The leadership structure of a group therapy environment has a direct influence on how the participants respond, according to a new study led by Dennis M. Kivlighan, Jr. of the Department of Higher Education and Special Education at the University of Maryland in College Park. “Co-leadership describes a group therapy leadership structure in which two therapists are partnered to facilitate meaningful interactions among group members,” said Kivlighan. “Today, co-leadership is a widely used leadership structure across various mental health, and is often utilized in the training of group psychotherapists.” Leadership structure can have advantages for a group, but can also have disadvantages. Kivlighan said, “For example, large groups often out-perform small group including time, energy, and expertise. Unfortunately, in larger groups, there is also more conflict, absenteeism, and less cooperation than in smaller groups.” He added, “Finally, members of large groups are less satisfied with their group.”

In an effort to identify which structure best supports positive group therapy outcomes, Kivlighan and his colleagues evaluated the interaction between leaders and adolescents in 32 group therapy clusters. The groups had as little as 3 members and as many as 12, and were assessed based on participant satisfaction and overall climate. The team found that members of larger groups participated less than members of smaller groups, except when they were co-led. “In the current study, consistent with our first set of hypotheses regarding group leadership structure, we found some potential advantages of co-leadership over leadership by an individual therapist,” said Kivlighan. “Specifically, group members in co-led groups reported greater benefits of therapy than those in individually led groups, as well as significant interactions of group leadership structure and group size in relationship to avoidance and relationship with the group.” Kivlighan added, “These results suggest that co-led groups have several advantages over individually led groups.”

Reference:
Kivlighan, D. M., Jr., London, K., & Miles, J. R. (2011, November 21). Are Two Heads Better Than One? The Relationship Between Number of Group Leaders and Group Members, and Group Climate and Group Member Benefit From Therapy. Group dynamics: Theory, Research and Practice. Advance online publication. doi: 10.1037/a0026242

I’m struck by the fact that people with addiction issues, when confronted with the destructive effects of their behaviors, often find it harder to stop. This is especially true, in my clinical experience, when it comes to compulsive sexual behavior, aka sex addiction. Why is that?

Therapy clients who struggle with drinking or substance abuse tend on the whole to accept – eventually, and with my ongoing support – that they do have a problem with drinking or using, and that these behaviors are an obstacle to happier living. Once “the cat is out of the bag”, they usually attempt to reduce or quit using, over time, or else quit therapy altogether.

Those struggling with compulsive sexual behaviors, however, may remain ambivalent for years, while remaining in therapy –  aware of their dependence on these behaviors and the destructive effects of same, while wrestling with whether or not they want to stop. It’s a matter of two steps forward, two steps back, over and over again, with no change in sight.

Additionally, it is often reported to me that there appear to be more people in Alcoholics Anonymous with long-term sobriety compared to those in Sex Addicts Anonymous or Sex and Love Addicts Anonymous or other 12-step programs for healthier sexuality. Those with long-term sexual sobriety – or “abstinence” – tend to be fewer in number. Again – how come?

I know there is a lot of controversy in the mental health field about whether sexual compulsivity is truly an “addiction.” It is not my intent here to address that complex question. Suffice it to say that the suffering of those who can’t stop, in the face of heartbreaking damage and loss, is staggering to behold. If one of the key criteria for an addiction is an inability to stop in spite of negative consequences, then compulsive sexual behavior more than qualifies as an addiction.

So, if one assumes we are in fact dealing with two actual addictions, we are still left with the aforementioned disparity between drug/alcohol vs. sexual sobriety. Is it because one can live without drugs or alcohol, but cannot “remove” sexuality from one’s being? We are, organically speaking, sexual creatures, and the goal of treating sexual addiction is not to remove one’s sexuality but to create healthier, more intimate and less self-destructive behaviors.

I suspect that, because we are dealing with sex after all, the issue goes even deeper. Sexual desires and fantasies often emanate from the very core and are difficult to interpret. Heterosexual men with compulsive sexual issues, for instance, may desire sex with other men while staying married to a woman; some pursue sex with transvestite prostitutes, in ways that put themselves at legal and medical risk. I know of high-functioning women who are compelled to conduct serial affairs, virtual or real, with men whose only apparent goal is to sexually “use” them in sadistic or degrading ways. These are people who have little to gain, it would seem, and everything to lose.

Another complication is that sexuality is a relational activity. It always implies another person, either real or fantasized. One can use heroin or drink alone, as many do. But it always “takes two to tango”, even if one of those people is a fantasy or “virtual” person. Even when one uses online pornography, for instance, another person is “present”, at least onscreen.

Close readings of sexual fantasies and compulsive behaviors can be revealing of one’s buried self-concepts and unexpressed needs; an S&M fantasy may represent a way of coping with an overbearing or shame-inducing caregiver, by sexualizing the pain and staying in control of the fantasy/scenario (even if one is the “M”). Those struggling with scenarios of dominance over others may be trying to compensate for intolerably low self-worth, an attempt to control chaotic emotions leftover from a traumatic upbringing.

My experience with straight men who compulsively watch porn often reveals a desire for a woman who can offer everything but demand nothing, and disappear when the encounter is over, before she decides he’s “too much” for her, or “gross,” or perverted, etc.  It’s a sort of mini-relationship, easily controlled by someone who usually has a desire for and deep fear of intimacy, who gets his needs met quickly and then signs off.

It’s almost as if these fantasies provide a window into the psyche, revealing unmet needs.   Like the need to feel in control, to express repressed desires, to sexualize (i.e. numb or self-medicate) hurtful or shameful feelings or other emotions that are unconscious or too difficult to articulate.

These are feelings and needs that cannot be expressed in their actual relationships – usually because they are perceived as “disgusting” or “too much” for their partner.  Of course, their partner very often has her own “stuff” and tends to be closed off, angry, controlling, etc.  It’s an extremely painful dynamic that I see with many of my male clients – straight and gay – who struggle with sexual compulsivity.

Why would a man, or anyone really, seek an “emotionally unavailable” partner? Because we tend to gravitate toward the familiar, even if what is familiar is dissatisfying or even abusive.

Very often the person chooses an emotionally closed off, or overly aggressive (or withdrawn) partner because, in reality, the alternative is too scary. It may sound strange, but what’s even scarier than not finding love – especially in cases of a traumatized upbringing, which includes just about everyone I work with – is actually finding it! Why is that? Because love can be lost or taken away, leaving the person abandoned and traumatized (again) – even more painful than being mistreated or ignored. In the latter case, at least you know someone is there.

Thus the person suffering from core interpersonal trauma – the result of a faulty caregiver, another human being – who ends up sexualizing their needs via the behaviors described above, hovers between a desperate yearning for and deep aversion to intimate connection. The sort of “mini-relationship” described above is often a substitute. It satisfies…for a while. One connects, finds relief via sex and affection (what’s actually virtual feels real at the moment) – then detaches before becoming too invested or emotionally “at risk” for abandonment.

That emotional risk, believe it or not, is usually more frightening than the prospect of the legal or health risks that accompany these behaviors. Abuse and emotional distance is familiar, even if painful, while the possibility of genuine love is new and terrifying.

Thus the compulsive behaviors are a temporary solution to the very real and shameful problem of a confusing inability to connect with others.  I say “shameful” because very often the feeling is something like, “I’m an idiot because I don’t know how to stop.  Why do I do such disgusting things.  What a piece of garbage I truly am.”  (Even if the person is outwardly successful, wealthy, etc.  As they say in recovery, it’s always an inside job.)

One of my clients once said in my office, with a smile on his face, “I have no love in my life.  I’d only ruin it if I did”.  This was a successful, married attorney with a compulsion to see prostitutes.

It took me a few moments to realize the smile was an awkward attempt to conceal shame, not any sort of bemusement. That smile was one of the saddest things I’ve ever seen.

What I want to stress here is the pain that needs soothing is, in part, not the result of an unrequited hunger for love, nor a fear of finding it, but rather an impossible non-reconciliation between the two.

Here are two opposing, powerful forces at work, with radically different agendas – one to connect, the other to protect.  Without help, this internal conflict results in unmanageable emotional turmoil and frustration. The cycle never ends, until the person says “enough,” and seeks help.

I’ll talk next time about how therapy can, when effective, provide a slow but steady path towards healthier intimacy and a chance to escape the suffocating shame and loneliness that so many of my clients describe as a slow-moving poison — leading them to behaviors they so desperately want to stop, but can’t.

Related Articles:
Super-sizing Sex
The Good and Bad Sides of Porn
Three Ways to Avoid Sex Addiction Relapse

Therapeutic immediacy (TI) is a term used to encompass any discussion between a client and therapist during a session. The therapeutic alliance formed between the two parties as a result of the discussion is fundamental to the success of treatment. “Recently, in order to capture the more interactive and dyadic nature of the therapeutic relationship, this definition has been broadened to also include any client-initiated disclosures of feelings about the therapist or their relationship, and the revised term of therapeutic immediacy has been suggested,” said Jason Mayotte-Blum of the Derner Institute of Advanced Psychological Studies at Adelphi University, and lead author of a recent study on the effect of TI. “Typical examples of therapeutic immediacy include exploring parallels between external relationships and the therapy relationship; client or therapist expression of in-session emotional reactions; inquiring about the client’s reactions to therapy; the therapist commenting on his or her experience of the client; supporting, affirming, and validating the client’s feelings in the therapy relationship; and expressing gratitude. Use of therapeutic immediacy in the therapeutic relationship can then act as a template for interpersonal functioning in the client’s outside relationships.”

Mayotte-Blum analyzed data from two case studies for his recent study. In both instances, the clients and therapists were not told that TI was the focus of the study. Mayotte-Blum and his colleagues examined data from 16 sessions over a four-year period and found that TI was used quite often by both the therapist and the client. Mayotte-Blum said, “Session excerpts of therapeutic immediacy identified prominent areas of treatment focus such as (a) the building of trust, mutual respect, and recognition of deep feelings with a male figure; (b) the generation of new relational templates and skills related to in-session discussion of the therapeutic relationship; and (c) Ann’s [client] increasing ability to tolerate intense affect such as sadness and anger.” He added, “Although it is unclear to what extent the use of immediacy was responsible for these therapeutic gains, we can surmise from these direct client reports that the use of immediacy was at least experienced as a positive and facilitative intervention during their treatment.”

Reference:
Mayotte-Blum, J., Slavin-Mulford, J., Lehmann, M., Pesale, F., Becker-Matero, N., & Hilsenroth, M. (2011, November 7). Therapeutic Immediacy Across Long-Term Psychodynamic Psychotherapy: An Evidence-Based Case Study. Journal of Counseling Psychology. Advance online publication. doi: 10.1037/a0026087

Many couples I work with come in with a large amount of stress and difficulty. The causes vary, but the behaviors people use to respond to the upset are often predictable. People who start out loving each other sometimes find themselves so burdened by stress and difficulty that they end up feeling frustrated in the relationship.

Research suggests that up to a third of married individuals report low marital satisfaction, and approximately 20% of all married couples experience marital distress at any given time. These numbers reflect what therapists see daily in their practices.

No one starts out being frustrated. Frustration comes after being unhappy, sometimes for a long time. Often, couples with the best intentions end up not being able to explain themselves to each other, or they won’t say what they really want to say, and as a result they feel tense, stressed and oftentimes frustrated.

The most frequent problem reported by unhappy couples is poor communication. Frustration can appear in many ways. It may come out as a curt answer to a question. Maybe it’s a rolling of the eyes, or a “whatever” response to a partner, or no response at all. Frustration can also be felt when one person ignores the other altogether.

Sometimes frustration is a slammed door, or a sigh. It’s a sign of exasperation from the frustrated person to the other telling them something is very wrong. It also broadcasts unhappiness and discontent. And it’s a problem. It keeps the frustrated person trapped in difficulty and leaves the other partner in the dark regarding the source of the problem.

What would be helpful is to discover how to talk about what doesn’t feel good in the relationship. Unfortunately, this is often difficult for couples who have not communicated with each other for a while. Over time, the breakdown in communication evolves into increased arguing, stonewalling, defensiveness, and contempt. Distressed couples tend to engage in these negative patterns of communication often and are unable to successfully repair the relationship after an argument.

If you find yourself answering your mate with frustrated gestures, you might want to think about what is happening to you. I am pretty sure you used to have very soft, loving responses in the early days. Maybe as time passed you found yourself unable to express your thoughts and feelings to your partner without worrying how he or she might react. It’s possible you may even have started keeping your thoughts and feelings to yourself, not wanting to bother your mate. But the more you kept your thoughts and feelings inside without speaking them, the more you might have felt yourself becoming stressed and uncomfortable.

This is the body’s natural response to too much tension. Marital stress can alter endocrine, cardiovascular, and immune function—key pathways from troubled relationships to poor health. This tension is a clear message about what it feels like when you can’t express yourself and you keep your feelings inside. You might have a sensation of all your feelings being trapped inside your own body and you can’t let them out, like you are frozen. You keep yourself suppressed and you suffer. At first you might be able to manage your increased stress. Maybe you exercise more or take up an activity. Maybe you yell at the kids instead or a co-worker. Perhaps you overindulge; too much alcohol, drugs, or food.

The more you figure out how to manage your challenges, the more you might be looking at your partner with disdain. You may start to believe that he or she just doesn’t care about what you think and feel. Individual and couple responses vary greatly; That’s when people start with the one word answers, or the disinterest, or the shaking of the head. These behaviors tell the other person you are not interested in them. These reactions indicate that you are unhappy.

If you are unhappy in your relationship, take stock of how you are feeling right now. Ask yourself, “Am I stressed and unable to talk to my partner about what is bothering me?” If you answer yes, start looking at the ways you do talk to your mate. Are you short and abrasive? Do you dismiss him or her? Do you just not bother because you don’t think anything will change?

If you answered yes to any of these questions, you

So how do you change your situation? You just took the first step; you recognized it. From here you might want to talk to someone: a friend, family member, religious mentor, or counselor. Get your long held feelings from inside yourself outside of your head by communicating them. Try to understand what is preventing you from talking to your mate about these feelings. Learn why you stay silent.

There are effective treatments for marital distress. No one begins as a perfect partner and a successful marriage depends on a number of skills, such as the ability to understand one’s own behavior and motives, to understand one’s partner, to argue and problem-solve productively, and to effectively negotiate differences—all of which can be enhanced by working with a marriage and family therapist.

You will likely feel better even after just a few sessions. You could also learn different ways to communicate your feelings that may give you confidence. When you leave your old behaviors – the eye rolling, sarcastic responses, non answers – and replace them with true expressions of your feelings, a number of things might also happen. Your stress and tension may decrease, and it’s possible you might even begin to experience some happiness, and that might feel pretty great.

When to Seek Professional Help

Over 98 percent of clients of marriage and family therapists report therapy services as good or excellent. After receiving treatment, almost 90% of clients report an improvement in their emotional health, and nearly two-thirds report an improvement in their overall physical health. A majority of clients report an improvement in their functioning at work, and over three-fourths of those receiving marital/couples or family therapy report an improvement in the couple relationship.

If you’re experiencing persistent relationship frustration, consider reaching out to a qualified couples therapist or marriage and family therapist. They can help you and your partner develop better communication skills and work through underlying issues contributing to your frustration.

For immediate support, you can:

Contact the Find a therapist directory

Call the SAMHSA National Helpline: 1-800-662-4357 for mental health resources

Reach out to your healthcare provider for referrals

References:

1. Regan, P., Walsh, S., Horton, R., Rodriguez, G., & Kaufman, L. (2025). Contextualizing marital dissatisfaction: Examining profiles of discordant spouses across life domains. Frontiers in Psychology, Collection date 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC11961942/
2. Association for Behavioral and Cognitive Therapies. (2021). Marital distress fact sheet. https://www.abct.org/fact-sheets/marital-distress/
3. American Association for Marriage and Family Therapy. (n.d.). Marital distress. https://www.aamft.org/AAMFT/Consumer_Updates/Marital_Distress.aspx
4. Heim, C., & Heim, C. (2025). How long-term couples cope with chronic stressors and adverse life course events in marriage: A qualitative study. The American Journal of Family Therapy, Published online: 18 Feb 2025. https://www.tandfonline.com/doi/full/10.1080/01926187.2025.2459688
5. Shrout, M. R. (2021). The health consequences of stress in couples: A review and new integrated Dyadic Biobehavioral Stress Model. PMC, PMC8474672. https://pmc.ncbi.nlm.nih.gov/articles/PMC8474672/
6. American Association for Marriage and Family Therapy. (n.d.). About marriage and family therapists. https://www.aamft.org/AAMFT/About_AAMFT/About_Marriage_and_Family_Therapists.aspx

In couples and sex therapy, one of the common themes that come up is that of acceptance. I strongly encourage people to accept their partner, and accept each other. I believe that acceptance is at the core of a successful intimate relationship. I discourage long lists of expectations and/or changes that people often bring into their relationships, which may be ideals of who their partner should or should not be, perhaps based on how a previous partner may have been or how the perfect partner should be. These ‘ideals’ or ‘shoulds’ can be quite detrimental not just to the relationship as a whole, but affect other areas of the relationship along the way, such as a couple’s sex life. Ideals and ‘shoulds’ can sound like judgments and criticisms, and there is just no room for hostility in the bedroom (well, in most cases). So limiting our lists to two very specific items is something I recommend; simply accept the rest. Acceptance conveys the message that we love our partner just the way he/she is, and that quite possibly we even admire them, look up to them, and still love and/or are in love with the same person when we met, and who we fell in love with. If we find we cannot accept our partner much of the time, and that we get angry too much, then taking a look at ourselves is the next step.

But there is another side of acceptance I want to talk about. There is a detrimental aspect of acceptance, and that is when it allows for things like abuse, manipulation, and control to take over the relationship. Being too accepting of all things, especially when they risk harming someone, is where learning to draw the line becomes important. Having boundaries is key, and knowing what one’s boundaries are is a good place to start. Some examples of behaviors that should be at least questioned and looked at include drug and alcohol use and abuse, violence of any kind (this includes physical abuse), sexual abuse towards anyone, including spouse, pets, and children in particular. Yes, there are some things we should not blindly accept. Accepting these often become like shoving things under the rug — a giant pink elephant in the room that everyone knows is there, but no one acknowledges or talks about. This is also sometimes known as denial (a concept that Sigmund Freud suggested was one of our coping mechanisms). Denying that there is a problem may often lead to trying to cover up the problem or fix the problem by accepting our partners behavior. I call this covering-up behavior enabling.

Enabling is simply trying to smooth things over, to keep things in peace and harmony, to keep the relationship together and intact, and while enablers definitely have their personal roots and reasons, enabling may have severe and detrimental costs. In the case of violence, physical abuse, and drug or alcohol abuse, the worst case scenario is death, but along the way there are many other costs. The enabling individual (or, enabler) may have to work harder and harder to make up for the addict or abuser’s behaviors to keep the relationship and family running smoothly. There may be financial hardships. There may be accidents or legal battles, and there may be a lot of physical or emotional suffering. Establishing boundaries for what is acceptable and unacceptable behavior is absolutely key. No, we cannot accept everything, for we risk becoming an enabler. The person who accepts too much must also take a look at him/herself.

Below is a link to some questions from TellingItLikeItIs.Net for you to ask yourself, to help you determine if you might be enabling some sort of otherwise unacceptable behavior. If you answer yes, I strongly suggest making some changes, determining and developing your boundaries and seeking out the help of a mental health professional.

Identifying Early Warning Signs of Enabling Behavior

Related Articles:

How Co-Dependents Come Into Therapy
The Quest for Wisdom
Saying No to the “Disease”

Lesbian, gay and bisexual (LGB) clients may form better alliances with therapists who have similar sexual orientations, according to a new study. This new study done by researchers at the Graduate School of Education at Fordham University examined gay and bisexual men in therapy who had therapists of the same sexual orientation. Trends found in the research may be applicable to the LGB community at large. Thomas I. Stracuzzi, lead author of the study, said that when LGB clients share the same sexual orientation with their therapists, they may achieve better treatment outcomes because the alliance developed between the client and therapist begins with identification and trust. Stracuzzi said, “From this perspective, LGB counselors may be more likely than their heterosexual colleagues to have the knowledge and attitudes associated with successful clinical work with LGB clients and the possibility that LGB clients may fare best with counselors who are LGB or are perceived to be LGB.” Additionally, some experts believe that cultural diversity, including universal-diverse orientation (UDO), self-reported or perceived, provides a common platform from which a LGB client and their therapist can develop a strong alliance. “For some LGB clients, it can be especially meaningful to work with a counselor who also is LGB,” said Stracuzzi. He added, “However, counselor disclosure may inhibit client exploration of issues related to sexual identity due to clients’ assumptions about how their counselor’s sexual orientation might influence the counselor’s understanding of and reactions to the client. For example, a gay male client may mistakenly assume that his gay male counselor understands aspects of his experience due to their shared sexual identity.”

Stracuzzi and his colleagues interviewed 83 male LGB clients. Of the therapists who worked with the men, some told their clients their sexual orientation, while others did not. The researchers discovered that the clients whose therapists revealed their orientation experienced a smooth, strong, working alliance. But the clients who assumed the sexual orientation of their therapists did not form strong alliances. The team added, “However, findings do suggest that LGB-affirming counselors should be aware that clients do not always accurately perceive their counselor’s orientation and that perceived similarity—whether accurate or not—may negatively affect the therapeutic process.”

Reference:
Stracuzzi, Thomas I., Jonathan J. Mohr, and Jairo N. Fuertes. “Gay and Bisexual Male Clients’ Perceptions of Counseling: The Role of Perceived Sexual Orientation Similarity and Counselor Universal-diverse Orientation.” Journal of Counseling Psychology 58.3 (2011): 299-309. Print.

Last week, I had the honor of attending and speaking at Postpartum Support International’s 25^th Annual Conference in Seattle, WA. I was moved and inspired by the amazing work gestating and being born in the perinatal world by so many compassionate professionals. (Refresher: “perinatal” refers to the time from conception, through pregnancy, on through the first year after having a baby.)

My dear colleague Gabrielle Kaufman, BC-DMT, NCC and I presented a workshop on special needs parenting as relates to the family experiencing perinatal challenges. Both Gabrielle and I have found in our practices a large number of women and families who are impacted by the double whammy of a perinatal mood/anxiety disorder (PMAD), coupled with parenting a special needs child. We felt it was important to highlight this population of folks who are in great need of resources and support. Although this subject could be an entire week-long conference, we discussed the following highlights that are pertinent for special needs families and the people that support them.

It’s hard to define special needs, as we all are special and we all have challenges. We choose to define special needs as a child in a family system who is experiencing the challenge of a neurological, emotional, behavioral, developmental, or physical disability. This challenge affects the entire family system on several levels.

1. One in 10 children have a disability (neurological, emotional, behavioral, developmental, physical)
2. Parents of special needs children are more at risk for depression and anxiety
3. Couples (parents) of special needs children benefit from support such as psychotherapy and regular date nights (50% or more of all special needs couples divorce)
4. “Neurotypical” siblings benefit from support in the form of sibling support groups, one-on-one attention from parents, and open-ended discussion of feelings/solutions to concerns associated with being a special needs family (i.e., role-playing how to handle being in public with special needs sibling, preventing parentification, etc.)
5. Stigma is real and exists, even in the 21^st century. Therefore, family discussions need to happen to address this concern and to build social support networks.
6. Family/couple/individual therapy and support groups were found to be helpful in buffering the effects of stress and lowering depression/anxiety in these family systems in several studies
7. The special needs family is exposed to chronic stress and therefore requires an ongoing stress management program that will lower the effects of cortisol and adrenaline (the fight or flight response) that develop. For example, self-care, yoga, psychotherapy, respite care, support groups.

Below are some helpful resources we found to be beneficial.

Resources

• Americans with Disabilities Act Home Page – Extensive information about the Americans with Disabilities Act
• The Arc of the United States – Chapters across U.S. offer information, support, and advocacy for people with developmental disabilities
• The Arc’s Information for Siblings – Provides information and training to start sibling support groups
• ARCH National Respite Network
• Easter Seals Southern California – After-school activities for children with disabilities using public school sites and community settings
• Family Voices, Inc. – Offers information, support, advocacy, and workplace information for families of children with special health care needs; many publications available to download for free
• Fussy Baby Network – Resources for families with fussy babies
• National Alliance for the Mentally Ill (NAMI) – Offers interactive “Special Needs Estate Planning Guidance System”
• National Autism Association – Clearinghouse of resources on autism spectrum disorders
• National Dissemination Center for Children with Disabilities – Online clearinghouse providing information and links on all matters related to childhood disabilities, resources, laws, research
• Sensory Planet – Clearinghouse of information for sensory processing disorders
• Sensory Processing Disorder Foundation – Information on sensory processing disorders

Organizational Aids:

• Children’s Hospital and Regional Medical Center/Center for Children with Special Needs – Offers “CARE Organizer” (forms to document child’s activities, therapies, medical bills, etc.) and the “CARE Notebook” (an expanding file folder to organize forms)
• Children’s Medical Organizer – Online organizer to keep track of family’s medical information, from immunization records to doctor appointments
• The National Center of Medical Home Initiatives for Children with Special Needs – Provides links to various types of organizers and health care notebooks
•  Think College – Has information and searchable database on special college training, courses, and assistance for young adults with disabilities

Books:

• Baskin, A., & Fawcett, H. (2006). More than a mom: Living a full and balanced life when your child has special needs. Bethesda, MD: Woodbine House.
• Celebi, J. (2008). Overwhelmed no more!: The complete system for balanced living for parents of children with special needs. Joan Celebi.
• Domar, A. (2001). Self-nurture: Learning to care for yourself as effectively as you care for everyone else. New York, NY: Penguin Books.
• Fogel Schneider, E. (2006). Massaging your baby. New York, NY: Square One.
• Gil, B. (1998). Changed by a child: Companion notes for parents of a child with a disability. Pella, IA: Main Street Books.
• Meyer, D. (1997). Views from our shoes. Bethesda, MD: Woodbine House.
• Seligman, M. (2004). Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: Free Press.
• Seligman, M. (2006). Learned optimism: How to change your mind and your life. New York, NY: Vintage.

Parental Self-Care:

• America On the Move Foundation – Information about healthy-eating and fitness; can register to work toward achieving health goals
• American Trails – State-by-state list of trails and greenways, groups, and hiking agencies
• Special Olympics – Opportunities for adults and children with intellectual disabilities for sports training and competition
• World Laughter Tour – Lists laughter clubs around the U.S. and Canada
• Global Family Yoga – Yoga resources for special needs families

Other Materials:

• Children with Special Needs and the Workplace: A Guide for Employers by the Center for Child and Adolescent Health Policy at the MassGeneral Hospital for Children
• Commonly Asked Questions About Child Care Centers and the Americans with Disabilities Act
• A Family Handbook on Future Planning edited by Sharon Davis, PhD
• Open Arms: Embracing a Bright Financial Future for You and Your Child with Disabilities and Other Special Needs by Easter Seals Disability Services and the National Endowment for Financial Education

This list of resources is far from comprehensive, as every day the Web has new sites on the special needs family. We chose to highlight a few websites and books which we found to be helpful for our clients and our practice, as perinatal psychotherapists.

As a unique form of short-term, complementary and alternative modality (CAM), clinical sexologists are largely under-recognized and under-used. Though it’s said we specialize in studying “what people do and how they feel about it,” sexology touches on everything from erotology to anthropology, law, medicine, psychology, anatomy and physiology (naturally!), gender studies, public policy, history, and so on. That’s because human sexual behavior is pervasive, it affects everything we collectively do and create. As a sexologist, my interests have included Asperger’s Syndrome and sexuality, Native Hawaiian sexual traditions, objectum sexuality, parenting transgender children, the effect of sensory dysfunction on sexual behavior, and the use of hypnosis to address sexual concerns. Almost anything can provide delightful grist for a perpetual, intellectual mill and this has been my joy. Sometimes useful clinical insights emerge from regarding artifacts or incidents through a sexological lens. However, even when there is no immediate clinical application, the overall effect is a deepened respect for the unstoppable and endlessly creative human engagement with eros.

For some, this process accelerates during a “unique baptism by fire” known as the Sexual Attitude Restructuring (SAR) process. At the Institute for Advanced Study of Human Sexuality in San Francisco (which pioneered SARs during an earlier incarnation as the National Sex Forum), this is no mere weekend of “Sexuality 101 and 201”. At IASHS, you are immersed for eight days in everything you always wanted to know about sex and possibly a whole lot of things you may wish you’d never seen. Explicit media and small group processing are integral aspects. The experience is intense. Even seasoned sexologists have been known to melt down. But a good SAR results in a near-unconditional acceptance of one’s own erotic quirks, and those of fellow human beings. One goal of SAR process is to discover exactly what aspects of human sexuality are personal turn-ons or turn-offs, so that clients are not harmed by the reactions of untrained clinicians. I can say, after having experienced two eight-day SARs, that my ability to hear just about anything is pretty good – and I know when and how to gracefully suggest a referral when out of my depth. For this reason, the American Association of Sex Educators, Counselors and Therapists (AASECT) requires a (briefer) SAR experience of everyone seeking certification through the organization.

AASECT certifies the separate categories of sex educator and sex counselor, but not the hybrid practice of clinical sexology, which does both. Though I have recently completed requirements for sex counselor certification, I am sorry my own professional category is invisible within an organization that has so many of us as members. However, I recognize the reasons for this. For one thing, standards for clinical training in sexology are not as defined or generally agreed upon as they should be. For another, right now in the public mind a “sexologist” may be anything from Masters & Jonson to a woman in lingerie groped in a darkened room during an episode of The Pick Up Artist.

However, clinical sexologists practice with Annon’s PLISSIT model: permission (P), limited information (LI), and specific suggestions (SS). We make referrals for intensive therapy (IT) if necessary. Our understanding of human sexual behavior is fostered by our training, which exceeds the sexuality education requirements of other professions. This depth enables us to attend to clients seeking techniques for sexual enrichment and/or short-term management of non-medical sexual problems. As complementary specialists, we work well in consultation with a range of licensed professionals. Within the ethical scope of our practice, we support sexual health, function, self-esteem, and the intimate capacities of our clients.

Mandy nuzzled her 3 month old baby happily as she warmed his bottle. It felt so good to breathe in his sweet baby smell and touch his soft delicate skin, his little body curled in a warm embrace into the curve of her neck. Mandy was starting to feel like she had her “sea-legs’ as a new mom and was particularly enamored of the fact that her new baby was sleeping through the night. The rough night-time awakenings were beginning to subside as baby Noah matured and slept for longer periods. She was looking forward to meeting a new mom friend in the park with their babies after she gave Noah a bottle.

Suddenly, in the wink of an eye, the tender moment vanished. Mandy watched the water warm Noah’s bottle on the stove. She  was blind-sided by a  horrific thought, flashing through her mind of the  water morphing into hot lava and scalding her baby boy. Mandy flinched, gasping and clenching tightly onto Noah, quickly backing away from the oven. The thought terrified her, and she could not believe such an image threatened to envelop her mind. Mandy’s entire body tensed as she began to pant, shallow breaths. She didn’t know it at the time, but, she was well on her way to her first panic attack after experiencing an intrusive thought…a hallmark symptom of perinatal depression and/or perinatal OCD.

Experiences like Mandy’s are common in some 20% of all child-bearing women who develop perinatal mood/anxiety disorders (the clinical term for depression/anxiety during pregnancy and up through the first year after having a baby). Some women develop symptoms of anxiety with intrusive thoughts while others may not experience these often debilitating and traumatic images. Others may have more depression symptoms with a smattering of anxiety, panic attacks, and sometimes intrusive thoughts.

PMADs (perinatal mood/anxiety disorders) are the clinical term for a myriad of symptoms under the umbrella of depression and anxiety from conception through the first year following childbirth.  In layman’s terms, perinatal challenges/neurobiochemical imbalances while pregnant and after having a baby often leave women completely stunned, horrified, and traumatized…because  women don’t know what hit them. And no one talks about it.

The reality is that PMADs are very common, and most likely under-reported due to the stigma connected to them. Mothers can be wracked with so much guilt about any of the symptoms, particularly if she has intrusive thoughts, that they are loathe to talk to a specialist to get help or to a family member. Many women report they feel like they are “going crazy” or afraid to be “like that woman on TV who killed her kids.”

I want to underscore the importance of supporting a woman who is experiencing intrusive thoughts to not delay in seeking help, to get help immediately with a trained specialist in perinatal challenges. The differential amongst these particular perinatal struggles is quite delicate. Furthermore, to receive the best care, she must have help from a skilled perinatal psychotherapist who can provide a comprehensive bio-psycho-social assessment and steer her in the appropriate direction for what is ideally a multidisciplinary approach to treatment.

This article is not intended to be a primer on the difference between perinatal intrusive thoughts and hallucinations since such is the subject of a workshop or conference. And, each set of circumstances requires a different course of treatment (both medically and in psychotherapy). Generally speaking, however, when a woman experiences intrusive thoughts, she is grounded in reality and horrified of the images that are occurring, feeling that her body is betraying her. She will often respond with disgust at the images and in turn demonstrate behaviors that lessen her anxiety and protect her baby (for example, Mandy avoided ovens for a time because such objects were a trigger for her). Intrusive thoughts can be part of perinatal depression and will remit with psychotherapy and in many cases, medication management (typically an SSRI), along with a good self-care plan and social supports in place.  Hallucinations, on the other hand, are considered a medical emergency and potentially part of a more rare PMAD, perinatal bipolar disorder or psychosis. In such a case, the woman is not grounded in reality, and hallucinations can cause her to do or say things that she would not normally do and have the potential to be life-threatening to her or the baby. If you suspect that you or a loved one are experiencing hallucinations, call 911 or go to your nearest emergency room immediately. Do not attempt to diagnose.

Fortunately for Mandy, she realized something was amiss in her brain biochemistry and immediately sought help with a trained perinatal psychotherapist. Upon consulting with a psychiatrist specializing in reproductive mental health, she agreed to try an antidepressant (Zoloft) to help her biochemistry restore itself. Mandy’s recovery was swift because she sought help immediately, she received support, non-judgment, validation, psycho-education, as well as cognitive behavioral strategies in psychotherapy to help her diminish the anxiety and intrusive thoughts. She worked with her therapist on a solid self-care plan and put in place the help of a doula (hired caregiver specifically for new parents). Mandy feels empowered now as a new mom, free of intrusive thoughts and filled with pride at the arrival of Noah in her life. She is now on to a full recovery, enjoying her 7 month old son. (Please note: swiftness of recovery times vary with each individual’s unique circumstances).

If you or someone you love appears to have intrusive thoughts after having a baby (or even while pregnant), do not attempt to diagnose her. Do find a trained perinatal specialist to help the woman you care about to get treatment. The good news is that PMADs are treatable and temporary, and with help, women recover fully.

Other useful resources:

• Postpartum Support International—www.postpartum.net – largest non-profit dedicated to PMAD awareness; vast clearinghouse of information on PMADs, down-loadable fact sheets, online support groups for moms and dads, chat with an expert, stellar bibliography of recommended books, latest research findings and trainings in the perinatal world; current legislation in support of PMAD awareness, destigmatization, and treatment; coordinator/volunteers link callers/e-mailers with trained professionals; warmline in English/Spanish
• Postpartum Progress—www.postpartumprogress.com – most widely read blog on perinatal challenges, by Katherine Stone; the reader can subscribe to a daily news feed and a daily affirmation of hope.
• Real Mom Experts - www.realmomexperts.com – website dedicated to supporting women with PMADs, written by perinatal psychotherapists; self-care techniques for moms

Great book on intrusive thoughts:
Dropping the Baby and Other Scary Thoughts: Breaking the Cycle of Unwanted Thoughts in Motherhood by Karen Kleiman and Amy Wenzel (2010). –excellent book for new moms dealing with PMADs, also for perinatal professionals

You’ve sat comfortably on your therapist’s couch for six months talking about everything under the sun; how you prefer to do your laundry, how nothing is ever good enough for your spouse, how irritating your mother is when she compares you to your older sister, how traffic makes you crazy.  You feel comforted, your feelings validated, your motivation lifted.  You walk out of there, pensive yet energetic, ready to face any challenge.  You feel like you are moving toward your goals with more clarity.

Then one day, it happens.  You’re feeling more depressed than usual, and you go to therapy.  As you talk about how sad you are today, you see a new look on your therapist’s face as she begins to ask you probing questions about your past.  You remember the first time you ever felt this sad, and the floodgates for unhappy memories are opened.  You begin to feel more depressed.  You feel quite horrendous, actually.  You feel like getting out of there, but your therapist encourages you to stay in your horrible feelings and explore them further.  The whole thing begs the question; “Why do I have to talk about this?” This is the first time you looked at your watch in session thinking, “Is this over yet or what?”

That day as you drive home from your session you begin to wonder how much therapy is really helping you, why you even decided to go in the first place, or perhaps that you really don’t need to be spending all this money on it when you could get massages instead and feel great every time.  You don’t feel the usual sense of clarity and optimism that you usually do after session.  Instead, you go home and take a long nap, more depressed than ever.

This is a common experience among therapy seekers.  At the six month mark, things begin to become difficult in therapy.  After six months to a year of consistent therapy, you and your therapist have developed a deep and strong enough relationship where he/she will begin to explore the more painful and therefore, more challenging to access material in your psyche.  Bad memories may start to surface, and emotions that pervaded your past may begin to show themselves again.  Believe it or not, this feeling like crap is a good thing!

Talking about painful material in therapy is beneficial because this brings the material into the present where it can be looked at and understood.  This is the time to feel uncomfortable so that your therapist can perform the psychological surgery that needs to happen for you to feel better later.  Draining an infection is never pleasant, but it is necessary.  Once the painful memories are out in the open, they begin to lose their power.  You feel less burdened by them as your therapist will help you carry their weight.  Verbalizing the emotions and sensations you feel as you remember helps your brain to better process the information, helping you to feel differently or change your perspective.

Much of how we feel, think and behave in the present relates back to the experiences we have already had.  Understanding the pain you carry, and why is an important tool for your therapist to have when working with you.  This enables your therapist to change how you feel, by understanding the root cause and then taking proper treatment channels.  These most unpleasant moments in therapy are the real work, and facing them is your most rewarding challenge.

It’s a classic. Of all the themes in the history of relational strife, the I’m Right, You’re Wrong story is by far the most common.

Like many things, we often take this argument for granted or overlook the magnitude of its influence. When couples enter into therapy together, it may be a hidden goal for each of them to convince their therapist that one of them is right and the other is wrong. They demonstrate this in many ways—either subtly or in more painfully blatant ways. By doing so, they hope to feel validated, and that feels good.

Being right gives you a rush of dopamine—the brain chemical associated with winning and victory. You may feel strong—even invincible. The problem with needing to be right is that if we hold it too tightly, it becomes a necessary component for feeling good in the relationship. Any time you are outsmarted, out-shouted, or out-whatever, you feel bad in the relationship. So if this is the game you’ve set up for yourself and for your partner, the relationship cannot logically thrive for both of you. When one is right, that partner is elevated to a higher power position and the other is knocked down a peg.

Effectively, this game creates division. We all want to be on the right side of the wall—not the wrong side. But that means your partner has to be on the wrong side. The more this dynamic is strengthened, the thicker that wall becomes, creating more division. You may feel nice and superior on your side of the wall, but you are drifting further and further from your partner. You become less connected, less caring, and may end up contributing less to the relationship.

[fat_widget_right]If you are convinced you are not the problem, and it is your partner that needs fixing, how does clinging to this belief affect the way you treat them or your attitude toward them? In therapy, I am never going to argue whether or not something is true. I am only interested in what works. What is it going to take for you to increase intimacy, compassion, and loving action in your relationship? I’m guessing that being right hasn’t worked so well in the past. Let’s try something different.

The first step will be to knock down that wall. After all, it isn’t made of bricks and mortar, but simply attitudes and beliefs that you alone are holding in place. How do you knock it down? Simply let go of it. Loosen your grip on it, and you will start to see it crumble. Let it go completely, and it will completely disappear.

One way to do this is to give your story a name or a title. The next time it comes up, say to yourself, “Here goes I’m Right, You’re Wrong again.” By doing this simple exercise, it creates a cognitive space between you and your thoughts about being right. It is the difference between being right and just being while having the thought about being right. It may not sound like a huge shift, but try it. You may find it makes a big enough difference that you are not compelled to react in ways that you might have when you were fused to your beliefs about being right.

Put down your weapons, and take off your armor. Nature has endowed us with the proclivity to feel protected and safe, so stripping your defenses may feel vulnerable and weird. This is the part where you have the uniquely human freedom to make an important choice. Many will take a quick look at the prospect of being unguarded and will clench their armor even more tightly. Being vulnerable means you might get hurt. But how do you expect to be intimate while swathed from head to toe in battle armor? Intimacy is best experienced naked—physically and emotionally. Vulnerability is an essential part of being open and deeply connected, and it’s a risk. There’s no other way, but once you make the choice to get naked—so to speak—the rest can be pretty fun.

Group therapy can be the most nurturing and also the most challenging form of therapy. It is highly effective. While it doesn’t replace individual therapy, it can be a great adjunct and a final step in the healing process.

Group therapy is very relevant for survivors of childhood abuse and in fact for any traumatized individual. Isolation and separation from communal support is a primary characteristic of trauma, and that is exactly what group therapy provides. Enduring recovery cannot occur in isolation, it can only take place within the context of relationships. The group serves as a symbolic societal witness to each victim’s experience, as it is retold and relived in the group process. Fundamental societal functions – being made to feel safe and seen, sharing emotional distress, validating one’s experience, minimizing shame, recognizing and encouraging strengths and taking personal responsibility are now played out within the group interaction. The successful group environment provides a corrective emotional experience in which past dynamics of self-blame, lack of trust, and silencing of the victim will be evoked and then worked through. These groups offer a quality of support and understanding that is simply not available in the survivor’s regular social environment. (more…)