The most common way to assess the outcome of therapy is to gather information relating to well-being, functionality, and problems that brought someone to therapy, and to do this both at the beginning of therapy and again at the conclusion of therapy. This allows a therapist, and the person attending therapy, to see the progress they have made and determine what areas may still need to be addressed in the future. Unfortunately, this outcome measure is rarely accurate, because a large number of people who receive cognitive therapy or talk therapies drop out prior to therapy conclusion.

Therefore, Slawomir Czachowski of the College of Medicine at the Nicolaus Copernicus University in Poland recently led a study utilizing a revised outcome tool. Czachowski altered the Psychological Outcome Profiles (PSYCHLOPS) tool to include questions pertaining to problems that could arise during therapy, not just those that were present when therapy began. Further, Czachowski repeatedly administered the revised PSYCHLOPS throughout the therapy process to gauge progress along the way.

Using a sample of 238 clients, Czachowski administered pre-therapy, during therapy, and post-therapy surveys. A total of 135 people completed all three assessments. The results revealed that those who experienced valid change increased from 56% to 81%. This suggests that the revised PSYCHLOPS method captured more accurate data than the traditional delivery method, or more change occurred because PSYCHLOPS was repeatedly administered.

Czachowski also discovered that 60% of the completers reported new problems during therapy. However, these problems were not more severe than any that they presented with and the level of change that occurred with respect to these new problems was equal to that that occurred for the prior existing problems.  In fact, completers were more likely to have new problems arise during therapy, or at least admit them, than those who did not complete therapy.

Another interesting finding was that during therapy PSYCHLOPS allowed Czachowski to recognize that non-completers had the lowest PSYCHLOPS scores before and during. This could help therapists identify and take steps to help those most at risk for early drop out. In sum, these results support intermittent PSYCHLOPS to measure therapeutic outcome. “A large proportion of outcome data is lost when outcome measures depend upon completed end of therapy questionnaires,” said Czachowski. “The use of a during-therapy measure increases data capture.”

Reference:
Czachowski, S., Seed, P., Schofield, P., Ashworth, M. (2011). Measuring psychological change during cognitive behaviour therapy in primary care: A Polish study using ‘PSYCHLOPS’ (Psychological Outcome Profiles). PLoS ONE 6(12): e27378. doi:10.1371/journal.pone.0027378

The term “enabler” has gained widespread recognition and use in popular culture and media over the past several decades. It is a label that can result in a great deal of anxiety and guilt for anyone who has been accused of being, or suspects that they may be, an enabler.

In its original context, enabling refers to a pattern within the families of people addicted to alcohol and drugs, wherein the family members excuse, justify, ignore, deny, and smooth over the addiction. This notoriously allows the addicted person to avoid facing the full consequences of his or her addiction, and the addiction is able to continue.

In a wider sense, enabling can describe a pattern of behavior that becomes organized among the family and friends of not just an addicted person, but any person who is exhibiting poor choices that harm themselves or others and for which they are not being held responsible.

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Who are enablers? Enablers can be romantic partners, ex-partners, parents, adult children, siblings, or friends. The one thing that all enablers have in common is this: they love someone who is out of control, and they find themselves taking more responsibility for the actions of that person than the person is taking for themselves.

The one thing that all enablers have in common is this: they love someone who is out of control, and they find themselves taking more responsibility for the actions of that person than the person is taking for themselves.

Who is enabled? The enabled person may be one who is refusing to take on responsibilities he or she would otherwise be expected to take on in the course of age- and stage-appropriate development. The enabled person may be exhibiting a range of poor choices with alcohol and drugs, ranging from abuse to addiction. This may also encompass poor choices around so-called “soft addictions” such as gambling, pornography, or excessive video gaming. He or she may refuse, or appear unable, to fulfill normative roles of adulthood. If a parent, he or she may underperform or disregard the responsibilities of parenthood. He or she may frequently disrupt romantic partnerships. The enabled person often displays poor money management, as well as disorganized academic and/or career-planning choices. He or she may quit or be fired from a series of promising jobs and educational or training programs. The enabled person often describes himself/herself as a victim of circumstances or of other people.

The enabled person’s behavior elicits a great deal of anxiety within the people who love him or her. This creates a dysfunctional system into which people who are close to, love, or care for the person can become enmeshed: compelled to organize their own behavior around the needs and choices of the enabled person.

Some who use the term “enabler” do so with a heavily negative judgment against the person who fulfills the role. It is commonly believed that enablers are knowingly, even willingly, complicit in the actions of the person they are enabling; that enablers support and condone the negative choices of the person they are enabling.

This is far from true. Enablers do not like or feel OK with what the enabled person is doing. To the contrary, enablers are often the ones most affected by, and most disturbed by, the negative behaviors of the enabled person. They feel extremely anxious about the destructive consequences that the enabled person could face.

Consider the following quotes from self-described enablers in therapy:

• “If I kicked him out, he would be homeless. He’s so irresponsible with money, he could never make it on his own. What else am I supposed to do?”
• “Every time I’ve tried to talk to her about her addiction to those pills, she’s gone on an even worse binge, and I’m afraid she will overdose.”
• “I know I shouldn’t have paid for his lawyer after the third DUI, but if he went to jail, he would lose his job.”
• “Every time she and her boyfriend fight, she crashes here. I let her because I know he can be violent, and I don’t want her to be hurt. I wish she would leave him for good.”

In other words, enablers detest the behaviors of the enabled, but they fear the consequences of those behaviors even more. They are locked into a lose-lose position in the family. Setting boundaries feels like a punishment, a rejection, or an abandonment of the person they love. Enablers may struggle with the guilt they would feel if the person they’re enabling were “left alone” to be hurt and damaged by the real consequences of their actions. In some instances, enablers are also protecting themselves and/or children from those consequences.

Enabling, therefore, is a distorted attempt to solve problems. Enablers desperately desire to find a solution to the issues at hand, but their attempts to do so are severely limited by the dysfunctional family system.

Enablers frequently find themselves thinking things like:

• “If only I can keep this person going through their current crisis, it will buy us another day.”
• “If I can’t change what they’ve done, at least I can help limit the damage of that choice.”
• “Maybe my loved one will wake up and come to his or her senses. Maybe a real solution is waiting right around the next corner.”

Enabling has the effect of releasing the enabled person from having to take responsibility for his or her behavior. Enabling means that someone else will always fix, solve, or make the consequences go away. When someone is in the throes of an addiction or other grossly dysfunctional behavior pattern, he or she begins to rely on the resources available. Enabled persons will come to expect that their behaviors are disconnected from consequences or negative outcomes. Enabled persons may even begin to hold their enabling family members in “emotional hostage” in order to keep this pattern going. They may learn to manipulate their enablers in order to ensure that the help and support keep coming.

In this kind of a system, everybody loses by inches. The enabler is desperate to prevent one enormous crisis, but winds up experiencing a constant state of stress as he or she attempts to manage each smaller daily crisis. Enablers generally are aware that they are being taken advantage of in some way; they often report feeling frustrated, unappreciated, and resentful.

The enabled person becomes stuck in a role in which he or she feels incompetent, incapable, disempowered, dependent, and ineffectual. He or she may gradually accept a self-concept that includes these negative traits, destroying self-esteem.

How, then, does the enabled person also “lose”? The enabled person may wish he or she felt in control of themselves, particularly with regard to addiction; but lacking the life experience and lessons that facing consequences brings, they may not know how to break those patterns. They may not have had the benefit of true self-reflection and self-evaluation of their behaviors. The enabled person becomes stuck in a role in which he or she feels incompetent, incapable, disempowered, dependent, and ineffectual. He or she may gradually accept a self-concept that includes these negative traits, destroying self-esteem and rendering the person even less likely to suddenly do a 180 and become responsible and self-sufficient in the future. The enabled person may essentially be prevented from building the skills and motivation he or she needs in order to practice responsibility and reach his or her full potential. Because the enabler(s) will always solve problems for them, the enabled person does not learn how to solve their problems themselves.

By this point, you may be thinking, “I can see some of the ways I have been enabling my loved one. What now?”

You must accept that while your enabling behaviors come from a place of love, enabling is an ineffective way of solving problems at best; debilitating to all involved at worst. You may buy another day or prevent another emergency, but in the end, you are only postponing the real solution.

The key to breaking the pattern of enabling is to return responsibility to the person it belongs to. This involves setting boundaries between yourself and your loved one. You can no longer attempt to take on responsibility for anyone else’s actions but your own. Your loved one’s choices are (and have always been) his or hers. Your loved one’s outcomes and consequences, as well, belong to him or her alone.

The enabled person lives in the same world, with the same rules, as everybody else. Managing their world for them means that they don’t learn to manage themselves within the world. He or she is very likely to have untapped internal and external resources which have not been utilized because the enabling pattern has short-circuited their growth.

When you set boundaries, you release your need to control the outcomes that your loved one experiences. You allow your loved one the chance to connect his or her own choices to the positive and negative experiences that naturally follow. Their choices, their consequences, and what they do or don’t learn from them are all on their side of the boundary.

On your side of the boundary, this means that you must learn to cope with, and internally manage, the anxiety of not being in control of your loved one. Many recovering enablers find that they must rely on their own sources of support to help them overcome the urge to control and enable. The fear of your loved one being hurt can be so overwhelming that setting boundaries and stepping back can be panic-inducing. Receiving counseling for further insight and support in this area is highly recommended.

When you stop enabling, this does not mean that you stop loving the person. It does not even mean that you cannot help him or her.

When you stop enabling, this does not mean that you stop loving the person. It does not even mean that you cannot help him or her. There is a difference between healthy help and enabling. Healthy help involves providing information, encouragement, and coaching to your loved one. You may give your loved one contact information for doctors, counselors, lawyers, or rehabilitation programs, without feeling the need to force him or her to accept this help. You may discuss with your loved one what the possible consequences of actions might be, without feeling as if you must make sure they make the choice you want them to make. Healthy help puts your loved one in control and allows you to take a secondary role.

Enabling is essentially love turned to fear, and help turned to control. The effects of enabling are toxic to all involved. With a solid understanding of what enabling is, and what it is not, there is hope for families who are acting out this pattern. An experienced individual and/or family counselor can be a valuable source of support for anyone who is looking to break enabling patterns.

I was not far from the shore in the fickle, warm Gulf of Mexico, a place I love. I was swimming, enjoying the sun, feeling deeply at peace. I loved the smell of the water, the feel of the air. I was carefree and at ease, like a butterfly on honeysuckle.

Then I was ambushed by a whirlpool, kidnapped from my reverie. I wasn’t paying attention, and I swam right into it, caught before I knew it was there. I’m a strong swimmer, and expected to swim out of the vortex and get back to shore, but I couldn’t. Each time I made it to the edge of the circle, I was forced back by the whirlpool. Each time I thought I was making my escape, I was sucked back in. I kept trying, but I couldn’t get out. I was getting scared. What if I drowned?

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I didn’t know it then, but built into every whirlpool is a backdoor, a path to survival, but when you’re in the middle of a whirlpool you can’t see it—you need someone outside, someone standing on the shore, to see you’re in trouble, to help find the solution, to show you the path so you’ll survive.

Lucky for me, there was a lifeguard standing on the shore; I screamed to him for help and he saw what was happening. I expected him to swim to me and rescue me, carry me out of the ocean like you see in the movies. I was prepared to be grateful—but that’s not what happened at all. Instead, he waded in a bit, careful not to get caught in the whirlpool himself, and pointed at something. I was angry; why didn’t he save me? I didn’t know what he was pointing at, but he insisted that I pay attention and pointed again until I saw the path out of that swift, inexorable current.

He was showing me how to escape, how to save myself.

This is like the therapist/client relationship, like what happens when I’m helping a client. I have a different perspective on what’s happening, even if I had a similar experience sometime in the past, in my own life, but to help I will stay slightly apart, so as not to get caught in the whirlpool. I will feel for you, but I’ll keep those feelings in check. It’s almost like being in two places at once—feeling close to your experience but a bit apart, too.

Inside your own whirlpool, you just can’t see. You don’t know what’s happening. Maybe you’ll even have the feeling that you’ve been through something like this before, but you don’t know what to do about it. With relationships, for instance, the kind where you split up and make up, over and over again. Each new breakup feels like other breakups in the past—you keep on breaking up/making up with the same person, and never make it to shore.

I will stand with you but a little to the side. We’ll find your path together, but then you must swim out yourself. I’ll help, but you have to do the work.

Sometimes people get very angry about that: If I know the answer, why don’t I just tell you? If I really cared I would rescue you, right?

I remember when I was in therapy myself. I was about 30 years old, recently divorced, mother of an infant, full-time social worker, and struggling financially. I did not know how to get out. I was stuck. I could not believe how I had arrived in such a miserable place, so I started treatment. I was almost completely hopeless.

My therapist listened to me, felt for and with me, showed me some of my less healthy habits, expanded my ways of thinking, and adjusted my vision. She loved me. She did not quit on me and did not let me quit on myself, either. She did not carry me out of my misery, but she was a positive example and helper, and I emerged, eventually, with a better understanding of the world and my place in it, so I could find my path and make it to shore. You can, too.

Attention deficit hyperactivity (ADHD) is characterized by cognitive disorganization, low attention, and impaired focus. Among the many symptoms and behaviors associated with ADHD are excess energy and externalizing behavior. Research has shown that as children with ADHD mature, their symptoms often decrease.

However, some children also exhibit signs of conduct disorder and personality problems, which exacerbate and perpetuate symptoms. This combination of psychological conditions can lead to violent behavior in some individuals. But does ADHD itself cause violent behavior?

That was the question posed by Rafael A. Gonzalez of the Forensic Psychiatry Research Unit at the University of London as the subject of a recent study. Gonzalez and his colleagues wanted to determine if ADHD by itself was linked directly to violent behavior in adults. And if so, what aspects of ADHD were most influential on violence?

To answer this question, Gonzalez reviewed responses from over 7,300 adults in the general population, using the Adult Self-Report Scale for ADHD. He also asked about violence, recurrence of violence acts, level of violence, and other comorbid issues. Gonzalez found that ADHD alone was only slightly predictive of violence. More specifically, the hyperactive behavior linked with ADHD, not the inattentive aspect, was the impetus for violence.

When Gonzalez examined levels of ADHD in relation to levels of violence, he discovered that the mild and moderate symptoms of ADHD were most closely related to repeated violent perpetration. However, severe ADHD was only associated with violence in the context of comorbidity. The most common conditions that appeared to be responsible for violent behavior in the adults with severe ADHD were personality problems, anxiety, and substance abuse.

“We thereby conclude that repetitive violence among persons with severe ADHD is associated with multiple forms of coexisting psychopathology but not ADHD,” said Gonzalez. Therefore, it is imperative that people with ADHD and co-existing psychological problems address the issues that could make them more susceptible to violent behavior. Future research should address the most effective ways to accomplish this.

Reference:
González, R.A., Kallis, C., Coid, J.W. (2013). Adult attention deficit hyperactivity disorder and violence in the population of England: Does comorbidity matter? PLoS ONE 8(9): e75575. doi:10.1371/journal.pone.0075575

Trauma brings with it flashbacks of memory and strong emotions, which are often uncomfortable and difficult to cope with. Typically these symptoms are followed by the fight-or-flight response. This is natural, as instinct tells us to do everything we can to avoid pain and discomfort. Unfortunately, avoiding trauma symptoms can be detrimental instead of helpful. Resisting and avoiding trauma symptoms often brings on more intense emotions as well as increased frustration, anger, and panic.

I often use this analogy to explain why this happens: Imagine you are out in the ocean, far from shore. Giant waves are coming, very intimidating and scary. The first instinct is to fight, to swim as hard as you can back to shore. However, unless you are a physical anomaly, you only end up exhausting yourself and don’t get closer to your goal of safety. When exhausted, you are at higher risk of drowning. Thus, survival experts advise that the best thing you can do in this type of situation is to allow your body to relax to conserve energy, floating instead of fighting. This gives you a better chance of getting through the ordeal and allows time to calm yourself so you can think clearly about what to do to in order to survive.

I advise clients to do the same thing when they are experiencing trauma symptoms. On many occasions, I have seen shock and confusion on their faces when I tell them to stop fighting their symptoms and to just go with them—not making them worse, but also not fighting or avoiding. It sounds absurd, I know, to advise against fighting panic, awful memories, intense emotion, and flashbacks. After all, don’t we want relief from those symptoms? Of course we do. It is natural to want to be without pain. I ask people to take a risk and try just riding the waves of their symptoms, experiencing and observing them without feeding into them and making them worse—all the while not trying to make them better, either.

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When we try to make our symptoms better by fighting or avoiding, we are often fighting a losing battle. The body and brain are amazing. They know what they need to do to work through trauma, and we often get in the way of that process because it is uncomfortable and sometimes downright painful. Healing often involves pain. Think about a time you had an injury of some sort (a broken bone, a sunburn, a cut, or any other physical ailment). Think about the healing process and how it wasn’t always comfortable. Often there are uncomfortable or painful sensations that come as a result of the body trying to heal itself. The same is true when we have experienced a traumatic event. Our brains need the chance to process what has happened. When we fight or avoid the discomfort, not only do the symptoms last longer and become more intense, but we become frustrated because we were not successful in getting rid of the symptoms as soon as we wanted to.The good news is this: I have seen the awe on the faces of people when they allow themselves to experience and observe their symptoms, and find that it does indeed work to decrease the intensity and duration of their emotions, flashbacks, and panic. They find that their symptoms have far less power over them and they are able to increase their ability to function in their lives. This is what riding the waves is all about. The goal is to decrease the suffering in a way that is conducive to healing.

To learn to do this, I would advise that someone experiencing trauma reach out for professional help for a few reasons. First, this process can be scary, and a professional can give you the support and monitoring necessary while you are developing this technique. Also, additional coping skills are helpful and necessary when one is learning to ride the waves of their symptoms. Lastly, a professional can help you to develop a comprehensive treatment plan for trauma that will be tailored to your individual needs so you can get the best outcome possible.

The diagnosis of “borderline personality disorder” carries profound stigma for many people. Even some mental health professionals use the term pejoratively, which is not difficult considering that the diagnosis itself implies that someone’s personality is flawed. In reality, the flaw lies within the diagnosis—not to mention all the painful and agitating symptoms that come with it.

I will go into more depth about these challenges, but first a definition is in order.

What Is ‘Borderline Personality Disorder’?

People who are diagnosed with borderline personality tend to have problems with unstable self-image, moods, and relationships. They may experience suicidal thoughts, self-harming behaviors, displays of anger or irritability, and periods of intense sadness or despair called “dysphoria” (the opposite of euphoria).

To receive a diagnosis of borderline personality, a person must meet at least five of the nine characteristics below. Keep in mind while reading the list that, in order to qualify for the diagnosis, the person’s symptoms must be longstanding and inflexible, not just occasional ways of relating to life:

1. “Frantic” attempts to avoid abandonment
2. Intense and turbulent relationships, with a tendency to alternate between seeing the other person as all good or all bad
3. Unstable sense of self, which could lead to radical changes in major aspects of identity such as career, religion, or sexual orientation
4. Frequent suicidal thoughts or self-harming behaviors, such as cutting
5. Impulsive behaviors in at least two other areas, such as substance abuse or binge eating
6. Wild mood swings with extremes of anxiety, irritability, or dysphoria
7. Persistent feelings of emptiness
8. Intense anger or rage that is often close to the surface
9. Brief periods of paranoia or dissociation when under stress

I have seen more than one writer refer to borderline personality as the equivalent of emotional hemophilia: when a person with borderline personality experiences a hurt, even a small one, the emotional bleeding is profuse. The suicide rate for people with borderline personality is about 10%. Most people—up to 90%, by some estimates—with borderline experienced neglect or abuse, particularly sexual abuse, during childhood. Individuals with borderline personality commonly view themselves as inherently defective, bad, or broken.

For many years, borderline personality disorder was considered untreatable. Now, decades of research and treatments have illuminated the errors in such thinking. For one thing, we know that many people “grow out” of the disorder as they age. For another, a great many people with the diagnosis respond positively to treatments such as dialectical behavior therapy.

Stigma and Borderline Personality

All personality disorder diagnoses are controversial. The mere phrase “personality disorder” situates the problem in the person’s personality, rather than neurology or life stressors (including trauma). GoodTherapy.org’s founder, Noah Rubinstein, LMFT, has even explained why he views personality disorder diagnoses to be flawed:

“I believe that by labeling a person as personality disordered or, in its more gentle form, stating that a person has a personality disorder, we are essentially claiming one’s personality, their person-hood, their essence, is fundamentally flawed. What else are we, other than our personality? Such a diagnosis is very, if not absolutely, likely to produce more shame, worthlessness, and rejection in a person who probably has enough of it already.”

I agree with his analysis. In some ways, the situation is even worse for people diagnosed with borderline personality. Any mental health diagnosis can engender feelings of shame, or of being “fundamentally flawed.” On top of that, feelings of shame and badness are both symptoms and consequences of borderline personality. This can create a vicious cycle, as if the diagnostic label alone confirms the feelings of defectiveness that came well before the diagnosis.

Too often, some mental health professionals add to the stigma. It is well known that some clinicians have applied the label “borderline” merely because they do not see an individual improving, or the individual poses challenges such as expressing overt anger toward the therapist. For some therapists, it is easier to blame the client for treatment’s lack of success than it is to look at the clinician’s own inability to help.

Another source of stigma concerns others’ tendencies to judge the person, rather than the person’s behaviors. Some, though certainly not all, people with borderline personality may cope or express their pain in ways that hurt those around them. They may yell or even be physically violent, make unrealistic demands, display intense sadness or anger at what seems a disproportionately small provocation, or even attempt suicide or hurt themselves in ways that make another person feel manipulated.

It helps to keep in mind the fundamental, excruciating pain that often underlies borderline personality disorder. Marsha Linehan, the psychologist who created dialectical behavior therapy, compares the behaviors of people with borderline personality disorder to those of people with painful cancer who will do anything to reduce their pain. The cancer patients may cry, scream, or attempt to “manipulate” others in order to get their pain medication. But we seldom view their efforts negatively, because we understand their abject suffering. Their behaviors make sense.

So, Should the Diagnosis Be Abolished?

I agree with other critics that the label “borderline personality disorder” can compound an already painful situation for people, especially the newly diagnosed. But I also find value in the diagnosis—not the name, but the concept.

Before diagnosis, people with borderline personality often feel bewildered. They may deeply experience their internal chaos yet find that few people understand. I have worked clinically with many people who felt soothed when they learned their problems fell into a distinct category that millions of other people shared. These people felt they were no longer alone.

Once people have a name for a condition, they can more easily find information about challenges and ways to heal. They can find other likeminded people in online support groups. Also, diagnoses enable clinicians to better treat people. Clinicians can draw from a large body of research on borderline personality to identify the best treatment options for individual clients.

The diagnostic label deserves to be changed, but the construct itself should remain, as long as it is supported by continued research. Some researchers, like the psychologist Judith Herman, think that borderline personality actually is a type of posttraumatic stress, and should be reclassified as such. But the idea has not gained much momentum in the field of psychiatric diagnosis.

Changing the name, too, is a pipe dream for now. The American Psychiatric Association only months ago released its first overhaul in almost 20 years of the Diagnostic and Statistical Manual of Mental Disorders, and the group never seriously considered altering the name. That is a shame. The name of a diagnosis should describe the problem—in this case, problems regulating emotions—not the personality. Others have proposed alternate names. My preferred label is one proposed by Dr. Linehan, “Emotion Dysregulation Disorder.”

What Can We Do to Diminish the Stigma?

Use the word “borderline” appropriately. Do not use the word “borderline” as an insult. This especially applies to mental health professionals. I have worked in the mental health field for almost 20 years, and it is disheartening how many times I have heard a professional say “She is so borderline,” or “What a borderline.” Borderline is an adjective to describe a series of symptoms, not a person. And it certainly is not a noun.

Be clear that stigma is undeserved. When we discuss how stigmatizing the diagnosis of borderline personality can be, it is necessary to make clear that the stigma is unfounded. Despite appearances or assumptions, the label does not truly mean that somebody’s personality is flawed. We need not buy into the pejorative meaning.

Exercise compassion. Whether you know somebody with borderline personality or have the symptoms yourself, always keep in mind the underlying pain and anger that can drive behaviors. This is not to say that people with borderline personality are not responsible for their behaviors and cannot make changes. Rather, a compassionate stance helps diminish shame. It also emphasizes the possibility that people can learn more constructive ways to manage their emotions.

Avoid stereotypes. The diagnosis of borderline personality captures a very heterogeneous group. Only five of the nine diagnostic criteria are required for a diagnosis. Two people with the diagnosis could have only one symptom in common. In fact, there are 256 different possible symptom combinations for borderline issues, and every person who has been diagnosed with borderline personality has his or her own unique stories.

Maintain hope. As I noted above, borderline personality need not be a lifelong struggle. The symptoms of borderline personality often mellow with age. Borderline personality disorder, as a diagnosis, also has the advantage of garnering significant attention among researchers, clinicians, and grant funders. New discoveries continue to be made.

More and more, we learn about effective ways to treat people who are diagnosed with borderline personality. These gains in knowledge lead to more hope: hope for people to heal, and hope for the condition, by whatever name, to elicit less stigma and more understanding.

References:

1. American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders – 5. Washington, DC: Author.
2. Gunderson, J. G., Stout, R. L., McGlasham, T. H., Shea, T., Morey, L., Grilo, C. M., Zanarini, M. C. et al. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Archives of General Psychiatry, 68, 827 – 837.
3. Leichsenring, F., Leibling, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. The Lancet, 9759, 1 – 7.
4. Lilienfeld, S. O., & Arkowitz, H. (2012). Diagnosis of borderline personality disorder is often flawed. Scientific American. http://www.scientificamerican.com/article.cfm?id=the-truth-about-borderline
5. Linehan, M. M. (1993). Cognitive behavioral treatment for borderline personality disorder. New York: Guilford.

October is Domestic Violence Awareness Month, or a time to begin to understand the effects of domestic violence, which have been researched extensively. Domestic violence is a social problem, affecting each member of a family—including kids, even when they are not the ones directly experiencing violence or aggression. Parents under stress can create children under stress. For children, witnessing domestic violence can lead to the development of many negative behavioral traits or mental health issues. Exposure alone can be traumatic.

Children who witness violence in the home are affected in ways similar to children who experience physical abuse. These children are also at a greater risk for both internalized and externalized negative behaviors, which can manifest socially, emotionally, psychologically, and/or behaviorally. Research shows us that boys exhibit more externalizing behavior, like fighting, bullying, lying, and cheating, while girls exhibit more internalized behaviors, such as anxiety, withdrawal, and depression.

In addition to potential problem behaviors, children also may experience psychological ramifications which lead to difficulties in school and lower scores on assessments of verbal, motor, and cognitive skills. Other limitations identified are slower cognitive development, lack of conflict resolution skills, limited problem-solving skills, and even a more rigid belief in gender stereotypes and reinforcement of male privilege.

When parents are engaged in any type of dynamic of domestic violence or aggression, their children can be at an extreme disadvantage when it comes to emotional development. They may tend to show higher levels of anxiety, lower self-esteem, and increased depression and anger. Violence puts a barrier between child and parent, making it difficult for children to develop a nurturing bond with either parent, which in turn can result in extreme anxiety or worry. The children may also display extreme separation anxiety when they go to school or when the parent(s) leaves. Studies show that separation anxiety even takes a physical toll, so children may complain of ailments like stomachache or headache as reasons they cannot go to school.

Exposure to domestic violence can create in the witness a sense of shame, guilt, and self-blame, conflicting feelings about a parent, fear of abandonment, symptoms of depression, and feelings of helplessness and powerlessness. With an increase in stress levels in the home, children can begin bedwetting again, lie to avoid confrontation, and have difficulty trusting others, especially adults. Stress is known to put any immune system in jeopardy—and children are no different. Stress and violence in the home can indirectly result in a short attention span, increased somatic complaints, and frequent illness.

Many children, as a result of exposure to domestic violence, become very secretive about their families and often do not invite friends to the home. They may begin to isolate and detach from the support that they could receive from those around them. Occasionally these behaviors are also linked to developmental delays and difficulty with emotional regulation, so that children feel shame, fear, confusion, and rage, often uncontrollable.

As these children age, it has been found that they also have higher levels of adult depression and trauma symptoms. Their reaction may be to internalize these symptoms, or they may cope with their stress by utilizing drugs or alcohol, fighting rules, ditching school, or running away. When child witnesses to domestic violence start dating, their relationships could have similar negative dynamics to ones their parents or guardians demonstrated. The risk of ending up in a controlling relationship or developing control issues is higher for these individuals.

It is important to note that not all children exposed to domestic violence will experience deficits or cope poorly. Some children demonstrate enormous resiliency and find ways to manage the tension in their homes. They might develop games or withdraw in order to manage the tension. Often they internalize the conflict and it resurfaces much later in life. In my practice, I see children who are high achievers with extreme expectations of themselves, who also have many outside interests, like sports or music. Outside interests and activities keep them out of the home most of the time, and these children tell me that this limits the amount of time that they don’t feel safe and gives them some sense of control in life.

The National Coalition Against Domestic Violence (NCADV) has created a website to help individuals who are in relationships plagued by domestic violence or provide people with resources to help family members and friends who are in abusive relationships.

References:

1. Brown, B.V., and Bzostek, S. (2003) Violence in the lives of children. CrossCurrents, 1, Child Trends DataBank
2. Edelson, J.L. (2006). Emerging Responses to Children Exposed to Domestic Violence. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennslyvania Coalition Against Domestic Violence. Retrieved 0ct 3, 2013 from michbar.org/publicpolicy/pdfs/Legislators_ResponsesDV.pdf

“You’re so selfish!” I hear this phrase too frequently when working with people who have trouble with separation and individuation. When children hear from their parents that they are selfish, it is typically understood as, “You are thinking about yourself when you should be thinking about me.”

In my psychotherapy practice, I meet many adults who grew up having internalized the experience that they are selfish if they choose their own needs and desires over those of their loved ones. Many continue to deny their own wants in favor of what they believe is best for their parents. Some have transferred their worries to include other relationships and, in the extreme, may avoid feelings of selfishness by providing for everyone else’s needs rather than their own. In most cases, people who believe they are selfish believe they are bad people. This guilt interferes with the ability to develop into separate individuals who know what they want and are comfortable getting it.

The power of guilty feelings about selfishness makes it very difficult to consider that selfishness is not by definition a bad thing. Selfish implies exclusive or excessive interest in oneself. It is unfortunate that parents who use “selfish” in an accusing way tend to use the term if the child’s focus on self in any way (not exclusively or excessively) conflicts with the parent’s needs.

I am going to briefly describe two people with whom I have worked who were severely limited by their inability to individuate because of their guilt over perceived selfishness. In our work, an important goal has been to understand selfishness as exclusive or excessive and to feel emotionally entitled to prioritize one’s own needs some of the time.

“Kate” felt trapped. She came into our session looking very agitated. “I can’t take it anymore,” she said. “I told Alan and the kids I had to visit my dad on Thursday night to help him make decisions about selling his apartment. I promised I’d come for dinner. My daughter Kim has a soccer game, and Alan is mad that I’m choosing my dad. He says I neglect our family. No matter what I do, I feel so selfish. They don’t get how painful it is for me to choose my dad over them. But when my dad needs me, if I say no, I feel the most selfish. He’s so helpless and upset when I’m not there for him. I know my mom will have some ideas, but he really relies on what I think. He’ll get anxious if I don’t come and advise him about this. I tried to tell him that I needed to come on another night, but he said, ‘It has to be Thursday. I’m your father, Kate, how can you be so selfish?’ ”

I reminded Kate that she was responding to that word again: “selfish.” I asked Kate what happens to her when she thinks she is being selfish with her father. I asked, “What buttons get pushed? What is the experience of thinking that you are selfish that makes you feel so trapped and unable to say no?”

Kate responded: “I feel like such a bad person. There is so much guilt. How could I upset my father? He gets so disappointed in me. I can’t stand that I could be such a bad person. You know, when I was a kid and this kind of thing happened, he would get a little teary and walk away from me and leave the room.  I felt like I hurt him so much. In those moments I thought he would never come back. It felt like a punishment. I guess I still become that scared little kid every time he asks me for something. I have no choice but to give in to his wishes. I’m not sure I even know what my own wishes are.”

Kate had come to therapy because she was having problems in her marriage. She frequently got caught up in trying so hard to please everybody that she never seemed to express or know herself. Her husband complained that he felt like there was no one there. In our work, Kate came to realize that in early relationships with her parents, she had been so attuned to their needs and wishes that she had not developed her sense of an individual self. She was beginning to recognize that in order to protect herself from feeling like a bad person, she had unconsciously neglected the development of her own desires and feelings. This was now creating a problem in her relationship with her husband.

When childhood years do not provide the conditions for separation and individuation, the repercussions for adult relationships can be serious. In particular, anxieties about selfishness toward parents can generate intolerable feelings of shame and badness that can exert a powerful influence in adult life.

“Tess” came to therapy feeling depressed and anxious. She was 25 years old, working as a clerk in a bookstore. She felt isolated and lonely. Her main social contact was her parents. Tess looks back on her childhood with mixed feelings. On the one hand, she has fond memories of enjoying school, being close to and having fun with her friend Isabel, loving her piano lessons and practicing. At the same time, she said, “Maybe I didn’t have enough friends or should have gone to extracurricular activities in school. But I didn’t really mind. I liked being by myself, and kids were nice to me. I just didn’t talk a lot or do a lot of stuff with them.”

I asked Tess, “So what makes you seem so uncertain about whether you had a positive experience growing up?”

Tess was silent and thoughtful and then said, “I guess I thought things were pretty much OK, but my parents, especially my mom, always seemed to think I should be doing different things.”

“What do you mean?”

“Well, she was always telling me I should call other kids or join a club or invite kids over. She compared me to herself and how many friends she had. She said she was worried about me since I seemed so socially awkward. Actually, I felt OK, but I had the feeling she thought there was something wrong with me. I was right. When I was about 12, I overheard her talking to my dad. Really, she was crying, not talking. She was very worried. She called me antisocial and said I was going to have real problems. The worst part of that memory is her crying something like, ‘I feel so hurt, she’s so different from me. She doesn’t seem to care about how this makes me feel.’ I was shocked! I ran up to my room and started to cry. I felt really scared. I didn’t know I could make my mom feel so terrible. I think that was the beginning of feeling it’s not OK to be me and that I was selfish not to be the daughter she wanted. But I also felt like if I was me, they would think these terrible things about me. After that, I just tried to please them, especially my mom. But I spent so much time trying to please them, I never thought about what I wanted.”

As Tess and I continued to talk, we became aware of how she was extremely reliant on her parents for feeling good about herself and for guidance. Tess was struggling with what to do with her future. She was considering graduate school in speech therapy or education. She also talked to me about her love for poetry and how maybe she would like go back to school for writing. “My parents think I’m better off with something more practical, so they suggested speech therapy or education,” she said. “I got some information about programs, but I can’t seem to get myself organized to apply. Speech therapy is my mom’s field, and it makes her so happy to think that I would be a speech therapist. I feel so good when she is happy because she approves of what I’m doing. When I think of pursuing poetry, I feel so selfish and so guilty. I know it brings up feelings in my mother of me being so introverted and awkward and makes her so miserable. I know I rely on her too much, but I hate to give up how good it makes me feel when I make her happy. It feels less scary when I go to them, maybe because then I don’t have to feel so bad and selfish if I consider what I want. … Maybe I don’t even want to be a poet.”

Both Kate and Tess were stuck in the dynamics of their early relationships with their parents. For both, the impact of their parents’ anxieties, aggression, and judgments had made it emotionally necessary to comply with demands regarding who and how they should be. Both had parents who were narcissistic and needed their child to be attuned to and accede to their wishes and desires. Not to do so was experienced as the child’s selfishness and wounding to the parents.

Hurting a parent can feel like inflicting a wound. This can make a child feel that the parent is impaired and unable to take care of the child and/or that there will be some retaliation. Terrible shame for being so “bad” and “selfish” is experienced. Kate and Tess, in order to protect themselves from these intolerable feelings and sustain a relationship of positive regard from parents, gave up knowing what they wanted and needed. In the safety of not knowing, they never fully developed their sense of self. They are unable to be clear about what they want for themselves, and rely heavily on parents for recognition and self-esteem.

But change is possible. Through their struggles, they can succeed in letting go of seeing themselves as selfish when they have a need or desire which differs from someone they love. This will allow for the emotional freedom to know what they want, think, and need. They can become their own, unique, individual selves.

Transpersonal therapy can be a powerful framework for using the expressive arts, such as music, drama, and visual art. But many people are unfamiliar with transpersonal therapy. You may be wondering what this term means and how it relates to expressive arts processes. Here’s what you need to know about transpersonal psychology and how it connects with expressive therapies.

What Is Transpersonal Therapy?

You have probably heard of the so-called “three forces of psychology”: behavioral, psychoanalytic, and humanistic. The classic examples that come to mind are Pavlov and his dog (behavioral); Freud’s dream interpretations (psychoanalytic); and Carl Rogers’ use of “unconditional positive regard” (humanistic). These examples are the stereotype of each of these psychological orientations. In truth, most therapists these days are influenced by more than one of the “three forces.”

And now, introducing transpersonal therapy (circa 1960s)—the fourth wave of psychology. The word “transpersonal” literally means “beyond the personal”—what Ken Wilber has described as “personal plus.” That is, it includes all of the personal and individual aspects of our experience, including our thoughts, physical sensations, and emotions, but it also moves beyond this personal framework to address our spiritual experience. Naropa University’s transpersonal counseling program clarifies this by including “mystical or religious experiences, intuition, different states of consciousness, creativity, and contemplative practice.”

Transpersonal psychology is also unique in its focus on wellness rather than pathology. A key idea in transpersonal therapy is the belief that all humans, under the right circumstances, will move naturally toward a state of wellness and wholeness. The role of the therapist is to guide the individual in this move toward wholeness by acting as a facilitator and not an expert.

Expressive Arts in Transpersonal Therapy

The expressive arts and transpersonal therapy make a great team because they are both focused on exploring a wider range of possibility outside traditional talk therapy. Expressive arts therapies can include:

• Art therapy
• Movement or dance therapy
• Drama therapy or psychodrama
• Music therapy
• Sand tray therapy
• Journaling or poetry therapy

Your specific experience in doing expressive arts with a transpersonal therapist will vary depending on your own creative interests, the therapist’s background and training, and the problems for which you are seeking help. In some cases, one expressive process might blend with another. For example, you might sculpt and paint a series of masks showing the different aspects of your personality, then create a skit in which you use the masks to act out a scene. You might then also write a journal entry or poem describing your experience of producing the skit. All of these actions would be undertaken with the guidance and support of your therapist. And, of course, any creative processes that you engage within transpersonal therapy will be handled with care by your therapist. Your therapist will assist you in exploring the emotional, intellectual, and spiritual meanings that you find in these processes.

In many instances, your therapist may encourage you to engage in imaginal processes. This term refers to an ability to relate to your own artwork, music, or writing as if it is a messenger. For example, using an imaginal process with visual art might mean that after you’ve painted a dragon-like creature, your therapist will help you to create a dramatic or written dialogue in which the dragon itself is given a voice.

Another common technique in transpersonal expressive therapies is to explore archetypes, evocative symbols that are found throughout human history. Some basic archetypes include the magician, the wise old woman, the hero, and the trickster. These symbols and their relationship to your own situation can be explored with various expressive arts practices such as journaling, visual art, drama, or sand tray therapy.

While some of you might prefer a more direct approach that is planned and structured with clear homework assignments, such as cognitive behavioral therapy, others might prefer the looseness of a more organic process that lends itself to the transpersonal realm. If you are lucky, you might even find a therapist who is skilled at applying an eclectic approach, combining different therapies for a dynamic outcome.

I was getting my morning cup of coffee, and while waiting to pay I saw others hand their money to the clerk and leave. When I attempted to do the same, another clerk rudely stated to me that she was helping someone. So I waited in line, watching others who came in after me be served before me. As I walked back to my office, a wave of emotions ran through me. Initially I was fuming. Why should I have to wait when others didn’t? Is it because I’m black? Was she being discriminatory? I thought to myself.

This is a place that I frequent with regularity, even going out of my way to get my coffee there because the staff is usually very friendly. So I began to doubt myself. The clerk who was rude was a different clerk than the one who took the people’s money. Was she a new employee? Did she not know that she could just take my money? Or maybe she was just having a bad day? My mind was racing with questions.

There I was, vacillating between anger and doubt and confusion from a seemingly simple interaction. This swirl of emotions is par for the course when you’re a minority or part of an oppressed group. We encounter these thoughts and questions and anxieties and doubts about the meaning or intent of others’ actions on a regular basis.

This is not to say others are always being racist/sexist/heterosexist/fill-in-the-blank. On the contrary, many times they aren’t. But this process of questioning and wondering is what we go through on a daily basis. We have to feel, review, and process these little interactions all the time, and it is an incredible weight to carry.

“Samantha,” who works at a law firm, is often asked if she’s bringing a date to social functions. Initially her coworkers asked her occasionally, but now it seems like multiple people, including her boss, are hounding her every time there’s a function. She isn’t out as a lesbian at work and wonders why her colleagues keep asking her about her private life. Are they trying to find out if she’s gay? If they do find out, will she lose her job? Or do they just want to know her personally? Samantha doesn’t know, but the thoughts and questions are a constant presence for her.

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Whenever you are part of a minority that regularly interacts with the majority, there are additional layers of thought and emotional processing that occurs. There is so much unconscious and invisible energy that goes toward deciphering the intent and motives of others. And then there are our own emotions while we consider what, if any, action to take. As we consider our options, we also consider any possible consequences or retribution. If Samantha brings a female date to the next happy hour, will people treat her differently? Will work become uncomfortable and unpleasant? Will it affect her boss’ perception and perhaps review of her? All of this requires a significant amount of emotional and even physical energy that can be exhausting.

So what can you do about it? As overwhelming as this is, there are ways to move through it. The first step is to acknowledge the burdens that you carry. Acknowledge that there are times when being a woman or gay or Muslim or Latino (or part of any minority group) is challenging. Acknowledge that being part of a minority means constantly attempting to discern people and situations that are discriminating against you from those who are not. There are times when it is difficult, if not impossible, to determine, while at other times it can be crystal clear. Acknowledge that this continuous questioning in your mind exists.

The next important step is to manage and cope with these emotions and experiences. Find friends and family members to talk to. Determine who will be supportive and understanding of you and your experiences and talk with them. Writing is another excellent way to cope with your emotions. It allows you to express your emotions without holding them inside and gives you a much-needed release. Exercise is another great coping mechanism. It is a physical way to expel your anger, sadness, and frustration. Go for a run, speed walk around the block, or do push-ups in your office to release the emotions.

Letting go is the final and most important step. This is an acquired skill and something that takes practice. Acknowledging and coping with the challenges are useful in managing your day-to-day life. But the ability to let go of the pain, anger, and confusion allows to you be more joyful and not hold onto the painful experiences that may occur throughout your day. Some people use prayer or meditation to let go. Others can let go after they exercise and feel the release in their body. Talking to someone who understands and has similar experiences helps me to let go. I also find that practicing gratitude and appreciation for what is good in my life helps me to let go.

What works for you? How do you manage the thoughts, emotions, and anxieties that come from being a minority?

Most people enter therapy wanting something. They seek relief from debilitating symptoms. They want help making a life-changing decision. They long to heal past hurts. Couples need tools for communication. Some want better self-control. Others search for the ability to reach their potential. The list goes on.

If their therapy has the right formula of therapeutic competence, perseverance, compatibility, and good fortune, those individuals will likely reach those goals. They’ll learn what they need to learn, internalize the therapist’s message or voice, and charge into the next challenges of their life.

But many people find that therapy also provides some unexpected benefits. When they leave, they realize they’ve gotten more than they bargained for—sort of a bonus for engaging in the experience. Here are four unexpected benefits of therapy I’ve seen in my own practice:

Depth: In polite society, we’re accustomed to having mundane conversations revolving around the weather, bullet points from work, some celebrity/sports highlights, and the story we just heard on NPR or Fox News. We skip along the surface because doing so is safe and universally accepted. Therapy pushes beyond the superficial to deeper introspective questions of personal experience, historical precedents, deep feelings, and drives—a variety of topics that would never end up on a Facebook status update. When people realize talking on this level is not just interesting, but also productive and healing, they want to recreate this depth in other relationships.

Empathy: It’s kind of ironic: The majority of people come to therapy wanting to understand their own problems and why other people impact them the way they do. But once they delve into their own issues, they discover insights that help them understand their lovers, their friends, their co-workers, and their bosses on a whole new level. A light bulb goes off and they may think, “Oh, that person’s worst experience was when he was abandoned by his dad. I understand why he reacted so strongly when I bailed on our plans.” People often learn to understand the people who inhabit their lives nearly as much as they understand themselves. Or maybe they become curious and ask a few more questions, which leads to this deeper understanding.

Contagion: I can’t count the number of individuals who came to therapy to learn more about themselves and before long, their friends were interested in finding their own therapist. It happens all the time. People feel empowered and excited about growing. Their mood, attitude, and/or behavior changes, and their friends are intrigued. Occasionally, individuals in an entire friend circle will seek their own help and everyone relates on a deeper, more functional level. Fixing your friends is not a reason to seek therapy, but it sure can be rewarding when this is the outcome.

Listening: When a person spends significant time with a professional listener, that person often develops the ability to listen. They sit for many hours with someone who keeps eye contact, pays attention, and indicates reflecting or recalling past information. People in therapy know how good it feels to be on the receiving end of that kind of attention and are more likely to replicate that for their loved ones. They’ve reaped the benefits of close focused attention, had it modeled for them, and can now show it to others.

At the risk of sounding too pro-therapist, the common thread here is that therapy helps people learn to adopt some basic therapeutic characteristics. They learn to talk on a deep level, to empathize with others, to discover the thrill of self-knowledge, and to listen well. This is to be expected, as we humans often take on the characteristics of the people we spend time with, from attitudes to behaviors to communication styles.

Like I said, these are the bonuses of therapy. The main objective is helping people relieve their symptoms and underlying issues. But if they can resolve their problem while becoming better listeners and empathizers with an ability to discuss deep issues in a way that positively impacts their inner circle, what’s the problem?

Sounds like a bonus to me.

Ryan Howes, PhD, ABPP, is a clinical psychologist in Pasadena, California, the founder of National Psychotherapy Day sponsored by GoodTherapy.org, and a writer for the Psychotherapy Networker Magazine.

Why do some things spark sexual excitement for one person while those same things leave another person quite uninterested?

I frequently speak to people who are upset because they’re indulging in sexually compulsive behaviors that cause problems in their lives. (I want to emphasize these are not the same as turn-ons or fetishes that any couple might happily incorporate into love-making or sexual play. No problems there!)

Sometimes sexual feelings and behaviors become a problem because they get in the way of healthy intimacy. For example, one man secretly discovered porn on Dad’s smart phone at an early age. Now he becomes sexually aroused whenever he’s alone and picks up his smart phone. Another grew up in a rural area where he peeked into the outhouse to watch female family members urinate. Now he uses spy cams in restrooms or pays prostitutes to give “golden showers.”

Women also find themselves thinking and participating in sometimes dangerous behaviors that are sparked by early experiences that are exciting, confusing, or, more often, traumatic. For example, if a woman experiences sexual, physical, or emotional abuse as a child she may move into adulthood finding that again and again she is attracted to dangerous, high-risk sexual encounters with volatile or unavailable people.

When sex becomes a problem, it is useful to explore our arousal template, which is a mix of physiology and learning based on relational or sexual experiences. A template is a pattern or blue print of how and why individuals think or behave in habitual ways. Arousal is an automatic knee-jerk sexual reaction that is usually closely related to excitement, fear, or how we’ve been wounded.

Almost anything can become an unconscious trigger that cues us to become sexually excited or aroused. The Internet provides thousands of examples. Numerous websites feature young girls (often fully clothed) smoking cigarettes. These sites cater to men who became obsessed as adolescents with girls who smoke. Objects that are sexualized include shoes, cars, lingerie, or anything made of leather. This last example can be linked with sensation (the feel of leather against the skin) or scent.

Emotions such as rage, fear, shame, pain, loneliness, and sadness trigger some people to sexual arousal, as do physical characteristics. Most of us can relate to feeling attracted to a particular height, weight, hair color, and body shape, as in, “well, s/he is really not my type…” Or perhaps someone is, and we are “hooked”—there’s that arousal template again!

It organizes what we believe about consent, equality, respect, trust, safety, dishonesty, domination, objectification, power, and control. Arousal templates also shape what is valuable, worthwhile, thrilling, or desirable, and just as importantly, what is to be feared and avoided. It is primarily an unconscious map of how we have become wired sexually, built on preferences already determined by basic survival instincts.

Fortunately, most of us are not compelled by violent arousal templates to act out in a violent manner. Fantasy can be a delicious and enjoyable way to spice up sex with a partner or engage in self-pleasuring. Some of us, however, are overwhelmed and debilitated by the vagaries of our arousal template.

Used in conjunction with experience of different types of sexual patterns and courtship developments, the arousal template is an essential tool to help therapists gradually detail components of a client’s sexual history. Each of us possesses a unique model of sexuality, formed at least in part by incoming family messages, childhood abuse or neglect, culture, the media, and, of course, religious influences.

As we explore and better understand our childhood relational experiences and memories we get to deconstruct our arousal template with what I like to call “compassionate curiosity.” As we explore these early messages, we can recognize and gently release old patterns that no longer serve us. This is what sexual healing is all about!