The reasons why some people find a healthy relationship unfamiliar, uncomfortable or difficult are very broad. It is difficult to define precisely what the causal factors are, because every individual brings a different experience of life to the encounter. We differ in how we perceive our everyday activities, our surroundings and other people. Alongside our instincts and drives, these differences help shape how we see prospective partners, friends, colleagues and anyone with whom we form a close relationship.
The question therefore concerns relationships at home, in private and intimate life, and at work. To understand it, we need to follow the development of the individual: how their biological makeup, emotional and psychological life, and experience of the environment become connected. These influences interact throughout life, and the relationship between them is different for every person.
Instincts and drives in early experience
My starting point is one of the foundations of psychoanalysis: the concept of instincts and drives. There are theoretical questions about how these develop, what is inherited, and how their expression takes shape during pregnancy and after birth. From a psychodynamic perspective, they are closely connected with the preservation of life, the need to survive and the capacity to respond to threats to existence. Their expression is individual from the beginning.
The experience of developing in the mother’s womb is also individual. It belongs to the biological formation of that particular child. From my perspective, the developing child shares the mother’s experience during pregnancy through the close connection between them. They remain joined during this period, while the child’s own biological makeup gives the developing experience its individual character.
Coming out of the womb and encountering the world as a separate human being brings a new range of experiences. The infant reacts to hot and cold, to contact and separation, and to changes in what feels nourishing or protective. Sensory experience is fundamental here. Something happens, and the infant responds before there is a developed capacity to think about what is happening.
These early responses contribute to the formation of mechanisms that continue to operate later in life. Some individuals are more immediately reactive. Aggressive responses may be more prominent in some than in others. As the infant becomes a toddler and a young child, these differences enter relationships with parents, carers, siblings, grandparents and other people.
The developing ability to engage with others involves a connection between immediate responses and the capacity to process experience through thought. An instinctive reaction can occur before conscious consideration. The person then needs a capacity to recognise what is happening, whether it feels pleasant or unpleasant, and whether to continue, withdraw or defend themselves. This is what I am referring to as a conscious filter: the ability to consider an experience and adjust the response to it.
These developments help establish what feels good or bad in relation to other people, the environment and the individual’s own internal world. In psychotherapy and psychiatry, we repeatedly encounter the importance of these early relationships, together with the person’s particular reactivity, in how they position themselves towards others and towards themselves.
It would nevertheless be a mistake to assume that early separation anxiety, hardship or even the loss of a mother at birth defines the whole course of a person’s life. In some individuals, an early difficulty remains highly influential. In others, development takes a very different direction. What follows depends on that person’s individuality and on the combination of biological, physiological, psychological, emotional and environmental circumstances they encounter. This is a process extending over many years.
In my experience, an immediate tendency to react may remain a prominent feature of a person’s functioning. An important question is where that reaction goes. It may be directed towards other people, or towards the self, as we can explore in some depressive presentations. The direction and meaning of the response have to be understood in the individual case.
As the person grows and begins to form relationships beyond the immediate family, these earlier connections enter the way they perceive others. Immediate responses become linked with thought, judgement and the attempt to understand whom they like and why. Sometimes the attraction is readily explained. At other times, it is experienced before any explanation is available. We feel a bond, a degree of commonality or a sense that we click with someone, without being able to identify precisely what produced it.
This is where a particular difficulty may emerge. A person may strongly desire intimacy, closeness and a good, reciprocal relationship. Yet once they enter such a relationship, they develop severe fears or anxieties. There may also be a physical reaction to intimacy. The relationship they wanted begins to feel unsettling, uneven, troubling or threatening.
The wish for closeness remains, but the experience of being close becomes difficult to bear. In understanding this, I return to the interaction between the person’s biological makeup, instincts and drives, early experience, and attachment to or disengagement from the important people in their life. The combination, and the way it is experienced, is particular to that individual.
The experience of care and the foundations of a healthy relationship
These early encounters take place in the child’s immediate environment. It is often assumed that if something appears kind, protective, loving and nourishing, the child will experience it in precisely that way. Clinical work shows that this cannot simply be assumed.
A person who has received considerable attention, affection and care may eventually experience it as suffocating. They may feel that they cannot breathe or become independent. In some clinical presentations, this sense of restriction is not adequately explained by what is happening externally. There is an internal transformation of the experience: what was offered as care acquires a very different psychological meaning. That becomes the person’s lived experience and something they carry into later relationships.
Some people develop a feeling that others are constantly observing, investigating or watching them. Overprotection from parents, grandparents or carers may be experienced as an invasion of privacy and individuality. The person may feel disabled by the degree of protection surrounding them. Sometimes this is accompanied by violent fantasies or a powerful wish to escape, and it shapes what they expect from future relationships.
On entering adult relationships, they may then seek an exceptional degree of freedom, with few bonds or commitments. They want to avoid the experience of being enclosed or watched over again. Another person may respond to similar overprotectiveness in the opposite way. They take it in, find it reassuring and come to regard it as necessary. Later, they may become equally protective of their own partner.
The protection may even be amplified. What this individual understands as a good expression of care is then experienced by their partner as intrusive. The partner wants room to breathe, to make decisions and to conduct aspects of life without a constant watchful eye. The difficulty emerges from the different meanings each person gives to the same kind of involvement.
Psychoanalytic ideas about projection and introjection become relevant to examining this process. We need to consider what has been taken into the person’s internal world and how that experience subsequently enters their expectations and treatment of others. An experience may have been internalised positively and then reproduced in a way that creates difficulty for someone else. Again, the actual meaning and effect depend on the individuals involved.
At this point, we need to clarify what we mean by a healthy relationship, and distinguish it from a relationship that has become strained or one marked by more serious pathology.
One basic premise of a healthy relationship is the ability to experience the good and the bad in the same person. We do not see the other as spotless, perfect or faultless. We recognise their favourable qualities alongside their limitations and the aspects of their behaviour that can be difficult.
A person may be exceptionally dedicated to their work and very good at what they do, yet become irritable, angry or unpleasant when exhausted. Both aspects belong to the same person. We can recognise the dedication and also acknowledge the effect of the irritability. Idealising their abilities while refusing to recognise anything difficult about them prevents us from seeing the whole person. Equally, an unpleasant encounter does not erase every good quality they possess.
A further premise is having realistic expectations of the relationship and what it can bring. Partners may encounter circumstances that seriously challenge the life they had imagined. Difficulties having children can become a major obstacle, especially when the relationship is established and both have formed expectations about a family.
How this is faced depends greatly on the partners. Some explore fertility treatment; others consider adoption or different ways of creating a family. Sometimes, within an extended family, relatives take responsibility for bringing up a child whose original circumstances have been difficult. Through the course of that upbringing, a close and lasting bond may develop. The significant issue here is how the people concerned take in the reality they face and what they are able to build together in response.
Understanding, empathy and tolerance are essential when difficulties arise. The partners need to be able to talk and exchange information about what is happening in their lives. When one person is under pressure, the other needs some understanding of that experience if support is to be possible. This two-way communication allows anxieties, worries and disappointments to become something the relationship can address.
Physical closeness and sexual satisfaction can also be important, in both heterosexual and same-sex relationships. In my clinical experience, however, the physical difficulty is frequently less central than the emotional or relational difficulty underlying it. An intense focus on physicality can sometimes become a smokescreen, preventing the couple from recognising what is troubling them in their way of relating.
Where the other foundations of the relationship are sufficiently developed, a difficulty with intimacy can be approached with tolerance and understanding. The partners can discuss it and take steps to improve their experience together. What matters in these cases is their capacity to remain engaged with one another while addressing the problem.
By contrast, some couples become aggressive and attribute the difficulties of the relationship almost entirely to physical dissatisfaction. The physical issue clearly matters to them, but it may not explain the wider disturbance. In these presentations, I regard the way the partners relate emotionally and psychologically as the central matter requiring attention.
A relationship may also encounter difficulties through the ordinary pressures of life. City living, constant work demands, family responsibilities and the expectation of being available almost continuously can create an accumulation of strain. That pressure can take a negative direction and begin to interfere with how the partners treat one another.
I would distinguish this situation from the more longstanding relational pathology being discussed here. The immediate difficulty may arise from the demands of the environment, rather than being primarily explained by early upbringing or the person’s instinctual life. It occupies a middle ground: a relationship may have been functioning well, but realistic pressures have progressively disrupted it.
Some partners become estranged because they have not communicated about those pressures in time. Their earlier understanding and tolerance gradually diminish. They begin to live increasingly separate lives, and the connection that once allowed them to support each other becomes weaker. These difficulties need to be understood in relation to the circumstances in which they arose.
When a good relationship is experienced as a threat
The more persistent relational pathology I am concerned with here involves difficulties a person carries into the relationship. These may already have appeared in encounters with parents, siblings, schoolmates or other people. Sometimes they are clearly visible to teachers or family members. At other times, they remain latent and become apparent only when the person enters a close or intimate relationship in adult life.
Whether the partners are of the same sex or different sexes, the underlying question concerns the capacity to engage with another human being. The manifestations may differ, but the difficulty can seriously interfere with the relationship.
The other person may be kind, caring, accommodating and empathic. They may want to communicate and build a two-way relationship. Yet those very qualities can be experienced as invasive or threatening. In more severe presentations, engagement itself can feel dangerous, as though it threatens the person’s psychological existence. The threat may be felt emotionally and psychologically, and it can also acquire a bodily expression.
The individual may then attack the other person’s stability and their capacity to sustain the relationship. What becomes intolerable is the partner’s ability to remain caring, receptive and emotionally available. The very qualities that could make the relationship nourishing are experienced with hostility.
The reasons have to be explored within that person’s own internal world. They may involve instinctual responses, early experiences or other circumstances encountered during upbringing. There is no single explanation that can be applied to every case. What we can observe is that the person’s responses turn a potentially good and developing relationship into something painful, difficult and, in some instances, seriously abusive.
It is important that this degree of difficulty is recognised early and brought to the person’s attention. Some patients can recognise how traumatic experiences have affected their view of others. Others begin to understand the part played in their experiences by ADHD, another form of neurodivergence or other difficulties affecting their functioning. What matters clinically is how the particular influences have operated in this individual and how they enter the present relationship.
Other people remain unaware of the difficulty. Their behaviour feels normal to them, even when the harm or distress it causes is clearly visible to those around them. They continue relating in the same way and may repeatedly create serious difficulties for their partners.
When I refer to pathology here, I am not necessarily describing homicidal behaviour or a threat to another person’s physical life. I am referring to a range of manifestations that attack the foundations of a relationship: its capacity for nurture, attention, affection and mutual care. These disturbances can affect the partners, their children and the wider life of the family.
Recognising the difficulty in psychotherapy
In treatment, we first need to understand the factors contributing to the difficulty. Diagnostic descriptions may be relevant, but they do not replace an examination of the individual. The patient’s capacity to recognise that there is a problem is fundamental to the work.
There is a significant difference between a person who recognises that something is troubling them and someone who attends because a family member, another authority or the law has brought them there. In the latter situation, the person may feel no concern and see no difficulty in themselves. The problem can be visible to everyone around them while remaining unrecognised by the person whose behaviour is causing it.
Proceeding as though there were already a shared understanding in such circumstances can lead to seriously unsuccessful treatment. That lack of recognition has to be addressed and challenged. In the work I am describing, awareness of the difficulty is the first essential step.
The next step is the capacity to engage in a two-way relationship with the psychotherapist and talk about the issues the patient experiences as pertinent and troubling. From there, it becomes possible to examine the past, including traumatic experiences or situations that may have contributed to the present pattern. Sometimes there has been obvious harm. In other cases, the difficulty has developed through experiences that did not appear damaging from outside.
The therapeutic relationship is particularly important because the patient’s way of relating may become directly apparent within it. What happens with a partner or another close person may also happen with the psychotherapist. The patient may respond to attention, care or an attempt at understanding in the same ways that have created difficulty elsewhere.
This is where transference becomes clinically significant. The psychotherapist encounters the relational pattern as something happening between the psychotherapist and the patient. The difficulty is available to be experienced, observed and examined within the treatment itself.
It is critical that this experience is used therapeutically and effectively. The patient’s responses in the encounter can provide a real indication of the way they relate outside treatment. Recognising and understanding the pattern while it is taking place gives the work a particular immediacy. This applies in the consulting room and in online psychotherapy, where the relationship between the psychotherapist and the patient remains central.
There are therefore many factors involved in how any person forms relationships, and many possible reasons why a fully developed two-way relationship can feel unsettling. In the presentations I have described, something potentially healthy may be experienced as dysfunctional, threatening or intolerable. The individual does not experience the encounter in the same way as the person offering it.
This brings us back to individuality. Each person develops their own attitude, perception of the world and internal representations of other people. Biological functioning, psychological life and environmental experience remain in continual interaction. We need to observe the individual in all three terms.
In my view, biology should not be underestimated or pushed into the background. Instincts, drives and the capacity to respond to hostility, threat and danger belong within our examination of the person. I am concerned that these roots are sometimes insufficiently acknowledged in contemporary therapeutic accounts. Human functioning is too complex for any one part of it to be set aside.
Developments in medicine and imaging, including applications of artificial intelligence, are increasing what we can investigate. Even so, what we observe in a person’s psychological experience is not simply interchangeable with what is visible through imaging. We still need to understand how the individual experiences and represents their life.
The differences between people facing serious physical illness illustrate this complexity. Why does one person cope with a particular threat to life differently from another? Their biological capacity to respond, including the strength and effectiveness of immune responses, forms part of the question. So do ways of life, family connections, relationships, nutrition, fluid intake and other circumstances. We need to examine how these factors operate together in that person.
The same attention to individuality is necessary when we consider relationships. The aim is a way of relating that allows empathy, kindness, a sense of togetherness and two-way communication. It includes being able to recognise the good and the bad in the same person, and to understand that any relationship will encounter hurdles.
At times, life and relationships will be difficult. Circumstances improve and deteriorate, and the people involved need to be able to receive those changes and respond with attention and care. Understanding why this feels possible for one person and unfamiliar or threatening for another requires us to keep returning to the particular human being and the life they have experienced.
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