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Chapter 1
Introduction
Core concepts of the Tavistock couple psychotherapy model
Shelley Nathans
This chapter provides the reader with an introduction to the key psychoanalytic concepts that are fundamental to psychoanalytic couple psychotherapy and highlight those that are the cornerstones of the Tavistock Centre for Couple Relationships (TCCR) model. This approach is rooted in psychoanalytic theory and technique and facilitates in-depth work with couples that is dynamic, capacious and creative.
There is an unquestionable demand for couple psychotherapy services in the United States and although there is a surfeit of techniques and couple treatment modalities, few formal training opportunities in psychoanalytic couple psychotherapy exist in the United States. 1 Some American psychoanalytic institutes offer elective courses in couple psychotherapy, but therapeutic work with couples has not been developed within the psychoanalytic training paradigm. As a result, many psychoanalysts and psychoanalytically oriented psychotherapists have not had the benefit of a rigorous training in couple psychotherapy and are left without access to a coherent psychoanalytic model to support their clinical work with couples.
A brief history of the Tavistock Centre for Couple Relationships
In contrast, clinicians in England have had access to high-quality education in psychoanalytic couple psychotherapy for many years because couple psychotherapy has been regarded as a distinct discipline with its own specific training, literature and identity (Clulow, 2009). The development of this professional identity has fundamental psychoanalytic roots that can be traced to its origin and association with the Tavistock Clinic and the Tavistock Institute of Human Relations. From their inceptions, these institutions incorporated psychoanalytic thinking to better understand and address the pressing social issues of the public, including the mental health of children, families and couples.
The awareness of the detrimental psychological impact of World War II on couples and families led to the establishment of the Family Discussion Bureau in 1948 (now called the Tavistock Centre for Couple Relationships2). This constituted the first formalized attempt to apply psychoanalytic concepts to the understanding and treatment of marital difficulties. Born out of a desire to address the needs of couples and families in distress, most particularly following the traumas of the war, the founders turned to psychoanalysis to deepen their understanding of the emotional pressures inherent in relationships (Ruszczynski, 1993). Using the ideas of Freud and Jung, and in consultation with psychoanalysts at the Tavistock Institute, such as Michael Balint, they developed an application of psychoanalysis to treating couples. The family welfare workers on staff were trained to attend to the unconscious dynamics in couple relationships and to the impact of transferences and countertransferences on treatment outcomes (Dicks, 1967).
In addition to the work of Freud and Jung, the model was influenced by the research and clinical endeavors of others working at the Tavistock, such as John Bowlby (1969, 1973), whose infant observation studies emphasized the issues of separation and loss. This research had a significant impact on the model for treating war victims and on the understanding of the importance of attachment between children and their parents, as well as between adults in intimate relationships.
Due to the high demand for services following the war, a group psychotherapy model was developed. This led to the application of psychoanalytic ideas to the understanding of groups ā a specialty for which the Tavistock has earned an international reputation. Isabel Menzies Lyth, a founder of the Family Discussion Bureau, formulated a highly influential theory of the unconscious forces that shape organizational life (Menzies, 1949). Wilfred Bion (1961) began his work on the unconscious phenomena that shape the behavior of groups at the Tavistock and his understanding of group dynamics and mental functioning is clearly evident in the Tavistock model of couple relationships.
The early model was also influenced by a number of other important psychoanalysts who were affiliated with the Tavistock, including Enid and Michael Balint, Elizabeth Bott Spillius and Henry Dicks. Dicksā seminal book, Marital Tensions (1967), integrating the ideas of W.E. Fairbairn and Melanie Klein, offered the first comprehensive theoretical and clinical application of psychoanalytic theory to couple relationships and served as an organizing text for analytic family therapy (Sander, 1993).
Today, the TCCR is internationally respected for its clinical rigor and scholarly contributions, for its training programs, for research on couple dynamics and couple psychotherapy, and for its numerous publications. The faculty of TCCR have authored or edited a number of influential books over the past two decades, and taken collectively, they provide a broad exposure to this theory (Ruszczynski, 1993; Ruszczynski & Fisher, 1995; Fisher, 1999; Grier, 2001, 2005; Ludlam & Nyberg, 2007; Clulow, 2001, 2009; Balfour, Morgan & Vincent, 2012). Despite these many contributions, this model is not widely known outside of the United Kingdom and, as such, what follows is an introduction to its historical development and contemporary practice.
Theoretical origins of the Tavistock couple psychotherapy model
The Tavistock theoretical model has evolved from its original Freudian foundation to a model that draws deeply from the work of Klein (1928, 1945, 1946), Fairbairn (1952, 1963), Bion (1961, 1962a, 1962b), Winnicott (1947a, 1947b, 1956, 1965) and Meltzer (1967, 1992). It is also extremely influenced by the contemporary British object relations theorists such as Britton (1989), Steiner (1993), Feldman (1989), Joseph (1989) and Rosenfeld (1964, 1983). In recent years, attachment theory and mentalization theory have had increasing influences on both the clinical and the research work at TCCR (e.g., Abse, 2013b; Clulow, 2001, 2009; Ludlam & Nyberg, 2007).
Henry Dicks (1967), an early member of the Tavistock Institute, developed the idea that couple interactions were largely based on unconscious, ambivalent relations to earlier love objects contained within each partnersā inner world. He maintained that these interactions could be understood using analytic concepts and techniques. Dicks combined Fairbairnās object relations theory with Kleinian theory to construct a model for working with couples (Ludlam, 2014). He observed that it was possible for one partner to perceive the other partner not as āotherā but rather as a reflection of some other person or as part of another person. He stated:
the perception of the partner as if the partner was not himself but some other person or part of a person. This coincided with dovetailing behavior by the subject in his or her own role taking ā as if in relation to the spouse one had to be oneās own parent, or could be a little boy or girl and not oneās ordinary adult self such as with friends or at work.
(Dicks, 1967)
Dicks described the utility of interpreting the persecutory nature of split off traits, weaknesses or faults that may be rejected by the self and projected into the partner, as well as the ways in which one partner may seek to find those parts of the self that are missing.
Object relations theory and couple psychotherapy
Object relations theory offers a particularly useful vantage point from which to view the couple as it can be conceptualized as attending to the juncture between the inner psychic reality and the external reality of interpersonal relationships. Fairbairn (1952), countering Freudās classical psychoanalytic model, offered the idea that individuals, from early on, are object seeking and that attachment to others continues throughout adulthood. He argued that early important relationships with primary caretakers and the qualities and experiences associated with these early relationships are carried within the individual throughout life. These experiences influence object choice and the qualities and subjective experiences of all later relationships. From an object relations perspective, the repetition compulsion can be viewed as a need to repeat painful experiences to maintain attachments to early objects. Thus, for the couple therapist, object relations theory offers a way of holding in mind the object relations field of each partner, the interpersonal dynamics between the partners and, most crucially, the ways in which both the intrapsychic and the interpersonal worlds exert mutual influence on one another.
Core principles of psychoanalytic couple psychotherapy
Psychoanalysis is not a theoretical monolith, and as there are various different psychoanalytic theories, it would be possible to use any of these models as a basis for practicing couple psychotherapy. Some common, core concepts link most of the theories contained under the psychoanalytic umbrella (Wallerstein, 1988), and these ideas can be used to distinguish psychoanalytic couple psychotherapy from other forms of couple treatment, such as systems theory (Bowen, 1978) or emotionally focused couple therapy (Johnson, 2004).
The basic principles that would characterize any psychoanalytic couple psychotherapy model are fundamentally embedded in the Tavistock model and serve as essential pillars upon which the theory and technique have evolved. The following section highlights the core ideas that are essential to understanding the psychoanalytic approach to couples.
Psychic determinism
A psychoanalytic theory of couples must rely on a psychoanalytic model of the mind. Specifically, the treatment would be influenced by one of the fundamentals of psychoanalysis ā the assumption of psychic determinism. The therapist would assume that at least some portion of the interactions between the partners is derived from unconscious structures or representations in each of the individuals and that this forms a dynamic between them. There would be an assumption that these unconscious structures would press in the direction of a tendency to repeat earlier object relations and this would be experienced or enacted within the life of the couple.
The unconscious
Owing to its intensity and intimacy, the couple relationship is the closest approximation to the early parentāchild experience. As such, the deepest elements of infantile and early developmental object relations tend to emerge within the adult couple and structure the dynamics between the partners, including the formation of what may be thought of as a mutual transference relationship (Ruszczynski, 1993), a shared unconscious (Kernberg, 1995) or a relational unconscious (Gerson, 2004). Consequently, psychoanalytic couple psychotherapy presupposes and privileges the unconscious, including the unconscious of each individual partner and the shared unconscious of the couple. In contrast, other types of couple therapy are generally more concerned with conscious communication processes, attitudes and beliefs systems, roles, negotiation and conflict resolution skills, structures of the daily life of the couple, and the current events impacting the dyad. This is not to suggest that these topics should never be a part of an analytically oriented treatment. Interventions in these areas can be useful and are often key to the therapistās attempts to provide containment. In psychoanalytic couple psychotherapy, the therapeutic action is oriented to the unconscious level.
In couple psychotherapy, the focus of the treatment and the object of therapeutic action is the relationship. Therefore, a primary concern of the psychoanalytic couple therapist would be the shared unconscious of the couple: the intersection of the content of each of the partnerās unconscious minds, including shared unconscious phantasies,3 anxieties and the unconscious processes that create the dynamic relationship between them.
The frame
Similar to individual treatments, the frame provides important functions in psychoanalytic couple psychotherapy. First, the frame provides the therapist with a standard, consistent way of setting up the conditions and boundaries of the treatment. Particular patient responses to these practices are meaningful and diagnostic and can therefore be useful as information in the treatment. When the psychoanalytic couple psychotherapist is in the practice of maintaining a consistent therapeutic frame, deviations from this may be relied upon as a resource, as an entry to understanding countertransference enactments that may provide clues to otherwise inaccessible unconscious material.
Second, and perhaps most importantly, the frame forms the holding environment of the therapy, providing a reliable, structured, bounded setting within which the conflictual, chaotic and unpredictable affects and phantasies may be gathered and safely contained in order to be experienced, reflected upon and understood. Policies and practices, such as those involving scheduling, fees and the boundaries regarding the types of contact between the therapist and the couple, are fundamental aspects of the frame. In couple psychotherapy, promoting a sense of consistency and predictability is important because the conflicts in intimate relationships can be extremely volatile and invoke highly regressed states accompanied by dramatic enactments. Many couples rely on their sessions, particularly in the early phases of the treatment, as the only safe place to discuss issues that they expect to be threatening or painful. Inconsistencies and breaks in the frame potentially erode the sense of containment provided by the therapist and the therapeutic setting. In contrast, consistencies in the frame, provided over time, promote containment for the couple.
For this reason, psychoanalytic couple psychotherapy is usually, although not always, framed as an open-ended, long-term treatment. Each couple is unique and the time required for treatment will depend on the specifics of that particular couple. Psychoanalytic couple psychotherapy is similar to psychoanalysis or individual psychoanalytic psychotherapy in that there is no standard, pre-determined period for the treatment. Time is necessary for both the therapist and the couple to understand the complex unconscious processes that are creating difficulties, to work through these issues in the presence of the therapist, and for the couple to internalize these insights and capacities such that they will be better able to relate to one another outside of the therapeutic setting
Partner choice
In addition to the conscious aspects of choosing a mate, the choice of a partner has a large unconscious component. Individuals seek out a person who will receive, via projective identification, externalized parts of the self and create the opportunity for the reenactment of old, unresolved conflicts by dint of externalization. Partner choice always seems to contain a dynamic tension between, on the one hand, transference repetitions based on the experiences of oneās past and, on the other hand, the hope that the new relationship will provide novel and better experiences. Put simply, when is a partner experienced as an important figure from oneās past (such as a parent or sibling), versus when does the partner offer an opportunity for reworking unresolved issues with oneās self and oneās objects? The repetition compulsion that drives these unconscious projections tends to create a defensive experience of living with the same, familiar objects. This always stands in dynamic tension with the developmental hope and phantasy of having a better or reconstructive experience. It is precisely the dialectical relationship between the representations of these objects that creates the oscillations between defensive and developmental relating within the couple. This is one of the main points of focus in the treatment and those trained in the Tavistock model attempt to track these oscillating cycles, both within the clinical hour and across time over the course of the treatment.
Transference and countertransference
One of the hallmarks of psychoanalytic theory is the concept of the transference. A distinct advantage of couple psychotherapy is that the couple arrives with their mutual tr...
