Recently I began a year of intensive training on couples therapy. I’m excited to expand to a new area of practice and will be back monthly to share my thoughts to the training experience.
Early in reading about couples therapy I came across the notion that ‘the couple is the patient.’ I found this baffling and a bit disconcerting! I know lots of people enter couples therapy hoping to save their relationships, but surely some of those relationships do not continue and in fact, some of the work must sometimes involve supporting people through saying goodbye. If the couple is my patient, does it mean I’ve failed if the couple ceases to exist? Furthermore, what does it mean for my relationship to the individuals involved if they are not my patients?
I’ve come to understand this maxim to concern primarily the field of attention and intervention in couples work. In individual therapy, my focus is one person’s lived experience. That experience, communicated through a variety of means during the therapy session, is the only access I have to that person’s world and the only place we (therapist and patient) can make discoveries or changes. Surely, I as the therapist become the stand-in for others in that person’s life through. Understanding how my patient and I interact can provide both important information and a place to play and experiment interpersonally. However, my role as a therapist, even one that counts my emotional responses in session as valuable information, is to prioritize my patient’s experience. I may have reactions, even strong ones, but I try to share them only when, and in such a way that, they are helpful and relevant to the work my patient is doing. A former professor used to tell us to ask ourselves “for whose sake?” when we considered an ethical quandary.
Obviously, the others in my patients’ lives whom they find themselves in relationship with are under no such obligation. They speak for themselves, and for their own sakes, and they interact in their own ways with the internal dynamics of my patients. This is one of the ways that a therapist-patient relationship differs from other relationships in our lives. It is also one of the fascinating aspects of couples work, in that partners are acting and speaking for their own sakes together right before my eyes. Here in the couples therapy room are the ways that each partner’s lived experience comes into sharp contact with the other’s. Here is the field where one person’s innocuous comment is, equally and at the same time, another’s searing critique. It is where patterns are developed to protect and preserve the individuals and the couple. It is the stage where we agree, often implicitly, on the roles we’ll assume in the relationship and the play that we’ll put on, in some variation or another, again and again.
This is what is unique and fascinating about couples therapy – the couple is, in real time, producing a version of their relationship dynamic that includes the interaction of their individual histories, defenses, and values. I get to see in real time how partners co-create the relationship pattern they are in, and when I intervene, I get to see how that pattern responds to a disruption. Couples are seeking treatment because their relationship patterns have become problematic, and so my task as a couples therapist is to help them disrupt the loops that have them stuck.
The same could certainly be said of individual therapy – people find themselves stuck in loops that they hope therapy will help them escape from. But in couples therapy, I get to see how each person finds themselves in relation to their partner, and together the three of us get to try to change the shape of the relational field and see what happens. We experience ourselves in particular ways in particular relationships; the self we are with our parent or our boss or our child or our therapist is different from the self we are with our partner. Partners in couples therapy have created a dynamic that is unique to them. They exist in relationship to each other in an unique way, and my aim is to help them explore and perhaps try to open up the space they find themselves in as a couple. This is the way I think that the couple is my patient.