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Tavistock Relatonships' Mary Morgan and Damian McCann attended this event and were able to contribute to a fascinating 4 days.

Here we feature a report on the event by the organisers: 

“Settings and Modalities in Family and Couple Treatment”, Rockville MD, February 1-4, 2018

An IPA/IPI conference reported by Jill Savege Scharff, adjunct member COFAP, and co-founder, IPI.

The International Psychotherapy Institute (IPI) collaborated with the Committee on Couple and Family Psychoanalysis (COFAP) of the International Psychoanalytic Association (IPA) to present an international conference on “Settings and Modalities in Family and Couple Treatment”.  The conference was organized by co-chairs David E. Scharff (also Chair of COFAP) and Carla Trusty-Smith (Chair, Couple and Family Program, IPI), with the support of Janine Wanlass (Director of IPI).  Participants came from the United States, Israel, Canada, Panama, Greece, and Russia to Rockville MD to engage with the IPA and IPI presenters, Mariângela Mendes de Almeida (Brazil); Anabella Brostella (Panama); Shlomit Ben Lavy, Anat Ben Salmon, Hanni Mann-Shalvi,  (Israel);  Li Zhen (China) Jeanne Magagna, Amita Sehgal, Damian McCann, Mary Morgan (UK) ; Jude Piercey (Australia), Elizabeth Palacios (Spain), Monica Vorchheimer (Argentina); Carl Bagnini, Leora Benioff, Shelley Nathans, Jim Poulton, David Scharff, Jill Savege Scharff, Caroline Sehon, Michael Stadter, Carla Trusty-Smith, Janine Wanlass, Richard Zeitner, and John Zinner (USA). Keynote presentations, student case presentations with clinical discussions, optional tracks on special topics, and small discussion groups provided a variety of learning settings. I regret that I can’t do justice to every presenter’s contribution as from the rich tapestry they wove I select threads that were highlights for me.

Thursday began with a focus on very young children and their parents.  From London and Brazil came presentations on helping parents with their difficult and unhappy under-5s. Of course parents expect the child therapist to be trained in child development and parent effectiveness preparation. But no matter how well trained, the therapist cannot help the child without the parents. As Jeanne Magagna put it, we NEED the parents to help us treat their child.  Together they can build a thinking space where the parents can observe their child more fully, develop a shared narrative of their child and her role in the family, and make links from their experiences as children to their child’s life now.  From there, parents at home create a daily routine review of their child’s day, and they can all explore the connections among the child’s experiences and the family history and social setting. Feeling secure in this loving, reflective parental cradle, the child grows in self-regulation, curiosity and connectedness. In this way the couple transmits a loving environment that is the child’s link to the past, present and future. 

Turning on Friday to the couple, we heard from Israel about the transgenerational transmission of conflict from the Holocaust to one couple seeking a perfectly-understanding object but instead experiencing a disappointing one full of violence and suicidality, and to another couple who had so concealed their Jewish identity that every request for being known was felt as an appallingly aggressive attack.  How can we speak about the unbearable?  Elizabeth Palacios (European regional co-chair of COFAP) gave a presentation on the couple’s need for continuing psychic work to get to know each other fully, and then showed convincingly how couple therapy could do more than individual therapy to help a couple reach the shared sadness underlying the dynamic of one partner living through and suffering from the other’s manic defense. Shelley Nathans described the need for couple therapy to augment individual therapies for sexual difficulty.  For instance when one partner has lack of sexual desire and the other has frustrated desire the couple can see how they combined to avoid the disorganizing forces of sexuality so as to avoid re-experiencing overstimulation, intrusion and lack of containment in early life. 

Moving on to family work, on Saturday David Scharff (Chair, COFAP) and I presented our brief encounter with a Chinese family.  The index patient was a 10-year-old boy who could not make any decision or speak up for his own choices, caught between the unresolved differences of his parents. We described the unusual 5-session frame of the intervention which occurred in an academic setting with a translator and a large audience.  We spoke about the boy’s symptom as a distillation of family dynamics stemming from a trauma legacy, and showed how playing spontaneously with him and his 4-year-old sister in the session could help the boy to find a voice. Then we discussed the cultural context and the treatment/teaching setting. We usually think of treatment as an intensely private matter but even in this strange setting a therapeutic exchange could occur. Mary Morgan (COFAP member) thought that this could happen because our internal setting was secure and enabled us to relax, engage in word and play, and make a safe, containing therapy space. Li Zhen viewed this family as one that represents not just the impact of the parents’ internal conflict but also the generational conflict between grandparents who live by Confucian principles of filial piety and young people who are looking for a way to live in the new China. In the transference the therapists represented a new world.

On Sunday Richard Zeitner (US regional co-chair of COFAP) presented some modifications of technique in dealing with couples in which one partner is seriously ill.  Even though we hold a firm frame for meeting with a couple, we may find ourselves doing individual therapy in the presence of the partner, and then find our way back to interpreting the couple’s unconscious collusion in maintaining a defensive polarization of health and illness.  It is as though two people are living in one person, said Leora Benioff (COFAP member), and Mariangela Mendes de Almeida advised attending to the theme and the affect that connects them rather than to the projections of internal object relations. Mary Morgan reminded us that a projective identification system like this exists to protect the couple from aspects of themselves that they are frightened of and she reminds us that therapists need to be patient in allowing the defensive process to continue until it is no longer needed.  Damian McCann responded that the modifications in the frame can be an acting out, an acting-in of the transference for subsequent analysis, or a spontaneous or surprising intervention that reflects a shift in the therapist that could release the couple from their entrapment in paranoid-schizoid functioning and facilitate a move to depressive concern.

As the international discussion on settings and modalities continues, differences among various approaches are becoming clearer.  The therapist of an under-5 year old may usefully also do parent counseling or couple therapy with her parents.  Others would see this as a distortion of the frame. Some of us who begin work with a couple will see only the couple. Others will see whichever part of the couple shows up for the appointment. Those couple therapists with a family orientation may include the children (or even a newborn) for some sessions to explore the couple-as-parents, work on coalitions that replace the vital marital bond, and relive childhood experience that can inform current couple relating.   Those with a purely couple orientation would not break the couple frame like that. Some couple therapists focus on each partner’s intrapsychic state and then looks to see how they connect through projective identification.  Others explore couple and family relationships in terms of the intra-subjective, inter-subjective and trans-subjective aspects.  There are similarities and differences, and clearly there is no one way to work with couples and families.  We need all the approaches.

One way to assess the value and meaning of a change in modality or setting is to consider it in terms of whether the therapist is expressing a defensively caretaking function or a truly adaptive containing function. We might also ask if the change made is an innovative movement forward or a regression to a traditional modality out of guilt. Let’s remember that there are individual, couple and family levels of organization. We can intervene at any level but we need to keep in mind what we are doing and where we are going. As Monica Vorcheimer (Latin American co-chair, COFAP) said, we see a wide diversity in contemporary psychoanalysis of couples and families but also a common ground in terms of our desire to understand the unconscious determination of symptom formation.  We want to maintain multi-ocular vision on the individual, couple and family in whichever treatment setting.

The take-away message is that various ways of maintaining and modifying the frame can be either helpful or destructive. The main point is that the therapist needs to examine the impact of any shifts in the frame and use it for therapeutic understanding. We identify with our preferred settings, and we work from an internal setting that is firm but flexible when deviations are called for.  And technical considerations aside, let’s acknowledge that, within the secure setting we create, we are subject to unexpected external forces and liable to our own error, but if we are willing to acknowledge our mistaken responses we can make reparation. Above all, we want to feel free to engage as thinking, feeling human beings.