The use of mediating techniques in cfp in an Italian public service family counseling centre

The use of mediating techniques in cfp in an Italian public service family counseling centre 

LA ROSA ELENA^[1]

 

What are “mediating objects”? Some theoretical and technical points

In the preface to Claudine Vacheret’s book on photolangage (2000), René Kaës (1999) asserts that “is not the means, the object, that is mediating; mediating is the function the object is carrying out, by virtue of some of its properties, inside a relational context prepared to produce a mediating effect within it”. [All translations in English as well as the underscoring are mine].

The first property of mediating objects is undoubtedly their concreteness (images, drawings, modeling clay, familiar objects, etc.): the fact that they are part of everyday life. At the same time, as Vacheret says (2000; 2002), they are also, “like the transitional object, equipped with double polarity”: in fact, “they are characterized, on the one hand, by their materiality and, on the other, by their symbolic character: their capacity to promote access to symbolization through playing and metaphors”. Thus, “the mediating object has a mediating function of access to transitionality”.

The aim is not to produce new tests or projective techniques. What we expect of these methods “is not the projection of structures or processes of psychic life, but rather the activation of associative processes” (Kaës, 1999), the production of a connection or a link between aspects that at the moment are not connected on either an intrapsychic or an intersubjective level. Therefore, mediation assumes disjunction or separation, and “the efficacy of the mediating process is based on the nature of disjunction (or perhaps its reason)” (Kaës, 1999).

In particular, for all that concerns the intrapsychic, the purpose is to make connections between what pertains to the Unconscious (primary process thinking, thing presentation, images, percepts, affects) and what characterizes the Conscious (secondary process thinking, word presentation, ideas, concepts, feelings). In other words, it is a question of promoting, in intrasubjectivity, the action of the Preconscious, which as we know from the first Freudian topographic perspective, mobilizes symbolization and access to latent contents.

However, the properties of mediating objects are not limited to the intrapsychic level, but may also potentially support a shared representation of emotions and feelings. These properties make a connection between the intrapsychic and intersubjectivity, which is especially important in couple and family therapies, as well as in group therapies. Vacheret (2000) considers the mediating object “a point of contact for the double link between the intrapsychic (connection between the three systems: Unconscious, Preconscious, Conscious) and intersubjective levels (the Individual and the Group, the Internal and the External). […] Mediation aids the psychic action of creating links, since the mediating object provides support for preconscious representations of the Individual and the Group”.

The mediating object takes the form of a place “in an intermediate position“ between subject and self, subject and the couple and/or the family group, patient and therapy, a “potential space” between the Self and Others. Likewise we may say that this “intermediary function” has important analogies with the maternal function and with the transforming aspects of internal psychic reality in comparison with external reality. It is enough to quote Winnicott’s concepts of holding, handling, nursing and object presenting, Freud’s idea of the barrier against stimulus as protection against the drives or the pressures of reality, and Bion’s reverie as the capacity to convert unrepresentable contents into new ones that make sense to the baby, mobilizing his imaginary. These issues, however interesting, risk opening up too many fields of discussion: in this text it is enough to consider the holding and transforming aspects inherent to mediating objects.

Having mentioned the general characteristics of mediation, I would now like to propose some considerations about the real possibilities of applying mediating techniques in Public Service Psychotherapies. Mediating techniques in Public Service Psychotherapies

To use them or not to use them? This is the initial question which I also encountered in other colleagues with whom I shared some perplexities in relation to the time, space and mission of the Institution where I work, a Family Counseling Centre in Padua province. In fact, due to the increasing number of users and a progressive decrease of psychotherapists on the staff, the time we can dedicate to patients for individual, couple or family psychotherapy has seen a drastic reduction: actually, seeing people once a week has become a luxury that we can rarely afford. Moreover, because I work in a Public Service that supplies psychotherapies for free, a sort of unwritten law recommends shortterm interventions so that more people may have the same opportunity to use the service. In other words, we fight every day against our own limitations and the unavoidable partiality of our interventions.

Therefore the first problem is related economically to the time needed to apply the mediating objects. Some techniques (for example A. Ancelin Schützenberger’s method of the genosociogram) require more than one session to be qualitatively meaningful in terms of symbolic connections within the genealogical history, both for the psychotherapist and the patients. Other methodologies (for example the above-mentioned photolangage) need  time for thought before the consultation, dedicated to the family or couple in their absence, in order to choose the questions and the materials to propose: this is time and “private” mental space not always so easy to get in a public context !

The second aspect relates to methods, measures and settings: how and for what purposes can we use mediating objects with couples or families when we cannot always guarantee regular frequency of sessions? Can associative links mobilized by these techniques be held at the heat of the moment for two (or sometimes even three) weeks before opening them again? In terms of psychic organization and defense mechanisms, is it not counterproductive to make symbolic links in a more intense way (with images or drawings, for example) than only with the use of words, afterwards leaving such a big gap between one consultation and the next?

However, in my opinion, all these questions, undoubtedly motivated by reality-testing with respect to the limitations of psychoanalytic psychotherapy in a Public Service facility, also conceal latent content: we may call it a super-ego dilemma, supposed fidelity to strict orthodoxy of the method. The clinician’s intrapsychic conflict may be summarized this way: “could we really use certain materials in psychoanalytic psychotherapy? Didn’t they teach us that analytic treatment for adults is almost exclusively based on words?”

In my point of view, I think it useful to reappraise a certain idealization in our professional practice and theoretical models if we perceive a big gap between the methods we use and the therapeutic aims we wish to achieve with patients in the public institution setting in which we operate. This re-evaluation helps clinicians to authorize and legitimize self-testing and to try out, together with their patients, new instruments and technical challenges. Therefore, returning to the subject of mediating objects, we could say that “in certain cases you may or rather you need to use them!”.

In which situations? At last year’s National Study Congress “Empirical research in group psychodynamic psychotherapy” (Padua, 17-18 February, 2012), G. Fava Vizziello emphasized mediating techniques, especially (but not only) with children and adolescents. First of all, these techniques are absolutely necessary in severe cases, psychosis, mentally retarded children, and in all situations of adults or adolescents with regression in ego functions, particularly when verbal language is absent or very limited. Next, alexithymia and psychosomatic cases undoubtedly benefit from the application of mediating objects. Moreover, for adolescents and children living in difficult family situations, it is very important for them to have an opportunity to work through their experiences and everything that has happened in their lives after hard decisions adults took for them or as a consequence of violence, aggressions or traumas in the family. This is oriented towards the recovery, through mediating objects (drawings, collages, photos, puppets, self-representations by choosing objects from their everyday life, etc.) of some of the lost emotional control.  In fact, just by virtue of being between the concrete-real and the symbolic world, the mediating object lends itself well to a function as organizer of experiences and a holdinghandling function of destructive and upsetting affects (play and transitionality).

Finally, with regard to the link between the intrapsychic and the interpersonal aspects, the specificity of the method, applied in family or couple psychotherapy, is to connect individual images to free associations of other members of the family. In this way we encourage patients to share the representation of feelings and emotions. We allow them to re-discover pleasure in family group relationships and also in the therapeutic alliance. This last element of finding pleasure in the therapeutic relationship is, as we know, particularly useful to reduce drop outs in psychoanalytic psychotherapies.

Generally speaking, apart from their use in specific psychopathologies, symptoms and syndromes, mediating objects meet emerging therapeutic needs in our contemporary historicalcultural context.

From a sociological point of view, the clinician has to consider everchanging family conditions and new family configurations (e.g. the increase of divorces or couple split-ups, single parents or reconstituted families, sudden and unexpected transferences of family members, the rise in couple sterility, with more children born with fertilization techniques MAP or originating from international adoptions, foster families, etc.). These conditions often upset and disconnect people from their stable and familiar reference points. Moreover, precariousness, an economic effect of globalization that affects jobs and monetary systems, at the same time builds up individual identities and interpersonal relationships based on “liquidity”. (This is the very well known definition from the philosopher Z. Bauman to designatethe instability of bonds: “Bonds without the Ideal” Bauman, 2003). In psychoanalytic terms, we may refer to “a general decline of the dimension of symbolic order”, which leads us to think of it as a real and proper “evaporation of the Father”, as efficaciously defined by M. Recalcati (2010), in his book entitled so meaningfully “Man without an Unconscious”. Lack of being, which previously introduced the wish, is now reduced to “emptiness”, “reified and frozen” into a “lack of something, disconnected from any wish”. In this sense, Recalcati deduces that patients today are characterized as “clinical cases of emptiness” in which we need to work more on holding anxiety than on the repression of desire.

In these cases, in absence of meaningful reference points, in a mortifying and paralyzing lack of symbolism, words themselves appear “reified”, emptied of all meaning. The global context has become imbued with loneliness, insecurity and “narcynism” (a new term coined by this author (Recalcati, 2010) as a humorous crasis between narcissism and cynicism). In psychoanalytic psychotherapy we need techniques such as mediating objects capable of mobilizing lively, connective and meaningful aspects of the Preconscious, stimulating them with the concreteness and materiality that often dominate our historical and socio-economic environment.

Specifically regarding psychotherapies in the Family Counseling Centre where I have been working all these years when I have weighed the feasibility of applying mediating techniques in different situations, we may summarize them as follows:

• Verbalization and understanding difficulties (e.g. foreigners or immigrants that have problems understanding the language of the new country)
• Mentalization problems and difficulties to recognize and verbalize their own affects (such as cases of alexithymia, psychosomatic disorders connected with sexuality and sexual disorders in the couple, pre-operative thinking and verbalization concentrated on concrete events)
• Lack of or poor functioning of the Transitional Area or of Preconscious activity in connecting the secondary process with the primary process
• Symbolization difficulties caused by repeated or early traumata suffered by the patient or transgenerational traumata transmitted from forebears in the family. (In 1999 Kaës wrote about the “siderizing effects of traumata” that need to be fluidified by mediating objects)
• Impulse disorders and impulsive personalities with a tendency to action: “to do something” (drawing, choosing photos, etc.) may help to contain their uncontrollable feelings and anxiety
• Extremely passive personalities that need to be stimulated to participate in interaction with other family members and /or with the psychotherapist
• In absence of resources and time to work adequately on defenses, particularly when verbal expression becomes banal, repetitive or very controlled with rigid neurotic defense mechanisms such as rationalization, intellectualization, phobic escape, obsessive control, etc.
• At every moment of therapeutic impasse that is not easy to resolve, considering the big gap between one session and the next in public service psychotherapies
• In every situation in which the clinician needs new links to understand the functioning of the patient, couple or family
• Also in other cases when the aim is to increase the patient’s awareness of his own inner feelings and psychic complexity and to promote more rapid access to some latent contents.

Obviously the list of cases for possible application could continue, but at this point of the article it is crucial to propose some arguments in relation to a few specific techniques I use in my clinical practice.

Which kind of mediating objects to use with which couples or families: some remarks based on clinical situations

The Genosociogram (A. Ancelin Schützenberger, 1993; 2007), Double-Moon Drawing (O. Greco, 1999) and Photolangage (C. Vacheret, 2000; 2002) are three different types of mediating techniques that offer several possible uses in diverse psychotherapeutic contexts and for a number of purposes.

Starting with the genosociogram, in Ancelin Schützenberger’s formulation (2007) “the role of the psychotherapist that deals with psychogenealogy is first of all reparative-integrative“. In the Family Counseling Centre this method, precious for recording anamnesis of the three generations, is in my experience also useful in certain specific cases:

• In psychotherapy with parents that suffered traumas in their family during childhood or adolescence (physical or psychological violence, sexual abuse, incest, etc.). Working through these experiences can help them, especially the parent/parents of a newborn baby, to avoid repetitions of the same traumas in their own children.
• In supportive psychotherapy with mothers going through a post-partum depression syndrome. Working on the family history through the generations promotes making peace with representations of maternal female forebears and with internalized objects. It also helps these mothers to resolve ambivalence and to move towards reparation (which, as S. Missonnier says (2003), is very important in “perinatal therapeutic counseling”) .
• In couple psychotherapy for personal or marital crises. The genosociogram makes it easier to work on the “couple’s internal group or unconscious drama” (R. Losso, 2000; R. Losso, A. Packciarz Losso, 2010). These authors discuss the intersubjective plot of conscious and unconscious wishes, expectations, ideals and fantasies of each partner, their own parents and previous generations. All these intertwinings construct the representation of the “internal family”. In marital crises, as we know, it is essential to promote awareness of unconsciously shared representations in order to assist working through.
• In every situation when from the beginning in our countertransference we feel enormous anxiety we cannot connect to any manifest content of our own or of the present family group. This anxiety could be due to unconscious transgenerational transmission that patients re-experience in which they include the psychotherapist.

In my opinion, because of its characteristics, the genosociogram could be considered a “preparatory technique”, for both patients and therapist, to commence an adequate psychoanalytic psychotherapy. In fact the genosociogram develops patients’ connecting ability and tests their capacity to use the psychoanalytic setting appropriately. Moreover this technique gives the psychotherapist useful indications regarding patients’ capacity for free association, their attitude in relation to accepting connections made by others (relatives or therapist) and to welcoming links between affects and thoughts, past situations and present problems, interpersonal exchange, individual aspects and transgenerational heritages. Because of its peculiarity, we could assert that the genosociogram creates an “intermediary space” between the person and their family links, between now and then; often, in cases of migrations or house moves, also between here and there, to a different place and a distant living context, which seems unreachable compared to the present situation.

Unfortunately, in terms of the time required, this technique is definitely expensive, especially in couple or family psychotherapies. In fact we need a first phase to collect the genosociogram, which requires at least one or two individual sessions, to start to create connections between signs and meanings. Afterwards we slowly share individual psychogenealogies within the couple or family. The facts that we have represented concretely on paper: people, places, professions, dates, significant events in personal and family life helps to visualize the conscious and unconscious “collage” of their ways of relating to each other. For this purpose we use patients’ free association and the psychotherapist’s reconstructions and personal free association. The consequence is that in the genosociogram, more than in other mediating techniques, the psychotherapist’s position and connective abilities are fundamental to make hypotheses and, as the author says (Ancelin Schützenberger, 1993), “to ask questions that open and speak” , “pulling on the red thread of the patient’s free association”.

Finally, in my clinical experience, I have noticed that the genosociogram cannot always guarantee the possibility of a positive result, because of limitations of both patients and psychotherapist. Sometimes patients have problems in understanding and welcoming connections made by the therapist between their family history and present symptoms or difficulties. Clinicians (especially if they are, as I was, in their early years of experience with these complicated and delicate techniques) may also have difficulties in choosing the “right signs” to activate appropriate working through at that specific moment of life the person is experiencing.

The case is different for the Double-Moon Drawing, a method invented in Italy by O. Greco (1999), applicable to both adults and children, to work on “the definition of borders and family pertinence”. This technique uses a shared spatial representation of links and relations, particularly in foster families, adoptions, recomposed families, divorce, etc., when long term and irreversible changes have occurred in the original family. In my clinical practice I apply it with adults in couple psychotherapy, especially in the following situations:

• In specific phases of the family’s life cycle (e.g. couple crises after one member decides to “take a distance” or “get out” of the family with marital infidelity or any kind of deception; during the necessary redefinition of the couple’s borders after the birth of a new baby or the entry into adolescence of the children)
• In specific phases of psychotherapy: for example, the DoubleMoon Drawing can be used at the beginning or in the preliminary consultation to help patients to be aware of their own symbolic position in the “relationship space” in connection with all the affectively important people in their lives. When the therapy is nearing its conclusion: re-applying the technique and comparing the two drawings of each member of the couple promotes a final evaluation of the therapeutic route and of changes achieved.
• In every situation in which borders are broken up or forced in the so called “internal family habitat” (Eiguer, 1983), due to different possible traumas (e.g. sudden and unpredictable loss of their house, temporary or definitive, due to economic problems or natural disasters; the necessity of returning to live with the husband’s or wife’s original family unit because of the death or sickness of close relatives, etc.). These problems are related to another concept of this author, “consolidation of the family body”. When the psychic world of the couple or family is based almost exclusively on the “external habitat” (the house itself, the living environment), the concrete loss also becomes catastrophic for couple or family relationships. In these situations it is very important to guide the couple in symbolic reparation of their “family borders” so badly damaged by events. To share in therapy some mental representations and meanings of “being a couple or a family” by using a simple and descriptive graphic drawing may offer precious help.

Compared to the genosociogram, this technique is clearly advantageous because of its simplicity, easy and rapid applicability, and understandable instructions that everybody can follow, including people with language difficulties or poor verbal expression. Also in conflictive couple situations when words become repetitive and full of stagnant anger and revenge we need to use an alternative way to mobilize reflective and imaginative capacities.

In the preface to the Ondina Greco book, Vittorio Cigoli (1999) asserts that the peculiarity of the method is “the valorization of symbolic acting as a base and a matrix for attributions of meaning”. […] What is produced is nothing that can be pre-thought; it is instead something that happens and emerges from the action”. 

Moreover this technique has a double polarization: on the one hand, when used in couple or family psychotherapies, it offers patients a possibility to improve focalization of the terms of the conflicts in a very immediate way (we could say that patients literally visualize them through spatial representations of links, exclusions, inclusions, etc.). On the other hand, the Double-Moon Drawing allows clinicians to verify their hypotheses on family relationships and thus it is an instrument of knowledge (in fact Cigoli describes a therapist as also being a “researcher” of family functioning).

The position occupied by the psychotherapist is not in abstinence and is not interpretive of graphic lines but, considering symbolic action, it is an associative and thought supporting role. In this way clinicians place themselves in an external position in relation to the action of patients.

This does not occur in another mediating technique, photolangage (C. Vacheret, 2000), in which the psychotherapist participates actively in the action by choosing a photo as do all the patients. In this way the analyst transmits to the patients that it is not dangerous to be actively involved in the action and suggests the possibility of identification with the therapist’s playing capacity and attitude to making associations and links between the images, feelings aroused by the images and thoughts.

Personally I think that the possibility for the psychotherapist to choose a photo and express personal comments about it, is a structured and original way to relate differently to our patients. In a previous paper (La Rosa, 2006), entitled “Acting and Thinking across the groups”, I observed that “the psychotherapist’s actions that develop the functioning of the patient include also using the person of the therapist as a source of emotional support”. [The analyst] “works as an identification model that guides the patients and helps them to be structured by various functions of the therapist himself”. In the case of photolangage, the intervention of the psychotherapist by choosing and presenting personal associative links stimulated by the photos is a very well targeted action. This action needs an “ad hoc thought” and assumes a form of “thinking that becomes acting” , but at the same time sets up working through, holding and handling, bearing emotional sense and meanings. In this point of view we are miles away from the original idea of psychoanalysis that “acting is always considered an acting out and is completely anti- therapeutic”.

Unfortunately, in terms of the time it consumes, photolangage, like the genosociogram, is expensive, in this case because it requires a supplementary time before each psychotherapeutic session. For Claudine Vacheret (2000; 2002) photolangage is based on “two mediating axes”: on one axis the dossier of photographs selected by the psychotherapist and on the other, “the question” built for the group for each session in each particular phase of therapy.

The fact of the analyst thinking of the patients, as a group and also as each singular member of the group, is very important for this method. Taking some time, structured as “different time” to think about the people before the effective consultation, is similar to the concept of “maternal reverie” (Bion, 1962), that the psychotherapist’s mind, in analogy with a mother and her baby, should be able to offer the patients if they need it. Nevertheless, to appropriately choose the questions and materials, we require thinking time, not so easy to carve out of the fast rhythm of a public service organization.

Considering this inconvenience, if I wanted to use this method, I needed to make a methodological re-arrangement of the original technique, introducing some variations that are functional to the setting in public service family psychotherapies. First of all, I do not organize group psychotherapies based exclusively on photolangage as the author proposes in her method, but occasionally and only in particular situations during therapy, I take as a cue her idea to use photos, questions about the photos and final confrontation in the group of “what do you find similar or different in the photos picked by the other members without expressing any interpretation or judgment about other people’s feelings and associations” (I believe that this last aspect is very useful to work at the same time on the patients’ empathic attitude and on their capacity to tolerate that someone else expresses different points of view from their own on something that affects the patients personally).

In my opinion, the fact that, only in a special session dedicated to photolangage, the group-conductor is directly involved and expresses himself/herself through symbolic action, could also work as an important moment of holding and affective restitution of intrapsychic processes and family group dynamics (exactly “the maternal reverie” mentioned above) in the hic et nunc of psychotherapy.

Moreover, because in Italy the original dossiers patented from C. Vacheret are not available, I built up, in the course of time and use, my personal dossiers of photos, divided into themes, sets and sceneries. I call this method “fotolinguaggio” (“photolanguage”), to distinguish it from the original photolangage© invented by the above mentioned author, and I apply it in the following cases:

• In group, couple or family psychotherapy, when it is necessary to use a mediating object to promote the passage from “thing presentation” (connected to the Unconscious and primary process thinking) to “word presentation” (related to the Conscious-Preconscious system of the first Freudian Topography and to secondary process thinking) (Laplanche, Pontalis, 1967).
• In particular moments of therapy: for example, in the initial and/or final phase, before or after separations for holidays, etc.
• On occasion of different kinds of difficulties or therapeutic impasses that may determine an interruption of the treatment or the drop out of one or more components of the family group.
• When it is necessary to re-discover pleasure within the family group and/or couple relationships and also in the therapeutic alliance, with the aim of making patients more confident of their possibility to enjoy the psychotherapeutic setting and to achieve some positive results.
• With commonplace difficulties in the couple or family due to individual characteristics or relational patterns, such as the following:
  • Severe intrasubiective and/or intersubjective communication problems;
  • Massive difficulties in sharing inner feelings and thoughts within the family or couple;
  • Constant use of language in a defensive way (rationalization, intellectualization, phobic escape, obsessive control, inhibition, etc.) or in a very moralizing way with a final effect of judging each other;
  • Lack of empathy or impossibility to put themselves in someone else’s shoes;
  • Difficulties to accept that other people may have a point of view completely different from theirs which could be right as well as theirs;
  • Etc…

Having mentioned in general the situations indicated for the use of different types of mediating objects, I would now like to explain them better with the example of a clinical case in which I have applied my personal technique of photolanguage.

A clinical case (fotolinguaggio)

In November 2011 the D.F. family came to the Counseling Centre where I work to request family psychotherapy as prescribed by the Public Mental Health Service, which was treating the daughter F. (29 years old) pharmacologically. She was also in psychoanalytic psychotherapy once a week with a colleague that works privately. Her symptoms consisted of panic attacks (that started in February 2011), impulsive behavior that often placed her in difficult or dangerous positions and phobias of different kinds of aggressive animals (crocodiles, sharks, etc.). After living on her own for a few years, she recently returned to stay with her parents (R., 61 and S., 56 years old) because of economic problems. Her sister V., 14 months older than F., married in August 2011 and moved with her husband to another town where she previously attended the university, many kilometers from Padua. The family conflict was massive but never with aggressive physical actings. The contrasts were between the parents and the daughter and also within the marital couple. After the preliminary consulting phase I proposed family psychotherapy once every 2 weeks, obviously without V. because of the distance.

From the beginning I was impressed by the use of verbal language in this family, centered on economic problems, full of vindications and accusations, very detailed regarding the daughter’s incapacity to do something, comparing her negatively to her older sister V. Words were constantly utilized in a moralizing and rationalizing way by the parents towards their daughter, in complaints about her personal incapacity and immaturity. But F. was also reproaching her parents for their marital lack of understanding and inconsistencies. In my countertransference I found this quite irritating and sometimes even boring.

In the first couple of months of psychotherapy we managed to define the “debts and credits” of each member of the family not just in a concrete way but in a more symbolic and meaningful way, in terms of expectations/demands and needs/wishes towards each other. Everyone felt they were “in credit instead of debt” and considered the requests of the others as excessive, intolerable, deeply characterized with orality (“sucking” or “devouring” demands). These feelings were not just between parents and daughter and vice versa, but also between the marital couple. From the beginning it emerged that the mother, when in the early stage of marriage and her two daughters were still little, had also suffered panic attacks, because her husband was always away on account of his job and she was lonely all day in a very isolated house to which the new family moved, definitely far away from their home town.

In general the communication difficulties in this family seemed to evoke a neurotic structure. In this structure, as A. Eiguer asserts (2001), “two cultures, the adult culture and the adolescent’s, come into conflict “. Disagreements on some points were typical: rules about sharing the house, rhythms of life, visitors, amusements, etc. It seemed that F. was confined in a never-ending late adolescence, with infantile oral dependency on her parents, expressed with pressing requests that, if unsatisfied, became a sadistic need to rob them of their precious things (her mother’s homemade jam, her father’s tools, etc.). The parents, sincerely upset and worried about F., did not know what to do to help her “to get out of there”. In every psychotherapeutic session there were no moments of silence, words were used like sharp weapons to cognitively convince each other and to cause a behavioral change. I had the feeling of swimming in a sea of verbosity that was not at all helping real access to shared emotions and to intersubjectivity. The few intrasubjective cues often offered by S., the mother, were always trivialized in terms of good common sense by R., the father. It was as if the entire family preferred to stay on a “surface level”, without going too deep, perhaps because of “fear of seeing what was underneath”. Sometimes I had difficulty to give any useful restitution about the family’s interactions, in the direction of opening some associative and more spontaneous processes.

Patients and psychotherapist were somewhat paralyzed by a massive use of rationalization in their language.

After 5 months some references emerged in relation to “fear of deep water and of what may be hidden underneath, with incapacity to swim in it because it is so dark”. In my mind I suddenly connected that verbalization with this family’s difficulties to afford the analytic process but I did not make any interpretation about resistance to therapy. For the next two sessions S. called me to cancel, referring to job problems. Until then they had all come to the sessions, always punctually. On one occasion S. asked me if she could eventually come by herself: she mentioned that F. said that “she did not want to come anymore because the therapy was more useful to the parents for their marital problems”; S. also reported that her husband, R., for his part, had agreed at first to continue as couple therapy but “at the end he refused to come if F. was not coming anymore, because the reason for psychotherapy to him was just to help the daughter to feel better”. I answered that it was important that all three were coming, “because if they wanted to terminate it was essential for them to make the decision together and to agree on how and who will finally continue…It was also important for us to be able to say goodbye to each other”. At this point one month had already passed after the last time I had seen them and I was wondering how to get out of the therapeutic impasse. Then I thought of the possibility to dedicate a session to photolanguage, with the aim of mobilizing the associative capacity in this family that seemed to me potentially well developed but defensively avoided in our interactions.

I chose for them around 20 photos with different subjects, some connected to the theme of water, the sea as deep or shallow, dark or transparent, and the creatures that live in it. There were also other landscapes, on the mountain or in the forest, some crafts or everyday objects, and some unknown artistic works. The question consisted of two parts: “What did you like the most, what made you feel satisfied about your psychotherapy and what did you dislike or made you feel unsatisfied about your psychotherapy? Tell it with the help of two photos, one to express what you did like and the other to express what you disliked”. In this way I proposed to work on two antagonist poles, promoting access to ambivalence. I tried to stimulate awareness of resistances with the aim of coming to an agreement about terminating family therapy or continuing with a different setting (e.g. couple or individual psychotherapy).

S., emotionally touched by the new task, picked up “Sparkling sea” to express what she liked the most in family therapy and “Sicilian Puppets” and “Labyrinth” to represent what made her feel unsatisfied. She said: “the dark water scares me, because you cannot see the bottom of it, but there is also light…and the light gives me hope”. Referring to the other two images she added: “I feel like a Sicilian puppet… with someone that maneuvers it. This is a terrible image for me …! Also, the Labyrinth is very distressing, because you cannot get out, wherever you go… you try everything, but you always end up against a wall…Also with my daughter F. I feel I cannot get out of problems… with her everything is black or white, she provokes me to see if I really love her or not…I have to prove it with my behavior and I fail every time!…[…] If you are a mother you wish to have happy sons and daughters. I know that I want to have everything right now, but it does not work like that… This is not how you get out of the labyrinth, I must learn to wait a bit… and after all there is hope!”

The confrontation in the family: “what do you find similar or different in the photos picked up by the other members without expressing any interpretation or judgment about other people’s feelings and associations” started pretty quickly, because F. chose the same photos as the mother to explain what she disliked, “Labyrinth” and “Sicilian Puppets”. F.’s verbalizations where not so different from her mother’s: “you cannot get out of here if you are inside, you are in or you are out…Like my mother, I am a person that expects to have everything right now, but I am aware that it cannot be like that…!”. “Here I feel always on alert, like Sicilian puppets, under cross-fire, like I am constantly at war. I feel lonely when we argue, they have this thing that I call “marital solidarity“ between the two of them, and I find myself alone…”. For the positive aspects she picked up “Cretan Love”, stimulating the curiosity and interest of both parents: they were astonished and declared they had not seen that photo. F. said: “This picture gives me serenity. I imagine my future family like that, having some stability in the future”. Her verbalization sounded ambiguous, because it was not clear whether she was talking about her own future couple with someone or about the parental couple. R. and S. caught this ambiguity too, and asked her for clarifications. This is how she answered: “for me it symbolizes stability, serenity in the future of my present family…with you I mean. How many other families have I got?!” The parents agreed in their totally different interpretation of the photo in terms of painful feelings and sadness.

1. said: “there is tenderness and love within the couple, but also suffering…really a very nice painting! Both the man and woman have sad and suffering expressions”. On his side, R. added: “for me it is a tragic photo…the woman, but also the man, seem to carry great inner pain…it is a union based on pain, on suffering…”

Then R. first commented on the photos chosen by his wife and daughter: “the sea is illuminated, it gives me a sense of tranquility, it is a calm, positive and serene sea, just a little bit rippled…I can understand that if you do not see the bottom of it, this can symbolize fear of the Unknown…[…] The Labyrinth means confusion, whereas the Puppets remind me of being maneuvered”. Finally he presented his photos: “Madonna of the Garden” for the positive aspects, and “After Chaos” for the negative ones. He said: “The mother that protects and accompanies the child represents the family… For me, as a man, it has the meaning of protecting the wife and children”. “The other one struck me as a really distressing image, a sort of tunnel I would not like to enter…but now, looking at it better, I can see an exit […] it is not so distressing, you can go through it”. S. and F. agreed in believing the first image was a religious statue, provoking R’s astonishment; she did not consider that possibility at all. S. said: “for me this is the Madonna, the mother par excellence… I wish I could be like her, who gave everything for her son! […] I do not know what to think about the other one, I am sorry!” On the contrary, F. preferred not to comment about the first image, because she declared: “I am going through a particular moment concerning Religion” […]. “The other one, instead, gives me a sense of shelter and envelopment“.

On the final phase I asked them to share feelings and considerations about “how it was to do this activity together”, “how they took the fact that other members of the family made different or antithetic comments towards their own photos”. For the first time in the psychotherapy some verbalizations emerged that opened up the possibility of dialogue: a divergent thought can be tolerated and coexist in a sort of nascent empathic attitude. In other words, for once the need to align all the personal convictions within the family was not prevalent. At this point I decided to insert my own choice of photos with respect to therapy with this family: “Bird’s-eye Bay” and “Turtle”. This is what I said: “I like the inviting little bay seen from the top, because of the possibilities it contains: crystal-clear water, a nice sea to swim in, protected from the winds, trees on the beach to find shade from the sun, etc….The turtle is what you can find in this water if you dive in, and it is not negative or unpleasant itself, it is the opposite! But the turtle makes me feel unsatisfied, because you cannot meet it if you do not enter the water…So, reversing the order of the two photos, the turtle, a curious and lively animal, could represent something nice and pleasant, a surprise,… everything interesting we can discover in the water and also in the therapy. Unlike the bay, simply because you can only see it from afar, this could be the less pleasant aspect…we do not know exactly how to get to it”– (“The path might not be easy to follow,” added R.). And I proceeded: “So we can decide together whether to remain on the surface and stop at this point with the therapy, which is all right anyway, and not going in to see what is under the water…. We can decide to not go deeper into some aspects, for example, who is the puppeteer of these puppets, what it is that makes them move…”.

In a low voice, almost imperceptible, S. said: “my puppeteer is F.!” And F. replied, in a  voice just as low as S.’s: “I knew it ! She feels manipulated by me if I ask her something!”. Then the family remained silent for a little while and this was the first time they were able to tolerate it. In an associative atmosphere, R., very touched, with deep-felt words remembered his own mother he loved very much. He said how sorry he felt about her if she was sad or upset because of him, for something that he could have done or said to her. He clearly verbalized his wish that his daughters V. and F. would behave towards their parents the same way he did towards his mother when he was young. At this point S. intervened to say how emotionally “heavy” R.’s wish has been for her, deeply present since their daughters were little: “an unattainable perfection that made me feel frustrated all my life, continuously compared to his brother’s wife about the way she was raising her daughters…”. Then F. reacted actively to her father’s projection: “I would like to not be compared to other people and I totally dislike coming here to see my mistakes emphasized by my parents…besides I always feel bombarded, in a state of alert… like the Sicilian puppet!…” As Eiguer says (2001), in families with neurotic functioning “the Oedipal attachment of the parent to his own parent […] is still alive” and determines “in the young person a rejection of passivity” and “a need of self-assertion”.

As a restitution I concluded as follows: “maybe in this period the whole family is wondering what kind of help they can get from therapy and if it is possible to stay in it despite the difficulties and fears, each in his or her own way, differently from the ways of the others. Is this psychotherapy a place I can feel is mine as a person and as a family or is it not?” At the end of the session the family decided without any doubt to continue the psychotherapy.

The use of the mediating object has probably helped me mentally to “live in the space” of the family psychotherapy in a more spontaneous way, overcoming the impasse phase that determined a temporary interruption of analysis. Stimulating some verbalization that was less cold and rationalizing compared to their usual communication mode, the mediating object illuminated the family group’s symbolic heritage, from “manifest accounting“ to “latent accounting” (according to the famous definition of Ancelin Schützenberger, 1993). All the rich material that emerged in this session (which we will not go into for reasons of overall length) became in the next months the object of working through and intra/intersubjective exchanges. S. said that “it has been like overcoming an impediment” and “after that session the atmosphere at home definitely changed”. The family agreed on the need to invite the oldest daughter, V., to the therapy. She participated actively in some of the sessions, making the long trip from her present home town. Over the next months more awareness emerged of mutual expectations and intolerance, which determined a reshaping of idealization and consequently an improvement in relationships in the family. Actually, after one and a half years, F. has gradually reduced pharmacological therapy by prescription of the psychiatrist and she is close to suspending it completely. After clearing up some of the reasons for anxiety and making some links concerning aggressive and destructive drives circulating in the family, they are now working on tolerance and gratitude towards each other. They all agree that at this point in therapy everyone is trying to put themselves in the others’ shoes, accepting that different ways of being can exist, something absolutely unconceivable at the beginning of their psychotherapy.

Conclusion

The use of different mediating objects has undoubtedly represented a technical challenge, a sort of test for the psychotherapist’s personal and professional capacities to be able to preserve the psychoanalytic setting even when new elements are introduced. In fact these elements that bring out a basic symbolic-creative ability, could at the same time be potentially destructuring. In my opinion it would not be possible to apply mediating objects in a really effective way, helping the Preconscious’ connecting job, without a solid but at the same time flexible theoretic psychoanalytic frame. Having this frame of reference it is a good idea to calibrate psychodynamically, situation by situation, to introduce the mediating object in a sensible, meaningful way.

In his classic book “Un divan pour la famille” [“A couch for the family”] (1983), A. Eiguer writes a poignant page about the relation between theory and technique, from which I would like to quote some sentences as I come to the conclusion of this paper.

“A technique without a conceptual base is inexorably destined to fail. […] In view of the constant challenge presented by families, the psychotherapist’s confidence in the reliability of his own method is very important. For this reason, theory has a double function. It acts constantly within the therapist as a thoughtful instrument towards the family. It allows us to refer the particular to the universal: this family to The Family. In this way theorization often establishes an intermediate space of play between the therapist and his object of study, a space he will love to use with pleasure”. [The English translation as well as the underscoring are mine].

Therefore, we can consider theory as an intermediate space of play, as is a mediating technique. Finally, after all, is it not possible to conclude that in any case the most effective mediating object for the clinician is always Theory?

English correction Susan Rogers

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[1] LA ROSA,PSYCHOLOGIST, PSYCHOTHERAPIST- FAMILY CONSULTATIONS- ULSS 16- PADUA-ITALY.