As a therapist, I incorporate and harmonise theories and interventions from a wide range of approaches that I have come across over the years. I do not believe in limiting myself to options that are fixed in a single approach as I work with a diverse group of clients and that requires me to be able to find ways of working with them on mutually acceptable terms. I believe that group and individual therapy can work well together, depending on what a client is coming to therapy for. Across time and culture, both ritual and group work have been used in many different ways as a means of accessing and containing emotions evoked by any number of experiences. I have developed both as part of my therapy practice. I have always been fascinated by rituals and see their use as helpful in therapy when clients are searching for ways of expressing thoughts or experiences that are beyond words. In addition, I am a believer in the power of group work as a way of facilitating healing and transformation in the broken moments of our lives – as well as a way of celebrating milestones and successes. As a result, I have worked with clients using both ritual and group work as a way of recognising important stages and events in their life. Rights of passage, the expressing of emotions, sharing meaningful stories and events, marking moments and experiences all held in a safe container, with a sacred presence that includes more than just client and therapist. 

I have facilitated many groups of different sizes and shapes. Group work, although daunting for many, can be immensely powerful. When we come together to tell our story and are witnessed by others, it can be profoundly cathartic and moving for all. Holding and participating in a group can act as a balm for the pain of life and be an important catalyst for the healing process. As talking therapy has many advantages and gifts, so does creating rituals. Clients speak of hearing my voice in moments outside of therapy which allows them to make different choices, receive an element of comfort and just know that although not physically present I am out there in the world rooting for them. In the same way, as a client might remember something I have said, creating a ritual contains many elements that can be reverted back to as touchstones during difficult moments or moments that hold unforgettable memories. Photographs, music, certain smells, memory boxes, places, objects and ornaments, books, clothing, jewellery are but just a few of the things that can be used in creating a ritual.

I see the creation of ritual as important as the ritual itself. It requires much thought as to its purpose and how it can be implemented. It allows the creative juices to flow as anything is possible. I see it as both exciting and faintly terrifying when asked to help create a ritual, especially those around grief and loss as I know that there will be moments where I touch my own grief. My desire to stand with my client whose lives are shaken by life stories that seem impossible to bear inspire me to move beyond my fear and take the strength and solace offered by bearing witness to the rich experience of being human.  

A while ago, I was deeply touched by the gift of trust instilled in me when a client I had been working with asked me to help create a Grief Circle to mark the death of her baby son. We had worked together on and off over a period of years, and part of her work had been around the several failed IVF attempts and miscarriages she had had.  On her fourth round of IVF, her ‘final attempt to get pregnant’, to her absolute delight, she became pregnant. As her stomach grew so did her excitement until her 20-week scan where she was told that her son had severe brain abnormalities and he almost certainly would not survive the pregnancy or if he did, he would die very soon after he was born. Her joy turned to disbelief, shock and grief as she tried to come to terms with all that the news involved. We worked closely together to prepare her for his birth and imminent death, to make things bearable. This included some small rituals such as her crocheting him a special blanket to be wrapped in as soon as he was born and writing him a letter. Her son, Noah was stillborn a month later when she was six months pregnant. 

We devoted a great deal of time in considering what the Grief Circle could look like and how she might make sense of her loss, whilst at the same time honour the memory of the son she had loved so much. What we created together was not only able to hold the beauty of the event, but the excruciating pain that was deeply moving and profound. The event was filled with all sorts of rituals that were relevant and poignant to the loss of her son. 

On hearing that I was writing a book, my client voiced that she would be “very honoured for others to learn from my experience” and so I share below some of what she wrote to me after we had created the Grief Circle and her experience of it. What we see if that a little like the ripples formed in the water when we throw a single stone in it.  – the ripples of ritual continued for a long while after the Grief Circle and as seeds are sown, we reap the beauty of new life whilst holding the loss of those who have gone before us.

“The Grief Circle you arranged for me was important in a way I think I won’t ever fully know. The impulse for it, the ritual of it, the impulse for it – every moment of it was beautiful in such a radical and full and deep way. It resonated with the deep grief within me and I felt a connection to the women in that circle in such a perfect and human and bereft and womanly way. It was wonderful that it so happened that the circle consisted of women who had never had children, women who had had young children, a woman who was pregnant, a woman who had struggled with fertility in the past, women who had both children and grandchildren and a woman who herself had lost a baby many years before. So we covered almost every state of motherhood. It was wonderful too that we held it just a couple of weeks after Noah was stillborn as I was so raw and open and in need of it.

I genuinely feel that those moments and the honouring of Noah together were among the most beautiful moments of my life. I felt so proud to be able to honour him, his life, his presence in the world, the potential that was gone; I also felt proud to honour the pain of the grief that is so specific to the death of a child and my touching of motherhood in such a painful way. I felt with these women the universality of motherhood and grief. I loved how we sat and listened so fiercely to the beautiful Bob Dylan, Forever Young’ (Slow Version) for him; I loved how each woman was asked to bring a poem or letter or the words of a song to read especially for Noah. I loved how you structured the time we had. I felt vulnerable and broken open but totally safe and held. I know that the fact that my own darling Mum was not alive to be there with me added to my bereftness and I felt I needed the Grief Circle to have other wise women sit with me and my grief.

You did something so very, very beautiful for me. So healing, so perfect. I wish I could put into words the enormity of it for my life and for Noah. We cried together and sang together in a way that felt tribal, primal, honouring and transformative.

Because of that Grief Circle, I did a number of other things that were ritualistic because I had known its power.  And I was able to share some elements of ritual with some of those closest to me. My husband and I had a beautiful funeral for Noah, led by an incredible celebrant. (we couldn’t have a funeral until many weeks after Noah was stillborn as we had to wait for the autopsy to be done.) it was just the three of us; she wrote a beautiful service which involved us listening to a couple of pieces of music, reading poems and drawing on some ancient rituals from different traditions. One of these was bringing oil and water as symbols. That morning, I watched my dear husband gather water from a small river near us into a lovely glass bottle, and I saw how he drew that water with such love. It had meaning for him that he could do something ritualistic, without really knowing it. The three of us stood by his tiny white coffin with the various symbols we had brought (a tiny teddy, a small statue of a mother and child given to me by a friend, some wool from the important crocheted blanket we had wrapped Noah in when he was born, the oil, the water) and spoke beautiful words. 

Some time later, we scattered Noah’s ashes at dawn at the foot of a beautiful tree on the top of an ancient and very spiritual hill. I can still feel the importance of feeling his ashes in my hands and touching the ground and the base of the tree and asking it to look after my beautiful Noah.

I then had what was almost like a Grief Circle with some close girlfriends who also had young children, who would have been Noah’s friends. I invited them to a special picnic to honour him, which was held by the tree where his ashes were scattered. It was a sunny afternoon, and we sat together, chatted, ate food as the children played. We then stood in a circle and I read Kahil Gibran’s ‘On Death’. We all cried. I had asked them all the bring headphones to listen to the piece of music we had played at the Grief Circle. Each of them walked on their own listening to the music whilst I looked after the children. I then asked each of them to write a note to Noah from them or their children for me to add to my memory box. It was incredibly special, and each said that they found it incredibly touching to be a part of.

One other ritualistic thing my husband and I did recently (as you know) was to send a card to family and friends, the women who were in the Grief Circle, and the nurses and doctors at the hospital which includes a seed packet that I had designed. This was so that Noah’s memory, wildflower seeds could be sown in places that need some flowers. I am also planning to do a small printed book for Noah called “Things You Have Known,” and in it, I will note down things Noah knew in his short life how we honoured him and how meaningful his presence has been in our lives. Babies in the womb can hear lots of sounds, and I had made sure he had heard Jane Austen, Mozart and Shakespeare, so I will include those references! And the beautiful poems and words brought by the women from the Grief Circle will be so important in this book. 

Of course, giving birth was a kind of ritual. Giving birth to a dead baby is not something I would have thought I’d ever be able to endure. But your help preparing for that possibility, meeting it as a ritual, was amazing: I was able to feel the experience fully and holding my very own baby in my arms is a moment I wouldn’t exchange for anything in the world.

In this past year, through doing these rituals, I feel I have been able to face the grief and the beauty and have been able to heal and share and feel held and strong. A dear friend recently described the amount of love we have as mothers as so strong that it was “impossible ….. unknowable”. That seemed to me to describe it perfectly. And even though I only touched motherhood so fleetingly, I felt – and continue to – feel this deep love and, through the Grief Circle so soon after Noah’s birth and the resulting rituals, I was able to express this love to my son as a mother. I had space to do so, permission to do so; my love could have a voice.

Overwhelmingly, I feel I have so much gratitude for having had the experience of having Noah. And for all the ways you helped me to heal through ritual, in particular the Grief Circle, I am so grateful to you.”

Over the years, I have been privy to many heartbreaking, breathtaking and inspiring stories shared with me by my clients. Whether sitting in a group or doing one to one therapy, I am often reminded that as much as we presume that others are not sharing a similar experience of life there is a part of each of us contained in every story I hear. Time and time again, I see, whether it be in individual therapy or sitting in a circle, how we are offered the opportunity to face our own unresolved issues. It requires courage and trust to be willing to fall into the abyss of our unshared stories and yet when caught by those around us; we can lie still in the embrace of love, validation and respect which allows us to rise no longer needing to hide the dark side of our humanness. Using ritual to mark these moments offers us something tangible to hold on to as a way of integrating the experience into our lives ……… just as we did for Noah. 

Somewhere deep inside, most often pushed away out of sight and mind, each of us knows that one day we will die. Most of us go about our day to day lives doing our best to ‘live’ and then in a moment, often when we are unprepared, fate opens a gate that allows the unthinkable to happen. To be given the news, or confirmation of fears, that one is dying is a direct blow to one’s sense of self as not only do we need to face the truth that we will no longer be, but we need to accept that we will be leaving behind all that we cherish. In my work, I have held space for many clients who have received a terminal diagnosis. Some I have an established therapeutic relationship with and others reach out as a result of the moment they were faced with the harsh reality of their mortality. There is often much uncertainty as the pattern of decline towards death varies from person to person and the timing of each death always a mystery. My deep desire is to support my client, with equanimity, as they find their way through the maze of a terminal illness diagnosis to a dignified and peaceful death. 

The work of Psychotherapist and Soul Midwife fit together perfectly as both encourage not only deep conversations but also the challenge of living life fully, until the end.  Just as a birth midwife supports a woman through the stages before a baby enters into the world, so a Soul Midwife supports people through the end-of-life stages before they leave their physical body. Most of us hope that when the time comes, we will die at home with our symptoms controlled enveloped by our loved ones. But not many of us achieve this. With dying clients, I adapt my boundaries so that I can support them on their journey, whether that be at home, a hospital or hospice. “Those who have the strength and the love to sit with a dying patient in the silence that goes beyond words will know that this moment is neither frightening, nor painful, but a peaceful cessation of the functioning of the body.” Elisabeth Kubler-Ross.

Although my work as a Soul Midwife is similar to that of Psychotherapist, there are differences. One of the first things that I do when a client talks to me about their terminal diagnosis is to establish what sort of support they need from me, which will determine how the roles merge or not. Although some consider a sudden death to be easier to deal with, it denies them and the survivors a chance to say goodbye. Anticipating death can enable a dying person to consider their options. In addition, there is the freedom for family and friends to arrange their priorities so that valuable time can be spent enabling the person who is ill to make the most of their final days. With death being one of the most critical moments in our life, there is the opportunity to treat it as such with reverence, honesty and courage. One of the starting points is to acknowledge the diverse emotions that inevitably emerge whilst coming to terms, or not, with the idea of dying.

Some diseases are known to be terminal from the time of diagnosis, whereas others may not necessarily be terminal at the first onset. I have had clients who have lived for several years with a terminal diagnosis and others for whom death came a matter of weeks from the initial consultation. Most of us struggle when things feel out of our control and dying challenges us to soften into the mystery of what will come next. Many go through Kubler Ross’s (1969) five stages: denial, anger, bargaining, depression and acceptance, and for some, the journey to acceptance is more manageable than for others. Each of us is our own expert as to what we can cope with and, because of that, I see my role to walk alongside my client, to guide them, educate them and trust them in every step they take towards their death – in their time and way.

Working with death has been one of my ultimate counter-transference challenges, and at times, I have relied heavily on supervision when I have felt as if the stitches holding closed an old wound have come undone. Thankfully, I have been encouraged and understood in ways that have strengthened my trust in myself to feel deeply and work effectively. As a result, I can draw on my own internal supervisor, therapist and mother to calm and guide me when facing not only my client’s mortality but also in the moments when I am being reminded of that of my loved ones and my own. The more I have explored my own history around death I have found the ability to be more open and honest with my clients who have touched my sensitivities with their fears, regrets, sadness and the unfinished business of living – thus enabling me to provide the much needed and meaningful support to them in their final days of life.  

There are a multitude of different reactions as clients come to terms with their life ending earlier than they had imagined. For some, they want to talk about and understand every detail. For others, they simply do not wish to know. Clients speak of the challenges they face in accepting their diagnosis and the fear at the thought of uttering the words to their loved ones. These moments can feel isolating and overwhelming, and therapy is a place where clients can share their truth without feeling the need to edit or adapt for me. It is inevitable that well established relationship patterns will influence how many of the important issues are addressed along with the various challenges faced by family and friends. It is not uncommon for clients to work on estranged or broken relationships in the hope that there can be some healing in the midst of their dying. It is essential for everyone involved to be cognisant that the environment within which they are operating is one of sadness and grief at the impending loss, but that does not mean that peace and solace cannot be reached for all involved.

Helping to facilitate a good death that enables growth and breakthroughs throughout the dying process and beyond, requires the sick person, their loved ones and their medical advisors to have the courage to have honest, transparent conversations in fiercely difficult moments. Gaining clarity as to what services are available is critical in offering additional peace of mind along with the experience of receiving and feeling support. Depending on what is required, these can range from financial aid, support groups, online forums and sites to a palliative care team who provide end of life care for those living with a life limiting illness. I often assist my client in setting out their wishes for the final days in a death plan, which includes what sort of funeral they would like, how and where they want to spend their ending days along with anything else that gives them a sense of closure before passing on.

As death is a process that involves mind, body and spirit, there are additions to talking therapy that can soften the final weeks, days and hours. Some clients have places they would like to see and things they would like to do. One last walk on a beach, to visit a church, gallery, restaurant or garden. If physically able these moments create tender memories that can soothe clients as they become less able to leave their bed. As time draws near, breathing techniques, along with a mixture of music, singing, singing bowls, poetry and toning can help ease anxiety and pain. Windows can be covered with coloured fabrics of choice that can offer soft light and a soothing environment. Favourite smells, white sage, juniper, sandalwood along with frankincense and myrrh can be used to still the mind and fill the air. If open to physical touch, massage is a beautiful reminder that they are not alone. Soothing touch in all different forms using essential oils, or not. A favourite of mine is to put a clients foot on my heart and gently sit there either with music, singing, toning or simple silence. Allowing the calmness of my soul to merge with theirs offering companionship in a very sacred moment.

Having witnessed clients at all stages of the dying process, I offer them my full presence by remaining open to the mystery of what is happening for them and between us. I am conscious that for most I am not part of their inner circle, but for a few, I am their only comfort. As a result, I tread respectfully and mindfully through the dying process offering my assistance as, how and when needed, without wanting to intrude. Whether clients have viewed death as an uninvited stranger or a welcome guest there comes a moment when death comes beckoning. Whether I am there or not I hold the hope that with their last breath they know that they are loved and that that love remains their companion, along with tranquility and trust, as they take their leave.

Kubler-Ross, E. (1969) On death and dying. New York: Macmillan.

Therapy is one of the few relationships that we enter into acknowledging that a time will come when it will end, and yet, so often neither therapist nor client is prepared for the powerful feelings that can emerge when faced with the actual ending. Attachment and separation are intertwined, thus by becoming attached in the therapeutic relationship, we have to accept that there will be a separation. Our ability to attach and detach will have a significant bearing on or our reaction to loss and, as a result, each of us will view the end of the therapeutic relationship differently. Bearing this in mind, I am always mindful of my client’s predominant attachment style when addressing the issue of the ending as the process leading up to the final session, for some, can be an anxiety-provoking and painful time.

At the start of my career, I would sometimes take my clients abrupt, unannounced ending personally, and when they left therapy unexpectedly would wonder what had happened. I would somehow make it personal and wonder what I could have done differently or better, sometimes feeling abandoned and unappreciated, triggered back to old beliefs of not being ‘good enough’. Today, I am aware that for the most part, clients find many different ways to avoid the pain and anxiety engendered by an ending that often has little, or nothing, to do with me. I also remind myself that just because a client disappears, it doesn’t mean that they didn’t get what they needed. For some, it might well be as simple as they got what they came for and have decided they no longer need further sessions, or to say goodbye. Above all, whatever the reason my clients have the right to choose when and how they end therapy, and for me, supervision is a place that I can take any unfinished business.

For the clients that imagine that as they leave the door for the final time, so does my memory of them, they are mistaken. So often, my work touches or re-opens my own wounds, and this has undoubtedly been the case around endings. Ending therapy is a real loss, not only for the client but for the therapist as well. The client-therapist relationship is often a profound and intimate journey that asks questions that can reshape identities and ways of being in the world for both. Although my own relationship to endings has changed over the years, I am still aware of my fragility around them. As my clients have learnt to tolerate endings and realise that they are not always as a result of something negative happening, so have I and for that, I am grateful. As as a result, I am better at what I do and trust what waits on the other side of the goodbye.

For those who want to experience a therapeutic ending, I see part of my role to not only support them in leaving therapy well but to guide them as they learn about themselves in the process. I am mindful not to collude with my clients whose emotions are triggered at the prospect of an ending. I make sure that we have plenty of time to work through what emerges to facilitate a valuable ending. For some clients fully completing the therapeutic journey can be the most enlightening and healing part of their whole therapy experience as they get to experience an end in a completely different way.

As the therapist-client relationship assumes some of the characteristics of a secure base, understandably, the ending of this relationship can trigger all sorts of unresolved past issues. For many, endings are associated with unfinished business, un-grieved losses, abandonment and a broken heart. Most of us revert to patterns of automatic response which have developed as creative adjustments for dealing with our feelings about loss or endings, and these are worth exploring. As we live in a constantly changing environment, we need to be mindful that our ways of behaving might have served us in the past or still serve us, in some cases, in the present, but can sometimes be misplaced. If our creative adjustments have become fixed around endings, they will stop us from responding to different situations accordingly. As a result, for some clients, their response to the prospect of therapy ending is no different to how they feel when faced with the sudden unexpected end of an intimate relationship. With the actual endings being different, the invitation is to explore the difference.

The client’s history and perspective, along with the length and depth of therapy all play a role in how facing the inevitable loss of the therapeutic relationship, will be experienced. Feelings of achievement and pride can often be overshadowed by feelings of fear, abandonment, grief, loss and anger as the reality of an approaching ending sinks in. Being willing to let go of a relationship that can stand alongside us as we touch the epicentre of our pain without being overwhelmed tests our trust in ourselves. The prospect of being fully responsible for what is precious inside us by leaving our therapist, who has become an ‘attachment figure’ requires us to commit to becoming that for ourselves. The need, sometimes, is to keep returning until we work through the fear and sense of abandonment reminiscent to past events and then, and only then, do we feel ready to ‘leave home.’

For those who feel cheerful and ready for the ending, these precious final sessions afford the opportunity to recognise our internal voice that feels joy-filled, proud, relief, complete or a mixture of them all. We can use the time to reminisce, reflect on our journey, seal and contain what has been achieved in therapy – express gratitude for the experience. However, the clients feel about the ending allowing them to acknowledge and feel their feelings is a vital part of the process. By exploring these feelings, therapy can be therapeutic up to the very end.

As my client stands to leave, I hold both the joy and sadness as our relationship as we have known it comes to an end. I marvel at their courage. I take pride in the relationship that has allowed my client to share parts of themselves that are hidden to the rest of the world. As my client ventures out into the world, I take pleasure in the knowledge that they have experiences and memories of valuable conversations that will provide nourishment to themselves, their loving relationships, friends and family. The extraordinary privilege replaces any tinge of sadness.

It is not uncommon for me to ask a client where they feel they belong and for them to consider quietly and, after a while, answer ‘nowhere.’ Belongingness is a basic human need, that along with the need to form attachments is universal among human beings across all cultures. Humans have an inherent need to be part of something outside of themselves and to develop and maintain at least a minimal amount of stable, positive and important interpersonal relationships. This can be with family, carers, friends, co-workers, community organisations or a team of some sort where they feel an accepted and appreciated member of a group.

Some of us have an innate sense of belonging that often comes from growing up feeling an esteemed and much loved member of a family which subsequently fostered the ability to enjoy secure attachments. For others, who struggle with the concept of belongingness, it is often as a result of not having experienced frequent positive interactions within a framework of long term care. Without feeling consistent attentiveness and security it is a challenge to feel ‘rooted’ anywhere and thus hard to experience belongingness.

The deep primal longing to belong is etched into our unconscious minds as we all need to give and receive attention – to love and feel loved. As belongingness is a fundamental human motivation, without it, we are vulnerable to feelings of loneliness, social anxiety and clinical depression. We can see just how strong the driver to belong is when we think of children who will do almost anything to feel loved or to belong as they remain loyal to abusive parents or abusers in general. Much of what human beings do is done in the service of belongingness and can continue long into adulthood sometimes overriding the physiological and security needs; such is the driver to satisfy the need.

W. Somerset Maugham speaks eloquently on behalf of those of us who have struggled with the idea of belonging:

‘It can seem as if everyone else belonged somewhere and to someone – I have an idea that some men are born out of their due place. Accident has cast them amid certain surroundings, but they have always a nostalgia for a home they know not. They are strangers in their birthplace, and the leafy lanes they have known from childhood or the populous streets in which they have played, remain but a place of passage. They may spend their whole lives aliens among their kindred and remain aloof among the only scenes they have ever known.’

I see Maslow’s hierarchy of needs rather like the roots of a tree. Each one is slowly tunnelling its way down into our subconscious and from there our beliefs and ways of being emerge. In Abraham Maslow’s hierarchy of needs, belongingness is part of one of his significant needs that drives human behaviour. The ranking is usually portrayed as a pyramid with more basic needs at the root, such as food, water, warmth and rest. The more complex needs near the peak, such as esteem needs and self-actualisation. The need for love and belonging is interpersonal and sits at the centre of the pyramid as part of the psychological needs. While Maslow suggested that the psychological needs are less important than the physiological and safety needs, he believed that the need for belonging helped people to search for companionship and acceptance through family, friends and other relationships.

The drive for belonging never goes away and is present at all stages of our lifespan. The fact that belongingness is a need means that we must establish and maintain a minimum quantity of lasting relationships which is difficult if you move around a lot. Being bought up in an orphanage, foster homes or fleeing a war torn country as a refugee, leaving family behind, challenges our sense of belonging. For others who although living with, did not feel part of their birth family, searching for and finding a sense of belonging is difficult in a different way. With parents who moved around a lot, clients of mine speak of the difficulties of entering new schools when friendships groups had already been established. Each time hoping to find a group to belong to, but soon being uprooted to start the journey all over.

For some of my clients who were sent away to boarding school at a young age, they felt their sense of belonging fade away replaced by the need for survival. Young clients speak of their craving for acceptance and want to belong to a peer group. As a result, they talk of having found themselves participating in sexual acts, breaking the law and abandoning their core values to satiate their craving. For each of us, our experience is different, but what threads us together is the feeling of being an outsider in a world where others appear to belong.

In therapy, one of the first things we address is the fallacy that we can make a home for ourselves outside ourselves without first establishing a deep rooted sense of home and belonging within ourselves. By recognising how some of us can perpetuate the feeling of not belonging by always projecting home and a sense of belonging onto others, we can start to understand how we do not always serve ourselves in our need to belong. The poet David Whyte states ‘to feel as if you belong is one of the great triumphs of human existence.’

It takes a lot of courage to be ourselves, to own our vulnerabilities and our feelings of isolation. Our work is to make ourselves visible in the world despite its apparent unrelenting need to change us. If we don’t abandon ourselves to belong and first turn our attention inwards, we find a place of belonging that no one can take away from us. It is only through being true to who we are, that we can make connections based on profound honesty, thus enabling a deep, rooted sense of connection and authenticity with those we meet. As we allow ourselves to be healthily rooted in who we are, and only then, are we able to rejoice in the true meaning of belongingness as – everything and everyone is waiting for us.

We know relatively little about what really makes a long term relationship work. If we think about the institution of marriage, for longer than not, they were arranged for social economic and political reasons, not for love. With the divorce rate being as it is we can but assume that many enter into marriage with unrealistic expectations and then find themselves confronting issues that seem insurmountable with the option of walking away seemingly the only one. Most of the couples I work with are in emotionally committed relationships whether that includes marriage or not. Many arrive at my door in a state of confusion and despair as the relationship they had imagined they were entering into is no longer bringing them the security, joy and comfort they had initially savoured.

I see myself as a therapist standing on the shoulders of those who have gone before me as well as those inspirational mentors and teachers I have met along the way. I owe much to those whose language, way of being and working fits with mine and from whom I can take forward in my work their presence and the gifts of their wisdom. Hedy Schleifer is one of those inspirational teachers for me. Witnessing her working, I am reminded that although structure and models are useful, they are not always appropriate in the moment. Instead, what is needed is the ability to be creative and spontaneous, moving beyond diagnosis and problems to teach couples what it means to really be alive and living in connection with each other rather than just coping and surviving.

Martin Buber, the Jewish philosopher when speaking of relationships, said, “Our relationship lives in the space between us – it doesn’t live in me or in you or even in the dialogue between the two of us – it lives in the space we live together, and that space is sacred space.” Having worked with many couples, one of the guiding principles I take with me from witnessing Hedy work and teach is the importance of treating the space that resides between couples as sacred. By the time couples come to therapy, one thing we can almost guarantee is that at least one of them, but probably both, have neglected to treat the space between them that way. Instead, it is filled with many of the toxic qualities that disconnect and distance them rather than keeping them deeply connected. A starting point for change is for the couple to recognise that it is the responsibility of the both of them to take care of their relational space. By acknowledging how important it is to value deeply and treat accordingly the space their relationship lives in, they can start the journey back towards a loving and conscious connection.

Many times couples come with the focus being visiting the wounds of the relationship. Although this is a necessary part of the work we do together, I have learnt that by only focussing on those issues, clients don’t have anything positive to work towards. Because energy follows what we focus on we need to focus on our hopes and dreams, not only our problems and disappointments. With this in mind, one of the first building blocks we work on, is for them to create the vision they aspire to for their relationship, thus fuelling hope and potential. This enables them to visit the pain and hurt that they have caused each other, knowing that they are working towards the shared dreams and aspirations they hold for their relationship as well. As with all therapy, it is not for me to force anyone to be open, honest or to share their deeper selves, but in the knowledge that couples work can be extremely challenging, I aim to offer an atmosphere that provides the healing potential even for those who are profoundly resistant and unsure. As they are the holders of the truth of their deepest longings, I see myself purely as their guide. By focussing on the potential of the relationship rather than only what is lacking, we include the possibility of transformation as couples start to see each other with new eyes.

In the book, Passionate Marriage David Schnarch speaks to the importance of differentiation in relationships, which can be a delicate balancing act. Differentiation is the ability to balance individuality and togetherness, which is especially important during difficult times. The ability to be close to our partner but at the same time holding on to a distinct sense of our individual selves, complete with our own feelings, needs, wants, values and perspectives. From this place, when we start to confront challenging issues, we are able to not only take care of ourselves individually but at the same time take care of our relationship. Beginning to consider our own individual wants and needs along with our wants and needs for our relationship is an integral part of rebuilding and renewing our relationship. So many couples focus on what they don’t have or don’t want and when asked what it is they do want or need they do not know. Connecting through conversation is integral to all relationships. Allowing our partner to express their wants and needs without judging them to be right or wrong allows for a meaningful relationship that doesn’t deteriorate into emotional fusion. By holding on to our individuality, we can agree with others without feeling as if we are “losing ourselves,” and can disagree without feeling begrudging and alone.

Hedy teaches that conflict is a friend: “growth that is trying to happen” and should be welcomed as an opportunity. Not easy if we have been bought up with the belief that conflict is ‘bad’, ‘scary’ or ‘should be avoided.’ Perhaps a good place to start is to see conflict as a way of being able to deepen intimacy and connection rather than a dispute or doing battle. When conflict arises, usually one partner will become like an octopus and the other a turtle. The more the energy of the octopus increases in the desire to be heard and understood the further into the shell the turtle will retreat. This dynamic can continue for decades with each partner triggering their ‘fight’ or ‘flight’ response. By intentionally focussing on truly understanding each other, we create safety, instead of reactivity in our relationship, thus allowing conflict to become the opportunity for growth and healing that Hedy speaks about.

By reframing how we see conflict and as a result being honest and transparent, couples can start to understand the impact of their behaviours on each other. I offer them a way to find each other again even when they have polluted the space between them with infidelity, criticism, hurt, anger, betrayal and all the different ways we do damage to each other. My commitment to my clients is to be 100% present, no matter what the outcome is, knowing that it is only when therapy enlists deep emotions that it becomes a dynamic force for change. For some, the damage is too great, and one or other decides they are unable to continue, for others, I can sit in awe as they emerge from the ashes of conflict worked through together. Whatever the outcome, I am clear on being able to guide couples towards a new way of relating that allows them to have a more empathetic understanding of each other that will serve them whatever course they choose to take. Through the power of connection, with commitment and forgiveness, relationships can be repaired, healed and transformed. It is not easy, but the rewards are profound.

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