Arthur C. Nielsen, MD, in his “A Roadmap for Couple Therapy” (Routledge, 2016), observes that “Another difficulty unique to couple treatment is that if the therapist spends too much time and too many consecutive sessions focusing on the symptoms or defenses of one spouse, he or she may feel (understandably) that the therapy has become too tilted against him or her. In such cases, the therapist may have to sacrifice thematic continuity in order to sustain a neutral position and the therapeutic alliance.” (p. 16)
This prompted me to think of my work with various couples, as well as some examples of couple therapy by colleagues when I have been the individual therapist for a client also in couple therapy. There are a number of ways in which over-focusing on one spouse at the expense of the other, and of the relationship, can happen.
One obvious way is when one spouse has an issue that actually does undermine the couple so much that it prevents the therapy from being balanced. For example, if one spouse is abusing alcohol, and refuses to acknowledge or deal with it, that issue may become the focus of couple therapy until the drinker is willing to address it. In such cases, I’ve told the couple that, once alcohol is no longer an obstacle to therapy, we will be focusing more equally on the issues presented by both spouses. As the quip says, “Each person is 100% responsible for 50% of the problem.” Of course, this can be a threat to the non-drinking spouse, who may see the partner’s drinking as the sole or main problem in their relationship; “We’ll be fine if you’ll just stop drinking.” But that’s not how it is.
Infidelity, past and present, is another issue in which, for a time, the focus can be more on one person than the other. Some marital therapists won’t work with a couple in which one spouse is engaged in a current infidelity—Sue Johnson won’t—while others therapists, for example, Esther Perel, will. This is a complex topic.
Aside from alcohol abuse and infidelity, there can be more subtle ways in which the focus in couple therapy can be unbalanced toward one spouse. A couple may have a narrative in which one spouse is responsible for most of their problems. There are psychodynamic advantages for both the “guilty” spouse and the “victim” spouse in that narrative, and their collusion in it prevents them from honestly exploring the obstacles that each contributes to their relationship. Such couples may welcome the therapist being more focused on one spouse than the other. The challenge to the therapist is to recognize the dynamic and help each partner, and both together, explore how each person contributes, and how their collusion protects them from seeing what’s really happening. I have seen cases in which the couple, already in collusion in the narrative that one spouse is the “guilty” party, draw the couple therapist into collusion with them in this narrative; undermining the therapy and creating what psychoanalytic therapists call an “enactment.” Enactments can be very valuable, but only when we have identified that we are in them and are working through them with our clients.
Nielsen says that the therapeutic relationship should be “Safe, but not too safe.” I think he means that couple therapy must include issues that will be difficult for all parties; for each member of the couple as an individual, for the couple as a couple, and for the therapist. If it doesn’t, the therapist ought to be asking why we can’t talk about what’s really going on here.
I was delighted not only to read that Dr. Einhorn took off from something I had written, but that he proceeded to amend it in ways that totally fit with other things I say in my recent book. Like Jay, I find that when addictions or infidelity are at issue, therapy must adapt and face the fact of differential contributions of the partners. I make this clear in my book chapter on sequencing interventions where I recommend modifications out of the gate on those two issues. The other one, Dr. Einhorn mentions, is also tricky as the partners seem to AGREE that one of them is the problem; these are what I term “identified patient” couples; and again we have to modify our work. In all three cases, therapists can be suspicious that below the surface, the other partner may be fueling the manifest problem, even as this is not always the case. So thanks to Dr. E. for so clearly noting modifications that I have also found essential.