Conjoint Family Sessions:
A Neglected Modality in the Contemporary Psychoanalytic Treatment of Children?

Carla Leone, PhD

The emphasis in contemporary psychoanalytic theory on the contexts in which experience emerges and is co-created has significant implications for the psychoanalytic treatment of children. A "two person psychology" model leads naturally to an increased recognition of the importance of targeting the quality of children's primary relationships, in addition to their internal experience. Yet while child analysts and psychoanalytic child therapists increasingly recognize the need for this work, many feel inadequately trained for this often crucial aspect of child treatment.

This is especially true of conjoint work with parents and children together. "I see children individually," a colleague recently told me, "and I work with their parents - much more than I used to in the old days - but I would never see them together! I just don't have the training," she explained, shaking her head, seeming half sorry, half proud. "I was trained psychoanalytically, you see."

This woman is not alone. Many talented, well-trained child analysts and analytic therapists who do excellent work with children and, separately, with their parents, look alarmed or askance at the very thought of having both in the same consulting room at the same time. Given the potential power and benefits of joint sessions (which I have enumerated elsewhere), this is quite unfortunate and, in some cases, deprives children and parents of an optimal treatment.

While lack of training is certainly a factor, I have come to believe that it is not the only (or maybe even primary) reason that more psychoanalytic conjoint work is not being done. After all, opportunities now exist for additional training in this area if desired. A number of articles have addressed the application of self psychological concepts to family work, including those by Anna Ornstein, Amy Eldridge, and David Shaddock, among others, along with my two papers on the subject. There have also been workshops and/or papers presented on the topic at most of our annual conferences for the past several years, and certainly consultation is available.

So why else is this work avoided? First, for many people, conjoint sessions simply do not seem psychoanalytic. Although basic psychoanalytic principles obviously still apply no matter how many people are in the room, family therapy has long been associated with family systems theory. It is thus viewed as the province of others and is therefore not part of our professional identity or our image of what is psychoanalytic.

Joint sessions may also seem less psychoanalytic or more superficial to some because each individual's inner world can't be explored as deeply as it can be in the individual setting. This is why I often do some combination of individual work with the child, separate work with parents, and some work with parents and child (or children) together. Importantly, however, family members can also often trigger or elicit feelings and reactions in each other that would never have occurred in an individual session. I have often been amazed (or appalled!) at how differently patients of mine have behaved in joint vs. individual sessions. Conjoint sessions can thus actually afford a level of depth - or breadth - that is unavailable in individual modalities.

Last, and maybe most significant, is what I call "family therapy anxiety". There are more unknowns with joint sessions and more things that can go wrong. We may wonder (consciously or unconsciously): Can I really hold all those people at one time? What if all hell breaks loose in there? What if people are abusive or hurtful to each other and I can't do anything to stop it? Or, alternatively, what if we all look at each other and no one - including me - knows what to say?

Ironically, it is just these moments when our psychoanalytic training can best help therapist and patients alike. The ability to listen carefully from within each patient's unique subjective perspective is especially valuable in conjoint work, where there are more subjective perspectives to grasp and appreciate. Accurate empathic understanding can also be the best way to defuse both hostility and awkwardness. Our understanding of narcissistic vulnerability, of defenses as natural measures of self-protection and of the rupture and repair process all also prove extremely useful when things get too heated - or too quiet. Finally, the concept of selfobject experience provides us with a framework for understanding both what family members need from us and what we are trying to facilitate between them.

Of course, there are times when it is best to see family members separately, as I have discussed elsewhere. But when our child patients and their parents can benefit from sessions together, it is important that we not let prior training, anxiety or misconceptions get in the way of developing the ability to provide them with this benefit. Just as other aspects of our technique may have changed since the days of our original training, so should this one.

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