A TALE OF TWO APPROACHES 

What do psychodynamic / analytical and
systemic / family therapy approaches share? 
How do they differ? 


Preparing for a workshop for an audience of psychodynamic individual and couple counsellors on Couple Therapy, "A Tale of Two" (see here for more of the kind of thing presented), Nick got interested in the above bridging question between approaches. For 20 years Nick has been at home both in psychodynamic and family therapy models. He had 5 years personal analysis arising from an unfinished analytical training. He supported a social work colleague becoming an (analytical) child psychotherapist - in a multidisciplinary CAMHS team that was family systems based (without family therapists). We didn't have an answer to how the two approaches integrated theoretically, but we "just knew" when to call her in to have a look. Even now if Nick saw an individual adult client for weekly appointments over a period of time, he'd still call on psychodynamic skills like transference etc. Organisationally though Nick was one thing then the other. So trainings and organisations demand tribal loyalty. Individual therapists may be eclectic. This is his attempt to name the overlaps and differences.
  • Both approaches build on reliable safe (ie not intruded on) personal attention and connection. This matters and is what works for therapy (cf parents who are not experienced, don’t know how, cannot bear a child’s or another person's distress).
  • Both are attentive to important (previously) unaware aspects: These need to be listened for, found, experienced, shared and named.
    • PsyAn does this by: free association, floating attention, “unconscious”;
    • FT by: open-minded curiosity, circular questioning, respect for all views.
    • PsyAn: tends to emphasise the past inner unawarenesses as a cause of present troubles, so that the search is required for blockages to be relieved – a rather problem saturated medical model approach;
    • FT: more likely to focus on otherwise unrecognised resilience and strengths, small immediate steps that enable future solutions quickly without deep or prolonged work (unless that is necessary).
  • Both look for relationship patterns that may be repeating:
    • PsyAn: more interested in past and inner representations of them, usually presuming an individual adult client in room on their own with one therapist over time with regular appointments - adults may appropriately be helped to come to terms with what they didn’t get as a child; the key transformation is seen to be in the transference / counter-transference work - though reliable frequent appointments must also feel like simple compassionate acceptance and permission to be who you are too!
    • FT: is more interested in present and ongoing family patterns that may even be happening in the room – with children it’s the first time (not repeating for them) and you want it to improve now not in a few years time after long therapy; FTists (ideally with live colleagues) will use their own inner feelings and responses to guide their work too; there is no need for attention to transference of past relationships or interpretations because the actual relationships are already happening if not repeating in the room with the original participants.
  • Both aim for accurate empathy:
    • PsyAn: is more a meditative mode while therapist is privately working hard with active theorizing on “what’s really going on here?”, leading to interpretations. There are those in any approach who may take a rather dogmatic even competitive “I know what's going on here… it's Oedipal .. it's trigenerational enmeshment .. ” stance. But in practice both kinds of practice now are more likely to use a more “I was wondering if … “ format.
    • FT: uses a much more active mode with curious (not-knowing the answer) questions, aimed at opening up the client’s new perspective “interpretations” on what’s going on. However of course the therapist is also busy reflecting in all directions and skillfully choosing questions. FTists may also use many active negotiated helpful interventions to try out ... Interpretations, questions, and interventions can all be part of accurate empathy for the family pattern and the individuals’ involved. Mentalizing (see below) may be part of this function, also helping the purpose of improved relationships.
Examples allow these similarities and differences to be explored:
    • In Nick's own analysis: 1. The scene when his mother delivered him aged 5 to boarding school had one level of story, where analysis uncovered a deeper distress (of Dad not being there to see him being brave). 2. Entirely wordless "regressed" nonverbal sessions were perhaps the most important part of the analysis (ie attachment with shared attention and compassion). The outcome of lengthy "treatment" is hard to show - a greater sense of personal integration of "permission to be who you are"; but Nick can't think of any particular problem or trait that it "cured".
    • A recent enquiry phone call from a family support worker wondering whether to refer a separated family, led to Nick's reflection that the sad and badly behaved teenage boy seemed not to be really wanted by either parent, so the worker was left "holding the baby”. The worker found this helpful enough to know what he needed to do.
    • A family therapist who is also a psychoanalyst uses a simple example in a first session with a family where he said to the 8 year old girl (using the family's name for depressions): “Did you think you caused your Dad’s illnesses?" The girl was clearly relieved by this, and later said that question was all she needed.
For comparison with Nick's ideas above, here is Peter Fonagy (eclectic psychoanalyst and leading thinker in the "mentalization" approaches) says all successful psychotherapies have three components:
  1. Attachment – a trusting relationship between therapist and client. 
  2. Mentalizing – the therapist's skilful creation of some kind of image of the client's mind, communicated so it "helps me organise myself". 
  3. Compassion - "permission to be who I am".  (Interview reported in The Psychotherapist, Feb 2013)

Compare too Carl Rogers' core tenets of Person-Centred Therapy : 1. Connection; 2. Acceptant attention to client’s incongruence; 3. Therapist congruence; 4. Therapist unconditional positive regard; 5. Therapist empathy. 6. Clients are to perceive all of these.

Once we have clarified the overlaps and differences, Nick suggests that couples work needs a foot in both approaches. Couple Therapy needs a blend of BOTH systems and psychodynamic approaches. In North America psychodynamic was excommunicated for a while and had to be smuggled back in to Couple Therapy (mostly in the form of attachment ideas). In Britain, Couple Counselling is still mainly psychodynamic, while Family Therapy has not had to get to grips with couple distress enough to realise something more is needed.

Lastly, on this discussion of bridging, modern developments in Couple Therapy add neuroscience to relationships – fight and flight, attachment, sex. Nick suggests then that Freud - who was a neurologist who set out to create a neurobiological basis for psychology, and theorised death, sex, aggression instincts - was perhaps not biological enough! But his clinical method was not addressed to the management of more heated relationship distress in couples and families, which requires a more directive style. Here is Nick's summary of Peter Pearson's description  of where we've got to:

The core of severe couple relationship problems is: Not a communication problem as many commonly think.  Nor is it a psychodyamic / relationship one.  It is both deeper and more immediate than those. It is: A powerful primitive brain-based emotional response that once helped animal attachment and fight or flight. But for humans now that primitive response system very much derails a couple’s reason, communication and relationship.  So to get back on track the animal / brain emotional level must be understood and managed.