Relational Work in Individual Therapy: Pitfalls and Possibilities

“She tells me she wants me to initiate, but she’s hot and cold, and I can never tell when she’s actually interested. So I hold back because I don’t want to get rejected, and she gets mad at me for it! I’m sick of trying to read her mind. I wish she would just come out and actually tell me what she wants!"

“He’s so caught up in his own head all the time, and he never pays attention when I’m giving him obvious signals. Then, of course, when he wants to have sex, he picks the absolute worst time–when I’m stressed out or busy or just really not feeling it. And then he gets his feelings hurt! Why can’t he put a little effort into seducing me, like he did when we were first going out? He used to make me feel so special. Now he just wants a quickie and to go on with his day.”

Two stories, one relationship. Imagine the picture you would form if you were working with just one of these clients in individual therapy. It is easy to see how your client perceives the problem, but you’re only getting half of the story and none of the relational dynamic. My clients almost always see the problem as something their partner is doing (or not doing). I’ll bet that’s true of your clients too. Unfortunately, very little progress will happen until your client identifies changes they want to make themselves, for their own reasons, rather than focusing on changes they want their partner to make.

When you’re dealing with sex issues in individual therapy, it’s very likely that you’ll discover some relational dynamics need to shift in order to make real progress. There are any number of ways this could play out: Maybe your client is experiencing sex pain but struggling to disclose it to their partner. Or perhaps your client is extremely frustrated about mismatched desire and doesn’t know any way to talk about it other than to pressure for sex. Maybe your client and their partner need some psychoeducation in order to have the kind of sexual partnership they want.

Ideally, you’d discover the client has some sex issues very early in your therapeutic relationship when it is still easy to suggest a shift to couples therapy. In fact, that’s so ideal that it is one of my reasons for bringing up sex in the very first session; relational issues, including those related to sex, shift more easily and faster when both partners are in the therapy room.

But that doesn’t always work out, for any number of reasons, and it’s good to be prepared to work with relational challenges without the other partner in the room. So, let’s imagine for the time being that you are working with an individual client who is focusing in session on relational challenges.

To be fair, it isn’t easy to see how we contribute to our own relational challenges, especially if nobody asks the right questions. Since the intersection of relational and sex issues tends to be particularly fraught, it can be quite challenging to find the right questions.

As an individual therapist, you can help your clients make enormous changes in their intimate relationships, including strengthening their ability to have tough conversations with their partners at home. But there are some missteps along the way that can make your individual therapy less helpful to relational change, or even worse, actually undermine relational progress.

Here are some common pitfalls, and how to avoid them:

• Inviting the partner to attend individual therapy as a guest, without a clear plan for what the client wants to get out of that session or how to support the partner. I’m not saying I would never do this, but when I have done it without enough planning it has caused more problems than it solved. Important steps include:
• Helping the client get clear about what they want to have happen in the session where their partner attends as a guest
• Preparing them for me supporting their partner in that session, which sometimes can feel like undersupporting the client.
• Potentially, preparing them for a challenge. If I think I’ll be challenging the partner in the guest session, I’m probably going to want to also challenge my individual client, so it doesn’t feel like an ambush to the guest/partner. I want to prepare my client for that possibility, so they don’t feel blindsided.
• Note: There’s one exception in which I won’t plan as extensively. Sometimes I just want to present some psychoeducation about sex to both partners at the same time. If it is very early in the individual therapy, I’ll do this with somewhat less planning and just have the partner come to the next session so I can teach them together. Examples include anatomy of pleasure, helping them navigate how to partner well when one partner is experiencing unwanted pain with sex, or supporting both partners as they learn to navigate trauma-related triggers during sexual interactions. The amount of prep needed depends on how difficult I anticipate the session being for the partner.
• Letting the focus of individual therapy be on the (not present) partner’s annoying behavior. This is a huge pitfall and a very common error therapists make, in part because most of us were trained to believe that being an empathetic listener is the most important aspect of our job. But in my opinion, therapy involves supporting personal change. I can only support personal change for someone who is interested in personal change. Consider how this might look with a desire discrepancy. If your client is the higher desire partner, they may feel unheard, rejected, trapped and resentful about their partner’s lower desire and how they communicate about it. If your client is the lower desire partner, they may feel pressured, conflicted, and guarded. Here are some steps I might take:
• I often explain to my client that I can easily see how annoying their partner is, but unfortunately they can’t change their partner, and neither can I. Only their partner can change themselves. So instead, let’s focus on what changes you yourself might want to make that would improve your life, your happiness, or your relationship. 
• I often ask Peter Pearson’s brilliant question: what do you do that makes it hard for your partner to give you what you want? This will lead us to a conversation about the responses of my client, and how their responses affect their partner. Now I’m working systemically, and we are discussing things my client might choose to change in how they are showing up in their relationship. 
• Asking the client if they have shared their complaint with their partner. This is a complicated one, because of course the client should definitely communicate about their desires, preferences and experiences in a clear and non-judgmental way, directly to their partner. The problem is, they probably think they have, and have become very frustrated with how their partner responded. My theory is that there is something they could do differently in their part of the communication that would make it feel more effective and less frustrating. 
• My best strategy here is to use two chairs to role play the conversation, imagining that their partner is sitting in the other chair. They can ask their question, or express what they want to express, and then move to the other chair and respond as their partner. I might ask them to react in the way that they’re afraid their partner will react, so that they can practice staying calm and focused and responding in a way that accords with the kind of partner and person that they want to be. In this manner, I get a vicarious look at the relational dynamics (or at least my client’s perception of them) while also focusing on my client. I can strengthen their skills with tough conversations without inviting an increase in their frustration through telling me about how it has gone badly in the past.
• This works really well when there is a disclosure they want to make to their partner about sex, or a request they have. If someone wants to communicate, for example, that more clitoral stimulation would be enjoyable for them, helping them get used to using specific and explicit language will be very important. You will also find out how the partner might respond, and then help your client figure out how to help their partner receive the information in a way that feels helpful. This might include sharing a diagram from a book, showing the partner where they like to be touched, or any other solution they might be able to think of.
• Rehashing a tough conversation without a clear focus on the individual client’s choice points. Here again, it is so easy to talk about what went wrong and how awful it felt. I think there is a place in therapy for rehashing a fight, but my operating premise is that in every conversation, everyone involved has the ability to make it go much better, or much worse. So if my client wants to rehash a fight, I want to keep the focus on what choices my client made along the way, and what their options may have been. Most people don’t think they had any choice at all about how they responded or participated in an argument, so I might start this conversation by saying: “Let’s talk about how that conversation with your partner went, but as you tell me about it, think about each moment as containing multiple options or choices. So, start by giving me a brief highlight of how it went, and then let’s see if together we can come up with some options for how to respond in each moment.” 

Helping individual clients strengthen their relationships is a real challenge, and it’s one that therapists ask me about frequently. This situation is especially common when sex issues are part of the work in individual therapy. Sex issues tend to involve a partner dynamic as well as embarrassment, shame, confusion, and very strong feelings and reactions.

Clients have conversations with their partners all the time, without our help. You have seen my strategies for helping them prepare well for the really challenging ones, debriefing with a focus on options, and taking the heat by doing the psychoeducation about difficult stuff with the partner as a guest to session.

I also talk to my clients about what skills contribute to satisfying and effective communication. Strengthening their skills in areas where they struggle becomes the work of the individual (yet also relationally focused) therapy. This skills that underlie effective communication are:

• the ability to identify what you want, feel, think, believe, and prefer before you try to express something about these things
• the ability to express that to someone else, focusing on your own perspective, and remaining calm and centered
• the ability to hold steady, and remain calm and centered while you hear what the other person wants, thinks, feels, believes, or prefers.
• the ability to remain calm and centered, in order to keep your own reactivity to a minimum, and even when either the other person has a big reaction to what is being discussed. This is very hard, and sometimes doesn’t work, in which case you’ll need:
• the ability to effectively make a time-out happen, and re-approach to discuss the topic again after the time out.

With these skills in mind, I use the following questions to guide my clients in preparing for conversations at home:

What do they want to communicate about themselves to their partner? Getting really, really clear on what they want to express can help make the conversation feel much more manageable. It can also help them plan to frame the discussion in a way that allows it to become an opportunity for their partner to learn more about them, without blame or resentment coloring the conversation.

What do they want to learn about their partner? When we’re afraid to discuss a topic, we tend to make a lot of assumptions about what the other person thinks! This is a great opportunity to clear out those assumptions and learn what’s really going on. Are there any questions they’ve been avoiding asking because they’re afraid of what the answer might be? Or are there any particular aspects of their partner’s experience that they can begin to access curiosity about?

How can they hold steady while they have the conversation? I’m sure that, as a therapist, you’ve got plenty of emotional regulation techniques in your back pocket; draw on those here, and help your clients learn what helps them stay calm and grounded in a challenging emotional situation.

Do they have a good strategy for a time out, and have they been able to use it? Is their partner on board with their plan? Here are a few key points:

• Both partners understand the plan and are willing to use it themselves, and are also willing to have their partner initiate the time out
• Both partners understand that whoever calls the time out is also responsible for re-approaching, rather than letting the topic drop or sweeping it under the rug
• Both partners see this as a good strategy to prevent damage to the relationship when the self-protective brain is in control and damage is inevitable.

If the partners haven’t got a time-out strategy in place, this is your opportunity to figure out which of the above strategies to employ. You might have the partner come as a guest to therapy to teach them both together about a time out, or you might help your individual client get clear on how they can initiate and follow through on a time out even if their partner has difficulty with it. Or you might help your client discuss the strategy with their partner in new and productive ways. Whatever the case, we all get reactive sometimes and a strategy for taking a break is crucial.