Monday, July 30, 2018

The Relationship between Marital Problems and Family of Origin Dysfunction

The essay In Consultation: Becoming a Therapist for Each Other: How to Deepen Couples Therapy by Ellen Wachtel Ph.D. in the Psychotherapy Networker from July/August 2018 answers a therapist’s question about a difficulty the therapist consistently ran into in his work with married couples. The question involved how to deal with the emotional difficulties of one of the members of the couple without derailing the work on the couples’ relationship issues.

Since in my experience both members of couples who seek marital therapy usually come to the relationship with pre-existing emotional issues – which I believe to be highly relevant if not crucial to their marital problem – that problem would come up no matter which member of the couple the therapist focuses on. Dr. Wachtel seems to understand this when she correctly points out that, “It’s common for one person in a couple to believe that the lion’s share of the problems in the relationship arises from the other’s emotional difficulties. As a firm believer that ‘it takes two to tango,’ I try to resist joining with that point of view.”

Unfortunately, she also adds, “But sometimes it’s just too big a stretch to see both partners’ contributions as anywhere near equal.” Nonetheless, she goes on to point out that, no matter how clear that seems to be,  the person “chosen” for individual work invariably reacts with, “’Why me? Shouldn’t she (or he) get therapy too?’ Or ‘I react the way I do because he’s so provocative.’”

I must say I agree with the member of the couple who says that. While one member’s dysfunctional behavior may be far more dramatic or dysfunctional than that of the other, in my opinion both members of the couple have a stake in their relationship continuing in its current dysfunctional form. The way this goes down and the reasons it happens were discussed in my previous posts “I’ll enable you if you enable me” and The Obvious Secret of Interpersonal Influence in Families.”

Briefly, each member of the couple is enabling the other member to maintain a role function that each believes necessary to stabilize their own parents, who are unstable due to an intrapsychic conflict that is shared by the entire family. I call this mutual role function support. Each member of the couple thinks the other member of the couple needs them to play this role because both of them compulsively act out their roles in the face of repeated and obvious drawbacks and negative consequences. Each person would deny this if asked for various reasons, so the other person has to guess why that person continues in their self-defeating or self-destructive habits, and they usually make the guess based on watching their partner interact with the partner’s parents (cross motive reading).

Wachtel comes very close to this formulation by recommending approaching the couple issues by saying, “We’re all stuck with some emotional issues from our childhoods, and even if we work on them in individual therapy, they’re still likely to have a hold on us. In our work together, we’ll try to find ways to keep these issues from affecting the relationship as much as they are now.” She also helps each member of couple construct their genogram to “get a window” into the source of problematic patterns. 

I would add that the emotional issues are not just from childhood but are in fact family emotional issues that are continuous and ongoing.

I have a lot of respect for Dr. Wachtel. She, along with her husband Paul, wrote a book called Family Dynamics in Individual Psychotherapy: A Guide to Clinical Strategies, the first edition of which came out in 1986.  This was one of the first books that attempted to integrate family systems ideas into individual psychotherapy.  (I must also admit I was a little annoyed when it came out because I was still trying to find a publisher for my first book, which attempted to do the same thing, and they beat me to it!)

Unfortunately, in this piece for the magazine, she falls into the exact same trap that Murray Bowen—the family systems therapy theorist who first started tracing dysfunctional relationship patterns through genogram construction—fell into. With his patients, as pointed out by Daniel Wile in his book on couples therapy, Bowen used education, logic, and collaboration to help educate his patients on the reasons for their self-destructive behavior. 

When he sent them back to their families of origin, however, he taught them to use the paradoxical interventions, therapeutic double binds, and strategic maneuvers that are part and parcel of Jay Haley’s alternative type of family systems therapy. In a way, he coaches patients to use this type of therapy on their family members instead of employing Bowen therapy. Wile asked why Bowen did not coach his patients on how to use Bowen therapy on their parents.

Wachtel starts to go down this route. She recommends to each member of this couple to offer support for, rather than merely challenge, the other member’s need to persist in each one's seemingly unproductive habits. In strategic family therapy, this is a paradoxical technique which often seems to have the opposite effect from what it seems to be intended to have: the partner might, in response to being given a green light, start to “be more able to hear his own internal voice that questioned the need to do the task.”

While this might help in couples that come from only mildly dysfunctional families, in my experience with more highly dysfunctional families, any good that comes from a paradoxical prescription will in fairly short order be undone due to the continued  and more powerful influence of the families of origin of each member of the couple. The parents and other family  member, as I often say, will invalidate the efforts of their adult child to step out of their dysfunctional family role with devastating effectiveness.

I find that members of a couple, with the right coaching, can move from the mutual role function support that attracted them to one another in the first place to becoming allies in the efforts of each to deal with his or her primary attachment figures. After constructing the two genograms, the therapist can help devise strategies for each member of the couple to stop dysfunctional interactions with each’s own parents. This can be done with the full understanding of the spouse so the spouse knows why their mate is suddenly trying to change things and understands how the devised strategies might actually work.

In fact, they can practice the strategies with each other. The spouse role plays the role of the other spouse’s targeted parent – and the spouse is usually well acquainted with that in-law and can do so very accurately – while the spouse practices the moves and countermoves planned with the therapist. This practice allows each one to stick with the script more effectively in the face of problematic responses from the parents.

I go into more detail about this process in my upcoming self-help book, due out November 1.

Tuesday, July 10, 2018

The Amazing Complexity of Environmental Research in Psychiatry

In my Psychology Today post of 12/24/12, Why Psychotherapy Outcome Studies are Nearly Impossible, I discussed the large number of variables that are not taken into consideration in those studies which bring any conclusions drawn from them into question. These include variations in therapist techniques that aren’t measured, sampling problems with people that can have wide variations in their proclivities and sensitivities, problems with finding an active control treatment, the lack of double blinding, and lack of complete candor by subjects.

The same types of issues apply to epidemiological research into environmental risk factors for various psychiatric disorders. Most studies try to measure the effect of a single environmental exposure on a single outcome—something that rarely exists in the real world.

In a “viewpoint” article from JAMA Psychiatry published online on June 6, 2018, by Guloksuz, van Os, and Rutten ("The Exposome Paradigm and the Complexities of Environmental Research in Psychiatry"),the authors discuss characteristics of the environment as they do function in the real world. They speak of multiple “networks of many interacting elements…”

Individuals are exposed to these elements as they accumulate over time, so that one single exposure usually means very little. Exposure also is “dynamic, interactive, and intertwined" with various other domains including those internal to individuals, what individuals do within various contexts, and the external environment itself—which is constantly changing. Last but not least, each individual attributes a different, and sometimes changing, psychological meaning to everything that happens to them. This meaning attribution can alter the effect of each environmental exposure dramatically.

Each environmental factor confers risk for a "diverse set of mental disorders." These factors are far from universal so that some people remain completely unexposed to them. They interact with each other so they are not independent. They are time sensitive. They are dose dependent even within similar environments, meaning individuals are not exposed to them at the same level. They can be subject to being confounded by each individual’s differing genetic propensities.

With all that to consider, drawing final conclusions from a few studies just does not cut it as real science. But the field tends to believe in those conclusions as if they were gospel.