Is a Confrontational Tone Necessary in Conjoint Therapy?

Is a Confrontational Tone Necessary in Conjoint Therapy?

Daniel B. Wile*

The dominant model in the field of conjoint therapy is the notion of the family as a unit or system (Beels & Ferber, 1969) and, in particular, as a homeostatic system in which change in one part requires compensatory adjustment in others (Jackson, 1957). This paper discusses t h advantages and disadvantages of the systems model and proposes an alternative approach, the paired bind model. The paired bind orientation retains the major advantage of the systems approach (its focus upon couple and family interactions) while eliminating its major disadvantage (its oppositional tone).

When psychotherapists first turned their attention to treating couples and families, they found themselves besieged, outnumbered, and in danger of losing their therapeutic neutrality. Family members would gang up against the therapist, engage in interminable squabbling, disqualify everything that they and everyone else were saying, deny the family had any problems, and either ignore the therapist completely or, even worse, integrate the therapist into their “pathological” family pattern (Satir, 1967; Minuchin, et al., 1967).

Therapists who tried family therapy usually responded in one of two ways. Some concluded that conjoint therapy was unworkable and, when faced with the possibility of family or marital therapy on future occasions, suggested, instead, that one or more family members go into individual psychotherapy. Others reacted by becoming increas- ingly active, countering the family’s insistent denial with even more insistent accusa- tions, or by functioning as a kind of family traffic cop.

The problem with these more active measures was that they conflicted with the accepted therapeutic model of the day which valued nonjudgmental listening and noncoercive interventions. It is here that family systems theory served a valuable historic function. The systems approach provided a new model which legitimized the kind of forceful and dramatic measures which were necessary if couple and family therapy were to be at all feasible. The metaphor of a powerful family system relentless- ly pursuing homeostatic balance not only reflected the conjoint therapist’s experience in doing family and marital therapy, but provided justification for engaging in sufficient countermeasures. It was not families or family members whom these therapists felt they were challenging, but family systems.

The major theoretical contribution of the systems approach, as just illustrated, has been to direct attention to the couple or family interaction rather than, as had generally been the practice, to focus upon the separate personalities and psychopathol- ogies of individual family members. In so doing, systems theorists corrected the clinical

*Daniel B. Wile, PhD, is a psychologist at the Counseling Services, California State Univer- sity, Hayward, Ca. 94542 and the Department of Psychiatry, Cowell Hospital, University of California Student Health, Berkeley.

July 1978 JOURNAL OF MARRIAGE AND FAMILY COUNSELING 11

error by which one family member (the “family scapegoat” or “identified patient”) was blamed for a problem which existed in another segment of the family or in the family as a whole.

One effect of this shift in focus from individual family members to family interactions was the establishment of a rationale for conjoint therapy. Those therapists who met with couples and families prior to systems theory did so without a formal theory or supporting tradition and often with concern that they might be providing a second class form of therapy. Systems theory provided the necessary rationale and tradition, establishing marital and family therapy not merely as acceptable therapeutic modali- ties, but in some cases as treatments of choice.

The major disadvantage of the family systems approach is its oppositional tone. According to the systems’ concept of homeostasis,’ the couple or family, having achieved some sort of equilibrium, is seen as resisting and counteracting all forces which threaten this equilibrium. Individual family members are viewed as active proponents of the family system, helpless victims of this system, or both. Since the aim of systems-oriented therapy is to challenge and change the family system, a task which requires disrupting the family’s homeostatic balance, these therapists often see their goals as directly opposed to those of the family (Haley, 1963; Zuk, 1968).

The concepts of homeostasis and family systems need not inevitably lead to family/therapist opposition. Family members appear to have mixed feelings about their family system, being committed to it while a t the same time disliking the severe limitations it places upon them. It seems possible, given these conflicting feelings, that members might resist the therapist’s attempts to change the system at some moments and collaborate with these attempts at others (Freeman, 1976). The impression generally given in the family systems literature, however, is that family members are almost entirely dominated by the family system (much as one might be possessed by the devil) and thus exert a constant oppositional force against the therapist’s attempt to change the system.

The opposition which these therapists experience between themselves and these families appears further heightened by the type of personal dynamic formulation they do sometimes make. A major reason family members resist attempts to change their basic patterns of interaction, some of these therapists seem to suggest, is because they are getting too much from the pathological family pattern the way it is. The notion here is that these people are enjoying some regressive, exploitative, self-indulgent, or pathological gratification which they refuse to give up. There is an unmistakable moralistic tone in this way of thinking about people which these therapists either do not realize or feel is justified.

A further factor which may contribute to the sense of opposition which conjoint therapists often experience is a tendency which some of them have to see family members as being duplicitous and manipulative, as using ploys to get what they want, or Eric Berne type games.

The systems approach thus appears to lead to a picture of the conjoint therapist struggling gallantly against great odds-against concerted family efforts to maintain homeostatic balance, against powerful family forces sabotaging all attempts to change the family system, against the insistent pressure of family members to maintain their infantile gratifications, and against the subtle maneuvers and deceits employed by family members. It is perhaps this general picture which accounts for the dramatic, forceful, and at times coercive measures taken by some systems-oriented therapists. Opposed as they believe they are by recalcitrant family members and by this powerful and uncompromising adversary, the family system, these therapists may feel impelled to use whatever means are at their disposal.

12 JOURNAL OF MARRIAGE AND FAMILY COUNSELING July 1978

Thus, Ackerman (1966) deliberately charms, ridicules, and bullies family members; Haley (1963) and Watzlawick, Weakland and Fisch (1974) strategically manipulate them with paradoxical instructions; Jackson & Weakland (1961) tactically place them in therapeutic double-binds; Haley (1977) systematically browbeats certain partners who fail to do the tasks he assigns them; Minuchin, et al. (1967, pp. 261,291,295) “frontally silence” overbearing wives to “rock the system” and show their passive husbands how to stand up to them; Speck (1965, p. 199) openly engages in “power struggles” with families; Satir (Haley & Hoffman, 1967) forcefully structures the therapeutic session and undercuts all attempts to challenge her control; and Zuk (1968, p. 50) intentionally sides with one family member against another, challenges the whole family, and does so in inconsistent patterns in order to shake them up, keep them guessing, and Yip the balance in favor of more productive relating.” Haley & Hoffman’s (1967) presentation and discussion of therapy sessions conducted by seven family therapists provide a vivid picture of therapists struggling against families and Beels & Ferber’s (1969) review of the family therapy literature appears in some sense a catalogue of confrontational and manipulative therapeutic measures.z

It is perhaps surprising, considering the dramatic nature of these methods, that they have been incorporated into the couple and family therapy traditions with such little discussion and debate. The assumption underlying their uncritical acceptance appears to be that measures of this sort are somehow necessary and unavoidable. An entrant into the field is often taught this general adversary orientation as if it were the only possible way of doing marital and family therapy.

My own conjoint therapy experience is a t variance with this traditional view. Confrontation and manipulation do not seem to me to be as necessary as these authors often suggest. It is my guess, furthermore, that other conjoint therapists may have had similar experience but have perhaps been limited in their recognition or acknowledge- ment of this fact by the absence of an official model or supporting tradition. The purpose of this paper is to present such a model and to offer it as a substitute for the homeostatic-systems approach. This alternative model, to which I have given the name, “paired binds,” is based upon a style of psychodynamic reasoning developed by Bernard Apfelbaum (1977).

The therapist with a “paired b ind orientation approaches families and couples with the assumption that each involved member is caught in a difficult conflict or dilemma with respect to the trouble-producing family situation. The task is then to lay out each of their intertwined dilemmas or paired binds for the whole family to see. The goal is to break through the alienation which has been forming among them with respect to that situation.

The paired bind orientation thus maintains the useful. aspects of systems theory, an unwavering attention to family interactions, while discarding what the author believes to be its unnecessary and deleterious adversary tone. Therapists who approach couples and families with a mental picture of family members caught in paired binds will be predisposed to intervene on the side of the family members against, or with respect to, their particular dilemmas. This contrasts with the homeostatic-systems model which appears to predispose therapists to intervene against the family system which, as is being argued here, often means intervening against family members.

This difference between homeostatic-systems and paired bind therapeutic approaches can be illustrated by considering the classic systems theory example in which one partner is demanding and the other is withdrawn (Fogarty, 1976). Jackson (1967), with his usual facility in characterizing couple patterns, pictures a demanding wife who asks her husband whether he loves her and a withdrawn husband who replies compliantly but unenthusiastically that he does. Jackson refers to this exchange and


the hurt and resentment which follow it as a “game” and states that husband and wife are helplessly enmeshed in a “self-perpetuating and mutually causative” couple system. Therapy for Jackson then consists of the therapist “behaving in such a way” that this couple pattern “must change” (p. 144). The implication here is that simply talking with them about their situation is not enough. Watzlawick, Weakland & Fisch (1974, p. 103), writing from a similar perspective, suggest the tactic of pointing out to such a wife that her demanding behavior, in contrast to what must seem to an outsider as “quiet, kind endurance,” on her husbands part, is “making him look good.” She, in an effort to stop “building him up in the eyes of others at her expense,” stops nagging him which, since the pressure is off, causes him to withdraw less.

The object of a paired bind approach, on the other hand, is to delineate the partners’ concurrent conflicts. With this in mind, the therapist would ask about the background thoughts and feelings tach partner had been having throughout the interaction. The resulting reconstruction generally produces a dramatically revised picture. It is likely to turn out, for example, that the wife had been struggling between a wish to discuss the lack of intimacy in their marriage and her fear her husband would feel pressured by this and withdraw further. She deals with this dilemma by supress- ing her wish. Since suppressive efforts are never completely successful, the wish breaks through at certain moments in the jarring, highly compressed, out of nowhere question, “DO you love me?’ Her fear of being demanding, in other words, has led to this intrusively demanding question.

The husband then finds himself in a dilemma where he can either be truthful at the expense of hurting her feelings and precipitating an unresolvable argument, or be polite and considerate, at the cost of suppressing his true feelings. His real feelings, we can imagine, are that he feels pressured by her question and criticized by the implied accusation that he has been insufficiently affectionate. At least a t the present moment, when he is feeling pressured, criticized, guilty, and resentful, he certainly does not love her. This husband, as his wife before him, deals with his dilemma by suppressing his true feelings. These feelings reveal themselves, however, in the toneless and perfunc- tory manner by which he says he loves her.

A major value in delineating these partners’ concurrent conflicts is that it allows each to recognize that his or her partner is in a difficult dilemma and is not simply the selfish, unreasonable, malevolent, or unfeeling person he or she had seemed to be. This can be quite relieving. The husband who had been seeing his wife as demanding and overbearing now recognizes her demandingness as a result of an attempt to be undemanding. The wife who had been seeing her husband as withdrawn and unavail- able now recognizes his detached compliance as an effort to protect the integrity of the relationship.

A successful paired bind interpretation interrupts the alienation which had been developing between partners by suggesting they are both seeking the same general goals. In some cases, a kind of division of labor springs up in which one partner takes responsibility for certain universal couple concerns and the other takes responsibility for opposite ones. The wife in Jackson’s example may be serving as spokesperson for the common wish to establish a more intimate relationship while the husband may be taking major responsibility for their common need to maintain the stability and evenness of their relationship and to guarantee a certain measure of separation. The fact that both partners are interested in both sets of issues can generally be demon- strated to them by pointing to other times in or aspects of their life together when they have taken the reverse positions.

In other cases the goals or concerns of the partners may be exactly the same but they find themselves a t odds because of the manner in which they pursue these goals or


express these concerns. We can imagine, for example, that Jackson’s demanding- withdrawn couple approached their marriage day in contrasting ways, he by seeking time away from her to think things over and she by desiring reassuring contact. Each partner’s manner of dealing with his or her fear of commitment would then have the ironic effect of increasing the anxiety of the other. The more he withdrew, the more she needed reassuring contact; the more she sought contact, the more he needed to withdraw. The alienation which developed between them could have been resolved by pointing out that they were both worried about the same thing, but were expressing this anxiety in contrasting ways.

Of perhaps even greater importance than the need of individuals to understand and sympathize with their partner’s position, is their need to understand and sympathize with themselves about their own dilemma. The wife in Jackson’s example is worried about being pushy while the husband is worried about being uninvolved. It may be with considerable relief, therefore, that this wife realizes that her reputation as a demanding woman is a result of her attempt to be undemanding, and that the husband considers that his reputation of being afraid of intimacy is a result of his effort to avoid the arguments which would disrupt the intimacy they do have.

The general effect of marital discord, in summary, is to leave both partners feeling stuck, hopeless, and blame-oriented, attributing the problem to their own personal deficiencies or to the deficiencies and unreasonableness of their partner. The value of the paired bind approach is that it loosens partners from this locked-in perspective by providing them with a noncondemnatory way of making sense out of their own and their partner’s behavior.

A problem with the systems approach is that it seems to reaffirm the partners’ locked-in, narrowed-down perspective and, in so doing, reinforce their self hate. The systems approach directs attention to the dysfunctional nature of the couple system, in Jackson’s example, the wife’s demandingness and the husband’s withdrawal. This predisposes therapists to think, and thus to talk, in terms which confirm the partners’ worst fears about themselves, suggesting in the present case, for example, that the wife is too pushy and the husband is too detached. It is perhaps interpretations made from this frame of reference, and the couple’s defensive reaction to them, which led systems- oriented therapists to conclude that talking with couples and families is unproductive (for example, Haley, 1977, p. 118-119).

A fully developed paired bind interpretation reveals the essential truth which lies behind each partner’s symptomatic or conflict-producing behavior. The wife’s impul- sive question, “DO you love me?, may be the closest this couple ever comes to recognizing and discussing the important truth that their life together has not turned out to have the satisfactions and intimacy which both in their own way had wanted. Every- day married life is filled with moments when one or both partners feel excluded, unappreciated, or disappointed. Couples who do not have a way of recognizing these feelings and talking about them are subject to a gradual build-up of resentment and alienation leading to a loss of feeling for each other and either emotional or actual divorce. The wife’s recurrent requests for reassurance can thus be used as a clue that something unsettling or alienating has just happened which needs to be discussed. Considered from this point of view, this woman’s wish to ask her husband whether he loves her is a valuable asset which the couple may be fortunate to have. Couples in which neither partner is a “specialist” in the moment-to-moment slights, deprivations, and dissatisfactions of the relationship have less chance of recognizing and thus dealing with the alienation which can so easily develop between people.

In a similar manner, the husband‘s compliant response, his attempts to smooth over difficult issues, and his statement when pressed, that he does not see the value in


talking about their problems, may be the closest this couple ever comes to recognizing that they do not have a way of dealing with conflict. Thus, while the wife is correct that there are critical deprivations occurring in the relationship which need to be talked about, the husband is correct that they presently have no way of talking about them. The object of a paired bind interpretation is to recognize these important insights and to make them usable and a platform for further discussion.

An essential difference between the homeostatic-systems and paired bind approaches is that the former appears to picture family members as resistant entities who will change only if forced to do so while the latter views them as struggling to work things out against difficult odds. In the classic family homeostasis situation, the emotional disability or symptomatic behavior of one member, the “identified patient,” is seen as being required for family stability. According to this view, the family will resist and sabotage any attempts to improve the psychological well being of this individual (Haley, 1963; Jackson, 1957). It has been my experience, on the contrary, that family members are as likely to be relieved and grateful as they are to be threatened and resistant when a problem they had attributed to the “identified patient” is redefined as a general family problem. This is only true, of course, if the family problem is stated in a nonaccusatory manner, that is, in terms of paired binds.

Both partners of a couple I saw recently agreed that their only major problem was the wife’s “neurotic symptoms”-her periodic worries about death and her inability to get along with her husband‘s mother. As soon as she began talking about either issue, he would interrupt and try to talk her out of these concerns, suggesting that she should take life as it comes along rather than worry about death and that she should take his mother, whom he agreed was a difficult woman, with a grain of salt. Although she may have felt vaguely misunderstood, she agreed he was probably correct.

The couple’s idea about therapy was that we should look at the wife’s early family experience to uncover the source of her “neurotic symptoms.” When I suggested these symptoms may have more to do with their present relationship than with any past problems she might have had, they did not become resistant, as the homeostatic model might have predicted, but were intrigued and encouraged. When we were then able to formulate the problem in terms of paired binds, they were pleased and grateful. This is not hard to understand. Their definition of the wife as the “identified patient” left them helpless to do anything about the problem. The suggestion that the difficulty might have to do with their ongoing relationship gave them hope that they might be able to deal directly with the situation.

The wife’s fears of death turned out, in part, to be her way of experiencing the alienation which had arisen between herself and her husband as a result of certain recent discordant events. Once this was established it became relatively easy to suggest that her fears could be used as a sensitive instrument for detecting issues or events about which it was important for them both to know. The husband, for his part, needed to talk her out of her fears because he felt that any unresolved problem between them might end their marriage. Once he had a chance to state this concern, a concern she also shared, it became an issue they could talk about rather than one upon which his only alternative was to act.

The wife’s other “symptom,” her difficulty dealing with his mother, turned out also to be a function of the marital relationship. The wife would have been able to manage his mother and help her husband in his own attempt to deal with this difficult woman, if only she felt her husband were on her side and understood her feelings about it. The husband, convinced that no one could possibly want to help him in the unrewarding task of dealing with his mother, and feeling guilty about exposing his wife to this problem, had been devoting all his efforts to instructing his wife not to take her seriously. The effect of this, however, was to convince his wife he did not understand


her feelings and that there was something wrong with her for not being able to follow his recommendations. What this couple was suffering from, in other words, was not the problem of dealing with his mother, but rather their inability to be resources to each other in this common task. Once the problem was stated in these terms, it became much easier to resolve.

The argument to this point has been that the confrontational or manipulative tone of much conjoint therapy is a product of the homeostatic systems model by which therapists conceptualize family and couple functioning. In addition to this theoretical justification for the use of coercive measures, there is a second and related pragmatic justification. These therapists, while perhaps agreeing that it may seem at times as if they are being manipulative or bullying, would point to the fact that their approach works. Furthermore, they might go on to say, an active, initiating, controlling approach of this sort is absolutely necessary if family or marital therapy is to be possible a t all (Jungreis, 1965). Kempler (1968, p. 95), putting it more strongly, says that “family therapy requires active participation if the therapist is to survive.” This pragmatic argument is an important one and brings up one of the historic services provided by systems theory. As described in the beginning of the paper, family systems theory legitimized the active therapeutic measures which seemed to be necessary in conjoint therapy.

I agree that therapists have to be active and forceful if they are going to have any effect on families. My suggestion, however, is that the particular methods which systems-oriented therapists employ, while perhaps providing a useful first approxi- mation, may no longer be necessary. It seems possible to exercise sufficient therapeutic leverage without having to coerce or manipulate, thus avoiding the unfortunate side effects which such methods produce.

Therapists who adopt the paired bind orientation being recommended here take the active role which is necessary to make conjoint therapy feasible. They interrupt stalemated family interactions, reconstruct the series of events leading up to this stalemate, ask the involved members their thoughts and feelings at each point in this reconstructed sequence, and end up by establishing as clear a picture as possible of the respective dilemmas in which the family members are caught. Such therapists are active and forceful but they apply this forcefulness to the task of delineating the binds in which these family members find themselves, rather than, as sometimes appears to be the case with the systems-oriented therapist, to the task of controlling or manipulat- ting family members.

Much of what I am recommending is what some conjoint therapists may have been doing all along, although perhaps tentatively and inconsistently, without having a name for it, and without having a recognized tradition to provide theoretical support. What I have sought to do in this paper is to legitimize such an approach, to provide it with a model, a name, and a respectability, and to dramatize the disadvantage of treating families as adversaries.

REFERENCES

Ackerman, N. W. Treating the troubled family. New York: Basic Books, 1966. Apfelbaum, B. A contribution to the development of the behavioral-analytic model. Journal of Sex

Beels, C . C. & Ferber, A. Family therapy: A view. Family Process, 1969,8, 280318. Fogarty, T. Marital crisis. In Guerin, P. J. (Ed.), Family therapy: Theory and Practice. New York:

Freeman, D. S. The family as a system: Fact or fantasy? Comprehensive Psychiatry, 1976, 17,

Haley, J. Strategies ofpsychotherapy. New York: Grune & Stratton, 1963.

and Marital Therapy, 1977,3, 128-138.

Wiley, 1976. F‘p. 144-153.

735-748.


Haley, J. Problem-solving therapy. San Francisco: Jossey-Bass, 1977. Haley, J . & Hoffman, L. Techniques of family therapy. New York: Basic Books, 1967. Jackson, D. D. The question of homeostasis. Psychiatric Quarterly Supplement, 1957, 31, 79-90. Jackson, D. D. The individual and the larger contexts. Family Process, 1967, 6, 139-154. Jackson, D. D. & Weakland, J. Conjoint family therapy: Some considerations of theory, technique,

Jungreis, J . E. The active role of the family therapist. In Friedman, A., et al., Psychotherapy for the

Kempler, W. Experiential psychotherapy with families. Family Process, 1968, 7, 88-99. Minuchin, S. Families and family therapy. Cambridge, Mass.: Harvard University Press, 1974. Minuchin, S., Montalvo, B., Guerney, B. G., Rosman, B. L. & Schumer, F. Families ofthe slums.

Satir, V. Conjoint family therapy, Revised Edition. Palo Alto: Science and Behavior Books. 1967. Speck, R. V. Some specific therapeutic techniques with schizophrenic families. In Friedman, A., et

Speer, D. C. Family systems: Morphostasis and morphogenesis, or ‘‘Is homeostasis enough?”

Watzlawick, P., Weakland, J . H. & Fisch, R. Change. New York: Norton, 1974. Wertheim, E. S. Family unit therapy and the science and typology of family systems. Family

Whitaker, C. Comment on Murray Bowen’s presentation. In Framo, J . (Ed.), Family interaction.

Zuk, G. H. Family therapy: Formulation of a technique and its theory. International Journal of

and results. Psychiatry, 1961,24, 3 0 4 5 .

whole family. New York: Springer, 1965. Pp. 187-196.

New York: Basic Books, 1967.

al., Psychotherapy for the whole family. New York: Springer, 1965. Pp. 197-205.

Family Process, 1970, 9, 259-278.

Process, 1973, 12, 361376.

New York: Springer, 1972. Pp. 169-171.

Group Psychotherapy, 1968,18, 42-58.

NOTES

%peer (1970) and Wertheim (19731, among others, have criticized the commitment of systems- oriented therapists to the homeostatic model. Despite their efforts, the homeostatic model appears to remain the central organizing concept for most of these therapists.

*The attempt to coerce or control is only one aspect of these therapists’ general approach. It is an important aspect, however, and appears to express an underlying attitude toward families. Whitaker (1972, p. 169), in response to Bowen’s dramatic account of how he manipulated a change in his own family, commented that “people who go into family therapy are master manipulators.”


Documents

Is a Confrontational Tone Necessary in Conjoint Therapy?