Psychiatric Annals

Integrative Psychotherapy 

Behavioral/Psychoanalytic Psychotherapy within Overlapping Social Systems: A Natural Matrix for Diagnosis and Therapeutic Change

Lee Birk, MD

Abstract

This article outlines a new integrated approach to psychotherapy based on the core ideas contained in its 1974 predecessor, "Psychoanalysis and Behavior Therapy"1 and also foreshadowed in the 1973 American Psychiatric Association Task Force Report, "Behavior Therapy in Psychiatry."2 The 1974 article made a strong case for the now-familiar idea of thoughtfully employing both psychodynamic and behavioral concepts and techniques in a new hybrid therapeutic approach that can (at least in part) be integrated conceptually as well as technically. Almost 15 years later, we know that a psychodynamic-behaviorai synthesis into a new "behavioral psychotherapy" is feasible and has in fact occurred.3 Thus the current article is able to build further on an already successful synthesis of behavioral and psychodynamic elements. It does this by attempting to establish a third major epistemologica! base for behavioral psychotherapy: social systems, a vital component for a maximally effective approach to psychotherapeutic change.

Clinically, for many complicated interpersonal problems, a social systems approach is literally indispensable, if one hopes to forge a balanced and realistic view of what is the actual problem requiring treatment. We cannot answer the vital question "Who is doing what to whom?" unless we talk to all of the participants in situ within the social systems in which they function. Behavioral psychotherapy, to be maximally accurate diagnostically and powerful therapeutically, needs to be based on three equally important knowledge bases: behavioral, psychodynamic, and social systems. Moreover, truly in vivo behavioral analysis and behavioral shaping can be carried out only within social systems. In discovering the actual problems, in selecting appropriate behavioral target symptoms, and in carrying out the therapy itself, the therapist works directly within a combination of social systems in which the problems occur.

METHODOLOGY WITHIN PSYCHOTHERAPY

When Freud began his work late in the 19th century, medicine and surgery still were without the basic tools of antiseptic technique, anesthesia, and antibiotics. Higher-order developments such as myoclonal antibodies, nuclear magnetic resonance, behavioral medicine,4,5 modern surgery, and organ transplants were inconceivable in 1895. Until about 1960, medical knowledge grew prodigiously. But during this same period, psychotherapy remained virtually unchanged in concept and technique. For over 50 years it remained nearly exclusively focused on individuals and dominated by a preoccupation with the unique relationship between the patient and the therapist or analyst. Such tenacity of focus can be understood, because historically it was the individual therapeutic relationship (alliance) that set in motion transference and also provided the occasion for a review and reworking of the patient's early development, pivotal identifications, and incorporations. All of these are indispensable tools if pervasive gains, which are both autocatalytic and enduring, are to come out of therapy. Franz Alexander's later addition of the concept of the "corrective emotional experience" was an important advance, but did nothing to lessen the emphasis on individuals viewed monadically, at the expense of social systems. So, from about 1895 to 1960, the broad growth of psychotherapy as a whole was impeded by an understandable, but unfortunately narrow, focus on individuals, as if they existed in isolation. Individuals exist within an overlapping set of social systems, interacting with other individuals in the systems, as well as with the systems themselves. The systems shape the individuals, while at the same time, the individual continuously shapes the systems.

SOCIAL SYSTEMS AS MATRIX FOR PSYCHOTHERAPY

Einstein, in a brief description of his relativity theory, said simply that "there are no hitching posts in the universe, as far as we know. . . ." He apparently meant that in the universe, no points can be assumed to be fixed and stationary, so that all motion must…

This article outlines a new integrated approach to psychotherapy based on the core ideas contained in its 1974 predecessor, "Psychoanalysis and Behavior Therapy"1 and also foreshadowed in the 1973 American Psychiatric Association Task Force Report, "Behavior Therapy in Psychiatry."2 The 1974 article made a strong case for the now-familiar idea of thoughtfully employing both psychodynamic and behavioral concepts and techniques in a new hybrid therapeutic approach that can (at least in part) be integrated conceptually as well as technically. Almost 15 years later, we know that a psychodynamic-behaviorai synthesis into a new "behavioral psychotherapy" is feasible and has in fact occurred.3 Thus the current article is able to build further on an already successful synthesis of behavioral and psychodynamic elements. It does this by attempting to establish a third major epistemologica! base for behavioral psychotherapy: social systems, a vital component for a maximally effective approach to psychotherapeutic change.

Clinically, for many complicated interpersonal problems, a social systems approach is literally indispensable, if one hopes to forge a balanced and realistic view of what is the actual problem requiring treatment. We cannot answer the vital question "Who is doing what to whom?" unless we talk to all of the participants in situ within the social systems in which they function. Behavioral psychotherapy, to be maximally accurate diagnostically and powerful therapeutically, needs to be based on three equally important knowledge bases: behavioral, psychodynamic, and social systems. Moreover, truly in vivo behavioral analysis and behavioral shaping can be carried out only within social systems. In discovering the actual problems, in selecting appropriate behavioral target symptoms, and in carrying out the therapy itself, the therapist works directly within a combination of social systems in which the problems occur.

METHODOLOGY WITHIN PSYCHOTHERAPY

When Freud began his work late in the 19th century, medicine and surgery still were without the basic tools of antiseptic technique, anesthesia, and antibiotics. Higher-order developments such as myoclonal antibodies, nuclear magnetic resonance, behavioral medicine,4,5 modern surgery, and organ transplants were inconceivable in 1895. Until about 1960, medical knowledge grew prodigiously. But during this same period, psychotherapy remained virtually unchanged in concept and technique. For over 50 years it remained nearly exclusively focused on individuals and dominated by a preoccupation with the unique relationship between the patient and the therapist or analyst. Such tenacity of focus can be understood, because historically it was the individual therapeutic relationship (alliance) that set in motion transference and also provided the occasion for a review and reworking of the patient's early development, pivotal identifications, and incorporations. All of these are indispensable tools if pervasive gains, which are both autocatalytic and enduring, are to come out of therapy. Franz Alexander's later addition of the concept of the "corrective emotional experience" was an important advance, but did nothing to lessen the emphasis on individuals viewed monadically, at the expense of social systems. So, from about 1895 to 1960, the broad growth of psychotherapy as a whole was impeded by an understandable, but unfortunately narrow, focus on individuals, as if they existed in isolation. Individuals exist within an overlapping set of social systems, interacting with other individuals in the systems, as well as with the systems themselves. The systems shape the individuals, while at the same time, the individual continuously shapes the systems.

SOCIAL SYSTEMS AS MATRIX FOR PSYCHOTHERAPY

Einstein, in a brief description of his relativity theory, said simply that "there are no hitching posts in the universe, as far as we know. . . ." He apparently meant that in the universe, no points can be assumed to be fixed and stationary, so that all motion must be defined relatively, between particular specified points; even the points themselves have meaning only in relationship to other points. In a parallel manner, human relationships are also inherently relativistic. If one works only with individuals, relationships between individuals cannot even be observed directly, much less scientifically studied or modified in vivo by differential reinforcement and behavioral shaping. This would be analogous to trying to understand astronomy by studying in detail only one planet or star at a time, without attempting to observe the motion of individual heavenly bodies in relation to each other.

WORKING INSIDE SOCIAL SYSTEMS

A more direct and powerful alternative to exclusive reliance on individual observation and therapy is called for, ie, working clinically within all the relevant social systems, literally inside them, or a replica of them. Because it is manifestly impractical to work directly within all the systems relevant to a person's problems, it is usually necessary to use group therapy to provide a practical replica of an individual's strengths and weaknesses in interactions with people outside his or her "natural" social systems, ie, the systems inherent within his or her marriage, family of origin, and own famHy.

In vivo exposure to the feelings of an adversary, directly experienced within couple therapy, or family or group therapy, at times can lead a person to enlarge an initial polarized view that he or she is a victim, innocently being "done to" by the other person. Such a conversion to a relativistic view, with its new empathy for "the other," can alter whole systems for the better by allowing positive change in perceptions and behaviors previously directed simplistically toward an adversarial "other," heretofore rigidly viewed as a diametrically opposed, implacably hostile opponent. Harry Stack Sullivan's aphorism, that "in being human, we are all much more nearly alike than we are different in any other way," comes to mind.

REUTIVITY IN PSYCHOTHERAPY

Until about 1960, blocks to the appropriate professional maturation of psychotherapy included not only preoccupation with the patient-therapist relationship, but also a rigid adherence to a radical extremism about confidentiality and the supposed purity of the therapeutic process. For about five decades, analytically trained therapists usually insisted on exclusion of all people other than the therapist and the "designated patient," from the therapy itself and from the diagnostic data collection that necessarily precedes therapy. This was catastrophically disadvantageous, because when a patient's problem included, for example, overt conflict between patient and spouse, it meant that such an approach, as Haley put it, was "like assuming a stick has one end."6 Unfortunately, this remained policy for most psychotherapists, even when the patient had come because of interpersonal difficulties: problems with peers, such as "communicating" or "getting along with people" or with family or marriage. It took a long time for group therapists, family therapists, and couple therapists to communicate to the psychotherapy profession as a whole that there can be no substitute for observing in vivo the interpersonal problems that bring people for help and for working within the system behaviorally, both diagnostically and therapeutically, by seeing such patients together - with their peers in group therapy, with their families in family therapy, and with their marriage partners in couple therapy.

Prior to these developments there was little deviation from adherence to a purely individual model for both diagnosis and treatment. In the case of marital problems, traditional psychotherapy was particularly slow to yield in its insistence on treating individuals in individual therapy. It is surprising, especially within marital therapy, that there was such entrenched resistance both to systemsthinking and to conjoint couple therapy, since the problems presented by married couples are not just "intrapsychic," but also quite conspicuously interactive and systemic. The social system of a married couple is of course "dyadic," but also, again quoting Haley,7 more than dyadic: ". . . to focus . . . [exclusively] on a dyad forces the observer to ignore the structure in which the dyad functions. ..." This larger structure typically includes two families of origin plus their interrelationships with each other, with each spouse, and with any offspring the couple may have.

Mittel man was one of the earliest explicit advocates (1944) for viewing symptomatic spouses as part of an interacting system.8 When a few years later9 (1948), he reported on his innovation of simultaneous psychoanalytic treatment for both the husband and wife in a marital dyadic system, it was regarded by many as radical, although there was precedent for it in Oberndorf 's earlier practice of psychoanalysis.10 In recognizing the importance of the couple as a system, Mittelman seems to have been prescient. Was he, however, only relativistically prescient, ie, prescient within a retarded profession? All the furor he provoked was in response, not to conjoint couple therapy, but only concurrent individual therapy (psychoanalysis) with both marital partners. Even this practice was never widely adopted, much less appropriately extended to include conjoint work within the marital system. Instead, different analysts or therapists continued, quite separately, to see people who were married to each other and in trouble with each other without the benefit of a single conjoint meeting with them, even diagnostically. Thus, psychotherapists in general, but especially psychoanalysts, for many more years continued to take a rigid stand against seeing anyone other than "the analysand" during the treatment process. Not surprisingly then, classical psychoanalysis, especially separate, simultaneous analyses for husband and wife, as Lief said, "earned a justifiably bad reputation for breaking up marriages."11

BEHAVIORAL OBSERVATION ANDBEHAVIORALSHAPING

In 1973, approximately 30 years after Mittelman, and following about 15 years of healthy ferment from many different sources both outside and inside traditional psychotherapy, the American Psychiatric Association published a Task Force Report, "Behavior Therapy in Psychiatry,"2 which explicitly advocated working within social systems over pure individual approaches:

In group, family and couple therapy ... the therapist has the enormous practical advantage of seeing maladaptive behavioral patterns unfold and develop in vivo. As a result, he can switch his strategy from relatively weak techniques of attitude change through verba] conditioning and a "corrective" extinction of emotional experiences, to a much more rapid and powerful method which is especially appropriate for patients whose primary problems center around their relationships with others. Many patients have problems that involve habitual subtle maladaptive interpersonal behaviors. Bringing them into fa treatment setting! where they can actually experience problems . . . can be extraordinarily important and catalytic diagnostically in terms of [exactly] what the patients' maladaptive behaviors are, and therapeutically, because these settings allow for the direct behavioral shaping of alternative modes of behavior.

Such "direct behavioral shaping" can and should include habitual and pivotal cognitions. Also, it should be collaborative with patients, not manipulative of them, done "with" them, not "to" them.

THE PENDULUM SWINGS

* What's Radical Now?

Now in 1988, the burden of proof lies on opponents to the use of both a behavioral and a systems approach to individuals in a troubled marriage. One would be especially hard pressed to find valid, defensible reasons for not establishing behavioral goals and for not seeing both members of a troubled couple conjointly, for at least part of the treatment. This is the "bottom line" after an extended review of many comparative outcome studies; prominent among the statistically supported conelusions of Gurman et al13 were these two:

* When a person seeks help from psychotherapy because of marital conflict - and this is true across multiple studies, many schools of therapy, and literally decades of data accumulation - it is demonstrably true that treatment that includes conjoint couple sessions enjoys much more success, in terms of outcome, than treatment that does not.

* When the therapist employs an active style of leadership, explicitly focusing on relationship matters, he or she helps the couple to design [behavioral] goals, and actively joins and leads them in systematically working toward these goals. Treatment outcomes are also demonstrably superior.

Gurman established that therapy for couples needs to involve the social system where the trouble is, and must be active and behavioral.

* The Mixed Therapy Group

Group therapy, in which relevant behaviors are directly observed, enjoys a strategic advantage over individual therapy,14"17 which of necessity is primarily based on retrospective accounts. Strategically, the most effective and efficient method for eliminating maladaptive behavior is to isolate it in vivo: to point it out, label it, and punish it, while at the same time systematically reinforcing alternative, increasingly adaptive modes of behavior.2 (The term "punish" is used strictly in its technical, learning theory meaning: "any stimulus immediately following a response which is observed to decrease the frequency of that response. Vindictive punishment, used to act out anger, is not meant here, nor should learning theory rationalizations ever be used to cloak therapist's countertransference problems, or to legitimize wishes they may have to be emotionally punitive.")

It must be emphasized that to isolate a behavior in vivo absolutely requires working inside the social systems in which the behavior occurs. Practically, therapists cannot physically follow their patients to observe directly how they interact with all the important but familially unrelated people in their lives; this is precisely why the psychotherapy group is so important as a knowledge base for diagnosis and therapeutic change. A therapy group, if it is a representative collection of unrelated peers, offers a practical way to escape reliance on retrospectivelybased methods that otherwise would limit therapy to a two-person system. In such a system, the only directly observed interactions are between the patient and the therapist. This is epistemologically disastrous, because in individual psychotherapy, all the human interactions dealt with during treatment (other than the unique one with the therapist or analyst), are subject to the perils of pure retrospective narration. That is, in conventional individual therapy, the patient has to recognize what in his behavior and feelings is relevant, observe it accurately, remember it, not distort it, and then also faithfully and without lapses report it to the therapist.

In group therapy, much relevant behavior is observed in vivo and is observed not just by the patient, but also by the therapist and all the other people present in the therapy group. This broadens the knowledge base being used in the therapy and improves its quality and accuracy. A second reason for the general superi - ority of group over individual therapies is that patients generally accept interpretations more readily, and are more lastingly affected by them, when they come from peers rather than from professional therapists. This is especially true in helping people to see and change relevant, deeply entrenched attitudes and behaviors. Such problems tend to be ego-syntonic, in the sense that people are either blind to them as problems or have surrounded them with a wall of virtually impregnable rationalizations, all devoted to maintaining the comfortable but maladaptive status quo.

OVERUPPING natural SOCIAL SYSTEMS

* Marital Problems Arising From Family of Origin Problems

Experienced couple and family therapists know that marital problems often derive from unsolved feeling-problems stemming from each spouse's family of origin.18"20 The trouble begins when each person in the dyadic system, rather than genuinely coming to terms with the inevitable feeling-problems that derive from his or her family of origin, merely "cuts off" the problems, along with the relationships that gave rise to them. "Token" or "facade" relationships with the cutoff family members usually continue, but not genuine deep relationships in which leveling, ie, expressing honest feelings about the real issue, ever really occurs. The trouble is compounded when the future spouses find each other, "fall in love," and hope for a magical solution to the old problems in the new idealized person. Their marriage, they feel, will somehow "make it all better." The reality, however, is that the "cut off state they share leaves them both with strong, unmet, and usually unacknowledged emotional needs, which each tries to fulfill through the other. As a result, the new mated relationship is heavily "overloaded."

In time, apparently as an extension of pursuing the wished-for solution, there is more and more idealizing of and overinvesting in the new marital relationship. Eventually, the married couple begins to function almost as if fused into one all-sufficient person, one person without the nagging emotional needs dimly suffered by both partners prior to their fusion with each other. Usually a few years later, when it becomes evident that this semiconscious attempt at repairthrough-fusion has failed to solve the old cut off feeling-problem with parents and other original family members, the old feelings - disappointment, frustration, anger, and sadness - come back. Now, however, the feelings return displaced and with double vehemence. Now they are felt toward the spouse, who by this time is no longer a savior-figure but a failed savior-figure.

There are two other unfortunate by-products of such fusions as they typically occur within troubled marriages. First, fusion leads people, quite erroneously, to believe that they know how the other person feels, and what he or she thinks and wants. People in the grip of this fusion/ "symbiosis" do not say "I think" or "I feel"; they say "Cynthia and I both feel . . ." or "Dick and I both think . . ." Obviously, this leads to multiple mistaken assumptions, miscommunications, and hurt and angry feelings. Second, like the metabolic conditions in diabetes, marital fusion leads to a peculiar kind of interpersonal "starvation in the midst of plenty," because the symbiotic stance leads people to ignore and reject input from others outside the overloaded marital relationship. Thus, even in the presence of other people offering useful feedback and new perspectives, a person in an emotionally-mired marriage can be remarkably resistant to perspective-restoring feedback, presumably because he or she has drifted into devoting so much attention to simply maintaining pseudounity with the partner. (If the two partners don't remain fused, they lose the comforting illusion of symbiosis; beyond this, and even worse, if they don't maintain the illusion of fusion, a whole Pandora's box full of "cut off" problems begins to reemerge powerfully into awareness.)

CLINICAL USE OF OVERLAPPING SOCIAL SYSTEMS

* Marital Therapy Plus Family of Origin Meetings

When psychotherapists work conjointly with a couple, or inside dyadic marital systems, they find that they can be markedly more effective, and can significantly improve outcomes, if they also do adjunctive work with the families of origin of spouses suffering from "cut off" types of marital problems. Clinically, sometimes it is best to approach the family work incrementally, by meeting first with siblings, sometimes even one at a time, then with one parent, then the other, then all together. In other cases, one can proceed effectively in far fewer steps or even go directly to whole family meetings.

In effect, the psychotherapeutic work starts within the marital dyad (the natural social system ostensibly causing the current trouble) and follows clinical leads that take the work back to where such feelings, overly intense because displaced, originated. The clinical leads are familiar in nature to every psychoanalytically oriented therapist who has worked with transference; essentially these are instances in which the observed intensity of feeling and behavior seem vastly out of line with the importance of current stimulus events. Usually, for a prepared listener, all this leads quickly back to the remote past, to critical events and people within the early development and family of origin of one or, more often, both spouses. All this happens incrementally. Via steady cumulation, the puzzle gradually fills in until the whole picture, complete with the true sources for the excessive intensity of affect between spouses, can be seen clearly by everyone present.

By design, there are six to eight people present besides the couple and the therapist: this uncovering work is accomplished, not in individual sessions or even simple conjoint couple therapy, but in couple group therapy. In this setting, the patient is typically the last to see clearly the relationship between old problems, cut off from the family of origin, and the present marital misery. The group process generated by the couple group is extraordinarily helpful in working through the inevitable and usually quite strong resistances, first to the relevance of family of origin issues, then to the feasibility and wisdom of actually having a series of family meetings to unearth and deal with old but still-important issues. Once the relevance of family of origin problems has become clear to almost everyone in the couple group, the patient typically begins to volunteer, with eerie intensity, a whole series of reasons why adjunctive family therapy cannot or should not be done in his or her particular case.

The group members in a couple group comprise a functioning artificial subsystem within the couple group. This subsystem is not governed by the same resistances and can therefore be used to stimulate and assist each couple, one couple at a time, in dealing with those resistances that otherwise would block family of origin work. Thus, as a couple group matures, it becomes true that most of its members have observed and participated in several cycles of discovery/resistance/dramatic breakthrough with regard to needed family of origin work. This fact operates to make a working couple group, as an evolving hybrid social system, progressively more powerful in catalyzing needed family work, and so in producing change.

When such formidable resistances can be successfully worked through, and within the couple group they usually can be, it then becomes possible to meet a few times with the patient together with crucial members of his or her family of origin. Usually, common realistic barriers of distance, expense, and often the advanced ages of many parents can yield finally to the influence of the couple group. It has not been rare for parents in their 80s to travel thousands of miles, even from other countries, to participate in such meetings. Family meetings ordinarily are remarkably brief; a typical case might require only three to eight hours over two or three meetings in as many days, although some other cases call for more prolonged family meetings of a dozen or more hours. Yet the beneficial changes apparently wrought within the dynamics of the marital dyad, the original unit of treatment, are frequently very significant. Couples may go from a tinderbox state of anger toward each other, which may break into open flames of rage at the smallest spark, to being strikingly more able to see each other as ordinary people. At this point, anger between husband and wife begins to seem much more rational, and more workable, apparently because it is now based not on displaced feelings, but on real, and therefore potentially changeable, behaviors of the other person in the relationship.

For the first time, the therapist and the other couples can now devote substantial attention to the real or "home-grown" adjustment problems present in the couple, those that are real because they are undisplaced. Now the emphasis can be placed on the couple's real problems through fostering improved communications and empathy, better anticipation of foreseeable conflicts, and when necessary, negotiation. Success is achieved when the couple group work plus the family meetings are effective in reversing the original pathogenic pattern of cutting off difficult feelings toward parents, siblings, and others in the family of origin, and displacing them onto the spouse. Feelings previously misdirected toward a spouse are appropriately redirected back to their original sources. This seems to free the marital relationship from its extra burdens, thus enabling the husband and wife to deal realistically with some of the ordinary problems of everyday life.

Such family meetings are almost always beneficial to the family of origin relationships, in contrast to patients' earlier resistance fantasies of unbridled destruction. Even in those unusual cases where improvement in family of origin relationships does not result, there have been no clear changes for the worse, and patients have not been sorry they involved their families. To quote one veteran of family meetings that were successful in improving his marital relationship, but largely unsuccessful in ameliorating his relationship with his widowed mother: "I'm glad that I can now say I have really tried to communicate with my mother ... I used to feel guilty and that the problems were all my fault, because I hadn't ever really tried. Now I know it's not all me: you saw for yourself how impossible she is!"

Many couples who have remained "stuck" despite several years of conjoint couple therapy, become dramatically "unstuck" in a comparatively short period of weeks to a few months, once they get to the point where unresolved issues with the family of origin can be acknowledged and dealt with in family meetings.

* Couple Group Therapy: Juxtaposing Natural and Artificial Social Systems

Using a couple group plus family of origin meetings to help people deal with marital problems is one clear example of the strategic juxtaposition of natural and artificial social systems to work through difficult resistances. The couple group is literally large enough to surround both husband and wife with new members of a new social system, a peer group of couples that contains them and their interactions, plus those of three or four other couples, or in all, six to eight other individuals. This new social system contains four to five natural social systems (four or five couples), but is itself an artificial social system. Because it is composed this way, the couple group is not automatically governed by the same built-in, heavily defended resistances strongly present in all three of the natural social systems implicit within couple therapy: the manifestly problematic marital dyad system, and the two systems comprising the family of origin of the husband and of the wife.

Clinical reports about the usefulness of couple group therapy for marital problems are by no means new or unique. In fact, reports that couple group therapy is often a treatment of choice over simple conjoint couple therapy are also not new.20"23 This article, however, advocates not just couple group therapy when indicated, but the purposeful juxtaposed use of artificial and natural social systems to facilitate overcoming resistances to other work needed in the therapy. Sometimes the needed other work happens to be work inside still other social systems, such as within a patient's family of origin, or within his own family, but many other times in any psychotherapy, the crucial resistance which is pivotally important to the success of therapy, may be due to something else - to taking lithium, to stopping drinking, to altering "workaholic" behavior patterns, or simply to learning to observe and express feelings.

In the example from marital therapy, the therapist not only purposely bypasses any extended attempt at separate individual therapies with the two spouses, he also bypasses working with them together in simple conjoint therapy. He does this in order to work with them conjointly within a larger social system, a couple group, because a couple group contains both natural and artificial social subsystems. Because it contains both, it seems justified semantically to call it a "hybrid system," part natural, part artificial. Functionally, it is because it contains both that it proves to have such vast therapeutic power in facilitating the working through of resistances. The new hybrid, the couple group, contains the marital dyad under more natural (less triangulated) circumstances than does simple conjoint therapy. But much more importantly, although it contains the marital dyad, it is not governed by all its usual habitual rules and defenses. Thus, the artificial subsystem within the couple group, composed of everyone in the group who is not a part of the particular dyad in the clinical "hotseat" at the moment, can operate, with the help and guidance of the therapist, to challenge the entrenched resistances and defenses built into the behavior patterns of that particular couple.

EVOLUTION OF PSYCHOTHERAPY FOR MARITAL PROBLEMS

Psychotherapy, at least for marital problems, has moved away from an initially pure focus on treating individuals; to recognizing the utility inherent in one analyst or therapist getting direct information from both spouses8-'0; to general agreement that conjoint therapy, or working with both spouses together within the problematic social system, is indicated24; to empirical, statistically validated evidence that working conjointly is better than working only individually.13 Since soon after Helen Kaplan's important book in 1974,25 there has been general agreement that, for couples whose problems include sexual dysfunction, treatment should be done conjointly by a therapist able to employ brief, focused behavioral sex therapy. This therapy proceeds via a series of behavioral/experiential prescriptions and is unusually strongly supported by comparative outcome studies. Although sex therapy is a complex art in itself, the technical details of which are beyond the scope of this article, it is relevant to note that a consensus has emerged that sex therapy should be part of the therapy when couples present with sexual dysfunction, and that it may often need to be integrated with other psychotherapeutic work with the couple. There has also been growing recognition that adding work within other social systems, especially spouses' families of origin, adds further to pragmatic results.18'20,22,24 Finally, many clinicians experienced in couple therapy have written about the special advantages of conjoint work carried out within couple groups. Some of those have even been clear in identifying couple group as a more effective method than simple conjoint work.22,25 The unique advantage of the couple group as a vehicle for getting past resistances to needed family of origin work apparently was first used (entirely independently) by Framo and by Birk, both in the early 1970s but first written about by Framo in 1976.26

FIGURE 1Overlapping Social Systems

FIGURE 1

Overlapping Social Systems

Finally, this article makes several points explicitly for the first time:

* Couple groups function as hybrid social systems, part natural and part artificial.

* The hybrid quality of couple groups, via the artificial subsystem elements, gives the couple group as a whole great inherent power to deal with resistances experienced by each of its component couples.

* The fact that couple groups are powerful, when used to work through resistances, derives from their juxtaposing natural and artificial social systems.

* There are many other clinical examples, outside couple therapy, of therapeutic potency in dealing with resistances which also derive from juxtaposing natural and artificial social systems. This may be useful in getting past a large variety of crucial resistances, across a broad range of clinical circumstances.

PRACTICAL APPLICATION

Table 1, which is based on the psychotherapy of an actual patient, lists the multiple social systems within which work was needed, and all the people (system-members) who are part of each of those systems. Figure 1 shows diagrammatically how the multiple systems overlap. Unfortunately, the diagram alone does not convey fully how effectively information gleaned from working within one social system can be catalytically useful in facilitating further exploration and discovery within another, especially if the early sources are later reworked. This process, exploited to the fullest, leads to the therapist working with the absolute maximum of information about "who is doing what to whom," which as Semrad aptly said, "is what psychiatry is all about."27

Table

TABLE 1Natural Social Systems

TABLE 1

Natural Social Systems

OVERLAPPING SOCIAL SYSTEMS

* Utility Within Psychotherapy

Up to this point, this article has been heavily concerned with psychotherapy for marital problems. This, in part, reflects the importance of the topic as a subject in itself. But this is also because marital therapy happens to be an especially rich and wellstudied example in psychotherapy of using multiple, overlapping social systems, as well as of purposely juxtaposing natural with artificial social systems. There are a great many other applications of these same general principles within the much broader field of psychotherapy as a whole. The author has worked with a large variety of other kinds of presenting problems, using a very analogous, integrated clinical approach. Impressionistically, it seems that the differences between the two kinds of patients are probably fewer than the similarities. The range of nonmarital problems effectively dealt with in treatment using such an integrated approach has included a sizeable number of individuals - several dozen at least - who presented initially with previously treatmentresistant cases: cases of severe neurasthenic depression; cases of paralyzing anxiety; and cases of angry, malignant, life-threatening rebellion. Group therapy for individuals can be used in a closely analogous way to work through crucial, otherwise seemingly insuperable resistances. The resistance may be due to needed couple therapy or family therapy; or it may be due to one of the "biological" therapies: "drying out" programs for those addicted to alcohol, lithium and/or antidepressants for people with affective disorders, and alprazolam for those with panic disorders, to cite only a few of the most common ones.

When a therapist employs multiple overlapping systems, like a good investigative reporter, he works and reworks all his sources again and again, one against the other. Pursuing multiple sources in the early rounds yields confusing, apparently conflicting, and even directly contradictory information. Using individual therapy alone, the therapist runs the risk of having everything merely seem simple and "clear." In reality, cases in "pure" individual therapy can be presumed to be equally complex, equally permeated by the uncertainties inherent in interpersonal relativity. In most cases, it merely seems clear, because in ignoring the ubiquity and transcendent importance of the relativity inherent in all human interactions, the therapist has not taken the trouble to hear firsthand all the other perceptions of the same events! In the reworking of sources (systems) for new information any time new information comes forth, one uses all the information gained in all prior contexts to catalyze the further discovery of still further information. This is the method of good investigative reporting.28 When one aggressively uses these methods clinically, the therapists feel as exhilarated as the good reporter.

SUMMARY

This article presents an integrated treatment method based on a new, relativistically oriented clinical epistemology. In addition, it makes four important new strategic points, three related to psychotherapy for marital problems, and one with broad significance for the whole of psychotherapy. The essential features of this new clinical method are:

* the purposeful cultivation of psychoanalytic insight (in marital applications this includes insight about transference displacement of feelings and conflicts from parents and siblings onto the spouse).

* direct behavioral observation and diagnosis within social systems;

* direct behavioral shaping within those same social systems;

* the use of multiple overlapping social systems, like an investigative reporter, for maximizing information about "who is doing what to whom";

* conscious recognition of the inescapable relativity inherent in all interpersonal interactions;

* preplanned and strategic, juxtaposed use of natural social systems (couple and family systems) together with artificial social systems (therapy groups) to reduce pivotally important resistances.

The new strategic points for couple therapy are:

* Couple groups function as hybrid social systems, part natural and part artificial.

* The hybrid quality of couple group, via its artificial subsystem elements, gives the couple group as a whole its power to cut through resistances experienced by each of its members.

* Couple groups are powerful when used to work through resistances because natural and artificial social systems are juxtaposed in all couple groups.

We also made a general point applicable to psychotherapy:

* There are many situations outside couple therapy where real progress is blocked by crucial resistances, in which unblocking is possible by utilizing the power of strategic juxtaposition of natural and artificial systems.

Although there is still no scientific validation of the method as a whole, or even of all its separate elements, clinical experience suggests that behavioral/psychoanalytic therapy within social systems, when appropriate and applicable, may be both effective and practical in helping troubled couples, and also in helping people across a broad range of life problems.

REFERENCES

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TABLE 1

Natural Social Systems

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