Cultural changes and therapeutic practice with the couple and family

Changes in culture and psychic functioning

 The contemporary world confronts us with a series of changes that affect the different ways of being in culture and psychic life.

We live in a time of urgency, of identity uncertainties, of crisis of authority, of a difficult confrontation with the experience of limits. We are witnessing a rapid transformation of the links between generations, profound changes in the relationships between the sexes, a transformation of family structures, the mixing of cultures.

We see the collapse of those internal and external references which, in the past, had provided the identifying elements necessary for social and individual stability, a collapse which has involved not only the structuring but also the functioning of the psychic life of the individual, the family and the couple.

The impact of these changes has not spared psychoanalysis, which has had to ask itself what theoretical and conceptual tools a psychoanalytical approach can most profitably use in the face of these new configurations, since the aim is not, of course, to invalidate the classical ones but rather to try to broaden the psychoanalytical perspective.

Kaës has indicated to us that the great part of psychic suffering and contemporary psychopathology is due to the «failures of processes that support the demands of psychic work imposed on the psyche because of its relationship with the body, with intersubjectivity and with meaning» and that «the psychic suffering of the modern world is a suffering of intermediary formations, processes of intrapsychic bonding and configurations of intersubjective bonds» (2012, p. 46, italian edition). Currently, the need to organize defences against insecurity emerges and we find more and more frequently a psychic functioning that makes use of very primitive defences. The defences have changed: repression and sublimation have given way prevalently to denial, division, dissociation, but also to “depositing” on the other, to encryption, to alienating identifications, according to the logic of the bond which, as Kaës (2009) indicates to us, is the logic of reciprocal inclusions and exclusions.

Symptomatic forms that particularly involve the body and dependence in bonding appear more and more frequently. The possibility of remaining in contact with one’s own psychic reality and that of others, such as the willingness to think and recognize suffering, seems to have diminished. Sometimes there seems to be a tendency to “get rid of psychic life”, felt as unbearable and in the face of which one feels powerless because there are no internal tools to contain and think about it: then one “deposits” it on others or uses others (Kaës, 2012).

It seems more difficult to acquire a capacity for subjectualization, that is, the process that determines the establishment of a sufficiently autonomous and differentiated self, such as to allow subjectification. Let us remember that, as Cahn (2006) indicates, becoming a subject requires the experience of specific forms of intersubjectivity, which he calls “subjectualizing functions of the family environment”.

The change in the characteristics of the suffering found in patients has meant that analysts’ attention has moved away from the structure of psyche and its primitive organization. From the content of the unconscious, the interest turned to its container, that is, psychic functioning. The accent has also shifted from the intrapsychic dimension to the interpersonal one and attention has focused more and more on the psychic functioning of the family group. In this way, we have been able to give more comprehensible meanings to the psychic contents that had no longer been possible to understand outside the family relationships. The presence of several subjects in the family or couple setting has allowed to deepen the characteristics of the interpsychic dimension, highlighting the psychic substance that unites the members of a group through shared dream spaces and unconscious alliances (Kaës, 2015).

The cure

 As the demand for care changed significantly over time and we found ourselves confronted with increasingly complex psychopathological frameworks, it became necessary to deepen our understanding of early mental states, to pay increasing attention to pre-symbolic functioning, somatization or acting out and non-verbal behaviour. It was the singularity and unpredictability of the situations that patients present that made us ask ourselves which clinical tools are currently more significant and appropriate to take care of them today.

What does it mean today to “cure” a couple or a family? What kind of listening is useful in a couple or family setting?

Winnicott in the article Cure (1970) said that this term, which has had a different use and meaning throughout history, originally meant taking care, being attentive, a meaning that has been lost, being replaced by the meaning of cure as a remedy to “eradicate the disease and its causes”. But for those who have a psychoanalytic training one cannot ignore the idea that taking care refers to the ability to sustain the relationship with the other by being “reliable”, allowing a dependence, establishing a setting that allows patients to deposit their non-me (Bleger, 1967), their undifferentiated parts, accepting their suffering and helping them to increase their ability to contain suffering.

Especially in the case of regressed patients, it has become increasingly important over time to create a “favourable environment” of care that must be able to adapt to the needs of the patients and that acquires the function of a therapeutic agent. The setting has progressively appeared to be one of the most significant elements for treatment, also due to the fact that in some pathologies such as narcissistic or psychosomatic and borderline personalities, internal objects are partial, split, fragmented and stored in different psychic spaces, or anxiety is such that transference cannot be established (Kaës, 2015, p. 186, italian edition).

The distinction between the function of the analyst as a mother-object who allows the manifestation of transference phenomena – and his/her function of support (holding) as a mother-environment – which, through the analytical setting, provides essential environmental elements that had not been experienced until that moment – has opened the way to a new conception of the setting (Winnicott, 1964). In some cases, the setting may represent the womb and body of the mother. In this perspective, the realization of the setting prevails over the transference process on the analyst, who accepts the levels of transference that the patients organize within the setting.

The conceptualizations of Bleger (1967) of the analytic setting as a “non-process” which differs from the “process” of psychoanalytic treatment and makes it possible are also important, especially today. Bleger considered the setting as the set of phenomena included in the therapeutic relationship between the analyst and the patient. The “non-process” of the analytic setting spontaneously becomes the repository of the symbiotic parts of the analytic couple as an invisible institution that escapes elaboration.

Also the contribution of Searles (1960) with the concept of the setting as a “nonhuman” environment to which the analyst must adhere by accepting to be part of it, placing himself in an undifferentiated position and suspending his differentiated function, appears very useful and significant today.

The analyst must accept to adapt the setting to the particular mental conditions of the patients. He is called to constantly re-establish the analytical qualities and the continuity of therapy through the aspects of a setting linked above all to the mental disposition of the patient. The setting thus becomes an expression of the analyst’s mental activity in an attentive listening to the patients’ needs. But what kind of listening can the analyst have in this disposition? We could remember that Aulagnier speaks of the “pleasure of hearing” which precedes the desire to “understand” which implies the activity of the “primary-secondary” (1975, p. 135, italian edition). What the analyst hears is the functioning of the family psychic apparatus and within it those subjects who are its “word-carriers” or “symptom-carriers”, what he/she is listening to is the existence or not of an intermediate space where everyone can experience themselves, and the possibility or not of transformation of the positions assigned in the context of relationships.

A family composed of father, a mother in her fifties and two sons in their twenties

They ask for therapy after recovery of their eldest son from hospitalisation, and lifethreatening coma, following involvement in a scooter accident. The collision had literally caused a “fragmentation of the body” of the young man with numerous fractures and damage to internal organs. As a result of this dramatic experience, in which the family found itself, for the first time, united and collaborative, they decided to seek family therapy so as not to lose the climate of closeness and union that had been achieved in that period. This was particularly important since the family history had been marked by violent acts, repeatedly acted out by the father towards the children, during their childhood. Beginning with the emergence in session of an alliance of the mother with the children against the father, with the passing of the sessions emerges the serious depressive state of the mother also treated with drugs, which gradually the father is able to indicate as always existing, sometimes keeping her in bed for whole days, even before the birth of the children. The father can express can express a deep and intolerable experience of abandonment, which made him feel powerless. He tried to get rid of it by violently attacking his children whenever there was the slightest difficulty: explosions saturated with irrepressible beta elements. At first I felt powerless and incapable of activating a thought about what was presented to me. It was internally difficult for me to distance myself from the alliance between mother and children who were judging the father guilty of violence directed at his children. I felt “thoughtless” like the father who unconsciously acted out for everyone the violence by undoing the possibility of thinking. As I was able to re-emerge from emerge from the state of “stupidity” and mental narrowness in which I had come to find myself, activating in me a possibility of analysis of my countertransference, I witnessed a progressive diminution of the father’s role of scapegoat, spokesperson, which he had at the start, whereas now the family stories of both of the spouses emerge, characterized by parental figures, especially maternal, detached, devaluing. It was possible to see the presence of a traumatic experience of lack of primary containment in both spouses, of serious failure of the maternal function of holding and also of acts of carelessness that could be defined as violent. These memories resurfaced with greater intensity after the birth of the children due to the stress that the needs and body care of the children had provoked. The couple’s bond, of a symbiotic nature, which had to contain the psychotic part of their personality (Bleger, 1967) could not be transformed in relation to the new needs that the presence of the children had introduced and the crisis of the symbiotic defence, container of their immature needs, had brought out the presence of dissociated areas in both, connected with experiences of non-integration and the emergence of strong anxieties. It can be hypothesized that, with the accident, through contact with the fragmentation of the son’s body, primary experiences of nonintegration had resurfaced and, later, with the recovery of “bodily integrity”, reached with the emotional participation and care of all the family members, the experience of re-integration had stimulated the emergence of a possibility of “representability” (Botella, 2001). This gave shape to a desire to be able to build, integrate that missing part of their emotional experience through which they could restart also internally a process of integration, in this case “psyche-soma”, which until then had remained unfinished because of «the inability to make psychic a state that, because of the same inability becomes excessive in energy, a non-attached perceiving» (Botella, 2001, p. 138, italian edition). One could, however, ask oneself whether the accident – even if recounted as (passively) suffered – could not also have been a challenge to death or a hidden suicide attempt. In this family there seem to be death themes left as in suspended animation.

The analysis of the countertransference, in which there were strong feelings of helplessness and annihilation, could allow the activation of a mental function of mirroring and containment and the setting could have a function of holding, of mother-environment, providing essential environmental elements not experienced until then, by responding in a transformative way (Nicolò, 2019), allowing the expression of experiences and explosive sensations and allowing for them to be integrated through the construction of a unity of the Self and through the possibility of representation of the analyst. A family and individual integration was progressively possible, since the symbiotic defensive alliance between the spouses was no longer necessary. Also the representative activity of the mind could progressively take shape in the patients allowing an evolution of the familiar and individual functioning of each one. The relationships between the family members have become animated; during the sessions it has been possible to joke, to recognize one’s own difficulties and the differences of each one. The bond between the siblings could also have its own space. I was also very excited to feel the emotionality circulating so freely and I felt that I had four people in front of me, each with their own pain. The familiar body didn’t seem so painful anymore. The possibility of separation also emerged as the family no longer had to perform the function of holding together in an undifferentiated way, due to the threat of depersonalization.

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References

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Searles, H.F. (1960). The Nonhuman Environment in Normal Development and in Schizophrenia. New York: International Universities Press. [Trad. it., L’ambiente non umano nello sviluppo normale e nella schizofrenia. Torino: Einaudi, 2004]. Winnicott, D.W. (1964). L’importanza del setting nelle situazioni regressive in psicoanalisi. In Winnicott D.W., Esplorazioni psicoanalitiche (pp. 115-121), Milano:Cortina. PsychoAnalytic Explorations, The Winnicott Trust, 1989.

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