The Embedded Self

An Integrative Psychodynamic and Systemic Perspective on Couples and Family Therapy

Mary-Joan Gerson

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780415992428
• eBook ISBN: 9781135850586
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1996, The Embedded Self was lauded as "a brilliant and long overdue rapprochement between psychoanalysis and family therapy conceived by a practitioner trained and experienced in both modalities of treatment." Mary-Joan Gerson's integrated presentation of psychodynamic and family systems theory invited therapists of either orientation to learn the tools and techniques of the other, to mutual benefit. Firmly grounded in detailed case presentations, her focus on family therapy examined its history, organizing concepts, and developmental approaches, and addressed practical questions of diagnosis, clinical interaction, and referrals.

A dozen years later, the psychoanalytic community is more open to integrating perspectives, and the growth of analysts working with couples and families necessitates an update of the material presented in The Embedded Self. Similarly, the family therapy community has deepened its interest in individual dynamics within systemic patterning. From a new and revised perspective on the possibilities of integration, Gerson covers the latest research in neuroscience and the transmission of affect within intimate relationships, with a new chapter on attachment theory and emotionally focused therapy. Sections on narrative therapy and psychoanalytically-oriented family therapy are expanded as well.

The Embedded Self was a sterling introduction to family systems theory and therapy, and enhanced the work of analysts and family and couples therapists alike. The second edition proves no different in its context but wider in its scope, further enhancing the work of the family therapist interested in individual dynamics, and preparing the psychodynamically-oriented therapist who seeks to extend her craft from the dyad to the triad, and beyond.

Chapter 1

Possibilities of Integration

“My main goal is to get them into individual treatment.”

“I started to see them as a couple. He was desperately trying to get through to her, and I wanted to help if I could.”

“An individual patient of mine asked for the name of a couples therapist. Although I think this will be helpful, I’m unsure of how to deal with this other modality.”

More and more psychoanalysts and psychoanalytically informed therapists see couples and families in their private practices and as part of their institutional responsibilities, or become involved in this form of treatment by referring individuals to a couples or family therapist. The increased openness to other interventions is commendable. But the tracking of clinical data when a person is seen simultaneously in individual and family or couples therapy is complicated. For the referring individual therapist, an awareness of the theoretical underpinnings and forms of intervention used in the family or couples work can facilitate this tracking across multiple levels of clinical abstraction.

Reaping the heuristic benefits of family systems theory requires immersion in it, but this may be in the form of a refreshing dip or full-fledge baptism. In the rest of this chapter, I opt for the dip and will talk about work with couples, for that is perhaps the easiest, most experience-near way for most analysts to get started in thinking about patients, and perhaps also themselves, in a systems perspective. In the next chapter, I will broaden my scope to families.

Families—their traumas and their struggles—are what psychoanalysts spend a great deal of their time hearing about. And yet how one hears this material will be the question. But couples are perhaps even more experience-near. Some analytic practitioners are already seeing couples, others are perhaps contemplating doing so, but all analytic practitioners have had ample opportunity and cause to ponder and wonder about what goes on in couples therapy and about how it is different than what usually seems to go on in their offices.

There are so many reasons to work with couples as a psychoanalyst. The vibrancy of interaction, the very different countertransference experience, and the rolled-up-sleeve kind of playfulness it requires are all gratifying. And while we are talking about gratification, I wouldn’t be honest if I didn’t mention that there is an ever-increasing consumer interest in and request for couples treatment.

The increased openness to couples therapy among consumers is sociologically and clinically interesting, and I can only muse about it. Relationships have become more complicated to negotiate in an era in which gender, sexual, and vocation roles are all very much in flux. It is probably not the case that intimate relationships are more difficult to establish during the first decade of the 21st century than they were during the last decade of the 19th century, when psychoanalysis first emerged as a domain of inquiry and treatment. However, intimate relationships seem to be more difficult to sustain today; witness the soaring divorce rate of the past few decades. This is in large part because sweeping changes in social ideology, represented most forcibly in the feminist revolution, have deconstructed time-honored assumptions and expectations regarding family structure. The premises of traditional ideology regarding the family now lie about—potsherds of a fractured vessel—requiring each couple and family to patch together for themselves an ideological framework for their lives that is both functional and serviceable. They must construct their own framework in which to address essential questions about interrelationship in a culture in which sustaining a bond with another person is an extremely difficult operation: What is “good enough” parenting? How can parents prepare children for a world that, in an age of information explosion, is relatively unpredictable? What is commitment in a postmodern culture? Does it still mean “forever” in any reasonable statistical or psychological sense? What can and should we pledge to each other? Exclusivity in an age of distracted consumerism? Oh, would that freedom made life simpler.

Then again, perhaps the general postmodern rotation toward external cueing and away from subjective self-examination has encouraged an interest in relationship-based therapy. Rather than pausing to reflect about our intention or effect, we are today cued to instant feedback via electronic communication, and are awash in media information and stimulation. It may be that in today’s zeitgeist looking at oneself seems more natural “in connection” than in our personal closets. Third, young couples, from whom the sharpest increase in couples therapy emanates, are nowadays impressively pragmatic. A troubled relationship for this generation—like most of life’s obstacles—can be actively taken on and, with expert help, reconfigured and resolved.

For myself, couples therapy was in a sense a natural clinical extension of my psychoanalytic identity. I emerged from psychoanalytic training with a particular respect for the interpersonal tradition, which persists today as its own tradition and is also well represented in the relational movement in psychoanalysis (Wachtel, 2008). One of the leading progenitors of the interpersonal perspective was Harry Stack Sullivan. I think that Sullivan’s (1950/1964) greatest contribution was to expand our psychoanalytic frame to include field processes, with particular reference to the patient–therapist relationship. His developmental theory reflected an emphasis on inter-personal processes—what today is referred to as intersubjectivity—such as the contagion of anxiety from mother to infant and the coloration of the self by the reflected appraisals of others. I think that the valuable of Sullivan’s concepts for a psychoanalytically oriented couples therapist is his personified self. Sullivan argued that our “illusion of uniqueness is precisely what prevents us from curing ourselves of our neuroses” (p. 216). According to Sullivan, we construct an image of ourselves that is generally positive—though not necessarily so—that becomes fixed in our consciousness. This self-representation buffers the anxiety of living. Once delineated, our self-personification remains impervious to interpersonal feedback, largely through the work of selective inattention. We discredit contradictory appraisals from others. I have written extensively in articles about how Western culture reinforces our sense of psychological autonomy and impermeability. Individualism, whether “egoistic, romantic, alienated or ideological” (Guisinger & Blatt, 1994), is our ideal, and couples therapists get to see it in operation in situ.

Sullivan also talked about experience that was not repressed, not denied, not dissociated, but simply unformulated because anxiety kept it from becoming part of the self. Donnel Stern (1997) has developed and elaborated the idea of unformulated experience, beautifully illuminating how what hurts us is not only what we keep out of awareness, but what we haven’t imagined within us as lived possibility. For me, what is unformulated in conscious experience for many partners is the degree to which they are prompted, shaped, and influenced by their intimate other.

There is a great deal written today about multiple self-configurations. Mitchell (1993) evokes the oscillating rhythm of integral and multiple self-experiences, and Bromberg (1998, 2006) has celebrated the “spaces” between different self-states. In fact, Jerome Bruner (1990) anoints the contemporary self “distributive,” a product of the variegated situations in which it operates. The de-centered self, however, is distributed in a culture that still privileges bounded identities and discreet personal experience. For me, the essence of psychological health is to be open to input, even shaping, from others, while maintaining a sense of continuity capable of sustaining the dialectics of self-experience. I think that individuals who grow into adulthood able to maintain a fluid balance between continuity and permeability often find relationship life very satisfying. But, the other side of this coin is that it is intimacy that most challenges this capacity. If there is little give in our sense of self and its embeddedness in the relationship, the objections of our significant others can feel unjust and, at their worst, annihilating. What can happen over time is that the cueing of insult or rejection immediately triggers the same redundant defensive reaction, and before long the repertoire of shared life is constricted and almost automatic. Actually, the artistry of couples therapy is to render support and holding for self-organization, the customary vantage point of Western psychological life, while inviting the couple to gaze out on the world from behind a new lens, one that includes attachment and interpenetration. I’ve written about ways to conceive of this work as live drama (Gerson, 2001a) or as a ritual (Gerson, 2001b) in which individual identities are reconfigured and reassembled.

One of the pleasures of integrative thinking is to track an innovative clinical concept as it moves across the aisle. One construct, to take an example close at hand, that has been most warmly embraced and elaborated among psychoanalytically oriented couples therapists is projective identification, first developed by Klein and particularly elaborated by Ogden. How tempting is it to divest oneself of an intolerable quality by cloning it on an intimate partner? If the essence of projective identification, as opposed to projection plain and simple, is in fact to remote-control that unacceptable quality, the intimate relationship with its active longings and dependencies offers the perfect technology. Similarly, Donnel Stern (2006) posed an interpersonal variant of projective identification recently. Stern cites Sullivan’s formulation of a triad of “me’s” that become organized in late infancy: good-me, bad-me, and not-me (Sullivan, 1953). For Stern, the unacceptable bad-me can be deposited into the account of a partner; so, too, can the uncannily disturbing not-me. However, the not-me is so alien and potentially so terrifying that if it is deposited in another in a relationship field, an endless, repetitive cycle of toxic and hateful representations ensues. Sullivan first spotted this dynamic in the press of individual treatment. Couples therapists see it all the time. In general, the sweep of the contemporary relational movement in psychoanalysis has legitimated all of us to move freely and integratively across theories and concepts. For myself, I have always been interested in figures who are today deemed relational theorists, particularly Winnicott and Fairbairn, and how their ideas can be applied to couples and family work. In fact, I very much feel that in some basic way, I “hold” the couple’s contradictory longings and antipathies in a Winnicottian frame that allows for experimentation and expansion.

Attachment theory has yielded a theoretical and empirical literature that has refined psychoanalytic thinking while also impacting family and couples work. There is a very specific and fascinating literature on couples attachment, which I will return to in Chapter 7. Just to offer a taste of this field of inquiry, a factor analysis of the most frequently used adult attachment scale yields two distinct anxieties of intimate attachment: fear of intimacy and fear of abandonment. These anxieties function as a crossbar allowing the clinician to sometimes unpack bewildering contradictions in relationship patterns. Attachment theory and systems theory are close cousins; both models emphasize the specificity of each relationship as yielding a particular attachment configuration, and both theories post the possibility of change throughout the life span—even, dare I say, without therapeutic intervention—due to the healing influence of significant others.

In a kind of chromosomal linking, attachment theorists have brought psychoanalytic theorists back to Freud’s original project—the investigation of how neurobiology shapes character—and family theorists have begun to consider the newly emerging interpretive possibilities. It seems clear that attachment schemas are primal, organized in procedural memory, and get triggered in psychic nanoseconds. Another recent development in the neuroscience area of great interest to us is the identification of mirror neurons. It turns out that as I watch you perform an action, my cortex produces a similar neuronal pattern, as if I were the protagonist and not a mere observer. These neurons may help us grasp a laboratory phenomenon that we witness daily in our offices, and certainly experience in our own lives: how we feel our emotional boundaries so readily dissolve in intimate relationships. Beebe and Lachmann (1998), citing Ginot’s work, describe how partners are able to induce similar affective and subjective states in each other through facial expression alone. And these are laboratory partners! How helpful these findings from neuroscience have been to me in integrating psychoanalytic thinking with active systemic intervention. Indeed, these findings help explicate why the playful approaches of family therapy, which are sometimes kinetic and nonverbal in form, and often not directly exploratory in content, may be necessary if the schema at hand are unsymbolized and overcued.

But, however useful the constructs from current psychoanalytic, attachment, and neuropsychological theory are, they don’t provide an adequate map for the therapeutic terrain of couples therapy. Why not? Because what we need when working with couples, particularly those caught in repetitive and redundant cycles of blame and disappointment, is an approach that focuses on how their psyches are linked, at times fused. A full elaboration of the phenomenon of multiple self-states would require, I believe, the positing of an additional self-state: self with significant other—a state often dissociated and at the very least disavowed.

We need a methodology that helps us penetrate how the experience of two partners is cross-joined. I recently published an article about the ethics of intimacy (Gerson, 2007) in which I talk about how subversive I can feel ethically in my office, where I have come to view the language of ethics—the principle of the golden rule—as a very linear and very convenient means for couples to stake out their autonomous sense of being wronged and righted. Much more interesting to me in working with couples is to look at how they share the same temptation of violation, or pretend not to.

So what shifts for the psychoanalyst in looking at cross-joined selves? Well, dynamics cycle rather than descend or ripple. By this I mean that we shift our focus from the richness of association or the depth of layered history to how the same patterns become enacted over and over again—and we do so very early on in treatment. In other words, we look at circularity and try to capture it, and better, interrupt it. If she nags and he withdraws, almost any disruption in this tiresome cycle will likely bring some relief and perhaps even delight. It doesn’t matter who started it; they’re both caught in the circuitry. Psychoanalytically, we are looking at transference and countertransference much more circularly today, but we contextualize each point of origin, we care where dynamics originate, and we chart carefully how they became elaborated. When working with couples, it is sometimes illusory to try to develop each person’s profile of dynamics or to seek the point of origin of fresh manifestations; instead, we focus on illuminating the cycle itself. If that cycle and its reciprocity can be captured, particularly with heightened affect, there is a strong possibility that the personified selves of each partner will change. He, seeing her in a fresh view, has to re-sort all her reflected appraisals of him. He never feels quite the same. This is the recognition that springs from embeddedness—when the rules of engagement change.

Throughout most of the work, the twosome is my focus: shared history and shared failures. This is true even when I meet with partners individually, which I do on occasion. Adopting such a focus entails a rotation in emphasis for psychoanalysts, one that takes some effort at accommodation. In fact, I think that if analysts concentrate too much on individual development and individual psyches, they only separate partners more, entrenching them in their autonomously held positions.

When we work with couples, we also often deal with the weight of two resistances, of one-plus-one discouragement, and I think it’s important to work more swiftly and perhaps more surgically—a shift for analysts—in order to upend redundant assumptions and personifications. In truth, I think there is something more typically American—progressive, pragmatic, and yes, optimistic—about the systemic view of relationship change. When we focus on interrupting patterning in a couple’s life, we often assume that with redundancy dissolved, a more generative bonding will naturally occur. When we work psychoanalytically, we delineate the possibilities of change and expansion more conservatively; albeit strange and serendipitous transformations do happen in our psychoanalytic treatments. Certainly we upend assumptions when we inquire or interpret in psychoanalytic treatment. But the challenges in couples therapy are often spicier and more direct. I am working with a gay couple in which one partner, purportedly empathically but actually cripplingly, details the psychiatric history of the other. I recently asked the partner why he needs three therapists in consultation: his analyst, myself, and his lover. It’s a jibe; it stings, but from the point of view of multideterminism, it is also descriptively true. The quality of my inquiry in couples treatment is sometimes more discontinuous than what I would use in individual treatment—what I am after is a more surprising version of “truth.”

I think it’s crucial and enormously beneficial to reflect on strengths as much as pathology. Actually representing a couple’s life together with any degree of positive affirmation is often the most shocking statement that the couples therapist can make. Partners in our offices are often joined in the certainty of their failure and shame. True, partners are sometimes chosen who will repeat hurtfulness, but also, people choose partners who will offer the possibility of rehabilitation. The meanest, below-the-belt gambits are often desperate attempts to connect. Once you really immerse yourself in patterning and circularity, some of the least likely candidates for positive description make the cut. I think I’ve been reframing dynamics for so many years now that possibilities for gratification and solace in the ugliest of scenarios very readily occur to me. Thus, unless one subscribes to a reductionistic, single-channel theory of masochism or repetition compulsion, which I don’t, one has to wonder why certain cycles of relating are endlessly replayed. To wit: You witness a partner behaving consistently critically and hurtful. Is it just sadism? Well, in fact, it’s also reassuring. This partner is actually expressing riveted interest and is nowhere near abandoning the object of contempt. Here I think that the systems literature has something crucial to offer us as psychoanalysts. I think we still function somewhat under Freud’s dark vision. Not that I’m Pollyannaish about human motivation. Many a morning reading the newspaper, I feel myself affirming the darkest view of human nature as hardwired and hopeless. However, I think we tilt too much in that direction in our psychoanalytic perspective. When I teach couples and family work to psychoanalysts and ask for case presentations, I generally have to take up the task of finding something encouraging, something kind and beneficent in the organization of intimate life. It’s as if we feel that to take people seriously, we have to capture darkness rather than light.

I think Edgar Levenson’s (2002) distinction between the poetic and pragmatic tradition in psychoanalytic practice is relevant to the kind of focus needed in couples therapy for the psychoanalyst practitioner. Levenson (2002) cites a time-worn, if not time-honored, dichotomy in psychoanalytic theory. One end of our evaluative continuum honors the functions of the mind, that is, the imagination—ergo the poetic. The other end of the continuum focuses on the exquisite skills necessary for negotiating the surviving in the interpersonal world, that is, pragmatics. As Levenson points out, these are different emphases, but they are inexorably connected, so that a pragmatic, gritty exploration of an enactment is always riffed by the patient’s imagination and becomes a poetic one. I do think that our work with couples tilts toward the pragmatic; what is most illuminating to look at when working with couples is what is happening between them in the room, now, to examine the intricacy of their engagement. Of course, I am not talking about practical pragmatics, that is, daily chores, division of labor, whose turn is it to pick up junior at soccer practice, or any of the other truly bana...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Preface
• 1. Possibilities of Integration
• 2. Theoretical Overview
• 3. An Orientation to Family Systems Theory
• 4. Controversies and Conundrums
• 5. Nested Contexts
• 6. Family Patterning
• 7. Attachment Theory: A New Frontier
• 8. Development From a Family Perspective
• 9. Diagnosis in Family Therapy
• 10. Interventions in Family Therapy
• 11. The Therapeutic Relationship
• 12. Playfulness, Authoritativeness, and Honesty
• 13. Referrals: Who? When? Where?
• Epilogue
• References
• Index