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

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?

Teaching Clients Active Listening Skills to Improve their Relationships

One of the most common questions I am asked when people learn that I am a therapist is, “How can you listen to all those people?” What prompts that question is a fundamental misunderstanding of what it actually means to listen to another person. In my work, I strive to make my patients better listeners, not just better at self-expression.

It is imperative that we challenge the assumptions people make about what it means to listen. Truly listening to another person so that they feel heard improves the quality of conversation and enhances the opportunity for understanding. It does not guarantee agreement, nor does it necessarily entail problem solving or changing anyone’s mind. Unfortunately, it seems that these days, people are far more interested in talking than listening, even if no one is listening to them.

As one patient said to me, “Once we stopped caring about facts, I was at a loss about what to say. Why bother to listen if the loudest person in the room always wins?” This can lead to what feels like a forced choice between joining the argument or leaving the conversation. Given the cacophony of disinformation and vitriol infecting our lives, strong listening skills are more critical than ever if we want to strengthen our connections.

It takes effort to be a good listener, but with practice the results can be truly life changing. Learning how is a teachable skill and foundational to good mental and physical health. There are five foundational components of active listening.

Five Foundational Components of Active Listening

First, an active listener must have a genuine interest in the other person, a curiosity to hear what they have to say. Too often we think we know what the other person will say before they speak, so we spend our time preparing our comeback rather than listening to what the speaker says. Or we write people off as soon as we learn one thing we don’t like about them, and refuse to listen to anything else they have to say. Consequently, our world gets smaller, and we have less intimacy.

Feeling trapped in this dynamic is a common complaint about familial interactions. For example, one patient shared, “Before I’ve even taken off my coat, my father will tell me that I must be so happy with my job. It’s because he is happy that I went into law like him. I brace myself before I get there for his greeting.” After many failed attempts to have a more nuanced conversation, she no longer tries to dissuade him of his belief but is saddened by how superficial their relationship has become.

Second, active listeners understand that agreeing to listen does not assure agreement. This needs to be recognized by both the speaker and the listener. If my goal as a speaker is agreement, I must make that clear up front. When a patient tells me about a fight they had with their spouse, I use my words to express understanding of their hurt feelings, not to say they were right and their spouse was wrong. Whenever we frame a conversation as having a winner and a loser, the quality of the relationship suffers.

Third, active listening is actually hearing what the speaker has to say and trying to understand their needs. Too often people attempt to show they are listening by trying to solve a problem. This often feels patronizing and may devolve into an argument. For example, a patient of mine reports, “When I come home from a bad day at work, all I want is for my wife to listen, not tell me what I could do differently. Tomorrow, when I am rested and have some distance from the situation, I might be ready to listen to suggestions for how to do things differently, but at that moment I just want understanding. Is that too much to ask?”

One strategy that can be helpful in these situations is for the listener to ask, “Do you want to be hugged, heard, or helped?” By clarifying the unstated need of the speaker, the listener knows the desired outcome for the interaction and what will feel like effective listening to the speaker.

Fourth, active listening involves acknowledging feelings as well as facts, without conflating the two. There is a truism in psychology that anxious people can’t listen, to which I might add, neither can enraged people. Communicating that I understand the depth of a person’s emotional state is a necessary precursor to understanding what has upset them so much.

Recently, a patient called to share that she’d been diagnosed with breast cancer. Before I asked her the stage of her cancer or what her treatment protocol would be, we discussed how she felt hearing that she has cancer. Asking about her feelings was essential to providing care for her. Later we would brainstorm how she could get the best medical care possible, but until she felt heard she couldn’t process the onslaught of medical information her physicians were sharing with her.

Finally, active listening requires listening to ourselves as well as others. By setting a time limit or voicing discomfort if someone is using offensive language or yelling, allows us to take care of ourselves as listeners and increases the likelihood we will be willing and able to engage in active listening. When being a better listener, we will hopefully find ourselves in more meaningful conversations that will enrich our lives.

***

Active listening can make us feel vulnerable. Sometimes the divide is too great and ending the conversation or ultimately the relationship is the right decision. But, hopefully, more often our efforts to listen will increase our understanding of one another and bring us closer. In our fragile world we need to honor the power of listening.

Questions for Thought and Discussion

How important is it for you to “teach” your clients to listen effectively?

Which of the author’s five components of active listening is most resonant with you?

Can you think of one of your clients who would benefit from improved active listening skills?

A Small Hope: Co-creating a Narrative of Grief – Part II

Bringing Memories to Life

“I want to remember the precious times we had together in those last weeks but already they are fading and I am forgetting,” Claudia said with resignation. It was now a month after Tom had died and the conversation had just shifted from the challenges of getting through each day.

“Is gathering up memories of the precious times something that you might like to do in this conversation?” I checked.

“Yes, those last four weeks,” Claudia said through tears. “From when we were told in the hospital Tom was dying and decided to come home. In the hospital, I asked one of the nurses, ‘How long does he have?’ and she replied, ‘Maybe a week.’ As you know, however, he lived for four weeks… Tom didn’t ask how long he had to live but I wanted to know.”

“Would it be OK to ask… what was important to you that you asked for the nurse’s guess as to how long he had to live?” I added the word “guess” as no one ever definitely knows and that uncertainty is often unfamiliar to people.

Claudia’s voice broke, “I just wanted to know how long I had with him. I think I was just trying to get a clear view of the future.”

“Did you have any hopes for what a clear view might provide you and Tom?”

“I was thinking this is valuable time. It clarified that we wanted him to come home,” Claudia affirmed.

“In this decision to go home, what kind of valuable time were you and Tom hoping for?” (22)

“It meant he could see the changes in the girls. They are so young they change rapidly, especially Libby who develops in small ways every week. I knew that visiting in hospital is just not the same. Everything is different, distorted and not in their natural state,” she explained. Visions of hospital rooms with their lack of privacy and noisy nights floated through my mind. I tried to imagine visiting such an unfamiliar environment frequently with a baby and young child.

“What does it say about Tom’s relationship with Imogen and Libby that he prioritised noticing small changes in them even when he was dying?”

Claudia smiled. “He treasured and valued every little thing about them. He’s been quite good at appreciating small things for a very long time,” she answered, speaking of Tom in the present.

“Could you tell me a story of Tom appreciating Libby and the small changes in her perhaps? And then Imogen and what he enjoyed about her?” I was aware that I was collecting memories, not only for Claudia, but for her girls as well. Together we would build a document of memories she could keep. (23)

After Claudia had shared some stories, I became aware we had diverged from what she had originally said she wanted to discuss. “I notice we have moved away from speaking about the four weeks you said you wanted to focus on. Would you like to continue on this track or would you like to spend some time talking about the last weeks of Tom’s life? What would you like to do at this point?” (24)

“The last four weeks. It’s fading so fast. I’ve even forgotten subtleties that were routine to me, like giving him his morning wash, and that was something I treasured doing,” Claudia stated. I was glad I had checked. I didn’t want the conversation to end without it having been what she wished.

“Would asking you about treasuring his wash be a good place to begin?” Claudia nodded and sat back on the sofa. “Would you like to walk me through how you went about giving him his wash?”

Claudia began to recall previously unspoken details of the daily routine with me, inquiring into their meaning. Towards the end of collecting as many details as I could I asked, “When you were washing him, was there a particular way you touched him?”

“Yes. When he was moving less, I would give him a little massage, or I’d move his legs around. I could tell he liked it. After his massage, we’d put frankincense on his palms and the soles of his feet and he’d go, ‘Oh, Frank!’ and wiggle his fingers making a joke!” Claudia laughed.

“Did he keep his sense of humour even…”

Claudia’s words tumbled out in her enthusiasm. “Always, right up until that last night. A carer came for the night to help. When she saw Tom she said, ‘Still unresponsive,’ so he wriggled his eyebrows at me. It was our little joke! Frequently through the day I would wash his face and I’d say, ‘Would you like a cool flannel or a hot flannel to wash your face?”

“When you were giving him that choice… what was your intention?”

“He had very little control over his life. He deserved respect,” Claudia explained.

“What did you want him to know by giving him that choice and respect…and control?” In tender tones Claudia answered, “He was still just as valuable. Even though he couldn’t move or see much, he was still my Tom, he was still the same to me.” Moved by her love and respect I responded, “May I ask, what would have Tom noticed that would have told him it was you washing him rather than someone else and that he was still the same to you?”

“He would have felt my love in the way I washed him. I was given a choice of washing him or having a carer do it. There was no way I was going to let someone else do such a personal, private thing for him,” Claudia stated, flicking her hair behind her. (25)

“What were you valuing, do you think, when you prioritised this loving moment with him and protecting his privacy even as you were parenting two small children and doing everything else that was required of you?” I reflected on the exhaustion that comes with parenting very young children. Such a choice was not right for everyone. Claudia lowered her voice, leaning towards me as she spoke, “I wanted to protect his dignity and have that intimate time with him.”

“May I ask, what did you experience as meaningful in the relationship when you managed to get that time together and share love and intimacy?”

“It felt like this was why we had him at home. It meant I was the one changing his nappy… And I did feel proud and honoured that I could do that for him. It’s not something a wife normally does for a partner, but I guess it was a new intimate thing we could do where there were precious few of those new things.”

Struck by her ability to generate such a deeply loving experience in something so far from what couples ordinarily do together, I responded, “What does it say about you that you felt proud and honoured to do that care for Tom … that you could find intimacy in changing his nappy for him rather than seeing it as a chore?” (26)

Thoughtfully Claudia answered, “I think I understood what he needed. I understood the best way to do that for him.”

“What was it that you understood about Tom in those last weeks that was important to you both?” Claudia pondered. “We were able to slow things down a bit.”

“How did you do this slowing?” I wondered. Claudia spoke slowly as she considered, “Just focusing on little things. I’d go and get him milkshakes and I’d say, ‘So what flavour milkshake do you want today and where do you want me to get it from?’ It was treasuring very small decisions. I got great pleasure from him eating or drinking something and he got to make decisions and think about that milkshake and what he wanted. Life zoomed in and focused on those nice moments.”

“What did you know, Claudia, perhaps about living with such a serious illness, or about Tom, that had you recognising that making a decision about the flavour of a milkshake was worth treasuring?” I couldn’t help but notice her extraordinary sensitivity to Tom’s experience and I hoped that my questions might draw Claudia’s attention to her wise and gentle care.    

Claudia laughed. “Tom knew his own mind. I would never make that decision for him, particularly around food,” she said, reminding me that Tom was a skillful and passionate cook. “Choices in his life were dwindling. He didn’t have a lot of control.” She dropped her head for a moment, reflecting. Tears glistened in Claudia’s eyes as another thought occurred to her. “Tom knew how much it would hurt me when he went.” The tears gathered and a sob escaped but she went on speaking. “He didn’t want to go but most of all he was worried about me…” Claudia started to cry unreservedly. Her face reddened as more of her body joined the experience of grief. Rather than a break in the conversation, it was as if these tears spoke what words couldn’t as we reflected on Tom’s love for her even as he was dying. (27)

Quietly, I eventually asked her, “What were these worries Tom held for you?”

Claudia was barely able to speak yet she persevered, wanting to express what the emotion meant in words. “He just knew how hard it was going to be… he cared enormously about me being alone.”

We were quiet for a time as Claudia continued to weep.

“He was sad for himself and the girls, but he was really sad for me,” she eventually explained.

I thought about Tom worrying about Claudia even as he lay in bed so sick. “What does Tom’s compassion mean to you? …. that he couldn’t bear to think of you being on your own…that he cared so much about what might happen to you…?”

“It was a demonstration of how much he loved me,” Claudia choked out. “I usually cried,” she explained, smiling at herself through the tears. “I felt guilty every time I cried and got comfort from him but he’s the person I turned to when things were wrong. He said comforting me was something he could do.” She stared at me with her eyes wide waiting for my response.

“Do you have a sense of what it was to Tom that you chose him to seek support from?”

Claudia exhaled, “I think he was thinking about the time when he wouldn’t be able to support me, and he was doing what he could.”

“How would Tom have understood the way you saw him when you sought comfort from him?”

Claudia considered, speaking what seemed like newly formed thoughts. “He was my best friend, and we were there for each other. It didn’t change when he was sick. I think it was hard but very important for him. It allowed him to show support for me, I guess. He saw it as something he could do for me when he could do so little, when I was doing so much for him. I didn’t feel the need to protect him.”

“What do you know about Tom that you knew you didn’t need to protect him?”

“He was strong. He said he wasn’t scared of dying.” Claudia let out a big, long sigh collapsing in on herself in seeming resignation.

“Would it be OK to ask you one more question about the way you shared your grief together?” Claudia nodded.

“What did you know about the relationship that told you that talking would be best for it?” I wanted to bring forward Claudia’s knowledge of their particular relationship because I knew that this kind of talking wasn’t best for everyone.

“It’s what we’ve always done,” she readily replied.

Our time was coming to an end. After I summarised what we had been discussing, I checked with Claudia, “How has our conversation gone today? Has the experience of reflecting on the last four weeks connected you with anything that is helpful or important to you?” (28)

“I think it’s highlighted how we did it according to our values. That’s incredibly important to me. It eases the pain just a little to know that,” Claudia responded.

“How might you carry that knowledge do you think? That you did it according to your values?”

“I guess by carrying on doing that with the girls,” she replied thoughtfully.

“Perhaps we might come back to that next time if it interests you…. but could I ask you something else? As you reflect on the last weeks of Tom’s life, was there anything that happened that moved you a little closer to being the person you want to be?”

With some energy and perhaps surprise in her voice, Claudia answered, “Now that I talk about it, lots of things. Doing it our way and speaking up to make that happen. The way I was able to show him how much I love him through what I did. It was so hard, but I was there to support him die the way he wanted to do it. I hadn’t really thought about it before.”

Turning Towards Pain

Claudia and I met each week until I was scheduled to be away on leave. (29) Before I left, we planned who Claudia might turn to in difficult times for support and what she might do. Not long after I returned, we were once again sitting in her home. After greeting each other warmly, Claudia brought her cup of tea into the living room, and we sat down.

“We had a fortnight gap this time, how did that go?” I inquired.

Claudia let a rush of air out. “My sister said, ‘Have you seen your counsellor this week?’ And I said, ‘No we couldn’t make it. Sasha was away.” And she said, “I always know when you haven’t seen her.” I thought I’d be fine, but I’ve had a really awful fortnight.”

“What is it that you do differently in the week when you’ve had a chance to talk?” I inquired, but I was off track. (30)

“I was thinking about what it was that changed. You know how I was feeling numb? Well, I’m raw now. I can’t seem to stop crying…” Claudia’s voice broke, and she could no longer speak. The pain gathered and eventually she sobbed, “It’s all the time… just crying all the time. I’m right back to raw and where is he? And how can this be happening?”

I listened, feeling the echoes of her pain. (31)

Claudia bowed her head and tightly wound her arms around her body. It was as if she was holding herself together. “I’m right back there… and that lovely numbness… that I was feeling has just gone,” she stuttered through the sobs. “It’s horrible… just that relentlessness… And I went to see a clairvoyant and she was just ghastly. I think that tipped me over the edge a bit. I realised I had a lot of hope riding on it.” She looked up at me with wet eyes.

My voice was soft. “May I ask …what were your hopes in seeing the clairvoyant?” I wasn’t surprised Claudia had visited a clairvoyant. Many people search for connection with someone who has died through spiritual understandings they hold.

“I didn’t realise until afterwards that I was hoping that it would be for real. I would have got a feeling of peace knowing that he is somewhere and can be with us. I didn’t get that at all. I just felt duped. I was already feeling quite low but hopeful, I realised afterwards.”

“Would it be okay if I ask a bit more about these hopes?” Claudia nodded as she blew her nose. “Would you mind speaking a little about what you were hoping for?”

“That he’s somewhere…And he’s not just puff gone. That he is somewhere and sometimes, somehow, he is around…that’s what I really want to believe…I need a message to say, ‘I’m OK, I can never see you again but I’m OK…and I know you are OK.” It is one of the hardest things I think, the not knowing.” I reflected on how much not knowing there could be surrounding illness and death.

Claudia’s anguish layered her words as she again tightly encased herself with her arms. “I’m stuck in this awful hole…I don’t know how to go on. I just don’t know how to hold on. I feel like I’m clinging on to a ledge. I have to but I don’t know how to keep going and going and going…” (32) I tried to imagine the relentlessness of continuing on. Her words created a vivid picture of the ledge. I made sounds of empathy as I listened, a witness to her pain and sorrow. “How important was knowing where Tom is in this holding on?” (33)

“Very important,” she cried.

“Yeah… yeah…,” I replied, almost crooning in my compassion for her. “What would it have given you in the holding on?”

Claudia cried, hiccupping as she answered, “Some sort of peace that he’s OK…that he’s with us…and that I might see him again…It’s so hard. It’s not like breaking up with someone and you know they’re OK. Somewhere they’re alive…”

“Completely different,” I affirmed.

Claudia voice was husky, “I just can’t get my head around it. It’s the absolute worst that could happen to me…I’m really struggling…” Her tears took over and we paused, neither of us hurrying or censoring her expressions of grief. “…and I’m sure having less help this week is making a difference. The family have been away. I’ve actually been feeling OK with my parenting.”

My ears pricked up. “Yeah…?” We had talked a lot about the impact of grief on her parenting as Imogen and Libby were Claudia’s top priority. However, I didn’t want to move Claudia away from her talk of the struggle sooner than she wanted so I resisted asking a question and kept my query very small.

“We’ve found a routine and I’m not shouting. I’m not feeling desperate about those times,” Claudia told me with an energy that conveyed to me she might have a possible interest in speaking further about her parenting.

“Is this something you would be interested in talking about?” When Claudia indicated, she would like to follow this direction I continued, “What’s allowed you to be OK with your parenting especially when there is so much struggle?”

“I think routine has helped. It’s soothing. And I’ve got really, really good at filling in the time now. Those girls are bloody tired by the end of the day because I’ve worn them out. Like last Sunday, we went to the markets and met a friend for breakfast, then we went to a school children’s art exhibition which was a couple of hours and then we went out west to see another friend. We got home at 6 P.M.” Claudia sighed, sounding exhausted even by the thought of what she had just relayed to me.

While being so busy was not Claudia’s preferred way of parenting prior to Tom’s death, this was a survival strategy she was using. “I’m really tired but that’s how I cope. Just fill in every hour possible. It’s not because I don’t want to think because I like to think about him. It’s just the only way I can cope with the kids. It’s helped.”

I returned to the aspect of parenting Claudia was feeling good about and, remembering Tom’s belief in Claudia’s parenting, decided to bring him into the conversation. (34) “And what would Tom make of you doing your parenting in a way that you felt good about? Finding a routine and being more how you want to be with the girls. What would he be thinking about that?”

“He’d be saying, ‘I knew you could. I’m proud of you.’”

We both smiled. With a lighter voice I asked, “What might Tom have known about you that allowed him to know you could do it?”

“That I put them first…,” she replied as tears trickled down her face. “…That I’ll always look after them…” Intensity and what sounded like determination entered her tones of sadness “…and I’ll hold onto that ledge for them…hard as it is…”

“Is Tom under your feet helping to hold you up a bit too?” I asked, wanting to add his support if it was there.

“I don’t know…I hope so…He would if he could…if he can he will…I forgot about the rawness. It’s so horrible.” I nodded.

“It’s only three months since he died,” Claudia told me with emphasis.

“No time at all and yet perhaps a long time too. How would you describe it?” I reflected, slowly waiting for what else she might be about to share. Claudia replied, crying as if her heart would break, “No time and yet forever. It’s part of why I hurt so much. How’s three years going to feel since I saw him? And thirty years? I feel like I’m only living for my girls…to give them a good life…and not enjoying any of it myself. The hole just keeps getting bigger.”

“Is it hard to imagine that the hole might stop expanding and steady a bit? That it might be less gaping one day?” I said, offering a future possibility.

“I can’t…”

I nodded.

“Is your wanting to parent the girls so they have good lives…” I began to ask as I looked to connect Claudia to parts of her life that might help support her keep holding on. Her virtuous desire to care for her children in spite of the pain of living stood out to me.

Claudia interrupted me, staunch as always in her love of her girls. “I want them to have good happy lives, absolutely.”

“How would you describe a good, happy life for your girls?” I invited, seeking to connect her with a future for them that might be possible to envisage.

“Doing things that stimulate them and interest them with me…positive times with me and …being strong in themselves…able to weather some storms… and get enjoyment out of things…and finding passions. I want that for them but not for myself. I don’t believe in having that for myself. I can’t see it again. It feels like it’s all gone…”

We paused together for a time and Claudia wept. (35) “I feel like something in my soul has gone… an intrinsic part of me.” Her description touched me as I murmured a quiet acknowledgment. After a pause I added, “May I ask what part of your soul would that be?”

“All of my adult self…is connected to Tom. Everything I do and think is influenced by him and our relationship. All my memories of being an adult…are with him. The way I view things is because of him. It is lovely and I’m very glad. But it’s such a wrench.”

“Was your soul entwined with his?” I wondered. Claudia nodded. “And was his entwined with yours?”

She nodded vehemently. “I don’t know where he is! It’s just so hard.” Claudia’s body shook and she put her head in her hands. It was my turn to nod as we both acknowledged the hardness. It was so hard (36). As we sat there for a time, I considered Claudia’s disappointment with the clairvoyant and how it had made the pain worse.

“I wonder if we can think about that a little bit…if we could figure something out, away from the experience you had with that particular clairvoyant…”

Claudia laughed heartily through her tears, “…Who believes in herself even if she is a complete fraud. I can’t accept that he’s not somewhere or not existing.”

“What are your understandings of possible places or ways that Tom could be existing?” I asked. People I meet with often have very different ways of understanding death even if they identify as belonging to a well-known faith tradition. They also often re-evaluate beliefs they’ve held for a lifetime in moments of illness and loss. I can never assume I know what someone believes.

“That he is part of the energy, the finite energy of the universe… that’s scientific,” Claudia explained to me. I listened attentively as she continued, “Or he could be in a different realm or a different world which is potentially scientific as well.”

“… like a parallel universe?” I inquired, noting her tears had stopped. “Yes. Or in some heavenly place, someplace souls go where there’s peace. I’m sure there are other frontiers but those are the ones I think of…I want him to be conscious somewhere and aware of us. If I think about another world or a heavenly place, he would be conscious of us.” She stared at the sky out the window. “What would a sense of Tom’s presence give you?” Claudia returned her gaze to me. “I would know he’s with us, present in our lives”.

“Do you think you have any impact on that sense of presence or how that presence could be felt?” I inquired. Claudia looked at me quizzically. “Clairvoyant people say we do, don’t they? If we can be open to it or not open to it.”

“I don’t know…Can you influence the way you feel Tom?” I wondered curious.

“I don’t know. I’d like to,” she affirmed. I cast my mind back to a previous conversation. “When we met last time, you mentioned you had felt him.”

Claudia confirmed, “I felt him really strongly.”

“May I ask what you were doing at the time?”

“I wasn’t doing anything out of the ordinary. I was probably having a laugh which was unusual as it was maybe two or three weeks after he died. The girls were playing around so a bit of a lighter moment and I was laughing with Libby playing peek-a-boo.”

“Would it be possible for you to have faith in yourself even if you can’t have faith in the clairvoyant you met?” (37)

“I’ve tried very hard to separate those two. It’s where I came to on Saturday. I didn’t have a very good experience with her but that doesn’t mean it’s all out. I didn’t pin my hopes on just one person. I booked two clairvoyants. I’ve booked the other one for August and I’ve heard she is authentic and very good. I’ll keep that booking. I’m not giving up on it altogether.” Claudia sounded calm.

Laughing, she added, “I can spare another $120! If she’s good!” I laughed in response before inquiring, “What about your own experience of feeling Tom was with you?”

“It was very strong. But it’s very easy to doubt myself. That’s what’s hard I think,” Claudia explained. “I had another experience where I was looking for a necklace and I felt Tom very strongly. I was looking and looking and then I found it one day and I had a very strong feeling that Tom had helped me find it. I know that sounds strange. But it was such a strong feeling that I said, ‘Thank you Tom! That’s for Imogen.’ It just came out. I need more! Greedy, greedy!”

“When you feel Tom with you, what does that feel like?” I asked curiously.

“Normal! The old normal,” she explained with energy.

“How do you know he’s there? When he helped you find the necklace, what happened that told you that?” I wondered, keen to learn more.

“It just felt like everything’s OK again.”

“Ah.” I sat back in my chair.

“And I don’t have to have this new normal. Both times I just felt lighter and happier. This nightmare is over or maybe not what it seems.”

“If you met with another clairvoyant whom you did or didn’t find authentic, could anyone take away those experiences that you’ve had?”

“No. They’re authentic to me,” Claudia stated.

“You said you want more of them…”

In a sing-song voice Claudia interrupted, “I do!” She was grinning.

I returned her grin. “On demand!” I echoed in the same sing-song tones. Claudia laughed. (38)

“They felt authentic to me and I’m a big believer in going with your gut instinct. I’m quite in tune with those things. They felt real.” Claudia sat back looking steady.

"I drove back to the hospice some time later reflecting on the many understandings people hold about what happens to a person after they die." (39)

New Understandings

Claudia returned to work and, as the routine settled and time passed, the pain of Tom’s death intensified. As Claudia explained to me, “It is now not just days or weeks since I last saw Tom, but six months. The longer it is since I last saw my Tom, the more I miss him.” I wasn’t surprised as many other people have described a similar experience to me.

It was a rainy day. Claudia had finished breastfeeding Libby and had returned from laying her down to sleep. She walked up the stairs with a heavy tread and sat down. “It feels like we are now in a new normal. The new normal makes me so sad. I don’t want a new normal. I want the old normal. I’m feeling guilty; sad and guilty.”

I made a few acknowledging sounds as she talked, “It is so tough. Who would want this normal when comparing it to having a partner they loved alive?” I paused a moment as I looked at Claudia’s drawn face. “Would it be helpful to share with me some more about this sadness and guilt?” I continued, wondering if it might be useful to get to know th

A Small Hope: Co-creating a Narrative of Grief – Part I *

This story is dedicated by “Claudia” to “Tom” in memory of his loving ways.

I would like to thank “Claudia” for her generosity in joining me in adventuring into new territories. There would be no story without her.

I would like to thank Aileen Cheshire, Catherine Cook, William Cooke, and Peggy Sax for their insights and helpful suggestions, and David Epston for his editorial support.

Introduction

Grief can be excruciating. The pain of loss may be overwhelming at times and its duration and intensity can be a shock to many. However, it is not always so. Relationships are shaped differently and there are many possible stories that can be told of such an experience.

The following illustration of Narrative Therapy (2) was originally written as a therapeutic document for a woman who had been forced to contend with the death of her partner while she parented their young children. “Claudia” (3), as she chose to call herself for this article, was experiencing significant loss. At the same time, she was struggling to find compassion for herself. I hoped that if Claudia viewed herself in a story of our conversations, the narrative might lend strength to the new understandings we were co-constructing. Claudia was enthusiastic about the idea of co-creating such a document and after going through a careful consent process, we agreed that we would record our conversations and write a story from the transcriptions.

Our purposes for writing a story evolved. As time passed, Claudia wanted to share her knowledge of grieving with others. When we discussed the possibility of sharing the story with a wider audience, I hoped the story might show the unfolding of therapy, and in particular, narrative practices that companion a person (4) and invite them to explore new meanings of their experience.

I have therefore added footnotes to the story [Ed. Note: Please see the original article for these notes]. The footnotes explain more of what I was thinking as Claudia and I spoke, and why I asked particular questions. They also include some thoughts on narrative practice with people who are suffering as they live with loss. You may choose to read the story and the footnotes together or separately.

For those of you who are interested in experimenting with writing a story, in contrast to other forms of therapeutic documents, please see an earlier paper I have written on writing narrative therapeutic letters. I have described the process of story writing and some of the possible benefits within that paper.   

A Cupful of Time Folded in with Love

“It’s urgent,” the community nurse told me solemnly. “Yesterday, Tom was told he was bleeding internally by the doctor at the hospital. When he heard nothing could be done to stop it, he asked his wife Claudia to take him home. Understandably, they are reeling; this has all happened so fast. We’ve offered counselling support and Claudia has agreed. She’s asked if you could ring after 10 o’clock so you don’t wake the baby from her morning nap.”

I walked back down the hallway towards my office reflecting on what it might be like to receive such news. Just after 10 o’clock I telephoned. Claudia answered. “Hello, it’s Sasha speaking. I’m one of the counsellors from the hospice. I understand you might be interested in meeting up with me. Have I got that right?” Quite often people have another understanding from a referrer, so I was tentative to give Claudia space to say what she wanted. (5)

“Yes, that would be great,” she replied.

“How would tomorrow suit you?” I asked, thinking of the urgency of the situation.

“Look, it’s very kind of you. I know it’s Friday tomorrow but it’s going to have to be next week. I’m sorry. I promised our five-year-old, Imogen, I would bake a cake with her tomorrow. It’s her birthday and I promised,” Claudia apologised in a rush.

“Are you the kind of mother who honours promises?” I asked with a smile in my voice. (6)

I heard Claudia let out a long breath. “She’s been looking forward to it all week.”  

Warmly, we now began to make a time to meet up. In the back of my mind, I was thinking about Claudia prioritising a promise to her daughter when she was possibly having the worst time of her life. Images of baking with my own young daughter many years ago floated through my mind. I wondered, “What might Imogen remember of this time when her Daddy was dying and when promises were kept to her five-year-old self? What might she say about the way she was cared for by her Mum at such a terrible time?” I also appreciated Claudia’s ability to put me off and say what she wanted. I was well aware it wasn’t easy to delay health professionals, especially to honour the wishes of a child.

I looked forward to meeting Claudia and Tom, and learning more about them.

A Surprising Renewal

I parked the hospice car down the road from the house, worried that the signage on it might communicate to the neighbours something Claudia and Tom wished to keep private. It wasn’t the anonymous unadorned car I usually drove. A young woman opened the front door of Tom and Claudia’s home and, as I looked at her animated face, I realised I knew her.

“Do you remember me?” she asked, wide-eyed, as if she could hardly believe who she was seeing.

“Yes!” I replied, flooded with memories. It was nearly 20years since Claudia and I had last seen each other. Her father had been dying at the time and Claudia was caring for him. I was working as a counsellor in a university counselling service and we had met together across the last 18 months of her father’s life. I easily recalled Claudia’s devotion to his care at a time when her contemporaries were more focused on parties and the opportunities study could provide them.

I walked further into a room that had ushered in many unfamiliar health professionals over the prior week, full of gratitude for this chance reunion and hopeful that it might make some difference for Claudia and Tom.

Claudia invited me to come into a bedroom for some privacy and together we sat on the bed. She was dressed comfortably in shorts and a T-shirt with her long, fair hair tied back off her face. Clothes that would be practical for parenting work and caring for Tom, I thought. There were dark circles under Claudia’s red, lidded eyes, easily visible because of her fair skin, and her face had a hollowed appearance in spite of her warm smile.

Claudia explained she had been up all night with their baby who was sick, and on top of that she herself had toothache. “Somehow, I am going to have to fit in an appointment with a dentist, but I don’t know how I’m going to find the time,” she exclaimed, throwing up her hands in dismay. After talking further, Claudia led me into a small, darkened room to meet Tom. He lay on a single bed unmoving and silent. Claudia touched Tom gently and he turned his head towards us. “This is Sasha,” she said. Tom looked up at me and we exchanged a greeting.

I sat down on a chair facing Tom while Claudia ignored the other chair which was placed near his pillow. Instead, she sat on the floor with her arm resting on Tom’s shoulder. Tom’s skin was a faded tan colour, suggesting to me he had once spent considerable time out of doors. In response to my greeting, he slowly shifted in the bed with jerky movements. Once he had settled, I leaned forward looking at him. “Tom, it’s lovely to meet you.”

He was a tall man I guessed, with fair hair and a kind face, softly lined around his eyes and mouth. “I’m aware talking can take a lot of precious energy. Is this an OK time for the three of us to talk together, or would you rather we spoke another time? I want to do whatever best suits you and Claudia. I can easily fit in either way,” I offered, smiling warmly at him.

“I’d like to talk for a bit. I won’t last long. We’ve been looking forward to it,” he responded, glancing at Claudia.

“When you find yourself beginning to tire, will you notice and be able to let me know?” I inquired, thinking I would need to be alert for any signs I was extending the conversation longer than he could comfortably manage.

“Claudia will know. She’ll tell us both.” Claudia nodded, her face soft and relaxed.

“Thank you.” Sitting back in my chair, I made myself comfortable while I looked from Claudia to Tom. “Illnesses have a way of taking over people’s lives and yet people are so much more than the illness they are living with. Would it be OK if I asked you a bit about yourselves and your lives before all this happened?” (7)

“Gosh it’s so nice to be asked that,” Claudia exclaimed. “It makes me feel like I matter, we matter. Tom’s a teacher and you probably noticed the garden. He grows plants from seed and often ones that are good to cook with.”

In a faltering voice Tom contributed, “Yeah… I’ve taught younger age groups and I love to garden and cook.”

“Food is very important in this house!” Claudia laughed.

Tom quietly added, “In the last year I’ve worked tutoring from home … it’s been ideal with me having cancer.” I considered asking Tom about how he lived with cancer but decided to pursue getting to know them more a bit more first. Claudia continued the conversation in a lively manner sharing with me stories of her work and interests.

“Tom, if I were to know Claudia as you do, what might I come to appreciate and respect about her?” (8)

Tom looked at Claudia as he answered me. “I love Claudia very deeply. She is kind. Really kind. I saw that from the first. She is honourable and dedicated to the people and things she believes in. Her loyalty is like none other and there is nothing I wouldn’t share or confide in her. Claudia is a wonderful, loving mother. Knowing that makes it easier for me to be sick because I know I will be leaving the girls in her care.”

“Could you tell me a story that illustrates some of these attributes you love and appreciate in Claudia?” (9)

Tom spoke of the care Claudia had given her father as he was dying. “She will always have your back,” he told me.

“What difference has Claudia ‘having your back’ made to you?”

“It has given me a whole new life that I wouldn’t have had without her. It’s meant I can be myself and pursue my interests. It has meant I have had the joy of becoming a father.”

Claudia responded by clasping Tom’s hand. “I love you so much,” she whispered.

After I asked Tom a few more questions, I turned to Claudia.

“Claudia if were to get to know a little of the Tom that you love so much, what might I come to respect and appreciate about him?”

“You’d appreciate his authenticity. Tom is real. He has a wicked sense of humour too! He’s always polite but he doesn’t suffer fools.”

“Would it be OK to ask you for a story of Tom’s authenticity and his wicked sense of humour?” I grinned at Tom and his eyes twinkled in return. Claudia launched into some stories with enthusiasm. Tom lay back quietly enjoying her words.

As the conversation progressed, it turned quite naturally towards the cancer and what they had been going through. I looked over to Tom and inquired, “What do you give weight to in your days as you live with this cancer?” (10)

“My family, being a father, I like to be involved with the girls,” Tom confided. A small smile emerged on his face. Tom tried to raise himself in the bed but, before Claudia could help him, slipped back down and, seeming to give up on a sitting position, rested his head on the pillow. When he looked comfortable again, I asked, “Could you help me to understand a little of what it means to you to be a father?”

“I love it! I wasn’t truly happy until I was a Dad. I took one look at Imogen, our eldest, and I fell in love.”

I was aware Tom’s words might carry meaning that could be passed on and retold down the years, perhaps providing solace for his girls.

“Could I ask you about this experience of falling in love?”

Contentment seemed to flow over his face for a moment, relaxing the lines as he contemplated my question. “Sure. I didn’t know what happiness was till Imogen came along. She made my life complete.”

“What did Imogen’s birth give you that has you experiencing this sense of completion and happiness?” I responded smiling.

Tom pondered, “I think it was a proper purpose….”

Claudia joined us. “…Being parents connected us to what’s important…I think Tom’s found a role that really fits him. He’s a good father.”

Tom’s quiet voice gained strength and the corners of his eyes turned up. “…And then Libby was born and I felt overwhelmed with wonder.”

“What had you overwhelmed with wonder when Libby was born?” I asked, collecting stories again. (11)

“Libby having her very own personality and the way she could let her feelings be known,” he responded with a chuckle. Claudia joined in, “He sent me a message when I was at work that said, “Baby does not want to sleep in the bedroom today. She was very vocal on the matter!” Claudia laughed. “Tom always appreciates her strength of character and being able to understand what she’s trying to say.”

Enjoying their delight, I responded, “What is important to you both that the experience of parenting has connected you to?”

“Our values and beliefs,” Claudia told me. Tom nodded, meeting Claudia’s eyes. “What we treasure.” I was keen to ask them more about their values and beliefs, but I didn’t know how long we might have for our conversation. Tom was likely managing fatigue and so I decided to pursue another path. I would return to the detail of what they treasured at a later date.

“Would it be OK to ask how this giving weight to what you believe in and treasure shapes your experience of living with cancer?” (12)

“It’s given us good times, wonderful times in amongst the hard stuff. The girls make each day worth living for,” Tom answered.

“We spent one morning just watching Libby learn to roll,” Claudia laughed.

Our laughter was cut off by sounds of crying from the room upstairs followed by shuffling as Tom’s mother walked quickly to attend to Libby.

Claudia tilted her head as she listened for signs Libby had been soothed. Tom stilled listening as well. “How will I do it without you?” she whispered, looking back to Tom. Tears began to flow down Claudia’s face. Stifling sobs, she rested her head on Tom’s chest and stretched her arms out as if to cradle the entire length of his body.

“I’m still here now. I’m still here now,” he crooned, patting her back.

“How will I raise the girls without you?” Claudia reiterated.

“I trust you. You will do a good job,” he said, trying to placate her. Tom continued to pat Claudia’s back in the age-old rhythm of comfort. I remained quiet, touched by her pain and his attempts to console her. (13)

After a time, I asked him, “What is it that you know about Claudia that allows you to trust her?”

Tom began to describe his faith in Claudia, gently patting her back all the while he talked.

“Could you tell me a story that illustrates this trust you hold for Claudia and her parenting?”

Tom expressed his admiration for Claudia as a mother. “She always puts the girls first.” He told me stories of her kindness and her beliefs about mothering, explaining how important their shared parenting beliefs were to them. As he spoke, Claudia listened silently, intent on his every word.

“How might you like to carry these beliefs you share forward so Imogen and Libby might know something of what is important to you as a couple and as a family?” I responded.

Claudia suggested they create a family charter that recorded their values. (14) Tom was enthusiastic about such a project and together we discussed what might be included in the document.

I checked with Tom as to how his energy levels were at regular intervals. Mindful that it is hard to send someone away, when I noticed his eyelids start to droop a little, I began to bring the conversation to an end.

“How has this conversation been going? Have we talked about what you hoped we might or have I taken us off track?” I checked.

“It’s been good,” Claudia said.

“Thanks. I liked talking,” Tom said warmly.

Claudia showed me out a few minutes later.

A Small Hope

Over the following week I heard that Tom had stopped eating and was now unable to leave his bed. The nurses told me that Claudia had insisted no one speak to her about his symptoms or deteriorating condition.

At the end of the week I went to see Tom and Claudia as we had arranged.

Claudia and I sat outside in the garden at an old wooden table. Tom was inside sleeping, too sick to talk. The garden provided a quiet private place away from the activity of the household as the extended family all worked together to care for him and the girls. Tired, harrowed faces had welcomed me and in the heavy movements of the family, I thought I could feel unspoken sadness weighing down their every step.

Claudia looked up as the leaves ruffled in the moving air. “It’s been a better week.”

“When you look back on the last two weeks, do you have some ideas about what has contributed to this week being better?” I asked, incorporating her words into my question.

“I’ve stopped looking ahead,” Claudia replied. Not wanting to presume what Claudia meant, I responded, “May I ask, where do you look when you’re not looking ahead?”

“No one can know exactly what’s going to happen, can they?” Claudia replied. “Now I only think about today and I have some hope.”

“Could you help me to understand a little of what this hope (15) is to you?”

Claudia paused, bowing her head.

“It is only a small hope,” she said in a quiet voice as if confessing something. “…To be with Tom, for another day or maybe even a few days.” Claudia looked up at me with tears gleaming in her eyes.

“May I ask what difference this small hope makes to you?” I replied, moved by the humility of her hope.

“It means I’m not crying all the time. I sat by the window and told Tom what I saw outside. We spent some time talking quietly together once Imogen was at school. I made him a little something for lunch and we sat together. He told me being together like that was ‘perfect,’ and he has never said that before.”

“As you look out the window describing the view to Tom, what does this small hope do that has Tom finding your time together perfect?”

“I can enjoy the moment and he feels that. It helps me forget what is coming,” Claudia explained.

“When you spend these moments that the small hope has given you, what has been made possible that hadn’t been there in the week before?” I knew that the week before had been distressing for them both.

“Close time together. Over the past few months, we’ve been arguing because of the stress and that isn’t us,” was Claudia’s reply.

“How did you come to find closeness in sharing the view from the window and talking and bringing Tom food?”

Claudia told me with eagerness now edging into her voice, “It’s what we’ve always done together, enjoyed the simple things. We like to enjoy those things that money can’t buy.” Claudia continued telling me stories illustrating this.

“What else do you do in the day that speaks to the closeness you share as a couple, and as parents together, and brings you closer to Tom?”

“Gardening,” Claudia readily answered. “I feel close to him when I do his garden and I will keep doing it. I just couldn’t do it before. I was too shocked. Now I have some hope and it gets me through the day.”

“How important is this hope in keeping you close to Tom and getting through the day?”

Firmness was in her voice as she stated, “Very, very important. It means I can enjoy some time with Tom and that is the most important thing to me. The time is so precious. And I don’t want to cry every minute.” We carried on talking about how Claudia and Tom were enjoying the window of time they still had together when Claudia confided, “Did you know I’ve stopped the nurses telling me about Tom’s symptoms?” She glanced up at me and paused, “Maybe that means I’m in denial, I don’t know.”

“What sort of talk are you encouraging or hoping for when you halt discussion about Tom’s condition?” I asked.

Her reply tumbled out. “I know what’s coming…I just want a little longer, just a little longer with him without thinking of that. It’s always there in the background but I don’t want to go there before I have to.”

I could easily understand why Claudia might want to protect the hope that was allowing her to savour time with Tom. To me it was not denial of his approaching death but rather embracing what was most important to her — close time with Tom before he died.

I left that day not knowing when Claudia and I would next meet. The uncertainty Tom and Claudia were living with made it difficult for Claudia to plan. We had agreed she would call me when she next wanted to meet.

The following week I heard that Tom was dying. The hospice nurses were visiting daily and every effort was being made to keep him comfortable.

One morning I arrived at work early. I sat down at my desk noting the light was blinking on my answerphone. I punched in the numbers to access my messages. There was just one. One of the hospice community nurses had called to let me know Tom had died. “Claudia would like to see you,” she said.  

“Such a lot has happened since we last met. Would you like to talk about the last fortnight or is there another place you would rather begin?” I asked, seeking to create some space for her to guide me as to how she wanted to begin our conversation. I didn’t know how talking about Tom dying would be for Claudia or what language she preferred to use. (17)

Claudia spoke slowly contemplating her words as if they were transporting her back in time. “I moved Tom back into our room after I saw you. I’m so glad I did. It was much nicer for him.” She smiled tenderly. “I lay beside him on the bed that last week as he was dying. I told him over and over, ‘You’re loved and you’re safe.’ It was just him and me when he died…” Claudia paused, her eyes staring unfocused. Returning her attention to me she resumed speaking. “The family had left for the evening to give us some time alone together, but I called them when I realised he was dying. They came straight back. In the end, he died like he’d wanted.”

I imagined Claudia reassuring Tom with her love. “May I ask… what difference did it make to Tom to feel loved by you as he was dying?”

Claudia sat back in the sofa. “I guess he could bear it. He’d had a tough childhood because he was different, and he was bullied a lot. But when he died, he had a family. He was loved. He had all the things that were really important to him.” She glanced at a photo of Tom and the girls on the wall. I too looked at the picture of Tom holding Libby while Imogen wrapped herself around his legs.

The slow pace and rhythm of my words matched Claudia’s as I returned my entire attention to her and expanded my previous question. “What did it mean to Tom to have a family and to be loved as he was dying do you think?”

“Everything. A chaplain visited Tom at the hospital just after we heard the news he was going to die. The chaplain asked Tom, ‘Has it been a good life?’ and Tom said, ‘Yes. It has been a good life.’ It comforts me to think that. He always said he’d got a life through me he’d never expected to have.”

I leant towards her as I replied, “What was it that he got from his relationship with you that made his life good?”

“He said he learnt new things. He became a father. He said because of our relationship, he got to have a life he wanted but never imagined having.” Claudia’s body stilled and her mouth turned down. I responded tentatively, “Would you mind sharing with me a little more about this good life that your relationship gave Tom?” I hesitated. “Might Tom have said it was a longed for life?"  

“It was a longed for life,” Claudia replied emphatically. She wrapped her arms around her body as if to hug herself and began to recall how she met Tom and the friendship they shared. The words came out quickly matched by the tears that fell from her eyes. After a few minutes of talking, Claudia slowed, releasing her arms from her body, and sat back on the sofa. “He said he’d always been on the outside and never felt like he belonged. It all changed for him when we were together. We both valued friendship and loyalty and it built our relationship.”  

I was spellbound by what they had given each other. “People mean many things when they talk about friendship and loyalty. What were yours and Tom’s understandings and how did they show in your relationship… that had Tom moving from feeling on the outside to stepping inside and experiencing belonging, friendship, and love…a longed for life?”

It was a long question and I said it slowly with expression. Claudia stared at me attentively. Eagerly she replied, “We had each other’s backs. Even if we didn’t agree, we always loved each other. We respected our differences and opinions. Our love was always there even in the way I cared for him. When Tom got sick, he said it changed how he dealt with having cancer.”

“How did this love you shared and the loving ways you cared for Tom influence how he lived with the cancer?” (18)

Claudia leant towards me, seeming oblivious to anything other than what she was about to express. “It meant he could go on enjoying his life. We were good at loving each other. We both changed and grew because of the relationship. I will never have another like it. It kind of gives me more to hold on to, and I keep saying to myself how grateful I am for my relationship with Tom, but it’s also so much more to lose.” Claudia lowered her voice, her passionate tones fading rapidly, and almost whispered, “I’ve been on the edge of a cliff for so long knowing there was a chasm ahead of me. I know I’m falling into it now but there’s this numbness. I hate it. It disconnects me from Tom. It’s like this isn’t real and it is.”

I reflected on the enormity of such a loss and Claudia’s ability to express gratitude at such a moment. “When you’ve had such a special relationship which both gives you more to hold on to and more to lose, how do you understand this sense of numbness?” Claudia nodded when I gave weight to the words “more to lose” and then replied hesitantly, “It’s an anesthetic. My body being kind maybe.”

“What does this sense of numbness speak to about the relationship you have with Tom and the magnitude of the loss do you think?” I wondered if the numbness was an expression of their close connection, and the magnitude of the loss Claudia was experiencing.

Claudia straightened her back and lifted her chin. “Tom dying is bigger than any loss I have been through before. Other people I have loved have died but nothing compares to this. Nothing!” She uttered the words emphatically as if arguing with an unseen audience. Then, making eye contact with me added, “Does that make sense?”

I nodded as she spoke, reflecting that she was in a much more informed position to speak of this than I was. “Losses are not the same, relationships are different, and circumstances are different. Would it be OK to ask what it is that contributes to Tom dying being an incomparable loss, the biggest loss you have ever experienced in your life?” I wanted to fully acknowledge her experience. (19)

Claudia wriggled back on the sofa unfolding her arms. Her chest rose as she took a deep breath. “He has been the most important person in my life. He is my best friend. I don’t want to forget.” I remembered h

Cognitive Reframing is the Key to Counselling High-Conflict Couples

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.

Reducing the Negative Impact of Reasonable Expectations on Healthy Relationships

On a daily basis, I have the pleasure of providing counseling services to couples hoping to strengthen their relationship together. Whether pre-engaged, engaged, recently married or married for decades, I help them to explore the similarities and differences between couples as well as within them.

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Barriers to Intimacy

While intimate relationships such as marriage have the potential for great happiness and joy, there is also the risk of frustration and disappointment. To assist these couples in strengthening their sense of relationship connection, we spend time exploring various aspects of their personal and relationship history, efforts that have already been taken to resolve the barriers between them, and identifying individual and relational strengths as well as growth areas. Of the many contributing factors to the difficulties these couples experience are the challenges they experience adjusting to differences between them — a very common barrier to healthy understanding and interaction.

For several years I have spent time helping couples not only identify their similarities and differences and the significance they play in their interactions, but also reframing their understanding and experience of those similarities and differences as less inconvenient and detrimental, and more appreciated, respected, and as potential opportunities for relationship enhancement.

Differences in assertiveness can be frustrating when one partner is expecting the other to be more open and direct, while the other partner is expecting that partner to tone it down a bit. Differences in preferred methods of quality time together can lead to distance if one partner is expecting a commitment to quality time to look like daily-initiated interactions, while the other partner is content with weekly, assuming that the commitment has been fulfilled.

In these cases, and others like it, reasonable expectations that are not healthily expressed or acknowledged can be a detrimental dynamic. After all, many feel as though what they are asking for or expecting is reasonable rather than too much. This fact often exacerbates their shared or individual disappointment since it hurts on one level to not have what one wants, and it hurts on another level to believe that the person you care about most doesn’t care enough to provide your reasonable minimal standard.

To address the detriment of reasonable expectations, I have found it useful to help them:

Identify their expectations

Own their expectations

Respect others’ expectations

Identify Their Expectations

Relationship expectations come from various sources. Sometimes we’re directly taught what to expect from a relationship from our parents or other loved ones. Other times we’ve learned by watching what has been modeled for us by parents or loved ones without anyone having to say a word. And yet other times, we have simply picked things up over the years, having sifted through life’s experiences, leaving behind what we did not care to experience and holding onto the things that we would look forward to experiencing.

Own Their Expectation

Over time, we develop a set of expectations that have years of justification, validation, and support. They can be so integrated into one’s view of the world that individuals are not aware that their expectations are not indicators of the “best” experiences and ways of doing things, but rather the experiences and ways of doing things that they have come to appreciate more than others. As such, before change can occur, they need to own their expectations as their own legitimate preferences. This does not make them any less valid. Rather, it allows for the opportunity to accept others’ differing preferences as legitimate.

Respect the Other’s Expectations

Once each member of the couple identifies and expresses their expectations and acknowledges them as their personal preferences, it can become easier to appreciate and respect the other’s expectations as reasonable preferences as well. And when that other person is the most important person in their life, for whom they have committed to helping meet as many preferences as possible, the challenge transitions from, “Why does my partner have such inconvenient and unreasonable expectations?” to, “How can I better understand why my partner has these preferences and how they can benefit our relationship even if they differ at times from my preferences and expectations?” This is a very different type of conversation, which at its essence is non-conflictual. This type of conversation seems a mutual win-win, with mutual respect, consideration, and care expressed along the way.

Consider the newly married couple who dated during college, married after graduation, and are now having difficulty adjusting to life after their honeymoon. Although they shared a goal of creating a new routine that prioritized their marriage together, they soon discovered that they had different expectations of what priority looked like. She expected them to maintain a frequency of quality time similar to what they had during college, including frequent shared classes, meals together, as well as a few shared extracurricular activities. It came then as a shock to her when her new husband no longer seemed interested in spending time with her, leaving her feeling lonely and misled. It was later revealed that her husband indeed valued and prioritized his marriage so much that he committed to dedicating all his “free time” to his wife; however, different from their shared college environment and routine, “free time” was now significantly less and came after spending nine hours of each day (including work and his commute) away from home, and consequently, his wife.

What helped resolve a potential connection- and intimacy-damaging misunderstanding was the couple’s effort to identify their individual and differing expectations on what their marriage would look like. Seeing the legitimacy of their own expectations influenced by reasonable conclusions based on past experiences helped them reduce defensiveness and judgment of each other’s differing expectations. This foundation then helped them see the legitimacy of their partner’s expectations for the same reasons and express that understanding in a way that created a safe environment for them to work and in which to create new shared expectations together, with both of their needs and desires in mind.

***

Reasonable expectations are just that — reasonable. However, the fact that they may be reasonable doesn’t mean that each of our clients is entitled to them, especially when the other’s expectations conflict with theirs. My challenge in working with these couples is to help each person to identify and own their preferences with appropriate value, while also avoiding the temptation to give them more value than they deserve; as doing so can lead to unnecessary and unhelpful relationship rigidity and emotional distance and separation.

Questions for Thought and Discussion

In what ways are this author’s premise for couples counseling similar to or different from yours?

How do you address differing expectations in couples counseling?

How might you have addressed the challenges of working with the couple described in this essay?

Powerful Therapy Strategies for Healing Wounded Couples

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?

The Existential Importance of the Penis: A Guide to Understanding Male Sexuality – Daniel N. Watter, EdD

Existential Sex Therapy in Practice

The practice of sex therapy and psychotherapy can be done utilizing many different modes and theoretical orientations. Yalom reminds us that existential psychotherapy does not represent a standard set of techniques, styles, or protocols. The concepts of existential therapy can be best understood as a lens or guide by which psychotherapy is practiced. Practitioners of all theoretical philosophies can bring an existential perspective to their treatment process. 

When I treat my male sex therapy patients, I follow a similar pattern with all as a starting point. Whether I am treating an individual male or a couple, I like to begin by asking about what brings them in to see me and allow the story to unfold in whatever manner they choose. I am particularly interested in the description of the problem, the conditions under which the problem manifests itself, and the timeline regarding when the symptom first presented. My goal is to begin to get an understanding of the meaning and protective/adaptive purpose the sexual difficulty may represent. Typically, men will present with little to no insight as to the reason for their sexual shutdown. They often describe a generally satisfying relationship with a partner they find attractive. Most of the men I treat, especially those experiencing erectile difficulties, will report relative ease at attaining penile tumescence, and engorgement will be maintained through extended periods of sexual foreplay. But the erection fades as intercourse approaches or shortly after penetration occurs. Typically, these men reveal a current history of satisfying and frequent masturbation. They will often express a vague notion of being anxious about sexual function and a firm belief that their penile difficulties have some medical basis. However, they are at a loss to explain how a physical or medical issue allows for erections that are fully functional during masturbation but not penetrative sex. Their partners are similarly stymied. 

Following the initial consultation, I will focus on family and developmental history. If I’m treating a couple, I will ask to do three individual sessions with each before resuming couples’ work. It is important to me to develop a good understanding of each person’s experience in his or her family of origin and to identify any patterns of trauma that might be getting triggered in the current relationship. I want to learn about the personalities of family members, their relationship with each of them, and their relationship with each other. I want to know if this was a family that was able to communicate about and/or demonstrate emotions, or if theirs was a family of secrets and repressed suffering. I want to know if there was any presence of substance abuse or domestic violence and/or parental neglect/over-involvement. In essence, I am looking to gain an appreciation for any family dynamic that may have felt threatening that could be reenacting itself in the current relationship and, thereby, creating a threat to the man’s existence and well-being.

Many highly regarded sex therapists will spend a great deal of time taking an in-depth sexual history. I do not, as I find much of the information in a standard sex history to be irrelevant, particularly in those men who have had a prior history of good sexual functioning. Through an existential lens, the sexual “problem” is often not about how the man feels about sex per se. The sexual problem is more typically understood as an attempt for the man’s penis to communicate some deep anxiety, concern, and existential threat to his existence. Therefore, to more fully comprehend the message the penis is sending, a comprehensive developmental/family-of-origin/ relational history will be of greater value. Let’s consider the case of Russ from the perspective of an existentially oriented sex therapist. 

The Case of Russ

Fifty-one-year-old Russ came to see me shortly after his wedding to Sarah. This was a first marriage for Russ and the second for Sarah. Both had come from traumatic families of origin, and Sarah’s first marriage was to a man who regularly abused her. Russ’s primary complaint was a lifelong inability to ejaculate. I began by asking Russ for a timeline regarding his ejaculatory difficulties. I have found that the time of onset of problematic sexual symptoms is often of great significance in understanding what may be triggering the current inhibition. While most men presenting with this complaint have their ejaculatory difficulty limited to their time with a partner and have little to no difficulty ejaculating during masturbation, Russ reported that Sarah was his first sexual partner, and ejaculation during masturbation was problematic as well, although it would occur on occasion. Given the unusualness of this situation, I asked if Russ had consulted a urologist or other physician, and he indicated that it was his urologist who provided him the referral to me. His urologist did not detect any medical explanation for Russ’s ejaculation problem. 

We next began to talk about Russ’s upbringing and family of origin. Russ came from a family with two professionally educated parents, both of whom enjoyed great professional success and respect. They also were rather puritanical and punitive. Russ was the oldest of four children, and the siblings all have minimal interaction with each other. Despite the fine professional reputation his parents possessed, Russ recalls them as constantly fighting, explosively angry, sleeping in separate rooms, engaging in multiple infidelities, and hardly being civil to each other. Neither had much to do with the children, his father due to excessive alcohol use and his mother using her work to avoid being at home. He recalls his mother telling him in a fit of rage that she never wanted to be a mother and blamed his father for forcing parenthood on her.

Russ also reported that laughter, enjoyment, and pleasure were not only absent in his home but were considered sinful and to be averted at all costs. Any expressions of joy were severely reprimanded and punished. As a result, Russ learned as a young boy to repress any feelings or demonstrations of delight, joyfulness, and pleasure. He recalled that to the present day, if he is enjoying a television show or a musical piece, he will turn it off. He does not enjoy comedians or most other forms of entertainment. His free time is spent reading serious, nonfiction books and tinkering with electronic devices. Regarding the specifics of sex, he reports a strong libido and easy arousal, but he begins to panic as he approaches ejaculation and, thus, ceases all stimulation. In addition to shutting down all sensations of pleasure, Russ reports learning to be exquisitely attuned to the displeasure of his parents. He was constantly scanning the home environment to head off any actions or commotions that would rouse the ire of his chronically unhappy and volatile parents. Russ grew up a very lonely child. Despite having three siblings, the home was minimally interactive, and Russ did all he could to avoid other family members. He spent a great deal of time alone in his bedroom or in the local branch library. He recalls few friendships with schoolmates, as his parents discouraged such contacts. His activities were primarily solo, and this pattern continued through college and his career. In high school, Russ discovered a love of the sciences, and he decided to pursue a career in medicine. While he enjoyed his studies, he found his clinical rotations to be laborious. For a time, Russ thought he had made a poor career choice until he discovered the field of pathology. Pathology afforded him the solitude he found comforting as well as the opportunity to pursue his interest in lab sciences. In addition, being a pathologist required minimal interaction with colleagues, offered steady, predictable hours, and relieved Russ of the burden of having to deal directly with patients. He had a reputation at work as a hardworking and dependable physician but also as a loner who showed little interest in the lives of his co-workers. Oddly, his workplace was where he met the person who would dramatically alter his life’s course, Sarah.

Sarah was a pathologist in the same lab as Russ. She was also a serious- minded and reserved person, but she was more social and outgoing than was Russ. She found Russ to be appealing for several reasons. She liked that he was smart, hardworking, and seemingly uninterested in office gossip and politics. She also discovered Russ’s dry, witty sense of humor as being particularly self-effacing and clever. She decided to ask him to join her for dinner one evening, and Russ, to his surprise, accepted.

Russ did not date and reports no prior relationships before meeting Sarah. He was quite taken aback when Sarah invited him to dinner, as no other women had ever pursued him. He liked Sarah, thought she was beautiful, and found her laugh to be quite charming. She always seemed to genuinely enjoy her conversations with him, and this was a most unfamiliar experience. Russ recalls being nervous before the date but also excited to go. He reported they had a surprisingly nice evening, and he felt a lightness that was both strange and pleasing. He very much wanted to continue dating Sarah. Fortunately, Sarah, too, recalled enjoying her evening with Russ, and the two began to spend a considerable amount of nonworking time together. Sex proceeded slowly, which was fine for them both. Russ was unable to ejaculate during intercourse and soon began to develop erectile difficulties. Russ found erections fairly easy to achieve and maintain until it was time for vaginal penetration. Russ would then begin to lose tumescence. Sarah was unflustered and patient, but Russ was frustrated. He wanted to be able to fully experience sex with Sarah, mostly because he did not want her to feel bad or worry that he wasn’t attracted to/interested in her.

It seemed readily apparent to me that Russ’s traumatic upbringing was affecting his sexual functioning. His penis was speaking to him and cautioning him against allowing himself to be vulnerable to others. We spent a good deal of time discussing his family of origin and how his penis might be trying to send him a message of prudence. Existentially, Russ suffered from fears of mortality and isolation. Specifically, Russ found his existence threatened by his feelings of vulnerability with Sarah. His past relationships with family left him vigilant against allowing others to get close and potentially harm him. He had spent most of his life as a loner, and this allowed him to feel protected and safe. However, meeting Sarah made him aware of the depth of his loneliness, and he longed for companionship and love. While his conscious mind was telling him how wonderful life with Sarah would be, his protective unconscious was alerting him to the peril and fragility of his existence should he allow himself to be exposed and laid bare to another. The threat of hurt, rejection, and grief was palpable as Russ continued to deepen his affection and connection to Sarah.

In addition to the threat of annihilation, Russ also was becoming increasingly aware of his isolation from self. His perpetual scanning of his childhood home environment and vigilance for any signs of upset from his parents made him unaware of what his own needs were. That, combined with the family’s disdain for anything pleasurable, left Russ in a constant state of anxiety during partnered sex. When in sexual situations with Sarah, Russ was so preoccupied with whether Sarah was responding positively that he was oblivious to his own sense of sexual arousal. Psychotherapy focused on Russ allowing himself to become comfortable with experiencing nonsexual pleasure and then moving to sexual pleasure during solo masturbation. A combination of dealing with the trauma of his childhood environment along with some directed behavioral suggestions allowed this to be accomplished over a period of several months.

Allowing himself to ejaculate during his time with Sarah proved more challenging, and improvements came about in small, inconsistent increments. Russ’s ability to fully let go when in the presence of another was (not surprisingly) difficult to overcome. Russ’s childhood home taught him to self-protectively be on guard against the ire of his warring parents. Hypervigilance in the presence of others became his lifelong strategy for survival. Overcoming the trauma of his childhood took considerable work in psychotherapy, but eventually, Russ was able to ejaculate in Sarah’s presence. First, he was able to ejaculate in her presence via solo masturbation. This then progressed to Sarah being able to bring Russ to ejaculation using her hand, and eventually, Russ was able to ejaculate during sexual intercourse. Each of these successive advances occurred inconsistently for quite some time but gradually became easier and easier to achieve. During times of emotional stress/dysregulation on either of their parts, Russ will regress, but such regressions are temporary and typically resolve in a matter of days to weeks. Both Russ and Sarah are pleased with their movement, and treatment is ongoing.

Russ and Sarah’s story illustrates many of the seminal points in existential sex therapy. Note the existential concerns of a threatened existence and the penis speaking through a self-protective shutdown of sexual functioning. Russ feared his existence would be snuffed out if he allowed himself to be emotionally close to Sarah or allow himself to feel joy/ pleasure. In addition, Russ became increasingly aware of his isolation from himself. When with Sarah, he was so consumed with scanning her reactions that he completely lost sight of his own desires. Russ’s anxiety about displeasing another meant that the only time he felt sexually comfortable was during solo sexual activity, when he could focus exclusively on himself with no distraction.

Russ was a man who was deeply untrusting of others, and this, along with his isolation from self, negatively affected his budding relationship with Sarah. While what makes psychotherapy work is always somewhat mysterious, it seems clear to me that a significant aspect of Russ’s improvement was the quality of the therapeutic relationship built between the two of us. Over time, Russ came to trust that my interest in him and his well-being was genuine. As his comfort with me increased, Russ was able to take more risks in therapy and reveal more and more of himself. In addition, he was able to venture into unexplored territory as he began to learn more about himself, his feelings, his fears, and his desires. Existential sex therapy, like existential psychotherapy, is rooted in the depth of the therapeutic relationship. The elements of connection, genuineness, compassion, and safety are the most potent tools available to the practicing sex therapist.

I am often asked if behavioral sex therapy exercises have a place in existential sex therapy. While I tend to use them sparingly, they certainly have an important place in providing some immediate relief of symptoms and encouraging patients to take risks and move forward. However, I believe that a therapy that was primarily based in behavioral exercises would have been ultimately ineffective for Russ. Russ had suffered so much damage from his family of origin that without doing deep trauma work with an existential lens, he would not have allowed himself to move toward tolerating the experience of pleasure. In addition, exercises that focused directly on the functioning of his penis would have been of little value until Russ better understood the messages of anxiety and trauma being communicated to him through his penis. Frankl’s process of dereflection allowed Russ to focus on triggering of childhood trauma and allow his protective unconscious to loosen its grip. Still, behavioral suggestions clearly had a place in Russ’s treatment, as merely working through the trauma of childhood would not have given him the sexual skills he required. I am often reminded of one of Yalom’s most important axioms: “Insight without action is merely interesting.” All good therapy needs to move the patient beyond the point of insight to take the necessary emotional risks to make use of such insights and awarenesses. As a result, even though the bulk of my therapy focuses on deep reflection and insight to assist the man in better understanding the message his penis is sending him, I often find behavioral exercises or suggestions to be of great value.

Let’s examine another case that illustrates the principles and process of existential sex therapy. 

The Case of Ascher

Ascher was a 44-year-old man who had been married for 21 years to Marcie. Both reported a generally satisfying relationship that had recently become distressed due to Marcie’s discovery of Asher’s many infidelities. Ascher admitted to frequent use of pornography, chatrooms, and sex workers. Marcie discovered Ascher’s transgressions after being diagnosed with a sexually transmitted infection at a routine GYN exam. 

Both Ascher and Marcie were religiously observant, and sexual intercourse was not attempted until after marriage. Sex seemed to proceed smoothly with little complication for the first 12 to 24 months of marriage. Both reported a high level of sexual satisfaction during this time. However, Ascher began to pull away from Marcie sexually, and their sexual frequency quickly diminished. When Marcie questioned Ascher about his apparent sexual avoidance, he offered some vague explanations and vowed to increase the frequency of his sexual initiations. Ascher did begin to initiate sex more often, but then he often would experience erectile loss just prior to vaginal penetration. Both Ascher and Marcie found this distressing, but Ascher was reluctant to consult his physician and instead just drifted further away from Marcie sexually. Marcie was troubled by Ascher’s lack of interest in pursuing an answer to this conundrum, and the two began to fight repeatedly. It was later discovered that Ascher’s reluctance to consult his physician was due to his awareness that his erectile difficulties did not occur during solo masturbation or inter- actions with sex workers. Had Marcie not been diagnosed with an STI, this cycle of sexual avoidance may have continued indefinitely, as divorce was not a consideration for either of them.

Ascher agreed to begin psychotherapy and consulted a “sex addiction specialist.” Sex addiction therapy proceeded for about a year, but improvement was minimal. Therapy focused primarily on behavioral interventions designed to control Ascher’s urges to sexually “act out,” as well as regular attendance at a 12-step sex addiction group. Ascher reported enjoying both the individual therapy and the group meetings and found the support he received from both to be very meaningful. However, Ascher felt that his issues were not being adequately identified and addressed, and change was negligible. Both Ascher and Marcie were frustrated by the lack of progress, and they were referred to me for an alternative approach to the problem.

My initial meeting was with both Ascher and Marcie, but their wish was for Ascher to receive individual psychotherapy. Marcie attended the session to be supportive and offer to be helpful in any way she was needed. However, Ascher felt he needed to “confront his inner demons” and wanted to do this via individual treatment. I agreed, as I thought Ascher’s difficulties preceded and were separate from his relationship with Marcie, and we agreed to begin individual therapy with the idea of bringing Marcie into the therapy at a later point if necessary.

Ascher and I began by discussing the onset of his problematic behavior. He reported that he had never felt sexually conflicted or compulsive prior to his marriage to Marcie. He reported loving Marcie and thought she was an outstanding wife, mother, and friend. He found his behavior puzzling, as he found her sexually attractive and enjoyed sex with her greatly. We also discussed his prior psychotherapy and what he found helpful and not helpful about it. Ascher recalled liking his therapist and felt great relief at being able to discuss what he had been keeping hidden for so long. He also enjoyed the support and camaraderie of the 12-step group but had a nagging sense that as inconceivable as it was to him, his problem was not really about sex, which was the sole focus of his prior therapy and the 12-step group. I asked him if his problem was not about sex, what did he think it was about, but he had no answer and found his situation to be quite puzzling.

We next began to talk about Ascher’s family of origin and childhood memories. Ascher was the oldest of five boys born to a religiously observant mother and father. He reports a generally happy home environment in which the laws and rituals of Judaism were practiced, celebrated, and enforced. Ascher was educated in Jewish day schools, where he received both secular and nonsecular education. He recalls enjoying school and being a very good and popular student. Ascher was very much committed to his religious teachings and practices but recollects always fighting a desire to rebel. He didn’t mind or object to any of his religious obligations but always felt an objection to being “controlled.” Ascher described himself as being an intensely curious youngster who frequently questioned the absoluteness of rabbinic authority and wanted to know what the “forbidden” experiences would be like. He had questions about the laws of kashrut (the requirement to keep a kosher diet) and often felt a strong urge to sample non-kosher food and, on occasion, did secretly indulge. As an adolescent, Ascher experienced the expected sexual urges and desires and would occasionally allow himself to masturbate. These transgressions left him feeling guilty but pleased by his displays of autonomy and independence. Again, it was not that Ascher felt forced into a life of religious observance that he did not want, but Ascher abjured feeling controlled, stifled, and limited.

Ascher reported that while he was eager to marry Marcie, he felt rather quickly like marriage was “suffocating.” This feeling was quite surprising to him, since he believed he enjoyed being with Marcie a great deal. Nevertheless, marriage quickly felt confining, limiting, and controlling. Since Ascher did not engage in premarital sex, he did not know how he would have behaved sexually in another relationship with someone besides Marcie, but he suspects he may have felt suffocated in any relationship that removed his ability to feel as if he had choices.

It was becoming increasingly clear that Ascher was reacting to feelings of being controlled (losing his autonomy) and suffocated. Existentially, this would correspond to Yalom’s dilemmas of freedom and mortality. Ascher’s problematic sexual behavior was likely his response to these internal and unacknowledged conflicts, much like his desire to sneak non-kosher foods when a young boy.

When I mentioned this to Ascher, he responded immediately and enthusiastically that this conceptualization resonated strongly. Ascher then described the strong obligation he felt to not disappoint his parents or to be a poor role model for his brothers. Throughout his life, he felt both proud of and burdened with these responsibilities. The combination of family and religious obligation often made Ascher feel as if his life was not his own, and he struggled with his desires for freedom and autonomy against the perceived constraints imbedded in so much of his life. He reported never having expressed these feelings to anyone before, and this was never explored in his prior therapy. As our discussion continued over the weeks and months, it became increasingly clear to Ascher why he was behaving as he was, and he felt that now that he had a substantially greater insight into the meaning behind his actions, he would have an easier time dealing with them. It was now time to ask Marcie to rejoin the therapy.

Marcie was pleased to participate in the therapy, and she had been doing important work on herself in individual therapy. She reported being pleased with Ascher’s new understandings and insights but found herself struggling with issues of trust. Her existence now also felt threatened, as she saw Ascher as not only someone she loved but also as someone who had the ability to do her great harm and destroy the life that she loved. It was determined that they would be best served by another psychotherapist for couples’ therapy, since Ascher wished to continue his individual therapy and growth with me. Both Ascher and Marcie agreed that this was the best way to go, and I referred them to one of my colleagues who did couples’ work. At the time of this writing, Ascher continues a productive individual psychotherapy with me, and the two of them are doing well in couples’ therapy, having recently begun resuming their sexual relationship.

The case of Ascher again highlights how the penis speaks for distressed men. Ascher shut down sexually when he began feeling suffocated and constrained. First, he pulled away sexually from Marcie. This was of great concern for her, and she began to push Ascher for an explanation. Since Ascher felt unable to express his feelings for fear of acknowledging his “less than pure” urges, he subordinated his emotions and tried to bypass them. He then tried to accede to Marcie’s wishes and continue to interact sexually with her, but his protective unconscious would not let his penis function, and the sexual shutdown took a much harder-to-explain path. All of this was further complicated by Ascher’s frequent use of pornography and sex workers. These outlets, while making Ascher feel extremely guilty, also provided him with the “reassurance” that he was not being controlled and still possessed the autonomy to rebel against expectations. Given the internal conflicts Ascher was battling, it is little wonder that a therapy primarily focused on behavioral exercises designed to increase sexual interest and improve erectile functioning fell short. Ascher’s protective unconscious would thwart all efforts to move into territory that created an existential threat to him. Until those unacknowledged and unexpressed conflicts had been exposed, Ascher was unable to understand, and therefore change, any of his problematic behaviors.

Oftentimes, behavioral sex therapy’s treatment failures alert us to the possibility that something else is going on, and it is in these cases that an exploration of existential issues may be most helpful. In the case of Ascher and Marcie, we see that once again, the penis speaks and, according to well-known psychologist and sex therapist Kathryn S.K. Hall [with whom I had personal communication, sometimes it yells!

***
 

In this chapter, we have explored many of the most salient features of existential sex therapy and how sex therapy with an existential lens differs from most traditional forms of sex therapy. Ascher’s case provides us with an excellent transition to our next chapter, hypersexuality, or what is often referred to as sex addiction. Many of the patients we see in sex therapy practice are not suffering from a sexual shutdown but what appears to be quite the opposite — a pattern of sexual behavior that they find difficult to control and manage. The existential issues in cases of hypersexuality are often most closely aligned with fears of death and mortality. Let&

How to Focus on Emotions to Help Volatile Couples Reconnect

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.  

Questions for Thought

  • What about the case of Camille and Lance challenged you?
  • What did you think about the therapist’s approach to working with them?
  • What are your own strengths and challenges when working with volatile couples?
  • What night you have done differently than the therapist in this case?
  • Did this case make you want to learn more or less about emotion focused therapy? 

Keeping or Ending Commitments, Excerpted from The Ethical Lives of Clients: Transcending Self-Interest in Psychotherapy

Keeping or Ending Commitments

A life without interpersonal commitments is a life untethered. Notice that I did not say a life without “relationships,” which can be fleeting. Commitment comes with obligations and an open timeline. It often involves sacrificing immediate needs. The person I am permanently committed to knows I’m invested in their well-being and makes life plans accordingly. However, if I’m in an intimate relationship that does not involve a permanent commitment, all I owe the other person is a respectful goodbye if I’m ready to move on. The same for most friendships: I don’t owe friends years of hard work (and maybe therapy) to maintain a relationship that has become hurtful for an extended time. In other words, committed relationships have an ethical dimension that simply being in a relationship does not. In the world of therapy, we have barely begun to take the ethics of commitment seriously as we work with our clients. To make this point more charitably: the therapy literature is rarely explicit about the moral dimension of commitment in how we work with clients in relationship difficulty. (There is scholarly work outside of therapy on interpersonal commitment—for example, Stanley, 2005, and Tran et al., 2019.). In this chapter, I focus on how therapists can support (and how they sometimes inadvertently undermine) commitment in two important relationships: marriage (by which I mean a lifelong, intimate relationship) and adult relationships with their parents (particularly as the parents become frail).

Therapy and Marital Commitment

Shortly after I finished writing Soul Searching in 1995, the therapy blind spot with the ethics of commitment came home to me in the form of stories I received from married people who were close to me. In telling their stories, which they gave me permission to do, I am aware that it’s possible that they misunderstood their therapists or did not recall the details correctly. However, they are all credible people to me, and their stories fit a pattern I have heard from many clients over the years about their experiences in therapy. This pattern includes stories from fellow therapists about their experience as clients. In other words, although I can’t vouch for the accuracy of any particular story, I can be confident in the overall trend.

Monica, a relative of mine, called from another city to say that she was stunned when Rob, her husband of 18 years, announced that he was having an affair with her best friend and wanted an “open marriage.”(1) When a shocked Monica refused to consider this alteration in their marriage, Rob bolted from the house and was found the next day wandering in a nearby wood. After 2 weeks in a psychiatric hospital for acute psychotic depression, he was released to outpatient treatment. Although during his hospitalization, he claimed that he wanted a divorce, his therapist urged him not to make any major decisions until he was feeling better. Meanwhile, Monica was beside herself with grief, fear, and anger. She had two young children to care for, a demanding job, and a chronic illness diagnosed 12 months before this crisis. Indeed, Rob had never been able to cope with her diagnosis or with his job loss 6 months after that.

Clearly, this couple had been through huge stresses in the past year, including a relocation to a different city where they had no support systems in place. Rob was acting in a completely uncharacteristic way for a former straight-arrow man with strong religious and moral values. Monica was now depressed, agitated, and confused. She sought out recommendations to find the best psychotherapist available in her city. He turned out to be a highly regarded clinical psychologist. Rob was continuing in individual outpatient psychotherapy while living alone in an apartment. He still wanted a divorce.

As Monica recounted the story, her therapist, after two sessions of assessment and crisis intervention, suggested that she pursue the divorce that Rob said he wanted. She resisted, pointing out that this was a long-term marriage with young children and that she was hoping that the real Rob would reemerge from his midlife crisis. She suspected that the affair with her friend would be short-lived (which it was). She was angry and terribly hurt, she said, but determined not to give up on an 18-year marriage after one month of hell. The therapist, according to Monica, interpreted her resistance to “moving on with her life” as stemming from her inability to “grieve” the end of her marriage. He then connected this inability to grieve to the loss of her father when Monica was a small child; Monica’s difficulty in letting go of a failed marriage stemmed from unfinished mourning from the death of a parent.

Fortunately, Monica had the strength to fire the therapist. Not many clients would be able to do that, especially in the face of such expert pathologizing of their moral commitment. I was able to get her and Rob to a good marital therapist who saw them through their crisis and onward to a recovered and ultimately healthier marriage.

In another case close to home for me, Jessie, a friend of my family, emailed me upset when her new counselor, whom she was seeing for depression and complaints about her marriage of less than a year, suggested that she consider a trial separation from her husband because an unhappy (but not highly conflicted) marriage was keeping her from feeling better. Jessie recounted the exchange: when she told her counselor that she was committed to her husband, the therapist kept repeating that she may not be happy again if she stayed in this marriage and that a “break” might help her. Upset with this counselor, Jessie turned to her priest, who also stunned her by suggesting that if her marriage problems were causing her depression, he could help her get an annulment, given the newness of the marriage. As with Monica, Jessie turned to me to ask whether this kind of undermining intervention was common in the field—and what she should do next.

In another example, the anxious wife of a verbally abusive husband who was not dealing well with his Parkinson’s disease reported that she was told at the end of the first therapy session in her HMO, which offered only brief therapy, that her husband would never change and that she would either have to live with the abuse or get out.(2) She was grievously offended that this young therapist was so cavalier about her commitment to a man she had loved for 40 years and who was now infirm with Parkinson’s disease. She came to me to find a way to end the verbal abuse while salvaging her marriage. When I invited her husband to join us, he turned out to be more flexible than the other therapist had imagined. He, too, was committed to his marriage, and he needed his wife immensely. That was the leverage, along with a change in medications, for him to start treating her better.

One of my students experienced serious postpartum depressions after the births of her two children. She told me that both of the therapists she had seen at different times challenged her about why she stayed married to a husband who did not understand her needs. (Her husband was befuddled by his wife’s moods and sometimes became impatient with her, but he was not, according to my student, a mean-spirited man). In the first session, one therapist said in a challenging tone of voice, “I can’t believe you are still married.” Although it’s fully possible that my student invited these responses by potent criticisms of her husband, it’s the job of a therapist to hold the presenting sentiments of a depressed, postpartum client with a degree of caution before giving advice about ending a marriage. However, as Schwartz (2005) observed, because of our empathic engagement, therapists are “powerfully drawn to our patient’s point of view in their assessment of others” (p. 276).

A final illustration involves a friend who went to a well-regarded therapist for his depression. After a number of months, the therapist requested that his wife come to a session. The following week after the conjoint session, the therapist recommended that, on the basis of what she had observed and heard from the client, he consider divorcing his wife. My friend responded emphatically that divorce was not on the table for him and that he loved his wife and was committed to her. The therapist persisted, maintaining that his marriage problems were complicating his depression. My friend pushed back even harder: “There is not an ounce of interest in my body for divorcing my wife.” The therapist’s final words were, “I’m just asking you to think about it.” As in the other stories, my friend contacted me for help in understanding what had just happened, wondering whether this was standard care in the field. In this case, part of his confusion was that he felt he had received excellent treatment from a therapist he had sought out because of her strong reputation. How could a therapist who seemed so thoughtful and skilled in treating his depression be so clueless and undermining when it came to his commitment to his marriage?

Why Many Therapists Approach Marital Commitment This Way

These illustrations should not be dismissed as examples of random bad therapy or incompetent therapists—or just the biased recollections of the clients. (As I said, although no doubt clients sometimes misinterpret their therapists, when similar stories come up repeatedly, including from colleagues as clients, they cannot be dismissed.) In my view, these stories reveal the challenge for many therapists of how to think about and address clients’ life commitments in situations when those committed relationships are sources of pain and distress. It’s not that therapists deliberately undermine marriages; the rub comes when the marriage seems to be harming their client or keeping them from achieving their therapeutic goals. As I have repeatedly argued, when we lack a way to think about ethical issues in everyday life, we fall back on the mainstream cultural priority of individual self-interest. We challenge clients to privilege their immediate self-interest over relational commitments. This looks like neutrality, but it’s a heavily value-laden stance, one the therapist is usually not conscious of holding in an individualistic culture.

I was not immune to this way of working as a young therapist. I learned to treat the divorce decision with what I thought was neutrality. I remember working with Mary Ann, a 35-year-old woman in an unhappy marriage who wanted individual help to decide whether to keep working to change her marriage or end it.(3) She and her husband had two small children. This was the height of the divorce boom in the 1970s, and a number of her friends had recently left their husbands. Mary Ann felt stifled in a bland relationship with a man who didn’t connect with her emotionally in the way she wanted and who expected her to do the lion’s share of the parenting and housework, along with her part-time job. Sound familiar as a marital complaint? As I sat with her, I realized that I’d never been taught how to work with someone on the brink of divorce. My training in marriage therapy started with the assumption that both parties wanted to stay together, at least for the time being. My training in individual therapy had taught me that my job was to help my clients clarify their feelings, needs, and goals and then make their own decisions without my values and viewpoints getting in the way.

So, I did a kind of rational-choice consultation with Mary Ann, helping her clarify what she’d gain or lose personally from her decision. “How would your life improve from leaving your marriage,” I asked, and “What might it cost you to leave?” I asked the same about staying: “What are the pluses and minuses of remaining in the marriage?” (I was studying statistics at the time and even imagined a two-by-two contingency table!) When she worried aloud about the effects of a divorce on her kids, I responded, “The kids will be fine if you’re happy with your decision.” Mary Ann ultimately decided to file for divorce and start a new life.

Even at the time, I felt odd about treating this client’s dilemma as if it were a decision that only affected her. And I felt sad that another not-so-bad marriage was biting the dust. Not that I’d have admitted this to a supervisor or peer, because a hallmark of a good therapist in my circles was to be cool about the rash of divorces we were seeing among our clients and peers. No one wanted to come across as a moralistic marriage saver. Divorce was a hard-won right and a legally supported, no-fault personal choice. At this point in the early 1980s, Putnam (2020) observed that “expressive individualism framed marriage as a limited liability contract dissolvable with a ‘no fault divorce’—‘expressive divorce’” (p. 152). The common wisdom was that a therapist should not get too involved beyond clarifying the options and supporting the client’s autonomy.

Looking back, I’m struck by my naiveté about what’s involved in leaving a marriage, especially one with children, and my innocence about my lack of influence on the outcome. Like most people facing this decision, Mary Ann was caught in a morass of ambivalent feelings and values. (Harris et al., 2017, documented the volatile ups and downs of divorce decision making). She’d made a lifelong commitment to her husband and now was considering withdrawing it. She wondered whether her expectations for this husband, or any husband, were realistic. She hadn’t done much psychological work on herself and didn’t have an idea of what good marriage therapy might accomplish. She worried about her economic future, and she was deeply concerned about the effect of a divorce on her children, who’d lose their daily connection to their father, take a financial hit, and face a series of substantial life changes. She also believed that her parents and friends would be shocked and upset with her if she left the marriage.

Mary Ann’s journey toward her decision was, like most people’s, highly unstable and marked by ambivalence (National Divorce Decision-Making Project, 2015; Vaughn, 1990). But despite this instability and the high stakes, I treated her as if she were thinking of changing jobs from Walmart to Target: what does each company offer you, and what would be the downside of staying or switching jobs? And, by the way, you owe nothing to your current employer as you make this decision. Maybe her choice of divorce was the best one, and maybe she would have made the same choice regardless of how I’d worked with her. But she deserved a complex therapy to match the complexity of her dilemma, not an oversimplified, “neutral” therapy that failed to engage both sides of her ethical dilemma. Her husband, children, and future grandchildren also deserved better from me. As the novelist Pat Conroy (1978) famously wrote, “Each divorce is the death of a small civilization.”

As therapists, we are midwives for relational deaths and rebirths, the shattering and rebuilding of committed intimate relationships that are at the heart of human experience. But you won’t find much training, writing, or even conversation among therapists about how we handle these moments in therapy. The result is that we’re each left to make things up on our own, mostly using the implicit ethical norms embedded in our culture and profession.

Adults’ Commitments to their Parents

Riding in an elevator once in Singapore, I saw a sign for one of the floors of the government center labeled something like “Parent Court.” When I inquired, I learned that it was a place where parents who felt neglected by their adult children could seek the help of the court to enforce filial obligations. I knew I wasn’t in Kansas anymore! In the United States and similar Western countries, adult children have no legal obligations to care for their parents (just as the parents have no legal obligations to their children when they turn 18). Adult familial relationships are voluntary in the ethical realm, not the legal one.

The field of psychotherapy has been hard on parents from the beginning, seeing them as primary sources of the pathologies in their offspring. Whether it’s toilet training in traditional Freudian theory or inadequate attachment bonds and authoritarian or permissive discipline in contemporary models, there are plenty of parent deficiencies to sort through with clients in therapy. However, I suspect that the working assumption among therapists was that you could work to recover from poor parenting in the past while still having a relationship with your parents in the present. That began to change in the 1980s with the rise of cultural interest in “the dysfunctional family,” including intrafamilial sexual abuse and codependency on problematic parents and other family members (Bass & Davis, 1988). Parents were not just toxic influences from the past; they were continuing to harm their adult offspring in the present. What’s more, they could be a threat to their grandchildren.

From the mid-1980s through at least the mid-1990s, many therapists joined the recovered memories movement in the field, believing without evidence, for example, in the near pervasiveness of multiple personality disorder brought on by intrafamilial sexual abuse (Acocella, 1999). I recall case consultations where therapists, again without evidence, said that 90% of women with bulimia had a history of incest in their families. The next wave was about the since-discredited claim of widespread satanic ritual abuse of babies and children. The upshot was a wave of therapist-encouraged cut- offs from parents and often from other family members who did not accept the claim of that abuse. Parents would receive “goodbye” letters, crafted with the encouragement of therapists, from their adult children, especially their daughters, who were more apt than their sons to be in psychotherapy. Our field got caught up in a huge wave of cultural negativity about family life (Wylie, 1993).

Eventually, there was a cultural pushback, highlighted by a New Yorker article and subsequent book by investigative journalist Lawrence Wright (1994) on satanic cult accusations and an acclaimed PBS Frontline episode, “Divided Memories” (Bikel, 1995), which featured a high-profile therapy clinic where nearly all clients were encouraged to achieve the goal of “detachment” by cutting off from their parents and, in some cases, from their spouses and even their children while they recovered their sense of self. In these and other cases around the country, the therapists involved were proud of their work and had a theoretical model behind it (if no research data). After successful lawsuits ensued, therapists quietly abandoned their practice of suggesting family abuse via recovered memories, and they stopped taking as accurate the notion of large numbers of dead babies as a result of satanic cult abuse.

But the idea of a therapeutic cutoff from parents (and siblings who ally with the parents) had been loosed in the field and continues in practice and books by therapists for the lay public, such as Campbell’s (2019) But It’s Your Family…: Cutting Ties With Toxic Family Members and Loving Yourself in the Aftermath. That author described in detail how she came to cut off all contact with her pathological father and mother, and she urged the same for her readers after they evaluated whether the criteria she offered fit their parents.

In the mid-1990s, as my own children were entering college, I gave a presentation to a group of college counselors that included interns and staff. The topic was the value of seeing college students as members of families instead of just as emancipated individuals. I will never forget an exchange with a junior staff therapist who asked, “Aren’t there times when the student’s family is so toxic, not only in the past but also still now, that it’s best that the student break off a relationship with them?” I replied that I had seen some tragic cases where the past abuse was not only denied but also continued with intensity and that in those cases, it can be useful for a young person to take a time-out from connecting with family. Then I thought to ask, “I’m curious. For what percentage of your caseload do you believe a family cutoff would be called for?” I froze in my chair when he said, “Maybe 40%.” The chill I felt was that I was soon to launch my oldest child to college—what if he developed emotional problems and saw this therapist? No one present offered a counterview, and we moved on after I mumbled something about this not being my experience. In retrospect, I wish I had challenged him about how he came to his perspective. It was a failure of nerve on my part that I vowed never to repeat.

I have heard many clients report encouragement by therapists to end relationships with parents and other family members, and I’ve seen this in my extended family. These days, whenever I hear about a definitive cutoff from family, I ask whether there is a therapist in the picture. To be clear, I believe that these therapists want to help their clients avoid unnecessary emotional pain by encouraging them to exit relationships that continue to cause this pain. It’s not that therapists hate families or that there are never situations that call for a strategic time away from abusive family members (in my mind, always with the hope for later reconciliation). Rather, these therapeutic interventions reflect a cultural orientation where all relationships are transactional—what is the benefit I am gaining versus the cost to my well-being? If the relative psychological cost of maintaining a family relationship is too high, the healthy thing to do is to end it. I later return to the case of Laura, whose story opened this book on the note of adult commitment to a difficult parent. Here I just note that Laura told me that she had several therapist friends who encouraged her to “ditch” her mother. Missing here are two ideas: first, that parent–child bonds are not psychologically disposable—they go on until the death of the parent and beyond—and second, that there is an ethical dimension to the parent–child (and other family) relationship. A permanent cutoff means that adult children have no moral obligation to respond to their parents’ current needs and the eventual frailty and end of life. These two levels—psychological and ethical— go together. Like it or not, we are emotionally tethered to our parents and they to their adult children. Therapists come and go, but not parents. As I’ve heard the psychologist Mary Pipher (2008) say, “Nobody calls out for their therapist on their deathbed” (p. 2).

I don’t have a one-size-fits-all formula for obligations to parents, especially when the parents are in need of support and help. There are so many factors, including the history of the relationship. Obligation to a parent who abandoned you at birth and has now reentered your life wanting support will look different from obligation to a parent who has shown consistent care and support over the years. How much to be involved personally, with openness and vulnerability, with a frail or dying parent will depend on how much emotional safety there is in the relationship. Then there is the complex issue of what forms of help are, well, helpful. As asked earlier in this book, when is taking a parent home to one’s own house the best decision for all concerned versus placing the parent in a care facility? Culture comes into play here: in some cultures, an out-of-home placement is seen as an act of cruelty, while in others, is it considered loving when done at the right time. My main point here is that the job of the therapist is to help the client navigate these difficult waters, discerning the interests of the self, parent, one’s spouse and children, and others. Moral foundation theory can help to sensitize us to competing ethical intuitions: care/harm, fairness/reciprocity, and respect for authority seem particularly relevant here. Good ethical consultation does not mean that the therapist has the answers but that the therapist honors the client’s commitment to parents in light of all the other factors involved.

The Craft of Ethical Consultation about Commitment

I use the LEAP-C (listen, explore, affirm, offer perspective, challenge) skills to demonstrate strategies for ethical consultation when commitment to a marriage or a parent relationship is on the table—that is, when a client is struggling about staying in a marriage or about cutting off or withdrawing support from a parent in need.

Listen

Listen for the ethical part of the client’s decision making. For marriage, it might be a dilemma over personal happiness versus the original commitment or the needs of the children. For adults with their parents, it might come out in the form of the client’s guilt, sometimes accompanied with resentment, over not doing enough for one’s parent. As with all forms of listening in ethical consultation, it’s important to give a full hearing to both sides of the dilemma and to how the client is expressing a number of moral intuitions in light of their life experience and their culture, including intuitions such as authority and loyalty that do not come readily to mind for a Western therapist. In Laura’s situation with her challenging, soon-to-be-frail mother, I listened carefully to her ambivalent feelings and thoughts: on the one hand, self-protective ones for herself in the face of current and future burdens (the current one focused on her mother’s criticisms, and the future one added caregiving) and, on the other hand, a sense that it would be wrong to cut off her mother. Her friends were listening mainly to the self-protective side of her ambivalence. Laura said she came to me for therapy because she believed I would also listen to the other side.

Explore

The nuances emerge during exploration. For parent dilemmas, these include the quality of the relationship now and in the past, the possibility of manipulation versus genuine need, the availability of other caregivers such as siblings, and the resources of the client to help the parent in light of other obligations. Often a decision will emerge from this exploration, one that the client can live with in terms of resolving the tension between personal needs and responsibility for parents.

For Laura, the exploration revealed the details underlying her sense that she could not just walk away from her mother: it didn’t seem right as the only child of a widowed parent. But she also lived with an emotional burden of listening to her mother’s weekly phone monologues about how others don’t treat her fairly, including her daughter. Her mother also offered critiques of Laura’s mothering (those hurt the most). I especially paid attention to how the client responded to her mother on these calls, uncovering how passive and annoyed she would become but not set limits. This exploration opened up possibilities for her to remain regularly in her mother’s life while building healthier boundaries.

In terms of marital commitment, the following is a series of exploratory questions that I developed for a specialized approach to couples work called discernment counseling, where at least one spouse is considering ending the marriage (Doherty & Harris, 2017):

  • What has happened to your marriage that has gotten you to the point where you are considering divorce? Notice that this is not framed as “What are the problems?” or “Why are you unhappy?” but in terms of the marriage being a major part of the client’s life that is now under question.
  • What have you or your spouse done to try to repair the relationship—to fix the problems before you got to the point where divorce is on the table? This question carries the assumption that marital commitment is worth an effort to find a way to maintain—the relationship deserves repair attempts if it’s broken.
  • What role, if any, do your children play in your decision making about the future of your marriage? This delicately crafted question brings the needs of the children into the conversation in a way that gives the client space to respond in a variety of ways.
  • What were the best of times in your relationship since the time you met— the times you had the most connection and joy? This question brings clients back to what they used to love about their spouse and what led to their original commitment.

The point behind questions like these is to show that exploring ethical dilemmas over commitment can involve more than “tell me about both sides of your struggle.” There are lots of nuances and often more than two stakeholders— for example, third parties such as children who will be affected by the decision. Laura, for example, weighed the effect of a parental cutoff on her children, who would grow up without contact with the grandmother.

Affirm

Affirming involves acknowledging and supporting the client’s ethical commitments. In Laura’s case, I explicitly affirmed her moral sense that she should not take her therapist friend’s advice to “dump” her mother like a bad boyfriend. I used words like these: “I appreciate that you want to do right by your mother even though she’s a difficult mother. It’s not easy, but you’ve decided it’s important that you stay in her life, especially at this time when she’s pretty much alone.” Laura sat up straighter in her chair and said, “Right. That’s the path I have chosen. Now I want to figure out how to do this and keep my sanity.”

Affirmations on divorce decisions are trickier because of the inherent volatility involved for many clients in coming to a conclusion. When clients bring up their ethical concerns, say, about their marriage vows or the children, I affirm them without suggesting that those concerns are determinative—they don’t necessarily mean staying in the marriage. It’s just that commitment has an important role in the decision. In contrast to how I used to dismiss these concerns, I’ve learned to simply acknowledge and accept them with language such as “I appreciate that you are taking seriously your original commitment to your marriage; leaving is not something you take lightly,” or “I hear your concerns about the children, and I’m glad you are taking these concerns seriously. There is a lot at stake all around.” By the way, many older clients with adult children and grandchildren are concerned about hurting these stakeholders. I affirm that concern as well. And, of course, I affirm the client’s right to think about their pain and harm to self from staying in a bad marriage and their concerns that a highly conflicted marriage can also be harmful to the children. That’s why it’s an ethical dilemma: there are legitimate needs and claims in tension.

Perspective

As mentioned, it’s often not necessary to share one’s perspective on an ethical dilemma because clients sort out how to proceed with the help of the listening, exploring, and affirming skills. In situations when commitment is in play, however, clients can often benefit from the therapist’s perspective on how to have a healthy, satisfying life while maintaining commitments to others, such as a difficult spouse or a burdensome parent. Self-sacrifice for the sake of ethical commitments can be difficult to sustain and, in some cases, may not be healthy or wise (as with an abusive spouse who will not seek help).

In the case of Laura, I shared a perspective this way:

ME: I hear you on your desire to be a supportive daughter to your mother—saying goodbye to her is not an option for you. Now let’s talk about how you can support her in a way that’s healthy for you. The current situation is not working: you feel burdened by her weekly calls, stressed for a day beforehand, and upset for a day or more afterward. You go through the week with negative thoughts about her and then feel guilty for being so negative. Do I have that right?

LAURA: Yes, exactly.

ME: So, your bind is that you don’t feel like a good daughter when you are in touch with her, and you would not feel like a good daughter if you abandon her. [Notice that I used explicitly ethical language— “good daughter”—because the client had been using that kind of language. I did not substitute nonethical language such as “responsive” or “measuring up”].

LAURA: Oh, my, yes!

ME: So, let’s think together about two things: what might be going on for your mother that she acts this way and how you can learn a healthier way to interact with her. Right now, it doesn’t seem as if you have good boundaries with her on the calls—you let her go on and on, and when she criticizes you as a mother, you’ve said you defend yourself and feel angry at her. My idea is that we would work to find a way for you to have healthy boundaries with your mother on these calls so that you feel you are there for her and protecting yourself at the same time. And by the way, it’s not healthy for your mother when she treats you poorly. So, a better-boundaried relationship would be good for both of you.

Here, I was offering a perspective on how Laura could take care of herself and her mother at the same time. Over the course of our work, she did find helpful ways to listen to her mother’s complaints about her life while at the same time setting firm limits when her mother started to offer personal criticism of Laura’s mothering. All of this was standard therapy work on my part. The point of emphasis for present purposes is that I framed this, in part, as ethical work, a way to resolve a moral challenge for the client who had wondered whether it was unhealthy of her not to walk away from her mother as others, including her therapist friends, had advised her.

In terms of offering perspective on divorce decisions, a key is to honor both sides of the ethical dilemma in two main ways:

  • Normalize the dilemma. It’s hard to know the right decision when dealing with ongoing personal suffering and hopelessness in a marriage, along with struggles about abandoning one’s commitment and putting one’s children at risk. And most people go up and down in their decision making.
  • Share concerns. When a client seems to be making an impulsive decision to divorce (say, right after learning of a spouse’s affair), the therapist can share some general wisdom about the value of slowing down in making a lifetime decision. I like to use the phrase of a wise collaborative divorce lawyer: “Divorce is never an emergency; it takes months to play out.” A separation can be an emergency decision when there is threat and risk, but deciding to divorce rarely has to be done immediately and in emotional turmoil. Another example of perspective is when a client seems to be downplaying a future consequence of a divorce. I recall a married man who thought that his adult children would readily accept his lover (because she was such a great person) if he ended the marriage to be with her. I offered an alternative perspective so that he could be more realistic in his decision making: the likelihood of resentment from his children, at least for some time. A final example was a client in a volatile marriage who said that he could just stay away from his wife until the last child left home in 6 years. I offered that I’ve seen this work sometimes for couples who already have a lot of distance and little conflict, but I wasn’t sure it would be feasible in his more engaged, high-conflict relationship, especially if it was his unilateral decision to stay married but be functionally single.

Challenge

To discuss challenges in intergenerational commitments, I switch to parent-to-child commitment because it’s more commonly needed there. Recall my discussion in the Introduction about Bruce, who was about to move away and abandon his children after his wife kicked him out of the house. When I asked him the exploratory questions of how he thought leaving his children would affect them, he replied, “I’m sure it will bother them for a while, but they’ll get over it before long.” Given the urgency of the risk (Bruce had come to what he said was a final session to wrap up our work before he left town), I decided to immediately challenge him with these blunt words: “I don’t think so. Walking out of their lives will affect them for a long time, even permanently.” Bruce soberly replied, “I know you’re right.” I asked why he thought what I said was right. “They will feel hurt and not understand why this happened. You know, I left my daughter in California the same way, and I think about how it affected her. I don’t want to do that again, but I don’t know if I can go back to that house and see my wife, not in the state that I’m in.” Bruce and I were now in accord that he wanted to keep his commitment to his kids. Our work now was to figure out how to do this while maintaining his fragile emotional equilibrium.

Ethical challenges require a caring relationship so that they don’t come across as judgmental. I recall a divorced father who learned that his 7-year-old son was calling his new stepfather “Dad.” My client felt terribly hurt and replaced. I empathized with his feelings. Then he told me that he had told his son that day that if he ever heard that he was calling his stepfather “Dad,” he would never see the child again. I was shocked and worried for the child, but I held on to the craft of ethical consultation by first connecting with my client:

ME: Joe, I know you are in a lot of pain about your divorce and scared to death about losing your kids’ love and affection. And I know that you would never intentionally harm your children. [Slight pause] I also have to tell you that what you said to Bobby probably hurt and wounded him and left him fearing that he could lose you. You are the only father he has, and he should not have to live with the fear that if he slips and calls someone “Dad,” he will lose you forever.

JOE: [Looking worried] Do you think he could feel that way? I just wanted to get through to him about me being the only one he calls Dad.

ME: I’m really worried for him right now. That was a big threat you made to him.

JOE: I can see it now. I was beside myself upset, and I took it out on him. What do I do now?

We went on to discuss how he could repair what he had done, beginning with contacting his son right after our session. We went over the words he could use to apologize and offer reassurance that his commitment was forever and not contingent on something his son would say.

Most therapists would be with me in cases of parent commitment to young children: ethical challenges can be appropriate there. When it comes to marital commitment, many therapists take a neutral stance on whether clients divorce and would be reluctant to go beyond sharing perspectives for the client to accept or not (Wall et al., 1999). My view is that while there can be good reasons to let go of a marital commitment, it’s a weighty ethical decision because it affects the welfare of at least one other person who made life decisions based on an expectation of continued commitment, and usually, there are additional stakeholders such as children and extended family members. Therefore, I am willing to challenge clients when I believe they are not including concern for other stakeholders in their decision making. Keep in mind that challenge generally only comes after using the other skills of listening, exploring, affirming, and offering perspective. Here are some examples:

  • Challenging a client to seek couples therapy. “I’m concerned that you are leaving your marriage without seeing whether it could become healthy again through good couples therapy.”
  • Challenging a client to let a spouse know the marriage is on the brink. “I realize you don’t think your spouse can change. Maybe so, maybe not. What I want to challenge you about is not signaling to her that you are so unhappy that you are considering divorce. It seems to me that she is owed a chance to see whether she wants to make changes that might preserve the marriage. She’s flying blind now.”
  • Challenging a client about ending a good-enough marriage when the client is depressed or in personal crisis. This challenge can take two forms: appealing to self-interest (“I’m worried that you will do something that you will regret when you are in a better emotional place”) and appealing to the interests of others (“This decision is going to affect a whole lot of people, such as your kids, and I’m worried that it’s hard for you to fully consider those consequences when you are feeling the way you do. You could look back with regret about the fallout”).

I end this chapter’s discussion of ethical commitment with words I wrote in Soul Searching:

Our therapy caseloads are like Shakespearean dramas suffused with moral passion and moral dilemmas. But we have been trained to see Romeo and Juliet only as star-struck, tragic lovers, while failing to notice that the moral fabric of parental commitment was torn when their families rejected them because of who they loved. We focus on the murder of Hamlet’s father and Hamlet’s own existential crisis, rather than on how Hamlet’s mother abandoned her grieving son. Commitment to loved ones, and betrayal of that commitment, are central moral themes in the human drama played out in psychotherapy every day. (Doherty, 1995, p. 46).

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From The Ethical Lives of Clients: Transcending Self-Interest in Psychotherapy, by W. J. Doherty Copyright © 2022 by the American Psychological Association. All rights reserved.

References:

1. This case example is from “Bad Couples Therapy: How to Avoid Doing It,” by W. J. Doherty, 2002a, Psychotherapy Networker, (November/December), pp. 26–33 Copyright 2002 by The Psychotherapy Networker, Inc. Adapted with permission.

2. This case example is from “Couples on the Brink: Stopping the Marriage-Go-Round,” by W. J. Doherty, 2006, Psychotherapy Networker, (March/April), pp. 30–39. Copyright 2006 by The Psychotherapy Networker, Inc. Adapted with permission.