Introduction from eshrink’s editor and daughter.

Dad’s introduction to his communication series got me thinking about stuff I’ve learned/witnessed as the daughter of a psychiatrist. In this post, eshrink will discuss marriage counseling, but his post contains useful information for any person in a relationship. There’s also some interesting behind-the-scenes shrink strategy for all of those armchair therapists out there 🙂

1970-something

I was 12 years old when I rode with my dad from Zanesville to Upham Hall at Ohio State University. It was a sunny, Monday afternoon in the summer. Each Monday, dad traveled to OSU to teach a class for the medical school. I would often ride along in order to visit my best friend Susan. Our family had moved from Columbus, Ohio, to Zanesville, Ohio, after I finished 5^th grade.

After dad finished teaching his class, he saw patients at an office in the Columbus suburb, Upper Arlington, which is where we had lived before moving to Zanesville. During this particular Monday, my friend Susan was busy during the afternoon, which meant I wouldn’t be able to visit with her until dad’s class was over. Dad let me sit in the observation room with the medical students. The lesson that day was about marriage counseling. A couple entered the room where my dad was and sat down. He explained the medical students were observing as OSU was a teaching hospital. Dad started the session by asking the wife what first attracted her to her husband. “Go back to when you first met, what attracted you to Bob?”

The demure woman dressed in a pink dress and cardigan sweater didn’t have a hair out of place and appeared to be one of those people who is extremely efficient and organized…maybe too organized, as she sat somewhat rigid with impressive posture.

She looked up to her left and seemed to soften as she reminisced about the first time she met Bob. It was a party at college. She said she had always been quite reserved, somewhat shy and felt out of place at large social gatherings. She saw this crowd of people around a man with a large presence and hearty laugh. She marveled at how he was the life of the party and effortlessly worked the crowd. When he talked to her, she felt as if everything was somehow lighter.

Next, was Bob’s turn…he remembers how “put together” Jane was and what a good listener she was. “I felt like I was the only person in the room when I talked to her. She listened and seem to ‘get me.’”

Next, dad asked Jane why she and her husband were here. She said she was unhappy in the marriage and had been for years. Dad continued to probe. After a few minutes, he reiterated what he had heard her say and asked, “Well, what is it about Bob that you think is making you unhappy.” Jane said he had changed. He had become so self-centered. He never asked her what she thought. He always had to be the center of attention. Everything was a big joke. She went on and on….describing all of the qualities that had first attracted her to Bob. In the adjacent observation room, the med students and I let out a collective gasp.

Dad will use this memory of mine to share some insights about marriage, relationships, and communication. Take it away dad….

Eshrink’s marriage counseling 101
It was quite a surprise to hear that Maggie had retained such detailed memories of the session she observed at the family study unit nearly 30 years ago. It could have been even longer, but I am not certain as to how sensitive Maggie is about age disclosure. As is common with those of my vintage, my long term memory is much better than for recent events such as where I left my car keys; consequently I do have some vague recollections of that day, but not of the specific couple involved. These unhappy people whom Maggie so eloquently described; had been referred to our clinic with a fairly common marital problem, which she also defined quite well in her introduction.

After looking at the prospects of sending four kids to college on an assistant professor’s salary, I had recently left my full time position on the faculty of the Psychiatric department of OSU for greener pastures. However, since I had enjoyed teaching, I hung onto one of my favorite subjects, namely marital and family therapy. After the move to Zanesville, I continued to spend one afternoon per week teaching at the Family Study Unit. The facility consisted of two rooms with a one way glass separating them. The format was very informal and participation was voluntary; consequently there were participants from a variety of disciplines including social work, psychology, medical students, and psychiatry residents. We received referrals from both the inpatient service and outpatient clinic. They were seen by the referring physician or by a volunteer from the group. The sessions were videotaped and discussed later by the viewers, but there was usually a lively discussion by the viewers during the session. Occasionally I would be challenged to be the therapist which must have been the case during the session which Maggie referenced (I am sure the students all welcomed the opportunity to critique the old man).
Opposites attract, but do they stick?
A reciprocal relationship as described in Maggie’s intro frequently leads to marital problems down the road. It is true that opposites attract, but it is also true that one must be careful of what he/she wishes for. Those behaviors which first attract two people to each other frequently become the source of their complaints after they are married. My explanation of this phenomenon is much more simplistic than her shrink’s who appears to be drawing on psychoanalytic interpretations. In my opinion Jane saw in Bob what she lacked and yearned for. Perhaps at that party she felt more comfortable in his presence, she might have felt safer as he diverted attention to himself and she could feel a part of the group without exposing her social ineptitude. Bob may have felt more comfortable in her presence as she listened to him; consequently he did not feel the need to utilize all that energy to gain attention. It seems likely that he noted her compulsive personality characteristics (“she was so put together”). It seems likely from the description of his behaviors that he was a big picture guy and the idea of an organized person in his life was appealing. She might even be able to help him get his s… together.
Courtship probably went well. He added some zest to her life, and his needs for approval were realized by her. He would have been impressed by her sound judgement, rational approach to life, and organizational skills which were in marked contrast to his cluttered lifestyle. He might have even asked for advice about personal matters from time to time. She would have enjoyed the playfulness that had been lacking in her life, the little pats on her backside, and the sharing of his sense of humor. They would have looked forward to seeing each other, and were lonely when apart. As a matter of fact it was as if a part of each was missing when they were separated. The affectionate feelings which resulted would have further enhanced the sexual attraction which they probably had felt at their first meeting.
The end of the honeymoon (6-8 years post nuptials)
Now let’s fast forward six or eight years, which was the most common time for marital problems to reach a crisis point in our experience. As Maggie pointed out the anger is palpable, and has erased any feelings of affection. There has been very infrequent if any sexual activity for months. There are probably a couple of kids. They disagree about childrearing practices. Bob says “Lighten up, let them be kids, if you keep them on a tight leash they will grow up to be uptight like you”. Jane’s response: “How would you know anything about the kids, you are never home. Wednesday is bowling, Saturday golf, Sunday you are plastered to TV watching your precious football”. “I never know what time you will get home. You spend more time with your friends than with your kids”. Bob: “Why would I want to come home? All you do is bitch at me.” Jane: ‘While you are out having fun, I am at home doing your laundry and cleaning up the messes you have made. I work all day too, but you expect me to do all the work around the house”.
This little vignette is what family therapists are faced with routinely. It is an example of an attack-attack system. When under attack one is likely to subscribe to the age old tenet that the best defense is a good offense; consequently it is natural for one to fight back. There are continued back to back attacks, and the situation soon escalates into a full blown fight. There are other ways to deal with an attack, and some of them can also be harmful to a relationship but we will save that for later. The attack-attack system is very inefficient as each blames the other; consequently nothing is accomplished, and resolution is impossible. There is also the risk that the escalation may result in violence.

It is helpful for the therapist to view the problems presented as caused by the system under which the patients communicate. This helps to prevent him from getting “sucked in to the system”, and becoming part of the problem or even aggravating it. For example, if one joins in the search to discover who is to blame he has become a participant rather than an observer, and he is apt to aggravate rather than contribute to a solution. It is characteristic of all communication systems that once one is incorporated into that system he loses sight of the big picture. It might seem a simple thing to avoid that pitfall, but time after time we observed therapists who were “sucked in”.

Interestingly, as we viewed videotapes following the sessions it would be obvious to the perpetrators that they had committed the sucked in sin, of which they were unaware during the session. Probably the best albeit least efficient way to deal with the problem is to have two therapists at a time. Of course in a private setting this would be much too expensive We are all conditioned to “join in a conversation” but the therapist’s role should be to observe and intervene rather than join. To be successful in modifying the system, he needs to become a meta-communicator, that is to communicate about their communications, or in other words to be able to look at the system from the outside. He then needs to help his patients understand how their system of communicating to each other is causing their problems.
Reframe Anger
In Bob and Jane’s case the goal should be to allow them to see how their never ending attacks on each other have compromised their relationship and prevented them from getting what they want from their relationship. It might be helpful to reframe their anger: “you two must care a lot about each other to become so angry that what you had was lost”. The response will usually be: “of course I care, he is the Father of my kids” and he with a similar response such as: “I am here aren’t I?” People rarely admit they don’t care, besides if they admitted they didn’t care it might be used against them. The hope is that this might stick somewhere in their brain so that when one is screaming at the other they might recall that exchange.
I feel…
joy, sorrow, anger, fear
Usually; it is necessary to use a more creative approach. One could be to give them an assignment to preface each comment they make to each other with the words: “I feel”, and having them practice in the session. One would expect Bob to say “I feel as if she is a bitch”. He would be reminded that this is an opinion not a feeling, and also told that there are four basic feelings namely: joy, sorrow, anger, and fear. Jane would likely interrupt with her own rendition of Who’s afraid of Virginia Wolfe, and inject a comment like, “See, he doesn’t have any true feelings, he is an insensitive asshole” or something equally flattering. She would be corrected also and asked how she felt about Bob becoming an asshole. At this point it might be more productive to stick with her for a while since men have usually been conditioned to not express feelings, and women are usually quite good at it. Her first response would probably be “it makes me angry”, and when pursued with “anything else? she would likely say “it makes me sad”. If we were lucky there might even be some tears.
Were we fortunate enough to get this far in the session we would have accomplished a lot. As we shrinks would say, we have reduced the conflict from a cognitive to an affective level of communication. In relationships emotions are more important than facts. If I say I am sad that’s that unless I am a liar. An ongoing debate to prove who is worse is difficult to carry on if only feelings are expressed. It has been said that perception is reality, and emotion always colors perception. That is undoubtedly the reason that we psychiatrists are often saying, “and how do you feel about that”? That principal is also useful in relationships of all kinds, but I will save all that for a future blog since I am approaching the length of writing allowed by my esteemed editor.
The Double Bind.
There have been multiple schools of thought regarding psychotherapy, the most recent and widely accepted being Cognitive Behavioral Therapy or CBT. Basically, it is based on the premise that how we think affects our emotions and behaviors, and seems to me to be a one size fits all approach. It is time limited, highly structured, but I preferred to go in the opposite direction and deal with feelings directly. One approach to these kinds of relationship problems which I have always found intriguing, and resulting in some success has been with the use of the therapeutic double bind or paradoxical admonition as it has sometimes been called. The double bind or catch 22 is not new. It involves creating a situation in which a person is put in the damned if you do, damned if you don’t position. Back in the days when mothers were blamed for all our troubles the classic example was when a double binding mother always gave her son two neckties for Christmas, so that when he appeared the next day with one of the ties on she could say “oh, so you didn’t like the other necktie.”
Give ’em hell therapy?
In like fashion, it is possible at times to produce a situation in which the patient is better if he does or better if he doesn’t. I have found this particularly helpful in treating some forms of sexual dysfunction, but that is another story. For Jane and Bob I might suggest they spend 20 minutes each evening at an agreed upon time to complain and berate each other for 20 minutes. My explanation might be that with so much pent up anger they both needed time to get it out of their system. In order to be fair, they must level their criticisms on alternate days with the one being criticized maintaining total silence. They would be instructed to set an alarm and not stop their criticisms until it went off. The timing and absolute silence on the victim would be emphasized several times, and the exercise would be billed as absolutely necessary as a prelude to a successful outcome of their therapy.

This rigidly designed homework might appeal to Jane’s compulsiveness and Bob might relish the idea of finally being able to tell her off once and for all. They must also agree to save all their criticisms for their turn and nothing critical or hurtful the rest of the time. It would be suggested that they take notes and save their criticisms and complaints until it was their turn to unload.

Failure by Design
Of course they will fail miserably at their assignment and find that it is virtually impossible to complain and berate anyone that long if there are no responses to feed their anger. Even if they do succeed they will have learned something about their need to beat on each other and when they fail at their tasks they may have developed some insight into how foolish and self-defeating their behavior has been. In similar situations, I have even had couples return laughing at themselves.
Of course marital therapy does not always lead to a resolution of problems, and it may even be that divorce is therapeutic in some cases. This is particularly true in those cases of chronically violent behaviors, and especially when children are at risk. The sessions may also reveal secrets which defy solutions, such as a pregnant mistress. Severe mental illnesses may require individual treatment of the afflicted; although supportive spouses can be most helpful, and I always attempted to see those patients with their spouses whenever possible.
What’s Next?
In future blogs I hope to write more about related issues including more about family relationships and therapies, some thoughts concerning the importance of how we communicate with each other and hints as to how we can do a better job of it.