Treating an Individual's Problem as a Marital Metaphor

We define the individual symptom as a tactical communication regarding the marital relationship. When a client presents with a localized problem, such as a phobia or a chronic pain condition, we do not view this as a failure of the individual’s biology or psyche. Instead, we view the symptom as a metaphor for a struggle within the couple. Jay Haley observed that a symptom is a way of dealing with another person while denying that one is doing so. It allows the individual to control the partner’s behavior without taking responsibility for that control. You must look past the clinical diagnosis to see how the symptom functions as a message. If a man cannot leave his house because of anxiety, the message may be that his wife is not allowed to leave him. We treat the marriage by addressing the phobia because the phobia is the marriage in a condensed form.

I once worked with a man who complained of severe, debilitating back spasms that occurred only on Friday evenings. He was a successful accountant who worked long hours throughout the week. His wife was a woman who felt neglected and frequently complained that they had no social life. However, every time they had plans to attend a party or a dinner, his back would seize. This forced the wife to cancel their plans and spend the evening applying ice packs to his spine. The symptom was a metaphor for the husband’s refusal to be dragged into social situations he disliked. By having a physical ailment, he could control his wife’s Friday nights without ever having to say that he was bored by her friends. He was not being a difficult husband: he was a sick man who needed his wife’s care.

You must observe how the partner responds to the symptom to understand its function. We see that the partner often becomes an amateur clinician or a full-time caretaker. This role gives the partner a sense of importance while simultaneously making them a prisoner of the symptom. When you are in the room with a couple, you should notice who speaks for the symptom. If you ask the husband about his depression and the wife answers by describing how hard it is to get him out of bed, you have identified the relational loop. The wife’s involvement in the depression is as significant as the husband’s low mood. We do not try to fix the mood. We try to change the way the wife manages the husband’s inactivity.

We recognize that every symptom has a price and a gain. The price is the suffering of the individual. The gain is the specific behavior it forces upon the other person. I recall a woman who developed a compulsive need to check the locks on every door and window in the house forty times before sleep. Her husband was a man who had been caught in an affair two years prior. The wife’s compulsion forced the husband to follow her around the house every night, witnessing her distress and helping her verify the locks. The metaphor was clear: the house was not safe because he had proven himself untrustworthy. Her checking was a literal manifestation of her need to secure their life against outside intruders. You would not treat this as a simple anxiety disorder. You would treat it as a marital Ordeal where the husband must earn back his status by participating in the wife’s ritual.

You should never accept the client’s initial definition of the problem as a purely internal event. If a client says they feel overwhelmed by work, you should ask how their spouse reacts when they bring that stress home. We look for the sequence. Sequence one is the client feeling stressed. Sequence two is the spouse offering advice that the client rejects. Sequence three is the spouse becoming frustrated and withdrawing. Sequence four is the client feeling even more stressed because the spouse is now distant. In this sequence, the stress is the tool used to test the spouse’s loyalty.

I worked with a couple where the wife suffered from recurring migraines. These headaches always occurred when the husband’s mother invited them for Sunday lunch. The husband was caught between his wife and his mother. When the wife had a migraine, the husband had a valid excuse to tell his mother why they could not attend. The headache solved the husband’s problem of divided loyalty. It also protected the wife from a direct confrontation with her mother in law. When you see a pattern like this, you must realize that the wife is performing a service for the husband. Her pain allows him to remain a good son while being a supportive husband. We call this a benevolent symptom.

We use the concept of the metaphor to design our directives. If the symptom is a metaphor for a power struggle, we use the symptom to shift the power. I once instructed a husband who had developed a nervous tic to only perform that tic when he felt his wife was being overly critical of his driving. I told him the tic was a signal that his nervous system was overloaded by her helpful suggestions. By making the tic a deliberate signal, I moved it from an involuntary symptom to a conscious communication. The wife could no longer see him as a victim of a neurological quirk. She had to see the tic as a response to her own behavior. This changed the hierarchy of the car.

You will encounter resistance if you try to explain the metaphor to the couple. We do not use insight as a primary tool. If you tell the wife that her hand washing is a way of telling her husband he is dirty, she will deny it and likely become more symptomatic to prove you wrong. Instead, you should speak the language of the symptom. You might tell the wife that her hands are the barometers of the family’s morality and that she must wash them even more thoroughly whenever the husband mentions his business associates. By prescribing the symptom in a relational context, you make the metaphor explicit without needing the couple to agree with your theory.

We understand that the symptom often protects a secret or a more dangerous conflict. I once treated a couple where the husband had developed a sudden, unexplained fear of driving over bridges. This meant the couple could not leave their small town. The wife was extremely frustrated but also very protective of him. Upon investigation, I found that the wife had been planning to move the family across the country to be closer to her parents, a move the husband dreaded but felt he could not refuse. The fear of bridges was a metaphor for the husband’s fear of the transition to a new life. He did not have to argue against the move because his phobia made the move physically impossible. You must treat the fear of the move to resolve the fear of the bridges.

You should look for the moment when the symptom ceases to be useful. A symptom will persist as long as it remains the most effective way to communicate a specific message. When you provide the couple with a more direct, albeit more difficult, way to communicate that message, the symptom often vanishes. We do not look for the cause of the symptom in the past. We look for the reason it is necessary in the present. If a child’s bedwetting brings the fighting parents together to wash the sheets, the bedwetting is a metaphor for the child’s role as a peacemaker. You must give the parents a different reason to cooperate if you want the bedwetting to stop.

I remember a case involving a woman who became paralyzed by indecision whenever she had to buy groceries. She would stand in the aisle for an hour unable to choose between two brands of cereal. Her husband was a controlling man who criticized every penny she spent. Her indecision was a metaphor for her lack of agency in the marriage. It was also a way of punishing him by making him wait for her. I instructed the husband that he must accompany her to the store and that he was only allowed to speak if she asked him a direct question. If he spoke without being asked, he had to pay her twenty dollars. The metaphor of her stuckness became a tool for her financial independence.

We utilize the partner as a co-therapist to change the nature of the symptom. You ask the partner to keep a detailed log of every time the symptom occurs and what happened five minutes before. This changes the partner from a victim of the symptom to an observer of the system. It also forces the symptomatic individual to realize that their behavior is being watched and analyzed. The symptom loses its spontaneous, involuntary quality. When a husband has to record the exact duration of his wife’s crying spells, the crying becomes a data point rather than a cry for help.

You must be prepared to follow the metaphor to its logical conclusion. If the symptom is a way of saying no, you must find a way for the person to say no without the symptom. I once worked with a woman who lost her voice every time her husband asked her to host a dinner party for his colleagues. The metaphor of her silence was her only way of protesting his social demands. I told her that since she had no voice, she must communicate only through written notes for three days. These notes were to be delivered to her husband by hand. This forced a different kind of intimacy and slowed down their interaction. By the second day, she had plenty to say and the voice returned. We view the return of the function as a sign that the marital message has been delivered through other means. The hierarchy of the marriage is established by who defines the problem.

We identify the person who holds the power in the marriage by observing who assumes the role of the translator. When you ask the symptomatic spouse a direct question about their distress and the partner answers for them, you have identified the primary protector of the symptom. We see this often when a wife explains her husband’s depression to you while he sits in a slumped posture. She might say that he had a difficult childhood or that his work environment is too demanding. By doing this, she defines his problem as an internal or external force that he cannot control, which simultaneously places her in a position of superior competence. You must recognize that as long as she is the expert on his despair, he has no reason to recover. His symptom gives her a role, and her role maintains his symptom.

I once worked with a couple where the husband had developed a severe tremor in his right hand that prevented him from signing checks or driving the car. The wife would immediately reach over and steady his hand whenever the tremor began. She did this with a look of intense pity that masked a rigid control over their daily schedule. We understand that this act of steadying his hand was not just a gesture of support: it was a physical reinforcement of his helplessness. To break this loop, you do not talk about their feelings of inadequacy. You give a directive that targets the helpful behavior. I instructed the wife that she was only allowed to steady his hand when he did not have a tremor. If his hand was shaking, she had to move to the other side of the room and describe a painting on the wall. This directive forced the husband to own his tremor and deprived the wife of her role as his physical stabilizer.

You must pay close attention to the way a spouse benefits from being the healthy one in the relationship. We call this the secondary gain of the protector. If one person is defined as the patient, the other is by default defined as the caregiver, the responsible one, or the martyr. This position carries immense moral weight and social capital. When you suggest that the patient is actually behaving in a way that helps the partner, the protector will often become the most resistant person in the room. I saw a man whose wife suffered from chronic, incapacitating fatigue. He would tell me how much he wanted her to be active again so they could travel. However, every time she showed a small spark of energy, he would remind her of the laundry that needed doing or a difficult phone call she had to make. His reminders were framed as helpful prompts, but they functioned as anchors that pulled her back into her exhaustion.

We use the technique of relabeling to change the meaning of these protective acts. Instead of calling the husband’s reminders helpful, you call them a way of keeping the wife from becoming too independent too quickly. You tell the husband that he is wise to keep her tired because a woman with that much energy might find her marriage too small for her. This move places the husband in a dilemma. If he continues to remind her of her chores, he is admitting he is afraid of her independence. If he stops, the wife is free to move. You are not asking him to change his feelings: you are changing the social consequences of his behavior.

The most effective directives are those that make the symptom more of a chore than the problem it is solving. We call this an ordeal. If a husband uses his anxiety to avoid going to social events with his wife, you do not analyze his social phobia. You prescribe a task that is more taxing than the social event itself. I instructed a man who felt too anxious to attend his wife’s office party that he was permitted to stay home only if he spent the entire duration of the party polishing every shoe in the house. He had to do this while wearing his suit and sitting on a hard wooden chair. He was not allowed to watch television or listen to the radio. His anxiety had to be productive. Faced with the choice between a boring party and three hours of solitary shoe polishing in a stiff suit, his anxiety became much less useful to him.

You will encounter spouses who attempt to sabotage the directives you give. This sabotage is a clear indication that the symptom is performing a necessary function in the marital hierarchy. When you give a wife a task to improve her husband’s functioning, and she forgets to do it, we do not view this as simple forgetfulness. We view it as her way of maintaining the status quo. I worked with a couple where the wife was instructed to give the husband a ten minute massage only when he successfully completed a job interview. She forgot the massage twice. I then changed the directive: she was required to give him a thirty minute massage only when he failed a job interview. Suddenly, she never forgot the massage. By rewarding his failure, she was able to maintain her position as the supportive caregiver for a failing man. When I pointed this out to them as a sign of her extreme devotion to his comfort over his career, the husband became so annoyed that he secured a job within two weeks to escape her suffocating care.

We also use the metaphor of the symptom to reorganize the sexual hierarchy of a marriage. Often, a physical symptom like back pain or a headache is used as a tactical maneuver to avoid intimacy without having to say no. Saying no is a move in a power struggle, but having a headache is an act of nature. To solve this, you must make the headache a part of the intimacy. You tell the couple that they must go to bed together, but they are not allowed to have sex. Instead, the healthy spouse must spend one hour delicately tracing the perimeter of the headache with their fingertips. They must do this in total quiet. This directive turns the symptom into a demanding ritual that requires the partner’s focused attention. Usually, the symptomatic spouse will find that the headache disappears because the price of having it, which is an hour of forced, quiet contact, is higher than the benefit of avoiding sex.

You should always look for the hidden symmetry in the marriage. If one person is the over-performer, the other must be the under-performer. You cannot change one without forcing the other to change. I once saw a couple where the wife managed all the finances, the social calendar, and the household repairs because the husband claimed he was too scattered and disorganized. He had been diagnosed with an attention problem. Instead of working on his focus, I gave the wife a directive to become even more disorganized than him. I told her she had to lose her keys once a day and forget to pay one utility bill. This forced the husband to step into the vacuum she created. He could no longer afford to be scattered because the electricity was about to be turned off. We do not ask the under-performer to do better: we make the over-performer do worse.

Every directive you issue must be delivered with absolute confidence in its necessity. If you waver, the couple will sense your doubt and use it as an excuse to ignore the instruction. We do not explain why the directive will work. In fact, providing a logical explanation often invites the couple to argue with the logic. You simply state that for the problem to change, this specific action must be taken. If a husband complains that his wife’s compulsive cleaning is ruining their marriage, you do not tell her to clean less. You tell the husband that he must supervise her cleaning for two hours every night and point out any spots she missed. By making him the supervisor of the behavior he hates, you change his role from a victim of her compulsion to an accomplice in it. The wife will usually stop cleaning compulsively just to stop him from hovering over her. The symptom loses its power as a metaphor for her control over the house when the husband is forced to share the responsibility for the ritual. The stability of the marital system depends on the predictable repetition of the symptomatic loop.

We disrupt this stability by introducing a price that the couple finds too expensive to pay. When a symptom serves a function in the marriage, it remains because the cost of the symptom is lower than the cost of facing the marital conflict directly. You change this calculation by making the symptom an ordeal. If a wife claims she cannot leave the house due to sudden bouts of agoraphobia, and her husband must therefore stay home to comfort her, you do not analyze her fear. You direct the husband to provide comfort in a way that is tedious for both of them. You might instruct him that every time she feels she cannot leave the house, he must sit with her in the middle of the living room and read the local phone book aloud for three hours. He is not allowed to stop, and she is not allowed to leave the room. This transforms the husband’s role from a supportive rescuer into a source of boredom. The symptom no longer provides the benefit of a pleasant evening together. It provides a chore.

We use the ordeal to make the symptom more difficult to maintain than the problem it was designed to solve. When you design an ordeal, you must ensure it is something the clients can actually do, even if it is unpleasant. It must be a task that is good for them in some abstract way but miserable in its repetition. I once worked with a husband who suffered from what he called uncontrollable outbursts of temper toward his wife. After these outbursts, the wife would cry and the husband would apologize, and they would spend the next two days in a state of artificial tenderness. This loop allowed them to avoid their lack of shared interests. I directed the husband that every time he raised his voice, he had to spend the entire next night polishing every piece of silver and every chrome fixture in the house until five in the morning. The wife was directed to sit in a chair and observe his work to ensure the quality met her standards. After three nights of polishing, the husband found he was much better at controlling his temper. The price of the outburst had become higher than the discomfort of sitting in the same room as his wife with nothing to talk about.

You must deliver these directives with the authority of a surgeon. If you present an ordeal as a suggestion, the couple will ignore it. If you present it as a clinical requirement for change, they will comply because they are desperate for relief. We do not explain the logic of the ordeal to the couple. We simply state that this is the required procedure for their specific situation. If the couple asks why they must perform such a strange task, you tell them that the mechanics of their problem require a mechanical solution. You are not interested in their insights into why they have the problem. You are interested in the fact that they are currently performing the problem, and you are giving them a different performance to execute.

Another effective strategy involves the use of the pretend technique. This is particularly useful when the symptom is presented as something the person cannot control, such as a hand tremor or a panic attack. You instruct the patient to pretend to have the symptom at a specific time when it is not actually occurring. You then instruct the spouse to pretend to help the patient. By making the symptom a staged performance, you remove its spontaneous power. I worked with a young woman who had frequent fainting spells that occurred whenever her husband talked about his mother. These spells forced the husband to drop the subject and attend to her. I told them that for thirty minutes every evening at six o’clock, the wife was to pretend to have a fainting spell in the kitchen. The husband was to catch her and lay her gently on the floor. He was then to spend fifteen minutes telling her all the things he liked about his mother while the wife lay there pretending to be unconscious. By the third day, the wife reported she no longer felt the urge to faint during their actual conversations. The maneuver took the involuntary nature out of the fainting and turned it into a scheduled event that the husband controlled.

We use the pretend technique to expose the tactical nature of the symptom without accusing the client of lying. You are not saying the symptom is fake. You are simply asking them to practice it. When a client practices a symptom on command, they are demonstrating that they have some level of voluntary control over it. This creates a paradox. If they can pretend to have the symptom, they can also pretend not to have it. You are shifting the hierarchy of the marriage by making the spouse an accomplice in the performance. The spouse is no longer a victim of the symptom. The spouse is now a director or a co-star. This move breaks the secret power the symptom-bearer holds over the partner.

When you move toward the final stages of therapy, you will often see the couple attempt to return to their old patterns. This is not a failure of the model but a predictable moment of systemic tension. We handle this by predicting a relapse. You tell the couple that while they have made excellent progress, you are concerned that they are changing too fast. You warn them that they might need to have a small version of their old problem next Tuesday just to make sure they are ready to give it up entirely. By prescribing the relapse, you put them in a bind. If they have the symptom, they are following your instructions, which means you are in control. If they do not have the symptom, they are proving you wrong, which means they are cured. Either way, the symptom loses its ability to function as an independent, uncontrollable force.

I once saw a couple where the wife had stopped her compulsive hand washing after we implemented a directive that required the husband to time each wash and record the water temperature in a ledger. During our eighth session, the wife mentioned she felt the urge to wash her hands returning. I told her that she must spend ten minutes washing her hands every morning at eight o’clock for the next week, even if she felt no urge to do so. I told the husband he must stand behind her and count the seconds aloud. By the time they returned for the next session, they were both annoyed with the task and with each other. The wife had stopped the washing entirely because it had become a boring obligation rather than a way to manage her anxiety or control her husband’s schedule.

We define a successful outcome as the reorganization of the marital hierarchy so that a symptom is no longer necessary. The husband and wife must find ways to influence each other directly rather than through the medium of a third party or a physical ailment. You know you are finished when the couple begins to argue about normal things, like finances or chores, without anyone having a seizure or a depression. The appearance of healthy conflict is a sign that the metaphorical communication of the symptom has been replaced by literal communication. We do not look for a marriage without conflict. We look for a marriage where the conflict is handled at the appropriate level.

You must be prepared to be the person the couple unites against. Often, as the symptom disappears, the couple will decide they no longer like your methods or your personality. They may claim your directives are silly or that you are being too demanding. We accept this as a positive development. If the couple can unite in their shared irritation with you, they are no longer united by one person’s illness. You have served your purpose as a temporary focus for their systemic energy. When they decide to leave therapy to get away from your directives, they are leaving as a functional unit. You have successfully shifted the power from the symptom back to the couple.

The final phase of the work is often the shortest. You have already disrupted the old loop and established a new hierarchy. Your only remaining task is to ensure the change is stable. You do this by slowly increasing the time between sessions. If you were seeing them every week, you move to every three weeks, then every six weeks. During these final meetings, you remain focused on their behavior. You do not ask how they feel about the progress. You ask for specific examples of how they handled a recent disagreement. You look for evidence that the over-performer has stayed back and the under-performer has stepped up. If the husband who was formerly depressed is now working and complaining about his boss, and the wife who was formerly his nurse is now pursuing her own hobbies and complaining about the husband’s long hours, the system has reached a new equilibrium. The communication is now direct, and the metaphor is no longer required for the marriage to function. The recovery of a function in one partner is always contingent upon a change in the behavior of the other.