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The History of Marital Therapy

from The history of couple therapy: A millennial review. Family Process, 41, 199-260. (2002).

Gurman and Fraenkel point out that relational therapy (formerly marital or couples therapy) has been largely neglected as its own specialty, even though family therapists do almost twice as much work with couples as work with multigenerational families. Sometimes it is traditional therapy just focused on the adult romantic relationship, but sometimes it is parent-focused work within the context of a family. They also note this is not such a bad ratio, as 40% of people coming to therapy attribute their problems to relationship issues. Gurman and Fraenkel define Four Phases in the History of Relational Therapy:



Phase I
1930 to 1963
Atheoretical
  • 1929 to 1932 – Three marital clinics opened; they were service and education oriented, and generally worked with individuals, discussing their difficulties adhering to traditional gender role expectations.
  • The closest thing to theory was what was borrowed from psychoanalysts. Problems between the spouses were seen as interlocking neurosis. Each spouse had a neurotic conflict inside them which they projected onto the other spouse; the other spouse accepted this because it fit with their own neurosis. Thus, a person with a need to control partnered with someone who depended on others. A person who was overly rational and unable to manage emotions partnered with a person who was overly emotional and unable to be rational.
  • In 1931 the first marital therapy paper was published
  • Theory was marginalized, as no one was really conceptualizing marital therapy as much more than individual analysis with two people who happened to be married to each other.



Phase II
1931 to 1966
Psychoanalytic Experimentation

  • Therapists are seen as telling truth from distortion, rather than creating a truth. One partner or the other must be wrong, and helping them see that was the point of therapy.
  • Most of the work was done in individual sessions, but some therapists experimented with conjoint sessions. However, they still treated the work as individual therapy, and one partner simply observed the analysis of the other partner for a little while each session.
  • Some started to downplay the role of the therapist, and focused for the first time on helping the spouses be “therapeutic” with each other.
  • Family therapy caught all the attention of therapists, and the marital therapy techniques weren’t innovative or particularly effective.



Phase III
1963 to 1985
Family Therapy Incorporates Other Approaches

  • Family therapy overpowers couples therapy, even though most of the famous family therapists mostly saw couples.
  • Jackson coined concepts like quid pro quo, homeostasis, and double bind for couples therapy, and began looking at how systems processes happened just between the two people.
  • Satir coined naming the roles members played (the soother, the agitator, the distractor…), fostered self-esteem and actualization in couples (and in families), and saw the therapist more as a nurturing teacher who could help the couple continue what therapy started on their own.
  • Bowen began working on a multigenerational approach to family therapy, and included couples work in his practice. He focused on differentiation (from the family, but also from each other in the couple), triangulation (within the family, but also as the couple sought others to become involved in their conflicts), and projection processes. The therapist was an anxiety-lowering coach who showed them how to calmly understand and accept each other’s anxieties and fears. He proposed a “societal projection process” or social scapegoating which I think was the forerunner of our modern awareness of cultural differences.
  • Haley focused on power and control (Madanes focused on love and connection) as key to udnerstanding why people do what they do in complex systems. He avoided focusing on insight, emotional catharsis, and conscious power plays. instead, he saw the system as more, and more important, than the sum of the parts (or people that make up the system).



Phase IV
1986 to now
Refining and Integrating

  • 1986 marked the publication of Gurman and Kniskern’s book summarizing the research to date on couples therapy. It allowed for therapists to begin to condense, test, refine, retest… what we knew about couples and healthy relationships. New theories, like Integrative Behavioral Couples Therapy, Emotionally Focused Therapy, and Solution-Focused Therapy developed, and all have received good empirical support. Couples therapy was used to treat depression, anxiety, and alcoholism, either working with the couple, or working with the couple as a critical part of individual treatment in special clinics.
  • Efforts were focused on preventing couples problems with programs like PREP. This marked a shift from understanding dysfunctional couples as partnerings of unhealthy people to understanding them as possibly healthy people under extreme stress through critical transition points in life.
  • Feminism, Multiculturalism, and Post-Modernism impacted the field as well, often showing us as a field that we were not as comprehensive, broad-minded, and free of biases as we thought we were.
  • Eclectic integration, brief therapy, and sex therapy treatment developed as subspecialties of a sort, and were incorporated into larger theories.



Four Shifts in the Field

  • We went from ignoring the individual in order to see the system to seeing the individual again as existing in a complex system
  • mental disorders are considered as unique problems housed in individuals, and while sometimes are the result of systemic dysfunction, more often system dysfunction aggravates individual issues.
  • Oddly, the most helpful theories were the ones that grew from individual theories, rather than the ones that grew solely from systems thinking.
  • While once seen as a subset of family work, today relational therapy is a vibrant and active area of its own.



Research Stages

Gurman and Fraenkel also denote three research stages for the field:

  • Stage I – 1930-1974 – the Search for Data – there’s not much there
  • Stage II – 1975-1992 – Exuberance – All over Gurman’s conclusions that couples therapy works!

  • Stage III – 1993 to now – Cautious Optimism – It works, and all of it works about the same. It gets good effect sizes, with 60%-75% of couples getting better, esp. when they are young, flexible, in low distress, and emotionally attached. While relapse might be high, it’s
    1) as good as individual therapy at managing disorders,
    2) cost effective,
    3) facing unfair criticisms and dealing with couples in crises with long term problems and short-term motivation.