Psychodynamic
see attachment
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select one of the following articles on psychodynamic therapy to evaluate
Aznar-Martnez, B., Prez-Testor, C., Davins, M., & Aramburu, I. (2016). Couple psychoanalytic psychotherapy as the treatment of choice: Indications, challenges and benefits. Psychoanalytic Psychology, 33(1), 120. https://doi.org/10.1037/a0038503
Karbelnig, A. (2016). the analyst is present: Viewing the psychoanalytic process as performance art. Psychoanalytic Psychology, 33(Suppl 1), S153S172. https://doi.org/10.1037/a0037332
Tummala-Narra, P. (2013). Psychoanalytic applications in a diverse society. Psychoanalytic Psychology, 30(3), 471487. https://doi.org/10.1037/a0031375
In a 9-10 slides, not including the title and reference slides. Include presenter notes (no more than page per slide) and use tables and/or diagrams where appropriate.
Provide an overview of the article you selected.
What population is under consideration?
What was the specific intervention that was used? Is this a new intervention or one that was already used?
What were the authors claims?
Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with clients. If so, how? If not, why?
Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article. Support your approach with evidence-based literature. COUPLE PSYCHOANALYTIC
PSYCHOTHERAPY AS THE TREATMENT
OF CHOICE:
Indications, Challenges and Benefits
Berta Aznar-Martnez, PhD, Carles Prez-Testor, PhD, MD,
Montserat Davins, PhD, and Ins Aramburu, PhD
Universitat Ramon Llull
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.
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 Kas (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-Martnez, PhD and Carles Prez-Testor, PhD, MD, Facultat de Psicologia,
Cincies de lEducaci i de lEsport 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; Ins Aramburu, PhD, Facultat de Psicologia, Cincies
de lEducaci i lEsport 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 dEconomia i Coneixement de la Generalitat de Catalunya.
Correspondence concerning this article should be addressed to Berta Aznar-Martnez, PhD,
FPCEE Blanquerna. C/Cster 34. 08022. Barcelona, Spain. E-mail: [emailprotected]
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Psychoanalytic Psychology 2015 American Psychological Association
2016, Vol. 33, No. 1, 120 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0038503
1
mailto:[emailprotected]
http://dx.doi.org/10.1037/a0038503
couple and family psychotherapy, couple treatment is now an area of therapeutic action
that has brought new challenges.
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 therapypsychoanalysis 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).
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 (19311966); (c) incorporation of family therapy (19631985); 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.
In Segallas 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 (in that
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the psychic determinants come from the inner world), and the intersubjective (in that the
psychic determinants include the other and the intersubjective context in which the
subject functions). The latter factors are fundamental in much of the suffering which
occurs in a couples 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 others 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).
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 persons 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.
Lemaire (1977) lists some conditions indicating couple treatment, namely: (a) that
both members agree to having therapy, although as we shall see below, this rarely
happens; (b) that they can distinguish between improved communication and continuing
to stay together (when couples come to therapy they frequently have communication
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3COUPLE PSYCHOANALYTIC PSYCHOTHERAPY
problems and improving communication is one of the first goals of the treatment in order
to be able to explore other issues later on (phantasies, families of origin . . .)); and (c) that
the therapist can intervene freely (more or less) without feeling bothered by the contra-
dictions of the other two conditions. In this same vein, Bueno Belloch (1994) and Castellv
(1994) emphasize that limits to couple treatment appear when: (a) when one of the
partners is forced by the other to come to the therapy and there is no change after some
sessions; (b) when it is feared that the new understanding that each person acquires in
therapy can be used pathologically; (c) when both partners form an alliance against the
therapist and frustrate all his or her efforts to bring about change; and (d) when it becomes
necessary to suggest individual therapy for one of the partners because the conflict cannot
be addressed in conjoint treatment.
According to de Forster and Spivacow (2006), another reason for opting for couple
treatment is that our discipline must take a flexible approach, catering to the needs of men
and women of our time, and to what society demands. Reforms in divorce law, more
liberal attitudes about sexual expression, increased availability of contraception, and the
greater economic and political power of women have all raised the expectations of
committed relationships so that their requirements now go well beyond economic viability
and assuring procreation (Gurman, 2011). Likewise, Segalla (2004), drawing on her own
clinical practice and that of other psychoanalysts, states that the demand for couple
therapy is now considerably greater, and this seems to suggest a cultural shift in which
efforts are being made to save marriages rather than simply to divorce. Moreover, there
are signs that would seem to support the clinical contention that relationships in later life
can influence patterns of attachment established during childhood (Clulow, 2003). Mar-
riage can therefore be a potentially therapeutic institution, a unique opportunity for
reworking unresolved problems from the past, which can be aided by a skilled therapist
(Gurman, 1992). In this case, the analyst needs to take into account a number of factors
which will be described below.
Psychopathology of the Couple Relationship
According to Balint (Family Discussion Bureau, 1962), the inner life of the dyad consists
of one partners desires, hopes, disillusions, and fears interacting with similar aspects of
the other partners internal world. Theories on conjugal life are based on this interaction.
There is progress and regression in the relationship of a couple, and this is described by
Dicks (1967) and further detailed by Willi (1978) and, later in Spain, by Font (1994). The
members of a couple strive to gratify needs and desires which date from very early stages
in their lives, and they may attain this gratification when their regressive or progressive
desires are accepted by their partner. Need for support, tenderness, affection, or devotion
can be requested and fulfilled within the couple relationship (Font & Prez Testor, 2006).
Ruszczynski and Fisher (1995) have meticulously described the role of projective
identification in psychoanalytic psychotherapy with couples. As is well known, projective
identification entails the capacity to induce the other to feel what is being projected, and
it has a central role in the psychoanalytic understanding of the couple. Phenomena like
projection, introjection, and retroprojection (the projection into the partner of what the
other partner has introjected from a previous projection of his or her partner) exist in all
couples and are fed and interact constantly in a back-and-forth interplay of projections.
We believe Hoffmans conceptualization (1983) is useful for understanding this
phenomenon as it divides it into three unconsciously acted out parts:
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1. Each member of the couple chooses what to see from all the characteristics of the
other; ones partner offers a host of signals, including the characteristics the
other chooses and is most likely to perceive. Other features, however, seem to be
blurred or hidden by the partner.
2. Once the partners characteristics have been chosen, they seem to confirm each
members own internal vision of the world and expectations; this suggests that
each partner tends to interpret the chosen characteristics in accordance with old
family relationships. Each member of the couple chooses real facts from their
partner, but then constructs a history of those facts based on his or her own
previous relationships.
3. Each partner unconsciously influences the other in order to test what they already
know or believe; this unconscious communication appears in the couple through
the mechanism of interpersonal projective identification (Ruszczynski, 1992).
Eventually, the intensity and repetition of problematic interactions begins to
dominate the couple-experience, and this tends to polarize the members (Gold-
klank, 2009). If this happens, the couple may seek counseling and, indeed, this
is the kind of couple we tend to find in clinical practice.
Along similar lines, Shimmerlik (2008) notes that the patterns of couple relationships
are formed in the enactive domain through a nonconscious implicit process of commu-
nication, part of which is stored in the implicit domain and remains embedded and enacted
in ones most intimate relationship, and can therefore only be accessed within the context
of this relationship.
Another way of conceptualizing these processes happening unconsciously between
partners, and which we believe is useful in diagnosis and hence in subsequent treatment,
is based on Dicks (1967) concept of collusion within couples. By collusion (which
derives from coludere or interplay between two people) we mean the unconscious
agreement that forges a complementary relationship in which each party develops parts of
themselves that the other needs, and gives up other parts of themselves which they project
onto their partner (Dicks, 1967; Font & Prez Testor, 2006; Willi, 1978). Other prominent
authors have similarly conceptualized this unconscious interplay between the members of
a couple as an unconscious base (Puget & Berenstein, 1988), dominant internal object
(Teruel, 1974) and conjugality (Nicol, 1995).
The concept of collusion starts with the idea that couples are formed on the basis of
personal styles that are complemented with flows and reflows, or with projection, intro-
jection, and retroprojection. These kinds of bonds arise within all couples, albeit differ-
ently in each couple, and they can be grouped into clusters based on admiration, care, or
dependency. Although certain levels of admiration, care, or dependency are needed in all
couples, it is important for the health of the couple that they occur alternately and not
rigidly. All couples have bonding styles in which certain characteristic features predom-
inate, but pathology appears when the bonding style becomes rigid (Prez Testor & Prez
Testor, 2006). One example of this was a couple treated in our center. The woman had
always spent much of her time caring for her husband, and the husband let himself be
cared for, which allowed both partners to meet their primary needs (caregiver-care
receiver). Then the woman was diagnosed with breast cancer and they had to change roles,
but neither member was able to take on the opposite role and pathology appeared. The
couple came to us seeking help mainly because of this inability to change roles. Accord-
ingly, we believe that collusion becomes pathological when the roles of each partner
become so rigid that it is difficult to exchange them. In keeping with this idea, Fisher and
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Crandell (2001), referring to the attachment theory, state that the hallmark of secure
attachment is the ability of each partner to change their positions of depending and being
depended on by one another in a flexible and appropriate manner.
Psychoanalytical Treatment of the Couple
As we have noted, during the 20th century many psychoanalytical therapists came to
accept the usefulness of welcoming couples and families into their practice, in contrast
with the classical tendency of working only with individual patients (talking cure). This
new framework has given rise to many questions and studies on the techniques adopted
by the therapist, sometimes leading to reconsideration of the classical boundaries of the
psychoanalytical setting. The scope of couple therapy has evolved substantially in psy-
choanalysis, and the object relations orientation has made a major contribution to the field
by giving couple therapists insights into the defensive, communicative, and structure-
building functions of unconscious processes, resistance, and work on transference
(Sander, 2004; Scharff & Scharff, 1991; Sharpe, 2000; Slipp, 1988). As mentioned before,
the role of the intersubjective is crucially important with regard to much of the suffering
in a couples relationship and thus should have a place in the design of therapy. When
including this dimension, the couples analyst needs to bear in mind some important
aspects that will eventually appear during the treatment.
In couple therapy, we often find that what initially attracted each partner to the other
lies at the heart of their complaints (Felmlee, 2001; White & Hatcher, 1984). Now,
collusively, they choose those aspects of their partner that confirm their worst fears about
themselves and their partner. Mutual needs, often on an archaic level, are stimulated in
couple relationships. Frustration and disappointment of these developmental needs often
lead to marital conflict. In many couples, difficulties can be understood as mutual attempts
to rectify the deficits of their injured selves (Livingstone, 1995). According to Kas
(1976), one great benefit of couple therapy is that it may hold out a chance to reelaborate
the unconscious alliances, pacts, and contracts that come from intergenerational and
transgenerational psychological transmissions and that have remained embedded in the
couple. In the clinical setting, the roles and rules adopted by couples often appear as
stemming from intergenerationally transmitted anxieties about unresolved dilemmas in
both members birth families. In this sense, Robert (2006) defines the couple as the place
where a person once again acts out and sometimes attempts to retain his or her infantile
side, regardless of the cost. Helping both members of the couple to recognize that their
fears are fundamentally similar is crucial in overcoming disillusionment and polarization,
and enables them to integrate solutions that they initially view as inimical (Goldklank,
2009). When both members of the couple accept responsibility for their own personal
contributions, blame and shame are somehow alleviated and the quality of their relation-
ship is enhanced (Scharff & Scharff, 2004).
In psychoanalytic couple therapy, as we view it, the therapist plays an active role in
which interpretative capacity is his or her main instrument. Stressing psychoanalytic
techniques to maintain a state of harmony, providing a secure base, recognizing nonverbal
signals of unconscious associations, and processing emotionally laden interactions are all
important when working with couples (Scharff & Scharff, 2004). In Teruels opinion
(1970), the destructive force of a couple can be managed by means of proper interpreta-
tions and the gradual acquisition of insight through introjection or internalization of what
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6 AZNAR-MARTNEZ, PREZ-TESTOR, DAVINS, AND ARAMBURU
the therapist does and represents for the couple in terms of his or her interaction in their
marriage.
No doubt, the main difficulty in couple therapy lies herein: how to interpret. Like
Lemaire (1980) and Castellv (1994), we would say that the interpretative focal point is
the couple, not one member or the other but both of them together, their relationship, and
their collusion, which is in keeping with the intersubjective dimension of couple treat-
ment. If we avoid the risk noted by Teruel (1970) and which Thomas (cited in Prez Testor
& Prez Testor, 2006) summarizes as individual interpretation in public, and focus
instead on interpreting their collusion, we may be able to help both partners gain
awareness of the functioning of their unconscious, which has led them to act out their
conflicts. When interpreting from an interpersonal perspective, the couple therapist affirms
that each member of the couple is complaining about something that truly exists, but to
which they both somehow contribute (Goldklank, 2009).
The mobilization of each partners unconscious defenses is coordinated and takes on
the guise of resistance emerging spontaneously in the session. Generally speaking,
progress is slowly made with the therapists interventions, in which analysis of the
defenses and anxieties of one partner is often used to analyze the others defenses and
anxieties in a pattern that is usually back-and-forth. The therapist tries to interpret the
collusion by showing the defenses and anxieties which have led the couple to form this
specific kind of internal dominant object (Teruel, 1974).
The work of acute understanding and integration of interpretations is performed in the
same way as in psychoanalysis or psychoanalytic psychotherapies. However, perhaps
acute understanding of one of the partners is quicker and more precise than with the other.
It is then wiser to adopt the pace of the slower one since a greater capacity for insight in
one member of the couple can become a weapon used against the other if the therapists
interventions do not set limits. In other words, it is important to adjust the pace of the
treatments progress to the slower or more fragile of the two partners.
The therapist must be aware of the nature of this movement, bear it in mind, and only
use interpretation when it can be addressed to both partners, in accordance with the
intersubjective dimension that shapes the design of couple treatment. The responses to the
therapists interventions may come from either partner and they often react, each one
offering rich associative material.
The theoretical underpinnings and intentionality of the interpretations correspond
equally to both transferential and extratransferential types. Both entail an effort to show
the couple what they do not know about themselves, to reveal those parts of their inner
world that are repressed or disassociated so that they can recover them and reintegrate
them into their psychological system as a whole. There are no totally and exclusively new
experiences solely determined by external conditions. Rather, all of them are filtered to a
greater or lesser degree through the primitive internal object relations that survive in
the unconsciousness of the persons entire life. In couple therapy, the goal is to
interpret the here and now of what happens in the session. Extratransferential
interpretations are more frequent. They are expressed and revealed in the couples daily
lives and permeate any event and relationship outside the session. Technically speaking,
the best course of action after every extratransferential interpretation is for the therapist to
try to identify and interpret the unconscious motives and fantasies which have led the
couple to bring certain facts and situations to the session and, on the basis of this, proceed
to the transferential interpretation itself (Prez Testor & Prez Testor, 2006). Nevertheless,
it is difficult for all of these internal conflicts to be expressed in transference at any one
point. Whatever the characteristic features and technique of each therapist, in the thera-
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
7COUPLE PSYCHOANALYTIC PSYCHOTHERAPY
peutic function the couple relives the fundamental structure of internally shared object
relations. Yet other nuances and particularities of these relations will never be manifested.
They require present actual realities in order to emerge and develop. Hence, the couples
internal world never appears as whole in the transference. Elements of it, both the most
pathological ones and those pertaining to the healthier parts of the personality may be
displaced, disassociated, or represented outside the therapeutic session (Lemaire, 1980;
Lemaire, 1998; Nicol, 1999). The members of each couple reflect their life events in
keeping with features of their own particular characters which are not always present in
therapeutic transference. If they are not interpreted, the conflicts, anxieties, and defenses
that have given rise to them may remain hidden and unchanged.
One reason given by classical analysts as an argument against couple or family therapy
was the idea that it would be problematic because of major complications stemming from
the multiple transferences and countertransferences entailed in the process. As described
above, in psychoanalytic couple therapies today, which include orientations from the
theoretical school of object relations, transference and countertransference are perceived
as dynamics inherent to the therapeutic relationship (Kaswin-Bonnefond, 2006). None-
theless, dealing with countertransferential responses in this kind of therapy is an even
more complex challenge. In the same vein, Prez Testor and Prez Testor (2006) noted
that the greatest difficulty facing couple therapists is managing countertransference. This
is often manifested in the form of extreme fatigue, which tends to lessen with experience.
If all psychotherapy involves observing the different levels at which the patients words
can be understood, or the different transferential and countertransferential movements,
these levels are necessarily multiplied in couple psychotherapy. The therapist will expe-
rience countertransference intensely. It is important, therefore, to be prepared to deal with
and contain a joint attack by both partners, who form an alliance to attack the psycho-
therapist who exposes their collusion
