequency with which marital discord is the precipi¬ tating complaint given by people for seeking mental health services,5 the clinical observations from family therapists on the impact of marital conflict on the psychosocial development of the children involved," and the increasing divorce rate in the United States7 all suggest marital therapy to be an important psychiatric intervention. In spite of this, the field of marriage and marital therapy has been relatively neglected by psychiatrists and psychiatric training programs." Various factors have been suggested as responsible for the neglect of this area." However, it is my belief that the absence of a coherent conceptual framework has been the most significant obstacle to clinicians interested in the field.
The absence of a coherent theory of marital therapy has been noted by others.10·" The field could perhaps best be described as consisting of many partial theories that focus either on individual psychopathology or on the properties of marital interaction systems. The degree of overlap that may exist between the partial theories is obscured by the absence of a common terminology, and there have been few attempts to link individual psychopathology with interaction difficulties. The empirically oriented clinician will note the lack of evidence to support the assumptions of many marital therapists12 and the frequent use of assumptions incapable of empirical testing. The purpose of this article is to evolve a theoretical framework for brief conjoint marital therapy that is both clinically relevant and capable of empirical testing. An attempt will be made to link individual psychopathology with interactional difficulties and to translate the contri¬ butions of psychoanalytically oriented therapists and behaviorally oriented therapists into a common terminol¬ ogy by employing concepts from cognitive social psychol¬ ogy. This undertaking will be attempted by first reviewing some of the major contributions from the partial theories, pointing out possible links between these theories, and then incorporating these contributions into a new model.
A relationshipssuggests .
Accepted
From the Clinics.
publication June 16, 1977. Department of Psychiatry, University of Chicago Hospitals and for
Reprint requests to Department of Psychiatry, University of Chicago, 950 E 59th St, Chicago, IL 60637 (Dr Segraves).
sex
LITERATURE REVIEW The reader is referred elsewhere for comprehensive reviews of the marital therapy literature.91113 For this selective review, treatment orientations will be separated
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into four groups: psychodynamic, general systems theory, communication training, and behavioral therapy. Psychoanalytic theory developed from an individual psychology. Thus, much of the work by psychodynamically oriented therapists has stressed the role of individual unconscious intrapsychic conflicts in the genesis and main¬ tenance of marital problems.1415 Much of this work has stressed the treatment of individual psychopathology. A literature has developed on the effects of variations from the traditional one-to-one psychoanalytic treatment for¬ mat on the development of "transference" to the thera¬ pist.1617 Implicit in many of these discussions is the assumption that resolution of the "transference neurosis" is one of the major curative mechanisms in individual analytically oriented psychotherapy and thus of marital conflict. The terms "transference" and "transference neurosis" have multiple meanings within the psychoana¬ lytic literature and are imprecisely defined. In clinical usage, it appears that transference refers to a social misperception, most frequently to the patient misperceiving the personality of the therapist. Thus, Nemiah18 defines transference as the "irrational attitudes towards the analyst that the patient brings to the analysis." Similarly, Sandier et al19 describe transference as "a special illusion which develops in regard to the other person." In a different conceptual framework, transference could be redefined as learned expectations of significant others and the carryover of this to new relationships.2" Transference neurosis refers to the point at which "transference phenomena are intensified into a neurosis. The patient regresses to earlier forms of relating."18 Within a social learning framework, transference neurosis might be understood as referring to the observation that social stimuli associated with emotionally meaningful dependent relationships more fully elicit distorted interpersonal perceptions. It is of note that some analytically oriented marital therapists report that the disturbed marriage contains the transference neurosis and that each spouse has developed a transference reaction to the other.2123 This point will be developed further in a subsequent section of this article. Other psychoanalytically oriented therapists have dis¬ cussed how intrapsychic conflicts can become manifest in a marital relationship and be treated in conjoint sessions.24 Certain of these clinicians utilize the theoretical frame¬ work of Melanie Klein and emphasize the concepts of "projective identification" and "collusion."25'2" Projective identification refers to a hypothetical intrapsychic mecha¬ nism whereby unacceptable unconscious feelings are projected onto the spouse, therapist, or some significant other person. Greenspan and Mannino27 suggest that a variety of terms employed by family and marital thera¬ pists, such as "trading of dissociations," "merging," and "unconscious collusive process," are descriptions of projec¬ tive identification. It is of note that the behavioral mani¬ festation of this internal psychic mechanism is consistent misperception of some aspect of the spouse's character. Greenspan and Mannino suggest that therapists can inter¬ vene in such a marriage by either interpreting the uncon¬ scious fears responsible for the defense mechanism or by directly confronting the mispreception and helping spouses
to observe behavior in each other that they had previously not perceived. This comment is an important link between the interpretive approaches and the more active interven¬ tions to be discussed below. General systems theory is one of the most influential conceptual frameworks in family therapy28 and underlies the theoretical thinking of many marital therapists. Jackson29,30 introduced general systems concepts to marital
therapy and emphasized the importance of the structural properties of interactional systems observed in couples. Thus, he described the constant and predictable reciprocal patterns of behavior observed in couples, the tendency of these patterns to remain unchanged and in homeostasis, and the emergence of compensatory factors (negative feedback) to restore equilibrium if something upsets this balance. Some of his major contributions to marital therapy are (1) his emphasis that the problem is in the system rather than in the units (people) composing the system and (2) his suggestion that therapeutic interven¬
tions should be focused on the interactional system. Simi¬ larly, Haley" states that the goal of a marriage therapist is to "provoke a change in the ways the couple keep the marital system stable so the system itself may undergo a change." Haley outlines the maneuvers a therapist can use to require spouses to change their behavior to one another. It is of note that some of Haley's therapeutic interventions bear a resemblance to those described by Greenspan and Mannino and could also be construed as techniques to disprove fixated misperceptions. For exam¬ ple, he suggests that the therapist relabel and "redefine the situation as different from, if not opposite to, the way they are defining it." The therapist should focus on the opposite of what the partners say about one another and emphasize the positive, thus undermining their usual ways of labeling each other. Although Haley is concerned only with descriptions of systems of interaction, it appears that he is making certain implicit assumptions about the units making up the system. He appears to be assuming that there is a reciprocal interrelationship between individuals' perceptions of each other and their behavior toward one another such that a change in this perception can occur either by a cognitive relabeling of observations or by observing behavior discrepant with the internal cognitive model. In many ways, Satir6 could be considered as a represen¬ tative of general systems theory, as this framework has clearly influenced her thinking. However, the main influence of her work on marital therapy has probably been her emphasis on communication skills. Certain of her techniques have been incorporated into sex therapy treat¬ ment approaches.32 Other workers have developed commu¬ nication training programs for marital couples, **··* and investigators have begun experimental work on the impact of modifying dysfluent communication in couples.'5 Satir's conceptual system, though presented in a simplistic outline form, is quite complex in its ramifications. The essence of her theoretical position is that there is a reciprocal interre¬ lationship between communication difficulties and indi¬ vidual self-concepts and self-esteem. She hypothesizes that healthy interpersonal relationships require the individuals involved to have a sense of individuality and relatedness. ...
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slightly differently,
she is
saying
that
people need feelings, images, and introjects and external reality (real other people), and that most of us have tendencies to project feelings and distort perceptions. She implies that a partial solution to this interpersonal difficulty is for people to learn and employ clear language that differentiates self from other and to use explicit language that limits the amount of distortion and projection possible. The contribution of her viewpoint for this presentation is the hypothesis that the use of clear and precise verbal feedback between couples limits the amount of distorted perception possible. In the last 10 to 15 years, behavior therapists have begun to make significant contributions to the treatment of marital discord. These therapists resemble the general system theorists in their emphasis on the use of active strategies to change observed behavior. The principal contributions of these therapists are their efforts to precisely define their interventions and to empirically test Stated
to learn to discriminate between internal
the effectiveness of these interventions. This work has recently been reviewed elsewhere. The bulk of this work employs concepts from opérant conditioning and from social psychological exchange theories.37'8 The specific contributions of these workers to marital therapy include their emphasis on the low rate of positive reinforcement, the use of negative reinforcement as a behavior change mechanism, and the absence of reciprocity of reinforce¬ ment exchange in unsatisfactory marriages.39'41 Thus, they have employed a variety of behavioral techniques, including the exchange of tokens for pleasing behavior, the use of behavior checklists, and formalized behavior exchange contracts. A variety of assessment procedures have been employed to test the effectiveness of the various behavioral treatment packages. A recent review of this literature concludes that the evidence for the effectiveness of these procedures is suggestive rather than experimen¬ tally demonstrated.3" It is of note that, although most of these behavior therapists have focused their efforts on transferring a behavioral technology to marital problems, a few have noted the role of cognitive misperceptions. Thus, part of Liberman's work with a difficult couple is remiscent of Haley's: "I actively redirected his attention from his wife 'the unhappy depressed woman' to his wife 'the coping woman.' "39 lpl131 Clearly, a variety of techniques and theoretical frame¬ works have been applied to the field of marital therapy. It would appear that a major block to an integrative theoret¬ ical effort is the seeming large dichotomy existing between the interpretive and the behaviorally oriented approaches. A similar situation exists in individual psycho¬ therapy, where there is a polarization between psychoanalytically oriented therapists and behavior therapists.42 It has been suggested that part of that polarization can be resolved by postulating that there is a reciprocal interrela¬ tionship between behavior change and inner cognitive emotional referents for that behavior such that mean¬ ingful psychotherapeutic change can be initiated by a change in either sphere.2"43 This same approach might facilitate integrative efforts in the field of marital ther¬ apy. However, in the field of marital therapy, the percep¬ tion of the spouse may be the crucial pivotal variable. '"
AN INTEGRATIVE MODEL This model is applicable to cases of chronic marital discord, which may be arbitrarily defined as marital discord of more than one year's duration. It is not applic¬ able to cases of marital discord in which one or both spouses have a diagnosis of psychosis, as additional factors may be involved in such cases." The model will be developed by a listing of specific hypotheses and definitions, with a discussion of either supporting evidence or of empirically testable predictions. 1. Because of the complexity and quantity of interper¬ sonal stimuli and the limited information-processing capacity of the human nervous system, man develops cognitive schémas or templates to organize his interper¬ sonal perceptions. These schémas influence the manner in which new information about people is perceived and assimilated. Similar hypotheses have been developed by numerous social psychologists,45-4" and an experimental literature concerning the conditions under which these schema exert their influence has developed.47 It is suggested that experienced psychoanalytically oriented clinicians either observe or intuit such schémas or hidden assumptions in their patients and refer to these schémas most frequently as "transference" phenomena. (This point was alluded to in the literature review.) This attempted redefinition of transference is important as it suggests that social psychological research on the manifestations and changing of interpersonal schémas might be applicable to
psychotherapy. hypothesized
2. It is
that in cases of chronic marital both spouses have schémas for the percep¬ tion of the mate that are markedly discrepant with the mate's personality. Clinically, this will be observed as a fixated misperception of the mate's character. This hy¬ pothesis clearly leads to the prediction that couples in chronic distress will misperceive one another's character more so than couples who are happily married. Dymond48 reported that happily married couples have more accurate predictions than unhappily married couples of each other's self-reports on the Minnesota Multiphasic Personality Inventory, thus offering tentative support for this hypoth¬ esis. Indirect evidence supporting this hypothesis was recently reported by Gottman and associates.49 In two studies, distressed and nondistressed couples did not differ in the way they intended messages to be received by the spouses, although they consistently differed in their perceptions of messages. Distressed couples perceived messages from spouses to be more negative. 3. It is hypothesized that these schémas or tendencies toward misperceptions were learned from previous inti¬ mate experiences with the opposite sex. This is basically a restatement of transference in terms of social learning theory. However, it differs from analytic hypotheses in that it does not restrict the acquisition of schémas to early childhood experiences and allows for the modification of schémas by interpersonal experiences in later life. 4. In cases of chronic marital discord, there has been a failure of discrimination learning in one or both spouses. The person has difficulty observing differences between the external reality of the present partner and internal images or cognitive schémas for the opposite sex. Such an
discord,
one or
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individual has a relative paucity of conceptual dimensions relevant to interpersonal perception, particularly of the opposite sex. This could also be referred to as a relative failure of "object differentiation" or as low "cognitive complexity." Hypotheses 3 and 4 can be tested by comparing the similarity of descriptions of spouses, oppo¬ site-sex parents, other significant members of the opposite sex, and the opposite sex in general in groups of happily and unhappily married couples. It is specifically predicted that there will be less differentiation of these descriptions (internal objects) in the unhappily married. The repertory grid method5" or interpersonal checklists51 could be
employed
as
research instruments.
5. It is predicted that these relatively undifferentiated images of the opposite sex will be more negative in the unhappily married. That the unhappily married perceive their spouses more negatively than the happily married is almost a truism. I am unaware, however, of any empirical documentation of the unhappily married's perception of the opposite-sex parent or previous partner as compared to the happily married's perception. 6. These distorted perceptions contribute to interac¬ tional sequences that maintain these distortions. This phenomenon has been described by numerous authors utilizing various theoretical frameworks. Various analyti¬ cally oriented therapists have spoken of the self-fulfilling prophesies of the neurotic,52 the tendency of patients to "repeatedly attempt to provoke the analyst to react in a manner similar to past object relations,""3 and of the somewhat more successful attempts to provoke the spouse to act in a similar manner.54 Other authors have noted the problem of circular causality in person-person relation¬ ships, and have referred to the phenomenon as the response-determined stimulus effect.47 Leary55 described how certain interpersonal behavior tends to invite recip¬ rocal interpersonal responses from the other person in the interaction. Similarly, Carson discussed how a given inter¬ personal style becomes self-perpetuating: "One of the most important processes involved is the encouragement of selfconfirmatory (complementary) reactions in others."46 ,pl51" It would appear that all of these authors with varying degrees of explicitness are hypothesizing that individuals have representational models for significant others and tend to behave toward other people in such a way as to invite behavior from the other that is congruent with that inner representational model. The importance of this hy¬ pothesis for the marital therapist is its implication that the behavior of each marital partner is partially the result of the behavior change maneuvers employed by the mate rather than necessarily the manifestations of enduring personality traits. Empirical validation of this is extremely difficult as it would involve coding of interpersonal behav¬ iors, correlating behavior patterns with their reciprocal patterns, and correlating this with descriptions of the other. However, work by the Oregon social learning group5"-57 on the reciprocity of parent-child interactions suggests that reliable codes of interpersonal behavior are available. Other work58 has indicated that measures of cognitive representations can be related to interpersonal
behavior. 7. Repetitive observation of spouse behavior
discrepant
with the internal model for the spouse will result in a change in the representational model. This may be a change in cognitive complexity (the new description for the spouse will be dissimilar to descriptions of other signifi¬ cant members of the opposite sex) or simply a change in the unitary representational model for the opposite sex from a negative to a more positive valence. The hypothesis that a person's representational model of the external world is modified by that person's experience of the world is a rather standard assumption in cognitive social psychol¬ ogy. The assumption that inner psychological processes such as transference reactions can be modified by an external reality discrepant with the perceptual distortion is a bit more controversial. However, many family thera¬ pists59 make the basic assumption that the social context influences inner processes, and recent work in individual psychotherapy has suggested that behavior change can influence inner symbolic processes.20 This hypothesis is difficult to subject to exact empirical testing. However, an indirect prediction from this hypothesis is that the behav¬ ioral reciprocity counseling therapies, which focus simply on increasing the rate of exchange of positively reinforcing behaviors between spouses, should produce changes in the perceptions of the spouses. In other words, the observance of positive behaviors from the spouse should be discrepant with the negative representational model of the spouse. 8. As this framework implies that perception of the spouse at any given moment is partially a function of the actual behavior of the spouse and partially a function of the representation model evoked, the degree of influence of the representational model on perception is a function of the ambiguity of the perceived situation.4" This implies that the use of clear and explicit communication patterns between spouses should minimize the amount of distortion possible. Also, repeated unambiguous verbal feedback discrepant with the inner representational model for the spouse would be expected to modify that model. This hypothesis can be tested by observing the effects of communication training approaches to marital discord, such as those developed by Thomas.60 It is specifically predicted that these programs will produce more accurate and more differentiated spouse descriptions. COMMENT
The purpose of this article was to evolve a model for brief conjoint therapy of chronic marital discord that satisfied four separate conditions: (1) that it be empirically testable, (2) that it translate contributions from the various partial theories into a common conceptual framework, (3) that it relate individual psychopathology to interactional difficul¬ ties, and (4) that it be clinically relevant. It is my belief that the eight hypotheses listed in the previous section meet the first three criteria. The relationship of the proposed model to the fourth criterion will be briefly discussed. The proposed model for conjoint marital therapy hypoth¬ esizes that individual psychopathology can be related to interpersonal difficulties by emphasizing the role of inter¬ personal misperceptions in eliciting and maintaining disturbed behavior patterns among intimates. Whereas in individual psychotherapy of neurotic or personality disor-
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ders, "transference reactions" of varying sorts might be involved, it is hypothesized that within the context of marital discord, fixated misperceptions of the opposite sex are primary in maintaining the disturbed behavior patterns. These cognitive schémas for the perception of intimate members of the opposite sex appear to be more readily elicited by interpersonal stimuli associated with emotionally dependent relationships. These eliciting rela¬ tionships can be either marriage or long-term psychother¬ apy; theoretically, the "transference reactions" should be
modifiable in either individual psychotherapy or in conjoint marital therapy. In individual psychotherapy, the "transference reaction" usually develops slowly, and hope¬ fully the patient is unsuccessful in provoking the therapist to act in accordance (collusion) with the inner represent¬ ational model for emotionally significant members of the opposite sex. In psychoanalysis, insight as it relates to transference can be viewed as a special type of discrimina¬ tion learning.43 The patient begins to discriminate between inner representational models and external reality. Similar phenomena can occur in conjoint marital therapy, although the differences between the two types of therapy necessi¬ tate differing levels of explanation for the observed phenomena and differing therapeutic techniques. The distinguishing features of conjoint treatment of
chronic marital discord would appear to be that the "trans¬ ference reactions" have already developed to the spouse, that these fixated misperceptions have contributed to
behavior patterns, and that the actual behavior of the spouse is similar to the inner representational model for the opposite sex. It is important to note that the seeming congruence of actual behavior of the spouse with the mate's representational model for the opposite sex is proposed to be primarily the result of the interactional history between the couple and not neces¬ sarily the product of enduring personality traits of the individuals. This is important, as numerous dynamically oriented theorists who have noted this congruence have speculated that neurotics select partners who will help to perpetuate their neurotic patterns.15-61·62 The complemen¬ tary need hypothesis63 of mate selection has been invoked to explain the peculiar contrasting personalities occasion¬ ally found in severe marital discord. This hypothesis has
recurring maladaptive
received no support from empirical studies.64-65 Rejection of these related hypotheses frees the clinician to more actively seek behavior change to reduce the congruence between inner representational models and external real¬
ity. Although there is overlap between the goals of conjoint marital therapy and individual psychotherapy, certain differences between the therapeutic contexts require differential treatment approaches by the therapist. The principal factors in conjoint therapy necessitating a different approach would appear to be the recurring maladaptive behavior patterns that confirm the inner representational models and the necessity for a bilateral disproof of these fixated misperceptions. As the observed recurring maladaptive interactional pattern is hypothe¬ sized to be confirmatory to both inner representational models, the initial therapeutic intervention of the therapist should be to disrupt this pattern. Techniques advocated by the general systems theorists are ideally suited for this task. The confirmatory interaction patterns can be further disrupted by the use of behavioral reciprocity counseling procedures to induce positive interchanges between spouses on the assumption that this behavior will be discrepant with the negative representational models. Techniques from the communication training approaches to marital discord can be selectively borrowed on the assumption that discrepant verbal feedback will similarly facilitate cognitive change. After a behavior change has occurred, the therapist can employ interpretations and redirection of perceptions to emphasize the contrast between the actual behavior of the spouses and previous models of the opposite sex. It is assumed that observed behavior, verbal information from the spouse, and cogni¬ tive relabeling all contribute to a cognitive shift in the perception of the spouse. The limitations and oversimplifi¬ cations of this beginning framework for brief conjoint marital therapy are obvious. However, this model can offer eclectic therapists of many differing basic orientations a unifying framework to organize their interventions as they borrow techniques from the partial schools. To my knowledge, this is the first attempt to formulate such a framework in a manner capable of empirical validation or invalidation.
References 1. Uhlenhuth EH, Lipman RS, Balter MB, et al: Symptom intensity and life stress in the city. Arch Gen Psychiatry 31:759-764, 1974. 2. Ovenstone IMK: The development of neurosis in the wives of neurotic men. Br J Psychiatry 122:35-45, 1973. 3. Kreitman N, Collins J, Nelson B, et al: Neurosis and marital interaction: I. Personality and symptoms. Br J Psychiatry 117:33-46, 1970. 4. Paykel ES, Prusoff BA, Uhlenhuth EH: Scaling of life events. Arch Gen Psychiatry 25:340-347, 1971. 5. Sager CJ, Gundlach R, Kermer M, et al: The married in treatment. Arch Gen Psychiatry 19:205-217, 1968. 6. Satir V: Conjoint Family Therapy. Palo Alto, Calif, Science and Behavior Books, 1967. 7. Canter H, Glick PC: Marriage and Divorce: A Social and Economic Study. Cambridge, Mass, Harvard University Press, 1976. 8. Martin PA, Lief HI: Resistances to innovation in psychiatric training as exemplified by marital therapy, in Usdin G (ed): Psychiatry, Education and Image. New York, Brunner/Mazel Inc, 1973. 9. Berman EM, Lief HI: Marital therapy from a psychiatric perspective: An overview. Am J Psychiatry 132:583-591, 1975. 10. Manus GL: Marriage counseling: A technique in search of a theory. J Marr Fam 28:449-453, 1966.
11. Olson DH: A critical overview, in Gurman AS, Rice DG (eds): Couples Conflict. New York, Jason Aronson, 1975. 12. Olson DH: Marital and family therapy: Integrative review and critique. J Marr Fam 32:501-538, 1970. 13. Christ J: Treatment of marriage disorders, in Grunebaum H, Christ J (eds): Contemporary Marriage: Structure, Dynamics, and Therapy. Boston, Little Brown & Co Inc, 1976. 14. Kubie LS: Psychoanalysis and marriage, in Eisenstein VW (ed): Neurotic Interaction in Marriage. New York, Basic Books Inc, 1956. 15. Lussheimer P: The diagnosis of marital conflict. Am J Psychoanal 27:127-131, 1967. 16. Giovacchini PL: Treatment of marital disharmonies: The classical approach, in Greene B (ed): The Psychotherapies of Marital Disharmony. New York, Free Press, 1965. 17. Greene BL, Solomon AP: Marital disharmony: Concurrent psychoanalytic therapy of husband and wife by the same psychiatrist. Am J Psychother 17:443-456, 1963. 18. Nemiah JC: Classical psychoanalysis, in Freedman DX, Dyrud JE (eds): American Handbook of Psychiatry. New York, Basic Books Inc, 1975, vol 5. 19. Sandler J, Dare C, Holder A: Basic psychoanalytic concepts: III.
in
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Transference. Br J Psychiatry 116:667-672, 1970. 20. Segraves RT, Smith RC: Concurrent psychotherapy and behavior
therapy:
Treatment of
psychoneurotic outpatients.
33:756-763, 1976. 21. Sager CJ: Transference in conjoint Arch Gen Psychiatry 16:185-193, 1967.
Arch Gen
Psychiatry
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couples.
22. Grotjahn M: Psychoanalysis and the Family Neurosis. New York, WW Norton & Co, 1960. 23. Litz T: The Person. New York, Basic Books Inc, 1976. 24. Sager CJ: Marriage Contracts and Couple Therapy. New York, Brunner/Mazel Inc, 1976. 25. Stewart RH, Peters TC, March S, et al: An object-relations approach to psychotherapy with marital couples, families, and children. Fam Proc 14:161-178, 1975. 26. Dicks HU: Marital Tensions. New York, Basic Books Inc, 1976. 27. Greenspan SI, Mannino FU: A model for brief intervention with couples based on projective identification. Am J Psychiatry 131:1103-1106, 1974. 28. Foley VD: An Introduction to Family Therapy. New York, Grune & Stratton Inc, 1974. 29. Jackson DD: Family rules. Arch Gen Psychiatry 12:589-594, 1965. 30. Lederer W, Jackson DD: The Mirages of Marriage. New York, WW Norton & Co, 1968. 31. Haley J: Marriage therapy. Arch Gen Psychiatry 8:213-234, 1963. 32. Segraves RT: Primary orgasmic dysfunction: Essential treatment components. J Sex Marit Ther 2:115-123, 1976. 33. Nunnally EW, Miller S, Wackman DB: The Minnesota couples communication program. Small Group Behav 6:57-71, 1975. 34. Miller S, Corrales R, Wackman DB: Recent progress in understanding and facilitating marital communication. Fam Coord 24:143-152, 1975. 35. Carter RD, Thomas EJ: Modification of problematic marital communication using corrective feedback and instruction. Behav Ther 4:100-109 1973. 36. Jacobson NS, Martin B: Behavioral marriage therapy: Current status. Psychol Bull 83:540-556, 1976. 37. Thibaut JW, Kelley HH: The Social Psychology of Groups. New York, John Wiley & Sons, 1959. 38. Homans GC: Social Behavior: Its Elementary Forms. New York, Harcourt Brace Jovanovich Inc, 1961. 39. Liberman RP: Behavioral approaches to family and couple therapy. Am J Orthopsychiatry 40:106-118, 1970. 40. Azrin NH, Naster BJ, Jones R: Reciprocity counseling: A rapid learning-based procedure for marital counseling. Behav Res Ther 11:365382, 1973. 41. Stuart RB: Operant-interpersonal treatment for marital discord. J Consult Clin Psychol 33:675-682, 1969. 42. Hunt HF, Dyrud JE: Commentary: Perspective in behavior therapy. Res Psycho Ther 3:140-152, 1968. 43. Birk L, Brinkley-Birk AW: Psychoanalysis and behavior therapy. Am J Psychiatry 131:499-510, 1974.
44. Greene
BL, Lustig N, Lee RR: Marital therapy when one spouse has a
primary affective disorder. Am J Psychiatry 133:827-830, 45. Kelly GA: The Psychology of Personal Constructs.
1976. New
York, WW
Norton & Co, 1955. 46. Carson RC: Interaction Concepts of Personality. Chicago, Aldine Publishing Co, 1969. 47. Stotland E, Canon LK: Social Psychology: A Cognitive Approach. Philadelphia, WB Saunders & Co, 1972. 48. Dymond R: Interpersonal perception and marital happiness. Can J Psychol 8:164-171, 1954. 49. Gottman J, Notarius C, Markman H, et al: Behavior exchange theory and marital decision making. J Pers Soc Psychol 34:14-23, 1976. 50. Slater P: Theory and technique of the repertory grid. Br J Psychiatry 115:1287-1296, 1969. 51. Laforge R, Suczek RF: The interpersonal dimension of personality: III. An interpersonal check list. J Pers 24:94-112, 1955. 52. Offenkranz W, Tobin A: Psychoanalytic psychotherapy, in Freedman DX, Dyrud JE (eds): American Handbook of Psychiatry. New York, Basic Books Inc, 1975, vol 5. 53. Kaplan SM: The analyst, the transference, and the representational world. Compr Psychiatry 17:47-54, 1976. 54. Symonds M: Marital disharmony and character structure. Am J Psychoanal 30:73-86, 1970. 55. Leary T: Interpersonal Diagnosis of Personality. New York, Ronald Press Co, 1957. 56. Patterson GR: The aggressive child: Victim and architect of a coercive system, in Hamerlynck LA, Handy LC, Mash JE (eds): Behavior Modification and Families. New York, Brunner/Mazel Inc, 1975. 57. Patterson GR: Parents and teachers as change agents: A social learning approach, in Olson D (ed): Treating Relationships. Lake Mills, Iowa, Graphic Press, 1976. 58. Czapinski J: Prosocial behavior as affected by the structure of the cognitive representation of others. Pol Psychol Bull 7:155-162, 1976. 59. Minuchin S: Families and Family Therapy. Cambridge, Mass, Harvard University Press, 1974. 60. Thomas EJ: Marital Communication and Decision Making: Analysis, Assessment and Change. New York, Free Press, 1977. 61. Ostow M, Cholst B: Marital discord. NY State J Med 70:257-266, 1970. 62. Dicks HU: Concepts of marital diagnosis and therapy as developed at the Tairstock family psychiatric units, London, England, in Nash EM, Jessner L, Abse DW (eds): Marriage Counseling in Medical Practice. Chapel Hill, University of North Carolina Press, 1964. 63. Winsch RF: Mate Selection. New York, Harper & Row Publishers, 1958. 64. Thorp RG: Psychological patterning in marriage. Psychol Bull 60:97117, 1963. 65. De Young GE, Fleischer B: Motivational and personality trait relationships in mate selection. Behav Genet 6:1-6, 1976.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Cambrdige University Library User on 09/20/2017
Cognitive Robert
Behavioral Model
Taylor Segraves, MD,
PhD
\s=b\ This article presents an integrated cognitive-behavioral model for conjoint therapy of chronic marital discord. The model is based on eight empirically testable hypotheses that are clinically relevant and integrate contributions from general systems theory, behavioral marital therapy, and psychoanalysis.
Disproof of cognitive schemas for the perception of the opposite (transference reactions) is hypothesized to be a common therapeutic mechanism in the dissimilar models of marital therapy. (Arch Gen Psychiatry 35:450-455, 1978)
wealth of evidence indicates the existence of important between marriage and psychiatric difficulties and the need for eclectic psychiatrists to gain skills in the field of marital therapy. An association between single and divorced marital status, psychological maladjustment, and psychiatric morbidity has been noted.1 Ovenstone2 and Kreitman et al3 reported evidence suggesting the role of marital interaction in eliciting individual neurotic behavior. The degree to which marital discord and separation are judged to be major life stresses,4 the frequency with which marital discord is the precipi¬ tating complaint given by people for seeking mental health services,5 the clinical observations from family therapists on the impact of marital conflict on the psychosocial development of the children involved," and the increasing divorce rate in the United States7 all suggest marital therapy to be an important psychiatric intervention. In spite of this, the field of marriage and marital therapy has been relatively neglected by psychiatrists and psychiatric training programs." Various factors have been suggested as responsible for the neglect of this area." However, it is my belief that the absence of a coherent conceptual framework has been the most significant obstacle to clinicians interested in the field.
The absence of a coherent theory of marital therapy has been noted by others.10·" The field could perhaps best be described as consisting of many partial theories that focus either on individual psychopathology or on the properties of marital interaction systems. The degree of overlap that may exist between the partial theories is obscured by the absence of a common terminology, and there have been few attempts to link individual psychopathology with interaction difficulties. The empirically oriented clinician will note the lack of evidence to support the assumptions of many marital therapists12 and the frequent use of assumptions incapable of empirical testing. The purpose of this article is to evolve a theoretical framework for brief conjoint marital therapy that is both clinically relevant and capable of empirical testing. An attempt will be made to link individual psychopathology with interactional difficulties and to translate the contri¬ butions of psychoanalytically oriented therapists and behaviorally oriented therapists into a common terminol¬ ogy by employing concepts from cognitive social psychol¬ ogy. This undertaking will be attempted by first reviewing some of the major contributions from the partial theories, pointing out possible links between these theories, and then incorporating these contributions into a new model.
A relationshipssuggests .
Accepted
From the Clinics.
publication June 16, 1977. Department of Psychiatry, University of Chicago Hospitals and for
Reprint requests to Department of Psychiatry, University of Chicago, 950 E 59th St, Chicago, IL 60637 (Dr Segraves).
sex
LITERATURE REVIEW The reader is referred elsewhere for comprehensive reviews of the marital therapy literature.91113 For this selective review, treatment orientations will be separated
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into four groups: psychodynamic, general systems theory, communication training, and behavioral therapy. Psychoanalytic theory developed from an individual psychology. Thus, much of the work by psychodynamically oriented therapists has stressed the role of individual unconscious intrapsychic conflicts in the genesis and main¬ tenance of marital problems.1415 Much of this work has stressed the treatment of individual psychopathology. A literature has developed on the effects of variations from the traditional one-to-one psychoanalytic treatment for¬ mat on the development of "transference" to the thera¬ pist.1617 Implicit in many of these discussions is the assumption that resolution of the "transference neurosis" is one of the major curative mechanisms in individual analytically oriented psychotherapy and thus of marital conflict. The terms "transference" and "transference neurosis" have multiple meanings within the psychoana¬ lytic literature and are imprecisely defined. In clinical usage, it appears that transference refers to a social misperception, most frequently to the patient misperceiving the personality of the therapist. Thus, Nemiah18 defines transference as the "irrational attitudes towards the analyst that the patient brings to the analysis." Similarly, Sandier et al19 describe transference as "a special illusion which develops in regard to the other person." In a different conceptual framework, transference could be redefined as learned expectations of significant others and the carryover of this to new relationships.2" Transference neurosis refers to the point at which "transference phenomena are intensified into a neurosis. The patient regresses to earlier forms of relating."18 Within a social learning framework, transference neurosis might be understood as referring to the observation that social stimuli associated with emotionally meaningful dependent relationships more fully elicit distorted interpersonal perceptions. It is of note that some analytically oriented marital therapists report that the disturbed marriage contains the transference neurosis and that each spouse has developed a transference reaction to the other.2123 This point will be developed further in a subsequent section of this article. Other psychoanalytically oriented therapists have dis¬ cussed how intrapsychic conflicts can become manifest in a marital relationship and be treated in conjoint sessions.24 Certain of these clinicians utilize the theoretical frame¬ work of Melanie Klein and emphasize the concepts of "projective identification" and "collusion."25'2" Projective identification refers to a hypothetical intrapsychic mecha¬ nism whereby unacceptable unconscious feelings are projected onto the spouse, therapist, or some significant other person. Greenspan and Mannino27 suggest that a variety of terms employed by family and marital thera¬ pists, such as "trading of dissociations," "merging," and "unconscious collusive process," are descriptions of projec¬ tive identification. It is of note that the behavioral mani¬ festation of this internal psychic mechanism is consistent misperception of some aspect of the spouse's character. Greenspan and Mannino suggest that therapists can inter¬ vene in such a marriage by either interpreting the uncon¬ scious fears responsible for the defense mechanism or by directly confronting the mispreception and helping spouses
to observe behavior in each other that they had previously not perceived. This comment is an important link between the interpretive approaches and the more active interven¬ tions to be discussed below. General systems theory is one of the most influential conceptual frameworks in family therapy28 and underlies the theoretical thinking of many marital therapists. Jackson29,30 introduced general systems concepts to marital
therapy and emphasized the importance of the structural properties of interactional systems observed in couples. Thus, he described the constant and predictable reciprocal patterns of behavior observed in couples, the tendency of these patterns to remain unchanged and in homeostasis, and the emergence of compensatory factors (negative feedback) to restore equilibrium if something upsets this balance. Some of his major contributions to marital therapy are (1) his emphasis that the problem is in the system rather than in the units (people) composing the system and (2) his suggestion that therapeutic interven¬
tions should be focused on the interactional system. Simi¬ larly, Haley" states that the goal of a marriage therapist is to "provoke a change in the ways the couple keep the marital system stable so the system itself may undergo a change." Haley outlines the maneuvers a therapist can use to require spouses to change their behavior to one another. It is of note that some of Haley's therapeutic interventions bear a resemblance to those described by Greenspan and Mannino and could also be construed as techniques to disprove fixated misperceptions. For exam¬ ple, he suggests that the therapist relabel and "redefine the situation as different from, if not opposite to, the way they are defining it." The therapist should focus on the opposite of what the partners say about one another and emphasize the positive, thus undermining their usual ways of labeling each other. Although Haley is concerned only with descriptions of systems of interaction, it appears that he is making certain implicit assumptions about the units making up the system. He appears to be assuming that there is a reciprocal interrelationship between individuals' perceptions of each other and their behavior toward one another such that a change in this perception can occur either by a cognitive relabeling of observations or by observing behavior discrepant with the internal cognitive model. In many ways, Satir6 could be considered as a represen¬ tative of general systems theory, as this framework has clearly influenced her thinking. However, the main influence of her work on marital therapy has probably been her emphasis on communication skills. Certain of her techniques have been incorporated into sex therapy treat¬ ment approaches.32 Other workers have developed commu¬ nication training programs for marital couples, **··* and investigators have begun experimental work on the impact of modifying dysfluent communication in couples.'5 Satir's conceptual system, though presented in a simplistic outline form, is quite complex in its ramifications. The essence of her theoretical position is that there is a reciprocal interre¬ lationship between communication difficulties and indi¬ vidual self-concepts and self-esteem. She hypothesizes that healthy interpersonal relationships require the individuals involved to have a sense of individuality and relatedness. ...
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slightly differently,
she is
saying
that
people need feelings, images, and introjects and external reality (real other people), and that most of us have tendencies to project feelings and distort perceptions. She implies that a partial solution to this interpersonal difficulty is for people to learn and employ clear language that differentiates self from other and to use explicit language that limits the amount of distortion and projection possible. The contribution of her viewpoint for this presentation is the hypothesis that the use of clear and precise verbal feedback between couples limits the amount of distorted perception possible. In the last 10 to 15 years, behavior therapists have begun to make significant contributions to the treatment of marital discord. These therapists resemble the general system theorists in their emphasis on the use of active strategies to change observed behavior. The principal contributions of these therapists are their efforts to precisely define their interventions and to empirically test Stated
to learn to discriminate between internal
the effectiveness of these interventions. This work has recently been reviewed elsewhere. The bulk of this work employs concepts from opérant conditioning and from social psychological exchange theories.37'8 The specific contributions of these workers to marital therapy include their emphasis on the low rate of positive reinforcement, the use of negative reinforcement as a behavior change mechanism, and the absence of reciprocity of reinforce¬ ment exchange in unsatisfactory marriages.39'41 Thus, they have employed a variety of behavioral techniques, including the exchange of tokens for pleasing behavior, the use of behavior checklists, and formalized behavior exchange contracts. A variety of assessment procedures have been employed to test the effectiveness of the various behavioral treatment packages. A recent review of this literature concludes that the evidence for the effectiveness of these procedures is suggestive rather than experimen¬ tally demonstrated.3" It is of note that, although most of these behavior therapists have focused their efforts on transferring a behavioral technology to marital problems, a few have noted the role of cognitive misperceptions. Thus, part of Liberman's work with a difficult couple is remiscent of Haley's: "I actively redirected his attention from his wife 'the unhappy depressed woman' to his wife 'the coping woman.' "39 lpl131 Clearly, a variety of techniques and theoretical frame¬ works have been applied to the field of marital therapy. It would appear that a major block to an integrative theoret¬ ical effort is the seeming large dichotomy existing between the interpretive and the behaviorally oriented approaches. A similar situation exists in individual psycho¬ therapy, where there is a polarization between psychoanalytically oriented therapists and behavior therapists.42 It has been suggested that part of that polarization can be resolved by postulating that there is a reciprocal interrela¬ tionship between behavior change and inner cognitive emotional referents for that behavior such that mean¬ ingful psychotherapeutic change can be initiated by a change in either sphere.2"43 This same approach might facilitate integrative efforts in the field of marital ther¬ apy. However, in the field of marital therapy, the percep¬ tion of the spouse may be the crucial pivotal variable. '"
AN INTEGRATIVE MODEL This model is applicable to cases of chronic marital discord, which may be arbitrarily defined as marital discord of more than one year's duration. It is not applic¬ able to cases of marital discord in which one or both spouses have a diagnosis of psychosis, as additional factors may be involved in such cases." The model will be developed by a listing of specific hypotheses and definitions, with a discussion of either supporting evidence or of empirically testable predictions. 1. Because of the complexity and quantity of interper¬ sonal stimuli and the limited information-processing capacity of the human nervous system, man develops cognitive schémas or templates to organize his interper¬ sonal perceptions. These schémas influence the manner in which new information about people is perceived and assimilated. Similar hypotheses have been developed by numerous social psychologists,45-4" and an experimental literature concerning the conditions under which these schema exert their influence has developed.47 It is suggested that experienced psychoanalytically oriented clinicians either observe or intuit such schémas or hidden assumptions in their patients and refer to these schémas most frequently as "transference" phenomena. (This point was alluded to in the literature review.) This attempted redefinition of transference is important as it suggests that social psychological research on the manifestations and changing of interpersonal schémas might be applicable to
psychotherapy. hypothesized
2. It is
that in cases of chronic marital both spouses have schémas for the percep¬ tion of the mate that are markedly discrepant with the mate's personality. Clinically, this will be observed as a fixated misperception of the mate's character. This hy¬ pothesis clearly leads to the prediction that couples in chronic distress will misperceive one another's character more so than couples who are happily married. Dymond48 reported that happily married couples have more accurate predictions than unhappily married couples of each other's self-reports on the Minnesota Multiphasic Personality Inventory, thus offering tentative support for this hypoth¬ esis. Indirect evidence supporting this hypothesis was recently reported by Gottman and associates.49 In two studies, distressed and nondistressed couples did not differ in the way they intended messages to be received by the spouses, although they consistently differed in their perceptions of messages. Distressed couples perceived messages from spouses to be more negative. 3. It is hypothesized that these schémas or tendencies toward misperceptions were learned from previous inti¬ mate experiences with the opposite sex. This is basically a restatement of transference in terms of social learning theory. However, it differs from analytic hypotheses in that it does not restrict the acquisition of schémas to early childhood experiences and allows for the modification of schémas by interpersonal experiences in later life. 4. In cases of chronic marital discord, there has been a failure of discrimination learning in one or both spouses. The person has difficulty observing differences between the external reality of the present partner and internal images or cognitive schémas for the opposite sex. Such an
discord,
one or
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individual has a relative paucity of conceptual dimensions relevant to interpersonal perception, particularly of the opposite sex. This could also be referred to as a relative failure of "object differentiation" or as low "cognitive complexity." Hypotheses 3 and 4 can be tested by comparing the similarity of descriptions of spouses, oppo¬ site-sex parents, other significant members of the opposite sex, and the opposite sex in general in groups of happily and unhappily married couples. It is specifically predicted that there will be less differentiation of these descriptions (internal objects) in the unhappily married. The repertory grid method5" or interpersonal checklists51 could be
employed
as
research instruments.
5. It is predicted that these relatively undifferentiated images of the opposite sex will be more negative in the unhappily married. That the unhappily married perceive their spouses more negatively than the happily married is almost a truism. I am unaware, however, of any empirical documentation of the unhappily married's perception of the opposite-sex parent or previous partner as compared to the happily married's perception. 6. These distorted perceptions contribute to interac¬ tional sequences that maintain these distortions. This phenomenon has been described by numerous authors utilizing various theoretical frameworks. Various analyti¬ cally oriented therapists have spoken of the self-fulfilling prophesies of the neurotic,52 the tendency of patients to "repeatedly attempt to provoke the analyst to react in a manner similar to past object relations,""3 and of the somewhat more successful attempts to provoke the spouse to act in a similar manner.54 Other authors have noted the problem of circular causality in person-person relation¬ ships, and have referred to the phenomenon as the response-determined stimulus effect.47 Leary55 described how certain interpersonal behavior tends to invite recip¬ rocal interpersonal responses from the other person in the interaction. Similarly, Carson discussed how a given inter¬ personal style becomes self-perpetuating: "One of the most important processes involved is the encouragement of selfconfirmatory (complementary) reactions in others."46 ,pl51" It would appear that all of these authors with varying degrees of explicitness are hypothesizing that individuals have representational models for significant others and tend to behave toward other people in such a way as to invite behavior from the other that is congruent with that inner representational model. The importance of this hy¬ pothesis for the marital therapist is its implication that the behavior of each marital partner is partially the result of the behavior change maneuvers employed by the mate rather than necessarily the manifestations of enduring personality traits. Empirical validation of this is extremely difficult as it would involve coding of interpersonal behav¬ iors, correlating behavior patterns with their reciprocal patterns, and correlating this with descriptions of the other. However, work by the Oregon social learning group5"-57 on the reciprocity of parent-child interactions suggests that reliable codes of interpersonal behavior are available. Other work58 has indicated that measures of cognitive representations can be related to interpersonal
behavior. 7. Repetitive observation of spouse behavior
discrepant
with the internal model for the spouse will result in a change in the representational model. This may be a change in cognitive complexity (the new description for the spouse will be dissimilar to descriptions of other signifi¬ cant members of the opposite sex) or simply a change in the unitary representational model for the opposite sex from a negative to a more positive valence. The hypothesis that a person's representational model of the external world is modified by that person's experience of the world is a rather standard assumption in cognitive social psychol¬ ogy. The assumption that inner psychological processes such as transference reactions can be modified by an external reality discrepant with the perceptual distortion is a bit more controversial. However, many family thera¬ pists59 make the basic assumption that the social context influences inner processes, and recent work in individual psychotherapy has suggested that behavior change can influence inner symbolic processes.20 This hypothesis is difficult to subject to exact empirical testing. However, an indirect prediction from this hypothesis is that the behav¬ ioral reciprocity counseling therapies, which focus simply on increasing the rate of exchange of positively reinforcing behaviors between spouses, should produce changes in the perceptions of the spouses. In other words, the observance of positive behaviors from the spouse should be discrepant with the negative representational model of the spouse. 8. As this framework implies that perception of the spouse at any given moment is partially a function of the actual behavior of the spouse and partially a function of the representation model evoked, the degree of influence of the representational model on perception is a function of the ambiguity of the perceived situation.4" This implies that the use of clear and explicit communication patterns between spouses should minimize the amount of distortion possible. Also, repeated unambiguous verbal feedback discrepant with the inner representational model for the spouse would be expected to modify that model. This hypothesis can be tested by observing the effects of communication training approaches to marital discord, such as those developed by Thomas.60 It is specifically predicted that these programs will produce more accurate and more differentiated spouse descriptions. COMMENT
The purpose of this article was to evolve a model for brief conjoint therapy of chronic marital discord that satisfied four separate conditions: (1) that it be empirically testable, (2) that it translate contributions from the various partial theories into a common conceptual framework, (3) that it relate individual psychopathology to interactional difficul¬ ties, and (4) that it be clinically relevant. It is my belief that the eight hypotheses listed in the previous section meet the first three criteria. The relationship of the proposed model to the fourth criterion will be briefly discussed. The proposed model for conjoint marital therapy hypoth¬ esizes that individual psychopathology can be related to interpersonal difficulties by emphasizing the role of inter¬ personal misperceptions in eliciting and maintaining disturbed behavior patterns among intimates. Whereas in individual psychotherapy of neurotic or personality disor-
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ders, "transference reactions" of varying sorts might be involved, it is hypothesized that within the context of marital discord, fixated misperceptions of the opposite sex are primary in maintaining the disturbed behavior patterns. These cognitive schémas for the perception of intimate members of the opposite sex appear to be more readily elicited by interpersonal stimuli associated with emotionally dependent relationships. These eliciting rela¬ tionships can be either marriage or long-term psychother¬ apy; theoretically, the "transference reactions" should be
modifiable in either individual psychotherapy or in conjoint marital therapy. In individual psychotherapy, the "transference reaction" usually develops slowly, and hope¬ fully the patient is unsuccessful in provoking the therapist to act in accordance (collusion) with the inner represent¬ ational model for emotionally significant members of the opposite sex. In psychoanalysis, insight as it relates to transference can be viewed as a special type of discrimina¬ tion learning.43 The patient begins to discriminate between inner representational models and external reality. Similar phenomena can occur in conjoint marital therapy, although the differences between the two types of therapy necessi¬ tate differing levels of explanation for the observed phenomena and differing therapeutic techniques. The distinguishing features of conjoint treatment of
chronic marital discord would appear to be that the "trans¬ ference reactions" have already developed to the spouse, that these fixated misperceptions have contributed to
behavior patterns, and that the actual behavior of the spouse is similar to the inner representational model for the opposite sex. It is important to note that the seeming congruence of actual behavior of the spouse with the mate's representational model for the opposite sex is proposed to be primarily the result of the interactional history between the couple and not neces¬ sarily the product of enduring personality traits of the individuals. This is important, as numerous dynamically oriented theorists who have noted this congruence have speculated that neurotics select partners who will help to perpetuate their neurotic patterns.15-61·62 The complemen¬ tary need hypothesis63 of mate selection has been invoked to explain the peculiar contrasting personalities occasion¬ ally found in severe marital discord. This hypothesis has
recurring maladaptive
received no support from empirical studies.64-65 Rejection of these related hypotheses frees the clinician to more actively seek behavior change to reduce the congruence between inner representational models and external real¬
ity. Although there is overlap between the goals of conjoint marital therapy and individual psychotherapy, certain differences between the therapeutic contexts require differential treatment approaches by the therapist. The principal factors in conjoint therapy necessitating a different approach would appear to be the recurring maladaptive behavior patterns that confirm the inner representational models and the necessity for a bilateral disproof of these fixated misperceptions. As the observed recurring maladaptive interactional pattern is hypothe¬ sized to be confirmatory to both inner representational models, the initial therapeutic intervention of the therapist should be to disrupt this pattern. Techniques advocated by the general systems theorists are ideally suited for this task. The confirmatory interaction patterns can be further disrupted by the use of behavioral reciprocity counseling procedures to induce positive interchanges between spouses on the assumption that this behavior will be discrepant with the negative representational models. Techniques from the communication training approaches to marital discord can be selectively borrowed on the assumption that discrepant verbal feedback will similarly facilitate cognitive change. After a behavior change has occurred, the therapist can employ interpretations and redirection of perceptions to emphasize the contrast between the actual behavior of the spouses and previous models of the opposite sex. It is assumed that observed behavior, verbal information from the spouse, and cogni¬ tive relabeling all contribute to a cognitive shift in the perception of the spouse. The limitations and oversimplifi¬ cations of this beginning framework for brief conjoint marital therapy are obvious. However, this model can offer eclectic therapists of many differing basic orientations a unifying framework to organize their interventions as they borrow techniques from the partial schools. To my knowledge, this is the first attempt to formulate such a framework in a manner capable of empirical validation or invalidation.
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