What is psychoanalytic couple therapy?

Psychoanalysis is a term that is often used to describe a type of intensive individual psychotherapy that draws upon a specialist knowledge base involving the field of unconscious mental life as first defined by Freud.  To practice it one needs to have completed a rigorous and specialist training, one that satisfies requirements for inclusion onto a recognized register of psychoanalysis such as that held by the British Psychoanalytic Council (BPC).   

Psychoanalytic psychotherapists generally accept that the unconscious is revealed in, and shaped through, relationships.  Psychoanalytically-informed couple psychotherapists regard the intimate couple relationship as being the locus at which the intra-psychic and interpersonal realities converge within an external setting.  Couple psychotherapy, then, ‘is the process of attending to the experience created by [these] three interacting variables with the purpose of achieving change’ (Clulow, 2011, p.3).  The therapeutic process of identifying and understanding the function of the unconscious processes operating within the relationship gradually leads to a change in the quality of interaction between the partners.

So how is couple psychotherapy different to psychotherapy with individuals? Are psychotherapists who have completed a psychoanalytic training to work with individuals equipped to see couples?  One significant difference lies in the setting.  During couple psychotherapy sessions partners sit on chairs or sofas positioned to face the therapist.  They do not lie on a couch facing away.  Secondly, there are three people in the room.  Uniquely, not only are both individuals forming the partnership present, but that there is an existing, pre-established level of intimacy between the two.  Generally speaking, at the point at which partners present for therapy each partner is looking for relief from, and help for their own often painfully-felt experiences within the partnership.   They also express how the relationship itself is no longer working for either of them, often illustrating this feeling by describing incidents where contact with the other has left each feeling unloved, uncared for, and emotionally depleted.  Oedipal anxieties can get stirred up as couple therapists, such as myself, are invited to observe and unconsciously participate in the couple’s relational dynamics.  Our therapeutic skill, one that is acquired during our specialized intensive training, lies in the delicate and sensitive management of each partner’s distress in the presence of the other whilst remaining alert to the nature of the relationship that the partners have co-created.  Theoretically we pay attention to each partner’s parental couple as an internal object, and our attention is focused on the shared internal objects within the partnership.  At all times we remain aware that the dynamics of the couple’s relationship can get readily and unpredictably re-ignited and enacted within the clinical setting and that we can become unconsciously drawn to participate in it.   

In order to assist partners with problems that are central to being a couple, namely those of intimacy, separateness, and sexuality, we couple therapists must be able to tolerate anxieties related to primal scene phantasies associated with intruding into the private lives of others.  Our clinical effectiveness rests upon the internal couples that we as clinicians mobilize personally and professionally to assist us in this work. 

My interest in the specialist field of couple psychotherapy developed through my experiences as a geneticist working at the Institute of Child Health, London.  During the early 1990s I was part of a team of scientists involved in developing gene therapy as a cure for a genetically inherited immunological disorder in children.  Almost all of the children afflicted by this particular disease die by age 13.  Being based in Great Ormond Street Hospital for Sick Children in London I was regularly confronted with distressed parents attending to their sick and often dying children.  I saw the effects of sustained emotional strain on each partner and on their relationship.  I observed how the quality of their relationship held the potential to influence each partner’s mental and physical wellbeing and, in varying degrees, that of others around them.  I began to view the couple relationship as the nucleus of micro-communities, the foundation of societies.  The importance of emotional wellness in couple relationships now took on new meaning for me.

In the years that followed my search for an in-depth, comprehensive and thorough training that would adequately prepare me to work with couples led me to apply to train at the Tavistock Centre for Couple Relationships (TCCR), the UK’s leading training institution with a global reputation for psychoanalytic couple psychotherapy and counselling.  I was delighted to be accepted onto TCCR’s disciplined and rigorous training, which is grounded in psychoanalytic theory and practice.  Psychoanalytic couple psychotherapists like myself who have graduated from TCCR are registered with the BPC through our professional body, The British Society of Couple Psychotherapists and Counsellors (BSCPC).  We have an international journal, entitled Couple and Family Psychoanalysis, that is dedicated to promoting the theory and practice of working with couple and family relationships from a psychoanalytic perspective.  Our journal also seeks to provide a forum for disseminating current ideas and research and for developing clinical practice, and offers a wealth of contributions from our colleagues around the world.  

It is encouraging to see that the interest in the field of couple psychotherapy is growing, and that the awareness amongst professionals that ‘thinking couple’ is a skilled specialism is increasing.   In recent years, the Couples Unit in the Adult Department of the Tavistock Clinic has begun to offer a course in psychodynamic psychotherapy with couples.  This course is aimed at clinicians interested in developing their practice to working with couples, and is accredited by the BPC.

Admittedly, the description of psychoanalysis that I have presented in my opening paragraph is a gross reduction of Freud’s vision of psychoanalysis.  In defining psychoanalysis as being ‘the science of unconscious mental processes’, Freud (1925) integrated the ‘art’ of therapeutic practice with scientific diligence.  Freud’s vision remains pertinent in today’s evidence-based culture: if we are to take couple psychoanalysis seriously, it seems essential that we are able to link its practice with research-based evidence of its effectiveness.

How Couple Relationships Shape Our World: Clinical Practice, Research, and Policy Perspectives, is a book produced as a joint venture between the BSCPC and the TCCR.  It offers clear evidence of how the quality of our most intimate relationship -  the adult couple relationship -  profoundly affects not only the ‘emotional, cognitive, and physical development of our children’, but also impacts upon ‘the likelihood of hospitalization, the rate of progression of disease in dementia, and even mortality rates’ (Balfour, Morgan & Vincent, 2012, p. xxix).   It provides data verifying what we already know, that unhappy couples are exposed to a greater risk of cardiovascular disease, obesity, diabetes and other health concerns (Meier, 2011); that relationship breakdown comes at a great cost to the individual and to the State and can lead to an increased risk of anxiety disorders, alcoholism, depression and even suicide.  Clinical studies conducted on the importance of involving the partner in treating depression in adult patients demonstrate ‘the superiority of couple therapy over an approved antidepressant regime both in reducing the symptoms of depression and in maintaining the improvement, …. couple therapy was not more expensive than pharmacotherapy’ (Leff, Assen and Schwarzenback, 2012, p. 181).  A clinician’s guide to couple therapy for depression is currently in the process of being published (Hewison, Clulow and Drake, in press).  It incorporates analytic approaches with behavioural and systemic ones in describing an integrated approach to treating depression through couple therapy.   

In conclusion, psychoanalytic couple psychotherapy works well alongside other modes of psychoanalytic psychotherapy.  It is a specialist, highly skilled approach to providing relief, support, and treatment for intimate couple relationships that have become problematic, and one that is compatible with ongoing individual therapy.  Psychoanalytic couple therapy is an effective application of psychoanalysis, and an exciting development in its long and prestigious history.  

References

Balfour, A., Morgan, M., & Vincent, C. (2012).  Introduction, pp. xxix.  In: A. Balfour, M. Morgan and C. Vincent (Eds.),  How Couple Relationships Shape Our World.  Clinical Practice, Research, and Policy Perspectives. London: Karnac.

Clulow, C. (2011).  Couple Psychoanalysis and Couple Therapy: Context and Challenge.  Couple and Family Psychoanalysis, 1:1.  

Freud, S. (1925).  An autobiographical study.  S. E., 20: 7-70.  London: Hogarth Press.

Hewison, D., Clulow, C., & Drake, H. (in press). Couple Therapy for Depression. A Clinicians Guide to Integrative Practice.  Oxford University Press.

Leff, J., Asen, E., & Schwarzenback, F. (2012).  Depression, couple therapy, research, and government policy.  In: A. Balfour, M. Morgan and C. Vincent (Eds.),  How Couple Relationships Shape Our World.  Clinical Practice, Research, and Policy Perspectives. London: Karnac.

Meier, R. (2011).  Briefing Paper 1.  London: Tavistock Centre for Couple Relationships, Tavistock Institute of Medical Psychology.  [www.tccr.ac.uk].