Psychoanalysis and psychoanalytic psychotherapy in Dublin

In my private practice as a psychotherapist, I see individuals, children and couples. The themes – love, loss, separation – may be similar but the therapeutic intervention differs in each context.

Making the appointment with a couples therapist is itself a critical step. It indicates to me that, already at this first consultation, there is a third party to this relationship: the ‘couple’ itself. Couples therapy seeks to treat the couple relationship. If both partners are not prepared to work on their shared relationship then what is required is individual therapy, not couple therapy.

Attending a therapist is not usually the first option when a couple experience difficulties in their relationship. They will have tried to discuss the problem with each other and negotiate a solution together. They may have consulted family, friends, their doctor, or a self-help book. Arriving at my consulting room may seem like the final resort. This is unfortunate because many relationships require only a brief intervention to resolve the issue.

When I see couples for therapy I ask a series of questions designed to clarify what has brought this couple to my consulting room. I ask about intimacy, communication, critical life events. I ask each one when was the last time they felt happy together as a couple. I listen for significant feelings: words like ‘happy’, ‘angry’, ‘bitter’, ‘hurt’. I ask about other feelings: ‘lonely’, ‘humiliated’, ‘put down’, ‘shut out’. I ask them to describe for me this couple they have brought for treatment, what its high-points and lows have been, where it originated, what it has come to mean to them.

Then, having established what is at stake for them in this process, I ask them to agree their desired outcome for this work. The aim of couples therapy must be to arrive at a solution that satisfies each partner, whatever shape that may take. The consultation offers a space in which feelings may be expressed in a safe way and options explored which might have been impossible to discuss without the therapist’s assurance of neutrality. Clearly, strong emotions must be freely articulated within the sessions and therefore the sessions must be properly structured so that they do not become intolerable to either partner.

In the initial consultation, I outline to each couple the following boundaries for the consultations:

Confidentiality: The confidentiality rule applies to the session: this means that couple sessions are confidential to the couple and any individual sessions are confidential to the individual concerned. I will encourage full disclosure to the other partner of any material discussed in the individual sessions but I will respect the individual’s privacy. What is important in this work is that anything relevant to the work may be disclosed in session with the therapist.

Discourse: The discourse in the session is based upon the principle of ‘subjective truth’. Therefore, I encourage each partner’s freedom of expression in the session without interruption by their partner. Each one will be invited to present their own narrative truth. Each one will get the same opportunity to speak freely. Each one must respect the truth inherent in what the other presents as their experience of the relationship. Each of us has a personal narrative for our life which offers a context and justification for our behaviour and beliefs. The work of each session is to express this foundational narrative, to articulate these assumptions and preconceptions aloud, perhaps for the first time. These beliefs need to be articulated in order to be explored and understood, in order to be amended or accepted.

Sessions: The initial consultation differs from subsequent sessions in several ways. It may be longer; it may involve note-taking (for name-checking, dates, pattern recognition). At this consultation, I may be able to posit an immediate hypothesis as to the problem’s cause and possible treatment. I will set out a schedule of appointments, establishing a time-line for the therapy. The first 4-6 sessions in couple therapy are usually quite close together and later sessions are spaced at longer intervals as the problem is treated. I ask couples attending a session to prepare beforehand, clearing their minds by perhaps walking to the session together or arriving a few minutes early to have a cup of coffee nearby. It is not a good idea to arrive directly form work, for instance. I agree with them a time and day that suits each party and then all subsequent appointments occur at that regular time. I stipulate that what is said in the session, remains in the session, unless it pertains to the homework.

Homework: The work in couples therapy is two-fold: the consultation with the therapist and the practice between sessions, outside the consultation room. When the couple have outlined their reason for presenting to therapy, the next step in the process is determined by the type of relationship difficulty requiring to be treated. I may ask for a history of their individual family of origin, in order to prepare a genogram. I may advise the couple on communication or listening skills and ask for these to be practiced in the session or regularly for 15-20 minutes at home. I may ask one or other partner to attend for some individual sessions. These exercises clarify the psychological triggers and the defensive behaviours which contribute to the problem at issue. They build trust in each other and in the resilience of the couple relationship.

Sex and Intimacy: The couple relationship is distinguished from other relationships by the sexual component, by a mutual sexual desire. However, I have found that it is more often the loss of intimacy that points to a relationship being in difficulty than an extra-marital affair or infrequent sexual relations. While sexual relations might persist, the couple could still have lost the particularly intimate connection that made their relationship erotic. “Love looks not with eyes, but with the mind”, as Shakespeare said. A sexually-charged glance, a thrilling touch, a secret joke – these are the erotic components of an intimate relationship that survives time and distance. When these no longer punctuate the relationship, there is a sexual problem. Intimacy is the peculiar pleasure in each other’s presence that particularises this couple, that makes of each a significant other. Loneliness is the classic symptom of a relationship in serious trouble. An affair may, for instance, be an attempt to re-discover that lost erotic component.

The work of couples therapy: Reflecting with a therapist upon the relationship, its origins and its development, within the context of couples therapy can be quite difficult. It is important that the boundaries of the sessions be supported and accepted by each party. During the session, each will be given an equal opportunity to speak at will, unless it is to interrupt the other. I endeavour to allow each one an opportunity to respond to the other’s statements, while respecting the subjective truth in each one. When the couple leave the session, I ask them not to indulge in a post-mortem on the way home. I urge them not to call or text each other about the material discussed except where it relates to the homework. I do encourage simple physical expressions of sympathy and encouragement, such as hand-holding and hugging, at these times when un-checked words might get in the way. In a relationship fraught with misunderstanding, the text message can be a deadly weapon. I stress that communication outside of the session differs radically from the discourse within the session, where the therapist offers a neutral reflection upon what is said and intervenes to speak for the absent third party to the work: the couple.

Therapy means work, it means movement, it means change. For a couple invested in the myth of ‘the way we were’ change can seem intimidating. But change is what distinguishes life from death. All living things – and this includes relationships – change. If the relationship cannot cope with changes (for example in their power dynamic or financial circumstances) then it will suffer. It may be that the current relationship impasse is a consequence of a traumatic life-event, for instance a bereavement. In such cases, working through the effects of the loss in a calm atmosphere within the session may be all that is needed to move on. Other changes may require a different treatment. A couple going through fertility treatment may come for support and a safe place in which to address their anxieties. A couple whose relationship has been distinguished by a vigorous sex-life will have to work hard in therapy to build another framework for a relationship devastated by erectile dysfunction. A post-Celtic Tiger couple who have reversed their former roles, the primary bread-winner becoming the primary carer, must question their investment in their old roles for the relationship to survive. A couple facing the empty-nest syndrome cannot transform overnight into that same pair of sexy teenagers in which their relationship originated twenty years ago.

For many of my clients in the initial consultation, the perceived aim of the therapy is to restore them to some idealised myth that they remember fondly from before their current difficulty. I cannot promise the recovery of that lost ‘perfect couple’. I do not promise the restoration of what is past. This is a work that is situated in the present and the future. It requires effort and commitment by both partners; effort in completing the homework assignments; commitment to the work, to each other and to the couple they wish to sustain. Shakespeare said it best: 
“Love from one side hurts, but love from two sides heals.”

In the first consultation, I endeavour to be completely honest, not offering or supporting false hope. I try to identify what the demands of the work will be for each party, so that there are no false assurances or misconceptions about what it will entail. I clarify with each partner what the desired outcome is, while bearing in mind that resolution, reconciliation, separation, and divorce are all equally possible outcomes in couples therapy.

MW/ Agalma/ August 2010