Thank you to everyone who responded to our August Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
August Quandary: Week after week, my client’s sessions focus on her issues with her partner, who dismisses her feelings, refuses to work on the relationship, and even seems emotionally abusive at times. Since she doesn’t want to leave the relationship, I think couples therapy would be tremendously helpful, but the partner refuses to go and gets angry when she suggests it. I worry she’s just spinning her wheels in individual therapy, since all she talks about with me are the changes she wants to see in her relationship. What should I do?
1) Do Therapy Under the Therapy
It's tricky when clients are persistently others-focused in session. On one hand, this client’s issues with her partner appear to be the presenting problem. On the other, less obvious, hand, it’s clearly not. There’s therapy, and then there’s the therapy under the therapy—the undercurrent, if you will. The truth is, while this client’s concerns certainly sound valid, she somehow benefits from focusing on her partner in therapy instead of herself. Since it seems like this therapist has done their due diligence in recommending couples therapy, to no avail, he—or rather, his client—is left with an enormous opportunity to dig deeper and get to the heart of the problem.
As I read this Quandary, I was reminded of my own experience in therapy years ago. My therapist, probably bored to tears hearing about all the ways my then-boyfriend had wronged me, asked me, “And what do you take responsibility for in the relationship?” Aghast, I’m pretty sure I responded with something like, “Haven’t-you-been-listening-he-did-everything-wrong-poor-me-he’ll-never-change-and-I-don’t-know-what-I-could-have-possibly-done-differently-I-did-everything-I-could-why-is-he-like-this?”
Joking aside, this was a pivotal moment in both my personal life and professional career. My therapist was right: I had a lot to take responsibility for, and realizing that required that I dive deeper into myself, my boundaries, my family of origin—you name it. It wasn’t a pretty process, but it sent me on a better trajectory toward healing than if my therapist hadn’t asked (or worse, joined me in my lamenting).
Fifteen years later, I can’t count how many times I’ve used that very question in my practice. It’s a powerful inquiry that jolts even the most insightful client to consider a new perspective on the problem, and it’s effective with just about anyone. Whether we’re talking about overbearing parents, enmeshed teenagers, codependent friends, or divorcing adults, anyone in a problematic relationship benefits from looking inward first. Something tells me this client is no exception.
There are many ways this therapist can frame it, from delicate to blunt: I noticed we spend most of your sessions talking about your partner. How do you feel about that? How does this relationship serve you? What do you gain by staying in this place with him? Why go to therapy to talk about someone else? How do you contribute to the unhealthy nature of the relationship? However you decide to approach it, remember: Your client continues to come to your office for a reason. Perhaps she’s spinning her wheels until she feels safe enough to go deeper. Ask her.
Kate Sample, MA, LPC
Eau Claire, WI
2) Foster Self-Sufficiency
Rather than focusing on what this client should do—couples therapy or not? Stay in the relationship or leave?—I’d start by doing an in-depth exploration of how she feels about what’s going on with her partner. When relationship tensions flare up, our right brain involuntarily makes us relive emotions from our childhood.
Asking several questions might help this therapist get to the bottom of why the client is getting stuck: What do you feel when your partner gets angry at you, dismisses you, or refuses to work on the relationship? What’s it like to feel this way? Are you ashamed of these feelings? Has anyone ever understood why you’re feeling this way? Do you remember the first time you had these feelings? Do you feel them often? What happens in your body when you feel this way?
It appears that this client may have spent so much time focusing on her partner’s behavior that she’s lost touch with herself. Her therapist writes, “All she talks about with me are the changes she wants to see in her relationship.” I suspect that she’s talking about the changes she wants her partner to make, not herself. This automatically places her in the position of helpless victim, since the only person any of us have any control over changing is ourselves.
If this client is reliving a prior instance of victimization, then she’s unconsciously placed her partner in the villain position, blaming him for her problems. If this is the case, I can see why he wouldn’t feel safe going to couples therapy, fearing being cast as the bad guy. I believe that in couples conflict, each partner has a responsibility for the problem, assuming one partner isn’t being verbally or physically threatened or assaulted. Perhaps this client isn’t noticing how she might be responsible for part of the problem, which could be achieved by being honest about where her feelings are coming from. If this is the case, I’d want to help her learn how to express her upset to her partner in language that makes it clear she isn’t blaming him for her feelings.
I suspect that once this therapist and client have deeply explored the client’s feelings about herself and her triggers, she’ll gradually learn to make her own decisions about how to proceed with her partner. She might even develop the courage to say she’ll only stay with him if each of them take responsibility for keeping the relationship intact by owning up to each of their roles in the conflict.
Jana Edwards, MSW, LCSW, BCD
Greenwood Village, CO
3) Be an Advocate
It seems the question we should be asking in this quandary is: Are we providing any value to this woman who would clearly benefit from couples therapy, even though her partner is unwilling to engage? I’ve been practicing therapy since 1979, and for years, I asked myself whether I was doing anything to help clients in individual therapy when couples therapy was warranted instead. Over the last couple years, I’ve been asking myself a different question: How can we say couples therapy is necessary if one partner isn’t willing to partake? Aren’t we trained to meet the client where they are?
In this therapist’s position, I’d want to work more with this woman individually before involving her partner. She seems to be ridden with anxiety and depression. I’d want to help her elevate her self-esteem, begin to see her value and self-worth, and manage her anxiety and depression. Personally, I don’t think this client could hold her own in couples therapy yet. But together, she and I could better prepare her to be confident in couples work, should it ever happen.
I think the COVID-19 pandemic makes it much harder for us to get a reluctant partner into couples therapy. Doing therapy over video chat, where we can’t offer the partner a friendly handshake, welcoming smile, or tea or coffee, makes getting buy-in a lot tougher. So, because this client doesn’t seem ready for couples therapy and her partner might be even more reluctant to participate now than six months ago, I’d say beginning couples work right now isn’t ideal. It’s one more reason this therapist should be focusing on individual therapy instead.
That said, there are many ways a therapist could help this client feel better about herself, so she could assert herself in the relationship. In addition to improving her sense of self-worth, I might educate her about abuse, and recommend books she could read that would help her learn new ways of navigating relationships. I could become her advocate.
In this sense, I’d no longer feel like I was wasting my time by seeing this woman individually, even though in an ideal world, couples therapy might be a better solution. We know that couples therapy works best when both partners are individuated. As Murray Bowen says, the Self is more attractive than then non-Self. Thus, our work becomes helping this woman become more of her Self—empowered, assertive, and informed to take on couples work at a later date.
Susan E Cohen, LICSW, LMFT, ACSW
Whidbey Island, WA
4) Ask “The Miracle Question”
I see this situation quite regularly in my practice, and there are few approaches that help my clients deal with it.
First, I determine the function of the symptom. In this case, it means asking how being in this relationship is serving the client. Obviously, it provides some sort of benefit for this client. So, together, we’d explore this possibility. For instance, the financial cost of leaving could be far greater than if she stayed in the relationship. Then, depending on the function of the symptom, we’d focus on that underlying function rather than the simple, surface question of whether she should stay or go. This is particularly important if the client staying is harmful.
Second, I find that sometimes it’s helpful for the clinician to contact the partner directly and invite them to the session. I’ve had some success with this approach, particularly if I indicate that their presence will help me help their significant other. Once both partners are present in the therapy room, it’s helpful to identify various patterns of interaction, which provide valuable information regardless of whether they stay together or not.
Third, I ask the client what some therapists refer to as “the miracle question,” with a twist. I ask, “If a miracle was to occur for you and our work together was successful, what would you be doing differently in your everyday life? How would you be feeling? What possibilities would you be experiencing and how would your life be different?” This can help focus therapy on areas which might lead to positive outcomes.
If all else fails, providing a good listening ear and commiserating together can be therapeutic in and of itself.
David Mensink, PhD, RPsych
Victoria, British Columbia, Canada
5) Refocus the Narrative
It can get quite frustrating to stand by and watch your client get stuck in a cycle of helplessness. It can also be difficult, as her therapist, to not feel a similar sense of helplessness and frustration. It sounds like this client has no answers to the dead end she’s reached with her partner, and expects her therapist to somehow find the solution for it.
I wonder if this client is ready to see that she can only focus on her role in the conflict, since her partner refuses to attend couples therapy. I’d help the client focus on what her role is in the conflict and change the way she responds to it. I’d ask her why she thinks her partner isn’t seeing her perspective, as well as what changes her partner wants, and her expectations. I’d also ask her what the emotional payoff is to be staying in what sounds like an emotionally abusive relationship. I’d further explore her family of origin issues and patterns and see how they might be playing out in her current relationship.
It’s challenging when you’re seeing only one half of the couple, akin to working with one hand tied behind your back. In such instances, I’ve found it helpful to draw attention to the client’s individual needs and whether they’re being met in the relationship. It’s worthwhile to explore if her well-being is linked only to this relationship or if there are other avenues to happiness. Sometimes our clients get stuck in the stories they tell themselves, like “I’ll only be happy if this relationship with my partner works out” or “I’ll only be happy if I am loved this way.”
What does it take for a client to step away from their usual narrative? Therapists can help with this process. It’s much more empowering for the client to focus on how she responds than on her partner’s refusal to engage in therapy or other healthy behaviors. That’s all we can really control, but it’s a healthy coping strategy for frustration and helplessness nonetheless.
Sukanya S., family therapist
Next Month’s Quandary: I work in a rural area and don’t have many options for referrals when it comes to clinical issues that aren't my specialty. Recently, my client Andrew has started showing symptoms of obsessive-compulsive disorder (OCD). He’s struggled with anxiety for a while, but the pandemic seems to have been a tipping point for him. I’m finding it difficult to help him mange his fears and behaviors around getting sick and spreading the virus. What should I do?
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