Situations that trigger a call for assistance with couples counseling are generally described as a need for improved communication, chronic conflict, lack of physical or emotional intimacy, or a desire to better understand the impacts of past trauma. Therapeutic work can evolve into tackling more specific long-standing disappointments in emotional and physical intimacy. Disconnection is often exacerbated incrementally by increased responsibility with children, aging parents, and cultural differences, among other things. Learning how to disagree effectively, understanding emotional boundaries, and refocusing on prioritizing the relationship are some of the works engaged toward rediscovering and deepening intimacy. An ability and willingness to hear one’s partner is a crucial skill often embroiled in a worldview that must first be understood and then explored.

There are prescriptive approaches where the therapist tells you what to do after an initial assessment. There are highly focused approaches really digging into an aspect of your relationship. There are discernment counselors specifically engaged in helping a couple decide if there is room for repair versus deciding to divorce. Additionally, eye movement desensitization and reprocessing (EMDR) have been accommodated to address couples counseling, particularly where there is trauma. There are therapists who take a holistic view of the relationship and serve as a guide in helping you to better understand each other and your points of conflict while also focusing on relationship skills. Some popular or well-known approaches include Gottman therapy and emotionally focused therapy (EFT) for couples. The former is a proactive prescriptive approach; the latter incorporates an aspect of psychodynamic therapy seeking to focus couples on their emotional patterns.

A psychodynamic approach looks comprehensively at what is happening and begins the work of deducing where misunderstanding consistently arises. This is partly captured in EFT’s concept of the maladaptive cycle in which our pattern-recognizing brain favors internal subjective assessment over external objective reality. But while EFT stays focused on emotion, a psychodynamic approach seeks to understand the origins of the misunderstanding, including the historical meaning held in those feelings. This is rooted in the development of our central nervous system within the first few years of life and depends largely on our primary caregivers, be they mother, father, uncle, grandparent, or other interested party. From them, we learn what feelings are because we are not born knowing this. We learn to understand first the visceral signals of frustration and anger, then more nuanced wistfulness, longing, anguish, peace, tranquility, and joy. We learn whether those we love tend towards trustworthiness and whether we are inherently lovable. We are tender and so vulnerable in our babyhood without the ability to recall specific events or interactions. And we carry these internal beliefs forged in preverbal experience applying them indiscriminately as the unwritten rules of relationship. The tricky thing is that we are often not consciously aware of our own rules; it is like the air we breathe, which we rarely have occasion to mindfully consider. Referred to as our attachment system, this acts like a reflex arc. And so, when our pattern-recognizing limbic brain is activated by a perceived threat or challenge, underlying rules of engagement are launched. This can leave our partners stunned and bewildered because they are not privy to the same set of rules. This looks like feeling righteous fury or indignation with no understanding of our partner’s dismayed confusion. It is challenging halting in the middle of this to parse out what is actually happening. For one thing, anger wants out, and both parties want validation in their often diametrically opposed positions. How do such disparities arise?

We become attached to our initial caregivers, a biological imperative necessary for our survival. Whether we generally trust people or not, rely on others for help, caring, and empathy or not is largely determined by this early relationship. When we cried in hunger as an infant, did our caregivers show up to comfort us most of the time, or were we consistently ignored? The outcome of these interactions repeated over time in a developing brain forges an attachment that is described as secure or insecure. And if insecure it is further delineated as anxious, avoidant, or disorganized. We recognize in couples therapy what role attachment styles play in drawing individuals closer to each other or driving them further apart. Some goals include recognizing this, digging deeper into the associated feelings, and then exploring how feelings can be leveraged for connection rather than disappointment and hostility.

A psychodynamic approach teases out and examines these implicit expectations. Cognitive insight understands intellectually what is happening first. For example, when one partner asks why the dogs are in the yard, the other partner’s brain might interpret an entirely different message (my father is yelling at me for not walking the dog) based on early repeated interactions and feel sudden overwhelming shame. Though it is actually an innocent question, the brain interprets far more than what is being communicated, responding to its own nuanced layers of underlying meaning. This is usually emotionally charged based on earlier experience, so when Dad yelled about the dog, it was not a gentle corrective experience and was perhaps laced with diminishment or derision. Emotional insight develops in experiencing those charged moments differently after developing the skills to recognize when it’s happening. This occurs both in the therapy room and between sessions in real-time with your partner; it must be emotionally felt to transform expectations. That is precisely why arguing in the therapy room can be so helpful. It is one thing to understand that an expectation of disappointment or feelings of shame is stirred in stereotypical moments. It is another to begin to feel differently when such moments arise. This is when the brain begins to really sense that the person in front of you does not, in fact, follow patterns learned early. This is the emotional undertow that ultimately transforms into a smoother current. This is the artful blending of family-of-origin dynamics into an entirely new relationship or system between partners, often an experience of tremendous intimacy as it evolves. Attachment styles and implicitly determined expectations are not static. Because the brain is always evaluating and changing in the face of input, expectations are dynamic, and we take advantage of that in a therapeutic relationship, both for individuals and for couples. Because this is an experiential process, it typically involves moments of intense emotion. While contemporary experience with feelings impacts our implicit expectations over time, it isn’t the same as the brain in a pre-verbal developmental state. This is a unique period in which information is soaked in like a sponge with no ability to discern. This is what can make conflict in intimate relationships so confusing and is also the nadir for growth and change.

There are additional challenges related to intimate relationships. Navigating the impact of addictions, for example, or the impacts of ADHD in one or both partners, a discovered infidelity, all can tear relationships apart. But this is not inevitable. All these things can be overcome if each partner is committed to the relationship. Lastly, unanticipated life circumstances can derail even the strongest of intimate bonds. Sometimes unexpected pregnancy, pregnancy loss, a sick child, illness, or death in the family can tear at the foundation of a close partnership. Couples therapy prioritizes one of our most important and durable bonds. Whether it is identifying salvageability or strengthening intimacy among the committed, counseling can help to mitigate and change ongoing destructive patterns. Learning relational skills and a deeper understanding of and connection with one’s partner can be a gratifying investment in personal growth. Sometimes this work can alleviate conflict headed for divorce. If not, there are resources for navigating divorce effectively to protect a co-parenting relationship.

Maire Daugharty is an anesthesiologist who expanded her expertise by earning a master’s degree in clinical mental health counseling, merging her long-standing interest in mental health with her medical background. As a licensed professional counselor, licensed addiction counselor, and licensed marriage and family therapist, she brings a well-rounded perspective to her private practice, where she works with adult individuals and couples on a wide range of concerns. In addition to her counseling practice, she continues to work part-time as an anesthesiologist and has a deep understanding of the unique challenges faced by clinicians in today’s medical landscape. To learn more about her practice, visit Physician Vitality Services.