Couples and Sex Therapy: Myths and Truths (Part 1)

Preston: [00:00:00] Hey, welcome back to How To Patient. I'm your host, Preston Roche, and I'm here with your co-host Margaret Duncan, and we have another guest here today who is 

Margaret: my best friend from residency and also. A couples and sex therapist and psychiatrist in reproductive in women's mental health, Dr. Nikki Hadda, 

Preston: Dr.

Nikki Hadda. 

Nikki Haddad: Welcome Nikki. So happy to be here. 

Preston: If you were, what would your walkout song be as a sex therapist? 

Nikki Haddad: Ooh, going. Let's get it on a classic. 

Preston: That's good. Marvin Gaye. Cool. So, um, you guys were in residency together, right? 

Nikki Haddad: Yes, indeed. 

Preston: And so Nikki, you, is Nikki okay. Or is it Dr. Hadda? Oh yeah. Of she remember of course.

Please 

Nikki Haddad: call me Nikki. 

Preston: Okay, nice. We're familiar here. So, um, I actually don't really know much about this type [00:01:00] of fellowship. How did you find that coming out of, out of residency? 

Nikki Haddad: It's a good question while it's unaccredited, so there's not that many fellowships in women's mental health around the country.

I think there's probably 12 total, and 11 of the 12 are very focused in perinatal. I. Women's mental health, so reproductive health around preconception, counseling, pregnancy, and then the postpartum period. The fellowship that I am in is the only one that exists right now that's actually not perinatal focused.

Oh. So it's more focused on trauma disorders, eating disorders, personality disorders, and other things that affect primarily women. Um, and the specific kind of physiology around that Trailblazer. 

Preston: Unaccredited. I think we should try say pre accredited, right? Yes. All, all fellowships are pre in the pre accreditation period.

I, I like that 

Margaret: the Nikki did two years of [00:02:00] one. Our residency has one of the fellowships, and so Nikki is not saying, she also did two years of specialized perinatal work. Oh wow. Outside her 

Preston: fellowship that she had during residency. Wow. Humble too. That's 

Nikki Haddad: that. Very humble. Yes. Um, yeah, that was part of why I didn't wanna do perinatal actually, is because, not that I know everything there is to know by any means, but I just wanted to expand my, I.

Kind of education around things that we didn't learn as much about. Um, so, you know, Margaret is doing a lot of the perinatal stuff now, and it's, it's so important too, of course. But I, my my kind of spiel is that women matter beyond just their reproductive capacities. And so I kind of like the concept of mm-hmm.

Preston: Women, women are more than baby ovens is your thesis. Yes. Yes. Wow. Well, that's, that's definitely gonna, um. Stir the pot a little bit and you know, I, I hope that you can convince some other people to agree with you, [00:03:00] but, um, I hope for those who are listening now, I'm, I'm being facetious. Like I really, 

Margaret: you didn't know he had called through before in the last episode, and so now he's like, 

Preston: yeah.

Now. Okay. Well now that we've dispelled miss about the perinatal, perinatal and women's fellowship. Let's talk about our icebreaker question. Nikki, you have the distinct honor of joining us for the icebreaker today, which is, what is one myth about romantic relationships that you wish you had learned earlier or that more people talked about?

Nikki Haddad: Hmm. That's a fun question. I. I think for me it's probably that when you meet the right quote unquote right person, that a relationship should be easy. Um, I think parts of a relationship are easy, but relationships require you to kind of wake up every single day and choose to be there for that person, choose to show up.

Choose to love them and they require time and energy and commitment and all of those things. And there's inevitably gonna be [00:04:00] challenges that come up as well. So I think the idea that if you're with the right person, things should be easy, is kind of a dangerous. Myth that doesn't allow people to grow in relationship with each other.

And one I definitely believed, 'cause I watched a lot of Disney Princess movies, I was like obsessed with those when I was little. And you know, the, the princess finds her prince and then lives happily ever after and life is good, yada, yada. And the movie actually ends right when they meet. Mm-hmm. Because the implication things there is no happily ever after.

Preston: It's just your imagination. Exactly. 

Nikki Haddad: Happily. A bar after doesn't really exist guys. And that's credit. We'll see. 

Margaret: Leave us reviews. 

Preston: Alright, thank you so much for listening tonight. 

Margaret: Okay, bye. 

Preston: So, um, that I really resonate with what you said. It, it reminds me of this, um, passage I was listening to the New York Times where they're talking about how to use metaphors for your relationship.

I think it was an advice piece for 2024 and they said that. People think that good relationships are like a [00:05:00] vase. It's pristine, it's beautiful. You know, you, you put it in the middle of the living room so it all can see, but the second it gets knocked over, it shatters and it can't withstand any kind of conflict.

And, and so they were saying try to make your relationship more like a basketball, something that you can bounce around and is durable you can play with. And if it, if it falls on the ground or, or is thrown against the wall, it's gonna come right back. And I really connected with you saying, you know, if the right person makes everything easy, then that's, that's it.

But, but with the right person, you should be able to withstand the hard things, you know, the whole basketball match, I guess. 

Nikki Haddad: I love that. And if the basketball deflates, you can reinflate it too. 

Preston: Yeah. 

Nikki Haddad: It's like more malleable. I think that's, so, I, I would love to read that piece. 

Preston: I'll see. I'll see if I can find it.

Okay. Afterwards. Okay. Well thank you for that wonderful and thoughtful answer. Hopefully Margaret can top it. I mean, not that it's a competition, but let's go. Let's, 

Margaret: and I talked about this [00:06:00] stuff ad nauseum, so, um, I can't top it is what I'm telling you. I think somewhat similar. Um, I think this idea that we're just automatically built with relational skills and they're either you have them or you don't, is kind of implicit.

Like it's not something that a lot of people talk about until something's wrong, whether in the relationship. I also think a lot of intrapersonal skills are inter, are required for good interpersonal relationships and so people come to therapy or they come to couples therapy when something is, usually when something's going pretty.

Feels bad or is going wrong in some way. And I think the cultural myth that it's like everyone just knows how to relate to people and that we don't need to talk about it or learn new skills, keeps people similarly to what you were saying, Nikki, like stuck. Mm-hmm. And it makes them think that they're like particularly uniquely messed up rather than like, oh yeah, you just, like, you guys don't know how to do this together yet, like you're learning a new dance.[00:07:00] 

Um, so similar I think in that it gets them stuck and like they can't change. 

Preston: Like the myth that social romantic relationships are as, as instinctual as breathing. 

Margaret: Mm-hmm. Mm-hmm. 

Preston: Can't be taught to the lay person. Yeah. 

Nikki Haddad: Mm-hmm. Yeah. Yeah. And you have to, to learn in the relationship, but also as an individual.

And we'll be talking about that I think in the podcast too, about the different components that you bring into a relationship and the, the stuckness that one can feel when it feels like things have to just be perfect, when in reality there's a lot that you can do to change yourself and thus change the relationship even if you don't have control over another person.

Preston: Mm-hmm. All great, all great points, Margaret. Uh, a close second. How about you? So, um, I'm gonna take a different approach and say that one myth that I believed for a long time that kind of drove me into relationships was that it's not okay to be alone. [00:08:00] And I think that the, everything we're fed from early on is like, you'll find someone, you'll find your, your prince charming or your princess, and like, everything's okay.

Don't worry, there's other fish in the sea, someone's gonna come along, but what's. Never said by that. And what's kind of implied by that is you won't be alone your whole life, almost like it's a bad thing to be alone. And so I think that there were a lot of times where I was in relationships and I, and they weren't right for me, I wasn't happy and I was afraid to get out of them because I was like, oh, well this is better than be alone.

At least I'm not by myself. And I think once I realized that I had to have a stable relationship with myself and really realized, oh, I could be happy in solitude. While then, that's actually the time where you become ready to accept someone else into your life. Yes. So you have, you have to accept the thing that you're afraid of to like, to make yourself, you know, a stable ship ready to sail the seas instead.

Instead of just trying to be a tugboat, I guess. [00:09:00] 

Nikki Haddad: Right, right. Yeah. As you were talking, I was thinking about the difference between being alone and being lonely and how lo you can experience loneliness in relationship with another person. And in some ways, that's almost more painful than being alone, but societally it's not as.

Acceptable in a lot of spaces. 

Preston: Absolutely. People will pity you when you're by yourself and it's almost like, I dunno, don't pity the person who's enjoying their solitude. Pity the person who's unheard in an unhappy relationship. Right. 'cause that person is far lonelier. 

Margaret: Yeah. It makes me think what you were saying, Preston, of this quote by, um, the who said.

Real love is guarding the other person's solitude, um, rather than the urge to kind of control or compress it. Um, which I think is, I don't think it has [00:10:00] to have, like, I think there's a lot of debates online that are like, do you have to love yourself before you can love someone else? It's like, it's not so simple and straightforward is all that, but I do think there is something about can you maintain.

The ability to not sprint away from yourself and your, like, inherent isolation in the world just because you're a human being, uh mm-hmm. And not sprint into a relationship because of it. 

Nikki Haddad: Yes. Yes. I think that's such a gorgeous quote. And the idea of guarding someone's solitude is an act of love in a lot of ways.

Like allowing someone to stay who they are while, while loving them and being in a relationship with them is kind of the, the key. 

Margaret: Okay, well, we are gonna take a quick break and afterwards we are gonna talk more about the model that Nikki operates in as a couple's therapist. Um, and later on in the episode, Preston and I have picked a fictional couple.

We are going to cosplay as, and that Nikki is going to take us through a problem and then we'll unpack what that was [00:11:00] like.

Okay. Nikki, I thought that us starting with. One of the questions is, you know, you're a psychiatrist. I think there's a lot of residencies that maybe people can see a couple, or they can do family work, especially in child. Um, but there's not as much of a focus on it anymore. Um, and so I'm wondering if you could talk a little bit about your certification and what drove you to go and get a separate certification.

That took a lot of time, effort, financial support, kind of to become certified and do the work you're doing. 

Nikki Haddad: It's a, it's a really good question. Um. I think that I've always known that sexual health and intimate relationships are important parts of overall wellness. I think we all know that as human beings and as psychiatrists, right?

It's part of what makes humans. Humans. So I. I think right [00:12:00] off the bat, my instinct was that a psychiatrist, we kind of have a duty, especially as people focused on the bio-psychosocial aspects of care to care about these things and ask our patients about these things, even if it's not as emphasized in training.

And so my. Specific kind of journey in that direction. Started when I was a PGY three and my psychodynamic supervisor, she happened to be a trained, certified sex therapist. And so she gave me a lot of wonderful advice and a lot of, um, supervision just generally related to all psychodynamic things, but included a lens in the sexual health world, um, and relational health world.

And so she really kind of opened my eyes to the importance of this work. And I think ever since implementing some of her strategies into my individual cases, whether it's psycho pharm or psychodynamic, I just recognized how much it opens doors for me and my patients' relationships. [00:13:00] And I think it's just made me a better psychiatrist.

And so I think over time I've just been more and more drawn to to that world, and I think that it makes us understand the whole person and creates better trust. 

Margaret: I mean, I think that a lot of us, like you're saying, kind of intuitively feel that whether with our therapy or our medication patients, obviously how central relationships are.

Um, did you. Knowing, I know you didn't always know go, you were gonna go into women's mental health, but like mm-hmm. Did you feel like as you started leaning towards that it became, because obviously perinatal, we just had a pelvic floor therapist on. I'm talking about kind of like sexual health, pelvic health, trauma, mental health.

Um, yeah. Did you feel like there's a connection there for you that as you've moved towards fellowship, it was like, okay, this connection is really present? Because that's definitely something I've seen in my perinatal clinic where it's like, okay. Absolutely. 

Nikki Haddad: Absolutely. [00:14:00] Yeah. I think in the perinatal space, I was seeing a lot of women who were pregnant or postpartum come in with sexual concerns or patients who wanted to get pregnant who had.

A variety of reasons that they couldn't, for example, like severe endometriosis or pelvic trauma, or even in perforate, hymen, um, you know, inability to have penetrative sex. There were so many different primary complaints that I would see in the perinatal space that I didn't feel like I had a wonderful grasp at.

Treating and talking to them about. And so that was definitely a big part of my wanting to get trained in this space, to be able to just offer them resources and also just lessen the stigma around a lot of what, what I was seeing. 

Preston: I think it's really interesting how you, um, framed it as a door to just like find deeper levels of connection, understanding with your patients, because that's something I see where people come to me, a [00:15:00] sexual complain.

It's almost never self-contained or has only something to do with the sexual issue. It's, it's usually, um, a way that some other disturbance in the relationship has manifested itself. And we're almost like trying to address that, like incongruence between, in the couple directly on May. Confront a lot of resistance using the sexual door as a way to kind of open up, like, why do we have these like mismatch expectations of each other?

Yeah. Why do you feel this need to perform all the time? Why do you have so much anxiety about like, confronting a sexual experience ends up like within seconds if you, if you know how to talk about it? Well, which, which I don't. So I've actually, I've actually like, dang, I wish I was like better at talking about sex because like, I wanna address all these like insecurities and concepts of self, but then I kind of get stuck where it's like, okay, like.

I can see from far away that, you know, something like premature ejaculation and, um, anxiety and, and some like narcissistic [00:16:00] organization may all be like very intimately connected in someone's like, um. Concept of themselves, but it's hard for me to like get there just on the, on the sexual path I guess, if that makes sense.

Nikki Haddad: Yeah. Well actually it's interesting you bring that up because I think that when people hear the phrase sex therapy, they think of one thing, which is that we're pretty much only gonna be talking about sex, which is just so not true. And what you were saying, Preston, about how normally an issue in sexuality or sex is kind of.

Telling a story of other things too, is just right on the nose. It's so true, and I think that when someone comes in with a sexual issue, usually we'll spend five minutes, 10 minutes talking about that, and then we delve into their trauma history and their childhood and their relationship with their mom, and the kind of classic things that you'd talk about in therapy, because everything is linked.

I mean, sex is [00:17:00] linked to everything else. Um, and so you're probably doing a better job of it than you think you are by Oh, thank you. By opening up those other doors. Yeah. 

Preston: Look at me, look at me. Doing a good job. Margaret. Margaret thinks I do a bad job. We, we did a, a mindfulness episode the other day and she like stopped me midway to tell me I was doing it wrong.

Margaret: Oh, Margaret, I love you. Was he doing it wrong? Yes.

Nikki Haddad: Um, I can't wait to unpack that in the couple's work later with you two. Oh, we can, 

Margaret: yeah, we can. Um, I guess one thing, I have a question for you. So obviously you're specialized in multiple ways. What do you think of like the general psychiatrists, um, understanding of this? I kind of think we're phobic. I think there's a lot of things we're phobic of a psychiatrist that we don't get rooted out in classic modern training.

And so I'm just wondering. Where do you think a general psychiatrist should be at with their [00:18:00] level of talking to patients about this? Outside of SSRIs? Can, 

Preston: yeah. Not only phobic, I think we're a bit prude about it. Yeah. 

Margaret: It was, I didn't wanna use that word, but 

Preston: yeah. How it's, how I feel like 

Margaret: I know 

Preston: here's an ss I also could cause some sexual dysfunction.

Anyways, moving on. And 

Nikki Haddad: whoa. Yeah. What, what, yeah. Yeah. Well, can you say more about the, the, the prude slash phobic component? 'cause I totally agree. 

Preston: Yeah. So. Um, at least when, when I am working with other, with like preceptors or attendings or especially as a student and I was kind of watching people talk about their sex lives with, or patients about their sex lives, usually they would say, are you sexually active?

Yes or no? It's like a binary question. And then mm-hmm. That was to inform whether or not they were gonna counsel 'em on the sexual dysfunction that might come with like taking Lexapro. Yes. And so a lot of times it was like, I'm not sexually active. Okay, well if you ever do Lexa Broken and cause sexual dysfunction, which is like, first of all, the most vague, unhelpful term ever, sexual dysfunction.

Like, 

Margaret: hey, [00:19:00] something at your core, you're maybe messed up. 

Preston: Yeah. So, and then, then they're like, usually it's like, what kind of sexual dysfunction? Oh. Like, you know, anorgasmia, which is like, it's hard to, to climax or sometimes your libido goes down. And for some patients, like they're like. I'm not having sex, I don't care at all about that.

Mm-hmm. But for other patients, like all of a sudden that becomes the stuck point. And then they go back and forth about sexual dysfunction for the rest of the visit and they're like, you know, I'm not interested in the meds. I don't wanna start them. And then I'm like, dang. Like I, I feel like a lot of it is like how you kind of.

Present it to them, you know? Yeah. And then how, how you weave someone's like relationship with sex into their medication, their mental health. And so I don't, I, I'm, I don't have any like formal sex training, but one thing I've started doing is saying like, okay, so like this, this has the ability to affect, you know, sexual performance.

And for a lot of guys, we find it like delays orgasm. So for people that have premature ejaculation actually is a way to treat it. Because it just kind of pushes the needle back for some people it goes too far back the other way and then becomes kind of [00:20:00] hard to, hard to ejaculate. 

Nikki Haddad: Mm-hmm. 

Preston: And so I'm like, so just like any other knob that we're adjusting for your mood, this adjusts one of the knobs for sex.

So I just want you to be aware of that and, and I think that sometimes, like me kind of almost presenting it. May I, maybe I'm being prude too, because I'm not talking about it as this like intimate thing, but I'm saying like, oh, you know, your sexual function is another knob that we're adjusting just like any other bodily function that you have.

Mm. Is, no, 

Nikki Haddad: I don't think 

Preston: I, I like decriminalize it a little bit. Okay. Thank you. No, I 

Nikki Haddad: think that, um, being able to say more than the phrase it could impact sexual dysfunction is a great place to start truly, you know, giving concrete examples about what SSRIs can do and then if something comes up, here's what we can do about it.

But I think like a concrete thing that I, I think all mental health practitioners could and should know how to do is. Initiate these types of conversations. So a practice that I started as a third [00:21:00] year, honestly, through my supervision, um, she taught me, taught how to have these conversations is first asking for permission with the patient.

Is it okay if we talk a little bit about sex? Um, if a patient has a strong trauma history or has any other reason that they wouldn't want to, they can say no. Okay. End of conversation or you can just quickly educate and, okay. Okay. That's fine. No, you should know these things. But if they say yes, then you can kind of ask, um, more generally what their sex life looks like and have an understanding of their relationship to sexuality.

Who are they attracted to? What kind of sex do they have, um, et cetera, et cetera. And then if and when you start a new medication, you can go into. Detail about what to actually look out for, right? I mean, you named a lot of the things actually that I would be asking a patient. Um, in terms of anorgasmia, low desire, changes in lubrication, um, changes in the relationship.

I mean, there's so many different aspects of sexuality that we know are correlated with psychiatric [00:22:00] medications. So. I think, you know, very basically that's the kind of thing that I would hope would be important to most mental health practitioners. That being said, I'm very aware that most mental health practitioners don't see couples.

Mm-hmm. Um, but I think it's still important for, I. People to at least have a basic understanding of how to ask about relational dynamics, because as we talked about individuals, we're constantly in relation with each other. That's what makes us people. And so knowing how to have those conversations, I would argue is also important.

Preston: It almost feels like you're doing a review of systems is, is what came through to me. Mm-hmm. You know, imagine if when you're, when like you're doing a review of systems on someone's organs and you're like, oh, and you know, any chest pain when you work out, shortness of breathing when you exert yourself.

And then we get to the GI and we're like, does poop come outta your butt? And they're like, yeah. And you're like, okay, moving on to, to, you know, you know, MSK. And it's like, no, we, we get into like the, the nitty [00:23:00] gritty specifics of everything and then we just kind of say sex, yes or no. Right. But I think it's really interesting how, how, like another organ system, you're breaking it down to someone's relationship with sex, how like the acts they, um, participate in who they're attracted to.

All those things are important to kind of flesh that out. So then you can see where do our medications fit into that paradigm. 

Margaret: There's so much that immediately is brought up in people and in us as providers. Um. In terms of the performance of sexuality and desirability politics and like the power dynamic that is in the room, even when you're adjusting an individual patient that I think your point, Nikki, of being like, can we talk about this?

And the answer can be yes or no, or not today, but maybe some other time is so important and to like. Do everything we can to, like many, many people have anywhere from discomfort to actual trauma around sexuality, [00:24:00] how they practice it. Even we don't get into things like assault or rape. And I think that making consent and autonomy so central is so important and.

I'm glad you brought that up because I, I don't know that we're taught how to talk about it in that way. I think people want mm-hmm. To make people feel comfortable. But how you actually do that is trickier. 

Nikki Haddad: Yeah, really well said. And I think that even if a patient's not interested in talking about sex right off the bat, it still means something to them that you're saying, listen, just so you know, this is a safe space to do so if and when you are ready, so even you.

Just starting that conversation yourself is going to again, open the door for future conversations for that person down the road when they feel more comfortable with you. And I also quickly wanna name, knowing who you are in relation to the patient is important [00:25:00] because, for example, I am a woman. Um, me asking my patients about sex may come off very differently than.

A cis man asking their patients about sex and kind of, um, encompass a different level of comfort. So just naming that, 

Preston: especially if they're like a really attractive cis man. 

Margaret: Totally. Can we cut that out? I, I 

Preston: run into that pro. 

Margaret: Can we, can we? He's five nine ladies. He's five nine.

Oh, 

Preston: oh, keep going. So you did all of this work with, um, kind of perinatal psychiatry, then started to focus on women and their trauma. But I'm curious, how did that other person get into the room? How did you start working with couples? 

Nikki Haddad: Couples. Yeah. Well, I've always loved, as I know many people do, Esther pll, I've listened to her podcast for a very long time.

She does couples um, therapy sessions, [00:26:00] and recently me and Margaret and many other residents started watching the show Couples Therapy on Showtime and. I just, I, I love it so much. I love the work. I think it's fascinating. Orna, so that's, or we met her.

Yeah, and she's just as amazing in person as, as on the show. And so I think as kind of fan girl, it's always been there in me, but from more of a professional and clinical lens, I think there are certain things that can only be touched in the couple space and you really kind of can't work on in individual therapy.

Um, for, I mean, an example of that would be. If, um, I, I have a patient who's a cis man who comes in and is having issues with erections, for example. He may come in thinking that this is his issue and his issue [00:27:00] only, right. And wanna get counseling on that. And maybe we talk about meds, maybe we talk about his own kind of therapeutic process going on.

But the reality is, is that there's two people in that sexual relationship. Mm-hmm. And at some point. We are going to have to bring his partner into the room to talk about how she's impacting him and he's impacting her and it's just inevitable. So there's really kind of only so much you can do with individuals for certain types of presentations.

Um, so I think that's quite appealing to me is knowing that I can just make this, this extra difference and go one step further with that second person in the room. 

Margaret: It's like trying to teach someone how to like, do like salsa or something, and then you're like, we're just gonna, I'm gonna show you your steps and then you go try it out.

Yeah, exactly. Yes. It's like that might work, sort of, but you aren't gonna get very far. 

Nikki Haddad: No. You'd just be fumbling on the dance floor. Yeah. 

Margaret: Yeah. I'd be like, no one [00:28:00] touched me. I can do this perfectly by myself. Um. Can you talk a little bit more about the specific training you did and, because I know one of the things that I learned in talking to you is like in the couples and sex therapy field, often the kind of highest standard of care is to be certified in both, which I think makes sense.

Mm-hmm. Um, but could you talk a little bit more about your specific training type? 

Nikki Haddad: Sure. Um, and just to note, I'm not yet certified as a sex therapist. I get trained through the South Shore Sexual Health Center, which, um, you can, anyone can actually look up their courses online. And so I've taken, I think 90 plus hours of individual courses and then 60 hours.

Of skills trainings, and then there's something called a Sexual attitudes Reassessment, the sar, um, which is a two day, 14 hour training, um, that kind of is more like a group therapy session that encourages you to look [00:29:00] inwards at your own. Mm-hmm. Um, relationship to sex and sexuality, and then. Take it outward and reflect on, on those processes.

And then of course you have to have, um, a clinical caseload of 300 hours minimum. So that's all that goes into the, the process of becoming a sex therapist. And then separately, I. There's something called the Couples Institutes, which many people use to, um, better understand couples therapy and dive into the developmental model, which is what I use in my couples work.

So doing those two things together is, is really fun because they're just so related. Um, sex therapy and couples therapy, you kind of can't have one without the other in a lot of ways. So that's, that's my background there. 

Preston: This like a. 

Nikki Haddad: I wish, but there's not. I 

Margaret: wish 

what 

girl? 

It'd be fun. You see why we're friends.

You see why we're friends? 

Preston: Yeah. I'm just, I'm just [00:30:00] like picturing like going into the testing center and everyone else is like taking the MCAT or the SAT and. It's just the Commis Sutra 

Margaret: later. Losers unlike pictures and general, 

Preston: no World is on that media tab. 

Nikki Haddad: See, that would be amazing. 

Preston: Um, remember, I don't know about you, Margaret, or, or, uh, you Nick Hiva on my step two.

It was always the most, like grotesque photos came up on my exam whenever the, the proctor was watching by walking by. 

Margaret: It was worse when you'd be like studying in a coffee shop before step two, and then it was like. Why is this tissue dead on this 

Preston: stop? Like that's a lot of labia. Whoa. For seven in the morning.

Nikki Haddad: I feel like for all the dermatology pages, they were all just so graphic. They be very careful around family. 

Margaret: Yeah. Okay. I mean, it would be 

like you're like at a nice little coffee shop and there's like pleasant music playing [00:31:00] and. Anyway. Um, okay. I think to get into a little bit more of the couples work, I know we have some questions we wanna do at the end that people submitted on Instagram.

Yeah. But, so a little bit about the developmental model that you are trained in. I didn't, and I've, Nick and I have talked about this, like I've read books on couples work and things like that, but like, I think this is. Such an interesting lens that at least I hadn't been given before you taught us.

Mm-hmm. Because I, I made her, I voluntold her that she would in the residency. Do you wanna talk a little bit about the developmental model? Preston, have you heard of this? 

Preston: No. Okay. This is all new to me. 

Nikki Haddad: I'd imagine most people have not heard of it unless they have some exposure to couples therapy, which again, most psychiatry residents don't.

I mean, I certainly didn't before diving into it, but basically the developmental model is. Considered in a lot of ways the gold standard of couples therapy for a lot of couples, therapists that you ask. Everyone has a different kind [00:32:00] of model that they use, but it's what I was trained in. And this was developed by Dr.

Ellen Bader and Dr. Peter Pearson at the Couples Institute in San Francisco. And Ellen Bader still teaches through the Couples Institute online. Um, and. It is really centered on looking at different developmental stages that couples go through in the course of their relationship, and less about pathology, more on understanding where development might have been halted in the course of a relationship.

And so it all sounds a little confusing, I think, when you first hear about it, but when you break it into stages, it makes a lot more sense, I promise. 

Preston: So, so what are those stages? 

Nikki Haddad: Yeah, so there's five stages. Um, the first stage is called symbiosis, and you may actually know that term from Margaret Mahler.

Remember her? No.[00:33:00] 

Preston: Re talking to me. 

Nikki Haddad: I don't know who I was talking to. I, yeah. Okay. Um. I was looking for Margaret. No, not familiar. We have to remember, we're 

Margaret: in a really psychodynamic program. 

Nikki Haddad: She, well, I had to relearn her studying for the, the boards recently, so I probably wouldn't have recognized that name before. But she created the process of childhood development theory.

Um, and so she talked about how. Children go through this normal stage of development from birth to five years, and that is, I believe it's normal autism. 

Margaret: Mm-hmm. 

Nikki Haddad: Symbiosis, differentiation, practicing reproachment, and then optic constancy. And so the idea in, in very simple terms is that a baby will start being kind of one with mom.

And so in the symbiotic state, almost like they're still in the womb, right? They're like attached to mom's chest all time, like Tom [00:34:00] Hardy and 

Preston: Venom. 

Nikki Haddad: Exactly. I don't even know that reference. 

Preston: He's a, he's a symbio. Yeah. 

Margaret: What, 

Preston: okay. I'm, I'm tracking. So, so when, when we first meld, we formed a symbiotic relationship where we're almost like mother and child, mother and fetus.

Not to get too edible. Yeah. About it. Okay. What is that, what is that stage like as a couple? 

Nikki Haddad: Great question. It's basically the honeymoon stage. In colloquial terms. Okay, so I'm sure we've all heard of the honeymoon stage. We've all probably experienced the honeymoon phase. It's basically when you think your partner is absolutely perfect, you put them on a pedestal, everything they do is adorable.

You know, they have no flaws. You're attached at the hip and you're just happily, happily head over heels in love. Mm-hmm. Um, Ellen Bader calls this temporary psychosis. Hell yeah.[00:35:00] 

Margaret: And I think Taylor Swift would agree. 

Preston: Yeah, 

Margaret: I think she would agree. 

Preston: Is this, is there a difference between Limerence and the honeymoon stage? Is this another synonym for it? 

Nikki Haddad: Mm-hmm. How do you define Limerence? 

Preston: I don't, I, I guess I see Limerence as almost like, like a fervent obsession with the other person.

So I think, I think it might be able to like exist within the honeymoon stage, but it feels like almost like something different. I love you, but I want to be with you. And also like if things were not to work out, like my world would, you know, like implode things. Yeah. You know, stars would collide. And I think Lis I think is also like 

Margaret: definitionally kind of like, I think you're right that it can exist in this stage, but I also think Limerence is more populated by fantasy than this is like everything's good and I'm seeing and feeling all the good things.

Limerence is often defined as like this obsessional kind of like. Existing in the single person? Yeah. Mm-hmm. Like fixation on the other. Mm-hmm. Yeah, [00:36:00] that makes sense. But I think this could exist in that or like someone could be more like 

Nikki Haddad: Yeah, I was, I'm just thinking, I like when you said RINs feels like, I'm actually not super informed about rin, but um, the idea that RINs is mostly fantasy did remind me a little bit of symbiosis because it is.

In a way, fantasy, you're kind of fantasizing about who you want your partner to be and who your partner actually is, um, when in reality your partner is not a perfect person. There's no such thing as a perfect person, 

Preston: but you're taking all their actions and you're almost like backend placing them into this fantasy.

You're building in real time, right? 

Nikki Haddad: Yeah. 

Preston: Okay, so, so symbiosis, the honeymoon stage, everything's perfect. This. They're the IIC human. Then what stage comes next? 

Nikki Haddad: Well, very quickly, just on symbiosis, because I think that when we talk about it, it sounds really amazing, right? It sounds like, well, why would everybody not wanna just sit in this stage forever?

Mm. It sounds so lovely and it's really lovely [00:37:00] and I think it's important actually, that relationships start in, in this first stage, and we know that if there's not a basis of symbiosis. That it's actually a lot harder to treat a couple that comes to you because symbiosis is a foundation for that relationship and a place for them to come back to when the going gets 

Margaret: tough.

Nikki Haddad: Mm-hmm. But it's also a crutch. So staying in symbiosis, it's reminding me a bit actually about what you were talking about earlier, Preston, about the fear of being alone is usually because. It's this attempt to maintain attachments and going beyond symbiosis really forces you to look into the existential anxiety, look into the void of being alone 

Margaret: the next step in the relationship.

It does. 

Nikki Haddad: That is it, and it's very scary. And it's scary to know how to maintain your self esteem without, um, the help from your partner in, in managing your emotional [00:38:00] triggers. And so that's why the honeymoon period is so strong and so powerful, and people just wanna live in it forever, but it's just not feasible and it's not healthy.

Margaret: You think there's an element to it of like the fantasy that like people enter a relationship and suddenly it's like so great and they're experiencing all these feelings of being known and all their hopes and dreams, like all these old stories also being played, enacted in it. 

Mm-hmm. 

Does that lead to people wanting to stay in that stage more?

I mean, this, this is like, you can't say this probably as a generalization, but like if, if they come from a place where they're like, EV I, everyone is awful. I don't have close friends, I don't whatever. Or they, or they have strong stories that have been like, this is gonna be the pinnacle of my life. Do you think Yeah.

Anecdotally, that gets people more likely to be stuck there? Like does the narrative impact it? 

Nikki Haddad: Yes. Well, I think a lot of things can impact it. Um, interestingly, one of the most common, and [00:39:00] we'll get to this, but common dyads that we see in couples is symbiotic. Symbiotic. So a lot of people actually get stuck in symbiosis.

But what's interesting is that it doesn't, it doesn't normally look very pretty like it's. Not looking very lovey dovey. It tends to look more hostile and passive aggressive, um, or more very kind of conflict avoidant. So, so the longer you stay in symbiosis, the less it looks, the way it starts out looking, it kind of takes a different shape, if that makes sense.

Mm-hmm. 

Preston: When you say symbiotic, symbiotic, do you mean that like one, one member of the parties and symbiosis and so is the other one? 

Nikki Haddad: Yes, exactly. So, so do you, do 

Preston: you like label. The patients say like, okay, I've identified one patient's in symbiosis. The other one is maybe on a different rung of this ladder.

Nikki Haddad: Yes, yes, exactly. Oh, interesting. Mm-hmm. 

Preston: Okay. I don't tell 

Nikki Haddad: the patient that, 

Margaret: but that's, 

Preston: sure. 

Nikki Haddad: That's how I think about it. It's 

Margaret: family feud thing [00:40:00] behind you that you're like, and you're not very developed. You're still 

Preston: on level one. Okay. So, okay. I'm, I am now excited to hear what level two is. Yes. I shouldn't call them levels, the level two, but the next stage of development.

Nikki Haddad: So the next stage of development, um, is my favorite stage to talk about actually, which is differentiation. And I like it because you just hear this word all the time when you're in supervision and doing your couples work. It's just so critical for, for couples, and really what it is, is learning how to manage your anxiety over di differences that arise in the individual and thus the.

When couples have been together for a while and boundaries start to merge, the process at differentiation starts and it's when you kind of learn how to sit with your partner and their differences without the anxiety of that conflict becoming overwhelming. And so I [00:41:00] think sometimes it's helpful to actually use concrete examples for this.

So one of the examples that I give is, is really small and that's intentional because differentiation tends to start out in very small ways. And that would be you and your partner always go to the grocery store and you get fish food, Ben and Jerry's ice cream. 'cause it's your favorite. I love fish food personally.

And one day your partner goes to the grocery store and they bring home half-baked ice cream because they were really craving it. And you're like, come on man, like I thought we always got fish food. They're like, no, I think we wanna, I wanna try this other thing. You know, you could react by saying, 

Margaret: oh, 

Nikki Haddad: that's a huge affront to our relationship.

Like, this was important to us as a couple. Or you can meet them where they are and say, okay, I'm willing to try this, this other flavor. Very, very small. But that is actually where these, these differences start to show. 

Preston: Mm-hmm.

For the last couple months maybe, was never that fond of [00:42:00] fish food, but because they were like, oh, I love this person. Everything, everything's great. And, and then, and as the honeymoon symbiosis wears off, they're like, oh, this is, I actually prefer half baked. So, so it's like, I can see how differentiation is an, an apt term for that because it's, it's your chance to say like, wait, I, I am an individual.

I have my own preferences. And kind of the, the fire of the fantasies died down a bit. 

Nikki Haddad: Yes, exactly. I feel 

Margaret: like there's also though, like there's the, like it was overwhelming and it like made me act differently than what maybe my preferences are away from this person. But there's also just the like very scary thing that like, no, we both did really like that a lot and now I'm changing.

Mm-hmm. Which I think is like a kind of existential threat when you're, especially if you're still in like the symbiotic. Okay. They can just change. Like you don't, the 

Preston: old me liked fish food. Yeah. If you don't like, sure. You're not me. 

Margaret: I'm a man now,

Nikki Haddad: new man. Right. No, it's so, it's so [00:43:00] silly, but it's also so true and this is the kind of thing that we'll see people will bring in, you know, like, but we always did this thing, and as you, as you guys are saying, you know, but maybe that person never actually liked. Fish. Yeah. And they were doing it for the other person.

Preston: But babe, that was our thing. You watched me play video games. We did every Friday 

Nikki Haddad: night. 

Margaret: Babe, you're so sexy. 

Preston: That was your thing. Yeah. You, you loved watching me play Cog. What? What's the deal? 

Nikki Haddad: What? Hell, 

Preston: you're gonna go read your book in your room. What's going on? Okay. Such a great 

Nikki Haddad: representation of a heteronormative relationship.

Preston: Okay. Wow. So, so we start to like kind of reconstitute ourselves as individuals in this stage? Yeah. And then that's when like the first very minor conflict is seeded. Okay. And then is there anything else? And then of course to differentiation. 

Nikki Haddad: Yeah. Well, of course it will then take bigger steps, right? So maybe that [00:44:00] starts.

Training for Marathon, 

or they moved to Pro 

Margaret: doing a 

Nikki Haddad: pushup challenge.

Some crazy stuff is happening with this. You know, 

Preston: I don't, maybe they just wanted some structure for their training plan and marathon's just like a natural goal. So still pretty in line with who they see themselves as. The Greeks 

Margaret: did. Man, the men yearned to run 26 miles. Yeah. Also, 

Preston: I'm five 10 by the way.

I just, you know, you said I was five nine earlier and I just needed to dispel that really quick. Okay, so, so bigger things start changing, you know, things are, the career changes also, you're a 

Nikki Haddad: runner. You're a runner, right? Preston? Yeah. 

Preston: Yes. Who are too? 

Nikki Haddad: Margaret? Yeah. Not as good as him. You run and, well, I, I think I knew you were running a marathon recently.

Preston: Yeah, I ran the LA Marathon. 

Nikki Haddad: Oh, amazing. So if you were in relationship with someone, for example, and [00:45:00] obviously you, you've done it so you know what goes into marathon training? My husband is training for a marathon that he is running next weekend actually. So I also know what goes into it and they spend a lot of time away from.

Home when you're training, right? It's these like hours long practice runs. It's a lot of time and space alone. 

Margaret: Mm-hmm. 

Nikki Haddad: That might be really triggering for a couple that has not yet differentiated. Mm. And so I think that, again, these, these small seeming things to us actually represent something a lot larger, which is no, I'm going to start searching for what is important to me as an individual and implement that as part of my relationship.

And you as the person who is receiving it and observing it, have to learn to sit with it and kind of deal with the anxiety that comes up without taking it as a threat. To the relationship. And that can be really hard, especially because it's pretty typical that one partner will [00:46:00] start to differentiate before the other does.

So the other person is kind of like just trying so desperately to pull that person back to symbiosis, right? It's scary. Scary to feel like they're, they're leaving the comfort of that. 

Preston: And I, I think I've noticed some, I feel like I've been in stages where I, I try to start differentiating again and. I can feel them trying to pull back into symbiosis.

Mm-hmm. And I think how they communicate that, or, or like the means at which like that tension is, is formed can also like influence the turbulence of the relationship, I guess. Yeah. So like, um, some people will try to pull someone back into symbiosis by almost like creating crisis or disaster. 

Nikki Haddad: Mm-hmm. 

Preston: And then that creates like a really big low, which puts you back on a high and then it almost, you end up both back in symbiosis.

On this like rollercoaster, which I guess when I think about the, yeah, the couples that have those like high highs and low lows, I feel like they're just like alternating between like euphoric symbiosis and then like [00:47:00] dysphoric calamity. 

Nikki Haddad: Mm-hmm. 

Preston: Without ever like, and then second one differentiates it, like it destabilizes the whole dynamic and they have to like.

Recorrect back into the maelstrom. So yeah, 

Margaret: I'm thinking of Rachel and Ross and friends. When she got the job, she got this, the, this job at Ralph Lauren, and she'd been like a waitress in the first couple seasons. And then she has a male boss and she's dating Ross and Ross cannot handle it, that she now has a priority and like is working with another person and flips out and that's why they go on a break and blah, blah.

Mm-hmm. But I'm like, this is that. This is, it's other things too, but it's like mm-hmm. And it was also the who's allowed to differentiate. There were some gender norms that came in there too. 

Preston: Okay. That's interesting. So I, I can picture you, Nikki, now in, in the patient room or like in the therapist's office and you're like, oh.

One of these clients is in symbiosis, the other one's starting to differentiate. And that's how you're starting to organize them. Mm-hmm. 

Nikki Haddad: Mm-hmm. Interesting. 

Preston: Exactly. 

Margaret: Okay. What are the next, because there's more stages, [00:48:00] right? 

Nikki Haddad: Yes, yes. We can get through the stages. Um, so there's three more. So stage three would then be exploration.

And so beyond differentiation then comes a point where you are kind of refining. Yourself in the relationship. So it's taking it one step further. So this is kind of individuation. So you're moving from we back to I, right? We're in differentiation. We talked about those different kinds of examples. This is a fuller understanding of the self I.

And who you are to your core as an individual, kind of separate from your partner because it's very easy to, to lose yourself in partnership, right? When two people are are melding together, it's very easy for that to happen. And actually, as we talked about, almost encouraged in some ways at the beginning.

And so in this stage, each partner's self-esteem is increasing apart from how things are in the relationship. So regardless of [00:49:00] how things are between the two of you, if you are doing really well at work that matters and that is, is enough to kind of keep you happy and and motivate you kind of internally and you're driven and you are seeking out these new friendships or relationships or hobbies or whatever that may be, and the state of really knowing what gives you deep satisfaction that's not actually related to the relationship is key to this stage.

It's a differentiation or almost like a bunch of stem 

Preston: cells, 

Margaret: the start of it. And then this stage is more like maintaining that you're connected to them, but still almost returning to who you were before the relationship and that expanding, but with the relationship there. Mm-hmm. 

Nikki Haddad: Mm-hmm. Mm-hmm. And as you can imagine, this doesn't happen unless the relationship is stable enough for it to happen.

Like, you kind of have to go [00:50:00] through those initial stages to reach this stage. 

Preston: Yeah. Otherwise, you'll just keep getting sucked back in. Okay. 

Margaret: Right. 

Preston: So, mm-hmm. So both, let's say we're, we're in a stable relationship, both parties have individuated at stage three. What happens then? 

Nikki Haddad: Then we head to reconnection.

So stage four reconnection. This is back and forth patterns of intimacy. So having moved through differentiation, then you've moved through exploration. You are now able as a couple to maintain your own point of view, your own sense of self without hostility, and you can then return to this deeper, more sustainable level of intimacy within the couple.

So it takes those kind of initial stages to get to this place where you can quote unquote have it all. Although we're not quite there yet. There's one more stage. Um, but you kind of learn like tangible things that you might look out for as a [00:51:00] couple's therapist that would indicate a couple's at this stage is you're no longer having difficult discussions, um, that turn into hostile discussions.

Or you may notice that there are. Things that couples just know how to do together. Like I know that on Tuesday and Thursday I take the trash out and on Saturday and Sunday my partner does it. It's not even a discussion. We know how to function in this relationship together. We can kind of pull our weights and we can also tolerate these other points of view that come up in relationship, especially when challenging things come up.

So that's usually an indication that you've reached that level as a couple, and then of course you kind of oscillate between your individual needs and then the needs of the couple in this stage two. 

Margaret: Mm-hmm. 

Nikki Haddad: And so why is this not the last stage I. Yeah, 

Margaret: like what's the problem with this stuff? Get 

Nikki Haddad: the last stage.

Margaret: Because I'm like, that sounds 

Preston: like, let's back it up. Yeah, that sounds good. I like more stages after this. Like, oh geez. 

Nikki Haddad: I feel like the last stage is [00:52:00] almost like nirvana. Like I don't know if I've ever seen a couple truly reach, maybe I have once or twice just there. And keep you dreaming, reach this stage.

Mm-hmm. Yes. And then the last stage is synergy. So this is joyful interdependence. So the, we is now nourished by the two individuals, assuming we're in a, you know, two partner, um, two person partnership, and neither person needs to make great sacrifices to benefit the we. What's interesting about the last aid is that it can kind of mimic symbiosis in some ways, and that couples tend to be quite affectionate and loving with each other.

But what's really crucial in terms of differences is that the two members of the couple, um, have these clearly defined sense of selves and ways of managing their differences and their emotional reactions. So it's interesting, you almost go a little bit back mm-hmm. To, [00:53:00] to the beginning, but in again, a much more sustainable way.

Margaret: It's like you can 

Nikki Haddad: tolerate the 

Margaret: closeness and not collapse. Mm-hmm. Back into each other, which I imagine would be harder than, yeah. 

Nikki Haddad: Right, right. And couples tend to create together, interestingly, during this stage. So give back to the world and a podcast. They make a podcast. Yeah.

Preston: It makes me think about like a chain. So it's like if I was one link of the chain. My partner's. The other link, it's like you have to learn how to like meld kind of, you like melt down the metal and then you slowly become an individual again. Yeah. While you're interlinked and then boom. You know what I mean?

Like I'm an individual circle. You're an individual circle, but we're totally interconnected. You know? Like 

Nikki Haddad: I love that 

Preston: strong chain. That is 

Nikki Haddad: a good metaphor. Beautiful. Beautiful imagery.[00:54:00] 

Preston: Hey, it's Preston and Margaret. Um, we went a little over with this episode, so if you're hearing this, it's because there's gonna be a part two, I promise. So I know we went over all the stages of what it's like to be in a couple from symbiosis to synergy. And you're probably excited to apply some of those and we're gonna get to do that, but it's not gonna be until next week when Margaret and I are gonna do some, um, couples role playing and we're gonna explore some of these dyads in real time.

We hope to Do we get to hear another 

Margaret: accent from Preston? 

Preston: Oh God, yeah. I'm applying a new, I'm applying a new accent currently pending. We hope to do more of these episodes where we start out teaching some parts of therapy and then applying it in real time. We still have to hone our timing and sometimes they might just end up being two episodes because there's that much content to get through.

So this is an experiment for us. We appreciate you being along for the ride. So like Harry Potter and the deathly howls, we're gonna have two parts now, 

Margaret: so come back next week for part two. Um, [00:55:00] we just wanna say as always, thank you guys so much for listening to us and helping us. Build up a community of people who are interested in mental health at kind of all levels.

One of the coolest things has been seeing your feedback and really is people in healthcare, in psychiatry, but also people who are maybe pre-med or just wanna know more. And so it's been really great to have you guys listen, engage, ask questions, always leaving us reviews is helpful for our metrics of the podcast and to help us keep making it.

Um. You can come chat with us soon on Instagram. We'll have a How to Be Patient podcast, uh, Instagram page. But for now, you can find us at our usual places, uh, pre row across platforms, right at it's pre row on YouTube at it's pre row. I think you're the only thing that comes up whenever I like had to search you to link you med student.

Yeah. It comes up. Did you mean Presto? Anyway, you can find me at Bad Art every day across Instagram, substack and TikTok. Mm-hmm. Um, and. You can also see our website for, um, human [00:56:00] content, which is how to be patient pod.com. Anything to add to that? This is the first time I'm doing the outro. No, that be 

Preston: Margaret.

You're doing great. Just yeah, keep it up. Thank you. Just keep that momentum like you're on an on-ramp. 

Margaret: Um, you can also find full episodes with visuals whether you want that or not. On Preston's YouTube, uh. Which, you know, sometimes you get to see the cats, which I enjoy. Thank you guys for, did we say thanks for listening a lot on it.

Yeah, 

Preston: just, just be like, thank you so much for listening. Just throw it away. Don't even think about it. 

Margaret: Thanks for listening. 

Preston: Yeah. Perfect. 

Margaret: We're your hosts, Margaret Duncan and 

Preston: Preston Roche. 

Margaret: Our executive producers are Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman and Shanti Brook, occasionally Lilac and Magnolia.

The Kaz as well. Um, our editor and engineer is Jason Porto. And our music is by Ooma Ben v to learn about our program, disclaimer and ethics policy submission verification, and licensing terms, and our HIPAA release terms. You can go to our website, how to be [00:57:00] patient pod.com, or reach out to us at How to Be patient@human-content.com with any.

Questions or concerns? How to be patient is a human content 

Preston: production.

How to.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [00:58:00] background.