What I Talk about when I talk about Patient.

There’s been a long standing debate in the therapy world, about whether to call people who consult us Patients or Therapy Clients.  For a while, as a young therapist, I found myself avoiding the use of “Patient”, in an overly zealous attempt to not pathologise whomever came into therapy with me. It was also very much part of working along CBT lines, the primary mode of intervention taught to us at the time, though during our training towards registered psychologist we had to put together our own approach, or at least develop and present a worldview which we based our imagined future selves as practitioners. I was adamant to not follow the more medical model of calling my paying clients “patients”, wanting to minimise the formality of our encounters and the possible power differential which may be created by that label.

But as I grew older and wiser and my knowledge base widened over years of sitting with people, doing additional training both for Continuing Professional Development as well as deepening my interest in many other fields which we did not receive in- depth training in(such a embodied psychotherapy, Mindfulness-based approaches, etc), I have come to appreciate what “patient” really means: someone who is suffering. And is it not true that every therapeutic encounter and intervention is about relieving suffering?

Every person sitting on my coach, is someone who is suffering. So that referring to him or her as a patient actually shows the deepest form of respect and awareness of that. Therapy is not simply a consultation where the therapist dishes out advice and guidelines to live a happy life: in that case “client” would be appropriate. Or if I am approached to coach someone through a life transition or workplace issue, I happily use “client”.

But when I talk about patients, it is with a deep awareness of the suffering, the psychological woundedness, and the need for being cared for if not cured in the safety of the therapeutic hour. As therapists we need to be able to hold the space for such suffering to be spoken about and sometimes sit helpless in the face of utter pain, simply witnessing such suffering. I often remind myself of how therapy is really about helping people to tolerate the previous intolerable, to help people distinguish between unavoidable suffering and suffering we inadvertently create for ourselves ironically as we seek relief from pain and suffering.

So yes, I think and talk about people who come to me for therapy as Patients. This has not prevented me from entering the therapy space in a collaborative way, of meeting people as equals. After all, I too, have been a patient on a coach and suffer in similar ways, sometimes simply by being human in an intrinsically unsafe and unpredictable world.


Communication problems?

I almost always hear this: “We don’t communicate!” when a couple sits on the couch across from me. After infidelity or some other betrayal, this is the most often cited reason that brings couples to therapy. Training to become a psychologist, this is also the focus of many marital therapy interventions: to teach couples how to communicate.

So, imagine their surprise when I gently say: “Oh yes you do. But maybe what you are communicating is the cause of distress in this relationship. Maybe what you are communicating is disconnection. And maybe we can together find out what this is all about”.

In fact, it is impossible to not communicate: we are always communicating something: even (and probably especially!) when we don’t say a word. Postures, facial expressions, eye contact, physical orientation in space, all “speak” volumes. And it’s usually these non-verbal clues which are picked up by our nervous systems; those are the messages which we respond to at a gut level.

I may at that point ask them to just notice how they sit in relation to another. (I have a small couch in my rooms, so that it’s almost impossible for two adult bodies to not touch when they sit side by side on it). And it is quite satisfying to see that shift: from being focused on the other person (and usually their shortcomings) to just noticing how much each communicates simply by how they are holding their own bodies in relation to one another: are they allowing physical contact, are they sitting as far apart as possible, do they hold their bodies in rigid poses even when touching? And to start becoming aware of how much it all says about how they feel in the moment.

Couples (or at least one of the two) are usually poised to start a long verbal rant of dissatisfaction and complaints and injuries, done to them by the other. So, to suddenly be alerted to what may be going on inside oneself, can be quite disconcerting. It’s not something that most of us know how to do. Some of us learn very early on in life how to not show and say how we feel, in order to preserve our attachment bond with our mother, or our primary caretaker. This results in developing our default way of being in the world, and will translate into certain communication styles in our adult attachment relationship.

This change in focus can be the beginning of a different awareness in each of the partners: to start taking notice of what is going on inside themselves, within the relationship space. I don’t believe that relationship counselling can be effective without this shift.

Simply teaching verbal communication skills may help a little, but not before people are aware of what is really going on inside themselves, and what is evoked for them in a particular relationship dynamic. Then there is the possibility that they could learn to communicate that more effectively, and congruently.

And how do you feel about that?

One of the reasons people enter therapy, is to learn to control their emotions. Some people even state that at the outset: “I want to learn to control my anger”, or “I need to control my anxiety”, or “My husband says I need to control my insecurity”, or some variation on the above. Or else, in the therapy process, it becomes clear that the patient believes that he or she needs to control their emotions: one sees that quite early sometimes when people struggle to retain their composure, or swallow away inevitable tears and even apologise for crying.

Of course, all such behaviour is an invaluable source of information to the therapist about someone’s way of being in the world. And hopefully the therapy client will learn that the therapeutic space is safe enough to express all kinds of emotions. But even when someone has relaxed into being able to express whatever emotion is present, it remains a challenge to help them realise that the key to healing is not learning to control emotions, but to allow the emotion to simply be deeply and viscerally felt, and to learn to use the information from the mind and the body which an emotion is trying to convey.

The greatest obstacle to allowing an emotion simply to be felt, is that we judge some emotions to be bad. In fact, any emotion which causes physiological discomfort seems to be labelled “bad”. This may be a moralistic issue: harmful behaviour fuelled by certain emotions may be judged harshly by families and societies and religious dogma, and so the emotion itself becomes labelled as bad or good. Anger is a good example of this: despite it being a very important and strength giving emotion, it gets confused with aggressive behaviour, and is often unwanted and feared.

It is true that emotions like fear, sadness and anger are uncomfortable and causes central nervous arousal which is felt in our bodies as unpleasant, and protracted experiencing of these states can be stressful. The impulse to want to control and therefore minimise these are understandable, but the simple reality that no emotion is “bad” can already be a powerful intervention.

Learning to simply become aware of the emotion, to become curious about why it is there, to let it find its natural expression in the visceral experience as it arises in our body and awareness, is the beginning of healing.

This is at the center of a more mindful approach to working with emotions: in fact, distress tolerance is a key skill which is taught in Dialectical Behavioral Therapy, developed for treatment of Borderline Personality Disorder.

Controlling emotions does not work as a long term strategy. Knowing that an emotion is a temporary state which can be tolerated, understood and expressed effectively, and learning to simply sit with an emotion with curiosity, openness, and mindful awareness is in itself a worthy therapeutic goal.

Telling the truth.

In my previous post I wrote about forgiveness, a complex process which seems to play an important role in healing of emotional wounds. In couples counselling I am often reminded that one of the most pernicious of these woundings is the hurt of infidelity by one’s partner. Robert Weiss, a well-known therapist and writer about relationship issues, writes in a Psych Central blog that: “it is the betrayal of relationship trust caused by consistent lying,rather than any specific sexual act, that both defines infidelity and causes the deepest pain to the betrayed partner”.

I find this to be accurate: that it is not so much what a partner has done, but the fact that he or she had been lying, which causes the rupture of the fragile fabric of what trusting another means. “I trust you” in fact means simply “I choose to believe that which you tell me is true”. Mostly it is not so conscious that we actually choose to believe what another says; often there is an unconscious assumption that this person whom I love is trust-worthy. Trust is nevertheless required to create an intimate relationship, because the feeling of trusting someone lets us relax and feel safe enough to in turn tell the truth and show of our deepest selves and vulnerabilities. So when a belief, or the assumption that one has been told the truth is shown to be false, enormous pain and suffering almost always follows: our sense of emotional safety is shattered. In fact, in the article by Robert Weiss, he likens this to being traumatised. No wonder forgiveness of this kind of emotional pain is hard to achieve.

It is no small coincidence then that lies are punished in children across many cultures and lying is regarded as sinful in many religious traditions: the original wisdom that lying can harm is taught in these ways. And yet, it seems that we all struggle with this from time to time. There are the “innocent” or white lies that we tell to avoid social discomfort, and there are the bigger lies we tell: Sam Harris wrote an excellent book about this: “Lying”, in which he explores the concept of truth telling from a secular, philosophical point of view. Brad Blanton, Ph.D, wrote about it in “Radical Honesty”, and shows from a psychological point of view how to transform our lives by telling the truth always. Both these books are worth reading.

Telling the truth can be quite complex and difficult. More often than not, we have learnt as children that telling how we feel and think, and asking directly for what we need, makes us vulnerable to be judged and rejected, so we learn to lie by omission, by not saying anything, and so amass a load of secrets and withheld truths. Even so, our basic longing is to be seen and heard, and when we feel that we cannot share our inner truths with our partner, it can create the space for another to step into. It is very seductive to find another someone suddenly whom we can tell everything without being judged: now here is something which I cannot share with my partner, and have to outright lie about. And so the betrayal of infidelity starts: deliberately lying about what one thinks, feels, or does, to protect the other (which is often offered as a reason for not  telling a truth), and oneself from the consequences of lying. Indeed a vicious cycle.

In a first couples therapy session I usually put it out there right at the start. I would say something like: “If one of you is having an affair and not willing to be honest about it and/or end the affair, these sessions may be a waste of time for you”. This is not  making a moral judgement about affairs as such: but it does emphasise how critical truth-telling is for therapy to work. It is not easy to risk judgement, being shamed, or being punished when one tells this particular truth. Very few people when asked will say, first time around,”Yes, I am having an affair”. In fact, it is the most denied truth in relationships. And yet, relationships can heal only when even this difficult truth is told, precisely because the wounding is not only the infidelity itself, but the layers and layers of lying which per definition, accompany it.

Of course, people do not only lie about their sexual behaviour outside of their primary intimate relationship. Depending on the ego integration and maturity of the person, he or she may lie about a host of other issues. If we are involved with someone who has a personality disorder, we may find the lack of truth-telling which often accompanies these disorders deeply harmful to our own sense of what is real and true(for instance, the person on the psychopathic spectrum of disorders is usually a masterful liar and manipulator). Ending such a relationship may be the only solution. The harm done when trust is destroyed like this is considerable and the recovery from such betrayal is often painful and difficult. Sometimes the only antidote is to, in return, learn the value of telling the truth personally, and to know that trust is about choosing to believe the other, and to remind ourselves that when that trust is broken, one can choose again to believe  the other, and forgive and accept the person back, or end the relationship.

Telling the truth may be the most important thing one can do in a relationship. By this I do not mean sharing every single thought that comes into one’s head in a torrent of  blow-by-blow truth-telling, or using the principle of truth telling to be brutal to others. I am particularly referring to telling the truth about how we feel in general, and in response to what goes on in the relationship. This forms the basis of good communication which is important in maintaining an intimate relationship. Of course, for that to happen, we need to be able to name our emotions, which requires reflection and self awareness, and sometimes sheer practice. When this is practiced by both people, being honest and open is easy, and relationship harmony usually follows. Telling our partner the truth about what goes on for us may be the most important strategy to preserve intimacy and create trust and  safety.

As a psychotherapist I help people find out what is real and true for them, to say it out loud without fear of being judged, to own their actions and thoughts and feelings in this way. I believe that living authentically is a central aspect of  psychological wellbeing, and telling the truth is the guiding principle for authentic living, and for creating nurturing relationships.

To forgive.

In therapy old hurts and betrayals often become the central focus as people start telling their stories and as they recall, often with great clarity, experiences of having been hurt by an important other: a parent, a friend, a lover: even a stranger who may have physically hurt and traumatised them. And sooner or later the issue of forgiveness comes up. I have often heard people wish out loud that they could just forgive and forget. Popular psychology and spiritual guidance advocate that forgiveness is an important step towards freeing us up from the stuck-ness of carrying painful memories and intense feelings around the hurt: often deep unresolved anger. So, the popular wisdom is that when you forgive, all will be well, your emotional wound will be healed and you will be restored to well-being.

Of course, there is some truth to this. But I have also often heard a patient say: I am not ready to forgive. And I think we should listen to our clients: forgiveness is often prematurely attempted or even pushed for in therapy by therapists and patient alike. This is a mistake in  my opinion: forgiveness as a simplistic strategy can never be applied like a band-aid to a deep emotional wound.

In addition, to forgive is not to forget.  Forgetting cannot realistically happen in the healthy brain, as if a switch had been thrown. And sometimes we even need to be able to remember, so that we can learn something about life and ourselves from the hurtful event.

What does it mean then to forgive? I think forgiveness is a complex process which takes time: to simply say out loud: I forgive you, does not necessarily work. It sometimes takes repeated confrontation with the hurt and anger which can stay in our psyches for a very long time. Forgiveness starts with acknowledgement of that pain. Forgiveness equally starts with fully allowing ourselves to feel righteous anger at the person who hurt us, and to find a way to express that anger, instead of minimising it, thinking that anger is bad for us, or a negative emotion. In fact, anger gives us the emotional and physical energy to take action, even to sometimes think up ‘revenge’ on people who have hurt us. To want revenge or some reparation is human and should  not be judged. In the therapy space this can be explored in fantasy, which often brings great satisfaction and relief when it’s fully expressed. I do not suggest that a therapist should encourage actual acts of violence or aggression, but to let the person give free vent to the wish to harm back the perpetrator is effective in discharging the anger, I have found.

Forgiveness comes with the awareness that the hurt and pain have actually not destroyed us, that we have the resilience to survive, and the ability to incorporate this hurt and all our  experiences in the telling of our life story. Forgiving then can only happen when what has happened has been accepted, and to know that it is in the past. It also helps sometimes to remind ourselves of this immutable truth: that people do what they do because they are who they are in the first place; that the person who hurt us is human, and possibly flawed or deeply wounded themselves.  Forgiveness requires a conscious decision, making a clear choice, to let go of anger towards someone who has hurt us. And the measure of whether we have truly forgiven someone, is when we have no deep emotional reaction to a memory of the person or the event: that we can recall and talk about what happened without acute nervous system arousal, as if it all is happening again.

And when we eventually do forgive someone who hurt us deeply, it does not mean that we can or should resume a relationship with the person who perpetrated the hurt. The latter is a common perception: If I forgive so-and so, I should welcome them back into my life. Of course this is not required. It may be a good spiritual or religious practice to try and love everybody, even our enemies, but in real life this is not so easily achievable. At most we can feel compassion after the anger has ebbed away.

If we have heard a heartfelt apology, we could make space again in our lives for that person.  Many people though, find that even when that happens, and there has been a subjective experience of having forgiven someone, the pain and anger appears again and again over time. I’ve heard many people anguish: “I thought I’d forgiven him/her, but here I am again, so full of hurt and anger. How will I ever get over this?” Forgiveness, like grieving, is not a once off thing, and many people cycle through the process again and again, as many times as it takes. And sometimes we never reach a state of complete trust and openness towards the person who hurt us ever.

Having said that, having forgiven someone does not mean we should allow the person whom we have forgiven the opportunity to hurt us again and again, even if we had accepted them back into our lives. So if someone hurts us again in the same way, we can choose again whether we want to stay in a relationship, even if we had forgiven them before.

Forgiveness is not a simple, one dimensional act, as popular psychology posits. It is complex, difficult and challenging, and the process sometimes takes a very long time. When it happens, we usually will have learnt what we needed to learn about ourselves and about what it means to be human; that we are not exempt from being hurt and that we very well may also be able to hurt others.

Forgiving others, and maybe even ourselves(but I will write more about that in another post) frees us up  from suffering from old hurts from the past. In that way it is important and useful to forgive, even if we do not ever forget.

To tell or not to tell.

One of the challenges for me as a therapist is to decide how and what information about myself to disclose to a therapy client. I am not referring to information which the client should have, like training background, experience, therapeutic orientation, professional affiliations etc which may already be in the public domain. This kind of disclosure could and possibly should form part of the intake session. I am talking about more personal information which reveals something of who I am, and how I live my life away from the therapy setting.

Of course even writing here, as myself, asks of me to consider where I stand regarding this controversial and difficult issue in psychotherapy. After all, if a therapy client or potential therapy client should read what I write, they would come away with certain ideas about how I think and feel, and opinions I may have. We were trained that the rule of thumb is to not reveal anything: to literally present yourself as the blank canvas onto which the client/patient can project their fantasies and ideas, and to be ruthlessly vigilant in not letting them know anything about yourself at all.  The idea behind that principle is that the person’s fantasies about what and who the therapist really is (an aspect of transference), becomes rich material to explore.

But as a highly intuitive therapy client recently pointed out the self evident truth to me: that in fact it is impossible to not communicate some information. Just my mere appearance, for instance,  is already somewhat revealing of aspects of who I am. How I dress, the colour of lipstick I prefer, my accent… The way we decorate our consultation rooms(this is a photo essay of therapists rooms in New York) is another subtle but important aspect of information gathered by a patient which all form part of an idea of who the therapist may be in terms of tastes and style preferences and even socio-economical status: particularly when working from home. I currently work at a clinic where I share rooms with two other psychologists so that the space is less personal, but I may start seeing people from home eventually, and I intend to decorate the room according to my personal taste. A therapist friend of mine who is busy being trained as a Jungian analyst, spoke about displaying a statuette of Kali in her rooms, and we wondered  how that would impact how patients will perceive this and respond.

It’s really impossible to  control every little detail which may give something away about ourselves. And I believe that we need not be too frantic about that either. But it is important to be as conscious and as clear as possible about what, why, and when to reveal information about ourselves. Whatever we reveal, either consciously or unconsciously, has an impact on the therapeutic relationship.

My way of working is to disclose about myself mainly when asked: and then to answer any question about myself which a therapy client wants to know, honestly and directly, but to always explore and inquire what prompted the question, and discuss how the information given by me, has affected the patient. A female patient who is in a very unhappy and unfulfilled marriage a while ago noticed that I had a new ring on my left ring finger and asked me if I had gotten engaged. A simple “Yes” and holding out my hand for her to look at the ring more closely, thereby acknowledging  her observational skills, and further “How is it for you to know that I recently got engaged?” lead to a very powerful and meaningful session where her fears and reasons for staying in a dissatisfying relationship, and her yearning for real connection and intimacy became conscious for her.

When I answer a question in this simple, direct way, I validate an observation or an intuition of a therapy client. Also, it is very human to be curious about you therapist’s life. I believe that is more important to answer honestly than to deflect the question as some strict psychoanalytical therapists may do.

Sometimes there are more personal and private issues which the therapist may not want to share with a patient. I have in the past, also said then: ” I would prefer to not bring that information into this space, if that is ok with you” and then proceed to inquire into what prompted the question. On reflection, that has not happened often. Of course, each therapist has to decide where they stand about which information they are willing to divulge. Some would be ok to state their religious beliefs and world views , some not. Some would be ok to reveal their sexual orientation, some not. I think that as Irvin Yalom so eloquently says in his book: “The Gift of Therapy”, most clients in fact do not want to know too much, and our fear as therapists that once we have shared something of ourselves, it would lead to continued demand for disclosure and violation of ethical boundaries are mostly unfounded.

In the age of social networking, sometimes our patients stumble across information about us, such as our Facebook account. Of course it is important to set the privacy setting to its most secure, but it has happened  that a patient could see timeline pictures and events I had shared with my friends, because she had become a Facebook friend of a FB friend of mine through a completely different set of friends, and my settings allowed friends of friends to see my information. Luckily she brought it into the therapy session and I could change the relevant settings. This also lead to exploring what was evoked for her, suddenly having had a window into my private world.

I have had friend requests from patients, which I always discuss in the session, or if it is a former client, I would write a message explaining the professional considerations and the ethical principle of not having social relationships with patients or former patients. I do however honour the interest and the need  of therapy clients to have a kind of a continued connection to someone who is or has been part of their own development and growth and healing. This prompted me to create a FB page as a professional entity, where I post this blog and also interesting articles and information about therapy and psychology, with no links to my personal timeline.

We show of ourselves all the time. We are fellow human beings , not aloof experts with all the answers and unaffected by life, despite out training. We suffer our own pain, we have our own joys. All of this informs who we are as therapists, and will seep into the way we relate to our patients. It cannot be avoided, but it needs simply to be noticed and consciously worked with(during supervision), particularly if it gets in the way of effective therapy. How and what and when to reveal should ultimately always be in the interest of the patient. Revealing too much can be inappropriate and burden the client with information they do not know what to do with, while revealing too little could affect how authentic and transparent  the client  perceives us to be, both potentially hampering and even harming the therapeutic process. It takes experience and practice and sensitivity to each individual therapy client to find this balance for oneself and then, however the patient responds or reacts,  to use that to deepen an understanding and insight.

I know that this is an issue each therapist has to address sooner or later, so how do you feel about self disclosure as a therapist? And if you are a therapy client or patient, how do you experience this issue? What is it that you are most curious about your therapist’s life? And how do you feel about your therapist’s way of handling this?

As good as it gets.

Most people come into therapy with the wish to “just be happy”. But what does it mean to be happy? And is it even possible to “just be happy”?

On the Self Help shelves in bookstores there is a proliferation of books which guarantee a more successful, better, more fulfilling, but especially happier life. These books reflect our wish for happiness, and our unease with suffering, pain, discomfort, uncertainty.Of course, I am not advocating that we should suffer unnecessarily, nor am I saying that self help books are of no value. But I have to admit: when I see titles making promises that if only a certain number of easy steps are followed, all will be well and you will have found true happiness, my therapist heart sinks. Real suffering requires real inquiry and time spent, with a therapist, finding out what is going on: not a checklist, questionnaire, or twenty positive self affirmations in your mirror every morning.

There are no quick fixes. Of course some issues are more easily resolved, and sometimes reading books and getting information that way can make a huge difference in our understanding and experience of what is going on for us. But usually our unhappiness is there for a reason: whether it is part of a normal response to an abnormal environment or event(such as trauma), and/or whether it rises from within us as a response to our own particular history. Our unhappinesses are usually  unique to our particular lives and requires telling about and inquiring into.This is done best in the presence of another who can hear and see and witness and guide and comment and ask questions, and ultimately help us become aware of what is going on and what is causing us to feel unhappy. Therapy can help us explore and try out new emotional, behavioural, mental: in other words psychological, alternatives, which help us to be normally unhappy, in stead of pathologically unhappy. Freud once famously said: ‘The aim of psychoanalysis is to relieve people of their neurotic unhappiness so that they can be normally unhappy”. I smiled when I read that first, even though at first glance it sounds pretty pessimistic.( Neurosis, by the way, is a general term “applied to a variety of mild disorders or conditions that are characterized by anxiety and phobias that don’t involve any altered senses of reality and don’t effect the entire personality”. http://www.alleydog.com/glossary/definition.php?term=Neuroses#ixzz2RGxTrr2 )

But when we are neurotically unhappy, it means that we are unable, because of unhealthy ways of experiencing our emotions and thoughts, to be resilient in the face of what happens to us in life. In therapy we can learn to inquire into those ways of feeling and thinking and behaving which get in the way of being able to experience if not ecstatic happiness, then an ease of being, or a sense of general wellbeing. In therapy we learn new ways to respond to our inner impulses and outer triggers in ways which enable us to have good relationships with others and ourselves, to feel generally good, calm, resourceful and satisfied, and able to take on the task of growing up and becoming more fully who we are.

This general sense of ease and wellbeing is as good as it gets. Being able to cope with what life throws at us in a way which fits our relationships and personalities and circumstances so that we don’t make the sometimes unavoidable suffering worse, is as good as it gets. Living an aware life, a life in touch with what goes on inside, does not guarantee permanent happiness: it does bring though a sense of self responsibility, of autonomy, and being one’s own person. Not happy shiny always, but alive and responsive to the world.

The gift of relationship crises.

I have been rereading an old favourite of mine: A wonderfully wise book by James Hollis, a Jungian analyst and teacher living in the US: “The Middle Passage: From Misery to Meaning in Midlife”. This is a truly remarkable book, and I have referred patients to this and other of his books. Rereading it again, I was reminded about how true it is that we tend to burden the other in our relationships and particularly marriages with the task of making our (often unconscious) dreams come true.  One of the biggest issues in failed marriages is the simmering resentment we eventually experience towards the other because they don’t fulfill that ideal.  This happens when two people  give up on their own individuation in service to the unconscious demand on each other to stay as they are to preserve a particular relationship dynamic.

Individuation is the process of becoming fully our individual, separate selves, with increasing awareness of what is true and real for us, and taking self responsibility for our development as we continue living our lives within the inevitable limits which fate brings. But when we surrender our inner truth to another’s agenda, as is so often required by socially accepted roles and rites in relationships, we do not live our own lives in an examined and aware way, and it often takes a failing relationship, to wake us up.

A relationship crisis can therefore be a first sign of the need to inquire into what is really going on for us. As Mr Hollis reminds us in this book: our intimate relationships can never be better than the relationship we have with ourselves. “All relationships, therefore, are symptomatic of the state of our inner life, and no relationship can be better than our relationship to our own unconscious”(p 47)

I think that these are incredibly true and powerful words: for all our relationships: with intimate others, with family and our own children, with friends and colleagues.

So the ultimate challenge then is to be able to look at ourselves, and ask the hard questions about what is going on inside of us and how it informs our thoughts and feelings, and behaviours , in stead of blaming or shaming the other party, or even(prematurely) severing ties.

Not easy, but possible. Sometimes it takes repeated failures or heartache to force us into doing this work:  when we lose lovers and friends, when we clash with work colleagues, and our relationships with family members and even our own children become fraught with tension, it can be the beginning of our own journey into becoming more self aware, self responsible, more grown-up, more fully ourselves. Ironically it is only when this happens, that we can have good relationships. This is why it is worthwhile to invest time and effort and in the case of therapy, money, into becoming familiar with ourselves, and learning to have a good relationship with ourselves. That is the ultimate gift to ourselves and others.

Working with couples.

I see a lot of couples in my practice. Most of the time, one of the pair is there reluctantly. Often it is because a despairing spouse has issued an ultimatum: “Either we go to couples counselling or I leave”. So by the time they enter my door, there is already so much distance, pain, disappointment, bitterness and anger between two people who, ostensibly, once loved one another, that even being in the same room is tense and fraught.

So starting couples counselling or therapy is usually a step taken when the relationship is on the brink of disintegration. This leaves very little space for maneuvering for a therapist, especially when the unspoken expectation is that the therapist should somehow fix the relationship, usually by fixing the spouse. It needs explaining that I don’t do that: fix people, that is, and that I am not playing judge either, and that a requirement for rebuilding the relationship is that each partner is willing to radically take responsibility for what they each bring to the relationship dynamic.

Another requirement is honesty: often the very reason that the relationship has broken down, is that there had been a slow erosion of intimacy through a series of withheld truths: and a build-up of resentment about the other not really being there in a committed and present way. Sometimes of course there has been infidelity, which causes the biggest breach of trust and a betrayal of the confidence of the other, and a rupture in the sense of connection and safety which people need to and long to feel in a marriage.

Sometimes there is clear personality pathology in one or both partners, or addiction issues, which can get in the way of the process  and which may require attending to before successful couples counseling and therapy can happen.

Which brings me to the question: what is successful couples counselling? It’s very simply that which the couple comes into therapy for: to find a way to restore the quality of the relationship so that it can be a safe space where two adults can have most of their needs met while living in harmony and mutual support and have an emotional and physical environment where they and their children, if they have any, can thrive.

Ultimately, the success of couples therapy lies not only in the skillfulness of the therapist, but in the willingness of each partner to tell the truth: to look at themselves and that which they bring to the relationship dynamic, to change behaviour which is not conducive to real intimacy.

Sometimes all that is required are heartfelt apologies: not just the catchall: ”I’m sorry if anything I’ve said or done has hurt you”, but a considered, real “Sorry” which shows insight and a sense of responsibility of own behaviour and the impact on the other there-of.

Sometimes all that is required is a reminder of how important it is to show appreciation: How a simple “thank you” can prevent a spouse feeling taken for granted or even used.

But usually it takes hard emotional work: willingness to look at oneself, deep commitment to change what is required in one’s own behaviour, humility, willingness to show one’s vulnerability, telling the truth about what’s really going on, and radical forgiveness when a partner shows real remorse for old hurts and betrayals.

Sometimes though, as a result of the extent of the breakdown, successful couples counselling can and should  lead to the ending of a relationship in a considered way, where issues have been clarified and unfinished business has been attended to, and two adults can move on with their separate lives with the least possible anger and bitterness, hopefully having learnt something about themselves in the process.

Working with couples is challenging: to hold the space for two people who are often angry and hurt, who often have not been heard adequately all their lives, who each have their own fears and insecurities, who often have to relearn even the simple act of communicating their emotional needs, is sometimes difficult. But that moment in the therapy room when two people truly connect again after sometimes years of indifference is deeply rewarding and reminds me of how important this work is.


So it’s that time of year: a New Year with promises and possibilities: which, I guess is why we choose this time to make those ubiquitous resolutions. But what is it all about? How did this practice of making New Year’s resolutions come about? I read about it a little here, and of course there are many references where one can find out about the origins of the practice.

As I am an inveterate list maker, I have made so-called New Years resolutions for almost all my adult life without really stopping to think much about it: using the list-making really as a way to organise my mind and my life. And as most people have experienced, I noticed that these resolutions very seldom are realised, and in my own life I have seem to have had the same items/topics appear year after year.  Very much like a To Do list which gets deferred from year to year in stead of  day-to-day.

When someone said, a couple of years ago: “Thank goodness you have not kept to ‘lose 5 kgs’, year after year, since by now there would be nothing left of you!” it made me laugh, but it also made me think: what may be the psychological impulse behind making these resolutions? And as it’s always about changing something about ourselves or our lives,  why is it that we want to change a particular aspect of our lives? What is wrong with ourselves just as we are?  That is of course the premise: that we need to be different, better somehow.  If we can accept ourselves as we are, there would be no need or reason to have these resolutions. Or could there be some value to this practice?

I think that there is. Providing that it is done mindfully. By that I mean a clear awareness of what is going on for us when we set, and why we set, a certain resolution. Why is it that we think for instance, that we MUST lose 5 kgs? Are we trying to change ourselves/ aspects of ourselves because of external, often superficial reasons? Or does this come from an internal sense that somehow we feel that we are not ok as we are?  Does it flow from a direct and true sense of  our wellbeing being at stake if we don’t take a certain action, like losing those 5 kgs? Of course, as a psychologist I would suggest that  we need to inquire into the why of it, in order to understand what may be going on for us. I think that the reason why so many resolutions never get realised, is that we are not sufficiently aware of why or indeed if we really want to change anything about ourselves.

The impulse to live our lives in a more meaningful way, whatever that may constellate for each of us, should not be underestimated. New Year’s resolutions are almost always about a striving for something more meaningful, some change which we feel would be good for us: to enhance our quality of life at the least. And that can never be a wasteful exercise, because it confronts us with the importance of making choices and remind us that we are not entirely helpless bystanders or victims of circumstance: that we have the capacity to  steer our lives along a path which is true and congruent with who we take ourselves to be. Every resolution can inform us of something inside of us which we yearn to see expressed, something about ourselves which is possible and could fulfil the potential and promise  of who we are.