Br. J. med. Psychol. (1976). 49, 183-187
Printed in Great Britain
The wider uses of conjoint psychotherapy BY GEOFFREY A. RICKARBY*
Conjoint psychotherapy presupposes that intervention will be with both partners of an established relationship seen together. A superficial view of such therapy might make it appear that the therapist or therapists are trying to form a therapeutic relationship with two individual people at the one time. Then a view might be taken that one is observing and interpreting the interaction of the couple. Further notions have had to be expounded, however, to explain phenomena indicative of merged identity and personality fusion (and confusion), repeatedly observed when interviewing dyads. Although this is based on projection (Dicks, 1963), it is more; this is because there is a collusive acceptance of projections (Williams, 1970) (at an unconsciousand pre-verbal level), and the taking on of roles from the partners object relationship phantasy. (The choice of partner is, of course, collusive at this same level.) Dicks (1%7) writes of ‘fluidity of ego boundaries’ and ‘sharing of feelings’, ‘making such couples into a unit around which some sort of joint ego-boundaries were drawn ’. Goethals (1973) in a theory of symbiosis takes Bowlby’s theory of attachment to emphasize the reciprocal nature of it and its recurrence in adult life. Another theoretical concept is to see the dyad as a system which subsumes the individual system (Meir, 1%9), and which is the relevant one to the intervening psychiatrist because of the intense social need of the human organism for the one-to-one relationship, to renew and repeat the primary dyadic relationship of motherlchild: the origin of adult-adult symbiosis. The dyad system is in dynamic interaction with its social suprasystem and individual subsystem, and is subject to development, change, and of course, dysequilibrium - malfunction or pathology in another view. It is also stable. Markowitz (1%9) analyses ‘the locked twosome’ in his discussion of therapistlpatient dyads which are unresolved. How much more is there ‘locking’ in parentlchild relationships and the secondary symbiosis of husbandlwife. A couple who seeks help saying ‘we are having trouble in our marriage’ is usually accepted by ‘helping personnel ’ as a dyad, but in many instances where there is dyadic stress one partner will present alone; usually with depression to the psychiatrist or a stress-illness to the GP. The covert message is ‘form a new dyad with me doctor. Let me split my interactive needs, you and I will be the good couple - my partner and I will be the bad couple’. But the original relationship is frequently intense, long term, stable, highly ambivalent and the presenting complaint a function of the relationship with only secondary relevance to the individual. . 1 Mr D., a 27-year-old motel manager, born in UK where his parents ran a club. As a teenager he would play snooker with the adults despite his mother’s disapproval, but sanctioned by his dominating and aggressive father. His father had died five years before. Mrs D. Australian born, also 27, had met her husband in England. Her own mother had been divorced twice and treated Mrs D. to open hostility and left her with relatives for years at a time. Mr D. had made three appointments with me that he had not kept. When he finally came he CASE
Rydalmere Psychiatric Hospital, Victoria Rd. Rydalmere, N e w South Wales 21 16.
G . A. R I C K A R B Y
was smartly dressed, polite and very passive. He said he was charged with stealing money from his employers. He said he had gambled compulsively for years, and he would lose large sums of money, mostly playing snooker. He had taken money to pay his debts and had been charged at a time when he could not make it up. When he related that his wife was losing trust in him, I asked if he minded his wife coming into the interview. He seemed relieved. Mrs D. was intensely angry at him; she thought it very probable he would go to jail. Her anger was long standing and stemmed from his habit of coming home late while she waited on her own. There was a lot of evidence of separation anxiety. She was able to be angry at him in an immediate and open way. He never became angry after three sessions he was able to say he thought that if he did become angry he might easily kill somebody: he had, he thought, nearly killed another boy when he was a teenager. What happened when he ought to become angry with his wife? They were both able to say this was when he gambled; not only gambled but played snooker with better players than himself so that he would have to lose. Therapy was interpretive and included relating their interaction now, to their previous relationships with parents. The gambling was seen so clearly by both together as a hostile equivalent directly determined by motherlson and husband/wife dyads, that it was difficult for such a self-punishing method of expressing anger to continue. The nature of both the pathology and its dynamics are often obvious when the two people are seen together, but first it is necessary to think in terms of the dyad system’s frame of reference, work through the resistance of all parties (the therapist, the presenting partner), to expose the dyad to diagnostic scrutiny. This resistance is not only due to the first partner’s need for justification of their position in the relationship and an attempt to get a third person to support their projections, it is a fear of the other partner that the therapist will do just that - support the presenting partner in their moral stance. Techniques of interpreting that the first partner does not really want the other one to be involved are helpful, plus writing warmly to the other partner, saying that seeing them together is most likely to help the unhappiness you are sure both must be feeling. The helper’s own resistance is often not as clear. There is the initial difficulty at not colluding with the presenting spouse and not taking an individual view of the situation. It is easier to collude - also the one-to-one relationship is familiar, safer and not intrusive. There can be fear of non-directive interviews with a dyad becoming out of control in some way - perhaps to do with unconscious phantasy of the sexualitylviolence of the primal scene. Anybody who intends doing conjoint therapy will find time well spent talking through these resistances with an experienced colleague. Assessment is best done in a threesome interview with little or no direction by the therapist. If the atmosphere is accepting then there is usually considerable expression of the usual interaction of the twosome. However, therapy may be more directive, e.g. where focal interpretations or re-grief work are attempted. CASE 2 Mr L. was an alcoholic in his mid-thirties who presented after an outburst of violence and abuse to his mother and wife together. He was also very passive and not in touch with his anger when sober. His wife was a chronically depressed woman who was unable to tolerate even a small modicum of guilt and projected her feelings of badness and worthlessness to her husband. He was very dependent on her and suffered intense separation anxiety if she was away, as well as a pathological jealousy syndrome. When seen together it was clear that Mrs L. was giving her husband numerous encouraging messages to drink (knowing he could not control his drinking), such as ‘I don’t mind if he just has a few drinks. I don’t mind him drinking, if only he wouldn’t behave
The wider uses of conjoint psychotherapy
that way.’ Not only did she need him to be bad and drink (like her own father), but she needed him to be undemanding sexually. Working through these factors with the couple produced an abstemious husband with self-esteem but a sporadically depressed and anxiously frigid wife. This, of course, needed to be worked with further. CASE 3 Mr and Mrs C’s eldest son was killed in a motor-bike scramble in 1959. He was Mrs C’s ally in the family. Neither were able to accept the death, or cope with their guilt or anger. Mr C. developed a conversion aphonia and Mrs C. alopecia totalis during the first months and first year respectively. Mrs C. ‘had always been dominant and capable but following the bereavement withdrew from their sexual relationship. Mr C. became more aggressive and his asthma stopped. Mrs C. then developed asthma which became progressively worse until she spent the majority of time in hospital away from Mr C. Her asthma was exacerbated at the anniversary of her son’s death and feelings of anger at her husband for not being with her. There was massive hostility between them. Mrs C. was referred by the in-patient physician. During the first interview she spoke much more about her husband and his meanness than she would about herself. It was clear that she was suffering from unresolved grief and also that her husband was intensely involved in this. He was reluctant to attend, being very defensive that he would be blamed for his son’s death and for many other things. They came together. Mr C. was very mistrustful of doctors, who kept his wife and made her no better, and angry about being brought into the situation himself. Mrs C. gave caustic ‘asides’ on his attitude, e.g. ‘He wouldn’t understand’. I saw them for three hourly interviewsat two-week intervals. I said that they had been unable to mourn the loss of their son for fourteen years and that Mrs C. was unable to accept that he was dead. They went on bitterly arguing as they did at home. I brought Mr C. back to the bereavement and he was able to bring out some of his feelings of anguish at the loss, and his bitter self-blame for teaching his son to ride a motor-bike. Mrs C. was amazed. In the second interview they both went over the event, particularly Mrs C. being unable to see the body and her husband’s anger at this. Again they were both surprised at each other’s feelings; they had never talked through the events together, let alone shared their feelings. It was not as dangerous as their phantasies had led them to believe. They cried but did not collapse. In the third interview they took up the details of the bereavement, telling it sequentially, each taking their turn telling the same story, with much shared anger at the experienced riders in the race. They returned to a country town. Follow-up showed an improved relationship, and only one week’s hospitalization in the following six months.
These three case histories could easily have been that of three individuals labelled ‘compulsive gambling ’, ‘alcoholism ’ and ‘pathologicalgrief/bronchialasthma ’. The six people involved were above average in intelligence, clearly in obvious distress, and when brought together with the therapist and their spouse, made use of the relationship and basic interpretive material very quickly. In 50 consecutive couples electing to have marital therapy in private practice, the majority, at stages of their referral or in their initial contact with me, were presenting as an individual problem. Six spouses ultimately refused to come. Of the 94 people seen, 52 expressed that they were significantly depressed and 25 of the 50 women expressed that they were frigid.
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Both of these ‘diagnoses’ are frequently accepted as an index of individual pathology, but in this setting they occurred as only part issues in a presenting dyadic disturbance. There were many other individual diagnoses which could have been taken if there had not been a choice to view the dyad as more relevant to their management. Following the notion of the relevance of the dyad system, some criteria may be suggested for intervention at this level: In general, where the presenting symptoms or manifest psychopathology are an essential part of the life of the dyad system. For example: (1) They serve as the only expression of the submissive or passive partner’s hostile feelings (e.g. case 1). (2) They are a collusion with the other partner’s projections (e.g. the ‘badchild’, the ‘persecuting parent’, or the ‘guilty one’). (3) They are an expression or representation of the polarity of the relationship (e.g. aggressivelsubmissive, sexuallanti-sexual, emotional/unemotional, intelligentl‘stupid ’1. This splitting into opposites is derived by projection and collusion and frequently causes stress when it is not flexible, and one partner must bear the stress of the whole family in his or her polarized role. There is in all these a common function of preserving the dyad but in a particular way. If the partners are listened to, the projections are their internalized perceptions of a parent, the polarization is that of their parents’ marriage, and the behavioural and affective elements are derived from their repetition of their early experience of dyadic relationships (Baht, 1972). There is great resistance to relinquish dyadic behaviour stemming from their phantasy of parental relationships, and where there are two varying family models there may be an initial struggle to establish their own interactions. When the behaviour of the dyad is looked at in detail, particularly for its meaning in terms of developmental experience of dyads, there is a strong feeling of the parents needing to be ‘justified’ (that the way they did it was ‘right’), and also the defence against a strong threat of loss. This latter is expressed in the way that if there was a new expression of dyadic behaviour, then ‘the parents ’ were no longer kept alive in the present relationship - and hence lost. When the therapist enters into the relationship he must continually re-examine the position he takes in relationship to, or within the dyad system. This may be in terms of unconscious phantasy; he may be the omniscient father who will administer ‘justice’ to the wrongdoers; an all-nourishing breast - a part-object. Or there may be a frank transference: a neurotic relationship may spring up immediately as if he was one partner’s father or he many represent the shared phantasy of a common-object to both. The triangular oedipal situation is easily reproduced a good case for a second therapist of the opposite sex and the sessions held as a foursome. The need is to understand, in order to avoid colluding and hence maintaining or even reinforcing the painful repetitive behaviour. In many areas of practice a decision may be taken to form a relationship with one partner only where the dyad is the relevant system. The irony that may happen then (with which we are all familiar) is that good psychotherapy often is divisive to the dyad and may lead to permanent disruption and pathology being expressed by the other partner, although the treated individual may be considerably improved. Individual and dyad response must be considered carefully when choosing to commence psychotherapy. When the other partner of a dyad is the parent of an adult, separation, of course, may be a desirable result, and individual therapy chosen deliberately for this reason. It is recommended that the use of conjoint psychotherapy for a wider range of psychiatric conditions be considered in the light of these criteria.
The wider uses of conjoint psychotherapy
Hypotheses and views of the significance of intervening with dyadic relationships are discussed, including discussion of 'General system theory ' to clarify the nature and relevance of dysfunction of the dyad system, compared with the individual system. Three illustrative cases are presented and discussed briefly. The resistances of 'presenting partner ', 'other partner' and therapist to conjoint therapy are examined. Criteria for intervention with the dyad are suggested, and the position of the therapist within the relationship is also examined. ACKNOWLEDGEMENT
I am grateful to Dr P. Morse, Acting Medical Superintendent, Rydalmere Psychiatric Hospital, for permission to publish this article. My gratitude to the late Pierre Turquet who taught me the practice of conjoint therapy.
BALINT, E. (1972). Fair shares and mutual concern. Inf. J. Psycho-Anal. 53, 61. DICKS,H. V. (1963). Object relations theory and marital studies. Brit. J. med. Psychol. 36, 125. DICKS,H . V. (1%7). Marital Tensions, pp. 68-69. Routledge & Kegan Paul. GOETHALS,G. W. (1973). Symbiosis and the life cycle. Br. 1. med. Psychol. 46, 91.
MARKOWITZ. 1. (1969). The locked twosome. Psychiat. Q. 43. 21 1-334. MEIR, A. Z. (1969). General system theory. Developments and perspectives for medicine and psychiatry. Archs gen. Psychiaf. 21, 302. WILLIAMS, M. (1970). Observations and hypotheses found useful in marital therapy. Internal publication. London: Tavistock Clinic.