Working with Angst in Counselling

What do you say to a client whose presenting issue is deepangst over the question of relationship? Whether the person is in a primaryrelationship and deeply unhappy, questioning whether to stay or to go, or theperson longs for that primary relationship in order to feel happy andfulfilled, the issue is a profoundly unsettling one to those caught up in it. Howare we, as mental health professionals, to be with clients’ inner conflicts ofthe partnering kind? What should our clients know when considering whether toenter — or to leave — a relationship? And how can we know if their impulsetoward partnering or toward singlehood is healthy or not for them? We entertainthe questions of what we might be looking out for with such clients, and whichnotions/modalities may be helpful in sorting through the questions.

Let us say up front that we are not considering herequestions of relationships where there has been violence or the client’s safetyis at risk. With few exceptions, these are situations in which the client needsto leave: the sooner, the better. Similarly, we do not address our remarks topeople who are deeply traumatised. Neither are we including in our discussionpeople who are happy in their relational status, whether that is wedded blissor blessed singlehood. Rather, we bring to your attention common relationalwoes where the client is either perpetually angsty over their status, or actsin unhealthy ways to eliminate the angst.

Needing to be partnered

One “red flag” to beware of — either in your clients or for them— is that of the person who must bepartnered to feel ok.

One middle-aged gentleman, an acquaintance of one of ourwriting team, delivered a touching eulogy at his wife’s funeral. “She is forevermy wife,” Mark declared, “[Despite her death], that doesn’t change.” Howromantic! How beautiful! Yet two months later, our writing team member learnedthat Mark had re-married: after just one month of becoming a widower — and hedidn’t even know the woman who became his second wife before the first onedied. Not only that, but the second wife came from a very different country andculture to the one in which Mark grew up. Quite simply, Mark had grown up witha powerful, controlling mother and many older and equally powerful sisters. Withouta woman around guiding and directing him, Mark literally did not know what todo. Years of unhappiness ensued as Mark realised that he had finished with one“boss” only to marry another one — and the second one was hard to understand!

Can’t plan or move on

Related to the first red flag is the person, usually onerecently made single, who believes that they can’t plan or move on until therelationship question is resolved. If they have just suffered a breakup, they maypine continually for the person, even if, while in the relationship, theyexpressed major concerns about the quality of it. Pippa, whose partner of fouryears broke it off, told her therapist that she was putting off decidingwhether to move back to the city she grew up in (a move she had desired in therelationship, but which he had resisted) until she saw whether there was achance of getting back together with the man. She continued to feel this wayfor months even though, when she spoke with him, he asserted that he was“settled” in his decision and even though Pippa had spent many hours in therapybefore the breakup questioning whether this was the “right” relationship forher given the many differences in values and preferred life activities betweenthe two of them.

Commitment-phobes

Rod went to his therapist wailing, “All I want is arelationship, but with the long hours and travel of my job, it’s just notpossible to have a relationship; I’m rarely in town”. Rod and the counsellorbegan working through ways in which Rod could get more time for things thattruly mattered. He got clearer on work-life boundaries, managed to reduce theamount of travel, and made other changes. After some months, he quit the jobwhich had demanded so much travelling and took up one which saw him workshorter hours, with little out-of-town travelling. He began to date women, butjust when a woman and Rod were getting closer, Rod would back off, oftenbreaking it off completely. After some months, he had an epiphany. Rod realisedthat he had set up his former lifestyle to shield himself from becoming tooinvolved in a relationship. It was very telling when he related how, as arecreational skin diver (meaning someone diving beneath the surface of thewater without SCUBA gear to breathe with), Rod could outlast anyone else in thediving club holding his breath underwater. “I learned to do that,” he said,“when growing up. My domineering mother would hug me so hard she wouldliterally squeeze the air out of me. I would just hold my breath until she wasfinished”. Rod’s impulse toward — and then away from — relationship was are-play of what he had to do earlier in life to survive.

Sometimes as therapists we must be vigilant about angst fromthe already-partnered, who contemplate returning to singlehood. They aretypically in relationships in which criticism, contempt, and defensiveness manifesttoxic patterns that undermine any possibility of relational harmony. This istrue whether our clients are the ones on the receiving end or are perpetratingthe behaviours. Behold the relational “red flags” of the Four Horsemen.

Partnered, but also critical, contemptuous, defensive, and stonewalling

Some relationship experts have written about what they callthe “Four Horseman of Relationship Apocalypse”. The phrase is a metaphordepicting the “end of times” in the New Testament of the Bible, describingconquest, war, hunger, and death. In the relational metaphor, it describescommunication styles that, according to research, can predict the end of arelationship (Lisitsa, 2013) — or, we would say, the demise of any genuinepossibility of right relating. So, what are the four “horsemen”?

Criticism

Is the unhappy client frequently critical of thespouse/partner? Alternatively, is the client on the receiving end of a partner’sfrequent criticism? We’re not talking here about the need to make a complaintabout a specific issue. Rather, it is the perpetual running-down of the otherperson’s character — smearing their whole being with a tar brush, so to speak —that is the problem. It sets up an escalating cycle of criticism andcounter-criticism which opens the door for the other “horsemen” to come ridingtriumphantly through.

Contempt

This, the second horseman, is seen when people treat theirpartners with disrespect, mocking them, ridiculing them, and/or using gesturesand paralinguistic expressions such as eye rolling, scoffing, or mimicking. Contemptoccurs when someone expresses long-held negative thoughts, attacking thepartner from a position of supposed moral authority. Apart from researchshowing that individuals engaging it get more colds and flu than average(contempt apparently weakens the immune system of the perpetrator), it also isthe single largest predictor of divorce (Lisitsa, 2013).

Defensiveness

Defensiveness, the third horseman, plays out inrelationships that are failing. It is usually a response to criticism in whichthe accused feels unjustly blamed, looks for excuses, and proclaims innocencein order to get the accuser to back off. The strategy isn’t usually successful,because it displays an inability to take responsibility for errors or faults,and shows the criticiser that his or her concerns are not being takenseriously. Defensiveness escalates hostility and doesn’t allow for healthyconflict management.

Stonewalling

When the first three horsemen havebeen running amok, trampling over the relationship, the natural response is tostonewall, which happens when the person on the receiving end of criticism orcontempt feels overwhelmed and withdraws, shutting down and stopping respondingto their partner. Stonewallers, feeling too “psychologically flooded” toconfront the issues with their partner, tune out, turn away, act busy, orengage in obsessive, distracting behaviours. This behaviour can all too quicklybecome a habit, one which is lethal to the relationship (Lisitsa, 2013).

Thus, we see the “four horsemen”depict a relational status of, “yes, I’m partnered at the moment, but I wish Iweren’t. I’m so unhappy.”

Cheaters

Some of the most intense relational grief occurs to thosewho are on the receiving end of a cheating partner. The hurt and sense ofbetrayal can be overwhelming, and the client may wonder: if the partner did itonce, what would keep him or her from doing it again? It is a question worthasking, as the client contemplates what is of value in the situation, andwhether to stay or go.

Which modalities help us to help clients move toward right relating?

While a solid therapeutic alliance provides one of thegreatest relational supports, there are also some important tools at ourdisposal to accelerate the gaining of insight and healing that will reducerelationship angst. Let’s look briefly at what some of the major “families” oftherapies can offer here.

Psychodynamic

One of the major benefits of psychodynamic therapies is thatthey can help clients gain deep insights into root causes of the problem. Admittedly,some of these modalities require intensive, long-term work, but much healingcan come from confronting situations of early unmet needs, as clients come tounderstand the relational templates they formed before they could even speak infull sentences. Several modalities stand out here.

Object relations

The aim of object relationstherapy is to help a client uncover early mental images that contribute topresent difficulties in the client’s relationships with others and adjust themin ways that will improve basic interpersonal functioning. Attachment theory,in particular, notes that if children are able to form a secure attachment totheir caregiver, they are likely to use that healthy relational template toform workable relationships in their adult years. Sadly, the converse is true,and those who have come to form an avoidant, dismissive, or disorganisedattachment — when caregivers have been cold, rejecting, or inconsistent — are likelyto form relationships characterised by the woes we have identified above.

Psychosynthesis

Acknowledging that human beingsoften have many unmet needs, this modality posits the existence ofsubpersonalities: sub-selves which constellate in order to help us meet needs,or to shield us from experiencing the pain of needs that we have decided cannotbe met. Mark, mentioned above, is likely to have a subpersonality whose worldview is that it’s a tough world, one that cannot be survived without apowerful, guiding woman to advise him. Working with subpersonalities helpsclients see how they can meet acknowledged needs in ways that serve the wholeself rather than just the narrower needs of the particular subpersonality.

Interpersonal Therapy

For a psychodynamic therapywhich is time-limited (often between 12 and 16 sessions), IPT helps clientsimprove their interpersonal communications in order to improve both mood andrelationships. Its theoretical foundations are a combination of attachmenttheory, communication, theory, and social theory. Clients with relational woesoften elicit negative or unsupportive responses from others unintentionally. Thisoccurs because those who have maladaptive attachment styles engage in specificcommunications which bring forth responses that do not meet their attachmentneeds effectively. When the poorly-attached person then reacts to thenon-need-meeting response, it often escalates tensions, deepening the cycle andpreventing those needs ever being met (Kiesler, 1979). Thus, this therapy canbe effective for those with specific interpersonal issues.

Schema-focused therapy

Self-defeating cognitive and emotionalpatterns that begin early in a person’s development and repeat throughout life constitute the context forschema therapy, which is an integrative approach to treatment combining the best aspectsof cognitive-behavioural, attachment, Gestalt, object relations, interpersonal,and psychoanalytic therapies into one unified model. Thus it would seek toidentify clients’ dysfunctional, pervasive themes or patterns in relationshipsdeveloped during childhood and elaborated throughout their life. The memories,emotions, cognitions, and bodily sensations that clients report give clues asto which of five main domains have been impacted, and are therefore playing outin the client’s relationships. Schema healing involves diminishing theintensity of all of these to the point that they no longer impair the client.The interventions are cognitive, affective, and behavioural. Thus, a clientlike Mark, whose issues arise in the domain ofindependence/autonomy, would learn to feel more comfortable relying on his ownresources when making decisions and organising life. 

Post-modern: Narrative and solution-focused

In these modalities where realityis seen to be socially constructed and maintained through stories, we can see away to help clients re-imagine their relationships through re-storying(narrative) and finding unique solutions based on a fresh assessment ofavailable resources (solution-focused). Narrative’s search for “sparklingmoments” and the quest of solution-focused therapy to know what was happeningwhen the problem wasn’t as much of a problem speak to a process of refocusing. Clientsin unhappy relationships, or those who desperately wish to enter a relationship,can learn to highlight different elements of their past: times, for example,when events showed that they were loved and loveable, or when they were able tosee that, indeed, they functioned very well autonomously, without a morepowerful other directing them.

Person-centred and positive psychology

Rogerian

Rogers’ person-centred therapy emphasisesthe self-actualising tendency in human beings and the need for therapy to helpclients overcome conditions of worth, a state of incongruence in which clientsbelieve that they are only worthwhile and lovable if they think, feel, and actin ways that meet the needs of others. This would seem to be a fairly spot-ondescription of either the client who stays in an unhealthy relationship becausethey must be in a relationship — anyrelationship — at all costs, or alternatively, the client who perpetrates theunhappiness of criticism, contempt, or defensiveness because that is all theyknow.

Positive psychology

This modality’s notion of anabundant universe and its focus on a person’s strengths and virtues can help thoselonging for love move forward with the confidence that there is enough love togo around, and that they have many positive qualities to offer a relationship,even if they have been disappointed in the past. The P.E.R.M.A. model ofhappiness (for Positive emotions, Engagement, Relationship, Meaning, andAchievement) underscores the importance of helping clients to refocus onto thatwhich is positive in their lives, engaging in activities that have meaning forthem and could lead to a meaningful achievement, whether or not the area ofprimary relationship is happening as they wish.

Humanistic, person-centred,positive psychologies can also help clients — or client couples — who havecreated toxic relationships with any of the “four horsemen” of relationalapocalypse.

CBT-based therapies

Therapies such as REBT, CBT, and ACT have a useful role toplay for the forlorn in love, in that unhappy relationships — or an unhealthylonging for one — almost always involve some elements of irrational, limitingthinking. Thus the role of the therapist may be to help ferret out the“shoulds” and other cognitive distortions which make clients so unhappy. ACThelps clients to distinguish between that which is out of one’s control andthus must be accepted, and that which may be amenable to change if the clientacts.

Summary

Relational challenges, especially those of primaryrelationships, are rife in modern life and often revolve around intense desireto be partnered, intense ambiguity about coming into relationship, or equallyintense dissatisfaction with the dynamics of an existing relationship. While arobust therapeutic relationship can offer both support and a model for howhigh-calibre relating can occur, as therapists we also have numerous therapiesat our disposal to help reduce relational woes while helping put the client ona more stable road of right-relating.

References

• Kiesler, D.J. An interpersonal communication analysis of relationship in psychotherapy. Psychiatry; 1979, 42(4): 299-311.

• Lisitsa, E. (2013). The Four Horsemen: Criticism, Contempt, Defensiveness, and Stonewalling. The Gottman Institute. Retrieved on 20 January, 2019, from: Website