Author: Ana Norio Bran

The words relationships and love are words heard throughout one’s lifetime. Often, the image that pops into our heads are scenes from movies, tv shows, and other media. The media’s portrayal of relationships has become our standard of what relationships and love are supposed to look and be like. We assume we find the one and live happily ever after. In actuality, relationships take work, but prior to working on the relationship as a couple, we first have to shift our focus and attention to acknowledge the two individuals that are in the relationship. We often forget that before getting into a relationship, we were once individual people who have decided to come together.

In Dr. Keith Sutton's workshop for clinicians on Integrative Emotionally-Focused Couples Training, he teaches that we can honor the two individuals that choose to come together into a relationship by examining each person as their own part of the relationship. Each individual brings something unique to the table, and in order for a couple to work, we have to first understand each person and how each person shows and receives love. 

The first real connections we have are with our caregivers. As children, we are like sponges that soak up information all around us, even if we aren’t fully aware. The household in which we grow up plays a huge part in how one might show love to their significant other. The attachment styles one has are based on what we experience as children, primarily from our caregivers. If a child grew up around a parent who is abusive, that child may learn that it is normal behavior. This pattern of learnt behavior may continue into romantic relationships if it is not addressed. Identifying the characteristics of what is a healthy relationship versus unhealthy relationship are not taught, but learnt through observations and experiences.

There are four different types of attachment styles: secure, anxious, avoidant-dismissive, and avoidant-fearful. Individuals with a secure attachment style are attuned with their emotions and are able to foster a safe, honest environment with their partners to speak out about upsetting topics. Individuals with anxious attachment style tend to struggle with their sense of self and romanticize about love with a positive view of their partner. Individuals with avoidant-dismissive attachment are emotionally distant from their partner and tend to suppress their feelings. Lastly, individuals with avoidant-fearful attachment style experience inner fluctuation of fear in being too close or too distant from their partners, which can lead to the relationship being volatile. It is important to note an individual’s attachment style when discussing behaviors within a relationship. 

Concurrent with attachment styles, it is also helpful to know individuals’ love languages. The different types of love languages are quality time, words of affirmation, receiving gifts, acts of service, and physical touch. Our love languages are how we tend to give, and wish to receive love.  Knowing your partner's love language can help in understanding how to your partner shows love, and how to show love to your partner, and communicate how your partner can show love to you.

So what does a healthy relationship look like compared to an unhealthy relationship? A healthy relationship is built around honesty, trust, mutual respect, and good communication. Self-esteem and self-confidence play a huge role in creating a safe space for both partners to be able to express their thoughts without judgement. There are many characteristics of an unhealthy relationship, but the main identifier of an unhealthy relationship is when one partner has more power over the other. This can lead to a potentially abusive relationship.
​
With Emotionally Focused Couples Therapy (EFT), the focus is to develop the skills to be able to develop a secure attachment with their partner.  This happens through understanding the cycle that gets in the way of each being able to communicate their love and care, and to be able to be responsive to each other.  Often each partner loves their partner, and wants to connect, but the way that each tries to reach the other one, they end up missing each other. Relationships are not like in the movies, where they're all romance all the time and easy, but instead, it takes work to create a relationship that is fulfilling to each of the individuals, and make it the best relationship it can be.  Through working on understanding our partners needs, our needs, and learning how to catch the cycle, we can strengthen our attachment bond, and have a relationship with a secure attachment, which is the foundation of true love. ​

Having a conversation about your mental health with another person can be challenging. Currently, physical health and mental health are not treated the same, especially in Western society. The existing stigma regarding mental health and the discrimination which often occurs, has created a significant barrier for people to seek help. Opening up to someone about your mental health struggles can lead to anxiety, feelings of shame, and uncertainty. You may wonder what the consequences of your disclosure will be, and how you will be perceived from that moment forward. Maybe you have already been speaking with a mental health professional and received a diagnosis, but have been keeping this a secret until now. Whether you have already spoken to a counselor, or if you will be speaking to someone about your mental health for the first time, taking the time to prepare for this delicate conversation can be an important first step. 

You can ask yourself the following questions in order to take charge of the conversation:
 
1. Why do I want to talk about my mental health? 
There could be various reasons why you have decided to speak about your mental illness or about seeing a mental health professional. People in your environment may have noticed a change in your mood or behavior. They might be asking questions and this could be the right time for you to answer them on your own terms. Sometimes it can be a relief to be able to share what you are going through with people close to you or with others in a similar situation who may be able to provide support. 
 
2. What are my expectations?
It is important to become aware of your expectations from the conversation. It is possible that the person you decide to talk to does not understand what you are going through, or reacts in a way that is not helpful to you. It may be tempting to stop talking about your mental health entirely if your expectations are not met. However, just because one person is not supportive does not mean that there may not be other people who could be of more help to you.
 
3. Who do I tell? How much do I tell?
Since details regarding your mental health are private information, it is fully up to you to decide who you feel comfortable talking with and how much you would like to disclose. Think about who you trust, who would be understanding, and able to help you.  When we have boundaries, we decide who we let in, and who we keep at an arm's distance.  Ideally, those we let in should be people we trust, and have given us reason to feel safe with them.  It may be useful to write down in advance what you would like to say. This could include:

• Received diagnosis 
• How you are feeling
• What you are struggling with
• What kind of help you would like to receive 
• Optional: share a pamphlet or website with accurate information about your mental health issue

Depending on the person you are speaking with, the conversation may look different. Here are some examples:

1. Sharing with a parent
Not all parents are equally informed about mental health issues. The range of reactions that can be expected is guilt, concern, fear, relief, confusion, and more. They may need some time to process and could have many questions.
 
2. Sharing with a colleague or boss
This situation can be complicated. You may want to keep the information you share limited. It could be enough to say: “I am experiencing some personal struggles, I would appreciate some flexibility/time-off/extra time, etc.”  Or, if you need to get time off to go to therapy, you can say, "I've got a health issue where I'll need to go to a weekly meeting.  I'll make up the time missed by coming in early that day".  You don't have to discuss what is going on if you are concerned that it will lead to a negative perspective on your work performance.  On the other hand, most everyone has struggled in their life, so explaining that you're going through a difficult time and getting help can help your boss make sense of recent work mistakes, as well as be assured you're addressing the issue. 
 
3. Sharing with a friend
Think about the pros and cons of speaking with a close friend versus a less close friend. Some people worry that their friendship will change, and that they will be perceived as a burden if they speak about their mental health struggles. On the other side, a friend who knows you well may be more compassionate, supportive, and ready to help. It is important to note that despite good intentions, friends might respond in ways that are insensitive or give unwanted advice. Therefore, take some time to consider which friend would be most able to give you the help you need and what the consequences could be for your friendship.
 
4. Sharing with a teacher or school counselor
Many schools and colleges provide students with a counselor or contact person. Teachers and school counselors may have limited capability to give you long-term help, however, they may be a good point of contact for further resources and guidance on how to connect with a mental health care provider. 
 
5. Sharing with a physician
When people experience mental health-related issues, they often reach out to their primary care physician instead of contacting a mental health professional directly. PCP’s provide mental health care services such as diagnosis and (medical) treatment. Although primary care physicians have a general capability to provide mental health services, their consultation sessions are shorter compared to a psychotherapy session. Furthermore, PCP’s do not have the extensive training that mental health professionals have. Therefore, your primary care physician can help direct you to a mental health care professional if you decide to seek specialized care. 
 
6. Sharing with a helpline
Consider calling or texting a mental health helpline for free and confidential support. Crisis hotlines do not only provide suicide prevention services, they also provide support for people who are experiencing mental health struggles or going through a difficult time. Furthermore, they can provide you with information on resources through referrals to mental health care providers. 
 
Finally, consider preparing for this conversation with the help of a counselor or therapist. If you have been going to therapy you could ask your counselor to dedicate a therapy session to prepare for having the conversation about your mental health. Have you not yet spoken to a mental health professional? Therapy can be a safe space for you to share your experience without being judged and with a trained counselor who is willing to help. 

It is important to not be alone with your struggles, and whether talking to a therapist, a family member, a friend, or even calling a helpline to speak with an anonymous stranger, not being alone in your head with your difficulties is important.  We are social creatures by nature and seek connection.  Research has found that loneliness is one of the number one factors for not living a long life.  When we can share our vulnerable parts with loved ones, often it signals empathy and for them to connect with us.  For many it might lead them to worry, and feel like they have to fix it.  Letting the person know you're having a hard time, but dealing with it through therapy, or working with a doctor can relieve the other person of feeling overwhelmed with wanting to help, and provide space for them to be supportive of you. 
 
Additional resources:
National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org  
 
Sources:
Mental Illness Stigma and Disclosure: Consequences of Coming out of the Closet
Understanding the impact of stigma on people with mental illness

​The change from doing most of therapy in person to doing all of therapy remotely has been a big shock for both clients and clinicians.  Many clinicians have never had to do video sessions, and have had to step out of their comfort zone and figure it out so they can be there for their clients during this time of need.  Clients had to transition from the comfort of their therapists' office to doing therapy in sometimes not so comfortable places (e.g. home, car).  Fortunately, doing therapy remotely also has its upsides.

1) Flexibility
Doing therapy remotely has created a great deal of flexibility for clients who no longer have to drive to the office and juggle multiple work, child, and family obligations to carve out time to focus on their own self improvement.  Although it can be a little harder with kids at home or having others in the house, the tradeoff of being able to see therapists during a lunch break or in the morning has made it easier for clients to get the help they've been needing.

2) Opportunity
Let's consider the things that often hold people back from committing to therapy: the therapists office is too far away, they don't want to take time off of work, the social stigma of talking to their manager about taking time off of work to go, family commitments, etc. Now with the ability to do virtual sessions people may find themselves more open to the idea of taking time out of their lives to better themselves.  Thanks to the flexibility of virtual sessions, clients are able to streamline getting help. Clients are able to begin the process of meeting therapists in a more efficient way, without having to leave their homes or find a day with no soccer practice to bring their child into therapy .  Working remotely also allows them to manage some of the anxiety about talking to a stranger about the problems they've been struggling with.  Lastly, for better or for worse, many problems that individuals, families, and couples have been dealing with have come to a head now that they are stuck at home.  It was much easier to avoid the problems, but now many of those problems have been exacerbated, creating a crisis, and an opportunity to do something about it. 

3) Connection via Screens
Many therapists, as well as clients prefer to meet in person, feeling as though meeting remotely doesn't give the same human connection.  It's true, you can feel the emotion in the room, and the connection when your therapist is really getting you, not just on an intellectual level, but what we feel inside.  I've been doing therapy remotely for over 10 years, although they are usually one off sessions if a client is traveling, sick, etc. and it has been very effective.  I was wary about starting with new individuals, families, and couples that I had never met in person, but I found that we were able to make a strong connection just as if we had met in person.  While in-person sessions may be ideal, being able to connect with my clients through a screen while making them feel seen, heard, and attuned to has not been an issue. Whether I'm working with a couple in crisis, a teenager frustrated with their parents, a family and their anxious child, or an adult struggling with depression and ADHD, we're able to connect just the same as if we were working in person.  

4) Move Forwards or Backwards
We can either move forwards or backwards, but usually cannot stay stationary.  Life continues to move on, and as they say in drug and alcohol counseling, "we are either moving towards our recovery or our relapse".  This is a time to move towards your recovery, rather than letting problems snowball. Many families I have worked with who have struggled to develop structure with their children are now forced into a scenario where they have to figure it out.  To work, do homeschooling, and keep children entertained day in and day out is hard, and its created the need to stop procrastinating and find a system that works.  Many couples I've worked with were able to go through the motions, avoid each other in the time between getting home from work and going to bed. However, being stuck at home has forced them to turn to each other, to fight and resolve arguments, and find a resource in one another that they were able to survive without before.  Several of the couples I work with have had to depend more on their relationship during this time, and have jumped into creating a more satisfying relationship for both partners.  Many adults I work with have begun to address the issues they may have been avoiding such as connecting with friends and family, finally facing their anxieties about their finances, starting to exercise, and setting goals that work with family.  This time of shelter in place and social distancing for many is creating a context where we can no longer avoid, and so choose to move forward, rather than backwards.  

5) Accessing Expertise
Finally, one of the biggest shifts of working remotely has been clients beginning to realize that distance doesn't matter, and they can get the expertise they've been needing. By removing the psychological barrier of needing to meet in person, clients are beginning to reach out from areas far away and finally work with someone who is trained to treat their specific problem.  Whether it be exposure and response prevention for OCD, EMDR for PTSD, family therapy for oppositional defiance disorder, Cognitive Behavioral Therapy for adult ADHD, or Emotionally Focused Couples Therapy for relationship and sex problems, clients are finally getting specialized assistance, rather than transitioning from therapist to therapist who has a generalist approach.  When working with an expert they're no longer talking about how their week was and just giving updates, but specifically addressing the problems they're dealing with and learning the tools to overcome their difficulties to create lasting change.  

There are many out there who are struggling, and many where things have gotten worse with their drinking or conflict at home, or loneliness becoming overwhelming, but with the help of a good therapist, this time in life can become an opportunity to move forward, rather than move backwards.  The majority of therapists I speak with have been experiencing great success in their work with clients, and are often surprised at how the difference between working in person and remotely is not as great as they had thought.  It's allowed people who have not been making progress in therapy to get the expertise they needed to create lasting change, and to everyone's surprise, a remote connection is still a strong and deep connection.  I applaud the therapists who are becoming flexible and creative to provide what their clients need during this time of shelter in place, and encourage clients to reach out and take this opportunity to make the change they've been knowing they've been needing to make!

W. Keith Sutton, Psy.D. is the director of the Institute for the Advancement of Psychotherapy (www.sfiap.com) in San Francisco where he provides effective, evidence based treatments such as Structural-Strategic Family Therapy, Cognitive Behavioral Therapy (CBT), Emotionally Focused Couples Therapy (EFT), and Eye Movement Desensitization Reprocessing (EMDR).  Dr. Sutton has expertise in children, adolescents, families, couples, and individual adults.  He treats issues such as ADHD, OCD, depression, PTSD, panic attacks, anxiety, substance abuse/addiction, oppositional defiance disorder, relationship problems, and self harm.  He also provides training through his Institute to licensed and prelicensed clinicians, and is the director of the nonprofit, Bay Area Community Counseling (www.sf-bacc.org), where he trains and supervises interns learning effective therapies and seeing clients in financial need.   Dr. Sutton is the past president of the Association of Family Therapists of Northern California (www.aftnc.org) and the founder of Bay Area Therapists Specializing in Adolescents (www.batsa.net).