Brief intensive intervention in a marital crisis

This report of short-term intervention in a troubled marriage details the evaluation and a turning point in an intervention that went on for approximately a month.

This paper was presented in a conference co-produced by the International Psychoanalytic Association’s Committee on Couple and Family Psychoanalysis. The conference highlighted issues raised by the use of mixed modalities in treatment, for example, doing family and individual analytic therapy, or couple and family therapy, at the same time and/or with the same therapist. This case illustrated a different variation of the usual setting in which we work: the implementation of a frequency and intensity of sessions almost jammed into a brief schedule dictated both by the urgency and limitations of the couple’s schedule. The couple was due to arrive in Washington, DC already knowing their time there would be limited to a few weeks. Nevertheless, the crisis situation in their marriage dictated that if there were to be any chance for the survival of their marriage, they would need intensive, brief intervention.

Therefore, the issues of the setting were prominent in this brief intervention: mixed individual and couple sessions, a rapid evaluation, followed by short-term intervention, all determined by the couple’s brief time in Washington. At times we had more than one session per day as well as extra-long sessions. My organizing principles followed the theme of developing a limited focus on current symptoms of marital breakdown with a dynamic transference focus on the most salient unconscious issues. (Stadter, 1996; Scharff and Scharff, 1987; Stadter and Scharff, 2000). I have also written about the phasing of individual and couple sessions in previous publications that are relevant to this intervention (Scharff and Scharff, 1987).

The object relations theory that I draw on in conceptualizing brief therapy draws on a rich tradition (Balint et al., 1972; Malan, 1976; Strupp and Binder, 1984; Budman and Gurman, 1988; Stadter, 1996). Because of the limits of time in brief therapy, it is important to limit the extent of regression and find a crisp focus on the presenting symptoms that can be seen to be emblematic of the individual’s or the couple’s difficulty. While there are many models of technique and focus (for instance, Davanloo, 1991; Horowitz, 1991) I follow the lead spoken for both by Balint and colleagues (1972), and Strupp and Binder (1984) who emphasize the importance of the therapeutic relationship. Thus, building trust is a central element, after which transference interpretation can become effective (Piper et al., 1991a; 1991b). While most of the literature focuses on brief individual therapy, Stadter and I have contributed an article applying this thinking to psychodynamic couple therapy (Stadter and Scharff, 2000).

The treatment

When John and Julia emailed me, they had been living and working in South America but would be back in Washington, DC for about a month before his next posting and would like to come in for intensive work about their marriage. I agreed by email to meet with them as a couple for an initial evaluation, and that if that meeting felt satisfactory to them and to me, we would continue with an intensive, brief intervention. What follows is the story of the essence of my work with them.

The first session was two hours long.

Julia was a nice looking, freckled faced, thin woman who spoke a diplomatic English with hardly a trace of her Latin American origins. He is from California, a Foreign Service officer on his way to Saudi Arabia, a tour not be especially hospitable for spouses.

The couple had been married four years, together for six. Early, they felt everything was meant to be, but early trust problems emerged. Since the last 6 months things were significantly worse. By February, John had nothing left. He said “I felt a lot of difficulty getting through to her. She had a lot of needs and she never trusted me. I had a friendship or affair in March, another before that to try and get Julia’s attention, and that led to our separation”.

Julia now spoke. “Until recently I felt these affairs were a cause for separation. We’ve been trying to hurt each other for six months”. John added that the relationship had been in decline over the last 5 years.

In this first session, John said, “I was sexually molested as a child. But I’d dealt with that before our marriage. Julia had an alcoholic father who killed himself before we met. I feel that’s caused of some of her trouble. I don’t know if it’s really the cause. This week we’ve done better talking but without enough about her part”.

Julia said, “He’s broken my trust, traumatized me. If that relationship was a friendship, why didn’t he tell me about it. He felt that I didn’t trust him. A year later he blew up and said these things were still affecting him. Maybe it is me, but I trusted him until six months ago.

In December, he blew up at an airport he told me 20 hurtful things. He got it all out without letting me discuss it. He felt better, but I felt terrible. It wasn’t normal discussion. When I found out about that woman he used to hurt me, his reaction was “I wanted to meet her, so I’ll fly you back to DC and meet with her. You’d be a bad mother anyway. It’s good to separate. We need a divorce. If we meet in the future and are in love okay, maybe! He’d made a reservation for Rio with a woman from Argentina. We were supposed to be transferred there for our next post”. She continued, “I have abnormal, dark thoughts – not suicidal, just no light at the end of the tunnel. How could this ever improve? So, I left, feeling cheated and betrayed, by his involvement and rejection for the last six months”.

I asked Julia about her past. “My father was alcoholic. I was reading about that and saw some effects from it”. But then she segued back. “John has some effects too. He was molested by his cousin. The family took the cousin’s side. If a friend betrays John’s trust, he cuts them off 100%. We’ve had a roller coaster through his infidelities. Then he was in Florida and went to a strip club and spent a lot of money; I found out about it. He reacted by rejecting me, it was another stab in the back he couldn’t explain”.

I asked about their first six years as background for this latest decline. There were early signs of trouble. They were isolated in a small town with episodes of discord and jealousy, Julia’s unfounded accusations, things that weren’t voiced.

John said, “But in the last six months, I gave up on our relationship. When she left. I thought I was free. I wish I could take back having gone to the strip club, but neither of us felt the marriage still existed. At least I didn’t”.

Julia said “I agree something happened inside. When we first met, we spent a lot of time together. I had a clean cut off from my ex-boyfriend, but John tried to get personal items back from his ex. I felt he shouldn’t disturb her. He agreed to tell me when she contacted him but he didn’t. Then he took away unrestricted email access and I lost trust”. John acknowledged leaving phone messages for Julia to find. “I was in a state of desperation to get through to her, and she couldn’t hear me”.

I said that Julia didn’t hear or trust John.

Julia replied, “Yes, trust issues are important for us both. Growing up with an alcoholic father, I questioned everything. I’d been lied to so often”.

I asked for more about her family.

Julia’s father came from a poor family. He drank from the time she was young. Julia’s mother sent her to bars to find him. When she was 21, he killed himself while he was in a treatment institution. When her father wasn’t drunk, she had a better relationship than with her mother. But he’d be drunk for 5 days and they’d fight. He’d get sober and expect to pick up their relationship as before. He never said he was sorry to her, which would have helped. It took her two years to get over his death. She said “Nobody before John said I was jealous or controlling and nobody accused John before this either”.

Julia said “Until I was two or three, we lived with my mother’s family. When we moved my grandmother was despairing and put a lot of guilt into my mother. My parents would often split up to go help their own parents. My mother was loving, but I resented that she never confronted my father about his drinking”.

I asked for more detail about John’s family.

“My family is both great and greatly flawed, and are invested in education. We’d live without things to send my brothers and sisters to college. I had a falling out with one brother and haven’t talked in years. They don’t understand what we’re going through. I have a good relationship to my married sister, but my brother holds out”.

John lost his security clearance after the affairs. Julia reported the affairs, and since he hadn’t reported them, it’s legally a breach of trust. And, around the time of their separation, Julia had actually worked with the same security officer who had investigated John. That set of complicated relationships had gotten in their way, too because it gave John additional reason to doubt Julia’s loyalty. Julia said that there are safe ways of reporting that would not jeopardize his security clearance, but he had not used these. He’s up for a new security clearance now, but he wouldn’t be going to Saudi Arabia if they hadn’t separated. He knows some Arabic and he’s in Washington for training. He’s thought about getting out of the Foreign Service, but he is planning to go to Saudi Arabia for this tour.

Discussion

In this first session I got a sense of the urgency of their situation. A couple madly in love, mutual idealization ruling the day, had quickly crashed through the glass bubble of that idealization, reaping the inheritance of trauma that seemed already to have characterized their individual histories. In this first session, however, they seemed very much a couple, interacting without a sense of mutual blame, at least for today, even although they gave the history of mutual disappointment that gave distant echoes of their deprivations and disappointment in each of their histories. Because the individual histories featured so prominently, I decided to see each of them individually, partly to see if there was enough commitment from each of them to go forward as a couple. Therefore, I saw them the next day for an hour each individually.

Individual session with Julia

Julia rehearsed all the downhill events of the marriage. John had become more secretive and reclusive over time, but in the last six months there were these two “affairs” which John said he bolted from before they became sexual. In one the woman had come onto him in a hotel room, and in another there were messages talking about calling him “her love”. Separation had been traumatic. He said it was over by offering her the pet, and changing the passwords on their accounts. He accused her when she took out half their money to buy a car, but she said she had lost trust in him.

She gave more family details. Her father started threating suicide when she was 13. She told him “I have the same thoughts as you do without threatening suicide”. His drinking increased, although the parents would get along when he wasn’t drinking. Her mother sent Julia to check on him in bars. Mother’s teen boyfriend had also killed himself. In the end, her father checked himself into a hospital under family pressure. The night before he killed himself he told Julia, “I love you still even if you don’t love me”. He hung himself, she thinks in desperation he’d never get over the drinking.

With John she feels that she went back because she read her Peruvian therapist’s book that if a couple could get over an affair it could give them a better marital foundation. I said to her that I thought she was afraid she would turn into her mother, controlling and desperate, and that John would become like her father.

She agreed. When John drinks she gets frightened although he insists it’s not the same. She agreed that she was afraid that she was becoming like her mother.

Discussion

The amount of trauma in Julia’s history came through even more tangibly, but so did her resilience. She seemed so far to have more capacity for staying with the couple, but this also raised the question of how much masochism was mixed in with her grit.

Individual session with John

In his individual interview, John agreed with Julia’s description of their pattern of decline. They hit it off beautifully at first, but she wanted to change him, so he had to give up on hobbies, interests and accomplishments as she became more controlling. In the recent relationships with the two women, he could not carry though sexually. In the first, he bolted. With the second, he knew he was trying to hurt Julia.

Turning to his early history, John told me that when he was six, a cousin living in his house had spanked him painfully on his genitals over several episodes, with further sexual abuse he couldn’t remember. At ten, his grandmother who had raised and loved him and who owned the house, had died. The cousin had moved back in, and the abuse resumed at 11, and this time he sought it out. He never told anybody.

At 15, he was fighting with his parents and had a destructive relationship with a girl, so he was sent to a church counselor who had John strip and massaged him 3 or 4 times. The counselor made him say that I loved him. He told his mother, who listened but never brought it up again.

In reaction to that episode, at 15 he convinced his parents to let him travel internationally alone. It taught him he could stand on his own. Despite dreams and traumatic flashbacks, something got him through it. He studied writing at the university with help of some mentors had managed to become proficient. He said “I’m not naturally talented. I was laughed out of writing programs, but in the end, I proved myself against the odds”.

He agreed when I said to him he felt his mother’s needs had always come before his, just like now with Julia. He said “In the beginning I felt Julia was the first person who ever loved me for who I was. Then I felt I lost myself entirely in the relationship. Now I can’t get a hearing”. He felt he had worked thought his abuse before he met Julia, and was comfortable with where he was. Then he felt that her actions over their marriage destroyed his identity, so he withdrew six months ago because he didn’t recognize himself and wanted to reestablish things.

Then he gave a more detailed story about the disputed strip club incident a few months ago. They had split up and when he went into the strip club, he was seduced. He was extremely drunk, got tricked into the situation, and then balked at the end and had to pay about $1000.00 to get out of it without sex.

At the end of the session, I talked to him about the perversity that had come to dominate his relationship with Julia. Now he was abusing her in order to inflict pain in order to obscure the hurt that he felt. The last six months had been dominated by inflicting pain, which translated their relationship into a perverse one. John agreed, saying he’d been desperate.

I said, “I think before that you were as speechless as you were at age 11. Part of you is still speechless. You’ve come to feel only in danger”.

He said, “When I met Julia I didn’t feel completely over the abuse, but I was in a comfortable place. I could get though anything and preserve what I was good at, but since then, I’ve lost that capacity”.

Discussion

Here again, I felt impressed by the amount of deprivation and trauma in his story, but also heard his insistence on his strengths and resilience. There was a denial about suffering pain, but a good deal of emphasis on the deprivation of parental attention and protection during his childhood that had led him to seek love and affirmation from his cousin in a way that combined attention and abuse. But his denial came through in a way that had not characterized Julia’s description of her situation.

The interpretive couple session at the end of evaluation

In the next session with the couple, I summarized what I understood so far: Julia’s anxiety about being in any marriage, and John’s struggle when they both hoped for an ideal relationship had had combined to produce an increasingly anxious and toxic climate. From the first, John, with his hard-won, fragile independence, had become reactive to Julia’s anxiety until he felt so hurt that he turned on her, reenacting his trauma history. Julia also had trauma from her parent’s difficult marriage, her mother putting her in the middle with father, her father’s repeated suicide threats, drinking, and final suicide. Red-faced, Julia began to cry. “I don’t know how he turned to hurting me the last couple of months. His anger hits me again as I hear you describe it”.

After hearing them talk in a more sympathetic way, I said, “There’s been a collapse as you tried to protect yourselves. But Julia, you’ve said that either you should work it out here, or you’d have to end things. And you both have guessed that these things would show up in a next relationship”.

John said he’d been saying since December that they might as well work it out together, but they had been unable to talk about their abuse histories. She had to choose her words carefully because if she used the word “abuse” or said “he was lying”, John would explode.

I said “You’ll need to listen to each other’s hurt without trying to defend yourselves at first. Abuse has returned in your marriage through these explosions and in Julia’s controlling attitude”. I spoke, in colloquial terms, about the projective identification of her rage which she would put into John, and how she would then experience her own rage coming back at her. It was really rage at her father for letting her down, just as she now felt John let her down.

John said “She explodes, too. She often puts pressure on me and that erases my desire”. They now discussed more details of the cycle of her pressuring him, and how this resulted in his not wanting to do things with and for her that might have been fine without the pressure.

I said “In those cases your need for autonomy takes over”.

We ended the session by agreeing on a plan of couple sessions on each of the available days before John left for Saudi Arabia and Julia left for Peru, a total of six sessions over the next 2 ½ weeks.

Discussion

I found the interpretive session encouraging. One of the purposes of making interpretations in the evaluation phase, whether it is one session, or as here, several sessions, is to test out whether the couple can make use of them. In Julia and John’s case, I found that the evaluation sessions themselves had produced a softening for each of them so that they now seemed more like a couple, more reflective individually and sympathetic to each other.

Of course, since the evaluation phase is also intrinsic to the brief intervention, it is more than just a period of setting up the work. Here it seemed to jump start a process of change of attitude. We can ask the role of the individual sessions in getting things going. I felt that, because of the mutual mistrust that was deeply seeded in the couple, it helped me to offer the relative privacy of the individual sessions, even although they each knew I would bring material they revealed back into the couple sessions. It was more the atmosphere of individually private space that seemed to facilitate their capacity to reveal details of their lives before becoming a couple and as a couple that lent a depth to what they said, relatively freed from worrying about each other’s reactions at the moment. That arrangement seemed to build an increased sense of trust in the contextual transference with me, an increased sense that I could provide holding and containment that we would need when we reconvened with the two of them together (Scharff and Scharff, 1987). Then we could draw on this added increment of transferential trust during the ensuing work, as illustrated in the session I will now describe. All the remaining treatment sessions were held with the couple together.

A critical couple double session

This session was the third session of the week, before three final sessions the following week. In the previous two sessions we had extended their histories and then returned focus to the current strain in the relationship. I give this session in detail because it marked the singular turning point in the whole treatment.

After catching me up on discussions since the session the day before, they explored the episode that occurred a month before, which they had described more briefly in the evaluation. Julia is convinced John does not tell her the whole truth about the money involved in this episode.

John says “She’s never satisfied by my accounts. I’ve told her everything!”

Julia said “When he tells me the story it’s so general that I feel I don’t know what happened”.

I asked John to walk us through it.

The fuller story was that he went to a seedy resort town to relax. He felt he didn’t know who he was anymore. He’d had a lot to drink, when a guy invited him into a club offering free drinks. A girl came out and talked the man into a reduced admission fee. After the free drinks, the girl asked him to buy more. Then, as he’s getting drunk, he is moved into a private room costing “only $100.00”. When he gets into the room, there’s a new man. The charges start to add up: $300.00 for the room; $100.00 to tip someone. Finally, over a $1000.00. He said, “As I went down the hall, I flashed back on the scene with my cousin when I was 6. The dread I felt brought me to my senses. I was able to get out of there for a lot less money than they wanted and without any sex”.

I asked how this echoed the cousin’s traumatic seduction.

He said “Going down the hall, I remembered my cousin leading me through a dark, dank, scary basement hallway. Then things got worse and worse in the room as he started to seduce me and then to hit me in the balls. He hit me and sweet-talked me”. The story sounded humiliating and frightening as he continued to elaborate.

I asked if he’d been in situations like this before as an adult, of getting conned or threatened.

He said “Many! But in none of them have I ever lost any money or been hurt. Because I’m big and I can negotiate my way out”.

I asked him to tell me about one of them.

He said, “One I always go back to was in Malaysia. I was going down an alley as narrow as that doorway to your office. Two guys were blocking my way. I could just make my way though and ran ‘til I got to a place with other people. Once you are with somebody, they give up and go away. I’ve reviewed the situation. I always walk away knowing that they’ll pick on somebody else”.

I noted the transference reference to “that doorway to your office”, I silently realized that he was feeling trapped right at this moment in my office and with the two of us. I was the “new man” who had suddenly appeared in an increasingly expensive trap. I decided not to interpret the transference fear directly, but to work through the displacement of his story.

Out loud, I said “This time in the resort town, you were more vulnerable than you were in Malaysia. You’d fallen apart and you were drunk when these con men played you. It was humiliating and, in that state, the trauma from age 6 flashed back”.

Now he gave more details about his childhood sexual abuse. It happened in his grandmother’s house. She had taken in his family as well as his cousin who was a deprived kid. By the time John was 11, things were different. His protective grandmother had died; the house was chaotic, and his parents even less attentive. He came to seek his cousin out because there was pleasure in it for him, too, this time.

We returned to Julia’s disbelief. She cannot reconcile the money he spent. He explains how he paid only for the hotel and food, but she refuses to believe him.

I said “Julia, you won’t get a reckoning on the basis of the money. The emotional story is where the reckoning has to be. That story is humiliating. It represents the breakdown of your marriage”.

I had seen Julia smiling and looking away as John talked about feeling sorry for this girl, that he had to take care of her because she had been inviting and given him a special price. Now I asked Julia about her smile.

She said, “It seems ridiculous he would feel he had to take care of this girl. Now, listening to the story, I feel nauseated. I can hardly stand to listen. I had just agreed to come back to him because I thought he wanted to give our marriage a try as well. Then this happens. I can’t understand why he would do this”.

I said, “Of course you also wonder whether John had sex with her”.

Julia said “In this episode and with the other woman, one reason I don’t believe him was that he never really felt like making love unless we were good emotionally, never if we fought. I think he was trying to find somebody to take him in emotionally instead of me”. John said “I finally realized in the middle of this episode that this was something I didn’t want to be doing. It won’t ever happen again”.

Finally, we discussed how their sex life had returned, but had become much more aggressive and not entirely pleasant. It now contains anger mixed in, something neither of them understands. This takes us back to the erosion of trust. As the session closed, I said to them that their mutual trust had been so eroded that if they were to decide to stay together, new trust had to be earned over time. It would be up to each of them to decide if they wanted to take that chance. All the events we had reviewed so far had unburied their previous traumas, and now those had to be dealt with, either together or individually. And I now interpreted the transference fear that doing so with me meant that our sessions also felt threatening.

John said “I liked the way the session went today. Julia could hear things”.  Julia said “Yes, it was painful but I appreciated hearing all this”.

Conclusion

 It is my hope that the extracts from sessions with John and Julia demonstrate three things. First, the process of a brief, intensive intervention with a couple in crisis. The intervention involved both couple and individual sessions during the evaluation, a series of long sessions scheduled to take full advantage of the limited time available and to give maximal impact. I and they hoped to explore and facilitate the possibility of change for the couple, but of course their future remained indeterminate at the end of the treatment.  I employed the specific mixture of settings in response to the limitations imposed by the couple: The sense of crisis in their relationship, the limited time they had accepted before even contacting me, and the need I perceived from the outset to hear from each of them individually when each of them felt trust had broken down in their relationship. While I would not have had such extended sessions in the ordinary practice of couple psychoanalytic therapy in my office if a couple was going to be in town and available over time, this practice of condensed and elongated sessions is a practice I have employed from time to time over the years when I receive an urgent request from a couple that resides out of town and who cannot travel frequently. The effect seems to me to concentrate the sense of urgency, and to flush issues out and bring them to the surface in a magnified way. While this may help the practice of assessment in this situation, it may also negatively affect our need to slow things down, to move away from a sense of crisis and to calm a couple’s anxiety. In this situation, I felt I had to accept that limitation.  Second, I wished to demonstrate the way that the focus narrows in this situation, allowing us only to review in detail some of the most upsetting recent episodes in their marriage, episodes that encapsulated the breakdown in trust and that could then be linked dynamically to traumatic elements of their childhoods. But we could not thoroughly explore the more distant antecedents.

Third, I wanted to demonstrate the careful building up of trust in the treatment relationship in general in a way that could contain the emergence of persecuting object transference that both threatened the treatment while, at the same time, provided an opportunity for working through in the “here-and-now-with-me” (Scharff et al., 2017). If allowed more time, I would have felt more secure in this task. Nevertheless, short term interventions as the one with this couple can provide a powerful experience, one that has a chance to help a couple find new direction for their marriage.

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