The GoodTherapy Blog

Whether or not we believe we should talk about sex with our therapist in treatment may have something to do with what we believe therapy is for or what the expected outcome is.

Are you going to therapy for a relationship issue? For a mental disorder such as depression or anxiety? To overcome trauma? Or because you are having a difficult time adjusting to a new situation? Therapy is useful for a multitude of issues, and no, sex may not be the most significant thing affected by a particular issue, but it definitely doesn’t hurt for the therapist to ask about it, to allow for the conversation to include some open, honest discussion not just about sex but also about sexuality, to at least let the client know it is okay to bring up the topic of sex in the therapist’s office.

Pervasive in our society is the inability to talk about sex, awkwardness, and embarrassment, which in turn leave us often bereft of the coping skills required to handle sexual issues in our relationship as they come up. When we avoid talking about sex with our partners, it can lead us down the path of avoiding talking about lots of other things as well. We all know that open, honest communication is key in successful relationships, so the absence of conversation and inability to talk about sex with our partners can be like a ripple effect in the breakdown of communication in a relationship. And when we go to therapy and our therapist also doesn’t feel comfortable talking about sex, the therapist in turn perpetuates what society has taught us—that sex is too taboo to talk about. This may be okay for some, but not for all. Some people want a more comprehensive experience. Some people want more than just a quick fix for their problems. Some people want to address the problems at their root. Some people want real change and real growth.

In treating relationships, sex must be addressed. Sex is not always everything, but in relationships it is definitely something. Most therapists treat some aspect of relationships. Even when an individual comes in for treatment for depression, anxiety, trauma, a new life situation, etc., if the person in therapy is involved in a relationship, or is dating, or even if they are single and celibate, a few questions encouraging open, honest communication about any concerns he/she has about sex can make all the difference in the world. Therapy should be a nonjudgmental safe haven where an individual can work stuff out, ask questions, and find answers. An avoidant therapist who is uncomfortable talking about sex sends a subtle message that can perpetuate feelings of shame, guilt, or embarrassment about sex, which in the end thwarts growth. Therapy should promote growth, not thwart it. In couples therapy, it is absolutely pertinent to ask about sex.

Feelings about our sexuality and our bodies are core in our lives. Many people walk around feeling bad about their desires or fantasies. Shame and guilt about sex are extremely common, and people have very little awareness of this. If a self-loathing, self-hating, guilt-ridden client comes to therapy, is it not best to address where the feelings come from? A client may not be that aware of the root of the problems. It is important for the therapist to open the door for exploration and discussion.

Therapists do not even have to be especially knowledgeable about sex. In fact, therapists rarely know anything about what the client has experienced, in terms of sex or any other aspects of the person’s life. Therapists are trained to ask questions in order to understand the client’s experience. The client is the expert on his or her experience. A therapist’s job is to ask questions and provide a nonjudgmental environment to foster the client’s growth. In looking at it from this model, therapists do not need to be well-versed in something to be open about it.

Therapy is a holistic health treatment that is helpful in guiding people to lead happier, healthier, genuine, and more honest lives all the way around. In therapy we attempt to break down the road blocks that prevent us from moving forward on our life journey, whether it be in our relationships at work or with our friends, family, or partner. Many psychological issues have a physical manifestation. It is important to remember that a sexual issue may be a representation of something bigger, stemming from depression, anxiety, or a relationship problem. We cannot treat problems in a vacuum. Mind and body are connected. When you leave sex out of treatment, the client’s journey remains incomplete.

Multiracial Hands Making a Circle A dear friend was telling me the other day about a bumper sticker that had symbols of some of the world’s religions and writing that said “coexist.” What a shame that as we approach the start of the Easter/Passover season, in which many of the world’s believers participate, people are far from accepting the right of others to worship as they see fit without judgment or condemnation. Why is it that many people feel that their religion is the one true way to believe in and connect to God?

I can only speculate from my perspective as psychotherapist and Yoruba/Lucumi priest. Here are some random guesses.

This attitude is a hedge against feeling inferior or less than. If someone follows the “superior” faith, then that means that they are superior and everyone else is beneath them.
It is a means of wielding control or having power over others. In other words, only the truly enlightened are capable of ruling, decision-making, or governing. This entitles them to natural resources, land, livestock, workers and so on.
It satisfies a sense of entitlement—to more wealth, power, prestige, position, material things, and opportunity. In reality, a sense of entitlement is just a defense against feeling shame, unworthiness, and powerlessness.
It is a way of fighting fear—of annihilation, conquest, enslavement.
It represents an urgent demand for respect and reverence. However, in reality, one cannot demand respect; it must be earned. And reverence should be reserved for the divine.
It justifies conquest and oppression of others—nations, individuals, a particular gender (in most cases, women).
It serves as a substitute for good parenting and can be used to threaten children with punishment on a divine level if they don’t behave.
It is a statement that people feel threatened by anyone who is different than themselves. Perhaps that goes back to instinct—the hardwired flight or fight response.

So what can we as individuals do to combat this worldwide pathologic response of religious fundamentalists who are ironically supposed to have a love of God and God’s children?

For one, we can be aware of our own biases and judgments. This can be a challenge, especially in extremist situations, such as in some parts of the world where women are treated so badly. We can try to all be New Yorkers as described on a New York City subway poster: NYC: where we accept your personal beliefs; where we are judgmental about your shoes. (That’s a joke.)
We can challenge others who claim religious moral superiority when we are in their company, pointing out the weaknesses of their positions (of course, only if it is safe to do so).
We can support individuals, groups, and others who promote tolerance and acceptance of religious differences (and other differences).
By the same token, we can boycott, whenever possible, those who/that promote intolerance. This statement is ironic in view of a recent news item I heard about the Christian right wanting people to boycott Starbucks, which was supporting acceptance of choice in relationships. (Asking New Yorkers to boycott Starbucks is totally unrealistic, I might add.) Probably goes for other parts of the country as well.

I’m sure my readers will have something to say about what I have written in this article. Please feel free to offer your own list of examples of reasons why it is so hard for many to coexist and what solutions are possible.

And if you’re a practitioner, have a joyful Easter-Passover holiday.

Making a diagnosis of generalized anxiety is sometime a tricky proposition. Anxiety has many manifestations as well as many underlying causes. Anxiety may be chronic and always at the edge of a person’s consciousness or the condition may flare up in acute episodes called panic attacks. Appropriate treatment is essential and typically involves a mix of cognitive-behavioral therapy, pharmaceuticals, and careful follow-up by the treating physician. Xanax (alprazolam) is currently one of the preferred medications for dealing with many anxiety-related psychological illnesses. Anxiety should not be ignored, as the effects of nervous tension and fear include a decrease in quality of life, along with possible secondary effects such as high blood pressure.

Researchers in the Netherlands recently tested a model for understanding the nature of anxiety in humans. At the same time, the experiment highlighted the effectiveness of certain medications at reducing some aspects of anxiety. Specifically, these researchers used the startling effects of white noise and electric shocks to induce surprise or fear in the subjects. In addition to Xanax, subjects were given Lyrica (pregabalin), diphenhydramine (a common sedative ingredient in over-the-counter cold remedies), or placebo. Individual anxiety levels were measured through subjective reporting and a number of objective tests, including eye movements, pupil dilation, and skin conductance. The design of the experiment included random shocks and noises, both with and without prior warning.

As expected, shocking events preceded by a warning produced less anxiety than those that came by surprise. Both Xanax and diphenhydramine reduced overall levels of anxiety but for very different reasons. Whereas Xanax works by altering certain neurotransmitter levels, diphenhydramine has a more general, systemic effect. Surprisingly, subjects given Lyrica showed very little modulation of their anxiety levels. Researchers surmised that because Lyrica takes longer (up to 6 hours) to reach peak effectiveness, the experiment wasn’t capturing an accurate picture of events.

This experiment confirmed that Xanax is effective at reducing one manifestation of anxiety: the so-called “fear-potentiated startle response.” However, the results were less informative about anxiety in general than the researchers had hoped. The sample size was too small to uncover any new revelations about the nature of human anxiety. Ideally, research will one day make the work of quickly and accurately diagnosing anxiety disorders much easier and more straightforward.

References
Baas, J., Mol, N., Kenemans, J. L., Prinssen, E. P., Niklson, I., Xia-Chen, C., et al. (2009). Validating a human model for anxiety using startle potentiated by cue and context: the effects of alprazolam, pregabalin and diphenhydramine. Psychopharmacology, 205, 73-84.

Abstract art Grief arises as a product of a loss that we have experienced. It is associated with losses that may include a person’s health, job, relationship, pet, or loved one. We may not be able to describe the roller coaster of emotions, yet we do know that we are not ourselves. When we feel out of sorts, sensations surface such as low self-esteem, illness, depression, and confusion, which can manifest into thoughts that our feelings are out of our control. As a result, this full-body experience may be difficult to process or verbalize. To mend this sorrow, the expressive arts can create a doorway to the unspeakable by opening all channels to the grieving body.

[fat_widget_grief_right]

Opening Up to Grief

Expressive arts therapy encourages movement of the imagination that we may struggle with during our grieving process. Our art influences how we look at, unblock, wrestle with, and shed light on the need to distance and detach from our pain. When we dodge grief to avoid, deny, or block the inevitable pain, the arts invite the imagination of these stuck places to come to the surface in images, movement, color, and sound. Our art process releases the tension of grief, allowing it to expand and contract, while providing a safe container in which this process can take place. When we create, we give ourselves permission to examine all that is happening within our grieving bodies.

“Art shows how the difficulty can contain its cure if channeled into life-affirming expression.”
-Shaun NcNiff

Understanding the Experience of Grief

There are five to seven stages often associated with the grieving process. They may be experienced as denial, pain, anger, bargaining, depression, upward turn, reconstruction, and acceptance. The experience can feel like a roller coaster ride of ups and downs, mood swings, and erratic behavior. When we drop in to our art-making, the grief is given containment—a place to be held. This containment permits the pain to speak and encourages our healing. Making sense of what is happening comes to light. We may notice this in a color that strikes a mood, or a picture that recalls a memory, or an emotion to be felt. It is an opportunity for the most vulnerable parts of a grieving body to speak, feel safe, be heard, and be externalized. Once the art is created, we can then dialogue with it further and support our need to metabolize all that is going on within us.

“The reward for attention is always healing.”
-Julia Cameron

Facing Grief and Piecing Life Together

Fragments of memories, like bits of broken glass, can be difficult to hold emotionally around anniversary dates, picture books, and mementos. They can feel like a jab to the heart, invite an unwanted memory, or open a floodgate of emotion. These fragments seek meaning and solace, yet can wander in and out, tugging and vying for attention at awkward moments. As we seek to piece our lives together after a loss, the expressive arts can heal us by giving these bits and pieces the attention they deserve and need. For a moment, we can sink into ourselves and allow our memories, thoughts, and feelings—those we desperately struggle with—an opportunity to speak, to be heard, and to be felt. Each time that we engage the process using the arts, we give ourselves a break, a breath, and a reprieve from the pain that seeks expression beyond talk therapy.

References:

Cameron, J. (1992). The Artist’s Way. New York: Tarcher/Putnam Publishing.
McNiff, S. (2004). Art Heals. Boston, MA: Shambhala Publications.

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

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

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

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

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

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

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

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

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

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

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

Here are her explanations of each category:

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

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

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

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

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

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

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

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

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

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

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

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

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

“This is a healing. I haven’t allowed myself to heal. I didn’t understand it. I mean I heard what people said when they said this, but I didn’t understand it – until now.”
– Independent filmmaker

At significant moments in sessions, we pay attention to the nuances of our client’s experiential process as it is conveyed through their verbal and nonverbal communication; and we rely on our own experiential process for our vital clinical intuition. We listen through these levels to grasp what our client is experiencing. It is inconceivable to consider the practice of psychotherapy without paying careful attention to experiential process.

But what is meant by experiential process? Are there different levels of experiential process? What does it mean when we say that someone is “too much in their head” or, for that matter, too much in their feelings? What makes one type of psychotherapy really experiential and another less so? Does experiential process have its own natural properties? If such properties exist, how can we know them? These are philosophical and theoretical questions of great value to clinicians.

This article is the first of a series introducing you to Eugene Gendlin’s philosophy of experiencing, its theoretical principles, and its clinical applications. As a philosopher and phenomenologist, Gendlin makes a rare contribution to our work because he addresses ontological questions about the nature of experiencing itself. While a growing number of clinicians, from different schools of psychotherapy, know the clinical value of his experiential focusing method, the philosophy itself is less well known. Ahead of its time, it can now be seen as providing an intellectual holding environment for some of the latest developments in intersubjectivity theory, self-psychology, trauma work, and what is now called the philosophy of the implicit.

My plan in this introduction is to give a brief background to Gendlin’s thought and then to show you how his conceptualization of the natural “laws” of experiential process have direct application to our work with clients.

Gendlin is a philosopher who collaborated with Carl Rogers when they met in 1952 at the University of Chicago. Gendlin’s first major work, Experiencing and the Creation of Meaning (1962), introduced the experiential dimension, and he went on to say that, based on his research (see below, re: The Experiencing Scale), client-centered therapy was not enough. Rogers acknowledged this, citing Gendlin’s contributions to his own article called “On a process conception of psychotherapy” (Rogers, 1958, p. 142). Gendlin went beyond the person-centered approach to describe his view of experiencing in what now is called the implicit dimension of meaning and “implicit knowing.”

Gendlin and his collaborators discovered that clients who showed no progress in therapy didn’t seem to have a capacity to “refer inward” in a particular way. Gendlin designed a way to capture and teach this natural process to anyone interested in working with their inner experiencing. In order to test the validity of the focusing method, Gendlin and Hendricks developed The Experiencing Scale, a statistically reliable method of measuring levels of experiencing. In the last 20 years, experiential focusing has been cited as an excellent example of a microunit of naturally occurring human change process (Patterns of Change), that can be worked with across most approaches to psychotherapy.

Consider this: You have within you—“beneath” your everyday practical use of language—another dimension, an inner language, that is an imagistic dialogue between you and your immediate experiencing. It is you speaking to yourself (and listening to yourself) in your own code. Gendlin calls it the “zigzag” between the everyday use of language and the way we may actually hold our experiencing in a “bodily felt” way.

We start the process when some situation in our lives—something we “find ourselves in”—feels stuck or painful. The problem beckons to us in a bodily way. We want to move into the place where meanings can reconstellate. To touch into this realm, we sit quietly, eyes lowered, with attention inside. We let form how exactly the situation touches us, how it is meaningful to us, but in an implicit way, not in words. You might say that It finds a way to let itself develop explicitly.

By staying still yet alert, our inner sensing seems to order itself; bodily felt senses (to be defined in the next article) carry within them a palpable sense of significance. As we let them come to us (we cannot in fact go after them!) they prioritize themselves. In a way, they tell us what we need to be attending to. As we hold them in our awareness, we let our words speak directly from our immediate sense of them. And, as this happens, something starts to happen, however subtle. Something starts to dawn on us. Our usual way of holding a situation starts to open—but it’s not only the situation. It is the way we “hold” the situation. We notice a palpable change. This was a good moment in a good therapy session.

If the above description seems familiar to you, that is probably because you have access to your own creative process; you refer to it without needing to know how it might work. The process has its own palpable efficacy. If you are taken by the process, Gendlin’s philosophy in action, you might over time find yourself “living the practice.”

Gendlin’s worldview has helped me to sit with the pauses, stuck places, and moments of uncertainty that are intrinsic to life, including to my life’s work as a psychotherapist. His view of the human universe lends a beauty to the process of meaning making, helping our clients and ourselves stay alive to the creative process that makes good therapy.

This first attempt to describe the microprocess of experiencing will be refined in further articles. In my next article, I will use clinical examples to demonstrate Gendlin’s principles so that you can see them in action.

References:
1. Depestle, F. (2007). The Primary bibliography of Eugene T. Gendlin. Retrieved March 3, 2012, from http://www.focusing.org/gendlin/gol_primary_bibliography.htm
2. Gendlin, E. T. (1962). Experiencing and the creation of meaning: A philosophical and psychological approach to the subjective. New York: Free Press of Glencoe. Second Edition, Evanston IL: Northwestern University, 1997.
3. Rice, L. N., & Greenberg, L. S. (1984). Patterns of change, intensive analysis of psychotherapy process. New York: Guilford Press, 213-248.
4. Rogers, C. R. (1958). A process conception of psychotherapy. The American Psychologist, 13, 142-149. Also in: Rogers, C. R. (1961). On Becoming a person: A psychotherapist’s view of psychotherapy. Boston: Houghton-Mifflin, 125-159.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Feb 14 Rosenquist image Wonderful Immagination Did you know that your imagination is a powerful tool for positive change? Or that, without your intentional guidance, it can be your greatest enemy? Many people neglect their imagination, allowing outside influences to guide and direct this powerful engine and then wonder why their lives are less than satisfying. Your imagination is yours to develop as you will, but ignored and neglected it can become a liability—the very source of depression, anxiety, interpersonal problems, and unconscious self-sabotage. Unless you take the initiative to choose your goals and begin to exercise discretion in what messages you allow your brain to receive and process, all the forces of marketing that bombard us on a daily basis—television, email, pop–ups, and Facebook—will shape your choices (and therefore your destiny) without your input, and often without your awareness.

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

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

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

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

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

Epicteus Happiness

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

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

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

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

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

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

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

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

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

References

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

Couples seek therapy to achieve better communication, increase trust, and enhance intimacy, among other reasons. Surprisingly, almost half of couples who enter relationship therapy do so with the goal of determining if the relationship is viable enough to continue. Although there is much research examining how therapy goals influence outcome, little attention has been given to the relationship between viability goals and outcome in couples therapy. To this end, Jesse Owen of the Department of Educational and Counseling Psychology at the University of Louisville led a study that looked specifically at how treatment goals expressed at the beginning of therapy affected eventual outcome with regards to maintaining the relationship.

Using data collected from 249 couples treated by various therapists, Owen looked at goals of improving the relationship compared to goals of clarifying the relationship’s viability. Owen examined intake paperwork to determine goals and discovered that the partners who had a goal of improvement had better outcomes than those who sought clarification. Specifically, couples who entered therapy to find ways to improve the existing relationship were nearly 80% more likely to be together six months after treatment than the couples who entered therapy wanting to know if they should separate or not. More than half of the couples who wanted clarification at the beginning of therapy had split up six months later.

Owen believes that these results underscore the impact of goal assessment, both for the couple and individual, at the beginning of treatment. Additionally, Owen emphasizes that the clinician has a significant influence on outcome, noting that even when a couple’s primary goal is clarification, they may consider other options as a result of the clinician’s hope and encouragement. The re-evaluation of goals throughout treatment is essential to achieve a positive outcome, even if that outcome is dissolution of the relationship. “The complex intersection of varied hopes, goals, and expectations, occurring often within an emotionally charged atmosphere, requires that clinicians ‘dance’ simultaneously with different partners.” Owen added, “Determining and tracking goals from the outset appears likely to help ensure that the therapist does not step on too many feet too often.”

Reference:
Owen, J., Duncan, B., Anker, M., Sparks, J. (2012, February 13). Initial Relationship Goal and Couple Therapy Outcomes at Post and Six-Month Follow-Up. Journal of Family Psychology. Advance online publication. doi: 10.1037/a0026998

Gtimage0214125 There are many different paths one can take to healing through Expressive Arts Therapy. Let’s begin by looking at a major component of this process, which is allowing the creative process to begin.

Releasing the Creative Spirit
Our healing journey is made possible by opening to our creative process. We invite flow again. We say, “Ah there you are, I’ve missed you.” When flow is permitted, we open a channel to buried treasures just beneath the surface of our unconscious yearning. We wonder why we waited so long to let go to our creative spirit. Perhaps we were bound by obligations, commitments, stress, and mundane efforts to keep our status quo. Whatever the reason, we find some comfort in releasing to our creative process again. Not all releasing requires that you pick up a paint brush, write a poem, or perform a yoga pose. And process isn’t just for painters, dancers, or musicians; it is blessed upon everyone in unique and interesting ways. I often find wandering in a gourmet kitchen store or letting my mind relax while sipping tea on a park bench to be useful when in need of some flow. You may prefer a brisk walk, baking a cake, or perusing a secondhand store as adequate letting-go activities. It is the releasing to yourself that is beneficial. It is the simple act of saying, “I matter enough” to allow myself this moment of time to release to what wants to come through me. Find what works for you, and don’t be afraid to try something new. There are jewels awaiting you when releasing to the unknown.

Decentering
We instantly know the feeling of decentering when we’ve hit it. It may come across as a silly fit of giggling or a playful rousing of exuberant combustive energy while forgetting the worries of the day. Decentering lies at the heart of Expressive Arts Therapy. It is letting go to the “imaginal reality through play, art-making or ritual” (Knill, 2005). It’s as if time has passed and we have forgotten, at least for a moment, the demands of the day and have awakened to the essence of ourselves by dropping into our senses. It is here that we notice and say to ourselves, “I’ve forgotten you.” Here, we release our creative spirit, welcome ourselves back home, and find missing parts of ourselves again. We get there not by way of doing, tasking, or driving, but by way of letting go to our deepest self—the playful unconditional child. We step away from ourselves as we know ourselves to be—lawyer, chef, accountant, candlestick maker—and release to the part of ourselves that doesn’t know, doesn’t plan, and doesn’t perceive what is going to happen next. This is the essence of decentering. Here, Expressive Arts Therapy may act as a vessel, assisting in bridging the gap between this tension of restriction and the releasing to flow.

Aligning With the Soul
Once we have been able to decenter from the outside work and into ourselves, the opportunity arises to align with the soul—the spiritual or nonmaterial aspect of ourselves. This alignment breathes new life into our expression by recalling a weightless way of being that we may have been missing. When we align with the soul, we say, “I remember you.” The lost part of our true being settles in to the wanting, needing, and arising of forgotten passions that our soul has longed for. Here, utilizing expressive arts, we might play with wild abandon, release to dance, stomp our feet, shake a tambourine, and howl at the moon. We remember our essence and it feels good. Whirling about, we thrust into our forgotten freedom and free our soul to experience again. We drop our roles, egos, and worries and rest into the place that we know satisfies us the most. When we allow this to happen, new information arises that we were not privy to before. Our insatiable longing is satisfied for a moment. At last, we have come home again.

Integration
Integration is a gathering and trying on of the bits and pieces we discover as we align with the soul. We have an opportunity to reflect, bring together, reinvent, and make ourselves new again. We can discard worn out habits, shed old beliefs, and remove residual roles of the past. We embark on meaning-making and try on this new information. Reflecting, we might take moments to journal our thoughts and ask ourselves, “What just happened—what does this mean?” Here, our process becomes one of answers and questions. Like trying on new shoes, we wonder, how does this fit?

Whether it is an instant “aha” or a deep look at a lifestyle change, we ponder the new information and attempt to assimilate it through our senses. Although not an expressive arts requirement, we might create a collage of images to bring together a clearer picture, write a lyric to express our feelings, or choreograph a narrative dance piece. Whatever comes to us, this is where we try on “Is this me; am I you?” The ego and spirit join hands and ultimately decide the usefulness of the new information. This process, throughout our lifetime, returns again and again.

Reference
Knill, P., Levine, E. G., Levine, S. K. (2005). Principles and Practice of Expressive Arts Therapy: Toward a Therapeutic Aesthetics. London, UK: Jessica Kingsley Publishers.