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Psychoanalytic Couple Therapy

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In this time of vulnerable marriages and partnerships, many couples seek help for their relationships. Psychoanalytic couple therapy is a growing application of psychoanalysis for which training is not usually offered in most psychoanalytic and analytic psychotherapy programs.This book is both an advanced text for therapists and a primer for new students of couple psychoanalytic psychotherapy. Its twenty-eight chapters cover the major ideas underlying the application of psychoanalysis to couple therapy, many clinical illustrations of cases and problems in various dimensions of the work. The international group of authors comes from the International Psychotherapy Institute based in Washington, DC, and the Tavistock Centre for Couple Relationships (TCCR) in London. The result is a richly international perspective that nonetheless has theoretical and clinical coherence because of the shared vision of the authors.

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Chapter One: An Overview of Psychodynamic Couple Therapy

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David E. Scharff and Jill Savege Scharff

Psychodynamic couple therapy is an application of psychoanalytic theory. It draws on the psychotherapist's experience of dealing with relationships in individual, group, and family therapy. Psychodynamic couple therapists relate in depth and get firsthand exposure to couples’ defences and anxieties, which they interpret to foster change. The most complete version of psychodynamic therapy is object relations couple therapy based on the use of transference and countertransference as central guidance mechanisms. Then the couple therapist is interpreting on the basis of emotional connection and not from a purely intellectual stance. Object relations couple therapy enables psychodynamic therapists to join with couples at the level of resonating unconscious processes to provide emotional holding and containment, with which the couple identifies. In this way they enhance the therapeutic potential of the couple. From inside shared experience, the object relations couple therapist interprets anxiety that has previously overwhelmed the couple, and so unblocks partners’ capacity for generative coupling.

 

Chapter Two: Shared Unconscious Phantasy in Couples

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David Hewison

In this chapter, I will present a historical review of the development of ideas about unconscious phantasy in individuals and in couples. I will look at the real and spurious distinctions between fantasy and phantasy and the argument about when in human life unconscious phantasy begins. Unconscious phantasies operating in a couple's way of relating are defended against by various symptomatic interactions, all of them preferable to a feared catastrophe. I will look at one example of defence against catastrophe—infidelity.

Fantasy or phantasy?

“Unconscious phantasy” is, firstly, a debated expression even before its nature as a concept is gone into: it is the result of an attempt in the late 1920s and 1930s by Freud's English translator, James Strachey, to render into adequate English, two German terms used by Freud: the noun “Die Phantasie” and the verb “phantasieren”. These terms were not coined by Freud, but themselves have a complicated and rich history in European thought—a history which Freud was aware of, but the subtleties of which do not always make themselves heard in the English translation. Strachey was attempting to distinguish between something capricious and whimsical, and something more imaginative and visionary. In this he was following the different strands of meaning that Plato's “phantasia” and “phantasthein”, purely mental activities with no connection with external reality, had evolved into through the process of adoption and translation from the Greek to the Latin and thence into the European languages. Strachey wanted to capture the “technical psychological phenomenon”, as he put it (Strachey, 1966). The difficulty is that Freud's German term means “the imagination, its contents and the creative activity which animates it” (Laplanche & Pontalis, 1973, p. 314). “Freud”, as Laplanche and Pontalis say, “exploited these different connotations of the common German usage”. The German “Phantasie” and “phantasieren” were used by writers familiar to the young Freud—“Goethe, Schiller, Hoffman, Tieck, Lessing, Fontaine, and Heine…to refer to creativity, but also to what happens in dreams, madness or when one falls in love” (Steiner, 2003, p. 3). These, of course, are not simply Strachey's “technical psychological phenomena”.

 

Chapter Three: Intimacy and the Couple—the Long and Winding Road

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Susanna Abse

Married love

By Kuan Tao-Sheng 13th Century AD Chinese painter, calligrapher, and poet.

You and I

Have so much love

That it

Burns like fire,

In which we bake a lump of clay

Moulded into a figure of you

And a figure of me.

Then we take both of them,

And break them into pieces,

And mix the pieces with water,

And mould again a figure of you,

And a figure of me.

I am in your clay

You are in my clay

In life we share a single quilt.

In death we will share one coffin.

Most couple therapists would agree that intimacy is a key part of any satisfactory relationship and that the drive for intimacy is compelling, leading us to make, break, and reform relationships throughout our life. Despite this passionate quest, the actual definition of intimacy is nearly as intangible as the experience itself. This paradox makes the search for intimacy rather like the search for the pot of gold at the end of the rainbow—elusive, exciting, and with a sense that when the rainbow fleetingly appears, it seems almost within reach. But as the famous Irish folktale reminds us, searching for the pot of gold at the end of the rainbow is based on a bit of trickery—there really is no end to a rainbow. The way the physics work, rainbows are actually full circles—only the horizon gets in the way of seeing the full circle.

 

Chapter Four: Attachment, Affect Regulation, and Couple Psychotherapy

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Christopher Clulow

Psychotherapy might be defined as the application of developmental psychology to understanding and changing problematic ways of relating—to ourselves and to others. The aim of this chapter is to apply to the field of couple psychotherapy insights originating from perspectives that have enhanced our understanding of human development, paying particular attention to attachment theory.

Attachment theory

For Bowlby, the author of attachment theory, humans were innately social animals, motivated from birth to seek and maintain connection with others. It was through these connections—relationships—that development occurred. Combining ethology (the biologically based study of animal behaviour) with psychoanalysis (the clinically based study of unconscious processes) Bowlby asserted that what happened within the archetypal couple of mother and infant helped to shape patterns of relating in adult life. In consequence it had huge significance for the mental health of communities. Physical proximity and syntonic emotional responsiveness were what infants needed most from those who cared for them to protect them from painful or threatening experiences, and to instill in them a sense of security (Bowlby, 1969, 1973). This sense of security provided the foundations for good relationships in adulthood. Without it, experiences of separation and loss might turn out to be psychopathogenic (Bowlby, 1980). The central tenet of his theory remains as robust as ever: it is through relationships that we absorb our sense of security as human beings, our potential for development, and the kernel of our sense of self—a self that is essentially relational. It is also through relationships that we learn to regulate our own emotional states and to be alive to those of others.

 

Chapter Five: Aggression in Couples: An Object Relations Primer

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David E. Scharff

Aggression in couples presents the clinician with some of our most difficult clinical problems. There have been some useful recent contributions to understanding violence and aggressiveness in couples, but they have not focused on the origins of aggression (Monguzzi, 2011; Ruszczynski, 2010, 2012). To understand aggression and the mental and physical violence that shows up in symptomatic couples, I begin with the developmental origins of aggression. Then I look at the way this is expressed in ordinary and problematic couples, and finally I provide some guidelines for understanding and treating symptomatically aggressive couples.

From the outset, I want to acknowledge that the psychoanalytic study of aggression is a complicated, rich field about which a great deal has been written. This contribution is only what its title suggests, a primer, and cannot do justice to the full range of valuable contributions in the literature or all the complexities of thought the subject warrants. This article is intended as an outline, a guide that might organise a way of thinking and working clinically, and therefore must remain open to accusations both of bias and incompleteness. I beg the reader's indulgence in this. My hope is that the synthesis of a few of the important trends in the field will offer some clarity for the practitioner early in her experience.

 

Chapter Six: Getting Back to or Getting Back at: Understanding Overt Aggression in Couple Relationships

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Christopher Vincent

Background

In our 1980s study of British family courts’ welfare officers and their clients, we observed that, in many of the intransigent post divorce disputes about childcare arrangements, it was unclear whether the continuing arguments between parents were serving the purpose of “getting back to or getting back at” each other (Clulow & Vincent, 1987, p. 211). That is, we were uncertain whether the highly angry interactions we were witnessing functioned to punish a former partner, or were an attempt to get back into a closer relationship, or were a confused amalgam of both objectives.

Most of the litigating couples we worked with were an exceptionally contentious group of parents and, as we reported, “Psychological survival was at stake for these parents. A petition for divorce could have the impact of a declaration of war, following which the world was divided into friends and foes” (Clulow & Vincent, 1987, p. 209). For these parents overt aggression was manifest through a number of channels often starting with the original divorce petition which, in a very high proportion of cases, cited the “unreasonable behaviour” of the respondent. In this way the “blame game” was started and could be continued through subsequent applications to the court for different remedies. For example, variation in childcare arrangements was the most likely reason for our involvement as welfare officers-come-researchers, but we were also aware of ongoing and often parallel proceedings to ban ex-partners from the former matrimonial home, to seek orders to prevent molestation and to seek variation in financial affairs. In these proceedings accusations by the aggrieved parent of unreasonably aggressive behaviour or domestic violence were often the reasons for seeking the eviction of a partner from the matrimonial home or asking the Court to make orders preventing further harassment. Moreover, the initiation of legal proceedings, whatever its justification, was often experienced as an aggressive act itself since it invariably threatened to destabilise established patterns of living, financial wellbeing and childcare arrangements.

 

Chapter Seven: Responding to the Clinical Needs of Same-sex Couples

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Damian McCann

Development in thinking about same-sex couples within the field of psychoanalysis is still very much in its infancy. Moreover, the continued reliance on heteronormative thinking as a guide to practice with lesbian and gay couples raises fundamental questions concerning our understanding and management of difference, as well as exposing practitioners and their professional bodies to the charge of homo-ignorance. This chapter aims to raise awareness of the clinical needs of same-sex couples as a means of increasing sensitivity and responsiveness when engaging psychotherapeutically with lesbians and gay men presenting for therapy.

The chapter begins with a brief consideration of the ways in which the psychoanalytic profession is responding to the challenges of theory and practice with lesbians and gay men. This is followed by an examination of working with difference, the ways in which unconscious processes affect the couple dynamic and the impact of this on the therapeutic relationship. Specific attention is paid to gender role socialisation, as a way of highlighting the particular qualities and differences within and between lesbian and gay couple relationships, and the chapter ends with an exploration of therapist factors.

 

Chapter Eight: The Selfdyad in the Dynamic Organisation of the Couple

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Richard M. Zeitner

With the increase in the demand for couple treatment and couple therapy training throughout the United States and Great Britain, there has also been a corresponding increase in the variety of psychotherapeutic strategies deriving from the literature pertaining to couple and family treatments (personal communications, Clulow, 2012; D. Scharff, 2011). These included those that are psychoanalytically oriented and those that are non-psychoanalytically based.

Although I use the word “strategies”, I am including in this a corresponding expansion of interest in understanding the functioning and the psychodynamics of the intimate permanent partnership—the couple. However, in spite of this expansion of interest in treating the couple, ironically, the therapy of the couple relationship remains one of the most difficult clinical enterprises—an area of practice throughout the mental health disciplines that is frequently over simplified and sometimes misunderstood. Even the term “marriage counselling” or the recommendation to “go see a marriage counsellor,” in my mind, frequently carries with it a simplistic connotation, suggesting implicitly that a couple, for example, that may have been having severe and longstanding difficulties in relating, even when the couple problem represents a significant contributor to a mental illness in one partner, after getting some good old fashioned advice on how to solve these problems, might possibly do a little better. The implication, however unfortunately, is often that the couple therapy is ancillary or palliative, and that the real “cure” will emanate from the medication prescribed and/or the individual treatment.

 

Chapter Nine: Dreams in Analytic Couple Therapy

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Jill Savege Scharff and David E. Scharff

Consulting to and supervising recently trained individual psychotherapists, we have found that many of them have heard that the dream is the royal road to the unconscious. Yet they do not know how to work with dreams, even though there are many thoughtful papers on the subject, beginning with Freud's Interpretation of Dreams (1900b). Little wonder then that analytic couple therapists may not know how to work with dreams in couple therapy. They tend to focus on the context of the couple relationship, the projective identificatory system of the relationship, the roots of its dynamics traced to family history, and the expression of mother–infant and oedipal dynamics in the couple's intimate life. Preferring these routes to understanding unconscious dynamics, analytic couple therapists too often overlook the analysis of dreams because they do not realise its power to “turn a page” in the couple's treatment (Quinodoz, 2002) and its value in treating sexual, marital, and family trauma issues (D. Scharff & J. Scharff 1991, 2004; J. Scharff & D. Scharff, 1994).

 

Chapter Ten: Why can being a Creative Couple be so Difficult to Achieve? The Impact of Early Anxieties on Relating

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Mary Morgan

Many couples struggle to relate in a creative way in which their relationship is potentially a resource to them, emotionally, cognitively, and physically. In order to function as a creative couple there needs to have been some favourable psychic development, particularly those developments in the early relationship to the primary object, oedipal development and adolescence. These developments come together later in a way that makes a creative couple relationship possible (Morgan, 2005).

Thought about in this way, one might see that the therapeutic challenge in working with couples is in helping the couple bring together and develop aspects that are there in some form, but have not yet come together in a way that allows a creative couple relationship. For other couples there are early difficulties in relating, especially in regard to the primary object, in which any intimacy is felt to be extremely difficult, even dangerous. The relationship to the primary object, usually the mother, is key, both because for most of us it is the only other relationship of such closeness prior to the intimate adult couple, and because this relationship at the earliest stage of psychic development is formative. It therefore functions as a crucial part of the template for later intimate relating. If, for example, the mother has been overly intrusive, projecting her own psychic contents into the infant or alternatively too distant and unavailable, the infant will carry this experience into later relationships. Even when the relationship to the primary object was good enough, other elements in later psychic development have to come together and lead to creative couple relating (See Morgan, 2005). For some, these elements have not developed sufficiently or exist in distorted and damaged ways, resulting in many difficulties for the adult including a most uncreative couple relationship. Such couples present a real challenge to the couple therapist. This chapter will offer a series of vignettes of work with such a couple.

 

Chapter Eleven: The Couple State of Mind and Some Aspects of the Setting in Couple Psychotherapy

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Mary Morgan

Psychoanalytic psychotherapy with couples requires a setting in which they feel held and their therapist is able to think. In discussing the nature of the setting, some of my thoughts are drawn from the fundamentals of psychoanalytic practice, while other aspects are specific to the couple psychoanalytic setting. The setting is primarily the analytic attitude and the couple state of mind of the therapist, but it also refers to the actual physical setting and arrangements in which the therapeutic process takes place. The two aspects are closely connected.

The couple state of mind

One of the most fundamental tools the couple therapist has is, I believe, a couple state of mind (Morgan, 2001). The couple therapist thinks of the couple's relationship as the patient (Ruszczynski, 1993) and this stance frames everything that goes on in the therapy. Thus the therapist is thinking about what kind of relationship the partners are creating and what unconscious phantasies and beliefs they have about being a couple. The therapist tries to hold a neutral position, in which, despite pressure from the partners to take sides, and sometimes a real sense inside herself that she is more sympathetic to one or the other, she is working with a relationship as a dynamic whole, an unconscious system in which each partner carries aspects for the other. These aspects can easily shift between them.

 

Chapter Twelve: Establishing a Therapeutic Relationship in Analytic Couple Therapy

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Jill Savege Scharff

Establishing a therapeutic relationship is the first task that faces the analytic couple therapist. This task is of crucial importance. The therapist approaches the couple, not as two individuals meeting the therapist, but as a couple. The patient is the couple relationship, not the two spouses who comprise it. To deal with the couple, the therapist must enter a couple state of mind as she addresses the task of the first interview and hopes to move beyond assessment into couple therapy. She brings a background in theory, a tuning of her self as a sound therapeutic instrument from years in personal therapy or analysis, and a dedication to supervision, peer supervision, and process and review of her work. She brings care and concern, tact and timing, to the task. She builds the therapeutic relationship as the context for the in-depth work that will occur if the couple proceeds to ongoing therapy. When couple therapy begins, she continues to work on maintaining her connection to the couple, and uses it for her understanding. The therapeutic relationship is the frame for the work and the focus of the work. It must be maintained, and it must be analysed.

 

Chapter Thirteen: The Triangular Field of Couple Containment

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Carl Bagnini

When working with couples, I search for clinical ideas that reveal the unconscious pathological matrix of couple relating and provide therapeutic guidelines for ameliorating their destructive hold on couple life. I admit to lapses in containment when I hate couples, which usually occurs when I am prevented from gaining satisfaction from therapeutic work. I have learned to accept hateful feelings when couples resist my help because I recognise their defensive function when I am feeling inadequate like a stupid object. I recognise countertransference regressions before too much of me gets wiped out by too much of a couple's projective identification—as when I enter a schizoid withdrawal and need a rescue team of ideas to pull me out. I get pulled in losing neutrality and become over identified with what the couple cannot comprehend. Becoming enmeshed in a couple's projective dance is a triangular dynamic that can lead to enactments when containment is bombarded by powerful and primitive affects.

 

Chapter Fourteen: Projection, Introjection, Intrusive Identification, Adhesive Identification

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David Hewison

This chapter addresses the nature and processes involved in the kinds of identifications formed by couples through projective and introjective mechanisms. It begins with Henry Dicks’ foundational studies of marital interaction (1967). Then it will consider the defensive processes that aim to protect couple relationships but have unconscious and unintended effects. The chapter goes on to discuss projective identification, introjective identification, intrusive identification, and adhesive identification—all different ways of trying to think about the unconscious impact that partners in a couple relationship have on each other. Clinical case illustrations flesh out the theoretical framework and the chapter ends by putting forward the idea that couples are meaning-making relationships, in which meaning comes through the taking-back of projections.

Projection

The basic idea of projection comes from Freud's (1911) work on a “Case of Paranoia” in which he tried to make some sense of a particular type of relationship between the inner and outer worlds. He wrote, “The most striking characteristic of symptom formation in paranoia is the process which deserves the name of projection. An internal perception is suppressed, and, instead, its content, after undergoing a certain kind of distortion, enters consciousness in the form of an external perception” (Freud, 1911, p. 66). In other words, when something we can't quite bear for whatever reason kicks off inside us, a process gets put into play which ends up with no sense of something going on inside us but instead with the idea of something actually happening outside of us. The location of the thing that is causing our troublesome perception shifts. Freud described projection very much in terms of a fundamental defence against external and internal unpleasurable excitations.

 

Chapter Fifteen: Negotiating Individual and Joint Transferences in Couple Therapy

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James L. Poulton

I had been working with an unmarried couple I will call Jessica and Karl for over a year, so I was familiar with the scene in front of me. Jessica was in tears, frustrated and confused by Karl's persistence in laying the blame for the couple's conflicts on her. Karl, in contrast, appeared calm, caring, and encouraging, but he was also effectively disengaged from Jessica's struggles and from the therapeutic process. The couple had been talking about Jessica's decision in the prior week to have lunch with her ex-husband—a decision that had followed an argument she'd had with Karl about his distant relationship with his daughter. Karl had begun today's session by reporting that the “same old stuff” had happened again: instead of talking to him directly about her anger, Jessica had acted it out and had “threatened our relationship.” Jessica had responded by claiming that her decision to see her ex-husband was not done in anger. Besides, she said, she had told Karl her opinions about his interactions with his daughter, so as far as she was concerned that was where the argument had ended. She added that if anyone was “threatening our relationship” it was Karl because he was so critical of her. As I listened to them, I felt a familiar bind: each partner wanted me to believe the other was the chief source of their problems, and did not want me to focus on their own contributions. Knowing I would encounter resistance from both, I began to explore the emotional foundations of the impasse they had once again constructed, both between themselves and within the treatment.

 

Chapter Sixteen: Narcissism in a Couple with a Cocaine-addicted Partner

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Carl Bagnini

Brief theory of personality disordered couples with sado-masochistic features

Contemporary psychoanalytic theory of personality disorders combines an appreciation of the particular difficulties of these patients in tolerating self—other differences, and most importantly, the lack of integration of life's pleasures and pains. Narcissism is ubiquitous but in extreme pathological forms we observe the dialectic between an individual and a social persona; we use Winnicott's characterisation of how a false self arises in understanding the social persona of narcissistic personalities (Winnicott, 1965).

In developmental terms, we assume a parenting situation occurred where little opportunity was present for safely separating and differentiating. An intolerance of reflection is assumed in the parent, leading to failures in empathic attunement, with the result of identity diffusion in the child. The child's basic curiosity may have been misinterpreted as arrogance, and deep shame may have been felt in areas of childhood sexuality and interpersonal striving. The child pulls into itself to protect the true self. She will construct inordinate defences, such as a paranoid sensitivity to the dangerous and exploitive human environment. False self defences are the child's bargain for survival of the true self ensuring its future potential under favourable conditions. In adult partner selection there is both a hope for a favourable human environment that fosters self esteem and trust, and dread of repetition of childhood exploitation and degradation (Rosenfeld, 1971). Affectively charged configurations are typical with narcissistic patients and their mates due to sharp personality distinctions in their relationships. Narcissistic partners are usually extraverted. They defensively split self—other relationships into idealised and denigrated parts, and project them into others. With marital partners the split is between libidinal and anti-libidinal motives that lack integration (Fairbairn, 1952). Primitive affects and anxieties flood reality testing keeping the marital relationship rigidly defined as: “you are with me or against me”. The introjected maternal object is rejecting and demanding and it presses into the couple's expectations and saturates marital expectations. The less narcissistic partner may carry the requirement of providing complete satisfaction to the other to make up for developmental deprivations, in contrast to the narcissistic partner who is unable to empathise with the all-giving other due to feelings of deprivation. This situation is one of narcissistic entitlement. The receiving partner cannot realise the full debt of his obligation to the giving other due to primary dependency conflicts. The narcissistic partner may have gained temporary specialness in childhood that was exploited by the parent who turned suddenly away, perhaps in favour of a new baby, while expecting continued adoration from the child. Both partners carry underlying and common features of shame and envy. The entitled partner envies and fears his partner's desire to please, while the other partner envies the apparent independence, ambition, and self preoccupation of the narcissist.

 

Chapter Seventeen: The Dream Space in Analytic Couple Therapy

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Tamar Kichli Borochovsky

The realm of dream is a relatively unexplored space in analytic couple therapy yet one that is full of potential. Exploring a couple's dreams opens a new space that lets us work at a profound level. The dream sphere opens a door to understanding the projective identifications occurring in the couple and in the transference and countertransference processes. Each dream gives access to an element of the couple unconscious

In this chapter, I (TKB) describe my view of the unconscious, the function of dreaming, and how to understand dream language. I show how dreams when combined give meaning to the inner couple link of a couple in analytic couple therapy with me. I present clinical vignettes from their treatment, showing work with three dreams: the husband's dream, the wife's dream, and my own dream. Dreams and vignettes from the context of couple therapy illustrate the emergence of the couple's unconscious fantasy, needs, and desires in the therapy.

I think of the unconscious as an invisible organ of the body, small but vital, like the heart pumping blood to the entire body, the stomach taking in nourishment, and the kidney clearing it of toxins night and day. I also think of the unconscious as an inner sense like the one that tells birds to migrate and newborn giraffes to stand up. Contemplating the invisible bodily organs and the unconscious from an individual stance like that, I do not readily see their social function as clearly as that of the hands, which in addition to having allowed us to hang from a tree and gather fruit, give us a way to reach out and touch others with a pat, a handshake, or a punch. Nevertheless the bodily organs and the unconscious do respond to social situations with increased or decreased activity, and shifts in their functioning send signals to others who respond even though they are not conscious of having seen any evidence of upset or arousal. The unconscious sends signals to the conscious part of the individual's mind in images, actions, symptoms, and dreams.

 

Chapter Eighteen: Clinical Narrative and Discussion: A Couple who Lost Joy

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Pierre Cachia and Jill Savege Scharff

Two-career couples in their early thirties experience conflict and stress over finding the right balance between work and family life, and between family time and couple time. The joy of finding each other and falling in love may become eroded by the pressures of marriage, work, and family life. Attending to babies and needy children, the mother and father may all too easily lose sight of themselves as husband and wife. When they come to the marriage with a shared sense of neglect and hunger for a good object, they find it all the more difficult to meet each other's needs and cope with the demands of family life. This is what happened to the couple whose problem we will study. The couple therapist will describe the couple's presentation and history gathered during the consultation and early phase of treatment. He then recounts in detail a session from the sixteenth month of treatment. As the narrative unfolds, we will interrupt from time to time for discussion of the couple dynamics, transgenerational influences, the therapist's countertransference experience, and the power of therapeutic action. Without reference to standard texts, we will simply focus on the clinical narrative to provide an experience-near illustration of analytic sensibility in couple therapy.

 

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