HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals


  • Maria KarantoniPsychologist - Systemic Psychotherapist
  • Eva EvangelopoulouPsychotherapist, Hellenic Institute of Psychoanalytic Psychotherapy for Children and Adolescents, Athens, Greece
  • intra-psychic experience
  • interpersonal communication
  • therapeutic relationship
  • psychoanalysis
  • systemic couple therapy


In families we see interpersonal and intrapersonal levels as intertwined. Thus emerges the need to address both. Quite often, when working with families and couples we have come across areas where systemic and psychoanalytic theories interconnect. In this paper we identify some of these issues: that of emotional experience and of therapeutic relationship.  We present a case study, a married couple (male and female) in therapy with two female therapists. We discuss our work with relational triangles, circular questioning, here-and-now interactions as we investigate circular causality at multiple levels of interaction; within the individual (intra-psychic level), between the couple (interpersonal), in the therapeutic system (therapists and clients), at an intergenerational level. With the instances presented we show how epistemology on intra-psychic experience and ‘being in a relationship’ accommodate interpersonal interventions, quite often a pathway necessary to bring about change.  We present our ideas as they have emerged from necessities of practice and are intrigued by the intersections between analytic and systemic contexts. Key words : psychoanalysis, systemic couple therapy, intra-psychic experience, interpersonal communication, therapeutic relationship

“How do couples pair and function?”

Marriage is a rule-governed system (not an altogether conscious one) in which “each party must receive something for what he gives and which, consequently, defines the rights and duties of the parties in the bargain” (Jackson, 1965 cited in Gerson, 2010, p.66).A marital and couple relationship in the western culture involves personal investment, a shared history and the emotional pressure of ‘making it work’. In other cultures, where marriages are arranged and are more like the joining of two families, the pressure is on ‘losing face’ and shame (Jenkins, 2006). In the present article we refer to western culture relationships and couples in accordance with the case study that follows.

When two people join in matrimony, they bring their beliefs, family scripts, mental maps, stories and narratives from their previous life experiences into their relationship. Their internal models interrelate with those of the other and build a new construct or, better yet, patterns of interaction, soundly based upon transgenerational scripts and past experience. These patterns of interaction are reciprocal. While some systemic authors have considered these patterns as circular (Watzlawick & Weakland, 1977), others within the psychodynamic tradition have placed the spotlight upon underlying interlocking dynamics. Melanie Klein, for example, postulates that object relations are present from the beginning of life. She suggests that the mother’s breast is the primal object, and the child is splitting between the good and bad breast. This results in splitting love from hate; thus the child intrοjects and projects. Therefore, object relations are formed by the interaction between internal and external objects and situations (Klein, 1957).

Neuroscientists have taken an interest in how couples connect, interact and interrelate. Focus on social-emotional cueing has led to some interesting findings regarding the patterns which govern a couple’s communication system.  Schore (2003) speaks of a ‘right brain-to-right-brain attachment communication’. The right hemisphere is central in evaluating social stimuli (facial expression, prosody, nonverbal communication, etc). It rapidly and nonconsciously assesses and then attributes negative or positive emotional significance.  Bonding in everyday life results in couples becoming attuned to each other’s body language, mood states, and nonverbal communication.  Dysregulating affect patterns in a couple trigger the procedure of negative attribution of social stimuli. Facial expression alone may act as a cue (quite often at an out-of-awareness level) for the other partner’s affective reaction (Gerson, 2010).

Attachment theory has some interesting answers to the question of how couples pair. It was Bowlby (1988) who initially postulated ‘seeking contact’ as a primary principle in individuals and identified two patterns of attachment: secure and anxious. Mary Ainsworth (Ainsworth et al., 1978 cited in Gerson, 2010) further extended the theory with her observations on toddler behavior in response to mother’s withdrawal in the ‘strange situation’ condition. Her categories of ‘secure’, ‘ambivalent’, ‘avoidant’ and ‘disorganised’ infants were further investigated by Ainsworth’s student, Mary Main, who developed the Adult Attachment Interview. Her assumption was that the representations adults have of their attachments with their parental figures (Main et al., 2003 cited in Gerson, 2010) predicted their own orientation toward attachment –secure or insecure (dismissing, preoccupied, unresolved)- i.e. towards their infants. Anxious individuals are hypervigilant and weary of abandonment. Avoidant individuals keep a distance in intimate relationships. Secure individuals in relationships are emotionally engaged, self-revealing and happy. An interesting implication here for therapy is that individuals who had had a ‘rotten’ childhood but could tell a coherent story about it were likely to have securely attached children. Coherent is the consistent and plausible reverie one makes of her past, acknowledging her feelings but also empathizing with her parents and their behavior.

There is no single answer to the question “how do couples pair?” on an attachment basis. The therapist can make her speculations with each couple she works with. Life variables such as sexual attractiveness, personal accomplishment, ethnic origin etc. also need to be contextualized (Gerson, 2010). Mary Main, however, has offered a pivotal shift for clinical research and practice to the level of representation in relation to attachment. She has cast light upon the significance of personal history in a way that is congruent to both systemic and psychoanalytic thinking.

Byng-Hall (2008) extends these findings with couples; he speaks of “attachment scripts”, i.e. shared expectations of how family roles are to be performed in various contexts.  In a family, scripts may be replicative, i.e. as experienced in one’s family of origin, or –less often– corrective, i.e. attempts at not repeating perceived mistakes experienced in the family of origin. He emphasizes upon relationships that involve more than one generation.

Another theory that tackles the question “how do couples pair?” has been introduced by Bowen. People chose spouses with equal levels of differentiation. Differentiation of self refers to the ability to separate one's intellectual and emotional functioning from that of her family. Those with ‘low differentiation’ depend on others' approval and acceptance. Those with higher differentiation recognize that they need others, but are not dependent upon others’ acceptance and approval.

Couple therapy:  a working model

The search for patterns is the basis of all scientific investigation (Watzlawick et al., 1967). The perspective we choose for our work in couple therapy is twofold; we take an interest in internal models and their link to earlier life experiences, but also consider interrelating models of interaction.

We consider relational impasse as the tip of the iceberg with underlying interactional, intrapsychic, intergenerational and sociocultural elements. Discourse about the connection between these elements, or rather levels of relating, is abundant in past and current literature and research and stems from both systemic and psychodynamic traditions. This assumption is underlying Mary Main’s attachment in adults; Byng-Hall’s internal working models between self and others (Byng-Hall, 2008); Minuchin’s complementarity (Minuchin, 1974); Bowen’s multigenerational transmission processes; Jenkins’ invisible contracts (Jenkins, 2006); Elkaim’s (1997) reciprocal double binds.

Melanie Klein gives an integrative developmental description. Throughout the description of the oedipal complex she outlines the interdependence of major aspects of development. The sexual development of the child is bound with her object relations and with all the emotions which, from the beginning, mould her attitude to mother and father. Anxiety, guilt and depressive feelings are intrinsic elements of the child’s emotional life and therefore permeate the child’s early object relations, which consist of the relation to actual people as well as to their representations in her inner world. From these introjected figures of the child’s identifications develops the super ego which in turn influences the relation to both parents and the whole sexual development. Thus emotional and sexual development, object relations and super-ego development interact from the beginning (Klein, 1975). Allen, Fonagy and Bateman (2008) suggest that problems can be traced to a crucial stage of development of the self, when the child searches the face of his primary object for representation of his own states of mind; failure to find this forces him into pathological solutions to achieve a containing organization.

From our search of the literature we find the ‘vulnerability cycle’ construct (Scheinkman & Fishbane, 2004) as an interesting working model for couple (and family) therapy.

Briefly, vulnerability is “a sensitivity that individuals bring from their past or current contexts in their lives to the intimacy of their relationships” (p. 281).  Just as a wound is sensitive to touch and anticipated pain (actual or perceived) when instigated, vulnerabilities are also sensitive to eminent ‘danger’, anticipate pain and therefore activate self-protective reactivity processes. These modes of reactivity are usually automatic as meanings from past experiences and present situation resonate. These reactivity processes are considered ‘survival positions’ which are construed by beliefs and strategies adopted by the individual in the past, in her family of origin, in order to protect self (and others). Survival strategies in childhood become fused into the interactional tapestry individuals carry within throughout life. When adaptive, these strategies lay the foundation for adaptation and flexibility; when ‘frozen’, they remain undifferentiated from reactive behaviours used in childhood and become problematic, leading to relationship impasse in adulthood. Examples of strategies conducive to ‘stuckness’ are life mottos such as ‘crying is a sign of weakness’, ‘women are not to be trusted’, etc. In other words, what was once protective for the individual may become cause for strife in the interactional dance of the couple in the present. To further extend along this line of thinking, the survival processes activated in one spouse in response to perceived pain (triggered by the other’s behavior) instigate the vulnerabilities of the other spouse who then initiates his / her own survival strategies, thus evolving into relational impasse. Let us consider the example of a couple in conflict (Byng-Hall, 2008). The husband’s fear of being rejected (an insecure avoidant strategy) was activated when his wife came ‘too close’ with her clinging behavior (insecure ambivalent strategy); when, however, he distanced himself she perceived this as ‘too far’ for fear of abandonment and engaged in further clinging behavior, thus promoting a vicious circle.

In the therapy room, a couple’s interactional patterns are seen as the dynamic inter-relation between each individual’s vulnerabilities, survival positions and mutual activation processes. These concepts are seen as interconnected in a circular way within the individual (intrapsychic level); but also at an interpersonal level, in the way the couple interacts. We acknowledge this multi-leveled function as circular causality. Therapy thus becomes the means for creating a coherent story; this requires the de-construction of the dominant narrative and myths and the emergence of subjugated stories yet untold. Circular causality is ourinvestigative spotlight in therapy with families as well. However, for the purposes of the present article we limit our accounts to couples.

Embedded notions

Let us consider for a moment the implications made so far: “Analytic perspectives can enrich transactional rules in systems theory” (Gerson, 2010, pp70). In psychoanalytic thinking, ‘relational’ is conceived as the individual’s internal world of object relations; systemic theory contemplates upon relational interdependence (Woodcock, 2009). Psychoanalytic psychotherapy focuses upon postulated unconscious mental processes; systemic family therapy is based upon the notion of the family as having a structural quality of a socio-biological system (Dare, 1979).

“Psychoanalytical family therapy utilizes the concepts of psychoanalysis to understand the psychological nature and tasks of individuals, the internal interpersonal longings and fears and the intergenerationally transmitted myths and scripts of family life. This mainly enriches and complements other models of family organization; interventions of an active, directive, strategic or paradoxical nature are given in a way that characterizes most family therapies. Psychoanalytic family therapy differs from other family therapies in seeking to understand the unconscious meaning of both process and family therapy interventions and, late in therapy, these hypothesized unconscious meanings may be communicated in the family” (Dare, 1988, p50)

Let us consider…In circular questioning in systemic therapy is the therapist not making use of the oedipal situation, i.e. the individuals’ capacity to conceive each other’s minds? Does she not become the third party in a dyadic relationship, establishing dyadic ties? Does she not assume a “not-knowing” position which encourages reflexivity? For therapy to progress, is the therapist not perceived as a “good enough parent” able to contain the uncontainable (experiences and struggles) between the couple?  Can’t we use what Foulkes (1957) has taught us about group dynamics and communication in the group-analytic approach?

We do not suggest the integration of systemic and psychoanalytic theory; their frameworks are too different. At the same time, we cannot turn a blind eye to the embedded notions we see in our practice. Our interest lays mostly in the necessities which have risen in our clinical practice. We single out two areas in which psychoanalytic ideas emerge from the background into the foreground of our work: (a) therapeutic relationship, (b) emotional experience.

  (a) The therapeutic relationship

The analyst co-creates a context with the client and her internal reality. Therapeutic relationship, namely transference - countertransference, is the cornerstone of psychoanalytic practice. The systemic therapist investigates the context(s) in which the family is embedded, i.e. relationship patterns, culture, subculture, economic and social forces. In systemic family and couple therapy three, four or five transferences are way too many to explore. It is across psyches that the therapist surveys, not within them. Work in the therapy room is twofold: (a) everyday experiences and interactions, (b) the members’ belief systems, their past experiences brought into their present relationships.

And this is where psychoanalytic ideas speak most strongly to the systemic context. It seems that individuals and couples inevitably bring their patterns of relating in the therapeutic relationship; as it is inevitable for the therapist to get involved in the interactive process, bringing in her own experiences.

If transference refers to the patterns of experience that a client enacts in therapy, i.e. ‘the living history of ways of relating’ (Scharff & Scharff, 1991, p203), then transference in couple therapy is a complicated issue. It involves at least three dyads; each individual and the therapist, and between the couple (Woodcock, 2009). Thinking in terms of transference helps the therapist consider relational patterns as brought into the therapeutic relationship. The concept of transference is not to be taken carelessly. However, it is important for the systemic therapist to be aware that unconscious processes are taking place in the therapeutic room.

On the other hand, how do family therapists reflect upon their own work?  How is the countertransference experience perceived?

Gerson comments (p225):

…our response to a family system can travel along several different channels. Thus, if a therapist had been a general mediator and peacemaker in his or her family of origin, a fighting, raucous family session might (depending on the degree of self-monitoring) stimulate that very response. Bowenian self-examination should alert one to this tendency. However, if one were also subject at a more unconscious level to acute guilt and then anger during interaction with one’s siblings, then these emotions might be simultaneously evoked by a similar encounter between the children in a family session. Would the unconscious experience of guilt and anger synergistically reinforce the impulse to make peace or would these unavailable feelings derail it? What is the genetic relationship between the dissociated emotions and the role response of the peacemaker? In the face of this kind of complexity the examined psyche becomes something of a life raft in systemic work ….

At a deeper level, the therapeutic relationship is determined by another process, projective identification. Briefly, at an unconscious level unbearable emotions become split off and are  _projected _ away from self, onto the other; within a relationship the other (i.e. the therapist, in this case) finds resonance for the  identification  within her own emotional repertoire (Flaskas, 2005). Jenkins (2006) describes an instance in therapy with a couple which highlights this notion. In the ninth session, the husband, who had a history of depression and physical and verbal outbursts, had given his wife an ultimatum for her to change. When asked if this was a fair view, the husband started to weep. The therapist describes his experience: “… almost a minute passed in silence, during which I experienced a powerful urge, which I knew I would have to address in some way, emotionally, intellectually, or cognitively. I knew that for me at least, it would feel like a barrier about the unspoken if I did not trust myself and said or did nothing. In a quiet voice, I said, ‘If I were your father, I would come over and hug you now’” (p.114). We wonder whether this moment of encounter fits in with Elkaim’s (1997) concept of ‘resonance’, which occurs when the same rule or feeling appears to be present in different but related systems.

(b) Emotional experience

Emotional experience occurs in the form of complex feelings and meanings. We are our feelings and how we deal with them. Feeling is the process of being. In order to trust our emotions we have to handle them with a special kind of wisdom or intelligence (Greenberg & Paivio, 1997).

Bion has offered the idea of emotional containment to the analytic relationship. He uses the metaphor of mother-infant communication to describe the relational process between therapist and patient as “…being with the patient in thoughtful reverie where emotional and symbolic meaning is held, interpretations are ventured, and thinking develops” (Larner, 2009  p.203).  It would be naïve to equate the emotional and relational intensity of analytic work to the (few in number) systemic therapy sessions. However, seen as the space between persons (and their internal representations), therapy in both disciplines touches upon common ground:  the therapist’s “not-knowing” position, or better yet “knowing-not-to-know” (Larner, 2009). The therapist cannot denounce her knowledge and experience but uses it to think through emotional experience and reflectively bring it into the therapeutic dialogue. Fonagy uses the concept of mentalization. Mentalizaton is the ability to perceive one’s behavior, thoughts and emotions as separate from those of the other. It helps realize the motives behind our actions and the actions of others, To mentalize means to make something mental or more elaborately mental. Mentalizing is holding mind in mind (Allen, Fonagy, Bateman,2008).

Moving further into the systemic realms, “emotion” is replaced by “emotional systems” as they are seen within a relationship. They are more like processes in a communication system (Bertrando & Arcelloni, 2009). The therapist also becomes part of the emotional systems in the therapy room. Awareness of her experience heightens her “senses” and encourages the unfolding of unspoken meanings.

A good example here is the function of anger (Bertrando & Arcelloni, 2009). If anger is seen as pertaining not to the individual but to the system, it may be considered as an emotion that has a protective effect;  it diverts attention of family members (and therapist) from other emotions (such as fear, pain, anxiety) if they are considered as “dangerous”, i.e. disclosing vulnerability and frailty. So, an angry member makes other members insensitive to other emotions and encourages hostility and polarization. Under this light, rather than denying or overrating anger, the therapist is geared towards investigating underlying meanings. What activates anger? What emotional state precedes anger? In the case study presented, it is the fear of frailty and incapability that triggered ongoing, rapidly escalating anger outbursts between the two spouses. The battling was so strong at times that it made it difficult for the therapist to resist being drawn in.

Clinical vignette

We have worked with Thomas and Elsa for approximately nine months. Thomas is in his late fifties, Elsa in her forties. They have come apart during their years of marriage with fierce outbursts and arguments – which at times have become physical on the part of the husband. The beginning of their relationship was pleasurable but has gradually deteriorated ever since their children were born. They now have four children; a 15-year-old girl, a fourteen-year-old boy, a twelve-year-old girl and a 10- year-old girl.

Elsa experienced the fierce divorce of her parents as a teenager. She lived with her mother, who re-married two years later. She had a distant relationship with her father and her stepfather ever since.

Thomas was the youngest child and the only boy in his family of origin. He remembers feeling despised by his mother and indifferent to his father. He is approaching the end of his career.

Thomas and Elsa are at the dawn of a new phase in their lives. Elsa’s early retirement has resulted in her mother –who looked after the kids when the parents were travelling– distancing herself from the family; Thomas is on the brink of retirement and re-assessing his life. The couple argues fiercely, mostly about how to discipline their son but also, as revealed later on in our sessions, about the husband’s promiscuity.

Elsa was a good-looking woman, rather closed and embittered. She spoke little about herself but retaliated at her husband’s accusations. Her children and mother were worried she suffered from depression. She saw the role of mother as a “burden”, and felt undermined by her husband who did not support her in setting boundaries to their children, especially their son who quite often became verbally abusive towards her. She resented her husband’s affairs with other women (and knew everything about them). Thomas encouraged the ‘independency’ in his children, especially his son, dismissing his wife’s concerns and appeals for collaboration. He felt enraged by his wife’s distancing from him and said he had little to no respect for her.

The couple fit

We spent sessions talking about his family; how his mother despised him for being born male and how indifferent his father was towards him. Elsa’s (perceived) discrediting stance towards him awakened this feeling of “de-valuation”. He persecuted her in demand of attention and care. But when Elsa halted at his command and stopped to listen to him, he retaliated with fierce accusations and resentment. It is as if he instigated her to abandon him (as his mother did). That is when she turned her back to him once again. On the other hand, Elsa did not speak much about her own past. When she did, however, her accounts were invested in pain and grief. Her story told of men who were either incapable or abusive. She had to make it on her own, estranged even from her mother who was engaged elsewhere, i.e. either her strife with her first husband or her bond with her new husband. She demanded from her husband to pursue her (not persecute her) and meet her specific needs, that of mother. Thomas was only capable of dancing to her beat when it came to disciplining the children. Which he didn’t. His outbursts confirmed her worldview that men are not to be trusted. Thus, she distanced herself from him. Following is an excerpt of their interaction which revealed their painful complementary inner match and how we worked through anger:

After several sessions where the wife had difficulties in coming to therapy with her husband, they arrive together. We welcome them and ask her what made it so difficult for her to come.

Elsa : I do not know. My husband told me that he is fine, and that I am the problem.

Therapist : We were wondering if you think that this is what we believe as well.

Elsa : Probably.

Therapist : Then if your husband asked you to come what would be different?

Elsa : May be I would not come because he always says the same and the same, and the only thing he does is to accuse me, as if he were Mr. Perfect.

Therapist : We are wondering if you feel that we support his opinion and if you are concerned that we are going to accuse you too.

Elsa : No, I do not feel like that, I trust you.

Thomas :  Stop this please, how many times have I asked you to come? How many times have I asked you to try for this marriage, for this relationship? I am working on my own… Alone… Did you ever respect me? When?....(laughs… shouts… there is tension in his voice). You never care…you look out only for yourself… do you hear me, ladies? Only for herself!

Elsa : You talk about me, instead of speaking about yourself and your girlfriend?

Thomas : (laughing) look what she brought into the discussion…

Therapist : You are talking about many things but also about a third person that comes in between you two.

Thomas : A third person, my ladies, what are we talking about now?… I should consider myself very fortunate and lucky that this person exists…she is a necessity, of course …because it is a need…I have to live somehow… since my wife does not come to meet my sexual needs, my needs for love… does not respect me.

Elsa : Do you hear what he says? …what am I? Am I an animal…to sit there for his needs... how many times have I told you to stop this relationship….(in a very angry voice)

Therapist : I wonder if this lover you mention satisfies any other desires and needs you may have.

Thomas : What else…only sex

Therapist : What exactly is this woman… can you tell us something more?

Thomas : She is a woman that you can… she is there for me….I connect with her; the time that I am with her we are together… emotionally, she is there for me.

Therapist : You are talking about a woman who satisfies a need, and this need seems to have a dual status; because you speak of a physical need but at the same time you speak of pleasure. It seems that with this woman you feel you unite emotionally, you are in balance with her and when you have sex with her you feel she understands you. This seems not to happen with your wife. It seems that you are together in a sort of compulsive way.

Elsa : I agree. It’s exactly like that… he is asking me to be together to satisfy his sexual need. I cannot be with him this way. I need to be moved; I am there, but I need something more to be moved.

The husband is very upset, shouting that there is no time for him… he is too old, and he is very afraid of death, of loneliness. He says he cannot stand her anymore… he shouts that he needs her to respect him, because he cannot stop remembering his mother and how much she neglected him… how she had not shown any interest in him. Therapist A urges him to start respecting himself, by making a decision which he has to stick to, because by having two women at the same time, he is not with either… He starts crying… very loudly he cries out that he does not respect himself… that he does not deserve anything... that he is the lowliest of all. That his mother brought him up infested with this feeling. He is the last of all. His wife observes him in silence and then starts crying as well. She gets up to leave the room because she does not want to see her husband cry. We keep her in the session. We ask her what it is that she cannot bear, and she answers that she cannot see him feel sad and watch him crying like a little child.

The atmosphere in the therapy room has changed. This is what M. Gerson (2009) describes as ‘the illuminated moment’. The two of them have joined together mentally.

Thomas : I cannot believe that my wife is crying for me, I cannot believe that she cares about me.

Therapist : You have a big sadness inside you, and you feel you have no worth. And this sadness you try to hide with anger. You project this onto your wife, that she is the one who does not give you value. But the truth is that you do not give credit and value to yourself.

The husband is very confused, but is also in a psychic pain that he carries from his childhood. He is very angry with his wife whom he de-values; she doesn’t recognize how good he is. In order to manage all these painful feelings he performs a major split between the two therapists. He feels therapist A as the bad object like his wife, like his mother, and therapist B like the good object. This splitting also has to do with his inner self since inside him there is the ideal self, his need to be perfect, and the realization that he is never adequate, as he always feels inadequate in the end; the other side of the same coin is de-valuation of self and others. Why is everything he does never enough? All this anger and the fact that his efforts are not recognized, is something he cannot bear and thus projects it to others in the end. These others are his wife, his children, his therapist.

In subsequent sessions we further discussed the role of the third person in their families of origin. We talked about the other members in Elsa’s family of origin, the time of her parents’ divorce, her relationship with them, her stepfather, how she felt during adolescence. We discussed similar things about Thomas’ family of origin.

We used paradox as a technique to help them become intimate with each other. The instruction was to stop having sex and to start flirting; to meet at a favorite place they used to go to in the past, to spend the night at a hotel without having sex.

The husband tried to come closer to his wife as a father, talking about the problems of their children. He stressed how well he managed all that. He did this to impress and gain the respect of his wife; he tried to make himself feel significant. But in this way he managed to impress the daughter and not his wife, via the Oedipus complex.

Parental Roles and Triangles

From our discussion it soon became clear how the couple brought their son into their relationship. He became involved via triangulation. George had taken on the heavy burden of uniting and separating his parents.

Bowen elaborates upon the concept of “triangles” to further explain how couples (and family members) connect and interrelate. A triangle is a three-person relationship system. It is considered the building block or "molecule" of larger emotional systems, because a triangle is the smallest stable relationship system. Kraemer adds: “regulating one’s place in a three person system is a basic human skill and lasts a lifetime” (Kraemer, 2009, pp 50). A two-person system is unstable because it tolerates little tension before involving a third person. A triangle can contain much more tension without involving another person because the tension can shift around three relationships. If the tension is too high for one triangle to contain, it spreads to a series of ‘interlocking’ triangles. This concept is especially useful with couples in trouble. For example, with the intention of deflating tension between parents, a child may intervene by presenting a problem; this becomes top priority for the parents, diverts them from their conflictual engagement and thus the child becomes ‘triangulated’ in their relationship (Byng-Hall, 2008).

In this couple, George was the regulator. By separating the mother from the father, George makes the father look useless and so the boy comes closer to his mother. He adjusted the distance between the parents, separating them and then uniting them. The pathology in this interaction is that this is done through a symptom; intense aggression at school, in his relationships with peers, at home with his sisters, with his parents. From instances described, we observed exactly how this worked. When the father came close to the son, then the mother became isolated. This is when the father instigated her. How? By provoking her (even by becoming physically abusive). This is when George came to her rescue, thus distancing himself from his father.

In our meetings we witnessed many triangles. An important triangle was that of mother-father-son. In one of our sessions, the father and mother got into an intense argument in their effort to get the facts right about a past incident involving their son. They demanded that Therapist A took a stand and be the one to decide who is right and who is wrong. Therapist A gradually felt overwhelmed, confused and frustrated and was at a loss for words. Therapist B, who had remained silent up to that point, caught her glimpse of despair. She wondered how George may feel in such instances. Did he feel angry? Confused? Pressured to choose between the two? This was a here-and-now opportunity to describe how the couple triangulated their son.

Thomas : She cannot bear this child. Have you seen how you talk to him? How you look at him? You have to love this kid. (Turns to the therapists) Do you know what she does at home? She is a watchdog. The boy asks if he can pierce his ear. So what? When you go against him, that is when he will do it. What does my wife do? She is an expert at controlling and oppressing. She does this to me as well. She wants to control everything. She wants to check if I am a good father.

Elsa : You are a fool to say such things. I will not let a 15-year-old pierce his ear! Don’t make me swear at you!

Thomas : But he will not do it, dear. He is just testing you. Relax and you will see he won’t do it. The worst thing that may happen is that he will eventually make the hole!

Elsa : Do you hear what he is saying?

Thomas : What am I saying? We are not the same. After all, I am the man of the house. I am the father, my opinion needs to be heard.

The mother does not seem to be listening. She does not give him space nor does she show confidence in the way her husband acts in his parental role. On the other hand, the father does not seem to recognize the work this mother is doing at home and the pressure she may be under. We approached this with a paradoxical message: “When George intervenes in your arguments, you should thank him for adjusting the distance between you once again!”

Concluding thoughts

It is not yet clear what makes family therapy effective. As the first generation of family therapists who inaugurated the great streams of theory and therapy within the realms of family therapy (Minuchin, Palo Alto, Michael White, etc.) are gradually retiring from the active foreground into the background of the therapeutic and theoretical scene, the question remains: “what makes family therapy work?” There is little consensus as to the factors which construe effectiveness in therapy.

If we consider therapy as the encounter between persons, then it is vital to include the self of the therapist. Simon (2006) argues that the best therapy is the one closest to the therapist’s world view, i.e. when the underlying theory of the therapeutic model closely matches the therapist’s worldview.

We see this as an interesting view of clinical practice, especially when two therapists are involved. To abide by common conceptual factors within family therapy is sine qua non for establishing the interpersonal context. But it is not enough. The ‘Self’ of the therapist maximizes effectiveness. This becomes even more interesting –and challenging– when ‘self’ becomes ‘selves’. When two therapists work together as a therapeutic couple the synergistic effect is maximized. We work together using relational triangles, circular questioning, here-and-now interactions as our tools for investigating circular causality. But we also work a lot at molding our personal histories and theoretical backgrounds into one coherent narrative. Personal therapy and supervision have facilitated our self-awareness; the challenge here has been to accommodate our training from a systemic and psychoanalytic background into the therapy room. This has turned out to be an interesting journey and has led to interesting revelations on effectiveness.

Special thanks to Dr. D. Sakkas for sharing with us his wisdom and giving us his invaluable support.

The present article appeared in the form of a poster at the EFPP conference (European Federation for Psychoanalytic Psychotherapy), organized by the Greek Federation of Group Analysis and Family Therapy in May 2012 in Athens.


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Read the next article:

ARTICLE 7/ ISSUE 4, April 2014

The contribution of family therapy to the treatment of immigrant adolescents’ behavioral problems

Dimitris Magriplis, Child and Adolescent Psychiatrist, Systemic Psychotherapist Couples Family
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