Articles by David H Jacobs Ph.D

man thinking about when to seek therapy

The Identified Patient

I typically meet men who describe problematic sexual behavior following an ultimatum given by their wife to get into treatment or else. They have been discovered. Their wife wants their sexual addiction treated. The men are sitting in my office because they want the marriage to continue. Why they want the marriage to continue, is frequently not that clear. There are often children, money, and property involved. Reputation is involved. The prospect of losing their familiar way of life is not attractive. Attachment to the wife is involved – not necessarily the same thing as love or intimacy. Guilt and shame are involved. The husband has become what we professionals often call the identified patient. As the term implies, the husband has been identified as the one with a problem that needs treatment, but what the actual problem is and what to do about it is frequently quite a bit more complicated than identifying the husband as the one with a conspicuous problem suggests.

I have come to realize, or at least to think, that it is unlikely that two people in a long term marriage fall into radically different categories, (i.e., one person really needs treatment while the other is as sound as a dollar, thank you very much). The term ‘identified patient’ was coined in part to dispel the idea that one person in a marriage or family was the one who had clinically significant personal problems and needed treatment. When I talk to the husband who has been busted and ordered into treatment by his wife, I invariably hear complaints about the wife from the husband, complaints that are long standing and have resisted whatever attempts he has made to resolve them to his satisfaction. The simple point is that a long term relationship is a co-creation by two people.

What is not simple is this: a person in a relationship, especially a long term marriage, must be understood both as a more or less self-contained and self-perpetuating personality and as a participant in something larger than his own personality (i.e., the relationship), something that he has not created all by himself and something he cannot control or alter all by himself.

I have read that people try to modify their job to fit their talents and needs, but usually there is only so much ‘give’ in a work situation no matter how much a person may wish to further modify it. I present this as an analogy.

I am trying to say that viewing a man’s behavior in marriage in terms of a self-contained personality can only go so far. I realize this is somewhat confusing. The marriage is what husband and wife together have created, but it is probably not exactly what they hoped to create either individually or as a couple (Karl Marx: ‘Men make their own history, but they do not make it just as they please.’). The reason is that husband and wife are historical beings, with the consequence that the importance and momentum of their past exerts a much greater influence on the course of their lives than they realize or can alter left to their own devices. Time goes by; eventually they have a marital relationship neither would have signed up for.

The husband in therapy, the ‘identified patient,’ is only half the story. But I don’t recommend marital therapy. Beneficial therapy requires being able to speak personal truths without fear of consequences. This is not possible in marital therapy. It is only possible in individual therapy. I now think what is realistic and responsible for people in a chronically troubled marriage is for both members of the couple to endeavor to ameliorate the effects of the past in their own individual therapy. The present and future can be different if the noxious influence of the past can be lessened. If this can be accomplished the two people who have married each other can be more free to construct a satisfying relationship with each other. There is no quick fix. Good faith is being in therapy to recognize the hand of the past in the present. That’s doing what can be done. There is no point to chicken or egg debates and recriminations in couples counseling. There is no use being taught how to communicate effectively or ‘non-violently’ because home alone with each other and enraged or whatever it all goes out the window. When you are less led by the nose by your troubled past you can figure out how to talk and relate.

I hope my message is not too confusing. Yes, the husband who has affairs etc. has a problem. If he did not have a problem he would not be hopelessly stuck in a marriage that he finds in important ways maddening and unendurable without heroic (desperate) compensatory activities. This may be a psychotherapy truism, but the principle here is that a person who cannot take care of himself in fundamental ways has a problem (being stuck in an unhappy, maddening, unsatisfying marriage is hardly taking care of yourself). The problem is not simply sex addiction. But at the same time a marriage is a co-creation, not a mono-creation. I have come to see that the dancers in the marriage dance are usually more or less equal in skill or lack thereof, to use this analogy. It is simply not realistic to overlook this or pretend otherwise.

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