Couples Therapy Archives - Psychotherapy.net

For the Love of the Game

Posted on January 14, 2026February 24, 2026 by rezendevknowfully.com

Have you ever had a client who asserts they do not need counseling, yet there they are, sitting with you? I have experienced this on more than one occasion. With these clients, I must often find creative ways to connect with them that offer a less threatening entry to the idea of talking to someone about life and their feelings about it.

A Reluctant Player Picks Up the Ball

One client in particular stands out, and I’m especially grateful to one of my counselors-in-training who helped build the bridge that allowed me to break through the client’s defensiveness. That moment opened the door to a genuine connection—one that invited him to work alongside me to improve his quality of life.

George was a 35-year-old male sitting in my office because his wife told him to get help or that she was going to leave. He had heard of me from a friend and that I was “good with military stuff” and since he was a Veteran, “well, here I am.” During our intake, George shared that he did not think his military time was relevant to his wife’s ultimatum. He said that she was often frustrated that after returning from work he would rather spend time watching sports than spending time with her. George didn’t perceive this to be a problem and thought she might simply be experiencing a period of neediness.

Around the time I was working with George, I had a counseling student/basketball coach who often used basketball metaphors for his own clinical skill development. Talk about opportune timing! I remember during one particular skills class he said that he had to overcome hurdles to complete one of his more challenging assignments. He said that this process wasn’t much different from reviewing a game replay film. This is when I realized how much I was learning from my student, so I decided to reach out to him to collaborate on this essay. I’m grateful to share that this marked the beginning of our journey together.

The Game Plan: Basketball as a Metaphor for Counseling

Working alongside my student taught me a great deal about the parallels between counseling and basketball, success in which depends upon continuous, real-time collaboration between the coaches and players to overcome barriers to victory.

Off the court and in the therapy space, making changes, evaluating resources, and identifying barriers are necessities. Often, clients start by presenting all the resources and support that are available to them. They discern throughout their counseling what issues they need to take to the court and which can remain on the bench. This process is parallel to the moment when coaches have to make the decision to bench a particular player for their own good or for that of the team.

In basketball, a player may indeed be able to score a few points, but giving them the chance to do so may not support the needs of the team as a whole or the be the best strategy for winning. Winning, even with the best players can still be a challenge. Unpredictability on the court is common and upsets happen. Just as in life, and in the therapy space in particular, unpredictable twists and turns must be considered, and strategies need to be revised. When working with George, where I was the counselor, but also a coach of sorts, we had to work together in order to discern clear goals and his true desires for the marriage.

The concept of “team” offered a useful metaphor for George’s place in the family. While I was working with him individually, I had to keep my eye on his team, or system. I had to account for both him and his “team.” He had come to counseling because his wife, his teammate, provided him with an ultimatum to go, or their marriage would end. The idea of losing her was not something he was willing to risk. That was not his goal, so we needed to strategize to come up with a game plan that would lead him, and his wife, to marital victory.

I was able to carefully navigate George’s system to understand his role within it, as well as explore his personal perception of what marriage and family meant, and the behavioral implications for not just him, but his “team.” I was able to reflect on his circumstances as if we were reviewing a game film. And just as game videos help players understand the difference between what occurred on the court and what they want to do differently next time, George was able to review, re-evaluate, and strategize before he resumed ‘marital play’ with his wife. Together, we created a therapeutic locker room, a nonjudgmental space to examine not only what was best for him, but also for his team.

This “locker room conversation” led to an exploration with George about his relationship with his wife, what he had to offer, and what he wanted in return, or in short, what he brought to the court of his marriage and what he needed in return. Even when players are at the top of their game, there are times when they need to come off the court and onto the sideline for both their own benefit and that of the team’s. The metaphor of shifting to the sideline and the “bench” to calmly and objectively re-evaluate his “game plan” seemed critical at this juncture in his marriage. Consultation with the coaching staff—me, in this case, served as a useful, and hopefully, productive “time out” in which George could decide what changes he wanted to make, if any.
I was able to process George’s strengths and weaknesses to support his awareness, processing, and empowerment towards goals. Coaches aid their athletes in understanding their skillset, areas in need of growth, and seek to empower them to improve upon their abilities to excel. To reach goals and excel requires analysis of strategies. Some skill sets may be more beneficial at specific times while others need to take the bench and allow their teammates to perform in order to obtain the overarching goal.

Collaboration between the clinician and client(s) and the coach and athlete(s) are essential to advance towards goal attainment. During George’s last session with me, he shared his fondness for a basketball movie called, For the Love of the Game. It was an apt ending for our work together, the results of which he could hopefully take back onto the court of his marriage.

Takeaways

I could have spent hours researching the sport, but true understanding only came through learning from someone who genuinely loves the game and is eager to share that passion. In the same way, I’m grateful to model for my student that even the most seasoned clinicians remain open to growth and committed to refining their skills.

Postscript: In working on this piece with Dr. Arcuri-Sanders, I (Daniel) was touched and honored to hear how she incorporated some of my thoughts and love for basketball into her clinical work with George. I felt validated in my pursuit of counseling licensure, my passion for basketball, and being able to connect the two.

Josh Coleman on the Roadmap to Healing Family Estrangement

Posted on July 2, 2025March 26, 2026 by Psychotherapy.net Team

Lawrence Rubin: I’m here today with Joshua Coleman, a psychologist in private practice in the San Francisco Bay area, and a senior fellow with the Council on Contemporary Families. He’s the author of numerous articles and book chapters, and has written four books, the most recent of which is The Rules of Estrangement. Welcome, Josh.

Joshua Coleman: Thank you for having me. Pleasure to be here.

The Face of Family Estrangement

LR: I’ll just jump out of the gate by asking you, why do you describe estrangement within families as an epidemic?

JC: Well, there’s a variety of reasons for that. One is, and I don’t know about you in your practice, but in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangement. Another reason comes from a recent survey by Rin Reszek at Ohio State, who found that 27% of fathers are currently estranged from a child. That’s a new statistic. While we haven’t really been tracking these statistics, non-marital childbirth is also a big cause of estrangement, which is 40% currently compared to 5% in 1960.Divorce is also a very big pathway to estrangement, especially in the wake of more liberalized divorce laws. When you look at the effect of divorce on families once there’s been a divorce, the likelihood of a later estrangement goes way up. This is especially so when you add social media as an amplifier, our cultural emphasis on individualism, influencers talking about the value of going ‘no contact’ after the divorce, and family conflict around politics, especially in the recent election. All these point to a rise in family estrangement, particularly parental.

LR: in the past few years, my practice, as well as those of my colleagues, has become flooded by clients dealing with this estrangementI know the there is a historical rise in divorce. Is there a parallel rise in estrangement with the rising divorce rate?

JC: I don’t think it’s a 1 to 1 relationship, but I think both occur in the culture of individualism, which prioritizes personal happiness, personal growth, protection and mental health. Prior to the 1960s, people would get married to be happy, but more often for financial security, particularly for women as a place to have children. But today, people get married or divorced based on whether that relationship is in line with their ideals for happiness and mental health and the like.The relationships between parents and adult children are constituted in a very similar way, people don’t stay in touch or close to their parents unless it’s in line with their ideals for happiness and mental health. It’s what the British sociologist Anthony Giddens calls pure relationships. Those are relationships that became purely constituted on the basis of whether or not they were inline with that person’s ambitions for happiness and identity. So, it’s a parallel process. I don’t think it’s completely dependent on divorce because there’s many pathways to estrangement.

LR: if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still marriedWhy is estrangement so different from other problematic family dynamics?

JC: Because of how disruptive it is to the adult parent and because of the cataclysmic nature of event and its consequences for the rest of the family. Once there’s an estrangement, it isn’t just between that adult child and that parent. It also can cause one set of siblings, or one sibling, to ally with the parent, another with the adult child. Typically, if the adult child cuts off the parents, they also cut off access to the grandchildren which can cause marital tensions for couples that are still married. So, it’s really a cataclysmic event in the whole family system.

LR: In your clinical experience, are there identifiable risk patterns for the eventuality of estrangement?

JC: Divorce is a huge risk, especially when it is accompanied by parental alienation, where one parent poisons a child against the other parent. Untrained or poorly trained therapists sort of assume that every problem in adulthood that can be traced back to a traumatic childhood experience. There seems to be no shortage of those therapists who think everything that is problematic in adulthood is due to some kind of family dysfunction or trauma.Another pathway to estrangement is when the adult child married somebody who’s troubled and says, “choose them or me.” Mental illness in the adult child is also potentially destructive. And last, when parents have been doing something much more psychologically destructive over the years, certain adult children just don’t know any other way to feel separate from the parent beyond cutting them off.

LR: Before we move forward, can you give us a clear definition of estrangement?

JC: It’s when there is little to no contact. If we’re just thinking of the parent-adult child relationship where there’s little to no contact, and underlying is some kind of, complaint or disruption in the relationship, the adult child is typically the one initiating the estrangement. They determine that it’s better for them not to be in contact with the parent or to grossly limit the contact. Maybe they send a holiday card or something, otherwise they have no contact with their parent.

LR: t’s a complete cut off.

JC: Complete cut off, or a nearly complete cut off. Exactly.

LR: the adult child may not be as motivated to solve the problem as the parent isAnd is the focus of your clinical work mostly on estrangement between adult children and their parents?

JC: Typically, because they’re the ones who are reaching out to me. Occasionally, I’ll have siblings reach out to me, but more typically it’s the parents who are estranged. From their perspective, they’re the ones who are in much more pain. The adult child may have cut off the parent because of their pain, but by the time the parent reaches me, the adult child has concluded that it is in their best interest to estrange their parent. So, the adult child may not be as motivated to solve the problem as the parent is.

LR: Do you have estranged grandparents reaching out to you?

JC: Yeah, and a lot of grandparents say, ‘look, I could probably tolerate estrangement from my child, but not from my grandchildren.’ This feels intolerable, particularly for those who have been actively involved with their grandchildren, as many of these grandparents have been.

LR: This “grandparent alienation syndrome” must be particularly tormenting for them. Have you experienced different cultural manifestations of estrangement?

JC: The data from the largest study, which was by Rin Reczek at Ohio State, found that, for example, Black mothers were the least likely to be estranged. White fathers are the most likely to be estranged. Latino mothers are also less likely to be estranged than White mothers. Fathers in general are very much at risk for estrangement regardless of race.There’s relatively low estrangement in Latin American families as well as Asian American families. And similarly, within Asia, we assume that there’s not a lot of estrangement because the culture of filial obligation is still quite active. So, estrangement tends to predominate in those countries and cultures, like ours, that have high rates of individualism and preoccupation with one’s own happiness and mental health.

Detachment Brokers

LR: That’s interesting. So, there’s a parallel between estrangement and the value particular cultures place on either individualism or commutarianism.

JC: Exactly. Some are much more communitarian, emphasizing the well-being of the family and the group, while others are much more individualistic, like we are here. The sociologist Amy Charlotte calls American individualism ‘adversarial individualism,’ which is the idea that you become an individual through an adversarial relationship with your parent, or you rebel against that. But not all cultures have that kind of adversarial positioning as the way that you become an adult.

LR: You had mentioned earlier that some therapists can actually make things worse.

JC: I think that all therapists want to do good, but some simply don’t think through all of the factors. We have to not only think about the person in the room, but also the related people, because estrangement is a cataclysmic event that affects many beyond the person sitting in front of you. Grandchildren are involved and get cut out from their grandparents’ lives. Siblings typically get divided into those who support the estrangements and those who don’t. It’s also very hard on marriages. It’s easy to get sidetracked into focusing on the mental health of the adult child who is cutting off their parent(s) in the name of self-care and self-protection. We have a rich language in our culture around individualism, but a poverty of language that’s oriented around interconnectedness, interdependence, and care.It’s easy to pathologize someone’s feelings of guilt or responsibility for a parent that may just be a part of their own humanity. By giving them the language and moral permission to cut off a parent without doing due diligence on whether or not that parent really is as hopeless as their client is making them to be, contributes to this kind of atomization.Therapists can contribute to the tearing apart of the fabric of the American family, acting as accelerants to that process. We become what the sociologist Allison Pugh calls detachment brokers in her book, Tumbleweed Society. When we support clients’ absolute need or desire to estrange their parents due to their need for happiness and personal growth, we help them detach from the feelings of obligation, duty, responsibility that prior generations just assumed one should have.

LR: Do you ever encourage or facilitate estrangement as a solution?

JC: The same way that I would never lead the charge into divorce with a couple with minor children because of the long-term consequences, I wouldn’t charge ahead with estrangement either. But I do try to help the person to do their due diligence on the parent. Let’s say the parent who is completely unrepentant and constantly shames the adult child about their sexuality, their identity, who they’ve married, or what their career is every time that adult child is around the parent. It’s sort of hard for me to ethically say, “give them a chance!”But I do think it’s our responsibility to ask them: what other relationships will be impacted if you decide to go no contact, is there some way to sort of have some kind of a relationship where you are protected from their influence, or why don’t we think about why is it so hard on you? A newly reconciled adult child recently suggested to me that, ‘if the adult child is insisting that your parents are the ones that need to change to have a relationship, maybe you’re the one that needs to change.’ I liked that because I don’t think everybody has to stay involved with their parents.I do think parents have a moral obligation to address their children’s complaints and empathize with them and take responsibility. Just like the adult children have a moral obligation to give their parents a chance. I work with parents every day who are suicidal or sobbing in my office, and that really gives you a different view of this.

LR: I imagine the most deeply wounded adult children are the most difficult ones to work with around reconciliation. Can countertransference enter the clinical frame at that juncture?

JC: There have been a few occasions where the adult child was so self-righteous and contemptuous of the parent, despite the parent’s willingness to make amends for their so-called crimes––which were more on the misdemeanor side than the felony side––they remained unforgiving. Even when the parent showed empathy and took responsibility in the ways that I insist that parents do, the adult child remained in this very censorious, self-righteous, lecturing place.There haven’t been very many times when I felt provoked on the parent’s behalf, but there have been a couple times where the adult child was earnest, open and vulnerable, and the parent was not willing to do some basic things at the request of the adult child, like accepting basic limits. The parent was insistent. I just felt like you can’t have it both ways. I remember thinking, ‘You can want to have your child to be in contact with you, but you’re going to have to accept the limits that your child is setting, otherwise, I can’t really encourage your child to stay in contact with you in the way that you want me to.’ The transference is worked on both sides of the equation.

A Roadmap for Change

LR: Is there a roadmap for healing estrangement as you suggest in your book?

JC: Typically, if the parent has reached out to me for the reasons I was just saying, the roadmap begins with taking responsibility and the willingness to make amends. I ask that they try to find the kernel, if not the bushel of truth in their child’s complaints. They can’t use guilt or influence or pressure in the way that maybe their own parents might have used with them, and they can’t explain away their behavior. They have to show some dedication to reconciling. It must come with some sincerity. The challenging part for parents is often that they can’t really identify with what they’re being accused of, particularly since emotional abuse is the most common reason for these estrangements.A lot of parents say, ‘wow, emotional abuse, I would have killed for your childhood.’ The threshold for what gets labeled as emotional abuse is much lower for the adult child than it is for the parents. So, a lot of the roadmap for the parent is just accepting that difference and learning how to understand why the adult child is labeling it as such and not really debating it with them or complaining about it. Instead, that roadmap includes a way to empathize with that and understand that those are the most key aspects.

LR: What about when the road to reconciliation has been damaged by physical/sexual abuse?

JC: You have to go there if you have any chance of healing the relationship. If a parent is lucky enough to get an adult child in the room after that child being a victim of more serious traumas on the parents part, the parent has to be willing to sit there and face all the ways that they have failed their child and how much they hurt and wounded them.And it’s not an easy thing to do, typically, because hurt people hurt people. There is high likelihood that the parent who did the traumatizing was traumatized themselves, but if anything is going to happen, it’s going to be because the parent can take responsibility and do a deeper dive and not sweep it under the rug. And that’s very hard work, especially for the adult child who must expose themselves.

LR: Would you work with the adult child separately from the parent and then together by collaborating with all the players in the same room?

JC: Typically, I will meet with each side separately because I want to see what the obstacles are, what each person’s narrative is, assuming that I think everybody’s ready to go forward, I’ll bring everyone together. I usually don’t keep them separate for more than one session, but not everybody is ready to go forward at the same time. If I think that people are sort of ready to engage, then I’ll do a session separately and then everybody together. I tell parents that this is not marriage therapy. The therapy is around helping the adult child feel like their parent is willing to respect their boundaries and accept versions of their narrative sufficiently that they feel more cared about and understood. It’s not going to be as much about the parent getting to explain their reasons or decisions, at least not early into the therapy. If therapy goes on long enough, and people are healthy enough to have that conversation, then it can happen. But it doesn’t always.

LR: What do you consider to be a successful outcome, and at what point do you say that’s enough for now?

JC: I think when they’ve all had enough time outside of therapy, and they were able, to debrief if there was conflict, and if I feel confident that they have the tools to walk them themselves through the conflict and resolve it. I try to help each person set realistic goals and let them know that they are going to make mistakes going forward. The goal isn’t to be perfect, but instead to communicate around feelings and taking each other’s perspectives so all members feel safe and skilled enough to overcome whatever conflict arises. I don’t want anyone feeling discouraged and helpless.

LR: What protective factors do you look for when working with estrangement? The glimmers of hope that you search for with your therapeutic flashlight?

JC: The biggest one is a capacity for self-reflection on the part of both the parents and the adult children. In the parent, I look for a willingness to take responsibility, the capacity for non-defensiveness, vulnerability, and tolerance for hearing their child(ren)’s complaints without being completely undone. For the adult child, I look for acknowledgment that what they’ve done is difficult for the parent, and that their own issues might have contributed to their decision to estrange them.I look for an adult child to say things like, ‘I acknowledge that I was a really tough kid to raise,’ ‘I’ve been a tough as an adult,’ ‘I can give as well as I get,’ or ‘I know that I have an anger issue.’ Those help me, as the therapist, to feel like, ‘okay, you’re not just here to blame and shame the others.’ It’s about a willingness and ability to come to a shared reality, which is important for these dynamics.

LR: At what point might you suggest stopping with a client?

JC: I’ll keep working with people as long as they want to get somewhere. I don’t usually fire clients. But, for example, if I have an adult child who is just insisting that their parent has to change, and it’s clear to me that the parent has changed as much as they’re going to, my goal would be helping them shift towards radical acceptance, rather than to keep beating their head against the wall. And similarly with a parent, if their adult child is just not willing to reconcile, then it isn’t useful for the parent just to keep trying and banging their head against the reconciliation wall either.

LR: Recognizing not only your own limitations, but those that the family system brings to you.

JC: Exactly! I think an important part of our work is to help people to radically accept what they can’t change and influence. As painful as that is to reckon with.

LR: What does radical acceptance mean in this context?

JC: The term came from Marsha Linehan who developed Dialectical Behavior Therapy. It’s not sort of a soft acceptance, but instead a deep dive that you have to do. She has a great quote that says, ‘the pathway out of hell is your misery.’ It’s a great quote because you must first acknowledge that you’re miserable and accept it and maybe not even hope for change. But it does mean you have to acknowledge that you’re currently in hell. And unless you can really accept that reality, nothing good is going to come of it. The other saying that I like that comes from mindfulness or Buddhism is that pain plus struggle equals suffering. That the more you fight against the pain, the more you’re going to suffer. So, I think those are useful concepts.

LR: In this context, at what point does grief and loss work enter the clinical frame?

JC: Grief work is really part of it. Even if I can’t facilitate a reconciliation, it is important helping parents to feel like, ‘yeah, I think you’ve turned over every stone here.’ At that point, it is important to help them accept it and focus more on their own happiness and well-being, and on other relationships. This would include working on self-compassion while mourning the loss of the relationship that may never be.

LR: In closing, Josh, can someone who’s trained in individual therapy do this kind of work?

JC: If you are an individual therapist, you can’t just sort of suddenly start doing couples therapy. You have to have some facility at keeping two subjectivities in your mind at the same time. You know, being able to, to speak to both people in a way that shows that you’re neutral, even when you’re temporarily siding with one person over the other. I think it’s important to have a sociological framework for this part. You also need to set your own limits and boundaries. Doing family work is a very different sort of orientation and requires a unique skill set.

LR: On that note, I’ll say thanks. Josh, I appreciate the time.

JC: It was my pleasure, Lawrence.

*******

Joshua Coleman, PhD, is a psychologist in private practice in the San Francisco Bay Area and a Senior Fellow with the Council on Contemporary Families, a non-partisan organization of leading sociologists, historians, psychologists and demographers dedicated to providing the press and public with the latest research and best practice findings about American families. He is the author of numerous articles and chapters and has written four books: The Rules of Estrangement (Random House); The Marriage Makeover: Finding Happiness in Imperfect Harmony (St. Martin’s Press); The Lazy Husband: How to Get Men to Do More Parenting and Housework (St. Martin’s Press); When Parents Hurt: Compassionate Strategies When You and Your Grown Child Don’t Get Along (HarperCollins). His website is www.drjoshuacoleman.com/.

The Art of Effective Couples Therapy: Negotiation, Compromise, and Sacrifice

Posted on May 21, 2025February 12, 2026 by Psychotherapy.net Team

As a therapist, the language I use can shape the way clients navigate their relationships as it provides a framework where thinking and behaving can take place. In couples therapy, my main goal is to help clients cultivate, commit, and execute on their shared vision. Over the past two decades, I have found that helping clients redefine negotiation, compromise, and sacrifice is essential for fostering healthier dynamics and building a sustainable strong foundation for the future of their relationship. These are terms that are often misunderstood yet widely used and profoundly impact the quality of their relationships.

Clarifying Expectations: A Foundational Practice

In casual, low-stakes situations, many individuals tend to effectively clarify expectations. For example, hiring someone to paint a house involves clear discussions about the scope, timeline, and payment. Yet in personal relationships, particularly romantic ones, expectations are often unspoken or assumed.

Couples often bring different goals, values, and assumptions into their shared lives, which can lead to misunderstandings unless explicitly addressed. When the vision for a relationship is not clear and agreed upon, it can leave room for mismatched priorities regarding resources, which could lead to further conflict in a relationship. For instance, one partner may dream of moving to a new city, while the other wants to stay near family. Similarly, one might desire children, while the other feels uncertain or uninterested. Financial priorities can also differ, with one valuing saving for the future, while the other emphasizes enjoying life in the present. On a more conceptual level, one might define privacy and secrecy very differently than the other person.

These principles, however, extend beyond romantic relationships and can help clients navigate workplace relationships, friendships, and family connections. Making these distinctions is critical. Specifically, when working with singles or couples to carve out their shared vision, understanding these concepts is essential to fostering healthy dynamics and avoiding long-term resentment. Addressing these needs, visions and expectations thoughtfully is crucial, as they directly influence resource allocation and life priorities.

Negotiation: A Daily Practice

Negotiations are what we do daily to navigate life when we are partnering with someone (where to go for dinner, who picks up the kids, etc.). Usually the stakes are not as high depending on the sensitivities within a coupledom, and some couples might not even call it that. When I bring up the word negotiation, depending on the cultural context of the clients, they might be surprised and sometimes even offended thinking: this is not the language we use in loving relationships, and it is best to be left to the business world where transactions happen.

The way I expand on the concept of negotiation and help clients to come around, is to explain that, in any relationship, there are certain currencies involved (again, going back to the language we use, many people think that currency is only applicable to monetary entities). Based on social exchange theory, we are all looking for an exchange of some sort when we are interacting with the outside world. This might not be conscious or intentional; nonetheless, it is always present.

Therapeutic Insight: Negotiation provides clients with a sense of agency, it helps individuals learn how to take accountability over what they desire in life, show up for it, and articulate it with their partner. Otherwise, we all have seen cases that one went along with the other only to find out somewhere along the way that “this is not what I wanted,” while the other person didn’t have a clue. As a therapist, I can coach clients to approach these conversations as opportunities for collaboration, encouraging them to listen deeply, receive what is offered, and then formulate their responses in a thoughtful and authentic manner.

Compromise: Balancing Individual and Shared Needs

Compromise often involves ensuring both partners feel their needs are valued. This step helps partners identify areas of alignment and divergence, usually without resorting to defensiveness or rigidity. It requires mutual give-and-take and intentionality to avoid one-sided concessions. It is not always meeting in the middle as it is believed to be, because healthy relationships are not based on equality or 50/50 as many of us working with couples would agree. They are based on equity where everyone involved is satisfied in their own ways.

Therapeutic Insight: It’s crucial to remind clients that compromise doesn’t always mean equality in the moment—it’s about creating equity over time. I encourage them to assess whether the “currencies” being exchanged feel worthwhile and sustainable.

Sacrifice: When It Becomes Unhealthy

Sacrifice often involves one partner giving up something significant, which can lead to resentment if done without open communication or equitable acknowledgment. For instance, one relocates for her partner’s job, leaving behind her career and community while not having a chance to assess her own needs in short and long term and without continued communication as things evolve with this move. Without mutual appreciation and a plan to address her needs, resentment may develop, impacting the relationship’s health.

Therapeutic Insight: Help clients reflect on whether a potential sacrifice aligns with their values and long-term goals. Sacrifice should be a conscious, collaborative decision rather than an expectation.

Cultural Context and Relational Dynamics

When I’m talking about relational dynamics, I am also talking about what defines them for individuals and couples. Cultural, religious, and gendered expectations often influence how clients perceive negotiation, compromise, and sacrifice. For one couple, sacrifice might be the way to go (and might even be expected of a good wife) and for another, it might just be a figure of speech while in reality the description of the dynamic resembles a negotiation pattern for the therapist.

I have found that exploring these factors is essential to helping clients identify patterns that may unconsciously shape their behavior. Meet them where they are and empower clients to define their relational values and vision, rather than defaulting to inherited scripts.

Some Practical Applications for Psychotherapy

These are some practical ways I have incorporated the above strategies into my clinical work with couples:

With singles, I encourage clients to clarify their non-negotiables and flexible areas before entering relationships. This self-awareness equips them to negotiate and compromise effectively when building connections.

With couples, I guide each to regularly revisit their shared vision—perhaps at the start of a new year or on anniversaries. This practice ensures their goals evolve alongside their individual and collective growth.

In the broader context, I try to apply these principles to familial and professional relationships, helping clients navigate complex dynamics with greater intentionality and respect.

Case Application

Rory and their kids loved skiing, while Hunter despised it—not just the sport but the cold and all the logistics involved. Before they had kids, this wasn’t an issue. They simply did their own things in winter, and no one thought much of it. However, once their kids reached skiing age, the dynamic shifted. Rory planned to spend every winter weekend skiing with the kids, and Hunter realized what this would mean for him.

In the first year of ski school, Hunter found himself waking up at six in the morning to help pack lunches, wrangle the kids’ gear, and drive 80 miles to the mountain. Rory and the kids thrived on this, but Hunter was miserable. He felt he had no options: staying home without a car wasn’t fulfilling, and joining in was even worse. To Hunter, it all felt like an unwelcome sacrifice.

Entering the second year, Hunter and Rory recognized that their dynamic wasn’t sustainable. They began to negotiate in earnest. Rory explained her perspective:

I grew up skiing; it’s my passion. It’s really important to me to pass that on to the kids because they love it too. I hardly get to see them during the week, and bonding with them over skiing feels really meaningful. I don’t want to give this up, but I also don’t like feeling guilty all the time. I know this isn’t working for you. Is there a way we can make this work for both of us?

Hunter shared his struggles and feelings of resentment, and through multiple conversations and creative problem-solving, they found a solution that worked for both of them. Rory took over 90% of the labor involved in ski school, including handling all the gear and logistics. Hunter agreed to pack lunches and have dinner ready when they returned. Rory bought a second car, so Hunter had options on weekends. Hunter decided he would join them for a few ski trips each season for family bonding, but otherwise enjoyed rare, unstructured time to himself—a precious commodity as a stay-at-home dad.

This arrangement worked beautifully. Rory was able to share her love of skiing with the kids, which was incredibly meaningful to her, while Hunter gained much-needed personal time and no longer felt trapped in a situation he despised. Hunter and Rory’s story illustrates how healthy compromises work; neither partner “won” nor “lost.” Instead, they both gave a little and got a little. Through negotiation and compromise, they reached a solution that felt equitable and allowed them to move forward with confidence and mutual respect.

***

Negotiation, compromise, and sacrifice are integral to shaping a life together. By teaching clients to differentiate these concepts, I hope to empower them to engage in relationships as active participants rather than passive followers. Healthy relationships require adaptability, mutual respect, and clear communication. Whether clients are building a life with a partner, strengthening family bonds, or deciding on a career path, these tools equip them to foster meaningful, sustainable connections. As a therapist, my role is to guide clients in creating these shared visions with intention, ensuring their relational choices align with their values and aspirations.

Questions for Thought and Discussion

How does the author’s work resonate with your own couples therapy?
Which of the three elements of change do you use in your clinical work with couples?
What additional or different interventions do you use with couples?
How would you have worked differently with Hunter and Rory?

Julie Bindeman on Reproductive Mental Health Care, Dobbs, and Beyond

Posted on October 23, 2024February 27, 2026 by Psychotherapy.net Team

Lawrence Rubin: Hi, Julie. Thanks so much for joining me today. You describe yourself as a reproductive psychologist whose specialty centers around reproductive challenges related to fertility, pregnancy, and abortion. Did I get that right, and can you elaborate a bit on what this professional identity means?

Julie Bindeman: Reproductive Psychology is not the kind of specialty you’ll find in graduate school departments. In fact, I’m working with some colleagues to look at what is the curriculum around reproductive health in graduate programs these days. Thus far, it’s not as encouraging as I would hope it would be.

The reproductive time period actually can be anywhere from the time somebody begins to menstruate or begins the ability to produce sperm, all the way to—for men and cisgender men—more so end of life, and for cisgender women into the early 40s-ish (from perimenopause through menopause). So, it’s several decades of a person’s life.

For so many of those decades, cisgender women in particular, spend time trying to avoid pregnancy. It becomes very interesting when everything that we’ve been taught about preventing pregnancy gets turned on its head when we want to become pregnant. We have a lot of conversation in our schools about sex ed, but we don’t have any about fertility and what that means and what that looks like.

So it’s the whole gamut between the attempts at getting pregnant, even deciding, “Do I want to have a family,” and considering that; “Do I want to have a family now with this person, do we feel like we’re compatible;” all the way to, “We’re struggling to get pregnant and we need to seek out a reproductive endocrinologist for infertility,” which is a very specialized doctor.

So, I think, because there’s a specialty in the medical world, and because psychology is a little bit slower to catch up, historically speaking, the idea of a moniker of a reproductive psychologist provides some clarity about what I do, which is different than other psychologists, but also is a very particular niche that involves a lot of study.

LR: This reminds me of a cartoon I once saw of two girls sitting on a park bench, reflecting on their lives ahead. One of them says, “Well, I think after my second divorce, I will…” It makes me think, Julie, that although the reproductive age physically starts around puberty, people’s ideas of reproduction and parenting and maybe even fertility—probably begin before they were born. Perhaps, a reproductive legacy.

JB: There’s a concept called the “reproductive narrative.” It encapsulates the idea that we all start having a reproductive story early in life, and that story changes, and it’s just as valid of a story if someone is not interested in parenting as it is if someone is very interested in parenting. And when we meet potential partners, we have to see how our reproductive stories mesh, and sometimes they mesh really well, and sometimes there needs to be some negotiation.

Reproductive Mental Healthcare in the Era of Dobbs

LR: If part of the reproductive narrative entails a chapter on the act of becoming pregnant either willingly or unwillingly, then I would think that part of that narrative, from the perspective of a reproductive psychologist, would include discussions around abortion.

JB: Here, let me assist you with it. One of the big concerns for some clients who come to me about deciding whether they should get pregnant or not, is, “Is it safe for me to carry a pregnancy in the state in which I live, and if it’s not, do we need to move?” They explore concerns like, “Do we need to move just for our pregnancy?” In certain states, people are really putting their lives on the line just to have a family.

LR: I’m not going to hide the fact that part of my intent for this interview was my interest, as I hope it will be the interest of many of our readers, in how the Dobbs ruling has impacted mental health clinicians working in the area of reproductive health. In that context, and first, how has Dobbs impacted Julie, the person of the therapist? We’ll get to Julie the therapist later.

JB: I wasn’t surprised. When the leak came in terms of what the ruling was going to be, there was already so much talk about. People were saying, “this can’t be it,” and “they’ll never do that,” and “we’re talking about established precedent for 50 years.” Unfortunately, I was sitting there saying, no, this is it, this is what the intention is. It’s only going to get worse from here.

I remember even having a conversation with my dad, who said, “No, that’s just like hysterical thinking.” Looking back to when the Dobbs decision was finally released, I wish I could say I was surprised. I was not! I had been seeing this coming since Trump was elected, quite honestly. That was the reason that I marched the day after the inauguration. I could see it coming. It was very clear to me that they were going to use whatever mechanisms of power that were available to restrict reproductive rights. So that was one part.

As a mom of someone who was born a cisgender female, I was and am also worried because my child has their whole life in front of them, and you know, I’m not sure if they’ll have a family or not. They might. They might not. That’s yet to be seen. So, I’m concerned for what their choices might look like and what is available.

I have two kids that were born cisgender male, and I worry about them and their potential partners. I knew this was going to impact IVF too. So, when the ruling in Alabama came down, people were like, “Oh my God,” and I was like, “Yeah, no, of course it’s going to IVF next, because the logical conclusion is personhood and personhood being conferred to an embryo.

LR: The second part of my original question is, “How has Dobbs impacted the way that you are in the room with clients who are thinking about it or going through the abortion process, and what advice springs from that for other clinicians doing it or thinking of doing it?

JB: I happen to live in a state (Maryland) that is very protective of reproductive rights and, in fact, has a shield law. I submitted a letter to the committee that was reviewing it when it was a bill to say that in addition to physicians, let’s protect mental health professionals, because I think that’s an important inclusion that we have, in terms of what we might know.

When I think about worst-case scenarios, I think about people connecting the idea of personhood or person status to a fetus, and then connecting it to laws that already exist. So, if you don’t realize you’re pregnant and you have some wine, is that now endangering the welfare of a child or child abuse? Or if you have an abortion, is that considered child abuse, feticide? I think they will go after women. Even though right now they’re going after physicians, I think they will go after women eventually. It just makes logical sense to me. So that’s sort of my catastrophizing, but again, I don’t think it’s that far off.

As a therapist, I think there have been several weeks of my career that have been indelibly difficult, and nothing I learned in graduate school has been helpful. I was a grad student during September 11th in Washington, DC. That was tough because how do you process an experience with someone when you’re living it too?

And I would say that for my clientele, the next time I had that experience was the 2016 election. I had clients, who, like me, were grieving, because we saw what the implications could look like.

And then I would say that the third time it happened in my career was the Dobbs decision. I had people calling who were panicked about it. “Are my embryos safe?” was a question I got asked a lot by clients, and I would be like, yeah, for now they are—you know, again, depending upon where you live.

Many of my clients were feeling helpless and angry, and of course, I shared that sense of anger and righteous indignation. I think it’s really challenging to be a clinician when you’re experiencing in real-time exactly what your clients are experiencing too, when you don’t necessarily have the perspective that often we are able to bring to our clients, when we’re not living what they’re living. When we do live what our clients are living, it’s so hard to have that sense of perspective, because our fear centers get activated, or at least mine does.

For clinicians who are either practicing or considering practicing in this domain, it’s important to know your state laws and how they apply to you. If you’re a clinician in Texas, for example, where they have that SB8—which is the bounty hunter laws that it’s so lovingly referred to as—clinicians are in danger under what that law is, and it is a civil penalty. So, anyone can rat you out for any reason, especially if they’re motivated by money. It’s a $10,000 fine. That’s not nothing! Most of us might not have that lying around to pay. So that becomes a very real risk.

There are other states that are starting to look at that. There are other states that are looking at assisting minors in having abortion care. So as clinicians, I think for the time being, HIPAA protects us, but it’s really important that we are careful about what we say in our notes because notes can be subpoenaed. And so, if I’m talking to a client about an abortion they are planning or an abortion they had, I’m not going to come out and write, “… spoke about abortion.”

I might say something like, “spoke about family planning” and have it be really vague. I think those of us that are practicing in PSYPACT states also need to be aware of what are the other laws in the states where our clients might be sitting in that we don’t necessarily know because they’re not necessarily connected to the statutes that relate to psychology.

LR: Would you say there is a dividing line/light switch moment between the way you walked into the room pre- and now post-Dobbs? On the morning after, pun fully intended, did you walk in more nervous, more fearful, and aware of having to be far more conservative or careful with your words?

JB: As a clinician who is very up to date on the laws of my state, which I know most others may not be, I’ve been an advocate for many years. I’ve helped to lobby to get some of those laws passed. And so, I wasn’t concerned, because I knew my state legislature—and in a lot of ways, I know many of them personally—that they were going to protect reproductive rights, and that is what they have done the last couple of years too. So, they did not disappoint.

Our state has done some really great things. As I said, they passed a shield law, they’ve expanded who can perform abortions. So instead of it having to be only a physician, it’s been expanded to physician assistants, nurse practitioners, and midwives, which is awesome. More care, we like it! Our Governor has gotten our own sort of storage of mifepristone and misoprostol— ‘mife’ and ‘miso,’ as it is.

So, I didn’t feel that light switch. One of my best friends who lives in Texas did feel that light switch. She had also been living under SB8 two years prior, so she was not surprised. She had had some time too, to be like, okay, now we’re really going to do this because we don’t have the Supreme Court protections. What’s happening in Texas is legal versus legally dubious.

LR: It sounds like one doesn’t even have to identify as a reproductive psychologist or work in concert with physicians to experience these issues, because anyone who practices couples therapy or family therapy might find themselves thrown into this reproductive ring. As such, it’s just smart to know your state laws, to connect with advocacy resources, and to be very, very careful of what you’re saying and how you say it. And based on your writing, you don’t bring up abortion explicitly but talk in hypotheticals.

JB: One of the things I do as a reproductive psychologist is to conduct third-party evaluations for prospective gestational carriers. And as part of that conversation, we talk about abortion and because they are not pregnant, there’s no concern. I can talk about abortion till I’m blue in the face. They are not pregnant. Everything is a hypothetical.

But I may talk hypothetically, if they live in Texas and there is a problem with the pregnancy. I may say something like, “You are now eight weeks pregnant. You cannot get care in Texas. Let’s talk about where you can go to get care? You know that your doctor is not going to be able to save your life should your life be on the line unless it’s really dire and, you would have to ask yourself if this is something I want to risk?” It’s about looking at each client’s risk profile, which has changed since Dobbs.

Abortion Counseling as Mental Health Care

LR: But, outside of these specific evaluations, you also do what you might call generic psychotherapy, where the issues may, but most likely will not come up. We are traditionally taught not to bring up religion or politics unless the client does, so is it the same when it comes to reproductive health and abortion if a client doesn’t broach the subject?

JB: Of course I bring it up. I bring it up because everyone thinks that once you get pregnant, it ends with a baby, and that’s just not the case. Not that I’m trying to freak my clients out that are newly pregnant and excited and whatnot, but we talk about, “Hey, have you had a conversation with your partner, should this pregnancy go in a way that you don’t expect? What might that look like? And, you know, it’s a hypothetical because it’s a very rare occurrence. And, I’d rather you have this conversation before it happens than have to have that conversation for the first time as it is happening because it’s just too much to unpack in that moment as you have to make a critical decision about the pregnancy.”

LR: You describe abortion as healthcare. Would you say that the kind of counseling that you do considers abortion as mental health care?

JB: Absolutely. I come at this from the side of the law of my state, which is specific in saying that mental health is a reason for someone to obtain abortion care past 24 weeks. I also come to it from a religious perspective, which may sound kind of odd, but in the religion that I grew up in and that I practice, which is Judaism, one of the tenets is that you save the existing person at all costs. My religion doesn’t see a developing fetus as an existing person. It sees it as a potential person. So, unless that fetus is basically sticking out of someone’s vagina—sorry to be so graphic—and has taken a breath, it is not a person.

LR: I just want to draw reader’s attention to a chapter in your new book that has a comprehensive table called, “Religious Points of View about Abortion.”

JB: When people think about this, and they’re like, “oh, but I don’t see people who are having babies because I work in geriatrics, or I work in pediatrics. This isn’t important to me. I don’t need to know this stuff.” And to that, I say, “actually you do, because how are you talking to your parents of the kids you work with about, what was the reproductive story that that child was born into? Were there losses before that child was born? After that child was born? Was it a long journey? Was it an uncomplicated journey? Was it fraught, and you weren’t sure this baby would ever get there? This is in addition to, was the baby in the NICU or anything like that, that you’re going to want to know about your patient.”

I also think it’s important because if we’re seeing young kids, their parents are often trying to expand the family, and sometimes it doesn’t work as easily as the first time. And so, how do you support a young child who knows there’s something happening with their parents but doesn’t know what it is and doesn’t have that understanding of what infertility might be or pregnancy losses might be? How do you help the parents talk to their child about it? How do you help, as a therapist, talk to the child about it, give them a place to have their own thoughts and expressions?

For those that work with an older population, and I’ve had older clients who have been still traumatized by the Dobbs decision, because of the abortion they had in the 70s, either pre-Roe or post-Roe. Or even talking about how this is going to impact so many people and having that empathy for it. And that sadness of what I thought I knew, what I thought I could trust, that 50 years of precedent went down the drain.

So, it’s come out in lots of different age groups, and I think it’s really important. I’ve had male clients talk about it too, their concern about abortion and it not being an option—and not in that kind of cavalier, like, I don’t want to deal with that kind of way, which I think we often ascribe to men when we’re talking about abortion. That doesn’t seem to be the case, but somebody I care about might be very impacted by this.

LR: What are some of the myths around abortion that clinicians—whether reproductive clinicians or not—need to consider when abortion enters the clinical frame?

JB: So let me first dispel a couple of myths that have existed about abortion. Abortion does not cause future infertility. Although I can’t tell you how many of my clients who had abortions when they were younger, and then as they wanted and were ready to have a family, struggled with infertility, how they made that causal. But I’m like, nope, there is nothing causal to that.

Abortions don’t cause cancer, so that’s really important to know. Also, there is no such thing as post-abortive syndrome. That is not a thing. I appreciate the American Psychological Association for a deep dive that they did in 2008. And one of their conclusions was, nope, there is no need to add something to the DSM about post-abortive syndrome. It is not a thing.

What I think is important for clinicians to think about is what research tells us, which is that most people with access to abortion feel relief. Now, there are some circumstances like terminating for medical reasons—I’m not lumping that into that. That’s a very different, specialized circumstance. But the majority of people who are seeking out mostly first-trimester abortions experience relief—95% of them!

In that 5% who might not, they might experience regret. And where this gets confabulated is the idea that regret becomes mental illness versus regret is a feeling just like lots of other feeling experiences a human can have. And it is a feeling that will come and go. And so, we don’t need to pathologize regret!

A Reproductive Psychologist’s Personal Journey

LR: For those among our readers who have read some of your other work, can you give us—and I don’t mean to diminish it in any way—a little bit of the experience you had as Julie, the mom, along your own challenging reproductive journey?

JB: When people ask me how I found this work, I tell them I came to it honestly. My early grad school experiences centered on teens and kids. That’s what I was really interested in, and so I worked at a high school, where one of my seniors was pregnant. The way the school managed it was incredible. They threw her a baby shower, and when the baby was born, different people watched the baby so she could still go to class so she could graduate on time. What an incredible community to circle around her and help her. It was amazing.

As I continued, I worked at another school that was Catholic, and one of my seniors got pregnant. That was a very different experience. It was interesting in that conversation where we had to sit with the mom and tell her what was going on, and the mom was like, okay, cool, we’ll get an abortion. And the kid was like, nope, I don’t want that.

At the time, I didn’t make much of those experiences. I later had my own kid. When he was about 18 months old, my husband and I reflected on how great he was and decided we needed another one because the world needs another one just like him—since all children, of course, are carbon copies of one another, right?!

We did not have an issue conceiving the second time, although I had in my mind it would be a little harder because I anticipated it would take six months. In retrospect, I guess I was ambivalent, thinking I would have more time than one month. I wasn’t quite ready to have another kid, but there it was.

That pregnancy was over just as soon as it started, when at eight weeks, the ultrasound showed that I had had a miscarriage. It’s called a “missed miscarriage” because it was shown on ultrasound and I had no knowledge of it. I had a D&C. Interestingly, I had begun specializing in postpartum health after my son was born, so after the miscarriage, I wanted to learn the difficulties of the postpartum experience.

We don’t talk about postpartum and how hard it is. We really don’t talk about pregnancy losses which seem to be shrouded in secrecy. So, it wasn’t until my own miscarriage that I realized how insensitive I had been when my friends had had miscarriages. I didn’t know what to say, and so I went to the platitudes, that I think most people go to because we want to be helpful. Rarely are platitudes helpful!

My doctor was optimistic and encouraged us to try again, which we did. I became pregnant very quickly, and while everything seemed to be progressing in those early weeks, I was bleeding. Our anatomy scan at 20-weeks suggested that we have a second opinion. We were referred to a maternal fetal medicine specialist (MFM), where we learned that our baby had hydrocephalus, and ventriculomegaly, in which the brain ventricles were measuring much larger than they should have.

We were told that the best-case scenario was that our baby could live into his 40s with the developmental quality of life of a 2-month-old. That was not a best-case scenario for me! That was not the life I would want to bring into this world, and it was not what I would want to do to my son, not what I wanted to do to my marriage.

We called our clergy and talked about options, one of which was labor and delivery, and the other was that we could drive to New Jersey for a surgical abortion. I was confused because I knew abortion was legal in my state, so why did we have to go somewhere else for surgery? I later pieced together that six months before, a physician named George Tiller, who had performed an abortion in Kansas, was shot to death. His death created so much of a chilling effect that the doctors in my area stopped performing abortions. I ended up having to labor and deliver a little boy who died. It was awful, and both very different, and compounded by my miscarriage. We were later told that this was a lightning-strikes-once situation, a one in a million, and that we should try again when we were ready.

It took me about four months before my cycle came back and my story gets redundant in this way. We tried for one month and got pregnant. I was very nervous during that pregnancy, which we learned was with a girl. I was getting scanned all the time and found out at 18 weeks that the also had ventriculomegaly, hydrocephalus, and partial agenesis of the corpus callosum. Because I was 18 weeks, I was able to access a surgical abortion with one of the kindest doctors to whom I was, and am, very grateful.

We tried again quickly because I didn’t know if I would have the courage to keep trying. And we got pregnant immediately, and this was a pregnancy where I didn’t feel any symptoms, and I was disconnected from it.

At 18 weeks, the MRI showed that we were having a girl and that she was healthy. I was excited and terrified. I asked them to show us the pictures of the last baby we lost and the baby I was carrying, and the differences were so clear. The brain of the baby I was carrying had all sorts of contrasting grays and whites, compared to the blackness in the image of the baby we had lost, which represented fluid. It was a beautiful picture. I went through the rest of that pregnancy fairly terrified, and I think my MFM probably had some vicarious trauma because she had been with me from the beginning.

We went back for my checkup at 36 weeks, and she asked me, “how do you feel about having a baby this week?” I had four more weeks so I said, “I’m good.” She half-joked, “it wasn’t really a question. You’re going to have a baby this week. When would you like to have your baby?” She just didn’t want anything to happen to this child. So, my daughter was born weighing 5 lbs. even. She was fierce. We had a “normal” stay in the hospital, and then they let us go.

When she was about 14 months old, I said to my husband, “hey, so, you know we always talked about three.” He looked at me like, “are you effing crazy?” I said something like, “I must be, but I really want to try for three. If it works, great. If it doesn’t, that’s fine.” And, again, we got pregnant the first time we tried. When we got an MRI at 18 weeks—and this pregnancy just felt so different to me because I was in a place where whatever happened, happened— and my husband was really excited because it meant we could get a minivan. I remember saying something like, “I will not get a minivan unless we have the number of children we might need for a minivan.” He was like, “okay!”Our son was born healthy, and now I have an 11, 13, and an almost 17-year-old. We are very, very done.

LR: I certainly appreciate the depth of your sharing, Julie. when you first started talking about it, I thought, “She’s probably told this many, many times, and it’s going to be very matter of fact.” But you told the story as if it was so fresh, and it just suggests to me that this part of your narrative will always be alive for you, as it problably is an will be for others who have had challenging reproductive journeys.

JB: Can I read you something as you say this?

LR: Sure.

JB: In the acknowledgement section in my book, I write about my story and actually dedicate the book, to the two babies we lost. “…I am grateful for these two babies I said goodbye to before I could say hello to, as they awoke me to the passion for reproductive mental health, and, primarily, the intersection of abortion and mental health.”

Ethics, Competency, and Advocacy in Reproductive Mental Healthcare

LR: This begs the question, “Are there limits to self-disclosure in reproductive psychology, reproductive psychotherapy?”

JB: It’s a really interesting question that I look at from two different vantage points. So, one vantage point is if you’re a therapist with just sort of a normal population, whomever that normal population might be, and you become pregnant, the pregnancy itself is a disclosure, isn’t it? Like there’s a point in pregnancy where you just can’t hide it, and so it’s a disclosure, and I think it’s useful for patients to know so that they can plan, and they’re not surprised.

And then, you know, there can be a lot that might come out in the transference around maternity and nurturance, and things like that. So, I think it can actually lend itself to a lot of really useful therapeutic material. I think if you’re working with the population that I’m working with, I didn’t have a choice but to disclose because I wanted to give my clients an opportunity to change therapists if they needed to. I wanted to acknowledge, “Hey, seeing me pregnant could be really triggering, and I don’t want you to feel like you have to stay with me. Because I get it, and it can be really, really hard.”

It also came out in other ways, like with a client for whom it took months to disclose that, as a child, she had experienced terrible sexual trauma committed by a relative. She was with me through my losses, and she was with me through the birth of my daughter. After my daughter was born, she was able to say she felt like her “badness” and “evilness” contributed to my losses. She felt responsible for them.

LR: That’s very sad.

JB: Yeah! We did some good work around that. Without the disclosure, that work couldn’t have happened. I didn’t show up at my office Friday afternoon after that first ultrasound. So, you know, I had to have someone tell my clients something. And again, lots of interesting things came out from it.

LR: a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional GroupDo the APA, ACA, and NASW have resources for clinicians who are finding themselves in this therapeutic arena, or who are considering or looking for guidance through live contact?

JB: Not so much within the larger professional bodies. Perhaps NASW. I couldn’t tell you specifically. Where I get a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional Group. Thats where a lot of the research and work is being done. APA has had more since the Dobbs decision. Sorry to be pitching my book, that wasn’t my intent, but the reason I decided to edit this book was because there wasn’t anything for the mental health professional that had a client that was now experiencing or considering abortion.

You can’t refer someone out when we’re talking about days or weeks to decide to have an abortion. You have that ethical obligation not to abandon our clients, and we have an ethical obligation to not practice outside of our competency. And so, this book is to fill that gap in between competency and not abandoning clients.

LR: Could you recommend a couple of potential paths for advocacy for clinicians who want to get into it and make a difference that way?

JB: I think it depends on how much you want to do. There are lots of advocacy opportunities such as volunteering for a state delegate campaign in your district and talking directly to them, I found that useful and interesting. Or, talking about it at a City Council meeting where you can go on the record. You can talk about healthcare in that kind of way. These are sort of smaller things that people can do.

There’s organizations like the National Abortion Foundation. They not only have abortion funds through them, but also provide a warm line to people. I don’t think it’s a hotline. They train people so that they can help talk to people that are struggling. So that’s a great organization.

There are lots of local abortion funds. That’s a great way to get involved again, you know, depending upon how involved you want to be. So, for a birthday fundraiser one year, I’m going to pick out an abortion fund. This is where I want my contributions to go, like, contribute to this in my honor.

I have lobbied at the state level, even not in my state. I’m happy to talk to anybody. And my husband had the opportunity to go to the City Council meeting, which is where our delegates were going to talk about what happened in session. He said, “I was going to share our story, but do you want to do it? I can give the time to you.” And I said, “Oh honey, they have heard it from me. They need to hear it from you.” I was really, really proud of him.

LR: It sounds like part of what got you through your pregnancies was you and your husband moving together as a unit. I probably should have asked this question earlier on, but “Have you had the experience of working with any women or families who have been denied abortion?” I know this was addressed in the “Turnaway Study” and is very state-specific.

JB: In my state, that is not an issue for people because it’s so protected here. That being said, I’m part of PsyPact, and was working with someone in a restricted state who had gotten a poor prenatal diagnosis and who was trying to decide what to do. Part of our worked centered around getting more information. A lot of her wait-and-see was about getting further along to get more information about the pregnancy. And every piece of information she got was like adding crap to the pile. There was never good news that she was given. It was just bad, bad, bad, bad, bad.

They got to the point where they felt, “our baby is not going to survive, and this is awful, and I think we’re both ready to terminate the pregnancy.” But she lived in a state where accessing that kind of healthcare was really challenging. She had resources, she was smart, and she had people that she could connect to that could help her connect to other people.

So, initially, her abortion was denied by the hospital. They’re like, nope, we’re not going to do it. And then it was denied by insurance, they’re like, nope, we’re not going to cover it. And the hospital is like, well, if your insurance says we can’t do it, we can’t do it. So, it was sort of this merry-go-round.

She was finally able to get connected to the vice president of her insurance company and shared with him what she had gone through, and what was happening, and what she needed in terms of healthcare. He pulled the strings he needed to pull so that she could have an abortion. But otherwise, she would have had to travel.

And we do see that a lot. We’re seeing more and more people that have to carry to term because they don’t have the luxury of traveling. And while abortion funds are great, they can’t fund the entire expense of traveling and procedures, particularly later in pregnancy.

LR: On that note, I want to alert readers to the importance of the Guttmacher Map, which lists the levels of abortion restrictions by state. Julie, are there any questions I should have asked, or that you would have liked me to have asked?

JB: I don’t know if it’s a question per se, but just something to leave people with. My abortions defined what I do and defined how I work and gave me purpose in terms of the scope of practice. However, they don’t define who I am. They are just a part of who I am, but they are not the defining measure.

And I think when some people experience trauma related to their abortion or traumatic abortions, it doesn’t mean that all abortions were traumatic, are traumatic. But when people experience that kind of trauma, it’s so easy to have it define them, that they become defined by their trauma. We see them all the time in our patients, regardless of what kind of trauma it was. Or they’re trying to run from it so much that they—so they’re not defined by it. Through a lot of work that I’ve done, I feel like it’s a part of me. It’s one aspect of me. It is not the whole description of me, but there was a time where it was—like it was all I was doing.

LR: This ties into your earlier mention of the reproductive narrative and how we are born into reproductive narratives that sometimes define the entirety of our reproductive journey. I’m reminded of clients who bring with them the legacies and trauma of their ancestors, such as slavery, the holocaust, and other atrocities.

JB: Well, if you’re thinking about Norma, who was the original plaintiff in Roe versus Wade, she was the third generation of people who had unintended pregnancies but had no recourse, and she wanted a recourse. What ended up happening in that pregnancy—she had already had two other babies who had gone into foster care and then eventually were adopted—and so this third one, she adopted out because the courts were (are) are really slow.

There is a fantastic book called The Family Roe. The way it is written, and how it weaves it all, is just incredible. I think you asked earlier, too, about what resources are available for clinicians. There is an email that you can subscribe to. It’s a Substack you can subscribe to, and the journalist’s name is Jessica Valenti, and her Substack is called Abortion Every Day. She is really keeping tabs on what is happening on a granular state level, not just federal, but she’s been keeping tabs about like, what is the status of getting abortion on the ballot in different states, and what are the shenanigans that some representatives are trying to do to prevent it.

LR: Clearly, we’ve only scratched the surface, so I’ll simply end by saying thank you so much, Julie.

JB: Thank you, Larry.

Working with In-Law Problems in Couples Therapy

Posted on March 14, 2024February 24, 2026 by Psychotherapy.net Team

One of the most common problems I see as a couples therapist is trouble with the in-laws and its impact on the couple relationship. It can be hard enough for clients to deal with their own parents, let alone their partner’s parents, who may disapprove of them (openly or covertly), be protective of their child (or the opposite, treat their child in ways that make clients want to protect their partner), or feel threatening to clients or the relationship in some other way. Relationships can be tough, and family dynamics especially can be challenging to navigate; combining intimate relationships and family dynamics can pose its own struggles.

The Negative Cycle

Something I see often in my office is couples who struggle with how to handle it when an in-law offends. When their parent does something that upsets their partner, I often see a now-familiar and predictable pattern that I call the “That’s not what she meant” dance. When the partner is hurt, the son or daughter sees a rupture in the family; a slow unraveling of the relationship between their partner and their parent. They want harmony and for the family to get along. So, in an attempt to preserve the relationship between parent and partner, they invalidate their partner’s complaints. It could sound something like this (a dialogue I have seen in my office):

“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”

“She didn’t mean it like that, she was just surprised.”

“But it hurt.”

“You’re making too big of a deal out of this. Don’t worry about it too much.”

[Partner pouts and turns away (or explodes)].

The adult child above likely has good intentions. They hear that their partner is upset, and they want to help. They try to make things better by trying to tell them there’s no cause to worry. But if there’s one thing I’ve learned about the human experience from being a therapist, it’s that feeling understood is important to all of us, and especially aggrieved partners in scenarios like this. When I hear things like “It wasn’t like that,” or “There’s nothing to worry about,” clients feel invalidated and unheard. The partner here is not soothed, but instead left feeling misunderstood and frustrated. They likely long to truly feel that their partner “gets” them and has their back.

To help these clients avoid getting caught in this all-too-common pattern, I try to teach them to validate their partner’s struggles. If their partner says that they’re hurt by something, I encourage them to take that at face value and not try to talk their partner out of their feelings.

A Strategy for Reconciliation

Often, I see that my clients are hesitant to validate their partner’s hurt feelings when they involve the actions of a family member. They may fear that they’ll make the disharmony in the family worse, and that their partner will move further away from getting along with their parent.

In instances such as these, I try to let my clients know that they don’t have to insult their mother or father to validate their partner’s emotions and to show them that they make sense. Showing their partner that they understand why their hurt makes sense and are there for them usually restores harmony in the family, as their partner won’t feel as alienated or marginalized when they know that you are right there with them, and they are heard.

As often as possible, I encourage my client to try responding to their partner like this, with validation, understanding, and support:

“It really hurt when your mom didn’t thank me for cooking and called my food too salty.”

“I’m so sorry to hear that, I can see why that hurts you. You put so much work into dinner and I know how much you love making people smile when they taste your food. And it was delicious. Is there anything I can do to be here for you right now?”

This response shows: I get it, I get you — and your feelings make sense.

Responding like this can help a client’s partner feel safe in knowing that they have someone on their team, and they aren’t alone in their feelings. This increased level of safety can soothe hypervigilance and make couples feel more comfortable and unified when it’s time to go see Mom and Dad, resulting in less tension and conflict.

Rick Miller on the Clinical Challenges of Working with Gay Sons, Mothers, and Families

Posted on December 20, 2023February 11, 2026 by Psychotherapy.net Team

Gay Sons and Their Mothers

Lawrence Rubin (LR): You may be known to our readers as the founder of Gay Sons and Mothers. But they may not be familiar with how extensively you’ve been trained and how long you've been practicing as a psychotherapist with a personal interest in working with gay men and their mothers.

Rick Miller (RM): I'm a gay man who grew up really appreciating the bond and love of my mother. And, in hindsight, as an adult, what it meant for me was that I got to be myself. She didn't necessarily know that I was gay, or maybe she did, but she never forced me to do anything differently than what I did.

And growing up in a world in the 1960s where it was prescribed, this is what boys do, having a mom who let me be me — and we did a lot of things together — was pretty miraculous. I hear so many stories about people growing up whose parents abused them or forced them to do things differently.

I wrote a book several years ago for clinicians about doing hypnosis with gay men. I thought it would be relevant to do the research or to seek out research about gay men and their mothers. I looked at the literature about gay men and their mothers to include in the book. You'd think this a cliché topic and that there would be way too much information to use. I couldn't find anything! I thought, I’ll write an article about this, and it ended up turning into video interviews. And from there, I started a nonprofit called Gay Sons and Mothers.

We are educating the public about the special bond between mothers and their gay sons and how she contributes to his sense of well-being in the world. It's a multicultural story that looks at strength, at disappointment, and is a very emotional topic.

LR: So, even before you and your mother had a conversation about being gay and you knew, you had no particular concern over sharing it with your mom. You didn’t worry how she would take it, how you'd be perceived, how you'd be treated. You were just free from the start to be you.

RM: Well, I was free to be me, but I didn't come out to them — meaning my parents, my mother and my father — until I was 21. So, it was interesting that I had the freedom to be me, but I didn't feel 100 percent free to be me because I waited longer to come out than I probably needed to in hindsight. Today, many kids are coming out at a much younger age to their parents. Of course, the world is very different.

LR: If you intuitively felt accepted by your mom and weren’t censored or limited in any way from being you — you haven't talked about your dad — why do you think it took you as long as it did to become public about it?

RM: Well, so, it was the early 80s. So, AIDS was hitting the press big time, and I suppose on one level, I was protecting her or them from thinking that something would happen to me, which, knock on wood, did not happen. I was afraid that I'd be rejected, and, not to sound callous, they were paying for my graduate school education, and I just made a mental note in my mind I was going to wait until I finished school to come out, which is so stupid.

Knowing my parents, of course, they wouldn't have done anything differently. It took them a while to come around, a month or so, which I thought was horrible at the time. But I look back and I think that my parents had to go through their own grieving when I came out to them. Of course, they knew I was gay long before I came out, but hearing it was definitive. And it took them a short time to acclimate and appreciate it. I was incensed at the time. And, often, I say to children and to parents, it's okay to grieve.

LR: Incensed about?

RM: They were not 100 percent supportive the second I came out to them. And the first thing my father did when I came out was to become a little weepy saying, “the world is unfair, and I'm worried about what that will mean for you.” I took it as supportive, for sure. And then he kind of changed the tune for a bit, and that is when things turned ugly, and again that lasted a few weeks and then everything turned around.

LR: Smooth sailing with your parents and especially your mom ever since.

RM: Yep. And I had a partner that I was moving in with at the time. So, what I did, which I shouldn't have done, was when I came out to them, I told them that I was moving in with the person they knew as my friend all at once, so that threw them a little bit.

LR: Overload! Going back to the second part of the earlier question about your foundation; how do you think clinicians can benefit from awareness of it?

RM: There's so much inherent in the videos that we share through Gay Sons and Mothers. It's not only about the relationship between a mother and a son, but that part in and of itself is so affirming. Clinicians can watch stories of sons and their mothers and appreciate what it is being gay. And it's not only mother in these interviews. Families are talked about. Extended families are talked about. Culture and religion are addressed in these videos.

So, there's a lot there, and, when mothers are struggling with their kids, I send them videos from Gay Sons and Mothers. On our website, there's a link to our Instagram page. We have a YouTube page. Sons watch. Most people — therapists included — watch these videos and have a deep emotional resonance around the issue of being included, being loved, being supported, being rejected. It's hard not to feel something when you're watching videos pertaining to these themes.

LR: A connection. How would you respond to a therapist or to a non-therapist who’s visited your site and says, “Yeah, well, what about gay sons and their fathers?”

RM: There's way more information in the literature about gay sons and their fathers than there is about gay sons and their mothers. And if there hadn't been any with fathers, I would have pursued that, as well. I grew up with a great relationship with my mother. I had the fame of saying to my siblings, “Mommy likes me best.” It carried me through. So, it seems completely perfect that that would be the focus of my work.

Historically, mothers in the 1970s — or even earlier in the psychiatric and the medical field — mothers were blamed for making their sons gay. And, so, with the lack of literature out there, what's missing is that mothers have the power to raise sons who are mentally healthy, just from being a good enough mother. And, so, that premise is so important to me that I've focused exclusively on mothers and sons.

The issue of fathers and extended family is embedded in the work anyway. So, this project, Gay Sons and Mothers, is inclusive of the entire family. And we're also expanding beyond just gay sons and mothers. We're talking about trans children and all sorts of things.

Intersecting Identities

LR: How has your advocacy and clinical work been informed by your own personal evolution?

RM: Oh, gosh, that's such a big question, but I think I can get there. I came out in 1983 — I was already a clinical social worker. In the 1980s, AIDS was emerging, and gay men were dying in big cities, and people were afraid. Homophobia was on the rise because people were afraid of catching AIDS. I was working in the AIDS field, doing volunteer work at this time, and I started working with the gay community from the start.

Boston, where I lived, was a progressive place. So, I was known in Boston as being an out gay male therapist. I mean, there was no web at that time, but anyone who knew me would know that I was gay. But I was also practicing in a very conservative place, Boston, Massachusetts, very hierarchical, very psychodynamic. So, in the professional world that wasn't the world of AIDS, I worked in a hospital. I kept a very low profile, and I felt like I didn't fit in the hierarchy of psychiatrists, psychologists, social workers.

I'm a social worker, and looking back at my evolution and my history, I wish I had put myself out there more because the contributions that I'm now making to the field in the last ten years as a writer, as a teacher, as someone who's done Gay Sons and Mothers, if I had the confidence to do some of this earlier, I would have done more research focusing on gay men, on gay men and their mothers, gay families. And I think I could have made a bigger contribution to the field.

What happened for me is I started my private practice in the mid 80s, and I switched to full-time private practice. So, I left the hospital. I left the agency where I was doing AIDS work, and basically, I hid in my office with the door closed for decades. And I was very successful in private practice, in part because of my clinical skills, in part because of my personality, and I got to hide.

Once I wrote my first book and I started teaching about working with gay men, I could no longer hide. And, at the time, I was probably 52 years old — 10 years ago. And I'm really glad it happened, but it forced me beyond a comfort level that was really important and good for me, and I wish I did that sooner.

LR: So, you came out of the closet before you came out of the office. I can see that your personal story could be used as an exemplar, not only for gay therapists, but for gay men, whether still not out or out. I would imagine that you don't impose your story on others. But by living it and being genuine, as you've always struck me, you are an unintended role model.

RM: Well, thank you for saying that, and it served me very well in my practice. I grew up in an upper-middle-class family with well-being and mental health and good physical health. And, to me, that's how everyone lived in the world, and that is so not the case. And so, as a gay man who had a sense of self, who worked with gay men, I served as a role model to other gay men, to all my clients really but specifically to other gay men who didn't have the good fortune that I did or didn't have the personality that I did.

So, my being outgoing was a very good clinical skill, and, fortunately, in my early 20s, I was in therapy with a therapist who was gay, who had a very good sense of himself, who had a great sense of humor, and who allowed me in the process of therapy to love myself. If I had chosen one of those uptight, analytical therapists in Boston instead, I don't know where I would be right now.

When I was looking for a therapist, I was given the name of eight different people. Back in 1983, I was calling their answering machines. On some, I was hanging up because I was frightened by them. Others shamed me through their tone, and thank God, I didn't work with them.

Clinical Challenges of Working with Gay Men (and their Mothers)

LR: What are some of the clinical challenges you've found in working with gay sons and their mothers?

RM: Long before I ever knew I'd be working with gay men and their mothers, I had a gay male client who was really struggling with confidence. He grew up in the projects outside of Boston, and his father left the family, and deprivation was a big part of his upbringing. So, one day, for whatever reason, I had his mother join him in a session and it was like the heavens opened up.

I understood him so much more, and the bond and the strength of their relationship was amazing. It helped so much in the clinical work. He was a catalyst that led to this project, Gay Sons and Mothers. Every now and then, I'd have another mother and son together, but it wasn't why they were in therapy. Once I started working on this project, various people consulted with me, families for help with their families. For some, in the field of psychotherapy, for others, through the nonprofit where, for free, I just consult with people and help them along.

What's been interesting is one mother and son that I'm working with right now in therapy are enmeshed with each other, and they're seeing me every two weeks. On certain days, it feels like couples therapy and I really have to work with them to detangle and let go of their expectations with each other. And, so, this is a divorced mom with an only child who's gay, and they expect each other to meet needs that goes well beyond what they should be for a mother and a son.

This isn't the case in all circumstances, but I think it's a great example of how it can be a bit of a burden on both ends to have this close bond that goes kind of way too far on both ends.

LR: So, enmeshment is one of the challenges. I imagine acceptance is another.

RM: So many gay men are way too careful, and they're not coming out to their families as soon as they might, or they give absolutely no details about their private lives to their families who really want more from them. So, that is another challenge, that in being careful, even once they come out, being careful continues to be their MO, even when they don't need to be, and people want more from them. They want to hear more details about their day-to-day lives or what they struggle with, or are they in a relationship with someone?

LR: And I wonder if these particular men are so cautious and close to the chest with their families, if they're even more so outside of the home.

RM: Correct. I'm working with a bunch of men in their 50s, let's say in their 60s, who came out in an era where it wasn't okay to be gay. And even though it's fine now and they have jobs where they are out, they, without even realizing it, are kind of slipping into modes of privacy and protecting themselves because it's a habit that's been with them through their life.

LR: I was going to ask you a little bit later about working with elderly gay men. But this seems like a good point to interject the question of, “what are some of the clinical challenges in working with elderly gay men whose mothers, I imagine, have long passed?”

RM: The most significant challenge is that they grew up in an era where they couldn't be out, where it wasn't safe, and many older men were kind of forced indirectly or even directly to live conventional lives and got married and had children without even questioning the freedom of living life as a gay man.

I had a great-uncle who was gay, and he never came out to my family. When I came out to my parents, they said, “Well, Paul has lived a good life. So, we know that you'll live a good life, too.” But this great-uncle, my grandmother's brother, was in his 80s when I came out. And he said to me, “I really appreciate that you have freedom that I didn't have, and I hope that you will keep my secret from your family because I just don't feel comfortable being out there.”

LR: Well, I wonder if that fear of abandonment, being cast out by remaining family is that much greater to an elderly man?

RM: He had an incredible social network. He lived in Washington and was cryptographer for the CIA because keeping secrets was something that they did well. So, he had the love of a community of people, and my mother, his niece, and us, meaning my mother's children who were generations below him. And he was still worried about our knowing. It was just a pattern that was ingrained for the time with which he was raised. It's that simple.

LR: Can you imagine taking homosexuality, or any significant part of your identity, to the grave?

RM: When he died, my mother and I went to Washington to clean out his house — he saved everything. There was a pile of letters that his gay friends wrote to him in the 1950s and the 1960s about falling in love with men that they met in cruising areas in parks, and how they couldn't tell their spouses and how tortured they were.

We were cleaning out his house with three of his close friends. My mother came to me, without saying anything, handed me the pile of letters, and I read them. And I thought poor Uncle Paul would die if I kept these letters, so I shredded them and threw them out. And it is my biggest regret because in these letters was the reality of gay history lived by all these men.

But, in my desire to be loyal to my great-uncle, I threw them out. And this was maybe three or four years after I had come out. I was still living in a careful way and more worried about loyalties. If I had these letters now, what they would mean? Oh my God.

LR: What clinical challenges have you experienced working with gay sons of mothers from other cultures, the Caribbean culture, the Asian, the Southeast Asian, or even African, where homosexuality is shunned and punished, sometimes even fatally?

RM: In these cultures, homophobia is rampant and masculinity and norms around masculinity are such that fathers are not accepting of their gay kids. Religious norms are such that being gay is a sin and these are beliefs that communities buy into without questioning. So, fathers are often emotionally and physically abusive to their sons. Mothers are forced to choose between their husband or their child.

Some mothers choose their husband over their child. I had a guy that I interviewed who was Latino, and his mother said to him, “First comes God, then comes your father, and then comes you.” So, when he came out, they sent him to an aunt's house far away to Texas where he would somehow have a different life for himself. He ended up responding to a personal ad from someone who he didn't know at the time was a human sex trafficker, and he became a victim of human sex trafficking. It's a tragic story, and he's now an advocate for all of this. But his parents kicked him to the curb and still don't accept him.

LR: Have you worked with men and mothers and their parents from other cultures, where the parents themselves were afraid of being sanctioned, punished, or harmed?

RM: You're saying that with a great degree of sensitivity and attunement. Most situations, that is exactly what the parents are feeling, but they don't recognize that in themselves. What they recognize is what they're supposed to believe, and that's what they've gone along with. I've worked with Mormon families who have rejected their children. I've interviewed a Latino Mormon man whose mother read his journal and packed up his bedroom one night and put all his belongings in the garage and said, “You're not going to live here anymore. What you're doing is a sin.”

Eventually, they came around and made up years later. These horror stories unfortunately exist. Some families that are less severe than the examples I gave don't let their kids come to family holidays. They insist that they not come out to extended family that there’s all these conditions. There's a woman named Caitlin Ryan who’s done a lot of research through her organization called the Family Acceptance Project. Her work shows that LGBTQ family members can gain acceptance with their children or their siblings through being exposed to other people that give a message that it's okay.

And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.

If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.

LR: I imagine there’s a significant number of these families that don’t make it successfully through therapy with you. This young man is left feeling just as isolated and rejected as before.

RM: Right. Or the young man will stay in therapy and build his own community, but, unfortunately, not with his family, outside of the family and elsewhere. That said, I am a family therapist. I’m a couples therapist. I'm totally optimistic. I never give up on families reuniting. And, last year, I worked with a fundamentalist gay man in his 30s, really successful in his career and in his life. But he didn't come out until his 30s to please his parents. I had three joint sessions with him and his mother, with the hopes of bringing them together. He never thought it would happen.

I met with her alone first, and she was talking about the Bible and blah, blah, blah, blah. They didn't stick with the sessions, and eventually started talking to each other. A couple of months ago, she was potentially diagnosed with cancer, and that's what brought them together more than anything else. And I wish it could have been sooner.

LR: How would you advise straight therapists working with gay men, beyond the standard of “unconditional acceptance?”

RM: You raise a very important issue about unconditional acceptance, and many well-intentioned straight therapists try way too hard with their gay clients. In my life, socially, I'll go to a party, and they'll say, “Oh, do you live where all the gay people live? And do you know so and so, and so and so, and so, and so?”

LR: Gay Jewish geography.

RM: Exactly, and often I do. But therapists who try to promote unconditional acceptance and convince their clients that they're gay-affirming and then offer, “Oh, I have a neighbor who's gay,” which actually may induce a lack of trust. The best way to promote unconditional acceptance is to simply say, “I’m straight. Are you comfortable working with me? I am accepting, and I've worked with other gay clients. But, please, if you feel any bit of discomfort, let me know. Let's talk about it.” To me, that's unconditional acceptance, and that's more welcoming than doing a sales pitch that ends up sounding like a microaggression more than anything else.

So, my mentor, Jeff Zeig, accepted me for who I was, and he’s a straight man. There was something so profound in that experience for me. Was he the first straight man that accepted me? No, but it was wonderful to have a mentor who didn't care if I was gay, didn't pathologize me, and said, “Write a book about working with gay men, the field is lacking this information.” It was so validating. And so, what he did for me, which all therapists ideally do for their clients, is embrace, love, support, and send me out into the world to be successful.

That is unconditional love, and that is what straight therapists can do for their gay clients. And what I say in the work that I do is you're giving your clients a bigger gift of healing than you would even recognize because your clients are coming into your office with their presenting problem, whatever that happens to be. It may have nothing to do with being gay. And, through the love and the acceptance and the respect that you're showing to them, they're getting additional healing from the experience of being in your office.

So, frequently, when people want a referral to a therapist who's a gay client, frequently I'll say, “Why don't you work with a non-gay therapist? Because there is extra work that you can have done, as a result.” Some people will do that, some people won't.

LR: I used to think it important to be colorblind, but we must see color to validate the experience of the “other.” that idea. Similarly, one can’t be gay blind, because being blind to that does not suggest acceptance. It suggests walling off and not affirming that person, not accepting that person. So, I imagine that a clinician working with a gay person has to be very cognizant of the stories, the history that this person brings into therapy.

RM: Yes. The words that are coming to my mind are cultural competence. And that's what we need in the field these days. And I, too, did the same that you just described. I worked with an Asian gay man and a Black gay man, and I cringe when I think to myself or I even probably said things aloud that it's not as bad as you perceive it to be, which is absolutely not true.

LR: It’s not affirming.

RM: Right. The best thing that we can do is to hear the experiences that our clients are bringing to our offices and trust that to be true. The other best thing that we can do to become culturally competent is to go to workshops or watch videos like this or read a few books or speak to your gay friends and family members about their experiences to get educated. It's not hard to do. I find that in our field of mental health there are many people who are well-educated and liberal in their thinking, so that they feel like they have all that they need to know.

But their gay clients are testing them indirectly and don't feel safe because they're presenting a norm that may be uncomfortable. The other thing that I found, and I've mentioned this to you before, is that the field in general, of course, is run by metrics and numbers. And the most successful clinicians and teachers in the field have large numbers of followers and huge turnouts to their conferences. When I teach, sometimes I get 20-25, maybe 40 attendees, if I'm lucky, at a big mental health conference. Well, that's not good for the conference.

So, I'm not advancing as I'm teaching about working with LGBTQ people. And there are very few courses offered at huge conferences, which is unfortunate. So, my advice to people who are organizing conferences is to put us in panels with other people, and that way we can kind of gain exposure and educate people.

LR: So, the idea of a gay-affirming therapist is more cliché than anything else I would think because if you're not a person-affirming therapist, you're not going to be a gay-affirming therapist. Am I getting it, right?

RM: Yeah, yeah. And I mean, interesting. A clinician that's worked a lot with the gay man or the LGBTQ population by nature is gay-affirming. I know through conversations with a person who has worked a lot with the LGBTQ population is gay-affirming, and they've cultivated acceptance and skills that are affirming and comfortable. As a person, are you a gay-affirming person? I'm not asking you that. I know that you are, but I'm asking people who are listening to this. Do you understand what it's like living life as an LGBTQ person in today's world?

And if you're honest with yourself, maybe there are things you don't understand, and there's ways of getting information. If you pretend that you are, you're fooling yourself. People are going to see beyond that.

LR: They’re going to catch up.

RM: So, when you go to therapy, you should be talking about your sexual life. Many gay clients, out of shame, won't even broach the idea of sex with their therapists. Or, when they talk about sex, their therapist winced because they don't believe in open relationships, or they think that gay men are too sexual, and their biases are coming forward. I h

Cognitive Reframing is the Key to Counselling High-Conflict Couples

Posted on July 20, 2023February 24, 2026 by Psychotherapy.net Team

It’s been my clinical experience that a majority of emotionally unravelled, destabilized couples present to treatment hamstrung by chronic, unresolved conflict. Some teeter precariously on the cusp of separation and/or divorce. In one recent case, the couple confessed to me, unsurprisingly, that “Our decision to come to therapy is a desperate, last-ditch effort to salvage our ‘war-torn’ relationship.” Sorrowfully, I’ve observed similar privations hovering menacingly over too many couples who come to treatment.

Being a Clinical First Responder in Couples Therapy

Often, in my efforts to help prevent the worst from unfolding, I’ve found it helpful to shoulder the exigencies of a first responder and lift the couple’s weighty emotional load by reassigning new meaning to their suffering. To do this, I’ll first administer a double dose of empathy, couched in caring authority, while delivering what I hope is a consolatory, reassuring, and reality-based perspective on the rigorous nature of the intimate relationship.

Then, if the couple appears amenable, I’ll gingerly introduce this complementary tongue-in-cheek, but important, cognitive reframe: “As painful as your emotional upheavals are, they reflect the steep price of admission to ‘intimacy land’s’ unsurpassed rewards and fulfilments, despite its topsy-turvy, rugged ride through what can sometimes be treacherous emotional terrain.”

As you might expect, my preliminary biddings at cognitive reframing often require me to periodically double back and re-apply a salve of empathy to obviate any appearance of downplaying or minimizing the couple’s suffering. Then, I’ll again underscore intimacy’s unrivalled complexities and the towering challenges that the couple surely must have wrestled with for so long and with so much accumulated frustration, dismay, confusion, and hurt.

Once the empathy appears sufficiently attuned and absorbed, I’ll ask the couple something akin to this: “Do you suspect, as I do, that your lamentable turmoil and the profound emotional pain that saturates it, are the hugely troublesome but expected outcroppings of these problematic complexities and challenges that commonly plague intimate relationships? However, notwithstanding these forbidding hurdles, here you are, willing to try to rehabilitate your relationship — I commend you!”

While the couple digests my efforts to impose new meaning on their grapples, I’ll ask them to carefully consider what they think stokes their fiery conflicts. As I weigh their responses, I’ll gently elbow them down another cognitive path by suggesting this: “Thoughtfully unpacked, your impassioned, outsized emotions can provide valuable ‘grist for the therapeutic mill’ because they expose a nexus of fundamentally valid personal needs and feelings, and importantly, your abilities to manage both.” I’ll stress, “It’s even intimacy’s ‘job,’ so to speak, to continuously unearth — throughout the countless interactions you have with one another — what your individual need management patterns or styles are like, revealing those that are well-developed, or functional and those that require further development.”

Pushing on, I’ll carefully warn the couple that despite intimacy’s tall promises of unequalled, incomparable personal fulfilments, one of its conundrums consists of a subtle but sinister “dark passenger” that is notoriously commonplace for weakening, even dismantling the individual identities of its constituents. This erosion of partner identity can easily be viewed as the direct, insidious consequence of the non or mismanagement of individual partner needs. Uncorrected, this loss of identity can gouge deeply at the core quality of the relationship.

When Couples Clients Dodge Conflicts

In many of my cases, I’ve witnessed the biting irony of partners who’ll myopically dodge even the slightest prospect of conflict and thus sacrifice themselves by under-managing or not managing their individual needs. Done with “golden intentions,” partners ofttimes deploy this misguided, potentially debilitating tactic for seemingly the “right” reasons: To be considerate of their partner’s differing needs, or to keep from rocking the interpersonal boat by avoiding the risk of conflict sparked by disparate individual needs and the regrettable upshot of painful emotional fallout.

However, I’ll point out that partners who attempt to duck, dance around, or otherwise evade their potentially conflict-generating differences — especially those who do so chronically — risk a nasty, backfiring accrual of metastasizing self and partner resentment.

I often have observed that when conflict-diffident partners opt to use this quick and easy out of conflict for the short-term gain of reducing tension, they paradoxically — and most often unwittingly — induce a downstream, longer-term escalation of couple tension. This proverbial “kick-the-can-down-the-road” pattern of conflict avoidance can diminish partner affection because it most often magnifies rather than lessens couple animosities, making them more pernicious and thus significantly harder to manage. Left untreated, unresolved conflicts create a fecund spawning ground of couple-crippling antipathy.

Conversely, well-managed needs can reduce, even eliminate long-term tensions, even though partners are often called upon to move toward rather than away from potential conflict. Further, well-managed personal needs can cleanse the emotional atmosphere of tension-preserving, lingering feeling debris by prophylactically applying the brakes to self and partner resentment that might otherwise ooze toxically into the partnership.

However, what happens when partners trend in the opposite direction and mismanage their needs by force-feeding their partners non-negotiated demands, manipulations, cajolery, or in some other manner, coerce, blame, or pressure their partners into gratifying their needs? For example, commonly, I hear partners grumble that they don’t feel heard or understood, often voiced as, “We don’t communicate,” or, “He/she never listens to me,” or some fault-finding variant on this complaint-driven, non-constructive relationship critique.

While the need to have one’s partner’s sensitive, respectful understanding is indisputably valid, when frustrated, it’s easily mismanaged with angry accusations and demands which then pulls the targeted partner’s attention away from the need’s legitimacy. Or very often because of a need’s fundamental validity, its gratification can be perilously taken for granted, meaning it’s not actively or effectively managed at all. Partners merely expect, often flutily, that their need for understanding will be met, especially when it’s perceived to be most needed.

I’ll reiterate that poorly managed or non-managed personal needs often become a couple flashpoint. For instance, a partner’s exasperated accusation, “You never listen to me!” most often immediately deploys the accused or “non-listening” partner’s defenses which can then lead to a galling and fruitless spinout in an emotional cul-de-sac of counter-attacking allegations.

Effective Need Management in Couples Counseling

By clear contrast, effective need management can look like this: “Your efforts to listen and understand me leave me feeling respected and cared for…thank you…this means so much to me…and I could sure use a dosing of it now…that is, if you have a moment.” Here, both partners are dealt an equal measure of respect. And while far less economic for time and/or energy, this investment in good need management can pay off in big emotional dividends, since it tends to pull partners toward one another.

Happily, neither partner is likely to be defensive. Instead, good need managers deliver a respectful compliment to their partners which, in turn, helps create a savory atmosphere of mutual respect. Surely, partners who respect one another are more likely to gratify each other’s needs.

Now moving ahead in a decidedly concrete fashion, I’ll encourage the couple to survey their shared history for “healthy exceptions,” that is, to search for instances when they may have effectively managed their personal needs and the feelings orbiting them. I’ll instruct the couple to meticulously and sensitively reference these noteworthy times, calling their attention to how they felt during this all-important personal obligation to themselves and the quality of their relationship, especially when it was done with little or no feather-ruffling.

I’ll encourage the couple to take a moment to reflect and comment on any residual or lasting glow of relational health they may now feel while recalling those moments of good personal need management. Equally important, I’ll ask the couple to try and identify the specific conditions which may have made these propitious partner exchanges possible for the clear therapeutic advantages of reinforcing, burnishing, or otherwise embellishing them.

Moreover, my hope is that this type of positive intervention will resuscitate at least a momentary tincture, if not more, of optimism in the couple. I’ve also discovered that periodic, well-timed infusions of hope can be an especially beneficial mode of intervention.

I’ve also found it helpful to dole out frequent reminders that effectively managing some individual needs may pose a temporary threat to the equanimity and stability of their relationship. I’ll frequently coach the couple to practice in session, with follow-ups at home, the calculated risks associated with the effective management of their needs. This entails summoning the courage to vulnerably enter the “emotional lion’s den.” I’ll promote this important step as key to effective personal need management, highlighting that it’s intimacy’s lifeblood — I risk therefore I am intimate.

Nonetheless, I’ll repeat, seemingly ad nauseam, that intimacy’s matchless portfolio of far-reaching, personally fulfilling enrichments are achieved in proportion to the couple’s efforts to acquire greater “intimacy intelligence” by intrepidly sharpening their skills of effective need management. Specifically, I’ll point out that these highly enviable rewards take their form in a gratifying uptick of self-esteem. Moreover, this uptick in self-esteem is usually accompanied by a flattering bonus — a commensurate boost in their partner’s esteem.

I’ll encouragingly describe how applying the orthodoxy of effective personal need management deepens the connection, or the integration, partners have within themselves, which is arguably a necessary precursor to a deep, meaningful connection between relating partners. I’ll be no closer to my partner than I am first close to myself. Again, I’ll stress that personal needs and feelings that are effectively managed ensure that partner identities are well-embroidered in a need-by-need, feeling-by-feeling fashion, a well-knit fabric of the self. I like to emphasize that the quality of the intimate relationship is a function of the quality of the partners who inhabit it.

As each session draws to its end, I’ll send the couple home with a small buffet of helpful maxims, like those just mentioned, “clinical love notes,” as it were. I’ll often remind the couple that the art of loving is rarely, if ever, perfected but it can be improved upon by taking on the lifelong prescription to hone the personal skills of effective need management. My intent here is to keep the work done in treatment fresh, alive, and well-practiced at home where it counts the most.

Powerful Therapy Strategies for Healing Wounded Couples

Posted on January 24, 2023February 11, 2026 by Psychotherapy.net Team

I remember greeting them for the first time in the lobby of my office. At first glance, they seemed like gentle people, kind to each other and to me. As they entered the corridor leading to my office, he deferred to her, politely allowing her to go before him as they entered the room. I recall thinking to myself, “I wonder why they're here?”

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But apparently this had been performance art, a quick bowing to public expectation. Soon after taking their seats, finding themselves safely sequestered behind closed doors and out of public earshot, those first-impression niceties vanished, and the emotional floodgates burst wide open. With what seemed like the disgorging of years of pent-up acrimony, accusations began to fly like the shrapnel of a bomb blast.

Blame and Accusations in Couples Therapy

She was first to launch her attack with the speed of a knee-jerk reflex. “He never listens to me…We don't communicate at all… I try to talk to him but it's like talking to a brick wall… I get so angry at him! I've tried everything.” Each new rendition of her complaining was an embellished and emphatic iteration of the previous one.

Notably, throughout her hair-pulling allegations, her eyes fixed solicitously upon me, as though she were expecting me to jump into the fray—once she'd fully discharged her accusations—and like a biased, one-sided arbiter, I was to join her in a corrective condemnation of her partner. Instead, probably to her great disappointment, I looked back at her with an empathic expression of heartfelt concern for her gnawing frustrations and deep hurt.

Amid her scalding allegations, her partner sat stoically, appearing inured to the barrage of insults and blaming he'd no doubt endured many times before. Then, with the first lull in her opening assault, when her “guns” appeared emptied and before she could “reload,” his defensive counter-indicting assault began with a fury matching hers, “She is always critical… She's so negative and judgmental… Nothing I do is right… I walk on eggshells all the time… It never used to be this bad… She used to be kind and loving… Now look at her… I don't know what happened.”

I've learned the hard way not to allow raw venting such as this to continue unharnessed for too long. I've found, probably as you have, that if “law and order” aren't soon imposed, the potential for a productive session soon diminishes, and can even irrevocably tip over into non or counterproductivity.

I typically jump in quickly, stop the mudslinging, and administer another dosing of empathy, followed by questions such as “Did you just give me a sample of how you talk to each other at home? If so, how do these conversations usually run their course?” As you might imagine, their answers are predictable: “Not good…We get nowhere…Things just get worse….”

Validating the Legitimate Needs Behind the Arguments

After allowing a moment for their answers to percolate, I typically find it therapeutically helpful to ask, “Do you think your upsets could be this intense were it not for the fact that each of you brings to the other important personal needs, indeed, very valid ones?” Of course, this is a therapeutically-baited question with a largely calculable answer.

But the question also flings open a window onto a wider batch of potentially therapeutic questions, like: “Wouldn't you agree the legitimacy of your needs is clearly evidenced by the strength of the emotions that attend them? And because of the importance of your needs, don't they beg for your best reasoning and problem-solving, in short, your best need management? Wouldn't this be more achievable in an emotional atmosphere of nonjudgementalism, mutual acceptance and respect?” More time for percolating.

In the case above, once we collaboratively agreed on these goals, I turned to her first and asked the seemingly obvious question: “Can you identify the basic needs at the heart of your arguments?” Her answer came swiftly: “I need him to listen to me.” I replied with a quick confirmation and a slight tweaking of her response, “Yes, your need is to be listened to, which seems perfectly reasonable to me.”

Then while my confirmation was still fresh, I turned to him and pointedly asked, “Is your wife's need to be listened to a valid one?” Put in this strategic manner, his affirming response was all but guaranteed because her need had been stripped of its biting and condemning emotional overlay, its legitimacy laid bare with plain and calculated neutrality. So, expectedly, his affirmative response was speedy and unequivocal. Then, without hesitating, I again responded with a deliberate, co-confirming, “I agree, your wife's need is valid.”

Now, in turn, I directed the same questions at him, first by asking him to clearly identify his needs. Foreseeably, he answered, “I want to be treated kindly and with respect.” Following the same protocol, I confirmed the legitimacy of his need which had just been divested of its own attention-gobbling, counterattacking emotion and was now openly “on parade” for its indisputable validity. Now, turning back to her, I asked in the same manner, “Does your husband's need for kindness and respect seem reasonable to you?” Again, you can guess her answer.

The stage was now set to bullhorn what had become increasingly obvious. Formerly vitriolic and contentious partners were questioning their use of blame and accusation and were now instead marching to the tune of mutual respect.

Moving Forward in Couples Therapy

I’ve been fortunate enough to apply this technique with relative effectiveness, so it has been my experience, and I suspect yours as well, that this purposeful trio of empathy, caring, and genuinely curious question-raising can soften these “marital combatants” to a degree that their cognitive flexibilities and problem-solving skills become more accessible.

Once this appears clear, I drive home the same critical point. “Could you be at odds with each other to this extent over needs that possess little, or no personal significance? And given the in-your-face evidence of the strength of your personal needs and the intense emotions that orbit them, what if we were to carefully examine how you manage them now, and maybe better, how you might more effectively manage them moving forward?”

The demanding work of implementing this strategy outside of therapy certainly belonged to the couple and others like them, but in my experience, these partners leave my office with a helpful set of tools, a cause for optimism, and hope for re-connection.

Questions for Thought

What is your reaction to the author’s approach to dealing with “warring” couples?

How do you address anger and blaming in your own couples work?

Can you think of a warring couple that you successfully helped? One with whom you were not successful and why?

How to Resurrect a Dying Relationship One Emotion at a Time

Posted on December 1, 2022February 11, 2026 by Psychotherapy.net Team

In my practice, I have borne witness to many romantic partnerships that have failed with time —often to the shock and dismay of one or both partners. For many of these couples, it is a stunning development that was mostly or even completely unforeseen. This downward relationship spiral is most poignantly captured in the phrase, “death by a thousand cuts.”

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Retrospective analyses or “relationship autopsies” of these deteriorating ties often evince what I have come to call an “erosion of affection.” When hotbed issues between partners are not adequately or amicably addressed or resolved, chronic grievances fester and lay the foundation for irreparable damage. Affection is diminished and negative perceptions replace whatever positive ones might have previously existed.

Case Study: Amy and Mark

Exemplary of this point is the case of Amy and Mark. Amy had been after Mark, her husband, for over a year to put his dirty socks in the hamper. Mark had repeatedly promised to cooperate, but rarely if ever did so. This exchange between Amy and Mark went on nightly and eventually both became angry with each other. Amy felt disrespected and powerless. and Mark, who came to think of and eventually call his wife “a nag” for her constant pursuit of his compliance, seemed even less inclined to cooperate with her incessant badgering over something that seemed so insignificant to him.

Perhaps at an unconscious level, Mark became disinclined to “give her” what she had been asking him for. More importantly, the stalemated issue of the socks had changed the atmosphere in the relationship. Amy’s frustration had grown into resentment both because of the socks on the floor and being called a name as “punishment for my persistence.”

It was helpful to learn — and apparently for the first time — that Mark had been diagnosed with Oppositional Defiant Disorder earlier in life and had a history of troubled interactions both personally and professionally. In his individual and marital treatments, he came to understand and accept his role in what he subsequently referred to as “the absurd socks situation that I created.”

Unresolved Issues Lead to Erosion of Affection

Therapeutic work with Mark and Amy benefited enormously from a rather unusual collaboration between me and the clinicians who were working individually with each member of the couple. The continuous informational exchange enhanced everyone's understanding of the historical antecedents to their difficulties with each other and provided valuable guidance for each therapist as the three treatments simultaneously continued. Initially, the level of anger about this and other unresolved issues between the two marital partners were causing considerable damage to their relationship.

An important effort was to help them to use their anger to strengthen their communication and accomplish stated goals rather than to continue to cause possibly irreparable damage by their verbal abuse toward each other. Once the anger eased and the overall emotional climate improved, I often had Mark and Amy replay their earlier troubled interactions. The “before and after” provided an important opportunity for them to see the differences and enjoy the benefits of their overall improved manner of relating to each other.

The Spotlight Shines on Negatives

An often-unrecognized consequence of unresolved issues like this one is that they infiltrate the marital system and lead to other accusatory and blameworthy exchanges. This pattern sets the stage for lower tolerance for the partner's other quirks, foibles, and irritating behaviors that earlier had been either trivialized or ignored. The spotlight shines with increasing brightness on the negatives since they might be the new focus, especially if there has been little or no conflict resolution.

In the case of Amy and Mark, the idea of dirty socks “laying around” unattended seems an apt metaphor for the degradation of their relationship. Cleaning up this mess seemed an equally powerful and positive metaphor for their improved relationship.

Seeking Counseling When the Erosion Has Passed the Breaking Point

Many couples who eventually seek my counseling assistance for their troubled relationships arrive at my office when the erosion of affection has already passed the couple’s breaking point, causing irreparable damage. This makes the therapeutic enterprise a more complicated, if not doomed, endeavor.

It certainly helps if both partners have, or can be helped to have, sufficient reflective awareness to acknowledge responsibility for the now troubled union and be willing to do the necessary work of restoration and repair. It is especially helpful if neither partner has quietly consulted an attorney and if the subject of separation or divorce has not been part of the recent dialogue between them.

***

I did not write this piece as an advertisement for couples therapy. However, I suppose I am recommending that couples and individuals seek help to avoid creating a collection of unresolved issues and unaddressed grievances that carry the potential to ruin their relationship. Much like knowing when to consult a physician if a worrisome physical symptom appears, partners in a relationship need to be reasonably alert to the development of potentially harmful issues that can subvert the quality of their relationship. This is especially true if those issues threaten to erode their affection and make their bond difficult if not impossible to repair.

Final Questions for Thought

What therapeutic strategies do you employ with couples like Mark and Amy?

What feelings did the case of Mark and Amy provoke in you?

How do you address your own feelings when working with couples destined to separate?

How to Focus on Emotions to Help Volatile Couples Reconnect

Posted on September 15, 2022February 11, 2026 by Psychotherapy.net Team

Suggested Tips for Practice

Develop flexible hypotheses for understanding family dynamics
Collaborate with each family member around therapeutic goals
Explore your countertransference around complex dynamics in family work.

Camille and Lance had been married for about seven years when I first met them. Their daughter, Hannah, was four at the time. I typically saw Camille and Lance twice monthly for about nine months. Their central goal for therapy revolved around managing anger during conflict and responding without reacting with defensiveness, criticism, or emotional withdrawal. They each expressed that empathy, or an ability to hear, identify with, and validate each other, was lacking in their attempts to express and resolve conflict.

Conflict occurred for them in vicious, seemingly unavoidable, and endless cycles of attack and withdrawal. Neither Camille nor Lance experienced their relationship as supportive or safe, and both seemed to have little understanding of the cause of their conflicts or dynamics that kept them apart. Lance and Camille regularly experienced hurt and rejection, unable on their own to engage constructively with one another during moments or episodes of volatility. They reported a desire to grow in their marriage by experiencing togetherness, as well as understanding, in the midst of conflict. However, their pattern made it almost impossible to break or heal from these cycles, leaving each of them stuck in perpetual states of defensiveness, criticality, and ultimately the experience of rejection. Almost always, Lance and Camille seemed to be just a disagreement or wound away from their next blowout.

Assessing the Problem

Camille often expressed her emotion through anger, criticism, or a vigilant effort to draw out an empathetic emotional response from Lance, while his go-to responses were anger, defensiveness, or withdrawal. They described a mutual experience of “hopelessness” regarding navigating and resolving conflict.

Adding to their pain was Camille’s and Lance’s disconnect from social support, as they lived a considerable distance from both of their families and had struggled to build social connections as a couple. There were also pressures related to both finances and Lance’s work schedule.

Camille, having close ties with her family, described her childhood as one in which she was nurtured and supported. Lance, who had very little contact with his own family, characterized relations with them as chaotic and he described a childhood in which he was left on his own for almost everything, including meal and school preparation and doing homework.

A Working Hypothesis

The more Camille and Lance were able to communicate vulnerably with each other about their own emotional hurt—which we distilled down as feeling “misunderstood, unsupported, and unappreciated” — the more they would experience love and mutuality (that is, feeling understood, supported, and appreciated) during conflict and in their marriage in general.

It was clear that Camille’s and Lance’s emotional experiencing during heated conflict occurred at a secondary, reactive level (anger or withdrawal) rather than out of the more vulnerable, primary dimension of their emotion (simply feeling misunderstood, unsupported, or unappreciated). How they expressed their needs for closeness or identity in their relationship determined the ensuing cycles of emotion by which closeness or identity was negotiated.

While it was likely that their current emotional styles and patterns of conflict response were rooted in past experiences, my therapeutic approach was focused primarily on the ways in which they expressed their hurt to each other in the here-and-now of their marriage, especially during conflict.

Clarifying a Goal for Therapy

The central goal of therapy for Camille and Lance was to reach a place where they could begin to experience mutuality and togetherness, as well as understanding and acceptance around their differences, especially regarding their experience of conflict management.

In reporting on goals, the couple agreed that they would “like to be able to set goals and boundaries together,” as they had prior difficulty in meeting common ground. They said of themselves, “we fight mean,” and “we can both be Dr. Jekyll and Mr. Hyde.”

To optimize chances for therapeutic success, every session and intervention would need to be grounded in the goal of facilitating more satisfying emotional experiencing between them, particularly during conflict. The work of therapy would involve increasing expressions of vulnerability in place of reactive expressions of defensiveness and criticism during conflict.

This change was to facilitate the delay of gratification in their individual desires to experience immediate validation, and in its place to nurture the development of a more meaningful and effective way of processing emotion and staying connected through hurt and nurturing intimacy.

Clinical Reasoning

An emotion-focused approach theorizes that couples experiencing difficulties in their relationship often are hiding and or repressing emotions such as fear or a need for attachment, and instead expressing emotions that may be defensive or coercive — primary” and “secondary reactive” emotions.

When these negative interactions solidify into patterns, couples often experience a loss of trust or a heightening of fear in their relationship, therefore further burying the primary emotions.

I theorized that Camille’s and Lance’s pattern of becoming angry or emotionally withdrawn during conflict was a pattern of conditioned defense, covering up primary emotions, cravings for understanding and support buried below the surface of their experiencing.

Clients with whom I have worked typically have internal resources for repair and growth in relationships. Their negative interactional patterns, which often are adaptive, coping styles can therefore be transformed into positive and healthy interactions. In these cases, couples counseling that focuses on emotions can result in transformative experiences.

As a therapist, I don’t see myself as an intrusive mechanic who fixes couples. Rather, accepting and validating clients’ self-experience is a key element in my therapeutic approach. Empathic attunement with couples also involves taking care to provide appropriate validation to one person without marginalizing or invalidating the experience of their spouse. It is a balancing act.

With Camille and Lance, I attempted to provide empathy and safety, as well as to engage in our relationship in a way that was collaborative and in which roles and expectations were clearly defined. Through many challenging and white-knuckled therapeutic hours with conflicted and often disconnected couples like Camille and Lance, I have found that a clinical environment marked by empathy, safety, and occasional structured directives provides the opportunity to build corrective emotional experiences and reconnection. By working in the here-and-now with them, and by integrating their at-home experiences into our in-session work, Camille and Lance became increasingly able to reflect on both their respective inner and relationship experiences in a far more adaptive way.

Intervention and Therapy Process

The family therapist Carl Whitaker advocated a nonrational, spontaneous, and creative experiential presence with clients as a means of engaging them at the hidden symbolic dimensions of their awareness. He said that for real change to occur, insight won’t do the trick. We need to engage each other emotionally.

While encouraging the spontaneous and creative side of therapy, Whitaker also understood the importance of providing focus and structure, “the experience of our being firm,” as he called it. With Camille and Lance, I attempted to use in-session directives that would drive the client-centered and emotion-focused processes in therapy. I also labored to redirect from more-of-the-same conflict cycles to processing the experience of emotion in their relationship.

If they were tempted to explain why they were angry, I let them know that they could choose between carrying on explaining, remaining in the safe position of knowing what they already knew, or exploring how they experienced anger, taking them to what they did not yet know. This was effective with Lance and Camille in facilitating a shift between defending, criticizing, or debating facts to sharing emotional experiences by exploring their own internal processes.

The following is an overview of the therapeutic process.

Sessions 1 & 2

My hope for these early sessions was to establish a working relationship with Camille and Lance, to open up the space for them to tell their story, to nurture understanding and relationship with them by listening empathically, and to begin to establish a therapeutic vision. At this time, I was focused on noticing and stirring curiosity about emotional experiencing in their marriage.

Camille and Lance described their reason for coming to counseling as “conflict.” They described the early family contexts that shaped them and theorized about their problems in marriage. They described their cycle of conflict as erupting when Lance experienced Camille as being “nagging, preachy, or undermining.” Camille compared Lance to her father many times, which frustrated him. She said she wished, in some ways, that he were more like her father.

Camille and Lance had, in these sessions and in sessions thereafter, described successful experiences of empathy during conflict. Early on, they communicated that when they experienced feeling heard or understood, they felt closer with each other and experienced more successful conflict. I hoped to begin to interact with and facilitate experiences of empathy between them, not merely by talking about these successful experiences of conflict but enacting them in-session.

Session 3 & 4

My approach during these sessions was to facilitate in-session interaction with their emotions in conflict. During the third session, Camille and Lance reported having a “not-so-good last couple of weeks.” They found themselves frequently getting into heated arguments around Camille, forcing Lance to have conversations with her about subjects that he did not want to talk about.

Lance described feeling “like my whole life is ‘I’m sorry,’” because Camille always “nagged” him about the things that she thought he should be doing. Lance described the conflict as being over “small things,” while Camille argued that they were over “bigger things.”

Lance frequently felt overwhelmed when Camille approached him about multiple concerns at once. Lance said he needed “time and space to breathe and think.” Camille said she wanted to process through these issues immediately.

A large portion of the third session was spent negotiating between them a way of giving mutually satisfying time, space, and understanding while in the heat of conflict. Between sessions three and four, I had them work together on a list of “rules for fair fighting,” which was used as a way of engaging them to establish boundaries and appropriate responses for conflict, a goal that they expressed early on.

Camille and Lance came to our fourth session still emotionally charged from a fight. Both described not feeling heard. I coached them to listen actively, and they reported feeling more heard by the end of session as a result of a slower, less reactive style of communicating around feelings.

Session 5 & 6

A goal during these sessions was to provide in-session experiences of communication between Camille and Lance, exploring and interacting with their emotional processes through emotion coaching strategies. Camille and Lance talked about the patterns of their fights and how they escalated quickly and got “off subject.” I facilitated the practice of active listening in an attempt to promote understanding and slow down arguments.

Session 7 & 8

During these sessions, we focused on the pattern of conflict between Camille and Lance.

Together we explored body language and other forms of meta-communication. Camille said, “He feels threatened by my body language, and I feel threatened by his.” Lance reported that he was frustrated and felt disconnected. He reported that when conflict is present, “I don’t want to talk about it.” During the conflict, Lance experienced “tiredness, numbness, deadness.”

During session seven, Camille and Lance reported having a conflict around finances after a trip to a wholesale store, where Camille spent a lot of money on things that Lance did not think they needed. During the session, I encouraged active listening and communication between the two of them as a way of assessing and intervening in their emotional processes during conflict.

During session eight, they described “hopelessness” as a common experience during conflict. Camille communicated that she experienced hope and safety when Lance looked at her in the eyes when she wanted to talk to him about something, rather than tuning her out. Lance communicated that he experienced hope and safety when he was given emotional and physical space to sit in the disagreement and then communicate about it again later.

They reported that they had experienced some dramatic and disappointing conflicts as well as “breakthroughs” in the past couple of weeks. During “breakthroughs,” they felt mutually understood and supported. At the end of the seventh session, Camille noted that she kept a record of Lance’s wrongs. I suggested that during the following week she keep a record of Lance’s “rights.”

Session 9 & 10

During these sessions, we explored how their personality differences affected their conflicts. Lance expressed difficulty in developing close friendships right now and in speaking up in groups, including with acquaintances and with coworkers. He also expressed being overwhelmed right now in his life, being busy with work, marriage, and parenting, among other things. I shared similar experiences of my own to normalize his experiences.

I noticed a lighter interaction between Camille and Lance during these sessions, which I pointed out. Even while discussing conflict, their conversation was more introspective and less frustrating. Previous conversations, especially about conflict, were less thoughtful and more reactive. I noticed a fresh team-based attitude in their in-session interactions and shared my observations. I also had a brief opportunity to observe both of them with Hannah, who had been waiting in the lobby during our session. They seemed gracious and loving with her.

Session 11

My hope for this session was to re-join with Camille and Lance after over a month’s break from therapy. Lance reported having begun taking medication for depression and social anxiety after communicating with his family doctor about his concerns. He originally began taking one medication but switched to another shortly after he began experiencing negative side-effects.

Camille and Lance reported having an argument while Lance was feeling “numb” from his medication. During the argument, Lance had not felt attacked by Camille. Feeling unattacked, he had been able to support and validate her, which turned out to be a meaningful experience for her. He reported that it was not meaningful to him because he felt “out of it.”

I explored the differences in the quality of their interactions during that conflict that created a more successful outcome. Camille identified that Lance’s non-defensive stance disarmed her reactive emotions, and they were both able to communicate more thoughtfully and vulnerably.

We explored the difference between primary emotions, such as hurt, sadness, or feeling misunderstood and unsupported, and secondary reactive emotions, such as frustration, anger, feeling “pissed off,” or feeling emotionally numb and withdrawn. After drawing a diagram of these dimensions of emotion, I explored the effects of communicating out of each dimension during conflict.

When one of them communicated out of anger or refused to communicate out of emotional withdrawal, the other either became frustrated or emotionally withdrew as well. During this sort of interaction, they mutually felt misunderstood and unsupported.

We then explored the possibilities of communicating vulnerably and honestly out of the oftentimes buried, primary emotion of feeling hurt or sad. When one of them chose to communicate non-defensively about an experience of feeling misunderstood or unsupported, the resulting mutual experience tended to be feeling “joined together” and “heard.”

Utilizing emotion-coaching and other experiential interventions, I hoped that they would begin to experience a restructuring of their patterns of interaction and of their experience of intimacy based on new understandings and meanings.

Session 12

Lance and Camille had a fight immediately before this session. Lance had been feeling exhausted and overwhelmed earlier in the day. When Camille brought him coffee as a gesture of love and support, Lance told her, “That’s the last thing I need right now.” This started an escalation, in which Lance quickly distanced himself and became emotionally withdrawn.

As I attempted to coach Lance to explore his own emotional process of wanting space, he seemed to become increasingly short in his responses and visibly uncomfortable. I found myself compelled to press for responses from Lance, almost demanding cooperation.

At some point, I began to come back to reality, noticing what had been a parallel process between my own experience of interaction and Lance and Camille’s. Changing course, I began to speak with Camille in a reflective way about what Lance may have wanted to say to her.

By the end of session, Lance began to speak for himself, became more engaged in dialogue around emotion, expressed regret for his own behavior, and was verbally supportive of Camille.

Session 13

Lance and Camille had canceled three sessions since we had met two months prior.

At the beginning of this session, I invited Lance and Camille into a dialogue concerning their commitment to counseling. This carefully initiated confrontation carried a message with it: that they, the couple, were responsible for their investment in counseling, and that I was committed to being invested with them only as long as they were themselves invested.

It was clear that they had discussed this concern among themselves and were already considering termination due to both of their work schedules. I noticed myself feeling proud of my own investment in their therapy and, in retrospect, my own sense of disappointment at their shortage of attendance distanced me from the reality of the two persons before me. And so, I did not expect the explanation Lance would give.

He began to reflect on their experience in therapy over the last year, telling stories of how they had become more capable of engaging with each other in satisfying ways despite disagreement. Having more positive experiences with each other around personal differences and beginning to develop more meaningful social relationships, Lance and Camille expressed feeling less energy towards counseling and more energy in life itself and with each other.

Lance commented, “Before we came in today, I told Camille we might be in a place where it would be better just to sit down with each other over coffee and discuss our relationship by ourselves.” Even though they continued to experience conflict—in fact, they reported having a significant fight earlier in the day—they were becoming more able to be with each other in such a way that was growth-inducing, having developed an increasing ability to self-soothe and remain nonreactively present with one another, rather than growth-inhibiting, reacting defensively to one another out of anxiety experienced in the moment.

At the end of the session, after talking about their progress and increasing sense of responsibility and capability in their marriage, they chose together to terminate counseling immediately. I celebrated with them by discussing their exciting future.

Reflections on Case Outcome

Camille and Lance, like so many other couples with whom I’ve worked, struggle in knowing how to manage the intense reactive emotions that they feel in the midst of conflict. They became better able to increase their capacities for emotional management and self-direction. They learned that they were not necessarily determined or defined by their impulses.

As Lance and Camille allowed me to sit with them in the midst of their anxiety, anger, and pain to search for bits of hope and seeds of change, I began to see a new paradigm evolving into being in their marriage: one marked by acceptance and stability and driven by intentionality.

Over the course of therapy, as we delved deeper into the intricacies of their emotional experiencing during conflict, Camille and Lance consolidated new positions, attitudes, and cycles of attachment behavior and began experiencing conflict in a more satisfying, growth-oriented way.

Lance and Camille began to take ownership of their own emotions and reactions. As Lance began to acknowledge and understand the ways that he withdrew from Camille at the whim of momentary anxiety, he began to act despite his anxiety, remaining engaged with Camille in an honoring way. As he did, he became more confident and less volatile.

As Camille began to acknowledge and understand the ways that she pressed for resolution on issues of difference, she began to make peace with anxieties that drove her behavior in the relationship. As she did, she became more confident and less volatile.

As intentionality increased little by little over time, confidence increased. As confidence increased, security, rather than anxiety, increased. As this security increased, Lance and Camille experienced an increasingly satisfying and loving relationship.