What Is Psychotherapy? Proc. 9th Int. Congr. Psychother., Oslo 1973 Psychother. Psychosom. 25: 149-153 (1975)

What Is Marital Therapy? Jean Pasmore The Cassel Hospital, Richmond

(1) Marital therapy is a limited, though not superficial, form of psychothera­ py with the aim of helping the partners to enjoy a more rewarding relationship; or with the aim of lessening some of the strains and dissatisfactions in the relationship. The second definition is more realistic, and is also a description of the way of working. The dissatisfactions in marriage are due to the discrepancies between the couple’s phantasy of what marriage, their partner, or themselves, should be, and the reality with which they find themselves confronted. The strains in marriage are diverse, but one common theme is mutual anxiety about emotional dependence on the other partner because of fear of rejection, of being let down by, or of being taken advantage of, by that partner. These fears lead to a false independence which is a denial of the need to depend on anyone. This internal conflict is often seen as if it were a struggle, not in the internal world of each partner, but between the partners. This struggle for power, or rather, against the need to depend on the other, invades all areas of the marital relation­ ship: money, work, driving the car, bringing up the children, but shows most clearly in the kind of sexual relationship. This becomes a fight rather than a mutually supportive and enjoyable experience. The woman expresses her fight with the man by denegating his sexuality ‘men only want one thing’ - and becoming frigid. The man deprives her of satisfaction by impotence or premature ejaculation. (2) In family therapy, the question is ‘What happens in this family?’ The approach is to identify the interaction between the members of the family, and demonstrate it to them in the hope that they can modify it.

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The emphasis is not so much on internal conflicts as on their external expression. In marital work of the kind done at the Cassel Hospital, the emphasis is on the internal conflicts in the partners which, if understood, can lessen the need for their expression in marital problems. (3) In an individual treatment wider issues are considered, and more empha­ sis is placed on the individual’s emotional development: past, present and future. In marital therapy these are only involved insofar as they illuminate the central problem: ‘What happens between these two people?’

The most important, indeed, vital condition, is motivation; that both part­ ners own their distress over the marital problem and want help with it, and have some hope that help is possible. This does not mean that patients should hope for some magical solution from treatment; a healthy scepticism is a much better basis for work. However, those people who cannot have any trust in the thera­ pist will not be able to accept help, and will destroy anything good which is offered to demonstrate that it cannot be good enough, like the patient who asks for extra sessions, but arrives late for those which are offered. Those who persist in denying distress, or see it only in the other partner (‘I am quite willing to see you, doctor, if it will help my poor wife’), have no motive to work on understanding their own part in the difficulties. The impetus to change the marital pattern does not spring only from the individual’s dissatisfaction and distress, but also from concern for the other partner. This must be distinguished from the false concern so often voiced about the feelings of the partner, out of fear, or resentment, or as a projection of the sense of failure. True concern implies a recognition of the partner as a separate and different individual, e.g. ‘I want her to enjoy it too’ is different from ‘I am so afraid she will not enjoy it and then she gets in one of her rages with me.’ Patients must be willing to learn about and accept their own internal con­ flicts and negative feelings. Not everyone is able to make use of interpretations, especially those con­ cerned with understanding the doctor/patient relationship. Those who are not prepared to work in this way cannot be helped by psychotherapy and must seek other kinds of help. So must those who are so defended against their own unconscious that they can only recognize superficialities. Interpretative psychotherapy is not appropriate for those who are too sick or rigid. So young patients, or new marriages, do best. Sometimes a couple marrying late in life bring a determination ‘to make up for lost time’ that helps work to be done very quickly.

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Conditions fo r Marital Therapy

What Is Marital Therapy?

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A ims o f Treatment Before any work can start, the patient’s immediate anxieties must be ac­ knowledged and to some extent relieved. These may be about the problem itself, or about the visit to the doctor and what this may entail. Unless these are expressed the therapeutic alliance cannot proceed, e.g. patient send by hospital or by GP cannot work until this cause for her anger is in the open. This ambivalence towards the therapist derives from earlier unresolved conflicts, often towards parents, where anger and despair have been so overwhelming that normal emotional development cannot progress.

Each partner has to become aware of and able to accept their own emo­ tional and psychological natures. For the woman, this means valuing her own femininity rather than seeing it as second-best to being a man, and enjoying the possibilities of her own genitals rather than comparing them unfavourably with the man’s. For the man, it means accepting masculinity, and enjoying his own potency and aggressivity without too much fear of its becoming destructive. Problems between partners in marriage can usually be resolved if commun­ ication between them does not break down, so restoring this communication is an important therapeutic measure. This involves seeking out the many reasons for failure in communication: guilty secrets, fantasies of the other partner’s feelings, and especially, fear of being thought weak or aggressive by the other partner, and also unravelling some of the mutual projection systems which are distorting the relationship and impoverishing the individuals, e.g. the woman who is ashamed of her own tenderness and feels this renders her vulnerable, projects this into her husband and complains of his weakness. The man who fears the power of his own anger may see it only in his wife and complain of her rages.

Settings In the marital unit at the Cassel Hospital the setting o f choice is joint treatment for two therapists to see the partners separately, at weekly intervals for 1 h, and for the therapists to discuss their work together between their sessions with patients. In this setting, the problems of each individual have first to be formulated in terms of their own psychopathology. This diagnosis is at­ tempted from the evidence of their present marriage relationship, of their rela­ tionship with the therapist, and of their relationship in early life with parents or

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Techniques o f Treatment


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Focus In short-term work with the marital relationship, it is essential to formulate and keep to a focus. Otherwise, the free ranging associations provide an everready escape route from the pain of discussing the presenting problem. The basic focus is always concerned with the difficulties over masculinity and femininity; the physical, emotional, and social roles of man and woman, e.g. a woman who is uncertain of herself as a woman and so feels inadequate or a failure as wife or mother.

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other significant people. An attempt is then made to put together the diagnoses of the two individuals to explain what happens between these two people and how they make use of each other. Occasionally couples are seen in a foursome, sometimes in the course of joint treatment or sometimes as an alternative throughout the treatment. In this setting, little attempt is made to relate the difficulties to their historical origins in the emotional development of the partners. Rather the emphasis is on the immediate situation as a demonstration of what happens between them during the sessions. Sometimes this setting does allow communication between the partners to be freer. In the safety of the session they are able to own their feelings and to show them to their partner in a way they have been afraid to do before. These feelings may emerge as anger and resentment, but often it is the feelings of tenderness and concern and need which have been concealed. Sometimes, only one partner is seen. This is most useful when the woman has a problem concerned with her fantasies about her own body and its use in intercourse. These difficulties can often be expressed with her, making use of the technique of using the moment of vaginal examination to explore her feelings. This technique has been described elsewhere and is especially valuable in cases of non-consummation. Fantasies often expressed are that she is too small for her husband, that the passage is a narrow, rigid tube through which nothing can pass without tearing or splitting, and the very important hymen fantasy, which seems to be a common heritage of all girls, but persists in many women in spite of sex education. This was vividly illustrated by the biology teacher whose confidence was eventually won by the doctor, so that during the examination, she was able to say that she thought there was a skin right across the passage through which her periods had come by ‘osmosis’. When the woman is able to recognize that these infantile fantasies do not correspond to the reality, often when she is able to examine herself, she can then have the confidence to encourage her husband instead of playing into his own fears of damaging her, and many of these marriages are consummated without it being necessary for the husband to be seen as well as the wife. But this approach may only deal with one factor in a complex situation, and so may be a prelimi­ nary to, or an incident in joint treatment of the couple.

What Is Marital Therapy?

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The immediate focus deals with defences against this basic problem, e.g. she often defends against her own uncertainty by storming against her husband’s failure to take the lead.

Use o f the Doctor/Patient Relationship

Request reprints from: J. Pasmore, MRCS, LRCP, The Cassel Hospital, Ham Common, Richmond, Surrey TW10 7JF (England)

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This is the key tool used in this form of work. The pattern of the patient’s relationship with the doctor demonstrates vividly the way in which he or she relates to the marriage partner, and how both of these derive from early rela­ tionships in the patient’s life. Many of the tensions currently present in the marriage are experienced in the interview between the doctor and patient. Obser­ vations of the patient’s patterns of relationship and of the therapist’s own feel­ ings can be put together and used to help understand the problems in the marriage, but of course this can only happen provided the therapist is able to notice, but not act upon, the reactions produced by the patient in himself.

What is marital therapy?

What Is Psychotherapy? Proc. 9th Int. Congr. Psychother., Oslo 1973 Psychother. Psychosom. 25: 149-153 (1975) What Is Marital Therapy? Jean Pasmore T...
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