I'm Back in the Game but I Forgot How to Play
"I'm Back in the Game, but I Forgot How to Play"
 
Case 1: Bob and Alec are seeking couples counseling. They have been dating for two years and moved in together six months ago. Since then, they argue frequently, seldom have sex, and both describe the other as "very different from when we were dating." Both wonder if the other is monogamous, and fear that this relationship will end like their last relationship.
Case 2: Robert has been in a relationship for two years. His partner says the relationship feels "dead" and that it is hard to get close to Robert. He is considering leaving Robert. Robert was left by his last partner of four years for similar reasons and has come for individual therapy to "keep this relationship from ending like the last."


These two examples are fairly common in private practice, whether you see individuals or couples. More and more, we see many gay and lesbian couples in which both have had one or more longer-term relationships (2-4 years) which ended, and now are in another relationship. As the therapist, there are of variety of issues that you may see.
 
Body Image: "You have to look good to find them, and look good to keep them." This could indicate a relationship based more on appearances than emotional connection, and fears of abandonment or rejection could lie underneath

Anniversaries: A new relationship reaches the same point at which the old one had problems, and partners feel pressured. Money issues, living together, and vacations can stir this, especially when one still has financial dealings with the ex

Coming-Out: One struggles with coming-out to family, friends, and co-workers (like with rings, or terms like my husband), and the more-open one is unsure how to respond, especially if the couple dates at the office

Sexual Activity: New relationships may raise new issues about kinds of sex and safe sex which didn't come up before. One partner may be more sure of what he likes, want an open relationship, or be HIV+ while the other is not

Previous Issues: One may struggle with old issues of career, family, or personality ("You mean it wasn't all his fault?"). Previous pathology, such as alcohol or drug use ("It was a lot of fun while we dated, but not any more") shows up, or reflection on past dysfunction leads to realizations about sexual abuse

Been there, Done That: Sometimes a couple feels they "know" how serious relationships work, and move too quickly. Others are "paranoid" and protect themselves against vulnerability after being "burned" by a past partner


So what does a therapist do?
 
Family of Origin Work: Classic Bowenian work like constructing genograms with discussion over relationships, patterns of intimacy and distance, money management, dysfunctional messages... For gay/lesbian couples especially, when it comes to defining our relationships, we have a lot of freedom but a lot of extra work

Insight Oriented Work: Focus on patterns of relationships, feelings stirred, and how the client handled them, and basic validation and reflection of feelings mixed with educational work to understand their value and how a partner can respond

Behavioral Work: Get the individual or couple to "get out and do something" like develop new patterns of communication, skills at money management, dating and hobbies... Or work on "5 Mistakes I Made in my Last Relationship" and ways to avoid them now

Refer: This one is sometimes harder, but know when to refer for medications, couples or individual work, even some psych testing

Consult: Talk to colleagues and gather more information, both to improve your work and keep your own issues out of it


What do you not do?
 
Cross Modalities: Don't provide couples therapy unless you are knowledgeable about it; likewise, don't start couples therapy after having seen one individual

Cross Boundaries: Stay neutral, don't empathize more with one partner, consult with one individual therapist, define "the problem" in individual terms, or "keep secrets"

Think You Know: Always remember, the couple or client never tells you the whole story. No matter how much you build a strong therapeutic bond, you are still an outsider