Reflections on working with couples when you only have one in the room

South Africa · CPD courses & CPD points · Health Professionals

I enjoy working with couples in therapy, but more often find myself seeing adults individually, many of whom are in a relationship and struggling in this area. From what my patients tell me, I often think that their partner would benefit from individual therapy or that together they would benefit from couple’s therapy; however, many of their partners seem unlikely to seek out therapy. It saddens me when I see the hard work my patients are doing, trying to mentalise and grow, learn about themselves and their relationships and making concrete changes in their ways of relating, and I know that the relationship can only improve so much without the partner also making conscious changes. However, I don’t let that dishearten me because I am often amazed at the changes that can come about through one person’s developing insight. Despite my gentle attempts to direct partners to their own therapy, I am inevitably left thinking about a couple with only one person in the room.

When I watched Tertia Myers’ talk about psychoanalytic couple’s therapy, I was listening with two ears, one as a therapist who works with couples, and another as a therapist who works with individuals in relationships. Tertia draws attention to the importance of the therapist’s awareness of and reflection on his or her countertransference responses when working with a couple. Equally, it seems important to be aware of countertransference responses towards members of a couple when working with the individual who is in a relationship. I am often aware of my countertransference towards my patient’s partner and my patient in the relationship, and use this to make interpretations about what my patients might feel, or wish me to feel about their partners.

I recall one particular patient who told me only awful things about her husband, and my dislike of him was so strong that I sometimes felt that my thoughts were loud enough that she could hear them. She did not remain in therapy for long, and although I racked my brain to think if I ever did give a hint at my feelings towards her husband, I know I never did so overtly. When I reflect on her early termination of therapy, I think about the powerful countertransference response I experienced, where I believed her when she told me that he was so bad, becoming unable to hold a neutral stance within myself, even if I did not verbalise my feelings. Even though I was aware of what was happening at the time, I struggled to observe and process these feelings sufficiently, and this might have helped me to take a step back from them and allow me to hold a space for her where she could work through her difficult relationship.

Tertia talks about three important areas that surface with couples: sex, money and children. All couples need to negotiate these areas and there are an infinite number of permutations. She puts forward that money is about power, and who has the say in the relationship. I would add that it is also about choices, whether people get to change jobs, stay home with their children or keep their motorbike, for example. Whether or not a couple chooses to have children, that space still has a place of negotiation in the relationship and its impact is felt. I’m always interested in my patients’ sex lives, as they reveal so much about the capacity to give and take and how our patients negotiate intimacy. It’s often through sex and money that anger is expressed and it’s easy to look here for clues to unearth patient’s frustrations with their partner.

Sometimes, I find myself theorising their partners with my patients, trying to make sense of the person they have landed up with. I believe this helps patients to have an understanding of and compassion towards their partner. However, I am often wary of spending too much time talking about the partner and often have to refocus my energy towards my patient and their experience of their partner, knowing that the patient’s portrayal of their partner is informed both by their partner’s real characteristics as well as patient’s fantasies and projections.

Tertia points out that one of the benefits of having the couple in the room is that you have the opportunity to see how they interact with one another. Of course, with only one part of a couple so much is disguised, and it is extra work separating out the fantasy and projections that take place in the relationship. There seems to be a delicate balance between joining empathically with our patients’ perception of their world, and taking a step back to return to our therapeutic mind, where we can hold a different perspective. In the space between these poles, the work of self-discovery that is so central to therapy can happen.