COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
Including couple treatment in psychoanalysis has required the setting of new parameters beyond the classical psychoanalytical setting, in which the treatment is individual. This article aims to define the clinical criteria for, and benefits of, recommending couple treatment rather than individual psychoanalysis or psy- chotherapy, and to identify the challenges and demands that this has entailed for psychoanalysis, from the standpoint of the analysis itself and also that of the therapeutic relationship. Couple therapy is a very complex endeavor since a host of factors must be borne in mind. The present paper discusses the specific features of these factors and how they influence the diverse mechanisms in the analytical relationship. A clinical vignette is included in order to demonstrate the mechanisms that influence therapeutic work in couple psychoanalytic treatment. COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
Keywords: couple psychotherapy, therapeutic relationship, transference, coun- tertransference, psychoanalysis, conjoint treatment
In psychoanalysis, couple treatment has required the setting of new parameters beyond the classical psychoanalytical setting. Thanks to the contributions of Dicks (1967), Pichon Riviere (1971), and Kaës (1976), who might be seen as representatives of the leading psychoanalytical schools (English, Argentine, and French, respectively) in the fields of
This article was published Online First March 23, 2015. Berta Aznar-Martínez, PhD and Carles Pérez-Testor, PhD, MD, Facultat de Psicologia,
Ciències de l’Educació i de l’Esport Blanquerna and Institut Universitari de Salut Mental Vidal i Barraquer, Universitat Ramon Llull; Montserat Davins, PhD, Institut Universitari de Salut Mental Vidal i Barraquer, Universitat Ramon Llull; Inés Aramburu, PhD, Facultat de Psicologia, Ciències de l’Educació i l’Esport Blanquerna and Institut Universitari de Salut Mental Vidal i Barraquer, Universitat Ramon Llull.
This article is based upon work supported by the agreement between the Universitat Ramon Llull and the Departament d’Economia i Coneixement de la Generalitat de Catalunya. COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
Correspondence concerning this article should be addressed to Berta Aznar-Martínez, PhD, FPCEE Blanquerna. C/Císter 34. 08022. Barcelona, Spain. E-mail: firstname.lastname@example.org
Although this type of treatment is widely accepted among psychoanalysts nowadays, the need of couple therapy and the factors that make couple psychotherapy the treatment of choice rather than individual treatment are issues that are still under discussion. Zeitner (2003, p. 349) describes the typical ways in which couple consultation and therapy are practiced by psychoanalysts as a “supplemental or even second-rate treatment which is palliative, supportive, informative, or preparatory for the real therapy—psychoanalysis or psychotherapy,” a view which shows that couple treatment is not held in high esteem by some psychoanalysts. However, couple therapy has the potential to provide valuable insights concerning individual and shared psychic organization, and also the dynamic functioning of marriage (Scharff, 2001). COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
The purpose of this article, therefore, is to provide further insight into the clinical indications for couple psychotherapy, its benefits, and how to go about this type of treatment. It also aims to examine the new challenges and demands that openness to welcoming couples into therapy has brought for psychoanalysis, from the standpoints of the analysis itself and the therapeutic relationship. Couple therapy has several clinical characteristics which differentiate it from individual therapy and these are highlighted in the paper.
Why Couple Psychoanalytic Psychotherapy?
Couple therapy is an area of psychotherapeutic practice that is long on history but short on tradition (Gurman & Fraenkel, 2002). The evolving patterns in theory and practice in couple treatment over more than 80 years can be seen as having four distinct phases: (a) nontheoretical marriage counseling training (1930–1963); (b) psychoanalytic experimen- tation (1931–1966); (c) incorporation of family therapy (1963–1985); and (d) refinement, extension, diversification, and integration (1986 to the present day) (Gurman & Fraenkel, 2002; Gurman & Snyder, 2011). According to Segalla (2004), recent cultural shifts have had a considerable impact on the ways in which psychoanalysis and psychotherapy are conducted and couple therapy has much to gain from postmodern theorizing. Analysts have mainly applied their methods to the individual rather than to the troubled dyad (Zeitner, 2003) even though 50% to 60% of their patients seeking therapy do so because of some kind of disorder in their intimate or other significant relationships (Sager, 1976). Moreover, as Gurman (2011) notes, partners in troubled relationships are more likely to suffer from anxiety, depression, suicidal impulses, substance abuse, acute and chronic medical problems, and many other pathologies. COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
In Segalla’s view (2004), emphasis on intersubjective and relational perspectives has had a major influence on the way the treatment process is conceptualized. The dyad is seen as an “interactive system” and the couple treatment is based on awareness of this system of mutual influence and regulation. Working with couples affords compelling evidence for the existence of a “psychology of interaction” and the ways in which emotional difficulties are, in part, determined by these factors (Dicks, 1967).
Similarly, de Forster and Spivacow (2006) hold that what couple treatment adds to the contribution of the classical Freudian model is the role of “the intersubjective,” which varies according to the type of psychic suffering. This dimension has crucial importance with regard to much of the distress in a relationship and must have a place in the design of therapy. All psychic functioning is constituted by both the intrasubjective
The latter factors are fundamental in much of the suffering which occurs in a couple’s love life and relationship. Hence, in couple treatment, certain factors are of particular importance: “the partner, bidireccionality, the unconscious interconnec- tions and the interweaving of the phantasies of both partners” (de Forster & Spivacow, 2006, p. 255). The psychic determinant of the suffering must be sought in an aspect of the functioning of the psyche which is not part of the Freudian psychic apparatus but which lies, rather, in the link between the members of the couple (the “intersubjective”). If this is not taken into account in the choice of a suitable treatment, the intersubjective dimension might be neglected in individual work. Since each partner has become closely associated with the other’s painful internal objects, conjoint psychoanalytic couple therapy has the potential of dealing with deeply ingrained, largely unconscious constellations that are usually thought to be treatable only by means of psychoanalysis or intensive individual analytic psychotherapy (Scharff, 2001). Nevertheless, it seems clear that conjoint treat- ments are vastly superior to individual treatments for couple distress (Gurman, 1978). COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
As for the clinical criteria for recommending psychoanalysis or intensive psychoan- alytic psychotherapy versus couple treatment, Links and Stockwell (2002) have described the clinical indications for couple therapy in the case of narcissistic personality disorder. We believe that these criteria can be applied in any case where couple therapy would seem to be indicated. First, Links and Stockwell state that the partners’ capacity for dealing openly with feelings of anger or rage must be assessed before deciding on couple treatment, although these will be worked on during treatment if one member of the couple is unable to deal with or express feelings that might be humiliating or that could prompt an attack on the other partner. In such cases we believe that individual treatment should precede couple therapy. Second, the person’s level of defensiveness, openness to the need for a relationship, and ability to have this dependency gratified should be evaluated as well. If one of the partners does not want to continue and improve the relationship the treatment will not be useful. This is not necessarily the case when both members of the couple want to separate or divorce. The important point in these circumstances is that the aim of treatment is shared by both parties and this can be assessed by the therapist in the preliminary interviews. If, after some sessions, it becomes clear that the objective is not shared by both members, the treatment will not be fruitful. Assessment of vulnerability is important. Some people feel that having their partners listening to interpretations could be belittling and humiliating and couple therapy could then be counterproductive. Third, the complementarity of the couple must be analyzed, together with the roles each one plays in the couple. If this complementarity exists, the couple can often make progress. In other words, when the therapist can show the couple that they are both participating in the dynamics of their relationship and that, whether they like it or not, each of them is (or has been) benefitting from the relationship, the treatment can be helpful. If both partners can see that each of them has personality aspects that benefit the other, they will be better able to understand their situation (as will be explained in more detail below). If a couple fulfils these three criteria, they can probably work together and establish, or reestablish, a stable marriage with a significant degree of complementarity based on more positive symmetrical patterns COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE
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