In therapy, many issues are covered, but sex may still be an uncomfortable topic for many clients and even therapists to talk about. Yet many people have sexual issues that need to be resolved in order for life to be the most fulfilling that it can be.

In general therapy, there may be an uncomfortable attitude in regard to clients and therapists talking about sex, an uncertainty of what constitutes sexual issues (considering there is a wide range of acceptable sexual behaviors, experiences, and attitudes in the modern world), and possibly a lack of guidelines for how to address sexual issues that may be occurring in client relationships.

Some experts have offered opinions and guidelines that general therapists might find useful in addressing sexual issues in therapy.

Sara Rosenquist, a board-certified clinical health psychologist who also specializes in sexual and reproductive health issues, said in an email that her clients tend to seek her out specifically for sexual issues, but she realizes this is not the case for many general therapists. “A whole lot of marital therapists are uncomfortable talking about sex, so they don’t ask or they don’t create the kind of climate in their sessions that would give patients the idea that they can talk about anything or bring up sexual issues,” Rosenquist said.

She said that she has certain ways that she approaches sexual issues with clients. “When I’m doing marital therapy with a contentious couple, I may ask outright about their sex life, or they might bring it up,” Rosenquist said. “But I don’t go fishing … I operate under the assumption that I am to work on the goals the patient brings to me with the material the patient brings to me.”

She said for certain mental health issues, it can be likely that the clients also have sexual issues to address. “If a patient is on antidepressants, there is about a 67 percent chance that they have sexual side effects, such as inability to orgasm, which is very frustrating and causes people to avoid sex to avoid the frustration,” Rosenquist said. “If one partner is depressed, there is a 50 percent probability that the other one is, too, and a high probability that the relationship is affected, particularly the sexual relationship.”

She thinks it is best to bring up the topic of sexuality with clients so they feel comfortable talking about it. “My advice to therapists would be to make it a practice to ask directly about sexual concerns and sexual side effects, thereby giving a clear message that you can talk about this in here,” Rosenquist said. “Most general therapists would avoid learning about ‘unusual’ sexual experiences because they are frankly not equipped to deal with it and they don’t want to lose the patient.”

She said that therapists also need to think about what their limits are in regard to treating sexual issues. “It is frustrating to me when the therapist sends them to me ‘just for the sex part’ instead of allowing me to treat the whole couple,” Rosenquist said. “Ethically we are supposed to know the limits of our competence, but in real life people are reluctant to refer out, and most feel that if they have sex, they’re competent to treat sexual concerns. And most couple therapists feel that if you treat the couple communication issues, the sex will fix itself. I find that often the opposite is true—that the sex difficulties are an important lightning rod, and if you treat that the communications improve.”

Along with therapists realizing their competencies in addressing and treating sexual issues, it’s important for them to avoid misdiagnosing or making assumptions with clients who have sexual issues. For example, just because a woman has multiple sex partners or has sex more often than other women, therapists should not jump to conclusions that she has sex addiction.

“A lot of general therapists lump ‘unusual sexual practices’ together as ‘sex addiction,’” Rosenquist said. “Doing so is not helpful. For one thing, ‘sex addiction’ is not in the DSM—but a variety of sexual practices/appetites behave as if addictive. Many variant arousal patterns and even some high needs for sexual contact/release interferes with genuine intimacy because the person is usually ‘scratching an itch’ (using sex to calm anxiety or satisfy a compulsion) and the sex becomes not so personal. Whenever sex becomes about scratching an itch for one person, it will kill desire in the other, and this, in turn, damages the relationship.”

Barbara Gross, a licensed master social worker and a sexual counselor for the Medical Center for Female Sexuality, said in an email that there are four basic categories of female sexual dysfunction that therapists can be aware of: desire, arousal, orgasm, and pain.

Here are her explanations of each category:

Desire: “We define desire as the ‘wanting aspect.’ Many women come to the Center and report that they are concerned that they have no interest in being sexual. It may be that they once had desire but now they don’t, or it is possible that they never really had much interest in being sexual. We often see low desire in women in their 40s, although it may also present in younger women.”

Arousal: “We explain arousal as the body’s ability to become lubricated and to experience heightened sensitivity or tingling in the genital area. Generally when a woman gets turned on, her vagina becomes wet and amenable to further sexual contact. If lubrication is not happening, a woman would be described as having hypoarousal. If a woman is in a constant state of arousal, she would probably be diagnosed with persistent genital arousal disorder.”

Orgasm: “An orgasm is a natural release of sexual tension through a series of muscle contractions that produces a pleasurable sensation. There are two types of anorgasmia, primary and secondary. Primary means that the individual has never had an orgasm. Secondary means that they were once able to have them but the individual is unable to have them now.”

Pain: “Women with vaginal pain generally have one of two types of sexual dysfunction. Vaginismus is the inability to have vaginal penetration. Vulvodynia is generally pain on the outer part of the vagina. Women most often describe it as a burning pain, though it is sometimes experienced as itching or general discomfort.”

There is a whole section in the Diagnostic and Statistical Manual of Mental Disorders (DSM) on sexual and gender identity disorders for therapists to refer to as well, and different associations are devoted to sexuality research, information, and careers, like the American Association of Sexuality Educators, Counselors and Therapists and the Society for the Scientific Study of Sexuality. These are all possible resources for therapists in regard to sexual issues.

Gross thinks there needs to be work on guidelines in general for therapists on addressing and detecting sexual issues. “I don’t think there are good guidelines for detecting and addressing sexual issues,” she said. “Many women suffer for years without being properly diagnosed or treated. For low desire they are often told to relax, take baths, and drink wine. These suggestions are ludicrous and result in further frustration and hopelessness.”

There are treatment options available for low desire, arousal and orgasm difficulties, and painful intercourse, she added. All of these sexual issues can be caused by different factors, so she said a comprehensive assessment is needed to look at psychosocial and physiological factors.

“In regards to pain, intercourse simply should not be painful. That is the basic guideline,” Gross said. “If you are having pain during intercourse you should seek help. Women often feel it is something that will resolve itself. We generally do not find that to be true. Both vaginismus and vulvodynia are treatable. If you have difficulty inserting a tampon, getting a pelvic exam or find penetration to be difficult or painful, seek help.”

She said certain myths need to be dispelled as well, including these most common ones she has dealt with:

Myth Number One: Women can have orgasms from intercourse. “Seventy percent of women CAN NOT have orgasms from intercourse. This is a fact. There have been countless scholarly articles about it and books published that attest to this fact, and yet I see women each day who feel they should be capable of doing it. They shouldn’t, and women and their partners should spend more time on clitoral stimulation, which consistently works to provide women with orgasm. And, everyone, men and women, should let go of the notion that women have orgasms from intercourse. Some do but most do not.”

Myth Number Two: Oral contraceptive pills have no negative side effects. “For millions of women, the pill is a great form of contraception. For women who are susceptible to sexual dysfunction, the pill can wreak havoc on your body. It can destroy your libido, deprive your vaginal tissue of necessary hormones for vaginal health, which in turn can cause pain. And it can reduce sensitivity in your clitoris. I believe this information should be shared with women when the pill is prescribed, and most often it is not.”

Myth Number Three: Sex is easy. “Good sex is a process of exploration both with yourself and with a partner. Like learning to read, good sex takes time, and you have to [learn] the basics first. You have to start with knowing your body and what feels good, and then you have to explore what feels good with each partner you have. It is not like it is in the movies. It is not a seamless scene without starts and stops and embarrassing moments. However, if you take the time, learn about yourself and who you are with, it is obviously one of the best parts of life.”

What are certain guidelines or information that you think would be useful for general therapists to have or know in order to address sexual issues in clients?

Related articles:
Dealing with Sex and Relationships in Recovery
Depressed by Disappearing Libido?
Sex and Anti-depressants

The only queer people are those who don’t love anybody. – Rita Mae Brown

Queer is a sexual identity that can be both a place of great pride and one of pain.

The term itself is a reclaimed one: Queer was once widely used—and is sometimes still used—as a slur against lesbian, gay, and bisexual people. Many people still view the term as derogatory and do not choose to use it. To many others, it is an inclusive term that grants the community power in its reclamation of the word.

Though “queer” was once intended to hurt those who now choose to use the term as an identifier, this word has become for many a word full of promise and hope. For some, it is the best way they can authentically describe their personal identity.

Queer is an umbrella term that describes sexual identity. The sexual orientation, sexual behavior, and sexual identity (OBI) model provides a way to talk about sexual identities with more accuracy (Cook & Pawlowski, 1991). In the OBI model, each of these concepts is different and separate from the others. Sexual orientation describes a person’s sexual or romantic attraction to another person. It’s not about behavior. It’s about the experience of attraction itself. Sexual behavior is used to describe the physical act of sexual activity. Sexual identity describes the way people identify themselves. Identity is personal; it’s something that each person can only decide for themselves. Gay, lesbian, bisexual, straight, and queer are all sexual identities (though there are many others). [fat_widget_right]

The OBI model provides a way to look at how these three pieces of ourselves interact. Typically it’s assumed that orientation, behavior, and identity are the same. For example, there’s an assumption that a man who identifies as gay is attracted only to men and participates in sexual behavior only with men. However, real life is much more complicated, and there is no “right” way for a person’s orientation, behavior, and identity to line up. For example, a woman might be attracted to both men and women, participate in sexual behavior with only men, and identity as bisexual.

The way we typically describe sexual identity is dependent on gender. For example, if a man says that he is straight, he is stating that he identifies as being attracted to women. Straight, gay, lesbian, and bisexual are categorical markers that designate a person’s gender and the gender they are attracted to. Typically, lesbian describes a woman who is attracted to other women, gay describes a man who is attracted to other men, straight describes a man attracted to women or a woman attracted to men, and bisexual describes a person attracted to members of their gender and of the “opposite” gender.

But what happens when someone who identifies as neither a man nor a woman? As both a man and a woman? As a feminine man or a masculine woman? What is the sexual orientation of someone who is attracted to people of any/all genders?

“I know I’m not a man…and I’ve come to the conclusion that I’m probably not a woman either. The trouble is, we’re living in a world that insists we be one or the other.” –Kate Bornstein

In the book Gender Outlaw: On Men, Women, and the Rest of Us, author Kate Bornstein lays out how a binary gender system, where being a man or being a woman are the only two choices, can be limiting. A person’s biological sex does not determine that person’s gender. Biological sex is the combination of hormones, chromosomes, and gonads a person is born with. Gender identity, however, describes a person’s internal sense of being a man, woman, neither, both, or other gender—it’s not based on the physical body but on how someone feels inside.

For many people, gender identity and biological sex seem interchangeable—A person’s sex as determined at birth is equivalent to their gender identity. But sex and gender are separate concepts and can line up in many different ways.

Transgender is one term that can be used to describe the experience of identifying with a gender that is different from the one that was assigned at birth. People who are transgender have discovered that their gender identity differs from their biological sex. Their true identity might be male, female, neither, or both. They might have a different gender expression entirely. Cross-cultural and historical views of gender suggest gender variance is a normal variation in human expression.

Gender identity and sexual identity are not the same thing, though we often treat them like they are. For example, a person can be a woman (gender identity) and be straight (sexual identity). Or she could be a woman (gender identity) and be a lesbian (sexual identity). Transgender describes gender, not sexual orientation. Trans people, no matter their gender, might identify as straight, gay, lesbian, bisexual, or queer (sexual identities).

To me, being queer isn’t who you’re sleeping with; it’s just an idea that sexuality isn’t gender-based, that it’s love-based.

—Ani DiFranco, Entertainment Weekly, May 2, 1997

Queer, as a sexual identity, is notably different than gay, lesbian, bisexual, and straight because it does not depend on gender. As an identity, the term queer has the flexibility to be inclusive of all people, not just those who identify as men and women. It describes someone whose identity is not heterosexual, but who may not fit into the other available gendered sexual identity categories.

If we look back at the OBI model, queer can be used to describe the interaction between orientation, behavior, and identity for many people who find their experiences much more complex than the terms gay, lesbian, straight, or bisexual allow for. While once a term of hatred, “queer” offers a range of possibilities today.

References:

1. Bornstein, K. (1994). Gender outlaw: On men, women and the rest of us. New York: Routledge.
2. Cook, A. T., & Pawlowski, W. (1991). Issue paper: Youth and homosexuality. The Respect All Youth Project, PFLAG.

“I’ve been suffering for years,” Marcelle said. “When I tell Andrew that he’s hurt my feelings, he gets angry. Can you imagine that? What kind of human being gets angry when he sees his wife crying?”

This is a good question, and one that I get asked often. The answer is that a person like Andrew, who gets angry at being told that he has—once again—done it wrong, is a human who has never heard a word of praise and experienced more criticism in his life than he knows what to do with.

Such a person—often, but not always, a man—is highly conflicted. In moments when he does not feel put on the defensive, he cares deeply for his wife, loves her, and doesn’t want her to hurt. On the other hand, when he thinks he’s being attacked, he reflexively circles the wagons to protect himself.

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“So finally, I got good and angry myself,” Marcelle went on. “How much of this can I take? I get mistreated and I can’t even express myself. That’s not right! That’s not fair! I deserve better, so I told him a thing or two. I let him have it. And, frankly, I felt much better after that.”

That’s a typical pattern—and highly destructive.

The Elusive Satisfaction of Retaliation
Marcelle has every justification in the world to feel hurt. It is also human for her to be angry at the cause of that hurt when he is so unsympathetic. But her reaction in this scenario is wrong. For one thing, she’s hurting herself more by lowering herself to his level. If she acknowledges that his anger is hurtful, then her anger is hurtful too. If she acknowledges that anger displays a lack of humanity on his part, then it displays a lack of humanity on hers as well.

Later, alone with her feelings, Marcelle will confide that the good feeling of “giving it back” was short lived. Over time, the idea that she had betrayed herself by stooping to his level gnawed at her innermost being. She had always liked herself for her own kindness and goodness. “Now who am I?” she wondered. Not only did she reduce herself to a level that she did not respect, but in doing so, she also became alienated from herself.

Many victims of mistreatment feel this way. They feel estranged from the person they thought they were, they don’t like the person they’ve become, and they’re still depressed over the way they were treated. They add depression to depression. Being mean and striking back is completely self-defeating.

How Retaliation Makes Bad Behavior Worse
There’s another, even worse problem with Marcelle’s reaction: it ensures that Andrew’s behavior will also get worse. Now that’s bad.

Andrew doesn’t want to be the bad guy that he is, but he has no clue how to make the awful feelings go away when he is repeatedly reminded of his failings. When he hears what comes across to him as a criticism, he is thrown into a pit of despair. After all, if he knew how to handle the problem in the first place, he would not have created it. Growing up in a home in which such things as compassion, sharing, consideration, and respect were not taught or modeled, he is unaware of how to deal with situations which call for these traits. How can he fix a problem he’s clueless about?

But Andrew does know the one thing he learned very well growing up: how to defend himself, strike back, or tune out. It’s only natural that when he feels attacked, he’s going to do what it takes to prevent those old feelings from rushing in. What better smokescreen than for him to attack back?

Will he feel better? No, just as Marcelle didn’t feel better when she retaliated. Will the marriage improve this way? Obviously not. What should be done?

Alternatives to Retaliation
Marcelle has to switch her approach from telling Andrew what he did wrong to what she wants him to do. It means changing a negative sentence to a positive one. This might not seem hard to do, but listen to what Marcelle has to say about it: “What about my feelings? Are you telling me to stifle my feelings? He’s my husband; shouldn’t I be able to tell my own husband that he hurt my feelings?”

Marcelle has a point. She should not have to stifle her feelings; she should be able to express them to her own husband. But we are not operating in a fair and just world. Her husband simply cannot hear this until he has healed from his past pain.

So Marcelle’s real job is to deal with her “shoulds.” Theoretically, she should be free to express herself, and in reality, she shoots herself in the foot when she does. What are Marcelle’s options?

• Marcelle has to make a list for herself of healthy ways to self-soothe such as doing affirmations, practicing relaxation and deep breathing, getting sufficient sleep and exercise, and deriving pleasure from her work and daily tasks. She can also journal or talk to a marriage counselor who is pro-marriage. All of these serve both as channels for her bad feelings and as ways to empower herself to feel good, despite the tough hand that she was dealt.

• Marcelle should learn to assertively ask for what she wants in very specific terms, such as, “When I come home with groceries, please help me with them, and please smile at me when you do.” She herself should be pleasant and smiling when making these requests. Andrew did not have the benefit of learning how to handle interpersonal relationships growing up, so part of his attraction to Marcelle was that she was so skilled at them. He is actually looking to her for a way out of the labyrinth. Furthermore, by being pleasant in her request, she is also modeling the very behavior she wants—and putting in a teaspoon of sugar to make the medicine go down.

Retaliation is not one of Marcelle’s options, but she will find that if she follows the options above, she will be empowered and happier, even before Andrew has started to “get it.” Eventually, he will “get it” and then they will both be happier.

Bad person feelings typically develop early in life. Although it may not be intended, children can get the message that it isn’t simply what they do or think or feel that is bad, but that they themselves are bad.  When these feelings are communicated, verbally or nonverbally, children soon learn to avoid them by working very hard to please and not disappoint parents. They may try so hard to be good (i.e., to be the child the parent expects), that they have little room to develop their own unique selves.

The Experience of “I Am a Bad Person”
When parents yell at their children or verbally or physically abuse them, we can imagine that this might frighten, shame, humiliate, or terrify a child.  But parents can also respond in more subtle ways that can damage a child. When a parent expresses hurt or disappointment by a sigh, a look, crying, head shaking, or leaving the room, the impact can be devastating: “How can I have done this to my parent? I must be a terrible person.” When the parent’s displeasure is expressed as hurt, it is especially difficult for the child to mobilize a strong sense of self and fight back.  The parent’s hurt is evidence that the child is a bad person. It then feels necessary to always please others and behave in ways to avoid the “I am a bad person” feeling.

People Pleasing
In my practice of psychotherapy, I frequently work with patients who have a strong desire to please. They often come to therapy when they find that their anxiety about pleasing others is having a serious impact on their lives.  Worry and rumination about whether or not someone “likes me” characterize most relationships.  Their concern is not only about the feelings of significant others; coworkers and casual acquaintances can create as much worry about being liked as a parent, spouse, or boss.
The focus on pleasing others interferes with developing the ability to consider what would be pleasing to oneself.  Alan came to therapy struggling with what to do with his life. At the age of 29 he wasn’t sure how much he really liked the woman he was dating. He felt he couldn’t trust his feelings. He also had doubts about his job and couldn’t figure out if he was being realistic in what he wanted. He reported that he was tired of trying to keep his girlfriend and his boss happy.  He wasn’t comfortable telling them what wasn’t working for him and he worried that he was too demanding. As is typical with people pleasers, he frequently second guessed himself and questioned what his true feelings were.  Alan spent so much time avoiding displeasing others that he hadn’t developed a sense of who he was, what he wanted, and how to get it.

Disappointment
When struggling with bad person feelings, experiences of disappointing and being a disappointment are prominent. My patient Diane often described how she felt a pit in her stomach or on the verge of tears when she thought she disappointed someone. But what was totally intolerable was when she felt she was a disappointment. She recalled that her mom would look sad and hurt and shake her head when Diane refused to wear what mom had chosen for her. She told me that it wasn’t simply that she felt that her behavior had hurt and disappointed her mother. Tearing up, she said “I felt that I am a disappointment and it felt like that defined my very essence.”
Diane also would become very anxious when she felt that someone disappointed her. She felt she had no right to such feelings and believed she was wrong or exaggerating if she allowed herself to feel that way. She told me “If I let my husband know some of the things that trouble and disappoint me in our relationship, I will hurt his feelings. Then I will feel terrible, that I am a bad person.”  What Diane described is her fear of asserting herself:  someone could get hurt and this will be proof of her badness.

The Tenacity of the Bad Person Feeling
Both Alan and Diane were overly attentive to pleasing others, not disappointing, and protecting themselves from bad person feelings. Both found it difficult and dangerous to please themselves, believing that if they focused on their own needs, they would create hurt and disappointment in others. Both worked to maintain a positive self-image by vigilantly trying to be sure that they never were experienced as having negative impact.
For people who struggle with bad person feelings, the most important goal in relationships is not so much to be related to with positive regard as to avoid negative regard. As a result, whatever positive regard is directed toward people pleasers tends not to be taken seriously.  Alan explained: “I know I bend over backwards to make sure no one is upset or angry or displeased with me. So when people like me, deep down I don’t give it much credence. Sometimes I think I am always acting.”  The point here is that the bad person feelings continue to define the person and are not easily changed by experiences of positive regard from others.

Changing the Bad Person Feeling
The bad person feeling typically digs its claws into the internal life of those who suffer with it.  It feels real, inevitable, and a fundamental part of “who I am.” The feeling defines how one thinks about the self and typically was developed through early relationships with significant others.  As one develops, many relationships mirror the dynamics of the parent-child relationship where the aim is to avoid hurting the other and to not feel like the bad person. Reflecting on these feelings, it is not so easy to consider that a parent, even without intention, was involved in the development of these terrible feelings. If that were to be accepted, it would mean accepting that I am the hurt one. This perspective turns the way the world has been understood upside down. With such a radical shift in thinking needed, how can these feelings be diminished?
You have to be willing to consider alternative ways of thinking about your early experience. Thoughts that once made sense have to be reflected on and reconsidered.  Even if at first, you can’t emotionally accept a new way of thinking, it is important to start by logically considering what you believe about your experiences, perceptions, and feelings. It will be important to become aware of how many of your relationships mirror the anxieties you felt (and feel) with your parents.
Objectively, you may be able to consider that children do no wrong even if a parent feels hurt when they have independent thoughts or don’t do as the parent asks. Can you apply this thought to yourself?  Can you become aware and intellectually accept that as humans in relationships, we all hurt those we love in unintended ways and that this does not make us bad people? Coming up with new ways of thinking about old assumptions is an important beginning in changing bad person feelings. However, it is not enough. To accomplish a change in your definition of self, from the bad person who is a disappointment to a good enough person who doesn’t always please and can disappoint from time to time, requires an emotional shift internally. Therapy is one means of facilitating this shift. Another means is to gradually use your rational thoughts to urge yourself to risk responding honestly.  By this I mean, it becomes necessary to first remind yourself “Yes, I am human and it is okay to express my own unique thoughts even if they are different. I know someone could respond negatively but this doesn’t mean I have done something wrong.”
This takes time. As you repeatedly risk the possibility of making a negative impact by asserting your separate thoughts and feelings, your tolerance for anxiety, risk taking, and bad person feelings will increase. You need to be able to gradually tolerate situations where you do hurt someone. The goal is to increase the experience of being yourself in relationships and learn that typically, you will not hurt the other by being a separate, individuated self. This lesson is crucial.  Most important is the emotional registering of the other person maintaining their acceptance, love, and admiration for you, even when they feel you have hurt, disappointed, or made them angry. This is the emotional experience that will finally lead to change. The end result is that your tolerance for the other’s feelings of anger, hurt, or disappointment are increased and the bad person feelings are diminished.

Related articles:
The Fear of Hurting the Other and the Inhibition of Self
The Price Paid for Being the Perfect Child
Getting to Know (and Esteem) Yourself

Without the tools to manage it, recurring and intense depression often breaks up relationships. The truth is, depression is hard to handle. One way to help make it through depressive episodes is by preparing a depression plan when the partner who experiences depression is not depressed. The aim of the plan should be to create a shared understanding about the changes in thoughts and behavior that depression causes, as well as a commitment to “stretch” to get through the difficult period of depression.

Separating the Person from the Depression
It takes a great deal of effort, on the part of both the depressed person and their partner, to separate the person from the depression. Yet doing this can be very important to maintaining the relationship. Try thinking of “Depression” as a third party in the relationship: an entity with its own unique thoughts and actions that it expresses through your loved one’s body. One way to do this is to establish the difference between how the depressed person acts when they are depressed and how they act when they aren’t.

For example, during an episode of depression, the depressed person may get much more sensitive to criticism. If both people know that, it can help them to remember that that behavior is the depression, not the person. The partner may want to be more careful not to be critical, or to not react to the depressed person’s overly sensitive reaction to criticism. “That is Depression speaking (yelling, crying, acting insecure, calling me names), not my loved one,” can be a useful mantra.

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This doesn’t mean the partner should take abuse. Partners still need to set limits—calmly, firmly and before accumulating resentment—about anything the depressed person does that doesn’t feel respectful. This may sound something like, “I know you’re in a lot of pain right now, but I won’t allow you to call me names under any circumstances. I’m going out now; let me know when you are confident you can treat me respectfully and I’ll come back.”

For the depressed person, it can also be helpful to remember that no matter what terrible things the depression is telling them (she doesn’t love me, she thinks I’m disgusting…), those thoughts are the depression interpreting what the partner says and does through a filter that turns everything to the worst possible scenario. If the depressed person can identify that this is the way Depression causes them to think before the depression happens, it can help them to remember that those feelings are likely distortions of reality, even though they may continue to seem real in the moment.

The depressed person can also prevent damage to the relationship by attempting to translate what they want to say (“You’re a skank”) into their own fears and sad thoughts (“I’m scared you’re going to leave me”) before saying it out loud.

Identifying Depressed Belief Patterns
Try making a list of messages that Depression gives, in general and/or for the specific person, in order to be able to look at it when depression hits. If every time the depressed person gets depressed, they become certain that their partner is having an affair, put that on the list. A list can be written from the point of view of the depressed person or the partner, or each can have their own. An example from the depressed person’s point of view could look like this:

“When depression hits, I see things differently and characteristically believe:

• My partner is having an affair
• I am ugly and undesirable
• I will never feel better
• I am a burden to everyone and would be better off dead
• I am inadequate in any number of ways
• I fail at everything I do
• My life is cursed
• Nobody loves me, or even likes me

“When I’m not depressed, all of this looks different. When I am depressed, I believe the depressed point of view is reality and the nondepressed point of view was distorted. This is not true and not helpful to my desire to feel good.”

Setting Boundaries for Caretaking
While it can be helpful for the depressed person and loved ones to define reality, loved ones can get burned out on reassuring the depressed person. They should do it only as much as it is possible to do so without resentment. They may need to pace themselves—can they do it once a day? Once a week? Give what support is possible without getting burned out or resentful, or starting to agree with the distortions (maybe I don’t love him, maybe he is disgusting). The rest of the time, the depressed person needs to do their own work: some alone, some in therapy, and some with other friends and people they feel comfortable talking to in order to soften the distortions.

Many years ago, a mentor of mine talked about how she coped with taking care of her partner who was dying of cancer. She wanted to be there, but not to feel resentful and burned out. She told her partner that she expected her to do everything she could possibly do on her own, and then my mentor would do the rest. So if her partner could get up and get a magazine for herself but didn’t feel like it, my mentor wouldn’t get it for her. This left her available for the kind of caretaking that her partner absolutely needed and allowed her to sustain her energy over a long period of time even as her partner’s needs increased. I thought this was a brilliant way of thinking about caretaking for loved ones. It’s so easy to want to rush in and do everything in the beginning and then burn out. Pacing oneself and seeing the other person take as much responsibility as they can helps the caretaker so much.

It is important for the depressed person to commit to “stretch” as far and do as much as they possibly can—as much as they would be able to do if they were alone. Then, if the partner is willing to act in a caretaking role, they can do what the depressed person absolutely can’t do. With depression, this can be tricky to identify. Only the depressed person knows where that line is, and it can be difficult for even them to establish. It also may change from day to day or minute to minute. A depressed person may have to spend a whole day psyching themselves up to get up and take a shower or to make a phone call—but then they may be able to do it, whereas earlier in the day they absolutely couldn’t.

It is also important for the depressed partner to “stretch” by giving expressions of love and gratitude to the caretaking partner. It may be very difficult for the depressed person to do this, but it is usually possible if the depressed person commits ahead of time and the caretaker reminds them that the relationship needs it.

Caretakers need to consciously keep their own life going as much as possible. If they can’t expect to be emotionally nourished by their partner when they’re depressed, they need to be sure to be “fed” by other family and friends, activities they enjoy, work, or whatever is available. They might consider going to Co-Dependents Anonymous for support with keeping boundaries and not giving too much. This can, ironically, free people up to be more available to the person who needs their care.

Maintaining Balance
Most depressive episodes do pass, and the person who experiences depression returns to their nondepressed personality and functioning. Both depressed people and loved ones have to try to remember this fact as they do everything possible to get through and resolve periods of depression. The most important thing to remember is that neither person should make big decisions about their relationship, or judgments about how things will be, until the episode is over.

A perception of artists as eccentric, different, and living on the social periphery seems to precede this group outside of therapy and, likely, within the context of treatment as well. There seems to be an unspoken premise that ingenuity is motivated by pain or pathology, or at least some might argue there is a sort of affiliation. Some might assume that this relationship is causal: that trauma causes creativity and thus most artists are contending with some type of affliction. An alternative possibility may be that art is not necessarily motivated by pain; rather the capacity for creative inspiration is something that is brought into the recovery process by those who have such inclinations. In other words, some survivors who are able to express through art may have access to a recovery tool that others do not.

The explanation for eccentricity may serve those outside of the life of the creative in the collective search for continuity versus holding a truth for the individual. Cultural positions regarding gender, race, and other demographic variables have been acknowledged as significant in how therapy plays out as well as having a significant impact on people as they attempt to navigate their lives and define themselves. To postulate art as a product of illness likely has implications within the therapeutic context and thus may be worthy of evaluation. Regarding creative inspiration as a resiliency factor in the same way as personality traits, support systems, and solid attachment histories could be relevant in our approach with this population. The focus here will be in identifying the ways in which creativity can respond to trauma and mitigate its effects while simultaneously acting as a supportive tool.

Traumatic symptoms place significant demand on individuals’ emotional lives; the persistence and intensity of flashbacks, nightmares, hypervigilance, and other challenges can be unrelenting. Repeated images of disturbing aspects of events, difficulty relating to others, and emotional flooding are clearly something to be contended with for survivors. Distortions in reality such as feeling generally distrustful of others, feeling generally unsafe, or even varying degrees of psychosis are also indicators that integration of painful material has not occurred. Digestion and piecing together the historical puzzle are necessary components of feeling better. Access to creativity may assist in regulating affect while working towards making sense of trauma.

The drive to write or perform music or dance, act, paint, or draw seems to exist or not exist in someone. Perhaps to some extent it can be cultivated; however it appears we all come to the table with our own idiosyncratic gifts. Creative motivation is often described as an illusive and illogical propellant that tends not to yield financial and social gain. The reward seems to be internal and is related not only to the product (i.e. a painting, story, piece of music) but to the process. Engagement in developing something creative (much like I am attempting to do now) can have a dissociative feel; there is a disconnect from reality and a hyperfocus that is quite distinctive (I refer to this as the creative stupor). There is an openness in the process, a permission to explore the unspoken, to be childlike, and to express with depth and abandonment.

The intersection of painful events and the creative process either in the context of therapy or outside of it can be salubrious in that both the art and the person benefit. [fat_widget_left]Barriers in discussing dark, shameful, or disturbing information can be softened with creativity; in fact it seems to be a conduit for undigested material. The juxtaposition of style and history may influence the artistic product, but the experience of engaging with art is most relevant to this topic. It appears to facilitate a connection to the extreme, which is what characterizes traumatic injury. The disengagement from reality while simultaneously connecting to experience may offer a unique means of working through unprocessed material. Additionally, themes presented in the artistic product may provide insight to both therapist and client as to where the focus of the work belongs or where the individual is stuck.

Explanations for phenomena logically influence our response to them. Defining the creative process or artistic product as a function of pathology likely effects the cultural response to art as well as the therapeutic context. The identification of those within this demographic as having a unique tool to inform us as their clinician as well as to aid in their process could foster a dynamic shift in the work we do. Conceptually, eccentricities in people, whether it be through art, a mathematical gift, or idiosyncratic ways of thinking could all be potential resiliency factors. This doesn’t imply that we assume our clients should use their gift therapeutically, rather that we maintain curiosity and openness to it while allowing it to inform our work.

Related articles:
Healing Through Expressive Arts Therapy
Shadow Work: Transforming Emotional Suffering into Freedom
Reasons why Trauma Treatment & Recovery might Be a Bad Idea

The idea of there being stages of grief has been greatly popularized and accepted over the last few decades. It is an idea that gives us perspective on our grief, like the red dotted line going across a map in an old movie to show the itinerary of the protagonists.

However, among professionals, theses stages have been slowly phased out of use over the years for lack of evidence from both research and casual observation.

Now, the old saying that “If you have a hammer, the whole world looks like a nail” comes to mind. Our preconceptions predispose us to experience things a certain way. If we look at our thoughts, feelings, and actions during grief, surely some of it will fit into the five stages Kübler-Ross described: denial, anger, bargaining, depression, and acceptance. This is because these are some of the reactions to loss. Yet these reactions do not tell the whole, or accurate, story of our grief experience.

Most people, according to recent research, do not arrive at acceptance last. Even when people express feeling shock and numbness, they have accepted their loss—they know that someone has died, or that they are divorced, or that they lost their jobs. Wishing something has not happened, or forgetting something that has happened, or feeling the surreal quality of what has occurred, is not the same as denying that it ever happened. To be truly in denial, we cannot consciously acknowledge what it is we deny, for the sake of our psychological well being. It is the very opposite of acceptance.

These days, new knowledge about how we grieve is beginning to filter through and influence how professionals provide grief counseling, and, it is hoped, how we support each other in grief as lay people. There is no longer any point in insisting that someone go through a stage he or she appears to be “skipping” or to feel that one is not “grieving right” if one does not experience certain stages of grief.

According to researchers Stroebe and Schut, we grieve by swinging between two main kinds of activities: loss and restoration.

Loss activities involve missing who or what was lost, crying, feeling sad, etc. This is what we usually associate with grief.

Restorative activities include feeling normal again, socializing with friends and family, enjoying good weather, remembering better times, etc. This is usually the unsung hero in grief, because it looks like what we think of as “normal” behavior, but in the context of grief, it is definitely a part of the experience of mourning and also what helps us to endure, and eventually integrate, our losses into our lives.

The back and forth of our thoughts, feelings, and actions between loss and restoration also give us a different road map for our grief. Rather than conceptualizing ourselves as “backsliding” or “getting worse when I thought I was getting better,” which happens with an idea like stages, using a model of grief that recognizes a natural and wavy progress helps us to know that we are moving forward, even when wistfulness strikes unexpectedly after some time basking in the sun.

It is natural to miss and yearn for someone, just as it is natural to feel better. We may not always want to feel better for fear of forgetting our loved ones or not showing how much we loved by how inconsolable we are, but it is part of our humanity that we can grieve and heal, lose and reconnect. Our pain helps us to remember, but let us not forget that our joy has the same capacity, too.

Reference
Stroebe, M., Henk S. (1999). The dual process model of coping with bereavement: rationale and description. Death Studies 23, 197-224.

Related articles:
Psychotherapy and the “Middle Way”
A Season of Grieving and Transformation
How to Be With Someone Who Is Grieving

Did you know that your imagination is a powerful tool for positive change? Or that, without your intentional guidance, it can be your greatest enemy? Many people neglect their imagination, allowing outside influences to guide and direct this powerful engine and then wonder why their lives are less than satisfying. Your imagination is yours to develop as you will, but ignored and neglected it can become a liability—the very source of depression, anxiety, interpersonal problems, and unconscious self-sabotage. Unless you take the initiative to choose your goals and begin to exercise discretion in what messages you allow your brain to receive and process, all the forces of marketing that bombard us on a daily basis—television, email, pop–ups, and Facebook—will shape your choices (and therefore your destiny) without your input, and often without your awareness.

When we don’t exercise careful choice over what we feed our imagination, we can end up developing habits of thought that impede success. Habits of thought are things like catastrophizing—thinking about worst-case scenarios—a habit of thought guaranteed to generate anxiety and/or depression; or habits of thought like filling in the blanks when you really don’t know—a habit of thought that can lead to all kinds of interpersonal problems if you make the mistake of believing that your imagination knows what is unknowable.

The first step to taking charge of your life is to take charge of your imagination. You can begin with a few simple exercises. Imagine a very unpleasant scene from a horror movie. If you allow this scene to fill up your whole imagination your feelings will follow—heart racing, palms sweating, a ball in your stomach, the whole nine yards. You see, your imagination cannot tell the difference between what is real and what is not. Now imagine that you are seeing the same unpleasant scene on a small flat-screen TV. Notice that you still have some of the same reactions you did before, but not as intensely. Now shrink the screen down to a very small size. Remember, this is your imagination, so you can do whatever you want with the image. Now turn the TV off.

Ok, that was interesting. But it was an unpleasant image. Now try it with a pleasant one. Bring up one of your all-time favorite memories. Perhaps recall a time when you really felt loved, or maybe a time when you had just accomplished something very hard and fairly important. Allow that image to fill your imagination and keep it on the screen in your mind. If it fades or slips, bring it back, and focus in on some random detail. The more you focus on some detail of this experience, the more vivid it will likely become and the more practiced you will get at using your imagination for your own good. While you’re focusing on this image in your mind, notice the warm feelings that result. Notice where in your body you feel these warm feelings of love, happiness, joy, and delight—usually right in the middle of your chest.

This is the power of your imagination to influence your emotions. All your thoughts and all your emotions are neurochemical events in your brain and in your body. So when you choose to develop your imagination and your ability to focus and direct your imagination, you gain the ability to guide and shift and direct your emotions as well. And when you have the ability to direct your imagination and modulate your emotions, then you also have the ability to influence the neurochemicals in your brain and in your body, too. Like all things mental, this ability is learned, and, like all things learned, this ability is made proficient through repetition. You do not learn to read overnight. You learn to read through repetition. Repetition makes proficiency.

Once you become proficient at managing your own imagination, you can do all kinds of other things—like set goals and define all the small steps that make up progress toward that goal. You can anticipate problems and anticipate solutions. You can try out various solutions and develop the confidence you need to translate goals into actions. You can step back from emotional triggers. You can pull yourself out of funks and you can stave off anxiety. You can even improve your sex life. But we’ll talk more about that later.

Related articles:
Changing Brain Chemistry, Changing Paradigms
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Research has shown that there is a genetic risk factor for suicide. However, until now, very few studies have looked at family history of suicide to determine how it affects second- and third-degree relatives and the maternal, paternal, or spousal influences. Because suicide is predicted to take nearly 1.5 million lives by the year 2020, according to the World Health Organization, being able to identify and treat those most vulnerable for suicidal ideations is vitally important. Current research has suggested the family risk factor for suicide to be anywhere between 17% and 55%. To get a more defined estimate of how suicide runs in families and how environmental factors impact the risk for suicide, D. Tidamalm of the Department of Clinical Neuroscience at Karolinska Institutet in Stockholm analyzed more than 50 years of data from the entire Swedish population. Tidamalm and colleagues assessed how many of the Swedes who had committed suicide during those years, a total of 83,951, had a relative who had also died from suicide, and they compared those rates to a control group.

The research revealed that full siblings had a higher risk for suicide than maternal half-siblings. However, maternal half-siblings were more likely to die by suicide than paternal half-siblings, perhaps because of shared environments. The study showed that identical twins were more vulnerable than fraternal twins, and even cousins were 50% more likely to commit suicide than the control group. Environment influenced the risk for suicide significantly as well. Full siblings were three times more likely to die by suicide than the children of suicide victims, whose risk was twice as high as the controls. Even spouses were more likely to commit suicide than the control groups. Tidamalm believes that degree of relation, combined with environment, is an important element for exploration in treatment. Tidamalm added, “The results confirm the importance of considering the family history of suicide when assessing suicide risk in clinical practice or when designing and administering preventive interventions.”

Reference:
Tidamalm, D., Runeson, B., Waern, M., Frisell, T., Carlstrom, E., Lichtenstein, P., Langstrom, N. Familial Clustering of Suicide Risk: A Total Population Study of 11.4 Million Individuals. Psychological Medicine 41.12 (2011): 22527-534. Print.

I am getting asked more about cybersex and online pornography addiction from therapists. It seems to be a growing problem in their practices. I thought I would address some of the fundamentals regarding how the addiction is sustained by the addict, or what I call the “start-stop relapse cycle.”

Eric is a 46-year-old computer programmer who described how hard it was for him to go “cold turkey” from cybersex during work. “I always go to the same chat room for cybersex. I feel comfortable there, and I typically find a good partner quickly. I always think about cybersex when I feel stressed from work and overwhelmed on the job. I always promise to only do it for a half an hour or hour, but time just slips by. Besides, my drive is stronger than my wife’s, so it won’t hurt, actually it will help our relationship, so I don’t go looking for someone in real life. Afterwards, I realize that I should not do this to my wife and also to my work. My boss will find out one day if I don’t stop doing this in my office. Each time I log off after cybersex, I promise myself that I will never do it again. I hate myself for all the wasted time I spent online and quickly try to catch up on the lost work. I go a few weeks, then the pressure seems to build up inside. I play mind games with myself, telling myself just a little won’t hurt. No one will know what I am doing. Sometimes I actually believe that I am in control. I wear myself down, and the whole process starts all over again and I feel defeated that I will never get rid of these feelings. The temptation is constantly there and relapse is just a click away.”

Relapse is a common struggle for anyone in recovery, but the problem often seems compounded by the need to use the computer while in recovery from cybersexual addiction. The relapse process is especially difficult for the cybersex addict due to the stop-start relapse cycle. The cycle is an internal dialogue that serves to maintain the compulsive behavior.

•    Rationalization – Users will rationalize that cybersex serves as a “treat” from a long, hard day of work often making self-statements such as, “Just a few minutes won’t hurt,” “I can control my net use,” or “I am right here at the computer, what the heck?” The user will try to justify the need to look at a few pictures or chat for a few minutes, but they soon discover that time slips by and the behavior is not so easily contained.

•    Regret – After the cybersexual experience, the users experience a period of deep regret. Once they climax, the addict feels guilt or shame for the behavior such as, “I feel guilty for how this is hurting my wife” or “I can’t believe I wasted all this time,” or “I am a horrible person for what I just did.”

•    Abstinence – The addict views the behavior as a personal failure of willpower and promises never to do it again, and a short period of abstinence follows. During this time, the addict temporarily engages in healthy patterns of behavior, resumes interests in old hobbies, spends more time with his family, exercises, and gets enough rest.

•    Relapse – The addict in recovery feels tempted to return to the computer during stressful or emotionally charged moments. They begin to crave and miss cybersex. They tell themselves that cybersex is the best way to relax and feel good about themselves. Or they begin not to care about the consequences. They remember how good cybersex felt both sexually and emotionally, and they forget how bad they felt afterwards. The rationalization period starts again and the cycle repeats itself.

How does an addict kick the cybersex habit when he or she needs to be on the computer for work? How can the addict stop abusing when relapse is just a mouse click away? Similar to programs that address overeating and food addiction, the addict will need to learn how to make healthy, positive choices about his or her Internet use because complete abstinence isn’t always possible in today’s technological world. There are two basic principles to follow:

Principle One: Learn to moderate legitimate use of the Internet.
Principle Two: Abstain from all contact with sexual material online.

As in food addiction, certain types of food trigger binge behavior. Let’s say chocolate or potato chips will trigger binge behavior but celery sticks will not, so avoidance of those “trigger” foods is a necessary part of recovery. Recovery from food addiction is about relearning how to eat in order to make more informed and healthier food selections, with success being measured through objective goals such as changes in caloric intake and weight loss.

To address cybersexual abuse and addictive behavior, the same basic steps are applied. First, it is important to determine the Internet activities, situations, and emotions that are most likely to trigger net binges. A particular chat room, a certain time of day, or the mood you are in just before you go online may all serve as “triggers” that will lead to inappropriate conduct and abuse. Recovery means relearning how to use the Internet in order to make better choices about time spent online, with success being measured through objective, measurable time management goals and abstinence requirements that are achieved and maintained. Goals should include a reduction in the number of hours you spend online in total, the ability to maintain abstinence from adult online content, and an increase in other offline activities.

Second, the addict must abstain from sexual material online. In this case, it means removing all the bookmarks and favorites leading to these sites, adding filters that prohibit sexual material from getting through the browser, or possibly changing the entire Internet Service Provider (ISP) system to one that is family friendly. These family friendly ISPs stop sexual content from the server end, so there is less chance of relapse. This has been found to be the most effective way to dealing with the addiction.

Related articles:
Super-sizing Sex
The Double Bind of Sex Addiction
Sex Addiction is a Relational Disorder

This years 2012 contenders in the GOP election process are presenting themselves as devoutly religious people. But what lies within these candidates beneath their religious presentation? Often in life we don’t get to see what lies beneath a person’s “good self” presentation, also called a mask. We don’t get to find out if that person really is religious, kind, caring, or not. The discrepancy is often hidden.

How does this occur? Children responding to trauma or abuse experience mean-spiritedness and destructiveness. It may even start out as simple anger, but anger that gets buried or distorted and twisted into something destructive. Many of us know not to act it out, for fear that we will be punished, made bad, abandoned. So, instead, we create a mask self to hide our destructive self. And we hold onto our mask for dear life, defending against discovery. In the meantime, our buried mean-spiritedness does have an effect on us and those around us, if only unconsciously.

Eventually, though, what we’ve hidden beneath our mask does manage to find its way into the open. It may slip through the mask in words we mean, but didn’t mean to say; in actions we’d like to take, but didn’t mean to act out; in actions we don’t take, but want to.

Lately many masks have been falling off—and the abuses of power and other dangers beneath the masks have been revealed. Numerous government leaders, corporate executives, and others have been exposed or have exposed themselves for their abuses of power: some sexual (Anthony Weiner); some financial (Bernie Madoff); some legal (Idaho Senate Republican Caucus Chairman John McGee, arrested June 2011 for DUI and vehicle theft); some ethical (Michael Jackson’s doctor, Conrad Murray); and some spiritual (among evangelical leaders, Richard Roberts, son of Oral Roberts, arrested January 2012 for DUI; among yogic leaders, Gurudev of Kripalu, who required celibacy of unmarried students while at the same time having sexual relations with some of his students; and among New Age leader, James A. Ray, who misused the Native American sweat lodge, causing several people to die, then fleeing the scene).

But it is a rare thing in a presidential election for candidates to tout their religious connection and the next day, or even the next sentence, to expose their mean-spirited, destructive side.

One candidate presents himself as a religious man, but creates ads that are lies, isn’t concerned about the poor, makes $10,000 bets in the middle of a debate, runs a very ugly, negative campaign in Florida, and repeatedly says he misspoke—things that he actually meant and came through his mask.

Another contender, claiming to be a reformed religious person, forgiven for his sins, revealed how arrogant, grandiose, and dishonest he is, not to mention unfaithful to two wives.

A third candidate, a state governor of, actively used his religious beliefs both as a basis for his policy and in his campaign ads and debates; but in his eyes his religious beliefs provide justification for imposing his will and his religion’s will upon the state and the nation. His state executes more prisoners than any other state in our nation, while he claims to be pro-life; makes it legally mandatory for girls to receive a vaccine even if their parents object; and makes it compulsory for any woman seeking an abortion to be given a vaginal ultrasound—even if it’s against her will and her doctor’s will.

Yet another challenger would like to use whether or not an individual follows “God’s law,” as the candidate defines it, to determine who can claim equality under the law; he doesn’t want to “make black people’s lives better by giving them somebody else’s money”; he claims the right to privacy doesn’t exist in the constitution; and he maintains it’s dangerous to use contraception in this country.

And still another contender quotes the golden rule, but only for foreign policy, not regarding race relations at home, and it turns out he’s revealed himself as racist.

What used to be hidden beneath the mask, especially the mask of “religiousness,” is coming out into awareness in the election process these days. But, most religious and spiritual traditions don’t teach about this truth, at least as far as common knowledge reveals: Identifying with our spiritual self cannot safely occur without also identifying and resolving the destructive aspects of ourselves (even if we don’t act them out). Since this is not taught, most of us don’t know what we’re seeing and experiencing. Most of us don’t realize that we’re witnessing the religious/spiritual mask falling off and the destructive, mean-spirited aspects of people coming out into the open from beneath it.

It may be coming out blatantly, obviously, and undeniably. It may be coming out vicariously, or second-hand. Like the people who cheered, “Yeah!” when a candidate was asked if he was saying society should just let an uninsured man die.

What lives within us beneath our mask is coming out, allowing us to see it, know it, and utilize what we see to help heal it. First, in our individual candidates and leaders, by our insisting that they do their own work with their destructiveness before they can run for office and lead us. Second, in our society and our world, by seeing it, naming it, talking about it, and not settling for it. And third, but probably the most important,  in ourselves. We need to see beneath our own masks, what is destructive and mean-spirited in ourselves, however hidden it may be. We need to commit to and actively work to heal those parts of ourselves, for the sake of the life within us, for the sake of the life immediately around us, and for the sake of the life all over our world.

Research has determined that eating disorders are caused by a confluence of factors. No one single factor is enough to cause someone to develop an eating disorder, but certain factors set the stage for a person to be vulnerable to developing an eating disorder. When it comes to eating disorders, the age-old question of nature versus nurture is answered simply: it’s a mixture of both.

An article published in Focus magazine states that, “In recent decades, researchers have increasingly appreciated the multifaceted contributions to the etiology and pathogenesis of eating disorders, including genetic, familial, developmental, and psychosocial influences” (Yager, et al., 2005).

Are eating disorders biologically based? In the sense that certain genetic traits must be present in order to render a person vulnerable to developing an eating disorder, yes. In the sense that, if the various genetic markers are present then the person in question will develop an eating disorder regardless of any other factor, no. Recent research on the genetic factors that contribute to the formation of an eating disorder reveals that, while genes are indeed a factor, they alone cannot cause an eating disorder. Cynthia Bulik, Director of the UNC Eating Disorders Program at the University of North Carolina at Chapel Hill School of Medicine, states that, “Genetics loads the gun, but environment pulls the trigger.” In other words, the genetic vulnerabilities must be there, but an eating disorder won’t emerge unless the right environmental conditions are present.

In an article co-written by Bulik and Suzanne Mazzeo, Associate Professor of Counseling Psychology at Virginia Commonwealth University the authors posit that, “Ultimately, the elucidation of causal models for eating disorders will no doubt include various types of genetic and environmental interplay…Clinicians and researchers must become educated in the nuances of GxE (genetic and environmental) interplay and avoid perpetuating purely environmental or purely genetic conceptualizations of eating disorder etiology” (2009).

[fat_widget_left]This speaks to the role of the family system, as one of several environmental factors, in potentially providing an eating-disorder-friendly habitat, so to speak, for a child whose genetic makeup renders her vulnerable to developing an eating disorder. Mazzeo and Bulik note that, “For decades, parenting styles have been unrightfully blamed for causing eating disorders. Considerable care must be taken when discussing GxE interplay not to convey the message that somehow parenting is to blame for these pernicious illnesses. Conversely, a purely genetic explanation should not be taken to mean that parents need not examine their parenting style and the influence it might have on children” (2009). They go on to say that the child’s genetically influenced constitution also shapes how that child will react to a particular parenting style. For example, a child with the genetic constitution for developing an eating disorder might be much more aware of physical appearance than his/her differently gened siblings. The child may ask for more feedback about his/her appearance, thus generating more comments about appearance from his/her parents (and others) than the other siblings receive.

So the interplay of genetics and environment is complex, and begins early on with environmental factors, such as parenting. Other environmental factors include life events and media influence. Authors John Briere and Catherine Scott report on how “Research suggests that individuals with eating disorders (EDs) are relatively likely to have been abused or neglected as children, or to have been victimized in adolescence or adulthood. These experiences, in turn, are often associated with a range of psychological symptoms, as well as, in some cases, a more severe or complex ED presentation” (2007).

It’s important to recognize that difficult life events, from a major move to physical or sexual abuse (which have been shown to be risk factors for bulimia), are experienced differently by a person who tolerates distress poorly, and a person who tolerates distress well. The ability to tolerate distress is, in part, genetically influenced, but also has to do with how distress tolerance was modeled and taught in the person’s family.

With regard to cultural notions about ideal body size and shape, everyone is exposed to media images of ultra-thin ideals, but not everyone develops an eating disorder. These things will affect someone with the “right” genetic markers differently from someone who does not have them. But how parents and other elder family members handle the media imagery, and whether they share the idealization of ultra-thin bodies, also influences the child.

Suffice it to say, eating disorders are complex, and their causes are equally complex. No one factor accounts for the formation of an eating disorder. Eating disorders are best understood via a biopsychosocial model, which takes into account genetics, our personal selves (thoughts, feelings and behaviors) and the familial and social contexts in which we grow up and live. When it comes to treating disordered eating, the latter two must be addressed. We can’t change our genetic makeup, but we can change the way we think, the way we manage our emotions, the way we behave, and, in adulthood, the circumstances in which we live. And we can avail ourselves of therapies that focus on healing the damage done by earlier experiences.

References

1. Briere, John and Scott, Catherine. (July, 2007). Eating Disorders: The Journal of Treatment and Prevention. “Assessment of Trauma Symptoms in eating Disordered Populations.” Vol. 15. No. 4.
2. Bulik, Cynthia M. and Mazzeo, Suzanne E. (January 2009). Child and Adolescent Psychiatric Clinics of North America. Vol. 18. No. 1.
3. Yager, Joel; Devlin, Michael J; Helmi, Katherine A; Herzog, David B; Mitchell, James E; Powers, Pauline S; and Zerbe, Kathryn J. (Fall, 2005). Focus. “Eating Disorders.”