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Psychotherapy's Greatest Debates - Page 6

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Confrontation in Couples Therapy Who Needs it?

By Terry Real and Sue Johnson

The joke goes, “How can you tell a couples therapist’s office? Answer: By the skid marks left by the men being dragged there by their wives.” Critics have charged that the entire therapy enterprise isn’t particularly user-friendly for men, claiming that there’s a mismatch between the touchy-feely atmosphere of most therapy and the emotional taciturnity manifested by many male clients. Others have claimed that therapists too often aren’t tough enough to break through the resistance offered by reluctant male clients. The lively dialogue that follows between two developers of contrasting couples therapy approaches not only explores the fundamental question of whether men and women really want the same thing in marriage, but also gives the reader a ringside seat as two outspoken practitioners demonstrate exactly how they’d handle a variety of challenges in couples work.

Q: Back in the heyday of feminism in the 1980s and early ’90s, therapists talked much more about gender-based power inequities in marriage. What do each of you think a good couples therapist needs to understand about the different ways men and women approach intimate relationships?

TERRY REAL: The idea that both the man and the woman are going to come into therapy with equal dissatisfaction, equal motivation, equal articulation about their emotional lives is just a fairy tale from my standpoint. Women are socialized to think more about relationships, and to be more intimate and emotional than most men. It’s part of traditional masculine culture that the definition of manliness is invulnerability. So it’s women who want more in their relationships and, by and large, it’s women who pick up the phone and call a couples therapist. Therapy isn’t a gender-neutral endeavor; it’s much more of a feminine endeavor, and men know this. So the idea that we therapists should use an evenhanded approach in the face of this situation is another fairy tale.

SUE JOHNSON: I think it’s clear that the expectations of marriage have changed radically from, say, when my mother got married. She was just looking for a provider, and her main question of my father was, “Do you have a suit?” not, “Can you talk about your feelings?” So I think Terry’s right about that. But while you have to pay attention to how people are socialized, from an Attachment Theory point of view, men and women aren’t so different. They both have the same fundamental attachment needs, although they might express them differently. The tricky part for men is how much shame they feel about their feelings that they’ve been taught not to talk about. But we know that on a basic level, the map for human emotions isn’t that different for men and women, and the needs aren’t that different.

Q: Terry, you talk a good deal about something you call “leverage” in the consulting room. Why is leverage such an important concept to you?

REAL: To understand the importance of leverage, you have to understand grandiosity, especially male grandiosity. Therapy and self-help have mostly focused on helping people come up from a one-down position of shame. But we don’t really talk much about what it means to help people come down from the one-up position of grandiosity. This is really pivotal in terms of working with men, because they typically tend to lead from the one-up, grandiose position, while women present in the more one-down, victim position.

From the viewpoint of motivation to change, the problem is that grandiosity doesn’t feel bad. In fact, it feels pretty good. For some people, it feels good to make out with your secretary, or to haul off and scream at somebody. Why change?

The other issue with grandiosity is that it impairs judgment, especially regarding the impact that you’re having on others and the negative consequences of your own behavior. What I’m saying is that you often have a grandiose, singularly unmotivated person in couples therapy and, when you do, you have to ask yourself, Why should such a person change?

The answer is that, as a therapist, you better have something in your back pocket that they really want, and/or you better be willing to zero in on the negative consequences that they want to avoid. However, that’s not how we typically teach therapists to think. We essentially teach therapists to replicate the traditional female role: be understanding, supportive, and nurturing to a fault. We teach them to do everything except put their foot down. As a result, most therapists do everything they can to keep grandiose clients engaged, except really think about finding leverage. But the reality is that if the therapist doesn’t know where the leverage is, the grandiose person really has no reason to listen.

JOHNSON: I don’t see it quite the same way. Perhaps it’s because I’m female, but I’m not so focused on power. I think couples therapists who understand human attachment have the biggest leverage in the world, because they understand that attachment is the most basic human need, whether you’re male or female. We all need to know that we matter to somebody else, and that somebody else has got our back—that they care about us, and, if you call for them, they’ll come. Of course it can feel good to rant and yell, but you don’t have to do that if you really have a platform of safety under your feet, where you know who you are, and you know you’re connected with your partner. Grandiosity is a sign that you’re feeling an enormous amount of vulnerability and you don’t know what to do with it. So what we tend to do in EFT [Emotionally Focused Therapy], instead of looking for leverage, is create safety to help people explore that level of vulnerability.

Q: So let’s get a sense of how each of you might work with this kind of a client.

REAL: The other day I was working with a kind of classic MIT nerd. He had a bit of an Aspergers-ish quality, and his presenting problem was that he wasn’t getting enough sex with his wife. He had absolutely no friends, and his wife had built up an enormous resentment of him over the years. So this guy was sitting in my office, doing this kind of self-stimulation rocking thing, talking about how lonely he was. While he was doing that, he was popping a pimple on his nose, and little rivulets of blood were running down his face. I said to him something that probably would have gotten me into trouble with my supervisor back in my student days, “Henry. The thing you’re doing with your nose—it’s disgusting.” He looked at me, and went, “Huh? Oh, OK.” I believe that until I pointed that out to him, he’d had absolutely no idea how interpersonally repulsive what he was doing was.

One of the things that’s important to teach grandiose men is what I call remedial empathy. I had a narcissistic fellow—a type triple-A, super-successful guy. He had two severely developmentally disabled kids, who were openhearted and lovely, whom everybody loved except him. But when he was honest with me, his real feelings about his kids was that he hated them because their disability was a narcissistic affront to him. For quite a few sessions, I talked to him straightforwardly about his selfishness, teaching him about empathy and about how to get out of himself to recognize the needs of other people.

Then one day, he came in looking like a different person and said, “I got it.” He told me this story of taking one of his two boys to a Red Sox game, stuffing him, as we do, full of sausage and candy and the rest of it. As he was driving home, this little boy starts to throw up, but he’s trying to hold the vomit in because he’s so afraid of his father’s angry reaction. This man said he looked into the terrified eyes of his little boy, and for the first time ever, felt absolutely appalled that his own son was so frightened of him that he’d hold in his own vomit. He said, “I realized in that moment that it’s not about me. It’s not about my injury. It’s about him and what he needs.”

He said that was a turning point in his life, and I believe it was. First of all, I believe that that this man’s transformation wouldn’t have happened had I not been confronting him about his selfishness, although I prefer to think about how I work with people as “joining with the truth.” I also think that he needed to learn how to replace selfishness with an absolutely different orientation and different skills. He needed to learn how to be a more intimate human being.

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