Working with Angst in Counselling
What do you say to a client whose presenting issue is deep angst over the question of relationship? Whether the person is in a primary relationship and deeply unhappy, questioning whether to stay or to go, or the person longs for that primary relationship in order to feel happy and fulfilled, the issue is a profoundly unsettling one to those caught up in it. How are we, as mental health professionals, to be with clients’ inner conflicts of the partnering kind? What should our clients know when considering whether to enter — or to leave — a relationship? And how can we know if their impulse toward partnering or toward singlehood is healthy or not for them? We entertain the questions of what we might be looking out for with such clients, and which notions/modalities may be helpful in sorting through the questions.
Let us say up front that we are not considering here questions of relationships where there has been violence or the client’s safety is at risk. With few exceptions, these are situations in which the client needs to leave: the sooner, the better. Similarly, we do not address our remarks to people who are deeply traumatised. Neither are we including in our discussion people who are happy in their relational status, whether that is wedded bliss or blessed singlehood. Rather, we bring to your attention common relational woes where the client is either perpetually angsty over their status, or acts in 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 be partnered to feel ok.
One middle-aged gentleman, an acquaintance of one of our writing team, delivered a touching eulogy at his wife’s funeral. “She is forever my wife,” Mark declared, “[Despite her death], that doesn’t change.” How romantic! How beautiful! Yet two months later, our writing team member learned that Mark had re-married: after just one month of becoming a widower — and he didn’t even know the woman who became his second wife before the first one died. Not only that, but the second wife came from a very different country and culture to the one in which Mark grew up. Quite simply, Mark had grown up with a powerful, controlling mother and many older and equally powerful sisters. Without a woman around guiding and directing him, Mark literally did not know what to do. 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 one recently made single, who believes that they can’t plan or move on until the relationship question is resolved. If they have just suffered a breakup, they may pine continually for the person, even if, while in the relationship, they expressed major concerns about the quality of it. Pippa, whose partner of four years broke it off, told her therapist that she was putting off deciding whether to move back to the city she grew up in (a move she had desired in the relationship, but which he had resisted) until she saw whether there was a chance of getting back together with the man. She continued to feel this way for 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 therapy before the breakup questioning whether this was the “right” relationship for her given the many differences in values and preferred life activities between the two of them.
Rod went to his therapist wailing, “All I want is a relationship, but with the long hours and travel of my job, it’s just not possible to have a relationship; I’m rarely in town”. Rod and the counsellor began working through ways in which Rod could get more time for things that truly mattered. He got clearer on work-life boundaries, managed to reduce the amount of travel, and made other changes. After some months, he quit the job which had demanded so much travelling and took up one which saw him work shorter hours, with little out-of-town travelling. He began to date women, but just when a woman and Rod were getting closer, Rod would back off, often breaking it off completely. After some months, he had an epiphany. Rod realised that he had set up his former lifestyle to shield himself from becoming too involved in a relationship. It was very telling when he related how, as a recreational skin diver (meaning someone diving beneath the surface of the water without SCUBA gear to breathe with), Rod could outlast anyone else in the diving club holding his breath underwater. “I learned to do that,” he said, “when growing up. My domineering mother would hug me so hard she would literally squeeze the air out of me. I would just hold my breath until she was finished”. Rod’s impulse toward — and then away from — relationship was a re-play of what he had to do earlier in life to survive.
Sometimes as therapists we must be vigilant about angst from the already-partnered, who contemplate returning to singlehood. They are typically in relationships in which criticism, contempt, and defensiveness manifest toxic patterns that undermine any possibility of relational harmony. This is true whether our clients are the ones on the receiving end or are perpetrating the 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 call the “Four Horseman of Relationship Apocalypse”. The phrase is a metaphor depicting the “end of times” in the New Testament of the Bible, describing conquest, war, hunger, and death. In the relational metaphor, it describes communication styles that, according to research, can predict the end of a relationship (Lisitsa, 2013) — or, we would say, the demise of any genuine possibility of right relating. So, what are the four “horsemen”?
Is the unhappy client frequently critical of the spouse/partner? Alternatively, is the client on the receiving end of a partner’s frequent criticism? We’re not talking here about the need to make a complaint about a specific issue. Rather, it is the perpetual running-down of the other person’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 and counter-criticism which opens the door for the other “horsemen” to come riding triumphantly through.
This, the second horseman, is seen when people treat their partners with disrespect, mocking them, ridiculing them, and/or using gestures and paralinguistic expressions such as eye rolling, scoffing, or mimicking. Contempt occurs when someone expresses long-held negative thoughts, attacking the partner from a position of supposed moral authority. Apart from research showing that individuals engaging it get more colds and flu than average (contempt apparently weakens the immune system of the perpetrator), it also is the single largest predictor of divorce (Lisitsa, 2013).
Defensiveness, the third horseman, plays out in relationships that are failing. It is usually a response to criticism in which the accused feels unjustly blamed, looks for excuses, and proclaims innocence in 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 taken seriously. Defensiveness escalates hostility and doesn’t allow for healthy conflict management.
When the first three horsemen have been running amok, trampling over the relationship, the natural response is to stonewall, which happens when the person on the receiving end of criticism or contempt feels overwhelmed and withdraws, shutting down and stopping responding to their partner. Stonewallers, feeling too “psychologically flooded” to confront the issues with their partner, tune out, turn away, act busy, or engage in obsessive, distracting behaviours. This behaviour can all too quickly become 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 I weren’t. I’m so unhappy.”
Some of the most intense relational grief occurs to those who are on the receiving end of a cheating partner. The hurt and sense of betrayal can be overwhelming, and the client may wonder: if the partner did it once, what would keep him or her from doing it again? It is a question worth asking, as the client contemplates what is of value in the situation, and whether to stay or go.
Which modalities help us to help clients move toward right relating?
While a solid therapeutic alliance provides one of the greatest relational supports, there are also some important tools at our disposal to accelerate the gaining of insight and healing that will reduce relationship angst. Let’s look briefly at what some of the major “families” of therapies can offer here.
One of the major benefits of psychodynamic therapies is that they can help clients gain deep insights into root causes of the problem. Admittedly, some of these modalities require intensive, long-term work, but much healing can come from confronting situations of early unmet needs, as clients come to understand the relational templates they formed before they could even speak in full sentences. Several modalities stand out here.
The aim of object relations therapy is to help a client uncover early mental images that contribute to present difficulties in the client’s relationships with others and adjust them in ways that will improve basic interpersonal functioning. Attachment theory, in particular, notes that if children are able to form a secure attachment to their caregiver, they are likely to use that healthy relational template to form workable relationships in their adult years. Sadly, the converse is true, and those who have come to form an avoidant, dismissive, or disorganised attachment — when caregivers have been cold, rejecting, or inconsistent — are likely to form relationships characterised by the woes we have identified above.
Acknowledging that human beings often have many unmet needs, this modality posits the existence of subpersonalities: 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 cannot be met. Mark, mentioned above, is likely to have a subpersonality whose world view is that it’s a tough world, one that cannot be survived without a powerful, guiding woman to advise him. Working with subpersonalities helps clients see how they can meet acknowledged needs in ways that serve the whole self rather than just the narrower needs of the particular subpersonality.
For a psychodynamic therapy which is time-limited (often between 12 and 16 sessions), IPT helps clients improve their interpersonal communications in order to improve both mood and relationships. Its theoretical foundations are a combination of attachment theory, communication, theory, and social theory. Clients with relational woes often elicit negative or unsupportive responses from others unintentionally. This occurs because those who have maladaptive attachment styles engage in specific communications which bring forth responses that do not meet their attachment needs effectively. When the poorly-attached person then reacts to the non-need-meeting response, it often escalates tensions, deepening the cycle and preventing those needs ever being met (Kiesler, 1979). Thus, this therapy can be effective for those with specific interpersonal issues.
Self-defeating cognitive and emotional patterns that begin early in a person’s development and repeat throughout life constitute the context for schema therapy, which is an integrative approach to treatment combining the best aspects of cognitive-behavioural, attachment, Gestalt, object relations, interpersonal, and psychoanalytic therapies into one unified model. Thus it would seek to identify clients’ dysfunctional, pervasive themes or patterns in relationships developed during childhood and elaborated throughout their life. The memories, emotions, cognitions, and bodily sensations that clients report give clues as to which of five main domains have been impacted, and are therefore playing out in the client’s relationships. Schema healing involves diminishing the intensity of all of these to the point that they no longer impair the client. The interventions are cognitive, affective, and behavioural. Thus, a client like Mark, whose issues arise in the domain of independence/autonomy, would learn to feel more comfortable relying on his own resources when making decisions and organising life.
Post-modern: Narrative and solution-focused
In these modalities where reality is seen to be socially constructed and maintained through stories, we can see a way to help clients re-imagine their relationships through re-storying (narrative) and finding unique solutions based on a fresh assessment of available resources (solution-focused). Narrative’s search for “sparkling moments” and the quest of solution-focused therapy to know what was happening when the problem wasn’t as much of a problem speak to a process of refocusing. Clients in 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 to see that, indeed, they functioned very well autonomously, without a more powerful other directing them.
Person-centred and positive psychology
Rogers’ person-centred therapy emphasises the self-actualising tendency in human beings and the need for therapy to help clients overcome conditions of worth, a state of incongruence in which clients believe that they are only worthwhile and lovable if they think, feel, and act in ways that meet the needs of others. This would seem to be a fairly spot-on description of either the client who stays in an unhealthy relationship because they must be in a relationship — any relationship — at all costs, or alternatively, the client who perpetrates the unhappiness of criticism, contempt, or defensiveness because that is all they know.
This modality’s notion of an abundant universe and its focus on a person’s strengths and virtues can help those longing for love move forward with the confidence that there is enough love to go 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 of happiness (for Positive emotions, Engagement, Relationship, Meaning, and Achievement) underscores the importance of helping clients to refocus onto that which is positive in their lives, engaging in activities that have meaning for them and could lead to a meaningful achievement, whether or not the area of primary relationship is happening as they wish.
Humanistic, person-centred, positive psychologies can also help clients — or client couples — who have created toxic relationships with any of the “four horsemen” of relational apocalypse.
Therapies such as REBT, CBT, and ACT have a useful role to play for the forlorn in love, in that unhappy relationships — or an unhealthy longing for one — almost always involve some elements of irrational, limiting thinking. Thus the role of the therapist may be to help ferret out the “shoulds” and other cognitive distortions which make clients so unhappy. ACT helps clients to distinguish between that which is out of one’s control and thus must be accepted, and that which may be amenable to change if the client acts.
Relational challenges, especially those of primary relationships, are rife in modern life and often revolve around intense desire to be partnered, intense ambiguity about coming into relationship, or equally intense dissatisfaction with the dynamics of an existing relationship. While a robust therapeutic relationship can offer both support and a model for how high-calibre relating can occur, as therapists we also have numerous therapies at our disposal to help reduce relational woes while helping put the client on a more stable road of right-relating.
- 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