Couples Archives - Page 3 of 4

Infertility on Both Sides of the Couch

Posted on September 20, 2013February 11, 2026 by rezendevknowfully.com

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

“I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished.” Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? “Should we start putting money into a college fund? Or should we begin grieving about not having a child?”

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. “How could she brutalize her body from treatments and spend so much money to conceive and carry?” I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. “The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments.” We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. “She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns.” She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.

Motivational Interviewing in End-of-Life Care

Posted on May 25, 2012February 11, 2026 by rezendevknowfully.com

Betty: A Case Study

When Betty answered the door and welcomed me into her living room, I couldn’t help thinking she looked almost like a different person from the Betty I’d seen just the day before: a neatly dressed, very composed 80-year-old woman. Today, her clothes were messy, her hair was disheveled, and she had bags under her eyes. Her husband, Frank, was resting in their room after his morning nursing visit. He had been diagnosed with prostate cancer a year earlier, and the treatment had been unsuccessful. The hospice team of which I was a member had been called in to assist with the final few days of his life, which is why we had met Betty and Frank the day before.

The nurse, spiritual counselor, and I had visited the couple in their home, as this was where Betty and Frank preferred for him to pass away. During the initial visit, Betty had engaged appropriately, was very pleasant and cooperative, and asked common questions about what to expect in this process. She had hired a caregiver for further support. She seemed to be coping well and had a strong supportive network with her children and neighbors. Frank had been a bit lethargic, but was able to engage with us as we discussed his care over the next few days. The visit had gone smoothly; we hadn’t expected any unusual problems.

But the morning after the initial visit, the nurse called me explaining that she had completed her daily visit and Frank had declined significantly overnight. He had been very lethargic and difficult to arouse during her assessment. Betty had asked the nurse if she could feed her husband, since he had only a few bites of food at dinner the night before and had not had breakfast. The nurse had informed her of the risk of feeding when a patient is closer to death, but felt that Betty was very resistant to this information. The nurse was calling me to ask if I could meet with Betty to address this resistance.

As a social work intern, this would be my first meeting alone with a client. As I was simultaneously enrolled in a graduate course on Motivational Interviewing, I decided to put my beginning skills to use.

Engaging the Client

I began by checking in with how Betty had been feeling since our visit the previous day.

“I feel good,” she said, “but I had a hard night last night with Frank waking up several times. He was moaning and confused, and even tried to climb out of bed. It really scared me, but I was able to call hospice and they walked me through giving him some medication to calm him down. It worked quickly and I was able to get some rest for a few hours.” She paused and touched her forehead absently. “I’m glad to have our caregiver here this afternoon so I can lie down and get more sleep. She was so helpful yesterday.”

I remembered from my MI course that open-ended questions, affirmations, reflections, and summaries (OARS) are key to building rapport and conveying empathy and understanding. When clients feel heard, they are not only more inclined to engage with the practitioner, but they are also more comfortable processing their ambivalence, and eventually reaching a resolution. I knew that Betty had had a fraught conversation with the nurse that morning, and that she must be feeling overwhelmed, so even though we had limited time, both in the session and in terms of Frank’s life, I began slowly.

“Wow,” I said. “It sounds like you had a difficult night caring for him. Caregiving for someone in the dying process is challenging. I’m really impressed that you’ve been doing this, while also recognizing you need some help and have hired a caregiver. I’m glad you called our main line for support, too. We’re always available to help.” The simple reflection and affirmation I used helped us start the visit well. Betty knew I was present and listening to her. I was also able to validate and affirm the challenges of providing caregiving at end-of-life and how well she was doing.

“I understand you met with the nurse this morning,” I continued, now that I saw Betty relaxing a bit in my presence. “How did that go?”

Betty paused and her voiced dropped. “Fine. She told me I should stop feeding my husband, but that’s hard because he could be hungry.” She paused again and then raised her voice. “She said that feeding him could hurt him, though. I’m not going to be the one to kill him!”

I reflected that Betty felt confused about what the nurse had told her about feeding.

Betty raised her voice again and spoke more quickly. “It’s really confusing. And it’s like she doesn’t really understand where I’m coming from.”

“She doesn’t see how much you value feeding Frank,” I nodded.

This exchange confirmed for me that Betty was struggling with understanding and accepting that her husband no longer needed to eat or drink as he was declining quickly. As the nurse had explained to her, feeding him would have likely caused more harm because as his body declined, it would not metabolize food and fluid as well, which could cause increased toxicity, pain, and discomfort.

Given the medical nature of this information, and especially because of the urgency of the situation, with Frank having only a few more days to live, it would have been tempting to believe that Betty’s inability to understand could be solved by intellectual persistence: maybe if someone explained the details to her again, she’d “get it.” But using an MI framework, I saw clearly that Betty needed to be met emotionally in her struggle before she could comprehend the medical problems that continuing to feed her husband would create.

In situations where there is a clear preferred outcome, it is often challenging for counselors and other helping professionals to steer away from what in MI is called the “righting reflex,” the temptation to tell the client what is best for her and what she ought to do. But this technique does not support client autonomy or self-determination, and defies the MI belief that the client is the expert. It also tends to pit the client against the therapist as an adversary or an authority against which to rebel. Telling Betty to stop feeding her husband could have caused her to shut down and damaged any trust she had in me that I understood her situation. Furthermore, the righting reflex may have robbed Betty of the opportunity to process her loss.

Change Talk

It is important to note that Betty acknowledged that she heard that feeding could be harmful and even said, “I don’t want to be the one to kill him.”

MI emphasizes two concepts called “sustain talk” and “change talk.” Clients engage in sustain talk when they discuss the status quo, or give reasons why they cannot make a change. Betty had been engaging in sustain talk thus far in our conversation, going through her reasons for believing she should continue to feed Frank. Change talk, which is any mention of change as a possibility, marks a client’s willingness and preparedness, however slight or tenuous, for change. A clinician using MI should emphasize and explore a client’s change talk through reflections and open-ended questions. This allows the client to focus on change rather than maintaining the status quo.

Betty’s statement that she didn’t want to be the one to kill her husband identified her ambivalence and was an example of change talk. It let me know that Betty was open to exploring the possibility of refraining from feeding her husband in this final stage of his life, though clearly she had not yet reconciled herself to this option.

Before we examined the change talk, I wanted to reflect Betty’s ambivalence and confusion while stressing how much Betty loved her husband and wanted nothing more than to give him the best care possible. “You’ve really taken on the role of being his caregiver and part of that role is feeding,” I began gently. “The way you see it, just because he’s at the end of his life doesn’t mean you should stop that role now. And as you said, he could be hungry.”

Betty sat forward in her chair. “Exactly!” she exclaimed.

Sensing I had struck a chord with her, I continued. “You also said that you heard the nurse explain that feeding could be harmful.” Here I was able to focus on both sides of the issue: one the one hand, feeding was part of her role as caregiver, and on the other, she was aware that it was risky and could likely cause more harm, which she didn’t want.

“Yes, but I don’t really understand why,” Betty said, her voice heavy now, and she slumped back in her chair a little. “I know if people don’t eat, they die, so I don’t want to have that guilt that I’m not feeding him and he dies. He’s my husband, and I want to do the best job I can.”

Noting that Betty was moving back into sustain talk, I continued with affirmations and reflections to build a sense of alliance. “You have taken excellent care of your husband, and your family, for the sixty-four years you’ve been married. Feeding is not only part of caregiving, but also a way you show your love for him, which is something I definitely understand. It sounds like if you stop feeding him you’re scared that it could hasten his death, which would make you feel guilty, like you’re responsible for him dying.” I was able to use this complex reflection—drawing on Betty’s implied statements and feelings as well as the words she spoke—to assign meaning to the feeding, explore the sadness of her changing role as a wife, and allow her to process the fear of hastening her husband’s death.

“Yes,” said Betty. “I’ve taken care of everything all these years. The cooking, cleaning, laundry, shopping. And he likes that I do those things. I want to take the best care of him all the way until his last breath.”

I affirmed her role by saying, “Something I’ve seen from you in the times we have met is that you are a very dedicated, loving wife, who wants nothing more than to care for your husband, especially at the end of his life.” I began to understand that Betty’s roles as wife and mother were not only central to her relationship with her family, but also to her personal identity. Although cooking and her other activities seem like minute household chores, these activities were how Betty showed her love for her husband and children. If she was no longer feeding, how could she express her love, especially at this most intimate time in life?

As I reflected Betty’s deep desire to provide the best care to her husband in his dying process, she became tearful. “I’ve cared for him for so long,” she said, “and I’m feeling very overwhelmed about this. I just can’t believe he’s dying. We’re high school sweethearts. I can’t remember life without him.”

I could really empathize with Betty in that moment. Although she had been able to understand intellectually that her husband was terminal, the emotional impact of the dying process weighed heavily on her. Thinking about what her life would be without her husband was devastating. “This experience has been really difficult and emotional for you,” I said. “It’s hard to even imagine life without him.”

With tears filling her eyes, all she could say was, “Yes.”

Ambivalence, Not Resistance

I was sensitive to not push her too far. We still needed to address the feeding, and if she became overwhelmed with grief, it would have been inappropriate to have that conversation. So I continued to affirm her. “I see just from listening to you that you and Frank are so incredibly in love and have been for a long time. You’ve created an incredible life together, have two wonderful children, three beautiful grandchildren, all are an extension of you two and represent your life and your love for each other.”

Reflecting on the lives patients and families have shared is a vital component in helping them experience a peaceful death with dignity. Processing their lives affirms they were special and facilitates closure. Here, affirming Betty’s desire to continue providing loving care helped her to feel understood and acknowledged. My acknowledgment of the specialness of her bond with Frank seemed to calm her down a bit.

I decided this moment was the opportunity to provide some education about Frank’s state, but first I needed to ask permission. Asking permission is essential in MI because it gives the client control of the session. In a careful tone I said, “Maybe if we could clear up some confusion about the feeding, then that could help you feel a little better and assured that you are taking the best care of Frank. Would it be okay if I shared some information with you about feeding at end-of-life?”

“Yes, I’d be okay with that,” said Betty. “The nurse just didn’t explain it to me well.”

“I can understand,” I said. “Sometimes we think it’s clear because we have this discussion often, but the family needs a little more education and I’m happy to provide that.”

“Yes. I just cannot understand how eating could be harmful.” She had become quite agitated again, her shoulders tense and limbs tense.

Maintaining a gentle tone, I explained, “It seems very unclear because when the body is healthy, it needs nutrients from food. As a person gets closer to death, the body doesn’t need the same amount of nourishment as it did when it was healthy. The body slows down and its metabolism slows down, so the food cannot be broken down at the same speed as when the body was healthy. Now that Frank’s body is slowing down, he can’t digest food in the same way, so the food and liquid gets kind of stuck in the body, causing more harm than good. I know that sounds strange, but does that make sense?”

She seemed puzzled. “So he can’t break down the food?”

“Exactly,” I told her.

I was becoming hopeful that Betty was beginning to understand the risks of feeding and we were about to make a break in resolving her ambivalence. But then she responded, “Well, what if I just give him less food?”

I suppressed a twinge of impatience. That question made me see that she was still unsure and possibly resistant to stopping the feeding. But although resistance can sometimes be frustrating for practitioners, an MI practitioner always rolls with the resistance and should avoid the righting reflex in times of client ambivalence. Betty’s question was simply her way of expressing that she was still unsure what was right.

Resisting the urge to use the righting reflex, I calmly said, “Well, sometimes that can be okay, but if the food is not soft and thick, there is a risk that it could go into his lungs and he would aspirate. That could cause an infection and actually hasten his death.”

My hopes that this education would help move discussion along were quickly halted when Betty said, “Oh. Well I’m glad to know this, but even if I gave him just a little, it couldn’t hurt him that badly, right?”

A Circuitous Route to Change

I was unsure how to move Betty out of her now entrenched sustain talk. Betty was trying to argue for feeding, even just a small amount of food. Sustain talk can be difficult to address, so I decided to offer some compromise and then affirm and reflect. With empathy, I said, “Well that is something that we can discuss with the nurse. I would just like to affirm what the food represents in your relationship. This is the way you’ve shown your love for your whole marriage, so that’s hard to stop that now. I know you don’t want to hasten his death by not feeding, but the scientific knowledge we have indicates that feeding could be more harmful.”

Betty immediately interjected with more sustain talk. “But he may be hungry,” she protested.

“I think that’s a great point,” I replied. “Unfortunately, we don’t know for sure if he is hungry or not.”

Betty interrupted and asked, “Do you think it’s better to not feed him because it’s more dangerous?”

I realized that Betty was looking to me as an expert, and as the hospice social worker, I was more of an expert on the issue. This is another temptation to resort to the righting reflex and simply use my authority to tell her she couldn’t feed him. But I reminded myself that this was Betty’s life and I did not know what was best for her. Any decision I made for her, she could still reject. She had to come to it herself. Furthermore, I needed to support her self-determination and autonomy. “Well, I think it’s better that you do what you feel most comfortable with,” I told her.

Betty appeared to appreciate this point as she sat back in her chair and relaxed her shoulders. My statement affirmed her autonomy and validated that I supported her self-determination. I realized I may not have acknowledged before that the choice had to be hers.

Although Betty had relaxed, she was somewhat hesitant. “I just don’t know,” she said. “This is so hard.”

I knew then that I needed to help Betty navigate the pros and cons of this decision. For this, I used an MI technique referred to as a decisional balance. Betty already had the information about the advantages and disadvantages of feeding and not feeding, but I needed to help her sort through them.

I asked Betty, “Well, what are some of the dangers of continuing to feed Frank?”

Betty reflected for a moment. “Well, he could choke. And you said the food could get stuck and he could aspirate.”

“Yes,” I replied, adding, “The body also cannot digest the food well, so it could store in his body and cause an infection. And what are some of the good things about continuing to feed him?”

Betty looked puzzled, but said, “Well, he wouldn’t be hungry.”

I gently replied, “Yes. If he is hungry, which we don’t know for sure and likely never will, the food could satisfy his hunger. But if the food doesn’t break down correctly or pass through his stool, then it could be more painful for him.”

Using the term “pain” seemed to resonate with Betty. Her eyes widened and she sat up in her chair. “Oh! I hadn’t thought of that. It could cause him pain?”

“Yes, think of it like this: if you eat more food than your body can handle, you get a stomachache. Now imagine not being able to get that built-up food out through your stool. That’s likely what it feels like.”

Betty smacked her arms down on the armrest and said, “Well, I definitely don’t want him to be in pain. Do you think that his pain and agitation last night was because I gave him some mashed potatoes?”

Betty seemed ashamed by this prospect. She moved in her chair and did not make eye contact with me.

Sensing her uneasiness, I softly said, “You know, we will probably never know. I’m glad that you knew to call for help when he was having new symptoms. That was very intuitive and shows that you knew what to do in a crisis.” I did not want Betty to feel guilty, because a number of factors could have played a role in her husband’s symptoms.

I wanted to return to the decisional balance to speed up our arrival at Betty’s decision about feeding her husband. “What are some of the bad things that could happen if you stop feeding him?” I asked.

“Well he could be hungry and that would make him more uncomfortable. But after talking to you, I'm not sure if he would be hungry because maybe he’s just too sick to be hungry,” Betty said sadly.

“So you’re thinking maybe he’s hungry, but we don’t know for sure. You also see that he could be far enough along in the disease process that his body isn’t feeling hungry anymore.” She nodded. To continue with the decisional balance, I asked, “And what would be the benefits of not feeding him?”

“Well you said that feeding could cause infection, so if I don’t feed him hopefully he won’t get sicker. Maybe he would live longer?”

A Breakthrough

I was so relieved to hear change talk: an acknowledgment of the possibility that Betty might stop feeding her husband. I felt that we were finally getting somewhere with her ambivalence. “He could live longer, and maybe even be more comfortable,” I told Betty.

“Yes, I want him to be comfortable,” Betty nodded.

“I want you to know that we really do understand how confusing it is to not feed your loved one at the end-of-life,” I affirmed. “It seems so unnatural because feeding is typically associated with us feeling better. And also with your relationship, feeding is not only part of your role as his caregiver for the past sixty-four years, but also the way you show him how much you love him.”

I wanted to ensure I normalized Betty’s ambivalence regarding feeding at end-of-life, as this is something that hospice clinicians discuss with families every day. Like many therapeutic interventions, normalizing is useful in MI because it makes clients feel comforted that they are not alone. This is especially critical in hospice because family members often feel isolated as their loved ones transition through the dying process. Affirming and normalizing Betty’s confusion regarding feeding, while also providing a complex reflection of Betty’s role as caregiver and how she expressed her love, helped us transition from the issue of feeding to ideas for how Betty could continue to express affection towards her husband in his final days.

“If we can brainstorm together other ways you could express your love,” I continued, “then maybe we can implement those into your caregiver role. Maybe things that are less risky, like reading to him, holding his hand, playing music for him. How does that sound?”

“That sounds nice. He loves reading.” A note of relief emerged in Betty’s voice. “We used to go to the library together and get books. Sometimes he’d read to me at night.”

“Wow,” I replied, “that is really special. So now you could maybe do that for him.”

She paused briefly. “Yes, I think he would like that. But can he hear me?”

Again, I wanted to avoid jumping into an expert role here, especially with what must have been an emotionally loaded question for Betty. “Well, what do you think?”

“I’m not sure,” she said. “He doesn’t respond like he can.”

“Would it be okay if I gave you some information about senses that some other families like to know?” I asked.

“Of course,” Betty said, “You’ve been so helpful, I want to know.”

“Well, we always ascribe to the belief that if there is breath, then there is hearing. Some studies have shown that hearing is the last sense to go before someone dies, so I always tell families to behave like their loved ones can hear them.”

“Yes, you’re right. I think he can hear me,” she said hopefully.

Peaceful Passing

Betty’s husband lived just two more days after this visit. I learned from the nurse that Betty’s husband declined even more the day after our visitand was actively dying, so I followed up with Betty and her children with telephone calls to assess the status of feeding and how they were coping. Betty and her children all confirmed that Betty had not tried to feed her husband again after our visit.

I learned from my bereavement telephone call that Betty spent the last two days she had with her husband reading his favorite books to him, writing him a long letter that reflected their life together and the impact it had on Betty, playing their favorite music on an old record player, and holding his hand and providing a supportive presence.

My visit with Betty not only provided her with important education about her husband’s dying, but also helped her process some of that anxiety so she could help Frank’s dying process be more dignified and peaceful. Like so many of the families I see, Betty needed someone to validate what she was feeling and also hear, understand, and affirm what feeding represented to her relationship with her husband.

Motivational interviewing skills, such as reflections and the decisional balance that I used with Betty, have been effective in my clinical practice with hospice patients and families who experience ambivalence with administering morphine for pain, hiring caregivers, or asking family members for help to protect the primary caregiver from burnout, and processing denial related to rapid decline.

Often families I work with are extremely concerned with doing everything “right,” so affirming that they are doing an excellent job caring for their loved one is very important for them because the feel empowered and validated. Although they may not be ambivalent about providing care, they are still at risk for becoming so overwhelmed that effective coping and a healthy life balance are damaged. Emphasizing individual strengths through genuine affirmations empowers the caregiver and results in better care and support for the patient. The patient having a peaceful death with dignity is not only valuable for the patient, but also for caregivers and family members as it decreases their risk for complicated bereavement.

The spirit of MI is rooted in the notion that the practitioner and client have a collaborative relationship. Once that relationship is established, the practitioner is responsible for evoking the client’s motivations, perspectives, and autonomy. Starting the visit with exploring and reflecting Betty’s motivations, understandings, and feelings regarding feeding allowed us to make progress on this issue. If I had come into her home telling her why she should not feed her dying husband, she likely would not have listened. Furthermore, she would not have had the opportunity to process their life and the emotional impact of her husband’s death.

MI techniques emphasize and foster a collaborative therapeutic relationship, which is critical in hospice work, and more generally in working with individuals and families coping with terminal illness. We clinicians are not the experts in our patients and families’ lives or their dying process. Using MI techniques not only helps hospice patients and families process their ambivalence, but are also extremely valuable in conveying empathy in a way that moves towards change.

My work with Betty was the first experience I had in applying MI to my clinical work in hospice. I was initially unsure how the MI skills, specifically reflections and affirmations, would help Betty resolve her ambivalence, but this experience showed me their value. I believe that my ability to avoid the righting reflex and simply repeat back to Betty her confusion and fear helped her feel heard and validated. The reflections also allowed her to process her thoughts that supported the ambivalence. These skills helped us establish a collaborative relationship as I was sure to never make her feel I was the “expert.” Although Betty saw me as more knowledgeable of the issue of feeding, I was not more knowledgeable in what was best for her. These skills allowed me to use the decisional balance, which ultimately led to her resolving her ambivalence and not feeding her husband again.

I feel tremendously honored to have the opportunity to work with hospice patients and families. Being present with patients in their dying process, and supporting their families as they navigate the demands of caregiving and effects of anticipatory grief, is an incredible privilege. I believe strongly that everyone deserves a peaceful death with dignity and am passionate about being part of providing that experience to all of my patients and families.

Esther Perel on Mating in Captivity

Posted on February 24, 2012February 11, 2026 by rezendevknowfully.com

Lori Schwanbeck: You are widely known around the world for your unique and thought-provoking stance on what makes marriage work. Can you tell us a little bit about your perspective and what makes it unique?

Esther Perel: I was originally trained in psychodynamic psychotherapy, but my real home for many years has been in family systems theory—I trained with Salvador Minuchin, and then in psychodrama, expressive arts therapies, and bioenergetics. And for many years, I worked extensively as a cross-cultural psychologist with couples and families in cultural transition, primarily refugees, internationals, and mixed marriages—interracial, interreligious, and intercultural couples.

LS: So you saw a lot of different people’s lives.

EP: Yes, I'm interested in difference. I'm interested in the relationship between the individual and the larger context, looking specifically at gender relations and childbearing practices. I then added my interest in sexuality, so that I'm now working at the intersection between culture, couples, and sexuality.

I also like to work with clinicians, be they physicians or mental health professionals, to promote the integration of sexuality within the couples therapy world, and to integrate relational thinking within the sexuality world.

LS: What do you think is missing in most clinicians’ approaches to working with sexuality and intimacy in the Western world?

EP: I just read a whole review article by Eli Coleman about sexuality training in medical schools, and it has undergone yet another major decline since 2010. We would have thought we were finally creating comprehensive training in sexuality for physicians, but we are not. So what is missing? First and foremost, for mental health professionals as well as for all health professionals, is training: the acknowledgment of sexual health as an integrated part of general mental and physical health. The vast majority of couples therapists have had no training in sexuality whatsoever—maybe an hour here and there. Couples therapy has become, over the years, a desexualized practice. Sex is the elephant in the room.

Couples therapy has become a desexualized practice. Sex is the elephant in the room.

Most therapists do not talk about it, don't know how to talk about it, and often wait for a couple to bring it up. And the couple themselves are often uncomfortable talking about it, so it remains the unaddressed subject, though it's often hardly insignificant.

A Better Sexual Relation

LS: You see our sexuality, our erotic life, as vital in the health of a couple.

EP: I see a couple's erotic life as an important dimension of their relationship because it is an integral part of the romantic ideal that is the dominant model of modern love. We took love and brought it to marriage or committed relationships. We then sexualized love. Then with the democratization of contraception, we liberated women from the mortal dangers that were associated with sex, and sex got separated from its sole reproduction function—as Anthony Giddens says, it became a reflexive project of the self, an ongoing process of self-definition. We have, for the first time in history, a sexuality within long-term relationships that isn't about having ten kids or a woman's marital duty, but that is rooted in desire, i.e., in the sovereign free will of individuals to engage sexually with their partners. And in the process, we have linked sexual satisfaction with marital happiness; that is what has made sexuality an important element of modern marriages.

I realized in writing Mating in Captivity that I was not interested only in sexuality, per se. And I certainly was not so interested in, "Are people having sex? How often? How hard? How many? How long? Are you a sexless couple because you have less than 11 sexual interactions a year?" and so forth. My interests lie not in the statistics of sex or the perfect performance industry that pervade our society.

Instead, I found I was really interested in what makes a couple feel a sense of aliveness, vibrancy, vitality—of Eros as a life force. When couples complain about the listlessness of their sex lives, they sometimes may want to have more sex, but they will always want a better sexual relation. And they will invoke the experience of renewal, of connectedness, of playfulness, of mystery, of regeneration, of power.

My distinction between sex and eroticism actually came out of my work in trauma. My husband directs the International Trauma Studies Program at Columbia, and he works a lot with torture survivors. I would wonder, "When do you know that you have reconnected with life after a traumatic experience?" It's when people are once again able to be creative and playful, to go back into the world and into the parts of them that invite discovery, exploration, and expansiveness—when they're once again able to claim the free elements of themselves and not only the security-oriented parts of themselves.

In the community of Holocaust concentration camp survivors in Antwerp, Belgium where I grew up, there were two groups: those who didn't die, and those who came back to life. And those who didn't die were people who lived tethered to the ground, afraid, untrusting. The world was dangerous, and pleasure was not an option. You cannot play, take risks, or be creative when you don't have a minimum of safety, because you need a level of unself-consciousness to be able to experience excitement and pleasure. Those who came back to life were those who understood eroticism as an antidote to death.

LS: That’s a very powerful statement. Do you find many couples that come to you dead in their relationships?

EP: Yes, but it's not always in their relationships. Sometimes they feel deadened inside of themselves as individuals.

I think that one of the prime motives for transgression is trying to beat back a feeling of deadness.

I think that one of the prime motives for transgression is trying to beat back a feeling of deadness. And the deadness isn't the fault of the other person at all. It may be a slow progression of an atrophy that has taken place inside themselves. I think that when people miss a sexual connection, there's often one partner who misses it more than the other. That longing, that yearning for that feeling of aliveness, of connection, of transcendence, of vitality, of energy, of rush is what people talk about. And on the other side of that, they will talk about feeling flat, feeling numb, feeling shut down, feeling dead.

LS: It sounds like you’re really talking about eroticism as an expression of libido, of life energy. How do you support couples in reinvigorating the passion in their lives?

EP: There’s a little exercise that I like to do, which I borrowed from the work of Gina Ogden. I ask the each partner in the couple to complete the statement, “I shut myself down when… I turn myself off when…”

We tend to talk about “what shuts me off” and “what turns me off”; we say, “You turn me off,” but we don’t often ask the question, “When do I turn myself off?” “I turn myself off when I look at an email just before going to bed. I turn myself off when I am disinterested in what you’re talking about. I turn myself off when I worry about the kids. I turn myself off when I remember my childhood.” What do I do to shut myself down? “I turn myself off when I don’t take time for myself.”

LS: It’s really about personal responsibility.

EP: That's exactly it. So the partners go back and forth, and they can come up with a list of 10 or 15 each. And then we come to, "I turn myself on when…I become alive when…"—not just sexually. Because if you're feeling dead, the other person can wear the nicest Victoria's Secret lingerie (and there is no Victor's Secret, you know), and it's not going to do anything because there's nobody at the reception desk.

Most of the time, in response to the "I turn myself on" question, people will say things like, "When I am with friends. When I go out dancing. When I take time in nature. When I take time for myself. When I've accomplished something that I'm proud of"—things that have to do with our sense of self-worth, our connection to meaning, and our sense of pleasure—things that make us feel alive.

Then you ask a person, "You tell me you like to dance. When's the last time you went to dance?" And if they tell you, "It's been months," or, "It's been years," then, before you start to work on anything connected to sexuality, you say to them, "I think it's high time you went dancing, since it seems to be something you really love to do."

LS: When you say that modern couples therapy has become a desexualized profession, it really sounds like you’re talking about more than just sex, but really about tracking and supporting aliveness in people.

EP: I think that there are a few forces that desexualize couples therapy today. One is the notion that sexual problems are the consequence of relational problems. Then it follows that, if you fix the relationship, the sex will follow. Therefore, if all sexual problems are relational problems of complicity, of intimacy, of communication, of trust, and all of that, then there are no sexual problems. So we don’t talk about sex because sex is just a consequence of something else.

LS: And you’re saying it stands alone as a phenomenon in a relationship.

EP: I don't think that sexuality is only a metaphor: "Tell me about the state of the union and I know by extension what happens in the bedroom." I think that sexuality is a parallel narrative. I think, in fact, that when you change a couple's sexual relationship, it has an effect on every other part of their lives.

When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core.

When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core, because it's everything: mind, body, spirit, breath.

Love and desire both relate and conflict. Looking at the way people connect and their emotional history is very important, but it gets translated into the physicality of self, and then it inhabits its own narrative. They are parallel stories and they need to be looked at as such. So that's one.

Another element of the desexualization, which is, I would say, stronger here in the United States, is related to the fact that the focus over the last decades has been on security, attachment theory, the need for safety, and much less on the need for freedom, sovereignty, and self-determination. This is because we are working within a context that is among the more egalitarian contexts of the West, and one where people are often so individual and so alone that all the theories that have proliferated have been theories of connection. In the few decades before, they were all theories of individuation. It's like in art: you have one wave succeeding another. This is not a time when, in this country, people are very interested in investigating the need for freedom. That happens in environments where people are a lot more oppressed, and where they are overly connected in layers of extended family. That is not the dominant concern here, existentially or socially. And sexuality plays itself in both realms. You need a certain security for sex, for some people—not for everybody. But you certainly need a lot of freedom for sex.

Balancing Security and Freedom

LS: Tell us more about how that need for security and need for freedom can coexist.

EP: For me, the reference person is Stephen Mitchell, who in his work in Can Love Last? looked at how modern love and romanticism have brought us to try to reconcile within one relationship, within one person, fundamentally sets of opposing human needs.

In every epic story—in The Odyssey, for example—there is the home and the journey, the travel and the base. Today we want our needs for security, predictability, stability, reliability, dependability—all the anchoring, grounding elements of our lives—to be met in the same relationship with the person from whom we also expect adventure, novelty, mystery, and all of that. We still want what marriage always gave us, which was about economic support, companionship, family life, and social respectability, and on top of it, we want our partner to want us, to cherish us, to be our trusted confidant and our best friend. In effect, we are asking one person to give us what once an entire community used to provide.

LS: It’s a lot to ask for.

EP: We've never tried to experience both like that at that level in the history of human relationships. We also live twice as long—a hundred years ago, we died seven years after we were done raising children. So the longevity of what we expect from a monogamous, committed relationship is also unprecedented.

There is something about the enshrinement of the modern couple that has basically made it this hermetic unit where we have get all our needs met, rather than understand that there are certain things you're going to get from your sister, your aunt, your grandmother, your best friend, your colleague. I think that we can have multiple intimacies that are friendships and deep relationships with other people.

The model for me is really seeing the movement between freedom and security, which are the two pillars of development—connection and autonomy, independence and dependence. I think they are the two main pillars of growing up. And it is the same as any system. Every system needs to balance homeostasis and growth. It isn't just on an individual level. And every system regulates change and stability. So do individuals regulate connection and separateness.

The image that I often use in my work with couples is little kids: if everything is nice and going accordingly, you will have your child sit on your lap very cozy, nested, at ease, comfortable. And at some point, the child needs to jump out and go into the world to meet what are called the exploratory needs: freedom, independence, separateness, autonomy, all of that. If the little kid turns around, which kids always do, and looks to see what's going on with the adult, and the adult says, "Kiddo, the world's a beautiful place. Go for it. Enjoy it. I'm here," often the child will turn around and go further, and experience at the same time connection and independence, freedom and security. At some point, she has enough, and comes back to base and plops herself into your lap again, happily returning as an act of freedom to a place where she feels welcome because it offers security as well as the respect for freedom.

But if, on the other hand, the little child turns around and the adult says, "I need you. I'm alone. I miss you. I'm depressed. I'm anxious. I'm worried. What is so great out there? Why don't you want to be with me? My partner hasn't paid any attention to me"—any of the messages that basically say to the child, without ever saying it in words, "Come back"—then there are a number of dominant responses. One common one is that the child comes back, because we'll do anything not to lose the connection, since that's the primary need.

But we will sometimes lose a part of ourselves in order not to lose the other. We will forgo our need for freedom and space and separateness in order not to lose the other and the connection. And we will learn a way of loving that will have a certain excess emotional burden, responsibility, worry, that is beyond the normal elements of love that have to do with mutuality, reciprocity, care, and responsibility—so much so that once I love you, I can no longer leave you enough to be able to experience the freedom and the unself-consciousness that are necessary for sexual excitement and sexual pleasure. The adult makes that motion into sex: the ability to be inside myself while I am with another. If, when I am with another, I have to leave myself, stay outside of myself, basically, I can't even culminate. Physiologically, we cannot come if we don't have a moment where we can be completely with ourselves and inside ourselves in the presence of another.

LS: So it’s really holding that dialectic of being both within yourself while also connected.

EP: Yes. But when you talk about intimacy, you need attachment as a precondition for connection. In the realm of desire, separateness is a precondition for connection.

Love needs closeness. Desire needs space.

LS: Could you give us a practical example from a couple that you’ve worked with of how someone can have both connection and separateness? And what does separateness mean within a relationship?

EP: Imagine the person says, "I turn myself on when I go to the movies alone." Not sexually, right? "I come to life. I connect to my desires in the realm of pleasure"—that broad sense of the word "sex."

Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter.

Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter. I work in the erotic space, if you want. It's not an act. People have had sex for generations and felt nothing. I am not into promoting people having sex, but having a certain relationship with a certain dimension of your life.

So, if they say, "I like to go to the movies," then the next question will be, "Do you go?" And you will listen to the degree to which they tell you, "It's hard for me to leave," or, "It's hard for my partner when I leave," or, "No, it's just a matter of circumstances. Lately, I haven't had a chance to go, but it's never been an issue for me," or, "When I come back, I'm always worried." The third child I didn't describe is the one who does go, but is constantly looking over his shoulder, making sure that the adult here isn't going to punish him, reject him, become depressed, or collapse on him when he returns.

So the person says, "I don't go often to the movies alone, or listen to music, or play my music for that matter"—or whatever it is—"because when I come home, I experience that anxiety, that knot in my stomach that I'm not going to be told, 'How was it? How wonderful,' or I'm not going to be told, 'Stay out as long as you want. Everything's fine. Enjoy yourself.' I'm going to be told when I leave, 'Again you have to go? When are you coming back? Why are you staying out so late? Why do you not want to go with me?' I'm going to hear comments that basically say, 'Give up your freedom so that I can feel secure.'"

That is a classic transaction in the couple, versus, "I'm happy for whatever it is that you are experiencing elsewhere, even when it has nothing to do with me, because you bring this back, and that makes you a more interesting and alive person that maintains a certain vitality between us."

LS: If we use attachment language, it sounds like you’re trying to cultivate secure attachment.

EP: Yes, and a secure attachment for me isn't a singular experience: there is not always just one person to whom we turn. And I think it's a difference in culture. There are loads of places in the world that are more likely to think that your partner is the person with whom you experience parts of your life, while friends and family provide the existence of multiple safe harbors.

LS: So secure attachment for you is about feeling securely attached in the world, in your life, but not exclusively attached to one person. That’s a big difference.

EP: Right. The enshrinement of the modern couple is connected to the exclusiveness. I don't think we are more insecure today than we were before, but I think

We bring all our security needs to one person, and then we blame them for whatever is missing in our lives.

we bring all our security needs to one person, and then we blame them for whatever is missing in our lives. God forbid you have conversations with others that you should be having with your partner, because that becomes an emotional infidelity. The system is rigged with injunctions against leaving the relationship in any way possible—not just in sexual terms.

A Vibrant Field Has Multiple Voices

LS: How are you finding your ideas are holding up in our Western culture? Are other therapists embracing them, or is there a push back that you’re finding when you teach?

EP: I think that a vibrant field is a field that has multiple voices. When I wrote my book, it wasn't written for professionals. I did not think that it was going to become one of those voices—that it would be embraced in the couples and sexuality fields, as it has by some. I'm happy that it is one of the many voices. One of the things that you get when you work cross-culturally, as I do, is that every time you hear a truth in one place, you know that another place is thinking of it completely differently. The pacifier, the baby's bed, the baby's crying don't mean the same thing in every culture. And it's very refreshing to be located in a much more multicultural, nuanced, nonjudgmental, relative way of thinking. It works for me.

I think that there are people who have difficulty with what I talk about, and there are people who find a tremendous sense of affirmation in what I talk about—this is how they have been thinking, and they've been looking for that approach. I'm glad to be part of the conversation, and I'm glad to be a stimulant in the conversation.

LS: You're certainly that, and it is very refreshing. It's almost like you're bringing that multicultural perspective of relationships into a multicultural perspective of how to do therapy, as well—how to hold and look at a relationship and embrace different perspectives

EP: I think that romanticism has appeared in every part of the world, even in very traditional cultures. And wherever romanticism has appeared, people are investing more in love than ever before, and divorcing more in the name of love—or the disillusions of love—than ever before. And

I think that wherever romanticism has appeared, there's a crisis of desire.

I think that wherever romanticism has appeared, there's a crisis of desire.

Originally, I wrote my book from the perspective of a European therapist observing American sexuality. I started the original article during the Clinton and Lewinsky scandal because I was very intrigued as to why this society was so tolerant towards divorce—you can divorce three, four times without much stigma these days—but it was very intransigent towards any transgression or infidelity, whereas the more traditional family-oriented world had always compromised towards infidelity (a burden carried primarily by women, I should add), in the name of preserving the family, and separated the well-being of the couple from the well-being of the family.

I had no idea that I would be going to 20 countries on book tour. In the process, I began to realize that a crisis of desire was nothing unique to this country. It is really part of the romantic model and the changing meanings of sexuality in modern committed relationship.

But there are some unique features to this culture that have to do certainly with its relationship to sexuality. First, it's a society that often relates to sexuality as smut or sanctimony, titillation on the one side, and condemnation on the other side. It vacillates between extremes.

Second, it's a society that has certain views about transparency, and about transparency as essential to intimacy: wholesale sharing, telling it all, being explicit, not beating around the bush. I think that this is a society that looks at honesty from the point of view of a confession. Minimal tolerance for ambiguity and the imponderables is what makes American business great, but it's not necessarily what other cultures bring into the private sphere.

Keeping Secrets

LS: You’re saying that the emphasis on complete transparency and honesty actually gets in the way of creating a vital relationship?

EP: I think that one should know that, while it is obvious in some cultures, like here, that if I can tell you everything then we are closer, there are other cultures—sometimes your own neighbors—who actually think that the ability to maintain privacy is what enhances intimacy, and not necessarily transparency.

LS: It’s a big difference.

EP: It’s a difference. And I think each one evolves in its own context. But it’s very refreshing to know that there is a whole other way of looking and thinking out there that totally throws off what you take for granted. Working in New York City, I get people from 15 countries coming into my office. I practice in many languages. I cannot assume that that a couple who came at nine o’clock and wants to tell each other everything is the same as the couple who comes at ten o’clock with a completely different notion of boundaries, individual space, the mandate for sharing, the hegemony of the word as a form of intimacy, gender structures, power dynamics, and so forth.

LS: The policy of not keeping secrets within the couple is also widely held among therapists here. I’m wondering if you have a different perspective. As a therapist, do you have the same policy that many therapists have of not holding secrets?

EP: There is a clear hierarchy of secrets. There is only one particular secret that therapists really grapple with in terms of credibility, ethics, and mode of working. If you tell your therapist that you have had a miserable sexual relationship with your partner for years, that you’ve been faking it forever, that you can’t stand his smell, or her looks, or whatever it is, you rarely will hear a therapist say, “Either you need to tell your spouse, or you have to go to individual therapy.” That’s also a big sexual secret. I cannot imagine a partner one day after 27 years finding out that their wife or their husband has been lying and faking to them all these years. They’d be no less crushed. But somehow that one doesn’t do it. It is really any one of the secrets in the range of the infidelity spectrum. And even if you raided your bank account, a therapist would not usually say, “If you don’t tell, I can’t start working with you.”

LS: So you have more of a subjective stance to the issue of whether or not full transparency between your clients is ultimately serving them.

EP: I think it needs to be examined. Sometimes it's dangerous. In the field of infidelity, I would align myself very much with the work of Janis Spring, Michele Scheinkman, Tammy Nelson, or Stephen Levine, who are examining the concept of keeping a secret. Today, in the first session with any couple, I will say, "I will see you as sometimes together and sometimes apart—I don't know how much of each. When I will meet you apart, it's because I think that there's certain conversations that may be better held alone, because you will be less defensive. You will take more responsibility. You will be more able to examine yourself quietly. You won't be in the reactive stance. And those will be confidential conversations, which means that each of you will probably tell me things that your partner may not know. And you will decide at what point you want to share that."

I'm often asked, "What do I do with the secret of infidelity?" I sit with it, because sometimes the secret is the therapy. Or, as Janis Spring says, "Giving up on the secret is the therapy." Then the question is, is revelation mandatory? It is often seen as mandatory here. The concept that intimacy needs to be rebuilt through transparency and revelation doesn't take into account that for some people, revelation may be more traumatic, which then is answered by other people who say, "But, somehow experiencing the trauma is part of rebuilding the relationship." But that's one view.

So I work with secrets. If I agree to work with the couple, I take the couple as it comes to me. It's not for me to decide what risks people need to take in terms of revealing their secrets. There are major power imbalances in society—major risks involved for women to reveal certain secrets, for instance. I very carefully assess with them what is safe. I've learned that when I go to Cuba, Mexico, and other places, I can't just take transparency as a norm without looking at the political and social implications of gender politics. In that sense, the dominant theories and trends du jour are not as contextual as systemic thinking used to be.

LS: What advice would you give to therapists in looking at their own erotic lives, in terms of how that’s going to affect the way they show up with clients?

EP: There are two levels: the professional and the personal. On the professional level, I think you want to continue to learn, renew yourself, grow. I think it's particularly important for experienced therapists to not stop growing, to not stop listening to other people.

Every time I go to a workshop or a conference, I know that I work differently the week that follows. I am filled up. I am renewed. I'm trying out new things, stepping outside of my own comfort zone. Every time I go and I lecture some place, I ask people, "Has my work grown? Has it changed? Have the ideas matured? I hope I'm not repeating the same thing." At this moment in my work, I have made new choices, different choices than the ones I certainly was trained with—or indoctrinated with, we could say, because they were never questioned.

I also think that it's very important for me, anyway, as a therapist, to read anthropology, history, poetry. The arts are a lot more able to deal with the complexities of love, sex, desire, and transgression than psychotherapy is. The greatest novels, movies, and poems capture the complexities and the contradictions of our life. I strive towards the embrace of the contradictions, or the dialectic, and not necessarily towards the dogma. I tend to work more on the side of art than on the side of science. And to work in the realm of art is to work with the unknown, rather than to want to simplify the known and to make it predictable and organized. I don't have a set model in that sense.

Maybe what people have appreciated about my work is the fact that I am questioning our assumptions. I really don't think I have the truth on things, even though I sometimes sound very confident. But I am willing to ask myself, "Is this the only way? And who says? And must it be this way? And for whom?" The people who come to study with me do so because I'm out of the box, not because they're going to get a nicely structured framework. There are a lot of other important elements to couples' lives, but it happens to be that this existential dimension is the one I have become very interested in. So I write about that.

And personally, make sure you stay alive. Make sure you stay in touch with your own experience of pleasure, of receiving, of giving, of sexuality, of your body. Don't disconnect, or you will bring that into your work, and it doesn't benefit anybody.

Assessing Partner Abuse in Couples Therapy

Posted on January 23, 2012March 13, 2026 by rezendevknowfully.com

Mark and Julie were in their late thirties, and had been married for seven years after living together for three. During their initial session with me, they expressed concern that they had been drifting apart over the past year. They were both under considerable stress. Julie’s planned six-month leave of absence from her job following the birth of their son Brandon had now lasted four years. Brandon required lots of Julie’s time: he was highly impulsive, displayed frequent temper tantrums, and recently bit another child at daycare. Mark supported the family as a salesman for a medical equipment firm, but getting along without Julie’s income meant longer hours and more frequent travel.

“We hardly ever have time for each other anymore,” said Mark. “And I’m out of town so often these days that it’s hard for us to readjust when I get home. Julie is always preoccupied, either with Brandon or something else, and our relationship isn’t a priority for her the way it used to be.”

“We don’t communicate well,” added Julie. “We argue about parenting Brandon, about my housekeeping, about Mark’s being gone so much of the time . . .”

“There’s an example of one of our problems,” Mark interrupted. “ I don’t feel like she appreciates how hard I work to support us. Traveling on business is no picnic, I can tell you. I miss being home with my wife and kid.”

To most outward appearances, this was a couple caught in the typical dilemmas of our age: how to balance work and home life, how to be both parents and intimate partners, how to get one’s own needs met while meeting the needs of the other.

Mark and Julie had been in conjoint therapy twice before; each stint had lasted about one and a half years. Their first therapist, they told me, helped them understand how their relationship replicated themes from childhood. A couple of years later, when their arguments grew more frequent, they decided to try a new therapist. Mark liked their new therapist’s pragmatic approach and appreciated learning how to make “I statements” and practicing reflective listening. Mark felt that he had finally gotten through to Julie about his concerns. Julie agreed that the therapy had been helpful, but wasn’t willing to continue because there was too much focus on Mark’s concerns and not enough on hers.

When I asked Mark and Julie how they argued, they reported that Mark frequently raised issues in an angry way. Julie would withdraw, and Mark would press for resolution. She sometimes burst into tears during these encounters, and he saw this as her way to avoid addressing his concerns. Yet they both reported that their arguments “never get physical.”

Over the next few sessions, I gave Mark and Julie typical homework assignments. We discussed taking time-outs when their interactions grew too heated. We reviewed and practiced reflective listening skills. They voiced an appreciation about each other every day. And despite difficulty finding a babysitter who could handle Brandon, they managed to schedule two “date nights” over the next two weeks.

I did not yet realize it yet, but I was making the same error as their two previous therapists: I was attempting to do couples therapy with an abusive relationship.

Obligation to Assess

Many therapists, including those of us with extensive clinical experience, frequently plunge into doing therapy before we have adequately assessed whom and what we are treating. It is in the nature of the therapist-client relationship that we cannot know the whole story from the outset. Our clients may be lost, confused, withholding, or in denial. They aren’t ready to divulge everything at a first session (and if they were, we would probably wonder why). In the cause of establishing a working alliance, we leave avenues of assessment unexplored until a more opportune moment. Assessment and treatment necessarily walk hand in hand as the ongoing process of discovery and healing unfolds.

However, none of this relieves us of the ethical and professional obligation to carefully assess factors that may undermine treatment. “Sometimes we collude with our clients’ denial systems, deliver services that are misdirected or even harmful, and allow problems to get worse, under the guise of providing treatment.” Meanwhile, our clients continue to believe they are getting help, and we continue to collect our fees. Whether the undiagnosed problem is addiction, bipolar illness, domestic violence, or some other weighty issue, part of our job is to make educated guesses and follow up on them.

One error I encounter with troubling frequency is the failure of couples therapists to assess adequately for partner abuse. By partner abuse, I mean the use of force, intimidation, or manipulation—or the threat to use any of those methods—to control, hurt, or frighten an intimate partner. Note that the definition can be met even if no physical violence is involved. Verbal and psychological tactics are more common; frequently, they are also more effective at controlling, hurting, or frightening another, and they can be more emotionally damaging in the long run.

I have met with couples whose seasoned therapists, over the course of several years’ treatment, missed the extent and severity of the physical and emotional abuse taking place at home. We might be tempted to believe that clients bear some responsibility for staying silent on the issue (whether out of fear or outright denial), but the obligation to assess rests firmly on our shoulders. For example, an abused partner may feel unsafe bringing up abuse in the presence of the other because of likely retaliation, yet many therapists have a policy of never meeting separately with one member of a couple they are treating jointly.

Regardless of the reason for the assessment failure, the tragic result can be months or years of continued abuse. “Suffering” is a pallid word to describe the soul-damaging, spirit-deadening impact of ongoing abuse on the abused partner and the children who live with it. The corrosive nature of some abuse leads to an erosion of the self that can be extremely difficult to reverse. The effects are cumulative and must stop before healing can begin. Additionally, abuse generally grows worse without intervention. Meanwhile, clients incur a sizable expenditure of time and money, and the therapist (and, by extension, our profession) loses credibility.

Common Misconceptions

Several common misconceptions hamper or prevent an adequate assessment of partner abuse.

“The couple report that they yell at each other, so they both contribute to the problem.”
Loud arguments should always suggest the possibility of partner abuse. Most abusive relationships involve some angry behavior by both parties; some involve mutually abusive behavior as well, although the degree of fear is generally much greater for one partner than the other. While both partners are responsible for their own behavior, one of them probably contributes disproportionately to the abuse.

“I spoke to them about partner abuse and they deny it is going on.”
As therapists, we know better than to accept clients’ analyses of their difficulties and to probe more deeply. “If an angry client reports that he believes in firm discipline but would never abuse his children, do we simply take his word for it?”

“It is my policy never to meet individually with clients I see in couples therapy.”
Adequate assessment for abuse cannot be accomplished with both partners in the room. Asking directly about abuse in a conjoint session puts the abused partner in a no-win position: to disclose and risk reprisal, or to deny and thereby avoid getting needed assistance.

“I have a ‘no secrets’ policy, so clients know that anything they share with me individually will be brought into the couples session.”
In my view, such a policy is designed to relieve the therapist’s anxiety and hinders rather than helps the client. As therapists, we often learn things we cannot or choose not to divulge. Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment.

“Even if there is undiagnosed partner abuse, I’m helping them resolve the underlying relationship dynamic.”
By its very nature, abusive behavior prevents the resolution of other issues. Abuse skews the relationship dynamic and leaves most of the power and control in one partner’s hands.

“I can teach them better communication skills until they trust me enough to disclose the issues they are withholding.”
Abusive partners easily subvert communication skills at home. “I” statements are meaningless if the intent is to hurt, control, or manipulate.

“I’m not taking a stand on the issue because I’m afraid the abusive partner will bolt from treatment.”
Again, the delusion here is that some treatment is better than none. What is needed is a referral to appropriate treatment, rather than maintaining the fiction that the couple is getting help while the abuse continues.

An Abusive Dynamic

At their next session, Mark and Julie reported that their second planned date night had started out well. They ate dinner at a quiet restaurant, reminisced affectionately about the first time they met, and held hands as they shared a frozen yogurt. Brandon was asleep when they got home, even though it was still relatively early. When they went to bed, Mark anticipated they would make love; Julie was tired and just wanted to curl up and go to sleep. Mark persisted, saying that this was the only chance they’d had for sex in a while so they’d better take advantage of it. Julie said she was tired of his “guilt trips.” He said she was frigid and accused her of withholding sex to punish him.

They had carried on late into the night as the argument broadened to include many other areas of disagreement. The conflict continued in my office the next evening.

” . . . And I appreciate how hard he works to support us,” Julie was saying. “But when he gets back from a business trip, he’s constantly finding fault with the way I keep the house, the things I wasn’t able to get to. He thinks I’m too soft with Brandon and that’s why he’s been acting up at daycare. It’s true that I could do a lot better job of housecleaning, and I paid the credit card late last month. My hands are so full with Brandon that everything else seems to take second place. I know I need to get better at setting priorities, like Mark says, but I feel like I’m doing the best I can and I wish he appreciated how hard my job is.”

Mark was restless but listened quietly while Julie spoke. When it was his turn, he spoke quickly, with increasing agitation and volume.

“She talks about not being appreciated. Well, she doesn’t do a very good job of appreciating me. I work really hard to support us at this level, and you’d think I could at least come home to a house that didn’t look like a bomb hit it. And Brandon is out of control because she doesn’t know how to set limits with him. He never acts up with me the way he does with her. Plus, she has the entire day to spend at home and take care of the things I can’t get to because I’m out of town. Brandon’s in daycare now, and she has so much free time to get together with her girlfriends for coffee . . .”

“Now, wait just a minute!” said Julie angrily. “That only started a couple of weeks ago!”

“No, you wait a minute!” replied Mark in a louder voice. “I don’t appreciate your angry tone, and I didn’t interrupt you when you were talking. I’d appreciate it if you could show me the same respect!”

“It’s hard to sit still while you misrepresent things,” she said petulantly, slumping in her chair.

“There you go again. When I give my point of view, I’m misrepresenting things. “ He turned to me. “You see how this goes. She never seems to respect my opinion. Everything I say, she counters it.” He raised his voice. “She treats me like she doesn’t even like me anymore! Ever since Brandon came along, our sex life has gone out the window. She always has something else on her mind, or she’s too tired, or I don’t know what.”

“Maybe if you treated me with more respect, I’d feel more like getting close to you,” Julie replied softly.

“See, there you go again. It’s always my fault!” said Mark. “We disagree on so many things, I’m really not sure what’s keeping us together anymore!”

There was a pause. Mark’s face grew darker and his brow furrowed as he spoke. The skin around Julie’s temples grew taut and her shoulders sagged.

“Tell me, is this kind of how things go at home?” I asked. “You start to talk about an issue, and things escalate? Mark, you seem angry and frustrated, and Julie, you seem angry and resigned. I can see that there are a number of issues on the table. But I’m wondering if I’m getting to see how your efforts at communication get off track. Is this how things go when they don’t go well?”

They answered simultaneously. “Pretty much,” said Mark. “This is mild by comparison,” said Julie.

“So what would typically happen at this point?” I asked.

“Mark usually kicks something, then leaves the room,” said Julie, hands crossed over her chest.

“Oh, really? What about you turning on the water works, then giving me the cold shoulder and playing the Ice Queen for three days?” said Mark, pointing his finger at her. “You left that part out. As usual!”

“OK, hold on a moment, both of you,” I said. With ten minutes left in the session, I felt the need to intervene, based on the growing escalation, the content and tone of the communication, and Mark’s increasing impulsiveness. I also feared that their disagreements were severe enough that continuing to talk about them would result in yet another argument as they left my office.

“There’s been a lot of heat expressed in this office today, and I’d like you both to cool off before you leave. I want you both to take a few nice deep breaths, s-l-o-w-l-y. Good. I want you to drop this argument, and I want you to agree not to talk anymore about these issues today.” We spent a few minutes addressing the difficulties they might experience in keeping to this agreement.

It was now clear to me that this couple was caught in an abusive dynamic. Mark had initially given the impression that he was listening to Julie, but he shifted restlessly as she spoke; when she finished, he responded quickly with an increasingly angry and critical tone. He blamed her for their problems and employed various strategies—such as exaggeration, distortion, and counterattack—to deflect any suggestion that he might also bear some responsibility for their difficulties. When Julie attempted to correct his misrepresentation of her coffee dates, he turned the tables by attacking her for the interruption and accused her of having less respect for him than he had for her. Mark felt free to express his anger but could not tolerate Julie expressing hers. He accused her of employing the very tactics he used (for example, “Everything I say, she counters it”). Mark demeaned Julie for the upset feelings she experienced following his angry outbursts and her subsequent need to pull away.

By contrast, Julie recognized some of her contributions and validated many of Mark’s concerns. Her brief efforts to defend herself were quickly overwhelmed by Mark’s responses. Her petulant tone and slumped posture were signs of defeat.

Indicators of Partner Abuse

Like Mark and Julie, clients in abusive relationships present with typical complaints: “We don’t know how to communicate with each other.” “We’ve been arguing a lot.” “We’re both under a lot of stress.” “We’ve needed counseling for a long time and he/she finally agreed.” “We disagree about disciplining the children.” Usually, their level of intimacy has declined.

More telling indicators are embedded in the relational dynamic that emerges in the consulting room. There may be unexplained tension in the room; certain topics appear to be off limits. “There may be a marked difference in the way and the degree to which each partner participates in the session.” The abusive partner may always start the session or, alternatively, always make the abused partner begin. One partner may be highly critical and judgmental, or exercise control through silence, intimidation, and manipulation. The other may speak hesitantly and haltingly—or, alternatively, may be hostile, resentful, and angry, seemingly out of proportion to the subject under discussion.

They may disagree on basic facts and have widely divergent views of the same events. Frequently, both partners are highly defensive and misconstrue what the other says, as though looking for an opportunity to act angry or hurt. They report or exhibit destructive communication patterns, such as escalation, invalidation, or a demanding/withdrawing dynamic. Impulse control may be poor. Problem-solving and conflict resolution skills are lacking.

Any of these symptoms are sufficient to raise suspicions of partner abuse. Alternatively, many abusive relationships present as typical relationships with occasional heated arguments that both parties have come to see as the necessary though undesirable price of an intimate partnership.

Assessment Protocol

When a couple comes to see me specifically because of my expertise in treating partner abuse, I typically employ a four-session protocol. I meet once with the couple, once separately with each partner, and then once more with the couple (or twice, if I need to gather further information or test hypotheses) to deliver my recommendations.

Alternatively, a couple like Mark and Julie may come to see me because they’re having difficulties and have decided to try therapy, and I might not begin to suspect partner abuse until they have seen me a few times. When I recognized the abusive dynamic in Mark and Julie’s relationship, I said to them:

“I think it would be helpful for me to set up an individual appointment with each of you so that you can share your concerns without having to worry about the other person’s reactions. I frequently do this in couples therapy, and given the volatility of today’s session, now seems like a good time.”

With an even more highly volatile couple, I might say something as innocuous as:

“During the last several sessions, I’ve had a chance to see how you interact with each other. As part of our work together, and in order to get to know you better, I’d like to schedule an individual appointment with each of you. I want to find out more about you, your childhood, family history—that sort of thing.”

I wait until the individual sessions to address the issue of confidentiality and “secrets.” With Mark and Julie, I began their separate sessions this way:

“This is a rare opportunity to get together with you, and I’m wondering if there’s anything you’d like me to know that you’re not comfortable saying with your partner in the room? If it’s something you want to tell me in confidence, I can keep it to myself. If it’s something I think would be helpful to discuss in a joint session, I’ll let you know that today, but I won’t disclose anything you don’t want me to.”

I also tell each partner that I would like to ask a series of questions about the kinds of behaviors that have occurred in their relationship. With the abusive partner, I am especially interested to learn whether similar behavior has occurred in any previous relationships, because it counters the common belief that the current partner is in some way responsible for the abuse. For this purpose, I use my own Abusive Behavior Inventory, an abridged version of which is included at the end of this article. I frequently supplement the specific questions on the inventory by inquiring about the first, last, and worst conflicts the couple has had.

Choice of Assessment Tools

To develop the Abusive Behavior Inventory, I spent one dreary weekend reflecting on all the variations of spousal abuse I had encountered during several years’ clinical experience and incorporated them with similar questionnaires employed at two agencies where I worked. I also referred to Patricia Evans’s The Verbally Abusive Relationship: How to Recognize It and How to Respond (Bob Adams, Inc., 1992) and Ann Jones and Susan Schechter’s When Love Goes Wrong: What to Do When You Can’t Do Anything Right (Harper Collins, 1992). An instrument similar to mine is R. M. Tolman’s Psychological Maltreatment Inventory (see “The development of a measure of psychological maltreatment of women by their male partners,” Violence and Victims 4 (3): 159B177, 1989).

I do not employ the self-administered Conflict Tactics Scale, developed and revised by noted researchers Murray Straus, Richard Gelles, and Susan Steinmetz. Despite broad acceptance as a research tool, it has numerous shortcomings in a clinical setting. For example, it measures violence only during the preceding 12 months, even though just one violent incident from many years ago may still be casting a shadow over the relationship. It does not ask whether the violence occurred in self-defense. And it equates acts that are inherently unequal due to men’s generally greater physical size and strength and women’s generally greater level of fear that men’s anger will erupt into abuse.

Using the Abusive Behavior Inventory in the individual interview allows me to uncover whether a pattern of abusive or controlling behaviors exists. This is accomplished best in the context of a clinical interview, for two principal reasons. First, clients provide much more information—factual, psychological, and emotional—than they would with a self-administered questionnaire. Second, clients may be so disturbed by their answers that they need an opportunity to process their reactions.

Comparing their answers side by side is an exceptionally useful diagnostic tool. Couples who corroborate each other’s answers generally exhibit greater awareness of problems in their relationships and are more often motivated to do something about them.

Suspicions Confirmed

As I suspected, my individual meetings with Mark and Julie revealed a long-standing pattern of moderate partner abuse. Despite their earlier contention that their arguments “never get physical,” on several occasions Mark had prevented Julie from leaving the room during an argument by standing in the doorway. Once or twice, he had slapped her shoulder as she walked away. He had grabbed her wrist a few times, in one instance hard enough to leave a bruise. He had also thrown several television remote controls and a cell phone when angry, and he frequently punched walls and slammed doors.

Mark sometimes used what he had learned in couples therapy against Julie: for example, by couching frequent critical and demeaning comments using a distorted version of an “I” statement, or by asserting that she was projecting her father onto him. When Julie raised a sensitive subject, Mark frequently got angry, yelled in her face, declared a time-out, stomped out of the room, and never returned to the issue.

Julie reported that her self-confidence had plummeted over the past few years, and she was feeling helpless and hopeless about her marriage. She said Mark had little sympathy for the chilling effect his behavior had on her libido and often criticized her for her infrequent interest in making love.

Recommendations for Treatment

When Mark, Julie, and I came together following my individual sessions with each of them, my recommendations went something like this:

“I have some thoughts about your therapy and where we go from here. We’ve discussed the issues and difficulties you experience together. For example, neither of you feels adequately appreciated, and you both report difficulty getting the other person to recognize and meet your needs. You’re both pretty good about identifying each other’s shortcomings but not so good about identifying your own. And it’s hard for you, even with me in the room, to discuss sensitive issues without getting into a heated argument.

“I think it’s clear to all of us that the two of you need couples therapy. But I think it’s premature at this point. It’s really just a matter of timing. You’re going to be spinning your wheels until you both have a chance to address your own issues. Then you’ll be able to take advantage of what couples therapy has to offer.”

In recommending separate treatment, there is a risk that the abusive partner will accuse the abused partner of having disclosed sensitive or confidential information that led to the recommendation. To minimize that risk, I cite only the behavior I observed or heard about in meeting with the two of them together when explaining my recommendation. If the abusive partner has acknowledged any abusive behavior—and it is extremely rare for the Abusive Behavior Inventory to bring no abusive behavior to light—I will refer to that as well.

In his individual session, Mark confessed that he had grabbed Julie’s arm once and frequently got so angry that he hit things. He also expressed remorse about it and a desire to change. So I added:

“And I appreciate your forthrightness, Mark, in acknowledging that you grabbed Julie’s arm and you don’t like the way you act when you get angry. That’s definitely something I can help you with.”

In the typical abusive heterosexual relationship, I generally refer the man to a men’s group with a focus on partner abuse (one of my own groups, or a colleague’s). I refer his partner to a group for women in abusive relationships. Other options include individual therapy with a therapist who has experience treating partner abuse, and group therapy for abusive women. I generally refer men who are being abused to individual therapy, since groups for this population are rare.

It is important to be resolute about my recommendations prior to the final assessment session so that I keep to them, whether or not the couple finds them acceptable. One or both partners will sometimes attempt to mount a persuasive argument for being seen together, and occasionally one of them will insist on having therapy together or not at all. My express purpose is to send a clear and unwavering message at this stage of treatment that couples therapy is premature—just as I would regarding family therapy with a parent who currently abused the children or who was an active alcoholic.

Arguments for and against conjoint treatment in cases of partner abuse are often heated and polarized among treatment professionals, in a process that runs parallel to the typical dynamics in an abusive relationship. By training and experience, I believe in the paramount importance of holding the abusive partner (or partners) accountable for his or her actions, regardless of what the other partner says or does. In abusive relationships, couples therapy undermines this goal by communicating, either overtly or by implication, that both partners bear some responsibility for the abuse.

There are practical considerations as well. Abusive couples who leave a session with unresolved issues are more likely to erupt afterwards. (I know, because many years ago I heard them yelling outside my office or pealing out in separate cars!) Additionally, conjoint therapy is generally not productive when control issues distort the therapeutic process or when either party fears serious repercussions for speaking the truth.

When is Couples Therapy Indicated?

Before I would consider treating an abusive couple together, they would have to meet several conditions.

Their answers to the Abusive Behavior Inventory match closely.
Past abuse was moderate to mild; currently, abuse is extremely mild or entirely absent.
The couple can adhere to a contract of no further abuse.
The abused partner is safe, unafraid, and able to mobilize resources if needed.
Both partners are motivated for treatment out of a sincere desire to grow and change.
Both partners are willing to be accountable for their behavior, without blaming the other.
The couple can use basic communication skills in a non-manipulative manner.

In short, couples therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment.

I presented Mark and Julie with two choices. They could each seek treatment with other professionals and keep me in reserve as their couples therapist at some future date. Or I could take Mark into one of my men’s groups, refer Julie to another therapist, and help them find a new couples therapist when Julie’s therapist and I thought they were ready. Mark’s reluctance to join a group, much less one led by a different therapist, led us to conclude that the second option was preferable.

Over the next three years, Mark and Julie both participated in group therapy supplemented by short bouts of individual work. I consulted regularly with Julie’s therapist to coordinate our treatment efforts, and we met together with the two of them from time to time to coach the couple through especially difficult logjams. Once Mark had achieved more than six months of abuse-free behavior, he and Julie began working with a seasoned marriage therapist who understood the dynamics of abuse. Julie ended her group work, but Mark remained for another six months because he had discovered that being accountable to other men helped ensure his continued recovery.

Conclusion

Treating partner abuse is a specialized field. Trainings in recognizing and treating the problem are helpful, but the only way to develop real expertise is through direct experience. To that end, I recommend that you become familiar with an assessment tool like the Abusive Behavior Inventory and practice administering it to a few colleagues. As with any new tool you add to your clinical repertoire, the greater your comfort in using it, the more at ease your clients will be.

Then, the next time you suspect partner abuse, you’ll be ready to assess for it. When you do, share your findings with colleagues, a supervisor, or an expert. If you discover your suspicions are groundless, you can breathe a sigh of relief. If your suspicions are confirmed, refer the couple immediately for further assessment, if necessary, and appropriate treatment. The hazard of proving your suspicions incorrect is small compared to the danger of leaving partner abuse undiagnosed and untreated.

In many ways, Mark and Julie experienced an ideal outcome. Their commitment to each other and to the process of change allowed them to leave their abusive dynamic behind. Mark was able to give up his sense of entitlement and develop greater empathy for Julie. Although some emotional scars remained, the damage was not so severe that Julie was unable to reclaim the genuine affection she had once felt for Mark.

But they were lucky: without any of these factors, a divorce was likely. And without appropriate intervention, the probable outcome would have been an uninterrupted, escalating pattern of abusive behavior, accompanied by additional years of unnecessary pain and suffering and the possible transmission of abuse to the next generation.

Sue Johnson on Emotionally Focused Therapy

Posted on July 17, 2011February 11, 2026 by rezendevknowfully.com

Foundations of EFT

Victor Yalom: Sue, it's great to be with you today. We might as well start with the basics. Can you just say a bit about what is emotionally focused therapy or EFT?

Sue Johnson: EFT is an approach that was developed in the '80s to work with couples, that now has a very strong empirical base. It's been tested. There's lots of outcome data. We know that we get results with lots of different kinds of couples. We know how we get results. As its name suggests, it's an approach that focuses very much on how people deal with their emotions and how they send emotional signals to their spouse, and then how this emotion becomes the music of their interactional dance.

It's an attachment-oriented approach. Attachment is a broad theory of personality and human development that focuses, also, very much on emotion. It's an attachment approach, so it assumes that we all have very deep needs for safe connection and emotional contact, and that when we don't get those needs, we get stuck in very negative interactional patterns; the dance music gets very complicated.

VY: Of course, humans are complex creatures. Emotions are an essential component, but we also have cognitions. Why do you focus on emotions?

SJ: We focused on emotion, in some ways, because they were pretty much left out of interventions, particularly systemic interventions—interventions that looked at relationships. Emotions were really considered the enemy. They were the things that people had difficulty with. Particularly, anger and conflict were considered the enemy. So there was a lot of focus on just teaching people skills to control emotion—to be nicer to each other.

And what we tried to do is say, "No, focusing on emotion and helping people send key emotional messages to each other that help the other person feel safe is the most important part of a relationship. It's the key part of the attachment bond. And we really need to teach people how to do that." So that's why we focused on emotion.

VY: And how did attachment theory become such a central component?

SJ: Really, couples taught us how to do EFT. We started looking at how couples got caught in being overwhelmed by their emotions, or numbing out their emotions, or putting very negative emotions out to each other, and getting caught in really negative cycles. But we didn't understand why these cycles were so powerful, took over the whole relationship and induced such distress in people. We knew there was something powerful here. And we learned how to help people get out of these negative dances and move into positive, trusting, more open dances with each other.

So we discovered how to do that, but we didn't really understand why this dance was so incredibly powerful, why it had the effect it did until

VY: And when you refer to the dance, you’re referring to the patterns that couples get into.

SJ: Yes, I think of the patterns of interaction in a relationship as a dance. And I like to think of emotion as the music of the dance. I think that is a shorthand way of talking about how powerful emotions are. It’s very difficult to learn skills and do a new dance that’s about tango when there’s waltz music playing. You end up going on with the music in the end. That’s what happens in relationships with emotion.

VY: What do you mean?

SJ: If I'm really hurting and really upset with you, and I'm vigilantly watching everything you do, waiting for some sign that I don't really matter to you and you are about to turn away from me, I discount the positive things you say, for a start. I wait for you to raise your left eyebrow and say something negative. And when you say that, I'm ready—I have all these catastrophic ideas and feelings in my body, and this felt sense of falling through space and insecurity. And I react like crazy. And you turn to me and you say, "But I was so sweet to you yesterday. Doesn't that count?" And if I'm honest, I would say no. So our emotional realities are very powerful.

VY: The kind of situation you just described is something that therapists often get tripped up on. When we’re in the room with a couple, things happen so quickly, even before we understand what’s happening and they’re off to the races.

SJ: That’s right.

VY: So how does the theory help us? How do you understand that?

SJ:

It really helps to understand that you're dealing with an attachment drama. You're dealing with dilemmas in human bonding.

It really helps to understand that you're dealing with an attachment drama. You're dealing with dilemmas in human bonding. So the emotions that you're dealing with are high-voltage emotions, because your mammalian brain sees these emotions—these situations—in terms of life and death: "Does this person care about me?" It looks like we're having a fight about parenting, but, in fact, if you tune into the emotions, oftentimes two minutes after the fight started—or two seconds after the fight started—the fight ends up being about attachment issues like, "Do you love me? Do I matter to you? If I hurt do you care? Are you there for me? Will you respond to me? Can I depend on you?"

I started to realize after we'd done the first outcome study that the logic behind these emotions was that they were all about attachment and bonding, and our deep human need for that secure bond.

Johnson's Flash of Insight

VY: How did that come to you?

SJ: It was a flash of insight, I’m afraid. It sounds corny, but it was one of those traditional corny "Aha!" things that just hit you in the head.

VY: How did that happen?

SJ: Actually, I was at a conference. We'd done the first outcome study of EFT. It had worked amazingly well. I couldn't really understand how it had worked so well, and I was at a conference listening to Neil Jacobson talking. And Neil Jacobson, who was really the father of cognitive-behavioral marital therapy, was giving a talk and basically saying that relationships are rational bargains, so what you have to do is teach people to negotiate. His theory was that you can negotiate almost anything, including affairs. And this was the theory of relationship underneath the behavioral approaches: you teach people communication skills so that they can problem solve and bargain better.

Afterwards, I and my colleague Les Greenberg, who originally helped me put together EFT for couples, were sitting in a bar, and he said, "He's wrong." And I said, "Of course Neil's wrong." And he said, "Well, why is he wrong?" And I said, "Oh, he's wrong because an adult love relationship is an attachment bond, and you can't bargain for basic responsiveness and safety and love." And that was it. And then suddenly the whole of John Bowlby, who I'd read, but who I'd never made the links—it was like somebody hit me with a sledgehammer.

I went home and wrote an article called "Bonds or Bargains," which ended up being in the Journal of Marriage and Family Therapy, even though Alan Gurman sent it out for review four times, and each time he got two people who hated it and who said that adult relationships were not attachment bonds like the bonds between mothers and children. They were adult friendships, and they were rational, and dependency was a problem, and we got over it. And the other half of the people said, "Oh, this is really new and interesting." And Alan Gurman finally said, "I can never get people to agree. They either hate it or love it. So, Sue, I like it so I'm going to publish it"—for which I bless him forever.

That was the first article—it came out in '86. And in '87 Hazan and Shaver, who were social psychologists, bought out their first little study of adult attachment. Bowlby always said adults had attachment, but we'd never really done anything with his remarks.

VY: So the interesting thing is you developed the theory and practice of EFT before you conceptualized the centrality of attachment in it, and it worked without that understanding.

SJ: It worked because, I think, we were Rogerian, and we understood how to create new interactions from a systemic point of view. But we didn't really understand why these new interactions worked so well.

And don't forget, also, in those days not much was written about adult attachment. Since then there have been hundreds of studies. It's a very rich literature now—lots of studies on adult attachment linking adult attachment to better health, feeling better about yourself, better ability to deal with stress. But in those days—in the '80s—nobody was writing about adult attachment. So there wasn't a literature sitting there that I could go to and say, "Oh, this is it." I just understood suddenly what I was looking at between adult partners, and how this paralleled the between the bonds between mothers and children, which many people still find very difficult to accept. They say, "No, they're totally different."

VY: It certainly goes against the strong sense of psychological independence that we cherish in the West and is so central to so many of our conceptions of psychological health.

SJ: Yes. I think what we've done is we've pathologized dependency. If you really think about it, though, how on earth do we get to be independent anyway?

Bowlby basically said for a child to really become independent, he has to be dependent first.

Bowlby basically said for a child to really become independent, he has to be dependent first. He has to be able to turn to other people and reach for them, and know how to connect with others in order to build this sense of self and in order to deal with how your self evolves and how big the world is. In other words, Bowlby basically said we're mammals. We need other people. A strong sense of self and the ability to be separate are tied to how connected you feel. They're not opposites—they're both the two sides of the same coin. We made a mistake in that.

In psychology and in therapy, we often see a little piece of the picture, and we go with that because that's all we can see. Then when the whole picture suddenly evolves, we can put things together in a different way.

VY: So you don’t like the ideas of co-dependency or enmeshment?

SJ: Well, enmeshment confuses anxiety about closeness and coercion, for one thing. It's a very vague concept, and a lot of it came out of watching families where adolescents were in deep trouble and the therapist was trying to help the adolescents assert themselves with the parents. There's nothing wrong with the word "enmeshment" if you put it in a very particular context.

Co-dependency came out of the addiction literature, and we used it as a global blame for people without understanding that we have amazingly powerful emotional links with the people we love. To say you shouldn't have those links is craziness. Those links are wired into our brains by millions of years of evolution. Bowlby says if you're a mammal, there's no such thing as real self-sufficiency. And there's no such thing as real over-dependency. But there are massively anxious behaviors around dependency.

What healthy people have is effective dependency, which means—and there's lots of research behind this now—the more you know how to turn to other people, the more you can trust other people, the more you can go inside of yourself and access, for example, your loved one's face when you're feeling upset or distressed, the stronger you are as a person, the better you feel about yourself and the more able you are to take autonomous decisions.

The more you know how to turn to other people, the better you feel about yourself and the more able you are to make autonomous decisions.

And I'm not making this up. I can quote you study after study, and you see it in therapy.

VY: I know that you can. And I know you can talk passionately and animatedly about the attachment literature for hours—

SJ: Yes, I can. It’s the best thing to ever hit psychology and therapy in the last hundred years, so there you go.

VY: Yes, you’re not one shy of opinions!

SJ: No. Life's too short to not put out what you think. And if someone can show you you're wrong, that's good.

EFT Techniques

VY: How did it change your thinking and the technique of EFT when you had that "aha!" moment and started to understand the significance of attachment in adult couples?

SJ: I think it helped me understand, on a deeper level, how powerful these emotions were that I was seeing in the couple. It helped me understand the power of fear in a couple—fear of abandonment, fear of rejection. It helped me understand the logic behind some of the apparently self-destructive positions people take in relationships.

VY: Can you give an example of the fear or the self-destructive positions?

SJ: For example, one of the classic ones in relationships is, "I feel lonely. I feel unsure that you care about me. I don't even know quite how to put that into words because I'm an adult—I'm not supposed to feel that way. But I somehow feel like I'm starving emotionally. And I decide that what I'm going to do is I'm going to make you respond. Ironically, I'm feeling all these feelings inside of abandonment and loneliness and fear, and what I say to you is, 'You never talk to me.'"

VY: What you're describing is what's underneath, unconscious, as it were—not what the person's actually saying, but what you posit is driving their behavior.

SJ: You don't have to posit it if you slow people down, and you say, "In the second before you get angry and tell your husband that he's ridiculous because he can't talk to anyone—in the second before you attack him to get his attention and to make him listen to you—what's happening to you?" If you just slow people down, there are enormously powerful universal patterns that you can see, and they fit very well with what John Bowlby saw in situations between mothers and infants.

There are only so many ways we have of dealing with our emotions. If I'm in a relationship with somebody and I want them to respond to me, and suddenly I'm not getting responsiveness and connection, I've got to reach for them and say, "Where are you? I need you." If somehow I'm afraid to do that or that doesn't work too well, then there are really only two alternatives. I get angry and shriek—children shriek or they get mad or they get aggressive with the mother, and so do we. We say, "Why don't you ever talk to me?" Unfortunately, if that gets to be a habitual pattern, I end up pushing you away. And in classic marital distress, the other person hears, "I'm being rejected. I'm disappointing. I'm messing up. I'm not pleasing this person. I don't know how to please this person. This hurts like hell. I want this fight to stop. I'm just going to stop talking."

So one person numbs out. And the more he numbs out, shuts down, shuts his partner out, the more his partner gets angry and pushes.

So one person numbs out. And the more he numbs out, shuts down, shuts his partner out, the more his partner gets angry and pushes. And that is the most classic dance of relationship distress in North America. It's a hot number. We all do it a lot.

VY: This is what you refer to as a cycle?

SJ: That's a cycle. And in Hold Me Tight, which is the book I wrote for the public a couple of years ago, it's one of the main "demon dialogues." What's important is if you understand that that drama is not about communication skills or your personalities, or that you're deficient somehow, but rather that drama is about both of you being caught in feeling disconnected from each other and not knowing how to handle it—if you understand that, what we first teach people to do in EFT is to basically understand they're scaring the hell out of each other. Then we teach them how to step out of the negative patterns, and then deliberately learn how to reach for each other—which is what mothers and infants and bonded partners and people who love each other in positive relationships naturally do—learn how to reach for each other and create loving, responsive, open emotional communication where they can get their needs met.

VY: Sounds nice.

SJ: It is nice. It’s fun to do, as well. As a therapist, it makes you feel like you’re actually really doing what you wanted to do in grad school when you decided to be a therapist.

VY: So how do therapists do that? The first thing, I guess, is to start to be able to identify, in your own mind, this dance—this cycle.

SJ: Yeah. At this point, we’ve been doing EFT for 25 years. We’ve set it out pretty clearly and we’ve even done research on what you have to do to make this work. First of all, you’ve got to create safety in the session.

VY: Okay, safety is number one. So how do you do that?

SJ: You do that by being empathic and by being emotionally present. Really, this is a Rogerian therapy. So you do that in the traditional Rogerian way, but I think it's more intense than Rogers really created because you also help the couple understand the drama that they're caught in. So you're a relationship consultant. You follow the couple's drama. You make it clear to them the steps they're doing in the dance.

VY: That's "Rogers plus," because you're not just reflecting back—you're starting to explain to them what you see that they're doing.

SJ: I think you have to do more than explain. You have to give them a felt sense.

You have to catch it as it's happening, and you have to help them see the dance they're caught in and how it leaves them both alone and hurting.

You have to catch it as it's happening, and you have to help them see the dance they're caught in and how it leaves them both alone and hurting. You also have to help them see that underneath this dance they're both in pain, and that this pain is just built into us. It's part of who are as human beings. So that is key. You have to create safety in the session. You have to help people explore their emotions so that they can talk about some of these softer feelings.

If you're always telling me that you don't want to hear me because I'm so angry, after a while all I show you is anger. And all I see you do is be cold and indifferent. And what we help people do is talk about the softer feelings that they don't even know how to name sometimes, and certainly don't know how to share. So the reactively angry partner will start talking about how "I feel lonely. I don't know what to do. I do get angry. I do get critical because underneath I'm so scared I don't matter to him."

And we will help her not only access that and work with those feelings, regulate them differently, integrate them so she can talk about those softer feelings—we'll help her turn and share with her partner in interactions where we scaffold the safety in. We help her share that, and we help her partner hear it—because one of the reasons you need a therapist is that sometimes you do give these clear emotional messages to your partner, and because of the negative music playing in the relationship, your partner doesn't even hear it. Your partner doesn't trust, doesn't respond to it.

VY: When you say you help them share these feelings with their partner—this is what you refer to as enactments, á la Minuchin, right?

SJ: Yes, although they’re much more emotional than Minuchin’s enactments usually were. To really summarize it, the EFT therapist creates safety, deepens people’s emotions using the attachment frame, to the soft feelings, the fears, the sadnesses, the hurts, sometimes even the shame underneath their reactive responses to each other, and then helps them send clear signals to their partner in very powerful interactions about their fears and their needs. Really, we teach people to help each other deal with these difficult emotions in a way that brings them closer.

VY: So if all goes well, you identify their pattern, you help them feel safe, you observe their pattern, you help them identify it, and then you help them start to express their deepest, vulnerable, unmet needs with each other. Then what happens?

SJ: It's basically the prototypical corrective emotional experience. And the reason it's so powerful is that we have these key change events in the second stage of EFT. In the first stage, we de-escalate the negative patterns so that people can stop and say things like, "Hey, we're caught in that thing again—that thing where I get angrier and angrier and you get more and more silent. This is the place where we both get hurt." And they start seeing the dance is the problem.

So they can have control over the negative interaction pattern, but that's not enough. I think lots of couples therapies get people there one way or another. The important bit for me is the second stage, where we actively use an attachment frame to help people to distill their attachment fears and their attachment needs, which in the beginning of therapy they are often not even aware of. And then we help them share that.

When that happens and the other person can respond,

sometimes for the first time in people's lives they actually feel that another person is there for them, that the other person cares, that they matter to someone.

sometimes for the first time in people's lives they actually feel that another person is there for them, that the other person cares, that they matter to someone. This is a huge event. It starts to redefine the relationship as a secure bond. And it's incredibly positive for people because we have mammalian brains.

VY: It can be. But take the example where one of the partners gets to the point where they can be incredibly vulnerable and open and express their unmet needs, and the other partner has their own intimacy issues and blocks, and that’s too much for them, and they reject it or they withdraw.

SJ: First of all, the therapist is there dealing with that. Secondly, you titrate the risks people take in EFT. You don’t ask people to take huge risks before they’ve done Stage One. So ideally you don’t let people get into that position. But, nevertheless, if someone shares and the other person can’t respond, the good EFT therapist will go in and help that person slow everything down. See, emotion’s fast. If you want people to regulate it better and integrate it and deal with it differently, you’ve got to slow it down.

VY: Yeah, and I’ve seen you work and you’re very good. You track people very carefully, and you’re very good at slowing it down.

SJ: Yes. So in that case, I would turn to the person. I would say, "Could you help me? Did you see your partner just turned to you and said, 'I am scared. I am. And that's when I get into my tank, but inside I'm always so terrified that you never really chose me. I never understood why you married me. I'm always terrified by the fact you could leave me any minute'—did you hear your partner say that?"

You'd be amazed at what people hear sometimes. I had one man who basically said, "I heard that she can leave me any minute." So you have to slow it down. You have to help people get clear, and then you have to say to the person, "What happens to you?" And often people don't know what to do with it, so they'll go cognitive. They'll say, "Well, she had a very difficult family, and it's really not my fault." And you say, "No, I'm going to slow you down." So you help people focus on what matters. You support them. And I help the person hear it. I might say "My sense is that's hard for you to hear."And then the person will slow down and focus and say, "Yes, I don't see her that way. It's so strange for me to really see that she's afraid of me. I can hardly take it in. I see her as so powerful. I don't even know what to do with it. It confuses me. I actually feel dizzy. I feel like there's no ground under my feet. I've been with this person for 30 years. I never see her as—you mean she's vulnerable and scared? I don't know what to do with that."

So you listen to him. He's going to the leading edge of his experience. I'm keeping him there and helping him process it. Then I help him distill that and say, "Could you tell her, please?" And he says, "It's so hard for me. I don't quite know what to do with this new message. I don't know what to say when you tell me that. And I almost don't know whether to trust it. That you would be scared of me—that's so strange for me." And that's fine.

VY: This is where, as a therapist, you have to be very grounded to stick with it.

SJ: Yes.

VY: And really go slow with them, be patient, but also persist in insisting that he not withdraw.

SJ: Yes, that's right. And we're pretty systematic now. We've got training tapes, we've got a workbook, we've got the basic 2004 text. It's laid out in a lot of detail, and we have a whole procedure for training therapists and registering therapists. You can watch people do this on a tape. But you're right. EFT takes a lot of focus, and you have to be able to work with people's emotions, and help them stay with them and develop them and deepen them. You also have to be able to track interactions, and help them create these new interactions with their partner.

So it's a collaborative therapy. You're doing it with people, but it's certainly not a laid-back reflective therapy. It's a therapy where you're dancing alongside your client, and the music's going, and you understand the music, hopefully. But it's an active therapy, because there's so much going on.

Training Couples Therapists

VY: I understand that you’ve put a lot of thought into how to train therapists and set up a systematic program of training, ranging from your externships to supervision, et cetera. What do you find are the most difficult things for therapists to learn?

SJ:

I think our profession has developed a profound distrust of dependency, and we don’t understand it.

I think our profession has developed a profound distrust of dependency, and we don’t understand it. We still are hung up on, "We have to teach people to regulate their own emotions, be independent and separate, and define themselves." I think that’s one thing. We don’t really understand people’s deepest needs.

VY: So just conceptually having a shift in this idea of dependency, autonomy—that gets in the way.

SJ: Yes. You’ve got to be able to accept that we’re interdependent and we need each other. Otherwise, you’re going to have a hard time with EFT. You’re not going to be able to listen to and validate people’s needs. You’re going to blame them for their needs. But the second one is you have to get used to staying with emotion and deepening it. There’s a beautiful quote by Jack Kornfield. He writes about Buddhism and he says something about, "I can let myself be borne along by the river of emotion because I know how to swim."

I think therapists have been traditionally quite scared of strong emotion because we haven’t really known what to do with it. And at this point in psychotherapy in general, and in EFT, I think, there’s been a big revolution understanding emotion and human attachment. And we do know what to do with it. There’s nothing illogical about emotion. And, actually, there’s not very much unpredictable about emotion if you really know how to listen in to it. But many of us have not been trained in how to really stay emotionally present with somebody and track emotion, how to deepen emotion and use it. I think that’s the biggest one that people struggle with in EFT.

VY: So it’s just being more comfortable with emotion and trusting yourself to stay with it.

SJ: That’s a big part of it.

VY: That’s in terms of the comfort of the therapist. In terms of the techniques to help people work with it, what are the hardest things for therapists to learn?

SJ: I don’t think the techniques are hard per se. They’re a combination of Rogerian empathic reflection, validating, asking process-oriented questions like, "What’s happening for you right now? How do you feel when this person says this? How do you feel in your body? What do you tell yourself in your mind? Do you tell yourself this means this person doesn’t love you?"

VY: What I see is the skill that refer to as "slicing very thin"—tracking emotions on a very minute, moment-to-moment level. Not just asking someone how they feel, because many people, as you know, can't articulate that.

SJ: No.

VY: So you go at it from many angles.

SJ: Well, we know what the elements of emotion are. The elements of emotion are initial perception, body response, a set of thoughts, and then an action tendency.

VY: Now you’re sounding like a behaviorist.

SJ: No, I'm not. That comes from the emotion literature. A good EFT therapist will go and ask simple questions about the basic elements of emotion. Somebody will say, "I don't know how I feel right now." And the EFT therapist will say, "How's your body feel?" The person will say, "I feel tense." And the EFT therapist will say, "What do you want to do?"—because there's an action tendency in emotion. The person says, "I want this to stop. I want to get out of here." So you know what's happening—there's some version of fear going on. So the therapist will ask simple questions, and constantly empathically reflect to help people hold onto their emotional experience and continue to work with it.

Sometimes a therapist will interpret—add a piece. "This is very difficult for you. Could it be a little scary?" And then the therapist will help somebody hold their emotion, distill it. And then will create an enactment: "Could you turn and tell your partner, 'When we start to talk about this some part of me just wants to run away'?" You make the implicit explicit. You make the vague concrete. You make the vague vivid.

It's much better, from a relationship point of view, for me to turn and say to you, "Victor, I don't know what to do with what you've just said, but there's something a bit scary about it and I just want to run away." That's much better than for me to just feel that and not be able to talk about it, and turn and leave the room. If I turn and leave the room and you are a mammal and you're in a relationship with me, your brain says that's a danger cue. "This person who I depend on can walk away from me any time." And you start to get really upset—whereas if I turn and say to you, "I don't know what's happening with me. This is a bit scary. I just want to leave," you're probably going to feel compassion towards me.

It's all about helping people learn how to hold on to that emotional connection. Our mammalian brains experience emotional connection as a safety cue. There's lots of neuroscience behind this now, by the way. This emotional attachment stuff is creating a revolution in our field.

The New Science of Love

VY: I just heard David Brooks speak. He’s done a great job with his book, The Social Animal, summarizing a lot of the attachment research, but he also warned of the danger of over-reading brain science. He said something to the effect that brain science is in such a state of infancy that to draw any definitive conclusions from it can be riding the next wave of popularity, but to make precise conclusions from it is overreaching.

SJ: I agree with David Brooks that you can't draw conclusions. Sometimes when I listen to people and they say, "Oh, we change the brain in psychotherapy," I don't know. I just feel like saying, "Well, you know, eating an ice cream changes your brain."

On the other hand, when you look at research like my colleague, Jim Coan, has done, that if you lie alone in a computer in an MRI machine or you hold a stranger's hand, your brain goes berserk when you see a sign that you're going to be shocked on your feet. And when your partner, who you feel safe and connected with, holds your hand and you can see that signal that tells you you're going to be shocked on your feet, because you're holding your partner's hand and you feel connected to them your brain does not go berserk, and the way you experience the shock is much less painful.

Now, David Brooks is right. We're not quite sure what it all means. But it's fascinating stuff, and it's taking us into new territory. And, just by itself, that one study supports all the hundreds of studies that have been done on adult attachment and infant and mother and father attachment that says that we have connections with very special others, and that it's basically all about safety and danger. We use that connection as a safety cue. And what I just said has huge implications for couple therapy, psychotherapy in general, education for society. So, yes, David Brooks is right and we are in the middle of a revolution.

VY: Speaking of that, I hear you’re writing a new book on the science of love.

SJ: Yes, because we really do have a science of love. It's in its infancy, but it's a strong, bawling little infant. It's not a fragile child.

We really do have a science of love. It's in its infancy, but it's a strong, bawling little infant. It's not a fragile child.

When I think about it, in the last 15 years our understanding of our most important adult relationships has absolutely gone crazy. It is a revolution.

And it's so important. I was just looking in my local newspaper today, The Globe and Mail in Toronto, talking about how the Canadian government is struggling with the fact that there are rising levels of anxiety and depression and we can't deal with it in our healthcare system. Well, I know what John Bowlby would say. John Bowlby would say, "Absolutely, because we're facing less and less social connection, less and less community connection, and 50 percent of us divorce. We haven't learned how to create these safe, loving bonds. We need to belong." And the way to deal with that sort of thing, from my point of view, is not for the pharmaceutical companies to get better pills. It's for us to really understand our need for human connection, and start educating people for that and understanding how crucial that is in terms of basic mental health problems like anxiety and depression.

VY: Can you give a little sneak preview of your book? One or two morsels?

SJ: I'm going to talk about oxytocin, the cuddle hormone. I'm going to talk about how sex is an attachment behavior. I'm going to talk about how we're basically monogamous and that those people who say that we're not suited for monogamy are out of their minds. I'm going to talk about all the science behind what happens when you have one of those little arguments with your partner in the morning that ends up wrecking your whole day, so that when five o' clock comes along you're not even sure why you married this person. That's what I'm going to try to talk about.

VY: We'll look forward to that coming out. Thanks for taking the time to talk today.

SJ: You're welcome.

Turning Blaming into Confiding in Couples Therapy

Posted on June 23, 2011February 11, 2026 by Psychotherapy.net Team

The defining task in a Collaborative Couple Therapy session is to create an intimate conversation out of whatever is happening—frequently a fight. Sometimes that means helping the partner who has just been accused deal with the accusation. Sometimes, and this is my focus in this write-up, that means reshaping the accusing partner’s angry statement. I speak as if I were that partner, translating his/her blaming statement into a confiding one, in a method similar to doubling in psychodrama. I show what this partner might be saying if the couple was having a conversation rather than this fight. Here are the principles I use for making these translations.

• Change the tone of voice
• Omit the blaming
• Report the blaming
• Add or substitute heartfelt feelings
• Append a question that turns the monologue into a dialogue
• Acknowledge

1. CHANGE THE TONE OF VOICE. If I can’t immediately think of ways to modify a partner’s angry comment, I repeat or paraphrase it, but now in a nonprovocative, nonaccusing, nondefensive, warm, intimate tone. Of course, if I can think of how to modify what was said, I still change the tone. None of the changes listed below would do much good if they were stated in the partner’s original angry, defensive, arrogant, sarcastic, contemptuous, or distant tone.

2. OMIT THE BLAMING. An important way to turn a partner’s fight-fostering comment into a conversation-fostering one is, of course, to omit (or at least reduce) the blaming, accusations, anger, attack. Lynn says to Fred, “You’re selfish, immature, and totally irresponsible to go out to a bar with your office pals after work, and come home late for dinner. You’re probably flirting with what’s-her-name in the next cubicle.” Moving in and speaking for Lynn, I say, “I’m going to restate what you just said but change the tone in order to help you get your message across to Fred. In my version, Lynn, you’d say, ‘I hope you can understand why I might be upset about your going to a bar and coming home late and why, given the situation, I might be imagining all kinds of things like your flirting with other women’.”

3. REPORT THE BLAMING. Another way to eliminate (or at least reduce) the toxic fight-fostering effect of blaming is to report the anger rather than unload it. Bob says angrily to George, “You’re nasty and mean-spirited and never think of anybody but yourself!” I move over and speak for Bob in an effort to show him what it would sound like if he were to talk about the anger rather than from within it. I say for Bob, “I can’t remember when I’ve felt as angry at you as I do now” or “As you can see, I’m still furious about that comment you made this morning” or “At times like this when I’m really angry at you, I forget all that I like about you and just see you in a super negative way.”

The effect of such reporting is to create a platform, a perch, a meta-level, a vantage point above the fray from which Bob confides being angry. Most of the other interventions on this list create such a platform or vantage point.

4. ADD OR SUBSTITUTE HEARTFELT FEELINGS. In a fight, people lose the ability to make “I” statements. They lose contact with their vulnerable, heartfelt feelings and become “you” statement generating machines. In speaking for a partner, I uncover these vulnerable feelings: the wishes, fears, worries, longings, disappointments, self-reproaches, shame, guilt, self-hate, loneliness, and so on. I reveal the “I” statement hidden in the “you” statement. Here, as in other instances in which I guess what the partner might be thinking or feeling, I use information gleaned from earlier in the therapy, label my comments as speculations (saying, for example, “I give myself about a 30% chance of being right”), and check back to see if my guess was correct (“Where was I right and where was I wrong?”). At times I recast much of the partner’s original statement, changing “you” statements to “I” statements. Sometimes, as in the following examples, I append a vulnerable feeling (an “I” statement) to the partner’s attack.

John snaps at Judy, “You’re being selfish thinking of going back to school when you’ve got our kids to take care of, and in this rotten economy. Don’t you ever think of anybody but yourself?” Moving in and speaking for John to Judy, I append “… and I worry that your going to school might be the first step toward your leaving me.”

Sylvia says to Bob angrily, “I’m tired of always being the one who has to manage the family: schedule everything, make all the phone calls, assign all the chores.” In saying “I’m tired,” her comment appears to be an “I” statement. But implied is: “You don’t do your part,” “You take me for granted,” and “You’re selfish and irresponsible.” Moving over and speaking for her to Bob, I add the following clearer underlying “I” statement to what she just said: “I feel lonely” or “I don’t like the kind of person I’ve become in this relationship.”

5. APPEND A QUESTION THAT TURNS THE PARTNER’S MONOLOGUE INTO A DIALOGUE In an effort to make their cases, partners often give little lectures presenting their evidence, making speeches, pronouncements, or indictments. They deliver monologues. I try to turn these monologues into dialogues by appending a dialogue-creating question. Sue expounds on her knowledge of interior decorating and denigrates Phil’s taste in an attempt to prove to him that she should have the larger say in what furniture to buy. Moving over and speaking for her to Phil, I append to what she just said, “What do you think about what I’m saying?” or “Am I convincing you?” or “You probably disagree with most of what I just said. Am I right?” or “Is there any part of what I’m saying that you agree with?”

6. ACKNOWLEDGE. In a fight, each partner argues his/her case and either ignores or refutes that of the other. Neither acknowledges the validity of any of the other’s points or admits weaknesses in his/her own case. In speaking for partners, I do this acknowledging and admitting for them by doing one or more of the following:

• Acknowledge what the other partner has been trying to say
• Agree with parts of it
• Recognize the other partner’s efforts or achievements
• Appreciate the difficult position the other partner is in
• Admit his/her (the person on whose behalf I’m speaking) own role in the problem
• Confide doubts about the validity or fairness of what he/she is saying
• Express concern about how the other partner might hear what he/she is saying

Acknowledge what the other partner has been trying to say. In a fight, each partner feels too unheard to listen, which is what keeps the fight going. In speaking for a partner, I do the listening for him/her. I demonstrate how it would sound if this person were to do a bit of active listening and acknowledge what the other partner has been trying to say.

Judy complains to Bill, “Are you at all aware that you hardly ever talk to me except to complain about things I haven’t done right.” Bill pays no attention to this and, instead, tells her what is on his mind: “You forgot to lock the front door again.” Judy pays no attention to this and, instead, repeats her concern: “That’s all you care about—the front door. What about the fact that we never talk about anything important, like about us?” Bill says, “Keeping the door locked is important. We’ve got a lot of valuable stuff in here. You’ve got to think about that.” Judy says, “I’ll tell you what you’ve got to think about, and it’s that I’m starting to feel closer to my friends than I do to you.” Bill says, “But this is serious. Half the time you don’t lock the door; it’s just luck that we haven’t been robbed.” Judy says, “Speaking of robbed, I feel totally alone in this relationship.” Bill says, “All I’m asking is for you to be a little more careful when you leave the house.” The partners go back and forth repeating their point (because the other appears not to have heard it), paying little attention to what the other is saying.

Moving over and speaking for Judy, I say, “I know you’re worried about my not locking the door, but I can’t listen to that right now because I’m so frustrated that you won’t listen to my concern, which is that we never have intimate conversations.” I could just as easily have moved over and spoken for Bill, saying: “I know you’re saying that I don’t talk enough, but I can’t listen to that right now because I’m so frustrated that you won’t listen to my concern about locking the door.”

Agree with parts of what the other partner has been trying to say. In a fight, neither partner gets the satisfaction of having the other agree with anything. Each partner rebuts or ignores what the other says. In speaking for a partner, I do the agreeing for him/her. “You have a good point that I…and I have a good point that….” Or, “If we weren’t in the middle of a fight, I’d admit to you that you are making some good points.”

Often I turn to one partner and say, “I’m going to repeat what you just said, but begin by agreeing, which would then put you in a better position to make your point.”

Gloria criticizes Ed for being too harsh with the kids. Ed criticizes Gloria for being too lenient. The argument goes back and forth in this way for some time. Moving over and speaking for Gloria, remembering what she had said in a previous session, I say, “You’re right that I can be too soft with the kids. I need to work on that. My concern right now is to get you to consider that maybe you’re too hard on them.”

Paul criticizes Cheryl for something she did. Cheryl’s justification seems to convince Paul, but instead of acknowledging that, he goes on to make another complaint. I say, “Paul, were you feeling at that moment, ‘Okay Cheryl, you convinced me. But it just reminds me of something else I’m upset about, which is that…’”

Recognize (at times even celebrate) the other partner’s efforts or achievements. Sam proudly describes doing what Ann had asked him to do—pay the bills and clean the bathrooms. Ann replies, “Yes, that’s good. It’s about time. You act like you’re still single. You don’t take responsibility.” Moving over and speaking for her talking to Sam, I say, “You obviously paid attention to what I asked for last time. That’s wonderful! I really appreciate it. I hadn’t thought you would. But—and I’ll make this a multiple-choice question, Ann—A, I don’t want to get too excited about it and get my hopes up that the change is permanent, or, B, it’s too small a part of what I want to be really excited about. Ann, is it A or B. Or is it C, something else entirely?” (When I am uncertain what the person is feeling, I often ask such a multiple choice question.)

In her original statement, Ann skipped over Sam’s achievement. I try to show how it might make sense that she did so and how it would sound if she hadn’t done so.

Appreciate the difficult position the other partner is in. In a fight, each partner feels too unempathized with to empathize, too worn down by his/her own struggle to notice that the partner is caught in one, too. In speaking for partners, I do the appreciating, empathizing, and noticing for them.

Sara says to Ralph, “You never stand up for me when your mother pulls one of her numbers.” Ralph says, “Can’t you just do what everyone else in the family does—just accept that that’s how Mom has always been and realize there’s no way to change her.” Hearing this argument, I look for the right time and moment to say for Ralph, “I feel bad that I haven’t protected you from my mother” and for Sara, “I see how you’re caught in the middle.”

Admit his/her own role in the problem. In a fight, each partner blames the other partner for the problem and denies or minimizes his/her part in it. In speaking for a partner, I do the admitting for him/her. “I came home frustrated and took it out on you.” Or, “I overreacted.” Or “I know it didn’t help that I…” Or, “I’m suddenly seeing you as my father, which I know isn’t fair” Or, “I’m feeling hurt, but you have no way of knowing that, because my hurt is coming out as anger.”

Express concern about how the other partner might hear what he/she is saying. In a fight, partners lower their heads and bull ahead without acknowledging that what they are saying is provocative. In speaking for a partner, I do the acknowledging for him/her, often as a kind of prefacing statement. I say, “I know you never like it when I bring this up, and that’s why I mostly keep it to myself, but it’s been really bothering me lately so I need to say something…” or “I know this is a criticism, but I need to say it anyway” or “I’m angry, so I’m probably not saying this in the best possible way” or “I hope you see my distress peering through my anger,” or “This could get us into trouble, but I want to talk about it anyway” or “I wish I could find a way to say it that wasn’t a criticism because there’s something important here that I want to get you to see.”

Admit doubts about the validity or fairness of what he/she is saying. In a fight, partners focus on making their case. They put aside (and often lose awareness of) any doubts or reservations they might have about what they are saying. In speaking for a partner, I reintroduce these doubts or reservations. I say, “I know this isn’t fair, but it’s on my mind so I want to say it anyway and it’s that…” or “I know I’m on shaky ground here because I do the same thing myself, but…” or “I go back and forth between blaming myself for this problem and blaming you and, as you can see, at the moment, I’m deeply into blaming you” or “For a fraction of a second I was pleased by the lovely thing you did—and began to hope that it meant that you’ve really changed—but then I thought, ‘Wait a minute. I’m not going to get my hopes up just to be disappointed again’” or “I know I’m difficult to live with, so I probably don’t have a right to complain about something you do that’s so minor, but here it is…”

In speaking for partners, I try to make their case more effectively than they had been able to do so themselves. I repeat what they had just said but now in a more disarming, engaging, and heartfelt way. At times, I shorten what they have said and at times lengthen it. At times I reformulate what they have said and at other times append something to it. My effort in each case is to restate what the partners have just said in a way that will give them greater satisfaction and that their partner will be better able to hear.

My purpose here was to list the principles I use for arriving at my statements for partners in an effort to turn their blaming statements into intimate ones.

Collaborative Couple Therapy With High Conflict Couples

Posted on April 16, 2011March 13, 2026 by Psychotherapy.net Team

What’s hard, when dealing with high conflict couples, is getting their attention. If they do register your presence, it is to recruit you to their cause, confiding in you conspiratorily, “Look what I have to put up with.” And if they do acknowledge what you say, it is to turn your comments into ammunition against their partners, assuring you, “I do what you’re saying, but he never does.” High-conflict couples attack each other at such high velocity that you don’t have time to think. And you may not get much chance to talk, either, if, as sometimes happens, they keep interrupting you. Here are various methods I have heard therapists use to deal with these couples:

1. Take control from the beginning by doing individual therapy with each in turn in the presence of the other or taking them through a structured sequence.

2. Separate the partners. See each individually for a session and then bring them together. Taking it a step further, some therapists tell certain high-conflict couples that they each need a course of individual therapy before even considering couple therapy.

3. Ask them how they met and what originally attracted them to each other. In so doing, you distract them from their fight and introduce something positive.

4. Establish and enforce ground rules such as “no name-calling.” In a videotape of her work with a high-conflict couple, Susan Heitler gave the couple two rules: 1) stop talking when I say to and 2) don’t interrupt when I’m talking to your partner.

5. Tell the partners “hold it” or “stop” or wave you hands between them. Forcefully take command, as does Terrence Real. Or wave off the interrupting partner (Robert-Jay Green does this, but then later adds the wonderful touch of apologizing to the partner he waved off).

6. Confront the partners with the counterproductive nature of their behavior, saying, for example, “Listen to yourself!” or “Blaming doesn’t help” or “Talk about yourself rather than about her” or “Do you want to be right or do you want to be married” or “You’re acting like a couple of three-year olds in a sandbox fighting over a pail and shovel.”

7. Hook them up to a heart-rate monitor and when either partner’s heart rate exceeds one hundred, get them to take a time out. John Gottman came up with this.

8. Interrupt a fight to play back the video of it. John Gottman and Stan Tatkin do this.

9. Pick up a book and tell them you’ll stop reading when they stop fighting and get down to business.

10. Tell them that things are going too fast for you to think. Rather than blame them for doing something wrong, you take responsibility for the need to slow things down.

11. Move in quickly when things suddenly erupt and say “What just happened?” Susan Johnson does this.

You have to be forceful when dealing with high-conflict couples who interrupt each other and interrupt you and thus make therapy difficult. My way is forcefully to enter on the side of both partners and develop what they are trying say rather than to confront them with the counterproductive nature of their behavior and urge them to restrain themselves.

Why do I want to develop what the partners are trying to say? Because anger is typically a fallback measure, in EFT terms a secondary emotion. It’s what you’re often left feeling when you can’t express what you need to say—you lose your voice—or when you can express it, but you can’t get your partner to listen. In a couple fight—and this is the definition of such a fight—there are two people who feel too unheard to listen.

So I try to get the partners to listen to each other. I try to show them how it would sound if they were to express what they needed to say and take in what the other is trying to say. I move over and speak for them, in a method similar to doubling in psychodrama. I try to turn their fight into an intimate conversation.

And I do something else. I try to shift the partners to the meta-level—what I call the platform—and get them talking collaboratively about their fight. I want to get them commiserating with each other about it.

So these are the things I try to do with high conflict couples (and, actually, with any couple):

Help them express what they need to say,
Help them take in what the other is trying to say
Create this platform.

There is a natural sequence of things I do in my effort to accomplish these purposes.

The first is to catch the fight in its early stages before it builds up steam. If I see the emotional temperature rising or if one of the partners lets loose a zinger, I jump in. If George says something angry to Rose, I move next to him and, doubling for him, that is, speaking as if I were he talking to Rose, I say, “As you can tell, I’m angry and that’s because I felt hurt by what you just said.” I turn his angry comment into a confiding one. If I can’t think of how to do this, I repeat some version of what he said but in a nonangry tone. Alternatively, I might help Rose deal with what George has said by asking her, “How much does what George just said seem an accusation and how much an understandable concern?”

If I’m unable to catch the fight before it starts and it really gets going, I try to translate the fight into a conversation—that’s number 2. I go back and forth between the partners, doubling for each in turn, trying to detoxify each person’s comments. This can go on for some time. Sometimes the fight goes too fast for me to keep up with. When that happens, I wait until I regain my bearings and then go back over what they just said, but detoxifying it (“first you said…, then you said…., then you said….”). I bring out the conversation hidden in their fight.

Third, if I am unable to translate the fight into a conversation, I make a statement for each showing how each partner’s position makes sense. “Jim, it’s understandable that you don’t like Brenda’s bringing up something you did 20 years ago. It makes you feel she’ll never let you live anything down. And Brenda, it’s understandable that you’re bringing it up because it’s the clearest example of what you feel Jim continues to do in more subtle ways today.”

If I fail to get the partners to appreciate how each of their positions make sense, I try to get the partners up on a platform—a meta-level—talking collaboratively about how they are being adversarial. That’s number four: talk about the fight:

I ask, “Are you getting something from this fight, a chance to say a few things or hear a few things? Or is this fight discouraging, what happens at home, and what you came to therapy to stop?”
Or I ask, “In what ways is this fight useful and in what ways is it not so useful?”
Or I ask, “You came in today feeling relatively good about each other, but little by little the good will disappeared and now you’re quite upset with each other. Do either of you have any idea of what brought about this shift?”
Or I ask, “What should we do about this fighting? Should I step in more quickly to stop it?”
Or I ask, “Am I doing my job in keeping things safe? Or am I allowing too much fighting.”

While I am doing all these other things, I look out for and focus on conciliatory moments. That’s number five. I say, “Hey, I want to go back to what happened just a minute ago. You made that sweet comment (or you had that sweet exchange). What allowed that to happen? What were you thinking and feeling just before you said it that led to it?” And to the other partner I say, “How did you feel hearing it?” I’m looking for moments when these fighting partners aren’t fighting—much like a narrative therapist or solution-focused therapist looking for an exception. At other times I try to create a conciliatory moment. When one of the partners says he or she feels lonely or disappointed, I harken back to earlier in the session, or earlier in the therapy, when the other partner expressed such a feeling. I jump at the chance to show that they share a particular reaction.

Turning now to the situation in which one (or both) partners makes long provocative statements, either repeating (belaboring) a complaint or stacking complaints one upon the other, I try to find a collaborative way to interrupt them. That’s number six: “interrupt tirades in a collaborative manner.”

I say, “I’d like to interrupt you here because I’m afraid that we’re losing Linda; she seems to be sinking deeper and deeper into the couch”
Or “Let me interrupt you here to find out how Linda is doing hearing this”
Or “I’d like to interrupt you here because you’re making some important points but I’m concerned that they are getting lost; I’d like to repeat them and then get a response to each from Lois.”
Or, “In the last couple of sessions things got pretty intense when one of you laid out a number of complaints in a row, so I think when that happens this session that I’ll move in and interrupt so we can have more of a conversation. What do you think about my doing that?”
Or I move in after a partner has made one or two points (or has made one point but has repeated it several times) and before he or she can repeat it again or go on to make the next point and I say, “Let me work with that; you’re saying that…” Or, more simply, “Okay, so you’re saying…” or “Let me interrupt here.”

If all these various efforts fail to rein in the fight, and I feel overwhelmed and powerless and don’t know what to do, I give myself a little pep talk—that’s number seven: “Console myself.”

I remind myself that although I don’t know what to do at the moment, I’ve always in the past been able to come up with something a little later.
Or I remind myself that partners who appear to ignore or reject everything that I and their partners say, often come to the next session having made changes that show that they had heard, but just weren’t in a position at the time to acknowledge it.
Or I remind myself that partners who fight the whole session sometimes come to the next session saying, “We needed that—a chance to let off steam. We feel better now.”

If it looks like the session is going to end with the partners angry at and alienated from each other, I talk with them about that. That’s number eight: appealing to the partners as consultants in evaluating and dealing with the situation.

I say, “Given what’s happened here today are you sorry you came?”
Or “What does a session like this leave you feeling about what we are doing here and whether these sessions are helping or just making things worse?”
Or “It looks like you’re going to end the session feeling angry and alienated. Is there anything either of you can think to do in this last couple of minutes to change that, or is it something that we shouldn’t even try to change?”

Another thing I do if it looks like the session is going to end with the partners angry at and alienated from each other is to ask what is going to happen after the session. That’s number nine. I try to create a platform—a vantage point above the fray—from which to speculate about what is going to happen.

I say, “Given how upset you are with each other, what is it going to be like driving home together, and tonight, and the next couple of days?”
“How are you going to get over this and how long is it going to take?
“Who’s the one more likely to reach out to the other?”

By anticipating with them what is likely to happen, I am trying to keep the aftermath of the fight from being the lonely, alienating experience it usually is. The three of us would be talking about it ahead of time. I follow up the next session by asking what did happen—what evolved from last session?

In this next session, I might ask whether they want to return to the issue they were fighting over the previous session? Or do they think that’s a bad idea because doing so will just get them back into the fight? That’s number ten: attempting a recovery conversation—revisiting the issue when they are not upset. If they want to make such an attempt, I guide them through it. And I jump in quickly if it does begin to turn back into the fight. Developing an ability to have recovery conversations is a premier goal of Collaborative Couple Therapy. In a successful recovery conversation, both partner come away feeling that the positions of each made sense.

To put all this together, I move in to keep the fight from happening. If it does happen, I try to turn the fight into an intimate conversation. If I’m unable to do that, I make an elegant statement for each partner showing how his or her position makes sense. If that doesn’t turn the session around, I try to get the partners on the meta-level talking collaborative about their fight. All the while, I draw attention to collaborative moments and interrupt partners (in a collaborative way) when they belabor or amass complaints. At various points in difficult sessions, I console myself. If it looks like the session is going to end with the partners angry at and alienated from each other, I appeal to them as consultants in dealing with this problem and ask what is going to happen after the session. In the next session, and if it is possible to do so without rekindling the fight, I conduct a recovery conversation. A major goal of Collaborative Couple Therapy is to enable partners to have recovery conversations in which they turn fights, problems, misunderstandings, and glitches into opportunities for intimacy.

Interacting Sensitivities in Couples Therapy

Posted on March 13, 2011February 11, 2026 by Psychotherapy.net Team

It is a typical night at Tom and Betsy's house. Tom has his nose in a newspaper. Betsy is leaning in the door of his study trying to talk to him, getting more and more frustrated at his periodic, vague “Uh huh.” After a few minutes of trying to entice him into a conversation, Betsy starts complaining, and then criticizing him for being cold. Tom snaps, “Can't you just once leave me alone?” Betsy yells, he withdraws further, and Betsy stalks out, thinking, “I'll give him all the alone time he wants!”

Tom and Betsy are caught in “interlocking vulnerabilities” (Carol Jenkin’s term) or “interacting (or reciprocal) sensitivities” (my term). Each partner responds to having his or her sensitivity inflamed in a way that inflames that of the other. Tom is sensitive to criticism and responds by disengaging; Betsy is sensitive to disengagement and responds by criticizing. Michele Scheinkman and Mona Fishbane call this pattern “the vulnerability cycle.” Scott Woolley calls it “the EFT (Emotionally Focused Therapy) Cycle.” Robert-Jay Green calls it the “problematic couple interaction cycle.” “Pursuer-distancer” (coined by Thomas Fogarty) and “demanding-withdrawn” (researched by Andrew Christensen) are earlier ideas out of which the notion of interacting sensitivities developed.

My purpose here is to distinguish two major subtypes of interacting sensitivities—“pursue-withdraw” and “attack-withdraw”—and to describe how the pattern of interacting sensitivities plays out in the couple relationship. Awareness of this pattern will help the therapist follow the flow of the session and enable the partners to appreciate what they are caught in.

In “pursue-withdraw,” one partner is sensitive to the other’s withdrawal (feels ignored, shut out, abandoned, rejected, lonely, uncared for, unloved, unlovable, or just not as close and connected as he or she wants) and responds by pressing for connection (time together, intimate talking, affection, sex), and the other partner is sensitive to pressing (feels engulfed, smothered, suffocated, bombarded, besieged, flooded, controlled) and responds by withdrawing (disengaging, abandoning, shutting down, closing off). The self-reinforcing nature of this exchange is clear. The more Bob disengages, the more Gloria needs reassuring contact. The more Gloria presses, the more Bob needs to disengage.

In “attack-withdraw,” the other major form of interacting sensitivities, one partner is sensitive to attack (complaint, blame, criticism, anger, reproach, scolding, demands, sarcasm, rejection, disapproval, humiliation, exposure) and responds by withdrawing; the other partner is sensitive to withdrawal and responds by attacking. Again, the self-propelling nature is clear. The angrier Ben gets, the more Alan withdraws. The more Alan withdraws, the angrier Ben gets.

In a fight, the withdrawn partner typically seeks to end the fight or, at least, take a time out. He or she is the one more aware of the destructive and stalemated quality of the fight. The pursuing partner typically wants to keep talking. He or she dreads ending the exchange without a resolution and on bad terms.

In practice, “pursue-withdraw” typically morphs into “attack-withdraw.” At some point, and in some cases very soon, the pursuing partner becomes frustrated and shifts from pressing for connection to reproaching for failing to connect: “Why are you so defended?” “How come you never talk to me?” “Living with you is like living alone,” “Hello, are you alive over there?” Such reproach creates an “attack-withdraw” pattern (unless, of course, the other partner responds with anger rather than with withdrawal, which would then trigger an “attack-attack” pattern. I’ll get to that in a moment). Here is an example of the shiftfrom “pursue-withdraw” to “attack-withdraw”.

Sally (inviting): What do you say we go for a walk?
Tom (vaguely): Maybe later.
Sally (encouraging): Come on. Let’s go now, while it’s still sunny out.
Tom: I want to read this book.
Sally (pressing): You can do that when we get home. Come on. You’ll feel different once we’re out there.
Tom: I’m really into this book.
Sally: (pressing): Well, okay, we don’t have to walk. Why don’t we just hang out and talk for a while?
Tom: I’m not in the mood.
Sally (shifting to attack): You’re never in the mood.
Tom (shrugs)
Sally (blurting out a hidden fear): Admit it—you just don’t want to do things with me anymore; that’s it, isn’t it…
Tom (looks up for a second): That’s not true.
Sally: Well, it is true. You’re like your father—the way he treats your mother. You’re getting to be more like him all the time.
Tom (Looks down at his book)
Sally: Aren’t you going to say anything?
Tom: I don’t know what I can say.
Sally (sarcastically): You could say, “Sure, let’s go for a walk. What a great idea! Thanks for suggesting it. You always make things such fun.”
Tom (looks unhappy)

Such “attack-withdraw” can go on for some time. At some point, and with some couples very soon, the attacking partner thinks, “I’m tired of being angry,” or “Oh my god, I’m sounding like my father,” or “This is starting to go nowhere fast,” or “I hate how whiny and needy I sound, even to myself,” or “You can’t change people, especially some people” or “You can’t get all your needs satisfied by just one person; I’ll call my sister,” Thinking such thoughts, the attacking person joins the withdrawn partner in disengaging. The result is a “withdraw-withdraw” pattern.

At times, the pursuing partner purposely withdraws, creating what looks like a “withdraw-withdraw” pattern. He or she secretly hopes that the withdrawn partner will miss the engagement and start pursuing. But the withdrawn partner is usually just relieved by the decrease of pressure and doesn’t pursue.

While one partner has remained withdrawn, the other partner has shifted from “pursue” to “attack” to “withdraw.” At some point, and in some cases very soon, the latter partner again becomes distressed by the lack of emotional connection and again starts pursuing, which triggers a repeat of the three-part sequence. Couples can go on for years repeating the sequence of “pursue-withdraw,” “attack-withdraw,” and “withdraw-withdraw.”

At some point in this repetition, the pursuing partner may become so resentful about the withdrawn partner’s lack of engagement that he or she bypasses the “pursue” and goes directly to the “attack.” From then on, the partners shuttle between “attack-withdraw” and “withdraw-withdraw.” The “pursue-withdraw” has dropped out. At yet a later point, the “attack-withdraw” may drop out, too. The attacking partner becomes so discouraged that he or she gives up, and the couple slips into a chronic “withdraw-withdraw” devitalized state.

The discussion so far portrays one partner as remaining in the withdrawn state even when the other gets angry. In some cases, however, the withdrawn partner responds with anger of his or her own: “Why do you always have to get so angry about every little thing?” “Don’t yell at me!” “You could use a crash course in anger management—my treat.” In some cases, the withdrawn rather than the pursuing partner is the first toburst into anger: “Stop trying to control me,” “Get off my back!” “Give me room to breathe,” “Back off,” “You never let up, do you?” “Can’t you do anything by yourself?” “You’re the neediest person I’ve ever known.” When the withdrawn partner attacks, the result is the pattern of “attack-attack” (if the other partner fights back), “attack-pursue” (if the other partner continues pursuing), or “withdraw-attack” (if the pursuing partner is now the one to withdraw).

Withdrawal and attack are not always clearly distinguishable. When you give your partner the silent treatment, you appear to withdraw. You relate to your partner in a grim, wooden, disengaged, monosyllabic way. But all the time, you are communicating anger. You are simultaneously withdrawing and attacking.

In summary, interacting sensitivities (the vulnerability cycle, interlocking vulnerabilities) has two main forms: “pursue-withdraw” and “attack-withdraw.” If the withdrawn partner remains withdrawn, the couple repeatedly passes through “pursue-withdraw” “attack-withdraw,” and “withdraw-withdraw.” As time goes on, the “pursue-withdraw” may drop out as may also the “attack-withdraw.” If the withdrawn partner doesn’t remain withdrawn, but instead attacks, the couple shifts into “attack-attack,” “pursue-attack,” or “withdraw-attack.”

We customarily think of a couple as being a particular type—for example, volatile, withdrawn, or pursuer-distancer. But if we look at what actually happens moment-to-moment, we see that couples often shift among several phases.

Knowledge of this shifting helps a therapist follow the flow of what is happening in the couple and understand how the partners are triggering each other—how, for example, Alex pursues because he feels abandoned and Judy withdraws because she feels cornered, which leads to mutual accusation, and, in an effort to avoid further damage, to mutual withdrawal. The therapeutic goal is to enable the partners themselves to observe their relationship in this way: to give them a compassionate vantage point above the fray—a platform—from which to monitor and manage their relationship. Such a vantage point is created by developing the couple’s ability to hold recovery conversations in which they go over their alienating interactions and appreciate how the position of each made sense.

Stan Tatkin on a Psychobiological Approach to Couples Therapy

Posted on February 8, 2011February 11, 2026 by rezendevknowfully.com

A Psychobiological Approach to Couple Therapy

Ruth Wetherford: So, Stan, let's talk about psychobiological couples therapy.

Stan Tatkin: Right. It’s actually a psychobiological approach to couples therapy.

RW: What is that approach all about?

ST: When we're talking about psychobiology, we're talking, really, about the brain and the body. And we're looking at five domains—the first being attachment. And by attachment I mean infant attachment as well as adult attachment.

The second domain is arousal regulation. We focus on preparatory, or anticipatory, systems that work alongside the attachment system, and that are embedded in procedural memory. These anticipatory systems prepare us for moving toward and away from others, based on history and experience. And this is read through the body —through the face, the eyes, the pupils, the voice or prosody of the voice, skin color, temperature, movement, posture, and so on.

The third domain is neurobiological development. We take a deficit-based approach, not a conflict-based approach, meaning that we don't really focus on conflict. We don't focus on what most people —couples, at least —bring into therapy as a presenting problem: money, sex, mess, kids, and time. That is what most everybody complains about.

Rather, we look at the couple's ability to be a co-regulatory team–to be able to manage each other, particularly during distress.

Rather, we look at the couple's ability to be a co-regulatory team–to be able to manage each other, particularly during distress. How good are they during stress? Everybody has conflicts, as John Gottman says. Every couple has conflict. We're looking to see how a couple handles conflict and whether they handle it in a secure functioning manner or in an insecure functioning manner.

The fourth domain is therapeutic enactment. We work with procedural memory. We work with the body, with a bottom-up approach. In other words, rather than use interpretation, we stage experiences so that couples have an enactment, or certain state of mind, state of body, online to work with. So it's really experience before interpretation.

RW: What are some examples of these?

ST: It's using a lot of psychodrama —going back to Moreno, but also Gestalt, pulling from Satir. By basically moving people into experience, using a bottom-up approach rather than a top-down approach, we avoid tapping into higher cortical areas first, which are really good at error correcting, really good at processing, but can also mislead the therapist.

In other words, higher level cognitive processing is not as reliable as the body. So we want to get at the body first.

And then the fifth domain is therapeutic narrative. This is the therapist's own stance about why couples should be together. It has to be a coherent narrative that, along with theory, explains where the couple has been, what their trajectory is, why they are where they are, and where they're going. The narrative is grounded in secure functioning relationship, as opposed to an insecure functioning relationship. So it's very much as it is when you're working with personality disorders: the therapeutic stance is very important.

RW: This is an integrative approach.

ST: Yeah, very.

RW: Let’s dive in and talk about how we can use this. Where would you start, with a therapist who is reading the article on Psychotherapy.net, and is very intrigued and wants to know more about how to apply it?

ST: It depends on which domain we’re focusing on. With the people in my training, we focus on all five domains, each having its own set of principles and goals. But I would say one of the first ideas for therapists to grasp is: what is a secure functioning relationship, and what is insecure functioning relationship? I would say probably the easiest way to parse this is that an insecure functioning relationship is fundamentally based in a system that is unjust, insensitive, and unfair.

RW: Relational injustice.

ST: Yes.

RW: How important do you feel it is for therapists to focus on their own levels of security of attachment in their general approach to clients?

ST: Well, that's a big question, and that's more about therapy for themselves. We're talking here about theory. There are therapists who might have an insecure attachment if they were tested, say, in a proper AAI [Adult Attachment Inventory] with a reliable coder. But they could still be effective therapists and understand what a secure functioning relationship is, and follow those principles.

Here's the difference between therapist self-awareness and education, adherence, and understanding of theory. I think the very first thing is, talking professionally —and again, this is also true for couples —it is entirely possible for two individuals to be insecure but to form a secure functioning relationship. That is, their model of relationship, the principles they follow, would be considered secure functioning. What we're comparing is a two-person psychological system based on true mutuality (good for me and good for you), versus a one-person psychological system with too much emphasis on self-values or -interests, rather than on relational interest.

But there are other factors —not just a two-person psychological system —that add up to secure function. The other, in terms of a primary attachment relationship, is a mutual protection of the safety and security system for the couple.

This means that both partners agree that the relationship comes first, and that the safety and security of the relationship come first. And the reason it comes first is because, without that agreement, neither can really thrive.

Looking at the mother/infant attachment system and what we know about that system, in terms of security, a secure relationship is based on attraction, not fear or threat. Insecure models base their relational glue around fear or threat. So protection of that safety and security system is a key feature of a secure functioning relationship.

Yet another factor is a lot of mutually positive, amplified moments between the two, which are usually face to face, eye to eye, sometimes skin to skin. That is actually called primary intersubjectivity —when two people are in close physical proximity and using each other's eyes and communication to amplify positive moments, which, by the way, have neurochemical parallels to them.

And then, secondarily to that, is joint attention, wherein partners focus on a third thing to amplify the relationship. That's another quality of secure functioning. Namely, first, a lot of mutually positive amplified moments between the two people, and then —this is really important —second, that the negative experiences that partners encounter individually and collectively are mutually attenuated and foreshortened by the couples' skill at metabolizing and managing distress.

So I would say those two are extremely important for secure functioning relationships: high positives that are mutually amplified, and negatives that are quickly repaired and corrected. Distress is relieved quickly, not dismissed. When you asked the question, "How does a therapist apply this or understand this," I think we first must understand what it is, and then adhere to that idea when looking at couples. And then, of course, it's very hard, if you're working in this way, not to grow yourself, and look for it yourself in relationship.

RW: It’s everywhere.

ST: Well, it becomes everywhere, because that’s where your focus is.

Avoidant and Angry-Resistant Styles

RW: Regarding the importance of the soothing being a mutual skill, it’s a very common complaint in couples work that one partner complains that, when there is a breach of empathy, or something that moves the interaction toward an insecure feeling, one person is usually more in the role of the one who bridges that distance. And that person complains. They want the other to be less avoidant, more engaging. And typically two people are differently skilled about the extent to which, in the moments of conflict, they can self-regulate and reach out to the other.

ST: That’s right.

RW: Any thoughts about that?

ST: We're looking for couples to be able to rely more on interactive regulation, coregulation. People who are insecurely attached —that is, basically the avoidant and what I call the angry-resistant on the other side —have different styles that are wired in from childhood, in terms of how they regulate. For example, the avoidant, who comes from dismissive and derogating parenting, relies on autoregulation, which is a form of self-stimulation, self-soothing. It's not just simply a defense: it is an adaptation from very, very early, and it's wired in. So this is a default position.

RW: Things like saying a prayer, singing a song, taking deep breaths, meditation.

ST: Or masturbating, or reading. Or singing, like you said, or performing, writing. Anything that doesn't involve another person —although there are things that involve another person, with which the avoidant person could autoregulate. In Kohutian terms, that would be using that person as a self-object.

So autoregulation is normal–everyone does it–but the avoidant over-relies on autoregulation.

So autoregulation is normal–everyone does it–but the avoidant over-relies on autoregulation. And that's a sign of a one-person psychological system. The thing with autoregulation is that it's a very energy-conserved state, almost dissociative. And the problem with the avoidant is his or her inability to shift from being alone to interacting. Avoidants can shift from interacting to being alone, but not in the other direction very easily.

The angry-resistant, by contrast, focuses and over-relies on external regulation. Angry-resistants require another person to help calm them down or stimulate them. They, in contrast, have a hard time shifting from interaction to being alone, not from being alone to interacting. So you have two one-person systems that avoid relying on interactive or mutual regulation, which is what we're trying to move couples toward.

The angry-resistant will feel some fear about separations and reunions, particularly about being dropped. But both partners have a responsibility to repair these reflexes with each other, regardless of whether they are avoidant or angry-resistant. So we have a lot of emphasis on getting the couple, especially during distress, to coregulate —eye to eye, face to face —and to make quick repair, make things right as soon as injuries or distress arises. This way there's no memory of the event.

RW: What are some ways you have found that help people to engage in face-to-face, mutual soothing activities? Do you talk to people about the theory?

ST: Sometimes I do. But, basically, I suggest to my students that we push the therapeutic narrative forward by expecting a secure functioning relationship, not just teaching it. We expect one. So when people are not operating in this way, we wonder why. Don’t forget, it’s not simply the avoidant who can create a tone that is threatening, and who starts a fight. Let me just say this: “the reason most couples enter into conflicts that are problematic is because of their inability to know how to manage one another. They don’t know how the other person really works.”

Getting Couples to Manage Each Other

RW: Do you teach them skills to help them overcome their deficits?

ST: Yes. Much of the therapy is really active and experiential. I do very long sessions —two to four hours, sometimes six hours, and they're all videotaped. And the reason for this is to be able to move the couple through a variety of states, which are very much like real life.

Instead of talking about events, we try to enact them and try to make the corrections in real time

Instead of talking about events, we try to enact them and try to make the corrections in real time, while they're in that state of mind. So this becomes a part of procedural memory, which is actually why they get in trouble in the first place.

RW: I’m inferring a lot of coaching.

ST: There’s a lot of coaching, yes.

RW: Like when you've asked them to have an interaction, you read the facial expression and tone of voice a certain way, empathically. The spouse you're teaching doesn't. They're not empathic. They break right there. You'll stop the interaction there or you may note that and use it in some way to help them read the other face. I can imagine how helpful that would be if I'm reading my partner's eyes as angry when it's interest or when it's confused. If I see criticism, based on my deficit —if everything is critical, you can teach me nuance. That would be great.

ST: The idea here is that each partner is in the other’s care. They’re not in the therapist’s care. So we want to point to each partner: “Did you see that on her face? Did you notice that?” I don’t want to be the only person noticing things. I want them to be able to see things. I should say that the room is set up in a particular way, like a staging area. Everyone is on chairs with wheels. So I can see body movement. I can turn to them. They can turn to each other, and I can see them turning away, as well. “So the emphasis is to get them to read each other. They have to be experts on each other.”

RW: You identified the domains of your focus. What are some of the goals of these different domains?

ST: On the attachment level, we want to educate both partners in terms of their attachment orientation. This isn’t to say that we’re going to give them jargon, but we want them to understand from where they came and how that has wired psychobiologically into their nervous system and every cell of their body, to normalize it. This is not a pathological view of human nature. This is a very natural view of human nature in terms of attachment, adaptation. We all adapt. And the nice thing about looking at developmental theory is we can get a picture, a sense, of how someone has to adapt to certain situations. And that gives us a sense of what the person is going to do in the future.

We want people to understand who they are, really, and to take responsibility for that. For example, if the avoidant is dismissive or derogating or gets angry when his or her partner approaches, then he or she must quickly fix that and make it right. But also, we want each partner to understand the other and to know how to manage the other in the best way. When we look at attachment, we know that it isn’t so much about personality; rather, it’s about the sense of competence and agency that two people in a dyad feel they have over the other. In other words, I know that I can manage you. I can shift your state if I need to. I can move you around if I want to, without the use of threat. I can do this in the best way.

And that’s what we want. We want couples to learn who they are. They didn’t get married to be different people. They got married to be just who they are. But they want to feel that they know how to manage the other person. So the emphasis here is very different. We’re not teaching people how to manage themselves. We’re teaching the proper way, which is how to manage each other. And this, again, is borrowed from developmental theory.

RW: Don’t you think it’s both/and?

ST: It’s both/and, but too many therapies focus on self-regulation.

RW: Exclusively.

ST: Right. The way that this works is that, in a primary attached relationship, it is much more efficient for me to manage your state than it is for me to manage my own. And one of the reasons it's more effective is that, the way we're wired, at close distances you can see what's going on in my internal state, my nervous system, before I know. I can see what's going on in yours before you know. This gives us an advantage. There's a reason this is built in at close distances. At far distances, we're interested in whether we're attracted or we're dangerous. But in close distances, we're able to see into each other's nervous system and to be able to respond in this dance of mutual regulation.

So that's what we want to encourage, on the attachment level. On the arousal level, we want to make sure that couples can talk about anything, do anything, without fear of dysregulation. One of the reasons therapy sessions are very long is

I like to set fires and put them out, or make messes and clean them up

I like to set fires and put them out, or make messes and clean them up —however you want to look at it. But we want to get into areas of difficulty so that partners are not afraid, so that they know how to co-manage these situations by tensing and letting go, and never getting into a situation in which they dysregulate one another. They must know how to stay in a play zone, even when they're fighting. This is a very, very important part.

RW: That's powerful —the role of play.

ST: It is. Couples should not be afraid of anything when it comes to each other, and they certainly should not be afraid of the relationship breaking simply because they’re in conflict. So we take off the table any fear having to do with the relationship breaking or falling apart on either side of the partnership.

The Elephants in the Room

RW: So if there is doubt that the person wants to stay, and they say, "Yes, I am thinking about divorce, and I can stop saying that in the middle of a fight but it's there. I don't know if I want to stay" —how would you take that off the table?

ST: Well, in the very beginning, if that is really a very strong message and one partner, at least, is drifting or pushing in that direction, this is where it gets kind of tricky.

I will go in that direction and push it all out. In other words, I call it "bending metal" —going in one direction or the other fully. I'm not in the business of breaking people up. But if there is resistance and there's one person saying, "I don't know if I want to do this," then I will go full bore into breaking them up, for the purpose of getting pushback or blowback. In other words, I want to find out what they're really made of, and I think one of the jobs for all therapists is to clarify what's going on.

RW: That’s very important because that’s the elephant in the room that the other spouse knows is there. And if the therapist is too afraid to push on it and bend the metal, then you really can’t get to building the security.

ST: Right. One of the reasons this approach goes fast is the therapist is very active and evocative, and even a bit of a clown-at-the-bullfight kind of person. I was trained psychoanalytically; this is very different because we want to push the boundaries and see what people are made of. So if somebody thinks he or she wants out of the relationship, then we have a session on “Let’s divorce,” and we’ll go all out. And then I will look for pushback. Now, much of the time, people are using this as a way to threaten the partner to get him or her to comply. But once it’s exposed that they really aren’t going to leave, they don’t want to leave, they can’t leave, then it gets taken off the table. Because we’ve already proven that the person is not being truthful. They’re using this as a maneuver to threaten the partner. So we want to get that off the table as soon as possible, and we do that by getting them to throw down, basically.

You can see this is taking a little bit from strategic family systems, too, in that we’re being a little tricky, but always in the interest of clarification. So that’s how that’s handled.

RW: And that would apply when a person is having an affair?

ST: Oh, that’s our bread and butter.

RW: How so?

ST: A lot of people end up coming in because either they are having an affair or they're hiding one. And in this model,

we think of affairs not as attraction to a third, but an aversion toward the primary.

we think of affairs not as attraction to a third, but an aversion toward the primary. So when two people assume the office —and I think of it as an office —of primary attachment figure, it's almost like the office of Presidency. The office of Presidency has a certain valence to it. Forget who's sitting in it. And then there's the person with his or her personality, which either adds to, amplifies, or whatever, the office.

So when two people assume the office of primary, this is a very intense relationship that resembles no current relationship, only past relationships. And, as such, people become deep family when in these positions. That is why a lot of problems arise. I call it the marriage monster. As soon as people get married or they enter into the relationship with a sense of permanence, all these attachment fears coming from procedural memory and experience begin to arise. So movements away and toward each partner we see as part of the predictable trajectory, and not just as happenstance or an accident.

So, most affairs, depending on who's having them, reflect the insecurity of the primary attachment relationship, not so much the attraction to the outside third person. Ironically, many people pick, as their affair, somebody who's almost identical to themselves. And one of the common things I'll hear, and I'm sure you hear too, is "Why aren't I like this with that person? Why do I feel this way with my sister or my brother and not with you? Why my friends don't do this to me?" My thought about that is, "Well, marry your friend and then see what happens." Because it is a phenomenon of marriage or commitment that this material starts to come up.

RW: Going back to the goals, you were naming the goal of the attachment domain is to move towards security.

ST: Move towards security and to understand who each person is and how to manage him or her.

RW: And then, in the arousal domain, the goal is to promote mutual regulation.

ST: Yes, we're promoting interactive regulation, which is a close monitoring of each other's face, voice, eyes, and body. And by the way, interactive regulation in this close proximity, and mutual gaze, are how we fall in love, most of us. So it's simply going back to the way we originally began anyway. But also, the goal is to learn how to do this so that you and I, as partners, can talk about anything. We can enter into any area of importance without fear of threat or dysregulation. And that's a major, major goal.

On the developmental level, the therapist really has to discover what deficits do arise —and we all have deficits, and especially they come up in relationship —to clarify those and to hopefully help move them along developmentally. Partners need each other to do that.

If I am with you, and I discover that you've never been able to read my face, you've never been able to read anybody's face, that is going to be one of the reasons we have trouble. And I may have thought you were doing this purposely, when actually you weren't. This is a deficit. This is something you've never been able to do. That changes the game in a lot of ways. And sometimes people will never get very good at something. Other times they can get better with the help of the partner.

RW: Okay, any other goals in the other domains?

ST: In general, we're moving people towards a secure functioning relationship. And that includes, like I said, true mutuality. In other words, everything we do is based on a social contract, borrowing a bit from attachment theory and John Rawls here —a social contract that's based in fairness and justice and sensitivity. So, if the relationship comes first —not us as people, but the relationship —and it becomes the air we breathe, the water we drink, our basic fundamental engine of energy to go through the day and to brave the world, then there are things that we have to do with each other to keep each other feeling attractive and attracted to the relationship. And one of those is making sure that every decision we make is one you're good with and one I'm good with. There is no dragging you along because it's good for me, but it doesn't have to be good for you.

So we're changing really from a monarchy, or dictatorship, to a system that is fair between these two generals, who are both in charge and they have to please other.

RW: If we’re not both happy, neither one of us is happy.

ST: Neither one of us is happy. And everyone who lives below us and around us will be unhappy, too. I kind of think of this as king and queen. If the king and queen are in disorder, everyone in the land is in disorder.

So that goes with kids and that goes with everybody we interact with socially.

There’s one more part here: the management of thirds. By this I mean third things, third people, third objects, third tasks. This could be drugs, alcohol, work, in-laws, friends, children, dogs, pets, and so on.

RW: Famous triangulation.

ST: A secure functioning couple has a kind of couple bubble around it, wherein the dyad comes first, and thirds are secondary. What this means is that the couple is aware that in public and in private they protect each other at all times. They don’t allow either of them to be the third wheel for very long, at least not without repair. In this way, everybody actually fares much better. So the management of thirds is a huge deal. As therapists, we can find out right away if a couple is mishandling this by the way they address us.

One of the reasons I have them on chairs with wheels is that I can see how they’re moving and who they’re talking to and who they’re addressing. If I notice the partner is talking to me, ignoring the other, or saying something about the other without checking with him or her, then I know both of them handle thirds poorly. And not just in the therapy session, but everywhere. So, another big goal is the management of thirds, in public and in private.

It’s great fun.

RW: It sounds like fun. What are some things that therapists can take from this to translate it into tactical tips, tools, and techniques?

ST: First of all, I would recommend that someone who wants to get into being a couple therapist do it wholeheartedly, because it is very different than working with individuals and families. It's a specialty. And I think, as such, it deserves a lot of attention and a lot of focus. Having said that, I think that it is next to impossible to see a couple, particularly in the beginning, for an hour. I think the therapy sessions must be long, to give therapists enough time to relax and not be pressured. Otherwise, the therapist, him- or herself, can become dysregulated, and pressured. More mistakes are made that way.

So longer sessions to watch the couple cycle through different states, to give therapists time to think and formulate. Begin to play very, very close attention, not to content, but to micro-expressions, micro-movements. I think therapists today should be trained —whether it's Paul Ekman's material or other places to get this training —to work with the body and be able to pick up very subtle but very significant cues on the face and the voice that reveal shifting states and emotions. This is very key to working with the body. I think it's important to try to avoid getting caught up in the content of what a couple's talking about and start watching, basically, these two nervous system interacting.

One thing I do want to say before ending here is that this is a maxim that I always use and say: people do not know what they're doing. This goes for us therapists, as well.

We do not know what we're doing most of the time, and we don't know why we do what we do

We do not know what we're doing most of the time, and we don't know why we do what we do most of the time. And there's a reason for this. When we are interacting with another person, we're using very fast-acting subcortical processes that never see the light of day in terms of higher cortical areas. We're simply acting and reacting very quickly, as we should. And then, when asked why we did what we did, we really don't know. But because we're human beings and because we don't like to not know, we make it up.

I could say that this is a function of the left hemisphere that confabulates, because it doesn't know what the right hemisphere and subcortical areas are doing. But this is the flow of data through the body and the brain. We act and react much faster than our cognition, and certainly our words.

So the therapist would do well to understand neurobiology and how the brain actually works and what people are really doing. A lot of things that are happening between two individuals —and this includes individual therapy —are sub-psychological. In other words, it's biological. It doesn't even get to the higher levels that we consider psychological or theory of mind. This is our most basic nature. Our number one imperative as human beings is to not get killed. It comes before love. It comes before everything else. And we have some very, very well developed —in terms of evolution —primitive areas of our brain that are very good at looking out for our survival. They don't give a damn about relationships or anything else. If it comes down to feeling threatened, we do war instead of love. That's what I'd say.

RW: And from there is the title of your new book with Marian Solomon.

ST: That's right. Love and War in Intimate Relationships: Connection, Disconnection, and Mutual Regulation in Couple Therapy. It is available through Norton in the Interpersonal Neuroscience Division. The official publishing date is February of this year.

RW: Congratulations on that book.

ST: Thank you.

RW: What kind of training are you planning to do in the future, so that you can disseminate and spread the word and help people learn this?

ST: We do trainings in Los Angeles; San Francisco; Seattle; Austin, Texas; Boulder, Colorado. Maybe soon to be in New Jersey. We also have an international group that we do training with, as well. So it’s spreading like wildfire right now. And if people want to get involved in the training, which is a great deal of fun, they’d have to go to this web address: www.ahealthymind.org, and the click on the city that’s nearest to them.

RW: Is there anything that that I haven’t asked you or that you haven’t had a chance to say yet?

ST:

Applications for Individual Therapy

We didn't really get a chance to talk about how this translates into individual work, but it does, because we're dyadic creatures. Individual therapy is a dyad. I will say that, as a cautionary note, being an individual therapist for so many years, I now view primary attachment relationships as sacrosanct. And if an individual does come to me and is in a primary attachment relationship, I will work my darnedest to get that partner in, to turn it into couple therapy. And the reason I do that is because when we're working with the primary attachment relationship currently, we're dealing with proxies: people who represent the past. And there's no more powerful system than that system. The therapeutic relationship tries to approximate that, but really can never do that for a variety of reasons. For one, the therapeutic relationship is asymmetric. So, when we have that capacity and that exists, I think we should shift to couples therapy. If the couple or the individual is unwilling to do that, I think it's incumbent upon the individual therapist to act as an adjunct —to move that relationship forward rather than try to compete with it.

So I think there are mistakes being made now with individual therapists who are competing with primary attachment relationships. And that would be a nice thing, I think, for people to start to learn not to do.

RW: It sounds like you’re suggesting that therapists not only promote secure attachment with themselves, but also with the primary attachment spouse.

ST: Right. Instead of trying to compete with it, we try to promote the one that already exists. Unfortunately, when we see one individual who’s in a relationship, we will never, ever know the truth. One person is not a reliable reporter of the relationship.

RW: Well, there are different truths. There’s my truth and then there’s your truth.

ST: After a while doing this, you understand again the principle that people don’t know what they’re doing. That’s true for everybody. So, in this work, working psychobiologically, we want proof. We want to see it. We don’t want to hear about it. We want to see it.

RW: I know that you’re familiar with the notion that in many situations we don’t know if people should divorce or stay together.

ST: That’s right.

RW: Particularly if they are at the long line of a series of many, many injuries and don’t have any capacity for repair and a very entrenched avoidant or resistant pattern of attachment. And let’s say one is growing and is seriously wanting to think about leaving. How do you deal with that? How do you deal with those moments when you are promoting the divorce rather than the increased security attachment?

ST: I only promote divorce as a trick. I only promote divorce to test the mettle of at least one person who is drifting in that direction.

RW: And if the metal yields?

ST: Well, if the metal yields, then no harm, no foul, because clarity is the most important thing. People aren’t going to do anything because you tell them to, not really.

I have stopped being the arbiter of who should be together and who shouldn’t.

I have stopped being the arbiter of who should be together and who shouldn’t. I assume that partners will no longer be together when they are no longer together. Until that time, they’re a couple, and I’m their couple therapist. And I continue to assume that my job is not to decide whether they’re right or wrong for each other, but to move them toward a secure functioning relationship. That’s my job. If they do not make it, they’ll be better the next time for therapy. But I don’t decide anymore. Now, when I have strong feelings about the couple not being together, it’s always countertransference that passes momentarily. There are a lot of therapists who’ve tried to break up couples, and I think this is actually morally wrong.

I think nature has its own path. Primary attached relationships are very complex and very strong. We don’t understand them fully. I think people are quite capable of ending things when they’re really, really done. And they’ll prove it. Otherwise, you’re the couple therapist until that time. That’s my belief.

RW: Thank you for this interview. It was very enjoyable.

ST: Thank you.

Bids for Emotional Connection in Couples Therapy

Posted on November 15, 2010February 11, 2026 by Psychotherapy.net Team

John Gottman’s concept, “bids for emotional connection,” is practically a complete theory of relationships in itself. Hearing the word “bids,” we picture partners reaching out to each other in a variety of ways. Gary Chapman, in his book, The Five Love Languages, lists five such ways: words of affirmation (“That situation was delicate and you really handled it beautifully”), touch (“How about a hug?”), quality time (“Let’s get a babysitter and make a reservation at Chez Alouette”), gifts (“This scarf was so gorgeous, it had your name on it”), and acts of service (“Why don’t you take a nap while I do the cleaning up?”).

Partners make bids to create, increase, maintain, and re-establish connection. Arriving home at the end of a day, we ask: “How was work today?” Noticing that our partner is preoccupied, we say, “What are you thinking?” Sensing something amiss, we send out a probe: “Are you upset with me about something?”

“Bids” are the active ingredient in a relationship. Gottman shows how people make bids in the fine grain of everyday life, often without knowing they are doing it: “Did you hear about…,” or “You’ll never guess what my sister told me today.” A lot is going on all the time in the form of these little signals that partners are often unaware of sending. These signals—these bids—are nonverbal as well as verbal: a wink, a smile, a shoulder rub, a gentle shove, or a mutual look of understanding about a friend’s quirks. What matters, Gottman suggests, is not depth of intimacy in conversation, or even agreement or disagreement, but rather how people pay attention to each other no matter what they talk about or do. What matters is the quality of attention, as my partner, Dorothy Kaufmann, puts it.

What the person making the bid wants, of course, is a positive response (“Oh yes—tell me. Your sister always has such a special angle on things”). What that partner doesn’t want is an angry response (“Don’t bother me; I’m not finished with the paper yet”) or no response (grunting in acknowledgement and continuing to read the paper). Borrowing terminology from Karen Horney, Gottman labels these three responses turning toward, against, and away.

Gottman’s major point is that repeated failure to turn toward in response to our partner’s bids leads our partner to stop making bids. The relationship sags and both partners feel lonely. Couples frequently find themselves in a devitalized relationship without knowing how they got there. Turning away or against their partner’s bids for emotional connection is how they got there.

Susan Johnson’s Emotionally Focused Therapy can be viewed in these terms. She focuses on the traumatic effect of having our bids for emotional connection rejected or ignored (our partner turns against or away), resulting in our being afraid to make further bids and, instead, attacking or withdrawing (turning against or away) in turn.

If turning away or against is a problem, shouldn’t we try always to turn toward? Perhaps. But forcing ourselves to be nice when we don’t feel nice also leads to devitalization or to a buildup of resentment that culminates in an explosion. And we may not always be able to turn toward; the impulse to turn away or against may be automatic or overpowering. Furthermore, the original bid might have been made in a manner that provokes a negative response—that is, it might have been offered anxiously, demandingly, reproachfully, or failing to take account of what the other is doing or feeling at the moment. Gottman says that temper tantrums may be bids in some situations.

But maybe we can create a vantage point above the fray—a platform—from which to report that we have turned away or against. We can say, “I know I’m over the top.” Or, “Wow, you don’t deserve my snapping at you like this.” Or, “I know I’m lousy company at the moment; I’m caught up in writing this thing.” We would be bringing our partners in on our concern that we are not doing right by them. We would be turning toward by acknowledging that we have turned away or against.

But it is difficult to be self-reflective in the heat of the moment. It would be easier to go to our partners later and say, “I was so focused on making that last paragraph work that I hardly said hello when you came in last night. I feel bad about it.” Or, “I hate how irritable I’ve been lately, and I’m sure you hate it even more.” Or, “I know I gave you a tough time when you made me those perfectly wonderful eggs this morning. I must have been still fuming over that comment you made Saturday.” Or “I keep forgetting that when you blow up like that it’s because you’re hurt.”

We would be making a bid to reconnect after having previously ignored or rejected our partner’s bid. We would be reconnecting in the act of talking about how we had been disconnected. We would be talking intimately about not having been intimate—which is perhaps the ultimate intimacy and the fullest way we can join.

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