Researching relationships: Attachment, affairs, and sex and intimacy over 65

Rose: I'm Professor Rose Capdevila. I'm the Associate Dean for Research for the Faculty of Faculty of Arts and Social Sciences here at the OU. I am proud and privileged to be hosting one of the inaugural lectures, part of a series which showcases our research, our teaching and our knowledge exchange.

So today we're going to hear from Professor Naomi Moller, who will talk about her research into relationships – ‘Researching relationships: Attachment, affairs, and sex and intimacy over 65’ is the title. Before we begin there's a bit of housekeeping. The lecture will be followed by a Q&A session so you can ask your questions, and we'll be taking questions both from the floor and online. Then there'll be some refreshments downstairs for everyone who's here in person. So anyone who's still using X, formerly Twitter, please feel free to post using the hashtag, #OUtalks. It's displayed there and @OpenUniversity, if you can, and let the world join us today. So for members of our audience via YouTube, please use the email address provided and keep your comments and questions brief so that we can address them during the Q&A.

So now it is time to introduce Professor Naomi Moller. So Naomi is a Professor in Psychology and Psychotherapy in the School of Psychology and Counselling in the OU's Faculty of Arts and Social Sciences. She has a long history of researching relationships, and her work has focused on attachment, family and couple relationship experience and therapy, reproductive technologies, infidelity, digital relating (including online counselling) and relational contributions to wellbeing.

As a psychotherapist, Naomi has a particular interest in exploring the experiences of specific sub-groups of clients in psychotherapy, with the aim of improving therapists’ ability to work with these groups. Her research projects include improving the integration of care for trans-adults and intimacy and ageing well. I would just like to add that Naomi is someone I work with, I co-supervise with her. She's an exemplary colleague, and it's always been an absolute pleasure to work with her. So now it gives me great pleasure to introduce Professor Naomi Moller.

Naomi: Thanks Rose, and thanks also to everybody in the room, and also people who are watching online. I’m really touched and grateful for your interest in my work. So when I was writing this talk I Googled ‘What is an inaugural lecture?’ and this phrase came up quite a lot. [“An important milestone in an academic’s career”] But for me, being an academic is a second career. My first degree was in English literature, and then I trained in newspaper journalism, and I worked in that field for six years. When I began thinking about training as a psychologist I started by doing Open University psychology modules, so I'm one of a select or lucky group who is both an OU academic and an OU graduate. There are quite a few of us. So I was appointed to Professor in 2021, so I've had a bit of time to get used to or sit with the new title, but I still sometimes find it quite strange. I think this is partly my imposter syndrome at work, but it's also because when I was doing my PhD in the US, I didn't know a single woman Professor who had more than one child, and I already knew back then that I wanted more than one. Also, because I didn't start my academic career until I was almost 40, I knew I would never be able to build the same kind of academic trajectory as someone who starts in their 20s. All this does mean that for me becoming a Professor feels like a milestone.

So I put on this slide some preliminary information. One thing to note is that I'm going to talk about some quite difficult topics, but I'm not going to do it in detail. Also, I am going to be using some clinical case material, but I've both changed details and anonymised it so it shouldn't be revealing of anybody. I also wanted to start by explaining why, when I'm supposed to be talking about my research, I'm going to be also talking about both my work as a psychotherapist and my personal life. At a simple level it's because my lived experience is that these different parts of me, researcher, psychotherapist, partner, parent, friend, daughter aren't actually separate. However, this is also about how I think about research. It reflects my research practice as predominantly these days a qualitative researcher and a researcher working in an applied field. Weaving practice and personal experience into this story of my research for me disrupts the idea of research as something that's purely objective and rational, and also challenges the idea that research can be neutral or unbiased. I think that there are other sources of knowledge, or other ways of knowing than research, and so this way of doing my talk is about honouring that.

So about 25 years ago I started my first clinical placement while I was doing my PhD in Counselling Psychology at the University of Texas in Austin. Shortly after I started I got pregnant with my first child, and by March 2000 I was in my fifth month and beginning to show and my clinical supervisor and I decided that I needed to formally disclose my pregnancy to my clients. One of my clients at the time was a young man who had a profound history of both neglect and parental abandonment. In our work together he was struggling to make sense of how this had impacted on him and potentially contributed to the many struggles he was having in work, in relationships and financially. In working with him I had this sort of deep sense of someone who was working incredibly hard to try and make a life for himself, to move forward from this past, but also while managing a deep wound that was still bleeding. So, as I had agreed with my supervisor, I told him I was pregnant and that I would need to stop working with him in three months. So when I told him he didn't say much for a moment or two, and then he said this, and I know it sounds like hyperbole, but it felt like he punched me in the chest. [You are going to look after him aren’t you?]

So holding this clinical example in mind, let's talk about attachment theory. This was a theory developed by John Bowlby who was a British psychoanalyst, and he drew on not only his clinical experience with patients, but also on theory and research in other fields, such as evolution and animal behaviour. Attachment theory today is complex, and it's been much expanded through the work of other theorists and a huge amount of empirical work, but a core idea is that the early experiences of babies and toddlers with their primary caregivers shapes how they learn to do or to be in a relationship, and also how they learn to manage their emotional distress. The mechanism that Bowlby proposed to explain how these experiences with caregivers shapes later relational behaviour and emotional regulation, was something that he termed attachment ‘internal working models’. These are kind of mental templates or sets of expectancy that are aggregated over time and repeated experiences. For example, you might have a template that says, ‘I am lovable’, or you might have a template that says, ‘If I ask for help, no one will respond.’

But attachment isn't just about babies. Bowlby saw attachment relationships as being important throughout life, as he said, ‘from cradle to grave’, and correspondingly, attachment theory holds attachment models are also important across the lifespan. So my interest in attachment working models dictated my doctoral dissertation topic. My PhD, I graduated in 2006, was titled ‘Attachment Working Models: Assessing non-conscious and self-reported components of attachment security’. So I'm going to read you one sentence from my thesis conclusion. ‘Further research is required before conclusions can be drawn about whether the paucity of statistically significant findings was due to problems with the study design or with, more generally, the idea of using cognitive paradigms to assess attachment working models.’ So for those of you who aren't experts in the room, in other words, I didn't find at all what I was hoping. Nonetheless, I did learn quite a lot about how early attachment experience is conceptualised to impact later relational functioning.

Moreover, by then, I'd done a number of other studies on attachment and crucially I'd been working clinically for quite a few years, and I’ve learned experientially how useful understandings from attachment theory are for psychotherapy. So there's a lot of psychotherapy research that focuses on attachment, but for me back then, one idea that I was really interested in was this notion of earned attachment security. That is the idea of someone who describes less than good experiences of parenting as a child how they can nonetheless somehow undo that legacy and can revise their attachment working models. This led me to do a questionnaire study which we published in 2002 with 250 undergraduate students, in which we found that participants who reported insecure childhood attachment, but current attachment security, were similar on measures of current distress and resources for coping, as those with both current and childhood attachment security. In other words, this study suggested that earned attachment security is in fact a thing. At the time there was hardly any research on earned attachment security, so I can perhaps legitimately say that this was a significant research finding. The study has been recently incorporated into a systematic review, the first on earned attachment security, and among the conclusions reached in the paper was that, “earning security requires a person to engage in intentional efforts to make sense of themselves and their histories.” and the review suggested that psychotherapy can be one pathway towards earned attachment security, not at all the only pathway, by the way. Researching earned attachment security helped me to learn about attachment, but perhaps more important, it also helped me to feel hope when I was working with someone like the client I described earlier.

So there's very little written about therapist pregnancy and what it means for the client, or the psychotherapy process and the outcome, which I find kind of odd because it happens quite a lot, right? We're talking about a predominantly female workforce. However, what there is suggests that clients can respond quite strongly. They can feel that their confidential secure space is no longer private, because yeah, he's listening, right? I know these things aren't logical, but it's how it’s experienced. They can feel abandoned, because very often therapist pregnancy means the work is ending and not when they want it to end, and it can evoke very strong emotional responses by bringing clients back to their own early childhoods. For my client this was clearly what had happened. It wasn't just that he was asking me to promise that I would not treat my baby the way that he had been treated. He was asking me to share in his horror, somehow made live in that moment, that anyone would ever treat a small child with such callousness. He was also asking me to step into the trauma of being a person who had been treated that way, and I got it, like I said, like a punch to the chest, a terrible but also a wonderful moment of connection. But it wasn't just my client who had feelings about my pregnancy. I had trouble getting pregnant, and this pregnancy was the result of IVF, and at the time I was terrified, probably very unreasonably so, of losing the baby. I was also very scared about becoming a mother because of my own attachment history, and in that moment I wasn't sure that I really actually trusted myself to “look after” my son as I wanted to. So becoming an attachment researcher was scary because it taught me how much I could damage my children, but it was also a way to understand the impact of my own history on me, and it seeded the idea that I could too challenge my attachment models and learn how to be a ‘good enough’ mother. I'm quoting Winnicott there, as well as a ‘good enough’ psychotherapist.

Further family developments, the kids by the way did consent to have these pictures. So after we arrived back from the US I found a counselling placement in NHS primary care that offered short-term counselling, and one of my clients there was a woman in her 40s who was referred by her GP because of depression and what was referred to as ‘relationship issues’. The first time I met my client she talked quite a lot about her prestigious job and seemed ashamed of the fact that she was struggling. Initially, she talked about her marriage and her family life in very positive terms, but later she began to talk about a sense of something being missing in her life, and eventually she told me about her affair. She described a relationship that was thrilling and made her feel vividly alive, how the connection and the sex felt electric. She also talked about feeling shame and deep sadness because she knew how hurt her partner would be, and how shocked her family and friends would be if they found out. It took me way too long to understand how much distress she was experiencing, and when she disclosed, I have to say almost in passing, that she'd been thinking about ending her own life or had thought about it, I was so shocked I didn't know what to say.

So I started researching infidelity rather by chance, after a colleague at a prior institution gave me an introduction to Andreas Vossler, who's sitting in the room. We both wanted to research relationships and he suggested researching infidelity. Our collaboration has been a really important part of my research story, and it began with a small interview study with Relate counsellors about their experiences of working with infidelity. This study was also my first experience of qualitative research and my first research mentor in the UK, Victoria Clarke, a really well-known qualitative researcher, is equally important in my research story. Our study led to a couple of papers, and it also led to this newspaper headline which came out of a conference press release. [Infidelity ‘can make relationships stronger’] I have to say my dad called me up and said, “Did you know that you were being quoted in ‘mmm’ paper?” But to be accurate, what was funny for me was that what we had found was that if after an affair a couple decided they wanted to work and try and mend their relationship, and if consequently they went to couple counselling, and if in couple counselling they were able to work towards some degree of understanding of relational factors that might have contributed to the affair, and if they were willing to forgive each other, then and only then, their relationship could, potentially, in the end, be better than before the affair. It’s quite a different kind of finding.

One paper that myself and Andreas wrote from that initial study explored how Relate couple counsellors defined infidelity, and how they reported their clients as defining infidelity. For example, one of the things that the counsellors said was that for many heterosexual couples penetrative sex was the most common definition of infidelity. But they also talked about clinical examples where lots of other kinds of sexual behaviours, such as a drunken kiss or using pornography, were framed as infidelity in some relationships. Equally, our Relate counsellors talked about relationship crises brought on by emotional, non-sexual infidelity, when a person develops feelings for someone else. But they also talked about their clinical experiences that any kind of close friendships, for example, potentially between two heterosexual women could be a cause for significant jealousy in some relationships. In other words, we found that infidelity could be defined in terms of particular behaviours, usually sexual, but equally, it could be defined in terms of impingement on the relationship, or even in terms of feelings if one partner feels betrayed. Couple counsellors also talked about how their couple clients in the therapy room, of course, deploy these multiple and conflicting definitions to justify their behaviours and their feelings. ‘It wasn't infidelity because it was a one night stand.’ ‘It isn’t infidelity because although I profess love, I haven't actually had sex with them.’ If you're trying to do quantitative research on infidelity having a clear and preferably behavioural definition is really helpful. However, the contribution of this paper was to suggest that actually in relationships, infidelity is rhetorically constructed. The implication of this for practice is that in couple counselling the focus shouldn't be on whose definition is right, whether or not in fact there was infidelity in the relationship, but on the impact versus usefulness of different definitions for the couple.

One thing that we noticed in the initial study was how often Relate counsellors talked about digital technology, both affairs conducted entirely virtually, and the crucial role of digital technology, communication devices, mobile phones, email, the internet, in affairs today. There's an expanding research literature that suggests people interact differently in digital spaces, and our own research suggests that this has implications for infidelity. For example, in an online questionnaire study, people whose partners had had an affair strongly believed that the internet facilitates affairs by creating a lot more options for straying, both planned affairs, for example, through ‘find an affair partner’ websites. There are some quite famous ones, and unplanned affairs that grow out of late night scrolling and chance online encounters. We had an example in the literature of somebody whose affair had started by playing Pictionary online, interesting. Our research in this area also suggests important implications for counselling, such that even if an affair is entirely virtual they cause enormous distress for partners, and that online affairs, like other kinds of online interactions, can have an addictive quality. Of course technology continues to advance. Consider the impact of things like ChatGPT and each development offers new potential ways for people to do relationships, potentially good, positive, potentially less positive for people in sexual and romantic relationships. For example, there are already digital girlfriend apps. I always think it's interesting that there aren't digital boyfriend apps, I don't know what that says, as well as Wi-Fi enabled sex toys that can be controlled by a person in another location. There are discussions in the literature forecasting the evolution of sex robots and debating their potential impacts on human relationships. Andreas and I went several years ago to a conference where somebody made the argument that in the future it will be a legitimate sexual affiliation to be affiliated that your sexuality will be robot. Really interesting. I don't know if this is going to happen.

Coming back to my client. I started working with this client just as I was beginning to do research on infidelity, and I didn't understand then that affairs can be hugely psychologically destabilising for both partners. Part of my client's distress came from the fact that she didn't understand why she was having the affair, because broadly she felt like she was happy in the relationship. These days I know that some experts in the area argue that affairs aren't always caused by “a problem” in the relationship or in the individual, and that some affairs happen for important and valid reasons that aren't to do with the primary relationship. But I think what also got in the way of me picking up on my client's distress was my unexamined assumptions about people who have affairs. I say unexamined because social attitudes towards infidelity in the UK tend to be negative. For example, the National Centre for Social Research found that public attitudes towards sexual behaviour in the UK have, in general, grown more liberal, except when it comes becomes to infidelity. In 1983 58% of people thought that having sex outside marriage is, “always wrong”, and 40 years later in 2023 it was only 1% less, ie, 57%. My client back then wasn't actively suicidal. She had no wish to die, and, in fact, could list lots of reasons why she would never do that, but she was unhappy enough that the thought had come into her mind. Looking back I think that I maybe missed this because there was a part of me that felt like she was in the wrong because she was having an affair, and was not inclined to offer empathy. I think the reason I didn't understand that I was failing to empathise with my client was because to understand that I would have to unpack the impact of my own family history of infidelity, in that my parents’ marriage ended when I was a teenager, because of an affair. I think it's telling that it's only from writing this talk that I've realised that doing research in this area has, largely unconsciously, partly been about my being afraid to repeat that history in my own relationship, and trying to work out how not to. Just a comment about the picture. So my partner and I have got married to each other three times, three different ceremonies, but we haven't got divorced yet, so that's why it's the second of three.

One kind of research leads to another. When Covid came overnight, psychotherapy practice moved online globally, and at that point it was really helpful to have a history of researching how relationships work in online spaces. In March 2020 in about two weeks, myself and Andreas and the team at OpenLearn Create developed a CPD course to support counsellors in moving their practice online. We shut the course last year, but in the period that it was open it had over 25,000 enrolments. Covid also revealed the lack of research on the process of counselling using video conferencing platforms. So during Covid, myself, Andreas and a group of colleagues did a study exploring the experiences of counsellors, and the group is currently looking at client experiences. What the research on counsellor experiences suggested was that video counselling is different than in-person counselling for several reasons. To get an example of how I'm going to play a few minutes of a video. Just to say, we make lots of videos like this in teaching at The Open University and in our counselling courses at the OU. The counsellor or the psychotherapist is always a real practitioner, but the client is played by an actor. As academics writing the course, we create a scenario and then the actor and the counsellor more or less improvise around it.

[Video]

Counsellor: Hey, Dominic, how are you doing?

Dominic: Alright Phil, how are you doing?

Counsellor: Yeah, nice to see you. Nice to see you.

Dominic: You too. You too. How's it all going?

Counsellor: Yeah, not too bad, not too bad. How are things with you?

Dominic: Yeah, yeah, not too bad, not too bad. Yeah, bit of a hard week. So I’m celebrating at the end of the week.

Counsellor: Ahh, well Dominic, just a moment. Is that a drink you're having?

Dominic: Yeah, yeah, it's only 2% though. He said. [Chuckling]

Counsellor: Sure, sure. I just want to take you back to… remember what we talked about at the beginning, when we had our first session. We talked about, you know, the rules, the rules of engagement.

Dominic: Oh, yeah.

Counsellor: Yeah, remember how we talked about not having any distractions. We talked about no alcohol, no cigarettes. You forgot.

Dominic: Come on man, look it’s the end of a long, hard week, you know? I mean, I'm here in my own house. You know, what's going to happen? What's going on? You know what I mean? You're talking to me like you're my mother, you know what I mean?

Counsellor: I understand.

Dominic: Well give it rest man will you.

Counsellor: Yeah, it's not about, you know, wanting to, you know, to make life difficult for you. But you know, for what we're doing today it's important for us to be devoid of any distractions, you know. We don't want anything that's going to interrupt the flow. We don't want anything that's going to just…

Dominic: Okay, alright, yeah, I mean, okay. Look I get what you’re saying, I get what you’re saying. Although I don't think how one tube of beer is going to absolutely, you know, knock us right off course. But no.

Counsellor: Yeah, I understand that. I understand that, yeah. But just, you know, in terms of, just…

Dominic: This is my home, you know, it's not easy sometimes, all this carry on, you know what I mean.

Counsellor: Yeah, yeah.

Dominic: So I can’t understand how one beer is going to mess things up. You know what I mean?

Counsellor: Sure, sure.

Dominic: And I think I've been doing okay with your rules up to now, you know what I mean?

Counsellor: Yeah, yeah, what's important, I understand the frustration. I understand, you know, in terms of how you might feel that I'm coming across like your mother, but it's…

Dominic: You absolutely are. I’m a grown man, you know.

Counsellor: Sure, sure, I understand that, and I have total respect for you, and I just think that, you know, we need to, you know, respect what we agreed, you know. So it's not really about trying to make things difficult. You can happily have a drink afterwards, you know, that's not a problem. But just as we agreed, you know, I think it's important for us just to maintain what we agreed.

Dominic: Alright, alright, I mean, do you want to continue with this one today?

Counsellor: Yeah, of course. Of course. You know, yeah.

Dominic: Okay, because I’m feeling like jumping off… ]

[End of Video]

Naomi: Any therapists in the room probably felt quite uncomfortable watching that. It's not easy working with client anger, but it's obviously part of the job, and something that comes up and often it's really clinically significant and important.

One finding from our study was that people do things in video counselling that they wouldn't do if they were doing counselling in person, say in an NHS setting. So you wouldn't normally crack up in an NHS setting with your beer, right? For a counsellor what this means is it's really important to contract with your client at the beginning about what you expect from them, and you might need to remind them, like Phil does with Dominic, that drinking alcohol in a session is not okay. So obviously Covid was a bit different, but you can see from the list here that people reported, these are therapists reporting, what clients are doing in their online session. I mean, some of them were fascinating, in the bath, I mean, really. They talk quite a lot about people going for a pee, putting the phone down, but you can hear them peeing. Doing it you realise suddenly that there are other people in the room, like the grandkids or friends around, and in semi-public places, walking around the house and doing the cleaning at the same time, why not really. You know what I mean. So when Phil was interviewed about this interaction, because we often want to have a bit for camera afterwards about kind of the clinical implications and the clinical thinking. One of the things that Phil talked about is for him it's about the fact that alcohol can modify the emotional experience, it's soothing, right? So actually, you don't want that in a therapeutic section. You want the person to be able to reach whatever it is that they're feeling and not to be sedated in that way. So it's not actually about him being some kind of puritan, it's about trying to maintain a space that will be useful in terms of practice. Also, the way we wrote this client, he has an incipient alcohol problem, so also important, right?

I mentioned the Covid CPD course, it’s the one in the bottom right-hand corner, but I put on this slide some of the other CPD courses that I've been involved in developing, all of these ones with Andreas. The courses are one way to bridge psychotherapy research and psychotherapy practice, which is for me really important given that I work in an applied area. So if you're doing research as a psychotherapist, and you're not trying to make that bridge, it's like, why are you doing it? It just sits in the book or in the journal.

So further family developments, my parents died within a few months of each other at the end of 2018 and the beginning of 2019, both of them after quite a few years of declining physical and mental health.

I don't have a lot of experience in working with adults over 65 clinically, but most of what I do have comes from a local community counselling organisation near where I live. It's the Third Sector charitable organisation, and I want to talk about two clinical experiences. The first was with an older man in his mid-70s, and the second was a woman in her late-60s. They were both married, and they both sought counselling because of low mood, but both also described marriages that were marked by seething resentments that had built up over many years. A day-to-day experience of angry sniping at each other, and they both described a distillation of relational happiness to the point that sometimes one look or one brief comment were enough to set off a huge argument. So the male client talked about his desire to leave his relationship, but also how that felt impossible. There were health reasons on both sides which suggested that he and his wife would not be able to cope alone, and the idea of ending a relationship after so many decades also felt overwhelming. Then a few months into the counselling he told me he'd been diagnosed with early stage dementia. Working with him then I felt like, and I know this sounds really kind of over the top but it really felt like this, that we were standing on the edge of some huge abyss and that it was filled with this kind of freezing darkness and these kind of howling winds. Then one day he told me this story about how he and his wife had had this huge argument that started over something really silly, like how he did or didn't do the washing up. He got so upset that he had to get out of the house to calm down, but because he was upset and because it was dusk, he suddenly realised he didn't know where he was, and he described getting more and more panicked, until suddenly somehow he realized where he was, and at the point where he realised that he was standing on the street where he'd been living for decades.

The female client started therapy in a really different place. She was still living in the same house with her husband, but they had separated. He'd started a new relationship, and they were discussing initiating divorce proceedings. My client and I spent quite a bit of time untangling her complex feelings about the end of her marriage, but as time went on, we also talked about the new possibilities that she could see opening up for her. During this period we talked a lot and in detail about sex as she sought out a number of sexual encounters. She talked about her experience of ageing as freeing her from some of the anxieties that had plagued her as a young woman, and how liberating and thrilling it felt to be what she called ‘naughty’. Then about six months after we finished counselling, she sent a postcard addressed to me at the counselling centre to tell me about her new relationship. I have to say getting that postcard made my day. I felt such a joy for her.

So turning to the current project, Intimacy and Ageing Well, which is an Open University-funded project through a scheme that the OU is running called Open Societal Challenges. The team includes myself and Andreas, Rebecca Jones and Jessica Carr, both of The Open University and Diana Teggi from Bath University. The social challenge that this project speaks to is the rapidly ageing population of the UK. The current projection is that 22% of the UK population, by the way this includes me, will be 65 years or older by 2034, that's almost a quarter, right? The implications of more older adults are, on the one hand, potentially higher economic costs for health and social care, and on the other hand, growing challenges for individuals and their families in supporting wellbeing and quality of life as people age.

The UK Government has in the last decade or so acknowledged that social isolation or loneliness is a health factor that's particularly important for older adults. It’s been shown to predict mortality actually. This acknowledgement has led to public health campaigns and intervention efforts. On the whole the focus has been on developing community engagement and the potential for new social relationships through things like social prescribing in the NHS. In other words, the types of intimate, affectionate, close attachment relationships that matter most to people have largely been ignored. This is despite the huge empirical literature, and I'm not just talking about the attachment literature, I'm talking about the broader relationship literature on relationships. The evidence is that having a good or a ‘good enough’ relationship fosters both mental and physical health across the age span. There's just one example, because I really like this one, a really big study found that having a good relationship with your partner is as important for your health as eating enough fruit and vegetables.

Our project comes from a belief that if as a society we want to foster wellbeing for older adults, we need to think about the value of supporting their intimate and loving relationships. This is a challenge because older adults experience relational threats. They're at much higher risk of bereavement. They're a higher risk of significant illness or disability, for themselves or for their partner. They're at higher risk of becoming a partner-carer, which radically changes the relationship. There are age-related shifts in sexual functioning, and let's not forget, there's a lot of stigma about the sexuality of older adults. Because there's a lack of theory or research on supporting older adult intimate relationships, it's been important for us as a team not to assume we understand what the issues are or what the solution should be. So we are starting by asking older adults and health and social care professionals that work with them. Because this is an exploratory beginning study, we decided to focus narrowly on intimacy, emotional, physical and sexual in romantic and sexual relationships, although we of course understand you can have intimacy in lots of different other kinds of current relationships. This is our study design.

So we're still collecting data and the survey interviews in fact, and the survey analysis is only in the very beginning stage. I can share one tiny finding from the two more quantitative questions that we asked. The chart shows how much intimacy our participants report experiencing in their lives. The red in the first column shows, for example, that 60% of our sample report experiences of emotional intimacy daily, or 4 to 6 times a week. The dark blue in that column shows that 27% report rarely or never experiencing emotional intimacy. Overall, the chart shows that there's a sizeable group that report experiencing no or very little intimacy, emotional, physical or sexual in their lives. As well as asking people about how frequently they experience intimacy, we asked them if they feel like they have enough. This is because we don't want to assume, for example, that everybody wants sexual intimacy. What's telling about those results is that depending on the type of intimacy, between 40 and 60% of our participants said that they do want more intimacy than they currently experience.

So back to the client. I included a couple of clinical examples because I wanted to acknowledge that while ageing has a fixed end, death, there are, of course, lots of potential ways that a person's story may play out. I also want to underline that the relationships a person has, for good or for bad, may well impact their trajectory. Working with older adults made me think about the possible therapeutic impact for both client and counsellor of knowing that there is a narrowing window of opportunity, a time limit for achieving change. It also made me think about what psychotherapy can offer with something like dementia. There's quite a bit of research actually on the importance of relationships in dementia, as well as on the role that psychotherapy can play in supporting people with this diagnosis. There's a reference there. For me at that time, working with this client meant working really hard to understand what it was like for them, and consequently, even if only for the 50 minute session, trying to ensure that they weren't alone in the terror about what was coming. I remember this client because it was really hard to do that. Then some years later, my dad was diagnosed with dementia, and we had known for some years that something was wrong, so the formal diagnosis wasn't a surprise. At some point my siblings and I moved him near me, and I'm really grateful because I saw more of him in that last year than I'd done for years and years before that. At the same time, and I'm sure that there are lots of you in the audience who will have your own personal experience, it was really hard sometimes. It would be really great if I could say that I was able to consistently hold on to what I had learned from that client about how frightening the experience of dementia can be for the person involved. But in the middle of it, my own feelings about the steady erasure of the man I'd known, my anticipatory grief about his death, my worry about all the practicalities of care. I got a call once from the police literally minutes before I was due to go on to a conference in London, saying that they'd picked him up because he was on a bus near where I live in Gloucestershire trying to go to Scotland. I was like, “Okay, I can't come right now.” So this kind of experience is not uncommon, right?

So all of this stuff, I also had quite strong feelings about some of the things that because of the dementia he said and he did. So thinking about it now, I also think that something else of course got in my way, my own fear about what ageing will bring for me. Will it bring dementia, for example? Now, when I talk about the ageing and intimacy project I have to date tended to emphasise that the project focus is relational wellbeing, something positive. Yet I think I can admit to all of you that my interest in this project is clearly driven as much by my fear as by my hope.

Okay, so concluding this talk, I hope I've made an argument for both the importance of relationships and the importance of researching relationships. Now for many psychotherapists it's obvious that relationships matter. There's a lot of theory and research that suggests that one of the biggest engines in positive client outcomes in psychotherapy is a ‘good enough’ relationship between the client and the counsellor. But it's also true that in the field of mental health more broadly, distress is typically understood in terms of psychiatric diagnosis which sits in individuals, and psychiatric diagnosis ignores both the broader social determinants of distress, like poverty or discrimination, and the huge importance of having ‘good enough’ relationships. One example of how this impacts how services get offered, it's really quite hard to get couple counselling in the NHS.

So I hope I've illustrated not only the influence of relationships in the different parts of my life as a researcher and academic, psychotherapist, partner, parent and adult child, but something also of the bidirectional influences between the research I've been involved with and my own relationships, at work, with my clients and in my personal life.

Lastly, I hope I have given you, whatever your own historical and current experience of relationships, the idea that the quality of your relationships, in all spheres of your life, matters, that you deserve to have ‘good enough’ relationships, and that if that is not your current experience that it could be possible for you to achieve them.

Just in case this talk has stirred up any difficult feelings, memories, there's a list here and everybody who's registered for the workshop will get this sent out, because obviously the URLs don't work on the slides, specific support for students and staff of The Open University, but also general references. Thank you.

Rose: Thank you so much. That was really great, really, really fascinating. It does say really interesting in the notes, but I think interesting always sounds a bit dodgy. It was fascinating and lots to take away from there. I thought it was really great and I liked the way you pulled things together out of those three different professional and personal threads. Anyway, so thank you for that. So now what we're going to do is we move into the question and answer period, so you guys can ask questions and make comments. So we can now go over to the chairs.  

Naomi: I told Rose that the key at this point is not to fall over.

Rose: I’m working really hard not to trip and fall. Okay, so here we are, like The One Show. So basically there's a roving mic so anyone who has any questions, please put up your hand. Also you can ask online. Please keep them short so people can all have their say. So yeah, comments, questions from the audience.

Zoe: Hi, I was wondering, I was really fascinated by your slide which had all the things that people do when they're having their counselling online, and I was wondering about couple counselling in that context. I was wondering, and forgive my ignorance, whether or not couple counselling does happen online where the couple are in one room and you're potentially somewhere a long way away, and what the particular issues, the mind boggles as to what the issues might be, you know, when dealing with a couple rather than just a single individual online.

Naomi: So I've done very little couple work because that's not my training. But what I will say, I know from the literature, and also we had some people talking about this, is that, of course, in any kind of couple counselling it's not uncommon that people have arguments, and actually that's kind of therapeutically useful because it helps you kind of unpack what the issues are. If there's an element of disinhibition, because there's this kind of idea of online disinhibition, it potentially can be worse. There's also an interesting debate about whether or not you want the couple in the same room, or whether or not that you want them in separate rooms, because that will also change the dynamic in quite important ways. Yeah, thank you.

Zoe: Thank you so much, Naomi. I wanted to speak to your point right at the end about given all the research around attachment, etc, and the importance of the therapeutic relationship and relationships in general, why you think NHS services, for example, still struggle to integrate that?

Naomi: That's a really interesting question that I'm not sure that I really understand the answer to. I think in my small experience not really as a researcher, but through a period working with the British Association for Counselling and Psychotherapy, and also with my colleague Felicitas Rost, around the campaign that was run around the NICE guideline for depression, is that there are quite a lot of political forces that get activated when the decisions are made about what kinds of therapies should be involved, and that one might argue that it should be a purely “scientific objective process”. But it isn't because, and it isn't even as if people agree about the way to come up with the ideas about that, but couple therapy actually got pushed out of the last NICE guideline for depression because there wasn't enough evidence. Felicitas is nodding at me so I think I'm not wrong about that. So I think it's about that, and, you know, and also some kinds of therapy are more researched than others. But the World Health Organisation in 2023 has moved from the idea that diagnosis is the most important way to understand mental health, and is now arguing that governments need to focus on social determinants, and it's doing that because if you locate the problem in the individual, then you take the pressure off governments from looking at the social determinants. So I'm hopeful perhaps that if the World Health Organisation is doing that it might begin to trickle down a bit.

Rebecca: Thank you Naomi, that was fascinating and so beautifully put. One of the things that frustrates me as someone who works on ageing and sexuality is this perception that older people can't benefit from counselling and psychotherapy, the sort of developmental view that they're at the end of their life course so there's no point, or they're too old to change or, and I've heard that from psychotherapists and counsellors, and I've heard it from older people. I don't believe that to be the case. I am sure you don't believe that to be the case. Do you think there's any scope for somehow changing minds on that and, you know, moving the dial?

Naomi: So as an example, I know BPS does work on this and Relate has done work on trying to promote the importance, for example, of sex and relationship therapy for that population. They ran a really lovely campaign. I think they're a population that has long been ignored and actually Claire sent me a link for an article that looked at how few older adults are being served in the NHS talking therapies, primary care intervention. So they are very neglected. I think the other thing that I'd heard is that when people go to their GP and they talk about low mood or feeling really anxious, the GP standard response, and obviously this depends, but the sort of unthought through response is, “Well you're old, of course you're depressed.” Also, actually, I know from an interview that I did on Friday for our project, I was talking to someone who is the manager of a home up in north Wales, and she talked about the fact that it's only in the last year that they have any mental health support in the district that's being sent around. I said, “You've never had anything like that before?” She said, “No, amazing, isn't it?”

Speaker: That was fascinating and very poignant, very moving actually. I was just thinking because you have talked about, you know, a considerable career, have you seen a change in people's perceptions? This is a bit related to what Rebecca asked, but a change in people's perceptions about who deserves some kind of talking therapy, what circumstances warrant the resource expenditure whatever, or the time involved?

Naomi: I suppose what tends to be very compelling in research used by the UK government is cost analysis. Our assumption, for example, in the ageing project, is that if we can demonstrate which is like a way long, you know, we're at the beginning of what would have to be a very long research trajectory, that you are maintaining, ‘health’ then it will get funded. So some of the interventions, I can think of my colleague Felicitas doing research on the economic benefits of interventions for complex mental health, also an underserved population in lots of ways, because I think it's about the money often. So you have to argue, I mean it shouldn't be about the money right, but you have to argue that in the long run it saves the NHS money.

Rose: Can I just ask something about the apps? I’ve got to also confess, Zoe over there told me about this app called Hot Pie, remember you told me about that Hot Pie and I was sitting at my computer, I thought I'd just give it a little go. I was writing up a chapter and I was really frustrated that it wasn’t ready. So it went, “How are you today?” and I went, “I'm really frustrated.”  I ended up having a really long conversation with this app that actually really helped in organising my thoughts and getting my chapter in. Then I found it quite terrifying, which is what Zoe had indicated it was, so I wonder if that's coming up for you?

Naomi: Several of us in the Psychotherapy and Counselling Team at the OU were at an international conference in Canada this summer, and there was a lot of stuff about the use of large language models like ChatGPT in therapy and what the options are. On the one hand, it's fascinating. There are development of online clients who respond and talk back to you. We're hoping to trial one by the way in our qualification that we're currently developing. So I think that's very brilliant. So you can get people who are learning to try for the first time not an actual human being. The other thing that's really interesting is one of the very first chat responses was actually way back in the 80s, I think, or 90s, there was a chatbot. If you swore at it it told you things like, “You must be very angry.” So it was kind of fun, right? So there's been a long term interest in all of this stuff. My assumption is that we will have much better over time a lot of that. I think there are two questions, it’s not an area I do research in, but the profession is worried about. One is, it's already clear that it can cause harm and there was a case this last year of a young girl who took her own life after the chatbot that she was working with suggested that that might be a good idea. It was in the newspapers really quite recently. The other thing that all of the developers were talking about was that in order to have more human interaction, you want to give the systems more creativity. The more creativity you give them, the less robotic they are, and the more likely they are to do this thing called ‘hallucinate’, where they just do something that’s completely random. So if you're in a context that's very high stakes that is quite worrying. I think the other argument on the contrary is that there's a general assumption that the level of distress globally will never match the number of practitioners, that it is unaffordable to provide therapy perhaps at the level that sometimes it is wanted. Therefore these systems may provide a partial solution, but it's not clear. Obviously it’s this area that this is going to have to be dealt with. The other thing I think we've been talking about is that the technology is moving so fast that it's going to be really hard keeping up, I think, in many technical areas, including ours. You know therapists, some wonderful exceptions, aren't usually very techy. It's quite a challenge.

Online: As childcare practices change between generations, do you see this coming through in older people's attachment patterns and their relationship needs/expectations?

Naomi: That's a really interesting question. So we've had quite a few debates about this actually in our production team. One of the ideas about attachment is that at least some of it is universal. One of the things I like about attachment research is it's been done all over the world. In tribal societies that have very little contact with other kind of groups, in lots of work done in Japan, for example, it's been done with lots of different kinds of groups. I found a study recently that was done on children where parents were travelling for work. It was a Chinese study. So at one level, the idea that all of us need ‘good enough’ relationships when we are small, that seems to be fairly non-negotiable. I think there is also really interesting questions and really interesting research that suggests that there are cultural variances. So, for example, in some social context when somebody is not ‘securely attached’, they're insecurely attached, they may look more like this, and they may look like that. So coming back to the question about does generational stuff change things? I'm sure it does, and what does a ‘good enough’ parent look like? Well, for me, for example, I mean for us I guess looking at my partner. We were asked at a parent meeting when the kids were somewhere in their early teens, whether or not we put online parameters on what they could search. That's an example of what's being framed as ‘good enough’ parenting these days. It wasn't something I'd have thought about. I think there's something for me about parenting needs to shift depending on the social context in which you're in. I guess also there's lots of war, sadly, around at the moment, but there's some quite poignant research about people who are very elderly now who had experiences during the Second World War. For example, as children who were taken from cities into the countryside. I don't feel like I've really answered the question, but I think I've given as much of an answer as I can.

Speaker: Hi, you sort of touched on an issue there in the answer to the last question about cultural issues affecting any psychotherapy intervention. I wonder how important that is. I come to this because I'm not a psychologist, I'm not a psychotherapist, but my academic discipline is in management and business, and I'm very aware that communications between different cultures, national cultures, or indeed, religious cultures, all sorts of different cultures can go really wrong. It can go really wrong across those boundaries. Now touching again on what you talked about a few minutes earlier, chatbots, generalities of answers to serious specific individual problems, I'd have thought could be very dangerous. So I'd just like you to talk around those issues about cultural influences and how they respond to specific individuals’ problems, can be very individual and not general.

Naomi: Absolutely. I think it's funny we're developing this new counselling qualification at The Open University at the moment, and we are centring it around that exact idea, the idea that as a profession we are over reliant on theorists who are white, heterosexual. I've said this to the team, we've talked about it a lot, but white, heterosexual, cis, non-disabled, upper class, highly educated, oh and by the way, dead, right. So that as a profession we need to be much more critical of the theoretical approaches that we've been handed and that we train in, in order to understand that people experience distress in lots of different ways in different cultural contexts, and what constitutes an empathic response, or even the right response, or a non-harmful response, will potentially vary a lot. I think the challenge of how to support people to be what's called ‘culturally competent’, so working here in the UK is a really interesting one. I worked in the US actually in a refugee organisation and I worked, for example, with a kid from Afghanistan who was developing terrible OCD, if you know what that is. I worked with spattered spouses from Iran. There's something really interesting, but also really complex about talking across that level of difference. I worked also with a woman from the former Yugoslavia whose whole village had been wiped out. She actually gave evidence at one of the UN war tribunals. She had the most terrible PTSD. Again we worked through a translator. I can't tell you, that was just amazing and not easy. So I think this question of what's effective and what's appropriate and what's ‘good enough’ is really complex. I was talking with somebody actually, one of my PhD students yesterday, and I think one thing that lots of therapists believe is that our job is to try and connect with someone where they're at and to listen. But being able to do that, I think my talk is full examples of me not being able to do that. So, yeah, it's the aspiration and it's not always possible, perhaps because you don't understand, or your own stuff gets in the way, but culture is really important I think.

Rose: We're actually out of time so if you put something quite short, or you can discuss it later. Well, thank you very much for a fascinating talk. My attention did not waver for a second. As part of this series we really, really welcome audience feedback. So if you could feedback, fill in the feedback form when it comes to you, that will be emailed to you, we really, really appreciate it. Also just what we usually do at the end of these is announce the next inaugural lecture, which will be called “Including whom?: Practices and consequences of inclusion and diversity” by Cinzia Priola. She's a Professor of Work and Organisation Studies in the OU’s Faculty of Business and Law, and that will be on 24^th October at 5pm. Details are on the OU website. Now I just want to say thanks again to Naomi. It was so interesting. I mean, really interesting, not that British interesting, genuinely fascinating and I loved it, and to all of you for coming to support the OU, both in person and online. Now those of you who are here can come to the auditorium to celebrate downstairs. So thank you very much and my last applause for Naomi.