Xamily systems theory has integrated the approach to the individual, the marriage, the family, the immediate environment, and the society into an interrelated, functioning whole.1 ' This process seems to have resulted in changes in clinical practice. What has resulted is a greater emphasis on the parenting of the children. Correspondingly, there has been a lessening of emphasis on the parents as individuals and on the core interpersonal-marriage relationship. Thus, it becomes important to underscore the principle that it is impossible to understand any of the three basic sets of relationships in the nuclear family (husband-wife, parents-children, siblings) in isolation from the others.4 Parental skills cannot be improved without an understanding of the marital relationship. The basic relationship in the nuclear family is that between the marital partners. The important functions of child rearing flow naturally from the marital relationship.
Having advocated the recognition of the principle of the importance of the marital relationship within the family system, one can give recognition to a positive consequence of the family systems perspective on the parenting function. When the extended family is brought into focus with the third generation's (grandparents') effect on the parents and their children, the functioning of child rearing is upgraded by the additional knowledge and understanding that results. John Bowlby's emphasis on understanding the effect of the grandparents on the marital couple is seen in his emphasis on frequently reported observations that the emotional attachment between the spouses is identical with the emotional attachment that each spouse had in his or her family of origin.3 If this is not modified by therapy, the same observation can be made about the emotional attachments that the grandchildren make as they develop. When therapy takes place (whether individual, marital, or family), the parental generation can learn that there are other role models and ways of relating in the marital relationships and in the parent-child relationships than those manifested in the grandparents' nuclear families.
In this article I will discuss the four patterns of marriage disorders and then describe the symptoms most frequently encountered in persons with marital problems.
PATTERNS OF MARITAL DISORDERS
In collecting data on marriage disorders for some 30 years, I found it possible to recognize specific clinical entities frequently encountered in the practice of marital therapy. I have reported on them in more detail elsewhere;5 here I want to present four of them. In practice, one finds combinations of these patterns and variations on these themes.
It is important to realize that not all marriage disorders fall into one of these categories. An understanding of those most commonly encountered, however, will make it relatively simple for the therapist to recognize disorders not included here. This is because one can derive normal values for marriage from these Psychopathologie marriage patterns and then recognize easily the workings of other patterns that fall on either side of the range of normal values. It is analogous to the laboratory testing blood-sugar levels, where the normal range of blood sugar is 80-120 mg. /100 ml. On either side of this normal range will be found low or high blood-sugar levels leading to diagnosable disorders.
As in other branches of medicine, the study of pathology has been of enormous value in contributing to psychiatry's knowledge of what is normal. Study of these four Psychopathologie marriage patterns makes it possible to discern the values that are "normal" for healthy marriages.
A healthy marriage is a union between two individuals who are
* capable of being self-supporting,
* capable of being supportive of the mate,
* capable of loving, and
* capable of commitment to the marriage union.
These "normal" values are in keeping with psychoanalytic concepts'1' of psychosocial development from the early symbiotic mother-child relationship, through separation and individuation, to maturity. Ideally in marriage, independence is equal, dependence mutual, and obligation reciprocal. An ideal, however, is not being proposed here, since there is a wide normal range of these values that still allows for a healthy marriage.
Marriage is not a static state but has changing stages of its own. Marriage is also one stage in each mate's life cycle. It is a phase in which further growth and development can occur through an intimate relationship or in which there may be an arrest or even regression in development. Marriage has the capacity to facilitate each partner's growth or to promote destructiveness.
The four marriage patterns to be discussed are the "lovesick wife and cold-sick husband," the "in search of a mother," the "dependent-dependent," and the "paranoid marriage" patterns.
The "lovesick wife and cold-sick husband" marriage pattern is characterized by a hysteric-dependent wife and an obsessive-compulsive, overly independent husband. The clinical entity is determined by the picture presented by such wives. They come for treatment with complaints of anxiety, depression, or physical symptoms. They reveal evidence of emotional decompensation but blame their distress completely on the fact that their husbands do not give them love. They tend to insist that they are healthy despite their symptoms but that their husbands are sick because they are cold and unresponsive. They see the solution to their problem to be a complete change in the husband's personality. Continued evaluations reveal that these wives' relationship with their husbands have become increasingly dependent and symbiotic. Central to their individual disorder is the issue of their inability to develop self-esteem and their subsequent need to search desperately for constant and unqualified approval from their husbands.
Study of the husbands showed marked variations, in contrast to the consistent picture of the wives in this pattern. The husbands are often intelligent, responsible persons who have established areas of competence outside their marriages. They showed little evidence of emotional decompensation and differed radically from their spouses in their lack of emotionality. The major disturbance, which varied greatly, was a difficulty in tolerating intimacy.
The major difficulty in this pattern is that the partners are unable to develop a viable pattern of intimacy that will allow the wives to maintain emotional homeostasis. The wives present a picture of arrested development, necessitating an experience of remothering so that they can complete the process of separation and individuation. The husbands, expected to do the remothering, are frightened by the wives' excessive demands, because these demands present a threat to them (the husbands) of regression to symbiosis.
The "in search of a mother" marriage pattern is the mirror image of the first pattern; here it is the husband who determines the clinical entity. The husbands have the problems of dependency needs, symbiotic attachments to women, and a lack of selfesteem. The wives and the "other women" are comparatively strong, capable, and supportive of the husband. Frequently, the husband comes first for help because his extramarital affair has surfaced. The history is usually one of a good marriage while the wife was almost totally devoted to taking care of the husband. When the marriage entered a new stage of taking care of children , the husband began to have an affair. Such husbands seem to be constantly in search for a mother figure to take care of, to protect and to love them. They are often irresponsible in their work and may have difficulty with alcoholism or drug addiction.
The wives and other women were characteristically mothering individuals who were reliable and dependable. They also illustrated a need to organize, dominate, and control situations. This type of marriage problem is not uncommon and may even be harmonizing until the husband enters into a liaison with an "even better mother."
The "dependent-dependent" marriage pattern has been described as the "double-parasite marriage." It is one in which there is no host. A passive-dependent husband is married to a passive-dependent wife. They are cared for by support systems in the extended family or by community agencies. It is a pattern in which two people desperately cling to each other because neither feels that he or she can make it alone. It may be filled with hostility, alcoholism, drugs, depression, and vocational failures. Each mate expects the other to do the giving, to be the mother figure. When these expectations are not met, anger and panic often appear. The disturbances occur very early in the marriage.
The "paranoid marriage" pattern exists in three different types, folie à deux, friction between a psychotic and a nonpsychotic mate, and conjugal paranoia.
Folie à deux is the most Psychopathologie of the three, but the pattern is seen the least frequently. Strange as it may seem, the appearance of folie à deux is very helpful in achieving an understanding of marriages that function healthily. In this clinical entity, there is a dominant mate who is psychotic and a dependent mate who adopts the same psychosis. The dependent one adopts the same delusions, hallucinations, and thought disorder so as to maintain a harmonious relationship in the marriage. The two become like twins, and from their viewpoint they have a harmonious marriage. There is no friction between them. They have a "good" marriage, but they are in trouble with reality. If the husband has the primary psychosis, he may be in trouble at work. If it is the wife who has the primary psychosis, she is having difficulties with neighbors or relatives. The husband must agree with her and side with her; otherwise the wrath will be turned against him.
This harmonious marriage with shared delusions helps us to understand harmonious healthy marriages. In the latter, the marital pair feel the same way and think the same way about things. They share the same biases and prejudices. These cause no marital friction, because a match-up has occurred. Neither gets into difficulty with reality because their ideas are in keeping with biases and prejudices of the society in which they live.
The most common form of paranoid marriage illustrates a severe marriage disorder. This differs from folie à deux in that the nonpsychotic mate decides that he or she is not capable of accepting, in toto, the thinking, the feelings, and the attitudes of the paranoid mate, and therefore friction occurs. It may be overt friction, with verbal or physical abuse, or covert friction, with nonpsychotic symptom formation in the mate or in the children. With overt friction, the nonpsychotic mate joins hands with reality to fight against being controlled by the paranoid mate. With covert friction through neurotic symptom formation, such as depression, the mate is fearful of fighting openly for fear of abandonment, homicide, suicide, or harm to the children.
Conjugal paranoia is a third type of paranoid marriage disorder. This is the pattern in which one mate develops a pathologic jealousy of the other, with delusional ideas about infidelity. The accused mate is constantly on the defensive, trying to disprove the paranoid contentions. Characteristically, the paranoid mate finds fault with, humiliates, and degrades the other. This often progresses to a frankly delusional state, with pathologic jealousy and delusions of infidelity.
To summarize the four pathologic marriage patterns: Marriage disorders occur when one or both mates have not completed the tasks of separation and individuation. One (or both) needs to utilize the other mate as a support system or as an alter ego to act in place of a piece of ego structure that has not developed within him /herself. In the "lovesick wife and cold-sick husband" pattern, she turns to her husband for help, and he turns away. In the "in search of a mother" pattern, the husband turns to the wife and to other women to support him in this same way. In the "dependent-dependent" pattern, neither husband nor wife has a mate capable of being the needed mother figure. In the paranoid marriage pattern, the psychotic mate needs an identical or mirror-image object with which to fuse.
In each of these pathologic marriages, then, disorder occurs when at least one mate is incapable of standing alone without too much imposition on the need-satisfying object. In healthy marriages at least one mate is capable of taking care of himself and of the other person, and usually both are capable.
SYMPTOMS IN MARITAL DISORDERS
One of the most useful ways of presenting marriage disorders is through a listing of the symptoms experienced by the mates in disturbed marriages. Among these symptoms are anger, love, adultery, problems about secrets, and sex.
Anger is the most frequently encountered emotional response in persons with marriage disorders. The anger may in time lead to aggression, violence, or such symptoms as phobias and depression. Most often the anger is expressed verbally and leaves wounds in the mate that may never heal. This often deafening sound can hardly be missed. What is frequently overlooked by the physician is overt physical aggression, with resulting wife and child abuse. The inability to handle anger effectively contributes greatly to the widespread breakdown of marriage today.
The intimacy of the marriage relationship facilitates the emergence of each partner's deepest wishes and needs. This makes both of them vulnerable to narcissistic injuries when lack of gratification of the needs or disappointment through unrealized expectations occurs. This may lead to open responses of hostility, anger, or primitive rage. When the anger is repressed, vague, difficult-to-diagnose symptoms affecting several body systems develop.7
In the psychological sphere, such symptoms as phobias, anxieties, obsessions, compulsions, and depression appear to result from the person's defensive management of underlying anger.
Statistics indicate that physical abuse is a problem in 15 to 16 percent of intact families.7 Of couples who come for help with marital problems, 20 percent report that there has been physical abuse in their marriage. The actual incidence is probably higher, because physical abuse is considered a taboo subject and because the criminal-justice system reacts and reports inconsistently when the physical abuse is called to its attention.7
Another syndrome related to anger is the "dyscontrol syndrome." This phrase is used for symptoms arising from poor impulse control, whether the cause is organic or functional.8 When present, the dyscontrol syndrome is manifested by physical abuse in marriage.
Although usually spoken of pejoratively, anger at times has an adaptive function serving as an energizing, expressive, discriminative response to stress. Anger may energize one's behavior by increasing the vigor with which one acts in response to stress. In chronic stress situations as experienced in marriage disorders, however, the anger has a disruptive effect by interfering with cognitive functioning and disrupting communication in the marriage. Intimately related persons may need help in expressing negative feelings in order to resolve conflict rather than merely to escalate a sequence of mutual antagonism.
Complaints of lack of love, as described in the "lovesick wife" pattern, are closely related to anger in marriage disorders. Women have traditionally voiced this complaint; today it is also heard from husbands, who sometimes contemplate leaving home because they feel that excessive demands are being made on them by their wives and children, without reciprocal love or appreciation being shown them.
It is pertinent that this emphasis on "love" is a late-20th-century phenomenon accompanying what has been called the companionship marriage. People may not have complained about the lack in marriage during earlier centuries when there was no expectation that affection would be the central part of the marriage. Today "being in love" is the main reason why a couple gets married, and "falling out of love," consequently, can be the main reason for getting divorced.
We used quotation marks around the word "love" in the preceding paragraph because these are obvious examples of pseudo-love. When the observation is made that love and hate are closely related, it is really pseudo-love that is being labeled love.9 The primitive reactions of pseudo-love are not related to mature love, which, in contrast, is experienced as something that makes the recipient feel good and is an underlying and fairly constant base for the relationship rather than a short-lived phenomenon. Mature love is the motivating power that enables the giver to offer strength, power, and peace to another person.10 hrich fromm emphasized the distinction between the two types in his statement:
Nonproductive or irrational love can be . . . any kind of masochistic or sadistic symbiosis where the relationship is not based upon mutual respect and integrity but where two people depend on each other because they are incapable of depending on themselves. This love, like all other irrational strivings, is based on scarcity, on lack of productiveness and inner security.11
In true or productive love - the closest form of relatedness between two people - the integrity of each partner is preserved. Although conflict and tension will surface under stress, the underlying base is joy and happiness, not hurt and hate.
Adultery is a problem that is common to marital disorders. It is estimated that 50 percent of married men or more have had an adulterous relationship at some time during a marriage.9 Adultery is often at the base of various physical complaints of the nonadulterous spouse or is the immediate precipitating cause of a suicide attempt. By such a gesture, one mate attempts to avoid the loss of love implied by the other's extramarital affair.
Discovery of the infidelity is experienced often as a severe narcissistic injury, with resultant feelings of helplessness, guilt, rage, and disintegration of coping mechanisms. In one-third of the couples discovery of extramarital sex leads to divorce, and in two thirds the marriage continues as efforts are made to heal the psychic wound. What appear to be the determining factors that matter to the couple are the meaning of the affair, the motive behind the liaison, and how the liaison is interpreted by the spouse.
Often, the initial presentation of the problem is through complaints from the uninvolved partner about the change in sexual interest or performance in the unfaithful mate. Although a suspicion of infidelity is present, it may not be voiced at first in the hope that there may be some other cause. The one having the affair may show symptoms of frigidity, impotence, inability to complete intercourse, or premature ejaculation. If the sexual difficulties persist with no adequate explanation, the result may be verbalization of unspoken suspicions and accusations of infidelity, which are often denied. Development of this disorder will be continued in the paragraphs on "secrets" that follow.
Secrets in marriage are a problem that can develop quickly from adultery. But there are many other types of secrets that one spouse may wish to keep hidden from the other. Some may be rather innocent: one of the mates may feel guilty or ashamed of things that happened before the marriage and fears he or she would suffer a loss of respect or love if the secret were found out by the marriage partner. They may include such issues as a previous mental illness, a criminal record in the extended family, early experiences of bestiality on the farm, or an isolated childhood experience.
Other secrets one spouse attempts to keep from the other may be more serious, such as a current active homosexual liaison or adultery.
During marital therapy, the management of a secret learned from one of the spouses becomes a delicate matter of confidentiality if that spouse does not want the secret revealed during therapy. This presents a difficult technical problem to the therapist; it is possible to handle the secret judiciously until the problem is resolved, but in accomplishing this the therapist must take care not to become one partner's ally at the expense of his relationship with the other.
Some marital therapists deal with the issue of secrets in a different way. These therapists announce to the couple at the first interview that the therapist does not want to hear any individual secrets and that if he is presented with confidential material, he will feel obligated to share them in the conjoint interviews. The objective of this approach is to have all secrets exposed and worked through during the conjoint interviews as a means of strengthening the marriage. It is also a test of the motivation m treatment and commitment to the marriage.
A different situation exists, however, when a dependent type of spouse feels guilty about what he has done (e.g., an act of adultery) and wants to help get rid of the guilt by dumping the burden on the shoulders of the innocent mate. If the therapist colludes, he does the adulterous mate a disservice by allowing him to miss the opportunity for personal growth by handling his own responsibilities. There is also a possibility that exposure of the secret to the other mate may cause a narcissistic injury that will never be forgotten or forgiven.
Sexual problems surface in marriage disorders as a manifestation of disturbed interpersonal relationships. Simple sexual problems can be handled by the proved techniques of sexual therapy originated by Masters and Johnson. When there is intense hostility, competitiveness, or lack of motivation in one or both mates, however, these techniques are not successful.
It is important that one seeking a deeper understanding of the role of sexual problems in pathologic marriages recognize that there are two clinical entities involving less than average use of sex in marriage. One is known as the happy-but-sexless marriage;12 the other is the unconsummated marriage.
In the happy-but-sexless marriage, the couple have very little sexual activity and yet appear to have a happy, productive marriage. The therapist must recognize that couples in happy, productive marriages vary tremendously in the frequency of their sexual relations. A happy-but-sexless union may develop in a happy marriage in which sexual activity has been great, as the result of some debilitating disease, such as cancer, diabetes, or renal failure (necessitating dialysis), or as the result of trauma. In many such marriages the couple continue to be happy and productive even though sexual relations may cease. It appears that when the bond between marriage partners is secure and stable in other ways, the loss of sexual relations does not necessarily make the relationship an unhappy one.
The unconsummated marriage is the other clinical entity in this category. Often in such situations the woman has not had intercourse even though she has been married for several years. Most of these marriages do not end in annulment or divorce. They continue on, and the therapist does not learn of them until the wives decide to do something about the underlying problems leading to their avoidance of sex. The husbands in unconsummated marriages are often gentle, timid, sexually naive persons. They love their wives, however, and are able to become sexually active without any treatment once their wives' problems are resolved.
Thus, sex rarely is the bond that either keeps marriages together or is the cause of their dissolution. The cementing bond is composed of intimacy and love - or, at least, a practical understanding on the part of both spouses of the mutual benefits they derive from their marriage.
This article has stressed the importance of the marriage bond in the functioning of the family system. The part marriage disorders play in family disorders can be seen from a study of the four Psychopathologie marriage patterns noted above. From such a study one can discern the normal values that must be present in a happy, productive marriage. The most common symptoms of marriage disorders are anger, complaints of lack of love, adultery, secrets kept from one spouse by the other, and sexual problems.
Working or enduring marriages may be far from ideal, but they are within the wide range of what is normal in marriage. It behooves the therapist not to introduce iatrogenic illness in his patients by attempting to promote "the ideal marriage" in the case of a marriage that is less than ideal but still within normal limits.
The "system marriage" falls within the "system family." Patterns of families are of such great variety that it is sometimes difficult to define the normal family in current industrial societies. Marriage patterns have also changed beyond monogamy, and recognition of differences is essential to the diagnosis and treatment of marriage problems within family problems.
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3. Cited in Bowen, M. Family Therapy in Clinical Practice. New York: Jason Aronson, 1978.
4. Nichols, W. C, Jr. The marriage relationship. The Family Coordinator 27 (1978), 185-191.
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6. Mahler. M. S.. Pine, F., and Bergman, A. The Psychological Birth of the Human Infant. New York: Basic Books, 1975.
7. Saunders, D. G. Marital violence: dimensions of the problem and modes of intervention. /. Marriage Family Counseling 3 (1977), 43-49.
8. Elliott, F. A. Neurological causes and cures of explosive rage. Med. Opinion 2 (1977), 33-46.
9. Martin, P. A. Love and hate in human sexuality. Med. Aspects Hum. Sexuality 10 (1976), 26-39.
10. Lindberg, A. M. Locked Rooms and Open Doors. New York: Harcourt, Brace, Jovanovich, 1974.
11. Fromm, E. Man for Himself. Greenwich, Conn.: Fawcett Publications, 1947.
12. Martin, P. A. The happy sexless marriage. Med. Aspects Hum. Sexuality 2 (19771. 75-84.