Teaching Analytic Candidates Couples Therapy

“You need only apply your understanding of transference, resistance, infantile sexual and aggressive conflicts, child development, externalization, and the repetition compulsion to the treatment of a couple rather than to an individual.” With this statement I introduced eight advanced candidates at the Association for Psychoanalytic Medicine to an elective course in psychoanalytically oriented couple therapy.

The candidates had requested such a course around the same time that I had proposed one to the curriculum committee. To my knowledge it is the first such course given in a psychoanalytic institute. The candidates had apparently sensed that knowledge of this area might serve them well in their work. Perhaps they were aware that a divorce rate near 50 percent is leading an increasing number of patients to seek marital counseling from more than 100,000 practitioners for what we 3,000–4,000 analysts are best equipped to treat: the manifestations of unconscious neurotic conflicts. While we are knowledgeable about the determinants of marital discord, we are waiting for patients with the well-internalized conflicts we consider the hallmark of analyzability.

Some of the candidates mentioned that they had on occasion seen a couple when, for example, a spouse “showed up” in the waiting room. They all had individual patients whose treatments were complicated by extensive externalized conflicts, and they seemed ready to explore this new modality of treatment.

We touched on the cultural, institutional, and personal reasons for favoring the traditional one-to-one mode of treatment. At the personal level, we acknowledged the greater level of comfort in treating one person, rather than two or three, as our traditional format resonates with that developmental period before the universal experience of a “third,” the presence of either a sibling or parental rival. Indeed, when one treats a couple there is often an immediate sibling transference or an oedipally tinged dynamic as one partner competes with the other for an exclusive alliance with the analyst. An early question raised by the class was, “When seeing a couple, are we treating the individuals or the marriage? Might these not be in conflict?” After some discussion that reflected the ambiguities involved, I emphasized that when working analytically with a couple, just as in individual treatment, we are there to interpret as best we can the critical dynamic intrapsychic and interpersonal conflicts and how they are linked. Just as in individual psychoanalytic treatment, it is not our job to “save” marriages or “free” individuals from unhappy marriages. This distinguishes our work from the many non-analytic approaches, both individual and family, which, having highly specific behavioral goals, are often excessively directive and active rather than introspective and interpretive.

“When seeing a couple, are we treating the individuals or the marriage? Might these not be in conflict?”

The candidates, immersed in the many controversies in our field, noted that recent developments in psychoanalysis provide more bridges to the treatment of couples. The increased emphasis on countertransference, intersubjectivity, interaction, and object relations theory makes the treatment of a couple more easily integrated with theory than our earlier more exclusively intrapsychic emphasis would have done.

Limited but Valuable Literature

I organized the course around readings and case presentations. The literature in this area is not extensive, and in this short course we were able to read the most salient papers. We began with an early mini-classic “Mutual Projection in a Marriage,” in which two individual treatments were supervised by the author T. F. Main. The students were skeptical about the somewhat miraculous “cure” of the couple. I likened it to the early cures Freud reported when he used hypnosis. The class appreciated the paper's clear delineation of the collusive mutual (transference) projection processes of a wife who projected her disavowed feelings of weakness onto her husband, while he projected his masculine strivings onto her. Not surprisingly, the presenting symptom was impotence. Viewed from the standpoint of current theory, such projections are part of compromise formations played out in a couple. I described such a dynamic from my own practice: A husband with psychopathic traits was married to a wife with an inflated superego. This guilt-driven couple fought endlessly over his crossing ethical boundaries, illustrating an early observation of Freud's that “unhappy marriages often supersede neuroses by satisfying an unconscious sense of guilt.” I noted Mittelman and Oberndorf's 1940s papers on their highly unconventional analytic treatment of both spouses of such unhappy marriages.

In the remaining seven sessions we read more recent papers reflecting current schools of psychoanalytic thought including object relations, developmental, and ego and self psychology. These readings illustrated the contributions of the major schools of psychoanalysis. Among them were papers on countertransference and on the complexities and hazards involved when individual and couple treatments are conducted simultaneously by two therapists. None of the candidates were treating couples, so we discussed some of my cases or their individual analytic treatment of married patients.

The students' positive evaluations of the course, discussing what they had learned about the applicability of analytic theory to couple treatment, confirmed my sense that this is an important area for further theoretical and technical advances. Work in this area must also address the serious loss of legitimacy of our field which has become too parochial and disconnected both from the social and biological sciences and from a clinical world vastly changed in the last fifty years. When Freud first wrote of the distinction between primary and secondary gain, he was acknowledging two roads worth taking. He continued his journey into the timelessness of each person's individual unconscious conflicts. Unconscious processes, however, also cross individual boundaries and, more often than not, are acted out and shared with spouses and partners. It is time we paid attention to this less traveled road; a deeper understanding of marital conflict requires a sophisticated theory and practice that is but an extension of the already rigorous analytic training we provide.