COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT

COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT

OF CHOICE: Indications, Challenges and Benefits

Berta Aznar-Martínez, PhD, Carles Pérez-Testor, PhD, MD, Montserat Davins, PhD, and Inés 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 Kaës (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-Martínez, PhD and Carles Pérez-Testor, PhD, MD, Facultat de Psicologia,

Ciències de l’Educació i de l’Esport 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; Inés Aramburu, PhD, Facultat de Psicologia, Ciències de l’Educació i l’Esport 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 d’Economia i Coneixement de la Generalitat de Catalunya.

Correspondence concerning this article should be addressed to Berta Aznar-Martínez, PhD, FPCEE Blanquerna. C/Císter 34. 08022. Barcelona, Spain. E-mail: bertaam@blanquerna.url.edu

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Psychoanalytic Psychology © 2015 American Psychological Association 2016, Vol. 33, No. 1, 1–20 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0038503

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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 therapy—psychoanalysis 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 (1931–1966); (c) incorporation of family therapy (1963–1985); 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 Segalla’s 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 couple’s 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 other’s 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 person’s 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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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 Castellví (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 partner’s desires, hopes, disillusions, and fears interacting with similar aspects of the other partner’s 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 & Pérez 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 Hoffman’s 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; one’s 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 partner’s characteristics have been chosen, they seem to confirm each member’s 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 one’s 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 & Pérez 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 (Nicolò, 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 (Pérez Testor & Pérez 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 couple’s relationship and thus should have a place in the design of therapy. When including this dimension, the couple’s 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 Kaës (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 Teruel’s 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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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 Castellví (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 Pérez Testor & Pérez 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 partner’s unconscious defenses is coordinated and takes on the guise of resistance emerging spontaneously in the session. Generally speaking, progress is slowly made with the therapist’s interventions, in which analysis of the defenses and anxieties of one partner is often used to analyze the other’s 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 therapist’s interventions do not set limits. In other words, it is important to adjust the pace of the treatment’s 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 therapist’s 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 person’s 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 couple’s 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 (Pérez Testor & Pérez 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-

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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 couple’s 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; Nicolò, 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, Pérez Testor and Pérez 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 patient’s 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.

The therapist must be aware of and alert to positive and negative transference toward him by each patient, separately and by the couple as a unit, as well as his or her own positive or negative countertransference toward them. Sometimes, a second professional acting as a cotherapist may serve to attenuate some of the transferential and countertrans- ferential feelings, rebalance the therapy system, and improve the therapeutic process. For instance, if a cotherapist who is the opposite sex of the therapist is included in the treatment of a heterosexual couple, this will help to bring out the transferences in a different more balanced way.

As we know, the therapist’s countertransference begins with first impressions, and it is important for the therapist not to take these as absolute truths or see his or her personal values and preferences as ideals by which to measure patients (Ehrenberg, 1992). How- ever, these initial impressions, both verbal and nonverbal, are unconscious communica- tions from the patients. A therapist who, unaware of his or her own countertransferential reactions, acts them out, runs the risk of entering into collusion with the couple and participating in the dynamics of their relationship (Goldklank, 2009). Slipp (1988) claims that in couple therapies based on object relations theory there is an interaction between the intersubjective worlds of the therapist and the dyad. It is essential that the therapist should be knowledgeable about the processes of projective identification and disassociation that influence the multiple transferences and countertransferences toward the therapist, and that are at work between the patients themselves. Objective countertransferential re- sponses of the therapist, adequately thought out and processed, (Kaslow, Kaslow, & Farber, 1999), must be employed when interpreting the interpersonal patterns used by the couple to keep their relationship functioning in its maladaptive way.

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In addition to transference toward the therapist and the therapist’s own countertrans- ference, there are other mechanisms at work between the members of the couple. These might be described as transferential-countertransferential (projections, introjections, and retroprojections). As a result, both partners not only experience their own transferential needs but they also have other subjective experiences in response to their partner’s transference toward them. The couple therapist must be aware of the intricate nature of these experiences. Working on patients’ transferences toward the therapist empowers them to build a structure and develop the capacity to nurture each other (Livingstone, 1995).

As we have noted, couple therapy is very complex because a host of factors must be borne in mind. We shall now discuss the specific features of these factors and how they influence the diverse mechanisms in the analytical relationship.

The Therapeutic Relationship in Psychoanalytical Couple Psychotherapy

In addition to the mechanisms that we have mentioned above, couple psychotherapy is also characterized by a series of specific features that make the therapeutic relationship more complex and require more effort by the analyst, who must be attentive to the different mechanisms that appear. When designing a couple treatment, the analyst will need to consider some points.

In couple therapy, there is a prior relationship between the members of the couple and this will naturally influence the relationship with the therapist (Symonds & Horvath, 2004). There is a third person in the room who shares a history of mutual frustration and each partner’s failure with the other. Couples tend to seek therapy together because each partner has repeatedly failed to respond empathetically to the other, or to offer the security the other needs. Each one has felt hurt by his or her partner and incapable of repairing the ruptures in their bond, and the defensive postures they both adopt create barriers to communication and intimacy (Livingstone, 1995). Early childhood experiences affect each partner’s capacity for responding to the other’s transferential needs and demands, as well as giving rise to problems in the communication between them. This situation often immerses them in a pattern of repetition of actions that enslave them. They are uncon- sciously recreating past scenes while yet living in fear of repeating them. They are facing what Stolorow, Brandchaft, and Atwood (1987) have defined as the fundamental conflict that can be treated and worked on in couple treatment. The marital conflicts and dissatisfaction that the couple brings to treatment are frequently the result of repeated attempts to resolve a childhood dilemma and changing these dynamics, which have worked for so long, is a highly complex undertaking because, in their resistance, the couple will often hinder the analytical work.

Numerous authors have discussed the phenomenon, which often occurs at the start of couple psychotherapy, when one of the members is more motivated than the other, or when one of them forces the other to attend. It frequently happens that the latter appears to be incapable of describing the problem and has little expectation of change. The other partner has high expectations and is willing to work with the therapist. Lemaire (1998) says that, in these cases, it is important for the therapist to help the partner who is less motivated to express his or her malaise in the joint interview until such a time as it would seem they would benefit from working together. When, with help from the therapist, the less motivated partner feels that his or her suffering and complaints are understood by the

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9COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

other, they may come to share a real desire for therapy. As Goldner (2004) notes, both partners must be always defined as partners.

In most couples who seek therapy one partner believes that the other is primarily responsible for the couple’s troubles. The therapist must tell them what they do not want to admit: that the couple is trapped in a system that they have jointly created. By means of unconscious yet observable maneuvers, each member of the couple prompts the other to keep repeating the same kinds of behavior which are seen as “problems.” In most cases, interpreting the couple’s problems from the interpersonal standpoint enables the partners to come together to solve the conflict. As noted above, interpretations of the coconstruction of problems are crucial for couple therapy. Each of the partners must be supported in turn so they can develop the ability to set aside their own needs and shift the focus from their own subjective existence in order to provide empathetic support to the other. In part, this ability can be strengthened through the bond with the therapist as the therapist helps each member and thereby reinforces their capacities and psychological structure (Livingstone, 1995).

Couple therapy often takes place in a setting characterized by conflict, emotional tension, vulnerability, and threat. Resentment, frustration, and hostility are frequently present at the expense of the collaboration, mutual concern, and respect which are so crucial to the therapeutic relationship and psychoanalytical work. Each partner feels threatened by the other. Chaos and fear of suffering further trauma prevail in this kind of therapeutic situation. The reason for this maelstrom of primitive emotions is that the partner is the closest equivalent in adult life to the early bond between mother and baby (Dicks, 1967). In this regard, Alexander and Van der Heide (1997) stress that extremely intense displays of rage and aggression often appear in couple psychother- apy and these may trigger strong reactions in the therapist. The hypothesis that the origins of this rage and aggression are to be found in early relational patterns and are reactivated in the context of subsequent intense relations provides valuable therapeu- tic insight which can be interpreted in order to help the couples in conflict to endure destructive interactions that are apparently based on rage.

The intensity of countertransferential relations is an important factor in the difficulty entailed in the couple interview, especially in the case of couple psychotherapy. The presence of both members, with all the concomitant countertransferential complexity, triggers multiple effects mobilized by the symbolic relationship of the primary scene. These difficulties translate into the fatigue felt by the therapist because of the need to attend to the convoluted countertransference phenomenon.

All of the complexity of the transferential dynamics and interplay of projections inside the couple must be understood as intricate in a multisubjective setting. In this setting, the members of the couple have a subjective experience of treatment and, more importantly, of the therapist. One highly significant aspect of this experience is the gradual revelation of developmental needs to the therapist. Both members of the couple need the therapist in order to function in a way that improves their sense of self cohesiveness and generates self-esteem. When one partner threatens to deny the other’s subjective experience, the therapist must intervene to protect that person from feeling invalidated. It is essential that the therapist should not make the mistake of playing the role of judge. Each subjective position should be treated as valid, although neither should be elevated to the status of concrete reality. Only when this multisubjective standpoint is encouraged can couple sessions become a safe enough place for transferences and narcissistic and archaic desires to surface and thus be worked on. The process of gradually creating—or negotiating—a

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10 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

vision of reality that encompasses the experience of all three participants is essential in transforming the marital conflict into empathetic mutual growth in the relationship.

Certain skills and knowledge in the couple about the transferential-countertransferen- tial processes must be interpreted. Both have profound needs that they hope their partner will meet. Some of these needs may be met, while others are not. The couple needs to know which of these needs must be manifested and accepted, and this is an extremely complicated undertaking. They need to know how to listen and allow feelings that may frighten them if they are expressed, especially if this entails one partner’s subjective experience of the other in a way that contradicts his or her self-image, or if it means dealing with problems that the person is ashamed of. Each partner must leave room for the other to express this kind of feeling and, if they feel supported by the therapist, who realizes how difficult this is, the task can be made much easier. Thanks to the therapist’s listening and understanding, the couple gradually sees that their ability to attain shared objectives is strengthened in therapy. Another difficulty faced by couples in treatment is the resistance of both members to being the one who initiates the change, since both partners often show strong unconscious feelings of loyalty toward the other, and they fear that changing might mean leaving the other behind, perhaps permanently. One partner does not want to commit to change without the other. It is important that the therapist should describe in detail the extent to which this loyalty to one another hinders their growth. The other protective aspect of resistance to change lies in the way each person relates with his or her own defensive responses and accusations. Each partner selfishly tries to frame the other as the promoter of change in an attempt to avoid being the first one to abandon the old rules or even their partner. They perceive their problematic refusal to budge as being protective of the other but it is also defensive, a kind of “couple contract” (Goldklank, 2009).

What is more, the fact that the relationship includes three people might also encourage each partner to try to ally with the therapist against the other partner, a factor that should be borne in mind since the potential consequences of this include abandonment of treatment by the partner who feels excluded. For example, it is not enough to be sensitive to the person who is making an effort to express demands but the therapist must also maintain empathetic sensibility to the experience of the partner who is the target of these demands. In the triadic universe of couple therapy another experience and an additional subjectivity are included. In this setting, both partners bring an insistent need to be at the center of the treatment, to be understood, and unlike the analyst, they do not have a strong enough self-reflexive or empathetic capacity, and neither are they able to subordinate their own needs and bring their partner’s needs to the fore. In many married couples, if the partners did have these skills, there would be no need for treatment. The therapist’s difficulty when interpreting—bearing in mind that the situation is triangular—is finding the right moment and way to share the interpretation, which should be joint, since one of the members may feel attacked, or may try to establish an individual alliance with the therapist (Pérez Testor & Pérez Testor, 2006). In this case, if no limits were laid down, a constant alliance would be established between the therapist and the partner who is better able to understand their shared unconscious background (Lemaire, 1998).

In couple therapy, everything that happens in the sessions has consequences in the couple’s real life which can then have a major effect in the treatment. For example, one member of the couple may reveal a fact or secret, which is experienced as a betrayal by the other, and this can lead to problems for the partners in their daily life, which will, in turn, affect the analytical relationship with the therapist and the analysis itself. At this point, extratransferential interpretation of what happens outside of therapy will be ex-

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11COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

tremely important to the success of the treatment, since whatever transpires between the couple outside of therapy cannot be ignored (Pérez Testor & Pérez Testor, 2006).

The couple’s individual capacities for working together are a key factor in couple treatment and an essential element in the success of the therapy. The therapist may influence and reinforce this capacity in the partners. Sometimes a shift is needed toward exploring the experience of the partner who listens to the other’s demands so that they can both develop a greater tolerance of the malaise. The therapist must always be aware of the multisubjective situation and the needs and vulnerabilities of both partners. The most difficult part is protecting the vulnerability of one of the partners without losing sight of the other. The therapist brings his or her own organizational principles and subjective sense of reality to the situation. We believe that the contribution of the self-psychology theory (Kohut, 1971) to couple treatment is interesting in terms of its legitimation of both subjects’ needs for development. A partner feeling that his or her needs are labeled or treated as infantile and/or undesirable, is likely to abandon therapy or even rupture the marital bond since reciprocal needs spur intense interactions within the couple. Attention must be paid to allaying each partner’s apprehension about performing the other’s developmental functions by exploring the fear that doing so would totally block expres- sion of the person’s own needs and desires.

Clinical Case

In order to illustrate the foregoing material, we now present a clinical vignette of a couple that came to our center seeking assistance. Pedro is 44 years old and Cristina is 42. They have been married for 15 years and have two children. Pedro works as an administrative assistant in a company manufacturing adhesive labels, and Cristina is the sales manager of a bank. At the first session, Cristina seemed very angry, hurt, and disappointed while her husband seemed contrite and repentant.

Cristina: I’ve been wanting to come here for a long time. I’ve asked him to come many times but he doesn’t believe in psychologists . . . but he finally agreed to come . . .

Pedro: I don’t have anything against psychologists, but I didn’t think we needed to come here. We can fix things ourselves. Well, at least that’s what I used to think. Now I think we need help.

Cristina: I just can’t take it anymore. Either we fix things or I’m leaving him. Two weeks ago I told him I wanted a divorce. At first he didn’t take me seriously, but when he saw that I meant it he called his mother to ask her for the name of a couple therapist. And here we are.

Therapist: It seems that you both feel as if things have reached the breaking point.

Pedro: No, no, it’s normal for couples to have their disagreements and if they can’t solve them, they have to go to the doctor . . . If you’re ill you go to the doctor and he gives you a pill . . . right?

Cristina: It’s not a problem for pills. The therapist is right. I’ve reached the breaking point. I can’t take it anymore.

Pedro: That was just an example. I’m not expecting him to give us pills.

When this first session started, the analyst noticed how the woman was unconsciously trying to ally herself with him, presenting herself as the collaborating half of the couple and adopting the role of the victim with whom it would be easy to engage in collusion. The therapist tried to rescue the husband, the half of the couple that has been forced to

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12 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

come to therapy. With this intervention, the husband becomes aware that his point of view is also important to the therapist, irrespective of his judgment of his wife, while the wife’s complaint shifts from being one-way to having shared meaning.

Cristina: Explain to the therapist why I asked you for a divorce. Tell him what you’ve done to me. You should be so ashamed . . .

Pedro: You’re really exaggerating; it’s not that bad . . .

Cristina: It’s not that bad? Tell him and see what he says!

Therapist: This is our first meeting and it would be helpful if you could tell why you’ve come, what exactly your problems are. The aim of the exercise is not to judge but to understand what is making you suffer.

The therapist explains the working methodology. They are not in a courtroom and he is not going to say who is right or wrong but, rather, he is going to help both of them to understand what is happening to them as a couple. It is very common for each partner to see the couple therapist as a judge who will prove them right. From the very first session, the analyst was aware of the “dyadic dimension of the demand or symptom” (Sommantico & Boscaino, 2006) as a way of understanding what belonged to the functioning of the couple as an entity, even if it was expressed in the guise of just one partner’s symptom. He also realized what the function of the conflict was for the couple and glimpsed its unconscious meanings. The analyst is sensitive to the wife’s demands, but he also tries empathetically to integrate the husband’s experience as the target of these complaints.

Pedro: Well, it was a bad time. I was under a lot of pressure.

Cristina: Excuses!

Pedro: Are you going to let me speak or are you going to interrupt me all the time . . .?

Cristina: If you’re going to be aggressive we’re not going to get anywhere. Can you see what I have to put up with? (to the therapist)

Therapist: Both of you are suffering and it is difficult to give each other room to be heard.

This is another attempt by the woman to ally herself with the therapist, which the therapist neutralizes with an integrative intervention that allows the situation to move forward. The analyst is witnessing a clash between the infantile parts of the couple (Robert, 2006).

In countertransferential terms, the therapist is aware of feeling closer to the man than to the woman, and he has no empathy with the woman’s role of victim. Being aware of this feeling, the therapist does not act it out by creating an alliance with the man. Then again, the couple gives the role of judge to the therapist but he feels the pressure of this and does not act it out. Transferentially speaking, the woman perceives the paternal aspects of the therapist and wants to behave accordingly, trying to show him that she is the mature part of the couple, and complaining about her immature husband. The man seems to link the therapist with maternal aspects by taking on the role of a badly behaved child and then trying to find excuses for this bad behavior.

Pedro: What happened is that I went to lunch with a female colleague without telling Cristina. When I mentioned it to her she got really angry because she says that a married man shouldn’t have lunch with a female colleague.

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Each couple shares an intradyadic space of their own, along with extradyadic limita- tions agreed to either implicitly or explicitly. In this case, the agreement was implicit. It had never been verbalized, but it was taken for granted. The fact that the husband had lunch with another woman without asking his wife first was seen as a betrayal. The joint interview enabled the analyst to see the scope of the “betrayal” and the “unfaithfulness.” The therapist does not judge whether this tacit agreement is right or suitable, but he can demonstrate how one partner is not in any position to meet the other’s demands adequately unless they have clearly stated their agreements. One of the partners, Cristina, tries to forge an unconscious alliance with the therapist because of her need to feel supported as the victim of her husband’s slight, and does not hesitate to label her husband as “unfaithful” to the analyst. In the case of Cristina and Pedro, the joint interview seems to indicate that the “betrayal” of an implicit agreement was not actually an act of unfaith- fulness but an outcome of the fact that that both Pedro and Cristina are excessively and collusively controlling.

Individual interviews do not allow the analyst to ascertain the other partner’s point of view on what has happened. The advantage of the joint interview in couple therapy is precisely the immediate “here and now” analysis. We work not only with the mental couple that patients bring to the consulting room but also the real couple, which makes it possible to expand the scope of couple analysis without forgetting that all couple therapy is always a focal treatment (Pérez Testor & Pérez Testor, 2006).

In the next session, the husband seems to feel more comfortable and refers to the previous session. A new focal point of couple conflict appears. This extends beyond the lunch with the female colleague and offers the analyst valuable analytical insight.

Pedro: Your complaints are exaggerated. I’ve never been unfaithful to you. It was just a lunch with a female colleague. It has nothing to do with the telephone conversations!

Cristina: It’s the same thing! Every time the flirting stops and I feel I can trust you, you prove the opposite and I have no choice but to look at your mobile phone or emails, and I always end up finding something. You’re just not trustworthy!

Pedro (to the therapist): Cristina is horribly unstable. Sometimes she ignores me and other times she’s controlling and watches every move I make . . .

In this session, the analyst formulates a hypothesis on the dynamics of the couple relationship: the woman’s difficulties generate this behavior in her husband, which in turn triggers jealousy in her and he thus gets her attention, even if it is in the guise of disproportionate control. Both are engaged in a game based on each partner’s struggle for power over the other. Given that this is a hypothesis, the analyst keeps this idea in the form of “floating attention” as he awaits confirmation.

In subsequent sessions, there are further revelations about the couple which enable the therapist to bring their positions closer together.

Pedro: You have always been much more successful at work, you’re a great mother who has a perfect relationship with our children, and I can’t come close to you in anything. You know that and you love it . . .

Cristina: There are so many things I value about you. You never mentioned any of this to me. It makes me really sad, but I also appreciate that you’ve been honest with me (crying).

The couple seems to feel that the therapy is a safe place where they can express their worst fears. Over the course of several sessions, the analyst manages to get both of them to see the husband’s flirting as a symptom of something that was not working in the

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14 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

relationship, something that joined them and yet pulled them apart at the same time. The husband was able to express how he did not feel valued by his wife. It seems that the “awkward, weak, and fragile” side of Cristina was projected onto Pedro and this allowed her to feel that she was the “strong, capable” partner.

In the exploration of their family backgrounds, Pedro tells how he was the third of five siblings, with two elder brothers and two younger sisters. His mother was a housewife who was totally devoted to her husband and children, while his father was a chemist in a sugar factory. Later on, his role in the family emerged: from an early age, he was the child who was the most troublesome to his mother because of his constant naughtiness and lack of interest at school, although he did end up finishing his basic education and took a course to be an administrative assistant, which qualified him for his current job, which he has held for 25 years. Cristina is the eldest of three children and has two younger brothers. Her father, who came from a well-to-do family, had his own lawyer’s office where her mother worked as a clerk. A very attractive man, he had been unfaithful to his wife several times, and the children had witnessed heated arguments between them. Cristina said that she had always been a model daughter who looked after her two considerably younger brothers. Moreover, her marks at both school and university were outstanding. In one of the sessions, the analyst expressed what seemed to have been the roles that both had played from a very early age.

Therapist: It seems that both of you have been repeating certain patterns of behavior and relationship. Pedro was a child who got his mother’s attention by being naughty, which seemed to shift her focus away from caring for her other four children, her husband, and her household. Cristina seemed to be the girl who could do everything: look after her brothers, do well at school, and deal with her parents’ conflicts, in which the successful husband was unfaithful to his wife and she forgave him. It would seem that you are unwittingly repeating this pattern in your couple relationship . . . and most probably each of you expects this kind of behavior from the other.

Pedro and Cristina accepted this interpretation and both of them agreed that this was somehow the pattern of relationship that characterized them. Thenceforth, both partners felt much more committed to each other and tried to understand the unconscious mech- anisms that had brought them together, even while both of them complained about these selfsame mechanisms.

By exploring the early encounters of this couple, we were able to confirm the hypothesis that what had attracted them at first was what was now tearing them apart (Dicks, 1967). They met during the wife’s last year at university at a party given by mutual friends. By that time, the husband was already working at his current job. When he saw her, he was captivated by her social skills and physical appearance, and she was attracted to him because, as she says, “he was the life of the party.” By the end of the night, after they had been talking for a while, he was too drunk to go home alone so she accompanied him to his door. After that, they started going out together and got married three years later. From the very beginning of their relationship, the woman adopted the role of the capable, responsible, and mature person, while the man was the needy, awkward one. In all likelihood, this is what attracted both partners to each other through the mechanism of projective identification, although it also gradually changed in the dynamic and deep- seated conflict in the couple. The model of relationship in the parental couples unques- tionably influenced both members’ choice of partner, as often happens. Cristina probably felt attracted to a man who was a kind of “awkward joker,” the opposite of her successful, distant father whom she associated with infidelity, couple conflicts, and her parents’

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15COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

suffering. On the contrary, Pedro had seen that one way of getting Cristina’s attention was through adolescent flirtations with other women, thus arousing jealousy in his wife, which gave him some measure of control over her. This would seem to reflect a hysteroid component of the woman’s personality: she does not feel desire when there is no other woman lurking on the horizon. This may be due to inadequate resolution of the Oedipal triangle since, even today, Cristina says that she has a poor relationship with her mother, toward whom she feels resentment for being weak and too forgiving of her husband’s infidelities, while also letting her conflicts with him radiate out to the other family relationships. In turn, Cristina says that she has always felt great admiration for her father, with whom she identifies. With regard to Pedro, we should note that when Cristina gave him an ultimatum he called his mother, which leads us to wonder whether he displays a lack of differentiation with her together with some degree of immaturity. In his wife, too, he seeks a person who can solve his problems and forgive his misdeeds, just like his mother did in his childhood.

As the treatment proceeded, both members of the couple attained the insight they needed to understand their fundamental conflict (Stolorow et al., 1987) and admitted that, despite their complaints about it, they had both participated in recreating it, since it somehow brought them closer together. With individual treatment, this process of under- standing would have been different. In this kind of therapy, the presence of the spouse and the intersubjective dimension helps the therapist to alleviate the suffering in the couple relationship. Finally, the couple ended the treatment with a significant improvement in their relationship since they were now both able to understand and respond to the other’s needs without feeling either attacked or judged by these needs. This improvement was also reflected in their relationship with their children. In other cases, couple therapy enables the two partners to understand that they cannot stay together and they decide to separate amicably, protecting their children from the separation as much as possible. In this case, too, we could consider the therapy successful. Couple therapy fails when it does not help the couple to change and they remain together pathologically or separate aggressively. The therapist should not try to “save” a marriage, since dissolving or saving a marriage is the couple’s responsibility (Gurman, 1985).

Conclusions

As the case study shows, sometimes, in contrast with individual treatment, working with couples holds out numerous benefits for both partners and their relationship. The “other” and the intersubjective context in which the subject functions are basic factors in much of the suffering that occurs in a couple’s love life and relationship and they would seem to indicate couple treatment as a good way to work on this kind of pathology.

The presence of the partner during therapy becomes a decisive factor in the way the treatment evolves and in the dynamics of the sessions. The couple works and grows together, and this has an enormous benefit in their real lives as both members learn and advance in understanding as a shared project. The feeling of working, learning, and growing in a mutual endeavor makes both partners more confident and eager to improve their relationship and this has numerous positive effects in their daily lives. Usually, especially if the treatment evolves appropriately, the partners eventually feel safer and more willing to express whatever they feel, and tell each other things that they would not say in a normal context. This, in fact, is one of the most useful therapeutic tools in couple psychotherapy. Another good reason for couple treatment is that if a couple with children

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16 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

overcomes their conflicts, the children also benefit since they are usually the objects of massive projections of their parents’ distress. The children of distressed couple relation- ships are more likely to suffer from anxiety, depression, conduct problems, and impaired physical health (Gurman, 2011).

Recent cultural shifts have also had an effect on the way psychoanalysis and psycho- therapy are carried out, and psychoanalysis has tended to focus on attachment pathology giving more prominence to couple psychotherapy. Nowadays, the values of a postmodern, society, or “liquid society” in Bauman’s words (2003), have had an impact on the choice of couple psychotherapy. The accelerated pace of life, the need for fast results, “liquid love” (Bauman, 2003) and the difficulties of intimacy, among other factors, have made couple treatment more suitable in some cases than individual psychoanalysis. The design of this kind of psychotherapy requires analysts to be knowledgeable about the mechanisms and factors that come into play in this kind of treatment.

As shown throughout this paper, new challenges and demands arise in psychoanalytic couple psychotherapy, thus making both the analysis and the therapeutic relationship more complex. We would say that the interpretative focal point is the couple, not either member but both of them together, their relationship, and their collusion. A basic technical guideline is the initial reframing of the problem, which requires individual goals to be transformed into goals for the dyad so that both individuals experience the analytical process as “our therapy.”

Transference and countertransference are also present in couple therapy and require the therapist to be sensitive to them. While all psychotherapy entails observing transfer- ential and countertransferential movements, in couple psychotherapy these levels are multiplied. Including a second professional as a cotherapist in order to work as a foursome (couple cotherapy) can smooth the progress of joint treatment.

For the therapist, handling the countertransferential responses in this kind of therapy is an even more complex challenge, since the situations are experienced in situ and involve matters that arouse more emotional responses in the therapist, these including parenthood, the couple, and birth families. The therapist will therefore experience intense counter- transference and must be ready at times to deal with a combined attack from both partners.

Bearing in mind this array of challenges and demands implicit in couple analysis, we believe that it is important to keep studying the different mechanisms that come into play in couple treatment with the aim of gathering new data for research and clinical practice within the framework of psychoanalysis.

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20 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

  • COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE: Indications, Challenges and Bene …
    • Why Couple Psychoanalytic Psychotherapy?
    • Psychopathology of the Couple Relationship
    • Psychoanalytical Treatment of the Couple
    • The Therapeutic Relationship in Psychoanalytical Couple Psychotherapy
    • Clinical Case
    • Conclusions
    • References