A damp early-winter late afternoon return from a daycare nursery. The outstretched hand of a two-and-a-half year old boy appears from beyond the canopy of a buggy, wheels swishing on the wet path below dripping trees:
M: Grandpa! There are two things to watch out Grandpa. One (index finger extended), dog-shit – we have to look out for dog-shit!
M: Two! (second finger extends) Cars! we have to look out for cars. Cars might squash us to bits Grandpa! We might get squashed to bits!
G: OK! I’ll look out for cars (far off headlights of a car appear)
M: Two things Grandpa! Dog-shit, and cars – cars might squash us to bits! (hand waves about)
G: Uh huh?
M: Grandpa? If I got squashed to bits by a car, you’d put me back together again, wouldn’t you Grandpa?
G: Yep, I’d do that
M: And Grandpa? If you’d got squashed to bits by a car I’d put you back together again!
G: Thank you M-
M: Yes I would Grandpa. I would! I’d put you back together again (hand and arm finally withdraw under the canopy)
An applied example of a young mind’s ‘inner working model’ of relationships, exploring a world of possibility, uncertainty, and how danger can be managed. A reason why psychoanalysis, developed more than 100 years ago in mittel-Europe by a Viennese doctor born in the 19th century, is still relevant to systemic practice now. Yet why so relevant? given that CBT offers a quite straightforward explanatory model in terms of relational schema (self-other-world) and Freud’s theories had only been developed from one-to-one experience (e.g. Freud 1914), whilst family relationships continued outside the consulting room albeit often talked about within it.
The answer lies in the three contributions, the first two longstanding, the last quite recent:
- a theory about the unconscious determinants of how people relate
- the interpretation of these during therapeutic contact, providing the principle means to effect change
- a way of being with the patient during this process.
A theory about the unconscious determinants of how people relate to one another
The initial ideas about the unconscious determinants of how people relate to one-another was initially based on ideas about drives (which has never seemed salient to family therapy development). These ideas became increasingly influenced by observations on attachment, mother-infant relating in particular (which self-evidently is salient). Depending upon the particulars of an individual’s early relationship-experience, an internal working model of how people relate to one-another develops that shapes their future relationships – engaged, hopeful, pessimistic, avoidant, incoherent, etc. Not so different to the fundamental relational schema that CBT describes, perhaps underpinning the day-dreaming of this little girl playing on her own.
The Adult Attachment Interview is an example of a contemporary structured enquiry designed to throw light on these developmental experiences from a psychodynamic perspective.
Psychoanalysis proposed that intimacy of early relationship-exchanges was based upon a close identification with one-another, unconsciously attributing aspects of oneself into the other in a reciprocal fashion. This occurred by two processes:
- Projective identification: where the other is perceived to possess certain qualities or capacities that correspond with particular characteristics or feelings of one’s own that aren’t easily acknowledged or contained by oneself
- Introjective identification: where the other experiences these projected feelings as if they were their own.
An example from everyday mother-infant interaction might be how a baby’s distress becomes shared by the mother, who provides an experience of emotional containment rather than the baby left with feeling overwhelmed. That containment would be much more difficult if the mother’s own early childhood had included abandonment experiences; evoking instead intense perhaps briefly-overwhelming feelings, perceptions of her un-soothed baby fusing with her own early infant-self.
Projective identification and introjective identification can only occur between people who matter to one-another. Recent neurobiology provides some support for the concept. Functional brain-imaging has demonstrated mirror-neurons, where even if only one of a closely-relating dyad is carrying out a particular action, both brains ‘fire up’ almost simultaneously in the exactly corresponding part of the brain. It is possible that this may even apply to anticipated behaviour.
Mirror neurons are proposed to provide the substrate for empathy and the development of an implicit non-verbal understanding of one another – an important facet of successful family relating, and also for a therapist’s intuitive recognition of an unspoken feeling state. Rober’s descriptions of the ‘unspoken’ may also be an example, as to find a voice for the unspoken requires multiple tasks of which an intellectual analysis of the presenting circumstance is only one task.
The interpretation of the unconscious mechanisms, discovered during therapeutic contact, constitutes the principle means to effect underlying change
This second contribution is less obviously related to family therapy. It arises from a theory about relating within the consulting room, where the analytic interest lies in the patient’s ‘told story’, not in its ‘historical truth’.
Psychoanalysis is not a linguistic process to discover distant ‘facts’ which could explain a patient’s current situation (e.g. cold parenting or past trauma, etc.). The analytic interest is why the story is being told, and being told now i.e. meaning not facts is important (though of course why might be to elicit the analyst’s warmer attention, or to share with the analyst – perhaps to emotionally process – traumatic experience that had never previously been shared). Attending to all that provides the richness of psychoanalysis — aware too that “in the ‘here and now’ of a psychoanalysis there is always more going on than we could ever know or interpret” (O’Shaughnessy 2013).
Transference: to fully understand ‘narrative truth’, the analytic interest lies in what impact upon the listening-analyst is being sought by the patient (whether consciously or unconsciously). As Joseph (2013) summarized: when “fragments of history come alive under our eyes”, to understand “what is being lived out by the patient and the role I am being asked to play”.
The understanding of this is embraced by the concept of ‘transference’, and the analyst’s central task is to understand the transference that is taking place. Such concepts were influential in the early history of family therapy but are rarely referred to now. However, transference offers a conceptual model of understanding how family members may perceive others in their family. Fields of transference within the family may be revealed, for example, as they provide family stories for a genogram.
Unlike family therapy, there is no one else in the psychoanalyst’s consulting room, so all of what occurs within it is examined within the bond between patient and analyst. This places the analyst or psychodynamic therapist at the heart of any communication, verbal and non-verbal, so their authority is pre-eminent (Spence 1986). The psychoanalytic process seems very different to any systemic family therapy session, and in many ways it is.
To understand this difference further, it might be useful to first consider in what ways a narrative approach to family therapy is similar to psychoanalysis. After all, a post-modern systemic purist is similarly disinterested in discovering facts; similarly endeavouring to establish ‘narrative truth’ by means of a linguistic process. Furthermore, also having no intention of arriving at a formulation that seeks to explain the problems that presented and had precipitated referral (very different to the approach described in this website).
However, despite that the final outcome of both has involved shared meaning-making, a narrative therapist – unlike most psychoanalysts – strives throughout to remain peripheral to their patient/s preoccupations. Although each refrains from any action or statement that might jeopardize their neutrality, an analyst would accept the impossibility of that.
From a narrative perspective, any transference response is likely to be ‘off the radar’, just as happened during Freud’s early work before transference was recognized as a phenomenon. Freud then considered it to be an obstacle to therapy, before finally understanding both the futility of ignoring it and the immense opportunities that seemed open up if it was instead explored.
Both narrative therapy and psychoanalysis are linguistic processes, but the principal forum for meaning-making in narrative therapy lies between family members, albeit to some extent co-constructed between them and their therapist. Very different to psychoanalysis, where any resolution of an analytic patient’s deep anxieties and unconscious defences is considered to wholly depend upon the analyst, an expert in the field of mental conflict and the only other person in the room. All change is considered to depend upon what the analyst says, making explicit by interpretation their deepening understanding of the patient over time.
The interpretation of unconscious material that emerges during treatment: although the concept of transference has a limited place in systemic therapy, psychoanalytical accounts of how to interpret material that indirectly emerges from previously unspoken feelings and thoughts have been useful to the work we describe. In particular, understanding how a family therapist may share their observations, based on what they have heard, observed, or felt during a session.
- to make their point timely (based on what’s just been said or happened)
- succinctly (family members had also just heard or observed what happened – the reason why ‘labelling’ is the more common way – and more accurate way- of describing interpretations in family therapy)
- doing so in plain English
- and doing so in a provisional way i.e. to open up an issue rather than to pronounce on it
- in addition, psychoanalytic writing emphasizing the importance of dosage (not too weighty to digest), and of accuracy rather than completeness (incomplete allows more room for family members to contribute their own thoughts, whereas inexact may leave them feeling misunderstood).
In the 1st edition of Integrated Family Therapy, labelling was described as one group of a set of four different types of skills useful in working with families. That group comprised six skills, three of which are observations of behavioural transactions between family members and three refer to otherwise unacknowledged feelings. The latter include:
- labelling something observed by the therapist in a particular family member’s demeanour (e.g. saying nothing but looking unhappily preoccupied)
- labelling what the therapist considers is some shared feeling that otherwise is not directly referred to i.e. talking about it seems to be persistently avoided (e.g. concern about the rapid physical decline of Rachel, Tom’s aunt and close to the family, who is now frail because of inoperable breast cancer)
- labelling their own feeling, in a therapeutic way.
For example, in response to observations made as the family talks of visits to the home of Rachel: I’ve just realised, each time [a visit to Rachel] is talked about I start feeling tense, anxious; wondering what’s going to be said or happen next. Then I notice Tom getting restless, you tell him off, everything calms down, me too, and then we all have trouble remembering what we’d been talking about before! Does anybody recognize that? Tom? That feeling of … worry, fearfulness perhaps, when anyone talks about visiting your aunt Rachel and her husband, so it’s a relief when we start to talk about something else instead?
Finally, the immensely useful psychoanalytic observation that significant interpretations may often induce feelings of sadness or loss, because something is now being faced that previously was denied or repressed (e.g. Rachel’s imminent death, and whether Tom’s mother is vulnerable to the same cancer too). Supporting the recipient/s as they face it is therefore important. In psychoanalysis the only source of support is the analyst who had made the interpretation, by providing a ‘secondary interpretation’: it must be really hard, loving Rachel knowing how letting go will be so painful, never knowing if and when that’ll happen, and maybe whether and if having to do that’ll be needed again?
In family therapy that support can be provided by a variety of different people – becoming a wider ‘lived experience’ that extends far beyond the consulting room, the therapist active only to ensure that support occurs.
However, it is important to note that in their follow-up ‘interpretation’ this family therapist had gone considerably further than Aron (2006) advocates, where an analyst’s self-disclosure helps enable a gradual mutuality between them and their patient. Based on the systemic therapist’s lived experience of the family, to tentatively open up a possible further unspoken issue (the children may fear that their own mother might become ill too). Such a step in psychoanalysis would be considered presumptuous, because it was providing explanation ahead of what the patient had actually brought to their session with the analyst, their ‘psychic reality’.
Interpretation is only part of the story of what else helps analytic patients: once considered central in the psychoanalytic process, many psychoanalysts now accept this is an inadequate understanding of what has helped some of their patients. Traditionally, the analytic process had been frequently compared to Winnicott’s ideas about maternal pre-occupation (which acts as a holding environment to facilitate the infant’s capacity to imagine and to think), whereby making interpretations from time to time, the analyst is giving back to the patient/infant something of patient’s/infants self.
It was now suggested that being with, rather than interpreting to, the patient may sometimes be the more important task, the intersubjectivity that Aron (2006) described. Interviewed past patients of Winnicott have recalled this as the most valued aspect of their analysis with him (Anderson 2014), that they felt that they could “be themselves” with him.
The lived experience of therapy: intersubjective space as the way of being between patient and psychoanalyst
This represents psychoanalysis’ third and most recent major contribution, bringing its thinking and work rather closer to what family therapists might consider. In a hugely influential article, Daniel Stern and colleagues wrote of the ‘something more’ (than interpretation) that is important in psychoanalysis: a “powerful therapeutic action (that) occurs within implicit relational knowledge”, vital moments of meeting between patient and analyst rather than change solely arising from a linguistic process i.e. explicit interpretation-work (Stern et al. 1998).
So instead of a “doer and done to” relationship, “a democratic or egalitarian” one where intersubjectivity – the field between patient and analyst – is a “brokered, dynamic process” (Benjamin 2004), involving self-disclosure. From a field that’s developed from the bond between them, “scenes and characters are awoken to life and find their embodiment” that are neither directly assignable to the patient’s unconscious mental life nor to that of the analyst (Ferro 2011). In short, the ‘lived experience’ of the analysis is considered as more than the sum of the psyche of its two participants, and is itself an important factor in treatment outcome. From this standpoint, interpretations are, at most, complementary acts to the “gradual acquisition of ‘implicit’ knowing’ that develops between the participants’ intersubjective exchanges” (Emde 2013). Presumably, mirror neurons well attuned with one-another.
Although this proposition has strongly influenced psychoanalytic thinking and practice, it is still controversial in some circles, where there are different views of it (for example, concern about dumbing down or being too a-theoretical). Furthermore, non-analytic psychotherapists would argue that it might simply encompass what psychological therapies research have described as a ‘general factor’ or non-specific factor, shared in common by many effective therapies.
We consider psychoanalytic thinking provides a specific approach to understanding of it that allows it to be more readily taught or acquired, and find Eigen’s observation of it useful. He described it in psychoanalysis as providing vital “psychic support” as the analytic patient works through/recalls/re-storys their past experience; “what is lived through and gradually established is a rhythm of breakdown-recovery” during treatment (Eigen 2013), which now occurring in a trusted relationship begins to incrementally correct past failures. So, not that far from Winnicott after all!
Can this theoretical development in understanding how change is brought about in psychoanalysis apply to contemporary family therapy too? Is being with a family as they are helped to talk deeply about experiences, both painful and resiliently managed, a vital aspect of the work of a systemic therapist?
And when family members continue to talk to one-another about such experiences beyond the consultation room, does that process continue i.e. without the continuing direct involvement of the therapist? Indeed, is that therapist – who is only likely to meet a family on a few occasions – able to have helped only because of the pre-existing bond between family members?
A case-illustration: the family sessions described in ‘Therapeutic Engagement’ demonstrates that ‘being with’ and making interpretation is not an ‘either/or’, because mutuality is key.
Aron has described the considerable demands this places upon the analyst: “ I am implicitly asking my patients to trust me with their minds, I struggle to obtain a position where I can trust them with my own mind and feel I have nothing to hide from them” (Aron 2006). This too was illustrated this by the case, where an honest self-disclosure by one of the two therapists had been important to treatment progression. Without this, could the 14-year-old late-adopted girl, referred because of her irritability and oppositional responding, been insistently asked? Why, why could you not agree to move aside (from in front of a kitchen drawer) … when all they wanted was just get a spoon?
It was, she eventually said, to prevent the adult, any adult, being “boss”. Unable to further explain, the young woman became deeply preoccupied (evidently remembering something); and when pressed to say what was happening, was overcome by volcanic emotions that caused her to splutter and cough before lapsing into silence again. Without this, when there was a sense of her awaiting a response, her gross discomfort and others’ concern for her acknowledged in the intersubjective space, could it have been possible to persist with the question? That seemed really uncomfortable. Why, why could you not agree to move aside? when all they wanted was just get a spoon.
Her answer “Because (she whispered) “something might happen” was then followed by what all those in the room were now expecting: complying would mean “ becos’ I was weak, I hadn’t been strong enough … to stop it happening”. Suddenly more child-like, her response precipitated her adoptive mother to take her in her arms, which the girl (always previously reluctant to allow) accepted, whilst steadfastly holding the therapists in her gaze. Re-experiencing breakdown had been important, and it had been contained – with a different outcome to that she had experienced psychologically-alone during childhood.
This example illustrates how ‘either/or’ resolves: working/talking deeply, questioning without mistrust, and ‘being with’ the family (as well as the importance of family members being with one-another during this process, which extends beyond the consultation room) are two sides of the same coin; there is no contradiction – one side facilitates the other.
The paradox of a ‘good-enough’ session: the likelihood that any deliberate effort to introduce a Winnicottian good-enough environment distorts the main task, because the session should belong to – and be shaped by – the family, not by their therapist.
To have had a good-enough experience is not the same as the therapist setting out to provide one; that would be to confuse means and ends. Contriving the means to establish a desired outcome may actually diminish its likelihood. That may seem like a paradox but it’s not: for example, any aim to help a patient or family grow would be undermined where the underlying disposition was that they (unlike the therapist of course!) were child-like, a danger psychoanalysis has long recognized.
Therapist’s self-knowledge is therefore vital for such work. The importance of this cannot be ascribed to psychoanalytic thinking and practice but there is no other psychological treatment approach that places as much emphasis upon it during training.
This goes beyond understanding the powerful and responsible position being trained for, where much of the work will involve vulnerable clients. The capacity to both engage and to sit outside a close interaction with clients (in order to carefully reflect on it) is a specialized task that self-evidently requires a good understanding of oneself in a therapeutic role.
Understanding transference phenomena, reflecting upon one’s counter-transference in the service of understanding the patient further, and the willingness to engage deeply in an intersubjective experience all require finely-grained acquired self-knowledge – able to both surrender to that experience (as Aron has described) and to maintain professional boundaries at the same time.
Personal analysis, close supervision of one’s work, and a growing capacity for self-supervision are the usual means of acquiring and maintaining these capacities for psychoanalytic work, but do not guarantee it. Since some of the responsibilities described above are encountered in family therapy, as the example above illustrates, there is no good alternative to some personal experience that involves sustained self-reflection, and close supervision of one’s developing work, without which affective attunement with family members can too easily become a hit-and-miss affair. The means to address both these training needs can be in short supply, to which there’s no easy answer. We acknowledge that both are often not found without considerable individual effort and time taken from therapists’ many other life-commitments.
Anderson, J. W. (2014). How D. W. Winnicott conducted psychoanalysis. Psychoanalytic Psychology, 31: 375-395.
Aron, L. (2006). Analytic impasse and the third: clinical implications of intersubjectivity theory. International Journal of Psychoanalysis, 87: 349-368.
Benjamin, J. (2004). Beyond doer and done to: an intersubjective view of thirdness. Psychoanalytic Quarterly, 3: 5-46.
Eigen, M. (2013). Response by Michael Eigen in a published debate on the controversy surrounding Winnicott’s innovations to what works and how in the psychoanalysis of adults. International Journal of Psychoanalysis, 94: 118-121. See also Rachel Blass’s introduction in the same issue which summarises Eigen’s main published work between 1986-2011.
Emde, R. N. (2013). Remembering Daniel Stern (1934-2012), a legacy for 21st century psychoanalytic thinking and practice. International Journal of Psychoanalysis, 94: 857-861.
Ferro, C. (2011). Clinical implications of Bion’s thought. In C. Mawson (Ed.), Bion Today. London: Routledge.
Freud, S. (1914). Remembering, repeating, and working through. In S. Strachey (Ed.), The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth Press.
Joseph, B. (2013). Here and now: my perspective. International Journal of Psychoanalysis, 94: 1-5.
O’Shaughnessy, E. (2013). Where is here? Where is now? International Journal of Psychoanalysis, 94: 7-16.
Spence, D. P. (1986). When interpretation masquerades as explanation. Journal of the American Psychoanalytic Association, 34: 3-22.
Stern, D. N., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth K., Morgan A. C., Bruschweilerstern, M., & Tronick, E. Z. (1998). Non-interpretative mechanisms in psychoanalytic therapy: the ‘something more’ than interpretation. International Journal of Psychoanalysis, 79: 903-919.