Relations d’objet et mentalisation en thérapie de couple

I describe how a combination of mentalization and object relations theory can help deescalate highly charged couple conflict.

As Chiara and Jamie walked into session and sat down, an image came into my mind – a raging fire, surrounded by walls of ice that were beginning to crack into sharp splinters. It felt alarming. Jamie sat in silence, Chiara exploded. Everything was very clear now, she declared; what had happened was beyond what anyone could tolerate, and she knew what she had to do. I looked quizzically at Jamie; he shrugged. While Chiara spat her anger at him, his expression, which at first had seemed inappropriately indifferent in view of her assault, began to alternate between despair and a cold, hateful resentment. I had to stop Chiara several times to get some sense of what exactly had happened.

Chiara and Jamie were a couple in their early 30s. They had been married for two years and wanted to start a family but were concerned about how angry they could get with one another. They had had an argument at the weekend that ended with Chiara throwing and breaking a small table. One of Chiara’s hobbies was dressmaking. She loved to transform vintage clothes into contemporary, edgy outfits, which she wore and sometimes sold to friends. Lately, she had not had time to do much sewing and the clothes she had bought had not inspired her. On Saturday, she had come back from a concert to find that Jamie had disposed of all the old garments she had been keeping in their living room.

Jamie, when he finally got to speak, said that Chiara had told him that she was going to get rid of most of them, but she never got around to it. Some of them smelt bad, he said; her stuff was everywhere and there was no room for his. Chiara argued that the clothes occupied only a small corner of the room, that throwing them away clearly meant that he wanted to get rid of her, and she had no option but to file for divorce.

It was as if each partner was convinced the other was trying to eliminate them. I wasn’t sure what to believe: was Chiara a hoarder? Was Jamie obsessive about tidiness? As I sat with them, more images came to mind, powerful, disturbing, as in a dark, graphic novel – Jamie out of his depth and drowning in a sea of clothes, Chiara’s dead body discovered in a rubbish bin. The images were intruding in my mind, taking up all the space, leaving no room for thought. I felt at a loss.

The above vignette has been fictionalised, but the dynamic in the room, the therapeutic process and the feeling I describe are very real. The feeling is one shared by many clinicians who have found themselves working with very dysregulated couples. It is where the idea of applying mentalization-based therapy (MBT) to high-conflict couples originates. At Tavistock Relationships, we offer an object-relations understanding of couple dynamics combined with a mentalization approach, and this article explores this approach in theory and in practice.

Objects relations and couple theory

 Kleinian object relations theory has its roots in Freud’s belief in the life and death instincts and posits the existence of very early unconscious phantasies. At the heart of the application of object relations theory to couple work are Klein’s concept of projective identification, Bion’s concept of the container-contained, Winnicott’s theory of the importance of the mother’s holding and mirroring the infant, and the resolution of the Oedipus complex.

According to Kleinian and post-Kleinian theory, in the primary infant-mother relationship, the infant defends against anxiety by projecting the unconscious phantasies and unwanted parts of the self that are causing this anxiety into the mother, who, through her attuned “maternal reverie” (Bion, 1962), is able to contain and return his or her projections in a detoxified form. This means that mother communicates that what the infant is expressing has a meaning and can be understood, and that its angry and destructive phantasies have not damaged her.

From an object relations point of view, the dynamic is similar in a couple relationship, but mutual rather than unidirectional. In an emotionally mature relationship, each partner is able to contain the other’s projections and the couple itself becomes a container.

Having an attuned primary care giver enables the infant to internalise a good object (a good mother) who provides containment. The experience of being understood and reassured is necessary for the infant to be robust enough to access the next stage of development and bear the feelings of rivalry and exclusion it might trigger. At this point, the infant learns to find his or her place outside of the mother-infant relationship and begins to form in his/her mind a model of a couple. Acceptance of the existence of a parental couple from which one is excluded (ie., working through the Oedipal configuration) is an essential step towards becoming able, as an adult, to tolerate ambivalence and fully invest in a couple relationship.  

The processes at play in the primary mother-infant relationship and the resolution of the Oedipal situation provide a paradigm for the dynamic of the adult couple relationship. They are the basis for such fundamental concepts as the couple’s projective system, the couple fit and the idea of an unconscious partner choice. Partners carry aspects of the self for each other. For example, one partner might carry ambition and competitiveness, which the other does not like in themselves. They, in turn, might carry the vulnerability and dependence that the other despises or fears in themselves. Provided the “fit” is flexible, it can function very well. However, if the system becomes fixed, or one partner no longer wishes to be the recipient of the other’s projections, conflict can occur.

Mentalization theory

Bateman and Fonagy (2016) define mentalization as an imaginative mental activity that enables one «to understand actions by both other people and oneself in terms of thoughts, feelings», wishes, and desires and to see oneself «from the outside and others from the inside» (p. 3). Mentalizing is both ordinary and crucial, as «it creates the psychological coherence about self and others that is essential for navigating a complex social world»

(p. 5).

Mentalization is based in attachment theory, developmental psychology and neurobiology. It shares with object relations theory the premise that failure of early maternal care impairs ego development. Mentalization focuses on the neural underpinnings of the link between this failure, the consequent failure to acquire or develop the ability to mentalize and later difficulties in forming and sustaining interpersonal relationships. The couple relationship is the most intimate relationship since the very first mother-infant one; as such, it presents both an opportunity for repair and a rich terrain for dysfunction and dysregulation.

Rather than focus on mother’s role as the recipient of unconscious projections, mentalization emphasizes the importance of the carer’s “contingent and marked mirroring” of the child’s emotional reactions (Bateman and Fonagy, 2016). The adult is able not only to represent the child’s emotional state accurately, but also to communicate explicitly to the child their understanding and ability to cope with this (for example, by speaking “motherese” – “Oh you poor baby – I know, mummy left you all alone in your cot, and you were crying and screaming, but it’s ok, I’m here now, see, I’m holding you now…”). The differentiation between the child’s and the adult’s experience is crucial: the mother saying that she understands why her baby is upset is different from showing that she too is upset and cannot deal with her child’s distress. It is also different from a mother imposing her own perception of a situation, for example by saying, “Oh you always cry as soon as I fall asleep. You just want me to get up and come to you, you’re doing it for attention”. A child’s ability to learn to understand their own and others’ mental states depends on whether they were adequately understood by a benign, caring adult. In the absence of such an adult, epistemic trust – the belief that “what the caregiver is trying to convey is relevant and significant and should be remembered” – does not develop and epistemic mistrust – the belief that «the motives of the communicator [are] malign» – grows in its place (Bateman and Fonagy, 2016, p. 24).

Although mentalization incorporates the concept of projective identification, it defines the infant’s wish to get rid of unwanted parts of the self as the need to get rid of the internalised self-representation (“the alien self”) provided by an inadequate and possibly malign primary carer (Fonagy et al., 2004). The “alien self” is a concept akin to Winnicott’s “false self” (Winnicott, 1965), with more aggressively intrusive and destructive overtones.

Without epistemic trust, the ability to learn from experience and to form interpersonal relationships is thwarted. This obstructs what Britton, referring to the Oedipal situation, describes as the creation of a triangular space that enables us to see «ourselves in interaction with others and [entertain] another point of view whilst retaining our own» (Britton, 1989, p. 87), and impedes the ability to develop intimate couple relationships in adult life.

Theory into practice

An object relations approach requires the therapist to access what is happening in the dynamic unconscious of the couple. Because of the need to clarify the different points of view, we tend to intervene and ask questions more often than in individual work. The focus is on what the partners and the therapist trigger in one another in the here and now of the consulting room. A more contemporary approach also highlights the present and the future at least as much as the past (Clulow, 2017; Morgan, 2016). However, our aim is usually to increase insight into the links between the partners’ relationships to their internalised parental figures and their current relationship. We maintain a neutral, nondisclosing stance, which allows for some free association and for transference – possibly negative – to take place and be explored; we use interpretation and allow for silence.  In some highly dysregulated couples, one or both partners might have traits and behaviours that would be described as personality disordered. In others, it could be argued that the couple itself exhibits such traits and behaviours (Nyberg and Hertzmann, 2018); each partner may function well individually outside of the relationship but something in the relationship, or something about being in a couple relationship, exposes a deficit in emotional regulation. Dysregulation comes from a situation that activates an insecure attachment pattern. Whether the subject reacts by “up-regulating”, which may manifest as shouting and being agitated (like Chiara), or by “down-regulating”, which may manifest as withdrawing and being cut off (like Jamie), when the brain is flooded with emotion and the pre-frontal cortex no longer regulates the firing from the limbic area and the brain stem, the ability to mentalize goes. In couples, the capacity to assess accurately one’s own and one’s partner’s states of mind and avoid misunderstanding intentions and feelings is then gravely impaired.

When insight into unconscious defences risks triggering more dysregulation because of past abuse or trauma, the overall goal of the therapy and the therapeutic stance may have to be reconsidered. MBT provides the key to an approach whose sole focus is to enable mentalizing. The point is not to dismiss or ignore the unconscious but to prevent dysregulation from hindering any fruitful work with it.

The first therapeutic step is to establish epistemic trust, which has a more primary dimension to it than the similar concept of therapeutic alliance. In order to enable this trust to develop, the therapist adopts the genuinely curious and open stance that the mother/carer did not provide in the client’s infancy. MBT recommends «an authentic “not-knowing” stance that forms the bed-rock for exploration of the patient’s perspective» (Bateman and Fonagy, 2016, p. 31).

In MBT, the emphasis on a genuine empathic validation of the client’s subjective experience goes hand in hand with the disclosure of the therapist’s perspective (which does not imply disclosure of anything personal belonging outside the consulting room), as opposed to his or her interpretation of what is in the patient’s mind. It is significant that the concept of “countertransference”, which in object relations couple therapy is mostly understood as a projection of what the couple is experiencing, is replaced in MBT by the concept of “counter-relationship”. This refers to the therapist’s experience in relation to the patient’s behaviour in the consulting room and is used to make the patient aware of his/her impact on another, and explain what the other thinks and feels, rather than provide insight into the mind of the patient.

In couple work, when the partners’ views on related events are contradictory, when mistrust and the belief in malign intentions overrule epistemic trust and each partner is the repository of the other’s projection, the essential task of enabling each partner to feel heard and understood can present the therapist with a powerful challenge.

Links with Chiara and Jamie’s pasts were discernible: Chiara’s father had been cruel, locking her out in the cold if she misbehaved; Jamie’s mother had been intrusive and controlling. Thinking that the couple were transferentially enacting with one another the relationship they had each experienced with the parent of the opposite sex helped me grasp the dynamic that was triggering the dysregulation. However, providing insight at this point might have made the dysregulation worse. Of course, you don’t have to be trained in MBT to know when not to make an interpretation. However, in the presence of a highly dysregulated couple, it is easy to become drawn into a non-mentalizing mode oneself and helpful to remember that the focus is solely on re-establishing the couple’s ability to mentalize. The ultimate goal is to stimulate the couple’s own capacity to understand their dynamic, rather than interpret and suggest meaning.

In the session described above, both partners were stuck in a non-mentalizing state of mind. To prevent the argument from escalating, I slowed things down by stopping the dialogue whenever the tone became heated and repeatedly rewinding to what triggered the emotion, and by stressing how difficult it was for me to hear – let alone understand – exactly what had happened. When their emotions had sufficiently abated for them to recover their ability to mentalize, it was possible, by using cues to trigger epistemic trust such as asking questions, maintaining eye contact, modelling turn-taking and listening, to identify, validate and explore the affect behind each partner’s actions. Eventually, both were able to recognise and tolerate the fact that they were both feeling that the other did not respect or want them. Awareness of a shared affect is not always productive with dysregulated couples, but in this instance it enabled Chiara and James to make room for each other’s mind. Starting from the concrete cause of their latest argument, it was eventually possible to comment on how difficult it can be to share not only physical but also “psychic space” (Britton, 2000).

Conclusion

 Morgan defines unconscious phantasies as «the stories we create to explain our experiences of relating externally and internally» (Morgan, 2017, p. 64). Perhaps the same can be said of theories. If so, object relations and mentalization tell the same story, with important variations. At the heart of the object relations narrative is a focus on the metaphor. At the heart of the mentalization narrative is a focus on the biological: «unlike other psychological psychotherapy constructs – the unconscious, transference – that have no link to particular brain functions, Mentalization is – appears to be at least… a function that we can identify at the level of the brain…» (Fonagy, Bateman, Asen, 2018).

An understanding of the psycho-biological roots of Chiara and Jamie’s potentially explosive behaviour dictated a particular therapeutic stance, while the powerful countertransference I experienced provided a metaphor that encapsulated the couple’s dynamic. When the images in my mind gave way to thoughts and words, I was able, over a period of several weeks, to work with both partners to help them recognise triggers and name the overwhelming affects they awoke in one another and in which I had been engulfed. The image of fire and ice helped them mentalize the way that Jamie’s cold, cutoff stance could provoke Chiara’s rage, and how her fiery temper could cause him to withdraw and become cutting. It served to represent and clarify the nature of the elemental force and conflictual dynamic that characterised their couple.

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