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Intellectual and spiritual dimension: A couple are primarily preoccupied with the tasks of social and emotional survival. Overcoming and negotiating the ordinary exigencies of living, house, work, money, children and their education and the health and satisfaction of the members of the family, are the experiences out of which a great deal of married life is made up. Nevertheless, all this does not go on in a vacuum. A couple need to share or be capable of constructing out of different visions a meaning for their married life. This means that they should be able to discuss and share, however minimally and simply, the value systems that govern their ideals. When their worlds are separated by a total gulf in significant intellectual, moral and social priorities, the unity becomes instead a coexistence. We have seen how the behavioural scientists can set about examining in depth the constituents of marital pathology. But having done so, it is natural to ask: what is the purpose of such an exercise? The purpose of research is to examine the changing form of marriage in the second half of the twentieth century. It is an age which is witnessing marital changes which are likely to be permanent features in most societies. In a pluralistic society like ours these changes are all secular values which are the common heritage of all. Everyone stands to gain by transforming marriage from a mysterious institution into one which is far more comprehensible and handled with contemporary insights. For the Judaeo-Christian tradition, the mystery is more than a secular complexity. From the time of the Old Testament, through the New and up to our day the husband-wife relationship has been seen as the symbol of the God-man relationship and the bond between the two as a channel of grace (Schillebeeckx 1976). Thus, for Jews and Christians the secular reality has been caught up and transformed into a divine reality. For many other religions also, marriage and family are sacred institutions. The fruits of research, therefore, apply in a practical way to all members of society as the means through which the changing nature of marriage can be examined and understood and couples helped to live the emerging reality with new insights. This secular knowledge is also used by the various religious denominations according to their own traditions to deepen their own spiritual insights. Marriage as a secular or spiritual reality is the common heritage of mankind and the behavioural sciences are contributing, through research, a major understanding of the large-scale changes occurring in it. Marital pathology and breakdown are symptoms, surface phenomena of this major transition, the consequences of which have the widest possible repercussions for the whole of society.
REFERENCES Chester R (1975) Politica 5, 335 Dicks H V (1967) Marital Tensions. Routledge & Kegan Paul, Boston & London Dominian J (1968) Marital Breakdown. Pelican, Harmondsworth Office of Population Censuses and Surveys (1976a) Population Trends 3. HMSO; p 3 (1976b) Population Trends 6. HMSO; p 40 Schillebeeckx E (1976) Marriage. Sheed and Ward. Stagbooks, London Skynner A R C (1976) One Flesh, Separate Persons. Constable, London
Mr Douglas Woodhouse (Chairman, Executive Committee, Institute of Marital Studies, Tavistock Centre, Belsize Lane, London NW3 5BA)
Referral from General Practice to Specialized Agencies The agencies that specialize in offering help to those with marital difficulties are few and they differ widely. The Probation and After-Care Service has, for many years, provided a service for clients with marital problems over and above its statutory work with offenders and their families. There are also some marital units within the National Health Service; an example is the Marital Unit of the Adult Department, Tavistock Clinic. In the main, however, specialized resources for marital work in the community are independent of the statutory services. These include the Institute of Marital Studies, the National Marriage Guidance Council and the Catholic Marriage Advisory Council. Though independent, all three agencies receive financial support from central and local government. Meanwhile, some psychotherapists in private practice and private agencies also work with marriages in difficulty. As would be expected, the treatment available varies in approach and orientation, as do the agencies in the constraints within which they work, and in the volume, the kind and the scope of the help offered. Such specialized marital agencies as there are differ at least as much as the specialized medical services available to patients through their general practitioners. An important aspect of referral is the quest for a match between patient need and available resources, and the GP faces his familiar task of
Open Section knowing in detail where and what is available to him and of discriminating in relation to the needs of any given couple. The Institute of Marital Studies (IMS) is a unit of the Tavistock Institute of Human Relations, which, though not part of the National Health Service, is in the same building as the Tavistock Clinic. The IMS has had close working links with the Tavistock Clinic since the unit was founded as the Family Discussion Bureau in the late 1940s. In an attempt to maintain financial viability, fees have been charged to clients for some years. These are below the cost of the service and no one is excluded because of an inability to pay. It is a small unit, the staff of which is committed to having at least one medical psychoanalyst consultant among its number. The staff group is interdisciplinary, but it comprises mainly social workers with extensive experience in other fields, most of whom have undertaken personal analysis or psychotherapy and some of whom have gone on to train as lay analysts. The IMS has three closely interrelated aims: (1) to provide a therapeutic service to those experiencing difficulty in their marriage; (2) To evolve training methods relevant to the marital and related family problems confronting workers in other settings; (3) In the light of therapeutic and training experience, to develop understanding of the processes of interaction within marriages and families and between workers and their clients with special reference to the organizational setting in which the encounter takes place. The important point is that the IMS is not primarily a service agency. All staff, without exception, carry cases, but only about one-third of available staff time is devoted to clinical work. This, however, is the cornerstone of the unit's work. Relatively small in volume (with 140-150 cases in treatment in any one year) clinical work provides the shared experience which is the prerequisite of advanced training and development work. We have so far seen over three hundred thousand couples in the IMS. These and the much greater volume with which we have been in touch through training and consultation in a wide range of settings have led to a perspective which can be stated as follows: emotional conflict and growth are closely related, both within the individual and between couples. I do not mean that conflict invariably leads to growth but that it is an important stimulus to it. In many seemingly problematic patterns of interaction there lies a potential for the personal development of each partner within it. Thus, our focus is not mainly on individual psychopathology, but more particularly on the meaning and purpose of the transactions between the couple - on the creative aspects of conflict and
499
those elements of pathology that point towards new solutions. Our experience suggests that more difficult marriages have this inherent potential for growth than is generally supposed, and that many are amenable to change in a climate in which their differences are seen to represent a struggle with impediments to development rather than symptomatology of which, if possible, they are to be relieved. It follows that there is a need in treatment to offer a containing setting to the couple as they embark on the endeavour to achieve intra-and inter-personal change. Our contact with GPs is mainly reflected by the fact that in the ten years since 1966, 168 different GPs have between them referred 284 couples. The number of referrals we have been able to accept has been virtually constant over the period, but the percentage coming from family doctors has steadily risen from 10 in 1966 to 27 in the year to April 1976. Referral is considered under the same headings as we have found useful when thinking about the provision of service, namely aspects which: (1) derive from the clients or patients and the interaction between them; (2) those relating to the worker (in this case the general practitioner) and his interaction with the patients who present him with their marital difficulties; and (3) those stemming from the setting, general practice, the context of this interaction. We need to add a fourth set: these derive from the relationship between the GP and the agency to which he refers and their
interaction. The Client/Patient Couple and their Interactions I believe it to be true that the incidence of what may be called displaced marital stress is very much higher than that of the people who explicitly acknowledge and complain about 'pain' in their relationship. Even those that bring their marital difficulties directly, at some level do so with mixed feelings. And whether overtly or covertly presented, their marital problems are introduced into what is usually a longstanding relationship with the doctor who will continue to be medically responsible for them. So far as I know, there are no studies which systematically explore the complex issues which determine why some people find their way to and settle with one professional rather than with another. But there is good evidence to suggest that, apart from such things as availability, accessibility and often the need for anonymity, and of trial and error in a search for what is felt to be a relevant response, a major factor is the symbolic role of the person to whom one chooses to reveal one's personal difficulties. If this is true, then to those who select their general practitioner - the most generally
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available professional - the doctor/patient relationship is important in just such a symbolic as well as an objective sense. I emphasize this because it makes it all the more significant that numbers of those who refer themselves to the IMS (over 50 % of our intake) choose not to discuss their difficulties with their GP, and some expressly wish to exclude him. Given that the majority of patients express their marital difficulties obliquely rather than directly in the first instance, for example, via a physical symptom or the difficulty of some other family member, then many of them, with their doctors, have to go through a process of redefining the problem. When this is accomplished and referral is mooted, they have then to face the disturbance of a familiar relationship, invariably of long standing, which is trusted and has a special meaning to them. Because of this it is not uncommon for referral to be construed by the patient as a rejection and for it to be abortive if it has not been acknowledged and properly worked through as part of the process of redefinition. Meanwhile, in the light of what is known about marital interaction, and the universal struggle with the tension and conflict inherent in the intimate, indeed primary relationship of marriage, along with the quest for relief, there tends to go an equally strong emotional pressure to maintain the situation. To contemplate change, even of a painful situation, is to face penetrating unfamiliar territory, the relinquishing of established ways of defending against anxiety and the giving up of 'the devil one knows'. Hence resistence and stress is encountered during any period in which change is attempted. A further dimension is added when the marriage itself is the 'patient'. Whatever the original mode of presentation and whoever was the spokesman, it is a couple who are the subject of referral, not an individual. We also have to recognize that a couple, especially in an established, ongoing relationship have created an entity, a dynamic system, in which each carries for the other aspects of themselves which they reject and of which they are usually quite unaware. This can lead, for example, to the familiar situation in which ambivalance about change is split between the partners, the one appearing to be committed to working on the difficulty, the other opposing every effort to do so. In situations such as this, some shift in the couple's mutual defensive system has to be achieved if the marriage, as such, is to be referred and treated effectively. The Referring Doctor and the Patient in Marital Difficulty
Christopher Clulow (1976 unpublished) in a paper concerned with therapeutic responses at the point
of referral, has drawn attention to the fact that those involved - the client or patient in his marriage, the referring worker in his setting and those in the agency receiving referrals - all share a common problem: the management of deep-seated feelings evoked by exposure to pain and distress. Mechanisms for coping with such feelings operate both within the individual and within the system or organization in which one works. The function of the organization in this regard has been clearly demonstrated by Isobel Menzies (1970) in her important study of social systems acting as a defence against anxiety. Experience shows that marital problems can give rise to intense difficulty in the matter of 'distancing' - especially as they so often present themselves to those who are nonspecialists so far as marital problems are concerned and whose working environments are geared to managing anxiety arising from other sources. Doctors will recognize the phenomena to which I am referring when they remember their own training and when they may have struggled with and found ways of resisting the tendency to believe they had each successive disease they studied. Marriage and its vicissitudes are not like mental or physical illness or delinquency or child neglect which we meet in our work, and in relation to which we mostly have good enough internal boundaries. How different, one asks oneself, are the marriages of many clients or patients from those of one's friends; how different from one's friends' marriages is one's own? And whether married or single we all have our parents' relationship inside us, one which has left an indelible stamp on the way we view ourselves and the world around us. So the clients' marital problems are always liable to be too near home for comfort. In so far as they are, the fact is likely to be involved in the timing, the method and the climate of a referral. The phenomenon has to be reckoned with; I do not believe it can be avoided and it is certainly no slur on one's professional competence to have to work to find, each for himself, what is a good enough working distance vis-a-vis each case. But I would like to suggest that it is always relevant to ask, 'Why am I referring these particular patients, at this particular time, in this particular way, and to this particular agency?' - or alternatively, 'Why can I not let them go to someone else?' The implications of the need to find an appropriate working distance between worker and client, doctor and patient, are general and extensive. Personal identification can lead to holding on to cases when referral would be appropriate or to precipitate efforts to transfer patients and their problems elsewhere. Beyond this, there often remains a pressing anxiety about what an intervention aimed at confronting the problem may provoke.
Open Section I have in mind, for example, a case in which the wife was the presenting patient; she had a long history of painful intercourse. The husband, who had been drawn in by the GP, later said of him, 'He never has much time but he always seems able to make space for you to talk'. When, after a short series of consultations, the doctor suggested referral to the IMS, both partners were enthusiastic, the husband feeling this was the first time he had been involved in what was now agreed to be a joint problem. The wife then became seriously depressed. The GP had to 'hold' this depression as well as anxiety about the couple's young children, before they got to the IMS and into marital therapy. As he made clear, he wondered whether he had misjudged the strength of their wish for change, not least because of the adverse reactions of other members of his practice.
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attempt to find the best available treatment. It also tends to confirm for the clients that what they find unmanageable within themselves cannot be contained by the professional setting either. Yet for many, a sense of containment is the most important communication that can be made.
The GP and the Specialized Agency In considering the interaction between the GP and the agency to which he seeks to send his 'marital patients', we need to keep in mind that the forces emanating from the nature of marital problems and interaction impinge as much on the specialized agency as they do on the GP. The difference lies in the fact that marital work is our primary task whereas it is not that of general practice. Referral of a case from a general practitioner to a specialized agency involves a 'transaction across a boundary' - and boundary problems are notorious (Miller & Rice 1967). Having noted some of the The General Practitioner's Setting In each setting a way has to be found to help staff potent emotional forces which may be involved, we sustain this kind of anxiety in a way appropriate to need to look upon referral not only as a rational itself and its function. Of their work in general attempt to obtain the treatment of choice for a practice, two of my Tavistock Clinic colleagues patient-couple, but also as a process through which a practice maintains its equilibrium and the purwrote: suit of a given primary task: general medicine. 'Our aim was to reduce the amount of splitting and Referral is, then, a function of managing what goes dissociation that so often occurs in patient care when on within the boundary of a particular practice; different professionals may be played off against one and to do so is, as it were, to enter the export another. This splitting can be a reproduction of the business. If we keep in mind the nature of the patient's need to keep various aspects of themselves in separate compartments; it can also result from the staff's human problems expressed in marriage which are reluctance to bear looking at the patient's situation in being exported and imported, it is small wonder that referral and intake can be problematic. toto.' (Brook & Temperley 1976). Graham & Sher (1976) pinpoint some imporOver the years I have been increasingly im- tant, additional issues which are often involved: pressed with the way couples and families manage to induce workers and agencies to be at logger- '. . . the traditional possessiveness of the helping proheads so that their own conflicts become external- fessions; the competition to be the one who is seen to be ized and acted out by the very people whose role is doing the best for the patients; the irrational hurt felt the patient reveals an intimate piece of information to contain and to treat. We have found in the IMS when one professional and not the other; the anxiety caused that it takes time and emotional effort to withstand to when one's method and techniques of working are such divisiveness and to distinguish what belongs scrutinized by the other; or simply when one wants to be to us and what to the clients in whatever is going rid of a problem - the pressure exerted on the other to on - and to understand it in a serviceable way. take the problem away.' Thus far I feel on safe ground, for the point is a general one. But as an outsider to general practice I They were talking about the interaction between a have no direct experience of the process at work in GP and a social worker sharing the care of patients this setting. However, a large number of GPs I within a practice, but very similar factors are at have talked with, both before and during my years work in the relationship between a referring GP in the IMS, have described how differences of view and a receiving agency. It is at the point when a and of personality between them and other couple are the subject of a transaction across the practice staff have been exploited, consciously or boundaries of two agencies that these matters are not, by couples and families, and in some cases liable to be articulated. The receiving agency also has to manage its how these splits and conflicts have even got into their own family relationships. They have also boundary, the inputs across it and what goes on made clear how a referral can be aimed at escaping within it. It must consider whether another case of a particular sort can be accommodated and helped this dilemma. Referral in such circumstances represents a given available resources, or even whether another manceuvre to avoid a problem rather than an such case can be tolerated, and if not, how to refuse
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the referral without disrupting an actual or potential working relationship with, for example, a GP. It must decide when not to take on too difficult a case and how to avoid colluding with the phantasy that some one, somewhere, can do the impossible; or again, how to avoid the trap of attempting to demonstrate that a couple can be rescued from someone else's 'failed' technique. And it must also consider how it can keep its intake procedure effectively under scrutiny relative to changing circumstances and yet keep the boundary sufficiently permeable to meet the needs of the clients, the unit and of colleagues in the field. The interplay of these factors, the difficulty in managing them and the inevitable ambivalence of clients has led us to be aware of the potential for dishonesty at the point of referral - on the part of all concerned. So as to better understand the processes discussed above, to test ideas and improve communication between ourselves and our referrers, we have, for some years, held an annual meeting to which all those who have sent cases in the past five years have been invited. Many have been GPs. The increase in GP referrals to the IMS coincides with the development of these meetings and there is evidence to show that referrals have improved both in timing and management. There are many fewer letters of the kind which says: 'Dear Doctor, Would you be good enough to give this couple an appointment; they have been in acute marital trouble for some time - Yours etc.', and more which convey, along with relevant history, the kind of brief but thoughtful exposition of what has been happening between'the couple and between them and the GP. Meanwhile, we have altered our intake procedure so as to make provision for a special response when the normal method seems likely to create difficulty. I think we have also become more
mindful, in the case of GPs, that they carry continuing responsibility for patient care, and that it is possible to recognize this fact in appropriate reporting back without breaking confidentiality. These meetings have also revealed the difficulties which arise in examining the referral process itself, involving as it does the complex interaction of the clients' system, the referrers' system and our own. Referring doctors have readily entered our world and have worked with us on some of our problems; we have entered theirs and have been told of some of their needs and dilemmas. What has yet to be achieved is a focus on our differences - in role, in task, and in orientation. For either party to get lost in and absorbed by the other's world can be helpful and is usually comfortable and gratifying, but it avoids working on the boundary between them where differences are manifest and sometimes painfully experienced. This problem is, of course, inherent in any marriage - the tension between separateness and identity - so perhaps we should not be too surprised at slow progress. The important thing is for the dialogue to continue. REFERENCES Brook A & Temperley J (1976) Journal of the Royal College of General Practitioners 26, 86 Clulow C (1976) 'Crossing the Bar', An Exploration of the Feelings and Difficulties Associated with Working at the Point of Referral. Paper read at Tavistock Clinic Technical Meeting, 14 June 1976. TIHR Document No. 2T 56 (unpublished) Graham H & Sher M (1976) Journal of the Royal College of General Practitioners 26, 95, 105 Menzies I E P (1970) The Function of Social Systems as a Defence Against Anxiety. Tavistock Institute of Human Relations, London Miller E J & Rice A K (1967) Systems of Organisation. Tavistock Publications, London
Proc. roy. Soc. Med. Volume 70 July 1977
Intellectual and spiritual dimension: A couple are primarily preoccupied with the tasks of social and emotional survival. Overcoming and negotiating the ordinary exigencies of living, house, work, money, children and their education and the health and satisfaction of the members of the family, are the experiences out of which a great deal of married life is made up. Nevertheless, all this does not go on in a vacuum. A couple need to share or be capable of constructing out of different visions a meaning for their married life. This means that they should be able to discuss and share, however minimally and simply, the value systems that govern their ideals. When their worlds are separated by a total gulf in significant intellectual, moral and social priorities, the unity becomes instead a coexistence. We have seen how the behavioural scientists can set about examining in depth the constituents of marital pathology. But having done so, it is natural to ask: what is the purpose of such an exercise? The purpose of research is to examine the changing form of marriage in the second half of the twentieth century. It is an age which is witnessing marital changes which are likely to be permanent features in most societies. In a pluralistic society like ours these changes are all secular values which are the common heritage of all. Everyone stands to gain by transforming marriage from a mysterious institution into one which is far more comprehensible and handled with contemporary insights. For the Judaeo-Christian tradition, the mystery is more than a secular complexity. From the time of the Old Testament, through the New and up to our day the husband-wife relationship has been seen as the symbol of the God-man relationship and the bond between the two as a channel of grace (Schillebeeckx 1976). Thus, for Jews and Christians the secular reality has been caught up and transformed into a divine reality. For many other religions also, marriage and family are sacred institutions. The fruits of research, therefore, apply in a practical way to all members of society as the means through which the changing nature of marriage can be examined and understood and couples helped to live the emerging reality with new insights. This secular knowledge is also used by the various religious denominations according to their own traditions to deepen their own spiritual insights. Marriage as a secular or spiritual reality is the common heritage of mankind and the behavioural sciences are contributing, through research, a major understanding of the large-scale changes occurring in it. Marital pathology and breakdown are symptoms, surface phenomena of this major transition, the consequences of which have the widest possible repercussions for the whole of society.
REFERENCES Chester R (1975) Politica 5, 335 Dicks H V (1967) Marital Tensions. Routledge & Kegan Paul, Boston & London Dominian J (1968) Marital Breakdown. Pelican, Harmondsworth Office of Population Censuses and Surveys (1976a) Population Trends 3. HMSO; p 3 (1976b) Population Trends 6. HMSO; p 40 Schillebeeckx E (1976) Marriage. Sheed and Ward. Stagbooks, London Skynner A R C (1976) One Flesh, Separate Persons. Constable, London
Mr Douglas Woodhouse (Chairman, Executive Committee, Institute of Marital Studies, Tavistock Centre, Belsize Lane, London NW3 5BA)
Referral from General Practice to Specialized Agencies The agencies that specialize in offering help to those with marital difficulties are few and they differ widely. The Probation and After-Care Service has, for many years, provided a service for clients with marital problems over and above its statutory work with offenders and their families. There are also some marital units within the National Health Service; an example is the Marital Unit of the Adult Department, Tavistock Clinic. In the main, however, specialized resources for marital work in the community are independent of the statutory services. These include the Institute of Marital Studies, the National Marriage Guidance Council and the Catholic Marriage Advisory Council. Though independent, all three agencies receive financial support from central and local government. Meanwhile, some psychotherapists in private practice and private agencies also work with marriages in difficulty. As would be expected, the treatment available varies in approach and orientation, as do the agencies in the constraints within which they work, and in the volume, the kind and the scope of the help offered. Such specialized marital agencies as there are differ at least as much as the specialized medical services available to patients through their general practitioners. An important aspect of referral is the quest for a match between patient need and available resources, and the GP faces his familiar task of
Open Section knowing in detail where and what is available to him and of discriminating in relation to the needs of any given couple. The Institute of Marital Studies (IMS) is a unit of the Tavistock Institute of Human Relations, which, though not part of the National Health Service, is in the same building as the Tavistock Clinic. The IMS has had close working links with the Tavistock Clinic since the unit was founded as the Family Discussion Bureau in the late 1940s. In an attempt to maintain financial viability, fees have been charged to clients for some years. These are below the cost of the service and no one is excluded because of an inability to pay. It is a small unit, the staff of which is committed to having at least one medical psychoanalyst consultant among its number. The staff group is interdisciplinary, but it comprises mainly social workers with extensive experience in other fields, most of whom have undertaken personal analysis or psychotherapy and some of whom have gone on to train as lay analysts. The IMS has three closely interrelated aims: (1) to provide a therapeutic service to those experiencing difficulty in their marriage; (2) To evolve training methods relevant to the marital and related family problems confronting workers in other settings; (3) In the light of therapeutic and training experience, to develop understanding of the processes of interaction within marriages and families and between workers and their clients with special reference to the organizational setting in which the encounter takes place. The important point is that the IMS is not primarily a service agency. All staff, without exception, carry cases, but only about one-third of available staff time is devoted to clinical work. This, however, is the cornerstone of the unit's work. Relatively small in volume (with 140-150 cases in treatment in any one year) clinical work provides the shared experience which is the prerequisite of advanced training and development work. We have so far seen over three hundred thousand couples in the IMS. These and the much greater volume with which we have been in touch through training and consultation in a wide range of settings have led to a perspective which can be stated as follows: emotional conflict and growth are closely related, both within the individual and between couples. I do not mean that conflict invariably leads to growth but that it is an important stimulus to it. In many seemingly problematic patterns of interaction there lies a potential for the personal development of each partner within it. Thus, our focus is not mainly on individual psychopathology, but more particularly on the meaning and purpose of the transactions between the couple - on the creative aspects of conflict and
499
those elements of pathology that point towards new solutions. Our experience suggests that more difficult marriages have this inherent potential for growth than is generally supposed, and that many are amenable to change in a climate in which their differences are seen to represent a struggle with impediments to development rather than symptomatology of which, if possible, they are to be relieved. It follows that there is a need in treatment to offer a containing setting to the couple as they embark on the endeavour to achieve intra-and inter-personal change. Our contact with GPs is mainly reflected by the fact that in the ten years since 1966, 168 different GPs have between them referred 284 couples. The number of referrals we have been able to accept has been virtually constant over the period, but the percentage coming from family doctors has steadily risen from 10 in 1966 to 27 in the year to April 1976. Referral is considered under the same headings as we have found useful when thinking about the provision of service, namely aspects which: (1) derive from the clients or patients and the interaction between them; (2) those relating to the worker (in this case the general practitioner) and his interaction with the patients who present him with their marital difficulties; and (3) those stemming from the setting, general practice, the context of this interaction. We need to add a fourth set: these derive from the relationship between the GP and the agency to which he refers and their
interaction. The Client/Patient Couple and their Interactions I believe it to be true that the incidence of what may be called displaced marital stress is very much higher than that of the people who explicitly acknowledge and complain about 'pain' in their relationship. Even those that bring their marital difficulties directly, at some level do so with mixed feelings. And whether overtly or covertly presented, their marital problems are introduced into what is usually a longstanding relationship with the doctor who will continue to be medically responsible for them. So far as I know, there are no studies which systematically explore the complex issues which determine why some people find their way to and settle with one professional rather than with another. But there is good evidence to suggest that, apart from such things as availability, accessibility and often the need for anonymity, and of trial and error in a search for what is felt to be a relevant response, a major factor is the symbolic role of the person to whom one chooses to reveal one's personal difficulties. If this is true, then to those who select their general practitioner - the most generally
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available professional - the doctor/patient relationship is important in just such a symbolic as well as an objective sense. I emphasize this because it makes it all the more significant that numbers of those who refer themselves to the IMS (over 50 % of our intake) choose not to discuss their difficulties with their GP, and some expressly wish to exclude him. Given that the majority of patients express their marital difficulties obliquely rather than directly in the first instance, for example, via a physical symptom or the difficulty of some other family member, then many of them, with their doctors, have to go through a process of redefining the problem. When this is accomplished and referral is mooted, they have then to face the disturbance of a familiar relationship, invariably of long standing, which is trusted and has a special meaning to them. Because of this it is not uncommon for referral to be construed by the patient as a rejection and for it to be abortive if it has not been acknowledged and properly worked through as part of the process of redefinition. Meanwhile, in the light of what is known about marital interaction, and the universal struggle with the tension and conflict inherent in the intimate, indeed primary relationship of marriage, along with the quest for relief, there tends to go an equally strong emotional pressure to maintain the situation. To contemplate change, even of a painful situation, is to face penetrating unfamiliar territory, the relinquishing of established ways of defending against anxiety and the giving up of 'the devil one knows'. Hence resistence and stress is encountered during any period in which change is attempted. A further dimension is added when the marriage itself is the 'patient'. Whatever the original mode of presentation and whoever was the spokesman, it is a couple who are the subject of referral, not an individual. We also have to recognize that a couple, especially in an established, ongoing relationship have created an entity, a dynamic system, in which each carries for the other aspects of themselves which they reject and of which they are usually quite unaware. This can lead, for example, to the familiar situation in which ambivalance about change is split between the partners, the one appearing to be committed to working on the difficulty, the other opposing every effort to do so. In situations such as this, some shift in the couple's mutual defensive system has to be achieved if the marriage, as such, is to be referred and treated effectively. The Referring Doctor and the Patient in Marital Difficulty
Christopher Clulow (1976 unpublished) in a paper concerned with therapeutic responses at the point
of referral, has drawn attention to the fact that those involved - the client or patient in his marriage, the referring worker in his setting and those in the agency receiving referrals - all share a common problem: the management of deep-seated feelings evoked by exposure to pain and distress. Mechanisms for coping with such feelings operate both within the individual and within the system or organization in which one works. The function of the organization in this regard has been clearly demonstrated by Isobel Menzies (1970) in her important study of social systems acting as a defence against anxiety. Experience shows that marital problems can give rise to intense difficulty in the matter of 'distancing' - especially as they so often present themselves to those who are nonspecialists so far as marital problems are concerned and whose working environments are geared to managing anxiety arising from other sources. Doctors will recognize the phenomena to which I am referring when they remember their own training and when they may have struggled with and found ways of resisting the tendency to believe they had each successive disease they studied. Marriage and its vicissitudes are not like mental or physical illness or delinquency or child neglect which we meet in our work, and in relation to which we mostly have good enough internal boundaries. How different, one asks oneself, are the marriages of many clients or patients from those of one's friends; how different from one's friends' marriages is one's own? And whether married or single we all have our parents' relationship inside us, one which has left an indelible stamp on the way we view ourselves and the world around us. So the clients' marital problems are always liable to be too near home for comfort. In so far as they are, the fact is likely to be involved in the timing, the method and the climate of a referral. The phenomenon has to be reckoned with; I do not believe it can be avoided and it is certainly no slur on one's professional competence to have to work to find, each for himself, what is a good enough working distance vis-a-vis each case. But I would like to suggest that it is always relevant to ask, 'Why am I referring these particular patients, at this particular time, in this particular way, and to this particular agency?' - or alternatively, 'Why can I not let them go to someone else?' The implications of the need to find an appropriate working distance between worker and client, doctor and patient, are general and extensive. Personal identification can lead to holding on to cases when referral would be appropriate or to precipitate efforts to transfer patients and their problems elsewhere. Beyond this, there often remains a pressing anxiety about what an intervention aimed at confronting the problem may provoke.
Open Section I have in mind, for example, a case in which the wife was the presenting patient; she had a long history of painful intercourse. The husband, who had been drawn in by the GP, later said of him, 'He never has much time but he always seems able to make space for you to talk'. When, after a short series of consultations, the doctor suggested referral to the IMS, both partners were enthusiastic, the husband feeling this was the first time he had been involved in what was now agreed to be a joint problem. The wife then became seriously depressed. The GP had to 'hold' this depression as well as anxiety about the couple's young children, before they got to the IMS and into marital therapy. As he made clear, he wondered whether he had misjudged the strength of their wish for change, not least because of the adverse reactions of other members of his practice.
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attempt to find the best available treatment. It also tends to confirm for the clients that what they find unmanageable within themselves cannot be contained by the professional setting either. Yet for many, a sense of containment is the most important communication that can be made.
The GP and the Specialized Agency In considering the interaction between the GP and the agency to which he seeks to send his 'marital patients', we need to keep in mind that the forces emanating from the nature of marital problems and interaction impinge as much on the specialized agency as they do on the GP. The difference lies in the fact that marital work is our primary task whereas it is not that of general practice. Referral of a case from a general practitioner to a specialized agency involves a 'transaction across a boundary' - and boundary problems are notorious (Miller & Rice 1967). Having noted some of the The General Practitioner's Setting In each setting a way has to be found to help staff potent emotional forces which may be involved, we sustain this kind of anxiety in a way appropriate to need to look upon referral not only as a rational itself and its function. Of their work in general attempt to obtain the treatment of choice for a practice, two of my Tavistock Clinic colleagues patient-couple, but also as a process through which a practice maintains its equilibrium and the purwrote: suit of a given primary task: general medicine. 'Our aim was to reduce the amount of splitting and Referral is, then, a function of managing what goes dissociation that so often occurs in patient care when on within the boundary of a particular practice; different professionals may be played off against one and to do so is, as it were, to enter the export another. This splitting can be a reproduction of the business. If we keep in mind the nature of the patient's need to keep various aspects of themselves in separate compartments; it can also result from the staff's human problems expressed in marriage which are reluctance to bear looking at the patient's situation in being exported and imported, it is small wonder that referral and intake can be problematic. toto.' (Brook & Temperley 1976). Graham & Sher (1976) pinpoint some imporOver the years I have been increasingly im- tant, additional issues which are often involved: pressed with the way couples and families manage to induce workers and agencies to be at logger- '. . . the traditional possessiveness of the helping proheads so that their own conflicts become external- fessions; the competition to be the one who is seen to be ized and acted out by the very people whose role is doing the best for the patients; the irrational hurt felt the patient reveals an intimate piece of information to contain and to treat. We have found in the IMS when one professional and not the other; the anxiety caused that it takes time and emotional effort to withstand to when one's method and techniques of working are such divisiveness and to distinguish what belongs scrutinized by the other; or simply when one wants to be to us and what to the clients in whatever is going rid of a problem - the pressure exerted on the other to on - and to understand it in a serviceable way. take the problem away.' Thus far I feel on safe ground, for the point is a general one. But as an outsider to general practice I They were talking about the interaction between a have no direct experience of the process at work in GP and a social worker sharing the care of patients this setting. However, a large number of GPs I within a practice, but very similar factors are at have talked with, both before and during my years work in the relationship between a referring GP in the IMS, have described how differences of view and a receiving agency. It is at the point when a and of personality between them and other couple are the subject of a transaction across the practice staff have been exploited, consciously or boundaries of two agencies that these matters are not, by couples and families, and in some cases liable to be articulated. The receiving agency also has to manage its how these splits and conflicts have even got into their own family relationships. They have also boundary, the inputs across it and what goes on made clear how a referral can be aimed at escaping within it. It must consider whether another case of a particular sort can be accommodated and helped this dilemma. Referral in such circumstances represents a given available resources, or even whether another manceuvre to avoid a problem rather than an such case can be tolerated, and if not, how to refuse
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the referral without disrupting an actual or potential working relationship with, for example, a GP. It must decide when not to take on too difficult a case and how to avoid colluding with the phantasy that some one, somewhere, can do the impossible; or again, how to avoid the trap of attempting to demonstrate that a couple can be rescued from someone else's 'failed' technique. And it must also consider how it can keep its intake procedure effectively under scrutiny relative to changing circumstances and yet keep the boundary sufficiently permeable to meet the needs of the clients, the unit and of colleagues in the field. The interplay of these factors, the difficulty in managing them and the inevitable ambivalence of clients has led us to be aware of the potential for dishonesty at the point of referral - on the part of all concerned. So as to better understand the processes discussed above, to test ideas and improve communication between ourselves and our referrers, we have, for some years, held an annual meeting to which all those who have sent cases in the past five years have been invited. Many have been GPs. The increase in GP referrals to the IMS coincides with the development of these meetings and there is evidence to show that referrals have improved both in timing and management. There are many fewer letters of the kind which says: 'Dear Doctor, Would you be good enough to give this couple an appointment; they have been in acute marital trouble for some time - Yours etc.', and more which convey, along with relevant history, the kind of brief but thoughtful exposition of what has been happening between'the couple and between them and the GP. Meanwhile, we have altered our intake procedure so as to make provision for a special response when the normal method seems likely to create difficulty. I think we have also become more
mindful, in the case of GPs, that they carry continuing responsibility for patient care, and that it is possible to recognize this fact in appropriate reporting back without breaking confidentiality. These meetings have also revealed the difficulties which arise in examining the referral process itself, involving as it does the complex interaction of the clients' system, the referrers' system and our own. Referring doctors have readily entered our world and have worked with us on some of our problems; we have entered theirs and have been told of some of their needs and dilemmas. What has yet to be achieved is a focus on our differences - in role, in task, and in orientation. For either party to get lost in and absorbed by the other's world can be helpful and is usually comfortable and gratifying, but it avoids working on the boundary between them where differences are manifest and sometimes painfully experienced. This problem is, of course, inherent in any marriage - the tension between separateness and identity - so perhaps we should not be too surprised at slow progress. The important thing is for the dialogue to continue. REFERENCES Brook A & Temperley J (1976) Journal of the Royal College of General Practitioners 26, 86 Clulow C (1976) 'Crossing the Bar', An Exploration of the Feelings and Difficulties Associated with Working at the Point of Referral. Paper read at Tavistock Clinic Technical Meeting, 14 June 1976. TIHR Document No. 2T 56 (unpublished) Graham H & Sher M (1976) Journal of the Royal College of General Practitioners 26, 95, 105 Menzies I E P (1970) The Function of Social Systems as a Defence Against Anxiety. Tavistock Institute of Human Relations, London Miller E J & Rice A K (1967) Systems of Organisation. Tavistock Publications, London
