By Rich Simon As therapists, many of us practice in two different worlds. In the first, we see polite, well-behaved, articulate clients with solid values. They engage fully in therapy, talk cogently about their problems, listen attentively to our responses, make reasonably good-faith efforts to follow our suggestions, and sooner or later get better. No wonder we genuinely like these people!

Casey Truffo On Doing The Work You Love And Making It Pay

Peer Supervision Groups that Work

By Eleanor Counselman

Three steps that make a difference

Q: I’d like to organize a peer supervision group, but I’ve heard their failure rate is high. What do you recommend? A: Peer supervision groups provide a welcome respite from the isolation of private practice and an informal, nonevaluative setting after years of formal supervision, particularly for young therapists. They offer valuable guidance on difficult cases and tough ethical dilemmas to therapists at any level of experience. And they’re free! However, as you note, many of them fail. In my experience, careful attention to the initial contract and the ongoing group process can make a huge difference in helping them sustain their membership and thrive. Though they’re often called peer supervision groups, it would be more accurate to call them peer consultation groups. Members don’t have direct supervisory responsibility for one another’s cases: they simply offer suggestions, which members can accept or reject. They typically have four to six members who have approximately the same level of professional experience or share a specific area of interest. Members meet on a regular, usually biweekly, basis. Group consultation, with or without a leader, offers advantages over individual consultation. It includes the possibility of multiple perspectives on the same problem and the reduction of clinicians’ shame about confusions and mistakes as they share similar stories about their struggles with difficult cases. Another benefit is peer interaction, which develops one’s professional sense of self. The hall-of-mirrors effect—seeing yourself as others see you—which is so potent in therapy groups, is a major component of the supervision group experience. Nevertheless, despite the many benefits, it’s challenging to start and maintain a consultation group, particularly if it’s a leaderless one. They can fail to thrive or suffer from “task drift,” moving them away from discussing clinical material and into a form of therapy. It can be difficult to integrate new members and maintain clarity about the group’s own process. Presenting cases in supervision in any format poses obvious risks to one’s self-esteem, and group dynamics add additional risks: issues of power, competition, exposure, and shame can lead members to drop out. It’s especially challenging to manage group dynamics in leaderless groups, as it’s usually the leader’s role to remain aware of what’s happening within the group, and without a leader in charge, shame or fear of being judged may silence members. The most successful leaderless groups seem to be those in which the group members find a balance between a focus on cognitive and emotional issues—talking about cases and about the feelings that arise when seeing clients—while consciously managing the functions that a designated leader would serve. These include protecting the group contract, setting and maintaining appropriate norms, and handling gatekeeping matters, such as bringing in new members. A crucial component of maintaining an atmosphere of group safety is regular, dependable member attendance. Without this, a group will never feel like a place to take risks. Members need to be willing to bring up concerns about irregular attendance because, just as in a therapy group, member lateness and absences can indicate issues that need exploring. Chronic irregular attendance can be demoralizing and cause a group to fail. When it comes to group safety and cohesion, Woody Allen was right: 90 percent of supervision group success is about showing up. A significant issue in any supervision group is shame and the reluctance to expose oneself. To make supervision groups feel safer, therapist David Altfeld developed a model of group consultation in which all group members simply share their emotional reactions and associations to a situation being discussed, instead of one person presenting a specific case issue and everyone else giving advice as resident “experts.” This procedure levels the playing field by not allowing members to compete for the best case analysis. It leaves room for highlighting emotional issues, countertransference reactions, and parallel process. Making everyone vulnerable in this manner avoids opportunities for excessive criticism (or its counterpart, excessive niceness) and encourages emotional sharing. Another group consultation model, developed by Irish therapist Bobby Moore, focuses only on minimal case information, such as a patient’s age, length of time in therapy, and perhaps a little demographic information. Then the presenter talks about his or her thoughts, fantasies, feelings, and associations about the patient and the therapy. Group members then share their associations. Following that, the initial presenter is invited to share any further associations. Only at this point does the presenter give the facts of the case and the clinical dilemma. Finally, the group thinks together about what’s been discussed and what it indicates about the case. For those interested in the power of the collective unconscious, this is a fascinating process to experience. To succeed, a consultation group must feel safe and useful to its members. Here are a few simple principles to follow: Clarify the group structure. The group needs to agree on the frequency and length of meetings, which is best accomplished with a predictable schedule. The group needs to agree on its task and focus: is this group for any clinical issue or just for couples, or trauma, or group therapy? How much time will the group spend on “schmoozing,” and will there be one or more than one case presented each time? What will be the presentation format? While most groups use verbal presentation, some groups are now using videoclips—which makes the discussion much livelier. Agree on membership issues. How many members will the group have, and how will new members be integrated? Once a group has formed, I believe that decisions about adding more members should be a group decision. While it may be tempting to accept a request from someone who wants to join the group, a total of six members seems to be the maximum number for each member to have enough opportunities for presentations. Attend to the group process and dynamics. While groups should build in a “schmooze” or “check-in” time, there needs to be an agreed-upon limit to the socializing, so that the group doesn’t become a therapy group or a coffee klatch. Without a leader, the members themselves must monitor the group’s procedures and raise any important issues. Some groups do this ad hoc; others schedule a regular review meeting to evaluate how things are going. Leaderless peer supervision groups can help clinicians at any stage further clinical learning and combat professional isolation. They’re likeliest to succeed when the group members have a clear working agreement, maintain regular attendance, and create an environment in which both emotional and cognitive learning occurs. Eleanor Counselman, Ed.D., is a past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts.

Women Who Cheat

By Tammy Nelson

Understanding the message of the affair

Even though our ideas about sex and sexuality have greatly advanced over the last half-century, our culture still holds a double standard about infidelity. While no one is entirely surprised by the behavior of a Bill Clinton, an Elliot Spitzer, or a Tiger Woods—men will be men, after all—we still tend to pathologize women or shame them (or both) for having affairs. In my view, far from being evidence of pathology or marital bankruptcy, a woman’s affair can be a way of expressing a desire for an entirely different self, either separate from the marriage altogether or still in it. An affair can be what I call “a can opener” for women unable to articulate for themselves why they’re unhappy in their marriages, much less empower themselves to leave or begin an honest conversation with their husbands about what they feel is wrong. In my practice, I’ve heard many women say, “I didn’t even know what I wanted until the affair was over and I realized that I really wanted to end my marriage,” or “I had no idea that I used the affair as a way to wake up our relationship.” Many infidelity treatment approaches today are based on the idea that the unfaithful spouse is a perpetrator, someone who wronged the other person. While the pain caused by infidelity can’t and shouldn’t be denied, it generally isn’t understood well enough that many women cheat because they struggle with their self-identity in their lives and lack of empowerment in their marriages. To some extent, the affair makes up for a felt lack of an adult self. Sometimes, understanding an affair as an unconscious bid for self-empowerment, relief from bad sex, or a response to a lack of choices or personal freedom is an important first step toward a fuller, more mature selfhood. Searching for the Bartered Self Sarah came to therapy with her husband, Rob, for couples therapy after he caught her cheating. Married for 10 years, he felt hurt, angry, and hopeless about the marriage. He sat across from Sarah on the couch, with his head in his hands. “I have no idea how we’re going to get past this. Sarah says she wants to work this out, but I don’t know if we can put this marriage together again after what she’s done.” Rob had read emails between Sarah and her boyfriend that explained in detail how much they were enjoying virtual sex—watching each other masturbating over a webcam—which had both shocked and devastated him. He’d thought their sex life was good, but admitted that having kids had gotten in the way of their relationship. He thought they still loved each other, and Sarah agreed. They were both unclear why the affair had happened, but said they wanted to recover their marriage, if possible. At the end of their first joint session, Sarah asked whether she could see me individually. Rob consented, so I asked if they’d be OK with an open secrets policy: what’s said in the individual session stays in the session. They agreed that whatever Sarah said could be kept private, though she could share with Rob what she wished to from our individual sessions. In our first individual session, Sarah asked if therapy could be a place where she could talk honestly about the affair. This led to a discussion of the difference between privacy and secrecy, both in her marriage and in her sessions with me. Keeping secrets in her marriage had given Sarah a sense of space—a secret place where she could grow her sexuality, dream her dreams, and keep a part of her that no one else had control over. Our first conversation revolved around how the space she’d created could be shifted from secret to private, and how she could keep a differentiated, individuated boundary around herself in her relationship. This could give her a healthy degree of separation from her husband without having to lie or be deceptive to stake out her space. I then explained to Sarah that, in my view, infidelity recovery has three phases: crisis, insight, and vision. The crisis stage occurs right after disclosure or discovery, when couples are in acute distress and their lives are in chaos. At this point, the focus of therapy isn’t on whether or not they should stay together or if there’s a future for them, but on establishing safety, addressing painful feelings, and normalizing trauma symptoms. In phase two, the insight phase, we talk about what vulnerabilities might have led to the extramarital affair. Becoming observers of the affair, we begin to tell the story of what happened. Repeating endless details of the sexual indiscretion doesn’t help, but taking a deeper look at what the unfaithful partner longed for and couldn’t find in the marriage—and so looked for outside of it—as well as finding empathy for the other, who was in the dark, can elicit a shift in how both partners see the affair and what it meant in their relationship. Phase three is the vision phase, which includes seeking a deeper understanding of the meaning of the affair and moves forward the experience and resulting lessons into a new concept of marriage and, perhaps, a new future. In this phase, partners can decide to move on separately or stay together. This is where the erotic connection will be renewed (or created) and desire can be revived. In this phase, the meaning of monogamy changes from a moralistic, blanket prohibition on outside sex to a search for deeper intimacy inside the marriage. A vision of the relationship going forward includes negotiating a new commitment. Establishing Safety During early sessions in the crisis phase of treatment, Sarah’s view of the world was shifting, and she didn’t know what she wanted. She wavered about whether she wanted to stay with Rob, wondering whether she should move on and seek genuine emotional independence alone or stay and try to be both fully herself and fully married to Rob. She wasn’t sure she could trust me to understand her and didn’t trust her husband, either, even though she herself had acted in a way that wasn’t trustworthy. Gradually, Sarah revealed that she’d felt that she had no space of her own in the marriage, literally or figuratively. Her husband had a home office, but she had no comparable space for herself. Her dependence on Rob was nearly total: he balanced the checkbook, paid the bills, earned the money, and told her when she could make ATM withdrawals. He even counted the cash in her wallet and decided how much she should spend at the hair salon. She’d never been encouraged or allowed to feel empowered and independent. As a result, she’d started rebelling against her husband like an adolescent against a too-strict father, sneaking out at night or during the day when he was at work and having clandestine sexual encounters. Sarah’s affair consisted primarily of quick liaisons in the back of her car. Her boyfriend met sexual needs not being fulfilled at home. Although the sex was quick, furtive, and secret, he gave her orgasms and oral sex and was willing to experiment in ways she found exciting. But while buoyed by the thrill and energy of this new relationship and her long-buried ability to feel pleasure—even wondering if she might be falling in love—she also felt guilty. Frightened by the growing intimacy with her lover when they were together, she began meeting him online, masturbating with him through a webcam. After Rob discovered the affair, he’d demanded Sarah’s email and voice mail passwords, which she gave him. Although this made her feel exposed, vulnerable, and humiliated, she thought her husband deserved the transparency—as the “innocent” party—and that she should be punished. All these thoughts conformed with many of society’s constructs about women who have affairs, but they reinforced her long-brewing resentment that her marriage wasn’t an equal partnership: she was the “bad child”; her husband, the aggrieved parent. At this point, I reframed the affair for Sarah in a way quite different from her own perspective (and that of many therapists). I asked whether it was possible that the infidelity was less a transgression than a move toward self-respect and self-empowerment. Could she have been seeking autonomy and individuation, as well as a more mature state of sexual development? Was she trying to find her voice, maintain a stronger sense of herself, create a personal boundary that no one could cross, and remain in her marriage? Yes, she’d betrayed her husband; this was beyond doubt, I added. And this method for finding herself was clearly not working if she wanted the marriage to survive. But perhaps she’d paradoxically tried to sabotage the marriage as a desperate attempt to develop more emotional maturity and become a more independent and grown-up wife. As we spoke, Sarah realized that, while her intentions in having the affair hadn’t been conscious, she did want to grow into a fuller woman and mature sexual adult. She admitted she thought she could bring that woman back into the marriage and into the relationship. This made one point crystal clear: she could no longer be satisfied with the marriage as it was. Gaining Awareness Having gotten a clearer portrait of Sarah’s marriage, we moved on to the insight phase of treatment. What did the affair mean about her? What did it mean about Rob? And what did it mean about their marriage? As we explored these questions, Sarah discovered quickly that the affair had far more to do with her marriage than with her husband, whom she said she loved and with whom she wanted to stay—but only if it could become a more equal partnership. When I asked what the affair told her about Rob, she said, “I felt that he wanted me to fill a certain kind of role; it wasn’t just about replaying my mother’s position. Rob liked being in charge, liked bossing me around and being a kind of father. I know why, too. He recently lost his job, and the only place he felt any power or control was at home. He was mad that they’d fired him and took it out on me. In a way, he’s always done that: when people reject him, he gets angry and controlling. But with us, the more he tried to control me, the more I wanted independence from him.” We worked in sessions to identify some key areas where she could feel more autonomy and still be in relationship with Rob. She started small, choosing their television shows, making decisions on where to go to dinner, instead of saying, “I don’t care where we go. Where do you want to go?” When Rob asked her to have sex, she told him she wasn’t ready yet, but would let him know when she was. Although Rob felt he had little or no control in these situations, he did begin to appreciate signs of the new, more adult Sarah, someone equal to him, with whom he could have a conversation and negotiate choices. He realized it was a relief that he didn’t have to do it all himself, and he actually felt less lonely in the marriage. When I asked Sarah what the affair meant about her marriage, she said, “In the affair, I felt stronger, more mature, sexier, calmer, more charming, and more alive.” We talked about whether she could integrate her sexier, more mature self into the marriage or whether the relationship was fundamentally flawed. To her, being in her marriage meant giving up a sense of personal power, while having an affair gave her a sense of independence, choice, and more control. She didn’t know how to have a grown-up relationship with her husband that encompassed safety and desire. Reenvisioning a Marriage Treatment in the third phase included helping Sarah get in touch with her fantasies and reconnect with pleasure—one of her greatest challenges in therapy. She felt guilty when she thought about her own pleasure, and had compartmentalized her needs into the affair, as something separate, wrong, and forbidden. Her fantasies and desires were something she felt shame about sharing with her husband. Bringing that sexual part of her into the marriage was the beginning of erotic recovery for her and for her marriage, but she still had to learn to connect with her desires and to communicate them to Rob. I asked her to write down some of her sexual fantasies and share what she thought the desire or longing underneath them was. For instance, if the fantasy was to have someone grab her hair and kiss her, was this spurred by a longing to be held, to be out of control, to know that she was wanted and desired, or all of the above? The goal was to normalize her sexual needs: her affair had been a breach of monogamy, not a sexual pathology. “If you could have anything you wanted, what would you ideally expect from your sex life with your husband?” Sarah answered shyly, “That he’d pursue me and we’d try new things in bed.” When I asked her if she knew what the longing underneath might be, she said, “My real longing underneath is to be totally special to him.” Sarah went on to work on a vision of a more intimate and adult sexuality. This included asking Rob to behave in ways that made her feel special and trying to make him feel special as well. By this point, she was committed to creating a mutual vision of a new monogamy with her husband, and I suggested they return for couples therapy and focus together on their erotic recovery. Several months later, Rob and Sarah are still working on an agreement for a new, monogamous marriage together. Sarah is committed to sharing her real thoughts and feelings with Rob. In this way, her adult self and her adult needs become a priority that can be talked about and negotiated in the relationship. She feels they’re now given as much importance as Rob’s needs. Rob’s commitment to Sarah is that he tries harder to share his feelings and work on creating a more emotionally intimate relationship. They both try to be conscious of the distant and disconnected roles learned in their childhoods, and focus instead on the emotional intimacy they really want from the relationship. Their new monogamy includes a focus on their erotic recovery. The affair created an erotic injury to their relationship, and Rob and Sarah continue to work on this as a goal of healing. They’ve made a commitment to sharing their fantasies and talking about what’s working in their love life. When they feel distant or dissatisfied, they want to learn to talk about it and turn toward each other instead of shutting down or turning to someone else outside the marriage. Sarah now understands that her journey to self-empowerment and freedom can happen at the same time that she’s a wife and partner. Her adult choices include staying in a mature, monogamous relationship, while creating space for working on her own self-identity. Her worth in the relationship continues to be a focus of our couples therapy. Her cheating makes sense to her now in the context of her life issues, but she has a new empathy for Rob and how it affected him. As therapists, it’s important to discern what our goal is for the women we treat in infidelity therapy. Are we helping them end an affair or end their marriage? Is it our job to remind them of their vows or simply to help them heal? By viewing women’s infidelity as a possible search for a new way of being, we can help them reenvision a fully committed relationship with greater empowerment and equality. CASE COMMENTARY By David Treadway While I admire the sensitive work Tammy Nelson did in rejuvenating Sarah and Rob’s marriage, both emotionally and erotically, I believe that zooming in too quickly to examine the root causes of an infidelity without addressing the emotional impact of the betrayal on both parties usually leads to incomplete healing. Although I say to couples that each partner is 50 percent responsible for what’s not working in a marriage, I always add that choosing to have a secret affair is 100 percent the responsibility of the unfaithful spouse. Most of the time, couples need a way of healing the fundamental breach of trust before being able to fully repair the relationship. In working with couples following a secret affair, I use a four-step model based on the treatment approach of clinical psychologist Janis Abrahms Spring: Step 1: The betrayed partners have as much time as needed to share their hurt, anger, and sense of devastation while unfaithful partners listen as nondefensively as possible without explaining or rationalizing their behavior. The therapist helps the partner who had the outside relationship to be compassionate and caring about the impact of the affair. Needless to say, this may take more than a single session. Step 2: The unfaithful partners are then taught to write a letter in which they take full responsibility for having done harm, indicating what they’ll do to ensure it won’t happen again and what concrete steps they’ll take to make amends. In addition to agreeing never again to see the other party in the affair, other ways to make amends might include giving up drinking for a year or getting rid of the boat where the affair took place. Step 3: The letter of amends is read in session, and the concrete actions that constitute an attempt at atonement are agreed upon by both partners. Step 4: Only at this point is the challenge of learning how to forgive discussed, and only if betrayed partners are ready to begin to work on it. If so, they’re coached on how to write a forgiveness letter that involves accepting the attempts at atonement and expressing a willingness to let go of a sense of injury. This all takes place with the understanding that forgiveness can’t be legislated; it has to grow over time. It’s my experience that patiently and thoroughly working through this difficult process without shaming and blaming is what allows a couple to move on to achieving a level of intimacy and trust that they typically never had before. I remember a man named Paul who’d gone on to transform his relationship with his wife after her affair and referred to their new sense of connection as his “second marriage.” In one of our last sessions, he put his arm around his wife, smiled at me conspiratorially, and said, “You know what I like best? Here I have this extraordinary woman and a brand new ‘second marriage,’ and the lawyers didn’t get a dime!” AUTHOR'S RESPONSE I agree with David Treadway’s observation that working with couples after an infidelity takes lots of finesse and that, of course, the feelings of the person who’s been deceived and betrayed need to taken into account and addressed. Like Treadway, I think Janis Spring’s “secrets policy” can be invaluable, offering helpful clinical guidelines for individual work when necessary. Since this case study was told from Sarah’s point of view, it doesn’t delve into Rob’s feelings, nor do we get to see much of the couples work. Instead, the focus is on the special issues of identity and empowerment for women who have affairs. If I’d told the fuller story of the therapy with this couple, I’d have devoted more attention to the third phase of treatment—the attempt to help them develop a new vision of their marriage, which I call the “new monogamy.” However, the most important message I hope readers take away from this case is that even after the wrenching pain of an affair, therapists still have an opportunity to help troubled couples create a new relationship with better communication, fuller intimacy, and realistic hope for a better future together. Tammy Nelson, Ph.D., M.S., a board-certified sexologist, licensed professional counselor, certified sex therapist, and Imago therapist, is the founder and executive director of the Center for Healing. She’s the author of The New Monogamy; Getting the Sex You Want; and What’s Eating You? David Treadway, Ph.D., is director of the Treadway Training Institute. He’s the author of Home Before Dark: First Year with Cancer and Intimacy, Change, and Other Therapeutic Mysteries: Stories of Clinicians and Clients.