Sunday, February 05, 2012

Carla Leone - An Intersubjective Approach to Couple Therapy

I have been working to learn intersubjective approaches to couple therapy - it requires much more attentional focus than working with individuals, but over the brief time I have been trying to use this model (having tried and rejected many of the traditional models of couple and family therapy), I have been impressed by how quickly couples can shift when they feel their partners can hear and meet their needs.

Carla Leone has written three excellent articles on working with couples from a Self Psychology and intersubjective approach - one of those papers is excerpted below (you can read the whole paper at the link in the citation below). I await a book from her - I think her approach to couple therapy is very useful.

David Shaddock has also written some good material on intersubjective couple therapy, including Contexts and Connections: An Intersubjective Systems Approach to Couples Therapy and a presentation given at the 25th Annual Conference on the Psychology of the Self, "Couples therapy as therapy: Fostering individual growth in conjoint contexts."



Citation:
Leone, C. (2008). Couple therapy from the perspective of Self Psychology and intersubjectivity theory. Psychoanalytic Psychology, Vol. 25, No. 1, 79–98. DOI: 10.1037/0736-9735.25.1.79

COUPLE THERAPY FROM THE PERSPECTIVE OF SELF PSYCHOLOGY AND INTERSUBJECTIVITY THEORY
Carla Leone, PhD

Excerpts:
A contemporary self-psychological, intersubjective psychoanalytic framework offers a wealth of concepts that are particularly applicable to the unique challenges of couples work. The concepts of selfobject experience, unconscious organizing principles, and learned relational patterns; an emphasis on listening from within the patient’s perspective; and the model’s approach to defensiveness and aggression, in particular, make it extremely useful for understanding and intervening with troubled couples. This framework differs from the classical and object relations approaches to couples treatment (e.g., Dicks, 1967; Scharff & Scharff, 1991) in a number of important ways, and thus offers an alternative psychoanalytic approach to this challenging but often powerful and rewarding form of treatment. (p. 80)

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The concept of selfobject experience, as originally proposed by Kohut (1971, 1977, 1984) and revised and extended by others (Stolorow, Brandshaft, & Atwood, 1987), captures much of what people are generally looking for in couples’ relationships: experiences that help them consolidate and maintain a positive, cohesive sense of self. More simply, people want a partner who makes them feel better, not worse. This generally means someone understanding, positive, and affirming; someone they can look up to, admire, and lean on in times of stress, who helps with the experience, modulation and integration of affect; and someone with whom they feel a sense of essential likeness and belonging—in other words, someone who functions as a reliable source of selfobject experience.

Troubled, conflictual couples are not reliably able to provide these experiences for each other. A lack of needed selfobject experience underlies most or all couples’ presenting problems, whether the problems involve conflict or disengagement, and whether overtly about sex, money, housework, parenting, in-laws, or whatever. (p. 81)

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Couples’ relationships are highly influenced by the extent to which each partner has developed a positive, cohesive sense of self and the ability to articulate, regulate, and integrate affect. People who have not done so are more dependent on others to provide self-functions, such as affirmation or soothing. They are more reactive to injuries or selfobject failures, and either too overwhelmed by their own affective experience or too affectively deadened to empathically grasp and respond to the experience of others. These deficits thus leave them with more intense needs for responsiveness, yet less capacity to be responsive. (p. 82)

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Couples’ relationships are also influenced by the particular ways partners experience each other and their interactions. According to intersubjectivity theory, people experience the world through the lens of their particular organizing frameworks–unique unconscious organizing principles or templates–that formed based on early relational experiences (Stolorow, Brandshaft, & Atwood, 1987). This is a contemporary definition of transference, which differs from previous views of transference as distortion, projection, and so forth. These unconscious organizing processes influence what partners expect and fear in relationships, what they notice or attend to, the psychic “meaning” of interactions, and their emotional and behavioral responses to others. (p. 83)

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Unconscious organizing principles or frameworks help explain how and why people so often end up with partners who are so tragically similar to early figures, despite having consciously intended to find someone very different. (p. 83)

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The concepts of the selfobject and repetitive dimensions of experience (Stolorow, Brandshaft, & Atwood, 1987), thought to exist in a figure-ground relationship to each other, help shed light on these questions. In the early part of a relationship, the selfobject dimension of experience is generally in the foreground. Each person views the other primarily through the organizing lens of the viewer’s selfobject needs and longings–as a potential source of needed selfobject experience. Through this lens, the ways the other person meets (or seems to meet) the viewer’s selfobject needs are in clearest focus, whereas the ways they do not are seemingly not noticed or attended to. This is the wonderful, exhilarating, blissful part of the relationship, before the new partners have ever experienced each other through the lens of the repetitive dimension of experience. (p. 84)

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At some point during this “honeymoon” or selfobject dimension phase, a selfobject failure or empathic rupture triggers the emergence of the repetitive dimension of experience. One partner then shifts to experiencing the other primarily through the lens of previous negative relational experiences. At this point, the partner’s similarities to previous disappointing others are most noticed and attended to. (p. 84)

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A final point about how partners end up with someone so painfully similar to early figures: people do not fall for just anyone who offers the missing selfobject experiences they need. ... Rather, we are particularly attracted to those who offer important selfobject experiences and seem (consciously or unconsciously) similar to early figures in important ways. The similarities feel familiar and offer the potentially more powerful corrective experience of getting the needed responses from someone very similar to the parents or caretakers–perhaps the next best thing to getting such responses from them directly. Unfortunately, of course, the similarities set the stage for terrible repetitions of previous disappointments as well. (p. 84)

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Self-capacities and organizing frameworks, discussed in the previous two sections, influence the way people behave in relationships. They affect how we typically cue others to our needs and feelings, what we do when we are hurt, disappointed or angry, how sexual feelings and needs are expressed, and so on. These patterns are internalized based on the interactional patterns the developing child witnessed and was part of. (p. 84-85)

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(Note: The concept of learned relational patterns as I use it here is generally consistent with the work of Stolorow and his colleagues, discussed above, as well as with the concepts of implicit relational knowing or implicit relational procedures as discussed by the Boston Process of Change group (Lyons-Ruth, 1997), Herzog’s “relational templates” (Herzog, 2004), Beebe and Lachmann’s patterns of self and mutual regulation (Beebe & Lachmann, 2002), and the work of Mitchell and other relational theorists on relational patterns (e.g., Mitchell, 1988, 1997). For the purposes of this paper, the nuances of the distinctions between these concepts are not relevant.) (p. 85)

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In this model, the essential goal of treatment is to help partners to become more able to function as a source of selfobject experiences for each other in a reliable, reciprocal manner. Doing so involves the ability to communicate needs clearly, grasp each other’s selfobject needs and notice each other’s cues, understand each other’s experience and behaviors, tolerate occasional empathic failures without experiencing them as threatening to the self, and repair empathic ruptures quickly. These abilities are related to the three areas discussed above: the state of the self, the organization of the experience of others (transference), and learned relational patterns.

Self-deficits are addressed by focusing on the self-experience and selfobject needs of each partner, such that the therapist becomes a source of selfobject experience for each. The goal is to facilitate the development of a more positive, cohesive sense of self, and the ability to experience and regulate affect adaptively. This process was originally conceptualized as the gradual internalization of functions initially provided by the therapist (Kohut, 1971, 1977) and later as a gradual reorganization of the experience of the self (Stolorow, Brandshaft, & Atwood, 1987). It occurs through a process of empathic immersion into the subjective inner world of each partner and the establishment of a therapeutic dialogue with each partner. Through this dialogue, each patient’s selfobject needs can be met his or her and self-experience illuminated, understood, and gradually transformed.

The dialogue also turns partners’ attention toward understanding how they came to experience themselves, others, and their current relationship as they do. The underlying meanings of each partner’s complaints are understood and illuminated, especially as they reflect unmet selfobject needs from early relationships and the influence of the repetitive dimension of experience.

The therapist and partners gradually identify and examine relationship behaviors or patterns in terms of how they developed historically and the purposes (such as defensive or protective) they are currently serving. The therapeutic relationship and the couple’s relationship serve to illuminate these old relational patterns and offer the opportunity to develop new relationships through which these old patterns and templates can be transformed.

The couple therapist focuses on developing a selfobject relationship with both partners and facilitating selfobject experience between them. She listens carefully to each partner from within that partner’s own subjective perspective and attempts to respond in an attuned manner to each partner’s selfobject needs of the moment. She attends carefully to the state of the self of each and makes every effort to make the sessions a safe place where narcissistic injury is minimized and empathic ruptures are quickly explored and repaired. The focus is on both promoting insight and understanding and on helping partners develop new relationship behaviors. Thus, interventions include empathic reflections and interpretations, setting empathic limits when needed, and directive or coaching interventions when these facilitate selfobject experience between the partners. (p. 85-86)

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Several aspects of self-psychology theory are particularly relevant to difficulties that commonly arise in the treatment of couples. These difficulties include cases in which the therapist understands one partner more easily than the other; those in which one or both partners are easily narcissistically injured, defensive, or resistant; and partners who are blaming, hostile, and/or aggressive. Self-psychological concepts most useful when dealing with these difficulties will be discussed in turn.

Equal Empathic Immersion
The concept of listening from within the patient’s own subjective perspective is a major contribution to individual treatment, yet is perhaps even more crucial in couple work where there is another perspective to listen within. An emphasis on understanding each patient from within his or her own subjective perspective can help therapists avoid a classic pitfall of couple work: the tendency to identify with or understand one partner more easily than the other and to intentionally or unintentionally side with one against the other.

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I have found it more helpful to pay close attention to my listening stance or vantage point and try to deliberately shift it whenever I notice that I am not equally empathically in touch with both partners. In general, whenever one partner’s view has seemed more correct, valid, or reasonable than the other’s, I have found that I am not listening to the less-valid-seeming partner from within that person’s own subjective perspective.
 
Ringstrom (1994) presented a compelling example of a couple in which the husband initially seemed to the therapist to be much more disturbed than the wife, just as the wife contended. However, when the man’s odd and alarming behaviors were explored and understood in depth from within his own perspective, what initially looked “crazy” to both the wife and therapist became much more understandable. I have had similar, though less dramatic, experiences on many occasions with couples.

Of course, deliberately shifting one’s listening stance is more easily said than done. Couple work often leads to intense emotional reactions in the therapist that can interfere with the smooth shifting of listening stances and achievement of the goal of equal empathic immersion. This work often involves sitting with partners who are intensely angry, hurt, or miserable, who are actively hurting each other before our eyes, and/or who are terribly stuck - unable to make their relationship work yet unable to get out of it. (p. 86-87)

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Narcissistic Injury and the Rupture and Repair Sequence
The risk of narcissistic injury seems to me to be even higher in couple work than in individual treatment modalities. Partners frequently injure each other during couple sessions, and empathic ruptures between therapist and patients are also more frequent because the therapist’s attention is divided. Thus, an understanding of narcissistic vulnerability and an emphasis on the repair of empathic ruptures are particularly important in couple work.

With this in mind, when working with couples I experience myself as vigilantly, constantly monitoring the state of the self of each partner and their moment to moment sense of injury as it is conveyed verbally and nonverbally. Although I certainly watch for and process empathic ruptures in individual work as well, I am less vigilant since injuries occur less often. With couples, I scrutinize each partner for signs of injury, “sniff it out,” and intervene quickly in an effort to reduce, recognize, and repair injuries. This can involve anything from a glance that conveys “Ouch, I know that hurt” to empathic limits on hurtful, abusive behavior, to seeing partners separately in certain circumstances if they cannot avoid traumatically injuring each other when seen together.

As I have discussed in more detail elsewhere (Leone, 2001), one of my guidelines for determining when to see partners (or family members) together versus separately is the degree to which they are able to be in the same room without constant traumatic narcissistic injuries to each other. A full discussion of the advantages and disadvantages of seeing partners separately is beyond the scope of this paper, but protecting each from further traumatic injury is an important factor to be considered when making this decision.
 
When partners are seen together, it is important that the therapist help them convey their unmet needs and complaints in a manner that is sensitive to the narcissistic needs of the partner who is the target of the complaints. The goal is to make the sessions a place where selfobject experience can occur, not selfobject injury. This may require the therapist to take an active role in empathically setting limits or containing patients who are intentionally or inadvertently hurting each other. (p. 87-88)

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For example, the therapist might say, “I understand how furious you are and how much you need to say this, but I want to help you say it in a way that increases the likelihood you can get the response you need.” The goal is to help partners take much better care of the other’s narcissistic needs while also conveying their own needs and complaints.
 
Whenever possible, the therapist can also point out and affirm any “forward edge” or growth-promoting aspects of a particular behavior or comment, whereas also noting its problematic or “trailing edge” aspects (Tolpin, 2002). (p. 88)

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Defensiveness and Resistance as Self-Protection
Self psychology’s view of defensiveness and resistance as “obligatory measures of self-protection” (Wolf, 1984) is an important contribution to individual treatment, but is perhaps even more important in couple work where partners are often more defensive and resistant than they are in the safety and security of the individual analytic hour. For example, couple therapists frequently struggle with couples in which one or both partners firmly believe the difficulties in the relationship are caused solely or primarily by the other person. Other examples include partners who argue with or reject any critical feedback they receive and couples in which one or both partners are extremely resistant to engaging in couple treatment despite clear relationship difficulties. In such cases, a focus on listening from within each partner’s own subjective perspective (which can be imagined, in the case of a spouse who is not present) and on understanding the self-protective function of the defensive behavior can be extremely useful.

In this model, the focus is not on confronting the defensiveness or overcoming the resistance but on understanding how such behaviors serve to protect a vulnerable self. (p. 88-89)

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Partners can also be helped to understand the function of defensiveness in themselves and each other. For example, those who are struggling with their partner’s refusal to enter couple treatment can be helped to see the partner’s reluctance to do so as natural and understandable given that person’s fears or previous experiences. I have often found that when one partner tells me the other will “never, ever, under any circumstances” agree to couple therapy, that person frequently understands very little about the reluctant partner’s reasons for refusing. When the willing partner is finally able to be empathic and responsive to the many legitimate reasons the reluctant partner has for refusing (fear of embarrassment, of being ganged up on, of retraumatization, or of loss; discomfort with a process that is not a social norm, and so on), the reluctant partner is often more amenable to reconsidering his or her decision. (p. 89)

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Aggression and Hostility as Expressions of Narcissistic Injury
Lastly, yelling, threatening, and aggressive words or even actions can be difficult enough to deal with in individual treatment, but when multiplied times two (or three, when the therapist gets angry, as well) they can be overwhelming. Self psychology’s conceptualization of anger and aggression as secondary to narcissistic injury or perceived threat to the self (Kohut, 1972) can help therapists stay grounded in the face of chaos and respond in ways that are most likely to help people move into a more vulnerable, less hostile place. 

Aggressive behaviors, including verbal aggression, can be understood as efforts to do one or more of the following: communicate the experience of injury or threat and put a stop to the injurious behavior, demand or otherwise elicit desperately needed selfobject responses, and restore or shore up the self. Anger, especially outrage and righteous indignation, can be energizing and vitalizing (Lachmann, 2000). These feelings “pump us up,” restore a sense of power and potency, and protect us from more vulnerable feelings such as hurt, sadness, or shame (Livingston, 1998). Aggressive ways of responding to disappointment or pain and of expressing angry feelings developed through the partners’ repeated early experiences of the ways these feelings were expressed and dealt with in their families.

With these concepts in mind, the therapist can respond to anger and aggression by empathically appreciating and legitimizing the angry person’s experience while also limiting its inappropriate expression. This involves first matching the angry person’s affective tone and summarizing his or her position in an emotionally intense manner that captures the person’s experience as closely as possible. Hearing one’s angry feelings accurately and powerfully articulated can have an immediately calming effect: people don’t feel as great a need to continue ranting or building a case once it is clear that their position has been accurately understood in depth. (p. 89-90)

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In addition to an accurate empathic encapsulation of the angry partner’s experience, the therapist may need to set empathic limits on the expression of anger to keep the session safe and to help structure and contain an out-of-control person. As discussed in the last section, the therapist should be careful to avoid using an authoritarian or reprimanding tone and should instead emphasize her empathic understanding of the reasons for the behavior, or its forward edge aspects, if any, whereas also gently limiting it. “I can see how that would have made you furious, how it would have hurt you and provoked you. And I think it’s very healthy for you to find a way to say, ‘no, I won’t be hurt in that old way anymore,’ but in order for that to happen, we’ve got to help you do this differently,” the therapist might say. (p. 90)

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Finally, once the angry person feels thoroughly understood and is in a calmer, more reflective place, the therapist can begin to focus on exploring and making sense of the anger in terms of the concepts just discussed. Rage can be translated into the language of unmet needs and injuries, old injuries that were repeated or reactivated by the current precipitant can be identified, and the influence of the patient’s particular ways of organizing experience can be explored. The energizing, restorative, or protective functions of the anger or outrage and the influence of each partner’s early experiences of anger can be identified and understood. (p. 90)

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Directive Interventions as Selfobject Experiences
Although understanding and explaining were the only intervention options for classical self psychologists, more recently noninterpretive interventions have been viewed as appropriate when they are experienced by the patient as a selfobject response (e.g., Bacal, 1990). For example, a number of authors have advocated a more intersubjective relatedness (Shane, Shane, & Gales, 1995) or subject-to-subject relatedness (Jacobs, 1995) between therapist and patient, when this form of relating is judged to be optimal for the patient. In this section, I suggest that directive, educating, or behavioral techniques can also be experienced as optimally responsive by some patients.

Consistent with this view, Connors (2001) recently discussed the role of active, symptom-focused techniques in the self psychologically informed treatment of anxiety disorders and behavior disorders. I agree with her assertion that “reduction of symptomatic problems strengthens the self and facilitates deeper levels of self-exploration and therapeutic involvement” (Connors, 2001, p. 74). This framework is consistent with the work of Basch (1988) regarding the “spiral” relationship between behavior change and selfesteem and his use of directive, advice-giving interventions in certain cases. It is also consistent with the work of those calling for an integration of psychoanalytic and behavioral or directive approaches (Bader, 1994; Wachtel, 1994).

The use of directive, educating or advice-giving interventions can be particularly important in the treatment of relationships, where the goal is not only self-development, but also interpersonal behavior change. Helping partners become more attuned and responsive to each other may require a more psychoeducational or directive approach at times, such as when trying to help partners learn how to comfort each other, seduce each other, express anger adaptively, or otherwise understand and respond differently to each other. (p. 93)

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In contrast, I advocate the use of directive techniques when (and only when) they are experienced by one or both partners as a needed selfobject response or when they facilitate a selfobject experience between the partners. Thus, they may be used at any point in the treatment after the therapist has developed some empathic appreciation for each partner’s selfobject needs and a sense of how each might experience more directive interventions. From a self psychological perspective, directions, advice, exercises, and the like can be understood as idealizing selfobject functions, in which the therapist is experienced as someone who can be looked up to as a source of wisdom, care taking, and so on. Thus, they are most appropriate in the context of an idealizing transference from both partners, or when both seem to need structuring, containing or guidance. They may be especially important with patients who did not experience their parents as providing these things. (p. 94)

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Conclusion
Self-psychology and intersubjectivity theory can be very helpful to clinicians struggling with the challenges involved in treating couples. Understanding and reframing conflicts in terms of underlying selfobject needs, the influence of unconscious organizing frameworks and learned patterns of relating help couples become better able to meet each other’s selfobject needs. Basic tenets of self psychology, including listening from within the patient’s perspective, careful attention to narcissistic vulnerability, and an understanding of the functions of defense, resistance and aggression can be particularly useful in avoiding common pitfalls of couple work. Finally, directive interventions can be useful when they are experienced by the couple as responsive to a selfobject need or as facilitating selfobject experience between them. (p. 96)
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