GoodTherapy | Individual Versus Couple Therapy: What Format Is Best for Marital ProblemsThe Textbook of Family and Couples Therapy describes the three “most common types of couples therapy”:

  1. Individual therapy;
  2. Conjoint couples therapy; and
  3. Combined couples therapy

In the first, a member of a couple is treated by an individual therapist, which, the textbook notes, is suitable especially for instances in which one spouse refuses to join marital therapy but a “poor choice, however, in the presence of marital disturbance and severe psychopathology…” Individual therapy for a marital problem does not give the therapist an adequately full picture of the marital interactions, nor adequate leverage to help both participants to symmetrically address their contributions to the problem. In general, because problems tend to be interactive, for one partner to make lasting changes for the better, both parties need to make changes.

In the second, “conjoint couples therapy,” both spouses are treated at the same time by a single therapist or team of co-therapists. Again, this form of treatment does not enable the therapist to see and therefore accurately diagnose the couple’s interactive patterns. Anyone can look good in individual treatment. Whole additional aspects of couples’ functioning appear once they are interacting with their partners around emotionally sensitive issues, and these are generally the issues that couples need help addressing.

[fat_widget_relationships_left]The third structure for couple treatment, “combined couples therapy,” refers to the combination of conjoint sessions that both partners attend together with ongoing or occasional individual therapy sessions for one or both spouses. That is, the therapist interweaves individual and couple sessions in a design that most meets the needs of this specific couple. “The combined treatment,” the textbook explains, “has the advantage of allowing the use of fantasies in individual sessions while providing easy access to transactional and communicational patterns” in joint sessions. Conflict resolution treatment generally employs the third of these “most common types of couples therapy.”

As described more fully in a recent article in the Journal of Marriage and Family Therapy currently available on the website of the American Association of Marriage and Family Therapy, such combined treatment offers important benefits:

One professional is in a better position to recognize, define, and point out [and thereby ameliorate] the intrapsychic and interpersonal dimensions of the symptom-problem, to be aware of the two-way street effects of one process on the other, to know areas in either process that are being avoided and impulses that are being “acted out” rather than confronted. He [or she] is able to appreciate the subtleties of the resistances and transferences and to form an integrated concept of where the individual client and the marriage is and what the client and marriage is doing in each phase of help even though each process may be conducted according to the techniques of that particular modality…

Conversely, when a person is in individual therapy with one professional and in marriage counseling with another, the two processes may go off in opposite directions. Also, resistances may go unnoticed, the transferences may become more split or diluted, and the continuity of the person’s emotional flow and life processes may become more compartmentalized.

For these reasons, conflict resolution treatment recommends the practice of asking people being treated to take a break from any prior individual therapists if they are going to enter into treatment with a conflict resolution therapist. At the same time, the therapist explains that s/he will be available at any time for either spouse to schedule individual sessions as they feel the need. I explain that in general if I am seeing one spouse individually, I like to keep things symmetrical and work also with the other; and at the same time if this is not possible for financial or other reasons, I can be flexible. I add finally that the individual sessions may be occasional, suggested by either one of the spouses or by me, and/or may be part of an ongoing weekly pattern of treatment. For people dealing with specific difficulties—for instance, when one spouse has a borderline personality pattern or is dealing with chronic depression—as many as three sessions a week, with one couple session and one individual session for each spouse, can be ideal, finances and time permitting.

Multiple research studies have demonstrated that individual therapy for a spouse in a distressed marriage may make a couple’s conflict worse, making divorce more likely. These concerns, and their import for practice, are explained in a chapter of the 2008 Clinical Handbook of Couple Therapy, as follows:

“Because we take a systems perspective and view the couple as the client, we have found that individual therapy may interfere with our couple work. We also tell clients that research indicates that the chance of divorce is greater if clients engage in individual therapy rather than couple therapy (Bray & Jouriles 1995). Therefore, we request that partners stop individual therapy during our couple treatment. There is a greater chance of dysfunctional triangulating when another therapist is involved” (p. 504).

Conflict resolution treatment recommends this same policy, that is, flexible inclusion of individual and couple sessions within an overall couple treatment format with one therapist handling all the treatment components. The one exception to the one therapist rule for couples is for treatment of problems that lie outside the therapist’s areas of competence. Referral for additional specialized treatments such as neuropsychological exams, medication treatment, or addiction cessation would always be appropriate, provided the couple therapist and the additional treatment professional agree on a clear division of labor between the therapists.

What is essential however with a protocol that includes both individual and couple treatment formats is explicit confidentiality procedures. Conflict resolution therapists are encouraged to explain at the outset of treatment their policies with regard to confidentiality. Will information disclosed in one spouse’s individual session become the property of the couple? If so, then is it appropriate for the therapist to share individuals’ communications to the therapist with the other spouse? I believe not. Information shared by the couple in the presence of the couple of course is bounded by confidentiality vis-a-vis anyone other than the couple. Information shared with the therapist by one spouse must remain similarly bound by confidentiality to remain with the therapist.

With these principles, one spouse who may be having an affair is able to work on how to disentangle from the affair. The individual sessions enable the straying spouse to utilize the therapist’s in order to extricate from what can be a difficult situation. This option increases the likelihood of a positive marital outcome.

At the same time, if one spouse is having an affair, the therapist has a responsibility to clarify when the affair is revealed that affairs are a violation of the marriage contract. It is ethically important for a therapist to clarify to an unfaithful spouse that continuing to conduct therapy with a secret partner on the side is not an ethical endeavor or an option. However a therapist can help a partner who is engaged in an affair to settle their internal conflict, that is, to choose either to stay in the marriage or to leave it for the new partner.

I have found that this dilemma of having to hold confidential information with regards to an affair is a situation that does occur, but rarely. In most instances, holding individual spouses’ confidential information in confidence is relatively easy and greatly benefits both spouses. They can then enjoy the gains of both individual and couple treatment, with both aspects of this integrated treatment enhancing each other.

A statue of a man and a woman are in an affectionate pose.Dramatic activities are powerful tools when used in a family therapy setting. One such tool is called psychodrama. An example of one type of psychodrama is family sculpting. The first step involves determining who has a sense of readiness to do their family sculpting at this time. I generally ask this question to the group and then wait to see who is interested in doing work. If more than one person is interested, I encourage each person to talk about how important it is for them to do work now, versus considering a later date. Whoever has the most pressing need is then afforded the opportunity to do the sculpting.

The individual is then asked to intuitively pick an event or an occasion from their childhood to present to the group. I ask them arbitrarily to pick an event or circumstance from when they were five years old. Later in the sculpting they are asked to pick additional events from age 10 and then eventually age 15. I will say more about this later. The person going through the sculpting is asked to choose a support person to be with them throughout the psychodrama. The person chooses someone he/she feels a connection with and feels safe around. As the individual recalls the setting, and whatever happened, he/she is asked to talk about the other people involved. As the individual introduces the people involved in the original setting, he/she is asked to choose somebody to play the part(s) of those initially involved.

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This is typically the stage of the sculpting where the individual really starts to sense the realness of what is about to happen. They begin to develop a sense of who might trigger the original mannerisms or energy that people possessed in the original setting. Paying attention to who the person chooses for each role can also reveal projections that the individual may have toward other group members. That is one of the reasons it becomes very important to de-role at the end of the sculpting. Once all of the participants are chosen, the individual then places them in the room according to where they would have been in the original setting and in relationship to where the individual him/herself was in the original scene.

The person then provides information about each individual, so that the people playing the roles will have a sense of what their character might say and how they might act. They can ask questions until they feel a degree of comfort with the role. This is typically a place in the activity where I assure the participants that I have a sense of their role and I will help them if they get stuck. I also make it clear that, if what they are saying does not seem accurate or helpful, I will intervene and provide direction.

While overseeing the group I remain available to be there for emotional support for the person being sculpted. The co-therapist may be asked to play a role. If he/she is not in a role then he/she can help provide information or direction to the participants. This person also plays the important role of tracking the group and must pay close attention to anyone who gets triggered into some of their own trauma as a result of the intensity and/or realness of the psychodrama.

The individual may choose someone to play his/her part in the drama or may play the role him/herself. This is determined through discussion between the individual and the group leaders. The main criteria for the person being involved as him/herself, is generally whether he/she feels prepared to get emotionally connected with the original pain or not. If he or she is not sure of the degree of readiness, it is better to move in the direction of not having a role for him/herself.

Someone experiencing psychodrama for the first time generally does better being less connected emotionally through having someone else play their role. This also allows him/her to see how impacted he/she was by the traumatic event, from the outside. This potentially provides an opportunity to be there for his or her own hurt parts that are revealed through the sculpting process. By getting to see their internalized process be externalized, the person, in some cases, makes their first connection with these hurt part(s), and thus begins to learn to acknowledge and be there emotionally for these parts of him/herself.

A market stallholder handing change to customer buying bread.When might earning more feel like making less for women? When it comes with the emotional baggage of being the primary breadwinner in a culture where men are expected to bring home the bacon. Earning a good income should be something for women to feel proud of, right? It is an accomplishment, a deserved reward for hard work. Yet many women feel conflicted about their status and ashamed of the role reversal. And this devalues their achievement.

Many women breadwinners downplay their success. Traditional values still dictate that the male partner in a heterosexual relationship should bring home a bigger paycheck. Male self-esteem is often linked with their financial prowess, and society has yet to challenge this expectation. Women’s financial success is such a taboo topic that the high percentage of women in this country who are primary breadwinners may be a surprise to many people. According to the U.S. Bureau of Labor Statistics, women are the sole or main breadwinners in almost a third of U.S. households. As the economy continues to falter, this percentage is predicted to climb, since unemployment has hit male-dominated fields the hardest.

Some women become primary breadwinners when they pursue a higher paying job, while their husband/partner chooses a path that offers less remuneration. A woman who is successful in real estate, for example, might earn more than her spouse who is an artist. Even if monetary success is not considered important when choosing a mate, most couples still face cultural expectations associated with this role reversal. Men can feel emasculated, women may be viewed as controlling, and both may worry about what others will think of them. A woman may resent her partner for not being able to support her, or may lose respect for him if he fails to search for better paying work, and a man may resent his breadwinner wife who seems so much more accomplished.

Women also may become sole breadwinners by default when their partner is laid off. Since the start of the recession, three out of four of those recently unemployed are men. This can be particularly devastating for families since women still only earn 78 cents to the dollar when compared to men. Women in these situations face the stress of earning the family paycheck, offering emotional support to a spouse who is often angry and demoralized, and containing their own frustration and resentment.

While ambivalence about breadwinner status may be commonplace, some women relish the opportunity. In one study, Rebecca Meisenbach interviewed female breadwinners and found that although some experienced guilt and resentment over their multiple roles, many were ambitious, took pride in their accomplishments, and enjoyed their independence. These women also found that it was critical to value their spouse’s contributions to the family, regardless of his financial success.

So how can women adjust to the primary breadwinner role, regardless of whether it is obtained by default or free choice? On the job, women need to lobby for equal pay, and challenge long-held misconceptions that men are solely responsible for their families, thereby warranting higher wages. Men and women need to resist judging one another by the size of their paycheck, and support the pursuit of a career path based on what is meaningful and fulfilling. Most importantly, couples need to communicate openly about the impact a woman’s breadwinner status has on their relationship. Partners need to remember what brought them together in the first place. Paying attention to what you enjoy and respect about your partner, how the intimacy you have can enhance your life, and how you can support each other’s career goals can hopefully offset any challenges to the relationship.

References

  1. Meisenbach, Rebecca. (2009). The Female Breadwinner: Pheonomenological Experience and Gendered Identity in Work/Family Spaces. Sex Roles. Retrieved from http://www.springerlink.com/DOI: 10.1007/s11199-009-9714-5.
  2. U.S. Bureau of Labor Statistics (2009). Women in the Labor Force: A Data Book. Retrieved from http://www.bls.gov.

GoodTherapy | Healing Complex Trauma, Part II: The Path to IntegrationMaybe you’ve been struggling with anxiety and panic and you’ve tried everything: medication, progressive relaxation, meditation, exercise, deep breathing, herbs, watching TV till your eyes glaze over in a stuporous fog—and still you’re feeling nervous, irritable, unable to focus, panicky, and tense.

What you’re missing might surprise you: you could be suffering from lack of sleep.

Studies show sleep deprivation to be one of the primary contributors to anxiety problems, depression, and other psychiatric disorders. Sleep appears to be very important for emotional regulation and processing.

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At University of California Berkeley’s Sleep and Neuroimaging Laboratory, assistant professor Matthew Walker’s experiment with sleep deprivation in humans showed that without sleep, the brain reverts back to more primitive patterns of activity. People then become less able to put emotional events into context and respond appropriately.

The amygdala is the part of the brain that prepares the body to protect itself when it perceives danger. When it senses danger, it sends a message to the prefrontal cortex, which then interprets and assesses the situation and decides whether to activate the fight or flight response. Under normal circumstances, the amygdala and prefrontal cortex work together to respond appropriately to danger while also keeping people from overreacting to emotional experiences. Under conditions of sleep deprivation, subjects’ amygdales and prefrontal cortexes stopped working together. Emotional centers were 60% more active, resulting in slower reflexes, increased irritation, problems with focus and concentration, and higher feelings of anxiety.

Other studies suggest that lack of REM sleep causes or worsens psychological problems. REM sleep, also known as dreaming sleep, is very important for processing emotions and memories, clearing the mind of the stressful events of the day, and dreaming. During this stage of sleep, the areas of the brain used in learning and developing new skills are stimulated. About 70 to 90 minutes after falling asleep, the first REM cycle occurs; ideally, people will have three to five REM episodes per night. Getting more and better REM sleep has been shown to boost people’s moods during the day. Fortunately, improving the quantity and quality of REM sleep you get is relatively easy.

Many experts recommend getting seven to nine hours of sleep per night, although some say that the quality of sleep is more important than quantity. Getting six hours of high-quality, uninterrupted sleep is more beneficial than eight hours of restless, interrupted sleep. You can immediately improve the quality of your sleep by making two important changes: change what you put into your body and what you do with your body, both during the day and when getting ready for sleep.

Change What You Put into Your Body

Change What You Do with Your Body

Getting adequate, quality sleep is extremely important for emotional regulation and processing. Fortunately, it is relatively easy to make changes in this area. Start today, and the effects can be felt almost immediately.

Reference:

  1. Yoo, S., Gujar, N., Hu, P., Jolesz, F.A., Walker, M.P. (2007) The human emotional brain without sleep: A prefrontal amygdala disconnect. Current Biology 17: 877-878

The human shadow carries with it the potential for global annihilation and the potential to regenerate and evolve our species. At the crossroads, which road shall we choose?

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I–
I took the one less traveled by,
And that has made all the difference ~ Robert Frost

Down the path less traveled you meet the mysterious, unfamiliar, and at times horrifying parts of yourself. Long ago, for good reasons, you rejected and exiled specific behaviors, emotions, beliefs, memories, and capabilities. For example: If you were raised in a home where being the Good Child, the Pleaser was rewarded, and being more Selfish or Outspoken was punished, you may have determined that being the Pleaser was the wiser path. The Pleaser then became one of your many Primary Selves. (more…)

A woman writes in a cafe.I enjoy writing to myself. Sound strange? I initially chose not to share this information with anyone else because I thought people would be confused by this statement. However, writing to myself is helpful to work, relationships, and self-evolvement. I hope this technique is beneficial to you as well.

Writing to myself is like having a conversation with my true self. Intimately revealing and increasing present moment awareness, it is just as helpful as meditation, visualization, or yoga in relieving stress. Writing to oneself can also help one work through depression or deepening intimacy with a partner.

So, how can you learn to write to yourself?

All you need is fifteen minutes a day, a pen, pencil, or a crayon (whichever works best for you), and an intention to be honest, true, and nonjudgmental to the writing that emerges from within. This method of journal therapy is most beneficial when you are feeling overwhelmed and/or when you are making an important decision. Begin by gathering a pen and paper to have on hand; try opening a window to let in fresh air; make sure you feel calm and ready as you start this activity.

Evaluate your goals, which may include:

The first step in this activity is to realize that although you may hear several different voices in your head (the critic, the people-pleaser, etc.), another voice exists that you can call your true self, your guardian angel, or your higher self. This inner voice knows peace and joy and guides you in making choices that feel right for you, without fear.

The second step is to write a question on a piece of paper. Try to find a question that concerns you deeply and affects your current mental health:

Once you have determined your question, sit in silence. Close your eyes. Breathe deeply. Notice the thoughts ebb and flow in your mind. Continue to focus on your breath for five minutes. As you calm, notice how your thoughts slow down.

Then write as if you’re having a conversation with your true self. A conversation might ensue as follows.

Q: What is bothering me?
A: I don’t know. What do you think is bothering you?
Q: I don’t know; that’s why I am asking you.
A: Well, sit still for a moment.
Q: How is that going to help?
A: Well, try it and see what happens.
Q: I am not here to sit still. Solve my problem.
A: Sitting still is the answer.
Q: How long do I have to sit still?
A: A couple minutes.
Q: Okay. I’m still. Now what?
A: Well, how do you feel?
Q: Not as bothered as before.
A: Great. Do you have another question?

The first time you attempt this activity you may not hear your inner voice, but don’t give up. Keep writing. It takes time and patience to hear your true self speak to you. The more you intend on finding that voice, the more easily you will hear it. With practice, you will learn to speak from your true self, and all the other voices (the whiny child, the people-pleaser etc) will take a back seat.

Good luck!

Man leaning against wallLow self-esteem can’t be hidden for long. It tends to show itself through thoughts, words, and behavior.

Since some behaviors are simply learned, and may have little to do with one’s level of self-esteem, it’s best to look at the overall picture rather than focusing on just one piece of information.

With that in mind, here are some signs that, taken as part of a larger pattern, may be an indication of low self-esteem. Please note that this is not a comprehensive list.

1. Thinking that “other people treat me badly because I deserve it.”

Imagine the following scenarios:

In each of these scenarios, the other person is being rude. If your tendency in these situations is to feel bad about yourself, that is a strong indicator of low self-esteem.

Practice focusing on the other person’s behavior, and trying to evaluate it objectively. Are they being appropriate? Kind? Reasonable?

2. Disliking people in general

Babies are born with a natural interest and trust in other people—you were born that way, too. If you now feel like people are not your thing, it’s almost certainly because of painful experiences that taught you that other people can be mean and hurtful. Even if you’re no longer in touch with the pain of the past, even if you don’t even remember those experiences, your sense of self and your own worth were undoubtedly shaped by the same experiences that created your dislike of people. Unfortunately, dislike and distrust of people make it hard to cultivate the very experiences that would prove people to be better than you expect, perpetuating a vicious circle.

Pick someone in your life who feels safe enough, and try opening up a little more than you ordinarily would.

3. Under- or overachievement

Overachievement is an attempt to bolster low self-esteem with impressive deeds when deep down, you don’t feel like the person you are is “enough” to be acceptable to others. Only more accomplishments can give an overachiever the feeling of being okay as a human being—at least, that is their hope.

Overachievers can benefit from allowing themselves to “slack off” and learning to tolerate the feelings that arise in the absence of productivity.

On the other side of the coin, your self-esteem might be so injured that you don’t dare attempt to achieve anything. As an underachiever, you may feel that if you should fail, it will only prove what you secretly already suspect: that you are woefully inadequate to the tasks of normal living. It’s better not to try, and instead enjoy the thought of having “potential,” than to attempt to achieve something and fail in front of everyone.

Underachievers can pay attention to feelings of fear of failure and practice making small attempts at doable activities, such as baby steps toward a larger goal.

4. Perfectionism

It’s long been known that perfectionists often experience low self-esteem.

For perfectionists, only something done perfectly is good enough to be acceptable to others. Ninety-nine percent success is the same as failure; only 100% is good enough (barely). Perfectionist might think they create their standards—that is, they may believe they’re  trying to please only themselves—but too-high standards are always based on early perceptions of what others expect from us.

Perfectionism is cured by doing things imperfectly on purpose. It may help to use a shame tactic: imagine that because of your perfectionism, everyone knows you’re insecure. It might help you to let go of it a little.

5. Alienation

Feeling somehow “different” and alienated from the rest of the human race is one of the most discouraging experiences one can have. Perhaps surprisingly, it’s one of the most common reasons people seek therapy.

This sense of alienation often results from emotional neglect when a person was young. Many of us who received the food, clothing, and shelter we needed for survival did not receive as much accurate empathy as we needed in order to understand ourselves as people.

Sometimes our caregivers were sick, depressed, or even deceased, and we were left alone too often. Sometimes they were there with a vengeance, sowing fear and discord. We didn’t get the opportunities we needed to bond with other people. Bonding creates a sense of security and connection that everyone—kids, adolescents, adults, seniors—needs in order to thrive. If you feel like an alien, know that you are not alone. You are a normal human being reacting in a normal way to the abnormal situation of emotional isolation.

Read and learn as much as you can about emotions, for these play an important role in the formation of relationships with both yourself and others. Practice self-acceptance: if you don’t, you will never feel accepted by others. If you can, find a therapist you feel comfortable with. A therapist can serve as a compassionate guide while you work on reintegrating yourself into the human race—where you very much belong.

Weary man rubs his eyes as he wakes.At the very core of our lives is sexuality. Though, as a society, we are not trained to talk openly and honestly about sex. Nonetheless, we grow up recognizing and knowing, intrinsically, the need we have for sex and the roles it plays; with one of it’s main functions being procreation. And, what is the other function of sex? Well, and pleasure, of course.

If only pleasure were such an easy thing for us to comprehend. As a society, not only are we discouraged from talking about the pleasure that sex brings us, we are also led to recognize the detriments of deriving too much pleasure. The lack of ability to openly acknowledge things which bring us pleasure, may also cause us to abuse those same things.

It is known as hedonistic to throw oneself into pleasure all the way, to be unable to find a happy medium. When we begin to neglect our responsibilities—work, family, friends—in search of personal pleasure, we then call this phenomenon an addiction. And, when someone comes to the end of the rope with addiction, they often recognize that the only way to undo the damage is to go into what we call sobriety, or recovery.

When an alcoholic or drug addict goes through recovery, it is possible that sex is at the core; however, it is one topic that often gets neglected. Much of recovery is spent addressing the relationships, which affected and were affected by the addiction, coming to terms with our addictions and understanding ourselves in relation to our higher spirit. All of these are, indeed, important items on the road of recovery. However, it is not every day that the role sex plays in an addiction is explored.

It is important to mention that drug and drinking problems can be sexual problems in disguise. Sex plays a major role for some individuals who become chemically dependent. And, to break down its walls, it’s necessary to understand the effects of sex addiction.

Sexuality is often one of the most fragile areas of a recovering individual’s torn self-esteem. Many of the issues of love and relationships, that come up for addicts in recovery from alcohol/chemical dependency, have something to do with sexuality, once the walls are broken down.

Sexual fears and insecurities may be the force that drives a user to drinking or use drugs in the first place. For example, many professionals point to early sexual abuse as the place where some anxieties began. It has been recognized that childhood sexual abuse is a risk factor in drug dependence. Research indicates that, of all the people in treatment, about half have been raped or abused, while a third are victims of incest. So, as practitioners, we have to recognize that sexual abuse may be damaging to feelings of self-worth, which, in and of itself, is a risk factor for drug use and abuse.

Not only is sexual abuse is a major contributor to addiction. Sexual and gender stereotypes are another. Some of the tried and true gender roles still hold in our society, even though we are seeing progress and change. Many women are still the primary home caregivers, putting the needs of men and children ahead of their own, neglecting their own need for support and intimacy. And, men are often still expected to be the initiators, the aggressors, and the breadwinners forgetting to express their emotions and feelings. Ignoring needs and feelings are risk factors for addiction.

In treatment we learn that preserving sobriety involves more than merely reshaping the habits of drug or chemical use, it also requires throwing away stereotypes and reshaping old attitudes that have been hammered in over the years. In treatment the addict learns to start taking care of his/her own needs. The addict learns that their recovery depends upon addressing feelings and emotions. The individual in recovery must talk about things like sexual abuse, sexual gender roles and stereotypes. And, likewise, must also talk openly talk about his/her sex life.

The key is to deal with sex after sobriety. Avoiding sex may leave an individual poorly prepared to cultivate relationships that don’t revolve around, for example, singles bars and drinking, causing an addict to lose that hard-earned sobriety within months or weeks. Unless treatment addresses both the dependency and sexuality, recovering addicts risk relapse with every close romantic encounter. Most treatment programs do recognize that it takes two to repair a relationship strained by chemical abuse, and will incorporate the partner of the addict in the treatment process.

Though many addicts may feel like doing so in recovery, running away from sex is not realistic; it’s better to put sex in the context of feelings and factors that make up the whole person. Here are some things for the addict to remember when it comes to sex:

1. Talk about sexual feelings of guilt and anger in order to heal. Addicts need to learn to recognize the patterns of feelings, sexual or otherwise, that drive them to drink or abuse substances. Only then are they ready for new relationships, or of rekindling an old one.

2. A recovering addict also needs to move slowly, whether in a new or old relationship. Concentrate on building self-confidence and self-image, first, before building up a sex life. For many, it may be a good idea to wait six months, or even a year, before beginning a new sexual relationship. Couples should focus, first, on sharing time and feelings together before jumping back into bed and into their old, unstable, erratic sex life. Sex therapy is also a good starting point.

3. Start over by focusing on really learning about your own body and feelings. The goal here is to help ease fears that sexual feelings are abnormal or strange. It is important to take the time to really learn (or re-learn) what one likes, sexually. Couples should focus on sensuality and should take the pressure off of sex and orgasm for a while and, instead, do things like take bubble baths, sensual massage, and mutual masturbation, and openly communicate with each other about sex. It is important to recognize that, just like there’s more to alcoholism recovery than not drinking, there’s more to sexuality than just sex.

An addict will very likely need to rewire his/her ideas about sex. Taking time and talking openly about sex are the keys. The addict who discovers that sex can be a bridge to intimacy, satisfaction, and a strong self-image, is likely to find deeper, more honest and satisfying relationships—sexual and otherwise.

GoodTherapy | Improving Body Image: Nine Steps for Positive ChangeLong after eating patterns and weight have stabilized, many women  with an eating-disorder continue to struggle with issues of body image. In fact, body dissatisfaction has become so prevalent, many authors propose it has sadly become simply part of the female experience. Body dissatisfaction is believed to be one of the highest predictors in adolescent girls who go on to develop an eating disorder.

The National Eating Disorders Association (NEDA) defines negative body image as:

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I am a psychotherapist who specializes in the treatment of adolescents and women with eating disorders. For several years I have been leading body-image therapy groups in my outpatient practice. What follows are some of the group topics we cover as well as resources and activities I have found useful for helping people with their body image.

Generally, the group therapy series is focused on improving body image and runs for eight to ten sessions, as outlined below:

Session 1: My Body Relationship.

How do I feel about my body? To introduce this topic, group members participate in an art activity exploring how they feel about different parts of their bodies—from head to toenails. When asked to voice to the group the body part they like most, frequently the women will speak about a part that allows them to pleasantly experience some aspect of life, for example: “My hands—because I love to play the piano.” This activity allows members to recognize that some parts of their body are just fine, in their eyes. It’s not all body hatred. Great! We can build on this.

Leslea Newman’s book SomeBody to Love: A Guide to Loving the Body You Have (1991) has journaling exercises to help people creatively work toward repairing a broken relationship with the body. She recommends writing love letters, having dialogues with body parts, speaking compliments into the mirror, and more.

Session 2: Create a Vision.

How do I want to feel inside this body? If I felt this way, how would I move differently, how would I interact with others differently, what would this free me to do and experience? Using guided visualization, to step into and experience this vision, allows each person to plant and hold in their awareness a goal to guide them in the work ahead.

Session 3: Contributing Factors.

How did I come to define beauty? What experiences and messages contributed to my personal body opinions? Using a time-line, each group member looks at significant life events and paralleling patterns of weight and feelings about the body. The women in group often speak of having felt “different” from their peers. They feel dissimilar in their relationships with one another and with food. They also feel ambivalence about their developing bodies. We take a critical look at the media and the conflicting messages received from advertising. NEDA offers a number of handouts useful in facilitating this discussion.

Session 4: Body Talk.

What’s being said inside my head? How we talk to ourselves and what is said has a powerful effect on how we feel. Thomas Cash, PhD, in The Body Image Workbook: An eight-Step Program for Learning to Like Your Looks (2008) tells us this talk is often self-defeating, derogatory, and distorted rather than realistic. His book and audio program provide people with specific steps and tools to help them become aware of their negative body talk and begin to transform these messages.

Session 5: Body as Camouflage.

What do I hide with my body? To explore this dynamic, each group member creates a collage with magazine clippings portraying the “inside me/outside me.” People have used this activity to explore their beliefs about what others assume and expect of them, the image they try to portray, and then what they really feel like on the inside. We explore how they have used their bodies to protect or distract them from certain feelings and what it has been like to live with such a dichotomy.

Session 6: Body as a Vehicle.

What can I do and experience, thanks to my body? Sondra Kronberg, RD, writes, “True body power is the power of the body to accomplish tasks and be the vehicle through which to experience life” (Fall, 2002). As a group, we meet for a nature walk, adapted from the chapter called “Sensual Walk,” in Working with Groups to Explore Food & Body Connections: Eating Issues, Body Image, Size Acceptance, Self-Care (1996). In silence, we mindfully pay attention to the titillation of all of the senses: “Notice the smell of air, the feel of the elements, the textures beneath your feet, the views along your route, the taste on your lips, the ever-changing sounds in the background or foreground” (1996). In processing the experience, we talk about beginning a new relationship with our bodies by celebrating all the amazing things our bodies do for us and allow us to experience. Using Thomas Cash’s chapter called “Adult Pleasant Activities List” (1996), members are asked to mindfully and joyfully experience something from the list each day for the next week.

Session 7: Body as Container.

What is this spirit, this essence-of-me that lives inside my body? Kronberg goes on to write about the importance of helping our clients find their “real beauty,” that is the beauty “stored inside of them” (2002, Fall). During this session, group members create a word and picture collage of favorite things, causes they passionately believe in, relationships that matter most, compliments received, qualities of character they admire in themselves. This activity is often a favorite and reminds participants that they are so much more than the size of their clothes.

Session 8: Body as a Rich Source of Wisdom.

What can I learn if I slow down and listen to my body? This session opens with a deep-breathing exercise to practice being still, quiet, and focused. We then explore “gut instinct”—where and how we experience it in our bodies and how we have used this information to reliably guide us. Members are also invited to explore feeling states in the same way. Using a body outline on paper, members draw where in their bodies they feel anger, sadness, or loneliness, noting the size, color, and shape of each, and what distinguishes one from the other.

Session 9: Body Respect.

I can honor and take care of my body. This is a brainstorming session of all the things we can do to take care of and nurture our physical selves. Belleruth Naparestek’s affirmations are used from A Meditation for Relaxation and Wellness.

The following is excerpted from her beautiful work:

Body image work is a critical step in full recovery from an eating disorder.

Recommended Reading:

References:

  1. Kronberg, Sondra. (2002, Fall). Nourishing a Healthy Body Image: A Nutritionist’s Perspective.  Perspective.
  2. Levine, Paula. (1993). The Meaning of the 3D’s, Eating Disorders & Awareness Prevention. Perspective.
  3. Naparstek, Belleruth. (2002). A Meditation for Relaxation & Wellness. Akron, OH: Health Journeys.
  4. Ressler, Adrienne. (2006, May) A Body to Die For: Advanced Training in the Treatment of Eating Disorders & Body Image Disturbance in Women. Perspective.
  5. Hawkins, Nicole. (2009). Battling Our Bodies: Understanding and Overcoming Negative Body Images. Center for Change. Retrieved from: http://centerforchange.com/content/battling-our-bodies-understanding-and-overcoming-negative-body-images

elder-couple-woman-in-focusIn this article I want to focus on one particular aspect of recovering from an affair: punishing the offending partner.

I am frequently asked, “How long is this pain going to last?!” That’s impossible to answer, but I do know one way to shorten the life span of your pain, and perhaps shorten the recovery process. What’s my secret? If you’re punishing your partner, stop. Why? Because punishment can slow the recovery process, thereby extending the pain you are working so hard to reduce.

In my office, I frequently hear the injured party telling their partner, “I want you to hurt for as long as possible, just like I do. You’re just going to have to take this punishment and deal with it!” The punishment begins in a wide variety of forms that ultimately prolong the injured party’s pain. In the early stages of recovery, dishing out punishment seems to provide the injured party a semblance of control after feeling profoundly powerless, helpless, and deeply wounded.

The Downsides to Punishment

First of all, punishment can lead to bitterness in one or both partners. Bitterness is swallowing a poison pill hoping the other party will die.

Second, it delays recovery due to the need for more repair. Punishment causes additional pain to a relationship already suffering on several levels. More pain means more recovery work. More recovery work takes more time. Inflicting emotional pain in someone else seldom leads to relief from our own pain because our brains are simply not wired to do that.

Punishing the offending partner means the injured party is working at cross purposes. For example, let’s pretend you are the injured party. Part of you wants to stop feeling so terrible and get your life back, perhaps save the relationship, or try to figure out whether or not the relationship even can be saved. Another part of you wants your partner to suffer, so you punish them. But punishing your partner, although understandable, only adds more pain to the relationship. The pain you feel as a result of the affair is real, deep, and pervasive. Adding pain to one side of the relationship while simultaneously trying to reduce it on the other side simply will not work. It is impossible to repair something that is simultaneously being damaged.

Alternatives to Punishment

  1. Realize that your desire to punish is normal, but it’s the consequence of your own pain.
  2. Understand that purposely causing pain for pain’s sake in your partner will not relieve your pain in the long run, even if it seems to provide a short-lived sense of satisfaction.
  3. Talk with your partner in detail about your pain! Expressing your pain gives you a greater likelihood of being heard and understood. It also provides an opportunity for your partner to experience their own pain derived from losing your trust, damaging their credibility, and losing their integrity, not to mention the realization that the relationship is in jeopardy. Punishment may divert them from facing those important issues and emotions.
  4. Remember, bitterness and punishment are damaging.

Think about it: If punishing the offending party must play a role, try to make it short-lived and limited. For when it persists, bitterness may take over, individual- and couple-healing is stalled, and your pain and recovery will be prolonged. Recovery from an affair is a long, arduous process, but the recovery process can be shortened if punishment stops. If need be, find a good counselor to help out.

How do you find a counselor who has an understanding of infidelity recovery? Ask if they have read Peggy Vaughan’s book, The Monogamy Myth. If not, look until you find a counselor who has. And if you haven’t read it, do so.

If you and your partner really want to do yourselves a favor, attend one of Brian and Anne Bercht’s workshops for couples recovering from an affair.

Limit the punishment, reduce your pain, and shorten the recovery process.

A lost stuffed animal, bunny sits outside one a bench.The final alcoholic family role I’d like to discuss in the context of recovery is the lost child. This is the child who stays under the radar, invisible, quietly decamping to his/her room, disappearing behind a stack of empty booze bottles or cloud of marijuana smoke. To paraphrase D.W. Winnicott, for a child it is normal to hide, but a tragedy not to be found.

What happens when a lost child gets clean and sober? To understand this, we have to look at what happened to make this child “lost” to begin with. This child, in a way, becomes, almost literally, a skeleton in the family’s closet. The child’s disappearance serves the dysfunction of the family in that this child will never divulge the family’s skeletons. There are many “elephants in the room” in such families; sometimes untreated addiction, other times abuse or neglect. The family’s collective shame must be hidden; the lost child serves as a kind of metaphor for what is repressed. When a child like this stays lost, he learns that his needs don’t matter, and so the adaptive hiding strategy becomes a way of life, later to be soothed and narcotized by the powder, needle, or bottle (as well as a series of codependent relationships).

The ambivalence this child struggles with in new-found sobriety arises from the advantages and disadvantages of the lost role. On the one hand, this person has protected his/herself from the vortex or volatility of the chaotic family dynamic. He/She has not had to enter into the fray and risk attack, injury, or humiliation. Invisibility becomes the best form of defense.

On the other hand, he/she lives with a kind of emotional anorexia and is a prime target for a host of destructive behaviors: self-harm (cutting, burning), eating disorders, sexual compulsivity, codependence, addiction, and so forth. This child wants to be heard, needs to be heard—but is terrified of being heard. Being heard means facing the feelings beneath the cloak of invisibility, and risking the judgment and/or abandonment of the family members who rely on him/her to stay quiet. Such a person carries heavy feelings of shame, guilt, rage, isolation, and a longing for (and terror of) human connection.

The question of whether the family can be helpful or destructive, as the child gets sober, hinges, not so much on the degree of the family’s past dysfunction, but on their current willingness to get honest and authentic. This family support, of course, is preferable to the lost child, more so than accusations of the child being bad by forcing them to look at long-hidden family secrets.

The family may consciously yearn for his/her sobriety while unconsciously defending against their own shame and guilt. I once knew the father of a l0st daughter, newly sober (my client); he was often enraged at her for a variety of puzzling reasons, until I discovered that he himself was an alcoholic who was terrified of having to face his own problems. His words said “get healthy” but his behavior said “let’s keep things as they were.”

It only takes one relatively balanced member of the immediate family who is willing to align with this newly sober lost person, and live in honesty rather than deceit, to bolster the addict’s support system. Having just one family member on board who loves and accepts the addict, who is not overly threatened by his/her recovery, can bolster a sense of hope. This actual relationship can shed light on the addict’s (usually futile) attempts—prior to sobriety—to find surrogates for lost family members.

Of course, the addict’s partner or family members often cannot or will not accept their loved one’s condition and desire to change, and are threatened by the prospect of recovery. They may defend this terror by insisting on seeing addiction as a moral failing or weakness. Still, the addict has a chance of success, as always, though the recovery work proves more formidable: this is a case that requires immediate support-building, as the lost person begins speaking the truth and breaking the bonds of repression. Like all addicts, he/she will require the support of a sober community, therapy, and intensive recovery work. Being rewarded with love, acceptance and higher self-esteem is often strong inspiration.

It is still amazing to me how threatened alcoholic family members become as their loved one becomes healthier; as order is threatening to chaos, health is threatening to the ideology of sickness, which casts a black pall over everything and fosters a sense of futility. Thankfully, recovery can lift the black veil of these (mis)perceptions, when the addict is truly ready to surrender and begin the slow, sometimes grueling, but always worthy, path towards wellness. This can happen without the aid and support of loved ones, but recovery comes easier when family, too, is willing to change.

Girl shaking boy and yellingEven though there can be life long debilitating psychological effects, sibling abuse may be the most ignored—if not accepted—form of domestic abuse (i.e. sexual, physical, emotional). Why is this kind of abuse ignored or minimized? There is a lot that is swept under the rug in the guise of “sibling rivalry.” And American law does not consider this a prosecutable offense unless a child is turned in by their parent(s). In other words, parents would have to be willing to file an assault charge against their own child. So parents keep this type of abuse within the family. And a lot of the time, they even blame the victim.

First some statistics: In an article entitled “A Major Threat to Children’s’ Mental Health,” Hart & Brassard reported that “There is evidence that brother-sister sexual relationships may be five times as common as father-daughter incest.” Finklehor and Baron, who are prominent researchers in the area of child abuse, state that “sibling sexual abuse is prevalent in a remarkably large quantity of individuals from virtually all social and family circumstances.” And a survey of 796 undergraduates of six New England colleges found that 15% of the females and 10% of the males reported having some type of sexual experience involving a sibling (Sibling Abuse – Wiehe). In this same publication it states that parents are aware of sexual abuse among siblings 18% of the time, emotional abuse 69% of the time and physical abuse 71% of the time.

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Sexual abuse aside, how do we define or recognize abuse among siblings? When there is an inequity in power between two adolescents and one uses control over the other to repeatedly hurt, threaten, or degrade, that is abusive behavior. Even name calling and ridicule can wear away at a child’s self worth and self-esteem. “Children are especially vulnerable to degrading remarks because it is during their childhood years that they are developing a positive sense of self.” Unfortunately, most parents see this behavior as sibling rivalry. And while most emotional and even physical abuse, should and can be handled by parents rather than the law, first parents have to recognize that it is abuse.

Sexual abuse is another story. Most incidents of sexual abuse by siblings go not only unreported but also undetected by parents. Most times, the siblings themselves recognize that what is happening is wrong and certainly it is recognized by society as wrong. So unlike physical and emotional abuse, this should be easier to detect by parents. But most kids don’t tell. They don’t tell because the older sibling is an authority figure, or because they are threatened or scared, or because they don’t realize that it is abuse because they blame themselves as much as their sibling for what is happening. And unlike physical or emotional abuse, it is happening secretly because the older sibling knows that they have crossed a line.

What causes one sibling to abuse another?

1. Acting out anger at parents on sibling or acting out anger at an older sibling on a younger sibling.
2. Parents overwhelmed by their own problems not paying attention.
3. Inappropriate expectations – older sibling given too much responsibility or freedom.
4. Mirroring parents behavior.
5. Viewing the behavior as normal by parents.
6. Socialization of males as dominant over females.
7. Contribution of victim. “Research supports the hypothesis that the behavioral patterns of the abused child tend to invite further abuse” (Wiehe). It becomes a vicious cycle.
8. “It is important to note that this interactional cycle theory does not blame the victim!” Rather it identifies a pattern in order to treat and help prevent further abuse.

What are the long-term effects of sibling abuse?

Time does not necessarily heal. Adult victims of childhood sibling abuse generally have lower self-esteem and are overly sensitive and insecure. They have trouble with relationships and repeat the victim role in their other relationships. They can have sexual functioning problems. There is continued self-blame at the same time that anger at their perpetrator is played out with others.

So how do parents and other family members distinguish between abusive and normal (sibling rivalry) behavior?

1. Is it age appropriate?
2. Does one child appear to be a constant victim?
3. Is the purpose of the behavior humiliation, sadism, to cause suffering, a result of a continual explosive anger?
4. Was the behavior planned, has it happened before, does the perpetrator feel remorseful?
5. Was property destroyed or animals abused?
6. The length and the degree of the behavior. One-time incidents, if serious enough (i.e. sexual abuse), can create a life long problem. Whereas name calling, ridiculing, and even teasing if done consistently and at certain vulnerable ages (i.e. between six and seven years and/or between eleven and twelve years of age) can also create life long problems.

We need to build awareness and educate families about the difference between abusive and normal behavior among siblings. Listen to children and believe them. Good supervision and encouraging openness about discussing sex while informing children to “own their own bodies” and respect others are simple, logical steps towards protecting our children from abuse by siblings, cousins and other children.

Important Notice

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