Psychoanalyticpsychodynamic couple therapy

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Couple therapy using a psychodynamic model began in the United Kingdom in 1948, when Dicks and his colleagues founded the Institute of Marital Studies. The theories and techniques involved have been ably reviewed by Daniell(4) and Clulow.(5) The central concept used is that the inner (unconscious) world of the two partners determines their interaction and their response to changing circumstances. It is as though each partner has an internal blueprint, both of themselves and each other, formed partly by observation but also partly by the influence of earlier experiences of intimate relationships with parents, siblings, or friends. As a result, there may be projections which lead one partner to attribute motives such as hostility or sadism to the other, whereas in fact this is a split-off and denied characteristic of the first partner. Other consequences of this unconscious process may be the actual choice of partner, and the system of shared fantasies and defences which builds up as the relationship continues.

In therapy, four premises are used,(5) which inform a relatively long-term and open-ended series of sessions. The first is that a person's emotional health is related to his or her capacity to manage both internal conflict and external stress: it is important to be able to experience fear as well as trust, pain as well as pleasure, doubt as well as certainty, frustration as well as satisfaction. Secondly, significant relationships can be used to resurrect, but also change, inflexible patterns of behaviour established in the past. Thirdly, unconscious processes need to be taken into account when attempting to understand problems in relationships. Fourthly, change takes time because it requires a reordering of perceptions of self and others, perhaps with the help of transference interpretations by the therapist involving both partners.

Therapy in this mode may be carried out by one therapist seeing both partners, but is more often done by two therapists either seeing the couple together or in parallel individual sessions with joint supervision of the two therapists. An intriguing aspect of this therapeutic format is that sometimes the two cotherapists find themselves interacting in unfamiliar ways, in sessions and between sessions, which are thought to represent the projection of fantasies and feelings by the couple on to the therapists, and the understanding of these projections can advance the therapy itself. If these insights are used to inform the therapists' interaction with the couple, the individual partners may be made aware of their own conflicts, fantasies, and projections, and thus be able to give up some of their repetitive patterns of behaviour and withdraw damaging projections.

The psychoanalytic approach has been an important source of theoretical ideas in couple therapy, especially the concepts of attachment and loss developed by Bowlby.(6) It has also the distinction of being the first theory to be adapted to this area of work. There are, however, some drawbacks to working in this way, as enumerated by Wile.(7) He sees the emphasis on negative impulses and emotions (e.g. dependence, narcissism, sadism, manipulation, and exploitation) as painting a rather unflattering picture of the couple in therapy. A more serious problem with the approach is that in psychodynamic couple therapy these ideas, whether of defence mechanisms, projections, or shared fantasies, are treated as if they were as real as observed behaviour, whereas in fact they must remain assumptions based on hypothetical constructs, and are really only valuable in so far as the therapy based on them is effective. (1)

The question of efficacy is raised later in the chapter, but it must be stated here that the psychodynamic therapies for couple problems have only seldom been submitted to controlled trial, and then usually in a relatively short-term form. The therapy may be quite long term, and the improvements seen are usually not dramatic, so that in the last analysis the approach has to remain of uncertain value.

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