Until the past several decades, psychotherapists believed they were a blank canvas onto which their patients projected all their unresolved issues from their childhood and their internal relational experiences with their parents. Nowadays, we believe that there is a close, real relationship between the patient and therapist that develops over time and may become the most important agent for change in the patient’s treatment. Both the patient and therapist bring to the relationship their own unconscious past relational patterns that originated in early childhood experiences, often between them and their parents.

It is crucial that the therapist monitor the nuanced interactions and enactments that occur over the course of the therapy. The danger in not paying close attention to the shifts between them and their patients could lead to serious negative consequences, such as repeating unhealthy relational patterns or driving the patient out of treatment. I recently encountered one example of such an enactment in my practice. Twice I mistakenly got the time wrong for one patient and I either had booked someone else during his time slot or I forgot to come to my office to see him. If I wasn’t monitoring the shifts in our relationship, I may have dismissed this as a simple error on my part instead of an interaction between us, and it could have well marked the end of his therapy. Luckily I was aware of how unusual this behavior was, as I have never mistaken a patient’s time slot in my 20 years of practice. This signaled to me that there must be an enactment between us that tells us something essential about the patient’s relational experience in the world. Sure enough, after exploring this together, we discovered his experience of feeling like an afterthought to his parents and friends most of his life. Instead of driving him away from treatment, this enactment elucidated something important about this patient’s relational dynamics and became an essential part of his healing.

I sometimes think that if a patient and I focus on nothing else but the twists and turns in our relationship, we still might be engaged in the vital process of therapeutic action that enables the patient to make long-lasting positive changes to his or her life. This relationship is unique in that I am a part of it, unlike all other relationships that I only hear about through the lens of their point of view. I can help patients come to understand deep-rooted relational patterns and have a positive experience of a relationship that might be unlike any other past or current relationships they have ever experienced. Such a healthy relationship can be a “corrective emotional experience” that can have everlasting changes for the patient.

I often reflect on how the skills we need to navigate our lives through adulthood were not taught to us in school. Most of us did not get taught how to identify and express feelings. We didn't take classes in how to nurture healthy relationships and how to sustain these throughout one's lifetime. While a great deal of effort may be given to one's career, an equal amount of effort might be missing when it comes to the relationships that we consider most important.

When the issues that bring people into treatment seem to center on their primary relationship, then couples counseling may be warranted as the preferred treatment modality. Unlike individual therapy where we delve into a patient's psyche to understand how one's unconscious processes inform current behaviors, in couples counseling the couple is the patient and the focus of our work shifts to attending to how the partners communicate, manage conflict, and show empathy for each other. Often my role is to teach specific skills along these lines. I might help them learn active listening and empathy skills. Perhaps I may teach effective ways to deescalate fights and constructively handle arguments. I may encourage partners to talk to each other and not simply to me so they can practice communication, thus bringing their relational issues directly into the room so that I can observe and intervene as needed. As the therapist, I am in the unique position of watching how they interact and I can pay attention to the moment to moment shifts in their conversation to see where they might get stuck or how conflict escalates.

As a psychodynamic therapist, I also place importance on understanding each person's individual history and how these intersect in their relationship. It is not arbitrary when two people find each other and embark on a journey to form and maintain a relationship. Each person brings to the table their individual relational dynamics that they learned as far back as childhood. Often people reenact in their current relationship patterns that they experienced in their parents' relationship or in their own relationships to their parents. These relational patterns continue to get repeated and played out in their subsequent relationships throughout life. When we can identify these relational patterns and how they are reenacted, then we can set about to shift these in healthier directions. When we come to understand how each individual is triggered by their partner and how that may be connected to experiences they had in childhood and adolescence, it helps each person develop a deeper understanding of their partner, an awareness of how their own behavior is impacting their partner, and the potential for greater emotional intimacy.

Relational patterns tend to get passed from generation to generation until someone takes the initiative to work through these in the context of psychotherapy. One can imagine how complicated this can be when each member of a couple is bringing to the relationship specific patterns that can be traced back to their own early relationships and those of the generations that came before. So a husband's behavior may trigger his wife in ways that are similar to how one of her parents triggered her or similar to how her parents and grandparents related to each other, and the same can be true for how the husband experiences his wife's behaviors. Usually these patterns aren't easily identifiable at the start of couples counseling, but over time, with the help of a trained therapist, they can be elucidated and worked on. The hope is that by working together in this way, each partner can come to experience a more rewarding and intimate coupling into the future.

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