Love,Grief,and the Therapeutic Relationship: An Essay

Abstract

This essay explores the development of mutual and platonic love between a client and therapist. The author, a psychotherapist herself, provides a first-hand account of her experiences as a client in long-term relational psychotherapy, including reflection upon her grief regarding the relationship’s abrupt ending due to her therapist’s cancer diagnosis. Drawing upon Martin Buber’s concept of the I-Thou Relationship, as well as contemporary research surrounding the vital role of the therapeutic alliance in psychotherapy, this paper encourages therapists to fully consider the tensions that exist between the contractual versus human aspects of psychotherapy practice while embracing the inevitably relational nature of the work. To acknowledge love for one’s clients is complex and fraught with ethical and professional risks, and to fully attune to our clients’ love for us may be uncomfortable; however, as this essay suggests, there are also profound risks in dismissing, minimizing, or pathologizing these feelings. While remaining committed to necessary professional standards and boundaries, this author’s experience suggests that full recognition of the mutual love that may develop between client and therapist embodies a relational and feminist ethos to practice, may enhance therapy’s outcomes, and importantly, emphasizes the common humanity shared between both parties.

I clearly remember the moment that I first told Terry, my therapist, that I loved her. After endeavoring, awkwardly no doubt, to make it clear that I did not mean “love” in a romantic sense, I explained that though I understood the maternal role she represented for me—the stuff Freudian clichés are made of—I would be offended if my use of the term “love” was therapized (and thus minimized) in this way. I was fully aware of my transference, and yet I was simultaneously grappling with a real and present love for her real and present humanity. Wasn’t this perfectly reasonable?—a genuine affection for a remarkable woman with whom I had spent hours and trusted with the most intimate parts of my psyche, all while feeling held, seen, and yes, loved, in return. And if it was indeed perfectly reasonable, why did it feel so fraught to use this l-word to describe this relationship?

I was Terry’s client for nearly 16 years. My perspectives on this therapeutic alliance are informed not only by my experiences as a client, however, as I am also a registered psychotherapist and certified music therapist. I am a music therapy professor, and I teach music therapy/psychotherapy theories and skills to graduate and undergraduate students. I am an experienced clinical supervisor and was recently Ethics Chair on the Board of Directors of my national professional association. I am, thus, well-versed and highly invested in the importance of ethical standards and boundaries in our therapeutic alliances. As a psychotherapist, I believe that the work of wholly being-in-relationship, in all of its joys and messes, though difficult to standardize or manualize, will best translate to our messy and relational human lives. Relationship is central in my work as a music therapist, too, wherein I strive to use the relational medium of music-making (Mitchell, 2023) to explore creativity and presenting issues in ways that are unique to each client with whom I work.

Flückiger et al. (2018) describe the therapeutic alliance as representing “an emergent quality of mutual collaboration and partnership between therapist and client” and infusing “every interaction throughout psychotherapy” (p. 318). Research indicates a strong predictive association between the strength of the therapeutic alliance and therapeutic outcomes (Baier et al., 2020; Flückiger et al., 2018; Krupnik, 2023; Tschuschke et al., 2022). Though studies diverge in how the alliance is defined and measured (Horvath, 2018), the “robust association” (Krupnik, 2023, p. 207) between alliance and outcome is consistent across research spanning three decades, with one recent meta-analysis of 295 studies demonstrating this association as stable across therapeutic approaches, client characteristics, and countries (Flückiger et al., 2018).

Gelso (2011) proposes that any therapeutic alliance includes three components that are “constantly interacting synergistically:” the working alliance, transference/countertransference, and the real relationship (p. 14). Defining the real relationship as “the personal relationship. . .as reflected in the degree to which each is genuine with the other and perceives the other in ways that befit the other” (pp. 12–13), he proposes that it is “the foundation of all that transpires” (p. 16). Gelso et al. (2014) note that, while transference is a natural occurrence within psychotherapy, so too may “reality-based and genuine love” be fostered, particularly in long-term work (p. 126). As Gelso and Kline (2019) remark, “There is virtually always at least a degree of taking to, caring for, and connecting to the patient that is based upon who the patient and therapist are as persons” (p. 144). Gelso (2011) states:

The kind of love experienced by both therapists and patients within the context of a real relationship might best be described as agape, a nonsexualized kind of loving that I believe occurs far more in effective psychotherapy. . .than therapists lead each other to believe. These loving feelings make for powerful and helpful real relationships. (p. 155)

The presence of this kind of love, rarely acknowledged in our literature, is normalized in writing by relational psychotherapists, particularly those associated with the Stone Center. Jordan (1995), in her assertion that “the most basic human need is the need to participate in relationship” (p. 56), proposes that relational practice requires that therapists are open to being “known,” “vulnerable,” and “emotionally and cognitively moved by the other person” (p. 55). Though therapist/client relationships are not “symmetrical,” Jordan suggests that they ideally foster “mutuality,” including “mutual empathy,” which occurs “when two people relate to one another in a context of interest in the other, emotional responsiveness, and cognitive appreciation of the wholeness of the other” (p. 57). Though she acknowledges that the topic of love must be approached cautiously, Jordan believes that talking about love in therapy can generate “creative transformations” for clients (Kottler & Carlson, 2009, p. 141). Mihalko (2013), a student of Jordan’s, in a letter penned to young therapists, states, “You need to both become a master at your craft and a master at loving a fellow human being” (para. 30).

Terry was no doubt a master at her craft. Through Terry’s humanistic, feminist, relational, and psychodynamic approach to psychotherapy, I experienced the attunement that my mother, because of her mental health issues, could not provide. I developed a healthy and reparative attachment. It was with Terry that I re-learned to cry and found genuine anger, rather than holding tightly to emotions lest I make others uncomfortable. With Terry, I practiced the tightrope walk of caring for others while no longer sacrificing my Self (Terry always capitalized the “S” in Self, conveying respect for my personhood). When I faced a serious health concern that required invasive diagnostic procedures and surgery, Terry assisted me in conquering the debilitating anxiety surrounding medical procedures that I had experienced since childhood. Terry led me in rituals of physically burning beliefs that no longer served me and planting new ones, along with crocus bulbs, in autumn soil. And it was Terry who dared me to create my first online dating profile while still maintaining my core belief that men were not attracted to me. I would like to think that I would have eventually lost my virginity had I never met Terry, but I’ll never be sure.

I cannot separate Terry’s craft and these therapeutic outcomes from our relationship, however. Terry’s genuine care for me was embodied in ways that transcended her duty in a contractual sense, for example, as she belly-laughed at my jokes and teared up at details from my past. Importantly, we did talk about our relationship, explicitly working to tease apart transferential elements from the mutuality that existed between us. Casting light upon transferential dynamics helped me to better understand myself and work through primary needs; acknowledging our real relationship affirmed for me that my care for Terry was not pathology, but rather was appropriately in-tune with the dynamic in the room and evidence of our shared deep capacity for relationship. It was usually me who requested these conversations, as I grappled with the inevitable tensions between our human mutuality and the still unavoidable power imbalance in our, in any, therapeutic alliance. I felt vulnerable in this, particularly as I knew that Terry was approaching retirement, a time at which the contract between us would take utter precedence. We talked about this too.

Then, over a year ago, I received an email from Terry, oddly vague in its request that we meet as soon as possible. I knew in my gut that something was wrong, though I endeavored to challenge my catastrophic thinking as the good client that I was. In my response, I asked if she could provide a bit more information about this unusual meeting request. I learned quickly that my gut was correct: Terry had metastatic cancer and needed to close her practice immediately to begin treatment. Her email was signed “Respectfully, with love”—the first time she had signed correspondence using that l-word.

We met the following day for what was indeed a thoroughly loving conversation. We reminisced about the most memorable moments from our work together, the funny, the tender, the impactful. She reflected on the evolution she had witnessed in me, and I tried to believe her. I cried, a lot. I asked if I could take a screenshot of us together; she agreed and suggested that we lift our arms so that in the photo it would look as though we were holding hands across the void of our two-dimensional Zoom boxes. In the end, I said, “I love you very much”—words I had considered saying previously but from which I had always stopped myself from saying in this direct way. A pause. Then,

“I love you too, Liz Mitchell.”

I understand that this relationship was never “mutual” in the give-and-take manner of a friendship or partnership. But it was mutual in its depth of care. It was real, the kind of relationship that Martin Buber describes as I-Thou, wherein we see the other’s wholeness and become “bound up in relation” (Buber, 1958, p. 7). Jordan draws upon Buber’s contrasting concept, that of I-It, when she admonishes traditional psychological diagnostic practices and treatment manuals for objectifying clients and turning them into “its” (Kottler & Carlson, 2009, p. 134). If therapeutic alliances are “deeply bipersonal” (Gelso, 2011, p. 161), I-Thou encounters, then we must interrogate the means-to-an-end mentality with which we usually conceptualize psychotherapy. Terry was not simply putting in time in order to be paid, though I did pay her, and she would have benefited from this remuneration. And though there were undoubtedly many therapeutic benefits to me, I bristle at the notion that I was using Terry in a transactional sense to simply improve my own life, because I cannot separate those transactional benefits from her relational presence. In Jordan’s (1990) rebuke of traditional Western psychology’s narrow focus on self-development, she proclaims, “People move into relationship, not simply to ‘get for the self’ or as a means to develop the self, but to contribute to the growth of something which is of the self but beyond the self: the relationship” (p. 11, italics in original).

As I endeavor to capture my own experience in words, I am struck, still, by its inherent paradox; that is, that my alliance with Terry was both fully contractual and fully relational. Certainly, the grief I have faced over this past year has highlighted the tensions that exist between these elements of a therapeutic alliance, throwing into relief both the reality of a contractually bound relationship and the depth of genuine love that I hold for this human being. These two elements are both fully true even as they exist in tension with one another.

I understand that the boundaries of the therapeutic relationship exist to keep both parties, particularly clients, emotionally safe. I signed up for this. And yet, I could not have foreseen the length of time we would work together, the transformational role that the work would hold in my life, or the depth of care I would grow to hold for my therapist. My grief at Terry’s sudden absence from my life is not merely the stuff of Freudian clichés, but rather, is a natural part of having been in a real relationship with a person worthy of my love. Every hour that she spent with me, I too spent with her. I was not the only one showing up for our sessions. Though I know far fewer biographical details about her life than she does about mine, I know her presence well.

My grief has felt disenfranchised (Doka, 1999) in many ways; it has been isolating and challenging to explain or even to acknowledge in many contexts. There are no social scripts for the sudden loss of a long-term therapist. From my own perspective as a psychotherapist, I am struck by the fact that, within this professional community, I have never heard an experience like this one discussed in an I-Thou sense. We may raise an eyebrow in concern that a client grieving their therapist had become overly dependent, not focused enough on their own individualized gain, but we do not affirm that the relational nature of our work means that it comes with genuine, human risks. Our clients may risk loving us. And this may lead to the heartbreak of sudden loss.

I am not suggesting that the topic of love is appropriate in all therapy sessions. I am aware that I am not a typical psychotherapy client; a psychotherapist myself, I hold an in-depth understanding of the theoretical constructs that underlie our work and an interest (enthusiasm, even!) in talking about them. I am also relatively healthy, in all senses of the word. Even those in our field who are most vocal about love’s presence in therapy still recommend caution. Jordan (Kottler & Carlson, 2009) notes the risk of misunderstanding when the term “love” is used in therapy and recounts the therapist’s duty to protect, given our field’s history of exploitation and abuse. Acknowledging the risk that patients and therapists alike may become conflicted or confused by the word “love,” Mihalko (2013) clarifies that he does not frequently tell clients that he loves them. He continues, however, by stating “I am not afraid to love and to say that I do when a moment of genuine honesty is the best intervention” (paras. 27–28). As Gelso (2011) says,

Psychotherapists have shied away from more profound affects such as love (and hate) in their professional writing. The word itself makes professionals uncomfortable, even squeamish, because it does not bespeak a very ‘professional’ relationship and because the word conjures up thoughts around sex and sexuality. However, agape is not sexual but instead reflects a very deep human caring, which is likely to have a healing effect in psychotherapy. (p. 156)

Psychotherapy training and continuing education teach clinical boundaries well; we are well-versed professionals when it comes to the valid risks of developing loving feelings or talking about love with our clients. It is imperative that we simultaneously acknowledge with our students and with one another that feelings of love will arise in our work and that there are also risks when we choose to not talk about love, particularly if our clients bring this topic to our attention. Gelso (2011) notes that it “does not help our patients” to shy away from the “deeply personal” nature of psychotherapy, even though it “may make us therapists more comfortable” (p. 156). Had my own need to acknowledge the presence of love in our alliance been met by Terry with therapy-speak—a dismissal of what I was saying combined with a clever shift of focus to my relationship with my mother, perhaps—I would have experienced a profound and harmful level of invalidation. I would have fundamentally doubted my self-awareness and my ability to discern relational dynamics, and that self-doubt would have transcended the therapeutic space. I have already acknowledged that recognizing love in the therapeutic space felt very vulnerable for me. It was not without risk. And yet the risks of not talking about and not being heard in it were far greater.

No doubt, it is easier as therapists to keep our care reigned in, to see our relationships as I-It (Buber, 1958), defined by contracts and instrumental benefits. Likely, there are clinical scenarios wherein this is an appropriate approach that best and most safely serves the needs of both parties. However, in scenarios wherein it is our aim for the relational nature of the work to translate to the relational nature of our client’s lives, we must risk wholeness: to be seen as whole and to see the other as whole. We can remain fully committed to ethical integrity while also being open to what unfolds in the I-Thou.

In my process of working through this grief over the past year, it eventually felt timely to seek out a new therapeutic alliance. Though any conception I had of griefwork involved an “intimate (unscripted) therapist-patient relationship forged in genuineness” (Yalom, 2002, p. 223), I initially felt self-protective. Should I try a more manualized approach? Or, should I find a new relationally-oriented therapist, knowing what I know? That therapy, just like any relationship, can end in heartbreak?

That is the crux. This is life in relationship, the life that my work with Terry was always preparing me for—a life in which, holding the truth that love may bring immense pain, I will still choose to be in relationship and to love.