INTRODUCTION

There is considerable evidence indicating an association between depression and relational distress. Couples experiencing depression describe more negative communication, such as blaming and complaints, further difficulties resolving conflict and less communication of love than couples that are not depressed (Coyne et al., 2002). Marital difficulties and discord may intensify the risk of low mood and depression due to increasing conflict and reduced social support (e.g., Whisman & Uebelacker, 2009). Accordingly, depression may be described as a ‘couple disease’ and involving partners in the therapeutic process may lead to significant consequences, such as avoiding relationship breakdown (Priestley et al., 2018). In this article, we refer to psychodynamic couple therapy as informed by object relations theory and the use of transference and countertransference as key guiding tools. Within this tradition, the landmark publication by Dicks (1967), integrating Fairbairn's theory of endopsychic structure and Klein's concept of projective identification, enabled this form of couple therapy to flourish.

Psychodynamic couple therapy is a longer term and open-ended approach where there is an in-depth exploration of personal meanings and a focus of 'making a short story long' (Nielsen, 2017). Accordingly, the psychodynamic model would help individuals with depression that might have experienced considerable past difficulties, including attachment problems, to 'repair a fragmented or broken self-narrative' (Valkonen et al., 2011, p. 239). The therapist listens to the couple and attends to unconscious dynamics, based on each partner's individual and family of origin's experiences (Hewison et al., 2016). Techniques used include attitude of impartiality; holding and containment; object relations history and attachment style assessment; interpretation of defence patterns and projective identificatory system; working with the unconscious, dreams and phantasies (Scharff & Scharff, 2014).

An important idea in psychodynamic couple therapy is that of an ‘internal parental couple’ or ‘unconscious phantasy couple’ informed by the experience of the couple's own parents' relationship. The internal parental couple is an emotional entity that is thought to guide unconscious beliefs and hopes that the couple have for their relationship. Partners who have internalised a parental couple that can work collaboratively around difficulties may feel a sense of psychic containment, which they may convey into their adult romantic relationships (Nyberg, 2018). In couple therapy, contextual transference stems from the couple's holding of each other, which is their shared environmental holding, and from the couple's mutual projective identification, which is their centred holding. The couple projects a feature of their individual and shared unconscious world to the therapist, who receives them as countertransference (Scharff & Scharff, 2014). This triangular setting of couple therapy, where the therapist is outside the couple, may encourage the couple to reflect on their relationship.

While the clinical theory supporting psychodynamic couple therapy would appear to lend itself well to supporting people experiencing depression, there is very little formal evidence base and hence, most Western nations operating a guideline-based approach to mental health care do not recommend this therapy. Recommended treatments for depression tend to be based on individual models of therapy, primarily cognitive-behavioural therapy. Where couple therapy is recommended, this tends to be restricted to behavioural couple therapy as in the UK guideline for depression (National Institute for Health and Care Excellence, 2022). However, service users' preferences may have a considerable influence on the commitment and sense of fulfilment with a specific therapeutic approach (McPherson et al., 2020). One criterion for the preference of one therapeutic model over the other might be the interest in a manualised and short-term approach focusing on present issues and problem-solving, which would lead to choosing behavioural couple therapy.

Psychodynamic couple therapy has been investigated and evaluated to a lesser extent than any other modality (Balfour & Lanman, 2012). Although lacking in significant formal evidence, specifically randomised control trials, psychodynamic couple therapy has been evaluated through analyses of routine practice-based data and uncontrolled studies (Barbato et al., 2018), demonstrating reasonable effect sizes. For example, a medium effect size (d = 0.64) was found following 40 weeks of couple therapy for depression (Balfour & Lanman, 2012); a large effect size (d = −1.04) was found following 23-week therapy (Hewison et al., 2016). These effect sizes are on par with many guideline-recommended therapies.

Exploring service user experiences of psychodynamic couple therapy can provide useful evidence to sit alongside outcome studies and can offer an experiential perspective to understand therapy processes and therapy potential. A meta-synthesis of client experiences of psychological treatments for depression (McPherson et al., 2019) demonstrated the potential for qualitative research to provide an additional lens on the question of psychological therapy for depression. Qualitative research has highlighted mechanisms of change that can be fed back into practice; as well as potential benefits and harms that merit further investigation within formal efficacy research (McPherson et al., 2019).

The current study uses qualitative methodology to explore the experiences of adults with depression who received psychodynamic couple therapy. In particular, the study is concerned with exploring what sorts of changes in mood or emotional distress clients experience; what, if any, changes are experienced in clients' relationships with their partner; and how clients experience the relationship with the therapist.

METHOD

Ethical Approval

Ethical approval was provided by a third-sector (charity) couple therapy provider and the University of Essex Ethics Board.

Design

The study employed a qualitative design to describe the multi-layered nature of psychotherapeutic dynamics, including the process of transference. The study adopted a critical realist approach which seeks to overcome the dualism between the views of positivism and interpretativism (Bhaskar, 2009). The approach acknowledges the potential for a causal relationship between therapy provision and therapy outcomes, though the process and outcomes may be experienced and framed in different ways. A phenomenological approach was also followed because it provides a lens through which to view lived experiences and what it means to exist among others (Heidegger, 1962). This offers a good fit with contemporary psychodynamic approaches, which share a common epistemological question of ‘what’ the other experiences rather than ‘why’ (D'Agostino et al., 2019).

Participants

Five adults took part in the study. Purposeful sampling was used to select ‘information-rich cases’ which are knowledgeable or have experienced a phenomenon (Creswell & Plano Clark, 2011; Patton, 2002). The sample size should be large enough ‘to allow a new and richly textured understanding of experience’ but also small enough ‘for deep, case-oriented analysis’ (Sandelowski, 1986). The idiographic aim of the current study required the sample to be sufficiently small for the participants to have a voice and for an exhaustive analysis of each interview to be conducted (Robinson, 2015).

Participants were recruited from a specialist psychodynamic couple therapy provider (non-NHS, charity) based in London, UK. All participants received psychodynamic couple therapy from an experienced psychodynamic couple therapist. Participants were working-age adults (18–65) who received open-ended psychodynamic couple therapy for at least 6 months (see Table 1) and who presented with depression. Participants who were still in a relationship with their partner, as well as those who had separated, were eligible. Participants were individuals who scored above the clinical caseness score at the start of therapy on the 34-item Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM; Evans et al., 2002). The CORE-OM score was mapped onto the Beck Depression Inventory to describe levels of depression in the sample. Participants were included if they had other comorbid presenting difficulties such as anxiety, sexual difficulties or couple conflict. Individuals with specific learning, psychotic or substance use, significant risk of self-harm and severe medical conditions were excluded.

Data Collection

Interviews took place between October 2019 and February 2020 and were conducted by telephone by a Trainee Clinical Psychologist who was not involved in any way in the therapy. Participants were interviewed individually, not as a couple, which allowed participants to express their individual thoughts on the therapeutic process and to avoid the partner influencing responses to sensitive questions (Aquilino, 1993). In joint interviews, participants tend to represent themselves as a couple by negotiating and co-constructing their narrative and ‘making sense of the world from within it, not detached from it’ (Taylor & de Vocht, 2011). In line with a phenomenological approach, it was crucial for participants to be fully able to express their own experience of therapy and not be influenced by their partner (Valentine, 1999).

Interviews consisted of open-ended questions in a conversational style, which lasted 45–90 min and were digitally recorded. The semi-structured topic guide addressed the relationship with the therapist; the experiences and the impact of psychodynamic couple therapy, including changes in mood, the relationship with the partner and the wider system.

Analysis

Data analysis followed thematic analysis (Braun & Clarke, 2013) with a phenomenological underpinning. Through careful examination of the individual's experiences of couple therapy, an attempt was made to describe the meaning for each participant. Hence, the truth of the experience of couple therapy, may be considered as an abstract entity, as individuals subjectively represent it in different ways depending on who is asking and the context. The analysis began with a search for meaning and an exploration of how the different meanings relate to each other. Subsequently, the meanings were organised into patterns, from which themes were constructed (Sundler et al., 2019). Thematic analysis using a phenomenological approach stresses the role of the researcher's reflective attitude and questioning their pre-understanding. Given the responsibility of the researcher to ensure the rigour and trustworthiness of the analysis, several strategies were put in place, including an audit trail, triangulation through multiple analysts, the use of participant quotes, reflective memos and a positionality statement. Candidate themes were indicated by the first author and reviewed by the other authors to minimise bias. The goal was not to find a consensus but to highlight the multiple ways to understand the data from a variety of perspectives (Patton, 2002). This process facilitated a degree of transparency in composing the final set of themes (Sandelowski, 1993).

RESULTS

Six themes were constructed from the data. These were: Sharing therapeutic space with a third person allows couples to listen; Fostering connections between couple and therapist; Re-enacting couple dynamics enables repair in the therapist–client relationship; Exploring the past enables new perspectives and communication; Endings: facing the future without a safe space; and Holding onto learning from therapy, and moving forward as a couple.

Theme 1: Sharing the Space with a Third Person in the Room Allowed the Process of Listening to One Another

Two distinct ontological understandings of the nature of the therapist being in the room were apparent. Most participants attended therapy with the assumption that the therapist would enable the couple to find better ways of communicating with each other, where the ‘neutral third eye’ was the objective that they wanted to attain for themselves in the long term.

For most participants, the therapist became a ‘referee’ who would observe the dynamic within the couple, mediate and become a safety net for discussions. For some, this went further in that the therapist became internalised in the partners' minds and enabled them to see the relationship from a ‘third-eye view’, which would lead to not needing the therapist in the room.

Paul described the therapist as a ‘referee’ that the couple had in front of them who facilitated the expression of ‘more objective meanings’ rather than words that seemed emotionally ‘charged’ within the home environment. Sandra discussed how the therapist demonstrated a ‘third-eye perspective’ on her relationship, and she felt ‘safe’ so that the couple were able to be honest with one another in the room. Sandra explained that she was able to ‘incorporate a third-eye view’ into decisions that she made within the relationship.

Emma, Zoe and Daniel took some time to adjust to the process of the third person in the room. Emma explained that she spoke to her partner differently, and it took her a ‘long time to feel comfortable enough’ to be able to open up in therapy. She referred to ‘different things flying around’ and ‘different agendas’ that partners would bring into therapy. Emma implied that the therapist would have ‘her own stuff’ when meeting with the couple.

It's very complicated because having three people there… There's just so much different things flying around (…) It takes longer and there are two of you and hear each person and to really work out what's going on. It's not so obvious or direct as when it's just one person with the therapist (Emma).

Daniel also explained that this process was ‘difficult at first’, but then the ‘calm voice’ of the third person would ‘add structure’ and was able to ‘mediate’. Zoe found the dynamic between three people ‘tricky’ at times and highlighted that once she and her partner felt ‘safe’ with the therapist, they used the space as a ‘safety net’ because they could address their difficulties during the week and experience a sense of ‘vulnerability’ in the room and continue the conversation following the session.

Accordingly, the therapeutic setting and the presence of the therapist observing acted as a catalyst for change in some couples. All participants agreed that this process enabled the possibility of sharing time and listening reciprocally to their partners: ‘therapy was a place where we could talk’.

Theme 2: Fostering Connections Between the Couple and the Therapist

Through the relationships formed with the therapist, there were three distinct active ingredients that fostered a sense of connection with the couple. First was the therapist's ability to appreciate them as individuals rather than as an entity. All participants highlighted that the therapist's capacity to ‘understand each of us’ was an important therapeutic process:

The therapist was incredible in understanding each of us and how we work as separate people. She understood how to try and communicate with us in order for us to communicate better in our relationship. After a couple of sessions, I actually enjoyed going and was looking forward to it (Sandra).

Second, participants stressed the importance of empathy in encouraging a sense of connection with the couple. Paul explained that he experienced the therapist as empathic through the ‘expression of the face or even the body language’. The therapist was able to formulate ‘small questions’ that made him feel comfortable discussing his difficulties. Sandra experienced the therapist as ‘calm, understanding and sympathetic’ and highlighted that she understood how to connect with the couple:

I feel that because she was so cool, calm, understanding and sympathetic, she really got to know each of us individually during the sessions. So, by week four, she knew exactly how to talk to us not in a friend's capacity, but you know how your best friends are able to…they use your nicknames or they use a colloquial language to get you to respond better (Sandra).

Third, neutrality was a crucial feature of establishing a connection with the therapist and addressing difficulties in the couple's relationship. The therapist was described as neutral because they did not disclose any personal information, and the couple was unable to ascertain if they were identifying more with one or the other. For example, Zoe appreciated the therapist's neutrality and felt she was ‘not taking sides’ or ‘pointing out faults’.

Theme 3: Couple Dynamics Played Out and Re-enacted in the Room, Enabled Repair in the Therapist–Client Relationship

Given the triangular setting of couple therapy, where the couples were joined by a therapist, couple dynamics were played out or re-enacted in therapy. Zoe and Emma explained that the couple's dynamics were ‘played out’ in the therapy room. For example, Emma explained that during the therapy sessions, she felt ‘quite dominated by her partner’ due to her family history where there were ‘strong personalities’. Emma explained that she would not be able to ‘stand up for herself’:

I felt quite dominated by my partner at times, and he could be quite aggressive and loses his temper a lot. I had a mum who was really strong-willed and shouted a lot (…) So that dynamic was going on. Then within the therapy, he (partner) was also really articulate and lovely and could sell himself in a very normal way. (…) I suppose in a larger group, I tend to withdraw in that way and sort of let other people go with it (…). I found a way to kind of get through it by not standing up for myself with that kind of thing. So that dynamic played out in therapy (Emma).

Emma described that at the beginning, the therapist was not able to ‘see these aggressive things’ that were occurring within the couple dynamics. This left Emma feeling that the therapist was quite ‘aligned to him’, where at times she did not feel that ‘she was taken care of’. However, once her partner Oscar started ‘acting out’ because Emma was able to ‘stand up for herself’, it seems that there was a repair process that occurred between the therapist and Emma. It seemed important to Emma that the therapist could ‘realise how difficult it had been for her’ and that ‘she could see her experience more clearly’, in order for this repair process to take place.

Theme 4: Exploring the Past Enabled New Perspectives and Communication

Participants highlighted that understanding of the past enabled them to understand their current behaviour as individuals and with their partner:

I think it made us look at our behaviour and where that comes from. Sort of learned behaviour perhaps from how our parents behaved or what we want from a relationship (…) It was our upbringing and our parents and various aspects like that. But also, the things that happened, such as how we dealt with bereavement, how we dealt with tough situations, how there's always been some sort of blame game or a way of working through together (Daniel).

Emma explained that she felt that her partner benefitted from making links with the past, which shed light on difficulties during his upbringing. Emma noted that even though they have spoken about this before, ‘hearing it from that outsider was really important and stimulating for him’. Emma felt that this process ‘empowered him’. Similarly, Daniel and Sandra explained that the therapeutic process of ‘drawing that back to past behaviour’ helped them understand their current behaviour:

…she would often find a way of drawing that back to past behaviour and sort of putting a mirror up to current behaviour and seeing the patterns (Daniel).

Creating links with the past was depicted as a beneficial experience for all participants, offering them new perspectives and enabling the process of improving communication. Paul explained how the exploration and understanding of attachment difficulties experienced by the couple's families during the war (a previous conflict in Europe) opened up new perspectives and made him aware of the importance of taking these into account in his relationship with his daughter.

The therapist told me that it takes three generations to overcome war issues. I realised about this even with my father, because (during the war) he did not belong to the ‘right side’ that didn't have an easy way to overcome this and to live in this society (…) They were living as refugees abroad and this was all his youth (…) So when I was asking him, did you talk about it with your friends? How could you have avoided that? He said that: ‘We just avoided it’ (…) I'm sure a lot of these kind of unsolved conflicts or behaviours are transmitted somehow. I try to be conscious of it. As a father, I do my best in using my understanding on these attachment patterns (Paul).

In a similar way, Daniel reflected on how his individual responses in his relationships were characterised by previous memories about how his parents might have behaved.

I think it made us look at our behaviour and where that comes from. You know, sort of learned behaviour perhaps from how our parents behaved or what we want from a relationship (…). I think perhaps how individually we learn to deal with situations, arguments or tense moments or stress. You know, my wife did it in a certain way she had learned and I did it in a way that I'd learned (Daniel).

However, Daniel explained that following the exploration of the past, the couple experienced a sense of ‘how can we go forward?’

There was sometimes a feeling between my wife and I that she (the therapist) didn't really look for a lot of solutions, sort of plans of how to move forward, it was more exploring the past (…) Putting the tools in place to actually build on future behaviour as opposed to just having an understanding of past behaviour (…) (Daniel).

Similarly, Emma highlighted that if the therapist noticed some relational patterns within the couple, they would have found it beneficial to receive some ‘guidance’ and ‘instructions’ on practical skills to facilitate communication.

Theme 5: Endings: Facing the Future Without a Safe Space

This theme examines the sense of loss and the fear of the future, along with feelings of courage to go forward together at the end of therapy. Some participants felt sadness over losing a space for them to discuss difficulties, which also reflects mourning for the breakdown of the relationship. Paul described his feelings of sadness about the therapy ending:

I found the end of therapy a bit sad. It was so comfortable for me, so positive that I would have liked to continue. I think if I was still living in London, I probably would have liked to continue (…) I think my partner and I are still so different, we still are not able to talk properly, as I would like to. The therapy space was a safe space for these conversations (Paul).

The process of separation from the therapist was an important step where, from a triadic relationship, the couple was back to their usual sense of intimacy. Daniel and Zoe noticed that the therapist was hoping to continue with therapy with them. They highlighted that they felt ready to end therapy, whilst the therapist did not seem to agree.

I think definitely she was very disappointed when we finished. When we said: ‘Right, that's enough’, she advised us not to. I think she thought it was too premature. …we felt that, and I think my husband felt that made sense, and we were ready to just sort face our relationship, the world together, and deal with problems that came just the two of us (Zoe).

Both Zoe and Sandra expressed their feelings of being welcomed back by the therapist where there would not be a ‘sense of shame or failure’ and ‘the door was open’. Sandra explained that the response from the therapist was ‘warm’ and ‘reassuring’. These responses seemed to have encouraged Sandra to use her ‘renewed energy’ for her well-being and for the relationship with her partner.

We actually left quite abruptly because financially it became not viable for us. I found a new job that was less money, it was less days per week, so much less stress. Actually, leaving therapy and knowing, from the therapist, that we could go back if we need it. It was there and that door was open still. It was really reassuring; is the way I'd put it (Sandra).

Theme 6: Holding onto the Learning from Therapy and Moving Forward as a Couple

Therapy appeared to have been an important experience for all participants. Zoe commented that she and her partner still feel ‘the benefit of therapy’; Sandra noted that the experience allowed her to ‘look at my whole life a lot differently’; and Paul was pleased to have received ‘many inputs’.

Being in therapy helped me realise how to communicate my feelings better, to express my wants and needs emotionally much easier. It actually made not just an impact in my relationship but it made me look at my whole life a lot differently (Sandra).

Participants reported that the emotional changes that they had made through the course of therapy were noticed by others, including relatives.

My wife noticed the changes (…) The children might have, but they didn't mention anything… I think without realising they were probably relieved that there was less tension in the house (Daniel).

Couple therapy appeared to have helped, not only in terms of mood difficulties but also in widening participants' life perspectives and choices. Most participants explained that therapy has been crucial in helping with mood difficulties where their lives became stagnant.

My mood was different, and I had a more positive outlook instead of just… It wasn't a negative outlook but there was no passion in my life. It was showing in every aspect of my life (…) I just was seen more joyful in my life by others (…) Therapy changed everything. I changed my job because I realised, I was in a really unhappy and unhealthy environment. I needed to change the way I looked because I was unhappy in the inside and so I was presenting this to the outside. Actually, I started to do that and dress and have my hair the way I wanted to (Sandra).

Paul explained that therapy helped him feel more positive, and personality features that were not showing when he felt depressed were returning. Paul moved back to his country of origin, and despite having to start his professional life back from scratch, he is ‘trying to open new doors’ and he ‘has grown’.

Therapy has seemed to have helped participants change their perspectives, connecting with emotions and expressing them to others.

Any anger or frustration I was having in my life, I realised that there were other options and choices I could make (…) It made me able to stand back and look at everything from a brand new perspective and actually go: ‘You know what, I am going to make that change that I wanted to. I'm going to do this (…) Without the therapy, I don't think I would have got there (Sandra).

Sandra and Paul also explained that therapy has helped them to connect with their emotions and to express their feelings to others and empathise with them.

I started to realise that reaching out to people for help was a sign of strength (Sandra).

Therapy appeared to have been an important experience in terms of improving communication and emotional expression within the relationship and with others. Most participants highlighted that not only did communication become smoother with their partner and other members of their network, but they were also able to mentalise rather than project their fears towards others.

We went through a huge personal transformation and we did as a couple as well (…) I think the big thing that came up for me was needing to allow myself to be vulnerable and ask for help. It felt difficult to be vulnerable sometimes. I also really started to feel the need to listen more, not just angry, shouting and not listening (Zoe).

Daniel noted that in the past, he and his partner would ‘blame each other for not being supportive’. Therapy seemed to have enabled a ‘continual form of communication’ allowing the emotional expression of the partner. Building on this dynamic within the relationship—the idea that it is ‘ok to be upset’—Zoe noted that her husband was able to understand the feelings of anxiety and insecurity underneath her expressed anger. She suggested that improved communication with her partner had a positive impact on the rest of the family dynamics, including the relationship between father and son.

When we were in couple therapy, my daughter was having a few friendship issues at the time as well, and now she doesn't have any of those issues at all. She's now in a very positive place. I think my son is also in a very strong place, and I think he's definitely got a stronger relationship with the father because I think his father is in a much better, happier and in a more positive place (Zoe).

Sandra explained that therapy has been helpful not only in her relationship with her partner but also with others in her wider network. Sandra explained that the process of ‘taking a step back’ and asking herself questions such as ‘What is going on with that person?’ enabled her to feel more compassionate towards others, which indicates her ability to mentalise with others. She also felt that therapy helped her to communicate better with the rest of her extended family and that consequently ‘fostered more communication among other people as well’.

Similarly, Paul found that therapy ‘unlocked the communication’ and enabled the couple to understand their ‘new reality’.

Therapy was a positive experience because it unlocked communication, we would go deeply in the conversation, we discovered and we confirmed through therapy that we were very different people in terms of aims and ways to look at life. I think through therapy we understood this concept of a new reality. It was a matter of time, conversations or words said, but absolutely it was therapy that unlocked this (Paul).

DISCUSSION

The study aimed to deepen our understanding of the experience of adults undergoing psychoanalytic couple psychotherapy. All participants had presented with depression, which was related to their relationship difficulties. Although the study does not provide further quantitative evidence of the efficacy of couple therapy for depression, the findings can help inform the practice of couple psychotherapy where one or both individuals in the couple are experiencing depression.

Analysis of the interviews led to six interconnected themes, which reflect some ways in which psychodynamic couple therapy may be a useful alternative in some instances to individual therapy for depression. In particular, the data indicate that the therapist, described as a ‘third person’, became a referee and mediated the communication within the couple, providing a different perspective, enabling a safe environment for reciprocal listening; the process of making links with the past enabled participants to understand their current behaviour as individuals and dysfunctional areas as a couple; the therapist's ability to understand the couple as individuals rather than as a unified entity was key; therapist neutrality and capacity to empathise with the couple was valued by participants. The data also revealed a number of benefits both for individual well-being and mood as well as in their relationships with their partner and others. The inter-relationship between depression and couple strain was apparent both in setting the context for coming to therapy as well as in the way the benefits of therapy manifested.

Of interest is the way in which individuals needed to be recognised as an individual by the therapist; and that when the individual felt seen as such by the therapist, couple dynamics could begin to improve. Carl Jung explained that: ‘The aim of individuation is nothing less than to divest the self of the false wrappings of the persona on the one hand and of the suggestive power of primordial images on the other’ (Colman, 1993, p. 107). In this sense, participants appeared to initially resist the therapeutic process by showing a ‘persona’, which was not their real self, to the couple's therapist. This persona, or ‘theatrical mask’, is in a conflictual and compensatory relationship with the ‘shadow’. When individuals experience depression, there might be tension between who they are and who they wish to be (Sharp, 1998), and this tension may get locked into a couple's relationship and need release.

According to Jung, due to the need for individuation, each person is considered to be in a ‘search for wholeness’, leading to self-acceptance (Lyons & Mattieson, 1993). This process occurs when the individual is able to recognise and assimilate their shadow, which is ‘the thing a person has no wish to be’, and if it is not owned, it may create an impoverishment of the personality and deprive the person of the ego strength to connect with others (Jung, 1959, p. 102). Therefore, the lack of acknowledgement of the shadow may lead individuals to project unwanted feelings to others. When feelings are contrary to the ego ideal, they are repressed so that the individual does not feel that they belong to them, and they are ‘split off’ or projected to the partner (Balfour & Morgan, 2018; Klein, 1952; Scharff & Scharff, 2014).

The quest for authenticity in couple therapy may be due to participants wanting to show their ‘true self’ in therapy, enabled by the presence of the third person in the room, whom they eventually came to trust. This need might have been suppressed prior to attending therapy by the need for compliance, initially with their parent's demands, then later by their partner and society (Winnicot, 1960). Similarly, Goffman (1959) explained that we all perform at the ‘front stage’ and we hide parts of ourselves in the ‘backstage’. Couple therapy may help individuals connect with their backstage self and show this self to the therapist and their partner to reconcile with it and feel accepted.

In the present study, findings also indicate that couples can become stuck in their own unhappiness through a cycle of arguments, blaming and not reaching out towards each other. Similarly, Lyons and Mattieson (1993) found that partners are in greatest difficulty when they desperately need to feel contained by the other and do not acquire the ability to recognise the other's needs, which might leave them with the conundrum of ‘who is the baby?’

Balfour and Morgan (2018) proposed that, in a similar predicament, the couple struggles to understand that they are creating a relationship rather than seeing the partner ‘doing something to them’. Linking their ideas back to Melanie Klein's postulation around the paranoid-schizoid position of functioning (Klein, 1952), they describe the importance of understanding the split part of the self and that the process of ‘taking it back’ into the personality may lead to the individual becoming ‘whole’ through the opportunity provided by the relationship.

This echoes Jung's definition of marriage or a committed romantic relationship as a ‘container’. This dynamic parallels Bion's idea of containment in the primary bond with caregivers, where unconscious communication is revealed in cycles of projective and introjective communication (Bion, 1962; Scharff & Scharff, 2014). The raw feelings and impulses in the couple dynamics may re-evoke early years' feelings of love and hate towards the primary caregivers (Rosenthall, 2007).

Findings from the present study highlight the impact of having a ‘third person’ present, delivering therapy. Participants expressed their initial difficulties adjusting to the dynamics of having a third person in the room. These reflections are consistent with the psychodynamic literature on the triangular frame of couple therapy. The setting of couple therapy between three people is similar to the ‘oedipal setting’ between the couple and the psychotherapist (Britton, 1989; Nyberg, 2018). Fisher (1993) explained that couples might experience ‘the anxieties of the triangle’ where each individual is capable of being a separate entity in a relationship with the other. The anxieties are around being excluded from the couple or being a part of the couple that excludes the third person. The process of mastering these anxieties allows for psychological space to think about difficulties. Accordingly, Balfour and Morgan (2018) explained that this triangular setting allows the process of witnessing the relationship difficulties being enacted by the couple and the therapist. The couple would experience the combinations of ‘being in’ and ‘being out’ at different points of therapy. This element of tolerating a triangular setting is crucial for couples who experience difficulties sharing a ‘psychic space’. Balfour and Morgan (2018) also explained that witnessing the therapist containing the triangular setting may lead each partner to become more interested in the other's experience and the meaning of the relationship's dynamics. This process may lead to a ‘third position’ where partners can observe and make sense of their experiences from different standpoints (Nyberg, 2018). Consequently, the study's participants highlighted the importance of the therapist facilitating a safe place where the couple's difficulties can be addressed.

Participants described different therapeutic ingredients that fostered a connection with the therapist. First, participants emphasised the importance of the therapist's ability to recognise their individual needs and personalities. This dynamic echoes what Bion described as the need for service users ‘being known’ in therapy. Bion (1962) and Fraiberg et al. (1975) referred to the process that initially occurs between infants and primary caregivers of being contained and linked this with the psychoanalytical relationship between therapist and service user.

Second, participants explained that the therapist's neutrality and impartiality were perceived as crucial features of couple therapy. This is consistent with psychodynamic literature on the therapeutic setting (Temperley, 1984). Gelso and Kanninen (2017) postulated that neutrality is an active ingredient in contact with the patient and does not imply that the therapist is indifferent or cold. They highlighted that neutrality allows the therapist to take an observer position and implies not taking sides with service users' inner or outer difficulties, which in turn encourages them to experience feelings at their pace rather than ‘gratifying’ the therapist's needs. Third, participants described empathy as a crucial therapeutic feature in connecting with the couple. The active ingredient of empathy is consistent within the literature and has attained a prominent position in psychodynamic processes (Orenstein & Orenstein, 2003).

Throughout couple therapy, participants explained that they discussed their individual family history and attachment style in relation to their current couple dynamics. Participants explained that they were concerned that their relationship dynamics were similar to their parents, where they would blame each other. These accounts are consistent with Rosenthall (2012), who explained that her patients would rebel against unconscious repetitions and say: ‘I didn't want to be like my parents, but that is exactly the way we are!’ (p. 160). A focus on attachment styles, which originates from psychodynamic tradition with Bowlby and Ainsworth's studies, inspired several therapeutic models, including systemic therapy (Johnson & Lebow, 2000). An assessment of attachment styles in couple therapy can inform the therapist of the key processes that delineate the nature of intimate relationships. This process could help lead the couple to a shared understanding of the origins of their difficulties, patterns and provide new perspectives.

Participants explained that the ability to understand where their individual difficulties stemmed from and hearing their partners' past experiences, enabled the couple to improve their communication within the couple dynamics. This echoes Hertzmann and Nyberg's (2018) reflections on the ability of partners to mentalise, which is characterised as the ‘curiosity of others' mental states, to ‘read’ one's own and others' psychic processes’ (p. 133). When partners are able to mentalise, they can appreciate that the other is separate and different from them, which, in turn, would lead to the couple having healthier ways of relating. The ability to mentalise is a socio-cognitive skill that is first developed in the parent–child attachment relationship, and an ample body of psychological literature supports its importance (Fonagy et al., 2002).

Consequently, some participants were pleased that couple therapy fostered their self-reflective skills, which they used to evaluate their learning and ability to communicate with their partner. Other participants were hoping to receive guidance and practical skills to improve their communication with their partners. This is consistent with a qualitative study that compared psychodynamic and solution-focused therapy experiences for depression and found that individuals with a ‘life historical inner narrative’ preferred long-term psychodynamic therapy, whilst the short-term solution-focused therapy counterpart supported the progress of a ‘situational inner narrative’ (Valkonen et al., 2011). Accordingly, couple therapy for depression, a behavioural counterpart model, includes problem-solving exercises during the sessions and as homework, along with communication exercises (Thompson, 2018).

Some participants expressed a sense of loss and sadness about the end of therapy because it was where the couple's difficult conversations took place. Shmueli (2018) provided the metaphor of the resilient eggshell, symbolising the couple's relationship as a container that had fractured. Scharff and Scharff (2014) explain that couple therapy aims for the loss of the relationship to be accepted and mourned. Other participants expressed that the process of separation from the therapist was an important step when the couple returned to their usual sense of intimacy by leaving a triadic relationship. Other participants felt that they were able to internalise a ‘couple state of mind’ (Balfour & Morgan, 2018). Colman (1993) explained that therapists work with couples to internalise the therapeutic containment into their relationship in the same way that the child internalises the parental containing function. This process would lead each member of the couple to be both a container and contained.

Participants explained that improved communication with their partner positively impacted wider family dynamics. This is consistent with research that found parents who are satisfied in their relationship tend to relate to their children with warmth and are likely to establish positive co-parenting relationships (Casey et al., 2017). Accordingly, Harold and Leve (2012) claimed that targeting the inter-parental relationship can offer ‘substantial dividends’, due to its importance in the family system, where spill-overs into the mother–child and father–child relationship may occur. This proposition is based on a vast body of literature that found strong associations between couple relationships and different facets of family functioning (Casey et al., 2017; Clulow, 2018; Fincham & Beach, 2010).

Limitations

Despite the richness of data, enabling a detailed focus on individual experiences of the couple therapy process and outcome, the very small sample size is a limitation, and these findings cannot be used to infer any conclusions concerning the efficacy of couple therapy for depression. The findings may also not be transferrable to other settings where psychodynamic couple therapy is provided. Moreover, all participants were White (although not all were British); and all were educated to a university level, indicating limited diversity in the sample. There was some diversity in terms of sexual orientation, with one participant in a same-sex relationship. Therefore, whilst the study offers some useful insights for developing theory and practice, it is important to recognise the limitations of a small sample lacking in diversity.

CONCLUSION

The aim of this research was to explore experiences of psychodynamic couple therapy among adults with depression. Participants sought to be seen as individuals throughout therapy and described the therapist's third-eye perspective, whereby the therapist became a referee and mediated communication within the couple. Participants were able to internalise the figure of the therapist providing containment leading to ‘a couple state of mind’. This is the first study to examine psychodynamic couple therapy for depression from a client's perspective. It highlights the intertwined dynamic between relationship difficulties and depression, which are already well documented. It goes on to illustrate the processes by which psychodynamic couple therapy might have the potential to enter into this complex dynamic and support couples to address their relationship difficulties in the context of depressed mood in a way that can potentially improve both of these. Given that participants were not able to make a clear distinction between these relationships and mood difficulties; this may reflect the difficulties that service users are confronted with in the current highly individualised model of psychological therapy services. These services may atomise and reduce individuals to a diagnostic label requiring ‘treatment’ for inter-related wounds and intertwined existential difficulties, whereas in-depth work with the distressed couple may become a precursor of well-being for the wider couple or family system. Therefore, it seems imperative to consider offering services which place more emphasis on the complex social systems within which people with depression exist.