The layers we wear: Understanding relational patterns and the slow work of change

In this article, we aim to shine a light on the underlying dynamics of how people operate in relationships. In particular, we explore what happens if a patient’s ways of being in relationships are no longer serving them well, but they aren’t fully aware of how they are relating. Moreover, if they can gain insight into their relational patterns, is this enough to bring about change? All of us go about the world without being fully aware of what we are doing. We carry out many actions unconsciously, such as walking and getting dressed. These automatic processes allow us to respond quickly and in tried and trusted ways, sparing our limited capacity for conscious thinking for unexpected situations that need our careful attention. How we view relationships and interact with others is also, largely, an unconscious process. These relational procedures , often formed early in life, can persist into adulthood and influence how patients engage with care and with clinicians. This can sometimes lead to clinical encounters where a person’s manner and ways of relating don’t immediately make sense to clinicians. Through a clinical vignette, we reflect on how continuity of care, careful observation and a psychotherapeutic lens can support a slow evolution in a patient’s relational patterns. We consider how rapport can be built over time, and how relational change may require a willingness – from both patient and clinician – to sit with discomfort and uncertainty and yet continue to meet.