By Rich Simon I’m only just now coming down into the real world from post-Symposium euphoria—a powerful, but mostly benign, emotional disorder that temporarily interferes with logical thought that reaches epidemic proportions in our offices after our annual conference each spring. But, as I recapture some of my cognitive facilities, it does occur to me that for many of us, coming to a vitalizing communal experience like the Networker Symposium induces a pronounced state of altered consciousness. Read more …
With this webcast session we ask ourselves how do we recognize, and share with our clients, the “Wisdom” we have gained. Join Ron Siegel as we discuss how to lay the groundwork of transformation to activate our overall awareness.
Learn how to bring freshness and novelty to your life and practice by moving beyond habitual patterns. Join Eugene Gendlin as he shows how to use our “Felt Sense.”
Today we’re becoming even more disconnected from one another. Join Tara Brach as she takes us through practices that can help you and your client move beyond the individual identity toward the fuller realization that we are all part of a larger whole.
Discover how writing fiction can evoke a personal narrative from clients, which lays at the heart of the therapeutic process. Join Irvin Yalom as he explores the meaning of authenticity in psychotherapy and art and how that wisdom can enhance your own authenticity with clients.
Do you or your client want to lead lives that are more joyous, connected, and empowered? Join Mary Pipher as she helps therapists discover how to face challenges and open up to the wider world without being overwhelmed.
Do you or your client need insight into the process of choice and judgement? Join Daniel Kahneman as he provides groundbreaking insight and helps therapists recognize the role of systematic biases in human cognition.
After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email firstname.lastname@example.org.
By Rich Simon Last November, we put together a webcast series on clinical wisdom, featuring what we considered to be some of the wisest people in the fields of psychology and psychotherapy. Those interviewed included a Nobel laureate, a renowned Buddhist teacher and therapist, a revered pioneer in mind-body psychotherapy, a famous therapist– Read more …
Q: One of my European colleagues is excited about “mentalization” and Mentalization-Based Treatment. What is it?
A: Mentalization refers to the mind’s innate capacity to make sense of social experiences and implicitly know how to respond to them. Think about the following examples. You arrive home and say, “Hi” as you open the door. Your partner says, “Hi” back. Without a second thought, you’re aware of the tension in his voice that suggests he’s had a hard day. Or after a meeting with an old friend, you experience an uneasy feeling. Reflecting on your time together, you realize that you’re feeling bad because your friend takes a superior attitude with you.
Mentalization enables us to understand the intention or purpose behind other people’s behavior from their tone of voice, facial expression, and body posture. Therefore, when someone comes toward us wearing a grimace and hunched shoulders, we “get” that he or she is upset and perhaps angry. We instinctively recognize that mental states—thoughts, feelings, beliefs, or attitudes—underlie almost all behaviors.
This concept was introduced into the clinical literature by Peter Fonagy of the Anna Freud Centre in London in the 1990s. In a series of papers, including “Thinking about Thinking” in 1991 and “Playing with Reality” with Mary Target in 1996, he explored the theory of mind’s central role in the development of a sense of self. Drawing on clinical studies of borderline personality disorder and violent behavior, he argued that the failure to read and get the implicit meaning of another’s actions led to the loss of impulse control, an unstable sense of self, and problematic relationships. In the last 20 years, the mentalization model of mind has gone from being an obscure aspect of Attachment Theory to the centerpiece of Mentalization-Based Treatment (MBT) for borderline personality disorder. It’s now being integrated into treatments for addiction, trauma, eating disorders, and other conditions. But how does it work?
While mentalization fosters an empathic awareness of the moods and mindsets of others, it also enables us to know what our own states of mind and body mean. Our brain–minds assemble information about the state of our body, the input of our senses, and our associative memories to grasp our own intentionality. We mentalize explicitly by reflecting on experiences, conscious narratives, and empathic communication with others. Our “social brains” have evolved over the eons to become highly specialized in “reading” others’ minds, and our own. Menninger Clinic psychologist and mentalization expert Jon Allen and colleagues believe that mentalization is at the heart of emotional and social intelligence, and is central to all interpersonal experience.
Fonagy asserts that mentalization represents the epitome of human cognitive evolution and is the foundation of all effective psychotherapy. In fact, research has shown that when people lose their ability to mentalize their experience—usually in the context of high affect and threats to emotional security—they have a hard time making sense of other people’s behavior and their own. They become reactive, impulsive, and self-centered, and lack perspective.
Fonagy’s early work examined the development of borderline personality disorder. He found that people who became borderline had fragile mentalizing capacities and were vulnerable to breakdown in close interpersonal situations. The research also revealed that these people had often grown up in families that inhibited mentalization skills. In abusive families, for instance, high levels of frightening feelings overwhelm and shut down children’s capacity to think about what’s happening. In addition, children may avoid reflecting on their parents’ intentions, since it could be terrifying to understand their confusing and, at times, hateful feelings toward them.
These findings dovetail with similar data generated by the Adult Attachment Interview, developed by psychological researcher Mary Main. She found that individuals who are able to reflect on their relationships with their parents with perspective and understanding were likelier to be secure in their attachments to others and have securely attached children.
Rather than being an entirely new form of treatment, mentalization-based therapy contributes to our understanding of what happens in many different approaches. Fonagy argues that achieving more stable and robust mentalization constitutes success in most treatments because it enables people to regulate their own moods more effectively and think coherently about themselves and what they want. By focusing on mentalization as a skill, therapists help clients understand more of the connection between how they feel, what they want, and how they act by themselves or with others.
Mentalization encourages a nonjudgmental attitude of curiosity, inquisitiveness, and open-mindedness toward the client’s subjectivity. Rather than assuming a role of expert, the therapist adopts a “not-knowing” stance, founded in the belief that we come to know what it’s like for another by inquiry, not by assumptions or formulations or by explaining clients to themselves. It’s a here-and-now, process-oriented approach. The therapist encourages the client to think about his or her experience, the goal being to learn to “think about feeling, and feel about thinking.” The therapist guides the client to step back and take perspective on their experience together in therapy: “Yes, that’s one possible meaning; what are others?” “How do you imagine it looks from my point of view?” He or she listens to the client’s narrative and seeks to explore the aspects that are being neglected.
Some critics have wondered what’s gained in using the term mentalization as opposed to empathy, psychological mindedness or affect awareness. Some find Daniel Siegel’s idea of mindsight a friendlier term referring to many of the same functions. But in my own practice, a focus on mentalization has deepened my understanding of the balance between affect and cognition and the need to integrate these aspects of experience. Of course, we all know, theoretically, that the therapeutic connection is at the heart of all good therapy, but understanding the moment-to-moment processes of mentalization can deepen a therapist’s understanding of just how shifts in the relationship can lead to lasting therapeutic change.
Steven Krugman, Ph.D., is a psychotherapist in Boston. He teaches about Attachment Theory and interpersonal neuroscience, and is on the faculty of the Psychoanalytic Family and Couples Institute of New England. Contact: email@example.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org.
By Barry McCarthy
Recovery from an extramarital affair asks a lot of partners. They must not only process painful feelings, repair the rupture of trust, and share their deepest vulnerabilities, but also take steps to build a new, resilient bond, both emotionally and sexually. Allocating the right amount of time to deal with the affair and determining when partners are ready to focus on the present and future marital bond is a struggle for both clinicians and couples.
Cheryl and Justin, a couple in their mid-thirties, were both demoralized and alienated when they arrived in my office. Two years earlier, Cheryl had discovered that her husband of nine years had been spending some $700 a month on Internet sex sites, massage parlors, strip clubs, and prostitutes. When she’d furiously confronted him, he’d refused to admit that his behavior constituted an extramarital affair, dismissing it as normal male fooling around. Cheryl had considered leaving the marriage, but she didn’t want her son and daughter to suffer the same pain, loss, and family fracturing she’d experienced as a result of her mother’s three divorces.Cheryl and Justin had received lots of conflicting advice from family and friends during the past two years. Some thought they should end the marriage and get a lawyer, while others encouraged them to see a pastoral counselor or marriage therapist. A friend of Cheryl’s even recommended that she forgive her husband in exchange for $5,000 worth of jewelry.
As their mutual bitterness escalated, the couple’s sex life ground to a halt. Cheryl accused Justin of being an irresponsible sex addict who was bankrupting the family, and Justin shot back that she was acting like the sex police. For two years, they remained stuck in mutual recrimination, unable to decide how to move forward. Finally, Cheryl’s older brother, an accountant, confronted them with the reality that they were spending more money on counselors, computer surveillance equipment, and a private detective than Justin had spent on all the sex sites, clubs, and prostitutes. Shocked by this realization, the couple accepted the brother’s suggestion that they see a clinician who specialized in marriage, sexuality, and extramarital affairs.
My approach to affairs is heavily influenced by the work of clinician–researchers Douglas Snyder, Donald Baucom, and Kristina Coop Gordon, who advocate that partners go through a three-phase process: (1) focus on self-care, slow down the process, and do no harm to each other; (2) make personal and relational meaning of the affair; and (3) decide to either recommit to the marriage or achieve a “good divorce.” In my work, I emphasize an additional phase: sexual recovery from the extramarital affair. Few theoretical and clinical models include this vital aspect of treatment.
Justin and Cheryl came in for a four-session assessment that included an initial couples session, an individual session focusing on each partner’s psychological, relational, and sexual history, and a couple feedback session with a recommended therapeutic plan. Not surprisingly, our initial session was difficult, since both were still trapped in a blame/counterblame cycle. Cheryl fluctuated between raging at Justin—calling him a jerk who was destroying her life and family—and begging him to love her and be a trusted partner. Justin barely looked at Cheryl, at one point muttering, “This is useless.” It was hard sitting with their pain, but such raw suffering is frequently part of the initial couple session.
The subsequent individual sessions were more productive. In listening to Justin’s story, it was clear that he brought a number of strengths to the marriage: he loved Cheryl, valued sex, cared about their family, and wanted to heal the marriage. But while Justin loved his wife and found her attractive, he was an anxious sexual performer and didn’t value marital sex. He couldn’t imagine his wife in the erotic role that most turned him on—that of a dominatrix. Justin eroticized transgressive sex, specifically the role of being a sexual submissive. “I’ve struggled with this my whole life,” he said, adding that he’d never revealed this part of himself to any intimate partner, including Cheryl.
Justin continued to resist labeling his secret sexual life as an extramarital affair. He rightly noted that a large percentage of men use porn and get turned on by socially unacceptable images and scenarios. Feeling my empathy and respect, he gradually grew less defensive and began to examine both the healthy and unhealthy components of his sexuality. While maintaining eye contact and reflecting how difficult this sexual split must be for him, I said, “You owe it to yourself to resolve these conflicts.” Once we acknowledged his sexual strengths—valuing sex, enjoying eroticism, and having regular orgasms—I looked him in the eye again and said, “Be honest with yourself. What don’t you like about what’s happening with you sexually?”
After a silence, Justin said in a low voice, “I’m embarrassed about spending so much money on sex clubs and all the rest.”
Gently, I pressed the issue: “After a sexual encounter, what do you think and how do you feel?”
More silence. Then he answered: “I just want to get away.”
After a moment, I suggested to Justin that keeping his sex club encounters a secret and de-eroticizing his wife were part of the problem. “Your sex is controlled by high secrecy, high eroticism, and high shame, isn’t it?” I asked. When he nodded agreement, I added, “Don’t you feel that’s a poison that you’re taking into yourself?” This was a new, non-shaming way for Justin to understand himself, the role of his secret sex life, and how it affected Cheryl. For the first time, he understood that his secret sexual activity did negate marital sexuality and, therefore, was an extramarital affair. His voice shaking, he said, “Dammit, Cheryl’s right. It is like an affair.”
In her individual session, Cheryl revealed that she’d grown up feeling fearful and inadequate in the sexual realm. Her mother had raised her to link sexuality with pregnancy and being labeled a slut. She never felt pretty or sexy enough and feared that no one would ever want to marry her, so when Justin pursued a relationship with her and proposed marriage, she felt she’d been saved. Now she was devastated by her husband’s lack of erotic interest. “I feel like a sexual neuter,” Cheryl said. “I can’t imagine that any man would think I’m attractive or want to go to bed with me.”
A crucial component of our sex therapy model is the couple feedback session. The goals of this 90-minute session are: the development of a new, more genuine narrative about each partner’s strengths and vulnerabilities, especially regarding sexuality; the creation of a therapeutic plan addressing the relationship, the affair, trust, and the couple’s sexuality; and assigning the first psychosexual skill exercise to be completed at home. As both partners confront painful personal, relational, and sexual realities during the feedback session, the clinician must be particularly empathetic, respectful, and caring.
I started the session by turning my chair to face Cheryl as Justin looked on. “Cheryl, you bring great psychological, relational, and sexual strengths to this marriage,” I began. “You want a marriage that’s satisfying, stable, and sexual. You’re committed to developing a healthier family than the one you grew up in, and you’ve survived the painful last two years and haven’t given up trying to understand what’s happening to you and Justin sexually. But you also bring major vulnerabilities. You deal with hurt feelings by becoming angry and attacking, your sexual self-esteem is low, and you’re now Justin’s worst critic.” I then turned to Justin and addressed the particular strengths and vulnerabilities that he brought to the marriage.
During this session, both partners learned new and valuable information about the other. Cheryl hadn’t been aware of Justin’s desire to be sexually submissive or his performance anxiety during sex. For the first time, she understood that her husband’s affair had been driven by his own internal sexual conflicts, rather than his judgment of her sexual desirability. Rather than having to defend herself by attacking him, she felt freed to be more emotionally present with Justin in a new way.
For his part, Justin hadn’t realized how desperately Cheryl needed his love and sexual desire, nor did he know how devastated she was by his loss of sexual interest in her and his avoidance of marital sex. For the first time, he took some responsibility for the impact of his secret sexual life. “I never wanted this to happen to you or to us,” Justin gently told his wife. “I never intended to hurt you.” Then, with my urging, Justin took her hand, looked into her eyes, and said, “I love you and want to be with you.”
This larger focus on the couple’s marriage and sexual connection enabled them to begin addressing the fuller meaning of the affair. Until then, it was as though Justin and Cheryl had been speaking completely different languages about the affair’s significance, and now finally were able to communicate in English. Both understood that the affair had nothing to do with Cheryl’s erotic allure and everything to do with Justin’s need to act out a secret sexual life that was split off from his married life. This crucial shift helped them reengage emotionally and begin experiencing themselves as allies instead of the adversaries they’d been in the last two years.
By the end of the 90-minute feedback session, the three of us were emotionally drained, but Justin and Cheryl exuded a new sense of hope. They committed themselves to a therapeutic plan for trying to rebuild a new marital and sexual bond. Toward the end of the session, I described a psychosexual trust exercise and asked them to practice it at home. It focuses on nude, whole-body touching that promotes safety and attachment. The trust position that Cheryl and Justin chose was her lying in his arms as he stroked her hair. Over time, this exercise helped them experience being part of an intimate team in confronting the past and building a satisfying new sexual connection.
Building a New Bond
Our next several therapy sessions were emotionally challenging as Cheryl and Justin continued to reveal painful hurts and disclose their vulnerabilities. At the same time, I continued to offer them encouragement and tools for developing a new, positive connection. In one session, I asked them to engage in the attraction exercise, in which each shared what they valued about their spouse emotionally, relationally, physically, and sexually. When Justin told Cheryl that he found her to be “a smart, attractive, loving woman with whom I want to share my life,” she teared up, but didn’t look away. “I need you to love and want me,” she replied, holding his gaze. “And I love and want you.”
I continued to express my belief that they could build a new marital and sexual bond by acknowledging the past and learning new ways to experience the healing value of touch, trust, and attraction. Rather than relying on traditional sensate focus exercises, I taught psychosexual skill exercises that related directly to sexual desire. Developing healthy sexual desire involves not only valuing intimacy, but also a willingness to try out erotic scenarios and techniques, and engaging in “non-demand pleasuring”—affectionate, playful touch that may or may not lead to intercourse.
It was Cheryl who took the initiative to promote sensual and playful touch both inside and outside the bedroom. Though Justin hated the clinical-sounding term “non-demand pleasuring,” he greatly enjoyed touching and being touched by Cheryl. In one session, with tears in his eyes, he told her, “For the first time since I was a kid, I feel there’s someone who really knows me, accepts me, and loves me.”
Facing the Tiger
We still needed to confront the most sensitive issue facing the couple: Justin’s variant sexual arousal—his need to play a sexually submissive role and be demeaned in order to be turned on. I explained to the couple that they had to commit jointly to a therapeutic strategy to deal with Justin’s sexual pattern. They could choose to accept it, compartmentalize it, or give it up as a “necessary loss.” Clinicians remain split regarding which strategy works for which couples.
Justin spoke first. He told Cheryl how much he appreciated her empathy and support for his dilemma and made it clear that he didn’t want her to become his dominatrix. “I don’t want that for either of us,” he told her. His choice was to relinquish his submissive sexual pattern as a necessary loss.
Cheryl was deeply moved, seeing his willingness to change his lifelong arousal pattern as a tremendous gift and a symbol of how much he valued her, their marriage, and their family. “Thank you,” she whispered.
Acceptance of the necessary loss strategy was vital, but not sufficient. With my encouragement, Justin also acknowledged to Cheryl that the combination of secrecy, eroticism, and shame surrounding his behavior had been destructive to their marriage. He took hold of her hands, looked into her eyes, and said: “I’m so sorry I hurt you. I’m totally committed to being your intimate sexual spouse. You can trust me.” He’d arrived at a place where he genuinely and deeply regretted his betrayal, yet was no longer sunk in shame and self-hatred. He was ready to learn to value intimacy, pleasuring, and eroticism within his marriage.
The challenge for Cheryl was to discover the erotic scenarios and techniques that turned her on and to risk expressing her own wishes. By giving each other the freedom to experiment and express his or her sexual voice, the couple began to find a new path. Justin discovered that when Cheryl was sexually involved and responsive, it enhanced his own involvement and arousal. Meanwhile, Cheryl found that feeling wanted and needed by Justin was her most powerful aphrodisiac. Gradually, the couple began to enjoy sex as a team sport.
This doesn’t mean that Justin’s issues evaporated. In an individual session with me, he acknowledged that being sexually submissive with a controlling, dominant woman was still a 100 for him in terms of erotic intensity. He didn’t believe that he’d ever experience that same degree of erotic charge during intimate sex with Cheryl. However, he understood that it was still possible to create a rewarding new couple sexuality. “It’s already happening,” he told me. He rated his sexual bond with Cheryl as a solid 85 in terms of intimacy, intensity, pleasure, and sexual satisfaction. He added with a grin, “Who knows where it’ll go from here?” As this case demonstrates, I advocate the both/and path that Cheryl and Justin negotiated with courage and commitment. Helping couples fully express difficult feelings and process the affair to make meaning of it enables them to build a stronger trust bond and a more satisfying sexual connection.
By Michele Scheinkman
Traditionally, couples therapists have assumed that if they helped couples repair their emotional relationship after a betrayal, their erotic bond will somehow magically flourish. Lately, however, many therapists have questioned this idea, realizing that the couple’s sexual connection is a delicate matter that must be dealt with directly and skillfully. This case illustrates a therapist’s sustained effort to explicitly help a couple develop a lasting erotic connection in the aftermath of infidelity.
A central feature of Barry McCarthy’s approach is his assessment of the couple by sequencing conjoint, individual, and conjoint feedback sessions. In doing so, he illustrates the effectiveness of individual sessions in disarming defensiveness and creating a safe space to explore erotic details that might otherwise remain secret. While the initial conjoint session gives him a full picture of Cheryl and Justin’s history and dynamics, it’s only in the safe environment of the individual sessions that McCarthy is able to understand their hidden vulnerabilities and yearnings.
While respectful and empathic of Justin’s desires for transgression and submission as elements of his sexual arousal, McCarthy firmly challenges his defensive justification that his extra-marital behavior was nothing more than a “normal male fooling around.” McCarthy asks a masterful question: “Be honest with yourself. What don’t you like about what’s happening to you sexually?” As Justin is encouraged to reflect on his sexual split, he’s forced to come to terms with the consequences of his behavior—the empty feeling after his transgressions, the money spent on sex clubs and all the rest, his loss of sexual energy toward Cheryl. In the individual session with Cheryl, McCarthy is equally skillful at uncovering her inhibitions and lack of sexual entitlement.
The million-dollar question in this case is what McCarthy calls “facing the tiger.” Can Justin really abdicate his desire for submission and pain? While McCarthy seems convinced that Cheryl will keep learning to be assertive and take sexual risks, he admits that Justin’s “variant” pattern is more complicated. Once again, he skillfully creates a narrative for solving the couple’s problem by posing Justin’s dilemmas in terms of choice and will.
McCarthy discusses three different alternatives for them. One possibility is for Justin to continue compartmentalizing his sexual needs. But with Justin’s now-heightened awareness of the painful consequences of his pattern, this isn’t an option. Justin also rejects the possibility of inviting Cheryl to play the dominatrix. The third choice, the one that Justin ends up choosing, is for him to relinquish his desires as a necessary loss for him, but a gain for the marriage. However, McCarthy isn’t naïve. Despite this reasonable choice, he understands that Justin’s intensely erotic yearnings for submission and pain will not miraculously disappear, so he keeps on working with Justin individually.
What lies ahead for this couple? Do we believe that entrenched sexual blueprints like Justin’s ever really change with therapy? Reading this case, we can say that, with McCarthy’s help, Justin and Cheryl may have broken the spell of secrecy and forbidden pleasures, once Justin shared his sexual dilemma openly with Cheryl and they’d entered a positive cycle of sexuality and intimacy in the marriage. The therapy seems to have helped them create a strong enough bond to deter the forces that might otherwise pull them apart again. But more than anything, it’s clear that this couple found a special therapist who’ll help them face any new crisis.
Barry McCarthy, Ph.D., a professor of psychology at American University, is the author of Discovering Your Couple Sexual Style, Enduring Desire: Your Guide to Lifelong Intimacy, and Sexual Awareness. Lana Wald, M.A., and a Ph.D. candidate in clinical psychology at American University, collaborated in this treatment and the preparation of this case study. Contact: email@example.com.
Michele Scheinkman, L.C.S.W., is a faculty member of the Ackerman Institute for the Family and in private practice in New York City. She’s written extensively on the topic of affairs, including “Foreign Affairs,” published in the July/August 2010 Psychotherapy Networker. Contact: firstname.lastname@example.org.
Tell us what you think about this article by e-mail at email@example.com.
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