Psychotherapy directed to improving the marital relationship, and “centered on the effortthe psychodynamics and behavior of two persons who are married.” (Sager, 1966)The possibilities inherent in marriage therapy have only been recognized in the 1960s, although its principles and approaches stem from a variety of sources. Among these are marriage counseling; Obemdorff’s psychoanalytic treatment of a case of folie it deux in a married couple, and his treatment of married couples in succession; Mit- telmann’s simultaneous analysis of marriage partners in different sessions; experiments on joint treatment of couples; studies of small-group dynamics; and group therapy of families, as developed by Ackerman, Bell, and Midelfort. See FOLIE A DEUX, FAMILY THERAPY, GROUP DYNAMICS.According to Sager, seven general methods are currently being explored; (1) successive treatment of husband and wife; (2) simultaneous treatment in separate sessions (“concurrent therapy”); (3) simultaneous treatment in joint sessions (“conjoint treatment”), sometimes with concurrent individual treatment (“combined therapy”); (4) therapy conducted by two therapists, each seeing one spouse, but conferring from time to time (“collaborative therapy”); (5) treatment of each spouse by a separate therapist, with joint or “four-way” sessions involving both analysts and both patients; (6) various types of group therapy, such as groups composed of couples with one therapist and groups with co-therapists; (7) family therapy oriented toward the parental relationship rather than the children.In conjoint and combined therapy, treatment is directed to the “sick marriage” and dependent on the couple’s awareness that they have a problem. The joint sessions are especially effective in eliciting reactions based on childhood relationships, but the greatest advantage of seeing the couple together is that their defense mechanisms and methods of dealing with each other come quickly to the fore and enrich the therapist’s knowledge of the dynamics operating within and between them. Moreover, historical material is often readily available, since each spouse can fill in the other’s gaps and correct distortions of memory.Joint sessions may be conducted on different levels. They can be primarily cathartic, giving each partner an opportunity to air his grievances in order to uncover the sources of discord. They can be used to work through specific problems, such as “Who’s in charge ” or to discover where the marriage is running smoothly and where clashes occur. Or the sessions can be conducted on a deeper level, and focused on free associations, dreams, unspoken communications, and the origins of defensive behavior.Various investigators have suggested that the conjoint approach is often effective when individual therapy fails, when distorted attitudes threaten to disintegrate the family, and when the relationships can be manipulated to produce greater harmony. On the otherhand, triadic sessions may be too threatening for some mates, or one mate may use the session to attempt to destroy the other. They are also contraindicated if one of the patients is strongly opposed to maintaining the marriage.As in individual therapy, no singletreatment approach can be recommended for all types of cases. Each situation must be evaluated individually and handled flexibly. Sager suggests that although individual sessions alone or joint sessions alone may often prove helpful, there are many instances where a combination of the two would be even more effective. He himself typically sees his patients in weekly conjoint sessions and also weekly individual sessions, though in some cases only the primary patient is seen individually. It usually takes three initial sessions to elicit the symptoms, evaluate the difficulties and potentialities of the relationship, and gather information on the history of the marriage. Every important aspect of the relationship is covered, including prior expectations, obligations engaged in before and during the marriage (the “marriage contract”), role perceptions of both spouses, how well they are filling their roles, origins of friction, extent of complementarity, relationship of each spouse to his parents and siblings, whether the marriage is repeating themes from the parents’ marriages, emotional attitudes toward the spouse, and relationships of each spouse to the children. The early conjoint sessions are devoted largely to broadening and deepening communication. An impartial attitude is maintained, and suggestions aimed at modifying the couple’s attitudes or behavior are avoided until communication and transference between the therapist and both parties are well established.