Marriage A Search For Healing

Jerry M. Lewis

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134866250
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This work reveals those key elements that make for greater bonding with couples in therapy. The author believes that improvement in the couples he treats almost always involves greater closeness and the development of greater capacity for intimacy. Change can come about in different ways for different couples. For some, insight appears to play to play an important role. Learning about one's central problematic relationship of childhood and its re-enactment with one's partner in adult life frequently involves also learning about the ways one subtly recreates this dysfunctional relationship structure.; For others, improvement appears to be closely related to experiencing new ways of dealing with conflict. This avenue of improvement relies in part on the understanding but, even more, on learning the approaches to conflict resolution. It is as if these couples need to hear over and over again the recordings that document their insensitivities and consequent failure. They must offer Each Other The Experiences That Are Emotionally Suppportive And Crucial for emotional and physical health and also give life its meaning.; Finally, the treatment approach outline also has significant effects on the therapists. Indeed, it may be difficult to know who learns most. Involvement as a couples therapist may have all sorts of impact on the therapists, and it will come as surprise that it is in the area of the therapist's capacity for intimacy that the greatest effect can be experienced.

1

At the Beginning

“We came,” she said, “because after all these years he has begun to chew me up. He’s so hostile, irritable with everyone, but with me it has been murder ever since he retired.” She reported all of this with obvious rage, her face contorted with contempt.

He sat glaring at me, and I guessed it was humiliating for him to be a patient or, at the minimum, a candidate for patienthood. I knew him only by reputation—good doctor, a general internist with a large practice and more than usual participation in hospital affairs.

“I may be depressed,” he said, “but, if so, it’s not all that far from what I’ve always been. Retirement has not been easy—maybe it never is—but a big part of it for me is her unavailability. She leaves after breakfast most days—all sorts of meetings, luncheons, charities, art lessons, whatever—she’s back home by five, we have a couple of drinks, eat, and most nights we’re in bed by 8—reading, lights out by 9:30 or 10. Not much of a life.”

“And during the day …,” I reflected.

“Oh, I walk 3–4 miles in the mornings, read, fix a bite for lunch, nap, read some more. Watch any sports but bowling and soccer on cable.”

“Alone most of the time….”

“Yeah. I’ve never been very social. You know what medical practice is like. It’s draining and I’ve gotten in the habit of not wanting much to relate socially, except, of course, with Nan—who’s never there.”

I nodded, turned to her and said, “Sounds like he wants more of you, but, for you, more of him means catching more hostility.”

“I am busy,” she responded, “but it’s no fun being with him. Perhaps I do stay away more than usual because of his anger. Most afternoons I know what it will be like when I get home.” She paused, glanced quickly at him and then, with some urgency, went on, “I need to be honest—we need to be honest—if you’re going to be able to help us. Jack is depressed—and different than ever before. He’s never been this hostile—and I believe that’s where all of this starts. My retreating is real, but it’s secondary to the anger in him.”

Here, I thought, is something of the fascination of this work. In the first several minutes, Nan and Jack have each presented a narrative and, although they share common features, each has a different point of origin. Nan believes that Jack has responded to retirement with an angry depression and that their marital difficulty springs out of that depression. First things first. She lets me know she wants me to focus on his depression.

Jack’s narrative acknowledges some degree of depression and, although retirement is a factor, it is more a relational issue—Nan’s unavailability and their shared inability to make the necessary changes in their relationship—that he sees as primary. He seems as interested in establishing with me the validity of his view as she is in documenting her perspective.

The issues of how the problem is to be defined and what the process of definition is to be are crucial to any helping process. Years ago, I was introduced to this subject through the writings of Michael Balint (1972). Balint was interested in how medical diagnoses were arrived at by family physicians. In some cases, Balint suggested, the doctor makes the diagnosis mostly by himself or herself. Acute infections, broken bones, bowel obstruction, cerebrovascular accidents, and other, mostly episodic, disturbances are examples.

Balint proposed, however, that such episodes of sharp deviation from health are the exception rather than the rule in general medical practice. More often, patients come to their doctors with diffuse complaints for which there are few, if any, objective findings. Balint suggested that under these more usual circumstances diagnoses are subtly negotiated by patient and physician. Most often, patients negotiated out of fear and were willing to accept diagnoses that had few serious and no fatal implications.

Family physicians often negotiated from a base of those illnesses for which they had confidence about their treatment plans. Doctors would be drawn to diagnoses for which they believed they could be most helpful. If nowadays, for example, a patient presented with loss of general zest, easy fatiguability, and diminished interest in sex, a doctor with recent success with thyroid hormones might try to negotiate a preliminary diagnosis of subclinical hypothyroidism; this could lead to the prescription of thyroid hormones. Another doctor with recent success with antidepressants, however, would be more likely to negotiate a diagnosis of atypical depression, thus justifying the prescribing of an antidepressant. As Balint suggested, diagnoses in many situations reflect the physician’s need to be helpful—the need to establish the presence of a condition that can be treated effectively.

Thus, Balint saw the diagnostic process in many clinical situations as a negotiated effort. Patients entered this process motivated to minimize anxiety about death, dying, and disability. Doctors negotiated diagnoses around their wish to be helpful and their fear of being unable to help. A successful collaborative process involved establishing a diagnosis that minimized the patient’s fears of death or disability and facilitated the physician’s ability to be helpful.

This orientation about diagnosis and the diagnostic process has shaped much of my thinking about clinical interventions. When is it most useful to the patient for the clinician to assign, more or less as the detached expert, a particular diagnosis and when is it most useful for the clinician to involve the patient in a negotiated diagnosis? As thus framed, the central issue is not the validity of the diagnosis; rather, it is its utility. Here, of course, another issue lurks in the background. A diagnosis is more apt to be useful if it increases the probability that both patient and clinician share a sense of agency. In other words, a diagnosis is considered useful to the extent that both patient and clinician believe there is something that each can do to effect the outcome.

Although Balint wrote about family physicians, general medical patients, and the subtle negotiation of many medical diagnoses, it seems that his ideas can be particularly helpful to mental health clinicians. Psychopathology is, with rare exception, the result of multiple causative variables, and the same syndrome in different persons can result from the interaction of different variables. The clinician’s theoretical orientation about psychopathology determines which factors he or she attends and around which he or she plans treatment. In a previous publication, I used Beahrs’ (1986) schematic representation of multiple variable etiology to illustrate how clinicians with descriptive, psychodynamic, and marital-family systems orientations would select those aspects of the case material that their theories emphasized (Lewis, 1991a). Again, the issue is not the validity of a particular perspective, but rather how best to help.

Most often, the best approach involves multiple perspectives and several different treatment modalities. As this is written, however, third party intrusions under the guise of efficient case management often proscribe any treatment modality that is not simple, brief, and deliverable by lesser trained clinicians. It is my belief that this unfortunate period of economically driven clinical reductionism will pass, and that our gravest danger is that we will not pass on to subsequent generations of clinicians the principles of high-quality treatment based on the use of complex multivariable models of psychopathology and multiple treatment modalities.

In Jack and Nan’s clinical situation the issue of definition (diagnosis) is initially important because it involves the tension between an individualistic definition (Nan’s focus on Jack’s angry depression) and a relationship definition (Jack’s focus on what is going on between him and Nan). Although there is tension between the two of them about the definition of the problem, there is no intrinsic reason these perspectives cannot be considered complementary. Indeed, if they cannot agree that both viewpoints are important, and if each pushes to have me validate only his or her perspective, that conflict may turn out to be an important part of understanding their situation. The clinician needs to acknowledge the differing perspectives and to avoid taking sides; rather, if possible, he or she would give something to each.

“I can tell,” I said, “that arriving at a proper understanding of this situation is very important to each of you—as well it should be. There is much more that I need to know, however, before we decide what is the best approach.”

They both stared at me and, although it may have been my imagination, I thought I could detect a slight softening in Jack and, perhaps, subtle disappointment in Nan.

“Well, let’s see,” I reflected … “where to start?”

At this point, I decided to move towards a period of more structured inquiry. I would ask a series of “easy-to-answer” questions, all the while making a few notes. I decided to do so for several reasons. First, I wished to move away from their tension and conflict until I had a chance to better sort out some of my initial impressions. Second, I wished to see how each would respond to my taking charge of the direction of the interview. Would either or both resist this change of focus and insist on continuing his or her own agenda? Third, I needed a period of less compelling attention to bring together my initial thoughts and feelings about them. For example, Jack might invite from me, as a physician, an early positive identification. On the other hand, because he was depressed and more uncomfortable than Nan and hinted that he was victimized by her distancing of him, I had to guard against prematurely deciding that he was the patient.

Nan seemed more assured and, in some ways, more definite about the validity of her way of seeing things. She had seemed a bit disappointed when I didn’t endorse her perspective. Could this represent my introduction to her sense of entitlement … her need to be right about most things? Would I need to recognize in myself early signs of negative feelings about individuals who are certain that their way is right?

These early impressions of my feelings are more like the tuning-up sounds of an orchestra before the symphony begins. More than anything else, I am tuning my instrument with the awareness that what I am experiencing may turn out to be more noise than music. Despite this tentativeness, it is important from the beginning for the therapist to closely monitor his or her feelings. They often provide important understandings and, if not monitored, can impede or destroy effective treatment.

Finally, the “facts” themselves are always interesting and frequently important. They place patients in certain cohorts, at certain stages of adult development, and provide clues about repetitive patterns, stressful ongoing life events, important losses, and a host of other issues important for understanding clinical situations. Clinicians who treat marital and family systems also want to know about the relationship as an entity: where it is now, where it has been, and where the participants hope it will go. Thus, I began to collect facts about Jack, Nan, and their marital relationship.

“Jack, you are how old?”

“Sixty-seven.”

“And you’ve been retired how long?”

“A little more than a year.”

“Nan, how old are you?”

“Sixty.”

Jack quickly corrected her. “You were 61 two months ago.”

“Easy to forget when you want to,” Nan responded in a matter-of-fact way.

“How long have you been married?”

Nan responded, “We got married during his last year of residency. I was a senior in college. It was 1953—that makes it 41 years.”

“Children?” I asked.

“Well,” Jack said, “we have two sons. Judd is 36, a plastic surgeon, married with two daughters. Stuart is 33, a lawyer, still single.”

I sensed from a hint of sadness in Jack’s voice that there was more to the story of their children. “Something else?” I asked.

Nan responded, “We lost our daughter—she was 17, our third child—she overdosed—it was 15 years ago but we’ve never gotten over it.” She seemed on the verge of tears and the need for comfort was palpable. I waited, but Jack stared straight ahead, and each seemed entirely alone with the awful sadness.

Finally, I said softly, “I don’t think you ever get over it. Maybe the pain becomes somewhat more tolerable, but get over it, no.”

Jack sighed and said, “We were so-so until then. I’m kind of a loner and Nan’s really outgoing and friendly so there has always been disagreement—but, it was manageable by each of us doing a lot of our own things. I read a lot, gardened, and Nan was always with people. But, after Diane’s suicide—well, somehow we couldn’t be together in our pain—probably more correct to say I couldn’t share my pain. I felt so responsible. So, since that time, we’ve been even more distant, had more separate lives.”

There may be nothing like the pain of the loss of a child. There are survey data to suggest that such a loss is considered one of the most severe life stresses (Holmes & Rahe, 1967). There is much to suggest that the circumstances of the death may make the loss more unbearable or less so. A child’s suicide may be the most grievous loss of all. When a clinician is with a person or couple who disclose such a loss, he or she can experience an emotional jolt. The immediate issue is whether to get caught up in that pain or to fight against experiencing it by keeping it “out there” as something that has no possible personal relevance.

The dilemma of how close to the experience of the patient one wishes to be is present in every clinical interview. How much does the clinician enter into the other’s experience, feeling what the other feels, and how much does he or she seek only to understand the experience? The clinician should be able to do both—to move into the experience and then retreat from it in order to digest and understand it. Both experiencing and understanding are elements crucial to the psychotherapeutic process.

There are, however, some experiences that are so charged with deep emotion for all of us that avoidance of them is tempting. The suicide of a loved one is one such experience. There are also experiences of others that have emotional implications for some but not for all individuals. A clinician whose father deserted the family when the clinician was very young, for example, may respond to patient material involving the theme of desertion with heightened emotionality and, perhaps, increased need to avoid experiencing the patient’s pain.

Thus, at this point in my initial interview with Jack and Nan I had another decision to make about the direction of the interview. As earlier in the interview, when I deliberately moved away from the tension between their conflicting narratives, I now must respond to the issue of Diane’s suicide and what sounds like the divisive role it played in their marriage. To not respond and to move on with my “factual” format could suggest that I am uninterested or afraid, but actively pursuing it at this point may involve moving into an area that Jack and Nan are not ready to face with me or with each other.

In such situations, the safest position to take is to share that decision with the patient or couple. One technique for doing so is to present a brief summary and see in which direction Jack and Nan move. I decided on such a course and said,

“Let me see if I’m beginning to understand. The two of you have always been very different—Jack, you’re more the loner and Nan, you’re more outgoing. It sounds like your marriage has always been one in which there was considerable emphasis on separateness, autonomy, doing your own thing. And then Diane’s suicide—the worst kind of tragedy—and somehow you couldn’t share much or any of that terrible pain. Rather, each of you has had to try and deal with it alone. So—it’s been that way the past 15 years. Now, Jack, your retirement, maybe depression, and more tension between the two of you.…”

The silence that followed was painful and it seemed to last longer than the 8 or 10 seconds that actually elapsed before Nan spoke. “I don’t know that we can talk about it. There’s so much water gone under the bridge—so much not being there for each other. Pain, disappointment, resentment—I always felt cheated by Jack. Everyone talked about what a good doctor he was, a wonderful listener, very empathic—really cared about his patients. Hell, I got none of that. I’ve had to find all of that with friends. For all these years I’ve felt shut out.…”

Tears began to roll down Nan’s cheeks, and Jack kept his eyes riveted on me. After a short silence, Nan continued. “Now that he’s retired and doesn’t have his patients to relate to, he suddenly wants to change everything—spend time with me and try to put something together that we’ve never had. I know he’s depressed and angry, but I’m not sure I have it in me to try to help. Maybe I don’t even want to—maybe I think his dep...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Dedication
• Acknowledgments
• Introduction
• 1. At the Beginning
• 2. Out of All the Millions of People …
• 3. Enduring Interactions and Collective Illusions
• 4. Competent Marriages and the Continuum of Marital Competence
• 5. A Theory of Marital Systems
• 6. Assessment: First Contacts
• 7. Assessment: A Structured Approach
• 8. Marital Therapy: Initial Considerations
• 9. Marital Therapy: Therapeutic Effects of the Assessment and Stabilizing the System
• 10. Marital Therapy: Teaching Relationship Skills
• Reading Notes
• References
• Name Index
• Subject Index