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Meeting the mental health needs of the millions of immigrants from diverse cultural backgrounds and homelands who now live in the United States may require more than a thorough knowledge of psychiatry or psychology, according to a number of cultural psychiatric practitioners.
Psychoanalysis seeks the sources of human motivation in the patient's interior life and past. It leaves to the patient responsibility for behavior in the present. Couple and family therapies focus on current behavior and leave responsibility for inner life and the past to the patients.
These statements, while not incorrect, are mere caricatures of the two approaches. At best, they are outmoded presentations of the most extreme positions of opposing and apparently incompatible schools.
I believe both approaches are not only compatible, but necessary, to clinical work and thought. As long ago as 1974, this issue was discussed by John F. McDermott, M.D., and Walter F. Char, M.D., in the article, "The Undeclared War Between Child and Family Therapy." Currently, couple therapists are paying more attention to inner life and psychoanalysts are seeing couples.
Analysts, aware of the need to remain loyal to the interests of their individual patients, worry they will take sides when working with a couple in conflict. They fear that a hidden bias toward one partner will destroy their objectivity. Couple therapists, aware of the complexity of dealing with immediate problems of communication, misunderstanding and destructive behavior, fear getting trapped in the endless byroads of the unconscious, thereby evading difficult issues in the present.
These errors are possible, but maturation of both psychoanalysis and couple therapy make them less likely. Psychoanalysis evolved from a practice in which the ideal analyst was inscrutable, listening and providing interpretations intended to correct distortions in the patient's inner life. Self-knowledge, detachment, objectivity and intellect were the most highly valued qualities in the analyst. Now, the analyst's capacity for empathy and active emotional involvement with patients are seen as essential to the therapeutic process. Analysis itself is a real-life experience. With this shift in emphasis, the people in the patient's life become important for their own qualities, and not just as objects of the patient's drives or projections.
In contrast to psychoanalysis, which explores the lasting effects of early experience, family therapy began by focusing on here-and-now interactions. Clarifying communication and rearranging roles were found to be powerful tools. Couple and family therapists have continued to use these interventions, as well as assigning tasks and rituals to patients between appointments. However, while dealing with families in which there had been severe trauma and abuse, it became clear that the damage from the past needed to be clarified, elaborated on and confronted in the present. This has led to a re-examination of the adequacy of a present-time approach as the exclusive therapeutic modality.
When sitting with two people in conflict, neutrality is neither possible nor desirable; one's sympathy changes from time to time. It is inhibiting to strive to remain evenhanded at all times, and it is constricting to try to keep one's leanings completely hidden. It is essential in individual treatment for the patient to have the conviction that the therapist's first loyalty is to him or her. Thus, it might seem destructive in couple treatment to say at one moment that you find yourself on the side of one of the partners. This is not dangerous, however, if it is clear from the start that your sympathies will shift.
There needs to be a continuous dynamic shifting of alliances. If one's sympathy remains fixed with only one partner, the treatment is unworkable. Focusing, for a time, exclusively on one member of a couple permits the exploration of that person's experiences and conflicts. During that time, the other partner is audience to the dialogue. Much can be learned when listening to a third party investigate a troubling area with one's partner.
Couple and family therapy has enlarged our understanding of transference phenomena. Transference, a phenomenon first described as an unconscious aspect of the relationship of analysand to analyst, also is present in nonanalytic settings. The need to rethink transference became clear when patients were concurrently in couple or family therapy and in individual treatment. Were the transferences similar, or different, in the different modalities? Did husband and wife have similar transferences to their shared therapist? And what about countertransference? Could it be negative to the husband and positive to the wife? Could it be negative to the couple, but positive to each individual? Understanding these transferences can be an important part of understanding the dynamics of a couple.
My colleagues and I invented the term transference field to describe this extension of transference beyond the analyst-analysand duo (Ehrlich et al., 1996). The term extends the concept of transference to include all the unconscious forces at play among a group of affectively involved people. These forces may be positive or negative, transient or enduring. In a treatment situation, this field also includes people who are not directly involved in any of the therapies. There are transferential aspects to all the relationships, whether patient-to-therapist, therapist-to-patient, patient-to-patient or therapist-to-therapist.
I treated a couple in which the wife was a beautiful, sensitive and creative middle-aged woman. She had achieved considerable success as a sculptor and was actively involved in the daily lives of her three adolescent boys. I was puzzled and frustrated by her lack of interest in my observation that her temper outbursts were adding to her husband's depression and passivity. I was delighted when she accepted a referral to a colleague with whom I have worked extensively.
I was looking forward to a change in her lack of insight. When nothing happened, I talked to her therapist, hoping for some understanding. Instead, I found he was having a similar experience. This was reassuring, since I had wondered whether countertransference issues were interfering with my ability to communicate on specific topics with thisotherwise insightful woman.
If I had not trusted my colleague, I could easily have blamed him for poor work. Into this mix of personalities, roles and relationships, we must also introduce the husband's individual therapist. The wife was contemptuous of this therapist who had not "made a man of him." She saw me as active and powerful and wished I would take on the job of making something of her husband. Being idealized in this way is highly seductive. This is a setup for a "split transference," me being the good therapist and the husband's therapist being the bad one. If the wife's therapist and I had accepted and reinforced this split, the result would have been a destructive deval-uation of both the husband and his therapy.
Many forces, conscious and unconscious, were at play in this situation. For me, some of these were: my attraction to the wife, my sympathy and, to some extent, identification with the husband, my affection for and rivalry with my known colleague, and my suspicion of the colleague whom I did not know. These forces are all potentially damaging to the therapy. The most powerful counterforce to this destructiveness is the willingness to be open with oneself and, to the degree it is appropriate, to be open with colleagues and patients. It may be shameful to act on these feelings; it is not shameful to have them.
Psychoanalysis had its early development within the traditional Western ideal of man as hero. English author William Ernest Henley declaims, "I am the master of my fate/I am the captain of my soul." Poet John Milton has the fallen Satan speak, "A mind not to be chang'd by time or place/The mind is its own place." The individual was considered a complete and boundaried phenomenon.
Contrast this with John Berryman, a more contemporary poet. In one of his "Dream Songs," a female student who has come to him in distress apologizes for crying. He says to her: "No,/go right ahead/Cry. She did, I did/I am her." How unheroic! How lacking in boundaries! We have softened.
Interdependence, affiliation, shifting boundaries and regression have all been added to the former assertion that the highest psychic achievement is autonomy. We, along with the general culture, have changed, but we have also exchanged insights with our neighboring disciplines. Psychoanalysis has learned humility not only from those who work with groups, couples and families, but also from the need to use chemicals to alter psychological states.
Psychoanalysis is adapting to a different ideal of humanity. I am myself, but I am different under different circumstances. My boundaries are not impermeable. With family, with friends, at work or in public, I am me, but I am not the same. As therapists, whether an individual, a couple, a family or a group is in our offices, we are dealing with only part of a larger system. We choose which part of this complex interweaving of people and society, past and present, we can work with, based on who is available, and also on our own talents and inclinations.
Our work is enriched when we remain aware that we are all parts of different wholes that are themselves only parts of wholes. Each perspective, while valuable in itself, is only one of many possible ways of seeing.
Dr. Ehrlich is on the faculty of the Psychoanalytic Couple and Family Institute of New England and the Center for Psychoanalytic Studies in Boston and is a member of the Boston Psychoanalytic Society and Institute.
Ehrlich FM, Zilbach JJ, Solomon L (1996), The transference field and communication among therapists. J Am Acad Psychoanal 24(4):675-690.
McDermott JF Jr., Char WF (1974), The undeclared war between child and family therapy. J Am Acad Child Psychiatry 13(3):422-436.