Marital Therapy: A Combined Psychodynamic — Behavioral Approach

312 Pages·1982·4.93 MB·English

by  R. Taylor Segraves M.D.

MARITAL
THERAPY
A COMBINED
PSYCHODYNAMIC - BEHAVIORAL APPROACH
CRITICAL ISSUES IN PSYCHIATRY
An Educational Series for Residents and Clinicians
Series Editor: Sherwyn M. Woods, MD., PhD.
Univer5i~1 of Southern California School of Medici/Ie
L05 Angeles, Califomill
A RESIDENTS GUIDE TO PSYCHIATRIC EDUCATION
Edited by Michael G. G. Thompson, MD.
STATES OF MIND: Analysis of Change in Psychotherapy
Mardi J. Horowitz, MD.
DRUG AND ALCOHOL ABUSE: A Clinical Guide to
Diagnosis and Treatment
Marc A. Schuckit, MD.
THE INTERFACE BETWEEN THE PSYCHODYNAMIC AND
BEHAVIORAL THERAPIES
Edited by Judd Marmor, MD., and Sherwyn M. Woods, MD., PhD.
LAW IN THE PRACTICE OF PSYCHIATRY
Seymour L. Halleck, MD.
NEUROPSYCHIATRIC FEATURES OF MEDICAL DISORDERS
James W. Jefferson, MD., and John R. Marshall, MD.
ADULT DEVELOPMENT: A New Dimension in Psychodynamic Theory
and Practice
Calvin A. Colarusso, M.D., and Robert A. Nemiroff, MD.
SCHIZOPHRENIA
John S. Strauss, MD., and William T. Carpenter, Jr., MD.
EXTRAORDINARY DISORDERS OF HUMAN BEHAVIOR
Edited by Claude T. H. Friedmann, MD., and Robert A. Faguet, MD.
MARITAL THERAPY: A Combined Psychodynamic-Behavioral Approach
R. Taylor Segraves, MD., PhD.
TREATMENT INTERVENTIONS IN HUMAN SEXUALITY
Edited by Carol C. Nadelson, MD., and David B. Marcotte, M,D.
A Continuation Order Plan is available for this series. A continuation order will bring
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MARITAL
THERAPY
A COMBINED
PSYCHODYNAMIC - BEHAVIORAL APPROACH
R. Taylor Segraves, M.D., Ph.D.
University of Chicago
Chicago, Illinois
Plenum Medical Book Company
New York and London
Library of Congress Cataloging in Publication Data
Segraves, R. Taylor, 1941-
Marital therapy, a combined psychodynamic-behavioral approach.
(Critical issues in psychiatry)
Bibliography: p.
Includes index.
1. Marital psychotherapy. I. Title. II. Series. [DNLM: 1. Marital therapy. WM 55
S455mj
RC488.5.543 1982 616.89/156 82-16653
ISBN-13:978-1-4684-4171-0 e-ISBN-13:978-1-4684-4169-7
DOl: 10.1007/978-1-4684-4169-7
© 1982 Plenum Publishing Corporation
Softcover reprint of the hardcover 1s t edition 1982
233 Spring Street, New York, N.Y. 10013
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
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Foreword
This book is welcomed to the series as a truly unique contribution to
the literature on marital therapy. It is written for the empirically oriented
psychotherapist, regardless of his or her discipline, who encounters
patients with marital discord and has been distressed by the absence of
an acceptable conceptual model for treatment. Psychoanalysis, behavior
therapy, general system theory, and social learning theory have all made
important contributions to treatment. But all too often these approaches
have focused either on individual psychopathology or on the formal
elements of marital interaction. This volume is the first to propose an
approach to marital therapy which is clinically sophisticated, empirically
based and which integrates important elements of seemingly disparate
theoretical systems. The result is a cognitive-behavioral model for the
treatment of marital discord which borrows from both psychoanalytic
and behavioral contributions by translating them into the language of
cognitive social psychology.
The author documents the toll in human suffering as well as the
ubiquitous nature of marriage-related problems. Despite the frequency
with which marital dissatisfaction and discord are encountered in clinical
practice, an amazingly high percentage of mental health professionals
have received inadequate training in either the theory or technique of
effective clinical intervention. The absence of a conceptual framework
linking individual psychopathology to interactional difficulties has wors
ened the problem for clinicians interested in conjoint treatment.
The author devotes several chapters to a thorough review of the
contributions of psychoanalytic theory, general system theory, and be
havioral marital therapy. There is an evenhanded and thoughtful review
v
vi FOREWORD
of these various contributions, the manner in which each has influenced
the other, and the similarity of many hypotheses which differing schools
agree upon but express in different language. The seeming dichotomy
between behavioral and psychodynamic therapy may be partially an
artifact and there is a review of the contributions which suggest that a
clinical integration is not only possible but useful.
From this base, the author's psychodynamic-behavioral model for
the treatment of chronic marital discord is developed. A linkage is made
between psychopathology and interactional data, and this aids in un
derstanding the enduring nature of maladaptive interacti<;mal patterns.
His clinical presentations demonstrate that marital partners form cog
nitive templates or schemas, roughly equivalent to the psychoanalytic
conceptualization of transference, for the perception of each other. These
schemas are often negative, distorted, and at variance wth the spouse's
personality. The problem for the clinician is that he or she is often faced
with a bewildering complexity of observable behavioral abnormalities
and distorted schemas. An important technical maneuver involves the
disruption of chronic maladaptive interactional patterns which confirm
the distorted inner representational models, after which interpretation
is used in the service of discrimination learning.
Moving from theory to clinical practice, the author provides a schol
arly and intellectually sound road map for effective therapeutic inter
vention in the conjoint treatment of couples. Synthesis and integration
are apparent at both the theoretical and technical levels, a welcomed
departure from the parochial and/or theoretically radical presentations
which have too often been characteristic in this field.
Sherwyn M. Woods, M.D., Ph.D.
Series Editor
Preface
This book is the result of years of struggle by the author to evolve
clinically responsible and empirically based approaches to the treatment
of interpersonal difficulties. During my development as a psychother
apist, I often became discouraged when my observations did not fit those
of my teachers or of then-existing theories. This happen~d first when I,
as a behaviorally oriented psychologist, noted with irritation that many
of my patients spontaneously discussed matters better suited for analytic
models of therapy. Later, as a dynamically trained psychiatrist, I noted
that behavior therapy often provoked internal psychological change in
patients. It began to appear that the therapies were not as dissimilar in
their effects as current theory suggested. More recently, as a marital
therapist, I often observed that behavioral change in one spouse produced
profound internal psychological change in the other spouse. This book
is the result of my observations of these clinical phenomena, which do
not fit any of the current theories of psychotherapy.
Throughout this struggle, Dr. Jar! Dyrud, professor in the Depart
ment of Psychiatry at the University of Chicago, has had a marked
influence on my thinking and development. Initially as a teacher and
clinical supervisor and subsequently as a colleague, he provided the
constant reminder that clinical theory should be regarded merely as a
temporary approximation to explanation. As a role model, he commu
nicated the message that clinicians and scholars have to bear the dis
comfort of attending to the full complexity of the phenomena being
observed, especially when the data observed do not fit one's favorite
theory. He also provided an often necessary reminder that one must
avoid premature theoretical closure and a retreat to theoretical or tho-
vii
viii PREFACE
doxy. Such a retreat is a disservice to our patients and students as well
as an act of personal dishonesty.
I would also like to acknowledge the influence of Professor H. J.
Eysenck, my Ph.D. supervisor some 10 years ago. Although Professor
Eysenck will probably disagree with many of the conclusions reached
in this text, his influence is clearly present. This text is a result of Pro
fessor Eysenck's impressing upon his students at the Institute of Psy
chiatry of the University of London the tenet that clinical and research
activities should not be viewed as separate undertakings. Empirical foun
dations for clinical activities are both necessary and possible. However,
this foundation need not take the form of radical behaviorism. Hypo
thetical constructs are perfectly acceptable in scientific theory as long as
they follow the basic principles of good theory constructions. He would
even agree with the author that the problem with psychoanalytic theory
has more to do with the structure of that theory than with its content.
Acknowledgment s
I would especially like to thank Dr. Daniel X. Freedman, Chairman of
the Department of Psychiatry at the University of Chicago, for his help
and encouragement during the preparation of this manuscript. His con
tribution was twofold: First, he created an academic climate in which
eclectic approaches to psychiatric problems were encouraged and fos
tered. Throughout my academic career, he emphasized that psycho
pathology is multidetermined, involving the interplay of biologic, psy
chologic, and social factors. More important, I am indebted to Dr. Freedman
for his example of personal integrity in the pursuit of knowledge. While
writing this text on marital therapy (a topic of lesser importance in many
academic circles) I was repeatedly reminded that he pursued biological
research at a time when psychoanalysis dominated academic psychiatry.
Two colleagues were especially helpful in critically reviewing this
text. I would like to express my thanks to close friends and colleagues,
Dr. Lolita Ang at the Illinois State Psychiatric Institute, and Dr. Thomas
Garrick at the Department of Psychiatry, University of California, Los
Angeles.
Last but not least, I wish to express my appreciation for laborious
and patient persistence during the preparation of this manuscript to Ms.
Runae Hartfield and Ms. Amelia Spenser.
ix
Contents
CHAPTER 1
Current Status of Marital Therapy 1
Psychoanalytic Treatment of Marital Discord ............................ 4
Behavioral Treatment of Marital Discord ................................ , 5
Beginning Rapprochement ................................................ 7
An Integrated Approach ................................................... 9
Clinical Ramifications ..................................................... 14
Overview ................................................................... 17
References ................................................................. 18
CHAPTER 2
The Relationship of Marriage to Psychological Well-being 21
Marital Status and Mental Health Service Usage ....................... 22
Marital Status and Psychiatric Hospitalization .......................... 24
Marital Status and Outpatient Clinic Usage ............................ 26
Psychological Well-being and Marital Status ............................ 28
Marital Status and Alcoholism ........................................... 31
Suicide and Marital Status ................................................ 32
Marital Status and Mortality ............................................. 34
Marital Discord, Psychiatric Impairment, and
Mental Health Service Usage ................................... 36
Divorce, Marital Discord, and Children ................................. 40
Sex and Marital Status Differences in Psychopathology ............... 45
Explanatory Hypotheses .................................................. 46
Trends in Divorce Rates .................................................. 49
Response of Mental Health Professionals ............................... 50
References ................................................................. 51
xi