BRIDGING THE GAP: SIMILARITY AND DIFFERENCE BETWEEN PSYCHOANALYTIC AND SYSTEMIC THERAPEUTIC...

BRIDGING THE GAP: SIMILARITY AND DIFFERENCEBETWEEN PSYCHOANALYTIC AND SYSTEMIC

THERAPEUTIC ORIENTATIONS

Mary Donovan

ABSTRACT In recent times much has been made of integrative tendencies andcommon ground between therapeutic orientations, previously locked into highlyoppositional frames. This is evident in the rapprochement between psycho-analysis and cognitive-behavioural therapy in adult mental health. It is a trendthat is also evident in the shifting relationship between systemic and psycho-analytic orientations. This paper begins with an overview of factors influencingthe wider integrative ethos before considering the specific circumstance of therelationship between systemic family therapy and psychoanalysis. The paperconsiders both the past history of oppositionality between the two orientationsas well as some current developments that might facilitate a more creativedialogue. Particular attention is paid to issues of similarity and differencebetween the therapeutic relationship in systemic family therapy and the psycho-analytic framework of the transference/countertransference. Implications fortherapeutic technique are explored. The aim is not to minimize difference butto encourage cross-fertilization between these therapeutic orientations in theinterest of patients/families who may benefit from an integrated response.

Integrative Trends in Contemporary Therapeutic Practice

The current status of the relationship between systemic and psychoanalyticorientations needs to be understood against the background of widerintegrative trends in the therapeutic field. This is influenced by the evidence-based ethos of our times, which scrutinizes clinical certainties againstmeasures of clinical effectiveness, cuts across old ideological rivalries andconcentrates minds on ideas of what works best for whom. Research findingshave, for example, engaged the interest of psychotherapists in generic factorssuch as the quality of the therapeutic alliance in helpful therapeuticoutcomes across the different therapies (e.g. Flaskas 1997; Pocock 1997;Eisler 2002). Recognition that many problems have multiple componentswith complex origins also tends to underscore the need for integrative

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MARY DONOVAN is a systemic psychotherapist with Barnet, Enfield and HaringeyMental Health Trust and in private practice. Prior to systemic psychotherapy trainingat the Tavistock Clinic she undertook a psychodynamic training at the WestminsterPastoral Foundation. Address for correspondence: CAMHS Team, FinchleyMemorial Hospital, Granville Road, London N12 OJE. [email: [email protected]]

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interventions with different components. In his account of integrative trendsbetween psychoanalysis and cognitive-behavioural therapy in the area ofpersonality disorder, Bateman (2000) writes of the growing recognitionthat experienced clinicians across the various therapy divides are alreadypractising in a highly flexible manner, bringing in elements of theory andtechnique drawn from other models. In their extensive review of outcomeresearch in child mental health, What Works For Whom, Peter Fonagy et al.(2002) also underline the integrative trend and speculate that for futureresearch reviews it may become increasingly difficult to distinguish thedifferent psychosocial therapies from each other (p. 397).

Evidence of integrative tendencies in contemporary therapeutic practiceraises the possibility that the gap between therapies may in fact be ratherdifferent from how we imagine it to be. Here the work of Fonagy et al. alsoproves revealing. In the child and adolescent mental health field theyidentify an emergent ‘pan-theoretical model’ which draws its inspirationfrom a combination of biological, systems, cognitive-behavioural andpsychodynamic perspectives. In fleshing out this model they note, forexample, that right across the range of therapeutic interventions the child isnow very rarely if ever viewed in an individualistic frame:

Problem behaviours, either of the child or at the family level, are formulated interms of interrelated and interreacting response systems and subsystems thatregulate the child’s behaviour and which simultaneously exert a regulatinginfluence on others within the same system. This tendency is as evident inmodern psychoanalytic perspectives . . . as in cognitive-behavioural ones.(Fonagy et al. 2002, p. 395)

What this underlines implicitly is the extent to which traditional systemicprinciples have in fact been subsumed into the other therapies. It is oneexample of the borrowing and border crossing that prevails in the thera-peutic field whether or not such borrowing is openly acknowledged. In thesecircumstances it is timely that we reappraise the frameworks and categorieswe employ to organize our thinking about similarity and difference betweenthe therapies and consider the implications for practice.

Psychotherapists in publicly funded organizations where the evidence-based ethos strongly prevails are perhaps more immediately exposed to thewinds of change that include greater emphasis on integrative practice. In theUK, child and family therapeutic services are most commonly offered inNational Health Service clinical settings where a multidisciplinary ethos haslong prevailed. Since the meeting ground for systemic and psychoanalyticclinicians is most commonly that of child and adolescent mental health it isarguable that the clinical context is already conducive towards dialogue andintegrative therapeutic models emerging. In recent times there has certainlybeen signs of a shift in the relationship between systemic and psychoanalyticorientations, particularly from the systemic side where a burgeoning

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literature now explores the relevance of psychoanalytic thinking for systemicpractice (e.g. Flaskas 1996, 1997; Pocock 1997; Larner 2000). What is striking,however, is that much of this work remains firmly inside systemic discourse,and the debate has lacked the critical edge that could only come from actualdialogue between clinicians/writers representing the two perspectives.

Historically the relationship between psychoanalytic and systemic thera-peutic orientations has been characterized by distrust and indifference,and there remains a danger that the weight of negative history may impedeor slow down productive exchanges in the present. In this paper I amarguing for a more co-operative engagement between the two therapeuticapproaches in the interests of patients/families whose difficulties do not fallneatly on either side of this particular therapeutic divide and who maybenefit from a more integrated response. For these people an entrencheddivide potentially restricts their therapeutic choices and makes it harder toaccess forms of help that might reflect something of the range of contem-porary expertise relevant to their difficulties. The paper also attempts tobroaden out the discussion to include therapists not located in child andadolescent clinical settings where the systemic/psychoanalytic debate hastraditionally been located. Issues relating to the interface between psycho-analytic and systemic approaches have a wide-ranging relevance acrossdifferent clinical contexts and are potentially of interest to any clinician forwhom questions of ‘what works best for whom’ are a concern.

Alongside the evidence-based ethos of our times another important factorinfluencing contemporary therapeutic trends is the enormous impact ofpostmodernist thinking, which challenges traditional ideas of the authorita-tive and objective clinician in favour of a social constructionist paradigmemphasizing a collaborative search for truth in the therapeutic relationship.The impact of postmodernism on both sides of the systemic/psychoanalyticdivide is difficult to exaggerate (e.g. Holland 1983; Hoffman 1991, 1992;McNamee & Gergen 1992 ; Renik 1993: Gill 1994; Goldberg 1994; Anderson1997). On both sides, voices of concern have also been raised about theextreme relativism of the stance that it can sometimes promote (e.g. Gabbard1997; Donovan 2003b). Nonetheless postmodernism infuses the spirit of ourtimes very powerfully in encouraging greater openness to different perspec-tives and paradigms. It is a key factor in the background to any discussionof current trends in psychotherapy and serves as a bridge for connectionbetween different therapeutic orientations where its influence is equally felt.

The Historical/Political Interface Between Psychoanalyticand Systemic Orientations

In 1997 the Journal of Family Therapy, the leading journal for systemicpractitioners in the UK, put together a special issue on psychoanalysis andsystemic approaches. This was significant for the theoretical development of

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the subject but was also a milestone in registering that the topic had comeof age and that enough people were interested for it to warrant this level ofattention. In her contribution to that issue, the systemic writer AnneMcFadyen observes that one of the major obstacles to more integrativethinking across the two therapeutic approaches has been the mutual dis-interest that for so long characterized their relationship. Yet, as Kraemer(1997) points out, paradoxically many of the founders of what is now knownas systemic family therapy were themselves trained in the psychoanalytictradition from which they subsequently distanced themselves.

Arguably the historical split between psychoanalysis and family therapyfollowed from the fact that the latter did represent a very radical paradigmshift in therapeutic conceptualization and treatment in the 1950s when itwas emerging. In Kraemer’s words: ‘the gravitational pull of the prevailingtheories was just too strong to allow for radical change’ (1997, p. 57).Family therapy needed to carve out its own separate space and path tosecure the future viability of a treatment modality organized around inter-ventions with whole family groups. It is important to recognize that psycho-analysis in our times has a very different flavour from the individualisticethos of the 1950s. Psychoanalysis has notably embraced object relationsthinking in subsequent years in a way that now locates it in a much moreharmonious connection with the relational and intersubjective ethos thatdrives systemic family therapy. One potential effect of the systemic/psycho-analytic split is a misleading inference of coherence and harmony on eachside of this divide. I am assuming throughout this paper that the terms‘systemic’ and ‘psychoanalytic’ imply broad categories of therapeutic orien-tation encompassing substantial diversity in thinking and practice. Here Ialso want to underline that, when we talk about the interface betweenpsychoanalysis and systemic family therapy, we are not talking about staticentities but ones that are of course evolving and changing in their ownright, and therefore the nature of the interface is also highly fluid andevolving.

The systemic writer Carmel Flaskas (2002) makes the point that for allthe historical oppositionality and distancing between the two therapies therehas always been a strand of family therapy that remained engaged withpsychoanalysis albeit as a minority interest. It should also be emphasizedthat the psychoanalytic tradition itself has embraced a family therapy orien-tation for some considerable time whilst keeping its distance from thedominant systemic tradition. There exists a small but distinctive group ofpsychoanalytic therapists who have over the years specialized in workingwith whole families and have written about this work in a way that under-lines their unconditional rootedness in psychoanalysis. Their perspective isrepresented notably in David Scharff and Jill Scharff’s (1987) text ObjectRelations Family Therapy and in the writings of psychoanalytic therapistsassociated with the Tavistock Clinic (Box et al. 1994; Brodie & Wright 2002).



Interestingly, the Tavistock model of psychoanalytic family therapy hasremained very separate from the systemic clinical training in family therapythat has for many years been offered by the Tavistock in its role as a leadingtrainer of family therapists. This institutional division is one that mirrorswider historical divisions. Clinicians who promote family therapy from apsychoanalytic perspective often have a primary allegiance to another disci-pline such as child psychotherapy and by and large do not involve them-selves in the professional training of family therapists, which remains thepreserve of the systemic family therapy tradition in the UK. One importantquestion for the future is how a more explicit engagement with the interfacebetween psychoanalysis and systemic family therapy might translate intofuture family therapy training programmes.

In Kraemer’s (1997) analysis of the relationship between the two orien-tations he makes the point that the debt owed to psychoanalysis by all subse-quent psychotherapies is immense and rarely acknowledged. In the specificinstance of the relationship between psychoanalysis and systemic familytherapy, it is perhaps also appropriate that psychoanalytic clinicians mightacknowledge the contribution of the pioneering generation of systemicfamily therapists in securing the viability of family therapy as a treatmentmodality and professional discipline. The complexity of some historical andpolitical aspects of the systemic/psychoanalytic debate is not my primaryconcern but it is an important framework in which to locate considerationsof the clinical interface between the two approaches.

The Systemic Tradition

The 1950s are generally identified as the founding era of family therapy. Inthis period a number of research projects came together that drew attentionto the role of the family in creating and maintaining psychological disturbancein one or more members (Bateson et al. 1956; Lidz et al. 1957; Wynne et al.1958; Jackson 1965a, 1965b). Jackson, one of the family therapy pioneers, wasamong the first to draw attention to the persistent patterns that typify familyinteraction processes. Departing from his psychoanalytic training with itsfocus on intrapsychic conflict, Jackson and other family therapy trail-blazerssuch as Gregory Bateson (1972, 1979) and Jay Haley (1970, 1971) formulateda theoretical stance heavily influenced by general systems theory (Von Berta-lanffy 1968) that would evolve into a therapeutic treatment which took familyinteraction processes as the preferred locus for change. Whilst the interven-ing years have seen a plethora of competing theoretical and clinical perspec-tives emerge from within what is now loosely defined as the systemic familytherapy tradition, it is this intense focus on relational processes and patternsthat arguably still defines contemporary practice. Recognition that familiesare more than the sum of their parts, and recognition that the interconnect-edness of these parts needs much attention if we are to understand the whole,

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underpinned the emergence of systemic family therapy and continues toinform this practice in all its diverse manifestations.

Later generations have of course refined and critiqued the originalinsights of the early family therapists and much has changed. One of themost significant of these changes is the move from a traditional ‘first order’perspective, which locates the family therapist firmly outside the familysystem, to a ‘second order’ perspective which sees the family therapist as anintegral and recursive part of the system in therapy, somebody who bothinfluences and is influenced by this system. Prominent among later contri-butions is that of Milan Systemic Therapy (Selvini-Palazzoli et al. 1978,1980), that emerged in the early 1980s. The original Milan family therapists,who also came from a psychoanalytic background, are best known forformulating the technical style of circular questioning that has been sopivotal in shaping current practice and which is intricately linked with thekey systemic construct of circular causality. This denotes the family thera-pist’s disengagement from linear notions of cause and effect in approachinga family system in favour of a recursive model of mutually influencingfactors. Circular questioning seeks to expose these recursive patterns ofinteraction in families and to locate the presenting issue within this widerinteractional frame. At its most basic level a family arriving for the initialtreatment session with a problem located in one child might be asked: whonoticed the problem first? Who is most worried about it? What did they do?Who did they speak with? In the course of the session one family membermight be asked to comment on the interaction between two other familymembers. One family member might be asked to compare the responses ofothers in the family to the presenting problem. Different family membersmight be asked to rate the severity of the problem as they see it. In this waythe problem itself is constantly defined and redefined in relational terms.Through circular questioning and similar techniques the therapist helpsfamily members achieve some reflective distance from their problem.Families are trained to step outside entrenched currents of interaction suchas blaming or scapegoating and into a more circular and recursive way ofthinking about their difficulties and functioning. The focus is as much onhelping to change the process and shape of conversation in the family as itis on changing the content of what is discussed. Collusion between one childand a parent might, for example, be interrupted as the parental subsystemis strengthened and reinforced, if necessary in separate meetings for theparents. It is this depth or ‘second order’ quality of the systemic changeeffected which secures its durability.

Over the years there has been growing recognition that the systemic styleof therapeutic practice has considerable relevance beyond the arena offamily meetings and can, for example, be successfully applied to interven-tions with work-based organizations (Cecchin & Stratton 1991; Campbell1996) as well as in the more intimate arena of psychotherapy with



individuals (Boscolo & Bertrando 1996). Not surprisingly, the latter contextin particular brings into sharp focus some interesting issues of similarity anddifference with a psychoanalytic perspective, and therefore offers a particu-larly useful context for exploring possibilities for a more integrated systemic/psychoanalytic response.

The Clinical Interface Between Psychoanalytic andSystemic Orientations

Case A1

Ms A attends once-weekly sessions in a child and family clinic that is predomi-nantly psychoanalytic in therapeutic orientation. She is a single parent with twoyoung children both of whom were presented initially with emotional andbehavioural problems. Ms A has a history of mental health difficulties and thereis a complex network of professional involvement that includes the communitypsychiatry service and social services who are involved because of concernsabout the children. My meetings with Ms A are part of a larger programme oftherapeutic intervention for this family. Their purpose is to help her with parent-ing issues and to support the therapeutic input,which her children are also receiv-ing. She has failed to engage with individual psychotherapy in an adult mentalhealth setting but finds it somewhat more acceptable to have help that is locatedin a child and family clinical setting. She rarely misses appointments and in herown way is engaged with our work. However, it is an engagement that is oftensilent, rather sullen and sometimes overtly hostile. The world that she brings toour sessions is filled with secrets,distrust and people who let her down. She allowslittle by way of exploration of her own childhood experience and is resistant tothe idea that it might have some relevance for her current difficulties.

This is a case where a strong and overtly negative transference dynamic isevident but it is not a situation that lends itself easily to interpretation of thetransference, and I use this technique sparingly as she seems to have great diffi-culty in engaging with this way of working and responds blankly. My impressionis that her way of being with me is not that different from how she is with otherpeople in her life but it is difficult for her to stand back from the immediacy ofthe situation to reflect on what might be happening. From a psychoanalyticperspective she might benefit from more frequent contact to create a contextwhere explicit technical use of the transference could be experienced as moremeaningful. However, this is not the situation we have and it is questionablewhether it is indicated given, among other things, the external demands of hersituation. Occasionally I will make reference to our relationship when I judgeit likely that she may be more receptive and here I would agree with thesystemic writer Flaskas (1996) that situations where an impasse seems to bedeveloping in the work are flashpoints for thinking about transference issueseven in work that is not explicitly psychoanalytic in orientation. I might, forexample, link a holiday break with feelings of anger and of being let down byme when she is perhaps talking about not coming back.

This is a clinical situation where I sometimes find myself drawing on systemictechnique to keep alive a sense of curiosity and to engage in a therapeutic

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conversation with this few-worded and distrustful client. One marked featureof the case is her highly enmeshed relationship with her older child, and in ourmeetings she can become deeply preoccupied and overwhelmed around suchthemes as ‘My child gets bullied all the time’ or ‘My child and I have a terriblerelationship’. Thinking about the systemic configuration of the family is helpfulin reinforcing the discipline of keeping both her children in mind in the work.I often draw on circular and reflexive questioning (Penn 1982; Tomm 1985, 1987;Brown 1997) in order to loosen up the rather fixed ruminative thinking thatpervades meetings and to help disperse attention throughout the family system.In this way the individual meetings are not that dissimilar from what mighthappen in a family meeting in that much of the focus is at an interpersonalrather than intrapsychic level. Most obviously, I might use circular questioningaimed at having a conversation with my client in which she can think herselfinto different patterns of being with and interacting with her children, forexample: ‘If you were not thinking about the bullying what else might you worryabout in relation to your older child? . . . If the bullying somehow got resolvedone day what impact do you think that might have on your relationship withyour daughter?’ I might also use mind-reading type reflexive questions (Tomm1987) that focus Ms A’s attention very specifically and continuously on hersecond, rather forgotten child, questions that constantly encourage her into theobserver position with respect to this child as in ‘What do you think youryounger daughter made of it when . . . ? . . . What might she have made of itwhen you and your older daughter were . . . ?’

This is very slow,painstaking, sometimes repetitive work in which I am mostlyhelping my client to think and, in particular, to think less rigidly, morecreatively and expansively about her own mental states including her beliefs,her feelings and so on, as well as those of her children, and to think also aboutthe links between them. I do so within the framework of the transference,which I keep in mind and occasionally interpret when I judge it likely that shewill find this meaningful. It is a piece of clinical work that to my mind unfoldsat the interface between systemic and psychoanalytic approaches and whereI consider it more productive to think about integrative ways of workingrather than ways that accentuate difference. I think about Ms A as repre-sentative of a great many people with whom I work in terms of the chal-lenge which her limited reflective functioning capacity (Fonagy et al. 1991,1993, 1994; Fonagy & Target 1996) presents in finding ways of engaging hertherapeutically. It is the search for ways of working with this very troubledclient group often presenting with problems located very concretely in theirchildren that has propelled my own work beyond the safety of any coretherapeutic modality and towards more integrative responses.

Integrative Responses: Implications for Therapeutic Technique

Many people, possibly the majority of those who access psychoanalyticallyinformed/psychodynamic therapy, will do so on a ‘non-intensive’ basis ofonce-weekly sessions or fewer. This is a good example of an area of practice



where there is much scope for bridge-building with other therapies includ-ing systemic therapy. My own experience of undertaking a clinical trainingin once weekly psychodynamic intervention was that the literature inform-ing our training was mostly drawn from a model of intensive three-to-five-times-weekly psychoanalytic therapy/psychoanalysis. Yet it is questionablewhether this way of working translates seamlessly into a model wherepeople are seen less frequently and where the transference relationship maytherefore be more diluted.

It is also the case that within the psychoanalytic field generally a key tech-nical concern now revolves around ways of working analytically with peoplenot readily amenable to a traditional psychoanalytic interpretive approach,and there are different shades of opinion on the status of interventions thatmight be seen to deviate from traditional psychoanalytic interpretive work.Child and adult analysts (Fonagy & Target 1996; Hurry 1998; Edgcumbe2000) have written about the developmental help or developmental therapycomponent of analytic work with some children and adults, and within thisperspective a distinction is sometimes drawn between the role of the analystas transference object and new developmental object. The significance ofthis distinction is that it allows for recognition of the therapeutic potentialin the analyst as a developmental object acting differently from the originaldevelopmental object being sought in the transference. This debate abouttechnique is relevant in the present context because, in my clinical experi-ence, it is here that psychoanalytic therapists can become puzzled by or evencritical of systemic family therapists’ perceived failure to interpret thetransference and address unconscious processes more explicitly. They mayeven conclude that what is being offered in systemic family therapy is acorrective emotional experience in so far as unconscious processes appearnot to have been articulated clearly in the work (Brodie & Wright 2002).Unfortunately such a stance implies, perhaps unintentionally, that psycho-analytic discourse itself is more harmonious on this issue than is the caseand leaves unacknowledged the substantial differences inside psycho-analysis between those who adopt a very rigorous interpretive stance andthose who take a much broader view of what constitutes therapeutic actionin psychoanalysis. For those who adopt the latter view there is, I believe,enormous scope for creative engagement across the therapy divide and forthe elaboration of integrative responses that draw on both psychoanalyticand systemic technique.

Gabbard and Weston (2003) write that:

Contemporary psychoanalysis is marked by a pluralism unknown in any otherera, and this extends to theories of therapeutic action. We no longer practise inan era in which interpretation is viewed as the exclusive therapeutic arrow inthe analyst’s quiver. Yet precisely what role insight, toppled off its prior pedestal(Sandler & Dreher 1996), retains among the range of interpretive and non-interpretive mechanisms of therapeutic action remains unclear. (p. 823)

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One aspect of Gabbard and Weston’s analysis is a concern with thetraditional neglect of conscious processes of thinking and feeling in thepsychoanalytic literature. They use the case example of a young woman withintrusive ruminative thinking about a failed relationship to illustrate theintegration of traditional interpretive analytic work with a more cognitiveorientation. On the one hand they describe how the patient came to under-stand her tendency to ruminate as a defensive strategy that once allowedher to cope with the uncertainty of having an intermittently abusive parent.This analytic insight-oriented work aimed at examining the unconsciousfunction of her rumination. At the same time the analyst also engaged veryactively in helping the patient to think differently at a more conscious level,for example, helping her to distinguish between rumination and introspec-tion. This proved extremely helpful in regulating the patient’s spirals ofnegative affect, as she began to catch herself getting caught up in repetitiveand destructive thinking patterns and was able to shift gear by being askedor asking herself questions about the function that rumination was servingat that specific moment, as in ‘What am I getting out of this right now? Whatwould I be feeling if I were not ruminating? What is doing this preferableto?’ To a systemic clinician’s ears it sounds like they are advocating a styleof questioning extremely similar to the systemic therapist’s use of circularand reflexive questioning to generate new patterns of cognition andcommunication. As such it is a useful example from within contemporarypsychoanalytic literature of the integrative ethos, its technical applicationand its value for particular client groups.

Just as the psychoanalytic literature may be engaging more with consciousprocesses – what of systemic therapy’s engagement with unconsciousprocesses? Why are family therapists so noticeably reticent about makingtransference interpretations, for example? To my mind there are a numberof interrelated issues involved here. From a technical perspective oneanswer is that transference interpretations frequently do not work in a wholefamily therapeutic context and may also draw attention to the therapistunhelpfully at a time when the focus is much more on getting familymembers to take responsibility themselves for a different kind of conver-sation. Psychoanalytic therapists who have experience of working withfamily groups may disagree but my impression is that the key element orvariable in such disagreement is often the very different capacities offamilies for insight-oriented work.

In understanding issues of similarity and difference between psychoana-lytic and systemic technique, it is important to recognize that systemic familytherapists have tended to work with families who are often not motivatedprimarily by an interest in interpretation of intrapsychic processes, familieswho have a relatively poor reflective functioning capacity and with whominsight-oriented work needs to be carefully constructed and timed. Overthe years systemic family therapists have in fact built up an impressive



repertoire of techniques for increasing such families’ reflective capacities. Tomy mind there is no reason why these systemic techniques cannot be usedalongside a more explicit engagement with transference and counter-transference issues when it seems likely that may be helpful and wherefamily therapists are trained to engage with these processes. Here I wouldecho the systemic writer Carmel Flaskas’s description of how she works withthe transference/countertransference dynamic:

I use my reflection about my countertranference first and foremost as a way ofcontaining myself and holding open my own capacity to think and reflect andI would leave open the question of whether this thinking may or may not behelpful and meaningful to the family. (2002, p. 229)

Flaskas is not only connecting here with psychoanalytic discourse but alsoimplicitly with a much broader strand of thinking in the contemporarysystemic field which draws attention to the ‘use of self’ by systemic therapistsin their work (Real 1990; Flaskas & Perlesz 1996; Speed 1999). Arguablythis aspect of current systemic thinking and practice can only be enrichedthrough ongoing theorization of the links and common ground with psycho-analytic theory and technique particularly around transference/counter-transference issues.

One unfortunate effect of the historical gulf between the two orientationsis that it has undermined many systemically trained family therapists’capacity to use aspects of psychoanalytic technique in situations where thismay be helpful. For the early generations of systemic therapists, many ofwhom had already undergone psychoanalytic training, the priority was moreabout carving out a separate therapeutic space for their new treatmentmodality. Later, as family therapy consolidated its position as a separatediscipline with its own training requirements, it then became less common-place for family therapists to bring personal experience of psychoanalytictherapy or training to their work and the gulf between the two orientationswidened. Writing about integrative styles of clinical practice in the area ofadult mental health, Bateman (2000) reminds us that it is usually thepreserve of the highly experienced ‘master therapist’. In the case of thepsychoanalytic/systemic divide it seems to me that the challenge of intro-ducing integrative ways of thinking and working at an earlier stage inclinicians’ training and development is still quite formidable, given currentdivides in the therapeutic field together with their implications for the scopeof professional training programmes and requirements. It is for this reasonamong others that the nurturing of further debate and engagement acrossthe systemic/psychoanalytic divide is so important.

Case B

Ms B, aged 21, attends once-weekly individual therapy in a private fee-payingsetting that is also predominantly psychoanalytic in orientation. Her first

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attempt to leave home failed dramatically when she was forced to withdrawfrom university due to the onset of severe anxiety-related symptoms. Herparents separated with much bitterness and acrimony during her childhood andin therapy she often presented with the kind of intense loyalty conflict reminis-cent of a young child. She self referred having been placed on a lengthy waitinglist for psychotherapy within the health service. Her father offered to pay forher therapy as she was not in a position to do so. This was agreed on the basisthat Ms B would have responsibility for arranging payment herself and I wouldhave no direct contact with her father.

Two years following the start of therapy a number of positive changes in MsB’s life were evident. She had successfully returned to her studies. She endedan unsatisfactory relationship and met somebody else. In many respects sheexperienced herself as more confident and in charge of her life but nonethelesssome of her anxiety-related symptoms persisted and were an ongoing source ofdistress. In our work Ms B was reasonably insightful and able to engage withinterpretive interventions. The shape of the transference was predominantlypositive. Negative feelings were kept at bay and generated considerable anxietywhen addressed. Whilst I heard much that was encouraging, I also heard aboutthe persistence of some of her symptoms and these seemed stubbornly imper-vious to my interpretative efforts. I was often left with the sense of an impasseat this stage in our work. Around this time I received a letter from Ms B’s fatheralso noting the persistence of some of his daughter’s difficulties and requestinga meeting with me to discuss what further help she might need. At one levelthe appropriate response seemed clear. To meet with her father would be abreach of the therapeutic boundary. The split-off feelings represented in theletter needed to be held in the transference so that they could become avail-able for interpretation. Nonetheless I found myself hesitating about how bestto respond.

In my countertransference I was aware of the sense of complaint in the airand feelings of anxiety about the consequences of turning down Ms B’s father’srequest. Would financial support for the therapy be withdrawn? However,beyond this I was also aware of the family therapist in me coming to the foreand imagining a meeting with Ms B and her father that might even be helpfulin moving the therapy on and breaking the impasse that I had sensed for sometime. I reflected on the immediacy with which Ms B sometimes brought currentpainful conflict with her parents into our sessions as well as the history ofconflict between her parents as it impacted on her. I also reflected on myexperience as a family therapist that, when people are struggling to separatefrom difficult relational dynamics in families, it is often paradoxically mosthelpful to bring them together in the therapy. I reflected on the oedipal issuesencapsulated in this episode and how they connected with Ms B’s early loss ofher father following the separation from her mother. It seemed that for me tomeet with her father would both satisfy a deep longing but also represent thefulfillment of one of her deepest dreads. Following much exploration with MsB it was agreed that, whilst I would refuse a meeting with her father on his own,I could – if she wished – offer a meeting to Ms B and her father together. Withhindsight this was a pivotal moment in Ms B’s therapy and in her efforts toseparate from her family. It opened up a rich seam of analysis in our work, which



had previously proved inaccessible to my interpretations. It brought into muchsharper focus Ms B’s own ambivalent feelings towards her father, but also hergrowing realization that the persistence of some of her troubling symptomsserved to defer separation from both her parents and successfully secured herposition as their joint dependent. In the course of subsequent work she was ableto make the decision that it was unnecessary for me to meet with her fathereither with or without her and that she could have this conversation with himherself.

Playing with the boundaries of individual psychotherapy or even contem-plating doing so, as happened in this case, is a charged and risky propositionthat should not be entertained lightly. Yet, as with any risk-taking or ‘leavinghome’, it can also be creative and growth promoting when undertakenthoughtfully. The value of thinking outside an individual frame in this case– even if switching frames did not need to happen concretely – was inopening up an area of stuckness in the work and ultimately in Ms B’srelationship with her parents which was making it difficult for her to moveon developmentally. Thinking through very specifically with Ms B how shemight have the type of conversation with her father that he invited me tohave with him was an important part of this process and within psycho-analytic discourse might even be thought of as a form of developmentaltherapy. In my experience this more active technical style, which I used withMs B at this stage in our work, can be helpful in shaking up very stuckinterpersonal dynamics. She was the eldest child of divorced parents whomaintained limited contact around parenting issues but for whom a level oflatent conflict also persisted. Looked at from a family life-cycle perspective(Carter & McGoldrick 1988), the challenge of separation and leaving homeresonated for this family and parental couple on many levels beyond theimmediacy of Ms A’s own difficulties in this respect. Taking account of thisbroader familial context is pivotal in an individual intervention of the typeundertaken with Ms B and may well include scrutiny of the appropriatenessof the chosen individual therapeutic frame on occasions. In cases involvingmuch younger children these issues are often a great deal more entangledand complex, and it is therefore not surprising that, in the field of child andadolescent mental health, issues of difference and integration between thedifferent therapeutic orientations and therapeutic frames has a particularresonance. The above case material of a young adult struggling to leavehome illustrates, I believe, the value of adopting this more integrative, dialec-tical mediation of systemic and psychoanalytic perspectives in areas of adultpsychotherapy. I am not suggesting that what I offered Ms B is necessarilydifferent from what somebody trained exclusively within a psychoanalyticorientation might offer. However, I am underscoring the way in which thiskind of intervention overlaps with systemically oriented individual therapy.Furthermore, I would argue that this kind of intervention, occurring at theborder of different therapeutic orientations and therapeutic frames, can only

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be enhanced by its explicit theorization in the psychotherapy literature andby dialogue between therapists of different orientations effectively engagingin very similar work.

Conclusion

This paper has focused on areas of commonality and difference betweenpsychoanalytic and systemic orientations and has made the case that in someclinical situations it is more useful to think of the two orientations in adialectical, interrelated frame rather than in rigid either/or categories. HereI want to emphasize that I am not taking issue with specialist therapeuticorientations as such or with specialist trainings. Rather my concern is that, inany climate where difference gets disproportionately emphasized and atten-tion deflected from areas of commonality, this may restrict the therapeuticchoices for some people and make it harder for them to access forms of helpthat might reflect something of the range of contemporary expertise relevantto their presenting difficulties. In this climate there is also a danger that prac-titioners are cut off artificially from significant reserves of therapeuticexpertise that have evolved elsewhere. Arguably, both the psychodynamic/psychoanalytic and systemic traditions have to some extent been mutuallyimpoverished by their history of oppositionality. My hope is that wider integ-rative trends in the therapeutic field might now facilitate a greater degree ofconstructive and creative engagement across this historical divide.

Note1. See Donovan (2003a) for additional discussion of this case material from asystemic perspective.

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BRIDGING THE GAP: SIMILARITY AND DIFFERENCE BETWEEN PSYCHOANALYTIC AND SYSTEMIC THERAPEUTIC...

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