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select one of the following articles on psychodynamic therapy to evaluate

Aznar-Martínez, B., Pérez-Testor, C., Davins, M., & Aramburu, I. (2016). Couple psychoanalytic psychotherapy as the treatment of choice: Indications, challenges and benefits. Psychoanalytic Psychology, 33(1), 1–20.

https://doi.org/10.1037/a0038503

Karbelnig, A. (2016). “the analyst is present”: Viewing the psychoanalytic process as performance art. Psychoanalytic Psychology, 33(Suppl 1), S153–S172.

https://doi.org/10.1037/a0037332

Tummala-Narra, P. (2013). Psychoanalytic applications in a diverse society. Psychoanalytic Psychology, 30(3), 471–487.

https://doi.org/10.1037/a0031375

In a 9-10 slides, not including the title and reference slides. Include presenter notes (no more than ½ page per slide) and use tables and/or diagrams where appropriate.

· Provide an overview of the article you selected.

· What population is under consideration?

· What was the specific intervention that was used? Is this a new intervention or one that was already used?

· What were the author’s claims?

· Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with clients. If so, how? If not, why?

· Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article. Support your approach with evidence-based literature.

COUPLE PSYCHOANALYTIC
PSYCHOTHERAPY AS THE TREATMENT

OF CHOICE:
Indications, Challenges and Benefits

Berta Aznar-Martínez, PhD, Carles Pérez-Testor, PhD, MD,
Montserat Davins, PhD, and Inés Aramburu, PhD

Universitat Ramon Llull

Including couple treatment in psychoanalysis has required the setting of new
parameters beyond the classical psychoanalytical setting, in which the treatment
is individual. This article aims to define the clinical criteria for, and benefits of,
recommending couple treatment rather than individual psychoanalysis or psy-
chotherapy, and to identify the challenges and demands that this has entailed for
psychoanalysis, from the standpoint of the analysis itself and also that of the
therapeutic relationship. Couple therapy is a very complex endeavor since a host
of factors must be borne in mind. The present paper discusses the specific
features of these factors and how they influence the diverse mechanisms in the
analytical relationship. A clinical vignette is included in order to demonstrate
the mechanisms that influence therapeutic work in couple psychoanalytic
treatment.

Keywords: couple psychotherapy, therapeutic relationship, transference, coun-
tertransference, psychoanalysis, conjoint treatment

In psychoanalysis, couple treatment has required the setting of new parameters beyond the
classical psychoanalytical setting. Thanks to the contributions of Dicks (

967), Pichon
Riviere (1971), and Kaës (1976), who might be seen as representatives of the leading
psychoanalytical schools (English, Argentine, and French, respectively) in the fields of

This article was published Online First March 23, 2015.
Berta Aznar-Martínez, PhD and Carles Pérez-Testor, PhD, MD, Facultat de Psicologia,

Ciències de l’Educació i de l’Esport Blanquerna and Institut Universitari de Salut Mental Vidal i
Barraquer, Universitat Ramon Llull; Montserat Davins, PhD, Institut Universitari de Salut Mental
Vidal i Barraquer, Universitat Ramon Llull; Inés Aramburu, PhD, Facultat de Psicologia, Ciències
de l’Educació i l’Esport Blanquerna and Institut Universitari de Salut Mental Vidal i Barraquer,
Universitat Ramon Llull.

This article is based upon work supported by the agreement between the Universitat Ramon
Llull and the Departament d’Economia i Coneixement de la Generalitat de Catalunya.

Correspondence concerning this article should be addressed to Berta Aznar-Martínez, PhD,
FPCEE Blanquerna. C/Císter 34. 08022. Barcelona, Spain. E-mail: bertaam@blanquerna.url.edu

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Psychoanalytic Psychology © 2015 American Psychological Association
2016, Vol. 33, No. 1, 1–20 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0038503

mailto:bertaam@blanquerna.url.edu

http://dx.doi.org/10.1037/a0038503

couple and family psychotherapy, couple treatment is now an area of therapeutic action
that has brought new challenges.

Although this type of treatment is widely accepted among psychoanalysts nowadays,
the need of couple therapy and the factors that make couple psychotherapy the treatment
of choice rather than individual treatment are issues that are still under discussion. Zeitner
(2003, p. 349) describes the typical ways in which couple consultation and therapy are
practiced by psychoanalysts as a “supplemental or even second-rate treatment which is
palliative, supportive, informative, or preparatory for the real therapy—psychoanalysis or
psychotherapy,” a view which shows that couple treatment is not held in high esteem by
some psychoanalysts. However, couple therapy has the potential to provide valuable
insights concerning individual and shared psychic organization, and also the dynamic
functioning of marriage (Scharff, 2001).

The purpose of this article, therefore, is to provide further insight into the clinical
indications for couple psychotherapy, its benefits, and how to go about this type of
treatment. It also aims to examine the new challenges and demands that openness to
welcoming couples into therapy has brought for psychoanalysis, from the standpoints of
the analysis itself and the therapeutic relationship. Couple therapy has several clinical
characteristics which differentiate it from individual therapy and these are highlighted in
the paper.

Why Couple Psychoanalytic Psychotherapy?

Couple therapy is an area of psychotherapeutic practice that is long on history but short
on tradition (Gurman & Fraenkel, 2002). The evolving patterns in theory and practice in
couple treatment over more than 80 years can be seen as having four distinct phases: (a)
nontheoretical marriage counseling training (1930 –1963); (b) psychoanalytic experimen-
tation (1931–1966); (c) incorporation of family therapy (1963–1985); and (d) refinement,
extension, diversification, and integration (1986 to the present day) (Gurman & Fraenkel,
2002; Gurman & Snyder, 2011). According to Segalla (2004), recent cultural shifts have
had a considerable impact on the ways in which psychoanalysis and psychotherapy are
conducted and couple therapy has much to gain from postmodern theorizing. Analysts
have mainly applied their methods to the individual rather than to the troubled dyad
(Zeitner, 2003) even though 50% to 60% of their patients seeking therapy do so because
of some kind of disorder in their intimate or other significant relationships (Sager, 1976).
Moreover, as Gurman (2011) notes, partners in troubled relationships are more likely to
suffer from anxiety, depression, suicidal impulses, substance abuse, acute and chronic
medical problems, and many other pathologies.

In Segalla’s view (2004), emphasis on intersubjective and relational perspectives has
had a major influence on the way the treatment process is conceptualized. The dyad is seen
as an “interactive system” and the couple treatment is based on awareness of this system
of mutual influence and regulation. Working with couples affords compelling evidence for
the existence of a “psychology of interaction” and the ways in which emotional difficulties
are, in part, determined by these factors (Dicks, 1967).

Similarly, de Forster and Spivacow (2006) hold that what couple treatment adds to the
contribution of the classical Freudian model is the role of “the intersubjective,” which
varies according to the type of psychic suffering. This dimension has crucial importance
with regard to much of the distress in a relationship and must have a place in the design
of therapy. All psychic functioning is constituted by both the intrasubjective (in that

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2 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

the psychic determinants come from the inner world), and the intersubjective (in that the
psychic determinants include the “other” and the intersubjective context in which the
subject functions). The latter factors are fundamental in much of the suffering which
occurs in a couple’s love life and relationship. Hence, in couple treatment, certain factors
are of particular importance: “the partner, bidireccionality, the unconscious interconnec-
tions and the interweaving of the phantasies of both partners” (de Forster & Spivacow,
2006, p. 255). The psychic determinant of the suffering must be sought in an aspect of the
functioning of the psyche which is not part of the Freudian psychic apparatus but which
lies, rather, in the link between the members of the couple (the “intersubjective”). If this
is not taken into account in the choice of a suitable treatment, the intersubjective
dimension might be neglected in individual work. Since each partner has become closely
associated with the other’s painful internal objects, conjoint psychoanalytic couple therapy
has the potential of dealing with deeply ingrained, largely unconscious constellations that
are usually thought to be treatable only by means of psychoanalysis or intensive individual
analytic psychotherapy (Scharff, 2001). Nevertheless, it seems clear that conjoint treat-
ments are vastly superior to individual treatments for couple distress (Gurman, 1978).

As for the clinical criteria for recommending psychoanalysis or intensive psychoan-
alytic psychotherapy versus couple treatment, Links and Stockwell (2002) have described
the clinical indications for couple therapy in the case of narcissistic personality disorder.
We believe that these criteria can be applied in any case where couple therapy would seem
to be indicated. First, Links and Stockwell state that the partners’ capacity for dealing
openly with feelings of anger or rage must be assessed before deciding on couple
treatment, although these will be worked on during treatment if one member of the couple
is unable to deal with or express feelings that might be humiliating or that could prompt
an attack on the other partner. In such cases we believe that individual treatment should
precede couple therapy. Second, the person’s level of defensiveness, openness to the need
for a relationship, and ability to have this dependency gratified should be evaluated as
well. If one of the partners does not want to continue and improve the relationship the
treatment will not be useful. This is not necessarily the case when both members of
the couple want to separate or divorce. The important point in these circumstances is that
the aim of treatment is shared by both parties and this can be assessed by the therapist
in the preliminary interviews. If, after some sessions, it becomes clear that the objective
is not shared by both members, the treatment will not be fruitful. Assessment of
vulnerability is important. Some people feel that having their partners listening to
interpretations could be belittling and humiliating and couple therapy could then be
counterproductive. Third, the complementarity of the couple must be analyzed, together
with the roles each one plays in the couple. If this complementarity exists, the couple can
often make progress. In other words, when the therapist can show the couple that they are
both participating in the dynamics of their relationship and that, whether they like it or not,
each of them is (or has been) benefitting from the relationship, the treatment can be
helpful. If both partners can see that each of them has personality aspects that benefit the
other, they will be better able to understand their situation (as will be explained in more
detail below). If a couple fulfils these three criteria, they can probably work together and
establish, or reestablish, a stable marriage with a significant degree of complementarity
based on more positive symmetrical patterns.

Lemaire (1977) lists some conditions indicating couple treatment, namely: (a) that
both members agree to having therapy, although as we shall see below, this rarely
happens; (b) that they can distinguish between improved communication and continuing
to stay together (when couples come to therapy they frequently have communication

3COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

problems and improving communication is one of the first goals of the treatment in order
to be able to explore other issues later on (phantasies, families of origin . . .)); and (c) that
the therapist can intervene freely (more or less) without feeling bothered by the contra-
dictions of the other two conditions. In this same vein, Bueno Belloch (1994) and Castellví
(1994) emphasize that limits to couple treatment appear when: (a) when one of the
partners is forced by the other to come to the therapy and there is no change after some
sessions; (b) when it is feared that the new understanding that each person acquires in
therapy can be used pathologically; (c) when both partners form an alliance against the
therapist and frustrate all his or her efforts to bring about change; and (d) when it becomes
necessary to suggest individual therapy for one of the partners because the conflict cannot
be addressed in conjoint treatment.

According to de Forster and Spivacow (2006), another reason for opting for couple
treatment is that our discipline must take a flexible approach, catering to the needs of men
and women of our time, and to what society demands. Reforms in divorce law, more
liberal attitudes about sexual expression, increased availability of contraception, and the
greater economic and political power of women have all raised the expectations of
committed relationships so that their requirements now go well beyond economic viability
and assuring procreation (Gurman, 2011). Likewise, Segalla (2004), drawing on her own
clinical practice and that of other psychoanalysts, states that the demand for couple
therapy is now considerably greater, and this seems to suggest a cultural shift in which
efforts are being made to save marriages rather than simply to divorce. Moreover, there
are signs that would seem to support the clinical contention that relationships in later life
can influence patterns of attachment established during childhood (Clulow, 2003). Mar-
riage can therefore be a potentially therapeutic institution, a unique opportunity for
reworking unresolved problems from the past, which can be aided by a skilled therapist
(Gurman, 1992). In this case, the analyst needs to take into account a number of factors
which will be described below.

Psychopathology of the Couple Relationship

According to Balint (Family Discussion Bureau, 1962), the inner life of the dyad consists
of one partner’s desires, hopes, disillusions, and fears interacting with similar aspects of
the other partner’s internal world. Theories on conjugal life are based on this interaction.
There is progress and regression in the relationship of a couple, and this is described by
Dicks (1967) and further detailed by Willi (1978) and, later in Spain, by Font (1994). The
members of a couple strive to gratify needs and desires which date from very early stages
in their lives, and they may attain this gratification when their regressive or progressive
desires are accepted by their partner. Need for support, tenderness, affection, or devotion
can be requested and fulfilled within the couple relationship (Font & Pérez Testor, 2006).

Ruszczynski and Fisher (1995) have meticulously described the role of projective
identification in psychoanalytic psychotherapy with couples. As is well known, projective
identification entails the capacity to induce the other to feel what is being projected, and
it has a central role in the psychoanalytic understanding of the couple. Phenomena like
projection, introjection, and retroprojection (the projection into the partner of what the
other partner has introjected from a previous projection of his or her partner) exist in all
couples and are fed and interact constantly in a back-and-forth interplay of projections.

We believe Hoffman’s conceptualization (1983) is useful for understanding this
phenomenon as it divides it into three unconsciously acted out parts:

4 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

1. Each member of the couple chooses what to see from all the characteristics of the
other; one’s partner offers a host of signals, including the characteristics the
other chooses and is most likely to perceive. Other features, however, seem to be
blurred or hidden by the partner.

2. Once the partner’s characteristics have been chosen, they seem to confirm each
member’s own internal vision of the world and expectations; this suggests that
each partner tends to interpret the chosen characteristics in accordance with old
family relationships. Each member of the couple chooses real facts from their
partner, but then constructs a history of those facts based on his or her own
previous relationships.

3. Each partner unconsciously influences the other in order to test what they already
know or believe; this unconscious communication appears in the couple through
the mechanism of interpersonal projective identification (Ruszczynski, 1992).
Eventually, the intensity and repetition of problematic interactions begins to
dominate the couple-experience, and this tends to polarize the members (Gold-
klank, 2009). If this happens, the couple may seek counseling and, indeed, this
is the kind of couple we tend to find in clinical practice.

Along similar lines, Shimmerlik (2008) notes that the patterns of couple relationships
are formed in the enactive domain through a nonconscious implicit process of commu-
nication, part of which is stored in the implicit domain and remains embedded and enacted
in one’s most intimate relationship, and can therefore only be accessed within the context
of this relationship.

Another way of conceptualizing these processes happening unconsciously between
partners, and which we believe is useful in diagnosis and hence in subsequent treatment,
is based on Dicks’ (1967) concept of collusion within couples. By collusion (which
derives from coludere or interplay between two people) we mean the unconscious
agreement that forges a complementary relationship in which each party develops parts of
themselves that the other needs, and gives up other parts of themselves which they project
onto their partner (Dicks, 1967; Font & Pérez Testor, 2006; Willi, 1978). Other prominent
authors have similarly conceptualized this unconscious interplay between the members of
a couple as an unconscious base (Puget & Berenstein, 1988), dominant internal object
(Teruel, 1974) and conjugality (Nicolò, 1995).

The concept of collusion starts with the idea that couples are formed on the basis of
personal styles that are complemented with flows and reflows, or with projection, intro-
jection, and retroprojection. These kinds of bonds arise within all couples, albeit differ-
ently in each couple, and they can be grouped into clusters based on admiration, care, or
dependency. Although certain levels of admiration, care, or dependency are needed in all
couples, it is important for the health of the couple that they occur alternately and not
rigidly. All couples have bonding styles in which certain characteristic features predom-
inate, but pathology appears when the bonding style becomes rigid (Pérez Testor & Pérez
Testor, 2006). One example of this was a couple treated in our center. The woman had
always spent much of her time caring for her husband, and the husband let himself be
cared for, which allowed both partners to meet their primary needs (caregiver-care
receiver). Then the woman was diagnosed with breast cancer and they had to change roles,
but neither member was able to take on the opposite role and pathology appeared. The
couple came to us seeking help mainly because of this inability to change roles. Accord-
ingly, we believe that collusion becomes pathological when the roles of each partner
become so rigid that it is difficult to exchange them. In keeping with this idea, Fisher and

5COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

Crandell (2001), referring to the attachment theory, state that the hallmark of secure
attachment is the ability of each partner to change their positions of depending and being
depended on by one another in a flexible and appropriate manner.

Psychoanalytical Treatment of the Couple

As we have noted, during the 20th century many psychoanalytical therapists came to
accept the usefulness of welcoming couples and families into their practice, in contrast
with the classical tendency of working only with individual patients (talking cure). This
new framework has given rise to many questions and studies on the techniques adopted
by the therapist, sometimes leading to reconsideration of the classical boundaries of the
psychoanalytical setting. The scope of couple therapy has evolved substantially in psy-
choanalysis, and the object relations orientation has made a major contribution to the field
by giving couple therapists insights into the defensive, communicative, and structure-
building functions of unconscious processes, resistance, and work on transference
(Sander, 2004; Scharff & Scharff, 1991; Sharpe, 2000; Slipp, 1988). As mentioned before,
the role of “the intersubjective” is crucially important with regard to much of the suffering
in a couple’s relationship and thus should have a place in the design of therapy. When
including this dimension, the couple’s analyst needs to bear in mind some important
aspects that will eventually appear during the treatment.

In couple therapy, we often find that what initially attracted each partner to the other
lies at the heart of their complaints (Felmlee, 2001; White & Hatcher, 1984). Now,
collusively, they choose those aspects of their partner that confirm their worst fears about
themselves and their partner. Mutual needs, often on an archaic level, are stimulated in
couple relationships. Frustration and disappointment of these developmental needs often
lead to marital conflict. In many couples, difficulties can be understood as mutual attempts
to rectify the deficits of their injured selves (Livingstone, 1995). According to Kaës
(1976), one great benefit of couple therapy is that it may hold out a chance to reelaborate
the unconscious alliances, pacts, and contracts that come from intergenerational and
transgenerational psychological transmissions and that have remained embedded in the
couple. In the clinical setting, the roles and rules adopted by couples often appear as
stemming from intergenerationally transmitted anxieties about unresolved dilemmas in
both members’ birth families. In this sense, Robert (2006) defines the couple as the place
where a person once again acts out and sometimes attempts to retain his or her infantile
side, regardless of the cost. Helping both members of the couple to recognize that their
fears are fundamentally similar is crucial in overcoming disillusionment and polarization,
and enables them to integrate solutions that they initially view as inimical (Goldklank,
2009). When both members of the couple accept responsibility for their own personal
contributions, blame and shame are somehow alleviated and the quality of their relation-
ship is enhanced (Scharff & Scharff, 2004).

In psychoanalytic couple therapy, as we view it, the therapist plays an active role in
which interpretative capacity is his or her main instrument. Stressing psychoanalytic
techniques to maintain a state of harmony, providing a secure base, recognizing nonverbal
signals of unconscious associations, and processing emotionally laden interactions are all
important when working with couples (Scharff & Scharff, 2004). In Teruel’s opinion
(1970), the destructive force of a couple can be managed by means of proper interpreta-
tions and the gradual acquisition of insight through introjection or internalization of what

6 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

the therapist does and represents for the couple in terms of his or her interaction in their
marriage.

No doubt, the main difficulty in couple therapy lies herein: how to interpret. Like
Lemaire (1980) and Castellví (1994), we would say that the interpretative focal point is
the couple, not one member or the other but both of them together, their relationship, and
their collusion, which is in keeping with the intersubjective dimension of couple treat-
ment. If we avoid the risk noted by Teruel (1970) and which Thomas (cited in Pérez Testor
& Pérez Testor, 2006) summarizes as “individual interpretation in public,” and focus
instead on interpreting their collusion, we may be able to help both partners gain
awareness of the functioning of their unconscious, which has led them to act out their
conflicts. When interpreting from an interpersonal perspective, the couple therapist affirms
that each member of the couple is complaining about something that truly exists, but to
which they both somehow contribute (Goldklank, 2009).

The mobilization of each partner’s unconscious defenses is coordinated and takes on
the guise of resistance emerging spontaneously in the session. Generally speaking,
progress is slowly made with the therapist’s interventions, in which analysis of the
defenses and anxieties of one partner is often used to analyze the other’s defenses and
anxieties in a pattern that is usually back-and-forth. The therapist tries to interpret the
collusion by showing the defenses and anxieties which have led the couple to form this
specific kind of internal dominant object (Teruel, 1974).

The work of acute understanding and integration of interpretations is performed in the
same way as in psychoanalysis or psychoanalytic psychotherapies. However, perhaps
acute understanding of one of the partners is quicker and more precise than with the other.
It is then wiser to adopt the pace of the slower one since a greater capacity for insight in
one member of the couple can become a weapon used against the other if the therapist’s
interventions do not set limits. In other words, it is important to adjust the pace of the
treatment’s progress to the slower or more fragile of the two partners.

The therapist must be aware of the nature of this movement, bear it in mind, and only
use interpretation when it can be addressed to both partners, in accordance with the
intersubjective dimension that shapes the design of couple treatment. The responses to the
therapist’s interventions may come from either partner and they often react, each one
offering rich associative material.

The theoretical underpinnings and intentionality of the interpretations correspond
equally to both transferential and extratransferential types. Both entail an effort to show
the couple what they do not know about themselves, to reveal those parts of their inner
world that are repressed or disassociated so that they can recover them and reintegrate
them into their psychological system as a whole. There are no totally and exclusively new
experiences solely determined by external conditions. Rather, all of them are filtered to a
greater or lesser degree through the primitive internal object relations that survive in
the unconsciousness of the person’s entire life. In couple therapy, the goal is to
interpret the “here and now” of what happens in the session. Extratransferential
interpretations are more frequent. They are expressed and revealed in the couple’s daily
lives and permeate any event and relationship outside the session. Technically speaking,
the best course of action after every extratransferential interpretation is for the therapist to
try to identify and interpret the unconscious motives and fantasies which have led the
couple to bring certain facts and situations to the session and, on the basis of this, proceed
to the transferential interpretation itself (Pérez Testor & Pérez Testor, 2006). Nevertheless,
it is difficult for all of these internal conflicts to be expressed in transference at any one
point. Whatever the characteristic features and technique of each therapist, in the thera-

7COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

peutic function the couple relives the fundamental structure of internally shared object
relations. Yet other nuances and particularities of these relations will never be manifested.
They require present actual realities in order to emerge and develop. Hence, the couple’s
internal world never appears as whole in the transference. Elements of it, both the most
pathological ones and those pertaining to the healthier parts of the personality may be
displaced, disassociated, or represented outside the therapeutic session (Lemaire, 1980;
Lemaire, 1998; Nicolò, 1999). The members of each couple reflect their life events in
keeping with features of their own particular characters which are not always present in
therapeutic transference. If they are not interpreted, the conflicts, anxieties, and defenses
that have given rise to them may remain hidden and unchanged.

One reason given by classical analysts as an argument against couple or family therapy
was the idea that it would be problematic because of major complications stemming from
the multiple transferences and countertransferences entailed in the process. As described
above, in psychoanalytic couple therapies today, which include orientations from the
theoretical school of object relations, transference and countertransference are perceived
as dynamics inherent to the therapeutic relationship (Kaswin-Bonnefond, 2006). None-
theless, dealing with countertransferential responses in this kind of therapy is an even
more complex challenge. In the same vein, Pérez Testor and Pérez Testor (2006) noted
that the greatest difficulty facing couple therapists is managing countertransference. This
is often manifested in the form of extreme fatigue, which tends to lessen with experience.
If all psychotherapy involves observing the different levels at which the patient’s words
can be understood, or the different transferential and countertransferential movements,
these levels are necessarily multiplied in couple psychotherapy. The therapist will expe-
rience countertransference intensely. It is important, therefore, to be prepared to deal with
and contain a joint attack by both partners, who form an alliance to attack the psycho-
therapist who exposes their collusion.

The therapist must be aware of and alert to positive and negative transference toward
him by each patient, separately and by the couple as a unit, as well as his or her own
positive or negative countertransference toward them. Sometimes, a second professional
acting as a cotherapist may serve to attenuate some of the transferential and countertrans-
ferential feelings, rebalance the therapy system, and improve the therapeutic process. For
instance, if a cotherapist who is the opposite sex of the therapist is included in the
treatment of a heterosexual couple, this will help to bring out the transferences in a
different more balanced way.

As we know, the therapist’s countertransference begins with first impressions, and it
is important for the therapist not to take these as absolute truths or see his or her personal
values and preferences as ideals by which to measure patients (Ehrenberg, 1992). How-
ever, these initial impressions, both verbal and nonverbal, are unconscious communica-
tions from the patients. A therapist who, unaware of his or her own countertransferential
reactions, acts them out, runs the risk of entering into collusion with the couple and
participating in the dynamics of their relationship (Goldklank, 2009). Slipp (1988) claims
that in couple therapies based on object relations theory there is an interaction between the
intersubjective worlds of the therapist and the dyad. It is essential that the therapist should
be knowledgeable about the processes of projective identification and disassociation that
influence the multiple transferences and countertransferences toward the therapist, and
that are at work between the patients themselves. Objective countertransferential re-
sponses of the therapist, adequately thought out and processed, (Kaslow, Kaslow, &
Farber, 1999), must be employed when interpreting the interpersonal patterns used by the
couple to keep their relationship functioning in its maladaptive way.

8 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

In addition to transference toward the therapist and the therapist’s own countertrans-
ference, there are other mechanisms at work between the members of the couple. These
might be described as transferential-countertransferential (projections, introjections, and
retroprojections). As a result, both partners not only experience their own transferential
needs but they also have other subjective experiences in response to their partner’s
transference toward them. The couple therapist must be aware of the intricate nature of
these experiences. Working on patients’ transferences toward the therapist empowers
them to build a structure and develop the capacity to nurture each other (Livingstone,
1995).

As we have noted, couple therapy is very complex because a host of factors must be
borne in mind. We shall now discuss the specific features of these factors and how they
influence the diverse mechanisms in the analytical relationship.

The Therapeutic Relationship in Psychoanalytical Couple Psychotherapy

In addition to the mechanisms that we have mentioned above, couple psychotherapy is
also characterized by a series of specific features that make the therapeutic relationship
more complex and require more effort by the analyst, who must be attentive to the
different mechanisms that appear. When designing a couple treatment, the analyst will
need to consider some points.

In couple therapy, there is a prior relationship between the members of the couple and
this will naturally influence the relationship with the therapist (Symonds & Horvath,
2004). There is a third person in the room who shares a history of mutual frustration and
each partner’s failure with the other. Couples tend to seek therapy together because each
partner has repeatedly failed to respond empathetically to the other, or to offer the security
the other needs. Each one has felt hurt by his or her partner and incapable of repairing the
ruptures in their bond, and the defensive postures they both adopt create barriers to
communication and intimacy (Livingstone, 1995). Early childhood experiences affect
each partner’s capacity for responding to the other’s transferential needs and demands, as
well as giving rise to problems in the communication between them. This situation often
immerses them in a pattern of repetition of actions that enslave them. They are uncon-
sciously recreating past scenes while yet living in fear of repeating them. They are facing
what Stolorow, Brandchaft, and Atwood (1987) have defined as the fundamental conflict
that can be treated and worked on in couple treatment. The marital conflicts and
dissatisfaction that the couple brings to treatment are frequently the result of repeated
attempts to resolve a childhood dilemma and changing these dynamics, which have
worked for so long, is a highly complex undertaking because, in their resistance, the
couple will often hinder the analytical work.

Numerous authors have discussed the phenomenon, which often occurs at the start of
couple psychotherapy, when one of the members is more motivated than the other, or
when one of them forces the other to attend. It frequently happens that the latter appears
to be incapable of describing the problem and has little expectation of change. The other
partner has high expectations and is willing to work with the therapist. Lemaire (1998)
says that, in these cases, it is important for the therapist to help the partner who is less
motivated to express his or her malaise in the joint interview until such a time as it would
seem they would benefit from working together. When, with help from the therapist, the
less motivated partner feels that his or her suffering and complaints are understood by the

9COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

other, they may come to share a real desire for therapy. As Goldner (2004) notes, both
partners must be always defined as partners.

In most couples who seek therapy one partner believes that the other is primarily
responsible for the couple’s troubles. The therapist must tell them what they do not want
to admit: that the couple is trapped in a system that they have jointly created. By means
of unconscious yet observable maneuvers, each member of the couple prompts the other
to keep repeating the same kinds of behavior which are seen as “problems.” In most
cases, interpreting the couple’s problems from the interpersonal standpoint enables the
partners to come together to solve the conflict. As noted above, interpretations of the
coconstruction of problems are crucial for couple therapy. Each of the partners must
be supported in turn so they can develop the ability to set aside their own needs and
shift the focus from their own subjective existence in order to provide empathetic
support to the other. In part, this ability can be strengthened through the bond with the
therapist as the therapist helps each member and thereby reinforces their capacities
and psychological structure (Livingstone, 1995).

Couple therapy often takes place in a setting characterized by conflict, emotional
tension, vulnerability, and threat. Resentment, frustration, and hostility are frequently
present at the expense of the collaboration, mutual concern, and respect which are so
crucial to the therapeutic relationship and psychoanalytical work. Each partner feels
threatened by the other. Chaos and fear of suffering further trauma prevail in this kind of
therapeutic situation. The reason for this maelstrom of primitive emotions is that the
partner is the closest equivalent in adult life to the early bond between mother and
baby (Dicks, 1967). In this regard, Alexander and Van der Heide (1997) stress that
extremely intense displays of rage and aggression often appear in couple psychother-
apy and these may trigger strong reactions in the therapist. The hypothesis that the
origins of this rage and aggression are to be found in early relational patterns and are
reactivated in the context of subsequent intense relations provides valuable therapeu-
tic insight which can be interpreted in order to help the couples in conflict to endure
destructive interactions that are apparently based on rage.

The intensity of countertransferential relations is an important factor in the difficulty
entailed in the couple interview, especially in the case of couple psychotherapy. The
presence of both members, with all the concomitant countertransferential complexity,
triggers multiple effects mobilized by the symbolic relationship of the primary scene.
These difficulties translate into the fatigue felt by the therapist because of the need to
attend to the convoluted countertransference phenomenon.

All of the complexity of the transferential dynamics and interplay of projections inside
the couple must be understood as intricate in a multisubjective setting. In this setting, the
members of the couple have a subjective experience of treatment and, more importantly,
of the therapist. One highly significant aspect of this experience is the gradual revelation
of developmental needs to the therapist. Both members of the couple need the therapist in
order to function in a way that improves their sense of self cohesiveness and generates
self-esteem. When one partner threatens to deny the other’s subjective experience, the
therapist must intervene to protect that person from feeling invalidated. It is essential that
the therapist should not make the mistake of playing the role of judge. Each subjective
position should be treated as valid, although neither should be elevated to the status of
concrete reality. Only when this multisubjective standpoint is encouraged can couple
sessions become a safe enough place for transferences and narcissistic and archaic desires
to surface and thus be worked on. The process of gradually creating— or negotiating—a

10 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

vision of reality that encompasses the experience of all three participants is essential in
transforming the marital conflict into empathetic mutual growth in the relationship.

Certain skills and knowledge in the couple about the transferential-countertransferen-
tial processes must be interpreted. Both have profound needs that they hope their partner
will meet. Some of these needs may be met, while others are not. The couple needs to
know which of these needs must be manifested and accepted, and this is an extremely
complicated undertaking. They need to know how to listen and allow feelings that may
frighten them if they are expressed, especially if this entails one partner’s subjective
experience of the other in a way that contradicts his or her self-image, or if it means
dealing with problems that the person is ashamed of. Each partner must leave room for the
other to express this kind of feeling and, if they feel supported by the therapist, who
realizes how difficult this is, the task can be made much easier. Thanks to the therapist’s
listening and understanding, the couple gradually sees that their ability to attain shared
objectives is strengthened in therapy. Another difficulty faced by couples in treatment is
the resistance of both members to being the one who initiates the change, since both
partners often show strong unconscious feelings of loyalty toward the other, and they fear
that changing might mean leaving the other behind, perhaps permanently. One partner
does not want to commit to change without the other. It is important that the therapist
should describe in detail the extent to which this loyalty to one another hinders their
growth. The other protective aspect of resistance to change lies in the way each person
relates with his or her own defensive responses and accusations. Each partner selfishly
tries to frame the other as the promoter of change in an attempt to avoid being the first one
to abandon the old rules or even their partner. They perceive their problematic refusal to
budge as being protective of the other but it is also defensive, a kind of “couple contract”
(Goldklank, 2009).

What is more, the fact that the relationship includes three people might also encourage
each partner to try to ally with the therapist against the other partner, a factor that should
be borne in mind since the potential consequences of this include abandonment of
treatment by the partner who feels excluded. For example, it is not enough to be sensitive
to the person who is making an effort to express demands but the therapist must also
maintain empathetic sensibility to the experience of the partner who is the target of these
demands. In the triadic universe of couple therapy another experience and an additional
subjectivity are included. In this setting, both partners bring an insistent need to be at the
center of the treatment, to be understood, and unlike the analyst, they do not have a strong
enough self-reflexive or empathetic capacity, and neither are they able to subordinate their
own needs and bring their partner’s needs to the fore. In many married couples, if the
partners did have these skills, there would be no need for treatment. The therapist’s
difficulty when interpreting— bearing in mind that the situation is triangular—is finding
the right moment and way to share the interpretation, which should be joint, since one of
the members may feel attacked, or may try to establish an individual alliance with the
therapist (Pérez Testor & Pérez Testor, 2006). In this case, if no limits were laid down, a
constant alliance would be established between the therapist and the partner who is better
able to understand their shared unconscious background (Lemaire, 1998).

In couple therapy, everything that happens in the sessions has consequences in the
couple’s real life which can then have a major effect in the treatment. For example, one
member of the couple may reveal a fact or secret, which is experienced as a betrayal by
the other, and this can lead to problems for the partners in their daily life, which will, in
turn, affect the analytical relationship with the therapist and the analysis itself. At this
point, extratransferential interpretation of what happens outside of therapy will be ex-

11COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

tremely important to the success of the treatment, since whatever transpires between the
couple outside of therapy cannot be ignored (Pérez Testor & Pérez Testor, 2006).

The couple’s individual capacities for working together are a key factor in couple
treatment and an essential element in the success of the therapy. The therapist may
influence and reinforce this capacity in the partners. Sometimes a shift is needed toward
exploring the experience of the partner who listens to the other’s demands so that they can
both develop a greater tolerance of the malaise. The therapist must always be aware of the
multisubjective situation and the needs and vulnerabilities of both partners. The most
difficult part is protecting the vulnerability of one of the partners without losing sight of
the other. The therapist brings his or her own organizational principles and subjective
sense of reality to the situation. We believe that the contribution of the self-psychology
theory (Kohut, 1971) to couple treatment is interesting in terms of its legitimation of both
subjects’ needs for development. A partner feeling that his or her needs are labeled or
treated as infantile and/or undesirable, is likely to abandon therapy or even rupture the
marital bond since reciprocal needs spur intense interactions within the couple. Attention
must be paid to allaying each partner’s apprehension about performing the other’s
developmental functions by exploring the fear that doing so would totally block expres-
sion of the person’s own needs and desires.

Clinical Case

In order to illustrate the foregoing material, we now present a clinical vignette of a couple
that came to our center seeking assistance. Pedro is 44 years old and Cristina is 42. They
have been married for 15 years and have two children. Pedro works as an administrative
assistant in a company manufacturing adhesive labels, and Cristina is the sales manager
of a bank. At the first session, Cristina seemed very angry, hurt, and disappointed while
her husband seemed contrite and repentant.

Cristina: I’ve been wanting to come here for a long time. I’ve asked him to come many times
but he doesn’t believe in psychologists . . . but he finally agreed to come . . .

Pedro: I don’t have anything against psychologists, but I didn’t think we needed to come here.
We can fix things ourselves. Well, at least that’s what I used to think. Now I think we need help.

Cristina: I just can’t take it anymore. Either we fix things or I’m leaving him. Two weeks ago
I told him I wanted a divorce. At first he didn’t take me seriously, but when he saw that I meant
it he called his mother to ask her for the name of a couple therapist. And here we are.

Therapist: It seems that you both feel as if things have reached the breaking point.

Pedro: No, no, it’s normal for couples to have their disagreements and if they can’t solve them,
they have to go to the doctor . . . If you’re ill you go to the doctor and he gives you a pill . . .
right?

Cristina: It’s not a problem for pills. The therapist is right. I’ve reached the breaking point. I
can’t take it anymore.

Pedro: That was just an example. I’m not expecting him to give us pills.

When this first session started, the analyst noticed how the woman was unconsciously
trying to ally herself with him, presenting herself as the collaborating half of the couple
and adopting the role of the victim with whom it would be easy to engage in collusion.
The therapist tried to rescue the husband, the half of the couple that has been forced to

12 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

come to therapy. With this intervention, the husband becomes aware that his point of view
is also important to the therapist, irrespective of his judgment of his wife, while the wife’s
complaint shifts from being one-way to having shared meaning.

Cristina: Explain to the therapist why I asked you for a divorce. Tell him what you’ve done to
me. You should be so ashamed . . .

Pedro: You’re really exaggerating; it’s not that bad . . .

Cristina: It’s not that bad? Tell him and see what he says!

Therapist: This is our first meeting and it would be helpful if you could tell why you’ve come,
what exactly your problems are. The aim of the exercise is not to judge but to understand what
is making you suffer.

The therapist explains the working methodology. They are not in a courtroom and he
is not going to say who is right or wrong but, rather, he is going to help both of them to
understand what is happening to them as a couple. It is very common for each partner
to see the couple therapist as a judge who will prove them right. From the very first
session, the analyst was aware of the “dyadic dimension of the demand or symptom”
(Sommantico & Boscaino, 2006) as a way of understanding what belonged to the
functioning of the couple as an entity, even if it was expressed in the guise of just one
partner’s symptom. He also realized what the function of the conflict was for the
couple and glimpsed its unconscious meanings. The analyst is sensitive to the wife’s
demands, but he also tries empathetically to integrate the husband’s experience as the
target of these complaints.

Pedro: Well, it was a bad time. I was under a lot of pressure.

Cristina: Excuses!

Pedro: Are you going to let me speak or are you going to interrupt me all the time . . .?

Cristina: If you’re going to be aggressive we’re not going to get anywhere. Can you see what
I have to put up with? (to the therapist)

Therapist: Both of you are suffering and it is difficult to give each other room to be heard.

This is another attempt by the woman to ally herself with the therapist, which the
therapist neutralizes with an integrative intervention that allows the situation to move
forward. The analyst is witnessing a clash between the infantile parts of the couple
(Robert, 2006).

In countertransferential terms, the therapist is aware of feeling closer to the man than
to the woman, and he has no empathy with the woman’s role of victim. Being aware of
this feeling, the therapist does not act it out by creating an alliance with the man. Then
again, the couple gives the role of judge to the therapist but he feels the pressure of this
and does not act it out. Transferentially speaking, the woman perceives the paternal
aspects of the therapist and wants to behave accordingly, trying to show him that she is
the mature part of the couple, and complaining about her immature husband. The man
seems to link the therapist with maternal aspects by taking on the role of a badly behaved
child and then trying to find excuses for this bad behavior.

Pedro: What happened is that I went to lunch with a female colleague without telling Cristina.
When I mentioned it to her she got really angry because she says that a married man shouldn’t
have lunch with a female colleague.

13COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

Each couple shares an intradyadic space of their own, along with extradyadic limita-
tions agreed to either implicitly or explicitly. In this case, the agreement was implicit. It
had never been verbalized, but it was taken for granted. The fact that the husband had
lunch with another woman without asking his wife first was seen as a betrayal. The joint
interview enabled the analyst to see the scope of the “betrayal” and the “unfaithfulness.”
The therapist does not judge whether this tacit agreement is right or suitable, but he can
demonstrate how one partner is not in any position to meet the other’s demands adequately
unless they have clearly stated their agreements. One of the partners, Cristina, tries to
forge an unconscious alliance with the therapist because of her need to feel supported as
the victim of her husband’s slight, and does not hesitate to label her husband as
“unfaithful” to the analyst. In the case of Cristina and Pedro, the joint interview seems to
indicate that the “betrayal” of an implicit agreement was not actually an act of unfaith-
fulness but an outcome of the fact that that both Pedro and Cristina are excessively and
collusively controlling.

Individual interviews do not allow the analyst to ascertain the other partner’s point of
view on what has happened. The advantage of the joint interview in couple therapy is
precisely the immediate “here and now” analysis. We work not only with the mental
couple that patients bring to the consulting room but also the real couple, which makes it
possible to expand the scope of couple analysis without forgetting that all couple therapy
is always a focal treatment (Pérez Testor & Pérez Testor, 2006).

In the next session, the husband seems to feel more comfortable and refers to the
previous session. A new focal point of couple conflict appears. This extends beyond the
lunch with the female colleague and offers the analyst valuable analytical insight.

Pedro: Your complaints are exaggerated. I’ve never been unfaithful to you. It was just a lunch
with a female colleague. It has nothing to do with the telephone conversations!

Cristina: It’s the same thing! Every time the flirting stops and I feel I can trust you, you prove
the opposite and I have no choice but to look at your mobile phone or emails, and I always end
up finding something. You’re just not trustworthy!

Pedro (to the therapist): Cristina is horribly unstable. Sometimes she ignores me and other
times she’s controlling and watches every move I make . . .

In this session, the analyst formulates a hypothesis on the dynamics of the couple
relationship: the woman’s difficulties generate this behavior in her husband, which in turn
triggers jealousy in her and he thus gets her attention, even if it is in the guise of
disproportionate control. Both are engaged in a game based on each partner’s struggle for
power over the other. Given that this is a hypothesis, the analyst keeps this idea in the form
of “floating attention” as he awaits confirmation.

In subsequent sessions, there are further revelations about the couple which enable the
therapist to bring their positions closer together.

Pedro: You have always been much more successful at work, you’re a great mother who has
a perfect relationship with our children, and I can’t come close to you in anything. You know
that and you love it . . .

Cristina: There are so many things I value about you. You never mentioned any of this to me.
It makes me really sad, but I also appreciate that you’ve been honest with me (crying).

The couple seems to feel that the therapy is a safe place where they can express their
worst fears. Over the course of several sessions, the analyst manages to get both of them
to see the husband’s flirting as a symptom of something that was not working in the

14 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

relationship, something that joined them and yet pulled them apart at the same time. The
husband was able to express how he did not feel valued by his wife. It seems that the
“awkward, weak, and fragile” side of Cristina was projected onto Pedro and this allowed
her to feel that she was the “strong, capable” partner.

In the exploration of their family backgrounds, Pedro tells how he was the third of five
siblings, with two elder brothers and two younger sisters. His mother was a housewife
who was totally devoted to her husband and children, while his father was a chemist in a
sugar factory. Later on, his role in the family emerged: from an early age, he was the child
who was the most troublesome to his mother because of his constant naughtiness and lack
of interest at school, although he did end up finishing his basic education and took a course
to be an administrative assistant, which qualified him for his current job, which he has held
for 25 years. Cristina is the eldest of three children and has two younger brothers. Her
father, who came from a well-to-do family, had his own lawyer’s office where her mother
worked as a clerk. A very attractive man, he had been unfaithful to his wife several times,
and the children had witnessed heated arguments between them. Cristina said that she had
always been a model daughter who looked after her two considerably younger brothers.
Moreover, her marks at both school and university were outstanding. In one of the
sessions, the analyst expressed what seemed to have been the roles that both had played
from a very early age.

Therapist: It seems that both of you have been repeating certain patterns of behavior and
relationship. Pedro was a child who got his mother’s attention by being naughty, which seemed
to shift her focus away from caring for her other four children, her husband, and her household.
Cristina seemed to be the girl who could do everything: look after her brothers, do well at
school, and deal with her parents’ conflicts, in which the successful husband was unfaithful to
his wife and she forgave him. It would seem that you are unwittingly repeating this pattern in
your couple relationship . . . and most probably each of you expects this kind of behavior from
the other.

Pedro and Cristina accepted this interpretation and both of them agreed that this was
somehow the pattern of relationship that characterized them. Thenceforth, both partners
felt much more committed to each other and tried to understand the unconscious mech-
anisms that had brought them together, even while both of them complained about these
selfsame mechanisms.

By exploring the early encounters of this couple, we were able to confirm the
hypothesis that what had attracted them at first was what was now tearing them apart
(Dicks, 1967). They met during the wife’s last year at university at a party given by mutual
friends. By that time, the husband was already working at his current job. When he saw
her, he was captivated by her social skills and physical appearance, and she was attracted
to him because, as she says, “he was the life of the party.” By the end of the night, after
they had been talking for a while, he was too drunk to go home alone so she accompanied
him to his door. After that, they started going out together and got married three years
later. From the very beginning of their relationship, the woman adopted the role of the
capable, responsible, and mature person, while the man was the needy, awkward one. In
all likelihood, this is what attracted both partners to each other through the mechanism of
projective identification, although it also gradually changed in the dynamic and deep-
seated conflict in the couple. The model of relationship in the parental couples unques-
tionably influenced both members’ choice of partner, as often happens. Cristina probably
felt attracted to a man who was a kind of “awkward joker,” the opposite of her successful,
distant father whom she associated with infidelity, couple conflicts, and her parents’

15COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

suffering. On the contrary, Pedro had seen that one way of getting Cristina’s attention was
through adolescent flirtations with other women, thus arousing jealousy in his wife, which
gave him some measure of control over her. This would seem to reflect a hysteroid
component of the woman’s personality: she does not feel desire when there is no other
woman lurking on the horizon. This may be due to inadequate resolution of the Oedipal
triangle since, even today, Cristina says that she has a poor relationship with her mother,
toward whom she feels resentment for being weak and too forgiving of her husband’s
infidelities, while also letting her conflicts with him radiate out to the other family
relationships. In turn, Cristina says that she has always felt great admiration for her father,
with whom she identifies. With regard to Pedro, we should note that when Cristina gave
him an ultimatum he called his mother, which leads us to wonder whether he displays a
lack of differentiation with her together with some degree of immaturity. In his wife, too,
he seeks a person who can solve his problems and forgive his misdeeds, just like his
mother did in his childhood.

As the treatment proceeded, both members of the couple attained the insight they
needed to understand their fundamental conflict (Stolorow et al., 1987) and admitted that,
despite their complaints about it, they had both participated in recreating it, since it
somehow brought them closer together. With individual treatment, this process of under-
standing would have been different. In this kind of therapy, the presence of the spouse and
the intersubjective dimension helps the therapist to alleviate the suffering in the couple
relationship. Finally, the couple ended the treatment with a significant improvement in
their relationship since they were now both able to understand and respond to the other’s
needs without feeling either attacked or judged by these needs. This improvement was also
reflected in their relationship with their children. In other cases, couple therapy enables the
two partners to understand that they cannot stay together and they decide to separate
amicably, protecting their children from the separation as much as possible. In this case,
too, we could consider the therapy successful. Couple therapy fails when it does not help
the couple to change and they remain together pathologically or separate aggressively. The
therapist should not try to “save” a marriage, since dissolving or saving a marriage is the
couple’s responsibility (Gurman, 1985).

Conclusions

As the case study shows, sometimes, in contrast with individual treatment, working with
couples holds out numerous benefits for both partners and their relationship. The “other”
and the intersubjective context in which the subject functions are basic factors in much of
the suffering that occurs in a couple’s love life and relationship and they would seem to
indicate couple treatment as a good way to work on this kind of pathology.

The presence of the partner during therapy becomes a decisive factor in the way the
treatment evolves and in the dynamics of the sessions. The couple works and grows
together, and this has an enormous benefit in their real lives as both members learn and
advance in understanding as a shared project. The feeling of working, learning, and
growing in a mutual endeavor makes both partners more confident and eager to improve
their relationship and this has numerous positive effects in their daily lives. Usually,
especially if the treatment evolves appropriately, the partners eventually feel safer and
more willing to express whatever they feel, and tell each other things that they would not
say in a normal context. This, in fact, is one of the most useful therapeutic tools in couple
psychotherapy. Another good reason for couple treatment is that if a couple with children

16 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

overcomes their conflicts, the children also benefit since they are usually the objects of
massive projections of their parents’ distress. The children of distressed couple relation-
ships are more likely to suffer from anxiety, depression, conduct problems, and impaired
physical health (Gurman, 2011).

Recent cultural shifts have also had an effect on the way psychoanalysis and psycho-
therapy are carried out, and psychoanalysis has tended to focus on attachment pathology
giving more prominence to couple psychotherapy. Nowadays, the values of a postmodern,
society, or “liquid society” in Bauman’s words (2003), have had an impact on the choice
of couple psychotherapy. The accelerated pace of life, the need for fast results, “liquid
love” (Bauman, 2003) and the difficulties of intimacy, among other factors, have made
couple treatment more suitable in some cases than individual psychoanalysis. The design
of this kind of psychotherapy requires analysts to be knowledgeable about the mechanisms
and factors that come into play in this kind of treatment.

As shown throughout this paper, new challenges and demands arise in psychoanalytic
couple psychotherapy, thus making both the analysis and the therapeutic relationship more
complex. We would say that the interpretative focal point is the couple, not either member
but both of them together, their relationship, and their collusion. A basic technical
guideline is the initial reframing of the problem, which requires individual goals to be
transformed into goals for the dyad so that both individuals experience the analytical
process as “our therapy.”

Transference and countertransference are also present in couple therapy and require
the therapist to be sensitive to them. While all psychotherapy entails observing transfer-
ential and countertransferential movements, in couple psychotherapy these levels are
multiplied. Including a second professional as a cotherapist in order to work as a foursome
(couple cotherapy) can smooth the progress of joint treatment.

For the therapist, handling the countertransferential responses in this kind of therapy
is an even more complex challenge, since the situations are experienced in situ and involve
matters that arouse more emotional responses in the therapist, these including parenthood,
the couple, and birth families. The therapist will therefore experience intense counter-
transference and must be ready at times to deal with a combined attack from both partners.

Bearing in mind this array of challenges and demands implicit in couple analysis, we
believe that it is important to keep studying the different mechanisms that come into play
in couple treatment with the aim of gathering new data for research and clinical practice
within the framework of psychoanalysis.

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20 AZNAR-MARTÍNEZ, PÉREZ-TESTOR, DAVINS, AND ARAMBURU

http://dx.doi.org/10.1080/01926188408250155

COUPLE PSYCHOANALYTIC PSYCHOTHERAPY AS THE TREATMENT OF CHOICE: Indications, Challenges and Bene …

Why Couple Psychoanalytic Psychotherapy?
Psychopathology of the Couple Relationship
Psychoanalytical Treatment of the Couple
The Therapeutic Relationship in Psychoanalytical Couple Psychotherapy
Clinical Case
Conclusions
References

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