As a psychosexual therapist, I have had to work on my own sexual issues in the knowledge that the degree of comfort I have in facing myself and my own sexuality will adjudicate the limits of the therapeutic support I can extend to my clients. Like most bought up in a culture of secrecy and shame, it is easy to allow my own discomfort to impact this most delicate of territories. I have worked to understand my own familial culture as I developed through childhood, along with my own experiences. I have thankfully found a place whereby I believe I can offer my clients a place whereby they can confront the truth of who they are and the challenges they are facing.

There are so many things that bring an individual or couple to therapy with sex often being one, but rarely immediately voiced. Over the years, I have learnt the importance of creating a space whereby my clients can address sexual issues, supporting them to find the language to say what has never been said or to put into words the secrecy-ridden issues that have been hidden away, shrouded in anxiety and shame. As clients are continually picking up cues of safety and non safety I find it useful to mention sex in our initial assessment meeting. This is amongst all sorts of other questions and normalises a topic that so many therapists don’t address. This sets the tone for my clients to know that sex is something they can discuss as and when they feel ready.

There can be little doubt that the shape of human sexuality and its behavioural expressions are many and varied. Few of us grew up in an environment where sex and sexuality was openly talked about. With no one to ask our questions to or allay our fears, many relied on the internet and or porn, which in itself often fuelled additional feelings of anxiety and inadequacy. Whether it be loss of desire, lack of confidence, inexperience, boredom or any of the many psychosexual issues, many of my clients have used therapy as a starting point in learning how to talk about sex and confront what, for some, has been hidden for many years.

There is not a one size fits all approach when working with clients around sexual issues. For me, I consider it essential to assess for levels of comfort or discomfort and at all times, be led by my clients. I remind myself of my own embarrassment when starting out on my psychosexual training and treat my clients with respect, offering them a “parental” acceptance as a sexual being. Always mindful of the existence of sexual anxiety I start with using my clients language as a way to be guided by them, respecting their sexual vulnerabilities and finding a common language from which our work can begin. Many clients find it difficult to come straight to the point. They fear making a fool of themselves, using the wrong words or causing offence by being too explicit. By being empathetic to the struggle, they can share their concerns and, with time, replace any shame and anxieties with acceptance and an understanding of themselves that hopefully offers them a way forward that will offer a more satisfying intimate life.

Sexual attitudes and taboos are powerfully shaped by the predominant culture, along with the expectations of what is seen to be ‘appropriate’ sexual behaviour. This cannot but impact how we behave sexually and what our expectations of ourselves and others are. Therapy is a place where we can acknowledge the full range and intricacies of human sexual expression and its motivations, whilst allowing us to focus on specific parts of it without losing sight of the whole. Sexual problems present in a multitude of ways, many indirect, locked away and hidden under a cover of shame and discomfort. Many clients come to me with no understanding of what is ‘wrong’ but with the knowledge and or sense that something is. It is hard to help ourselves if we do not understand the cause of our sexual problems.

What often strikes me is how clients see issues as separate from the whole. One of the first things we work through is to understand that sex, intimacy, compassion, passion, love and partnership all work together in harmony. It is often the case that when one of these factors is not present, or under strain, that is when sexual problems arise. One of the tasks of therapy is to support individuals and couples to move their sexual expression and thoughts about the sexual experience from non verbal to verbal. So many people live with unspoken thoughts, concerns, frustrations and disappointments that cause distance and conflict. Therapy offers a place to practice conversations for those that come alone and somewhere were couples can start fo respectfully share their truth, working towards creating a new, and mutually satisfactory, way of relating sexually.

Living in a culture whereby sex is cloaked in secrecy and consequential silence, we need to consider some of the myths and messages that people carry that prevent them from discussing their sexual domain. There is so much fear, along with thoughts: “Sex is private.” “It’s embarrassing.” “I don’t want her to leave me.” “I don’t know what to say.” I see my role is to normalise discussing sex as well as to educate those who have no real understanding of sexual anatomy and physiology.

I am not someone that often uses diagrams, but one that I use often is the diagram of the sexual arousal circuit. One of the benefits of this is that it shows clearly that sexual problems are usually in response to something that is not solely located in the genitals. Sexual response can be described as an electrical circuit that can start from body, emotion or mind, but that also has three break points in each area. By working through this model, it allows clients to understand the possible roots of their problem, and gives us something to focus on.

The first break point occurs when there is inappropriate stimulation or pain. Understandably pain often cancels out any possibility of response and causes people to start to dread, put off and resist sexual contact as they begin to associate it with pain. There are many reasons for pain which can be discussed once bought out into the open. The same goes for inappropriate touch. There is so often an assumption that our partner will know what will bring us pleasure and with that a lot of pressure for the partner to do so. One of the things that I often ask my clients is whether they actually know what pleases them, whether they know their bodies, what turns them on, how they like to be touched. So often the answer is ‘no’ with the expectation that somehow arousal will happen. This is where psycho education plays a part.

The second break point occurs when the mind is pre-occupied with other things. When sex fails, it is often as a result of the state of our relationship rather than touch. When there is much unspoken between a couple, it creates a disconnect that makes sexual connection challenging. Our frame of mind, attitudes towards our self and our partner as well as many other things influence how much we want sex, how aroused we get and how much we enjoy it. Outside influences such as work, financial worries, young children and other internal/external stressors all impact our ability to relax and become aroused.

The third break point is often caused by “spectatoring”. As examples, men worried about erectile dysfunction, premature ejaculation. Women concerned about what their body looks like in certain positions, whether they are taking too long to orgasm. There are so many differing thoughts, belief systems, messages and myths about sex and sexual performance that take the mind away rather than focussing on connection and pleasure. Through exploration clients can start to reframe and challenge some of the myths and anxieties, as well as any negative past experiences that they have they have been bringing to their sexual relationships.

It is surprising how many people will say that they fall into one or even all of these categories. It is a useful model to work from, giving me and my client(s) a concrete platform from which to explore the details of sexual behaviour that so often reflect the meanings, beliefs, perceptions and values that shape them and impact their sexual relationships. I am aware that each detail is intimate and by working collaboratively, we create a platform from which they can be kinder, more honest and realistic to themselves and their sexual partner.

Because sex is so often veiled in secrecy many people are often quietly wondering whether they are okay. With the fantasy model of sex holding up standards that are for the most part unattainable, many of my clients questions whether their sex life is ‘normal’ and have a deep fear that by sharing their thoughts and concerns they will be seen as abnormal, strange or weird. Therapy offers a safe haven where clients can put their anxieties to one side and feed themselves with the understanding that there is an incredible range of sexual thoughts, feelings, fantasies and problems. By taking time to explore themselves, their fears, anxieties and struggles they can move forwards in their lives with hope in the knowledge that they had the courage to go where many fear to go.

Trust is complicated and very difficult to define. It is fundamental to life as without it we live internally isolated and fearful. The parent-child relationship is our first social relationship that teaches us that we can communicate in order to get our needs met as part of our human impulse for survival. When as a baby, we can count on our primary caregiver and trust them to meet our most basic needs for love, food, affection and stimulation we feel secure. As a result, our attachment to our caregiver goes from strength to strength, and we learn to trust not only that person but the world around us. As Winnicott keenly observed, infants cannot exist alone. ‘Sow a thought and you may reap an act; sow an act and you reap a habit; sow a habit and you reap a personality, sow a personality and you reap a destiny.’ ( Holmes 1993 : 210).

John Bowlby formulated the basic principle of attachment theory whilst working as a psychiatrist at the Tavistock Institute. This experience led Bowlby to consider the importance of the child’s relationship with their primary caregiver in terms of their social, emotional and cognitive development. He transformed the thinking about a child’s tie to their primary caregiver and its disruption through separation, deprivation and grief, and led Bowlby to formulate his attachment theory.

Attempting to understand the intense distress experienced by infants who had been separated from their parents, Bowlby witnessed that separated infants would go to extraordinary lengths to either prevent separation from their primary caregiver or to re-establish proximity. Bowlby used the term ‘attachment’ to describe the emotional bond that develops between an infant and their primary caregiver and suggested that to feel attached is to feel safe and secure. He believed that the quality of the attachment evolves over some time as the infant interacts with their caregiver and is partly determined not only by this prime interaction but the past attachment experience of the caregiver herself and the consequent parental behaviours created as a result of that experience.

Mary Ainsworth, first a student and later a colleague of John Bowlby, conducted research based on Bowlby’s theory and herself devised an experimental procedure called the Strange Situation Test. She used this to measure secure and insecure emotional attachments between toddlers and their primary caregiver, which is still used today to assess attachment styles in children. Based on the responses observed by the researchers, Ainsworth described three major styles of attachment: secure attachment, ambivalent-insecure attachment, and avoidant-insecure attachment. Later a fourth attachment style was added called disorganised-insecure attachment, which was based on the research of Main and Solomon.

The human attachment system takes several months to develop. In the first few weeks and months of a child’s life, the caregiver must be at the child’s disposal to fulfil all their needs. If this happens, a healthy sense of self, along with trust in themselves and others, can gradually develop. Over time, the child starts to construct beliefs about the self and others based on its associated experience. As time goes by, children naturally form expectations about the availability and receptivity of their caregivers.

Bowlby theorised about the implication of the infant-caregiver bonding, suggesting that it shapes the quality of our relationships with both ourselves and others throughout our lifespan. He believed that over time these interactions generate internal working models of ourselves and others that influence how we behave and our view of relationships. If we experience consistent and robust support from our caregivers who model to us that the world is safe to explore, we develop a secure sense of self. In addition to starting to understand that we are worthy of love and attention, we learn to combine trust in others with trust in ourselves.

Conversely, if we grow up believing that the world is unsafe, filled with people who cannot be trusted; if we experience loss or separation, or threats of those, this erodes our trust in ourselves and others. As a result, we develop an insecure attachment, often seeing ourselves as worthless and unworthy of love. From this place, it is hard, and sometimes impossible to trust, whether it be ourselves or others causing difficulties in relationships; creating distance between people who might otherwise be close. As a result, we can develop a loss of confidence, anxiety, depression as well as the fear of commitment or resolute independence, all a result of the firmly held belief that people are ultimately untrustworthy.

I believe that the majority of parents hope to provide their children with a secure attachment. What we need to consider is that things happen, which are out of our control. These have the potential to impact our children’s attachment pattern, in the same way as perhaps our parents challenges affected ours. Relationships break down; death occurs, addiction, tragedy, unexpected traumas and stresses that cannot but affect how our caregivers manage to continue with their lives as well as being the best they can be for their children. Thankfully, attachment styles are not fixed.

Although our childhoods are an intense compacted moment of our development, that can have a disproportionate impact on our life; hope lies in the fact that life itself is a process whereby we continuously change and grow. Much of my personal journey towards being a ‘good enough’ therapist has meant looking at my own issues. In therapy and supervision, I have had to consider my own ability to care for and function as a secure base for my clients. Without understanding my own defensive patterns relating to attachment and any resulting unresolved issues, I would not be able to foster secure attachments in my clients who present to therapy with attachment issues. There are many benefits to this both personally and professionally. One of the advantages is my belief that, whilst problems in early years can create unstable attachments, adult attachments can be changed. Through the process of therapy and or through a secondary attachment relationship, we can re-work our internal working models offering us a more connected way of living.

Considering that research on adult attachment recognises that interpersonal functioning has an impact on the quality of relationships formed between therapist and client, I am mindful of what attachment styles my clients have. I see my role as not dissimilar to that of the responsive mother who provides her child with a secure base from which they can explore the world, as the conditions under which an infant develops a secure attachment are not unlike those conditions for effective therapy. Bowlby’s view was that the therapist would be seen as an attachment figure whether the client is aware of it or not. From the therapists perspective, it feels essential to hold this thought.

One of the significant components of therapy is building a strong therapeutic alliance, with trust being an essential part of the foundation. Trust takes time, and understandably many clients who come to therapy will not automatically trust me. Many have had experiences whereby their trust has been broken, and I am well aware that trust needs to be earned. Trust is not black and white, either you do, or you don’t. Some people can trust more easily than others and are, in fact, better at being trustworthy and judging trustworthiness. For some of my clients, they are trusting in some situations and not in others, for others, they start with zero trust. For some clients, an essential part of beginning to trust is recognising sessions ending does not mean that they are being abandoned. An often new and comforting realisation that they can experience being attached and then apart without feeling anger, fear or need.

I aim to offer a therapeutic relationship that teaches my clients what life is like when there is someone there for them, not just in our sessions, but out in the world on whom they can rely. Someone that respects their boundaries and who is a nurturing, empathetic and continuing figure who they can understand and trust as such. From this base, they can explore the way that they regulate themselves in relation to others and can then attempt to reshape old emotional habits, introducing new ones. Guntrip (1975) has well described the therapist’s job: ‘It is, as I see it, the provision of a reliable and understanding human relationship of a kind that makes contact with the deeply repressed traumatised child in a way that enables (the patient) to become steadily more able to live, in the security of a new real relationship, with the traumatic legacy of the earliest formative years, as it seeps through, or erupts into consciousness.’ (Bowlby 2005 : 182)

Trust is a lifeline for any person insecurely and anxiously attached, thus living with the unseen scars that impact their ability to form and maintain healthy relationships. Watching someone tentatively start to put down the roots of trust based on our relationship never ceases to humble and inspire me. Many have to work hard to move through the internalised beliefs that say it is “bad” to trust. Others who have suppressed their feelings of dependency for many years, have to move through feelings of intense shame as they start to re-emerge. What I remind my clients is that there is no rush. We are interdependent, and hopefully, a time might come whereby having learnt to trust in therapy they might be willing to risk trusting others. With courage and willing determination, clients can find a place in therapy to tell their stories and face their individual darkness. Emerging with a new and kinder perspective on the value of relationships, they can start to trust in themselves as well as an other and gain enough of a secure base from which they can throw such a lifeline to others.

Holmes. J. 1993, John Bowly And Attachment Theory. Routledge: London

Bowlby. J. 2005, The Making and Breaking of Affectional Bonds. Routledge: Oxon

For many people, their relationship with their body is the cause of much unhappiness. Is it any wonder when we live in a society that steadily and unfairly suggests we should be changing it in one way or another? Chronic body dissatisfaction is an epidemic with negative body image issues impacting both men and women who believe that there is something ‘wrong’ with their bodies. There are four aspects of body image: Perceptual, affective, cognitive and behavioural. How we see ourselves, the way we feel about the way we look, the thoughts and beliefs, we feel about our body and the things we do in relation to the way we look.

I have worked with many clients who despite varying forms of camouflage, feel intense dismay with their physical appearance. To a greater or lesser extent, they are fixated on what they do not like about their body with the sincere desire to alter or hide it. They feel acutely self-conscious and ashamed comparing themselves to others along with the standards that have been shaped by rampant social and cultural ideals. As a consequence, they live with eating disorders, various forms of self-harm, isolation and mental illnesses all driven by the lottery we have all been made to play without ever being asked. For most of us, there is a relatively good correlation between what we think we look like and how we appear to other people, but for others, it is as if there are two different people – the one we see and the one they see when they look in the mirror.

For some people, their appearance becomes the single most crucial aspect in defining them as individuals, and they hold attitudes such as ‘I am my nose’. For my client who was fixated on his nose, his whole life was impacted by how he saw and imagined others saw his nose. From my perspective, there was not anything out of the ordinary about his nose, and yet it prevented him from entering into relationships, making friendships or doing many other things. Each day he battled the crippling shame of his physical appearance that deprived him of achieving his deepest longing – to have an intimate relationship and family.

When feelings of being self-conscious or ashamed become out of control, it often leads to body dysmorphic disorder. This does not mean being vain or self-obsessed. It is a profoundly distressing and life-limiting experience whereby we cannot stop thinking about one or more defects or flaws in our appearance that often cannot be seen by others. We become so obsessive in our belief that some aspect of our body or appearance is seriously flawed that we go exceptional measures to hide or fix it. Clients of mine are so embarrassed, ashamed and anxious about their physical appearance that they find themselves avoiding social situations, friendships and intimate relationships with the impact being devastating to their lives. For some looking in the mirror is so traumatic that their only option is to cover any mirrors that are in their home.

We are not born hating our bodies, and yet we live in a culture that teaches us to do so. Society sends us messages about how we are supposed to look, and as a result, we attach our worth to the size of our body and physical appearance. Young children with access to the internet and social media live in a culture in which peers and the media broadcast the thin and beautiful ideal in a way that negatively impacts how they view their developing bodies and as a result their self-assurance. Suddenly their childlike inhibition is replaced by a cycle of self-shaming thoughts and behaviours. They become preoccupied with comparing themselves to others. Once thoughts have been held long enough and repeated enough times, they become beliefs, eventually, the beliefs become biology. By trying to change themselves to be like others, it starts them on the path of dishonouring their authentic self, allowing how they feel about their bodies to influence how freely they can inhabit it.

Many parents are not aware of how their low self-esteem can be passed on to their children. With the hatred of our bodies profoundly, negative messages about them are passed on unconsciously from generation to generation. Many of us were bought up with caregivers who made negative comments about their bodies. Consequently, in addition to societal messages, what we witness at home dramatically shapes how we see ourselves. We see food being restricted, excessive exercise and endless adverse messages that make us start to examine our own bodies in mostly negative ways. As a result, the attitude that our bodies are in some ways ‘wrong’ gets internalised, often at a very young age, and sets the stage for our future relationship with our body. We unconsciously start our journey of self-loathing as we stare at ourselves in the mirror as part of an ingrained ritual of self-hatred. As we undress for bed, we look in the mirror and zoom in on parts of our body that we dislike the most – the parts we want to change and wish were different, and the descent into self-loathing and shame continues. For some, their friendships are bonded over their shared body dissatisfaction sharing diet tips, and details of surgeons that they hope will ‘fix’ their body, and then their living can begin.

The constant repetition of negative thoughts about our appearance infiltrates how we act and behave. By the time some of my clients come to see me, they are living with the consequences of a life based on how they think they look. For others, they come as a result of an accident or illness that has changed their body image suddenly. I am reminded of a young man who contacted me by telephone as he did not want me to see him as he told me that he had been diagnosed with testicular cancer while at school. He had been too embarrassed to say anything about the changes that were taking place in his body that by the time he went to the doctor, he had to have one of his testis removed. He was so deeply ashamed that it was preventing him from entering into any form of intimate relationship for fear that it would be noticed. Whether the change is permanent or temporary, the impact of an illness or accident will be different on everybody. It can affect all aspects of their lives, including sexuality and intimacy. Body image changes as we get older and in a society that seems to revere the young that can be very difficult for clients who somehow feel unattractive and invisible due to the natural process ageing. Whichever category clients fall into, body changes can be very disconcerting. It can take a fair amount of time before they ‘see themselves’ once more when they look in the mirror. Supporting my clients through both physical and psychological changes such as fear, anger, hopelessness, and sadness is a way of normalising their concerns, thus reducing shame and stigma.

That we have the potential to modify our destructive and unconscious patterns is a truth I see proven in my practice often. Change is possible and self-love should be too, and yet it is not as easy as it sounds. It requires great courage and self-belief not to get swept up in ways of being that unless consciously fought against seem to infiltrate our psyche without us even noticing. A first step towards making a positive change in our lives is to acknowledge that we are co-operating daily with a system that is making us deeply unhappy. Much like someone living in an abusive relationship who finally leaves because one day they realise that if they stay their life will never improve, each of us must recognise when and where we are co-operating with our own persecution.

I have done all sorts of work with clients on their body issues. Depending on what they are coming with, I have used drawing as one way for them to compare how they see their body in relation to how I do. So often being visually confronted by the difference in perception of body shape and size is enlightening. One client spoke of ‘one of the most memorable exercises we did was you getting me to draw how I saw my body. When we went through the drawing together, I could see that it was not a real representation of how I looked. I had drawn myself as if I was an alien being, and it was a profound moment, recognising that the image that I was looking at on paper was the image I had in my head and yet not the reality at all.’

Chair work is always a useful way of exposing our critical inner voice and the messages we give ourselves about our appearance. It can also help us make connections to where this voice may originally have come from. Like the client who always wore shoes that were too small from him remembering the voice of his mother who bought him ill-fitting shoes so that he did not have ‘monstrous feet.’ Another client remembered ‘you speaking about us all having both positive and negative voices in our heads, and it had never occurred to me. You spoke about how the negative voices will probably remain as part of us, but we have a choice as to whether we continue to feed the negative or feed the positive. I saw how out of balance the voices I had in my head were and have since made a conscious effort to be mindful of when I am being negative towards myself and balance it with the positive. My positive voice makes me feel so comforted that I can manage the moments where I find myself inadvertently being critical of my body. I carry you with me every day hearing your voice telling me to be kind to myself.’

With other clients, they have asked me to take photographs of them so that they can see what they look like at different angles and in different moments as they have lost sight of what they really look like. I have worked with women who have felt so ashamed of their bodies that they have attempted to cover them up in varying ways. The look of pride on the face of a client I had been working with for several years, when she turned up in a dress. Prior to that she had lived in fear of other people’s judgements and comments about her ‘too thin’ body. As a way of protecting herself, she used to wear extra layers of clothing, always with a coat, ‘to make myself look bigger’ no matter how hot it was outside. The first time a client who thought her ‘legs were too thin and hairy’ wore a skirt moving through the belief that people would notice and be ‘repulsed’ by her. The tender moments where I have stood with a client as they have revealed a part of themselves that has been left disfigured through illness or surgery or birth disfigurement. Standing firm in awe and tenderness as they moved through the fear of exposing their vulnerability and shame.

Being wholly and genuinely human means standing securely in the knowledge that our physical appearance is only a part of who we are. In accepting that we are imperfect, we can turn our attention to shining warmth and kindness into our dark tender place of self doubt, replacing it with appreciation, acceptance and love.

This thing that we call grief that connects us all is one of the most talked about topics in my therapy room. Grief can refer to any form of loss as a person may grieve the loss of a loved one, a limb, a home, a sense of self and much else. ‘We are all in grief. All have experienced loss. Even if your loved ones are still alive, there is a place within of disappointment and loss because we live in a world where everything changes’ (Levine: 97).

For this piece, I am going to use the word grief to indicate the experience of losing a loved one to death. Something that all of us as human beings will face at some stage in our lives and, as a result, something that unites us all. It is useful to bear in mind that there are many types of death: accidental death, suicide and violent death, to name a few. There are also many different stages of life at which people die, as well as experience the grief of death. Different kinds of relationships, backgrounds, original attachment patterns and divergent circumstances inevitably shape and influence the meaning of each loss, and all these ramifications present endless implications to me as a therapist. 

People have been grieving for thousands of years – long before the advent of health professionals. It is a natural process, and yet the empirical reality is that many people seek help with their grieving process in the form of therapy and bereavement support. This may be in part because of the increasing secularisation of our age and consequently, the general loss of shared ritual and periods of collective mourning. For example, the Shiva house of the Jews, the Irish wake and the Hindu Sredu, are important but are declining publicly sanctioned opportunities for the grieving and their wider community to come together. So whereas previously, people would have been consoled by a collective belief in God and an afterlife, looking first to priests and religious institutions for comfort in their grief, now, perhaps because so many no longer adhere to such formal religious beliefs, they are more included to turn to their family doctor or therapy.

In addition, the excessive mobility and increasing speed of our modern society further lends itself to this change of focus. In the past, extended families and communities were in closer proximity than today and neighbourhoods provided cohesive support systems in which people were more available to help each other cope with loss. It seems that in contemporary Britain, there is an almost complete absence of any established ritual and guidance around death and bereavement. In a mass society that appears to prioritise consumerism, youth and technology, engagement with death is often avoided perhaps because it implies a failure to heal, cure or solve.

In modern Western society a more restrained attitude and the subduing of the natural expressive sounds of grief such as wailing and keening contrasts strongly with African and Arabic nations which embrace public displays of grief and allow their emotions to be visible and heard, helping the mourner to express themselves within a shared, public space. In addition, many spiritual traditions recognise a particular time period, such as a certain number of weeks as a timeline for bereavement, thus acknowledging, allowing and respecting the need to mourn. All this seems to be lacking in our culture where, mostly, mourners do not manifest their pain outwardly or even follow a specific dress code. Instead, the bereaved are expected to work through it themselves, as if mourning were solely a private process.

Regardless of our personal views on grief, what is clear is that mourning often involves a culturally appropriate process to help people cope with their grief. While many cultures mourn differently, the process usually serves a common purpose: acknowledging and accepting death, saying goodbye, grieving for a specific time period and some means of continuing to honour the deceased. Ultimately the mourners are encouraged to move through their loss and form new attachments. ‘Grief is really a social process and is best dealt with in a social setting in which people can support and reinforce each other in their reactions to their loss’ (Worden: 87). Bearing this in mind I question whether we in the Western World are partly responsible for creating the need for bereavement counselling as what appears to be a natural community support in other cultures seems very different here.

Grief reactions can have physical, emotional, cognitive, behavioural, sexual and spiritual components, varying in length and disruptiveness. ‘Grief, writes Parkes, ‘is a process and not a state’ (1998: 7). For some people, their attitude to death, funerals and the immediate aftermath seems to be a social embarrassment, almost as if death is a taboo subject. For others, it seems as if they believe that there is a time limit for grief, after which it should simply be ‘got over.’ This makes it difficult for the clients of mine who struggle to ‘fill the void’ that people talk about after someone’s death. For them, they feel rushed and well as ashamed to be ‘still grieving’ and concerned that they will ‘never stop grieving’ and the judgements they will face from others. The language of ‘closure’ is often used, implying that there is an end point to which we need to get to. It also assumes that people want closure, that there is a ‘right’ way of getting there and that people even understand what it means.

You cannot rush grief. It is not a linear process and it takes huge courage to open the door to it once it knocks. The challenge that I face each time I meet a bereaved client is to find a way forward together, bearing in mind that an individual’s grief is as unique as their fingerprint. This involves listening intently to their story, acknowledging their feelings and guiding them towards a new, different and meaningful life without the deceased. It does not necessarily mean filling any ‘void’ or ‘closing’ anything. What we are working towards is how they want to adjust to a new reality and integrate the missing person into that reality.

Bonhoeffer, who was a Lutheran theologian who lost many friends and family members in World War 11 wrote :

Nothing can make up for the absence of someone whom we love, and it would be wrong to try and find a substitute; we must simply hold out and see it through. That sounds very hard at first, but at the same time, it is a great consolation, for the gap, as long as it remains unfilled, preserves the bonds between us. It is nonsense to say that God fills the gap; God doesn’t fill it, but on the contrary, keeps it empty and so helps us to keep alive our former communion with each other, even at the cost of pain.

Although there is nothing fundamentally different in working with the bereaved than with any other client group, it is worth considering that grief presents an extra dimension for both clients and me facing existential concerns and unresolved losses of our own. Therefore I believe it to be imperative that I have addressed and, when necessary, continue to address my fears and beliefs around both my own inevitable death and those closest to me. There are few things of which we can be absolutely certain, but death, our own and that of others we care about, is one of them. ‘Each person must make his way through life encompassing two important facts. If he loves, there will be great reward of human intimacy, in its broadest sense; and yet when he does so, he becomes vulnerable to the exquisite agony of loss. And one day – he knows not when or how – he will die’ (O’Connor: 107).

I have come to know that everyone grieves differently, at different times, in different ways, and with different intensities and as a result, I remind myself always to remain open to working with what each individual presents in the here and now. Grieving is one of the hardest and most painful experiences a human can endure. I firmly believe that by finding the courage to work through it, in our own way and in our own time – we can appreciate life with a renewed passion and can engage in choices and changes with a more profound sense of personal meaning and a greater understanding of ourselves and others – which can only be a good thing.

Levine S (1998) Who Dies. Wheaton; Exeter, GB

O’Connor R (1997) Undoing Depression. Little, Brown and Company; New York

Worden W (1983) Grief Counselling and Grief Therapy. Tavistock; London

The susceptibility to develop intense feelings for your therapist has been known and talked about since the early days of psychoanalysis. It is often the theme of jokes and curiosity from others when I mention that I am a therapist. Yet for the client who experiences erotic transference, it can be a profoundly confusing, distressing and shameful experience, with nothing the slightest bit amusing about it.

Is it any wonder that on occasions our clients fall in ‘love’ with us, or at least think that they have? The setting we work from sets the tone for a calm and comfortable environment where our clients are the focus of our attention for the duration of the session. We meet them with intense curiosity and prolonged eye contact, along with unconditional positive regard. We are rarely critical, pre-occupied, snappy or disinterested. Instead, we present with our full presence, empathy, curiosity, patience and a willingness to stay attendant to them no matter what they share. 

Which of us does not yearn to be met in this way by our intimate partner, family and friends? The reality is that life is full of distractions and limited time and so the therapeutic relationship is ripe for erotic transference, which if not handled with care, has the potential to cause considerable disruption to clients personally and in their social and family life. Storr states ‘In the practice of his art, the therapist must treat those patients who make declarations of love with tenderness and understanding. It is important to realise that the love that is shown by the patient for the therapist is just as ‘genuine’, even though it may not be as realistic as love occurring outside the therapeutic situation.’ (Storr, 1979: 78)

Transference whereby clients transfer feelings for a significant person, often parents, onto their therapist, is part of the therapeutic relationship. The transference, whether affectionate or contentious, is often unconscious and necessary to inquire into as part of the therapy. Erotic transference is a term used to describe the feelings of love, as well as the fantasies of a sexual or amorous nature, that a client experiences about their therapist. This needs to be handled with the same respect and interest as anything else a client might bring to therapy. 

I see part of my role as a therapist to find a way to create an atmosphere of openness and safety, where topics such as attraction and sex can be freely explored, especially as for so many people talking about sex openly is often associated with shame and insecurity. By being both transparent and thoughtful, working through erotic transference can often help clients understand problems that initially brought them to therapy.

It is imperative not to ignore transference as it emerges, which can on occasions be problematic, especially if the feelings transferred are those of love, idealisation or eroticism. Freud was clear-cut in his advice for handling romantic love in therapy, stating that the therapist must neither respond nor dismiss the client’s love. Instead, we need to regard a client’s love with the same composure brought to bear on their other feelings. To remain interested, curious and engaged without becoming personally invested. 

We need to acknowledge that as humans, we are all vulnerable to moments where – when faced with erotic transference – we can respond in unhelpful ways. Sometimes where we find ourselves in our own lives can tip the balance in how we react to a client’s attraction to us. On one side, we run the risk of becoming the seductive therapist, using our clients as a source of comfort and validation. On the other side, we can become the punishing therapist, feeling annoyed or ashamed that the situation has arisen. As a result, we quickly close down the topic, thus replaying what potentially happens to clients outside of the therapy room. As a result, we deny them the potential to gain a greater understanding of themselves and the cause of their feelings. 

In those moments, I am grateful for my internal supervisor to keep me on track. Instead of either fanning the flames of love, or making my client feel ashamed in having expressed their feelings for me, I can sit confidently in the middle. I can validate their feelings while letting them know that what they are experiencing is not only a normal part of the therapeutic relationship, but a vital part of our work together.

Sitting in the face of erotic transference, we can find our powers of restraint pushed to the limit. Each of us has known the intensity of feelings we can have for another person and the challenge when we realise that there is no possibility of anything developing in the way that we had hoped. Accommodating these feelings from our clients, especially at their most insistent, needs to happen if the therapeutic relationship is to survive. A robust framework on which I can rely is imperative.

The intimacy that I experience in the therapy room is different from the intimacy that I experience in the outside world. As a starting point, my client and I co-create ground rules and boundaries that I do not set outside of a therapeutic relationship. When erotic transference emerges, it is easy to feel in some way incompetent and vulnerable to the potential misunderstandings and upset that can occur, especially if the transference becomes obsessive and compulsive. Transference of this kind can influence a person’s judgement and interfere with their self-government, which in turn can leave them vulnerable to sexual, emotional and financial misconduct. 

Working within a clear ethical framework is useful, especially when working with erotic transference, as most bodies state clearly that no therapist should have a sexual relationship with or behave sexually, towards their clients. It is well documented that the impact of a sexual relationship between therapist and client is nearly always confusing and negative, even if the therapy has ended. “Research shows that a sexual relationship between client and therapist is almost always traumatising and abusive in the long run, even if the relationship starts after counselling has ended.” (Joyce & Sills, 2001: 148). Despite this, clients in the throes of erotic transference can be tenacious in their belief that a sexual relationship would and could be possible, even if they are already in one outside of therapy. This can put an enormous strain on the therapeutic relationship, especially if there is counter erotic transference.

Erotic counter transference is a normal part of working as a therapist, however similarly to my clients, it is not always easy to manage. In order to be congruent, it is important for me to take my feelings and any concerns I might have to my supervisor. This in turn shows my willingness to do what I am  asking my clients to do by being willing to bring out into the open and explore any erotic feelings I might have towards my clients. 

Sometimes when faced with a direct question such as “do you find me attractive?” or “if I finish therapy with you can we have a relationship?” it is easy to feel put on the spot and pressured to answer. As I have gained more experience and confidence over the years, I can gauge whether to explore the reasoning behind the question or reply directly. Depending on my client, the strength of the therapeutic relationship and the intensity of the erotic transference will often determine how I respond. At all times I am mindful of the courage it takes to ask the question and do my best not to minimise, avoid or move away from it. Once my client is clear, although not always accepting, it opens up the possibility of exploring all and everything that arises in our sessions.

I am always conscious not to exploit the transference in any way. As erotic transference can last over a long period of time, consistency, as well as my integrity and care for my client, is what has seen me through times when I have been on the receiving end of it. I don’t believe in changing the boundaries originally agreed in the face of erotic transference. That said, I do occasionally re-state  them, especially if the erotic transference is relentless. The intensity of feelings can be highly flammable and sometimes problematic and out of control. While my client is working through them, I feel it is essential to remind them that – no matter how strong or insistent their feelings may be – I will always adhere to the ethical code to which I subscribe, even when therapy has ended. This is part of my commitment to them, their safety and their well-being.

Erotic transference emerges for many different reasons and not only in the therapy room. As with everything else, the levels of intensity with which it occurs varies dramatically. Where there is a reliance on another person for help, whether it be medically or any other situation where we are dependent on another for assistance or support, we can experience intense emotional responses. Often the client/therapist relationship is a unique experience, and for some, it may, at times, be unconsciously associated with a promise of love. Erotic transference often comes about as a result of a need to feel special amongst what they perceive to be a wealth of unseen competitors, whether other clients or people in my non-working world. Another reason for its occurrence is a way of regaining control of the relationship to win power and approval. I have also experienced it as a way of testing to see whether I am trustworthy. Some clients have a desire to be so powerful – so seductive – that their wish to conquer me would be their ultimate victory, showing that anyone can be corrupted. The fantasy can be persistent and persuasive as well as dangerous. Some clients feel gratitude and attraction and want to show their affection sexually. A client with sexual abuse in their history may confuse sexuality with intimacy. Whatever causes the transference to emerge, most clients are searching for an emotional relationship rather than a physical one. As the ‘love’ they feel is one way, it tends to echo a parental relationship rather than a reciprocal romantic one. Their feelings are almost always infantile and sensual rather than adult and sexual.

By remaining gentle and clear, clients are able to work through all the feelings that they have confused with ‘love’. I see myself similar to the guides I have had in my own life, that when lost, have directed me home. By walking alongside my clients and remaining open and curious – with clear boundaries in place – my desire is that they can fully experience the erotic transference, whilst also trusting that I will bring them home safely to themselves and their loved ones, with tenderness and respect.

Storr, A. (1979) The Art of Psychotherapy. London. Heinemann.

Joyce, P. & Sills, C. (2001) Skills in Gestalt Counselling & Psychotherapy. London. SAGE Publications

By the time a client arrives in the therapy room, most have exhausted the strategies they have thought of to try and solve their issues. They are looking to me for support as they face whatever is happening in their world that is causing them concern and or distress. For me, doing therapy is like being an artist with the instrument being my client. What I enjoy about utilising skills learnt as a Gestalt therapist is that it allows me to be creative within a stable frame. I never want to be the therapist that relies solely on my experience, and as a result, stops taking intuitive and creative risks. I see how creativity and intuition can move the therapy from being stale and predictable to dynamic and alive within a few moments. Creativity is everywhere we look in life. I believe that effectual psychotherapy depends on me, as the therapist, being willing to step out of my comfort zone on occasions and, where relevant, take the risk in suggesting experiments that may or may not end up being useful. I am mindful aways that each of my clients is different. No story the same and what might work for one client might not with another. Any creative intervention or suggestion always includes my client and determines whether it is followed through or not.

One of the things I have done over the years is to collect things that might be useful in sessions at a later date, a sort of library of tools. Music has been something that I have used in different ways and have a catalogue of both used, and yet to be used, experiments that involve sound in one way or another. What we know is that music can subtly bypass the intellectual part of the brain and directly connect with the subconscious. Depending on the moment and my intuition, music has often be both helpful in reframing a problem in a different light as well as allowing my clients to express in ways outside of the expected talking therapy. I have no doubt that each of us can think of a piece of music that can bring back memories. It is something most people can relate to and can have an immediate impact on our mood. We can be transported back years and bring back to our mind’s eye moments where music played a part in an experience we had. A piece of music or a particular sound can lift our spirits and console our soul; having a profound effect on our health, and well being, not only physically, but mentally and emotionally as well.

I have several drums which I use in different ways. It is thought that drums were the first musical instrument used back in prehistoric times. Beating on things to produce a sound is said to have begun in the early stages of human development. Drumming is a way to connect to our bodies, to our spiritual self and one another. It began as an echo of the human heart. The first sound we hear is the sound of our mother’s heartbeat. The heartbeat is something that is shared by all of us and a reminder that in that way we are all connected. I have used drums with clients who have wanted to express emotions hidden deep within them that have no words. By banging on a drum, they can connect with feelings that are buried, hard to communicate or they feel they are too shameful to speak. I have used drumming as a way for clients to link back to their bodies. For those who have difficulty soothing themselves I have sat and gentle drummed the rhythm of the heartbeat and allowed my client to be metaphorically taken back to the safety of their mothers womb, and rest there a while. A gentle reminder that no matter how alone they may feel we are all connected to humankind through our heartbeat.

Music is a magical medium and powerful tool. I have clients whose profession it is to play an instrument. I have sat and listened to them play their instrument bringing their individual quality and unique energy to the fore. By doing this, they are choosing to share with me an aspect of themselves that cannot be seen and often has no words. Clients have bought pieces of music for me to listen to. Music that they have chosen to use are part of a service for the death of their child, family member or friend; Music that represents feelings of deep loss, as well as music that represented their joy in overcoming difficult moments. We sit together immersed in the potent emotions that emerge, and I am transported to a different place, hearing their narrative in the notes played and the words sung.

Now that I am not doing face to face sessions, as a result of the pandemic. I have noticed a difference in how my clients are ‘arriving’ to therapy. My sense is that the journey they used to take was time for them to leave one world behind before entering their private world of therapy. They had time to reflect and consider what they were feeling and things they wanted to address. Now they are often staying in the room they have been in all day, they are at home or in an office, swiftly moving from work to therapy. They regularly arrive on the call pre-occupied for varying reasons, and there is a distinct difference to their arrival. There is little time or space for them to come not having had a break, rushing from one environment to another. As a result, I have started to use wind chimes, with some clients, as a way to give them the time and space to settle in the therapeutic space. They can leave the busyness of their world and move from their intellect to their heart space, allowing us to connect and their work to begin.

In the same way as music can inspire and delight, it can also soothe and relax. With clients who struggle with anxiety, sleep problems or trauma responses; music, as an external resource on which they can rely, can support them to reground and settle. Chanting and mantra can lead to sustainable healing. By regulating the rhythm of our breath, we can slow down the thought waves of our brain. By doing this, our body becomes more relaxed, thus reducing the limbic activity and stress response of the brain, a useful tool in moment of distress.

I had a client who I will call Max, who arrived having recently been diagnosed with a terminal illness. Our work together took place throughout a couple of years and as he slowly deteriorated we needed to find alternative ways of communicating, as he started to go blind and lose the power of speech. We found drumming to be a useful and connecting way of enabling him to express his emotions. Sometimes frantic and loud and at other times a faint whisper of a beat. There were moments when he was filled with fear, and I would sit with him gently beating the drum. Imagining the sound of his mother’s heart beat, he would settle peacefully with his fears fading away with the belief that they were going to be reunited. The last time I saw him, his wife had called to ask if I would come over. He was slipping away and had asked for the sound of the drum. I took several drums with me, and for a while, his wife and I sat quietly drumming reminding him that he was not alone and that our beating hearts would be a thread of connection for always. It was beautiful, moving, sad, and a moment I will never forget. Our co-created creativity allowed us to be flexible and, as a result, deep healing and peace was achieved before the sun and earth tilted out of balance.

Jealousy is an underlying human feeling found in everyone, and yet of all the emotions few willingly admit to succumbing to the green-eyed monster without feeling an element of shame. Many people blend jealousy with envy as they are difficult to separate, but although part of the same picture, they are different. Jealousy is thought to be triadic (you, the thing or person, and the antagonist who might succeed in connecting where we have failed). Whereas envy is dyadic (you and the thing). Peter Van Sommers, in his book Jealousy suggests: “Envy concerns what you would like to have but don’t possess, whereas jealousy concerns what you have and do not wish to lose.” Envy occurs between only two people and is best summed up as; I want what you have. It could be the desire to have a characteristic, possession or another covetable thing that belongs to someone else, such as wealth, status or appearance. Jealousy, on the other hand, feels as it if touches the nerves lines to our heart, often creating more extreme reactions. Jealousy always involves a third party and is more generally associated with sex, a rival for attention or affection and our desire to protect what we consider to be ours whether possession or right. Both envy and jealousy involve comparisons that reflect a feeling of inadequacy and low self-esteem, which leads to the feeling of shame causing hidden turmoil that is often neglected.

Jealousy is a common theme in storytelling and so universal in human nature yet, despite this, there appears to be much reluctance in acknowledging it. Some believe that the colour green has been linked with jealousy as far back as to the ancient Greeks. They concluded that jealousy developed as a result of the overproduction of bile, which turned human skin slightly green. What we do know for sure is that jealousy is a powerful force that, once trapped in its hold has the potential to lead people to do appalling things. Arthur Lynch muses ’Jealousy is one of the wickedest of all the passions. But reprehensible though it is, jealousy is almost rather to be pitied than blamed – its first victims are this who harbor the feeling.’ 

When working with my clients, I see just how discombobulated they can become when in the whirlwind of jealousy. Outside of sexual relationship, people can become jealous for a variety of other reasons. Most common causes include sibling rivalry whereby we consider that one or more of our siblings receives more attention, or is favoured above ourselves, by our parents or caregivers. In the workplace, we can feel that our position is at risk with employers seemingly respecting others above ourselves. In friendships, we can feel competitive when we sense that someone else’s friendship is prized more than ours. This has been particularly prevalent emerging from lockdown when we have been allowed to create small bubbles of people who we can start to see. Some of my clients have been struck by how they haven’t been the ones to be initially included in these bubbles and, as a result, have struggled. They talk of their jealousy having witnessed others seemingly liked more than themselves. For those of us with perfectionism qualities, it is easy to compare ourselves to others fearing that their success will somehow negate or impact our own. These examples make it difficult for us to be generous in our desire for those around us to be loved, feel special or succeed as, somehow, with that happening, we are triggered into feeling insecure.

It is normal to experience feeling jealous, but it is when we act on our jealousy by becoming destructive, intense or irrational that problems occur. Someone experiencing high levels of sexual jealousy often has difficulty trusting their partner. I have witnessed clients who have had their electronic devices bugged, spying devices installed in their homes, cars and phones being tracked. All aspects of their privacy invaded. When there is extreme jealousy behaviour can become abusive, and out of control at one end of the spectrum, people kill, hurt and abuse when in a jealous rage. Whatever level of jealousy any of us might experience what we do know is that it is a destructive emotion that often leads us to act in ways of which we are not proud and threaten the very thing that we hold dear by our behaviour.

Two leading causes of jealousy are the fear of abandonment and low self-esteem. When we doubt our value, jealousy serves as an antenna that looks for evidence to prove our fear that others will be preferred and valued above us. That somehow we are not good enough, sexy enough, talented enough or loveable enough and that; as a result, we will be left.  We feed the messages that live deep inside each of us. They conspire to keep us from seeing our true worth causing us to be eaten alive with feelings of inadequacy and jealousy. As bathetic as it may sound, the start is within. With support, you can enter the solitary world of your unease, turning your attention to the roots of your jealousy. With time you can reframe your internal dialogue and choose to put your energy into feeding yourself with loving kindness that shelters you in moments of doubt.