There are occasions in which one's best psychotherapeutic efforts are not effective or help only modestly. If the effort has taken place for a relatively long period, the therapist has several options. One is to ask a colleague for consultation. A second is to reexamine one's understanding of the patient's dilemma.
In this essay, I will discuss some of the attempts to reappraise my understanding of one type of such stalemates-that involving couples therapy with a severely conflicted couple. Over the past several decades, this situation has occurred in a hand- ful of couples with whom I have worked.
The partners in one of these couples were both in their mid-30s and had been married for 12 years. Each was attractive and articulate. Both were also successful: she was a media consultant and he was a law school professor. They were independent and strongly opinioned. Each had experienced significant childhood trauma: she at the hands of an alcoholic father and with a mother who was unable to protect her sufficiently; and he as a victim of parental discord and divorce who had been sent to live with grandparents and, subsequently, experienced severe loneliness.
Their relationship had been conflicted from the start. Several weeks of truce (during which they enjoyed similar interests) were followed by a raging conflict, with angry blaming of each other terminated either by emotional retreat (hours or days of silence) or by one of them actually leaving for some hours. Threats of divorce were not uncommon but were never carried out. Each was in individual therapy, which seemed helpful in their developing deeper understandings of themselves, but their intensely conflicted relationship pattern was mostly unchanged.
In the several years I worked with them as a couple, there was only modest progress. The frequency and intensity of their periods of conflict were moderated, and at times, they could listen respectfully to each other. In my office, however, it was rare for conflict not to erupt. When it did, the affect was intense and the blaming pervasive. These uncomfortable periods were often difficult to interrupt-my taking a very directive stance often resulted in only a momentary cessation.
As the sessions went on it became impossible not to be impressed by the stereotyped nature of their conflict. Although the content of each clash differed from one episode to the next, the sequences of their behaviors were entirely predictable. Blaming and escalation were the rule. Even their changes in posture were coordinated as closely as the movements of experienced dancers moving toward and away from each other.
My mostly ineffectual efforts to help them change their destructive relationship pattern included a wide variety of interventions, ranging from behavioral prescriptions to psychoeducational tactics to interpretive suggestions.1 They were faithful in keeping their appointments and doing their homework assignments, but the basic conflictual pattern persisted. On several occasions I suggested a consultation or that another therapist with a different approach might be a helpful direction in which to move. They demurred, saying that they trusted me and, despite the stalemated situation, wished to continue.
Under such stalemated conditions, the therapist needs to reexamine his or her understanding of the relational dynamics in play. More specifically, what underlying purpose is served by the repetitive, stereotyped, conflictual interaction pattern that at a very different level requires a type of subtle cooperative behavior from both partners? It is in this sense that they can be understood as colluding in the repetition of a jointly constructed and clearly painful dance.
In the search to better understand the interactional pattern and the failure of treatment interventions to do more than partially modify it, the problem is deciding which theoretical lens offers the most promise. The more-or-less standard lens, that of systems theory, suggests that anger and conflict produce emotional distance-a distance that protects each participant from his and her underlying fears of dangerous (but desired) intimacy. When both partners have such fears, they are likely to collude in periods of distance-producing conflict. This way of understanding the couple previously described is a coherent way of looking at their dilemma, but my interventions based on making closeness less dangerous have not been very successful.
A second theoretical lens is derived from psychoanalytic theory and emphasizes their shared use of projective identification. In this format, the fo- cus is on each partner's unconscious projection to the other of undesirable characteristics within the self, and then behaving in ways that encourage the partner to respond to or "act out" the undesirable projection. Although shared projective identifications may serve diverse purposes (including, of course, ridding the individual of unwanted aspects of the self), at the relational level, I believe that they are designed to produce predictability. In a world filled with uncertainty and randomness, and since the couple had personal histories of injury from early caregivers, creating a predictable response from one's partner-however painful-can be experienced as safety. At the very least, knowing what is going to happen next, that at some level one can produce a highly predictable response from the other, can mean he or she has some control in a dangerous interpersonal world.
Although I believe that reciprocal projective identification is a valid way of understanding this couple's relational dynamics, it, too, has not led to impactful interventions.
A third theoretical lens is one that emphasizes existential constructs. The collusive, stereotyped pattern of conflict is understood as allowing each partner to avoid deeper anxiety stemming from existential ultimate concerns. In particular, the pattern allows them to avoid facing the concern of existential isolation, or feeling alone in the world. In this approach to their interactional pattern, each partner avoids the anxiety of being without a central relationship that buffers (somewhat) the dread of isolation.
"However fleeting, there are moments when I feel less alone," is one way to frame the issue. One sees couples who remain in chronically conflicted relationships and are aware that they stay together because there are such moments.
Once again, this interpretive lens brings possible understanding, but its usefulness has been limited in this case.
In using these 3 interpretive lenses as examples, I am clearly avoiding the obvious: I have become an important part of their system. The couple gives numerous examples of this: "What would Lewis say?" "What has Lewis taught us to try when we find ourselves beginning to behave this way?" "How is Lewis going to help us rescript this episode?" These questions only touch the surface of the fact that I am now part of the problem.
Although I find each of them very likeable as individuals, their co-contructed relationship mostly defies my efforts to be helpful to them. Much of their continuing pattern may involve their reaction to an authoritative parental figure-a presumed expert whose power must be unconsciously negated-even if the price is the continuance of a mutually destructive relationship pattern. In such a scenario, I begin to feel the helplessness that, in part, disarms me, and they defend against their shared fears of what happens in an interpersonal system in which a parental figure has more power than he or she has.
This interpretive lens involves both the reality of my approach to couples therapy (I am often authoritative) and their transference fears. They do not retreat from therapy; it continues to be an important source of hope for them. At the same time, their shared, fear-based resistance to change facilitates the continuance of the status quo.
As I hope has been made clear, psychotherapists need to have multiple theoretical lenses available to them and must search for that which offers the greatest utility. Usefulness triumphs truth-stalemates are particularly effective teachers of that lesson.
Marriage as a Search for Healing: Theory, Assessment, and Therapy.
New York: Brunner/Mazel; 1997.