Adam Polnay is a Consultant Medical Psychotherapist and main author of the Cambridge Guide to Psychodynamic Psychotherapy.
Adam Burley is a Consultant Clinical Psychologist and Professional Lead for the Specialist Trauma Service in NHS Lothian. He is on X: @DrAdamGWBurley
In her memoir, The Instant, Amy Liptrot captures the feel of the internet buzzing in our ears, and the siren call of definite answers and one-click solutions for the most complicated problems. Through the telling of her own story, including her relationship with alcohol, Liptrot contrasts this yearning for instant relief and for things to ‘just be right’ with the painful realities of slow, ordinary change across a lifetime.
Similarly, we — our patients and ourselves — may be drawn to quick fixes for aspects of our lives. In the area of emotional and mental health, for certain troubles, like a temporary period of feeling down or a reaction to a loss, a short-term focus may indeed be appropriate and enough. But when it comes to more deep-seated patterns in how we relate to others and navigate the world, change is rarely instant nor easy.
“David’s childhood climate appeared to be one of neglect and risk: to himself and his possessions.”
Relational change is slower, perhaps because of the nature of how we engage with others: this could be understood as a largely unconscious process, influenced by practices formed early in life.
In this article, we explore what happens when our automatic ways of being in relationships are no longer serving us well. Moreover, if we can observe what we are doing, is this enough to change things?
Illustrative clinical scenario
To help explore the topic of slow relational change, I (Adam Polnay) introduce an illustrative clinical scenario (see Box 1).*
| Box 1. Illustrative clinical scenario — ‘David’ |
| David sought help from the out-patient service where I was working. Prior to seeing me, David had consistent support over several years from a housing officer who had encouraged him to turn to health care.
We first met in winter. David said he had been feeling depressed for years and wanted to understand how things had got to this point. David came to each appointment wrapped in many layers of clothing and kept them on. For some months, David rarely mentioned the actual name of anyone in his life, past or present. I had an image in my mind of distant, non-descript figures out there, which felt cold and somewhat disheartening. As we moved into spring and the weather warmed, David continued to wear the same heavy layers he had bundled up in during colder months. One afternoon, David sat in full sun by the clinic window, pulling at his collars and perspiring under his shirts, coats and shawls. I felt hot and uncomfortable watching but was not sure what, if anything, I should say. David caught my eye, as if interpreting my gaze, and said: ‘A few years ago, a friend, he takes me down south to try and cheer me up. It’s 30 degrees. My friend says, “Why are you keeping your coat and hat on, are you crazy?” I’m grumpy as it’s so bloody hot. He’s getting annoyed and says I’m “being destructive” … He eventually ditches me, like everyone does … ‘ David was brought up ‘always between homes, but never at home’. He would say in an unconcerned tone that he was ‘left to his own devices’, which seemed to mean that his basic needs were often neglected. As a child, David learned that if he put his clothes away, they would go missing, and he would end up feeling cold and exposed for long periods. He later elaborated, ‘I just feel safer with them on and won’t be parted from them.’ In his life now, David struggled to make use of various services, including seemingly benign facilities like the library, because it meant trusting the library staff and showing he needed their help. He circled the library but could not bring himself to go in. |
David’s childhood climate appeared to be one of neglect and risk: to himself and his possessions. Faced with inescapable cold — both physically and emotionally — he learnt not to rely on others and instead to look after himself. He kept vital possessions (clothes, food, money, and personal information) close to his chest.
David let people in — up to a point. After all, he came to see me. He repeatedly brought themes of distance from others and anxieties about trust, and expressed this content with a sparseness of detail that could leave me feeling held on the outskirts of his experience. Overall, my impression was that he was wary of making himself vulnerable and putting his trust in others.
Learning about relationships
When we face prolonged or repeated situations — whether mainly good, bad, or a mix of both — our ways of living and interacting adapt to fit the circumstances, driven by our physical and emotional needs. We interact with ourselves and others automatically for the most part (some may say unconsciously), responding and acting in certain ways without fully realising or questioning what we are doing — as with David’s wariness about showing vulnerability or trusting others. Mark Solms, author of The Hidden Spring, explains that these adaptations are deeply learned and can become part of our personality structure. They take time to learn and are ‘hard to forget’.1
The first few years of life are a sensitive period for learning many things, including what relationships tend to be like and how we interact socially. Adolescence is also an important phase where rapid social development can take place. While these early ways of being with people are not set in stone, learning new ways and updating the old can be a difficult and slow process. Even when our lives change, we may still — to varying degrees — experience the world through the lens of our early adaptations. The US psychotherapist Jonathan Shedler frames this as a difficulty in sensing ‘that was then, this is now’.2
“Our relationship procedures are closer to walking or riding a bike.”
These ideas might help explain why David’s adult ways of functioning remained so deeply influenced by his early experiences. He continued to perceive, predict, and relate to the world as a rather threatening and dangerous place, even though the external threats appeared to have reduced since his childhood.
His layers of clothing were not really an issue for him, but his layers of relational mistrust seemed to be playing a part in depressing him. David was really attached to these ways of being, but in our early consultations he did not seem all that curious about them — even though they now seemed to be creating at least as many problems as they solved.
Becoming more aware of our patterns in relationships
Our relationship patterns, or ‘scripts’, as some therapists call them, are mostly automatic. These deeply learned adaptations have various names in different therapy traditions: ‘core schema’, ‘object relations’, and ‘reciprocal roles’, for example. Neuroscientists use the word ‘procedures’. We quite like this dry term as it conveys something of the unquestioning acceptance, almost detachment, we have about some of the things we are, paradoxically, most wedded to. Our associations — the deep links in memory between things — are also important. For example, David had formed a strong link between the act of undressing to store his clothes and the aversive experiences of losing them and feeling cold and exposed.
Our procedures for how-to-be-in-relationships cannot be brought directly to mind in the way we can recall factual information or specific scenes from the past. Our relationship procedures are closer to walking or riding a bike. Many people think you go round a corner on a bicycle by turning the handlebars, but it turns out we do it mostly by leaning the bike while engaging our core muscles.
Emily Dickinson writes, ‘The mind is so near itself — it cannot see, distinctly’.3 If we want to gain perspective on how we operate in relationships, we may need to make careful observations and enlist the help of others. We might confide in friends we trust to find out their reflections and observations on how we handle certain situations (though don’t necessarily expect them to answer straightforwardly!). Sometimes, unbidden, those we are close to tell us painful ‘home truths’ about aspects of our interactions. These can be hard to take but may hold riches if we can come back to them once we have licked our wounds. If we are becoming depressed by our interactions (such as not trusting others), we might, if we are secure enough, consult someone in the caring professions. Or, we might turn to certain forms of psychotherapy where the ways we relate to others, including the therapist, are on the table as a valid topic to observe and understand.
New experiences and change
“… for someone on the brink of managing or not managing, small shifts can make all the difference.”
Gaining a perspective on our automatic responses is important, but to deeply change how we relate we need to then try out and experience a somewhat new and different way of being, and then repeat that experience many times. While learning a new physical skill may be a drawn-out process, change in the ways we relate to others is often much harder. We typically have deep attachments to our old ways of interacting because they may have once protected us, even if they no longer serve us well today. They are familiar, and the prospect of change can evoke something of the original anxieties that led to us developing these procedures in the first place. David had learned to be wary of relying on others to survive in the world, physically and psychologically. For some of us, re-visiting or exploring alternative ways to be in relationships might be unthinkable or seem like madness.
We might liken learning new ways of being in relationships to attempting to learn a second language as an adult. Anyone who has tried this knows how challenging it can be, as the sensitive period for easily learning languages has long passed. If we moved to Spain for an extended period — we’re talking years here — and immersed ourselves in the language and culture, we might eventually speak Spanish passably. Our English might even pick up a slight Spanish accent. Even so, we will never forget our mother tongue; it can’t be unlearnt.
Similarly, with relationships, through repeated new experiences over years we may be able to learn the basics of new ways of interacting with others (learn a second language), or update our old procedures (develop a new accent). Nevertheless, our early ways may still feel the most natural. This helps us to understand and have compassion for the time it can take to contemplate change and then work things through.
Illustrative clinical scenario continued — the value of small, slow changes
I (Adam Polnay) could see David’s cautious approach to trusting others in how he related to me. When we first met, he said little. However, over the course of a year, he slowly began to relate his story.
David seemed to carry into our contact the connection he had developed with his housing officer in the years before coming to the clinic. After a year of meeting, as the weather turned colder again, he began to mention people’s names. His housing officer’s name. Then the name of someone he met on the steps outside the library. David said his terror of relying on others had softened slightly.
The appearance of these names in David’s narrative could easily be overlooked as a small detail. But for David, whose first ‘language’ was mistrust, this suggested an important shift. I think these real names reflected David developing slightly closer relationships with others, as well as risking trusting me with this new information. A mentor of mine once advised me not to underestimate the importance of small changes; for someone on the brink of managing or not managing, small shifts can make all the difference.
When I’m feeling hopeful, I think the therapeutic setting provided by our regular meetings may have allowed David to experience his feelings of caution and mistrust within a relationship, to sit with that unease, and still continue to meet to see what might emerge. Stephen Mitchell, a US psychotherapist, refers to this process as discovering ‘something new from something old’.4
Conclusion
Some clinical encounters can be resolved relatively quickly, whereas those to do with longstanding relational dynamics may entail a slow evolution. When it comes to our underlying, unconscious ways of interacting with others, meaningful change takes careful observation of our patterns, steady contact with others, new experiences, and patience for the long view.
| Key points |
| 1. Our earliest relationships involve depending on others for care. During sensitive developmental periods, we learn what relationships tend to be like and how to interact socially. 2. Our procedures for how-to-be-in-relationships are deeply learned and largely automatic. 3. These procedures for how relationships work map onto later relationships with providers of care. 4. Healthcare relationships may, therefore, for some people, be a place of anxiety but also offer the potential for new experiences and to update or learn new ways of relating. 5. Meaningful relational change takes time. While many healthcare appointments may be relatively short, offering a consistent presence over time is likely to support a process of slow evolution. |
Authors’ note
The clinical scenario is a fictional illustration informed by Adam Polnay’s clinical experiences.
Acknowledgements
We thank Allan Beveridge, Angela Drinnan, Daniel Smith, Lindsey Gilling, and Rhiannon Pugh for their helpful suggestions on the manuscript.
References
1. Solms M. The Hidden Spring: A Journey to the Source of Consciousness. London: Profile Books, 2021.
2. Shedler J. That was then, this is now: psychoanalytic psychotherapy for the rest of us. Contemporary Psychoanalysis 2022; 58(2–3): 405–437.
3. Dickinson E. Emily Dickinson, Amherst, Mass., autograph letter to Thomas Wentworth Higginson, 15 April 1862. 1862. https://www.digitalcommonwealth.org/search/commonwealth:kh04mv60w (accessed 17 Dec 2024).
4. Mitchell SA. Influence and Autonomy in Psychoanalysis. New York, NY: Routledge, 1997.
Featured photo by Pawel Czerwinski on Unsplash.
