עודכן ב: מרץ 14
Supportive psychoanalytic couple psychotherapy
Ziva Levite, Idit Honigman, Hana Cohen, Liora Rehes, and Gidi Shavit
This paper aims to deepen understanding of the application of supportive psychoanalytic psychotherapy in work with couples and to anchor it in psychoanalytic theory and practice. It is based on the experience of collaboration between experienced couple therapists and supervisors, who face the frustration intrinsic to supportive psychoanalytic couple psychotherapy (SPCP). The article defines the principles of supportive psychoanalytic psychotherapy and discusses its application to couple psychotherapy, highlighting the therapist’s role. A case example employing supportive couple psychotherapy is discussed for the purpose of clarifying and illustrating the essence of this therapeutic approach.
Keywords: Supportive psychotherapy, psychoanalytic couple psychotherapy, supportive psychoanalytic couple psychotherapy, splitting, projection, holding environment, countertransference.
Even when patients do not get cured they are grateful to us for seeing them as they are
(Winnicott, 1971, p. 117-118).
Psychoanalytic psychotherapy concentrates on insights that enable development and change, while challenging defences and encouraging integration. Yet, not all individuals are helped by working with deeper unconscious material. There are some who have difficulty in containing the anxiety involved in insight-directed psychotherapy. They require holding and containment rather than interpretive work (Kernberg, 2000; Rockland, 1989). Joseph, writing about patients who are “difficult to reach” says, " It is very difficult to reach them with interpretations and therefore to give them real emotional understanding" (Joseph, 1975, p.75).
We propose therefore that, for couples, who might in psychological terms be similarly categorised, supportive psychoanalytic psychotherapy offers a more appropriate approach. Change using this type of psychotherapy is characteristically infrequent and slow. Therapy sessions are typically filled by partners’ attacks on each other and on the therapist that are so emotionally intense that there is space for neither change nor development (Bollas, 1987; Ruszczynski, 1995). In order to survive this demanding and challenging process, both partners, the couple's relationship, and the therapist, all need to be held and contained. This article is an attempt to deepen understanding of supportive psychoanalytic couple psychotherapy (SPCP) and to anchor it in psychoanalytic theory and practice.
SUPPORTIVE PSYCHOANALYTIC PSYCHOTHERAPY
Kernberg (1999) makes a distinction between psychoanalysis, psychoanalytic psychotherapy, and psychoanalytic supportive psychotherapy: "...the objective of psychoanalysis is fundamental structural change, the integration of repressed or dissociated unconscious conflict into the conscious ego. In expressive or psychoanalytic psychotherapy, the objective is a partial reorganisation of psychic structure in the context of significant symptomatic change. The objective of supportive psychotherapy is symptomatic improvement by means of a better adaptive equilibrium of impulse/defence configurations, with a reinforcement of adaptive defences as well as adaptive impulse derivatives" (Kernberg, 1999, p. 1078).
The aims of supportive psychoanalytic psychotherapy are to enhance the ability to adapt, strengthening the potential for more mature ego functioning, facilitating the development of the ego, reducing the use of defence mechanisms and making them more flexible, reducing symptoms and distress, and improving self-esteem. All these changes are expected to help clients moderate and control their behaviour and increase their capacity for coping with developmental and adaptive tasks (Jonghe et al,1994; Werman, 1988).
In the context of enhancing adaptive abilities, ego psychology theory distinguishes between “ego-modifying” and “ego-supportive”. Ego-modifying practice seeks to modify basic personality patterns and structures, mainly through insights into unconscious conflicts. Ego-supportive practice seeks to strengthen the ego in places of deprivation or damage where there are deficits or impairments, by reconstructing, maintaining, and enriching the adaptive functions (Goldstein, 1995). Ego psychology highlights the role of the environment and the individual’s innate abilities in the development of the ego. The ego makes use of defences to protect the individual from anxieties and conflict, provides adaptability, and mediates between the individual and the environment (Goldstein, 1995; Jonghe et al, 1994).
Psychoanalytic supportive psychotherapy techniques are directive, structured, here-and-now oriented, educative, confronting, and interpretive. Kernberg emphasises that to achieve the objectives of psychoanalytic supportive psychotherapy it is not helpful to use deeper unconscious material. He recommends using the preliminary steps of interpretive technique, clarification, and confrontation. "...it utilises cognitive and emotional support, that is, statements of the therapist that tend to reinforce adaptive compromises between impulse and defence by means of the provision of cognitive information (such as persuasion and advice) and by means of emotional support (including suggestion, reassurance, encouragement and praise)." (Kernberg, 1999, p. 1082). Joseph also observes that it is important to keep interpretations immediate and direct and in constant contact with what is going on in the session (Joseph, 1975).
Consequently, interventions are focused mainly on present behaviour and on conscious thoughts and emotions, and intended to ease symptoms through a more adaptive balance between drives and defences. In addition, psychotherapists intervene in the patients' environment with assistance in coping with transitions, stress, and anxiety, and to improve their functioning and adaptation. The therapeutic relationship is a corrective one, giving the opportunity to learn how to relate to others and maintain relationships (Goldstein, 1995; Jonghe et al, 1994; Pinsker, 1997; Rockland, 1989).
Psychoanalytic couple psychotherapy
From a psychoanalytic perspective, an understanding of couple relationship dynamics includes:
(1) That there are three entities in the relationship present in therapy: the two partners and the relationship between them (Ruszczynski, 1993).
(2) That an individual shapes his/her relationships according to past significant relationships.
(3) That the choice of a partner is a process whereby individuals are attracted to each other based on similar emotional needs and similar internal objects.
(4) That the relationship offers a “promise” at the conscious and unconscious level to repair what was lacking in earlier relations.
(Bagnini, 2012; Ludlam, 2007; Ruszczynski, 1993).
Marriage provides a “container” in which the internal conflicts of each partner can be externalised and made accessible in the interactive processes that the partners develop between them; each partner projects his/her internal object relationships onto the other. As a result, both collude in keeping alive the hope of repairing and resolving these internal conflicts (Colman, 2014; Morgan, 1995).
The fate of the relationship depends on the couple's internal object relational development (Ruszczynski, 1993). The development of object relations and its implication for couple relations can be described as a continuum ranging from mature object relations to primitive object relations (Levite, 2009). Klein describes mature object relations as representing the depressive position, and primitive object relations as representing the paranoid-schizoid position. The paranoid-schizoid and the depressive positions represent developmental moments and are normal and universal. People move in and out of these positions throughout their lives. While the main anxiety in the paranoid-schizoid position is fear of the annihilation of the self, the main anxiety in the depressive position is fear of losing the object (Klein 1940, 1986a, 1986b). As we shall elaborate below, couples who might be best helped by supportive psychoanalytic psychotherapy are those who have primitive object relations and live primarily in the paranoid-schizoid position.
Supportive psychoanalytic couple psychotherapy (SPCP)
SPCP aims at reducing the couple's use of defence mechanisms, especially those of splitting and projection, and at creating a therapeutic environment where the couple's pattern of defences can be displayed, recognised, and acknowledged. SPCP further aims to promote self-differentiation, increase adaptation, develop new means of coping, strengthen and broaden tolerance of a range of emotions, discover alternative avenues for expression of negative emotions (i.e., balancing affect regulation), and create new, positive experiences for each of the partners and their relationship with each other and their environment. Such processes enable each partner to claim a projected aspect of self and the better toleration of ambivalence, mourning, and grief (Feldman, 2014; Middelberg, 2001; Willi, 1982).
The process of SPCP is structured, focusing on clarifying partners’ internal and external realities; the therapist’s role is to help partners to construct new ways of looking at and being in these realities. Much of the therapy is devoted to supporting each partner’s observing ego, working slowly and carefully so as not to flood them with paralysing anxiety (Goldstein, 1995; Jonghe et al, 1994). The couple therapist gathers information about the partners' relationship in order to discover and point out behaviours that are destructive, confusing, and ineffective. A great deal of attention is also devoted to the couple's defensive behaviours, and the ways they communicate, both consciously and unconsciously. The therapist strives towards clarification of adaptive defences so as to reduce the use of these behaviours, or make them more flexible, while also strengthening adaptive defences. Through the therapy process, partners learn to channel their anger, first through the therapist, and then through the use of other strategies, that are likely to create a space for their relationship for being, making mistakes, and making reparation (Nyberg, 2007; Rockland, 1989). This way, the couple can develop from “object relating” toward “object usage.” It is a developmental process in which the other is experienced as not under the individual’s omnipotent control (as in “object relating”), but as independent, separate, and real -“object usage” (Winnicott, 1968).
Couples who might be helped by supportive psychoanalytic couple psychotherapy
Couples who might be best helped by SPCP are those who have primitive object relations and present in a paranoid-schizoid state of mind. Often early care in both partners was lacking. Such a loss or deprivation in childhood results in a shared experience of the world as a threatening place, together with the association of intimate experiences with fear and pain. Britton (1989) suggests that as a result of a failure of maternal containment an individual cannot develop a third position of self-observation. He or she is not a participant in a relationship, but a witness and observer of the subjective self, and consequently, lacks the ability to acknowledge or take responsibility for personal aspects and impulses, leading to difficulties in feeling safe in intimate relationships (Britton, 1989).
These couples are vulnerable to establishing relationships in which each partner has little psychological autonomy and therefore they tend to develop interlocking, mutually unsatisfying, patterns of engaging (Morgan, 2005). They also lack ways to cope with emotional complexity such as frustration, anger, rage, hate, pain, or ambivalence. In such emotional states, anxiety peaks, and as an emergency measure, the ego retreats into primitive defence mechanisms, such as splitting, projection, denial and blame, that warp perceptions of reality and weaken ego functions (Balint, 1951; Dicks, 1967). These psychological mechanisms refer to ways in which the subject, in phantasy, splits off and expels unbearable and unwanted mental contents into the object. If too much of the personality is projected, the personality can become impoverished, weakening personal boundaries and resulting in a confused sense of self (Klein & Riviere, 1937). In couple relations, splitting and projective mechanisms serve both as a defence against unbearable feelings, and as a defence and barrier against intimacy. Partners project onto one another, and the projected parts enter the partner in an effort to control, possess, or repair (Balint, 1993; Feldman, 2014; Ruszczynski, 1993).
The individual's efforts to prevent his aggressive and destructive phantasies from damaging the loved object are described by Klein as a process of reparation. The nature and the outcome of reparation in primitive or mature relations differ. Meltzer distinguishes between two types of reparation: reparation as defence against anxiety and reparation as “something more genuinely in the service of the objects” (Meltzer, 1978, p. 114). In primitive relations, reparation is doomed to failure, since the injuring partner is incapable of recognising his aggression and the damage caused to the loved object. There is thus neither a real sense of guilt, nor any recognition of the other's pain. The injured party does not feel reconciliation, love, or reparation, but rather the other’s anxiety and contempt. Partners experience rage as more powerful than reparative love (Klein & Riviere, 1937).
Those who experience themselves as destructive and as endangering their partner, their love object, need constant reassurance from the other that they are worthy of love, that they are not aggressive or harmful. This constant and mutual reassurance is achieved through a sense of uniformity and omnipotent control of one another, a shared defence mechanism that enables the couple to stay enmeshed, while preventing them from experiencing the intimidating and threatening mutual dependence (Ruszczynski, 1993).
The conviction that only their partner can provide for them and repair childhood deprivation, leads them to experience any separateness as dangerous. They establish rigid patterns of projective identification which they resist changing. When there is not enough separateness, any change, disagreement or conflict provokes extreme reactions that quickly escalate into frequent outbursts of rage (Colman, 2014; Feldman, 2014).
These couples are poorly equipped to provide containment for each other. Instead, partners serve for each other what Meltzer termed “claustrums”, in which each feels as if they are suffocating and trapped inside their partner. Unconsciously, the experience is one of being entombed, whereby projections are not contained, but imprisoned in the other (Feldman, 2014). When one partner is perceived as not providing enough holding and containment, the other experiences repetition of childhood deprivations, and responds by either attacking and/or cutting-off.
In such cases, instead of intimacy and mature interdependence, the relationship is maintained by conflict and hatred. The couple’s conflict becomes a vehicle for communication (Levite & Cohen, 2012). Bollas’ (1984) term “loving hate” seems to capture this dynamic. “The subject finds that only through hating or being hateable can he compel an object into passionate relating” (p. 222). A person hates an object not so as to destroy it, but rather so as to preserve it. Hate is not the opposite of love, but rather a substitute for love (Bollas, 1984). What is feared, as Freud stressed, is indifference, of not being noticed by the other.
Ella, forty years old, and Moshe, forty-seven years old, have been married for fifteen years. They have three children between the ages of seven and twelve. Both work at Ella's family business.
Moshe grew up in a kibbutz. His childhood memories are filled with a sense of loneliness and detachment from his family. His employment history is characterised by difficulties in commitment, and a sense of alienation. Ella comes from a wealthy and enmeshed family. All her life she worked in her family’s businesses, but, lately, she has been trying to forge an independent career.
Ella and Moshe were referred for therapy by the school psychologist after presenting with great difficulties in communicating and making joint decisions. When the couple began therapy, they were estranged and agitated, expressing feelings of failure, anxiety, despair, and lacking hopes for change.
The main issue in the couple's relationship is whether one can be autonomous in a collective. Both Moshe, due to his experiences on the kibbutz, and Ella, due to her experiences in her family of origin, feel that it is impossible to be part of a family and connected with its power and resources, while at the same time, be autonomous and authentic. For them, the authentic self is equated with weakness, abandonment, and loneliness, while the collective ego is equated with strength, resources, and togetherness. Each of these polarities represents one side of an internal conflict that is externalised into conflict between them. The couple alternate roles; while one holds the “authentic ego”, the other holds the “collective ego.” This leads to mutual projections, splitting, distrust, and high anxiety. Consequently, whenever one partner talks about change, it leads to a process of splitting between notions of good and bad, wealth and poverty, intimacy or autonomy, the individual or the collective, and both of them feel existential anxiety.
The process of supportive psychoanalytic couple psychotherapy
Siegel (1992) points out that the couple therapist rarely knows at the beginning whether a couple has the ability to metabolise deeper process and benefit from insight-oriented work. Joseph (1975) warns that it takes time to diagnose patients who appear to be working and co-operating, although in fact only part of the personality is made available, while another needier or potentially responsive part is kept split off.
The course of SPCP can be divided into two distinct stages. In the first, the couple generally seeks therapy, because the equilibrium between them has been disturbed and they are flooded with anxiety. They want to reduce their anxiety, stabilise their relationship, and restore its balance. At this stage, both couple and therapist have great hopes for change. In the second stage, there is less anxiety and the therapist begins to feel that the “working through” of couple therapy can be accomplished through insight, introspection, and change on both intrapersonal and interpersonal levels. However, as the couple’s anxiety lessens, their motivation to continue therapy and make changes also lessens.
At first, it seems as if couple and therapist share the same goals, but this is a misconception which confuses both all three. Time and again, it seems as if the couple is gaining some insights about themselves, the other or the relationship, but after a short while they repeatedly return to the starting point. The partners are unconsciously collaborating to preserve their state of despair. Since they desperately need each other as the repository for their projections, they have minimal motivation to change and so give up the partner as a container for projections. The therapist eventually realises that there is a gap between her aspiration for insight and change and the couple’s aspiration for homeostasis. Defensive splitting and projection, a difficulty in containing and tolerating change, and the lack of capacity for introspection become more and more apparent. Due to these disparities, such couples often have a history of several unsuccessful couple therapy attempts, in which they felt frustrated, disappointed, and abandoned by the couple therapist.
They need the therapist to experience the feelings, such as pain, shame, anger, resentment, frustration, and disappointment that they have difficulty registering. They need to know that the therapist can experience, contain, and survive these feelings (Waska, 2008). The therapist’s acceptance, holding, and understanding help to decrease the partners’ anxiety and facilitate an experience of calm that was not part of the couple’s inner or interpersonal resources (Siegel, 1992).
The practice of SPCP
The therapist in SPCP is active, both verbally and non-verbally, placing an emphasis on experiential interaction. The guiding principle is that of strengthening the couple’s ego functions, which translates into an improvement in daily functioning and strengthening the partners’ ability to deal effectively and responsibly with differences, conflict, frustration, and disappointment (Goldstein, 1995; Jonghe, 1994).
Treating the couple together provides a space for both partners and the relationship they create. A couple therapist who respects the space that the couple requires will be able to provide the necessary structure and security for creating a supportive, holding, and protective setting (Waska, 2008). The therapist who accommodates each of the partners according to their personalities and needs serves as a model for holding, containing, acceptance, empathy, and continuous survival, which enables the couple to deal with the similarities and differences between them (Bagnini, 2014; Balint, 1951). The therapist provides a model for the couple to identify with in their relationship with each other and with their environment. This identification affects the functioning of the ego, both directly and indirectly, and allows the partners to internalise good objects and create a mutual holding environment (Waska, 2008).
In couple psychotherapy, a holding environment is complex and must be tailored to the changing and different needs of each partner and the relationship between them. Creating such an environment in couple therapy includes strengthening the patients’ sense of security, going at their pace, speaking their languages, encouraging them, providing positive reinforcement, and being mindful of their ideas and doubts about their internal and external worlds. When there is "good-enough" holding, each individual’s internal resources are strengthened. Partners will learn to distinguish between and trust their respective senses of their inner and outer worlds. The experience of stable and flexible ego boundaries enhances and facilitates good connection between the psyche and soma, and fosters the growth of the inner world and creativity. A holding environment also enables individuals to accept aggression as part of one’s self, to make space for significant others, and promotes the ability to care about others (Winnicott, 1971).
When a couple constitutes a holding environment for each other, it enables an understanding that each is a nurturing, non-threatening partner, and that disagreements are accepted and are not necessarily indications of rejection and abandonment. It also allows flexibility and space to manoeuvre along the continuum of closeness-distance; intimacy-autonomy; dependence-independency (Dicks, 1967; Ruszczynski, 1993; Waska, 2008). Without "good-enough" holding, the personality is founded on deprivation, and vulnerabilities and childhood traumas accumulate (Winnicott, 1971). When the couple's holding environment fails, distress and anxiety in both partners lead to difficulties in coping with external and internal reality..
Partners serve as mirrors for one another. Winnicott considers the mother’s face as a mirror for her child, helping him develop his own self as autonomous and unique. When the mother reflects that her child evokes interest and curiosity, this has a curative aspect (Winnicott, 1960). Couples most suited to a SPCP approach, however, mirror each other as frightening and destructive. By containing the partners' projections, the SPCP therapist will enable the couple to tolerate better the anxiety and shame related to their part in the destruction of the relationship, and will serve as a positive mirror that enhances their trust in themselves and in their abilities and strengths. Through their experience of continuous survival, holding, containing, and empathy, the couple therapist helps the partners to realise that they are not as destructive as they experience and perceive themselves. Unconsciously, they may feel that they have damaged their love object through the projection, leading to fears of retaliation. According to Winnicott, when a child attacks his/her mother (therapist/partner) and she retaliates, (i.e., does not survive the attack), the child feels that his omnipotent power, aggression, and destructiveness are dangerous and so he must be cautious. The retaliating other is experienced as persecutory, and the individual’s aggression becomes a source of anxiety, which must be disposed of. When the parent (therapist/partner) survives and does not retaliate, the child realises that his aggression and destructiveness are limited (Winnicott, 1971).
If the therapist survives without retaliating, it reassures the couple that there are boundaries between self and other, object and subject and that dialogue between one’s own needs and those of the other is possible. This lessens both partners’ experience of being destructive, so that they can reflect on their abilities to change themselves and to make reparation. In this process, they are motivated by a need to feel that their love is greater than their hate. The therapist also reflects the partners’ abilities to contain their aggressive impulses, to see one another as separate entities, and to experience themselves and their partner as good objects. This experience is a vital part of the ability to give and receive love, pleasure, and comfort, and to be at peace with oneself and one’s own destructiveness, greed, and self-hatred.
Such couples often feel anxious about the therapy and the therapist, but this may be masked by avoidance and distancing. Sometimes, they cannot accept a supportive attitude and may attack the therapist with anger, hate, and devaluation of the therapy. This dynamic was clearly manifested in the case of Ella and Moshe. When the therapist praised them, they attacked her, belittled her remarks, and claimed that she did not understand them. They even added that this was not the first time she had misunderstood them. The therapist was left with the feeling that she had attacked rather than praised them. Therapists’ understanding and empathy are perceived as invasive. The therapist should aim to “survive” and allow the patient to express these feelings, while helping him to work out why he feels this way and how he can express his feelings differently (Feld, 2004).
It is the objective of the SPCP approach that in the course of the therapeutic process, the partners will learn how to notice the first signs of potential deterioration, pay attention to verbal and non-verbal cues of impending conflict, anticipate conflicts in advance, recognise the mechanisms they can use to attain better self-control, and explore alternative ways of reacting to distressing and conflictual situations. The therapist’s insistence that each partner takes an “I position” (for example, “I think”, rather than “we think”) allows the couple to become more flexible in their use of defence mechanisms, and to form a relationship in which differences need not become a source of anxiety. The couple therapist addresses each partner, asking them questions that relate to them as individuals and forcing them to take an “I position”. These may be questions about their opinions, views and feelings, what they like (colours, food), why they find certain points difficult, and why and when they feel criticised and attacked. This helps to develop the third position, which promotes a capacity for self-observation. Self-observation enables introspection, and recognition of the difference between the internal and external worlds, and between self and others (Britton, 1989). Only then, can underlying anxieties be experienced and addressed. The partners can then learn what to expect from one another and to moderate interactions that were previously out of control (Ruszczynski, 1995; Morgan, 1995; Waska, 2008). Interventions in SPCP include role-playing, encouragement, and providing information. When the couple has to cope with their social environment, they sometimes need concrete information, such as how to deal with their children’s school, government offices, and the like. Such interventions include also giving advice and suggestions (Goldstein, 1995; Kernberg, 2000; Pinsker, 1997; Rockland, 1989; Werman, 1988).
Giving advice in SPCP is a significant intervention aimed at helping the couple in anxiety-provoking situations in which they feel helpless (Vincent, 2001). For example, when Ella and Moshe felt attacked by their son’s teacher, the couple therapist helped them construct a strategy in which they learned and practiced when and how to present their viewpoint and how to respond to disagreements. Giving advice in psychotherapeutic settings is a debatable, complex matter. Rockland (1989) warns that the therapist's advice must be clear, direct, and adapted to the couple’s needs. If the therapist suggests an inappropriate solution, there is a danger that the couple will feel that they cannot act independently to help themselves. Instead of empowering them, building confidence and promoting adaptation, the couple becomes dependent on the therapist, and their lack of functioning and adaptation is exacerbated (Goldstein, 1995; Pinsker, 1997). Vincent (2001) suggests further that therapists should carefully examine their motivation for giving the couple advice. He warns that sometimes, a couple can cause the therapist to feel helpless and to “lose her voice”, and then she may choose to give advice or speak too much.
As aforementioned, conflict serves such couples as a means of preserving their relationship, a conflicted relationship being better than none at all. It is important that the therapist allows it to happen during therapy sessions. SPCP offers the couple a setting in which to manage their quarrels in ways that enable them to learn to express what they feel without experiencing themselves as destructive and destroyed. For example, when Moshe describes his sense of helplessness and frustration at work, he blames Ella and her family. In return, she attacks him, unable to tolerate the guilt she feels through her identification with his helplessness. Her inability to contain Moshe’s feelings forces her to confront her own similar feelings and she is flooded with hostility and aggression, rather than empathy and tenderness. When one of them is hurt, he/she attacks and blames the other. Instead of trying to reassure the one who is hurt, the other partner counter-attacks. Obviously, mutual attacks make it difficult for couples like Moshe and Ella to feel safe, intimate, or to preserve their interpersonal boundaries. Therapy sessions are full of verbal outbursts in an attempt to circumvent insecurity and helplessness. When conflicts surface, the therapist must set clear boundaries and rules for their management. When a spouse reacts to destructively to disappointment, the therapist should intervene and discuss with the couple the feelings that led to this behaviour, stressing the belief that they can survive the painful, frustrating experience ,and respond differently, having learned to recognise one another's needs.
The therapist offers "psychological" information intended to help the couple learn about the influence others have on them and they on others. They learn how to recognise and understand others’ needs and how to respond to them constructively. For example, Moshe claims, “If you would support me for once, I would not get so angry and we would be able to talk.” To this Ella retorts, “How can I support you when you are always trying to control me, and you never listen to me?” In the course of the therapy, Ella was able understand her anxiety and to say to herself, “He is not attacking me. He is trying to convey his feelings. I can listen”. This way, the partners learned to see each other not only as an assailant, but also in terms of their respective inner child. This allowed each to hear the child’s cry, the wish for love, and satisfaction of needs that lay behind the frustration.
It is important to note that SPCP not only aims to enable couples to accomplish stabilisation and restoration of homeostasis, but, it seeks long-term benefits, even though the changes are limited and slow. Winnicott’s observation is very helpful for SPCP: "Psychotherapy is not making clever and apt interpretations; by and large it is a long-term giving the patient back what the patient brings. It is a complex derivative of the face that reflects what is there to be seen. I like to think of my work this way, and to think that if I do this well enough the patient will find his or her own self..." (Winnicott, 1971, p. 117). SPCP seeks to be a process that helps to strengthen the self, to claim more projected aspect of self, and to tolerate better ambivalence, mourning, and grief. It also aims to improve the ability of each partner to see, and be seen by, the other, as well as to see the relationship as an entity in itself. For instance, during therapy, Ella began to change, and decided to leave the family business. Moshe felt threatened, which he manifested with anger and by belittling both the therapist and his wife. After experiencing holding and containment of Moshe’s anxiety, which made room for his wife to change without it threatening him, the couple was able to interact differently and allow more space for them both to feel autonomous and loved.
Another way to promote long-term change is through individual psychotherapy. Concurrent individual treatment is critical in helping both partners manage projections better (Feldman, 2014). In individual therapy, each partner can gain more understanding of the projective patterns, and try to integrate better individual issues in ways that facilitate the development of the object relational world and psychological growth.
The couple therapist in SPCP and countertransference
Countertransference is an important means of gaining valuable insights into the therapist’s and the couple's unconscious (Solomon & Siegel, 1997). It requires the therapist to be judiciously aware of his or her conscious and unconscious identifications and assumptions, prejudices, inter-generational messages, and theoretical and practical orientation. Rockland stresses that even though supportive psychotherapy does not focus on the patient’s insights, this does not mean that therapists do not have to work on their own insights. The therapist’s psyche is a therapeutic instrument; so projections from and onto it offer a means of understanding (Rockland, 1989).
In couple therapy countertransference provides valuable information about couples’ phantasies and anxieties. In SPCP, however, countertransference may become intolerable and undermine the therapy. The couple’s intrapsychic phantasy becomes a form of interpersonal transaction that may stimulate intense experiences in the therapist. Partners can evoke a strong countertransference due to their unrealistic expectations of each other and of the therapist, and due to their splitting, projections, and blaming. Partners unconsciously project their intolerable feelings onto the therapist, leading him or her to feel anxious, defensive, confused, incapable, and angry. The therapist must manage frustration at the slow, minimal changes in the couple, as well as intense feelings that occasionally include a sense of helplessness and worthlessness (Ruszczynski, 1993). Ella and Moshe’s therapist felt that "there was an undercurrent of disturbance and anger and impulsivity. It would be very hard to know where I stood with each of them"… "There is venom in the way Ella talks that is intimidating. At the same time, her hunger for attention and her need to be right in all this is heartrending". Our experience is that in supervision, therapists often report that both partners are distressed, and that they project their distress onto each other and onto her. This leads to feelings of paralysis, despair, helplessness, and lack of space for observing, thinking, and experiencing.
In couples most suited to a SPCP approach the death wish is stronger than their desire to grow; hence the therapist feels flooded with despair, failure, frustration, and helplessness for extended and taxing periods of time. Sometimes, when this happens and the therapist has trouble holding the couple, she may externalise this feeling through vindictiveness and hostility or, she may retreat defensively into a passive position (Perkel, 2007; Winnicott, 1971). For example, in Ella and Moshe’s case, the therapist wanted to terminate the therapy prematurely; she could not feel and think during sessions and therefore could not speak.
At other times, couples project their own grandiose feelings onto the therapist, expressing great admiration for her, and treating her like an omnipotent, all-knowing, and all-giving parental figure. The therapist must, however, bear what the couples cannot, and take care not to yield to the temptation of fulfilling their ideal phantasies of being “the good, perfect couple therapist.” In an attempt to “save” the couple, the therapist may feel obliged to “do something", instead of trying to understand what she is experiencing and noticing the split. When the partners feel disappointment, frustration, and anger toward her, they will instantly turn against her, stop seeing her as ideal, and perceive her as a frightening, persecuting other (Solomon & Siegel, 1997). As Moshe and Ella’s therapist describes, “There was a sense that the world must conform to their actions. When this does not happen, they become enraged and there was some break down in their sense of reality as well as their ability to modulate their affects".
Sometimes the therapist's intervention may become a trap whereby she is perceived as abandoning and a threat to one of the partners, and as a supporter and empathiser of the other, so being simultaneously an ideal and persecutory object. Due to the phenomenon of splitting, support and abandonment are interchangeable, as partners feel that if the therapist does not completely empathise with them, she must be against them. As the therapist describes Ella: "I often feel overwhelmed by the force of her personality, as if there is no room for me to get in at all, except in agreeing with her".Often the partners attack the therapist, the good object. Their neediness leads them to attack the very people on whom they are dependent, resulting at times in the therapist feeling irrelevant and meaningless (Joseph, 1975). On the one hand, they express distrust and rejection of any help or dependence; on the other, there is a cry for help. Unfortunately it is usually experienced as hostility, rather than as a cry for help. For example, in Ella and Moshe’s case, the therapist invested a great deal of effort to make the therapy setting one that facilitated dialogue, but her remarks were repeatedly rebuffed with complaints, such as, “It’s obvious that you weren’t there, otherwise you would understand”. In supervision the therapist expressed her distress, “I feel that my interventions are causing the couple to feel attacked by me.” In spite of the supervision, the therapist continued to feel helpless in the face of repeated attacks. She kept forgetting any insights that came up in supervision, and that she was not able to think. She found herself repeatedly trapped in the couple’s powerful splitting and projective mechanisms.
SPCP requires that the therapist does not panic or retaliate against couples, and does not become bored or angry. It requires a therapist who is prepared for her patients’ rejection and hostility, and to be, at times, the "bad object". Being a bad object requires the therapist to struggle, not just to hold that representation for the patient, but also to fend off an intolerable, self-representation of her own (Davies, 2004). More specifically, the couple therapist has to muster understanding, empathy, patience, tolerance, expertise, and reliability; to feel worthwhile, and to survive feelings of helplessness in addition to the slow progress of the therapy.
In order to remain present in these painful, often intolerable places, the therapist herself needs holding and containment. Team work through case conferences, consultation, and supervision, are essential. Supervision serves as a holding environment and a container that helps the therapist to cope emotionally with the couple’s high levels of anxiety. Such a holding environment enables therapists to avoid entrapment in splitting and projective processes, and to help with countertransference reactions in ways that allow introspection and awareness of her own pain. The therapist’s presence describes her ability and willingness to be emotionally with the couple, to constitute a stable presence of listening, identification, holding, protection and containment (Solomon & Siegel, 1997).
Supervision helps the therapist not to act out of her countertransference response. In supervision, the couple therapist can process feelings of failure, frustration, and helplessness that lead to questions such as, “What is stuck here? What am I not seeing? What am I not hearing? Why do issues keep repeating themselves in spite of all the insights? What am I doing wrong? To what extent can I commit to the therapy? To what extent can the couple tolerate dependence and intimacy? What are the couple re-experiencing? What am I re-experiencing? What are my blind spots that prevent understanding what is happening?” (Feldman, 2014; Waska, 2008). Davies suggests a further question: why do we come to hate that version of ourselves that emerges when we are with them? (Davies, 2004). Supervision enables consideration of these kinds of questions, because the space for self-reflective processes is not compromised by the couple's intense unconscious communication.
Summary and Conclusion
SPCP is suggested as the appropriate approach for those who require holding and containment rather than deeper insight work. It is most suitable for couples who have primitive object relations and live predominantly in a paranoid-schizoid position. We have described the example of Moshe and Ella, who because their early care was lacking experienced difficulty tolerating intimate relationships. Defending against unbearable feelings and fears of intimacy, they made massive use of splitting and projection and had minimal motivation to change. Such patterns of behaviour are addressed by SPCP by creating a therapeutic environment where the couple's pattern of defences can be displayed, recognised, and changed. Through work to promote self-differentiation, increase adaptation, strengthening tolerance of a range of emotions arising from internal and external realities, it seeks to enable couples to achieve a sense of equilibrium.
SPCP techniques are directive, here-and-now oriented, educative, confronting, and interpretive. They include reassurance, encouragement, role-playing, giving advice and suggestions, and providing information. Such interventions were found appropriate for Moshe and Ella. Interpretations should be immediate and direct, and include only clarification and confrontation. SPCP’s approach is thus characterised by emotional intensity and slow change.
SPCP seeks to enable partners to identify signs of deterioration, to learn means of attaining better self-control, and explore alternative reactions to their distress and differences. The therapist sets clear boundaries for disputes, reassuring that a dialogue is possible. As in the case of the couple described, she might intervene by asking, “What is it that you trying to convey"? and "I can hear your anger, but also your frustration and pain. Can you elaborate on that?” The therapist’s role is thus to create a safe space to protect couples against external and internal danger, in the hope of supporting them creatively to reflect on their ability to change and make reparation.
Because in SPCP, countertransference may become intense and intolerable, it is best suited to therapists who can contain their patients’ rejection and hostility, by being their "bad object". In the couple case we described the therapist was challenged and tested. In order to survive and be present in these demanding and challenging processes, the couple therapist herself needed a supportive and holding setting. Team work through case conferences and supervision, is thus essential to enable therapists to be aware of and avoid entrapment in projective identification processes, as well as to tolerate the frustration of the slow progress of the therapy.
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