Psychodynamic Family Therapy: Uncovering the Unconscious

• This therapy is derived from *principles of object relations and Freudian theory. * • The goal for psychodynamic family therapy, as with individual psychodynamic therapy, is *more self-awareness, which is created by bringing unconscious material into conscious thought. * • At the heart of this practice is the notion that *current family problems are due to unresolved issues with the previous generation. * • Interpersonal function is *distorted by attachments to past figures* and by the *handing down of secrets from one generation to the next. * • The psychodynamically oriented family therapist wants to *free the family from excessive attachment to the previous generation* and wants to help family members disclose secrets and express concomitant feelings (e.g., of anger or grief). • *Change is created through insight* that is often revealed in one individual at a time, in a serial fashion, as others look on. • In order to loosen the grip of the past on the present, the therapist uses several tools (including interpretation of transferential objects in the room, interpretation of projective identification, and the use of the genogram to make sense of generational transmission of issues). • In family therapy, transferential interpretations are made among family members, rather than between the patient and the therapist, as occurs in individual therapy. • For example, when Mr. Bean says "I guess I am not an expert when it comes to female problems," the therapist may have asked, "Who made you feel that way in your family of origin?" When he reveals that he has felt this way since his sister's suicide, he comes to understand how an old lens distorts his current vision (i.e., he still feels so guilty about his sister's death that he does not feel entitled to weigh in with opinions about his daughter's anorexia).

This therapist is like a lead-testing scientist who tests for levels of lead in one's garden to assess the legacy of toxins from previous homeowners. Only when the true condition of the soil has been revealed is the current homeowner free to make decisions about whether the soil is clean enough to plant root vegetables; somewhat contaminated, so that only fruit-bearing bushes will be safe; or so toxic that only flowers can be grown without hauling in truckloads of clean, fresh soil Examination of the past enables the current gardener, and, by analogy, parents, to make informed choices about how the current environment needs to be adjusted and what kind of growth is allowable.

• Shared belief that the past is active in the present • Initial experiences with attachment and connection are particularly relevant • Focus on how interpersonal and intrapersonal dynamics influence one another • Each approach has coined terms to describe phenomena in family systems

*James Framo* invites parents and adult siblings to come to an adult child's session; this tactic allows the past to be revisited in the present. This "family of origin" work is usually brief and intensive, and consists of two lengthy sessions on 2 consecutive days. The meetings may focus on unresolved issues or on disclosure of secrets; it allows the adult child to become less reactive to his or her parents. *Norman Paul* believes that most current symptoms in a family can be connected to a previous loss that has been insufficiently mourned. In family therapy, each member mourns an important loss while other members bear witness and consequently develop new stores of empathy. *Ivan Boszormenyi-Nagy* introduced the idea of the "family ledger," a multigenerational accounting system of obligations incurred and debts repaid over time. Symptoms are understood in terms of an individual's making sacrifices in his or her own life in order to repay an injustice from the past. *Adelaide Johnson 's* notion of superego lacunae: gaps in personal morality passes on by parents *Erik Erikson:* sociology and ego psychology *John Bowlby* *Nathan Ackerman:* The Psychodynamics of Family Life (1958) - the first book dealing strictly with diagnosis and treatment of families.

• *Nathan Ackerman* largely credited as the *father of psychodynamic approaches to family therapy* -Traditionally trained as an analyst -Based on Freudian ideas -Mental conflict arises when children learn and mis-learn that expressing basic impulses will lead to punishment -Conflict is signaled by unpleasant affect Ackerman greatly influenced and concentrated on the study on psychosexual stages on character formation and was *one of the first clinicians to attempt to integrate insights from individual psychotherapy* with the then newer ideas from systems theory. He is *best known* for his contribution to the *development of the psychodynamic approach to family therapy.* With regards to family therapy, Ackerman incorporated the idea of "the family being a social and emotional unit." His main focuses, with respect to family therapy, were intergenerational ties and conflicts, the influence of long-term social change impacting the family, the developmental stages of the family as a single unit, the importance of emotion within the family structure, and equal amounts of authority among parents. Ackerman connected *family context and the unconscious to pathology* *"Interlocking pathology"*: an *unconscious process that takes place between family members that keeps them together.* Unwritten rules about behavior, feelings, etc. are in place. *If members violate the rules they either leave the family system to become healthier or they are drawn back into dysfunctional patterns and behavior in order to stay connected.*

*Nagy*( 1920 - 2007), a *Hungarian American psychiatrist* was *one of the founders of the field of family therapy.* *emphasis on loyalty, trust, and relational ethics* -- both within the family and between the family and society -- made major contributions to the field of family therapy since its inception in the 1950's. A *student of Virginia Satir* and an accomplished scholar and clinician, Nagy was *trained as a psychoanalyst* and his work has encouraged many family therapists to incorporate psychoanalytic ideas with family therapy. *Nagy* is perhaps *best known* for *developing the contextual approach to family therapy*, which *emphasizes the ethical dimension of family development.* Based on the psychodynamic model, *contextual therapy accentuates* the need for *ethical principles* to be an *integral part of the therapeutic process.* Nagy believes that *trust, loyalty, and mutual support* are the *key elements* that *underlie family relationships and hold families together*, and that symptoms develop when a lack of caring and liability result in a breakdown of trust in relationships . The therapists' role is to help the family work through avoided emotional conflicts and to develop a sense of fairness among family members. The contextual model proposes relational ethics - the ethical or "justice" dimension of close relationships - as an overarching integrative conceptual and methodological principle. *Relational ethics* focuses in particular on the nature and roles of *connectedness, caring, reciprocity, loyalty, guilt, fairness, accountability, and trustworthiness* - within and between generations.

The contextual model, in its most well-known formulation, proposes four dimensions of relational reality, both as a guide for conducting therapy and for conceptualizing relational reality in general: *(1) Facts* (e.g., genetic input, physical health, ethnic-cultural background, socioeconomic status, basic historical facts, events in a person's life cycle, etc) *(2) Individual psychology* (the domain of most individual psychotherapies) *(3) Systemic transactions* (the domain covered by classical systemic family therapy: e.g., rules, power, alignments, triangles, feedback, etc) *(4) Relational ethics.* *These dimensions are taken to be inter-linked.*

*Multidirected partiality* is the *main methodological principle of contextual therapy*. Its aim is to *evoke a dialogue of responsible mutual position-taking among family members*. It consists of a sequential, empathic turning towards member after member (even absent members), in which both acknowledgement and expectation are directed at them. It is an alternative to the more common 'neutrality' or unilateral partiality of other approaches. It requires an appreciation of the *'ledger'* from each person's point of view, even that of the current victimizer. For example, a family comes into therapy desiring to fix their son's outbursts and oppositional defiant behavior. The therapist (and possibly a co-therapist where appropriate) would firstly seek basic information (including any relevant clinical or medical information), construct a genogram if possible, and have each family member explain their side of the story (either conjointly or in individual sessions as appropriate), in order to begin to understand the problem in terms of background facts, the relational context (i.e., intergenerational, interpersonal, and systemic), and deeper motivational factors (e.g., psychological processes, hidden loyalties and legacies, ledger imbalances, destructive entitlement resulting from real or perceived injustices, scapegoating, parentificationof the child, etc.), and not simply (as is commonly done in some other approaches) in terms of the 'behaviour', 'systemic interactions', or 'narratives' of the family and the son. Having gained this preliminary understanding of the situation, the therapist would firstly address any issues requiring urgent attention (e.g., physical welfare, prevention of violence, etc.), especially in relation to the interests of the most vulnerable member(s), whether or not they are present at the therapy sessions. The therapist would then go further, carefully and sequentially *'taking the side' of each member* (while seeking to maintain overall balance, but not 'joining' the family as occurs, for example, in structural therapy), the aim being to begin a genuine dialogue of mutual accountability, to reduce the reliance on dysfunctional acting-out, and to find resources (e.g., hope, will) for rebuilding relationships through mutual acknowledgement of both entitlements and obligations, shifts in attitude and intention and redemptive or rejunctive (i.e., 'trust-building') actions, that will in turn build individual and relational maturity and integrity (i.e., self-validation and self-delineation - contextual counterparts of Bowen's differentiation), and trustworthiness, which contextual therapists see as the ultimate relational resource for individual and family well-being. The contextual approach allows for the inclusion of many significant aspects of other approaches to psychotherapy and family therapy, provided that they are consistent with the overarching contextual principle of multilateral therapeutic ethical concern and accountability. In 1957, *Nagy* *established* the *Eastern Pennsylvania Psychiatric Institute (EPPI)* and served as codirector and cotherapist along with social worker Geraldine Spark. Nagy was also an *active researcher of schizophrenia* and family therapy and *coauthored Invisible loyalties: Reciprocity in intergenerational family therapy (Boszormenyi-Nagy ; Spark, 1973).*

1. Healthy psychological development based on good early environment - parents - good object relations 2. Positive attachment with mother 3. Separation/individuation - provision of reliable support from mother is necessary 4. Parents need to be empathetic and model idealization 5. Nagy: "loyalty and trust provide the glue that holds families together"

While non-psychoanalytic family therapists look at problems in interactions between people, *psychoanalytic therapists look at problems in the actual people in the family.* *Symptoms* come from *attempting to cope with unconscious conflicts and the anxiety* that signals the *emergence of repressed impulses.* Some problems can occur with parents not accepting children's separation *Kohut:* mirroring and idealization - when these needs aren't met from parents, children go on to be showy and seek admiration Fixation and regression in families - after marriage, people can go back to behaviors seen when they were younger *Nagy:* symptoms occur when trust breaks down in relationships - individuals feel the effects *Kernberg:* blurred boundaries between family members

1. *Free family members of unconscious restrictions* so that they'll be able to interact with one another as whole, healthy persons on the basis of current realities rather than unconscious images of the past. 2. Therapy focuses on *supporting defenses and helping communication* instead of analysis of defenses and finding repressed needs and impulses

1. *Insight is necessary:* want family members to understand and accept repressed parts of personalities. Need to work through previously unresolved issues from early development. 2. Important for *the therapist to establish a sense of security*

• *Don't focus on reassuring or advise or confronting*; silence is important. If the therapist does intervene it's to provide empathic understanding to help member of the family open up. • Analysts also *clarify things* that appear to be *hidden or need clarification* • *Mostly used with couples.* • *Explore four areas with couples:* internal experience, history of the experience, how partner can trigger the experience, and how the context of session and therapist's input might contribute to the situation

*Object Relations* is a theory of the *human personality developed from the study of the therapist-patient relationship as it reflects the mother-infant dyad.* The theory holds that the *infant's experience in relationship with the mother, or primary caregiver, is the primary determinant of personality formation* and that the infant's need for attachment is the motivating factor in the development of the infantile self. It is an amalgam of the work of British analysts *Ronald Fairbairn*, *Donald Winnicott*, and others of the British Independent group, augmented by that of *Melanie Klein* and the Kleinian group *Focus is on the first three years of life* and their *emphasis* on the experience of the *mother-infant relationship* as a major component of psychic structure formation. The character structure organized by this time provides a sense of personal identity that endures and remains relatively constant over time.

• Object Relations theory and therapy focus on internal objects. An *internal object* is a *piece of psychic structure that formed from the person's experiences with the important caretakers in earlier life.* • It is captured in the personality through the process of internalization, so that the personality thereafter bears the trace of that earlier relationship. • The *internal object* is *neither a memory nor a representation*, but is *rather an integral part of the self's being*. Internal objects become expressed in the individual's choice of, and interactions with, other people (i.e., external objects) in their present life. • Internal objects may also be modified through relationships with present external objects (such as the therapist).

*Internal objects are just one component of the self. In brief, the self comprises:* *(1)* the old-fashioned concept of the ego as an executive mechanism that modulates self-control through its control of motility, sphincters, and affect states, and that mediates relations with the outside world, *(2)* the internal objects, and *(3)* objects and parts of the ego bound together by the affects (feelings) appropriate to the child's experiences of those object relationships. *The self, then, refers to the combination of ego and internal objects in a unique, dynamic relation that comprises*

• Object Relations is an inclusive technical term that spans the intrapsychic and interpersonal dimensions. • It refers to the system of interactions and inter-relationships between the various elements of the self, which are then expressed in the arena of current relationships with other people. • Internal objects and other parts of the self are reciprocal with outer objects so that, in any relationship, the personalities are mutually influenced by each other. • *That is, external relationships are in constant interaction with internal psychic structures.*

Object relations theory puts the relationship between the therapist and the patient at the center of the way of working. While the therapist and patient join together in the task of examining the patient's internal world and its effect on the patient's relationships, at the same time the patient and therapist are in a relationship themselves. This therapeutic relationship forms the laboratory in which the therapist learns most centrally about the patient's ways of relating and the difficulties they include. As the therapist processes the experience of this current relationship, he or she is able to inform the patient about this experience. In this way, patient and therapist have a current shared relationship that both can study and learn from. The patient (or couple, family or group) establishes a current relationship with the therapist that reflects the internal object relations set that is brought to all of their relationships. The therapist's task is to experience these current expressions of object relationships by making himself or herself available to the fantasies, feelings, etc. that arise within them specifically in response to the patient. • This way of working is characterized by the use of what Freud termed transference and countertransference. • Object relations theory views the patient's transference as the expression of their internal object relationships within the therapeutic relationship itself. • Countertransference, on the other hand, is seen as the basis for the therapist's ability to understand and fully interpret the patient. The set of countertransference feelings and attitudes that are stirred up in the therapist during a course of therapy form a model of what happens inside the people with whom the patient is in relationship. Providing that therapists have been well trained and have had personal therapy so that their own personal issues do not interfere prominently, they are then in the position to use their internal experience with their patient to make sense of the patient's ways of relating. Object relations therapists, therefore, monitor their internal states of feeling and the ideas, associations, and fantasies that occur to them during treatment in order to make sense of the relationship with the patient. While the therapist does not report these experiences in raw and unmetabolized forms to the patient, they will examine them thoughtfully as the best set of clues as to the patient's problems in relating in depth, and will then use the countertransference to inform the ensuing interpretation of the transference.

Choices that families make, including partner choices, are based on *unresolved internal object relations issues* .... patterns repeat themselves *until awareness increases* and choices are made to *differentiate from past objects.*

Which function in ways unique to that family during developmental phases of the individuals and family. Which can be noted by the family therapist who attends to the family system as its members relate to each other and as a group relate to the therapist *Which repeat patterns of interaction embodying old ways of feeling and behaving rooted in earlier experience with each other and with families of origin.*

*Not symptom resolution, but:* • *Return to appropriate developmental phase of family life*, with a *capacity to master developmental stress* • Improved ability to *work as a group* • Approved ability to *differentiate* and to meet the needs of individual group members

Derives from psychoanalytic principles of: • Listening • Responding to unconscious material • Developing insight • Interpreting unresolved patterns from the past (repetitions of previous trauma) • Working in the transference and countertransference toward understanding and growth. • Provision of the space within a frame • Management of the environment • Promotion of reflection and curiosity • Giving feedback, support, advice, interpretation • Working through • Termination • Enlarging the field of participation • Encouraging interaction • Enlarging the field and depth of inquiry • Question feelings and value affective exchange • Object relations history

• Husband and wife psychiatrists who are *directors of the International Institute of Object Relations Therapy in DC* • *Unconscious themes* expressed in dreams and fantasies are evoked and investigated, *family histories* are explored and they relate to current relationships, interpretations are made to the family, insight is sought and transference and countertransference feelings are explored. • *Emphasis* is placed on *attachment and the possible destructive effects of early separation from caregivers.*

Scharff, D. E. and Scharff, J. S. (1987). Object Relations Family Therapy. Northvale, NJ: Jason Aronson Scharff, D. E. and Scharff, J. S. (1991). Object Relations Couple Therapy. Northvale, NJ: Jason Aronson Scharff, J. S. and Scharff, D. E. (In Press). The Primer of Object Relations Therapy, New, Expanded Edition. Northvale, NJ: Jason Aronson Scharff, J. S. and Scharff, D. E. (1994). Object Relations Therapy of Physical and Sexual Trauma. Northvale, NJ: Jason Aronson. Scharff, J. S. and Scharff, D. E. (1998). Object Relations Individual Therapy. Northvale, NJ: Jason Aronson.

*Internal psychic structure is built from the attachment relationship* When the *mother is unresponsive* an *infant experiences her as rejecting* and then "introjects" the experiencing of the mother as a rejecting object The *self* deals with this by *splitting this introject off from the image of the ideal mother *and pushing that into the unconscious This rejected object is then further split off into the *"need exciting"* (associated with longing) and *"need rejecting"* aspects (associated with rage) *The personality now consists of the:* *Central self:* attached to feelings of satisfaction and security to an ideal internal object *Craving self:* longlingly but unhappily attached to an exciting internal object *Rejecting self:* angrily attached to a rejecting internal object Fairburn would identify that the *rejecting object relationship system further suppresses the exciting object relationship system* *Couples therefore unconsciously look for lost parts of self in their partner*********** Longevity in marriage is then influenced by the goodness of fit between their lost parts of self and the de-repression of repressed parts of self (or another way of saying this: *each partner holds the potential to re-traumatize and potentially heal the other*). Klein would highlight the role of projective identification in marriage *(or "induction")* Induction or PI arises from infancy as a mental process of unconscious communication that functions along a continuum of defense to mature empathy

*Projection:* expel a part of self that is denied (or overvalued) and sees the spouse as if he/she were imbued with these qualities -If the projection fits then the spouse has valency *Projective Identification:* the spouse may or may not identify with the projection. In an ideal situation the spouse transforms the projection in a way that allows the individual to introject a modified version of self (containment and introjective identification) *Mutual projective and introjective identificatory processes:* while this process is occurring with one spouse the same is true for the other. Together the couple is containing and modifying each other's internal versions of self and object. -This governs mate selection -Falling in love -Quality of the sexual relationship -Level of intimacy -The nature of the marriage in general

*Projective and introjective identificatory* processes are *not mutually gratifying* Containment of the spouse's projections is *not possible* Cementing of the object relations set happens instead of its modification

*Setting the Frame*-includes the number ; length of sessions, the fee, management of the beginning ; end of session, and establishment of the way of working *Creating Psychological Space for Understanding*-dealing with the couple relationship rather than the individuals *Listening to the Unconscious*-be free of the need to get information and to make sense of things. Listen to the communication from the couple as a system. Listen for unconscious communication. Following themes, noting the meaning of silence, and working with fantasy and dream material. *Following the affect*-moments of emotion in sessions, in which projections and PI's become apparent.

Tends to be less concrete and measurable, consistent with the goals of therapy and the view of symptoms. Symptoms are the pathway to understanding so the elimination of them is not the primary goal. *Generally focused on mutual projective and introjective identifications* To improve the couple's holding capacities, improve capacity for empathy, intimacy, and sexuality

Setting the frame Listening to the unconscious Holding the neutral position Creating the psychological space: through development of a holding capacity to bear the anxiety of the emergency of unconscious material and affect through containment and to modify it through internal processing of projective identifications Use of Self Developing negative capability: "The therapist is without memory or desire" and remains skeptical of his/her views and hypotheses about the couple. Interpreting defense/anxieties about intimacy (about being seen by each other without projections)

*Harville Hendrix, Ph.D.*, with his *wife Helen LaKelly Hunt*, is the *creator* of *Imago Relationship Therapy.* *Hendrix* is best known for his book *Getting the Love You Want*, a New York Times best-seller, which gained popularity after Hendrix appeared on The Oprah Winfrey Show. With his wife, he founded the nonprofit organization Imago Relationships International, which trains therapists in Imago Therapy.

Getting the Love You Want: A Guide for Couples, 1988 Keeping the Love You Find, 1993 Giving the Love That Heals, 1997 Receiving Love, Atria, 2004

Assists couples in *unveiling their unconscious components* (the *Imago*) *that* *determine their choice of mate.* This therapy *combines spiritual and behavioral techniques* and *marries them* with *western psychological methodologies.* It arms the couple with the tools necessary to relate to each other and themselves in a positive and caring way, and reveals the emotional pathway formed in childhood that led them to their current situation. *Imago relationship therapy* involves *viewing a conflict between a couple as the answer to the situation*, not the cause of the disharmony. By *examining the conflict* itself, a *couple can unlock the key to the solution*. *Conflict* often arises as a result of an *underlying emotional discontent felt within the context of the relationship.* Outwardly it is *expressed through criticism, anger, and dissatisfaction.* When this situation presents itself, *many couples choose to turn to others for comfort and love.* *Imago Relationship Therapy* helps a couple *explore the root of the emotional hurt or need* and determines what *elements causes those issues to manifest as strenuous and negative comments, feelings, and behaviors.* Communication is often severed or non-existent when couples first seek therapy. By understanding that both parties of the couple are communicating from different sources of needs fulfillment, the dialogue becomes deciphered in a manner that is accepted and empathized by both parties. Couples who engage in conflicting behavior learn to realize that although the disagreements are not a threat to self-preservation on the conscious level, *they are on the unconscious level because they attack very real emotional perceptions.* *Our primitive selves revert to innate beliefs that in order to be adequately protected we must be outwardly loved.* Therefore, on a very real and subconscious level, *the lack of loving and accepting emotion results in a perceived threat.* As we *mature into adulthood*, we come *armed with our own roadmap* to help us *sustain our life force.* *In some cases, our maps are quite disjointed and subjective, making us more vulnerable to the threat of danger than our partners would assume.* This roadmap is what is referred to as "The Imago." *Imago therapy* focuses on *guiding each partner to understand and accept each other's map and furnishing them with the skills necessary to work as allies for the completion of those blueprints.*

*Nathan Ackerman* largely credited as the *father of psychodynamic approaches to family therapy*; traditionally trained as an analyst; Ackerman connected family context and the unconscious to pathology *Theoretical Rationale for Intervention Approach:* • Based on *Freudian ideas* • Mental conflict arises when children learn and mis-learn that expressing basic impulses will lead to punishment • Conflict is signaled by unpleasant affect: *anxiety or depression* • In order for conflict to be resolved there must be a *strengthening of defenses against a conflicted wish* or *defenses must be relaxed sufficiently to permit some gratification*

To *reduce conflict in the family* through understanding the *interplay between the intrapsychic and interpsychic dynamics at work within the family.* *Major goal* is to *free the family of unconscious restrictions*. Often accomplished through *interpretations of events and insight* on the part of family members regarding these events. *Differentiation*-Outcome is that family members are able to interact with one another without being weighted by unconscious processes of the past. *Crisis resolution*-focus is more on symptom reduction and fortification of defenses

*Transference*-in family therapy is utilized to understand dominant feelings within a family unit and delineate what emotions are being directed toward which people. Important to not personalize and utilize these interactions as a platform for dealing with unproductive emotions and styles of interaction with one another *Dream and Daydream Analysis*-Identification and analysis of needs not being met within the family *Confrontation* *Interpretation*-bringing unconscious conflicts into consciousness. Is insight oriented in that by bringing these issues to light they can be critically examined and somewhat resolved. *Focusing on Strengths* *Life History*-helps you reflect with the family on present and past patterns of interactions

Good enough mother/father Catalyst for change-work to generate interactions and facilitate the processing of ongoing problems

Often accomplished through *interpretations of events and insight* on the part of family members regarding these events. *Differentiation*-Outcome is that family members are able to interact with one another without being weighted by unconscious processes of the past. *Crisis resolution*-focus is more on symptom reduction and fortification of defenses

Linear focus on cause and effect material Expense in terms of finances and time in treatment Higher than average intellectual abilities typically required Lacks empirical research (although there are some nice longitudinal studies indicating that insight-oriented approaches to family/couple therapy, broadly defined as a dynamic approach, have better long-term consequences/outcomes for the family/couple several years after the completion of therapy).